By Stefanie Amelung, RPh, Dipl.-Pharm.1,2 (left), and Carina Hohmann, RPh, PhD3 (right)
Pharmacy Department, Heidelberg University Hospital, Heidelberg, Germany 2
Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany3
Department of Pharmacy, Klinikum Fulda gAG, Fulda, Germany
Clinical Pharmacy Practice in Germany
Drug therapy of patients is becoming more complex, thus making drug prescribing more challenging. In clinical practice, a wide range of drug-related problems (DRPs) are common in hospitalised patients and can result in prolonged hospital stay, patient morbidity and mortality, and increased costs (1-3). Clinical pharmacists can help identify, resolve and prevent DRPs through medication reconciliation and medication review at hospital admission and discharge (4-6). Despite numerous activities of German pharmacists targeted at improving patient safety in drug therapy, specialization in clinical pharmacy does not exist in Germany.
The first patient oriented services in Germany were established in the 1970s and originated within hospital pharmacy practice (7). In the 1980s, aspects of clinical pharmacy became part of an educational program, involving three years of training in a German Chambers of Pharmacists-certified hospital pharmacy. Participants that pass the final exam acquire the additional title “Specialist in Hospital Pharmacy” (German: Fachapotheker für Klinische Pharmazie). In 2016, nearly three out of four pharmacists working in a hospital pharmacy acquired this specialization.
By 1999, German universities took notice that it was paramount for pharmacists to stay abreast of changes in pharmaceutical care. Subsequently, clinical pharmacy became an examination subject and teaching profession (7, 8). Currently, only 15 of the 22 faculties of pharmacy in Germany have the status of professorship in clinical pharmacy. It is therefore not surprising that the call for specialization and further education to address patient safety comes from hospital pharmacists themselves (9).
The role of the clinical pharmacist in Germany has evolved over time, especially in the last few years with the focus mainly on providing comprehensive drug management including optimization of drug therapy and identification, resolution and prevention of DRPs (10-13).
However, clinical pharmacy services in German hospitals are not yet established nationwide. According to a Benchmark Survey in 2015 of the European Association of Hospital Pharmacists, there were 0.3 pharmacists per 100 beds employed in German hospitals (the lowest of the survey) as compared to the European average of one pharmacist per 100 beds. In the same year, Germany counted 1721 hospitals (without rehab clinics), of which only 22 percent had a hospital pharmacy (14). Since it is rare for a pharmacist to work in a hospital that does not have a hospital pharmacy, most German hospitals do not benefit from clinical pharmacy services. There is even less data available describing pharmacist services in the neurocritically ill patient population in Germany.
Optimizing Pharmacotherapy in Acute Neurological Illness
Two studies at the Hospital of Fulda, Germany, explored the impact of the clinical pharmacist in optimisation of drug therapy in the hospital setting and in transitions of care focusing on patients with ischaemic stroke. First, the nature and frequency of DRPs along with pharmaceutical interventions from hospital admission to hospital discharge were investigated (15). A total of 271 DRPs were documented in 155 patients (1.8 DRPs per patient). The DRPs, coded with the classification system APS-Doc (16), occurred mainly in the categories drug, indication, and dosage. DRPs in the category indication were stroke-related in 80 percent of the cases and referred mainly to antihypertensive medication (undertreatment), secondary prevention (noncompliance with treatment guidelines) and statin therapy (omission of therapy). These results highlighted that a clinical pharmacist working with this patient population can provide valuable contributions as part of a multidisciplinary team, leading to optimised and safe pharmacotherapy.
In a second study, a medication report was developed as one part of the discharge letter that provided systematic detailed information on all medication changes during the hospital stay and reasons for the changes. This was done to improve the transition of care process and to increase the adherence rate of the primary care physicians (PCPs) to the hospital discharge medication plan (17, 18). The impact of the medication report was evaluated in an open, prospective, interventional study in patients with transient ischaemic attack (TIA) or ischaemic stroke. In the control group (CG), current medications were documented by the neurologist in the discharge letter. In the intervention group (IG), the clinical pharmacist included the medication report with detailed information in the discharge letter, which was also approved by the neurologist.
In order to evaluate the impact of the medication report, the PCP was interviewed by phone three months after hospital discharge about the current medication list. The impact was measured on the basis of adherence to recommended medication therapies in the discharge letter. Overall, 156 patients were enrolled in each group. By providing detailed information in the discharge letter, adherence rose significantly in the IG for the entire medication regimen, including antithrombotic drugs and statin therapy. This study highlighted that providing detailed information on discharge describing medication changes may lead to substantially improved adherence to discharge medications, potentially resulting in better secondary stroke prevention.
The role of the pharmacist in Germany has changed over the last few decades toward a more patient-oriented practice. The clinical pharmacist has become an invaluable member of the multidisciplinary team and takes part on ward rounds and team discussions at the time of prescribing drugs. There is increasing evidence that the participation and subsequent interventions of clinical pharmacists in the healthcare team have a positive impact on drug safety and clinical outcomes for the patient. The studies described highlight the important role of the pharmacist in the medication use and transitions of care processes within a stroke unit in Germany.
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