Clinical Pharmacy Services

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Clinical Pharmacy Services ADAP Clients

• Stephen Berk, RPh
• Acting Chief
• California AIDS Drug Assistance Program Unit

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Clinical Pharmacy versus Pharmacy

• Pharmacy
• Attention is on the drug
• Clinical Pharmacy
• Attention is on the patient or population
  receiving the drug

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Traditional Pharmacy
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Clinical Pharmacy

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Attention to patient or population receiving the
medications

• Maximizing the clinical effect of medicines
• Using the right medication at the right time
• Minimizing the risk of adverse events
• Educate about possible side effects
• Monitor and improve adherence
• Preserve scarce resource dollars
• Less resistant virus
• Less opportunistic infections
• Possibly less side effects requiring additional
  therapy

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Why Clinical Pharmacy Services

• Benefit to the Client
• Benefit to the Program
• Benefit to Society

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Benefits of Service

• Several studies indicate client society
  benefits
• Journal of the American Pharmacists Association
  (APhA) 2008
• Aetna presentation at Academy of Manage Care
  Pharmacy Meeting 2008
• Kaiser study in J. Acquired Immune Deficiency
  Syndrome 2007

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APhA

• Clients with multiple medical conditions and
  complex drug therapies
• Significant improvement in drug therapy goals
  achieved
• Drug problems resolved
• Total annual health expenditures decreased

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Aetna Study

• 2,400 clients identified as candidates for an
  adverse drug event not disease specific
• 15 drop in adverse drug events
• Cost avoidance ranged from 476 to 2,506 per
  patient per year
• Low touch intervention
• Letter to prescriber
• High touch intervention
• Phone call to prescriber

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Kaiser Study

• Observational Study with two arms (1571 clients)
• (A) sites with HIV trained pharmacist
• (B) sites without HIV trained pharmacist
• Outcomes Analyzed
• Changes in plasma HIV RNA level
• CD4 T-cell counts
• Service utilization
• Hospital days, ED visits, and office visits

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Kaiser Study

• Results
• Clients exposed to clinical pharmacist more
  likely to achieve HIV RNA level lt 500 copies/mL
  at 12 months
• At 24 months, practice size impacted results
• Practices with gt50 clients less impacted by
  clinical pharmacist
• CD4 T-cell counts not significantly affected

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Kaiser Study

• Conclusions
• Positive association between clinical pharmacist
  and plasma HIV RNA control
• Decline in office visits at 12 months
• Limitations
• Did not document interventions
• Did not analyze impact on health care costs

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Medi-Cal HIV Pharmacy Pilot

• 10 HIV Specialty Pharmacies
• 4 pharmacies from one organization
• Reimbursed additional 9.50 per prescription
• Measure results of specialized services

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Medi-Cal HIV Pharmacy Pilot

• Services Offered
• Evaluation of clients ability to adhere - 7
• Identify manage adverse drug reactions - 7
• Management of side effects - 7
• Tailor drug regimen to fit clients lifestyle - 6
• Individualized counseling when overuse or under
  use is detected -6

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Medi-Cal HIV Pharmacy Pilot

• Services offered
• Refill reminders - 5
• Individual appointments with pharmacist - 4
• Adherence packaging - 4
• Peer advocates - 4
• Home visits or weekly phone call - 4
• Other health assessments (blood pressure) - 4
• Medication reminders (pagers, alarms) -3

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Medi-Cal HIV Pharmacy Pilot

• First year evaluation (UCSD Skaggs School of
  Pharmacy and Pharmaceutical Sciences)
• Higher medication adherence rates
• Fewer excess fills
• Fewer contraindicated regimens
• More clients remained on single type ART strategy
  throughout 2005

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California ADAP

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California ADAP

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California ADAP

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Clinical Services in California

• Relatively New
• Quarterly Clinical Update for Pharmacies
• Pipeline Medications
• Recent Approvals
• Adherence Tips
• Review of Prescription Claims
• Duplicate Therapy
• Drug Interactions
• Contraindications

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Clinical Services in California

• New Drug Pipeline Monitoring
• Determine Place in Therapy
• Estimate Price
• Project Usage
• Clinical Drug Information for Medical Advisory
  Committee
• Criteria for Medication Use
• Input from PBM
• Input from Medical Advisory Committee

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California ADAP

• Future Plans
• Pharmacy visits?
• Partner with AETC
• Pharmacist education ?
• Use of ADAP Claims Data for Adherence Monitoring
• Medication Therapy Management
• Reimbursement ?

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California Limitations

• Staff
• Unit Chiefs (Pharmacist) Time Spent Doing
  Administrative Duties
• Need to Hire Pharmaceutical Consultant
• Need Research Staff to do Data Mining
• Knowledge Level of Dispensing Pharmacies
• Good in Specialized Pharmacies
• Access to Care Issues if Limit ADAP Participation
• Retrospective Review
• Damage Already Done

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Barriers to Providing Services

• Geographic
• Urban or Rural Location
• Large Client Population
• Over 31,000 Unique Clients Served in CY 2007
• Large Pharmacy Network
• Over 3,000 Statewide ADAP Participating
  Pharmacies
• Financial
• Program
• Pharmacy

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Finally.

• Ideal situation
• Thorough pre-treatment counseling
• Patient understands goals of therapy
• How regimen relates to patients daily schedule
  and meals
• Explain side effects, when they may occur and
  treatments for side effects
• Pill boxes, pagers, timers, or medication maps

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Finallycontd

• On-going follow-up
• Check in session 2 weeks after initiating therapy
  for new patients
• Pill counts
• Side effect management
• Monitoring for lapses in adherence for seasoned
  patients
• Pill or treatment fatigue

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Finally. (really)

• In the Meantime
• Educate providers (pharmacy and prescribers)
• PPIs and Atazanavir
• Efavirenz and women of child bearing age
• Synchronize prescription fills
• Use available data to improve care
• Clients with low CD4 counts on PCP prophylaxis
• Review for duplicate therapy
• Review for appropriate prescribing practices

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Questions