Clinical pharmacy sounds like a technical term rather than a caring term. When analysing the wording, however, “clinical” goes back to the Greek “κλινειν”, which means “to bow”, in the sense of caring for people. Freely interpreted, one could consider clinical pharmacy as an umbrella term covering all caring activities in pharmacy practice.
The term “clinical” does not necessarily imply an activity implemented in a hospital setting. A community pharmacist may perform clinical activities as well as a hospital practitioner. While the discipline of pharmacy embraces the knowledge of synthesis, chemistry and preparation of drugs, clinical pharmacy is more oriented to the analysis of population needs with regards to medicines, ways of administration, patterns of use and drug effects on patients.
The clinical pharmacist is a dynamic person working in a dynamic environment. One can define his or her universal lifecycle as comprising four phases: growing, working, reflecting and supporting (see Figure 1). Growing is guaranteed by the educational process, which develops knowledge, skills and attitude. During the past 15 years curricula have been adapted (ie, more clinically oriented) everywhere in Europe. Whereas the accent was more on beta sciences or fundamental sciences, more time is now devoted to alpha (behavioural) and gamma (medical) sciences. The first movement was away from the exact scientific disciplines, such as physics and mathematics. This led to a certain form of “compartmentalising”. Now the term “translational sciences” has been introduced. As Zerhouni states:
“It is the responsibility of those of us involved in today’s biomedical research enterprise to translate the remarkable scientific innovations we are witnessing into health gains for the nation. In order to address this imperative, we at the National Institutes of Health (NIH) asked ourselves: What novel approaches can be developed that have the potential to be truly transforming for human health? To help crystallize these ideas and develop tangible strategies to advance our efforts, three years ago the NIH initiated a series of consultations with the research community to define major scientific trends collectively, with the goal of identifying thematic areas that no single NIH institute or group of institutes could tackle alone, but that the whole of the NIH needed to address.”(1)
Clinical pharmacy can be a nice forum to apply these translational sciences. Curricula at universities are converging with the professional environment. However, training at university remains theoretical, and at the end the pharmacy internship can be considered a “royal pathway to practice”.(2) Table 1 demonstrates the link between basic academic disciplines and the responsibilities of daily practice.
It is clear that creativity and enterprise are necessary to combine all these disciplines. Working with this background will automatically lead to reflection. Sooner or later there is the desire to define what we are representing as clinical pharmacists. When the message is clear, education can be organised.
Examples of applied clinical pharmacy
From the outer world the question about outcomes arises. The role of clinical pharmacists in the care of hospitalised patients can be taken as an example. Kaboli et al reviewed the published literature on the effects of interventions by clinical pharmacists on processes and outcomes of care in hospitalised adults.(3) Thirty-six studies met inclusion criteria, including 10 evaluating pharmacists’ participation on rounds, 11 medication reconciliation studies and 15 on drug-specific pharmacist services. Adverse drug events, adverse drug reactions or medication errors were reduced in seven of 12 trials that included these outcomes. Medication adherence, knowledge and appropriateness improved in seven of 11 studies, while there was shortened hospital length of stay in nine of 17 trials. No intervention led to worse clinical outcomes, and only one reported higher healthcare use. Improvements in both inpatient and outpatient outcome measurements were observed. The authors concluded that the addition of clinical pharmacy services in the care of inpatients generally resulted in improved care, with no evidence of harm. Interacting with the healthcare team on patient rounds, interviewing patients, reconciling medications, and providing patient discharge counselling and follow-up all resulted in improved outcomes.
Some particular areas can be covered by clinical pharmacists. In recent years medication errors have received considerable attention, as they cause substantial mortality, morbidity and additional healthcare costs. Ten years ago Bootman et al stated: “For every dollar spent on drugs in US nursing homes facilities, $1.33 in healthcare resources are consumed in the treatment of drug-related problems,”(4) to which Lazarou et al added: “Adverse drug effects are between the fourth and sixth leading causes of death in USA.”(5) In 2005 Guchelaar looked at risk assessment models, adapted from commercial aviation and the oil and gas industries, in order to develop them for use in clinical pharmacy.(6) The clinical pharmacist is best placed to oversee the quality of the entire drug distribution chain, from prescribing, drug choice, dispensing and preparation to the administration of drugs, and can fulfill a vital role in improving medication safety. Most elements of the drug distribution chain can be optimised; however, because comparative intervention studies are scarce, there is little scientific evidence available demonstrating improvements in medication safety through such interventions. Possible interventions aimed at reducing medication errors, such as developing methods for detection of patients with increased risk of adverse drug events, performing risk assessment in clinical pharmacy and optimising the drug distribution chain, are challenges for the clinical pharmacist.
Pharmacists are well trained to register data in a methodological way. This can be particularly useful when adverse drug reactions are considered. Van Grootheest et al reported on the participation of the pharmacist in national spontaneous reporting systems for adverse drug reactions (ADRs).(7) They conducted a review of the literature to investigate the involvement of pharmacists in ADR reporting. In addition, they evaluated the pharmacists’ actual contributions in 2001 by means of an international questionnaire-based survey among the countries participating in the WHO Drug Monitoring Programme in September 2002. Apart from the numbers of pharmacists’ reports, respondents were asked to indicate their assessment of both the quality and the significance of the contribution. Of the 68 participating countries, 41 responded by returning the questionnaire. The appreciation of pharmacists’ ADR reports is high in those countries that have more experience with greater numbers of pharmacists’ reports. The countries that received fewer reports from pharmacists gave lower scores to their contribution. If the specific contribution pharmacists can make to the quantity and quality of ADR reports was to be exploited to a greater extent, this could lead to a substantial improvement of the international ADRs reporting system. At the same time the clinical pharmacist can confirm his reason for existence by coming up with “hard” outcomes.
A last example is the critical care pharmacist as elaborated by Horn and Jacobi.(8) They reviewed the history, training requirements, contributions to patient care outcomes and workforce issues of critical care pharmacists. They concluded that critical care pharmacists are recognised as essential members of the critical care team as a result of their contribution to medication safety, improved patient outcomes and reduced drug costs and as a source of drug information and provider of education. A growing number of pharmacists practise in critical care. Additional opportunities exist and can be met if an adequate supply of trained specialists can be developed.
In general the ECHO model can be taken as a reference for measuring outcomes. ECHO stands for economic, clinical and human outcomes. The economic and clinical outcomes can be considered as the “hard” and more quantitative outcomes. The human outcomes are related to quality of life and behaviour; they are categorised as “soft” or more qualitatively oriented outcomes.
The role of the ESCP
The European Society of Clinical Pharmacy (ESCP) tries to scientifically back the wide scope of activities within clinical pharmacy. The ESCP was founded in 1979 with the following mission statement: “Clinical pharmacy is a health specialty which describes the activities and the services of the clinical pharmacist to develop and promote the rational and appropriate use of medicinal products and devices.”
The Society has about 850 individual members from 58 different countries, mostly European. The structure of the ESCP is made up of a general and an executive committee, along with a research, an education and a publication committee. Members are grouped in 11 SIGs (special interest groups) focusing on particular topics (see www.escpweb.org/site/cms/sigselect.asp for more information).
The activities of ESCP centre on the yearly conferences. The most recent conference took place in Istanbul on 25–27 October 2007. The theme was “Implementing clinical pharmacy in the community and hospital setting: sharing the experience. You can access abstracts from previous conferences at www.escpweb.org/site/cms/contentViewArticle.asp?article=2337. Conferences consist of plenary lectures, pharmacological updates, workshops, a masterclass and teaching courses. Table 2 lists some of the topics covered at the ESCP conference sessions. When selected, these are presented either as an oral communication during a poster discussion forum or as a poster.
There are already conferences planned for the future – an international workshop on “The oncological patient and the clinical pharmacist’ in Leuven, Belgium in May 2008; an international symposium in Malta in October 2008; and a joint meeting with the American College of Clinical Pharmacy (ACCP) in Orlando,FL, USA, in April 2009. Apart from these international meetings, national patient-oriented teaching courses take place regularly (there have already been three in France).
In April 2007 a joint seminar was organised with the European Association of Hospital Pharmacists (EAHP) in Prague. Hospital pharmacists from Eastern Europe were invited, and 27 colleagues took the opportunity to assist at workshops related to “safety at the patient’s bedside”. The EAHP did the logistical work and the ESCP provided speakers for this event.
To get an idea of the scientific output of these conferences some examples are listed in Table 3.
The ESCP produces its newsletter four times a year, an electronic version of which is sent to all members. Conference programmes with all abstracts are distributed during the conferences.
A scientific society needs a scientific journal, and Pharmacy World and Science (PWS) is the journal included in the membership fee. Every year six issues are published. PWS also edits the abstracts of the ESCP conferences.
The ESCP supports research projects on a European level. At the moment one observational study is running on the use of antimycotics in European hospitals; while another one on coxibs has finished (Eurocox). The fundamental message of the latter was that even when using a different methodology, in a different context, but aiming at the same target, consistent results can be obtained. The target for Eurocox was (un)safety claims on coxibs. The output confirmed that cardiovascular and gastrointestinal safety of coxibs cannot be taken for granted and that co-medication enhances the pressure on health expenditure.(9)
Support of clinical pharmacy practice
The software edition Cybele (medication during pregnancy and lactation) is freely available on the ESCP website (www.escpweb.org/site/cms/contentViewArticle.asp?article=2333). Cybele has been launched in Belgium as a supportive tool in medical and pharmacy practice. The database contains most of the DCI drug names commercialised in Europe.
Starting from the title page the user gets:
- A search facility for chemical names.
- A lexicon related to pregnancy and lactation.
- An index of the system.
At the moment only a Dutch and a French version of the program exist, but we are currently working on an English translation with international partners.
Clinical pharmacy is about caring for patients in a multidisciplinary environment. Pharmacy students are trained all over Europe to fulfil the expectancies of modern healthcare. Interventions by clinical pharmacists can lead to positive outcomes, such as improved safety and enhanced comfort for patients. For the ESCP, clinical pharmacy activities are an interesting study area. Analysis, intervention and evaluation are the cornerstones of an ever-technically evolving health system, where the essentials of providing care remain the same.
- Zerhouni EA. Translational and clinical science – time for a new vision. N Engl J Med 2005;353:1621-3.
- Verstraeten A, Laekeman G, Leemans L, Augustijns P, Kinget R, Clement M, et al. Pharmacy internship: the royal pathway to practice. Pharm Educ 2006;6:11-19.
- Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006;1669:955-64.
- Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med 1997;157:2089-96.
- Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta- analysis of prospective studies. JAMA 1998;279:1200-5.
- Guchelaar HJ, Colen HB, Kalmeijer MD, Hudson PT, Teepe-Twiss IM. Medication errors: hospital pharmacists perspective. Drugs 2005;65:1735-46
- van Grootheest K, Olsson S, Couper M, de Jong-van den Berg L. Pharmacists’ role in reporting adverse drug reactions in an international perspective. Pharmacoepidemiol Drug Saf 2004;13:457-64.
- Horn E, Jacobi J. The critical care clinical pharmacist: evolution of an essential team member. Crit Care Med 2006;34 Suppl:S46-51.
- Laekeman G. How European was Eurocox? ESCP Newsletter 2007;2.