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Can J Hosp Pharm. 2009 Sep-Oct; 62(5): 353–354.
PMCID: PMC2826996

Overcoming Barriers to Adoption of Guidelines and Use of Proven Interventions: It Is My Table!

In the current issue of the CJHP, Barry and others1 describe the reasons for non-use of proven interventions from the perspectives of clinical pharmacists within their health care organization. Of particular interest to me were the 2 most common reasons identified by the authors: a team preference to defer management of these issues to the outpatient care provider and issues related to workload and priorities.1

Recently, baseline data for the CSHP 2015 objectives were published in the Hospital Pharmacy in Canada 2007/2008 Report.2 The chapter on CSHP 2015 provided a comparison of current levels of pharmacists’ performance against the CSHP 2015 targets.2 As noted by author and former CSHP President Emily Musing, “While the data indicate that pharmacists actively apply evidence-based methods to the improvement of medication therapy, they do not seem to be as actively involved in the implementation and management of evidence-based drug therapy protocols.”2 According to Musing, “It is possible that . . . individual pharmacists are less frequently involved in the implementation and management of the protocols, possibly due to inadequate pharmacist resources to do so.”2

Taken together, the findings, speculations, and recommendations of both groups of authors1,2 led me to ask the question, “What should be guiding the clinical pharmacist’s priorities?”

Let me address the 2 main reasons that Barry and others1 cite for pharmacists not focusing on interventions that have been proven to improve patient outcomes.

The concern regarding workload and priorities is easiest to dispel. Beneficence, nonmaleficence, respect for autonomy, and justice are the 4 commonly accepted ethical principles applied to health care.3 All other principles being equal, beneficence (i.e., seeking to do good so that the patient’s health can benefit) should be guiding our priorities.

If pharmacists are not providing certain aspects of pharmaceutical care because of inadequate human resources or lack of time, then why are these neglected activities considered to have lower priority than others? Let us take a look at the common activity of managing acute pain, typically perceived by hospital pharmacists to have greater priority than managing chronic disease. Not to underestimate the important and prominent roles of pharmacists in acute pain management,4 but is our traditional focus on acute care always in the best interest of the patients we serve? Or are we sacrificing the critical issues in favour of the urgent ones?

For example, what is the relative value of pursuing acute pain management? The individual patient certainly benefits from experiencing less pain (at least for a couple of hours). But is that of significance in the patient’s overall quality of life, especially if compared with focusing on a proven intervention that has been documented to decrease patient morbidity and mortality? How can we make a case that the most valuable end point can be achieved by focusing on the patient’s chronic conditions? Do we need to calculate an NNT (number needed to treat) or NNI (number needed to intervene) to ascertain the number of patients for whom acute pain medications would have to be optimized to save one patient’s life and compare that with the number of patients who would have to be started on osteoporosis medications to prevent a broken hip (a condition with known high mortality rates)?5

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Regarding the team preference to defer management of these issues to the outpatient care provider, the fact that patients are not receiving these proven interventions when they arrive from the community leaves one wondering on what basis the team (including the pharmacist) expects that postdischarge management of these pre-existing conditions is going to be any better. Isn’t this analogous to the “it’s not my table” syndrome, whereby a restaurant customer needs his or her server, is unable to get the server’s attention, and encounters further frustration when another server responds with the stock phrase “It’s not my table”? This isn’t good service in a restaurant, and it isn’t good pharmaceutical care.

Traditionally, hospital pharmacists have focused on acute or urgent issues; this is justified especially when these issues, left unattended, would prolong the hospital stay or increase morbidity. In contrast, when it comes to chronic disease management, some of the same pharmacists respond by asking, “Shouldn’t the community pharmacist be doing that?” I don’t think so, especially when the evidence suggests that most community pharmacists are not “doing that”!6 I certainly do not wish to downplay the significant findings of numerous published studies (the Study of Cardiovascular Risk Intervention by Pharmacists [SCRIP]7 and SCRIP-Hypertension,8 to name just a couple) that have demonstrated the effectiveness of community pharmacy–based interventions in improving patients’ health outcomes. But that potential is far from being realized today. In the meantime, can we accept the “it’s not my table” mentality as justification for not addressing concerns related to chronic disease in the hospital setting?

Barry and others1 recommend that efforts to increase utilization of proven clinical interventions should “focus on changing pharmacists’ perceptions of priorities.” I applaud their efforts to challenge the status quo and look forward to seeing the outcome of their continuing efforts to address these critical “care gaps”. Other institutions may wish to follow their lead by adopting the “It is my table!” attitude.

References

1. Barry A, Loewen P, de Lemos J, Lee KG. Reasons for non-use of proven interventions for hospital inpatients: pharmacists’ perspectives. Can J Hosp Pharm. 2009;62(5):381–385. [PMC free article] [PubMed]
2. Musing E. CSHP 2015 Babich M, Bussières JF, Hall KW, Harding J, Johnson N, Lefebvre P, et al., editors. Hospital pharmacy in Canada 2007/2008 report. Hospital Pharmacy in Canada Editorial Board; 2008 [cited 2009 Jun 6]. 81–89.89Available from: http://www.lillyhospitalsurvey.ca/hpc2/content/2008_report/cshp_2015.pdf
3. Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. Oxford (UK): Oxford University Press Inc; 2001.
4. Erstad BL, Puntillo K, Gilbert HC, Grap MJ, Li D, Medina J, et al. Pain management principles in the critically ill. Chest. 2009;135(4):1075–1086. [PubMed]
5. Qaseem A, Snow V, Shekelle P, Hopkins R, Jr, Forciea MA, Owens DK, Clinical Efficacy Assessment Subcommittee of the American College of Physicians Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;149(6):404–415. [PubMed]
6. Doucette WR, Kreling DH, Schommer JC, Gaither CA, Mott DA, Pedersen CA. Evaluation of community pharmacy service mix: evidence from the 2004 National Pharmacist Workforce Study. J Am Pharm Assoc. 2006;46(3):348–355. [PubMed]
7. Tsuyuki RT, Johnson JA, Teo KK, Simpson SH, Ackman ML, Biggs RS, et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP) Arch Intern Med. 2002;162(10):1149–1155. [PubMed]
8. McLean DL, McAlister FA, Johnson JA, King KM, Makowsky MJ, Jones CA, et al. SCRIP-HTN Investigators A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: Study of Cardiovascular Risk Intervention by Pharmacists–Hypertension (SCRIP-HTN) Arch Intern Med. 2008;168(21):2355–2361. [PubMed]

Articles from The Canadian Journal of Hospital Pharmacy are provided here courtesy of Canadian Society Of Hospital Pharmacists