Collaborative Drug Therapy Management by Pharmacists - 2003

American College of Clinical Pharmacy, Raymond W. Hammond, PharmD, FCCP, Amy H. Schwartz, PharmD, Marla J. Campbell, PharmD, Tami L. Remington, PharmD, Susan Chuck, PharmD, Melissa M. Blair, PharmD, Ann M. Vassey, PharmD, Raylene M. Rospond, PharmD, FCCP, Sheryl J. Herner, PharmD, and C. Edwin Webb, PharmD, MPH


Pharmacotherapy. 2003;23(9) 

In This Article

History of Pharmacist Collaborative Drug Therapy Management in the United States

The passage of the Federal Food, Drug and Cosmetic (FDC) Act of 1938 and the Durham-Humphrey amendment of 1951 led to the legal separation of prescribing (by physicians) and dispensing of drugs (by pharmacists). Before these acts, pharmacists could prescribe drugs legally. In the 1951 act, prescription drugs were differentiated from nonlegend, over-the-counter drugs, and it became illegal for pharmacists to refill legend drugs without authorization from a patient's physician.[7,8] These restrictions were deemed to be in the best interest of patients and the health care system. The 1997 ACCP position paper on CDTM outlined these events in more detail.[1] Since that time, pharmacist involvement in drug therapy management has evolved in a manner that integrates pharmacists' services with those provided by physicians and other health care providers. This collaborative practice approach has developed in an attempt to improve efficiency and quality of care.

More recently, pharmacists have gained recognition as drug therapy experts at the national level. One example that continues to serve as a template for new CDTM programs is that developed by the Indian Health Service (IHS). In the 1960s, pharmacists in the IHS began assuming an active role in drug therapy management. In 1973, under a grant from the National Center for Health Services Research and Development, the IHS developed the Pharmacist Practitioner Program, in which specially trained pharmacists provided drug therapy management services in collaboration with physicians.[9,10] A 1-year review of this program found that quality of care, as judged by physicians, was satisfactory and patient acceptance was excellent.[11]

A later report demonstrated that pharmacists were able to provide patient monitoring between physician visits, extending the interval needed between physician visits.[12] In 1974, the Department of Health, Education, and Welfare enacted a drug regimen review regulation for nursing homes in an attempt to improve the quality of drug prescribing in that health care setting. In 1984, the results of a study were published in which clinical pharmacists, working within physician-supervised protocols, managed the drug therapy of patients in a skilled nursing facility.[13] The results of this controlled study indicated that patients in the group managed by pharmacists had significantly fewer deaths, were discharged more often to lower levels of care, and were prescribed fewer drugs than the patients in the traditional care group. The estimated health care savings due to clinical pharmacists' management of drug therapy in a skilled nursing facility were $70,000/year (in 1984 dollars) for every 100 beds. In 1995, the Veterans Health Administration began allowing pharmacists with advanced training to participate in CDTM, with scope of practice determined at the practice site.

The 1997 position statement described in detail the success and expansion of early CDTM pilot projects in California, Washington, and Florida.[14,15,16,17,18] The Health Manpower Experimental Act of 1972, a unique experiment in California, allowed students of the allied health professions to be trained in areas that were then beyond their legal scope of practice. In 1977, California Assembly Bill 717 was introduced, authorizing drug therapy management by only those pharmacists involved with the pilot projects. The project was so successful in saving health care dollars that legislation was passed in 1981 allowing all pharmacists practicing in California-licensed acute and intermediate health care facilities to provide drug therapy management.[14] Pharmacists, pursuant to a prescriber's order, were authorized to adjust drug dosage, order laboratory tests, perform physical assessments, and administer drugs. In the intervening years the law has been expanded twice. In 1983, pharmacists were further authorized to initiate drug therapy.[15,16,17,18] By 1994, the types of practice sites covered by the authorization had been expanded to include clinics and systems licensed as health care plans (e.g., managed care organizations). The site- and practice-specific protocols range from pharmacist-managed nutritional support in the inpatient setting to antihypertensive drug management in the outpatient setting.[15,16,17,18]

Other jurisdictions followed California's lead. The state of Washington first authorized pharmacist participation in drug therapy management under protocol in 1979. Currently, pharmacists in Washington provide these services in institutions, managed care clinics, and community settings.[19,20] In 1986, the Florida legislature created a third class of drugs for pharmacists to use in treating patients with acute illnesses.[21] Florida pharmacists are authorized to use this formulary independently in the management of minor illnesses. At the time of publication of the previous CDTM position paper, 14 states and the federal government had adopted legislation or regulations authorizing pharmacists to engage in CDTM. By the end of 2002, 38 states allowed for various types of CDTM authority within the scope of practice of pharmacists ( Table 1 ).


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