Connecting Pharmacists and Other Health Care Providers (HCPs) towards Drug Therapy Optimization: A Pharmaceutical Care Approach

Background Pharmaceutical care services offered by pharmacists rationalize drug therapy, improve patient quality of life, and save patients' lives. This study was designed to optimize patient drug therapy through pharmaceutical care services offered by a pharmacist in consultation with other health care providers (HCPs) at a tertiary care hospital. Methods This descriptive study was conducted to assess the role and effectiveness of pharmacists in optimizing drug therapy outcomes. The study was carried out at an internal and pulmonary medicine unit of a tertiary care hospital in Srinagar, Jammu and Kashmir, India, with a total of 50 health care providers (HCPs) (24 doctors, 16 nurses, and 10 pharmacists). A total of 182 patients (males and females) of all age groups were recruited into the study over a period of nine months. Patient-specific pharmaceutical care plans initiated by the pharmacist based on drug therapy-related needs and problems were used to address and optimize drug therapy outcomes in consultation with other HCPs. Results A total of 388 drug-related problems (DRPs) with an average of 2.29 DRPs per patient were identified, for which 258 pharmaceutical care plans as interventions were proposed, out of which 233 (90.31%) were accepted and implemented. Preassessment and postassessment by HCPs on services rendered by the pharmacist showed a positive change in attitude among HCPs with respect to their endorsement and acceptance of the pharmacist's services in providing direct patient care. Conclusions Pharmaceutical care services offered by pharmacists helped in optimizing drug therapy and patient care.


Introduction
Clinical pharmacists are specially trained practitioners who provide direct patient care by ofering services like pharmaceutical care [1]. Pharmaceutical care is the direct, responsible provision of medication-related care wherein the pharmacist works in collaboration with other HCPs and patients to optimize drug therapy outcomes [2,3]. Te concept of care, therefore, emphasizes establishing relationships with other HCPs and patients to achieve desired drug therapy outcomes. However, this concept of care can only be achieved if pharmacists and other HCPs agree on each other's roles because the perceptions of HCPs regarding the pharmacist's role can reduce the level of their cooperation [4,5]. As the number of pharmacists rendering clinical services per occupied bed increases, mortality, drug costs, total costs of care, and length of stay decrease [5,6]. Te clinical and economic outcomes from a group of patients who received pharmaceutical care showed that, upon frst assessment by the pharmaceutical care practitioner, more than ffty percent of the patients had one or more drug therapy problems identifed and resolved. Moreover, the healthcare savings realized from pharmaceutical care were found to be huge [7,8]. At the time of this study, there were no data available in published literature barring one study [9] on pharmacist-led services or interventions ofered at any public health facilities in the region of Jammu and Kashmir. Tis concept has yet to take of in any of the healthcare facilities here, and pharmacists are still viewed as mere drug dispensers by patients and other HCPs alike. Given this dismal scenario, a beginning was made by this study to highlight the role of pharmacists working with other HCPs in providing direct patient care at a tertiary care hospital.

Study Design.
Tis descriptive study was carried out for a period of nine months at an in-patient department of a tertiary care hospital in Srinagar, Jammu and Kashmir state, India. Te study was conducted to assess the role and efectiveness of pharmacists in optimizing drug therapy outcomes.

Study
Population. Study population included HCPs and patients of the super specialty respiratory medicine unit of the study hospital.

Inclusion Criteria.
All patients, including both males and females, belonging to all age groups, admitted to the internal and pulmonary medicine units, and having consented to participate, were included in the study.

Methods.
At the outset, a preassessment of the HCPs in the study unit was conducted to determine their attitudes and perceptions toward the role of pharmacists in providing direct patient care. Te assessment was conducted using a self-administered, prevalidated questionnaire that was internally developed and validated using Delphi and the feld pretest method [10,11].
Following this, a patient-specifc continuous assessment by the pharmacist was carried out on a daily basis. All medical and medication information was collected by the pharmacist through patient/caregiver interviews, patient case notes, medication charts, and laboratory data. Patientspecifc data were assessed, and all drug therapy-related needs and problems were identifed and classifed using PCNE criteria. Tose drug-related needs and problems identifed through the assessment fndings were presented, discussed, and validated by attending HCPs. To manage patients' medical conditions, pharmaceutical care action plans were developed by the pharmacist in consultation with the attending physician, which included interventions to address patients' drug-related needs, resolve drug therapy problems, and achieve the goals of therapy. Te pharmacotherapy interventions included initiating new drug therapy, discontinuing existing drug therapy, changing the product and/or dosage regimen, and patient education. All interventions were adopted, implemented, followed, and documented in accordance with the revised criteria provided by the Pharmaceutical Care Network Europe and the American Society of Health-System Pharmacists [12,13].

Ethical Standards.
Necessary ethical clearance was obtained from the Institutional Ethics Committee vide reference number SIMS 131/IEC-SKIMS/11-4579. All volunteers were educated about the purpose of the study.
2.6. Statistical Analysis. Data were analyzed using SPSS version 24. Descriptive analysis was done using means. A Student's t-test was used to evaluate prepharmacist and postpharmacist-led interventions in attitude and perception scores.

Results
A total of 182 patients and 50 HCPs from the study unit were included in the study. Most patients (53.8%) were aged between 60 and 70 years, and most HCPs were doctors (Table 1). Te prepharmaceutical care services assessment revealed that there is a lack of knowledge and negative attitudes and perceptions among HCPs about pharmacy and a pharmacist's role in improving patient health, reducing medication errors, rendering patient counseling, and providing drug information. Only 12% of HCPs agreed that clinical pharmacy services will improve patients' health, and only 10% agreed to accept the involvement of pharmacists in the drug and disease management of patients.
Services like pharmaceutical care, patient counseling, and drug information were not rendered prior to this study ( Table 2). Te patient-specifc assessment revealed that a total of 1260 medications were prescribed for 182 patients, with an average of 6.92 drugs per patient. Antibiotics were identifed as the most prescribed drugs at 34.36%, followed by proton pump inhibitors (PPIs) at 21.17% ( Figure 1). A total of 388 DRPs in 182 patients were identifed, with an average of 2.29 DRPs per patient. Patient-specifc health-related problems were mainly associated with the drug use process (Table 3). All drug-related problems encountered and all drug-related needs identifed during the assessment were addressed, and corresponding action plans were imparted in consultation with the attending physicians and nurses. For the 388 DRPs, 258 interventions were proposed, out of which 230 interventions were accepted and imparted.
A total of 65 interventions were imparted at the patient level, 75 at the prescriber level, and 93 at the drug level (Table 4). Among the drug-related needs of study patients, gastric discomfort, hypokalemia, tachycardia constipation, and oral fungal infections were the most common conditions requiring therapeutic interventions (Table 5). Postassessment by HCPs of services rendered by the pharmacist in providing direct patient care revealed the services to be

Discussion
Trained pharmacists are best suited to assist HCPs and patients in the prevention of drug-use problems and to achieve optimal and desired outcomes from drug intake [14]. In developing countries, irrational prescribing, dispensing, and administration practices have long been reported [15][16][17][18]. Our study provided some insight into the use of medicines by HCPs and patients, including factors afecting drug therapy outcomes. Several published studies have reported the existence of a communication gap between pharmacists and doctors [19,20] and that the acceptance of pharmacists providing direct patient services is dependent on physician perceptions of pharmacist competence [18,21,22]. Pharmaceutical care services rendered through our study were designed to bridge the existing gaps among HCPs and patients so that efective communication is utilized, managed and coordinated care is delivered, and drug therapy outcomes are improved. Drug administration-related errors, including patient noncompliance, accounted for the largest proportion (33.76%) of observed DRPs. Factors that could be responsible for such errors include communication defcits among HCPs and patients, a lack of knowledge, inadequate manpower, and a lack of time to counsel patients. It has been reported that pharmaceutical care appears to increase patient awareness about medication side efects [23]. Te present study proposed 258 pharmacist-led interventions, out of which 233 interventions were accepted and implemented. Physicians who collaborate with pharmaceutical care practitioners have validated the work of the practitioners, and patients are also recognizing the benefts of pharmaceutical care [24,25]. In these ways, pharmaceutical care intervention has stimulated greater involvement with the health care system, thus increasing utilization and improving the quality of patient care.
Tis study marked the beginning of pharmaceutical care services being ofered by a trained pharmacy practitioner. As evident from the results, 80% of HCPs agreed that all necessary and important services under pharmaceutical care were rendered at the patient and prescriber levels. Moreover, 100% of the participants agreed that, as a healthcare team, they do accept the involvement of pharmacists in drug and disease management. Given the changing role of pharmacists and pharmacy automation, physicians need to be proactive and fnd new ways of collaborating with pharmacists to enhance patient safety and care. Working directly with pharmacists, particularly in medication errors, is one way to do that. When physicians, pharmacists, and patients share responsibility for care, powerfully good results are obtained [26][27][28][29].
Pharmaceutical care is a much-needed service, especially in our setting, and therefore it is high time to recognize the need for and importance of implementing such services on the ground. Te present scenario in Jammu and Kashmir state, characterized by heavy doctor workloads, defcits in providing drug information, education, and counseling services to patients, and increased use of drugs, is ripe for trained pharmacists to play greater roles, and one such avenue is by ofering pharmaceutical care services at both clinical and community levels.

Strengths and Limitations.
Our study was the frst of its kind in the entire state of Jammu and Kashmir and tried to introduce the concept of pharmaceutical care in a hospital for the frst time on a pilot scale. However, our study had several limitations, and therefore, further research is warranted to fll the identifed gaps. Te study was conducted for a brief period of nine months and was restricted to specifc patients of one hospital; therefore, the results and interpretations are limited to the study hospital only. Te inclusion of these services in other hospitals would have increased the number of both interventions and outcomes. Disease outcome measures and patient followup after discharge were not included in the study because of time constraints. Additionally, the costs, quantitative preventability, and predictability of DRPs were not measured.

Conclusion
Pharmacist-led pharmaceutical care services were rendered for the frst time at the study hospital. As evident from the results, pharmacist-led interventions helped in the optimization of drug therapy through coordinated care with other HCPs. With better professional services and skills, pharmacists can become more acceptable to other HCPs as an integral part of the healthcare team. Healthcare facilities in the developing world need to keep pace with fast-changing trends by establishing departments of clinical pharmacy and involving pharmacists in medical ward rounds so that drugrelated problems can be minimized, patients' drug-related needs can be addressed in a better manner, patients can be counseled on their prescribed therapies, and the clinical outcomes of treatments can thereby be maximized.

Data Availability
Data are available upon request to the corresponding author.

Conflicts of Interest
Te authors declare that they have no conficts of interest.