Abstract
Keywords
Introduction
Chronic diseases are a significant cause of morbidity and mortality, especially in patients with poor adherence.1-3 The increase in morbidity resulting from patient nonadherence may in turn cause undue burden on the health care system. Furthermore, medication adherence may decline when barriers to obtaining medication refills are present, resulting in increased risk of complications.4,5
As the number of individuals seeking medical care increases, the demand on physician time similarly increases. Many physicians feel that patient care may not be optimized because of time constraints and numerous patient care activities requiring completion outside of an office visit.6,7 In addition to face-to-face office visits, primary care physicians (PCPs) must review and respond to medication refill requests, phone and email messages, and laboratory, imaging, and consultation reports. 8
Multidisciplinary team approaches to patient care and chronic disease management, such as those involving pharmacist-physician collaborations, have resulted in positive outcomes in patient care as well as patient and physician satisfaction.9-11 Collaborations such as pharmacist managed refill clinics have successfully increased time efficiency, patient safety, and patient satisfaction.12-16
The purpose of this study is to demonstrate the impact of a clinical pharmacist managed medication refill clinic on physician workload.
Methods
Setting
Baytown Health Center (BHC) is a primary care community health center within the Harris Health System, a community-owned, safety net health care organization. BHC primarily serves the residents of Baytown, East Houston, and the surrounding communities in eastern Harris County.
Baytown Health Center Medication Refill Clinic
Between 2008 and 2010, the BHC family medicine department faced an increased workload due to a physician shortage as full time equivalents decreased about 45%. The 4 remaining physicians were tasked with assuming care for patients who no longer had a PCP due to the vacancies. As the workload continued to increase, medication refill request response times were often delayed. The organization’s policy mandated a 72-hour turnaround time from the initiation of the request to the dispensing of the medication. When a delay occurred, there was the potential that the medication would not be available for patient pick-up, further contributing to nonadherence. As a result, a new collaborative service, the BHC Medication Refill Clinic (MRC), was developed with the goal of decreasing physician workload and increasing patient safety and satisfaction.
Study Design
This was a retrospective chart review. Patients were included in the intervention group if they had a medication refill request processed by the clinical pharmacist from October 2008 to November 2010. During the same time period, physicians processed all other refill requests that did not meet inclusion criteria.
Intervention
Under a collaborative practice agreement, the clinical pharmacist dedicated 2 hours each day to review chronic medication refill requests for the physicians. Refill requests were generated in response to a patient request at the BHC pharmacy. Those made for medications used to treat diabetes, dyslipidemia, hypertension, chronic heart failure, asthma, chronic obstructive pulmonary disease, thyroid disorders, chronic allergies, acid reflux, anticoagulation disorders, chronic inflammatory pain (nonsteroidal anti-inflammatory drugs [NSAIDs]), as well as diabetes supplies were addressed by the clinical pharmacist. All other requests were excluded and forwarded to the designated physician. Changes to the protocol were permitted based on periodic assessment of refill request volume. The clinical pharmacist reviewed the patients’ pharmacy record and electronic medical record (EMR) for appropriate laboratory monitoring and adherence with medication and physician follow up visits. Patients with requests that did not meet these standards were given reminders with their refills or contacted directly to ensure compliance (Supplementary Methods).
End Points
The primary end point was the quantity of medication refill requests processed, assessed at baseline, 3 months, and following protocol changes. Secondary end points included quantity and type of interventions implemented to improve patient care.
Results
During the study period, the BHC MRC processed 5706 refill requests while consistently maintaining a 48-hour turnaround time. Physician refill request volume decreased approximately 60% following the establishment of this collaborative service. The average daily refill request volume per physician decreased from 10 to 4 after the initiation of the MRC; the average daily refill request volume for the MRC was 25 (Figure 1). Protocol revisions occurred twice during the study period. By March 2009, BHC had 7 physicians, so NSAIDs and allergy medications were removed from the MRC protocol to decrease the volume. The average daily volume decreased to 2 per physician and 20 for the MRC. In April 2010, the protocol was adjusted to more evenly distribute the refill requests between all 6 providers, including the clinical pharmacist. In addition to the MRC, the clinical pharmacist provided chronic disease state management for patients referred by the BHC family practice physicians. During these visits chronic medications were also refilled. The increased volume of patients referred for this service further necessitated the redistribution of medication refill requests. Following the protocol change, the average daily refill request volume per physician was 7, and the average for the MRC was 11.
Average Daily Refill Request Volume Per Provider
Of the 5706 medication refill requests processed by the MRC, 4864 (85%) were approved and 842 (15%) were denied. In all, 2380 (42%) required an intervention, with some refill requests requiring more than 1 intervention. Most commonly, patients were given reminders that laboratory tests (887) or physician visits (900) were almost due. Other issues identified included patients requesting the incorrect medication and patients not submitting prescriptions for refills (Table 1). The most common reason for refill request denial was due to an updated prescription that was already issued at the time of the request (482), an overdue physician follow-up visit (308), or overdue laboratory monitoring (192). Thirty-three refill requests were denied because continued medication therapy was deemed inappropriate after pharmacy profile and EMR review.
Medication Refill Requests Requiring Interventions.
Discussion
The findings of this study demonstrate the positive impact of a clinical pharmacist managed medication refill clinic. Through the collaborative relationship with the physicians at BHC, the clinical pharmacist decreased physician workload while ensuring inappropriate medication refill requests were addressed. Patients were notified regarding required laboratory monitoring, follow-up appointments, and/or medication changes due to duplications or contraindications, leading to increased patient safety. An advantage of the collaboration was that the clinical pharmacist had the ability to review both the pharmacy medication record as well as the EMR, helping to easily identify medication noncompliance, incorrect medication requests, therapeutic duplications, and requests for which the patient already had a prescription on file.
The clinical pharmacist consistently processed medication refill requests in a shorter time period than required by the organization. The decrease in the physicians’ refill request volume also allowed them to meet the 72-hour turnaround time for medication refills and focus on other patient care activities. Fulfilling turnaround times was self-reported.
For a number of BHC patients, transportation was a major factor affecting compliance because of the lack of public transit between the surrounding communities. Patients made multiple trips to the pharmacy if their medication refill was not processed in time, and some patients missed doses due to lack of transportation to return to the pharmacy for a subsequent visit. By adhering to and improving on the medication refill request processing time, we presume patient compliance and satisfaction improved since the number of visits to the pharmacy would have decreased.
A limitation to this study was the inability to directly measure the impact of decreased medication refill request volume on physician time and productivity. While the clinical pharmacist processed refill requests during a specified time period, the physicians worked on them sporadically throughout the day as time permitted. We estimated that a medication refill request required on average 4 to 5 minutes to process given that the clinical pharmacist processed about 25 requests in 2 hours. Thus, at the height of the physician shortage, we estimate that the physicians each recovered 30 minutes per day, to focus on other patient care activities. We also did not objectively measure physician satisfaction in this study; however, the physicians who participated reported overall satisfaction with the collaborative service. Finally, we did not design this study to directly measure the impact on medication compliance or patient satisfaction, but these are measures that warrant future study.
The outcomes of BHC MRC support expanding future pharmacist-physician collaboration to decrease physician workload, increase patient safety, and increase patient and provider satisfaction. The daily work flow of the clinical pharmacist in this study was similar to the physicians with the majority of the day dedicated to direct patient care visits. As the clinical pharmacist’s direct patient care volume increased, the MRC protocol required adjustments to reflect the decrease in time available to process refill requests. A future model of the MRC could be extended to involve a trained pharmacist whose primary responsibility is the MRC, thereby allowing for an expanded protocol to further decrease physician medication refill request volume.
Conclusion
The establishment of the BHC MRC demonstrated that a clinical pharmacist–managed medication refill clinic decreased physician workload while improving refill request processing time. Additionally, the clinical pharmacist improved patient safety by ensuring that appropriate laboratory and medication monitoring were performed, patients followed up with their physicians in a timely manner, and medication-related problems were identified.
Supplementary Methods
Clinical Pharmacist Medication Refill Clinic: Baytown Health Center
Summary of Protocol (2008)
Clinical pharmacist will process applicable refill requests daily for 2 hours. Goal turnaround time is 48 hours.
Clinical pharmacist may authorize the maximum refills as outlined in number 3 if: Last PCP visit <6 months ago Lab monitoring requirements are met Medications fall within categories listed in number 3
The following may be authorized: Up to 12 refills total or 365 days: diabetes testing supplies Up to 6 refills total or 180 days: medication for allergies, acid reflux, and NSAIDs Up to 3 refills total or 90 days: medication for hypertension, diabetes, cholesterol, thyroid disorders, asthma, COPD, chronic heart failure, and for warfarin
Requests fulfilling last PCP visit requirement but requiring lab monitoring may have refills authorized based on the clinical pharmacist’s clinical judgment (not more than 60 days)
Clinical pharmacist may authorize a 30 day supply if the last PCP visit was >6 months but <12 months ago to ensure patient has time to schedule an appointment
PCPs will be notified on the same day of any refill request denials. Requests will be denied for the following: Medications prescribed by physicians outside of the system for indications which the patient is not seen for at Baytown Health Center Last PCP visit was more than 12 months ago Previous approval had been given by pharmacist and patient did not follow up as instructed If in the clinical pharmacist’s clinical judgment that continued therapy is inappropriate
Laboratory Monitoring Requirements (2008)
Footnotes
Acknowledgements
The authors would like to acknowledge the Baytown Health Center Pharmacy staff for their support with the implementation of this service.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.