A Renal Transplantation Advanced Pharmacy Practice Experience

Abstract

Objectives

To establish and evaluate an ambulatory care renal transplantation clinic advanced pharmacy practice experience (APPE).

Design

Students spend 5 weeks performing pharmaceutical care activities for renal transplant patients, presenting health-related topics, and conducting research. A paired t test was used to determine differences between students' pre- and post-APPE test scores. Standardized evaluations completed by the preceptor and the students were used to evaluate learning and the APPE.

Assessment

Posttest scores were significantly higher than pretest scores (n = 17; 88.2 ± 7.3 vs 55.9 ± 22.4; p < 0.001). Overall, students found this APPE enjoyable and believed that it increased their knowledge concerning transplant medicine and patient care.

Conclusion

With the recommendation that all transplant programs have clinical pharmacy services, it is imperative to train students to care for transplant patients. Information in this manuscript can be used as a guide for utilizing the combined resources from schools of pharmacy and transplantation centers to implement a renal transplant ambulatory care APPE.

INTRODUCTION

Renal transplantation is the preferred treatment of choice for many who suffer from end-stage renal disease. In 2003, approximately 15,140 individuals in the United States received a kidney transplant.¹ Because transplant patients often have several diseases, such as hypertension, diabetes, dyslipidemia, and infectious diseases, in addition to being immunocompromised due to immunosuppressant therapy, they take numerous medications. The typical renal transplant patient takes more than 10 different medications per day, and many of these medications have significant adverse effects and are associated with numerous drug interactions. Furthermore, renal transplant patients are particularly prone to non-adherence because of the number of medications they take, which, in most cases, are needed for the rest of the patient's life or as long as the individual has a functional graft.^2-5

There are approximately 250 renal transplant centers in the United States.⁶ Many of these centers have a pharmacist as part of their interdisciplinary team providing direct patient care services to renal transplant patients. Renal transplant patients who have a clinical pharmacist involved in their care have better health outcomes compared to patients who do not. For example, renal transplant patients who received clinical pharmacy services and traditional transplant clinic services had decreased healthcare cost and greater adherence to immunosuppressant therapy compared to those patients who did not receive clinical pharmacy services.^2,7-10 The cost of medications during the first year posttransplant was significantly lower for patients who had a clinical pharmacist involved in their care compared to those who did not ($13,033 vs. $15,726; p < 0.05), with patients seen by the clinical pharmacist having a mean total cost/charge of $2,614 less per patient than those who did not have clinical pharmacy services.¹⁰ Also, the mean 1-year immunosuppressant therapy adherence rate for patients seen by a clinical pharmacist was significantly higher than the adherence rate of those who did not have clinical pharmacist involvement (n = 24; 96.1% vs. 81.6%; p < 0.001).⁹ Since clinical pharmacists can have a positive impact on RTPs, it is important to provide appropriate APPE training for pharmacy students who may assume this role after graduation. In fact, the United Network for Organ Sharing (UNOS) recommends that all transplant programs have at least one clinical transplant pharmacist who is responsible for providing pharmaceutical care to solid-organ transplant recipients (see Table 1 for UNOS Specific Responsibilities of the Clinical Transplant Pharmacist).¹¹ Although the American College of Clinical Pharmacy (ACCP) has indicated that greater than 190 ACCP members have declared an interest in transplantation or immunology, less than half of the 190 are said to precept pharmacy students at their practice sites.¹² Since no published literature is available describing how to train pharmacy students during their APPEs concerning the care of transplant recipients, this manuscript provides a detailed description and evaluation of the Ambulatory Care Renal Transplantation Clinic APPE at the Medical College of Georgia. This manuscript presents a unique teaching-service model that may be used by schools of pharmacy and transplantation centers to increase educational/training opportunities for pharmacy students, provide faculty support for scholarship endeavors, and enhance transplant recipients' health outcomes through pharmaceutical care activities.

Table 1.

UNOS Specific Responsibilities of the Clinical Transplant Pharmacist¹¹

DESIGN

The Medical College of Georgia (MCG) is associated with a 483-bed teaching hospital that performs approximately 70 adult renal transplants per year and provides post transplant care for over 700 adults. This institution is one of the sites for University of Georgia APPE rotations.

Description of the APPE

During the last year of the pharmacy curriculum, students at the University of Georgia (UGA) complete 8 five-week APPEs. Five of the 8 APPEs are required courses in hospital pharmacy practice, community pharmacy practice, outpatient medicine, and acute medicine (2 APPEs). In addition, students complete 3 elective APPEs designed to increase the depth and breadth of knowledge acquired during their required courses and provide opportunities for individualized interests (examples of elective APPEs include nuclear pharmacy, acute medicine experiences, and compounding). The primary goals for APPEs are to assist students in developing practice skills and to refine professional behavior required for successful independent and collaborative pharmacy practice.¹³ Pharmacy students are selected for the Ambulatory Care Renal Transplantation Clinic APPE by either requesting the rotation or by assignment from the UGA Office of Experiential Learning. Although this APPE can be taken as an elective, it satisfies the outpatient medicine experience that is required.

Upon establishing the Ambulatory Care Renal Transplantation Clinic APPE, it was important to gain the support of all stakeholders, including the Director of Transplant and the Chief Transplant Nephrologist at MCG. Several meetings were held with the nephrologists, nurses, and clinical pharmacist to discuss the role of the pharmacy student, which is to learn as much about transplant medicine and patient care as possible. Healthcare professionals were told that they could ask the student any medication-related questions and were to view the pharmacy student as part of the transplant healthcare team. Furthermore, the clinical pharmacist understood that as he felt each pharmacy student gaining confidence and was confident that the student was ready to assume the responsibilities of patient care, he could let the student provide care to patients in a more independent fashion. However, the student would still have to review each patient care recommendation with the clinical pharmacist, the preceptor, or the nephrologists before implementing the recommendation.

The preceptor for the Ambulatory Care Renal Transplantation Clinic APPE at MCG is a transplant pharmacist who is an associate professor at UGA's College of Pharmacy. To effectively utilize the resources available from MCG and UGA's College of Pharmacy, it was essential to establish clinical pharmacy transplant services that accomplished the patient care needs of the MCG transplant center while simultaneously fulfilling the teaching, service, and research needs of UGA (and the UGA faculty member). Due to the uniqueness of the position and to meet the multiple expectations from both institutions (UGA and MCG), the preceptor, along with the support of the Chief of Transplant at MCG, sought extramural grant funding to pay for the salary of the clinical pharmacist. In 1997, grants paying for the clinical transplant pharmacist position were secured. The principal investigator was the preceptor of the rotation, and preceptor's responsibilities included implementing clinical pharmacy transplant services, educating pharmacy students in transplant medicine, and conducting transplant (medical) research studies. The Ambulatory Care Renal Transplantation Clinic APPE experience was established in 1999. As of 2005, the transplant clinical pharmacy services continue to be funded by grants obtained by the preceptor (faculty member).

Due to the small working area and the intensity of student training, only one pharmacy student at a time is assigned to the APPE. This allows for optimal direct patient care experience and preceptor time with the student. The clinical pharmacist in the Renal Transplant Clinic is available during clinic time (clinic time is 4 days a week for 4 hours per day). The clinical services provided by the pharmacist include obtaining medication histories, and reviewing patients' examination data and medication regimens with an emphasis on optimizing medication therapy to achieve desired outcomes and minimizing adverse medication events. The clinical pharmacist also promotes patients' medication adherence by educating them concerning their medication therapy and how to properly take their medications, and serves as a drug information source for transplant team members by providing pharmacotherapy recommendations to the nephrologists with the goal of achieving the desired patient health outcomes.^8,9

Both the clinical pharmacist and the preceptor train pharmacy students during the Ambulatory Care Renal Transplantation Clinic APPE to perform pharmaceutical care services for renal transplant patients. Specifically, students are taught how to properly obtain a medication history from a patient and optimize desired outcomes. Since renal transplant patients are prone to medication non-adherence, students are trained to detect non-adherence via patient interviews, performing pill counts, reviewing pharmacy dispensing records, and monitoring drug concentrations in blood. The student works with an interdisciplinary team of healthcare professionals including nephrologists, nephrology fellows, pharmacists, nurses, social workers, and personnel from the Medication Access Program (MAP). MAP is a statewide network whose objective is to increase medication adherence by increasing access to medications for solid-organ transplant patients residing in Georgia. The preceptor of this APPE is the Founder and Director of the program. MAP has expertise in increasing transplant patients' access to medications by enrolling them in programs that provide medication assistance such as Medicaid, Medicare (Medicare pays for 80% of outpatient immunosuppressant therapy for patients who qualify), pharmaceutical companies' medication assistance programs, Medicare-approved drug discount cards, and various other programs. A large portion of the renal transplant patients from MCG is receiving MAP services.

The APPE Schedule

Week 1

The goal of the first week of the APPE is to get the student acclimated to the transplant clinic environment. The Ambulatory Care Renal Transplantation Clinic APPE requirements, grading system, and student responsibilities are reviewed during the students' orientation (reviewing APPE syllabus) on the first day of the APPE. On day 1, the student takes a 10-question pretest to assess his/her knowledge base about transplant medicine. Although the test is graded, the grade achieved on this test is not considered a part of the APPE grade. After taking the test, the student is introduced to the transplant team and, at the end of day 1, the student receives an assignment to (a) review their therapeutics textbook concerning renal transplantation, and (b) make a list of goals that he/she wants to achieve (or at least work on) during this APPE.

Day 2 is the first day that the student is in clinic. The preceptor spends the entire day with the student in clinic, where the student observes the preceptor while the preceptor performs pharmaceutical care activities. Usually by the end of the clinic, the student is performing medication histories and the healthcare team members begin asking the student medication-related questions. After each clinic (starting with day 2), the majority of the student's time is spent following up with patients who were seen earlier in clinic and assessing important laboratory findings that are available after clinic hours (clinic hours are 8:00 AM - 1:00 PM daily). In the afternoons (1:00 PM - 4:00 PM), starting with day 2, the student works closely with the nephrologists, nurses, and clinical pharmacist in adjusting patients' immunosuppressant therapy doses, and calling in prescriptions to pharmacies. The student calls those patients whose medication doses were changed after their clinic visit to provide new instructions for taking their medications. From 4:00 PM - 5:30 PM, the student and preceptor review common medications used in renal transplant patients and reading materials assigned to the student on day 1 of the APPE. At this time, the student also reviews his/her APPE goals with the preceptor. The preceptor helps the student identify achievable goals and promises to work with the student to help achieve those goals during the 5-week experience. Examples of goals that have been stated by several students include: (1) increasing their ability to multitask; (2) improving presentation skills; and (3) enhancing interaction skills with other healthcare professionals.

On days 3-5, the student meets with the transplant clinical pharmacist and attends clinic. The clinical pharmacist imparts as much knowledge as possible to the pharmacy student about how to care for renal transplant patients. The afternoons of the student are spent following up with patients. The latter part of the afternoon (approximately 2 hours each day) is spent with the preceptor discussing various topics and presenting patient cases (see Table 2). Patient case presentations involve reviewing, in a systematic format, a patient that the student has seen in clinic (a sample renal transplant patient case is available upon request from the author). This includes discussing the patient's chief complaints/problems, present and past medical histories, medication list, clinic and laboratory findings, medication monitoring parameters, and the student's assessment of the patient's drug-related problems; identifying and resolving drug-related problems; and developing a pharmaceutical care plan.

Table 2.

The Ambulatory Care Renal Transplant Clinic APPE Schedule

*Student orally presents at least one renal transplant patient to the preceptor each day

Week 2-Week 3

These 2 weeks are dedicated to increasing the student's knowledge and skills concerning: (1) performing pharmaceutical care to renal transplant patients; (2) patient presentations; and (3) increasing patients' access to medications. The clinical pharmacist attends clinic with the student and as the pharmacist feels more comfortable with the student's skills, he allows the student to provide pharmaceutical care to patients more independently. Over the course of these 2 weeks, the student has at least 5 sessions during which he/she presents over 10 different renal transplant patient cases to the preceptor. The student also reviews with the preceptor a variety of disease states and how to medically treat/manage these diseases, such as hypertension, diabetes, dyslipidemia, and various infectious diseases that are commonly seen in transplant patients. The student spends time with a MAP member who teaches the student about common resources used to increase transplant patients' access to medications. All students are required to do a project during this APPE and present that project to the transplant healthcare professionals at MCG. The student is involved with study design, data collection, and various parts of the analysis of the project. An abstract of a project that an APPE student helped to conduct is available upon request from the author. Refer to Table 2 for specific activities for week 2 and 3.

Midpoint Evaluation

Students receive feedback from the preceptor throughout the APPE; however, written evaluations of the student by the preceptor occur at the midpoint (2.5 weeks into the experience) and last week of the APPE. A standardized evaluation form that is required by the Office of Experience Programs at UGA is used for this evaluation and is available upon request from the author (the evaluation form utilizes aspects of Bloom's Taxonomy of Educational Objectives, with the highest level of learning at the “evaluation” category and the lowest level of learning at the “knowledge” category).¹⁴ By the end of the second week, the preceptor has met with the transplant team and has gathered information about the performance of the student's delivery of patient care. This information, along with the preceptor's assessment of the student's skills and knowledge base, is used as part of the formal midpoint student evaluation that occurs during the middle of the third week. The student is also asked for feedback on the experience during the third week concerning whether he/she is achieving his/her goals for the APPE. By identifying these deficiencies, the course may be tailored, in a manner that does not sacrifice the quality of the APPE, to help the student meet his/her goals.

Week 4-Week 5

The student spends a large portion of the last 2 weeks of the Ambulatory Care Renal Transplantation Clinic APPE providing pharmaceutical care to transplant patients and working on his/her project. The student continues to meet with the preceptor in the afternoons after following up with patients seen in clinic. During weeks 4 and 5, a significant amount of the preceptor-student time is spent discussing the project that the student is conducting. The student has to have the project completed by the end of the fifth week, and then presents the project to the transplant and MAP team during the last week of the APPE. On day 25, the student attends transplant clinic in the morning, and the transplant personnel usually take the student to lunch, as it is the last day of the APPE. Later that afternoon, the student is given a written transplant examination. Immediately after completing the test, it is graded and reviewed with the student along with the preceptor's final evaluation of the student's performance while on this APPE.

ASSESSMENT

Evaluation of Learning

On the first day of their APPE (prior to seeing patients and reviewing renal transplant pharmacotherapy), students on the Ambulatory Care Renal Transplantation Clinic APPE took a pretest concerning the medical management of renal transplant patients. At the end of the APPE (last day), students took a posttest assessing their knowledge concerning medication therapy of renal transplant patients. To limit the concern of grading bias and for ease of grading, both tests were fill-in-the-blank format. All tests were graded by the preceptor, documented, and reviewed with each renal transplant APPE student. All pretest and posttest scores were entered in Microsoft Excel (version 8) and then downloaded into SPSS (version 11.08) for analyses. A paired t test was used to detect any differences between the pretest and posttest scores. An alpha priori level of 0.05 was used. Posttest scores were statistically higher than pretest scores (n = 17; 88.2 ± 7.3 vs 55.9 ± 22.4; p < 0.001). Students who had completed 4 APPEs or more had greater pretest scores than students who had completed less than 4 APPEs prior to taking the Ambulatory Care Renal Transplantation Clinic APPE (p < 0.05); however, there were no differences in posttest scores between these groups. Using the standardized evaluation form, students are formally evaluated twice during the APPE. The first is the midpoint evaluation. The second is the formal evaluation during the fifth and final week of the APPE. The same standardized form is used for both evaluations to allow the student to see his/her progress over the APPE. The grade that the student achieved on the project is also included in the final evaluation and is used to calculate the student's final grade in the APPE.

Evaluation of the APPE

Each student completes a formal clerkship/preceptor evaluation form for each APPE. The mean and standard deviations for each of the items on this evaluation for this APPE from 1999 to 2004 are provided in Table 3. With the exception of community and hospital practice experiences, the mean score for all APPEs conducted in 2003 is provided. Only direct patient care experiences are included, as they have greater similarities to the Ambulatory Care Renal Transplantation Clinic APPE as compared to other experiences such as community pharmacy. Overall, students found this APPE experience enjoyable and indicated that it increased their knowledge of renal transplant medicine and patient care (Table 3).

Table 3.

Means of Items on the APPE Evaluation Form^*

^*Evaluation form used to evaluate all APPEs, except community pharmacy practice and hospital pharmacy practice experiences (another form is used to evaluate these two experiences)

^†Responses based on a Likert-type scale ranging from 1-5, on which 1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree

Obstacles and Barriers of Developing this APPE

Since this document may be used by others as a template for developing an ambulatory care renal transplant APPE or for developing a rotation that utilizes extramural funding to finance clinical pharmacy services, student training, and research, it is important to discuss obstacles and how they were resolved or minimized. See Table 4 for a listing of the top 4 challenges and resolutions to these barriers.

Table 4.

Important Challenges Encountered and Resolutions Found for a Renal Transplant APPE

SUMMARY

One of the educational outcomes developed by the Center for the Advancement of Pharmaceutical Education (CAPE) includes pharmacy students being able to design, implement, monitor, and adjust pharmaceutical care plans that are patient-specific and evidence-based. Furthermore, students should be able to “communicate and collaborate with prescribers, patients, caregivers, and other involved healthcare providers to engender a team approach to patient care.”¹⁵ The Accreditation Council for Pharmacy Education (ACPE) also supports these outcomes.¹³ APPEs provide pharmacy practice faculty members with the opportunity and environment to teach pharmacy students how to perform pharmaceutical care and interact with other healthcare professionals in addition to pharmacists. The Ambulatory Care Renal Transplantation Clinic APPE provides a unique experience that allows students to use information that they learned from their therapeutics (didactic) lectures. It also allows students to build their knowledge of disease state management and provides the opportunity for students to provide patient care. This manuscript briefly describes how the Ambulatory Care Renal Transplantation Clinic APPE was created at the Medical College of Georgia and presents evidence of student learning. Also, the manuscript describes a unique collaborative approach to establishing a “win-win situation” for a patient care center and college of pharmacy by providing patient care services, student education and training, and faculty support. This manuscript should be used as a guide for other institutions considering implementing an ambulatory care renal transplant clinic experience to train doctor of pharmacy students.