Dear Colleagues,
Below is an extract from the Medscape Website (www.medscape.com). I have had to delete parts so that it can be sent by email. If you want to see the original (or search the Medscape website for more articles) then please visit the website. For those using Netscape or Internet Explorer you can probably click on the links throughout the article. I have not sought the permission of the authors to redistribute their article since the FIPList is a closed newsgroup. Please do not retransmit it without seeking permission.
Have a pleasant weekend.
Alan
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Drug Benefit Trends(r)
The Community Pharmacist's Role in Disease Management
Authors: Wendy P. Munroe, PharmD, Christina Dalmady-Israel, PharmD, BCPS, MedOutcomes, Inc.
Abstract:Disease management is attracting considerable interest as an alternative approach to health care delivery and reimbursement. Several attributes of the profession of pharmacy contribute to its ability to play a vital role in the provision of disease management within an integrated health care team. Pharmacists have the knowledge, the opportunity for direct patient interaction on a recurrent basis, and the patient trust to provide pharmaceutical outcomes management to help achieve the desired outcomes from drug therapy. This article explores a redefined role for the pharmacist in disease management. [Drug Benefit Trends 9(9):74-77, 1997. (c) 1997 SCP Communications, Inc.][PARA][PARA]Introduction[PARA]In response to the expanding influence of managed care, disease management is attracting considerable interest as an alternative approach to the delivery of improved patient outcomes and lower cost. This trend emphasizes the optimal use of drugs as a cost-effective means of managing illness. For pharmacy, the disease management approach moves beyond product-oriented services such as generic substitution, therapeutic substitution, and formulary compliance, which are designed to minimize drug costs, and focuses on services to improve clinical outcomes. In this view, a prescription becomes a cost-effective solution to a medical problem instead of just an expense. Adherence monitoring, patient education, drug therapy management, and other patient-focused services are used in the disease management model to improve clinical outcomes, which, in turn, lead to reductions in overall health care utilization and expenditures.[PARA]There is growing evidence that traditional methods of prescribing and dispensing medications do not ensure the safety and effectiveness of drug therapy. Typically, patients are given prescriptions and are expected to do the best they can in managing their own therapy without the information and skills needed to administer and adhere to prescribed regimens. The consequences of this approach are
"therapeutic misadventures," which are costly to the health care system and to the individual. Drug-related problems cost an estimated $76.6 billion and cause 119,000 deaths a year[1]; nearly 10% of hospital admissions have been reported to be the result of noncompliance[2]; and an estimated 23% of elderly individuals who enter nursing homes are there because they can't, don't, or won't manage their medication properly.[3][PARA]Although not all drug-related morbidity can be avoided, many problems are preventable through appropriate patient monitoring and follow-up. Pharmaceutical care is a term that describes this process and the new role being adopted by pharmacists in caring for their patients.[PARA]Pharmaceutical Care[PARA]Pharmaceutical care is the systematic and continual monitoring of the clinical and psychosocial effects of drug therapy on a patient.[4] It goes beyond merely transferring medication information to patients to establishing collaborative relationships with them to devise useful medication regimens, anticipate and manage potential drug-related problems, and reduce logistical barriers to patient adherence. Currently, no health care professional has clearly accepted responsibility for this service component, but several factors serve to position the pharmacist to provide this service:[PARA]* Community pharmacies are conveniently located and offer a nonthreatening, yet professional, environment in which patients can address their health care concerns--pharmacists are often the most accessible health professional. [PARA]* Pharmacists are widely respected and trusted by the public. [PARA]* Pharmacy education addresses many of the issues that are central to disease management programs: medication administration, adherence issues, and monitoring and managing the drug-use process. [PARA]The primary objectives of pharmaceutical care are listed in Table I.[5] By realizing these objectives--avoiding adverse reactions, improving clinical outcomes and therapy adherence, and decreasing drug-related hospit
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l and physician visits--the larger goal of decreasing overall health care costs can also be achieved. To achieve this, the pharmacist must work in concert with other members of the health care team. [PARA]The Pharmacist's Role in Disease Management[PARA]In the disease management model, all elements of the health care delivery system work together. The pharmacist's contribution to the overall management of the patient is to serve as the drug-therapy manager. In this capacity, pharmacists work with patients and other health professionals to design individualized therapeutic plans that seek to achieve specific outcomes. Pharmacists also support patients as they follow the steps necessary to meet therapeutic goals and determine barriers and pitfalls that prevent patients from following prescribed regimens. Therapeutic monitoring is used to ensure the realization of desired outcomes and provide continual feedback to patients. All of this information is documented and shared with the patients' physicians and other health care providers. [PARA]Thus, using an interdisciplinary team approach, the pharmacist can build on the physician's therapy strategies. The interchange of patient information between physician and pharmacist can lead to a coordinated care approach in which the pharmacist monitors the patient's progress, compares it with the physician's therapy goals, and notifies the physician if complications arise. In this way, pharmacists serve to identify potential drug-related problems and prevent the occurrence of more serious complications.[PARA]Requirements for Success[PARA]Confidence and cooperation of patients. Disease management requires more than just monitoring medication profiles and lab test results. It requires motivating patients to make positive behavioral modifications. Lifestyle changes, although effective, are often difficult to accomplish or sustain. They require the establishment of a rapport and trust between the patient and the provider. Pharmacists have the opportunity for direct patient contac
t on a recurrent basis, which is not available to other health care providers, and can make use of this access to establish these relationships. The community pharmacy is usually an easily accessible and nonthreatening environment, which, in and of itself, can have a positive influence on the drug-use process and patient outcomes. Phone interactions with patients are also used in some models as a means of influencing behaviors: for example, increasing adherence through telephone reminders. But, although this type of interaction may address some aspects of disease management, it does not allow for the comprehensive monitoring provided by lab monitoring and physical assessment.[PARA]Confidence and cooperation of physicians. A coordinated care approach by physician and pharmacist increases the likelihood of positive patient outcomes. Pharmacists may share objective monitoring information, adherence data, and other pertinent information with physicians by letter, fax, or email. This additional information gathered by the pharmacist may give the physician a better picture of the patient's adherence to the regimen and response to therapy between the regularly scheduled visits. Physicians with more direct exposure to pharmacists tend to be more positive about pharmacists' contributions, as evidenced in a report issued by the US Inspector General's Office of Evaluation and Inspections. The report notes, "physicians and pharmacists who practice in rural or small communities appear to interact more effectively with one another than those in large communities, because they are more familiar with one another and share a higher proportion of patients in their respective practices."[6] The development of this essential familiarity is facilitated through direct contact among pharmacists and physicians practicing within the community. [PARA]Access to relevant patient data. Appropriate databases are needed to identify, assess, and propose solutions to drug-related problems. In addition to the traditional medication history, it i
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necessary to gather and evaluate additional information pertaining to the patient's medication usage: [PARA]* personal limitations--physical, mental, and emotional--that may influence the patient's ability to use the drug product as intended;[PARA]* the patient's level of understanding of the disease and the effects of therapy;[PARA]* the patient's eating, sleeping, work or school schedules, and other activities that would influence the development of a workable medication regimen; and[PARA]* the patients' administration technique for demanding dosage media such as inhalers and injections.[PARA]Much of this information is not currently gathered on a routine basis, and to do so requires a trusting relationship between the pharmacist and patient. Patients must feel secure and believe the pharmacist truly cares in order to discuss concerns and problems regarding a treatment regimen. [PARA]One of the perceived barriers for community pharmacists in the provision of direct patient care is poor access to patient information. However, lack of direct access does not obviate the provision of valuable patient care services. Pharmacists, for example, can create their own databases from patient interviews and monitoring activities. This information is reviewed from a different perspective than that of physicians, and it can serve as a valuable resource in improving drug-therapy outcomes. Focusing on the drug-use process and contributing unique data necessary for patient care help position the pharmacist as an important member of the interdisciplinary team. [PARA]Practice management. Pharmacists serious about providing disease-management services are making radical changes in their practice settings. They are redesigning their pharmacies to incorporate private consultation areas, changing work-flow patterns, and changing staff responsibilities. Technicians are assigned many of the dispensing functions, and pharmacists have reserved time to provide disease-management services. In some models, patients are seen by appointment
every 6 to 8 weeks, with the average intervention taking 15 to 20 minutes.[7][PARA]Monitoring Medication Use[PARA]Pharmaceutical care involves prospectively evaluating a patient's drug-therapy regimen and clinical course. For the pharmacist, the major goal of monitoring is to optimize therapy by ensuring efficacy, minimizing toxicity, and resolving problems that threaten a patient's adherence or access to a particular therapy regimen. To accomplish this, the pharmacist should perform assessments and interventions while monitoring a patient's utilization of and response to therapy. These assessments and interventions should be performed continuously, throughout the entire course of therapy, not just at one point in time.[PARA]Pharmaceutical care consists of 5 basic interrelated service components.[5][PARA]Drug-regimen review. This process usually occurs when a new prescription is dispensed, and it extends beyond the currently available computer-based screening programs. Direct patient-pharmacist interaction tends to be brief, with the objective being to ensure that the patient is being provided with safe and appropriate drug therapy. The screening activities listed can only supplement pharmacist services, not supplant them. The most sophisticated allergy-checking program, for example, can not interview the patient to evaluate the nature and severity of the reaction and thus determine whether the situation is clinically significant for the patient. Computer technology is an important tool for the pharmacist to use in the delivery of optimal patient care, but it is only a tool. Items to assess in performing a drug-regimen review include screening for:[PARA]* allergies and intolerances;[PARA]* interactions (drug-drug, drug-disease, and drug-food); [PARA]* inappropriate dosing regimen, dosage, duration, route, and dosage form;[PARA]* mismatch between medications and indications;[PARA]* duplicative therapy; and[PARA]* cost-effectiveness.[PARA]Medication administration issues. Pharmacists can help patients establish a
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seful medication schedule and employ proper administration techniques by ensuring that patients have the knowledge and skills to use the medication(s) appropriately and are doing so consistently. This is accomplished through periodic patient interview and patient demonstration of drug administration techniques. Pharmacists should also assess the patient's ability to comprehend instructions by looking for hearing, visual, or mental impairment; illiteracy; and limited English comprehension.[PARA]Adherence issues. After ensuring the safety and efficacy of the drug regimen and assessing the patient's knowledge and medication administration skills, the pharmacist should address adherence issues. The object is to reduce the logistical barriers to obtaining and taking the medication while, at the same time, motivating and supporting the patient.[PARA]The pharmacist should identify and document patient characteristics that can affect the drug-use process, such as physical handicaps, degree of family and other social support, and financial concerns. The pharmacist should also assess the extent and pattern of each patient's nonadherence and develop strategies for improvement with the patient. The information needed to accomplish these tasks is obtained through the patient interview once a therapeutic alliance with the patient has been established. Intervention outcomes should be monitored and new strategies employed as needed. [PARA]Symptomatology. The objective of this level of service is to monitor and to teach patients to self-monitor for symptoms consistent with a desirable therapeutic response, a therapeutic failure, an adverse drug reaction, or sequelae of the disease under treatment. The pharmacist serves as an "early warning" mechanism for the health care team by identifying possible symptoms of existing conditions and referring the patient for appropriate care.[PARA]Drug therapy efficacy. This activity provides the final evidence of whether care has been good, bad, or indifferent. The pharmacist evaluates the eff
ect of care on the health status of the patient. In addition to clinical parameters, the effects of therapy on emotional health, quality of life, and the patient's satisfaction with health care services can be evaluated. This information can be obtained by asking patients directly about how they feel their therapy is working, about the number of school or workdays missed, and about the number of activities or plans changed because of illness. Monitoring results can then be shared with patients and their physicians. Physicians can use this information to adjust or fine-tune treatment plans, and patients can use it to follow their progress toward established goals. This type of feedback allows patients to play a more active role in the management of their own health, which may lead to increased adherence to treatment regimens and a better appreciation of the therapeutic value of their medications.[PARA]Compensation[PARA]Patient-focused pharmacist intervention using the model described was shown to reduce total health care costs in patients with hypertension, diabetes, hypercholesterolemia, and/or asthma.[7] The total health care costs per member per month, adjusted to account for differences in age, the presence of other health problems, and disease severity, were significantly lower in the intervention group than among the controls ($723 versus $1017, a difference of $294).This resulting cost savings could be used to adequately compensate the pharmacists, based on the scope of care delivered as well as the benefits provided to patients and the health care system. This compensation could take a number of forms, from fee-for-service to capitation.[PARA]Conclusion[PARA]Drug therapy is a common and effective treatment strategy in disease management. The shift away from micromanaging the pharmacy benefit toward seeing drug use in its proper perspective--integrated with other medical care--has begun. Pharmacists have unique expertise that is vital to ensuring the maximum benefit of this mode of therapy. In addition, th
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direct patient contact historically enjoyed by pharmacists places them in a unique position with regard to disease management today, enabling them to intervene with physicians to ensure proper prescribing and with patients to ensure adherence and positive outcomes.[PARA]About the Authors[PARA]Dr. Munroe is President and Dr. Dalmady-Israel is Clinical Associate, MedOutcomes, Inc., Richmond, Va.
Table 1 - Objectives of Pharmaceutical Care
* Avoid or adjust for interactions, therapeutic duplications, and allergies
* Ensure cost effectiveness of the drug regimen
* Monitor for and avoid or minimize adverse drug reactions
* Maximize achievement of therapeutic objectives
* Decrease emergency department visits, physician office visits, and hospitalizations caused by drug-related problems
* Improve adherence to therapeutic regimen
* Improve clinical outcomes
Alan W Davidson
General Secretary, FIP
a.davidson@fip.nl
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