Mortality, staff levels show link in pharmacies
July 1, 1999 4 minutes read
Mortality, staff levels show link in pharmacies
Two new studies show a connection between the number of patient deaths and staff levels in hospital pharmacies as well as other services. One study, published in May,1 identified four clinical pharmacy services associated with lower hospital mortality rates.
The other study, published in February,2 confirms that mortality increased or decreased with different staffing levels and skill combinations. Key points from both research projects follow.
Pharmacy services and patient mortality
Four clinical pharmacy services (followed by definitions) are associated with fewer hospital deaths:
1. Drug information services. (Pharmacist assigned to be available for drug-related questions.) Prevented 10,463 deaths; per-admission cost, $1.06.
2. Clinical research. (Hospital pharmacist is principal investigator or co-investigator, with his or her name likely to appear on the published paper.) Prevented 21,125 deaths. Median yearly pharmacist salary cost per hospital for conducting clinical pharmacy research was $5,656; each $1 of salary time resulted in an average of $14 in grants.
3. CPR team participation. (Pharmacist is active team member, attending most cardiopulmonary arrests.) Prevented 5,047 deaths at a per-hospital cost of $8 per CPR event.
4. Drug admission histories. (Pharmacist provides admission histories.) Prevented 3,843 deaths; per-admission cost, $1.10.
The researchers cite this as the first study to associate reduced mortality with centrally based and patient-specific pharmaceutical services. It is the first to also quantify the potential impact of the services. Specifically, within the records of 3,763 hospitals (roughly 78% of U.S. hospitals), there were as many as 40,478 fewer deaths per year where the four above-mentioned pharmacy services were in place.
Based at the department of Pharmacy Practice, in the School of Pharmacy at Texas Tech Univer-sity Health Sciences Center in Amarillo, the authors used records from the Chicago-based American Hospital Association, and the Health Care Financing Administration (HCFA).
This study identified the associations — not cause-and-effect relationships — between lower mortality rates and pharmacy services. The data were adjusted for severity of illness. The researchers note, "Since mortality rates are associated with quality of care, these services are likely quality of care indicators for both hospitals and pharmacies."
Why the associations? The investigators admit they were not able to find specific reasons. However, they offered educated guesses regarding the four pivotal pharmacy services:
1. Drug information services — An unbiased source of drug information might promote better patient care. Or, the presence of such a service may be a sign the medical staff is open to collaboration with pharmacists.
2. Clinical research — Happens primarily in academic health care centers where teaching hospitals have lower mortality rates.
However, since only 47.2% of the hospitals were teaching hospitals, another explanation is that pharmacy departments that conduct research may employ more highly trained and skilled pharmacists.
3. CPR team participation — Perhaps a pharmacist’s presence at codes promotes better drug therapy decisions. On the other hand, the inclusion of a pharmacist might be a sign of a collaborative attitude among the physicians.
4. Drug admission histories — Other studies show that adverse drug events in hospitals are often preventable if detected early, and pharmacists are perhaps better able to detect drug-related problems than other health care providers.
Study covered 14 professions
Overall staffing levels and patient mortality
Staffing levels in 14 professions were studied. The investigators used only full-time personnel who worked on inpatient services. Department administrators such as pharmacy, nursing, and medical technology counted as departmental personnel, not administrators.
The mortality data are severity-adjusted for Medicare patients from 3,763 U.S. hospitals, the same ones as those used in the pharmaceutical services research summarized above.
The average annual number of deaths per hospital was 593 in 1992, when the research data were collected.
Personnel categories include:
1. Administrators-
2. Physicians
3. Medical residents+
4. Registered nurses+
5. Licensed practical/vocational nurses-
6. Physician assistants
7. Registered pharmacists+
8. Medical technologists+
9. Dietitians
10. Occupational therapists
11. Physical therapists
12. Respiratory therapists
13. Social workers
14. Total hospital personnel+
+ As these categories of personnel increased, mortality rates per occupied bed decreased.
- As these categories of personnel increased, mortality rates per occupied bed increased.
The investigators indicate no surprise at the absence of association between numbers of staff physicians and hospital mortality rates. Less than one-third of the sample had a full-time physician on the payroll. Regarding lower mortality in hospitals with medical residents, they surmise that it could stem from better care due to physician involvement, or simply to decreased resident caseloads.
The authors observe, "This is the first study to show a negative clinical outcome associated with hospital administrator staffing levels." However, they don’t know the reasons for higher mortality associated with increased administrator staffing.
They specially point out the association of licensed practical/vocational nurses with higher mortality because staff reduction plans often replace registered nurses with less skilled nursing personnel. The specific effect between the number of medical technologists and hospital mortality rates is unknown.
Nonetheless, the researchers suggest that hospitals with more medical technologists may be able to respond more rapidly to orders for lab tests. Other factors might include better quality control in labs.
One limitation of the study is that current staffing levels differ from those of 1992, the year the data were collected. Another limitation, note the researchers, is that hospital performance is determined by structure, process, and outcome. "We examined one measure of structure [staffing levels] and one outcome measure [HCFA’s Medicare mortality rates], but did not examine process."
References
1. Bond CA, Raehl CL, Franke T. Clinical pharmacy services and hospital mortality rates. Pharmacotherapy 1999; 19:556-564.
2. Bond CA, Raehl CL, Pitterle ME, et al. Health care professional staffing, hospital characteristics, and hospital mortality rates. Pharmacotherapy 1999; 19:130-138.
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