Trends in Collaborative Drug Therapy Management

Karen E. Koch, PharmD

Disclosures
In This Article

Background

Pharmacists with advanced degrees or extensive clinical training and experience have the pharmacotherapy knowledge and the clinical skills necessary to provide CDTM. They are in a pivotal position to help resolve several of the major problems driving health care reform. With an estimated 10% of all hospital admissions attributable to medication-related morbidity and mortality,[17] there is a clear need for better drug therapy management. Pharmacists are in the best position to answer this call because they have more extensive pharmacotherapy training than any other health care provider. Pharmacists can provide more timely access to health care services, optimal pharmacotherapy selection, and better compliance monitoring, thereby decreasing drug misadventures (adverse effects or errors) and improving outcomes.

CDTM requires an agreement between the physician and the pharmacist. The American College of Clinical Pharmacy (ACCP) position paper[7] stated that CDTM agreements usually encompass the following essential elements: a collaborative practice environment, in which physicians and pharmacists are willing to share responsibility for the patient; direct communication with patients; and access to the patient's medical records, including history, assessments, and laboratory and procedure results. A CDTM agreement should also specify the pharmacist's knowledge, skills, and abilities and require that all activities be documented.

Collaborative management agreements exist throughout the United States, and any pharmacist participating in such an agreement is providing CDTM. Half of all states' regulatory authorities do not formally recognize CDTM; thus, even though pharmacists in these states provide CDTM, they are limited in what they can do. There is considerable variation in the pharmacy practice acts of states that recognize CDTM. Some states limit pharmacist activity, such as to monitoring therapy or vaccine administration, while more permissive states allow the pharmacist to assess, initiate, modify, monitor, and administer.

Most states grant pharmacists "dependent" prescribing authority through a collaborative arrangement in which the physician makes the diagnosis, determines a therapeutic plan, and then delegates the medication selection, monitoring, and management to the pharmacist.[9,10] "Prescriptive authority," the term that describes pharmacists' permission to directly initiate and modify drug therapy, is irritating and unacceptable to many physicians; therefore, other, more descriptive terms are often used: "drug therapy management under protocol" or "protocol dispensing." ("Collaborative management" is used in this article to describe the full range of pharmacists activities.)

Regardless of its name, the ability to directly initiate and modify (prescribe) enables pharmacists to be more efficient and lessens physician office visits and telephone calls for pharmacotherapy management.[9] Prescriptive authority, similar to what nurse practitioners have in all 50 states and physicians assistants have in 41 states, helps to legitimize pharmacists' CDTM activities. Being formally recognized as a prescriber is the first step toward recognition and payment for cognitive services.

Although individual states are now debating pharmacists' prescriptive authority, pharmacists were able to legally prescribe medications before passage of the Federal Food, Drug and Cosmetic Act of 1938.[7] Sulfonamides had been introduced in 1935, and a compounding catastrophe resulted in 107 deaths. So just when pharmacotherapy was getting interesting (the dawn of antimicrobials), the federal government developed legend labeling: "dispense only under a physician's authority" and "may be habit forming." Another revision of the federal standards, the Durham-Humphrey Amendment of 1951, made it illegal for a pharmacist to refill a legend drug without physician authorization.

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