# Connecting Pharmacists and Other Health Care Providers (HCPs) towards Drug Therapy Optimization: A Pharmaceutical Care Approach

Authors: Mir Javid Iqbal; Geer Mohammad Ishaq; Abdullah A. Assiri
Journal: International Journal of Clinical Practice
 (2023)

---

## Abstract

Background. Pharmaceutical care services offered by pharmacists rationalize drug therapy, improve patient quality of life, and save patients’ lives. This study was designed to optimize patient drug therapy through pharmaceutical care services offered by a pharmacist in consultation with other health care providers (HCPs) at a tertiary care hospital. Methods. This descriptive study was conducted to assess the role and effectiveness of pharmacists in optimizing drug therapy outcomes. The study was carried out at an internal and pulmonary medicine unit of a tertiary care hospital in Srinagar, Jammu and Kashmir, India, with a total of 50 health care providers (HCPs) (24 doctors, 16 nurses, and 10 pharmacists). A total of 182 patients (males and females) of all age groups were recruited into the study over a period of nine months. Patient-specific pharmaceutical care plans initiated by the pharmacist based on drug therapy-related needs and problems were used to address and optimize drug therapy outcomes in consultation with other HCPs. Results. A total of 388 drug-related problems (DRPs) with an average of 2.29 DRPs per patient were identified, for which 258 pharmaceutical care plans as interventions were proposed, out of which 233 (90.31%) were accepted and implemented. Preassessment and postassessment by HCPs on services rendered by the pharmacist showed a positive change in attitude among HCPs with respect to their endorsement and acceptance of the pharmacist’s services in providing direct patient care. Conclusions. Pharmaceutical care services offered by pharmacists helped in optimizing drug therapy and patient care.


---

## Body

## 1. Introduction

Clinical pharmacists are specially trained practitioners who provide direct patient care by offering services like pharmaceutical care [1]. Pharmaceutical care is the direct, responsible provision of medication-related care wherein the pharmacist works in collaboration with other HCPs and patients to optimize drug therapy outcomes [2, 3]. The concept of care, therefore, emphasizes establishing relationships with other HCPs and patients to achieve desired drug therapy outcomes. However, this concept of care can only be achieved if pharmacists and other HCPs agree on each other’s roles because the perceptions of HCPs regarding the pharmacist’s role can reduce the level of their cooperation [4, 5]. As the number of pharmacists rendering clinical services per occupied bed increases, mortality, drug costs, total costs of care, and length of stay decrease [5, 6]. The clinical and economic outcomes from a group of patients who received pharmaceutical care showed that, upon first assessment by the pharmaceutical care practitioner, more than fifty percent of the patients had one or more drug therapy problems identified and resolved. Moreover, the healthcare savings realized from pharmaceutical care were found to be huge [7, 8]. At the time of this study, there were no data available in published literature barring one study [9] on pharmacist-led services or interventions offered at any public health facilities in the region of Jammu and Kashmir. This concept has yet to take off in any of the healthcare facilities here, and pharmacists are still viewed as mere drug dispensers by patients and other HCPs alike. Given this dismal scenario, a beginning was made by this study to highlight the role of pharmacists working with other HCPs in providing direct patient care at a tertiary care hospital.


## 2. Methods

### 2.1. Study Design

This descriptive study was carried out for a period of nine months at an in-patient department of a tertiary care hospital in Srinagar, Jammu and Kashmir state, India. The study was conducted to assess the role and effectiveness of pharmacists in optimizing drug therapy outcomes.


### 2.2. Study Population

Study population included HCPs and patients of the super specialty respiratory medicine unit of the study hospital.


### 2.3. Inclusion Criteria

All patients, including both males and females, belonging to all age groups, admitted to the internal and pulmonary medicine units, and having consented to participate, were included in the study.


### 2.4. Methods

At the outset, a preassessment of the HCPs in the study unit was conducted to determine their attitudes and perceptions toward the role of pharmacists in providing direct patient care. The assessment was conducted using a self-administered, prevalidated questionnaire that was internally developed and validated using Delphi and the field pretest method [10, 11].Following this, a patient-specific continuous assessment by the pharmacist was carried out on a daily basis. All medical and medication information was collected by the pharmacist through patient/caregiver interviews, patient case notes, medication charts, and laboratory data. Patient-specific data were assessed, and all drug therapy-related needs and problems were identified and classified using PCNE criteria. Those drug-related needs and problems identified through the assessment findings were presented, discussed, and validated by attending HCPs. To manage patients’ medical conditions, pharmaceutical care action plans were developed by the pharmacist in consultation with the attending physician, which included interventions to address patients’ drug-related needs, resolve drug therapy problems, and achieve the goals of therapy. The pharmacotherapy interventions included initiating new drug therapy, discontinuing existing drug therapy, changing the product and/or dosage regimen, and patient education. All interventions were adopted, implemented, followed, and documented in accordance with the revised criteria provided by the Pharmaceutical Care Network Europe and the American Society of Health-System Pharmacists [12, 13].


### 2.5. Ethical Standards

Necessary ethical clearance was obtained from the Institutional Ethics Committee vide reference number SIMS 131/IEC-SKIMS/11-4579. All volunteers were educated about the purpose of the study.


### 2.6. Statistical Analysis

Data were analyzed using SPSS version 24. Descriptive analysis was done using means. A Student’st-test was used to evaluate prepharmacist and postpharmacist-led interventions in attitude and perception scores.


## 2.1. Study Design

This descriptive study was carried out for a period of nine months at an in-patient department of a tertiary care hospital in Srinagar, Jammu and Kashmir state, India. The study was conducted to assess the role and effectiveness of pharmacists in optimizing drug therapy outcomes.


## 2.2. Study Population

Study population included HCPs and patients of the super specialty respiratory medicine unit of the study hospital.


## 2.3. Inclusion Criteria

All patients, including both males and females, belonging to all age groups, admitted to the internal and pulmonary medicine units, and having consented to participate, were included in the study.


## 2.4. Methods

At the outset, a preassessment of the HCPs in the study unit was conducted to determine their attitudes and perceptions toward the role of pharmacists in providing direct patient care. The assessment was conducted using a self-administered, prevalidated questionnaire that was internally developed and validated using Delphi and the field pretest method [10, 11].Following this, a patient-specific continuous assessment by the pharmacist was carried out on a daily basis. All medical and medication information was collected by the pharmacist through patient/caregiver interviews, patient case notes, medication charts, and laboratory data. Patient-specific data were assessed, and all drug therapy-related needs and problems were identified and classified using PCNE criteria. Those drug-related needs and problems identified through the assessment findings were presented, discussed, and validated by attending HCPs. To manage patients’ medical conditions, pharmaceutical care action plans were developed by the pharmacist in consultation with the attending physician, which included interventions to address patients’ drug-related needs, resolve drug therapy problems, and achieve the goals of therapy. The pharmacotherapy interventions included initiating new drug therapy, discontinuing existing drug therapy, changing the product and/or dosage regimen, and patient education. All interventions were adopted, implemented, followed, and documented in accordance with the revised criteria provided by the Pharmaceutical Care Network Europe and the American Society of Health-System Pharmacists [12, 13].


## 2.5. Ethical Standards

Necessary ethical clearance was obtained from the Institutional Ethics Committee vide reference number SIMS 131/IEC-SKIMS/11-4579. All volunteers were educated about the purpose of the study.


## 2.6. Statistical Analysis

Data were analyzed using SPSS version 24. Descriptive analysis was done using means. A Student’st-test was used to evaluate prepharmacist and postpharmacist-led interventions in attitude and perception scores.


## 3. Results

A total of 182 patients and 50 HCPs from the study unit were included in the study. Most patients (53.8%) were aged between 60 and 70 years, and most HCPs were doctors (Table 1). The prepharmaceutical care services assessment revealed that there is a lack of knowledge and negative attitudes and perceptions among HCPs about pharmacy and a pharmacist’s role in improving patient health, reducing medication errors, rendering patient counseling, and providing drug information. Only 12% of HCPs agreed that clinical pharmacy services will improve patients’ health, and only 10% agreed to accept the involvement of pharmacists in the drug and disease management of patients.Table 1
Demographic details of the study patients and HCPs.
Age in yearsMaleFemaleTotalN (%)N (%)N (%)Study patients13–1902 (1.0)1 (0.5)03 (1.6)20–5948 (26.3)33 (18.6)81 (44.5)60–7071 (39.0)27 (14.8)98 (53.8)Total121 (66.4)61 (33.5)182 (100)Health care providers (HCPs)Doctors22 (44)2 (4)24 (48)Nurses3 (6)13 (26)16 (32)Pharmacists7 (14)3 (6)10 (20)Total32 (64)18 (36)50 (100)Bold referring to the total.Services like pharmaceutical care, patient counseling, and drug information were not rendered prior to this study (Table2). The patient-specific assessment revealed that a total of 1260 medications were prescribed for 182 patients, with an average of 6.92 drugs per patient. Antibiotics were identified as the most prescribed drugs at 34.36%, followed by proton pump inhibitors (PPIs) at 21.17% (Figure 1). A total of 388 DRPs in 182 patients were identified, with an average of 2.29 DRPs per patient. Patient-specific health-related problems were mainly associated with the drug use process (Table 3). All drug-related problems encountered and all drug-related needs identified during the assessment were addressed, and corresponding action plans were imparted in consultation with the attending physicians and nurses. For the 388 DRPs, 258 interventions were proposed, out of which 230 interventions were accepted and imparted.Table 2
HCPs assessment of services during prepharmacistand postpharmacist-led interventions (N = 50).
StatementsPercentage agreementPreintervention,N (%)Postintervention,N (%)P value, N (%)Do clinical pharmacy services help in improving patients’ health?12 (23.5)50 (100)<0.001Pharmaceutical care services address patients’ drug needs and problems20 (39.2)43 (84.3)<0.001Pharmacists help to optimize patients’ drug therapy with other HCPs14 (27.7)45 (88.2)<0.001Pharmacists should give reliable drug information to HCPs5 (9.8)45 (88.2)<0.001Pharmacists should counsel patients on the appropriate use of drugs22 (43.1)49 (96)<0.001Pharmacists should give cost-effective alternatives whenever required22 (43.1)38 (74.5)<0.001A pharmacist can help in minimizing medication errors in the ward15 (51)49 (96)<0.001Pharmacists can help in improving the quality of patient care in the ward20 (39.2)50 (100)<0.001A pharmacist can help as facilitator among HCPs and patients12 (23.5)50 (100)<0.001HCPs will accept the involvement of pharmacists in the drug and disease management of patients10 (19.6)50 (100)<0.001Figure 1
Most frequently used drugs during the study period (N = 1260).Table 3
Cause of DRPs as per PCNE classification.
TypesCause of DRPN%Drug selectionInappropriate drug (including contra-indicated)20.51No indication for drug00.0Inappropriate combination of drugs, or drugs and food71.80Inappropriate duplication of therapeutic group82.06Indication for drug treatment not noticed00Too many drugs prescribed for indication30.07More cost-effective drug available112.83Synergistic/preventive drug required and not given246.18New indication for drug treatment presented00Total5514.01Drug formInappropriate drug form30.07Dose selectionDrug dose too low10.25Drug dose too high30.07Dosage regimen not frequent enough82.06Dosage regimen too frequent123.09No therapeutic drug monitoring41.03Pharmacokinetic problem requiring dose adjustment00Improvement of disease state requiring dose adjustment133.35Total4411.34Treatment durationDuration of treatment too short00Duration of treatment too long112.83Total112.83Drug use processInappropriate timing of administration or dosing intervals266.70Drug underused/underadministered123.09Drug overused/overadministered153.86Drug not taken/administered at all246.18Wrong drug taken/administered112.83Drug abused (unregulated overuse)20.51Patient unable to use drug/form as directed4110.56Total13133.76LogisticsPrescribed drug not available71.80Prescribing error (necessary information missing)71.80Dispensing error (wrong drug or dose dispensed)287.21Total4210.82PatientPatient forgets to use/take drug/noncompliant5113.14Patient uses unnecessary drug225.70Patient takes food that interacts20.51Patient stored drug inappropriately143.60Patient dissatisfied with therapy despite optimal clinical and economic treatment outcomes30.80Total9223.71OtherAdverse drug event102.57Drug treatment more costly than necessary30.77Total133.35Grand total388100%A total of 65 interventions were imparted at the patient level, 75 at the prescriber level, and 93 at the drug level (Table4). Among the drug-related needs of study patients, gastric discomfort, hypokalemia, tachycardia constipation, and oral fungal infections were the most common conditions requiring therapeutic interventions (Table 5). Postassessment by HCPs of services rendered by the pharmacist in providing direct patient care revealed the services to be beneficial and effective in managing patients’ drug therapy. All HCPs agreed that, as a healthcare team, they do accept the involvement of pharmacists in the drug and disease management of patients.Table 4
Pharmacist-led interventions at various levels during the study period.
Level of interventionType of pharmacist led interventionN% age(1) At the prescriber levelPrescriber informed only031.16Prescriber asked for information041.55Intervention approved by prescriber4818.9Intervention not approved by prescriber124.65Intervention proposed, outcome unknown083.10Total7529.1(2) At the patient levelWritten information provided145.42Patient referred to the prescriber218.13Spoken to family member/caregiver3014.62Total6525.2(3) At the drug levelDrug changed083.10Dosage changed197.36Formulation changed020.77Instructions for use changed4115.89Drug stopped093.48New drug started145.42Total9336.0(4) Other interventionOther interventions at the patient level155.81Side effects reported to authorities103.87Total2509.7Total interventions made at various levels258100Bold referring to the total.Table 5
Most common DRPs and their management during the study period.
DRPsNo. of events,N(%)Identified causeManagementGastric discomfort108 (46.95%)Oral antibiotics NSAIDsGastric protection/counselingHypokalemia51 (22.17%)DiureticsSupplements/diet managementTachycardia47 (20.43%Beta-agonistsSelective agonistsConstipation46 (22.17%)AnticholinergicsDietary counselingFungal infection/dryness of mouth44 (19.13%)Steroid use/nebulizationMouth gargles and oral hygiene counseling


## 4. Discussion

Trained pharmacists are best suited to assist HCPs and patients in the prevention of drug-use problems and to achieve optimal and desired outcomes from drug intake [14]. In developing countries, irrational prescribing, dispensing, and administration practices have long been reported [15–18]. Our study provided some insight into the use of medicines by HCPs and patients, including factors affecting drug therapy outcomes. Several published studies have reported the existence of a communication gap between pharmacists and doctors [19, 20] and that the acceptance of pharmacists providing direct patient services is dependent on physician perceptions of pharmacist competence [18, 21, 22].Pharmaceutical care services rendered through our study were designed to bridge the existing gaps among HCPs and patients so that effective communication is utilized, managed and coordinated care is delivered, and drug therapy outcomes are improved. Drug administration-related errors, including patient noncompliance, accounted for the largest proportion (33.76%) of observed DRPs. Factors that could be responsible for such errors include communication deficits among HCPs and patients, a lack of knowledge, inadequate manpower, and a lack of time to counsel patients. It has been reported that pharmaceutical care appears to increase patient awareness about medication side effects [23]. The present study proposed 258 pharmacist-led interventions, out of which 233 interventions were accepted and implemented. Physicians who collaborate with pharmaceutical care practitioners have validated the work of the practitioners, and patients are also recognizing the benefits of pharmaceutical care [24, 25]. In these ways, pharmaceutical care intervention has stimulated greater involvement with the health care system, thus increasing utilization and improving the quality of patient care.This study marked the beginning of pharmaceutical care services being offered by a trained pharmacy practitioner. As evident from the results, 80% of HCPs agreed that all necessary and important services under pharmaceutical care were rendered at the patient and prescriber levels. Moreover, 100% of the participants agreed that, as a healthcare team, they do accept the involvement of pharmacists in drug and disease management. Given the changing role of pharmacists and pharmacy automation, physicians need to be proactive and find new ways of collaborating with pharmacists to enhance patient safety and care. Working directly with pharmacists, particularly in medication errors, is one way to do that. When physicians, pharmacists, and patients share responsibility for care, powerfully good results are obtained [26–29].Pharmaceutical care is a much-needed service, especially in our setting, and therefore it is high time to recognize the need for and importance of implementing such services on the ground. The present scenario in Jammu and Kashmir state, characterized by heavy doctor workloads, deficits in providing drug information, education, and counseling services to patients, and increased use of drugs, is ripe for trained pharmacists to play greater roles, and one such avenue is by offering pharmaceutical care services at both clinical and community levels.


### 4.1. Strengths and Limitations

Our study was the first of its kind in the entire state of Jammu and Kashmir and tried to introduce the concept of pharmaceutical care in a hospital for the first time on a pilot scale. However, our study had several limitations, and therefore, further research is warranted to fill the identified gaps. The study was conducted for a brief period of nine months and was restricted to specific patients of one hospital; therefore, the results and interpretations are limited to the study hospital only. The inclusion of these services in other hospitals would have increased the number of both interventions and outcomes. Disease outcome measures and patient follow-up after discharge were not included in the study because of time constraints. Additionally, the costs, quantitative preventability, and predictability of DRPs were not measured.


## 4.1. Strengths and Limitations

Our study was the first of its kind in the entire state of Jammu and Kashmir and tried to introduce the concept of pharmaceutical care in a hospital for the first time on a pilot scale. However, our study had several limitations, and therefore, further research is warranted to fill the identified gaps. The study was conducted for a brief period of nine months and was restricted to specific patients of one hospital; therefore, the results and interpretations are limited to the study hospital only. The inclusion of these services in other hospitals would have increased the number of both interventions and outcomes. Disease outcome measures and patient follow-up after discharge were not included in the study because of time constraints. Additionally, the costs, quantitative preventability, and predictability of DRPs were not measured.


## 5. Conclusion

Pharmacist-led pharmaceutical care services were rendered for the first time at the study hospital. As evident from the results, pharmacist-led interventions helped in the optimization of drug therapy through coordinated care with other HCPs. With better professional services and skills, pharmacists can become more acceptable to other HCPs as an integral part of the healthcare team. Healthcare facilities in the developing world need to keep pace with fast-changing trends by establishing departments of clinical pharmacy and involving pharmacists in medical ward rounds so that drug-related problems can be minimized, patients’ drug-related needs can be addressed in a better manner, patients can be counseled on their prescribed therapies, and the clinical outcomes of treatments can thereby be maximized.



---

*Source: 3336736-2023-01-14.xml*