Clinical pharmacist Managed Oncology Clinic In University Hospital

Graduation Project
CLINICAL PHARMACIST
MANAGED ONCOLOGY
CLINIC IN A UNIVERSITY
HOSPITAL
DR. Sara Shaheen
Fathy Mohamed Al-Azhary

C l i n i c a l p h a r m a c i s t m a n a g e d o n c o l o g y c l i n i c Page 2
1-background
The purpose of the Symposium on Clinical Pharmacy is to describe the present and
future functional roles of clinical pharmacists in drug research, professional
education, and patient care. Clinical pharmacy is a relatively new professional
discipline, being only about 15 years old. This new breed of pharmacists is patient
rather than drug product oriented. The discipline arose out of dissatisfaction with
old practice norms and the pressing need for a health professional with a
comprehensive knowledge of the therapeutic use of drugs. The clinical pharmacy
movement began at the University of Michigan in the early 1960s, but much of the
pioneering work was done by David Burkholder, Paul Parker, and Charles Walton
at the University of Kentucky in the latter part of the 1960s. Clinical pharmacology
is a professional discipline that combines basic pharmacology and clinical
medicine. Its development began in the early 1950s, primarily as a result of the
efforts of Harry Gold. It has had a slower growth than clinical pharmacy but it has
made many important contributions to our knowledge of human pharmacology and
the rational use of drugs.
Beginning a new therapy for cancer can be frightening, especially when the patient
will be responsible for administering the medication at home. Often, these oral
cancer therapies have complicated schedules, strict administration guidelines, and
troublesome side effects. Helping patients understand how to safely take their oral
cancer medication and educating them on what to expect is extremely rewarding.
By checking in with patients periodically during treatment, we may be able to
identify a problem before it becomes severe and communicate this to the patient’s
oncology care team.
First we must know how clinical pharmacy began and it’s evolution through years
and what’s the meaning of clinical pharmacy , One of the most important
origination that form a great role in the evolution of the clinical pharmacy is ACCP
“American College of Clinical Pharmacology”
ACCP Founded in 1979 with 29 individuals to advance the evolving practice of
clinical pharmacy. ACCP now serves as the organizational home for nearly
10,000 clinical pharmacists.

The American College of Clinical Pharmacy (ACCP) is a professional and
scientific society that provides leadership, education, advocacy, and resources
enabling clinical pharmacists to achieve excellence in practice and research.
ACCP's membership is composed of practitioners, scientists, educators,
administrators, students, residents, fellows, and others committed to excellence in
clinical pharmacy and patient pharmacotherapy.
So we have to know the meaning of clinical pharmacy ,,
Clinical Pharmacy is a health science discipline in which pharmacists provide
patient care that optimizes medication therapy and promotes health, wellness, and
disease prevention. The practice of clinical pharmacy embraces the philosophy of
pharmaceutical care; it blends a caring orientation with specialized therapeutic
knowledge, experience, and judgment for the purpose of ensuring optimal patient
outcomes. As a discipline, clinical pharmacy also has an obligation to contribute to
the generation of new knowledge that advances health and quality of life.
Clinical pharmacists care for patients in a ll health care settings. They possess in-
depth knowledge of medications that is integrated with a foundational
understanding of the biomedical, pharmaceutical, sociobehavioral, and clinical
sciences. To achieve desired therapeutic goals, the clinical pharmacist applies
evidence-based therapeutic guidelines, evolving sciences, emerging technologies,
and relevant legal, ethical, social, cultural, economic and professional principles.
Accordingly, clinical pharmacists assume responsibility and accountability for
managing medication therapy in direct patient care settings, whether practicing
independently or in consultation/collaboration with other health care professionals.
Clinical pharmacist researchers generate, disseminate, and apply new knowledge
that contributes to improved health and quality of life.
Within the system of health care, clinical pharmacists are experts in the therapeutic
use of medications. They routinely provide medication therapy evaluations and
recommendations to patients and health care professionals. Clinical pharmacists
are a primary source of scientifically valid information and advice regarding the
safe, appropriate, and cost-effective use of medications

In a brief words
“Clinical Pharmacy is a health science discipline in which pharmacists provide
patient care that optimizes medication therapy and promotes health, wellness, and
disease prevention. The practice of clinical pharmacy embraces the philosophy of
pharmaceutical care; it blends a caring orientation with specialized therapeutic
blends a caring orientation with specialized therapeutic knowledge, experience,
and judgment for the purpose of ensuring optimal patient outcomes. As a
discipline, clinical pharmacy also has an obligation to contribute to the generation
of new knowledge that advances health and quality of life.”
As with any discipline, research is critical to the advancement of clinical
pharmacy. The need for pharmacist-researchers who possess both clinical
pharmacotherapy knowledge and biomedical research skills was recognized in the
Millis Commission Report in 1975.The Millis Commission defined "clinical
scientist" as an individual equally skilled and trained in a science and in pharmacy
practice. Their definition is consistent with the general definitions of clinician-
scientist used by the National Institutes of Health (NIH) and the Canadian
Institutes of Health Research.
The American Association of Colleges of Pharmacy (AACP) conducted a survey
that documented the severe shortage of pharmacy faculty in the United States. In
2002, of 67 schools responding to the survey (80% response rate), 417 faculty
positions were open, almost all of which were for positions in either pharmacy
practice (223 positions) or the pharmacy sciences (190 positions). With the steadily
increasing number of pharmacy schools and class sizes, the need for qualified
individuals to teach and advance the field of clinical pharmacy will continue to
expand. The need for pharmacist-researchers who possess both clinical
pharmacotherapy knowledge and biomedical research skills (of which clinical
pharmacy research is a subset) is critical as overall drug use increases and as
technology and science allow us to move toward better targeting of and more
individualized approaches to drug therapy.

2-Aim of the work
The aim of the clinical pharmacy is to ensure the patient's maximum well-being
and to play a meaningful role in the safe and rational use of drugs. The main goals
of clinical pharmacy are:
1. To assist the physician in doing a better job of prescribing and monitoring drug
therapy for the patient.
2. To assist medical and para-medical staff and documenting medication incidents
correctly.
3. To maximise the patient's compliance in drug use process.
Qualities of clinical pharmacist:
1. Communication Skill. The clinical pharmacist should have good
communication skills, in order to communicate with the patient and co-
professionals freely and effectively.
2. Clinical Skills. The clinical pharmacist should have thorough knowledge about
etiology of a disease, signs, symptoms. pathophysiology, laboratory tests,
pharmacokinetics. etc. He should be clinically trained for providing information on
rational drug use, related drug therapy, and for reviewing drug doses.
3. Professional Relationship. He should be able to understand and appreciate the
role of medical and para-medical staff wherever possible. He must accompany
physician on medical rounds to assist him by providing drug informations. The
physician, pharmacists and nurses should develop an inter-professional relationship
with each other to enhance the quality of patient care.
4. Empathy. Clinical pharmacist should possess a deep sense of shared
responsibility towards medical care of patients. It will help him in taking
medication history and gaining patient's confidence.
5. Monitoring Drug Therapy. Clinical pharmacist must help in monitoring drug
therapy because it is an on-going process and keeps on changing depending upon
patient's conditions.
Oncology pharmacists have a vital role in the health care team. Pharmacists
possess specialized knowledge about medications and how they work to fight
cancer. They work with the medical and nursing staff to maximize the benefits of
drug therapy while trying to minimize toxicities. Pharmacists also help coordinate
the complete medication plan, from inpatient chemotherapy infusions to what
medications need to be taken at home. Additionally, oncology pharmacists work
with the health care team to educate patients about what to expect during treatment
and ensure that each medication is given at the right time and dosed correctly.

Pharmacists perform daily evaluations of medication profiles to ensure each drug is
dosed appropriately. Pharmacists are also active in educating patients and family
members about what to expect during chemotherapy and following up with the
health care team to adjust medications if the patient is experiencing side effects
from chemotherapy.
No matter the setting, oncology pharmacists are true experts in the medications
used to treat cancer, as well as the medications used to manage complications of
cancer and side effects from its treatment. They can explain to patients exactly how
their medications should be taken. They can look at a patient’s current list of
medications to identify any worrisome drug interactions and then provide guidance
on managing these interactions. Oncology pharmacists also explain what side
effects may occur and assist in managing these side effects. Finally, oncology
pharmacists work closely with a patient’s oncologist in order to achieve the best
possible outcome.
And being able to manage a patient’s supportive care plan, which often focuses on
pain, neuropathy, nausea, or vomiting. Inorder to bring to this role in utilizing the
medication we must have the in-depth medication knowledge that an oncology
pharmacist has in order to best serve our patients.
Basic components of clinical pharmacy practice
1. Prescribing drugs
2. Administering drugs
3. Documenting professional services
4. Reviewing drug use
5. Communication
6. Counseling
7. Consulting
8. Preventing Medication Errors
Scope of clinical pharmacy
Drug Information
Drug Utilization
Drug Evaluation and Selection

Medication Therapy Management
Formal Education and Training Programs
Disease State Management
Application of Electronic Data Processing (EDP)
What activities can be undertaken to achieve the aim of clinical pharmacy?
The aim of clinical pharmacy is the best use of medicines.
Many activities can be undertaken to promote the best use of medicines.
Some clinical pharmacy activities include :
 Documentation of patient pre-admission medication history
 Documentation of patient allergies (including medication allergies)
 Medication reconciliation (checking that medicines taken before
admission are continued in hospital if still necessary)
 Clinical review of medications to ensure the patient is being treated as
best as possible
 Participation in ward rounds
 Discharge medication counselling
 Patient referral
 Therapeutic drug monitoring
 Restriction and monitoring the use of antibiotics
 Providing continuing education for other staff on the best use of
medicines
 Drug use evaluation
 Health promotion activities
 Providing written information

3-Rationale for the project proposal
What do clinical pharmacists do?
Clinical pharmacists:
 Assess the status of the patient’s health problems and determine whether the
prescribed medications are optimally meeting the patient’s needs and goals
of care.
 Evaluate the appropriateness and effectiveness of the patient’s medications.
 Recognize untreated health problems that could be improved or resolved
with appropriate medication therapy.
 Follow the patient’s progress to determine the effects of the patient’s
medications on his or her health.
 Consult with the patient’s doctors and other health care providers in
selecting the medication therapy that best meets the patient’s needs and
contributes effectively to the overall therapy goals.
 Advise the patient on how to best take his or her medications.
 Support the health care team’s efforts to educate the patient on other
important steps to improve or maintain health, such as exercise, diet, and
preventive steps like immunization.
 Refer the patient to his or her doctor or other health professionals to address
specific health, wellness, or social services concerns as they arise.
Why should we consider clinical pharmacy?
Clinical pharmacy services are of considerable importance in all the hospitals
because clinical pharmacist can serve as a guide to physician for safe and rational
use of drugs. A clinical pharmacist can help to achieve economy in the hospital by
planning safe drug policies, suggesting means of reductions of waste, by
preventing misuse or pilferage of drugs and in the preparation of budget by
forecasting future drug needs of hospital, based upon their, drug utilization
patterns.
With a growing but already wide range of medicines and the increasing prevalence
of chronic diseases in all countries the best use of medicines is of growing
importance.

Some of the outcomes of clinical pharmacy and the best use of medicines are
 Better patient health outcomes
 Better patient medication understanding
 Better patient medication usage
 Decreased cost to the government and patient (decreased use of unnecessary
medicines, decreased risk of hospital admissions from medication issues)
 Increased availability of medicines (medicines are used on only the people
who need them)
How do clinical pharmacists care for patients?
Clinical pharmacists:
 Provide a consistent process of patient care that ensures the appropriateness,
effectiveness, and safety of the patient’s medication use.
 Consult with the patient’s doctor(s) and other health care provider(s) to
develop and implement a medication plan that can meet the overall goals of
patient care established by the health care team.
 Apply specialized knowledge of the scientific and clinical use of
medications, including medication action, dosing, adverse effects, and drug
interactions, in performing their patient care activities in collaboration with
other members of the health care team.
 Call on their clinical experience to solve health problems through the
rational use of medications.
 Rely on their professional relationships with patients to tailor their advice to
best meet individual patient needs and desires.
The Clinical Pharmacist
Stating explicitly that the clinical pharmacist cares for patients in all health care
settings emphasizes two points:
1) that clinical pharmacists provide care to their patients (i.e., they don’t just
“provide clinical services”), and
2) that this practice can occur in any practice setting. The clinical pharmacist’s
application of evidence and evolving sciences points out that clinical pharmacy is a
scientifically-rooted discipline; the application of legal, ethical, social, cultural, and
economic principles serves to remind us that clinical pharmacy practice also takes
into account societal factors that extend beyond science.

By stating that clinical pharmacists assume responsibility and accountability for
achieving therapeutic goals, the definition makes it clear that they are called upon
to be more than consultants. Further, the mention of managing therapy in direct
patient care settings is particularly important because it reinforces existing
definitions of the term “clinical.”
That is, clinical pharmacists are involved in direct interaction with, and observation
of, the patient. In addition, it is noted that clinical pharmacists practice both
independently and in consultation/collaboration with other health care
professionals, making it clear that they are members of an autonomous profession
within their scope of practice, yet also function as members of a cooperative health
care team. At the conclusion of this paragraph, attention is drawn to the scientific
impact of clinical pharmacist researchers by stating that they generate, disseminate,
and apply new knowledge that contributes to improved health and quality of life.
Roles Within the Health Care System. By noting that the clinical pharmacist is an
expert in the therapeutic use of medications, this section indicates that the clinical
pharmacist is recognized as providing a unique set of knowledge and skills to the
health care system and is therefore qualified to assume the role of “drug therapy
expert.” In addition, this expertise is used proactively
to ensure and advance rational drug therapy, thereby averting many of the
medication misadventures that ensue following inappropriate therapeutic decisions
made at the point of prescribing. Stating that the clinical pharmacist is a primary
source of scientifically valid information and advice on the best use of medications
emphasizes that the clinical pharmacist serves as an objective, evidence-based
source of therapeutic information and recommendations. This expertise extends
beyond traditional medications to include nontraditional therapies as well. Finally,
indicating that clinical pharmacists routinely provide therapeutic evaluations and
recommendations underscores the fact that their daily practice involves regular
consultation with patients and health care professionals regarding medication
therapy evaluations and recommendations.

4-Introduction
Clinical oncology is a major participant in any multi-disciplinary team, which
would meet regularly to discuss site specific cases of tumors. Other members
would be site specific surgeon, palliative care physician, radiologist, pathologist,
specialist nursing staff and appropriate hematologist and medical oncologist.
It consists of three primary disciplines: medical oncology (the treatment of cancer
with medicine, including chemotherapy), surgical oncology (the surgical aspects of
cancer including biopsy, staging, and surgical resection of tumors), and radiation
oncology (the treatment of cancer with therapeutic radiation).
Oncology is concerned with:
 The diagnosis of any cancer in a person (pathology)
 Therapy (e.g. surgery, chemotherapy, radiotherapy and other modalities)
 Follow-up of cancer patients after successful treatment
 Palliative care of patients with terminal malignancies
 Ethical questions surrounding cancer care
 Screening efforts:
o of populations, or
o of the relatives of patients (in types of cancer that are thought to have
a hereditary basis, such as breast cancer)
There needs to be a common shared understanding of the roles of the doctor in the
contemporary healthcare team. ...Such issues need to be urgently considered by
key stakeholders and public consensus reached before the end of 2008 .
To date, the information published regarding workforce implications has focused
on physicians, nurse practitioners, and physician assistants. But oncology clinical
pharmacists also can assist with direct patient care and patient education activities.
Much effort and research have been presented over the past 3 years about the
future of the practice of oncology. It is estimated that a significant shortage of
qualified oncology and hematology health care professionals will be seen by 2020.
To date, the information published regarding workforce implications has focused
on physicians, nurse practitioners, and physician assistants. However, another
clinical resource has been overlooked in available research and publications. There

are a growing number of oncology clinical pharmacists who can assist with direct
patient care and patient education activities. In fact, in certain states, clinical
pharmacists are providing direct patient care. Nationally speaking, although it is
not uncommon for a clinical pharmacist to practice at this level, there is a paucity
of literature documenting this practice. This article serves to introduce these
concepts and logistics.

5-review of literature
This was a retrospective descriptive analysis of clinical interventions by the
clinical oncology pharmacist from
September 4, 2004 to October 27, 2006. Interventions were categorized as either
drug-related or consultative. Drug-
related interventions included medication reconciliation, dosing, and adverse effect
management and prevention.
Consultations incorporated drug information questions, patient visits, and patient
education sessions. Information was extracted from an online documentation
program linked to medical charts.
Results.
A total of 583 clinical interventions were documented among 199 patients.
Average time spent per intervention
was 10 minutes. Drug-related and consultative interventions accounted for 35%
and 65%, respectively. Included among
the drug-related interventions were adverse events (131), medication reconciliation
(52) and dosing (22). Consultation
services consisted of patient education (143), patient visits (124) and drug
information (25). The on-site pharmacist saved
$210,000 by admixing chemotherapy. Patient and colleague surveys evaluated
pharmacist services with positive ratings of
95% and 98%, respectively.
Conclusion.
Analysis of clinical interventions, cost-savings, and feedback from patients and
colleagues confirmed
beneficial services provided by a clinical pharmacist in this outpatient oncology
center.
OBJECTIVES: To assess the effect of clinical pharmacist interventions on the
clinical outcomes in oncology patients.
METHODS: A total of 100 patients received their chemotherapy cycles with
clinical pharmacy interventions were enrolled in the present study during January
2007 to January 2008. Clinical pharmacy interventions
include: Detecting medication errors by using a modified form of the American
Society of Hospital Pharmacists (ASHP) worksheet. Correcting those errors and
sending recommendations to the medical staff.

RESULTS: The clinical pharmacy interventions reduced the number of
medication errors from 1548 to 444 which was statistically significant (p_0.004). A
total of 1104 clinical pharmacy interventions were documented in this present
study. Forty-five percent of clinical pharmacy interventions have led to increase in
the efficacy of chemotherapy regimen and 54.7% have led to decrease in the
chemotherapy toxicity. Seventy six percent of the errors recorded in the present
study occurred in the prescribing stage, about 20%in the administration stage and
3.8% in the dispensing stage.
CONCLUSIONS: The clinical pharmacy interventions among oncology patients
can reduce the number of medication errors; improve the clinical outcomes through
increasing chemotherapy efficacy and reducing the toxicity.

6-methodology
The World Health Organisation defines the rational use of medicines as a
situation where ‘patients receive medicines appropriate to their clinical needs, in
doses that meet their own individual requirements, for an adequate period of time,
and at a price the patient can afford’.
The best use of medicines can be expanded from this definition.
The best use of medicines is occurs when
 The most effective medication option is used based on strong evidence
 There is an indication for use
 There are no contraindications for use
 The dose is correct
 The Route is correct
 The frequencyis correct
 The Duration of treatment is correct
 The Formulation is correct
 It is appropriate for patients age
 It is appropriate for patients weight or Body Surface Area (BSA),
depending on which is more applicable
 It is appropriate for the patients renal function
 It is appropriate for the patients hepatic function
 It is appropriate considering other clinical investigations for the patient
 It is important to ensure that
 Appropriate monitoring can be completed
 Medicine is taken at the appropriate time in reference to meals
 There are no drug interactions
 (if not possible, the drug interactions should be managed
 appropriately with appropriate monitoring where appropriate)
 Medicine use is cost Effective The best use of medicines requires
understanding from the doctor, pharmacist, other health workers and the
patient.
 The best use of medicines is not always practiced. For example
 Doctors can sometimes feel pressured to give medicines to patients even
if it is not needed
 A patient may take medicines without speaking with a health worker
 A doctor may prescribe a medication but the patient may not use it

 Pharmacists may not ensure that the patient can take the medicine
properly
Where can clinical pharmacy happen?
As mentioned in above sections, the best use of medicines (the aim of clinical
pharmacy) is the responsibility of many health care workers. This should be an aim
of practice in all health care facilities, whether are pharmacist is there or not.
Clinical pharmacy activities can be practiced in a range of areas, including
 Hospital wards
 Hospital clinics
 Inpatient pharmacy department
 Outpatient pharmacy department
 Community pharmacy
 Pharmacists may assume that clinical pharmacy only occurs on wards
interacting directly with patients and other health care workers. However,
all pharmacists should be clinical pharmacists, at least to some extent.
 There are many advantages of completing clinical pharmacy activities on
a hospital ward, including
 Access to patient information
 Access to other health care workers
 Access to patients
 Access to processes involving medicines use
 Participation in ward rounds
 Participation in discussions on patient management
Although the ward provides many advantages to conduct clinical pharmacy
activities it is not always possible to do this.
If it is not possible to conduct clinical pharmacy activities on hospital wards,
other areas can be used to promote the best use of medicines.
The disadvantage is that the pharmacist is unlikely to have easy access to the
resources, information and staff that a ward based clinical pharmacist would.

7-Budget
 One time costs:
 IRB Review Fee $1744 + 29% = $2250.
 IRB Continuing Review Fee $ 581 + 29% = $750.
 IRB Amendment Review $ 388 + 29% = $500
 IRB Preparation Fee $ 1500 (suggested fee)
 Administrative Fee $ 3000 ( suggested fee)
 Investigational Drug Pharmacy set-up fee
 Archive document storage fee $100 / year * 7 years
 Source document binders $8.00 per patient * X patients
 Advertising for Recruitment Fee
 Total
 Indirect Cost 29%
 Total One time costs
Principal Investigator:
Division:
Protocol Title:
Protocol Number:
Sponsor:
IRB Approval Number:
Start date:
Study duration:
List all procedures and all visits
Total
per
Procedure Baseline Visit 1 Visit 2 Visit 3 Final Visit patient Sponsor Other
History and Physical 200$ 50$ 50$ 50$ 50$ X
Lab tests 300$ 300$ 250$ 50$ 300$ X X
MRI scan 1,500$ 1,500$ X
Study Drug administration 35$ 35$ 35$ X
Sub total 2,000$ 385$ 335$ 135$ 1,850$
Indirect rate 29% 580$ 112$ 97$ 39$ 537$
Total per visit 2,580$ 497$ 432$ 174$ 2,387$ 6,069$
* Consider 10% inflation per year for multi-year trials
Start-Up Costs: (One Time Fees) Start-Up Costs
IRB Initial Review Fee 1,744.00
IRB Amendment Review 581.00
IRB Continuing Review 388.00
IRB Preparation Fee 1,500.00
Subject Recruitment 5,000.00
Investigational Drug Pharmacy set-up Fee 1,000.00
Data Archival fee (100/yr for 7 years 700.00
Direct Costs 10,913.00
Indirect Costs (29 % of Direct Costs) 3,164.77
Sub Total Start-Up Costs: $14,077.77
Payer
Insurance -
Standard of
Care

The budget must total the estimated patient costs plus all one-time allowable
fees.
All industry sponsored expenses are subject to F&A (Facilities and
Administrative Costs) or Indirect Costs – (Overhead)
Industry sponsored clinical trials must use the Indirect rate of 29%. Federally
sponsored clinical trials indirect rate is 54%. You do not pay indirects on
patient care costs in Federal trial budgets.
IRB Review Fees
Initial review - $2250 ( $1744 + $506 indirect rate)
Continuing review - $ 750 ( $ 581 + $169 indirect rate)
Amendment review - $ 500 ( $ 288 + $112 indirect rate)
Points to Remember
 University Expenses (Direct Costs and F&A Costs) Must Be Reflected In
The Budget.
o Personnel (salary and fringe benefits)
o Office and Clinical Supplies
o Pharmacy Fees
o Laboratory Fees
o Patient Reimbursement Fee (e.g., travel, parking)
o Publication Costs
o Institutional Review Board – IRB Review Fees
o Determine if there will be professional charges required for the
technical tests performed. An example would be an ECG with
interpretation by a Cardiologist.
o Either edit the sponsor’s budget or create an Excel spreadsheet to
reflect all costs of the trial.

Health Expenditures has been increasing as a percentage of the nation’s Gross
Domestic Product (GDP) (Accounts for 15-20 %).
»In USA, Sales of nonprescription drugs have increased from $700 millions in
the 1950s to well into the billions of dollars ($287 billion in 2007).
»Thus, for half a century clinical pharmacy has been succeeding to set its feet
strongly and thoroughly through its activities in the healthcare services.
Whereas substantial numbers of studies have reported improved patient care and,
in some cases, reduced costs at individual clinical sites, none have evaluated the
impact of clinical pharmacy services and pharmacy staffing on the total cost of
care in our health care system.
Of 104 studies published between 1988 and 1995, 89% described positive
financial benefits of these services, with a mean cost: benefit ratio of 16.70:1
(every dollar invested in clinical pharmacy services resulted in a cost
reduction of $16.70).
Improved drug therapy should have a profound impact on the total cost of care
by decreasing:
1.Lengths of hospital stays.
2.Adverse drug reactions.
3.Infection rates.
4.Law suits.
5.Number of personnel to care for patients.
and so on.
»Thus, clinical pharmacy services may increase the efficiency of health care and
reduce costs.
There are a lot of clinical pharmacy services that work on that, including but not
exclusive to:
1.Centrally delivered services:
1.Medical treatment evaluation.
2.Drug and poison information.
2.Patient-specific services:
1.Adverse drug reaction (ADR) monitoring.

2.Drug therapy monitoring.
3.Drug counseling.
4.Medical rounds participation.
It is estimated that in this process each dollar of pharmacist salary cost was
associated with $31.92 reduction in total cost of care.
An unbiased source of drug information may promote better patient care and thus
reduce total cost of care.
»This service may contribute to lower total cost of care, as up to 28% of all
hospital admissions which were attributed to drug-related morbidity and mortality.
Having trained personnel to provide information could reduce these costs. In
addition, ADRs in hospitals are often preventable if detected early, and could be
reduced with better information systems.
»The presence of this service may also indicate medical staff open to input from
pharmacists and likely to accept recommendations on drug therapy, which may
result in lower costs.
Since the drug information service is often the process for formulary management
coordination in the hospital, it is important in controlling drug costs that are a
component of the total cost of care.
In the process, Each dollar of pharmacist salary cost was associated with $602.16
reduction in total cost of care. It also resulted averagely in 10.3 fewer
deaths/hospital/year.
»Thus, Pharmacist-provided drug information should be considered one of the
foundation clinical pharmacy services for hospitals.
Adverse drug reactions are the most common untoward events occurring in
hospitals and significantly increase the cost of care.

»The presence of this service indicates a hospital that has an active program to
detect and prevent ADRs, and thus may reduce the cost of care associated with
these problems.
This service has a profound effect on health care cost savings, as it limits:
1.Hospital Readmissions.
2.Extensive drug use.
3.Hospital stay period.
»In the process, each dollar of pharmacist salary cost was associated with
$2988.57 reduction in total cost of care.
Since medical rounds is where key decisions are made regarding patient care,
pharmacists' participation may prospectively ensure optimum drug therapy, thus
improving patient care and reducing health care costs.
»It may also indicate a hospital wide system that allows many health care
professionals to have direct input into decision making, thus improving health care
and reducing costs.
Although this was one of the more expensive clinical pharmacy services (total
salary), it was associated with the greatest reduction in total cost of care/hospital.
(Around $ 8,000,000/hospital/year)
»In the process, each dollar of pharmacist salary cost was associated with
$252.11 reduction in total cost of care.

8-Challenges
Despite a societal need for clinical pharmacy scientists, some barriers exist.
Challenges that pertain to all clinical investigators, including pharmacist-
researchers, are enhancing public participation in clinical research, guaranteeing an
adequately trained workforce, and obtaining funding. The difficulties facing
clinical pharmacy researchers are similar to and in some cases amplified compared
with those faced by some other clinical researchers. In addition, the increasing
competition for suitable patients, conflicts of interest and their impact on public
opinion of clinical research, increasing regulation, and privacy concerns all affect
the ability of pharmacists to recruit necessary participants for clinical research.
The ACCP's strategic plan lays out a direction for advancing their research
mission. The ACCP envisions that within the next 10-30 years, a significant
increase will occur in the number of clinical pharmacy scientists who will serve as
principal investigators for pharmacotherapy research, generate a substantial portion
of the research that guides drug therapy, and compete successfully with other
health care professionals for research funding. It is also envisioned that ACCP
members will commonly serve as principal investigators for pivotal clinical trials
and other pharmacotherapy research, and will compete successfully for research
funding that creates new knowledge and guides drug therapy. The ACCP has set
goals to increase the impact of pharmacist-initiated research, to encourage the
pursuit of research careers by clinical pharmacists, and to foster individual
members in their research and scholarly capabilities.
Challenges to be considered
There are many factors to consider when setting up a clinical pharmacy
service, and these may include
 Potential staff
 Ability to train staff
 Potential time to be allocated to a clinical pharmacy service
 Where the clinical pharmacy service will be based

 What clinical pharmacy activities will be completed In practice, a pharmacist
may identify less busy times in the pharmacy where they can prioritise clinical
pharmacy activities according to health centres needs and the pharmacy’s ability to
address those needs. Examples may include
 Pharmacist A in Pacific Island Country A identifies counseling to outpatients as a
problem.
The pharmacist chooses to complete training to improve counselling practice or
create medication leaflets to assist this process.
 Pharmacist B in Pacific Island Country B identifies medication understanding of
inpatients as a problem. The pharmacist chooses to create discharge medication
lists and complete comprehensive discharge medication counselling for patients
going home
 Pharmacist C in Pacific Island Country C is approached by a doctor from the
diabetes clinic who believes patient understanding important for disease
management. After discussion, the pharmacist agrees to provide medication
counselling to priority patients at this clinic Implementing a clinical pharmacy
service
When it comes to implementing a clinical pharmacy service consideration should
be given to the following
 Approval to implement a clinical pharmacy service (department approval,
hospital approval etc.)
 Promoting your service to other health care professionals
 Compiling the required clinical resources for the clinical pharmacy service
 Compiling standard operating procedures to facilitate a consistent service
One of the major challenge we face that who can do clinical pharmacy ?
Clinical pharmacy is normally provided by a pharmacist.
In many countries pharmacists are not available so other health care workers may
complete the activities of a clinical pharmacist.
The specific skills of a clinical pharmacist should include, but not necessarily
limited to
 Knowledge of medicines (doses, frequency, mechanism of action, indications for
treatment, contraindications for treatment, adverse effects, interactions, available
formulations, how to monitor treatment etc.)

 Knowledge of clinical presentation, diagnosis, pathophysiology and management
of common disease states
 Ability to identify issues with medicines use and suggest management strategies
 Knowledge of drug information resources (what resources to use, how
to use these resources)
 Knowledge of culture of the community and common perceptions about
medicines in the community
 Ability to communicate appropriately and effectively with patients and other
health care workers in a professional manner
 Knowledge of commonly used herbal or alternative medicine in the area
However, clinical pharmacy activities can be provided by other health care
workers to ensure the best use of medicines.
The best use of medicines is the responsibility of all health care workers.
Prescribers (doctors, dentists and some nurses) have the greatest responsibility to
ensure the best use of medicines as they prescribe medicines.
It is obvious that prescribers have a great responsibility to practice
the best use of medicines.
However, other health care professionals can also contribute to the best use of
medicines, for example
Nurses can contribute to the best use of medicines
.
Often nurses are the prescribers of medicines.
They spend the most time with patients and have significant knowledge
of medicines and disease processes.
Nurses can also contribute by observing patients and assisting with identification
of medication effects and adverse drug reactions
A dietician may notice that a patient has suffered from gastric upset since starting
a medicine (e.g. NSAID or corticosteroid) which has resulted in decreased app
etite; the patient’s condition is worsening as a result. If the dietician speaks with
the prescriber the
therapy can be improved. This increases the chance of better health outcomes for
the patient
 Physiotherapists often need to recommend the use of anti - inflammatory
medicines or other medicines for pain management. They need to make patients
aware of the side effects of those medicines. They also need to be aware of
patients’ other conditions and medicines being used and will consult the doctor if
needed and advice the patient appropriately.

A physiotherapist may also notice that a patient has become quite dizzy (e.g. due to
some blood pressure medications), making it difficult to do some exercises in
hospital and maybe
when the patient goes home. If the physiotherapist speaks with the prescriber
the therapy can be improved. This could significantly improve the health outcomes
of the patient
A pharmacist or pharmacy department may be able to provide training in the use of
medicines to these health care workers so they have the ability to contribute to the
best use of medicines.
Monitoring the impact of a clinical pharmacy service
Reason for monitoring the impact of a clinical pharmacy service include
 Maximizing benefit to your patients
 To justify ongoing support for a clinical pharmacy service
A range of indicators can be monitored to measure the impact of a clinical
pharmacy service, and these may include
 Clinical interventions
 Number of patients who have received medication counselling
 from a clinical pharmacist
 Number of ward rounds attended by the clinical pharmacist
 Number of patients who had a clinical review completed by a clinical
pharmacist
 Number of referrals received by the clinical pharmacist to complete a
clinical review
Although it is important to measure the impact of a clinical pharmacy service, it
should be noted that monitoring the service should never
compromise the clinical pharmacy service. Therefore,
monitoring should be completed by selecting a few indicators which are simple to
gather data on.
In particular, it is a very large task to monitor clinical interventions.

9-Conculsion
oncology clinics provide an excellent opportunity to involve pharmacists. A clinical
pharmacist has a significant role in outpatient clinics and can potentially lead to
an overall decrease in health care costs and to an improvement of the quality of
patient care.
10-Summary
The clinical pharmacy movement began at the University of Michigan in the early
1960
ACCP Founded in 1979 and had a great role in it’s evolution
importance in all the hospitals because clinical pharmacist can serve as a guide to
physician for safe and rational use of drugs. And decrease medication errors and
drug use evaluation .
we face many challenge as fund and the educational process that helps in to
increase the knowledge of different fields of the pharmaceutical science.
And we can get from this that :
Clinical Pharmacy has become a trend at the developed countries in the light of the
hard pressing economical crises and political conflicts. By its activities and
services, it contributes a lot to alleviating the burden on the annual medical budget.
»Its cost savings luster persuaded the governments to invest a lot in it and give
greater roles to the clinical pharmacists, thus improving the general healthcare
service.

11-Refernces
http://sci-hub.org/doi/10.1200/JOP.000037
http://www.accp.com/docs/about/ClinicalPharmacyDefined.pdf
http://www.accp.com/about/clinicalPharmacyDefined.aspx
http://www.ucdenver.edu/academics/colleges/pharmacy/currentstudents/OnCampusPharmDStudents/
StudentOrganizationsNew/OutsideOrganizations/Documents/ACCP_Information_slides.pdf
http://en.wikipedia.org/wiki/Clinical_pharmacy
http://www.medscape.com/viewarticle/540716_4
http://en.wikipedia.org/wiki/Oncology
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936477/
http://jop.ascopubs.org/content/4/4/172.full
http://sci-hub.org/doi/10.1177/107815529900500104
http://opp.sagepub.com.sci-hub.org/content/early/2011/01/14/1078155210389216.short
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2932500/
https://www.rcr.ac.uk/docs/general/pdf/THEROLEOFDOCTORJune2008.pdf
http://www.medscape.com/viewarticle/755894
http://ashpadvantage.com/leaders2011/docs/_Workshop%204_Clinical%20Dashboards%20Proceedings.
pdf
http://www.pppmag.com/article/1204/September_2012/Financial_Analysis_of_Drug_Management_an
d_Pharmacy_Costs/
http://www.slideshare.net/srkhere/clinical-pharmacy-16402443
http://www.bopawebsite.org/contentimages/wysiwyg/Michael_Dooley_and_Robert_Duncombe.pdf
http://www.ncbi.nlm.nih.gov/pubmed/7016931
http://courses.polhncourses.org/mod/resource/view.php?id=31253

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