Trends in Collaborative Drug Therapy Management

Karen E. Koch, PharmD

In This Article

Experience With CDTM

Collaborative drug therapy management is most widely practiced in acute care settings, where there are a collaborative environment, patient access, and patient information.[7,18] Pharmacists often work with pharmacy and therapeutics committees and develop protocols for managing patients' pharmacokinetic consultations, anticoagulation therapy, nutrition support, pain management, and a myriad of other pharmacotherapy needs. In this scenario, the physician would write "per pharmacy" or "per specific protocol" next to an order, and the pharmacist would be empowered to act within the authority of the established protocol. For example, a hospital pharmacist providing anticoagulation services would assess the patient, determine an initial dose, order coagulation studies, monitor and adjust therapy, and document actions and patient progress daily in the patient's medical record.

Although CDTM is now most common in acute care settings, it started in the ambulatory care clinics of the Indian Health Service (IHS) in the 1960s.[19] The IHS trained and empowered pharmacists to provide primary care to ambulatory patients living in American Indian reservations. In 1977, an assessment of the patients managed by these pharmacist clinicians demonstrated satisfactory quality of care and excellent patient acceptance.[20] The federal health system continued to recognize and promote clinical pharmacist services when the Health, Education and Welfare Department enacted a drug regimen review regulation for nursing homes in 1974. A 1984 study of nursing home patients found that those in the prescribing pharmacists' group used fewer drugs and had a lower mortality rate, more frequent transfers to lower levels of care, and lower costs of care.[21]

Expanding Services

Just as most inpatient CDTM services started with pharmacists providing pharmacokinetic dosing of aminoglycosides, most ambulatory services started with pharmacists managing anticoagulation therapy. The benefit of these clinics has been demonstrated; and both the American Society of Health-Systems Pharmacists (ASHP) and Novation provide anticoagulation management training programs. Pharmacists have expanded CDTM services to manage a variety of diseases or symptoms in various settings:

  • Ambulatory oncology clinics -- managing pain and chemotherapy-related nausea and vomiting.[22]

  • Adult medicine clinic -- providing protocol-based prescription refills and evaluations.[23]

  • Dyslipidemia clinic -- reducing cardiovascular risk by managing cholesterol through lifestyle modifications and cholesterol-modifying drugs.[24,25]

  • Chronic pain clinic -- managing chronic nonmalignant pain and cancer by protocol.[26]

  • Outpatient psychiatric clinic -- monitoring, evaluating, and adjusting psychiatric drug therapy.[2,27]

  • Home and hospice care settings -- managing symptoms based on algorithms.[28]

  • Retail pharmacy -- prescribing and administering immunizations.

The measure of CDTM success is that once services are offered, they usually grow. In 1996, Schumock and colleagues


published a critique of 104 studies that assessed the economic outcomes of clinical pharmacy services. Although only half of these studies would qualify as CDTM (drug therapy management, pharmacotherapeutic monitoring, or pharmacokinetic monitoring), 89% of all studies found that clinical pharmacy services had a beneficial financial impact.

There is considerable interest in project ImPACT (Improve Persistence and Compliance with Therapy), an ongoing, 2-year community pharmacy-based demonstration project that is documenting pharmacists' contributions to the management of patients with lipid disorders. The project was initiated in 1996, and its interim report[29] concerning 469 patients who have continued in the project for an average of 14 months found that 84% of patients were compliant with their medication therapy. The authors found that 44.3% of these patients met their National Cholesterol Education Program (NCEP) lipid goals.


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