Phar vol 22_1 20-03-2000 13:03 Pagina 27

Commentary

The need for clinical pharmacy

Giovanna Scroccaro, Manuel Als Almiana, Annemieke Floor-Schreudering,
Ye c h i e l A . H e k s t e r a n d Yv a n H u o n

Pharm World Sci 2000;22(1): 27-29.

2000 Kluwer Academic Publishers. Printed in the Netherlands.
Annemieke Floor-Schreudering (correspondence),
Manuel Als Almiana, Yechiel A. Hekster, Yvan Huon and
Giovanna Scroccaro: European Society of Clinical Pharmacy,
International Office, Theda Mansholtstraat 5b, 2331 JE
Leiden, The Netherlands
E-mail: office@escp.nl

Minimising the risk of treatment-induced adverse

events, i.e., monitoring the therapy course and
patients compliance with therapy;
Minimising the expenditures for pharmacological
treatments born by the NHS (National Health
Service) and by the patients, i.e., trying to provide
the best treatment alternative for the greatest
number of patients.

Introduction

Level of action

Clinical Pharmacy is a commonly used term in

pharmacy practice and in pharmacy literature.
Nevertheless, the term is still incorrectly interpreted
and used. In many instances, only the hospital pharmacist is believed to perform clinical pharmacy activities, while the community pharmacist is not.
Moreover, some believe that the only clinical task is
patient counselling.
For this reason ESCP through its Executive
Committee feels the need to define the correct meaning of clinical pharmacy, pointing out the objectives
and the activities related to the discipline.
The list of references at the end of this paper summarises the most relevant recently published work on
the impact and usefulness of clinical pharmacy services.

Clinical pharmacy activities may influence the correct

use of medicines at three different levels: before, during and after the prescription is written.

Overall goal of clinical pharmacy

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The overall goal of clinical pharmacy activities is to

promote the rational and appropriate use of medicinal products and devices. These activities aims at:
Maximising the clinical effect of medicines, i.e.,
using the most effective treatment for each type of
patient;

3. After the prescription

Counselling
Preparation of personalised formulation
Drug use evaluation
Outcome research
Pharmacoeconomic studies
After the prescription is written, clinical pharmacists
play a key role in communicating and counselling

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1. Before the prescription

Clinical trials
Formularies
Drug information
Clinical pharmacists have the potential to implement
and influence drug-related policies, i.e., making decisions on which drugs deserve to be marketed, which
drugs should be included in national and local formularies, which prescribing policies and treatment
guidelines should be implemented.
Moreover, clinical pharmacists are actively involved
in the conduction of clinical trials at different levels:
participation in Ethical Committees; study monitoring; dispensation and preparation of investigational
Meaning of the term Clinical Pharmacy
Clinical Pharmacy is a health speciality, which drugs.
describes the activities and services of the clinical
pharmacist to develop and promote the rational and 2. During the prescription
appropriate use of medicinal products and devices by Counselling activity
Clinical pharmacists can influence prescribers attithe individual and by society.
Clinical Pharmacy includes all the services per- tudes and priorities in choosing the correct treatformed by pharmacists practising in hospitals, com- ments. Activities in this sense include a continuous
munity pharmacies, nursing homes, home-based care comparative feedback service on physicians prescribservices, clinics and any other setting where medi- ing practice, organisation of educational activities
and, ultimately, the direct professional contribution of
cines are prescribed and used.
The term clinical does not necessarily imply an the pharmacist at the time the prescription choice is
activity implemented in a hospital setting. A commu- made.
The clinical pharmacist monitors, detects and prenity pharmacist may perform clinical activities as well as
vents harmful drug interaction, adverse reactions ad
a hospital practitioner.
While, on one hand, the discipline of pharmacy medication errors through evaluation of prescriptions
embraces the knowledge on synthesis, chemistry and profiles.
The clinical pharmacist pays special attention to
preparation of drugs, clinical pharmacy is more
oriented to the analysis of population needs with the dosage of those drugs, which need therapeutic
regards to medicines, ways of administration, pat- monitoring.
Community pharmacists have also the additional
terns of use and drugs effects on the patients.
The focus of attention moves from the drug to the possibility of making prescribing decisions directly,
when over the counter drugs are counselled.
single patient or population receiving drugs.

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patients. Pharmacists can improve patients awareness of their treatments, monitor treatment response,
check and improve patients compliance with their
medications. Working in a multidisciplinary team,
clinical pharmacists can also provide an integrated
care from hospital to community and vice versa,
assuring a continuity of information on risks and benefits of drug therapy.

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In several cases the clinical pharmacist handles special

preparations like parenteral nutrition bags or chemotherapy mixtures. This task requires clinical skills, since
single patients characteristics and needs are taken
into account.
Drug use review (DUR) is another key activity. DUR
offers useful information to the prescribers and the
health authorities on the penetration at local level of
the scientific guidelines, highlights prescribing errors,
and it represents a useful research and audit instrument in areas with lack of scientific evidences.
Clinical pharmacists play an important role in the
post-marketing clinical studies the so-called effectiveness studies.
It is common knowledge that randomised controlled trials (RCTs) are conducted in selected populations, both in terms of characteristics and number.
These patients may have very different characteristics
from the patients evaluated and cured by doctors in
daily practice. Inclusion criteria in RCTs are very selective in terms of age, disease, concomitant drugs used
etc. These studies are very important to evaluate drug
efficacy (e.g., the effect of a drug in an experimental
trial setting), but they do not give information neither
on effectiveness (e.g., the effect of a drug in a real
world situation) nor on the safety on large populations [1]. Effectiveness adjusts the results on the real
effect by variables present in the daily practice, like
accessibility to health care services and drugs, patient
compliance, drug-drug interaction, among many
others.
Drug dispensing is an ideal activity to start building
prescription databases and, at the same time, collaborate with clinicians on planning studies and surveys
on specific patient populations. The integration of
such databases with data related to patients outcomes makes possible to perform the so-called outcome research. The main objective of outcome
research is the evaluation of the effectiveness of the
alternative therapies.
The integration of patients outcomes (clinical,
humanistic or both) with cost information constitutes
the basis for performing pharmacoeconomic studies.
In these studies, incremental costs of treatment alternatives are compared with their incremental benefits.
Without results on outcomes of real patients, pharmacoeconomic studies can only be performed with
the modelling technique, with the consequent possible bias.

Background knowledge of clinical

pharmacist

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In order to make appropriate and correct interventions during the prescribing process, clinical pharmacists need both a strong clinical background, as well
as evaluative tools to correctly judge the evidences
available for the treatments. Thus, they need to know

very well the diseases characteristics and their progression; the characteristics of medicines, their mechanism of action, their formulations and the way they
interact with the human body. In addition, they need
to be able to evaluate the real value of a drug, analysing randomised controlled trials; they need to assess
risk, analysing epidemiological studies; and they need
to evaluate the economic burden of a treatment related to its advantages for the patients.
Schools of Pharmacy in Europe do not satisfy the
minimal requirements for an appropriate education in
clinical pharmacy, since they are still linked to an old
model of pharmacy activity, e.g., based on chemistry
and basic sciences knowledge.
A few universities have modified their curriculum
including topics such as epidemiology, pharmacoeconomics, clinical medicine, communication skills, the
latter being particularly indicated for community
pharmacists.
The majority of new graduates in pharmacy will
work either in the community or the hospital setting.
The curricula should reflect this trend, including topics of interest and innovation for practising pharmacists.
In the US, it is common practice in many universities to teach clinical pathology and medicine to
pharmacy and medical students in the same class.

The impact of pharmacy services has been

proven as effective
Several studies have been published on the effect of
clinical pharmacy services on different patients outcomes: humanistic (e.g., quality of life, satisfaction),
clinical (e.g., better control and management of
chronic diseases), economic (e.g., reduction in health
care costs).
A recent study published on Social Science and
Medicine this year reviewed all published papers from
1984 to 1995 on the impact of pharmacy services on
patients outcomes [2]. Forty-one papers were evaluated, of which 31 regard hospital pharmacy services
while the remaining 10 are on community pharmacy
services. The most frequently studied activities of hospital pharmacists were prescription monitoring and
adverse drug reaction reporting. Concerning community pharmacists, prescribing errors identification was
the most common topic studied. The review concludes that clinical pharmacy services are effective in
reducing health care costs, in improving the services
and quality of care.
From the recent medical literature, the following
studies have reported that clinical pharmacy services
can reduce hospital mortality rates, preventable
adverse drug events and medical costs.
Reduction of hospital mortality rates
A multi-center observational study conducted in 3763
hospitals in the United States showed that hospital
mortality rates decreased as particular categories of
hospital staff increased. The staff categories were
pharmacists, medical residents, registered nurses and
medical technologists. (Bond et al., Pharmacotherapy
1999) [3].
A second study published by the same author [4]
found that the presence of specific clinical pharmacy
services was associated with a significant decrease in

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mortality rate. In specific, there was a difference of pensing, generally requiring a contact with the pre195 death/ year/ hospital between hospitals with staff scribers. A total of 1503 interventions on 201.000
pharmacists conducting clinical research versus hospi- prescriptions were recorded.
tals without research specialists.
The most frequent interventions were on modalities of drug administration, followed by drug substiReduction of the rate of preventable adverse drug tution and generic substitution. A multidisciplinary
events caused by ordering errors
panel has then evaluated the impact of the intervenA recent study published in JAMA in 1999 [5] has tions, demonstrating that efficacy was improved in
found that pharmacists participation in medical 24% of the cases, an ADR was prevented in 32% of
rounds in the intensive care unit reduced by 66% the the cases, and a hospitalisation was avoided in 16%
occurrence of preventable adverse drug events of the cases.
caused by ordering errors. The study was conducted
at the Massachusetts General Hospital in Boston in
collaboration with the Harvard School of Public Conclusion
From the information presented above it is clear that
Health.
The researchers compared the number and type of clinical pharmacists have the potential to contribute
preventable ADEs in the ICU due to prescribing errors in rationalising drug use and improving the safe use
prior to initiation of the study and after the addition of drugs. This is in the benefit for the individual
patient and for society. It is of great importance that
of a senior pharmacist to the Unit care team.
pharmacists become properly trained in this respect
to fulfil the requirements society can expect from
pharmacist as health care providers.
Reduction of the medical costs
An extensive review of the literature on measuring the
impact of clinical pharmacy services on economic
outcomes showed that clinical pharmacy activities are References
effective in reducing health care costs [6]. Commonly, 1 Krumholz HM, Radford MJ, Wang Y et al. National use and
effectiveness of beta-blockers for the treatment of elderly
results were expressed as net savings or costs avoided
patients after acute myocardial infarction: National Co-operative Cardiovascular Project. JAMA 1998;280:623-9.
for a given time period or per patient. Seven studies
expressed results as a benefit-cost ratio. They differed 2 Inditz MES, Artz MB. Value added to health by pharmacists.
Social Science and Medicine 1999;48:647-60.
in type of clinical pharmacy services, site of provision 3 Bond CA, Raehl CL, Pitterle ME, Franke T. Health care professional staffing, hospital characteristics, and hospital mortality
of services and resources invested in the service.
rates. Pharmacotherapy 1999;19(2):130-8.
Nevertheless, the results were impressively positive,
4 Bond CA, Raehl CL, Franke T. Clinical Pharmacy Services and
with calculated average benefits to cost of 16.7 to 1.
hospital mortality rates. Pharmacotherapy 1999;19(5):556-64.
In other words, for every dollar invested in clinical ser- 5 Leape LL, Cullen DJ, Clapp M. Dempsey et al. Pharmacist participation on physician rounds and adverse drug events in
vices, on average $ 16.70 was saved thanks to the
the intensive care unit. JAMA 1999;282(3):267-70.
presence of these activities.
6 Schumock GT, Meek PD, Ploetz PA, Vermeulen LC and the
Publications Committee of the American College of Clinical
Pharmacy. Economic evaluations of Clinical Pharmacy
Improve of efficacy and ADR reduction
Services 1988-1995. Pharmacotherapy 1996;16(6):1188A recent study analysed the impact of community
1208.
pharmacists interventions [7]. During a 12-week 7 Hawksworth GM, Corlett AJ, Wright DJ, Chrystyn H. Clinical
pharmacy interventions by community pharmacists during
period, fourteen community pharmacies recorded all
the dispensing process. Br J Clin Pharmacol 1999;47:695-700.
the interventions on prescriptions beyond drug dis-

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