Pharmacists want to counsel, but few do
Barriers are lack of time, patient loads, attitudes
Griffith NL, et al. Survey of inpatient counseling by hospital pharmacists. Am J Health-Syst Pharm 1998; 55:1,127-1,133.
Ask hospital pharmacists if they believe patient counseling is vital to the growth of their clinical status and future, and they'll probably say yes. Ask if they believe that as pharmacists, they are the most qualified to provide counseling, and they'll likely say yes as well.
Ask if they currently are providing patient counseling, and they'll probably say no.
That is surely the case in Ohio, based on a survey of 192 hospital pharmacists in a variety of settings across the state, compiled by pharmacists at the Ohio State University Medical Center in Columbus.
The survey's lead author, Niesha Griffith, MS, pharmacy coordinator at the medical center, makes a sobering by-the-numbers case for the necessity of patient counseling: the $100 billion annual cost of patient medication use noncompliance; two million hospital admissions a year tied to noncompliance factors; and 125,000 deaths each year also directly related.
And with the majority of states mandating the "offer of" or availability of prescription drug counseling, "pharmacists are not solely responsible for these disappointing statistics, but they can be an important part of the solution," posits Griffith. She also points out that while the 1990 Comprehensive Omnibus Budget Reconciliation Act also mandated an offer of pharmacist counseling for Medicaid patients, COBRA '90 specified community pharmacists counseling outpa - tients, thereby excluding hospital pharmacists and their inpatient population from the law.
But that's no excuse, Griffith says, putting it on the heads of pharmacists to push for counseling systems and hospital administrators to realize the need and deliver the resources. "Hospital pharmacists have unique advantages over community pharmacists," she says, citing access to patient records and private hospital settings as the primary advantages.
But in Ohio, 67% of pharmacists responding said they do not counsel patients. Twenty-one percent said they counsel one to two patients per day. The numbers then drop considerably: Just 5% said they counsel three to four patients a day, and 2% said they counsel more than six patients a day.
Griffith says her survey mirrors others done nationally exploring the reasons pharmacists, although willing, are not counseling patients about medication. Not surprisingly, the No. 1 reason is lack of time and/or an excessive workload, along with the lack of a private setting or the physical layout of a pharmacy in relation to where the patients are, as well as the hurdle of patient attitudes.
Griffith goes on to doubt the validity of a national survey by the American Society of Health-System Pharmacists reporting that the number of institutions providing education or counseling to inpatients grew from 19.1% in 1990 to 74.4% in 1994. It's not the methodology of the survey she doubts, but the difference between what responding hospital administrators and even pharmacy directors believe or would like to be perceived as happening, vs. the day-to-day reality.
Lack of time a key barrier
Whatever the case, the numbers from the Ohio survey are disappointing. Along with the overall low numbers of actual counseling, 28% of respondents said counseling was limited to specific patient populations, 26% said counseling services are available on an "as needed" basis, and 20% said no services were available, among other factors under the heading of the level of discharge counseling.
As to the barriers of inpatient counseling, 107 respondents cited lack of time, 75 cited inadequate staffing, 43 said patients were not accessible (with 33 noting that notification of discharge was inadequate), and 51 cited a lack of support outside the pharmacy. Those reasons received the most citations among two dozen possible barriers, from which responding pharmacists were asked to limit their choices to a maximum of five factors.
Pharmacists also were asked to select their top five from a similar number of positive facilitators in place where some counseling was being done. The largest number of pharmacists, 55, chose having the pharmacists near the patients in a decentralized, satellite, or clinical capacity. The availability of resources such as patient records was cited by 43 pharmacists, while 26 also chose support from outside the pharmacy - from administration, nurses, and physicians - as a top priority.
In a similar category of choosing suggestions to improve inpatient counseling, the majority of respondents, 49, cited making changes that would provide more time, 38 cited providing adequate staffing, and 20 each cited identifying patients and putting pharmacists near patients, echoing many factors making counseling a reality in some settings.
Pharmacists 'duty-bound' to counsel
Griffith makes that point clear in an analysis that goes beyond the raw numbers by grouping the types of pharmacists responding. "[Central ized] managerial and staff pharmacists reported inadequate staff as the second-greatest barrier to counseling, but decentralized pharmacists and pharmacists with both centralized and decentralized roles cited lack of a well-designed counseling program as the second-greatest barrier to counseling," she states.
Griffith also notes that whether responding pharmacists were currently counseling, they often had similar notions. For example, 31% of pharmacists who said they did counsel, and 32% of those who didn't, said simply being near patients was a "primary facilitator" in making counseling a reality.
Griffith says only hospital pharmacists can make increased patient counseling a reality and that they are duty-bound to do so, "in an effort to prevent acute care readmissions due to drug misadventures and noncompliance."
And if that's not enough motivation, how about saving your job? "Many pharmacists practicing in the hospital setting will soon be required to expand their practice to include more outpatient-related pharmaceutical services."
[For more survey details, contact Niesha Griffith, MS, pharmacy coordinator, Ohio State University Medical Center, 500 West 12th Ave., Columbus, OH 43210. Telephone: (614) 293-8000. Original article reprints can be obtained through Jon Schommer, PhD, associate professor, OSU College of Pharmacy, at the same address.]
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