Clinical Pharmacy Practice in Acute
Neurological Illness in Germany
By Stefanie Amelung, RPh, Dipl.-Pharm.1,2, and Carina Hohmann, RPh, PhD3
Affiliations:
1 Pharmacy Department,
Heidelberg University
Hospital, Heidelberg,
Germany
2 Department of Clinical
Pharmacology and
Pharmacoepidemiology,
Heidelberg University
Hospital, Heidelberg,
Germany
3 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
PHARMACY COLUMN
(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.
Stefanie Amelung,
RPhm Dipl.-Pharm
Carina Hohmann,
RPh, PhD
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