Thread by @brandontoner

FUNDAMENTALS OF PHARMACY PRACTICE — A Threadapolooza Study Break

LET’S START WITH A MAP

“What does a pharmacist do?”
“That’s a lot of school to count pills.”
“Legal drug dealer”
“Medication-advocate”

… The role of the pharmacist and the process of pharmaceutical care is not well understood by a lot of people I talk to — so let’s take a bit of a tour!

Some intro stuff:

There is a whole team of people behind the pharmacy counter.

Pharmacists
Pharamcy Technicians
Pharmacy Assistants
Clerks

Each have a separate role to play in the delivery of care and safe distribution of medication.

I’m going to talk generally about the role of the pharmacist from a clinical perspective, but the role is more broad — overseeing the overall function of the pharmacy.

I’m also talking from the Canadian pharmacy perspective — and pharmacy varies quite a bit in different regions and practice sites.

Pharmaceutical Care! What’s that?

Pharmaceutical care is a SYSTEMATIC process to ensure that each medication that a person is prescribed is:

1. SAFE (no harm)
2. EFFECTIVE (do good)

... this can be broadened into:

The patient's 4 DRUG THERAPY NEEDS:

1. Indication (reason for use)
2. Safety
3. Effectiveness
4. Adherence (patient is willing and able to take it)

From these needs, we can assess whether drug therapy is well suited to meet these needs... any GAPS in these needs become DRUG THERAPY PROBLEMS (DTPs).

There are 7 distinct drug therapy problems that may be identified by pharmacists.

Related to INDICATION:

1) Unnecessary drug
2) May benefit from a drug

Related to SAFETY

3) Dose is too high
4) A side effect

Related to EFFECTIVENESS

5) Dose too low
6) Ineffective drug

Related to ADHERENCE

7) Patient unwilling or unable to take the medication as directed

Here are those 7 DTPs summarized!

And some elaborations on those, highlighting some common scenarios…

The patient's drug therapy needs are the CORE. Everything from there either supports the ability to detect DTPs, or the management of them

DTPs are the pharmacist's *diagnosis*. Identification, prioritization, and management of DTPs is an important part of the role of a PhC.

*DTPs resolved* is the main clinical KPI for pharmacy.

Find problems related to drugs, and help to resolve them. Do that as much as possible to promote medication safety and judicious medication use.

So what are the other components? What other pieces are there to this system? How are DTPs identified and prioritized? After they are identified, how are they managed?

Here are some components:
- Assessment (get the facts)
- Identification and prioritization of DTPs (make an assessment)
- Identify any learning objectives (to resolve the DTP)
- Research (find information)
- Make a plan
- Monitor the plan

The domain of ASSESSMENT is what creates the *information* that is used for evaluating the patient's drug therapy needs.

Assessment is used to fill-in gaps, update data, and investigate the status of a health condition so that we can better understand the patient’s needs.

Assessment is also very SYSTEMATIC — and the data gathered from patient assessment is summarized and presented in the CASE PRESENTATION format.

This may be familiar as a component of the patient's CHART.

Parts of the case presentation:
- ID
- Reason for Visit
- History of Present Illness (HPI)
- Chief Complaint (CC)
- Past Medical History (PMH)
- Family History
- Social History
- Allergies & Intolerances
- Medications
- Vitals
- Review of Systems
- Investigations
- Labs
- Summary

This systematic format of presenting a patient case is important because it allows for a systematic way of THINKING and assessing the status of the patient.

From here, it is easier to see patterns and gaps. If this was written as a story or narrative, it would be harder to pull out relevant details and facts.

The case presentation supports consistency and clarity.

OK so assessment has been completed, and we've got some facts.

What next?

https://twitter.com/brandontoner/status/1339305012560846850

From here, we can assess the patient's drug therapy needs.

https://twitter.com/brandontoner/status/1339303289138110466

*KEY POINT* Drugs are not the answer for all ailments.

The pharmacist is one member of the team, with a specific area of focus: DRUGS.

So when we assess a patient it is through the context of their drug therapy needs. PhCs are the *drug therapy* experts.

However — we also keep an eye of the patient's holistic health needs.

Holistic health care is challenging — in many ways our medical systems are hyper-specialized. It is challenging to get a 30,000' view. There are many health care professionals, each with areas of expertise.

This is a keen area of focus for me — I believe that with stronger *systems of care* and simplified collaboration, we can maintain context, and support patients more holistically.

Long ways to go, but I am VERY optimistic for the future.

BACK TO THE THREAD.

So we've completed an assessment, identified and prioritized some DTPs. Now what?

We need to make a plan.

Before we make a plan, we need to assess our knowledge and readiness. Medicine is complicated, it's not possible to have all of the nuance memorized.

There is a LOT of information out there. And the best place for it, likely isn't in your head. Resources are important.

So we think about what we need to know to make a sound plan, and build some learning objectives.

https://twitter.com/brandontoner/status/1335294346111954953?s=21

Once we have a L.O., we can determine the right SOURCE of information to direct our research efforts towards.

Knowledge, comprehension, and application = Tertiary and Secondary literature.

Analysis, synthesis, and evaluation = Primary and Secondary

Tertiary literature (e.g. textbooks) — these are great for an overview and background, but are less suited towards recommendations that may change as the body of evidence evolves.

Secondary literature (e.g. UpToDate) — these are practice summaries that are a bit more granular and agile than textbooks, and can provide a really helpful lens, but again may be slower moving and subject to higher degrees of bias.

Primary literature (e.g. Pubmed) — This part is complex. Lots of nuance to using to primary literature. Let's riff on that a bit.

Advantages of primary literature for exploring learning objectives:
- Newest information available
- You can make your own assessments of validity and importance.
- Estimate of effect sizes.
- Able to answer more specific clinical questions.

Risks of using primary literature:
- Takes a longggg time to parse through (inefficient)
- Can get caught up in the weeds. Placing too much stock in a single study may lead you to inaccurate conclusions.
- A significant amount of skill is necessary to interpret properly.

Ultimately, each level of literature is important for exploring your learning objectives.

More general and background = tertiary/secondary
More specific and recommendation-driven = primary/secondary

When using and evaluating medical evidence, though — it is important to have a good understanding of the factors that can influence its relevance and results.

This domain is called CRITICAL APPRAISAL, a component of EVIDENCE BASED MEDICINE (EBM).

OK QUICK RECAP:
- Make assessment
- Find problems
- Think

So how do we decide on recommendations and a plan?

This is veryyyy multi-faceted but let's try to outline some components.

Goal: We want safe, effective, and in alignment with the patient's PREFERENCES, OPINIONS, and VALUES.

Those preferences, opinions and values are part of the patient's MEDICATION EXPERIENCE and their context of care. Finding solutions that match the patient's medication experience is the HEART of individualized care.

Some questions to explore the medication experience:

General attitude about taking meds?
Understanding of their meds?
What do they want/expect from meds?
Concerns?
Cultural, religious, or ethical factors?
What is their medication-taking behaviour?

Parts of decision-making:
- Patient's medication experience
- Clinical experience
- Medical evidence

Each of these parts is balanced and adequately weighted in an evidence-based medicine practice.

Before we go to the evidence, we need some GOALS. This is what we hope to accomplish with our plan.

Once we've got some goals of therapy, we start thinking about some interventions.

So how do you approach medical evidence? 4 components:
- Clinical Question
- Search Strategy
- Critical Appraisal
- Application

The CLINICAL QUESTION is what guides your SEARCH STRATEGY.

Patient
Intervention(s)
Comparator(s)
Outcome(s)

e.g. In patients with atrial fibrillation is rivaroxaban superior to warfarin for reducing the risk of stroke?

Then using your clinical question, you start your search — I usually begin with secondary literature, then move to clinical practice guidelines, then primary literature and clinical trials to get more specific.

When looking at evidence, it’s important to consider the TYPE of evidence.

Lower = more raw & unprocessed.
Higher = more synthesized

Higher does not = better though!

Each type of evidence has a role in creating the landscape of understanding. As a clinician, you need to be able to understand the strengths and limitations of each, to answer your clinical question.

This is critical appraisal.

When assessing the primary literature it is important to have a systematic approach:
- Validity (is the study well-designed?)
- Importance (are the results generalizable and important)
- Applicability (can the results be applied to my patient?)

There are a number of threats to VALIDITY that need to be considered:
- Bias
- Chance
- Confounding

When you're considering the IMPORTANCE, it is important to consider the effect size. Think:

"What are the results?"
"If the results are true, do I care?"

And for APPLICABILITY, think: "Is my patient similar to those that were studied?" Is it reasonable for me to expect similar results? Why or why not?

BACK TO THE PATIENT CARE PROCESS

RECAP:
- Got some facts (assessment)
- Identified some gaps in care (DTPs)
- Did some research
- Weighed in the patient's medical experience

Now we use that to make a plan with the patient.

The plan could be anything that will address the stated drug therapy problems.

It could involve drug, and non-drug solutions. The pharmacist may implement some parts of the plan independently, or work with the rest of the care team (esp. physician) to implement interventions.

Once the plan is set, we need to monitor the plan to make sure:

- The intervention is tolerated and safe
- That it's working
- That the patient continues to be willing and able to follow the plan.

It is important to not leave the patient behind! They are at the center. If the patient doesn't buy into the plan — the plan needs work.

Adherence is a great indicator of patient-centeredness — your patient is MUCH more likely to follow a plan they understand & helped create.

Monitoring blends into continuous assessment and the cycle continues on forever.

Oh yea, gotta tag @threadapalooza !

Thanks everyone for playing!
Thanks @visakanv for hosting.

I’ll be using this thread as scaffolding for future expansions 🧵

Now that you have some context — here's a look at one of the futures I'm trying to create:

https://twitter.com/brandontoner/status/1338327291949101058

Hovering over the whole system is this meta-layer of reflective practice that drives continuous improvement…

https://twitter.com/brandontoner/status/1321601883404980226

There are cycles of learning both WITHIN the system and in relation to the SYSTEM ITSELF.

Back in September, I made the decision to RETURN to school to enhance my understanding of pharmacy practice.

My mission is to improve the integrity of the pharmaceutical care process within the community setting. To support teams in understanding and integrating this system.

I believe that strong systems create strong outcomes.

And I believe we can do better.

I believe that clinical decisions in care-settings can be improved by enhancing our CONTEXT.

Better information = Better patient care.

The goal:

*Right information* in front of the
*Right person* at the
*Right time*

In *real practice* this system is less clean-cut and linear.

A clinical practice is a chaotic environment sometimes, and often time and resources challenge the effective delivery of good care.

Given these contsraints, strong systems are EVEN MORE important.

My study of information management, PKM, software, technology, philosophy, etc. is allllll anchored in this mission.

This is the long ball.

My goal is to become an expert in the intersection between INFORMATION and PHARMACEUTICAL CARE.

Thank you for coming to my @TEDTalks