Frontline Pharmacist
F rontline Pharmacist Implementation and expansion of a pharmacist-managed spirometry service
S
pirometry is a pulmonary function test that is routinely performed in hospitals and physicians’ offices to assist in the diagnosis of asthma and chronic obstructive pulmonary disease. 1 Spirometry can also be used to monitor patients who have already been diagnosed with a respiratory disease. Traditionally this test is performed by respiratory therapists, nurses, and medical assistants in a physician’s office. Data have demonstrated that pharmacists can competently perform spirometry testing.1-3 Pharmacists trained in performing quality spirometry services can provide a valueadded service that can be integrated with other clinical pharmacy services in the care of the pulmonary patient. Background. Crozer-Keystone Center for Family Health (CKCFH) is a community-based family health clinic associated with Crozer-Keystone Health System, a five-hospital health system in Springfield, Pennsylvania. The health clinic, a training location for the CrozerKeystone family medicine residency program, provides medical services to patients with a variety of acute and chronic medical conditions, including respiratory disease. To optimize the quality of care within the practice, the medical director discussed expanding the role of the clinic’s pharmacists. The pharmacists’ only clinical role at that time was within
an anticoagulation monitoring service, which was well received by the medical staff. Based on the need to address the large number of patients with potential respiratory disorders, a pharmacist who was also a registered respiratory therapist
recommended his expertise to implement a spirometry service. The medical director first discounted the need for this service since it was already performed by both the nursing and medical assistant staff within the office practice. The pharmacist asked the medical director if he could review the spirometry tests to determine if the testing quality was consistent with American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines. These
guidelines state that forced expiratory volume (FEV1) and forced vital capacity (FVC) should be measured at least three times, with the differences between the two largest FEV1 values and two largest FVC values being within 150 mL.4 A brief review of tests performed by the nursing and medical assistant staff revealed that the testing did not meet ATS/ERS criteria, putting into question the accuracy of the respiratory diagnoses made. Based on these data, the potential value of improving the quality of the spirometry testing, and the complexity of medication issues in these patient populations, the medical director decided that the pharmacist would be the optimal health care professional to lead the spirometry service. Program development. Before the spirometry service was offered, the medical team, which included the attending physician, medical residents, interns, nursing staff, and the clinical pharmacist, addressed four important issues: (1) targeting specific patients who would benefit from this service, (2) scheduling patients outside of normal scheduling procedures, (3) finding the time needed to perform this comprehensive service, and (4) determining how to provide patient follow-up. The new spirometry service began in November 2008, with one pharma-
The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or [email protected]).
Am J Health-Syst Pharm—Vol 71 Jan 1, 2014
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Frontline Pharmacist
cist performing all spirometry testing. Patients were referred to the pharmacist for spirometry testing after evaluation by the primary care physician within the family medicine residency program. The spirometry service is provided once or twice per month and is designed to see a maximum of five patients per day. The frequency of the service was based on the number of patients with a respiratory complaint or disease, pharmacist scheduling, and patient room availability to perform spirometry testing. Patients are only scheduled for the spirometry service; appointments are not integrated with the scheduling of patients with other medical disorders. Role of the pharmacist. The pharmacist’s roles include calibrating the spirometer on the day of testing, setting up a portable nebulizer and delivering a prescribed bronchodilator, participating in obtaining pulmonary medication history, spirometry testing before and after bronchodilator use, pulse oximetry testing, and consulting with the medical team about patients’ spirometry test results, including pharmacologic recommendations when warranted. In addition, the pharmacist educates patients and caregivers on smoking-cessation strategies and inhaled drug delivery devices (i.e., metered-dose inhaler, drypowder inhalers, and jet nebulizer). The time needed to perform these comprehensive services ranges from 60 to 75 minutes per patient. Preliminary outcomes. From August 2008 to January 2010, this pharmacistmanaged spirometry service saw 51 patients, 19 (37%) of whom were identified as having an obstructive or restrictive pulmonary defect. The pharmacist achieved quality measures of spirometry testing based on ATS/ERS guidelines in 77 (75%) of 102 of spirometry tests. In addition, accurate spirometry testing assisted in the addition, discontinuation, or alteration of pulmonary drug regimens in 41 patients (80%) seen in the clinic and the need for further diagnostic testing or physician referral in 14 patients (27%). Also, Medicare financial reimbursement received for spirometry services for these
16
51 patients totaled $4375.80.3 Since the initiation of this service until the time of writing, the pharmacist has performed over 150 spirometry tests. Expansion of spirometry services. Based on the initial success of the program at CKCFH, expansion of spirometry services to other practice settings seemed warranted. At this time, Quality Family Physicians (QFP), a privately owned family medicine practice consisting of three physicians in northern Delaware, was exploring ways to expand its team-based care services. Since July 2009, the practice has partnered with two pharmacy faculty members from the Philadelphia College of Pharmacy to assess the outcomes associated with pharmacist-provided services within a medical home in a small, privately owned physician practice. The pharmacistprovided services initially focused on patients with diabetes, dyslipidemia, and hypertension, as well as patients with psychiatric disorders. Based on patient and physician satisfaction as well as clinical outcomes of these services, the physicians and pharmacists from QFP and the Philadelphia College of Pharmacy considered various avenues for expansion of the pharmacist-led services. Through a needs assessment at the practice and communication with the CKCFH pharmacist, it was decided to expand the pharmacist-led services at the QFP site to patients with respiratory disorders. After consultation and training provided by the CKCFH pharmacist, QFP initiated a pharmacist-led spirometry service in May 2011. QFP service and pharmacist roles. The pharmacists at QFP are available one full day and two half-days per week. Patients referred into the program with potential respiratory disorders and requiring spirometry are scheduled with the pharmacists by the receptionist staff and integrated into the pharmacists’ schedule with the other patient visits. Before initiating this service, pharmacists provided training and patient information sheets to the receptionist and medical assistant staff. This was identified as an important step in implementing the service, as most
Am J Health-Syst Pharm—Vol 71 Jan 1, 2014
were unfamiliar with spirometry yet are at the frontline for questions and are responsible for providing key procedure information to the patient. At the initial visit, the pharmacist obtains a detailed pulmonary and medication history, performing spirometry testing before and after bronchodilator use, delivers the bronchodilator via a nebulizer, reviews the spirometry results with the physician, and develops and implements a physician-approved treatment plan. Treatment plans may include pharmacologic and nonpharmacologic therapies, smoking-cessation instruction, education about additional diseases, and instruction on the proper use of medication delivery devices included in treatment plans. Follow-up visits are scheduled with either the physician or the pharmacist, with most of the pharmacist follow-up centered on patients requiring medication. The time for initial visits ranges from 60 to 90 minutes. Followup visits are 30 minutes long. Billing for the spirometry services provided and for the office visit, when warranted, as well as any subsequent office visits, is done under the physician using the appropriate Current Procedural Terminology codes via standard medical office billing, as the physician physically visits with each patient at all of the pharmacist-led encounters. Preliminary outcomes for QFP service. For the 34 patients seen in the spirometry service at QFP between May 2011 and September 2012, 82.5% of spirometry tests met current ATS/ERS guidelines for quality measures. In comparison, 70–88% of tests performed by trained spirometry technicians met the older, less-stringent ATS quality measures.5 Applying these older ATS standards to the QFP pharmacist data, 92% of the tests met these quality standards. Obstructive or restrictive pulmonary abnormalities were observed in 35% of patients. Pharmacists made various recommendations that were implemented for inhaled medications, including the use of short-acting b-agonists (24% of Continued on page 17
Frontline Pharmacist Continued from page 16
patients), corticosteroids (21%), anticholinergics (15%), and long-acting b-agonists (12%). A total of 44% of patients received referrals to specialists. At the time of writing, pharmacists had performed over 70 spirometry tests. From a reimbursement perspective, payments to the practice generated by this service averaged $144 per initial visit. Challenges and future direction. Characteristics that made spirometry and delivery of pharmacist-led comprehensive care to patients with potential respiratory disorders successful in both practices included physician support, pharmacist training, a team approach to therapeutic plan development and implementation, and onsite spirometry testing. Challenges that exist for broader adoption of pharmacist-provided spirometry services include physician and patient unfamiliarity with pharmacists in these roles, current lack of training in spirometry for most pharmacists, and lack of direct reimbursement channels. As observed in these two practices, such challenges can certainly be overcome. Additional metrics that should be evaluated in future pharmacist-managed spirometry services include quality as-
sessment of provider and patient satisfaction, patient outcomes data (i.e., decreased emergency department or primary care physician visits and decreased hospitalizations), and cost-effectiveness studies. A promising venue for the expansion of these services is within innovative practice models such as the patientcentered medical home (PCMH). Patients with respiratory disease are logical targets for treatment by the interprofessional teams found in the PCMH, with pharmacists being uniquely qualified to assist with the complex demands of medication selection and delivery in this patient population. The ability of pharmacists to provide quality spirometry services would only enhance their value in the PCMH from both a clinical and an economic perspective. The incorporation of community pharmacists into the provision of these services should be explored to maximize access and convenience for patients. 1. Castillo D, Guayta R, Giner J et al. COPD case finding by spirometry in high-risk customers of urban community pharmacies: a pilot study. Respir Med. 2009; 103:839-45. 2. Fuller L, Conrad WF, Heaton PC et al. Pharmacist-managed chronic-obstructive pulmonary disease screening in a com-
munity setting. J Am Pharm Assoc. 2012; 52:e59-66. 3. Cawley MJ, Pacitti R, Warning W. Assessment of a pharmacist-driven point-ofcare spirometry clinic within a primary care physicians office. Pharm Pract. 2011; 9:221-7. 4. Miller MR, Hankinson J, Brusasco V et al. Standardisation of spirometry. Eur Respir J. 2005; 26:319-38. 5. Enright PL, Skloot GS, Cox-Ganser JM et al. Quality of spirometry performed by 13,599 participants in the World Trade Center Worker and Volunteer Medical Screening Program. Respir Care. 2010; 55:303-9.
Michael J. Cawley, B.S.Pharm., Pharm.D., RRT, CPFT, FCCM, Professor of Clinical Pharmacy [email protected] Jennifer Reinhold, Pharm.D., BCPS, Assistant Professor of Clinical Pharmacy Vincent J. Willey, Pharm.D., Associate Professor of Pharmacy and Vice Chair Department of Pharmacy Practice and Pharmacy Administration Philadelphia College of Pharmacy University of the Sciences Philadelphia, PA
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130084
Am J Health-Syst Pharm—Vol 71 Jan 1, 2014
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F rontline Pharmacist Implementation and expansion of a pharmacist-managed spirometry service
S
pirometry is a pulmonary function test that is routinely performed in hospitals and physicians’ offices to assist in the diagnosis of asthma and chronic obstructive pulmonary disease. 1 Spirometry can also be used to monitor patients who have already been diagnosed with a respiratory disease. Traditionally this test is performed by respiratory therapists, nurses, and medical assistants in a physician’s office. Data have demonstrated that pharmacists can competently perform spirometry testing.1-3 Pharmacists trained in performing quality spirometry services can provide a valueadded service that can be integrated with other clinical pharmacy services in the care of the pulmonary patient. Background. Crozer-Keystone Center for Family Health (CKCFH) is a community-based family health clinic associated with Crozer-Keystone Health System, a five-hospital health system in Springfield, Pennsylvania. The health clinic, a training location for the CrozerKeystone family medicine residency program, provides medical services to patients with a variety of acute and chronic medical conditions, including respiratory disease. To optimize the quality of care within the practice, the medical director discussed expanding the role of the clinic’s pharmacists. The pharmacists’ only clinical role at that time was within
an anticoagulation monitoring service, which was well received by the medical staff. Based on the need to address the large number of patients with potential respiratory disorders, a pharmacist who was also a registered respiratory therapist
recommended his expertise to implement a spirometry service. The medical director first discounted the need for this service since it was already performed by both the nursing and medical assistant staff within the office practice. The pharmacist asked the medical director if he could review the spirometry tests to determine if the testing quality was consistent with American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines. These
guidelines state that forced expiratory volume (FEV1) and forced vital capacity (FVC) should be measured at least three times, with the differences between the two largest FEV1 values and two largest FVC values being within 150 mL.4 A brief review of tests performed by the nursing and medical assistant staff revealed that the testing did not meet ATS/ERS criteria, putting into question the accuracy of the respiratory diagnoses made. Based on these data, the potential value of improving the quality of the spirometry testing, and the complexity of medication issues in these patient populations, the medical director decided that the pharmacist would be the optimal health care professional to lead the spirometry service. Program development. Before the spirometry service was offered, the medical team, which included the attending physician, medical residents, interns, nursing staff, and the clinical pharmacist, addressed four important issues: (1) targeting specific patients who would benefit from this service, (2) scheduling patients outside of normal scheduling procedures, (3) finding the time needed to perform this comprehensive service, and (4) determining how to provide patient follow-up. The new spirometry service began in November 2008, with one pharma-
The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or [email protected]).
Am J Health-Syst Pharm—Vol 71 Jan 1, 2014
15
Frontline Pharmacist
cist performing all spirometry testing. Patients were referred to the pharmacist for spirometry testing after evaluation by the primary care physician within the family medicine residency program. The spirometry service is provided once or twice per month and is designed to see a maximum of five patients per day. The frequency of the service was based on the number of patients with a respiratory complaint or disease, pharmacist scheduling, and patient room availability to perform spirometry testing. Patients are only scheduled for the spirometry service; appointments are not integrated with the scheduling of patients with other medical disorders. Role of the pharmacist. The pharmacist’s roles include calibrating the spirometer on the day of testing, setting up a portable nebulizer and delivering a prescribed bronchodilator, participating in obtaining pulmonary medication history, spirometry testing before and after bronchodilator use, pulse oximetry testing, and consulting with the medical team about patients’ spirometry test results, including pharmacologic recommendations when warranted. In addition, the pharmacist educates patients and caregivers on smoking-cessation strategies and inhaled drug delivery devices (i.e., metered-dose inhaler, drypowder inhalers, and jet nebulizer). The time needed to perform these comprehensive services ranges from 60 to 75 minutes per patient. Preliminary outcomes. From August 2008 to January 2010, this pharmacistmanaged spirometry service saw 51 patients, 19 (37%) of whom were identified as having an obstructive or restrictive pulmonary defect. The pharmacist achieved quality measures of spirometry testing based on ATS/ERS guidelines in 77 (75%) of 102 of spirometry tests. In addition, accurate spirometry testing assisted in the addition, discontinuation, or alteration of pulmonary drug regimens in 41 patients (80%) seen in the clinic and the need for further diagnostic testing or physician referral in 14 patients (27%). Also, Medicare financial reimbursement received for spirometry services for these
16
51 patients totaled $4375.80.3 Since the initiation of this service until the time of writing, the pharmacist has performed over 150 spirometry tests. Expansion of spirometry services. Based on the initial success of the program at CKCFH, expansion of spirometry services to other practice settings seemed warranted. At this time, Quality Family Physicians (QFP), a privately owned family medicine practice consisting of three physicians in northern Delaware, was exploring ways to expand its team-based care services. Since July 2009, the practice has partnered with two pharmacy faculty members from the Philadelphia College of Pharmacy to assess the outcomes associated with pharmacist-provided services within a medical home in a small, privately owned physician practice. The pharmacistprovided services initially focused on patients with diabetes, dyslipidemia, and hypertension, as well as patients with psychiatric disorders. Based on patient and physician satisfaction as well as clinical outcomes of these services, the physicians and pharmacists from QFP and the Philadelphia College of Pharmacy considered various avenues for expansion of the pharmacist-led services. Through a needs assessment at the practice and communication with the CKCFH pharmacist, it was decided to expand the pharmacist-led services at the QFP site to patients with respiratory disorders. After consultation and training provided by the CKCFH pharmacist, QFP initiated a pharmacist-led spirometry service in May 2011. QFP service and pharmacist roles. The pharmacists at QFP are available one full day and two half-days per week. Patients referred into the program with potential respiratory disorders and requiring spirometry are scheduled with the pharmacists by the receptionist staff and integrated into the pharmacists’ schedule with the other patient visits. Before initiating this service, pharmacists provided training and patient information sheets to the receptionist and medical assistant staff. This was identified as an important step in implementing the service, as most
Am J Health-Syst Pharm—Vol 71 Jan 1, 2014
were unfamiliar with spirometry yet are at the frontline for questions and are responsible for providing key procedure information to the patient. At the initial visit, the pharmacist obtains a detailed pulmonary and medication history, performing spirometry testing before and after bronchodilator use, delivers the bronchodilator via a nebulizer, reviews the spirometry results with the physician, and develops and implements a physician-approved treatment plan. Treatment plans may include pharmacologic and nonpharmacologic therapies, smoking-cessation instruction, education about additional diseases, and instruction on the proper use of medication delivery devices included in treatment plans. Follow-up visits are scheduled with either the physician or the pharmacist, with most of the pharmacist follow-up centered on patients requiring medication. The time for initial visits ranges from 60 to 90 minutes. Followup visits are 30 minutes long. Billing for the spirometry services provided and for the office visit, when warranted, as well as any subsequent office visits, is done under the physician using the appropriate Current Procedural Terminology codes via standard medical office billing, as the physician physically visits with each patient at all of the pharmacist-led encounters. Preliminary outcomes for QFP service. For the 34 patients seen in the spirometry service at QFP between May 2011 and September 2012, 82.5% of spirometry tests met current ATS/ERS guidelines for quality measures. In comparison, 70–88% of tests performed by trained spirometry technicians met the older, less-stringent ATS quality measures.5 Applying these older ATS standards to the QFP pharmacist data, 92% of the tests met these quality standards. Obstructive or restrictive pulmonary abnormalities were observed in 35% of patients. Pharmacists made various recommendations that were implemented for inhaled medications, including the use of short-acting b-agonists (24% of Continued on page 17
Frontline Pharmacist Continued from page 16
patients), corticosteroids (21%), anticholinergics (15%), and long-acting b-agonists (12%). A total of 44% of patients received referrals to specialists. At the time of writing, pharmacists had performed over 70 spirometry tests. From a reimbursement perspective, payments to the practice generated by this service averaged $144 per initial visit. Challenges and future direction. Characteristics that made spirometry and delivery of pharmacist-led comprehensive care to patients with potential respiratory disorders successful in both practices included physician support, pharmacist training, a team approach to therapeutic plan development and implementation, and onsite spirometry testing. Challenges that exist for broader adoption of pharmacist-provided spirometry services include physician and patient unfamiliarity with pharmacists in these roles, current lack of training in spirometry for most pharmacists, and lack of direct reimbursement channels. As observed in these two practices, such challenges can certainly be overcome. Additional metrics that should be evaluated in future pharmacist-managed spirometry services include quality as-
sessment of provider and patient satisfaction, patient outcomes data (i.e., decreased emergency department or primary care physician visits and decreased hospitalizations), and cost-effectiveness studies. A promising venue for the expansion of these services is within innovative practice models such as the patientcentered medical home (PCMH). Patients with respiratory disease are logical targets for treatment by the interprofessional teams found in the PCMH, with pharmacists being uniquely qualified to assist with the complex demands of medication selection and delivery in this patient population. The ability of pharmacists to provide quality spirometry services would only enhance their value in the PCMH from both a clinical and an economic perspective. The incorporation of community pharmacists into the provision of these services should be explored to maximize access and convenience for patients. 1. Castillo D, Guayta R, Giner J et al. COPD case finding by spirometry in high-risk customers of urban community pharmacies: a pilot study. Respir Med. 2009; 103:839-45. 2. Fuller L, Conrad WF, Heaton PC et al. Pharmacist-managed chronic-obstructive pulmonary disease screening in a com-
munity setting. J Am Pharm Assoc. 2012; 52:e59-66. 3. Cawley MJ, Pacitti R, Warning W. Assessment of a pharmacist-driven point-ofcare spirometry clinic within a primary care physicians office. Pharm Pract. 2011; 9:221-7. 4. Miller MR, Hankinson J, Brusasco V et al. Standardisation of spirometry. Eur Respir J. 2005; 26:319-38. 5. Enright PL, Skloot GS, Cox-Ganser JM et al. Quality of spirometry performed by 13,599 participants in the World Trade Center Worker and Volunteer Medical Screening Program. Respir Care. 2010; 55:303-9.
Michael J. Cawley, B.S.Pharm., Pharm.D., RRT, CPFT, FCCM, Professor of Clinical Pharmacy [email protected] Jennifer Reinhold, Pharm.D., BCPS, Assistant Professor of Clinical Pharmacy Vincent J. Willey, Pharm.D., Associate Professor of Pharmacy and Vice Chair Department of Pharmacy Practice and Pharmacy Administration Philadelphia College of Pharmacy University of the Sciences Philadelphia, PA
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130084
Am J Health-Syst Pharm—Vol 71 Jan 1, 2014
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