Pharmacist interventions, formulary conversion tools, and warfarin discharge education take top honors at annual seminar

Studies of pharmacist interventions during comprehensive medication reviews, the impact of new tools to aid drug selection from a hospital formulary, and a project ensuring that hospital patients receiving anti-clotting drugs are properly educated upon discharge took top honors at the Department of Clinical Pharmacy 17th Annual Spring Research Seminar.

The poster session, covering a total of 34 projects and highlighting research by UCSF School of Pharmacy student pharmacists, residents, and faculty members, was held on April 27, 2015, on the Parnassus campus.

Rifkind Award winners

Winners of the 8th Annual Gary Rifkind Spring Research Seminar Awards are:

Student pharmacists

Anh Doan, PharmD; An-Chi Tseng, PharmD; and Lily Xia, PharmD (all class of 2015); for “Pharmacist Interventions from Comprehensive Medication Reviews.”


Clara Mikhaeil, PharmD, for “Impact of a formulary alternative clinical decision support tool on inpatient medication prescribing and discharge orders.”


Heidemarie MacMaster, PharmD, volunteer faculty member in the Department of Clinical Pharmacy and UCSF Medical Center Diabetes Management Specialist, for “Evaluation of the Efficacy and Safety of Venous Thromboembolism Prophylaxis Protocol.”

The Rifkind Awards of $1,000 each were created to recognize and inspire clinical pharmacy research. They are the gift of School of Pharmacy alumnus Gary Rifkind, PharmD, ’60.

Analyzing interventions from medication reviews

The poster lead-authored by Doan, Tseng, and Xia evaluated the impact of comprehensive medication reviews (CMRs) on patient care by analyzing data from the UCSF MedList Clinic—a recently created service in which pharmacists, pharmacy residents, and supervised student pharmacists conduct phone or in-person interviews with high-risk patients recently discharged from the hospital, patients referred by physicians, or patients attending community outreach events.

Other studies have shown the value of such pharmacist consultations in hospitals, nursing facilities, and after discharge in reducing drug-related problems, costs, and re-admissions. But few studies have detailed the specific types and frequencies of the interventions pharmacists make in patients’ regimens during CMRs, such as the new UCSF pharmacy service.

The results: Using data collected on 113 patients who underwent CMRs via the UCSF MedList clinic, Doan et al. found that 228 drug-related problems were identified—or an average of about two per patient. The pharmacists found 25 cases of drug-drug interactions, 41 issues of adherence (difficulties in following a regimen), 49 adverse drug events (side effects), and 108 cases where prescribed drugs or their doses were not deemed appropriate and/or effective. Those findings led to direct communication with the patient about medication problems in 90 percent of the cases and communications with their primary health care providers in 76 percent of the cases.

The authors noted that future studies are needed to evaluate the impact of these pharmacist communications on patient health and economic outcomes, as well as whether primary health care providers accept the interventions.

Assessing the impact of a formulary alternative tool

The study by Mikhaeil and colleagues evaluated the impact of a new electronic alert integrated into the computerized drug ordering system at UCSF Medical Center in April 2014. One of various clinical decision support (CDS) tools, the alert was specifically meant to help prescribers find a drug among those selected to be kept on hand at the hospital—a list known as a formulary—that is therapeutically equivalent to the medication a patient being admitted is already taking. To that end, the new CDS tool includes conversion tables that allow providers to order the equivalent doses of an alternative medication from the medical center formulary.

The study assessed the four medication classes for which the new alert was implemented, including two that treat high blood pressure (ACE inhibitors, angiotensin receptor blockers), one that reduces stomach acid production (proton pump inhibitors), and one for lowering cholesterol (statins). Mikhaeil et al. analyzed nearly 6,000 medical center medication orders for those classes of drugs during six-month periods before and after the implementation of the new CDS tool.

The results: The study found the formulary alternative alert did not increase prescribers’ formulary adherence (about 8 percent of ordered drugs remained non-formulary requests, the same as before). However, before the new CDS tool was added to the system, 47 percent of medication orders were appropriately converted (correct dose and frequency) from the patients’ prior-to-admission medication to a hospital formulary option, whereas after its implementation, 62 percent were appropriately converted to the formulary drugs—a significant improvement.

Standardizing warfarin discharge education

For a variety of reasons, hospital patients can be at increased risk for blood clots in the deep veins of the legs. Such clots can break loose into circulating blood, becoming a venous thromboembolism (VTE) that can then cause damaging and life-threatening blockages of arteries in the lungs.

However, such VTEs are largely preventable and treatable through the use of anti-clotting (anticoagulant) medications—including warfarin, the most commonly prescribed such drug—both during and after a hospital stay.

In 2013, the U.S. Centers for Medicare and Medicaid activated six core measures aimed at reducing VTEs and improving outcomes. At UCSF Medical Center, a multidisciplinary workgroup was formed the same year to improve VTE-related patient care by achieving 100 percent compliance on applicable measures, including the education of patients being discharged from the hospital on the continued safe and effective use of warfarin—the only measure where the institution did not consistently meet the mark.

The poster by MacMaster and colleagues detailed how the workgroup analyzed gaps in workflow and assigned roles for identifying affected patients, educating them at discharge, and documenting that work. Interventions included standardizing teaching points and printed materials given to patients to be comprehensive and to comply with new regulatory language on issues ranging from dietary advice for maintaining warfarin’s effects, to the need for its monitoring via blood tests, to warfarin’s potential interactions with other drugs.

The results: Beyond updating patient education materials, the patient care improvement project combined reeducation of pharmacy and nursing staff with timely review of noncompliant cases leading to follow-ups and clarifications with staff. Documentation of patient education was standardized and moved from paper to the electronic medical record. Roles were delineated: Pharmacists and student pharmacists would take the lead in identifying, educating, and documenting, while nurses would serve as a safety net for warfarin patients being discharged without documented education.

Over several months in late 2013, UCSF Medical Center compliance with this VTE core measure increased to 100 percent. It has since been sustained as measured by pharmacist post-discharge audits and via follow-up with those patients found to have incomplete documentation of their warfarin education.


School of Pharmacy, Department of Pharmaceutical Chemistry, Department of Bioengineering and Therapeutic Sciences, Department of Clinical Pharmacy, PharmD Degree Program

About the School: The UCSF School of Pharmacy aims to solve the most pressing health care problems and strives to ensure that each patient receives the safest, most effective treatments. Our discoveries seed the development of novel therapies, and our researchers consistently lead the nation in NIH funding. The School’s doctor of pharmacy (PharmD) degree program, with its unique emphasis on scientific thinking, prepares students to be critical thinkers and leaders in their field.