Evolution of hospital-based pharmacy teaching programs from 1989 - 1998

This study evaluated hospital involvement in pharmacy education. Databases from four U.S. National Clinical Pharmacy Services Studies and the American Hospital Association permitted detailed trend analysis. The study population included acute care general medical surgical hospitals: 1989 n = 1174, 1992 n = 1597, 1995 n = 1102, 1998 n = 950. Clinical pharmacy services offered in 50 percent or more of PharmD affiliated hospitals in 1998 were: drug-use evaluation, inservice education, pharmacokinetic consultations, adverse drug reaction management, drug therapy monitoring, protocol management (aminoglycosides, nutrition, antibiotics, heparin, warfarin, and theophylline), nutrition team, and medication counseling. Patient-focused care programs varied among the hospitals by teaching affiliation in 1998 (chi^sup 2^= 61.1, df=6, P

INTRODUCTION

The modern version of Doctor of Pharmacy (PharmD) education began in the inpatient teaching hospital environment of the general medicine ward. Inpatient hospital rotations, which focus on the delivery of direct patient care pharmacy services, remain the foundation of most PharmD curricula. Pharmacy students' education and training in clinical pharmacy is often most efficiently delivered within the structure of teaching hospitals and their affiliated clinics. Therefore, the continued evaluation of the extent to which hospitals and colleges of pharmacy collaborate in the education and training of pharmacy students is of critical importance to educators and practitioners alike.

Colleges of pharmacy are struggling to keep pace with health care changes and concomitant pharmacy practice initiatives. Transition to the entry-level PharmD program combined with a decrease in the number of inpatient beds has substantially increased demand for expanded PharmD clerkship sites. Furthermore, educators and practitioners alike realize that PharmD education requires that students be actively trained in the delivery of direct patient care pharmacy services. Both clinical sites and clinical pharmacists (or clinical specialists) are essential ingredients for quality pharmacy education. Unfortunately, at the same time that hospitals are decreasing their inpatient census there is an acute shortage of pharmacists, particularly in specialized clinical roles. The increased demand for clerkships created by more students coupled with the downsizing of hospitals and a shortage of clinical pharmacists create a constant pressure to evaluate clerkship sites.

The National Clinical Pharmacy Services Study is the largest hospital-based pharmacy database in the United States. It is a continuing project designed to assess the evolution of hospital-based clinical pharmacy services and track the direct patient care involvement of pharmacists. National studies conducted in 1989, 1992, 1995 and 1998 provide a longitudinal database for comparison(1-4). This paper presents the 1998 teaching hospital data and evaluates changes in pharmacy teaching hospitals over the last nine years. It is the last National Clinical Pharmacy Services Study conducted prior to the switch to the entry-level PharmD program for many colleges. Thus, this report provides baseline data for evaluating the clinical services available to meet the increased clerkship demands in the year 2000 and beyond.

METHODS

Detailed methodologies of the 1989, 1992, 1995, and 1998 studies were previously published(1-4). A questionnaire was mailed to the director of pharmacy in each of the acute care, general-medical surgical hospitals or acute care pediatric hospitals that had 50 or more licensed beds according to the respective (by year) American Hospital Association's (AHA) abridged guide(5). Specialty hospitals such as rehabilitation and psychiatric hospitals were not included.

Definitions of questionnaire terms and subsequent groupings used in the analysis are given in the Appendix. Data analysis was based on grouping hospitals by six factors shown to be associated with statistically significant variation in the provision of clinical pharmacy services. Rationale for selecting these six factors was published previously(1-4).

In this report, hospital teaching affiliation was assigned to one of four exclusive categories: (i) hospitals affiliated with a school/college of pharmacy PharmD program; (ii) hospitals affiliated with a BS (Bachelor of Science) in Pharmacy program only; (iii) hospitals without a college of pharmacy affiliation but affiliation with other health care teaching programs (nonpharmacy teaching); and (iv) hospitals without any affiliation with any health care education program (nonteaching). Hospitals affiliated with both BS Pharmacy and PharmD programs were categorized as PharmD affiliated hospitals; as provision of services between these two groups of hospitals was previously shown not to differ significantly(4). Membership in the Council of Teaching Hospitals (COTH) was determined from the AHA database(5) applicable for the respective study year.

The Health Care Finance Administration's (HCFA) Medicare Case Mix Index for the respective year was used to assess the severity of illness for hospitalized patient(1-4). The HCFA case mix index is a relative measure of severity of illness for Medicare patients. It is based on diagnosis-related groups for Medicare patients and compares each hospital's cost per case relative to a national average for a given year. The HCFA Medicare case mix index correlates well with a hospital's overall case mix for Medicare and non-Medicare patients. All data were reduced to a machine-readable format. The SPSS 9.0 release was used to perform the analysis(6). Statistical tests used included simple descriptive statistics, chi-square analysis, and one way ANOVA preceding Scheffe multiple pairs comparison of the means(7). The a priori level of significance for all tests was 0.05. The 1998 data are compared to 1995 data to aid the reader's understanding of recent trends. Data from the 1989 and 1992 studies are provided when a longer trend analysis may be helpful to the reader. A detailed pharmacy teaching hospital analysis was published previously for the 1992 and 1995 studies(8,9). As a similar paper was not published for the 1989 study, this paper required determining certain descriptive data from the archived 1989 electronic database.

RESULTS

General

Detailed teaching affiliation data was available for 950 acute care general medical surgical and pediatric hospitals through the 1998 survey. Respondents and nonrespondents did not differ by hospital size but did differ by geographic region and hospital ownership(4).

Of the 950 hospitals in the 1998 survey, 63 percent had a teaching affiliation with a college (or school) of pharmacy (defined as present if at least one student was trained in the hospital in the previous year). Among pharmacy college affiliated hospitals, 16 percent were a member of the COTH versus two percent of nonpharmacy teaching hospitals. This distribution was unchanged from 1995.

Of the 1998 hospital respondents that were affiliated with a college of pharmacy, 75 percent had a written plan for expanding clinical services or implementing pharmaceutical care. However, only 54 percent of hospitals without college of pharmacy affiliation had such plans. A written ethics code for pharmacists was required in 39 percent of all 1998 hospitals regardless of college affiliation; which increased from 31 percent in 1995. In 1998, pharmacists had the authority to make entries into the medical record documenting their clinical activities in 85 percent of college affiliated hospitals versus 70 percent of hospitals not affiliated with a college of pharmacy. In 1998, a medication error reporting system was operational in 96 percent of both college of pharmacy affiliated and hospitals without pharmacy college affiliation.

Table I shows the variation in 1998 hospital teaching affiliation by factors known to be associated with variation in the provision of clinical pharmacy services. PharmD programs predominately used a mix of small and medium-sized hospitals. BS Pharmacy programs had many more affiliations with small-sized hospitals than medium or large-sized hospitals.