Activities to improve hospital prescribing

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Editor, – As a director of pharmacy in an Australian public hospital, it was naturally with some interest that I read the recent discussion of activities to improve hospital prescribing (Aust Prescr 2001;24:29-31). Jonathan Dartnell correctly points out that much prescribing in hospitals is undertaken for acutely unwell patients by relatively inexperienced prescribers, and that factors such as rapid staff turnover and poor information systems can exacerbate the problems caused by these factors. It was particularly disappointing, therefore, to discover that the discussion fails to address the important roles played by hospital-based pharmacists in advancing the quality of prescribing.

Advanced clinical pharmacy services are widely established in our hospitals, and make a substantial contribution to the quality of prescribing in these institutions (and the wider community). A properly resourced clinical pharmacy service allows experienced pharmacists with specialist expertise to work alongside hospital-based prescribers to improve outcomes for patients through activities such as drug therapy monitoring, or screening for adverse drug reactions and interactions. Despite Dr Dartnell's assertion that there is little information available about drug use in our hospitals, pharmacy departments around Australia maintain active drug utilisation evaluation programs, providing a sound basis for locally targeted educational strategies, and underpinning audit and feedback activity that can make a real difference to prescribing patterns. In contrast to confrontational approaches such as the enforcement of prescribing restrictions, a co-operative approach that brings together doctors, nurses and pharmacists in a multidisciplinary effort to improve prescribing has a durable and positive effect upon prescribing practices.

Neglecting recognition of the role of skilled clinical pharmacy practitioners in influencing prescribing is a curious omission from a discussion focused upon ways to improve drug use in hospitals. Simply providing information (such as prescribing guidelines) is not enough. Without the sustained contribution of clinical pharmacists as a way to influence prescribing in hospitals, and the substantial contribution that these practitioners make to averting drug-related harm, health care in Australia would be a great deal less safe, and in all probability, much more expensive. Appropriate recognition of this contribution by funding agencies and hospital administrators is long overdue.

Chris Alderman
Associate Professor
Quality Use of Medicines and Pharmacy Research Centre
University of South Australia

Dr Jonathan Dartnell, author of 'Activities to improve hospital prescribing', comments:

I agree that pharmacists are essential contributors in improving hospital drug use, as are patients, doctors, nurses, quality improvement teams, clinical pharmacologists, clinical epidemiologists, behavioural scientists and administrators. I deliberately avoided defining the roles of any of the players apart from doctors as their contributions can, and do, change depending on the availability of personnel and resources in any given setting. While we would wish otherwise, clinical pharmacy services are variably established, implemented and supported. In some hospitals advanced clinical pharmacy services are routine, in other hospitals basic clinical pharmacy is not available.

In the examples cited in my article, pharmacists were key players providing academic detailing, developing and implementing guidelines, auditing and providing feedback. This was in the context of multidisciplinary programs, such as drug usage evaluation (DUE) programs. I recognise their importance and strongly support them, but most hospitals do not have DUE programs and those that exist are not necessarily based in pharmacy departments.

A major constraint in conducting DUE is the limited drug use data that are available without resorting to manually intensive methods. The few electronic data that are available are not linked to prescribers, patients and indications, and as these data are not standardised, inter-hospital aggregations and comparisons are difficult. Community prescribing data has its own limitations but national data are available.