Practice report Prescribing and transcribing—2010
PRACtice RePORT
ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing—2010 Craig A. Pedersen, Philip J. Schneider, and Douglas J. Scheckelhoff
T
he ASHP national survey of pharmacy practice in hospital settings focuses on practices and technologies for managing and improving the medication-use system and the role that pharmacists play in this effort. The national surveys are organized according to six steps in the medication-use process: prescribing, transcribing, dispensing, administration, monitoring, and patient education. Each year, the survey focuses on two components in the medication-use process. The 2010 survey evaluates practices and technologies related to prescribing and transcribing. The most recent three surveys therefore represent a composite picture of the ways hospitals and health systems are managing and improving the entire medicationuse system and the current role that pharmacists play in medication-use system management. In assessing prescribing and transcribing practices, the present study was intended to describe and trend the process of formulary system management; the use of drug policy
Purpose: Results of the 2010 ASHP national survey of pharmacy practice in hospital settings are described. Methods: A stratified random sample of pharmacy directors at 1968 general and children’s medical–surgical hospitals in the United States was surveyed by Internet and mail. SDI Health LLC supplied data on hospital characteristics; the survey sample was drawn from the SDI Health hospital database. Results: In this national probability sample survey, the response rate was 28.8%. Patient-specific pharmacist activities are increasing, as shown by the substantial use of pharmacist empowered therapeutic interchange programs, extensive prevalence of pharmacist review of medication orders before doses are available for administration to patients, and the widespread use of pharmacist consultations by prescribers, with almost complete acceptance of pharmacist recommendations. Pharmacists are also leading antibiotic stewardship programs, managing anticoagulation medication therapy, addressing pharmaceutical
tools by the pharmacy and therapeutics (P&T) committee to improve medication use; the extent of phar-
Craig A. Pedersen, B.S.Pharm., Ph.D., FAPhA, is Healthcare Consultant, Mercer Island, WA. Philip J. Schneider, M.S., FASHP, FFIP, is Clinical Professor and Associate Dean, University of Arizona College of Pharmacy at the Phoenix Biomedical Campus, Phoenix. Douglas J. Scheckelhoff, M.S., FASHP, is Vice President, Professional Development, American Society of Health-System Pharmacists, Bethesda, MD. Address correspondence to Dr. Pedersen, 3758 78th Avenue, Southeast, Mercer Island, WA 98040 (
[email protected]).
waste management, and standardizing i.v. infusion concentrations. Electronic health information is rapidly being adopted, with the use of electronic medical records and computerized prescriber-order-entry to improve prescribing and use of medications. Metrics are commonly used to track and monitor trends in operational, clinical, and safety performance in hospital pharmacy departments. Pharmacist and pharmacy technician staffing has increased significantly, while vacancy rates have declined. Conclusion: Pharmacists contribute to improving prescribing and transcribing. Patient safety is now a priority for medication management. Index terms: American Society of HealthSystem Pharmacy; Computers; Data collection; Interventions; Manpower; Medication orders; Personnel, pharmacy; Pharmaceutical services; Pharmacists, hospital; Pharmacy, institutional, hospital; Physicians; Prescribing; Rational therapy; Records Am J Health-Syst Pharm. 2011; 68:669-88
macist consultations; the provision of drug information to prescribers; the process of medication order
The assistance of Lilliana Morales, LaKisha Sears, the staff of ASHP, and the pharmacy directors who participated in the survey is acknowledged. Supported by a grant from Merck & Co., Inc. The authors have declared no potential conflicts of interest. Copyright © 2011, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/11/0402-0669$06.00. DOI 10.2146/ajhp100711 Am J Health-Syst Pharm—Vol 68 Apr 15, 2011
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Practice Report Prescribing and transcribing—2010
receiving, evaluation, and transcription; and the use of computerized prescriber-order-entry (CPOE) systems, electronic medical records (EMRs), and other medication safety technologies. This study also evaluated medication safety and quality-improvement activities, implementation of standardized i.v. infusion concentrations, antibiotic stewardship programs, use of key metrics to measure pharmacy department performance, anticoagulation management by pharmacists, pharmaceutical waste practices, pharmacist participation in outpatient clinics, pharmaceutical acquisition costs, human resource commitments and turnover, and estimated national vacancy rates for hospital pharmacist and pharmacy technician positions. Methods Prescribing and transcribing practices in U.S. hospitals and health systems were evaluated using methods similar to those of past ASHP surveys.1-9 Questionnaire development. The 2010 questionnaire was developed and pretested using procedures suggested by Dillman.10 Questions from previous surveys that pertained to topics of interest in this survey were evaluated for clarity and response. Data on hospital characteristics (i.e., number of beds, U.S. Census Bureau region and metropolitan statistical area,11 ownership, and medical school affiliation) were obtained from the SDI Health LLC 2008 hospital database.12 Survey sample. From the SDI database of 6975 hospitals, a sampling frame of 4898 general and children’s medical–surgical hospitals in the United States was constructed. Specialty, federal, and Veterans Affairs hospitals were excluded. Hospitals were stratified by size before sampling, and random samples of hospitals within each stratum were taken to select the sample of 1968 hospitals. Because we employed a primarily 670
electronic data collection method, and given the available evidence that Internet-based surveys typically have lower response rates,10 we increased our sampling by 50% from recent surveys.1-3 We sampled 450 hospitals with fewer than 50 beds to compensate for historically lower survey response rates in hospitals of that size. We sampled all hospitals with 600 or more staffed beds (n = 128) to ensure that data were obtained from enough of such very large hospitals to provide reliable estimates. Three hundred hospitals were sampled in each of the other hospital size categories (Table 1). To minimize survey sample verification costs, we used the same sample used in the 2009 ASHP survey but added 648 hospitals. In April 2010, each of those 648 hospitals was called by an independent firm (Reliance Teleservice, Arnold, MD) to verify the name of the pharmacy director. After eliminating hospitals that were no longer in business or no longer had pharmacies, hospitals without a permanent director of pharmacy, and hospitals whose pharmacies were unwilling to provide the name of the director of pharmacy, the adjusted sample was 1968 hospitals. Data collection. Pharmacy directors in the sample were contacted up to four times during the survey period. We used a mixed-mode survey method. However, unlike the 2009 survey, in which survey recipients were initially offered a choice of completing a paper or an online survey,1 2010 survey recipients were initially offered only an online method of entering responses (Qualtrics, Provo, UT). The first contact letter explaining the survey and directing recipients to the online data collection site was mailed to all pharmacy directors in the sample in June 2010. To increase the response rate, respondents were entered into a drawing for three $100 gift cards as an incentive. Nonrespondents were contacted a second time (10 days after the initial contact)
Am J Health-Syst Pharm—Vol 68 Apr 15, 2011
and, if necessary, a third time (two weeks after the second contact) by mail or e-mail if an e-mail address was available. Finally, a paper survey booklet was mailed by courier to the remaining nonrespondents in August 2010; recipients were offered a choice of completing the paper survey or the online survey. Data analysis. Each hospital in the sample was assigned a unique identification number that allowed the survey response to be matched with the hospital characteristics in the SDI database. As with past reports in the ASHP survey series, data in this report are presented by hospital size categories based on number of staffed beds to more closely align with data compiled by the American Hospital Association.13 Because of the stratified random sampling procedure, it was necessary to employ a design-based analysis,14 which results in more accurate population estimates. Data were outputted by Qualtrics using an SPSS, version 16.0 (SPSS Inc., Chicago, IL), readable file and converted to an Intercooled Stata, version 8, readable format using DBMS Copy, version 7 (Conceptual Software, Inc., Houston, TX). All nondesign-based analyses were conducted using SPSS 16.0. All designbased analyses were conducted using Stata 8. To account for the sampling method, weights were assigned to respondents to adjust their contribution to the population estimate. The weight was 17.49 for hospitals with fewer than 50 staffed beds, 8.27 for hospitals with 50–99 beds, 14.59 for hospitals with 100–199 beds, 7.58 for hospitals with 200–299 beds, 4.69 for hospitals with 300–399 beds, 3.13 for hospitals with 400–599 beds, and 2.42 for hospitals with 600 or more staffed beds. The strata were the categories based on the number of staffed beds, and the finite population correction was the total number of hospitals in the population (4898).
Practice report Prescribing and transcribing—2010
Table 1.
Hospital Characteristicsa Characteristic
No. (%) Respondentsb
No. (%) Nonrespondentsb
No. (%) Surveyedc
No. (%) Populationd
All hospitals 566 (28.8) 1402 (71.2) 1968 (100) 4898 (100) Staffed beds e
