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

Disclosures

Pharmacotherapy. 2003;23(9) 

In This Article

Impact of Pharmacists Performing Collaborative Drug Therapy Management

The number and types of CDTM practices has increased substantially since 1997. Pharmacists in a variety of practice settings are providing clinical services through arrangements structured with individual physicians, physician groups, and institutions. The body of evidence in support of pharmacists providing clinical services has grown. Economic, clinical and humanistic outcome assessments have been performed in many practice environments.

Much of the evidence supporting pharmacist involvement in CDTM is derived from experience in ambulatory care settings. In a 1999 review, 95 studies were identified, including 21 that represented community pharmacy practice.[42] The goal of the investigation was to identify gaps in the literature regarding clinical, economic, and humanistic outcomes analyses. The research methods of each study was analyzed to develop recommendations for future endeavors. All three types of outcomes, as well as combined outcomes, have been addressed in the pharmacy literature; however, no single report has addressed all three areas. The research methods included surveys, retrospective reviews, prospective open-label trials, and randomized, controlled studies. Despite efforts to control for confounders and biases, methodologic flaws were appreciated. Most of the studies reported positive outcomes resulting from pharmacist interventions; however, the impact of methodologic flaws remains unclear. To ensure the integrity of future investigations, the authors recommended more randomized, controlled, multicenter trials, with power analyses.[42] Collaboration among pharmacy practitioners (i.e., multicenter analyses), as well as combined clinical, economic and humanistic outcomes assessments, were highly encouraged.

In a similar analysis, previous recommendations regarding ambulatory clinical pharmacy services were updated.[43] Insight regarding how ambulatory practice has changed over the past decade was provided along with recommendations to ensure continued expansion and success. Advice was provided regarding how to overcome stereotypical perceptions often encountered during communications with the lay public, insurers, and legislators. The authors evaluated outcomes assessments from different ambulatory care settings, describing positive findings and pitfalls. Similar to the 1999 review, concerns related to research design and methodologic parity were described, as were recommendations for randomized, controlled, multicenter trials, specifically with respect to identifying the effects clinical pharmacy services have on morbidity and mortality. A study that demonstrated that clinical pharmacy services improved morbidity and mortality in patients with heart failure was highlighted.[30] Another study showed similar improvements in patients with coronary heart disease.[27]

In 1996, the results of an analysis of economic evaluations of clinical pharmacy services from 1988-1995 were published.[44] In 2003, an update of this analysis compared and contrasted the original findings with 59 newly identified, more recently published studies.[45] A trend toward more reports from ambulatory settings (including community practice) was noted. The number of pharmacotherapeutic or disease management programs had increased, with less emphasis on specialized and targeted drug programs. These changes are consistent with those being seen in clinical practice. Inclusion of studies and reports from other countries was a new addition, thus emphasizing the expansion of CDTM.

Similar to the previous analysis,[44] 85% of the studies in the 2003 analysis[45] reported positive results. Median cost-benefit analysis data remained consistent (4.09:1 vs 4.68:1 for previous and 2003 analyses, respectively); however, mean values changed dramatically (16.7:1 vs 5.54:1, respectively), which was attributed to a lone outlier in the original analysis. Limitations were discussed, one of which was the need for enhanced efforts when developing research protocols. Recommendations were consistent with those presented previously.

In an effort to promote the merits of contemporary pharmacist patient care services to legislative officials and others, 10 national pharmacy organizations joined forces in 1999 to form the Alliance for Pharmaceutical Care. One document developed by the Alliance, "Evidence of the Value of the Pharmacist,"[38] summarized some of the key literature supporting the efforts of pharmacists from the past decade.[26,27,28,29,30,31,32,33,34,35,36,37]

As noted earlier, the ACP-ASIM recently released a position statement that provides positive, if somewhat narrow, support of CDTM.[6] However, this was not the first position statement from a nonpharmacy group regarding CDTM. In 1997, the Infectious Diseases Society of America (IDSA) published a document noting physician support for CDTM. Whereas the ACP-ASIM statement was more global in focus, the IDSA document specifically addressed collaboration among hospital (clinical) pharmacists and infectious diseases specialists (physicians).[46] It is important to note that the overall tone of the ACP-ASIM paper suggests enhanced appreciation and understanding of pharmacist roles and responsibilities.

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