2 pharmacies embark on outcomes research
Plaguing question: What really matters?
Johns Hopkins Bayview Medical Center operates a 331-bed acute care hospital and a 255-bed chronic care facility in Baltimore. There, director of pharmacy and management services Burt Finkelstein, PharmD, is embracing the pharmacist’s role in outcomes reporting, and he’s doing it with little help.
"We’re interested in outcomes and the management of outcomes. Our organization is structured around outcomes these days, and they do indeed mean different things to different people," says Finkelstein. His hospital recently hired a director of outcomes management, whom he ultimately hopes will take on that role for the entire hospital system. The director now is coordinating outcomes pilot programs and database compatibility for the two facilities making up the medical center.
The most ambitious outcomes venture the pharmacy is involved with, he says, is a multivariant analysis of congestive heart failure patients. Here the hospital has hired a consultant for this outcomes and software analysis, which includes the control of ace inhibitors and other drugs.
"It started off as a financial outcomes project. We have congestive heart failure patients in large numbers, and we were looking at dollars spent per patient, but we also believe there are good outcomes data to support various ways of management. A cardiologist might say, "Put these patients on ace inhibitors," while the exercise people would say to do other things. So we’re looking at antihypertensive medicines, the lab input, and things like exercise," Finkelstein says.
With data collection completed, he says the analysis aspect of the outcomes study is just under way. "We did not go into this with a goal in mind. I think we’re looking for truth with a small t instead of a capital T," he adds. "The other thing we’re doing here on a smaller scale is looking at individual DRGs and the effect of care maps or clinical pathways on outcomes. We’re taking an interdisciplinary approach," he says, to measurements such as length of stay and costs, while other variables are identified for patients as either "staying on or falling off the path, and whether that’s good or bad if that happens."
Other outcomes projects at Johns Hopkins involving the pharmacy include the optimal types of coagulation during elective hip or knee replacement, an analysis of antiemetics in terms of surgical care maps, and whether the effects of PN inflammatory agents affect length of stay and, therefore, outcomes.
Questionnaires and software
Lexington Medical Center in West Columbia, SC, operates a 250-bed hospital and 352-bed nursing home. Director of pharmacy Robert Spires is taking a twofold approach to outcomes reporting while moving the pharmacy into a clinical and systemwide structure.
"In the past year, we did away with the departmental focus and came in with the interdisciplinary focus. We’ve decentralized the pharmacy to merge with nursing and do clinical work," he says. This includes physician consults, drug interactions, adverse reactions, and an antibody monitoring program. Pharmacists also conduct asthma clinics and a respiratory rehab program at Lexington.
"We’re trying to focus on the interdisciplinary and the outcomes, and how the team approach effects the outcomes," Spires says. To get started, the pharmacy began interviewing all patients coming in for admissions for next-day surgery. "We take a drug history at that time and ask questions about drug therapy and conduct follow-up, so once they are admitted we have a good drug history," he says. Afterward, the pharmacy and nursing units do follow-up questionnaires daily.
The other tool Spires uses is the Clinitrend computer software program to attempt to tie in the patient interviews with a numerical value system based on the time and cost spent on the drug consultations. He’s also using the software to chart interventions centered around time and dollars saved. These reports can be printed and sent to the system’s pharmacy and therapeutics committee as a track of outcomes.
"That’s what we’ve evolved to at this point. It’s not perfect yet. It’s hard to quantify dollars and time, but I think this software is the tool to do that with. We started with one pharmacist on one floor, and it grew. We began looking at drug interactions, then adverse reactions, and just kept going. I think any pharmacy could do it that way."
[For more information, contact Burt Finkelstein, PharmD, Director of Pharmacy and Management Services, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224. Telephone: (410) 550-0100. Robert Spires, RPh, Director of Pharmacy, Lexington Medical Center, 2720 Sunset Blvd., West Columbia, SC 29169. Telephone: (803) 791-2000.]
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