When Carrie Lagasse, PharmD, BCPS, joined the faculty at UF Health Shands Hospital, she collaborated with a multidisciplinary task force to evaluate the utilization of activated factor VII. The group had convened to find and implement strategies to reduce use of a clotting agent that cost the hospital about $4,500 a dose. Lagasse, who had spearheaded an antimicrobial stewardship program at her previous hospital, thought she could help influence prescribers to be better stewards of the costly drug.
Collaboration with this task force opened the door for Lagasse to lead other medication stewardship initiatives throughout the hospital. In her daily practice, Lagasse draws not only on medication expertise but also on leadership skills. Her vision of pharmacists as leaders and influencers in patient care comes through in her passion for resource stewardship, her participation in hospital committees, and her role as director of Shands’ PGY1 pharmacy practice residency.
Lagasse started her career as an infectious disease specialist at University of Kansas Hospital, where she implemented an antibiotic stewardship program. When a family move brought her to Gainesville, FL, she wanted to continue her work with medication stewardship beyond just antibiotics. “We have limited resources, and taxpayers and institutions pick up the slack when we use resources inappropriately,” Lagasse said. “[The pharmacy team] and I want to make sure that we provide optimum care to our patients in the safest and most efficacious way, and I think we can do that cost effectively.”
A relatively new member of Shands’ faculty, Lagasse saw an opportunity to promote medication stewardship and cost-effective care. Factor VII had been a top monthly cost at the hospital for quite some time when a task force formed to address the issue. While all high-utilizers of the agent had been invited to join the force, not all accepted. The physician group conducted a comprehensive literature review on the evidence for factor VII use among various patient populations.
That’s when the task force reached out to Lagasse. She felt she could support their mission with her experience with the University Health System Consortium Clinical Resource Manager database (UHC-CRM). She asked the group to identify the diagnoses and procedures for which physicians used factor VII, and she asked them which hospitals they considered peers. Using UHC-CRM, which allows member hospitals to compare themselves on given metrics, Lagasse demonstrated that physicians at other hospitals were using comparably less factor VII, and perhaps the physician group at UF had an opportunity to reduce factor VII utilization.
“I wanted to show them that other institutions had equivalent or better outcomes in patients with equivalent or greater acuity without the use of factor VII,” said Lagasse, who is a clinical specialist in drug policy development and resource utilization. The task force used Lagasse’s findings to work with the Pharmacy and Therapeutics (P&T) Committee on new criteria for utilization.
Today, Lagasse reviews the case of each patient who receives factor VII. A hematologist further evaluates the cases of any patients who don’t appear to meet criteria. If the hematologist agrees that the case represents a nonapproved use, the prescribing physician receives a letter that describes the approved use, explains why the patient didn’t meet the criteria, and recommends that physicians petition the P&T Committee if they feel that evidence exists to support the given use.
This initiative has increased compliance with factor VII utilization criteria at Shands from 40% to greater than 90%. Lagasse noted that prescribers can eventually become desensitized to certain tactics, such as the current letter-writing campaign. Compliance rates will most likely drop again, indicating a need for Lagasse and her colleagues to change tactics. “It’s necessary to treat your approach to resource utilization as a fluid endeavor that constantly requires adjustments,” she said.
Lagasse’s contribution to the factor VII initiative has led other physicians to seek her leadership on stewardship of resources in their departments.
Leading others to be better stewards of medications isn’t just about medication expertise. It’s about communication skills that cultivate trust. “You can be the smartest person in the room, but if you can’t communicate with somebody in a manner that’s effective, they’re not going to hear your message,” she said. “Delivering your message with confidence makes others confident in you.”
It takes diplomacy to communicate to a physician that his or her use of a particular drug might not be optimal. “The message can’t be ‘you’re doing something wrong,’ or ‘you’re spending too much money.’ We just need to make sure that what we’re spending is giving us the outcome that we desire.”
Lagasse admitted that she’s been kicked out of some meetings for presenting unwanted information on optimal medication use and that she’s been welcomed with open arms at others.
Lagasse cultivated the skills necessary to walk this diplomatic tightrope through her participation in numerous multidisciplinary committees. Lagasse is secretary of the P&T, chair of its formulary subcommittee, and a member of the medication safety subcommittee, in addition to sitting on all the pharmacy practice residency committees in her role as residency director.
She appreciates the opportunity to see her nursing and physician colleagues’ perspectives. “We can’t work in silos and still provide our patients with the best care. As a pharmacist, I have certain ideas of how things should be done, but that may not be what works best in a nursing or physician environment,” she said.
Participation in multidisciplinary committees, Lagasse noted, helps ensure that the right people are around the table to develop processes that are safe for patients while imposing the least amount of trouble on the health care providers involved.
Through her work on these committees, Lagasse has seen many changes at Shands over the last couple of years. She is perhaps most excited about the ways in which implementation of an electronic medical record has allowed pharmacists to take on more clinical responsibility and do what they were trained to do.
Pharmacist duties in medication distribution and verification have decreased with the advent of the electronic medical record. This has allowed pharmacists to perform more medication reconciliation, assist in transitions of care, and provide discharge counseling.
The hospital may also enlist the help of pharmacists in reducing 30-day readmission rates. “Pharmacists can try to identify those social or financial issues that may prevent somebody from getting a medication prior to the discharge process,” Lagasse said. “We want to set up our patients to succeed and not have to bounce back to our institution because they weren’t able to get their medication.”
Leading by example
Through her work with medication stewardship and her participation in numerous committees, Lagasse learned firsthand that pharmacy leadership in a hospital can improve patient care and raise the profile of the profession. Her goal is to foster such leadership skills in her five PGY1 residents, too.
Leaving clinical skills up to residency preceptors, Lagasse said she prefers to help residents cultivate their professionalism and watch them grow as people. She expects residents to participate in hospital committees, and next year for the first time, residents will join a leadership journal club as well.
Lagasse remembers her own personal growth when she was a pharmacy resident. Before residency, she always imagined she’d practice pharmacy in a research role at a government agency, such as CDC. It was a preceptor that showed her the impact she could have in a hospital and at a patient’s bedside. Lagasse hopes to teach her residents the same thing.
“I’ve been fortunate to have excellent mentors in my career over the past 12 years,” Lagasse said. “I want to pay that forward to somebody else. I know how heavily I rely on those people. I want to be that person for somebody else.”