Chapter Nineteen

Drug Information in Ambulatory Care

Debra L. Parker

Learning Objectives

After completing this chapter, the reader will be able to

• Describe the importance of drug information provided by the health care professional in the ambulatory care setting.

• Discuss the importance of access to up-to-date formulary information in the provision of care in the ambulatory setting.

• Identify sources with links to full-text evidence-based practice guidelines.

• Describe desired characteristics of drug information resources specific to the ambulatory environment.

• Describe reputable drug information sources geared toward the health care professional that are also useful in providing drug information to patients.

• List ways that practitioners may address concerns regarding access to information.

• Discuss importance of providing drug information regarding disposal of unused, unwanted, or expired medications and immunizations.

• Identify resources providing quality-assurance indicators for optimal provision of ambulatory care.

Key Concepts

Introduction

This textbook covers a long list of drug information topics and skills, although not every clinician will use all of these skills on a daily basis. The clinician in the ambulatory care setting routinely utilizes multiple drug information skills on a daily basis to not only provide drug information to patients and other health care providers, but to function competently and efficiently within this practice setting.

The ambulatory care practitioner is required to use a variety of drug information skills and resources during routine encounters with patients to provide information at a personalized and appropriate level. Before doing so, the practitioner must know where to look for appropriate information, and how to interpret and practically apply this information to a specific patient or population. This is where many practitioners may be challenged.

This chapter discusses the resources and skills commonly needed by the ambulatory care provider in order to provide appropriate drug information. Topics covered will include (a) commonly used references for prescription formularies and for obtaining evidence-based guidelines, (b) desired characteristics of drug information resources and examples of those particularly useful to the ambulatory care clinician, (c) information resources pertinent to the current trends in ambulatory care, such as the proper disposal of unused or unwanted or expired medications, (d) preventive health information (specifically regarding immunizations), and (e) quality-assurance measures in ambulatory care.

Ambulatory care encompasses a variety of settings. For example, an ambulatory care practitioner may be a clinician who practices in a community pharmacy (including persons in medication-dispensing roles), a community-based clinic or office, an outpatient setting of an institutional care facility, or someone who provides on-site services within an employer-provided wellness and disease management program. As such, the case scenarios within this chapter include scenarios where the provider is in a medication-dispensing role as well as where the provider is in a nondispensing role.

Why Focus on Drug Information Specifically in the Ambulatory Care Setting?

Although the provision of health care takes place in a variety of settings, ranging from hospital and long-term care facilities to patients’ homes, the emphasis in today’s patient care environment is to provide as much health care as possible in the outpatient, ambulatory setting. This may or may not be a setting that dispenses medications. It is also commonly recognized that patients are increasingly technologically savvy and utilize the Internet and news media to provide self-care in the outpatient setting. The quality of the medical and drug information patients obtain themselves varies widely, depending on the source (see Chapters 4 and 5 for drug literature evaluation); however, even when quality information is obtained by a patient or family member, someone with clinical expertise and drug information training is necessary to explain medical information and to provide guidance in the decision-making process.

Finally, with increasing numbers of team-based patient care models such as patient-centered medical homes (PCMHs) being established across the country, the provision of accurate, comprehensive drug information in the ambulatory setting is growing exponentially, as it is crucial to (a) researching appropriate medical treatment, especially of chronic conditions, (b) bridging the gap between data provided from health information technology and how to most effectively use these data to treat patients on an individual and population-based basis, and (c) educating patients regarding their treatment.

Providing Drug Information in the Ambulatory Setting

“I CAN JUST GOOGLE^® IT MYSELF”

Given the name of a medication, the average lay person may well be able to Google^® the name of the drug, and would very likely find general information regarding its use and side effects. Blogs regarding the experiences of other people with that particular medication may also be easily found, as well as anecdotal comments about the drug and the condition being treated, including outdated information. The average patient is, in fact, able to access a plethora of information via Web sites and blogs; however, the reliability, accuracy, and timeliness of this information can vary widely, as discussed in Chapter 3. While some of these sources of drug information may be reputable, they are impersonal and can only offer general information to the reader. Such sites typically advise patients to talk with their practitioners for specific personal questions.

WHAT SHOULD THE PUBLIC (OR OTHER HEALTH CARE PROVIDERS) KNOW ABOUT UTILIZING CLINICIANS TRAINED IN DRUG INFORMATION VERSUS PERFORMING THEIR OWN SEARCHES?

Health care providers fill an important role in the provision, interpretation, perspective on clinical application, and, perhaps most importantly, providing patient-specific application of drug information that is often targeted toward the layperson by the media. While there is an ever-increasing trend toward patient empowerment, self-care, and self-education, the lay public is often unaware that the health care provider has access not only to the same Web sites as the patient, but also to professional literature and databases (see Chapter 3) that expand and often provide critical analysis of the information the public accesses. The lay person is unable to access and/or interpret such information. Depending on their clinical training, even certain health care providers may also lack knowledge regarding available resources and how to best interpret health information data.

Although in some cases, individuals may be able to personally access secondary or even primary literature, interpreting this information and putting it into context with their personal health conditions as well as with current evidence-based guidelines (see Chapter 7) require a health care professional trained in drug information. Interpreting and evaluating primary literature (see Chapters 4 and 5) as well as locating and interpreting evidence-based guidelines are skills that require training and practice. These activities call for an individual trained in drug evaluation and with expertise in these areas (see Chapters 3, 4, 5, 7, and 8).

The ambulatory care practitioner is the person with the greatest opportunity to fill the role of medication information provider and interpreter to the lay public. The definition of the ambulatory care practitioner is changing, with a growing number of health care settings (e.g., particular PCMHs) lending themselves to providing streamlined, comprehensive outpatient care. Any medical care delivered on an outpatient basis is considered ambulatory care. For example, an ambulatory care practitioner may be a clinician who practices in a community pharmacy (including persons in medication-dispensing roles), a community-based clinic or office, an outpatient setting of an institutional care facility, or someone who provides on-site services within an employer-provided wellness and disease management program.

Although proficiently providing drug information is a skill which requires training and practice, often the biggest challenge for ambulatory care practitioners is not providing the needed drug information skills proficiently, but convincing the public that they offer a unique skill in drug information beyond the Internet.

Unfortunately, many practitioners place too little emphasis on the need for their involvement in interpretation of drug information, assuming that other health care professionals and even the public itself, with adequate access to information databases, can research and answer their own questions. In 2001, it was reported that in 1 year, approximately nine million hospital admissions and over 18 million emergency room visits in the United States (U.S.) were caused by incorrect use of medications.¹ Although these data were published several years ago, this is an issue that has not resolved. Consider a study conducted in Vancouver, Canada, published in 2008, which reported pharmaceuticals were the cause of 12% of emergency room visits and resulted in significantly longer length of stays for those patients admitted.² In a 2011 study published by Budnitz and associates, of over 100,000 medication-related emergency room visits, only 1.2% of medication-related emergency room visits were attributed to what were classified as high-risk medications.³ Finally, according to a 2012 update from the Centers for Disease Control and Prevention (CDC), over 700,000 emergency room visits are made in the United States every year as a result of what are often preventable adverse drug events.⁴ The circumstances behind these statistics are certainly multifactorial, and may include nonadherence or misuse of medications, lack of communication between patients and health care providers, and clinically inappropriate prescribing patterns. Paramount to correcting each of these factors is the research, interpretation and communication of drug-related information to all parties.

In today’s environment, with direct-to-consumer advertising (see Chapter 23) and increasing numbers of nonprescription medications that were formerly available only by prescription, the decision to use a medication is not made solely by prescribers, but also by patients themselves. It is evident that all decision makers need guidance. Who guides these decision makers? Unfortunately, the answer is often no one.

There is certainly not a lack of available drug information, nor is there, for many individuals, a lack of accessibility. What is lacking, however, is the provision of quality drug information provided by a practitioner trained to do so for not only patients, but for other health care providers.

The emphasis placed on drug information in the curricula for different types of health care professionals vary widely; however, it can be said that pharmacists are the health care professionals with the greatest amount of time devoted to this topic in their professional training. As such, this profession bears the responsibility to educate both the public and fellow health care providers. Examples of this type of education in the ambulatory setting may include (a) whenever possible, ensuring that biased sources such as pharmaceutical salespersons are not the main source of new product education for prescribers, (b) leading or facilitating discussions with prescribers regarding newly published studies, meta-analyses, and clinical guidelines, with emphasis on an understanding of limitations of these publications and how they apply specifically to those prescribers’ patient populations, (c) researching and answering drug information questions (which may or may not be patient-specific), (d) writing newsletters regarding topics pertinent in the media, and/or in the condition-specific clinic(s) in which the pharmacist works, (e) “debunking” misperceptions that may arise from direct-to-consumer advertising regarding exaggerated efficacy or risk associated with treatments, (f) providing basic statistical training including terms such as relative risk versus actual risk of treatments, and how to determine them. In addition, it is worth mentioning that in order to provide patient-specific drug information, complete medication profiles must be obtained, and this often involves communication between not only outpatient/ambulatory care clinics, but one or more pharmacies to get the full picture regarding all pertinent medical conditions and medications. Regardless of which method(s) are used to educate fellow clinicians, it is vital that pharmacists are prepared to explain the vital role they play in assisting others to understand and use medications in the safest and most effective way possible.

In today’s busy society, the case for the pharmacist (and subsequent pharmacist-provided drug information) needs to be concise and to the point. Until that case is made to the public and other payers for health care, including both employers and legislators, it is likely that pharmaceuticals will continue to have the unintended effect of increasing, rather than decreasing morbidity and mortality, and contributing to rising health care expenditures.

The following section discusses resources integral to the provision of drug information in ambulatory care.

Drug Information Responsibilities in Ambulatory Care

Integral drug information-related responsibilities of the ambulatory care clinician are many. Several key responsibilities include (1) assisting prescribers and consumers to find the most cost-effective drug to treat a given condition, (2) ensuring a prescribed medication is appropriate and follows current treatment guidelines, (3) ensuring a patient’s understanding of the appropriate use of their medications (see Chapter 20), (4) guiding others regarding the proper disposal of unused or unwanted medications, (5) delivering preventive health information, and (6) incorporating quality-assurance indicators into daily practice.

Practitioners who may not be the initial prescribers of medications (e.g., those who work under consult agreement, collaborative practice agreement, or who work with supervisory physicians or collaborating physicians) must be familiar with this information. Regardless of the U.S. state in which a clinician practices, and regardless of health care provider degree (e.g., PharmD, Physician Assistant, Nurse Practitioner), sound recommendations regarding modifications in drug therapy, drug therapy renewal, and initial drug therapy recommendations all hinge upon a solid understanding of drug formularies, appropriate practice guidelines, and drug information database considerations.

DRUG FORMULARY INFORMATION

Key to assisting prescribers and consumers in finding the most cost-effective treatment is familiarity with drug formularies. Whether a clinician is prescribing or filling a prescription order, formulary restrictions increasingly influence medication usage patterns.

A formulary is a list of medications that are approved to be paid for or provided at a discounted rate through prescription insurance plans. It is important to note that even if a medication is not included on a formulary (i.e., is considered “nonformulary”), or is not listed as a preferred option by the payer for a patient’s prescription drugs, the prescriber is not bound to this when deciding whether to prescribe that medication and nothing prohibits the pharmacist from filling an appropriate medication for a patient, regardless of its formulary status.

Additionally, there are some medications that, while on formulary, may require prior authorization from the insurance company before it will be paid for. That does not mean it cannot be dispensed—it only means that if the patient wants the insurance company to pay for the medication, additional information must be provided in advance regarding the medical need. The pharmacist plays an integral role in working with the prescriber on a patient’s behalf to obtain an insurance company’s authorization to fill a prescription for such a medication.

What formulary status ultimately affects is the amount the patient will personally pay for a medication. Several useful tools exist to assist in determining formulary restrictions and then making decisions as to risks versus benefits of abiding by these restrictions.

Center for Medicaid and Medicare Services

The Center for Medicaid and Medicare Services (CMS) is a government agency within the U.S. Department of Health and Human Services that is responsible for the administration of this country’s Medicare and Medicaid services, through which medical and prescription benefits are derived for select components of the populations, traditionally for the poor, elderly, and disabled. Historically, private insurances have modeled reimbursement structures for medical and medicine-related costs after the CMS model. Current health care reform in the United States is anticipated to result in increasing numbers of persons who were either uninsured or underinsured (without adequate prescription insurance to cover medical-related costs) to now being insured through either Medicaid or other government mandated programs. In other words, the landscape of prescription coverage will change, and many patients’ prescription constraints will shift from those related to personal finance to those related to formulary restrictions.

In addition, it remains a fact that the largest proportion of the population taking prescription medications are already Medicare recipients. These persons’ drug coverage is provided through a component of Medicare called Medicare Part D. Through this program, various insurances provide government-funded prescription coverage for Medicare recipients. Each insurance company has a different formulary, or list of drugs that are provided at a reduced price to Medicare recipients. As such, understanding formularies and their restrictions, as well as the ability to access to Medicare drug plan (i.e., Medicare Part D) formulary information is paramount. Although many patients may select their own Medicare drug provider and plan, others often look to their pharmacist to assist them in this decision. Drug plan selection is done largely online and is based on a patient’s prescription profile as well as geographic location. A pharmacist is an ideal person to assist with this process as this is the provider likely to be most familiar with various drug classes listed on drug plan formularies as well as acceptable over-the-counter and generic alternatives to specific medications. Information to guide selection is available at http://www.medicare.gov and clicking on the link to “Find health and drug plans,” https://www.medicare.gov/find-a-plan/questions/home.aspx. Users choose their state of residence and enter their prescription drug profile (i.e., the list of prescriptions the patient takes). The program will then provide a list of Medicare Part D plans that include some or all of the medications the patient takes, as well as information regarding the status of each drug in a particular plan, and the number of pharmacies that participate with a plan in a given state. Users, including prescribers, can also download complete formularies, as well as appeals and exceptions forms. These are forms that may be completed, usually by the prescriber on behalf of the patient asking for consideration of payment for a drug due to extenuative circumstances or a situation specific to that patient. This Web site can be used by patients alone or may be used by a provider on behalf of the patient. Additionally, it is useful for the provider needing to complete necessary forms for patients requiring a medication not covered on their formulary plan. Finally, although not required to prescribe for medications on a patient’s specific drug plan, providers may use the site to determine if a drug will be paid for, and if not, if there are acceptable therapeutic alternatives that will be covered.

An additional method for obtaining formulary information via the Internet is by typing the name of the prescription insurance provider+formulary+the calendar year you desire (e.g., 2015) in the Internet search engine (e.g., Google^®, Bing™). Most prescription insurance providers will have Web pages that include a full formulary guide, a list of covered medications listed by drug or by drug class, medications tier status in which participants are subject to varying levels of copayment options for a given drug (depending on its formulary status) links to suggested alternatives to a medication if it is not covered, and links for forms necessary for prior approval, appeals, and exceptions. An advantage to using these Web sites is immediate access to information and necessary forms. Each prescription insurance provider, however, will have a different Web page design and there is often not consistency as to where the user will find information.

Epocrates^®

Many clinicians may be familiar with Epocrates^®, Inc., software programs (http://www.epocrates.com/). Epocrates^®, Inc., markets programs with a variety of content areas including calculations, continuing medical education, diagnostics, a medical dictionary, disease state information, drugs, pill identification, medical news, and tables. These content areas are bundled into various data packages, some of which are free. All Epocrates^® programs, including those that are available at no cost, include both national and regional formulary information, including Medicare Part D. Users can access formulary status and restrictions for over 3300 brand and generic medications. Users of these programs select the formulary or formularies they desire to include in their searches. Epocrates^®, Inc., updates formulary information at least once per week.⁵

Epocrates^® accounts may be established on the Internet, but for those practitioners who work without Internet access; these programs are downloadable to handheld electronic devices (e.g., iPhone/iPad and Android). This program may prove the most practical solution for providers who require timely formulary information and who operate without full Internet access. It is strongly recommended, however, in light of increasing amounts of current drug information available exclusively online, or for which online access provides regularly updated information not otherwise available, that all providers of drug information and direct patient care insist on Internet access in order to ethically and competently perform their responsibilities.

Electronic Prescribing (e-Prescribing) Platforms

Clinicians with prescribing privileges should also note that electronic prescribing (e-prescribing) platforms provide drug and formulary information at the point of care. In a 2008 study conducted by the Agency for Healthcare Research and Quality (AHRQ) and published in the Archives of Internal Medicine, prescribers utilizing e-prescribing platforms with formulary decision supports (FDS) were significantly more likely to prescribe tier 1 (least expensive) medications, with resulting significant potential cost savings.⁶ Chang and associates evaluated over 21,000 prescriptions for just over 1 year, and reported in 2010 that generic drug use was 6% higher, formulary drug use was 3% higher, and cost savings for the payer and prescription drug member was over 17% higher for those prescriptions electronically prescribed.⁷

Lexicomp^®

Finally, as outlined later in this chapter, Lexicomp^® online drug information, http://lexi.com, also contains useful formulary information.

It is important to note, however, that knowledge of formulary status of medications is only one part of the prescription decision-making process. Whenever they exist, evidence-based clinical practice guidelines should guide prescriptive decision making.

CURRENT PRACTICE GUIDELINE INFORMATION

It is beyond the scope of this chapter to discuss in depth the development and the interpretation of evidence-based clinical practice guideline recommendations (see Chapter 7). It is important to note, however, that ambulatory practitioners have the responsibility to remain up-to-date regarding current practice guidelines. No individual can be expected to know the current treatment guidelines for every condition; however, clinicians can and should be expected to be able to retrieve this information quickly and efficiently. The following outlines several sources for such retrieval.

Perhaps most useful to the ambulatory care clinician may be the databases that include mobile applications. The Centers for Disease Control and Prevention Web site includes free mobile apps (compatible with iPhone/iPad, Android, and Microsoft Windows 8) for a variety of medical conditions, available at http://www.cdc.gov/mobile/mobileapp.html.

Clinicians searching for current practice guidelines may also wish to visit the National Guideline Clearinghouse (NGC), http://www.guideline.gov. This compilation of evidence-based clinical practice guidelines is a project of the American Health Insurance Plan (AHIP) and the AHRQ, and is a public resource for evidence-based clinical practice guidelines. The NGC includes links to full-text current treatment guidelines, guidelines in process, as well as archived guidelines. Side-by-side comparison of two or more treatment guidelines for a given condition is also available. Users may search this site by disease/condition, treatment/intervention, or organization.⁸

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