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Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections

Robert MacLaren, PharmD, FCCM, FCCP; C. A. Bond, PharmD, FASHP, FCCP;

Steven J. Martin, PharmD, BCPS, FCCM, FCCP; David Fike, PhD

Crit Care Med 2008 Vol. 36, No. 12

Reporter R2余宗興Supervisor 沈修年醫師

2009/01/12

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Pharmacists are greater roles

•GuidelinesGuidelines developed by the Society of Critical Care Medicine deem pharmacists as an essential component for providing quality care to critically ill patients

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However…

~only 62.2% of the 1034 respondent ICUs in US hospitals pharmacists provide direct patient care

~similar to nearly 20 yrs prior (64.8% of the 668)

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This study explores…

• Clinical pharmacy services in critically ill Medicare patients with severe infections – death rate– length of ICU stay– Medicare charges– drug charges– laboratory charges

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Materials and methods• The type and level of pharmacy services

provided to ICUs were obtained from a 20042004 national survey.– American Health-System Abridged Guide to Healthcare– US Department of Health and Human Services

• Clinical pharmacy servicesClinical pharmacy services were defined as – at least a partial pharmacista partial pharmacist full-time equivalent

specifically devoted to the ICU for the purpose of direct involvement in patient care.

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ICU infections - 3 groups• Infections were defined using International International

Classification of Diseases, Ninth Revision, Classification of Diseases, Ninth Revision, Clinical Modification codesClinical Modification codes.

• ICU outcome data were drawn from the 2004 modified Medicare provider analysis and review.

• Depending on the infection studied, the involvement of clinical pharmacists was evaluated in 8,927–54,042 patients8,927–54,042 patients from 265 to 265 to 276 hospitals276 hospitals.

• Significance for all tests was p<p<0.050.05

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Results

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Nosocomial-Acquired Infections

• Of the 382 institutions382 institutions that responded to the original survey, 272 hospitals were identified by the CMS as having at least one Medicare patient in the ICU with nosocomial infections.

• These 272 study hospitals had 25,023 ICU patients with nosocomial infections (based on ICD-9-CM codes) that represented 8.6%8.6% of all 291,144 total Medicare patients

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In ICUs without a clinical pharmacist

mortality was 23.6%23.6% higher (p=0.001; odds ratio=1.29, 95% confidence interval [CI]=1.20 –1.38)

In ICUs without a clinical pharmacist

mortality was 23.6%23.6% higher (p=0.001; odds ratio=1.29, 95% confidence interval [CI]=1.20 –1.38)

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Community-Acquired Infections

• Of the 382 institutions382 institutions that responded to the original survey, 265 hospitals were identified by the CMS as having at least one Medicare patient in the ICU with community-acquired infections.

• 89278927 ICU patients with community-acquired infections (based on ICD-9-CM codes) that represented 9.7%9.7% of all 92,286 Medicare patients

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In ICUs without a clinical pharmacist

mortality was 16.2%16.2% higher (p=0.008; odds ratio=1.22, 95% CI=1.07–1.38)

In ICUs without a clinical pharmacist

mortality was 16.2%16.2% higher (p=0.008; odds ratio=1.22, 95% CI=1.07–1.38)

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Sepsis

• Of the 382 institutions382 institutions that responded to the original survey, 276 hospitals were identified by the CMS as having at least one Medicare patient in the ICU with sepsis.

• 54,04254,042 ICU patients with sepsis (based on ICD-9-CM codes) that represented 9.8%9.8% of all 550,208 Medicare patients

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In ICUs without a clinical pharmacist

mortality was 4.8%4.8% higher (p=0.008; odds ratio=1.06, 95% CI=1.02–1.11).

In ICUs without a clinical pharmacist

mortality was 4.8%4.8% higher (p=0.008; odds ratio=1.06, 95% CI=1.02–1.11).

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Discussion

• This study documents the beneficial…

• But…

Why ? unknown !

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Presumably…

• Pharmacotherapeutic knowledge• Helps guide and monitor antimicrobial

therapy in terms of – the choice of agentchoice of agent, dosagedosage, durationduration, – culture and sensitivity dataculture and sensitivity data, – pharmacokinetic and pharmacodynamic – adverse effectsadverse effects, – cost-effectiveness, – ancillary treatments– education.

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Compared to other studys• Our results concur with the results of several single-

center studies that demonstrated ICU pharmacists enhance clinical and economic outcomes of critically ill patients by reducing the occurrence of adverse drug adverse drug eventsevents and administration errorsadministration errors

• Bond and RaehlBond and Raehl demonstrated that the involvement of clinical pharmacists in the management of vancomycin or aminoglycoside antibiotics, anticoagulation, antiepileptic drug therapy, and antibiotic prophylaxis in surgery is associated with – lower mortality rateslower mortality rates of 6.7%–120.6%, – shorter hospital staysshorter hospital stays of 10.2%–14.7%– lower total chargeslower total charges of 3.1%–11.2%.

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Cost-effect

• In 2006, the mean pharmacist hourly hourly salarysalary was $56.19

• Assuming a clinical pharmacist would spend approximately 30 mins per day assessing each patient in terms of drug therapy management, the average average pharmacist cost per ICU staypharmacist cost per ICU stay is $406.20 per patient with these infections.

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Cost-effect

• The benefit-cost ratiobenefit-cost ratio for patients receiving clinical pharmacy services is 24.81:1 (ICU)

• Outside the ICU, the mean 8.94:1 reported in 23 studies

• All hospitals should strongly consider employing clinical pharmacists to care for ICU patientsICU patients.

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Limitations

• Low response rateLow response rate (11.8%).– Therefore, the hospitals and ICUs in

our study may not be representative of all US ICUs

– However, respondent and nonrespondent intuitions were similar in terms of institution description, daily hospital census, and US census nine-region geographic distribution

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• Only 8.6% –9.8% of all Medicare patients in the ICU with the specific infections sizeable patient populations (8,927 to 54,042)

• Because patient acuity and outcomes are similar between MedicareMedicare and non- non- Medicare patientsMedicare patients potentially be extrapolated to non-Medicare ICU patients

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• ICD-9-CM codesICD-9-CM codes, some of which overlapped the various infections studied because they shared similar microbial similar microbial etiologiesetiologies.

• Although CMIsCMIs indicate that the severity of illness in ICUs with and without pharmacists was comparable for each infection, using CMIs for clinical comparisons is not validated.

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• Many ICU or hospital staffing, structure, or process variables have been shown to improve patient outcomes and may affect our results– nurse-to-patient rationurse-to-patient ratio,

– availability of intensivist servicesintensivist services,

– ICU and hospital policies and protocolspolicies and protocols

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CONCLUSION

• Demonstrate that the services provided by clinical pharmacistsclinical pharmacists in caring for critically ill patients with infections – lower ICU mortalitylower ICU mortality– shortened ICU stayshortened ICU stay– reduced chargesreduced charges

• Hospitals should stronglystrongly consider employing clinical pharmacists to care for ICU patients.

Team work

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Thank you !