Measuring outcomes of a pharmacist-run travel health clinic located ...

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From 1999 to 2009, approximately 290 million visits were made by U.S. citizens to overseas international destinations such as the European Union, the Caribbean, Asia, Central and South America, Oceania, the Middle East, and Africa. 1 The World Health Organization recommends that travelers “consult a travel medicine practitioner or physician four to eight weeks before departure in order to allow sufficient time for optimal immunization schedules to be completed.” 2 Despite this recommendation, many travelers do not seek the advice of their physician or other health care provider to learn about and protect themselves from otherwise preventable food-, water-, and vector-borne diseases before departure from the United States. Furthermore, approximately 22% to 64% of American travelers report some health problem that might have otherwise been prevented during travel (e.g., diarrhea, respiratory infections, dermatological conditions); however, less than 10% actually seek medical attention while traveling. 3 A survey conducted in 2004 indicated that only 36% of travelers sought travel health advice before departing the United States. Among individuals who did not seek advice, 22% did not perceive a need to do so, 20% did not perceive a risk At a Glance Synopsis: The current work describes the experiences of a pharmacist-run travel health clinic at an independent community pharmacy in southern California. Insight is provided into patient acceptance of pharmacist-made recommendations, reasons for refusal of recommendations, effect on self-reported understanding of travel-related issues, and satisfaction with the clinic. Among 283 patients, overall acceptance of pharmacist-made recommendations was 84.7%. The primary reason for patient refusal of a recommendation was self-perceived low risk for infection. A satisfaction survey among 82 patients found that 96% were satisfied with their overall visit. Patient satisfaction with the clinic and pharmacist services was correlated with overall patient acceptance. Analysis: The authors believe that this travel health service can be reproduced within other independent community pharmacies, especially when a strong collaboration exists among the travel clinic pharmacist, pharmacy store owner, and supervising physician. The highest rate of patient acceptance was for the yellow fever vaccine (96.8%), probably because the majority of patients in this clinic were traveling to yellow fever endemic areas within South America and Africa, for which yellow fever vaccination normally would be indicated and recommended. For independent community pharmacies to more broadly implement similar travel health clinics, further study of the costs associated with starting up and maintaining such clinics as well as their profitability is necessary. PHARMACIST-RUn TRAvEL HEALTH CLInIC SPECIAL FEATURE of illness at their travel destination, and 10% were too busy to either make an appointment or keep their scheduled appointment. 4 The results of this survey indicate that few Americans are aware of the medical issues that surround international travel and the need for protection against bothersome (e.g., travelers’ diarrhea, cutaneous larva migrans) and potentially fatal (e.g., yellow fever, malaria, rabies) travel-related diseases. Community pharmacists can play a vital role in patient education and disease prevention because of their high visibility and accessibility to the general public in local communities. In most states, collaborative practice laws exist that allow pharmacists to administer routine and travel-related vaccines and/ or to furnish medications to their patients under a physiciansupervised collaborative practice protocol. As a result, community pharmacies can offer a unique experience whereby patients can receive all necessary vaccines, oral medications, and other travel supplies, as well as in-depth patient education regarding their travel plans, in one clinic appointment. Properly marketed and advertised, community pharmacy–based travel health clinics may help to increase the overall percentage of individuals seeking travel health advice and may help to increase public awareness of the multitude of diseases that can occur during travel and the importance of preventing them. Hendricks Pharmacy is an independently owned community pharmacy that is part of the Good Neighbor Pharmacy Provider Network. It is located in and has been serving the needs of the greater Claremont, CA, area for more than 50 years. The clientele of the pharmacy consists largely of college students and retirees who use the pharmacy not only for its traditional dispensing, home delivery, and compounding services but also for receiving routine immunizations such as influenza, hepatitis B, and tetanus booster. In addition, the pharmacy offers screenings and patient education for common diseases such as diabetes, hypertension, and dyslipidemia. In July 2007, Hendricks Pharmacy established an international travel health clinic that follows a pharmacist–physician collaborative practice protocol. The clinic is located in a completely private area within the pharmacy and has all necessary supplies and equipment (e.g., syringes, sharps containers, biohazard waste containers, separate refrigerator/freezer with vaccines, computer with Internet access) contained in it to help facilitate patient care activities. Further, the clinic is adjacent to and has direct access to the main pharmacy and dispensing areas to help facilitate workflow between locations. This clinic usually cares for patients within a radius of 15 miles from the pharmacy, as the clinic is the only one of its kind in the immediate area; however, patients have come from as far away as 100 miles for care in isolated cases. After the pharmacist’s consultation in the travel health clinic, the patient’s insurance plan is billed for services rendered; however, most patients pay out of pocket because travel-related vaccines and medications are not generally covered by insurance. The international travel health clinic has been made visible in large part because of extensive marketing and promotion through in-store flyers and posters, mailed advertisements and letters, and physician detailing. J o u r n a l o f t h e A m e r i c a n P h a r m a c i s t s A s s o c i a t i o n www.japha.org M a r/apr 2010 • 50:2 • JAPhA • 175 175 3/1/10 12:49 PM
SPECIAL FEATURE PHARMACIST-RUn TRAvEL HEALTH CLInIC The pharmacist–physician collaborative practice protocol under which the clinic operates allows the pharmacists, community pharmacy residents, and student pharmacists at Hendricks Pharmacy to administer all necessary vaccines and to furnish appropriate travel-related medications to patients before their departure. In addition, the clinic is recognized as an official yellow fever vaccination center by the Centers for Disease Control and Prevention. The clinic’s director (K.M. Hess) completed a community pharmacy practice residency focused largely on travel health and is currently a full-time pharmacy practice faculty member who teaches in the area of immunizations and travel health. He also holds the Certificate in Travel Health (CTH) from the International Society of Travel Medicine (ISTM). According to ISTM, the CTH “recognizes individual excellence in knowledge in the field of travel medicine, associated with pre-travel care and consultation.” 5 The clinic is staffed with one to two pharmacists, two to three student pharmacists, and a community pharmacy practice resident; however, most consultations are done by K.M. Hess. The goals of this clinic are to help improve patient health status by educating patients about health and personal risks such as malaria, travelers’ diarrhea, and other non–vaccine-preventable diseases, as well as advising them on good health practices to prevent food-, water-, and vector-borne diseases while traveling. During the study period (July 2007 to October 2008), 283 patients were seen at this pharmacist-run travel health clinic for advice and recommendations regarding a variety of destinations ranging from Western Europe to Sub-Saharan Africa. The majority of the patients’ travel destinations were located within South America or Africa, where a need may have existed for vaccinating them against yellow fever. During this time period, more than 700 travel-related vaccines and medications were either administered or dispensed according to the clinic’s collaborative practice protocol. Few reports appear in the literature regarding pharmacist-run travel health clinics in the United States. Two previous studies described a pharmacist-run telepharmacy-based travel clinic service that predominately serves members of a large health maintenance organization. 6,7 Another study described the implementation of a pretravel health program within a local supermarket chain. 8 To our knowledge, no published study has evaluated patient outcomes and satisfaction associated with a pharmacist-run travel health clinic within the independent community pharmacy setting. Patient satisfaction with travel-related services provided by a primary care provider was evaluated in another study, which found that satisfaction was associated with receiving care in one location; however, no objective measurement of satisfaction was included. 9 Objectives We sought to examine the effectiveness of a pharmacist-run travel health clinic by analyzing patient acceptance and refusal rates to pharmacist-made recommendations, changes in patient understanding of travel-related issues, and patient satisfaction with this travel health clinic. Finally, we aimed to explore factors influencing these outcomes. 176 • JAPhA • 50:2 • M a r/apr 2010 www.japha.org Methods This study consisted of both a retrospective review of all patient records and a prospective survey of all patients who made appointments in the travel health clinic during the study period (from July 31, 2007, to October 31, 2008; n = 283). Institutional review board approval was obtained from the primary author’s institution. A retrospective review of patient records was conducted by analyzing all pharmacist-made recommendations that were logged into the clinic’s database, which is continually updated after each patient visit. This database contains information on each patient, including their age, gender, destination of travel, and all recommendations made by the pharmacist and acceptance or refusal of these recommendations by patients. All pharmacist-made recommendations were derived from a systematic evidence-based review of well-established, commonly used, and frequently updated Internet-based travel medicine programs (e.g., Travax, Tropimed, TravelCare) and from each patient’s specific travel itinerary obtained from their travel history form, which was submitted to the clinic before their scheduled visit. Patients obtained this travel history form by downloading it from the pharmacy’s website (www.hendrickspharmacy.com). Descriptive analysis of the retrospective data from patients seen at the travel clinic was conducted to determine the rate of acceptance of pharmacist-made recommendations per vaccination type and overall across all vaccinations. Acceptance was calculated as the ratio of number of administered vaccines to vaccines recommended by the pharmacist. Correlational analyses were conducted to test the likelihood that acceptance of one type of travel vaccine was related to acceptance of others. In addition, an exploratory survey was developed to help evaluate patient satisfaction with the services provided by the clinic, possible reasons for refusal of any recommendation made, and patient understanding of travel-related issues. Multiple-choice questions on a four-point Likert-type scale (1, strongly disagree; 2, disagree; 3, agree; 4, strongly agree) were used to determine patient understanding of travel-related issues and patient satisfaction with the travel health clinic. Openended questions were used to determine patient perceptions of the travel health clinic. The survey was reviewed by a panel for face and content validity and was initially administered by the investigators via phone from a private office during normal business hours between 9:00 am and 5:00 pm. Three separate attempts were made to reach patients by phone during this survey stage, which lasted for approximately 2 months. Patients who could not be reached by phone after three call attempts or who opted to take a written survey instead received their survey in the mail to complete at home. Patients who received a mailed survey were given approximately 2 weeks to complete it. All mailed surveys included a self-addressed stamped envelope. As an incentive for completing the survey, all respondents were enrolled in a drawing for one of six gasoline cards, each worth $50. Prospective data collected from patients via the survey were analyzed using descriptive statistics to obtain satisfac- J o u r n a l o f t h e A m e r i c a n P h a r m a c i s t s A s s o c i a t i o n 176 3/1/10 12:49 PM
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