American College of Clinical Pharmacy
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ACCP Report - November 2019

President's Column

Extending the Frontiers of Practice, Interprofessional Collaborations, and Research

Written by Brian L. Erstad, Pharm.D., FCCP, BCPS


Although ACCP’s mission and vision statements do not use the term interprofessional, it is clearly inferred by ACCP’s mission statement, which references partnerships, collaborations, and alliances, and by its organizational vision statement, which refers to practice in patient-centered, team-based settings. Similarly, the updated version of ACCP’s strategic plan unveiled in 2017 refers to collaborations with other health professionals, patients, and interprofessional groups. As the medication experts, clinical pharmacists can assume indispensable responsibilities on the interprofessional health care team. This was reflected in the themes of Presidents Buck, Kolesar, and Nesbit, titled “Interprofessional Collaboration: From Theory to Reality,” “Implementing Interprofessional Precision Medicine,” and “Medication Optimization Across the Care Continuum,” respectively. During my presidential year, I intend to expand on this interprofessional focus with my theme, “Extending the Frontiers of Practice, Interprofessional Collaborations, and Research.”

In particular, I want to increase ACCP’s outreach to health professions organizations and associations that are interested in fostering interprofessional collaborations, partnerships, or alliances. This aspect of my theme most applies to the third priority of ACCP’s strategic plan, positioning clinical pharmacists for success. This priority states that “ACCP will position clinical pharmacists by (1) developing and contributing to evidence-based guidelines that influence practice and (2) communicating and disseminating the value of clinical pharmacists in achieving medication optimization.” I envision a future in which every clinical practice guideline with substantive recommendations on medications is developed with a clinical pharmacist’s involvement.

Similar to many of my clinical pharmacist colleagues, I have used recommendations from clinical practice guidelines in my practice and embraced the term evidence-based without hesitation. However, as discussed in videos of interviews with past and current leaders in the evidence-based movement, the concept generated much controversy in the field of medicine even before introduction of the phrase “evidence-based medicine” in a 1992 paper by Gordon Guyatt.1 This controversy is exemplified by a sarcastic publication purporting to perform a systematic review of randomized controlled trials to determine whether parachutes were effective in preventing major trauma.2 Some critics have gone even further in their criticism of evidence-based clinical practice guidelines.3

Regardless of such criticism, I think it highly unlikely that the number of evidence-based clinical practice guidelines will wane in the near future. Therefore, I welcome ACCP’s focus on this priority. For ACCP members who are not experienced in developing clinical practice guidelines, this will require education and training that includes evidence assessment. Prestigious nongovernmental organizations such as the National Academy of Medicine (NAM) recommend a critical appraisal of evidence during the development of clinical practice guidelines. NAM has published eight standards pertaining to the development of clinical practice guidelines, two of which explicitly refer to use of evidence.4 NAM standard 3 refers to training in the appraisal of evidence for patient and consumer representatives on guideline development committees, and standard 5 refers to establishing evidence foundations and rating strength of recommendations. Although NAM has not recommended any particular system for evidence evaluation, the Grading of Recommendations, Assessment, Development, and Evaluation (or GRADE) working group has developed an approach to grading the quality of evidence and strength of recommendations often used by professional health care organizations involved in guideline development. As with evidence-based medicine and clinical practice guidelines, the GRADE approach has its critics, and limitations of GRADE methods have been published.5 Nevertheless, widespread use of the GRADE methods makes it important that clinical pharmacists understand the basic tenets of the system and that ACCP members involved in guideline development have more extensive training in using these methods. Similarly, the movement to systematically spread and improve the use of guidelines in routine practice will require the training of some ACCP members in the emerging field of implementation science. I am confident that ACCP’s organizational leadership and member involvement will only enhance the quality of future clinical practice guidelines and their appropriate implementation.

I was ACCP’s committee liaison to the 2017–2018 Public and Professional Relations Committee, which was charged with “providing recommendations to the Board of Regents on methods to increase the number of ACCP members actively engaged in the work of national guideline panels, consensus conferences, and similar expert interprofessional task groups.” Both individual members and PRNs were consulted to determine the extent of current member involvement and suggestions for increasing future member involvement. In its deliverables relative to the charge, the committee quantified the extent of ACCP member involvement in national guidelines and panels and listed known or perceived prerequisites for such involvement. The 2017–2018 Public and Professional Relations Committee report provides the background information needed to extend ACCP’s current outreach activities to groups that currently do not have clinical pharmacist involvement, but should. Moreover, we must be selective in our engagement, given that interorganizational collaborations require resources, particularly in the form of staff time. Recommendations from the 2017–2018 Public and Professional Relations Committee in conjunction with ACCP staff input will help guide the decision-making process.

One of my committee charges related to clinical practice guidelines addresses an issue raised in ACCP’s recent member surveys. Trainees and new practitioners often cite recommendations from clinical practice guidelines in the clinical setting without a full understanding of the important issues related to guideline development. Such issues include potential methodologic limitations related to the transparency of the guideline development process, determinations of the quality of evidence, and analysis of the strength of recommendations. Therefore, one of my committee charges relates to instruction in the critical evaluation of clinical practice guidelines.

Other committee charges for the upcoming year reflect priorities in the College’s strategic plan raised by recent past presidents of ACCP, but in need of ongoing attention. Such priorities include disseminating and implementing comprehensive medication management, supporting and extending clinical pharmacists’ involvement in precision medicine practice/research, and using health care–related technologies to advance patient care. Of note, in keeping with ACCP’s priority to develop clinical pharmacists, I have involved at least one student and one resident in each of this year’s committees or task forces on which students and trainees were eligible to participate.

In closing, I wish to thank all the candidates who agreed to be balloted for ACCP elected office this year. Your volunteerism is commendable and attests to your strong commitment to the College. I also want to express my thanks to the ACCP staff members – they keep our organization running on a day-to-day basis and are truly the “invisible ingredient” behind the College’s success.

References:

  1. Smith R, Rennie D. Evidence-based medicine – an oral history. JAMA 2014;311:365-7.
  2. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003;327:1459-61.
  3. Upshur REG. Do clinical guidelines still make sense? No. Ann Fam Med 2014;12:202-3.
  4. Institute of Medicine (IOM). Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press, 2011. Available at https://doi.org/10.17226/13058.
  5. Norris SL, Bero L. GRADE methods for guideline development: time to evolve? Ann Intern Med 2016;165:810-1.