- Email: [email protected]
Drug Therapy Management: An Empirical Report of Drug Therapy Problems, Pharmacists' Interventions, and Results of Pharmacists' Actions
RESEARCH
Drug Therapy Management: An Empirical Report of Drug Therapy Problems, Pharmacists’ Interventions, and Results of Pharmacists’ Actions Randal P. McDonough and William R. Doucette
Objectives: To determine the number and types of drug therapy problems identified by pharmacists at six community pharmacies, identify the interventions made by these pharmacists in their attempts to resolve drug therapy problems, and determine the results of the pharmacists’ actions taken to resolve drug therapy problems. Design: Retrospective review of patient records from pharmacies.
Setting: Six community pharmacies that had participated in Project ImPACT: Hyperlipidemia. Patients: One hundred sixteen patients from Project ImPACT: Hyperlipidemia. Intervention: Drug therapy problems, pharmacists’ interventions, and results of pharmacists’ actions were identified and categorized. Drug therapy problems were classified into seven categories, pharmacists’ interventions into six categories, and results were categorized into eight types. Frequencies and descriptive statistics were calculated for the measures.
Results: A total of 512 initial drug therapy problems were reported for 116 patients in the 6 pharmacies. In addition to the initial interventions, pharmacists documented another 545 times in which they intervened on the original problems. There were 354 (69.1%) drug therapy problems associated with hyperlipidemia and 158 (30.9%) with other conditions. Overall, most common types of drug therapy problems were needs additional therapy (39.8%) and nonadherence to therapy (31.1%). The most common discretionary pharmacist interventions were patient education and physician communication, which occurred on average 4.63 and 3.30 times during the project period. The most common consequence of a pharmacist intervention was an increase in patient adherence, which was reported for almost half of the patients. Conclusion: Drug therapy management (DTM) for patients with dyslipidemias identified frequent drug therapy problems associated with both hyperlipidemia and other conditions. Pharmacists used interventions that included laboratory testing, patient monitoring, patient education, and physician communication to influence patient adherence and optimize drug therapy. Although further research is needed, the findings of this analysis are promising for the more widespread adoption of a DTM role by community pharmacists.
Keywords: Drug therapy problem, hyperlipidemia, drug therapy management, nonadherence, community pharmacy. J Am Pharm Assoc. 2003;43:511–8.
As the U.S. population ages, the use of medications to treat chronic conditions continues to increase. The widespread chronic use of medications is leading to growing concern about the safety and cost of drug therapy, especially among high-risk patients who have multiple medical problems requiring complex drug therapy Received August 5, 2002, and in revised form November 12, 2002, and December 26, 2002. Accepted for publication April 4, 2003. Randal P. McDonough, PharmD, MS, is associate professor (clinical), College of Pharmacy, University of Iowa, Iowa City, and pharmacist, Main at Locust Pharmacy, Davenport, Iowa. William R. Doucette, PhD, is associate professor, College of Pharmacy, University of Iowa, Iowa City. Correspondence: Randal P. McDonough, PhD, S513 PHAR, University of Iowa, Iowa City, IA 52242. Fax: 319-353-5646. E-mail: [email protected].
Vol. 43, No. 4
July/August 2003
regimens. Recent studies have identified unsafe medication use in the community-dwelling elderly,1-3 indicating a need for improvement in the management of drug therapy for patients in this highrisk group. These reports and others have led the Institute of Medicine to call for actions to address medication safety.4 The data on the extent of drug-related problems (DRPs) in community-dwelling patients are limited, as is the list of possible solutions. Only a few population-based studies have documented the types and frequencies of DRPs experienced in the community.5-8 In these studies, the overall frequency of DRPs per patient ranged from 0.8 to 4.2. One approach to addressing the safety and cost-effectiveness of drug therapy is systematic drug therapy management (DTM) for high-risk community-dwelling patients. Such an approach is used
Journal of the American Pharmacists Association (www.japha.org)
511
RESEARCH
Drug Therapy M anagem ent
in long-term care settings in which a pharmacist regularly reviews a patient’s drug therapy and provides feedback to physicians. Although not mandated by law, community pharmacists are beginning to implement similar types of medication management services for some of their ambulatory patients.9-15 DTM services by pharmacists can be arranged on a continuum. At one end, pharmacists are more narrowly focused on drug therapy issues associated with dispensing functions (i.e., drug interactions and adherence).16-22 At the other end of the continuum, pharmacists provide ongoing DTM services for select individuals who have multiple comorbidities requiring complex therapies (i.e., case management).23-25 Other types of services fall between these two ends of the continuum. For example, lipid management,26-28 smoking cessation,29 anticoagulation management,30-35 and health screening services36-38 fall in the middle of the DTM continuum. Also, disease state management services39-54 fall somewhere between point-of-care services and case management. The focus of the study reported in this article was on the identification and management of drug therapy problems within Project ImPACT (Improve Persistence and Compliance with Therapy): Hyperlipidemia, a disease state management program provided by community pharmacists that targeted patients with dyslipidemias.
Objectives The purpose of this secondary analysis was to evaluate DTM activities performed by community pharmacists working with local physicians for patients with dyslipidemias. The specific objectives were to determine the number and types of drug therapy problems identified by pharmacists at six community pharmacies, identify the interventions made by these pharmacists in their attempts to resolve the drug therapy problems, and determine the results of the pharmacists’ actions taken to resolve drug therapy problems.
Methods Project Im PACT: Hyperlipidem ia Project ImPACT: Hyperlipidemia was a 2-year demonstration project focusing on pharmacists’ contributions to managing the drug therapy of patients with lipid disorders.10 The primary outcomes of that project were persistence with and adherence to medication therapy and achievement of lipid levels according to National Cholesterol Education Program Adult Treatment Panel II guidelines.10 A competitive application process was used to select participating pharmacies. A total of 26 community pharmacies in 12 states completed the project. Participating pharmacists were trained in lipid management and the study protocol. In Project ImPACT: Hyperlipidemia, DTM activities were evaluated to determine whether collaboration among patients, pharmacists, and physicians contributed to meaningful progress toward
512
Journal of the American Pharmacists Association (www.japha.org)
achieving patients’ cholesterol management goals. During quarterly visits, pharmacists checked lipid levels in the pharmacy and then consulted with the patients. Project pharmacists acted to identify, resolve, and prevent drug therapy problems that were preventing patients from achieving their therapeutic goals. It is the practitioner’s ability to identify and resolve potential or actual drug therapy problems that is one of the central tenets of DTM.55 Using a systematic problem-solving approach to drug therapy, pharmacists can help ensure safe and effective use of medications.56 The pharmacists who participated in Project ImPACT: Hyperlipidemia followed a detailed protocol that emphasized a collaborative process of care for their patients with dyslipidemia. The protocol called for project pharmacists to identify and enroll patients at risk for coronary artery disease, and their efforts focused on achieving improved outcomes related to their patients’ dyslipidemia.
Selection of Pharm acies The subset of pharmacies selected for this investigation was chosen based on the number of patients enrolled in Project ImPACT: Hyperlipidemia, the pharmacists’ documentation of clinical activities, their performance of DTM activities, and logistics associated with travel and available resources for completing the analysis. The documentation required for participation in this secondary analysis included the required forms from Project ImPACT: Hyperlipidemia and a patient chart with ongoing progress notes describing care delivered to patients. A telephone interview was conducted before the site visit to verify the pharmacists’ clinical activities, availability of patient charts, and their willingness to participate in this subset analysis. Pharmacists representing six project pharmacies were asked and agreed to participate in this analysis. The Human Subjects Committee of the University of Iowa reviewed and approved this retrospective review. Study Design The data used in this secondary analysis were abstracted from patient records used by the pharmacists during Project ImPACT: Hyperlipidemia. From each of the 6 pharmacies, up to 20 consecutive cases were selected for review. Thus, information for 116 of the 540 Project ImPACT: Hyperlipidemia patients was evaluated. The investigators in this analysis were blinded to the identity of individual patients. The data were collected during a site visit to each of the six participating pharmacies. The data collected from the patient records included patient demographics (sex, age, medical conditions, medications), number and dates of patient visits, drug therapy problems identified, pharmacists’ actions taken to resolve drug therapy problems, and consequences of the pharmacists’ interventions. Frequencies for each type of drug therapy problem, pharmacists’
July/August 2003
Vol. 43, No. 4
Drug Therapy M anagem ent
interventions, and results of pharmacists’ actions were tabulated from the data. Each drug therapy problem was categorized into one of seven types of drug therapy problems: need for additional therapy, unnecessary drug therapy, wrong drug, dose too low, adverse drug reaction (ADR), dose too high, and poor adherence.55 This classification of drug therapy problems was chosen because it is a recognized and frequently cited classification in the literature. If a drug therapy problem was described but not classified by the pharmacist, one of the researchers selected the category that he believed best fit the problem. It was necessary for the researchers to select the category for approximately 20% of the drug therapy problems in this analysis. After the data were collected and collated, the pharmacists’ interventions fell into six categories: two called for by the project protocol and four that were discretionary. The two protocol-driven interventions were laboratory testing performed and patient monitoring. The discretionary interventions made by pharmacists fell into one of four categories: educating a patient, communicating with a physician, recommending an action to a patient, and making a referral to another practitioner. Last, pharmacist intervention results were defined in this study according to the following categories that were derived from examination of the data: making a change in drug therapy, adding a drug, stopping a drug, increasing patient adherence to drug therapy, decreasing patient overuse of drug therapy, increasing patient adherence to nondrug therapy, decreasing patient nonadherence to nondrug therapy, and other outcome.
Results Data from a total of 116 Project ImPACT: Hyperlipidemia patients were collected from the 6 pharmacies. Baseline patient demographic information was collected for each patient (see Table 1). Seventy patients (60.3%) were women, and the mean age was 55.31 years (standard deviation [SD] = 11.53). This group of patients was predominantly white (n = 111; 95.7%). The average
RESEARCH
number of long-term medications taken by the patients was 4.45 at the onset of Project ImPACT: Hyperlipidemia, and 55.7% of patients were taking 4 or more long-term medications. About 80% of the patients had 2 or more medical conditions, with a mean of 3.2 medical conditions per patient. On average, the patients made 8.97 visits (SD = 3.14) over a mean time of 22 months (SD = 8.54). This equates to a patient visiting a pharmacist about every 2.6 months, which is consistent with the Project ImPACT: Hyperlipidemia protocol, which called for quarterly visits. Over the course of Project ImPACT, the pharmacists who provided the care analyzed here identified a total of 512 new drug therapy problems for this group of patients (see Table 2). This equates to an average of 4.4 new drug therapy problems identified per patient. In addition to the initial interventions, the pharmacists documented another 545 follow-up visits, during which they addressed the 512 original problems. The number of new drug therapy problems per patient ranged from 0 to 12 during Table 1. Descriptive Statistics for Patients Sex, no. (%) Men 46 (39.7) Women 70 (60.3) Total 116 (100) Age, years Range 29–82 Mean ± SD 55.31 ± 11.53 Race, no. (%) White 111 (95.7) Other 3 ( 2.6) Unknown 2 ( 1.7) Total 116 (100) No. of medications at start of Project ImPACT: Hyperlipidemia Range 0-13 Mean ± SD 4.45 ± 2.43 No. of medical conditions at start of Project ImPACT: Hyperlipidemia Range 1–9 Mean ± SD 3.17 ± 1.81 No. of visits made during Project ImPACT: Hyperlipidemia Range 3-19 Mean ± SD 8.97 ± 3.14 IMPACT = Improve Persistence and Compliance with Therapy; SD = standard deviation.
Table 2. Types of New Drug Therapy Problems Identified
Drug Therapy Problem
Hyperlipidemia No. (%)
Other Indication No. (%)
Total No. (%)
Need for additional therapy
142 (40.1)
62 (39.3)
204 (39.8)
Nonadherence to therapy
125 (35.3)
34 (21.5)
159 (31.1)
Adverse drug reaction
31 (8.8)
29 (18.4)
60 (11.7)
Drug dose too low
34 (9.6)
13 (8.2)
47 (9.2)
0 (0)
19 (12.0)
19 (3.7)
11 (3.1)
1 (0.6)
12 (2.3)
Unnecessary drug therapy Drug dose too high Wrong drug therapy Total
Vol. 43, No. 4
July/August 2003
11 (3.1)
0 (0)
11 (2.2)
354 (100)
158 (100)
512 (100)
Journal of the American Pharmacists Association (www.japha.org)
513
RESEARCH
Drug Therapy M anagem ent
Table 3. Frequency of Follow-up Visits, by Type of Drug Therapy Problem
Intervention
Mean ± SD
Per New Problem
Lab test performed
8.72 ± 3.04
Follow-up Visits Drug Therapy Problem
Frequency (%)
Table 4. Pharmacist Interventions per Patient During Projecta
Nonadherence to therapy
294 (54.0)
1.85
Patient monitoring
7.00 ± 4.21
Needs additional therapy
160 (29.4)
0.78
Patient education
4.63 ± 3.66
Unnecessary drug therapy
47 (8.6)
2.47
Communicate with physician
3.30 ± 3.09
Adverse drug reaction
16 (2.9)
0.27
Patient recommendation
1.45 ± 1.96
Drug dose too low
12 (2.2)
0.26
Referral
0.02 ± 0.13
Drug dose too high
12 (2.2)
1.00
4 (0.7)
0.36
Wrong drug
the project. Of the 512 drug therapy problems identified, 354 (69.1%) related to hyperlipidemia, and the remaining ones (30.9%) related to other conditions and/or medications. Table 2 shows the frequency of new drug therapy problems related to hyperlipidemia or other conditions. Overall, the majority of new problems were due to the patient’s need for additional therapy (39.8%) and nonadherence (both underuse and overuse) to therapy (31.1%). Together, these two categories constituted more than 75% of the hyperlipidemia drug therapy problems identified by the pharmacists. The remaining problems included ADR (11.7%), drug dose too low (9.2%), unnecessary drug therapy (3.7%), drug dose too high (2.3%), and wrong drug therapy (2.2%). Table 3 shows the number of follow-up visits performed for each type of drug therapy problem. More than one-half (54.0%) of the follow-up visits involved nonadherence to drug therapy. Nearly one-third (29.4%) of the follow-up visits addressed a need for additional drug therapy. The third most frequent problem reported during follow-up visits was unnecessary drug therapy (8.6%), which also had the most follow-up visits per new problem (2.47 follow-up visits). The most frequent pharmacists’ interventions were lab test (lipid profile) and patient monitoring (related to patient adherence to medications and lifestyle changes), each of which occurred an average of 8.72 and 7.00 times, respectively (see Table 4). The Project ImPACT: Hyperlipidemia protocol called for these services to be performed at each project visit. Thus, this rate is nearly the same as the average number of visits (8.97). The most frequent discretionary pharmacist intervention was patient education, which occurred on average 4.63 (SD = 3.66) times per patient during the study period. Pharmacists also documented their communication with physicians on average 3.30 (SD = 3.09) times after their visits with patients. If the protocol-driven patient monitoring and lab tests are excluded, the average number of pharmacist interventions is 9.4 per patient. This is equivalent to more than one intervention per visit, beyond the protocol-driven patient monitoring and lipid testing. As shown in Table 5, the results of pharmacists’ interventions
514
Journal of the American Pharmacists Association (www.japha.org)
IMPACT = Improve Persistence and Compliance with Therapy; SD = standard deviation. a Mean time patients were enrolled in Project ImPACT: Hyperlipidemia was 22.00 (SD = 8.54) months.
Table 5. Frequency of Results of Pharmacists’ Interventions Result of Intervention
No. of Patients (%)
Patient increased adherence to nondrug therapy
56 (48.3)
Hyperlipidemia drug added
54 (46.6)
Hyperlipidemia drug therapy changed
43 (37.1)
Patient increased adherence to drug therapy
25 (21.6)
Other drug added
22 (19.0)
Other drug therapy changed
13 (11.2)
Hyperlipidemia drug therapy stopped
13 (11.2)
Other drug therapy stopped
8 (6.9)
Patient decreased adherence to nondrug therapy
7 (6.0)
Patient decreased adherence to drug therapy
2 (1.7)
Other outcome
reported a
73 (62 .9)
a Includes patients starting to use a diet log, patients decreasing
cigarette smoking, patients losing weight, patients reducing alcohol consumption, and patients achieving low-density lipoprotein goal.
were categorized as changes in drug therapy, effects on patient adherence, and other results. For each result, we calculated the number of patients for whom the result was reported. The most common result of pharmacists’ interventions was an increase in patients’ adherence to nondrug therapy, reported for 48.3% of the patients. Specifically, through ongoing educational interventions, pharmacists were able to help patients by suggesting changes in diet and exercise. The next most frequently cited results of the pharmacists’ interventions were the addition of medication to treat hyperlipidemia (46.6% of patients) and changes in therapy related to hyperlipidemia (37.1% of patients). Patients’ increase in adherence to drug therapy (21.6% of patients) and a medication added for a condition unrelated to hyperlipidemia (19.0% of patients) were the next most common results of pharmacists’ interventions identified in the analysis. Other types of results, reported for 62.9% of patients, included patients using a diet log, decreasing cigarette smoking,
July/August 2003
Vol. 43, No. 4
Drug Therapy M anagem ent
losing weight, reducing alcohol consumption, and/or achieving low-density lipoprotein goal.
Discussion N um ber of Drug Therapy Problem s The pharmacists participating in this secondary analysis identified more than 500 new drug therapy problems for 116 patients over nearly 2 years of DTM. The patients managed at these six pharmacies can be considered complicated in that they had multiple medical conditions at the onset of Project ImPACT: Hyperlipidemia and, on average, were taking more than four chronic medications. On average, 4.4 new drug therapy problems were identified per patient enrolled in the project in these 6 pharmacies. Since the pharmacists met with each patient approximately nine times during the project, this equates to one drug therapy problem being identified about every other patient visit in which DTM was performed. The frequency of drug therapy problems identified is slightly higher than that found in prior studies, which ranged from 0.8 to 4.2.5-7 To compare these findings with those from previous studies, we calculated an annualized rate of drug therapy problems. This rate equaled 2.4 drug therapy problems per patient per 12 months. This is the same annual rate reported by Ernst et al.5 in another disease state (arthritis) management service provided by community pharmacists. This rate is lower than the annual rate of 4.2 drug therapy problems per patient reported by Kassam et al.6 for a drug therapy management service for elderly patients. The lowest rate of drug therapy problems was found for the most general patient population, in which Cipolle et al.7 reported an average rate of 0.8 drug therapy problems per patient annually. The findings from the present study add to our description of drug therapy problems in community-dwelling patients. The results shown in Table 3 demonstrate the longitudinal or ongoing nature of some drug therapy problems. Of note is the persistence of nonadherence to drug therapy. Given the focus on hyperlipidemia, which has few or no symptoms, such a finding is not surprising. Patients’ nonadherence to medications used to treat hyperlipidemia has been identified as a common, enduring problem.57-59 Because of the complex nature of nonadherence, continued attention by pharmacists was needed to try to improve adherence to the prescribed therapy. Also, there were instances where pharmacists communicated their recommendations to physicians but did not receive a response back. During subsequent follow-up visits, the same problem recurred, requiring a similar intervention by the pharmacists, including communication with the physicians. There may be other reasons why some of the drug therapy problems persisted, but further inquiry is beyond the scope of this analysis. Future research is needed to characterize the “life cycle” of drug therapy problems in community-dwelling patients.
Vol. 43, No. 4
July/August 2003
RESEARCH
Categories of Drug Therapy Problem s These findings apply to the population of patients who are using medications to treat a dyslipidemia. For this group, more than 70% of the drug therapy problems were due to a need for additional therapy and nonadherence to therapy. A need for additional therapy was often related to a patient not being at goal for lipid levels. That is, the pharmacist found that the patient was not at the treatment goal and believed adjusted or additional therapy (e.g., higher dose, new medication) was needed. As stated previously, the high level of nonadherence to the lipid medications was not unexpected. However, nonadherence was also reported for the other medications the patients were taking. This could be due to the number of medications they were taking, which averaged more than four per patient at each assessment. Further comparisons among this study and three studies of DTM in the community show that the most commonly reported drug therapy problem in each study was “needs additional drug therapy.”5-7 The frequency with which this problem was identified in each study ranged from 23.0% to 56.4% of new drug therapy problems. ADRs were the second most reported type of drug therapy problem in the studies by Cipolle et al.7 and Ernst et al.,5 at 21% and 17.3%, respectively. Nonadherence to drug therapy was the second most frequent type of drug therapy problem found in the present study (31.1%). In the other three studies, rates of nonadherence ranged from 9.0% to 15.9%. Given that improving adherence to prescribed therapy was a focus of Project ImPACT: Hyperlipidemia, the higher rates of nonadherence are not unexpected. Dose too low and wrong drug were the next most frequent types of drug therapy problems reported in the four studies, ranging from 5.1% to 15.1% and 2.2% to 16.0%, respectively. The variability of some of these types of drug therapy problems suggests that the patient population and the scope of the DTM service affect the numbers and types of drug therapy problems identified. More research is needed to improve our understanding of how to identify and manage drug therapy problems in the community. In this study, one difference between the frequencies of drug therapy problems for the two categories of indications (i.e., hyperlipidemia versus other conditions) was the percentage of ADRs identified. ADRs represented only 8.8% of the problems for hyperlipidemia, but they represented 18.4% of the problems for the other indications. One explanation for this difference is that the medications used to treat hyperlipidemia may be better tolerated by patients than other medications they may be taking for other conditions. The most frequent ADRs associated with medications used to treat hyperlipidemia were flushing from niacin, followed by myalgias from statins. In contrast, given the number of therapies identified for the other indications, the types and frequencies of ADRs were substantially higher. Work is needed to improve our knowledge of which DRPs are likely to be associated with different conditions and therapies. While much of the effort has focused on documenting drug interactions and adverse reactions, better characterization of other DRPs is needed.
Journal of the American Pharmacists Association (www.japha.org)
515
RESEARCH
Drug Therapy M anagem ent
Pharm acists’ Interventions As mentioned previously, patient monitoring and laboratory testing were performed at almost every patient visit, consistent with Project ImPACT: Hyperlipidemia’s protocol. The project demonstrated that these activities could be performed in community pharmacies. As DTM becomes more commonplace, community pharmacists will be able to make greater use of patient laboratory results.60 Some pharmacists are likely to perform these tests in their pharmacies, while others will obtain the needed information from commercial laboratories. Pharmacists can contact such laboratories and communicate the importance of having patients’ laboratory results forwarded to the pharmacy. Of course, patients would need to sign an appropriate form to allow the release of this medical information. Patient education was the next most frequently documented pharmacist intervention. The education provided by the pharmacists was multifaceted and included education about medications and lifestyle changes. Pharmacists affected the day-to-day activities of patients through this education and coaching. They discussed dietary strategies to reduce caloric and fat consumption. They discussed ways to increase patients’ activity levels based on patients’ preference. Also, they discussed strategies to improve patients’ adherence to drug therapies and recommended dietary supplements. This patient education was often needed to keep patients engaged in these efforts, as they would at times become nonadherent to either lifestyle changes or their medications. Pharmacists addressed these issues on multiple occasions. Another frequent intervention was communication with physicians, although frequency varied by pharmacy. The pharmacists at the six study sites documented a communication intervention with physicians for approximately 40% of the visits. Pharmacists who appeared to most influence physicians’ therapeutic decisions tended to send them regular (e.g., quarterly) patient assessments, stating whether or not the patient was at goal, what lifestyle modifications they were making, and their current drug therapy. Although the pharmacists may not always have provided a specific recommendation, the information provided to the physicians appeared to influence the physicians’ prescribing behavior. We observed that pharmacists did not always provide specific recommendations to physicians, but the information they communicated appeared to alter the patient’s therapy. Thus, physician communication became an important, and at times essential, intervention to resolve a therapeutic problem. However, in some instances the absence of a specific suggestion may have limited the pharmacist’s ability to influence the physician. Because of a lack of proximity between many community pharmacists and physicians, alternative communication procedures must generally be established. For example, a pharmacist and physician should jointly determine the best method and frequency of communication. Efforts to improve the coordination of care can be instrumental in gaining a physician’s support for DTM services.
516
Journal of the American Pharmacists Association (www.japha.org)
Results of Pharm acists’ Interventions Pharmacists’ DTM efforts also positively influenced patients’ adherence to treatments for hyperlipidemia and other conditions. This was especially true for nonpharmacologic treatments (e.g., lifestyle changes). Pharmacists used education to inform patients about diet and exercise. For example, some pharmacists reported discussing the use of diet logs with patients. Also, pharmacists appeared to motivate some patients to try to make lifestyle changes. Influencing patients’ adherence to prescribed therapy is an appropriate role for pharmacists caring for patients with chronic conditions. Another frequent consequence was the addition of another drug for a condition other than hyperlipidemia. The drug therapies that were added included antihypertensive medications, oral antidiabetic agents, hormone replacement therapy, and calcium supplements. For each of these “other” indications, practice guidelines may direct therapeutic decisions by providers (e.g., achieving a certain blood pressure or blood glucose, making sure that women are receiving the appropriate amounts of daily calcium). By encompassing these conditions within their DTM activities, the pharmacists were successful in getting some of their patients on appropriate therapies and moving toward the goals of therapy for chronic conditions other than hyperlipidemia. Lack of documentation was a recurrent problem when collecting the data for this secondary analysis. Pharmacists did not document the type of drug therapy for about 20% of the DRPs identified. Also, when examining the documentation of the pharmacists’ interventions, it was often difficult to determine the specific recommendation that the pharmacist made to the physician. Many times, a detailed search of a patient’s record was required to identify the result associated with the pharmacist intervention. Pharmacists must take credit for their work, and a lack of complete documentation makes it difficult to determine the impact of their DTM activities. This finding suggests a need for training programs for pharmacists that emphasize documentation as an essential part of DTM.
Limitations In this study we analyzed the drug therapy monitoring performed by pharmacists for a sample of 116 patients enrolled in a program focused on patients with a dyslipidemia. We limit our conclusions to this patient population. However, our findings add to our understanding of DTM for a population of patients using long-term medications. About 20% of the drug therapy problems were classified by one of the authors, since in those instances the pharmacists did not label a particular problem. The authors’ judgments were based on the information provided in the patients’ charts. A single judge, who knew each case and was well trained in the classification scheme, made the judgments. It is possible that these classifications differed from those the project pharmacists would have made.
July/August 2003
Vol. 43, No. 4
Drug Therapy M anagem ent
Conclusion The complex drug therapy of some community-dwelling patients appears to warrant systematic DTM. In this particular analysis, pharmacists in 6 pharmacies found 512 new drug therapy problems for 116 patients enrolled in a disease state management program. Although the pharmacists were focusing on hyperlipidemia, they identified drug therapy problems associated both with medications intended to treat hyperlipidemia (69.1%) and with medications used to treat other conditions (30.9%). Need for additional therapy and nonadherence were the drug therapy problems most frequently identified (70.9%) for these patients. A key finding was the prevalence of the longitudinal nature of some drug therapy problems, especially nonadherence. The pharmacists whose interventions were studied in this secondary analysis were capable of finding and resolving new problems that arose during the course of monitoring their patients while continuing to manage recurrent problems that patients were experiencing. Improved patient adherence to medications and lifestyle changes was a frequent finding in this analysis. Although further research is needed, the findings of the analysis are promising for the more widespread adoption of a DTM role for community pharmacists. The authors declare no conflicts of interest or financial interests in any product or service mentioned in the article, including grants, employment, gifts, stock holdings, or honoraria. The authors thank the American Pharmacists Association Foundation for supporting this project and, in particular, Bill Ellis and Ben Bluml for their efforts in making this project a reality. Also, we would like to recognize Brian Isetts for his leadership and support during this project. An earlier version of these findings was presented at the Annual Meeting of the American Pharmaceutical Association in San Francisco on March 18, 2001.
References 1. Mort JR, Aparasu RR. Prescribing potentially inappropriate psychotropic medications to the ambulatory elderly. Arch Intern Med. 2000;160:2825-31. 2. Hanlon JT, Schmader KE, Rubry CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49:200-9. 3. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community dwelling elderly. JAMA. 2001;286:2823-9. 4. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human—Building a Safer Health System. Washington, DC: National Academy Press; 2000. 5. Ernst ME, Doucette WR, Dedhiya SD, et al. Use of point-of-service health status assessments by community pharmacists to identify and resolve drug-related problems in patients with musculoskeletal disorders. Pharmacotherapy. 2001;21:988-97. 6. Kassam R, Farris KB, Burback L, et al. Pharmaceutical care research and education project: pharmacists’ interventions. J Am Pharm Assoc. 2001;41:401-10. 7. Cipolle RJ, Strand LM, Morley PC. Outcomes of pharmaceutical care practice. In: Pharmaceutical Care Practice. New York, NY: McGraw-Hill; 1998. 8. Currie JD, Chrischilles EA, Kuehl AK, Buser RA. Effect of a training program on community pharmacists’ detection of and intervention in drug related problems. J Am Pharm Assoc. 1997;NS37:182-91. 9. Shibley MC, Pugh CB. Implementation of pharmaceutical care services for patients with hyperlipidemias by independent community pharmacy practitioners. Ann Pharmacother. 1997;31:713-9.
Vol. 43, No. 4
July/August 2003
RESEARCH
10. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in Project ImPACT: Hyperlipidemia. J Am Pharm Assoc. 2000;40:157-65. 11. Bunting B, Horton B. The Asheville Project: Take a fresh look at the pharmacy practice model. Pharmacy Times. October 1998 (suppl):11-9. 12. Herborg H, Sondergaard B, Froekjaer B, et al. Improving drug therapy for patients with asthma part 1: patient outcomes. J Am Pharm Assoc. 2001;41:339-50. 13. Cardina M, McElnay JC, Hughes CM. Assessment of a community pharmacy-based program for patients with asthma. Pharmacotherapy. 2001;21:1196-203. 14. Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hypertensive patients after care provided by community pharmacists in a rural setting. Pharmacotherapy. 1997;17:1274-85. 15. Park JJ, Kelly P, Carter BL, Burgess PP. Comprehensive pharmaceutical care in the chain setting. J Am Pharm Assoc. 1996;NS36:443-51. 16. Rupp MT. Value of community pharmacists’ interventions to correct prescribing errors. Ann Pharmacother. 1992;26:1580-4. 17. Dobie RL, Rascati KL. Documenting the value of pharmacist interventions. Am Pharm. 1994;34:50-4. 18. Knapp KK, Katzman H, Hambright JS, Albrant DH. Community pharmacist interventions in a capitated pharmacy benefit contract. Am J Health Syst Pharm. 1998;55:1141-5. 19. Rupp MT, DeYoung M, Schondelmeyer SW. Prescribing problems and pharmacist interventions in community practice. Med Care. 1992;30:926-40. 20. Rupp MT. Evaluation of prescribing errors and pharmacist interventions in community practice: an estimate of “value added.” Am Pharm. 1988;NS28:766-70. 21. Christensen DB, Holmes G, Fassett WE, et al. Influence of a financial incentive on cognitive services: CARE Project design/implementation. J Am Pharm Assoc. 1999;39:629-39. 22. Smith DH, Fassett WE, Christensen DB. Washington State CARE Project: downstream cost changes associated with the provision of cognitive services by pharmacists. J Am Pharm Assoc. 1999;39:650-7. 23. Petty DR, Zermansky AG, Raynor DK, et al. Clinical medication review by a pharmacist of elderly patients on repeat medications in general practice—pharmacist interventions and review outcomes. Int J Pharm Pract. 2002;10:39-45. 24. Cowper PA, Weinberger M, Hanlon JT, et al. The cost-effectiveness of a clinical pharmacist intervention among elderly outpatients. Pharmacotherapy. 1998;18:327-32. 25. Hanlon JT, Weinberger M, Samsa GP, et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med. 1996;100:428-37. 26. Tsukuki RT, Johnson JA, Teo KK, et al. Study of cardiovascular risk intervention by pharmacists (SCRIP): a randomized trial design of the effect of community pharmacist intervention program on serum cholesterol risk. Ann Pharmacother. 1999;33:910-9. 27. Simpson SH, Johnson JA, Tsuyuki RT. Economic impact of community pharmacist intervention in cholesterol risk management: an evaluation of the study of cardiovascular risk intervention by pharmacists. Pharmacotherapy. 2001;21:627-35. 28. Furmaga EM. Pharmacist management of a hyperlipidemia clinic. Am J Hosp Pharm. 1993;50:91-5. 29. Kennedy DT, Giles JT, Chang ZG, et al. Results of a smoking cessation clinic in community pharmacy practice. J Am Pharm Assoc. 2002;42:51-6. 30. Knowlton CH, Thomas OV, Willamson A, et al. Establishing community-based anticoagulation education and monitoring programs. J Am Pharm Assoc. 1999;39:368-74. 31. McCurdy M. Oral anticoagulation monitoring in a community pharmacy. Am Pharm. 1993;10:61-70. 32. Reinders TP, Steinke WE. Pharmacist management of anticoagulant therapy in ambulant patients. Am J Hosp Pharm. 1979;36:645-8. 33. Davis FB, Sczupak CA. Outpatient oral anticoagulation: guidelines for long-term management. Postgrad Med. 1979;66:100-9. 34. Norton JL, Gibson DL. Establishing an outpatient anticoagulation clinic in a community hospital. Am J Health Syst Pharm. 1996;53:1151-7. 35. Ansell JE, Buttaro JL, Thomas OV, Knowlton CH. The anticoagulation guidelines task force. Consensus guidelines for coordinated outpatient oral anticoagulation therapy management. Ann Pharmacother. 1997;31:604-15.
Journal of the American Pharmacists Association (www.japha.org)
517
RESEARCH
Drug Therapy M anagem ent
36. Elliott ME, Meek PD, Kanous NL, et al. Osteoporosis screening by community pharmacists: use of National Osteoporosis Foundation resources. J Am Pharm Assoc. 2002;42:101-10. 37. Tice B, Phillips CR. Implementation and evaluation of a lipid screening program in a large chain pharmacy. J Am Pharm Assoc. 2002;42:4139. 38. Madejski RM, Madejski TJ. Cholesterol screening in a community pharmacy. J Am Pharm Assoc. 1996;NS36:243-8. 39. McKenney JM, Sliining JM, Henderson HR, et al. The effect of clinical pharmacy services on patients with essential hypertension. Circulation. 1973;48:1104-11. 40. McKenney JM, Brown ED, Necsary R, Reavis HL. Effect of pharmacist drug monitoring and patient education on hypertensive patients. Contemp Pharm Pract. 1978;1:50-6. 41. Reinders TP, Rush DR, Baumgartner RP, Graham AW. Pharmacist’s role in management of hypertensive patients in an ambulatory care clinic. Am J Hosp Pharm. 1975;32:590-4. 42. Hawkins DW, Fiedler FP, Douglas HL, Eschbach RC. Evaluation of a clinical pharmacist in caring for hypertensive and diabetic patients. Am J Hosp Pharm. 1979;36:321-5. 43. Swain JH, Macklin R. Individualized diabetes care in a rural community pharmacy. J Am Pharm Assoc. 2001;41:458-61. 44. Berringer R, Shibely MC, Cary CC, et al. Outcomes of a community pharmacy-based diabetes monitoring program. J Am Pharm Assoc. 1999;39:791-7. 45. Baran RW, Crumlish K, Patterson H, et al. Improving outcomes of community-dwelling older patients with diabetes through pharmacist counseling. Am J Health Syst Pharm. 1999;56:1535-9. 46. Schilling KW. Pharmacy program for monitoring diabetic patients. Am J Hosp Pharm. 1977;34:1242-5. 47. Tiggelaar JM. Protocols for the treatment of essential hypertension and type II diabetes mellitus by pharmacists in ambulatory care clinics. Drug Intell Clin Pharm. 1987;21:521-9. 48. Jaber LA, Halapy H, Fernet M, et al. Evaluation of a pharmaceutical care model on diabetes management. Ann Pharmacother. 1996;30:238-43.
518
Journal of the American Pharmacists Association (www.japha.org)
49. Coast-Senior EA, Kroner BA, Kelley CL, Trilli LE. Management of patients with type 2 diabetes by pharmacists in primary care clinics. Ann Pharmacother. 1998;32:636-41. 50. Rupp MT, McCallian DJ, Sheth KK. Developing and marketing a community pharmacy-based asthma management program. J Am Pharm Assoc. 1997;NS37:694-9. 51. Herborg H, Sondergaard B, Froekjaer B, et al. Improving drug therapy for patients with asthma—part 2: use of antiasthma medications. J Am Pharm Assoc. 2001;41:551-9. 52. Grainger-Rousseau TJ, Miralles MA, Hepler CD, et al. Therapeutic Outcomes Monitoring: application of pharmaceutical care guidelines to community pharmacy. J Am Pharm Assoc. 1997;NS37:647-61. 53. Pauley TR, Magee MJ, Cury JD. Pharmacist-managed physician-directed asthma management program reduces emergency department visits. Ann Pharmacother. 1995;29:5-9. 54. Knoell DL, Pierson JF, Marsh CB, et al. Measurement of outcomes in adults receiving pharmaceutical care in a comprehensive asthma outpatient clinic. Pharmacotherapy. 1998;18:1365-74. 55. Strand LM, Morley PC, Cipolle RJ, et al. Drug-related problems: their structure and function. DICP. 1990;24:1097-107. 56. Strand LM, Cipolle RJ, Morley PC. Documenting the clinical pharmacist’s activities: back to basics. Drug Intell Clin Pharm. 1988;22:63-7. 57. Jackevicius CA, Mamdini M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002:288:462-7. 58. Tsuyuki RT, Bungard TJ. Poor adherence with hypolipidemic drugs: a lost opportunity. Pharmacotherapy. 2001;21:576-82. 59. Kiortsis DN, Giral P, Bruckert E, Turpin G. Factors associated with low compliance with lipid lowering drugs in hyperlipidemic patients. J Clin Pharm Ther. 2000;25:445-51. 60. Millionig MK, Jackson TL, Ellis WM. Improving medication use through pharmacists’ access to patient-specific health care information. J Am Pharm Assoc. 2002;42:638-43.
July/August 2003
Vol. 43, No. 4
Drug Therapy Management: An Empirical Report of Drug Therapy Problems, Pharmacists’ Interventions, and Results of Pharmacists’ Actions Randal P. McDonough and William R. Doucette
Objectives: To determine the number and types of drug therapy problems identified by pharmacists at six community pharmacies, identify the interventions made by these pharmacists in their attempts to resolve drug therapy problems, and determine the results of the pharmacists’ actions taken to resolve drug therapy problems. Design: Retrospective review of patient records from pharmacies.
Setting: Six community pharmacies that had participated in Project ImPACT: Hyperlipidemia. Patients: One hundred sixteen patients from Project ImPACT: Hyperlipidemia. Intervention: Drug therapy problems, pharmacists’ interventions, and results of pharmacists’ actions were identified and categorized. Drug therapy problems were classified into seven categories, pharmacists’ interventions into six categories, and results were categorized into eight types. Frequencies and descriptive statistics were calculated for the measures.
Results: A total of 512 initial drug therapy problems were reported for 116 patients in the 6 pharmacies. In addition to the initial interventions, pharmacists documented another 545 times in which they intervened on the original problems. There were 354 (69.1%) drug therapy problems associated with hyperlipidemia and 158 (30.9%) with other conditions. Overall, most common types of drug therapy problems were needs additional therapy (39.8%) and nonadherence to therapy (31.1%). The most common discretionary pharmacist interventions were patient education and physician communication, which occurred on average 4.63 and 3.30 times during the project period. The most common consequence of a pharmacist intervention was an increase in patient adherence, which was reported for almost half of the patients. Conclusion: Drug therapy management (DTM) for patients with dyslipidemias identified frequent drug therapy problems associated with both hyperlipidemia and other conditions. Pharmacists used interventions that included laboratory testing, patient monitoring, patient education, and physician communication to influence patient adherence and optimize drug therapy. Although further research is needed, the findings of this analysis are promising for the more widespread adoption of a DTM role by community pharmacists.
Keywords: Drug therapy problem, hyperlipidemia, drug therapy management, nonadherence, community pharmacy. J Am Pharm Assoc. 2003;43:511–8.
As the U.S. population ages, the use of medications to treat chronic conditions continues to increase. The widespread chronic use of medications is leading to growing concern about the safety and cost of drug therapy, especially among high-risk patients who have multiple medical problems requiring complex drug therapy Received August 5, 2002, and in revised form November 12, 2002, and December 26, 2002. Accepted for publication April 4, 2003. Randal P. McDonough, PharmD, MS, is associate professor (clinical), College of Pharmacy, University of Iowa, Iowa City, and pharmacist, Main at Locust Pharmacy, Davenport, Iowa. William R. Doucette, PhD, is associate professor, College of Pharmacy, University of Iowa, Iowa City. Correspondence: Randal P. McDonough, PhD, S513 PHAR, University of Iowa, Iowa City, IA 52242. Fax: 319-353-5646. E-mail: [email protected].
Vol. 43, No. 4
July/August 2003
regimens. Recent studies have identified unsafe medication use in the community-dwelling elderly,1-3 indicating a need for improvement in the management of drug therapy for patients in this highrisk group. These reports and others have led the Institute of Medicine to call for actions to address medication safety.4 The data on the extent of drug-related problems (DRPs) in community-dwelling patients are limited, as is the list of possible solutions. Only a few population-based studies have documented the types and frequencies of DRPs experienced in the community.5-8 In these studies, the overall frequency of DRPs per patient ranged from 0.8 to 4.2. One approach to addressing the safety and cost-effectiveness of drug therapy is systematic drug therapy management (DTM) for high-risk community-dwelling patients. Such an approach is used
Journal of the American Pharmacists Association (www.japha.org)
511
RESEARCH
Drug Therapy M anagem ent
in long-term care settings in which a pharmacist regularly reviews a patient’s drug therapy and provides feedback to physicians. Although not mandated by law, community pharmacists are beginning to implement similar types of medication management services for some of their ambulatory patients.9-15 DTM services by pharmacists can be arranged on a continuum. At one end, pharmacists are more narrowly focused on drug therapy issues associated with dispensing functions (i.e., drug interactions and adherence).16-22 At the other end of the continuum, pharmacists provide ongoing DTM services for select individuals who have multiple comorbidities requiring complex therapies (i.e., case management).23-25 Other types of services fall between these two ends of the continuum. For example, lipid management,26-28 smoking cessation,29 anticoagulation management,30-35 and health screening services36-38 fall in the middle of the DTM continuum. Also, disease state management services39-54 fall somewhere between point-of-care services and case management. The focus of the study reported in this article was on the identification and management of drug therapy problems within Project ImPACT (Improve Persistence and Compliance with Therapy): Hyperlipidemia, a disease state management program provided by community pharmacists that targeted patients with dyslipidemias.
Objectives The purpose of this secondary analysis was to evaluate DTM activities performed by community pharmacists working with local physicians for patients with dyslipidemias. The specific objectives were to determine the number and types of drug therapy problems identified by pharmacists at six community pharmacies, identify the interventions made by these pharmacists in their attempts to resolve the drug therapy problems, and determine the results of the pharmacists’ actions taken to resolve drug therapy problems.
Methods Project Im PACT: Hyperlipidem ia Project ImPACT: Hyperlipidemia was a 2-year demonstration project focusing on pharmacists’ contributions to managing the drug therapy of patients with lipid disorders.10 The primary outcomes of that project were persistence with and adherence to medication therapy and achievement of lipid levels according to National Cholesterol Education Program Adult Treatment Panel II guidelines.10 A competitive application process was used to select participating pharmacies. A total of 26 community pharmacies in 12 states completed the project. Participating pharmacists were trained in lipid management and the study protocol. In Project ImPACT: Hyperlipidemia, DTM activities were evaluated to determine whether collaboration among patients, pharmacists, and physicians contributed to meaningful progress toward
512
Journal of the American Pharmacists Association (www.japha.org)
achieving patients’ cholesterol management goals. During quarterly visits, pharmacists checked lipid levels in the pharmacy and then consulted with the patients. Project pharmacists acted to identify, resolve, and prevent drug therapy problems that were preventing patients from achieving their therapeutic goals. It is the practitioner’s ability to identify and resolve potential or actual drug therapy problems that is one of the central tenets of DTM.55 Using a systematic problem-solving approach to drug therapy, pharmacists can help ensure safe and effective use of medications.56 The pharmacists who participated in Project ImPACT: Hyperlipidemia followed a detailed protocol that emphasized a collaborative process of care for their patients with dyslipidemia. The protocol called for project pharmacists to identify and enroll patients at risk for coronary artery disease, and their efforts focused on achieving improved outcomes related to their patients’ dyslipidemia.
Selection of Pharm acies The subset of pharmacies selected for this investigation was chosen based on the number of patients enrolled in Project ImPACT: Hyperlipidemia, the pharmacists’ documentation of clinical activities, their performance of DTM activities, and logistics associated with travel and available resources for completing the analysis. The documentation required for participation in this secondary analysis included the required forms from Project ImPACT: Hyperlipidemia and a patient chart with ongoing progress notes describing care delivered to patients. A telephone interview was conducted before the site visit to verify the pharmacists’ clinical activities, availability of patient charts, and their willingness to participate in this subset analysis. Pharmacists representing six project pharmacies were asked and agreed to participate in this analysis. The Human Subjects Committee of the University of Iowa reviewed and approved this retrospective review. Study Design The data used in this secondary analysis were abstracted from patient records used by the pharmacists during Project ImPACT: Hyperlipidemia. From each of the 6 pharmacies, up to 20 consecutive cases were selected for review. Thus, information for 116 of the 540 Project ImPACT: Hyperlipidemia patients was evaluated. The investigators in this analysis were blinded to the identity of individual patients. The data were collected during a site visit to each of the six participating pharmacies. The data collected from the patient records included patient demographics (sex, age, medical conditions, medications), number and dates of patient visits, drug therapy problems identified, pharmacists’ actions taken to resolve drug therapy problems, and consequences of the pharmacists’ interventions. Frequencies for each type of drug therapy problem, pharmacists’
July/August 2003
Vol. 43, No. 4
Drug Therapy M anagem ent
interventions, and results of pharmacists’ actions were tabulated from the data. Each drug therapy problem was categorized into one of seven types of drug therapy problems: need for additional therapy, unnecessary drug therapy, wrong drug, dose too low, adverse drug reaction (ADR), dose too high, and poor adherence.55 This classification of drug therapy problems was chosen because it is a recognized and frequently cited classification in the literature. If a drug therapy problem was described but not classified by the pharmacist, one of the researchers selected the category that he believed best fit the problem. It was necessary for the researchers to select the category for approximately 20% of the drug therapy problems in this analysis. After the data were collected and collated, the pharmacists’ interventions fell into six categories: two called for by the project protocol and four that were discretionary. The two protocol-driven interventions were laboratory testing performed and patient monitoring. The discretionary interventions made by pharmacists fell into one of four categories: educating a patient, communicating with a physician, recommending an action to a patient, and making a referral to another practitioner. Last, pharmacist intervention results were defined in this study according to the following categories that were derived from examination of the data: making a change in drug therapy, adding a drug, stopping a drug, increasing patient adherence to drug therapy, decreasing patient overuse of drug therapy, increasing patient adherence to nondrug therapy, decreasing patient nonadherence to nondrug therapy, and other outcome.
Results Data from a total of 116 Project ImPACT: Hyperlipidemia patients were collected from the 6 pharmacies. Baseline patient demographic information was collected for each patient (see Table 1). Seventy patients (60.3%) were women, and the mean age was 55.31 years (standard deviation [SD] = 11.53). This group of patients was predominantly white (n = 111; 95.7%). The average
RESEARCH
number of long-term medications taken by the patients was 4.45 at the onset of Project ImPACT: Hyperlipidemia, and 55.7% of patients were taking 4 or more long-term medications. About 80% of the patients had 2 or more medical conditions, with a mean of 3.2 medical conditions per patient. On average, the patients made 8.97 visits (SD = 3.14) over a mean time of 22 months (SD = 8.54). This equates to a patient visiting a pharmacist about every 2.6 months, which is consistent with the Project ImPACT: Hyperlipidemia protocol, which called for quarterly visits. Over the course of Project ImPACT, the pharmacists who provided the care analyzed here identified a total of 512 new drug therapy problems for this group of patients (see Table 2). This equates to an average of 4.4 new drug therapy problems identified per patient. In addition to the initial interventions, the pharmacists documented another 545 follow-up visits, during which they addressed the 512 original problems. The number of new drug therapy problems per patient ranged from 0 to 12 during Table 1. Descriptive Statistics for Patients Sex, no. (%) Men 46 (39.7) Women 70 (60.3) Total 116 (100) Age, years Range 29–82 Mean ± SD 55.31 ± 11.53 Race, no. (%) White 111 (95.7) Other 3 ( 2.6) Unknown 2 ( 1.7) Total 116 (100) No. of medications at start of Project ImPACT: Hyperlipidemia Range 0-13 Mean ± SD 4.45 ± 2.43 No. of medical conditions at start of Project ImPACT: Hyperlipidemia Range 1–9 Mean ± SD 3.17 ± 1.81 No. of visits made during Project ImPACT: Hyperlipidemia Range 3-19 Mean ± SD 8.97 ± 3.14 IMPACT = Improve Persistence and Compliance with Therapy; SD = standard deviation.
Table 2. Types of New Drug Therapy Problems Identified
Drug Therapy Problem
Hyperlipidemia No. (%)
Other Indication No. (%)
Total No. (%)
Need for additional therapy
142 (40.1)
62 (39.3)
204 (39.8)
Nonadherence to therapy
125 (35.3)
34 (21.5)
159 (31.1)
Adverse drug reaction
31 (8.8)
29 (18.4)
60 (11.7)
Drug dose too low
34 (9.6)
13 (8.2)
47 (9.2)
0 (0)
19 (12.0)
19 (3.7)
11 (3.1)
1 (0.6)
12 (2.3)
Unnecessary drug therapy Drug dose too high Wrong drug therapy Total
Vol. 43, No. 4
July/August 2003
11 (3.1)
0 (0)
11 (2.2)
354 (100)
158 (100)
512 (100)
Journal of the American Pharmacists Association (www.japha.org)
513
RESEARCH
Drug Therapy M anagem ent
Table 3. Frequency of Follow-up Visits, by Type of Drug Therapy Problem
Intervention
Mean ± SD
Per New Problem
Lab test performed
8.72 ± 3.04
Follow-up Visits Drug Therapy Problem
Frequency (%)
Table 4. Pharmacist Interventions per Patient During Projecta
Nonadherence to therapy
294 (54.0)
1.85
Patient monitoring
7.00 ± 4.21
Needs additional therapy
160 (29.4)
0.78
Patient education
4.63 ± 3.66
Unnecessary drug therapy
47 (8.6)
2.47
Communicate with physician
3.30 ± 3.09
Adverse drug reaction
16 (2.9)
0.27
Patient recommendation
1.45 ± 1.96
Drug dose too low
12 (2.2)
0.26
Referral
0.02 ± 0.13
Drug dose too high
12 (2.2)
1.00
4 (0.7)
0.36
Wrong drug
the project. Of the 512 drug therapy problems identified, 354 (69.1%) related to hyperlipidemia, and the remaining ones (30.9%) related to other conditions and/or medications. Table 2 shows the frequency of new drug therapy problems related to hyperlipidemia or other conditions. Overall, the majority of new problems were due to the patient’s need for additional therapy (39.8%) and nonadherence (both underuse and overuse) to therapy (31.1%). Together, these two categories constituted more than 75% of the hyperlipidemia drug therapy problems identified by the pharmacists. The remaining problems included ADR (11.7%), drug dose too low (9.2%), unnecessary drug therapy (3.7%), drug dose too high (2.3%), and wrong drug therapy (2.2%). Table 3 shows the number of follow-up visits performed for each type of drug therapy problem. More than one-half (54.0%) of the follow-up visits involved nonadherence to drug therapy. Nearly one-third (29.4%) of the follow-up visits addressed a need for additional drug therapy. The third most frequent problem reported during follow-up visits was unnecessary drug therapy (8.6%), which also had the most follow-up visits per new problem (2.47 follow-up visits). The most frequent pharmacists’ interventions were lab test (lipid profile) and patient monitoring (related to patient adherence to medications and lifestyle changes), each of which occurred an average of 8.72 and 7.00 times, respectively (see Table 4). The Project ImPACT: Hyperlipidemia protocol called for these services to be performed at each project visit. Thus, this rate is nearly the same as the average number of visits (8.97). The most frequent discretionary pharmacist intervention was patient education, which occurred on average 4.63 (SD = 3.66) times per patient during the study period. Pharmacists also documented their communication with physicians on average 3.30 (SD = 3.09) times after their visits with patients. If the protocol-driven patient monitoring and lab tests are excluded, the average number of pharmacist interventions is 9.4 per patient. This is equivalent to more than one intervention per visit, beyond the protocol-driven patient monitoring and lipid testing. As shown in Table 5, the results of pharmacists’ interventions
514
Journal of the American Pharmacists Association (www.japha.org)
IMPACT = Improve Persistence and Compliance with Therapy; SD = standard deviation. a Mean time patients were enrolled in Project ImPACT: Hyperlipidemia was 22.00 (SD = 8.54) months.
Table 5. Frequency of Results of Pharmacists’ Interventions Result of Intervention
No. of Patients (%)
Patient increased adherence to nondrug therapy
56 (48.3)
Hyperlipidemia drug added
54 (46.6)
Hyperlipidemia drug therapy changed
43 (37.1)
Patient increased adherence to drug therapy
25 (21.6)
Other drug added
22 (19.0)
Other drug therapy changed
13 (11.2)
Hyperlipidemia drug therapy stopped
13 (11.2)
Other drug therapy stopped
8 (6.9)
Patient decreased adherence to nondrug therapy
7 (6.0)
Patient decreased adherence to drug therapy
2 (1.7)
Other outcome
reported a
73 (62 .9)
a Includes patients starting to use a diet log, patients decreasing
cigarette smoking, patients losing weight, patients reducing alcohol consumption, and patients achieving low-density lipoprotein goal.
were categorized as changes in drug therapy, effects on patient adherence, and other results. For each result, we calculated the number of patients for whom the result was reported. The most common result of pharmacists’ interventions was an increase in patients’ adherence to nondrug therapy, reported for 48.3% of the patients. Specifically, through ongoing educational interventions, pharmacists were able to help patients by suggesting changes in diet and exercise. The next most frequently cited results of the pharmacists’ interventions were the addition of medication to treat hyperlipidemia (46.6% of patients) and changes in therapy related to hyperlipidemia (37.1% of patients). Patients’ increase in adherence to drug therapy (21.6% of patients) and a medication added for a condition unrelated to hyperlipidemia (19.0% of patients) were the next most common results of pharmacists’ interventions identified in the analysis. Other types of results, reported for 62.9% of patients, included patients using a diet log, decreasing cigarette smoking,
July/August 2003
Vol. 43, No. 4
Drug Therapy M anagem ent
losing weight, reducing alcohol consumption, and/or achieving low-density lipoprotein goal.
Discussion N um ber of Drug Therapy Problem s The pharmacists participating in this secondary analysis identified more than 500 new drug therapy problems for 116 patients over nearly 2 years of DTM. The patients managed at these six pharmacies can be considered complicated in that they had multiple medical conditions at the onset of Project ImPACT: Hyperlipidemia and, on average, were taking more than four chronic medications. On average, 4.4 new drug therapy problems were identified per patient enrolled in the project in these 6 pharmacies. Since the pharmacists met with each patient approximately nine times during the project, this equates to one drug therapy problem being identified about every other patient visit in which DTM was performed. The frequency of drug therapy problems identified is slightly higher than that found in prior studies, which ranged from 0.8 to 4.2.5-7 To compare these findings with those from previous studies, we calculated an annualized rate of drug therapy problems. This rate equaled 2.4 drug therapy problems per patient per 12 months. This is the same annual rate reported by Ernst et al.5 in another disease state (arthritis) management service provided by community pharmacists. This rate is lower than the annual rate of 4.2 drug therapy problems per patient reported by Kassam et al.6 for a drug therapy management service for elderly patients. The lowest rate of drug therapy problems was found for the most general patient population, in which Cipolle et al.7 reported an average rate of 0.8 drug therapy problems per patient annually. The findings from the present study add to our description of drug therapy problems in community-dwelling patients. The results shown in Table 3 demonstrate the longitudinal or ongoing nature of some drug therapy problems. Of note is the persistence of nonadherence to drug therapy. Given the focus on hyperlipidemia, which has few or no symptoms, such a finding is not surprising. Patients’ nonadherence to medications used to treat hyperlipidemia has been identified as a common, enduring problem.57-59 Because of the complex nature of nonadherence, continued attention by pharmacists was needed to try to improve adherence to the prescribed therapy. Also, there were instances where pharmacists communicated their recommendations to physicians but did not receive a response back. During subsequent follow-up visits, the same problem recurred, requiring a similar intervention by the pharmacists, including communication with the physicians. There may be other reasons why some of the drug therapy problems persisted, but further inquiry is beyond the scope of this analysis. Future research is needed to characterize the “life cycle” of drug therapy problems in community-dwelling patients.
Vol. 43, No. 4
July/August 2003
RESEARCH
Categories of Drug Therapy Problem s These findings apply to the population of patients who are using medications to treat a dyslipidemia. For this group, more than 70% of the drug therapy problems were due to a need for additional therapy and nonadherence to therapy. A need for additional therapy was often related to a patient not being at goal for lipid levels. That is, the pharmacist found that the patient was not at the treatment goal and believed adjusted or additional therapy (e.g., higher dose, new medication) was needed. As stated previously, the high level of nonadherence to the lipid medications was not unexpected. However, nonadherence was also reported for the other medications the patients were taking. This could be due to the number of medications they were taking, which averaged more than four per patient at each assessment. Further comparisons among this study and three studies of DTM in the community show that the most commonly reported drug therapy problem in each study was “needs additional drug therapy.”5-7 The frequency with which this problem was identified in each study ranged from 23.0% to 56.4% of new drug therapy problems. ADRs were the second most reported type of drug therapy problem in the studies by Cipolle et al.7 and Ernst et al.,5 at 21% and 17.3%, respectively. Nonadherence to drug therapy was the second most frequent type of drug therapy problem found in the present study (31.1%). In the other three studies, rates of nonadherence ranged from 9.0% to 15.9%. Given that improving adherence to prescribed therapy was a focus of Project ImPACT: Hyperlipidemia, the higher rates of nonadherence are not unexpected. Dose too low and wrong drug were the next most frequent types of drug therapy problems reported in the four studies, ranging from 5.1% to 15.1% and 2.2% to 16.0%, respectively. The variability of some of these types of drug therapy problems suggests that the patient population and the scope of the DTM service affect the numbers and types of drug therapy problems identified. More research is needed to improve our understanding of how to identify and manage drug therapy problems in the community. In this study, one difference between the frequencies of drug therapy problems for the two categories of indications (i.e., hyperlipidemia versus other conditions) was the percentage of ADRs identified. ADRs represented only 8.8% of the problems for hyperlipidemia, but they represented 18.4% of the problems for the other indications. One explanation for this difference is that the medications used to treat hyperlipidemia may be better tolerated by patients than other medications they may be taking for other conditions. The most frequent ADRs associated with medications used to treat hyperlipidemia were flushing from niacin, followed by myalgias from statins. In contrast, given the number of therapies identified for the other indications, the types and frequencies of ADRs were substantially higher. Work is needed to improve our knowledge of which DRPs are likely to be associated with different conditions and therapies. While much of the effort has focused on documenting drug interactions and adverse reactions, better characterization of other DRPs is needed.
Journal of the American Pharmacists Association (www.japha.org)
515
RESEARCH
Drug Therapy M anagem ent
Pharm acists’ Interventions As mentioned previously, patient monitoring and laboratory testing were performed at almost every patient visit, consistent with Project ImPACT: Hyperlipidemia’s protocol. The project demonstrated that these activities could be performed in community pharmacies. As DTM becomes more commonplace, community pharmacists will be able to make greater use of patient laboratory results.60 Some pharmacists are likely to perform these tests in their pharmacies, while others will obtain the needed information from commercial laboratories. Pharmacists can contact such laboratories and communicate the importance of having patients’ laboratory results forwarded to the pharmacy. Of course, patients would need to sign an appropriate form to allow the release of this medical information. Patient education was the next most frequently documented pharmacist intervention. The education provided by the pharmacists was multifaceted and included education about medications and lifestyle changes. Pharmacists affected the day-to-day activities of patients through this education and coaching. They discussed dietary strategies to reduce caloric and fat consumption. They discussed ways to increase patients’ activity levels based on patients’ preference. Also, they discussed strategies to improve patients’ adherence to drug therapies and recommended dietary supplements. This patient education was often needed to keep patients engaged in these efforts, as they would at times become nonadherent to either lifestyle changes or their medications. Pharmacists addressed these issues on multiple occasions. Another frequent intervention was communication with physicians, although frequency varied by pharmacy. The pharmacists at the six study sites documented a communication intervention with physicians for approximately 40% of the visits. Pharmacists who appeared to most influence physicians’ therapeutic decisions tended to send them regular (e.g., quarterly) patient assessments, stating whether or not the patient was at goal, what lifestyle modifications they were making, and their current drug therapy. Although the pharmacists may not always have provided a specific recommendation, the information provided to the physicians appeared to influence the physicians’ prescribing behavior. We observed that pharmacists did not always provide specific recommendations to physicians, but the information they communicated appeared to alter the patient’s therapy. Thus, physician communication became an important, and at times essential, intervention to resolve a therapeutic problem. However, in some instances the absence of a specific suggestion may have limited the pharmacist’s ability to influence the physician. Because of a lack of proximity between many community pharmacists and physicians, alternative communication procedures must generally be established. For example, a pharmacist and physician should jointly determine the best method and frequency of communication. Efforts to improve the coordination of care can be instrumental in gaining a physician’s support for DTM services.
516
Journal of the American Pharmacists Association (www.japha.org)
Results of Pharm acists’ Interventions Pharmacists’ DTM efforts also positively influenced patients’ adherence to treatments for hyperlipidemia and other conditions. This was especially true for nonpharmacologic treatments (e.g., lifestyle changes). Pharmacists used education to inform patients about diet and exercise. For example, some pharmacists reported discussing the use of diet logs with patients. Also, pharmacists appeared to motivate some patients to try to make lifestyle changes. Influencing patients’ adherence to prescribed therapy is an appropriate role for pharmacists caring for patients with chronic conditions. Another frequent consequence was the addition of another drug for a condition other than hyperlipidemia. The drug therapies that were added included antihypertensive medications, oral antidiabetic agents, hormone replacement therapy, and calcium supplements. For each of these “other” indications, practice guidelines may direct therapeutic decisions by providers (e.g., achieving a certain blood pressure or blood glucose, making sure that women are receiving the appropriate amounts of daily calcium). By encompassing these conditions within their DTM activities, the pharmacists were successful in getting some of their patients on appropriate therapies and moving toward the goals of therapy for chronic conditions other than hyperlipidemia. Lack of documentation was a recurrent problem when collecting the data for this secondary analysis. Pharmacists did not document the type of drug therapy for about 20% of the DRPs identified. Also, when examining the documentation of the pharmacists’ interventions, it was often difficult to determine the specific recommendation that the pharmacist made to the physician. Many times, a detailed search of a patient’s record was required to identify the result associated with the pharmacist intervention. Pharmacists must take credit for their work, and a lack of complete documentation makes it difficult to determine the impact of their DTM activities. This finding suggests a need for training programs for pharmacists that emphasize documentation as an essential part of DTM.
Limitations In this study we analyzed the drug therapy monitoring performed by pharmacists for a sample of 116 patients enrolled in a program focused on patients with a dyslipidemia. We limit our conclusions to this patient population. However, our findings add to our understanding of DTM for a population of patients using long-term medications. About 20% of the drug therapy problems were classified by one of the authors, since in those instances the pharmacists did not label a particular problem. The authors’ judgments were based on the information provided in the patients’ charts. A single judge, who knew each case and was well trained in the classification scheme, made the judgments. It is possible that these classifications differed from those the project pharmacists would have made.
July/August 2003
Vol. 43, No. 4
Drug Therapy M anagem ent
Conclusion The complex drug therapy of some community-dwelling patients appears to warrant systematic DTM. In this particular analysis, pharmacists in 6 pharmacies found 512 new drug therapy problems for 116 patients enrolled in a disease state management program. Although the pharmacists were focusing on hyperlipidemia, they identified drug therapy problems associated both with medications intended to treat hyperlipidemia (69.1%) and with medications used to treat other conditions (30.9%). Need for additional therapy and nonadherence were the drug therapy problems most frequently identified (70.9%) for these patients. A key finding was the prevalence of the longitudinal nature of some drug therapy problems, especially nonadherence. The pharmacists whose interventions were studied in this secondary analysis were capable of finding and resolving new problems that arose during the course of monitoring their patients while continuing to manage recurrent problems that patients were experiencing. Improved patient adherence to medications and lifestyle changes was a frequent finding in this analysis. Although further research is needed, the findings of the analysis are promising for the more widespread adoption of a DTM role for community pharmacists. The authors declare no conflicts of interest or financial interests in any product or service mentioned in the article, including grants, employment, gifts, stock holdings, or honoraria. The authors thank the American Pharmacists Association Foundation for supporting this project and, in particular, Bill Ellis and Ben Bluml for their efforts in making this project a reality. Also, we would like to recognize Brian Isetts for his leadership and support during this project. An earlier version of these findings was presented at the Annual Meeting of the American Pharmaceutical Association in San Francisco on March 18, 2001.
References 1. Mort JR, Aparasu RR. Prescribing potentially inappropriate psychotropic medications to the ambulatory elderly. Arch Intern Med. 2000;160:2825-31. 2. Hanlon JT, Schmader KE, Rubry CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49:200-9. 3. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community dwelling elderly. JAMA. 2001;286:2823-9. 4. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human—Building a Safer Health System. Washington, DC: National Academy Press; 2000. 5. Ernst ME, Doucette WR, Dedhiya SD, et al. Use of point-of-service health status assessments by community pharmacists to identify and resolve drug-related problems in patients with musculoskeletal disorders. Pharmacotherapy. 2001;21:988-97. 6. Kassam R, Farris KB, Burback L, et al. Pharmaceutical care research and education project: pharmacists’ interventions. J Am Pharm Assoc. 2001;41:401-10. 7. Cipolle RJ, Strand LM, Morley PC. Outcomes of pharmaceutical care practice. In: Pharmaceutical Care Practice. New York, NY: McGraw-Hill; 1998. 8. Currie JD, Chrischilles EA, Kuehl AK, Buser RA. Effect of a training program on community pharmacists’ detection of and intervention in drug related problems. J Am Pharm Assoc. 1997;NS37:182-91. 9. Shibley MC, Pugh CB. Implementation of pharmaceutical care services for patients with hyperlipidemias by independent community pharmacy practitioners. Ann Pharmacother. 1997;31:713-9.
Vol. 43, No. 4
July/August 2003
RESEARCH
10. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in Project ImPACT: Hyperlipidemia. J Am Pharm Assoc. 2000;40:157-65. 11. Bunting B, Horton B. The Asheville Project: Take a fresh look at the pharmacy practice model. Pharmacy Times. October 1998 (suppl):11-9. 12. Herborg H, Sondergaard B, Froekjaer B, et al. Improving drug therapy for patients with asthma part 1: patient outcomes. J Am Pharm Assoc. 2001;41:339-50. 13. Cardina M, McElnay JC, Hughes CM. Assessment of a community pharmacy-based program for patients with asthma. Pharmacotherapy. 2001;21:1196-203. 14. Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hypertensive patients after care provided by community pharmacists in a rural setting. Pharmacotherapy. 1997;17:1274-85. 15. Park JJ, Kelly P, Carter BL, Burgess PP. Comprehensive pharmaceutical care in the chain setting. J Am Pharm Assoc. 1996;NS36:443-51. 16. Rupp MT. Value of community pharmacists’ interventions to correct prescribing errors. Ann Pharmacother. 1992;26:1580-4. 17. Dobie RL, Rascati KL. Documenting the value of pharmacist interventions. Am Pharm. 1994;34:50-4. 18. Knapp KK, Katzman H, Hambright JS, Albrant DH. Community pharmacist interventions in a capitated pharmacy benefit contract. Am J Health Syst Pharm. 1998;55:1141-5. 19. Rupp MT, DeYoung M, Schondelmeyer SW. Prescribing problems and pharmacist interventions in community practice. Med Care. 1992;30:926-40. 20. Rupp MT. Evaluation of prescribing errors and pharmacist interventions in community practice: an estimate of “value added.” Am Pharm. 1988;NS28:766-70. 21. Christensen DB, Holmes G, Fassett WE, et al. Influence of a financial incentive on cognitive services: CARE Project design/implementation. J Am Pharm Assoc. 1999;39:629-39. 22. Smith DH, Fassett WE, Christensen DB. Washington State CARE Project: downstream cost changes associated with the provision of cognitive services by pharmacists. J Am Pharm Assoc. 1999;39:650-7. 23. Petty DR, Zermansky AG, Raynor DK, et al. Clinical medication review by a pharmacist of elderly patients on repeat medications in general practice—pharmacist interventions and review outcomes. Int J Pharm Pract. 2002;10:39-45. 24. Cowper PA, Weinberger M, Hanlon JT, et al. The cost-effectiveness of a clinical pharmacist intervention among elderly outpatients. Pharmacotherapy. 1998;18:327-32. 25. Hanlon JT, Weinberger M, Samsa GP, et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med. 1996;100:428-37. 26. Tsukuki RT, Johnson JA, Teo KK, et al. Study of cardiovascular risk intervention by pharmacists (SCRIP): a randomized trial design of the effect of community pharmacist intervention program on serum cholesterol risk. Ann Pharmacother. 1999;33:910-9. 27. Simpson SH, Johnson JA, Tsuyuki RT. Economic impact of community pharmacist intervention in cholesterol risk management: an evaluation of the study of cardiovascular risk intervention by pharmacists. Pharmacotherapy. 2001;21:627-35. 28. Furmaga EM. Pharmacist management of a hyperlipidemia clinic. Am J Hosp Pharm. 1993;50:91-5. 29. Kennedy DT, Giles JT, Chang ZG, et al. Results of a smoking cessation clinic in community pharmacy practice. J Am Pharm Assoc. 2002;42:51-6. 30. Knowlton CH, Thomas OV, Willamson A, et al. Establishing community-based anticoagulation education and monitoring programs. J Am Pharm Assoc. 1999;39:368-74. 31. McCurdy M. Oral anticoagulation monitoring in a community pharmacy. Am Pharm. 1993;10:61-70. 32. Reinders TP, Steinke WE. Pharmacist management of anticoagulant therapy in ambulant patients. Am J Hosp Pharm. 1979;36:645-8. 33. Davis FB, Sczupak CA. Outpatient oral anticoagulation: guidelines for long-term management. Postgrad Med. 1979;66:100-9. 34. Norton JL, Gibson DL. Establishing an outpatient anticoagulation clinic in a community hospital. Am J Health Syst Pharm. 1996;53:1151-7. 35. Ansell JE, Buttaro JL, Thomas OV, Knowlton CH. The anticoagulation guidelines task force. Consensus guidelines for coordinated outpatient oral anticoagulation therapy management. Ann Pharmacother. 1997;31:604-15.
Journal of the American Pharmacists Association (www.japha.org)
517
RESEARCH
Drug Therapy M anagem ent
36. Elliott ME, Meek PD, Kanous NL, et al. Osteoporosis screening by community pharmacists: use of National Osteoporosis Foundation resources. J Am Pharm Assoc. 2002;42:101-10. 37. Tice B, Phillips CR. Implementation and evaluation of a lipid screening program in a large chain pharmacy. J Am Pharm Assoc. 2002;42:4139. 38. Madejski RM, Madejski TJ. Cholesterol screening in a community pharmacy. J Am Pharm Assoc. 1996;NS36:243-8. 39. McKenney JM, Sliining JM, Henderson HR, et al. The effect of clinical pharmacy services on patients with essential hypertension. Circulation. 1973;48:1104-11. 40. McKenney JM, Brown ED, Necsary R, Reavis HL. Effect of pharmacist drug monitoring and patient education on hypertensive patients. Contemp Pharm Pract. 1978;1:50-6. 41. Reinders TP, Rush DR, Baumgartner RP, Graham AW. Pharmacist’s role in management of hypertensive patients in an ambulatory care clinic. Am J Hosp Pharm. 1975;32:590-4. 42. Hawkins DW, Fiedler FP, Douglas HL, Eschbach RC. Evaluation of a clinical pharmacist in caring for hypertensive and diabetic patients. Am J Hosp Pharm. 1979;36:321-5. 43. Swain JH, Macklin R. Individualized diabetes care in a rural community pharmacy. J Am Pharm Assoc. 2001;41:458-61. 44. Berringer R, Shibely MC, Cary CC, et al. Outcomes of a community pharmacy-based diabetes monitoring program. J Am Pharm Assoc. 1999;39:791-7. 45. Baran RW, Crumlish K, Patterson H, et al. Improving outcomes of community-dwelling older patients with diabetes through pharmacist counseling. Am J Health Syst Pharm. 1999;56:1535-9. 46. Schilling KW. Pharmacy program for monitoring diabetic patients. Am J Hosp Pharm. 1977;34:1242-5. 47. Tiggelaar JM. Protocols for the treatment of essential hypertension and type II diabetes mellitus by pharmacists in ambulatory care clinics. Drug Intell Clin Pharm. 1987;21:521-9. 48. Jaber LA, Halapy H, Fernet M, et al. Evaluation of a pharmaceutical care model on diabetes management. Ann Pharmacother. 1996;30:238-43.
518
Journal of the American Pharmacists Association (www.japha.org)
49. Coast-Senior EA, Kroner BA, Kelley CL, Trilli LE. Management of patients with type 2 diabetes by pharmacists in primary care clinics. Ann Pharmacother. 1998;32:636-41. 50. Rupp MT, McCallian DJ, Sheth KK. Developing and marketing a community pharmacy-based asthma management program. J Am Pharm Assoc. 1997;NS37:694-9. 51. Herborg H, Sondergaard B, Froekjaer B, et al. Improving drug therapy for patients with asthma—part 2: use of antiasthma medications. J Am Pharm Assoc. 2001;41:551-9. 52. Grainger-Rousseau TJ, Miralles MA, Hepler CD, et al. Therapeutic Outcomes Monitoring: application of pharmaceutical care guidelines to community pharmacy. J Am Pharm Assoc. 1997;NS37:647-61. 53. Pauley TR, Magee MJ, Cury JD. Pharmacist-managed physician-directed asthma management program reduces emergency department visits. Ann Pharmacother. 1995;29:5-9. 54. Knoell DL, Pierson JF, Marsh CB, et al. Measurement of outcomes in adults receiving pharmaceutical care in a comprehensive asthma outpatient clinic. Pharmacotherapy. 1998;18:1365-74. 55. Strand LM, Morley PC, Cipolle RJ, et al. Drug-related problems: their structure and function. DICP. 1990;24:1097-107. 56. Strand LM, Cipolle RJ, Morley PC. Documenting the clinical pharmacist’s activities: back to basics. Drug Intell Clin Pharm. 1988;22:63-7. 57. Jackevicius CA, Mamdini M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002:288:462-7. 58. Tsuyuki RT, Bungard TJ. Poor adherence with hypolipidemic drugs: a lost opportunity. Pharmacotherapy. 2001;21:576-82. 59. Kiortsis DN, Giral P, Bruckert E, Turpin G. Factors associated with low compliance with lipid lowering drugs in hyperlipidemic patients. J Clin Pharm Ther. 2000;25:445-51. 60. Millionig MK, Jackson TL, Ellis WM. Improving medication use through pharmacists’ access to patient-specific health care information. J Am Pharm Assoc. 2002;42:638-43.
July/August 2003
Vol. 43, No. 4