|Year : 2014 | Volume
| Issue : 2 | Page : 79-83
Emerging drug therapy management: Need of the day
Uday Venkat Mateti1, Anantha Naik Nagappa1, Noorunnisa2, P Gayathri2, Asim Priyendu1, Shima Rose Kachappally2
1 Department of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
2 Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||19-May-2014|
Anantha Naik Nagappa
Department of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Drug therapy management (DTM) is one of the new terms introduced recently and is defined as "services that optimize therapeutic outcomes for individual patients." DTM programs if implemented effectively can greatly enhance patient care, leading to improved overall health, while at the same time decreasing overall health care system costs by reducing improper medication use, preventing adverse drug events and other undesirable outcomes and supporting achievement of therapeutic goals. The safe, effective, appropriate, and economical use of medications is the influencing goal of DTM. Doctor of Pharmacy (Pharm D) reflects an evolutionary change for pharmacy students in the field of pharmacy practice to a more patient-centered focus and there is a great necessity of a Pharm D course in a country like India, where it's required to achieve better drug control and compliance among patients, who are unknown to drug knowledge. The combined patient treatment by a physician and pharmacist is the ultimate and superior most way of achieving better patient compatibility.
Keywords: Doctor of pharmacy, drug therapy management, patient care
|How to cite this article:|
Mateti UV, Nagappa AN, Noorunnisa, Gayathri P, Priyendu A, Kachappally SR. Emerging drug therapy management: Need of the day. Int J Health Allied Sci 2014;3:79-83
|How to cite this URL:|
Mateti UV, Nagappa AN, Noorunnisa, Gayathri P, Priyendu A, Kachappally SR. Emerging drug therapy management: Need of the day. Int J Health Allied Sci [serial online] 2014 [cited 2020 Feb 21];3:79-83. Available from: http://www.ijhas.in/text.asp?2014/3/2/79/132690
| Introduction|| |
Drug therapy management (DTM) is defined as "service (s) that optimize therapeutic outcomes for individual patients". One of the major goals of DTM is to reduce overall health costs besides improving therapeutic outcomes for patients. Other goals of DTM include enhancing patient adherence through education, detecting and resolving adverse drug reactions and optimizing the effectiveness of medication regimens.  India has genetically diversified population with different ailments seen throughout various seasons across the country. Since most of the people live in rural parts and they follow different system of medicine such as ayurveda, homeopathy, etc., there is an increased need of auditing the patient's medicines, especially when he/she starts allopathic drugs along with other systems.
| History of drug therapy management|| |
From the beginning, pharmacy profession has been trying to implement pharmaceutical care and faced challenges in penetration from consumers, employers and health plans and struggled to understand exactly its identity and true value. Pharmacists faced a lot of barriers in providing pharmaceutical services, which include barriers associated with facilities such as store layout, lack of privacy, and overall lack of space. Excessive workload, lack of time, and lack of personnel have also been commonly cited as barriers to the provision of cognitive services.
Furthermore, lack of financial support and legal liability are known to inhibit the provision of such services.  Medicare Modernization Act of 2003 (MMA) was introduced in United States, with the help of which pharmacy profession came up with the term "DTM". DTM is the provision of pharmaceutical care services to diverse groups of patients, which was practiced by pharmacists since many years. As per the Center for Medicare and Medicaid Services, of MMA each Medicare Part D plan should establish DTM Programs (DTMPs) for eligible beneficiaries as part of their benefits. DTMPs were designed to "optimize therapeutic outcomes through improved medication use" and "reduce the risk of adverse events, including adverse drug reactions". Pharmacists were the only health care provider specifically mentioned as potential DTM providers. 
| Advantages of drug therapy management|| |
In recognition of DTM, the federal government as per the MMA act of 2003 provides pharmacists with the opportunity to expand and to be reimbursed for direct patient care services offered. Programs of this kind represent the pharmacy profession's shift from a product focused to patient-centered practice. The prescription medications can be made effective by prescribing the right medication at the correct dose and for the proper duration, providing medication accessibility to the patient, ensuring the patient's medication adherence, monitoring whether the drug therapy objectives are being met, by minimizing adverse events and by providing patient education regarding their medications for effective management of their condition, especially for high risk patients on chronic medical conditions and/or elderly patients on complex medication regimens.  The effective implementation of DTM services offered by DTMPs can result in enhanced patient care, leading to improved overall health, while at the same time decreasing overall health care system costs by reducing improper medication use, preventing adverse drug events and other undesirable outcomes and supporting achievement of therapeutic goals. The safe, effective, appropriate, and economical use of medications is the overarching goal of DTMPs. 
| Role of doctor of pharmacy in the drug therapy management|| |
Doctor of Pharmacy (Pharm D) program is a new concept introduced for pharmacy students in the field of pharmacy practice, which focuses on more patient-centered care. The American Association of Colleges of Pharmacy (AACP) designed Pharm D curriculum to produce a scientifically and technically competent pharmacist who can apply this education in such a manner as to provide maximum health care services to the patient. Now, preparing pharmacists who can take up the expanded responsibilities of the patient care and ensuring the provision of rational drug therapy, is the present goal of all the pharmacy schools. As per AACP, the clinical component is the most important area of instruction of the Pharm D curriculum. The clinical component involves effective interaction with patients and with practitioners of other health professions. This is essential to the patient counseling, which is at the heart of the pharmacy renaissance. Pharmacists with a Pharm D degree are well-equipped to provide these services. 
| Framework of drug therapy management|| |
The purpose of the basic structure of DTM service delivery in clinical practice is to facilitate teamwork among the pharmacists, patients, physicians, and other health care professionals, to promote safe and effective use of drugs, and achieve optimal patient outcomes. DTM services in all patient care settings should support the establishment and maintenance of the patient-pharmacist relationship. The framework of DTM is presented in [Figure 1]. The detailed description of the core elements of DTM services are summarized below. ,,
Drug therapy review
The drug therapy review (DTR) deals with the systematic process of collecting patient-specific information, assessing medication therapies to identify drug-related problems (DRPs), developing a prioritized list of medication-related problems, and planning to resolve them. The patient or caregiver and the clinical pharmacist are involved in DTR, and is conducted preferably in person and on the one-to-one basis. The one-to-one interaction enhances the clinical pharmacist-patient relationship. This results in early detection of DRPs and thus can minimize emergency situations, hospitalizations, and medication misuse. Patient education and training on the appropriate use of medications and monitoring devices and explaining the importance of medication adherence and helping them understand treatment goals.
Personal prescription record
At the end of a complete DTR, the patient should receive this record, which contains detailed information about his or her medications (prescription and nonprescription medications, herbal products, and other dietary supplements). The personal prescription record (PPR) is created with a purpose to help patients in self-medication management. The maintenance of the PPR is a combined effort of the patient, pharmacist, physician, and other health care professionals. Patients should be encouraged to maintain and update this continuous document. Patients should be advised to carry the PPR with them at all times and share it at all health care visits and at all admissions to or discharges from institutional settings to help ensure that all health care professionals are aware of their current medication regimen.
Medication action plan
The medication action plan (MAP) is a patient-centric document, which consists of a list of instructions for the patient to use in tracking progress for self-management and health concerns and gives the information regarding what they need to do to address those concerns and associated actions that have been taken.  The MAP is completed by the patient working collaboratively with the clinical pharmacist and other health care provider. In institutional settings the MAP could be established at the time the patient is discharged. 
Intervention and/or referral
The clinical pharmacist provides consultative services and intervenes to address DRPs. Interventions may include working with the patient to address specific medication problems and/or collaborating with other health care providers to monitor or resolve existing or potential DRPs. Interventions should be made to meet the unique needs of each patient to optimize outcomes. Goals of therapy should be established in association with the patient or caregiver. It is not a compulsion to solve DRPs in a single visit. Clinical pharmacists should prioritize goals and plan follow-up treatment as and when required, the clinical pharmacist may refer the patient to other health care providers, such as physician or a another clinical pharmacist with specialized training.
Documentation and follow-up
Documentation is the important element of the DTM service model. The pharmacist documents all the services and intervention (s) performed in an appropriate manner for evaluating patient progress and sufficient for billing purposes. DTM documentation includes creating and maintaining an ongoing patient-specific record that contains, a record of all provided care in an established standard health care professional format e.g. S = Subjective observations, O = Objective observations, A = Assessment and P = Plan.  In general, documentation will be completed electronically on paper. The inclusion of resources such as a PPR, a MAP, and other practice-specific forms will assist the pharmacist in maintaining consistent professional documentation. The use of consistent documentation will help facilitate collaboration among members of the health care team while accommodating practitioner, facility, organizational, or regional variations.
| Role of clinical pharmacist in institution based patient care|| |
The policies and procedures in institutional settings are little different from those depicted for ambulatory settings. In these settings, there is active participation by clinical pharmacists in the medication selection decision as part of the medical care team. The various steps involved to optimize drug therapy for hospitalized patients are shown in [Figure 2]. 
|Figure 2: Flow chart representing steps to optimize drug therapy for hospitalized patients|
Click here to view
| Challenges for pharmacy transition to clinical care|| |
Optimizing the role of a pharmacist in patient care has been the modern focus of the pharmacy field. The recent introduction of the Pharm D course in the pharmacy education is one of the breakthrough achievements in this regard. The perception of pharmacy profession is changing in the society. The role of pharmacist has reached beyond the stage of compounding and dispensing of medicines to drug intervention and DTM for patient care in the hospital setup. In spite of recent changes in the trend of the pharmacy profession, there are some barriers observed in the effective implementation of pharmacist led DTM. The barriers include, lack of awareness among the public about the range and benefits of the clinical services which a pharmacist can offer, lack of more structured pathway for development of new models of patient care, poor integration of community pharmacists into local clinical teams and lack of knowledge among other health care professionals about the potential impact, which a pharmacist can have on the patient's medicine management. 
| OVERCOMING THE BARRIERS: WHAT'S NEEDS TO BE DONE || |
Increasing the awareness of clinical services that are provided by pharmacist such as counseling about minor and major ailments, prescribing suggestions, providing support for managing long term conditions (asthma, hypertension, diabetes etc.,) public health interventions such as smoking cessation and weight management, etc., can improve the scope of the clinical pharmacy profession. There is a much felt need in the hospital, clinical, and community settings that the regulators frame policies regarding the implementation of pharmaceutical services in the local clinical teams and the impact of pharmacists to make the health care and medication therapy management more efficient, should be stressed upon. It's high time that the pharmacists recognize the need to shift their focus away from dispensing and supply of medicines toward providing a broader range of services keeping the ultimate goal of helping patients get most benefit from their medicine and maintain health.
| Conclusion|| |
India is a multi-ethnic nation with wide genetic diversity. It is not necessary that a drug would achieve same action and activity with same efficacy as that achieved in some other individual. The reason lies on the concept of individualization of drug therapy, which states that no two individuals could show same response to a same drug under similar diseased condition due to different personal profile and health factors. This hastens up the need of such a medical service that can overpower these drawbacks. Physicians are expertise mainly in diagnosing a disease and prescribing drugs. But for ensuring patient compliance and acceptability, the job of a pharmacist comes into play. Pharm D professional is trained in such a field. There is a great necessity of a Pharm D course in a country like India, where it's required to achieve better drug control and compliance among patients, who are unknown to drug knowledge. The combined patient treatment by a physician and pharmacist is the ultimate and superior most way of achieving better patient compatibility.
| References|| |
|1.||Friedrich M, Zgarrick D, Masood A, Montuoro J. Patients' needs and interests in a self-pay medication therapy management service. J Am Pharm Assoc (2003) 2010;50:72-7. |
|2.||Blake KB, Madhavan SS. Perceived barriers to provision of medication therapy management services (MTMS) and the likelihood of a pharmacist to work in a pharmacy that provides MTMS. Ann Pharmacother 2010;44:424-31. |
|3.||Linton A, Bacon TA, Trice S, Devine J, Cottrell L, McGinnis TJ, et al. Results from a mailed promotion of medication reviews among Department of Defense beneficiaries receiving 10 or more chronic medications. J Manag Care Pharm 2010;16:578-92. |
|4.||Consensus Document Workgroup. Sound medication therapy management programs. J Manag Care Pharm 2006;12:S2-13. |
|5.||Academy of Managed Care Pharmacy. Sound medication therapy management programs, Version 2.0 with validation study. J Manag Care Pharm 2008;14:S2-44. |
|6.||National Association of Chain Drug Stores-Pharmacies: Improving Health, Reducing Costs. Available from: http://www.maine.gov/legis/opla/healthreformpharmacies.pdf. [Last cited on 2013 Jan 15]. |
|7.||Garrett DG, Bluml BM. Patient self-management program for diabetes: First-year clinical, humanistic, and economic outcomes. J Am Pharm Assoc (2003) 2005;45:130-7. |
|8.||Currie JD. The case for pharmaceutical care. In: Rovers JP, Currie JD, Hagel H and McDonough RP (ed). A Practical Guide to Pharmaceutical Care. 2 nd ed. Washington, DC; American Pharmacists Association; 2003. p. 3-14. |
|9.||Zierler-Brown S, Brown TR, Chen D, Blackburn RW. Clinical documentation for patient care: Models, concepts, and liability considerations for pharmacists. Am J Health Syst Pharm 2007;64:1851-8. |
|10.||American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: Core elements of an MTM service model (version 2.0). J Am Pharm Assoc (2003) 2008;48:341-53. |
|11.||Executive summary of the continuity of care in medication use summit. Am J Health Syst Pharm 2008;65:e3-9. Available from: http://www.ashpfoundation.org/MainMenuCategories/PracticeTools/MyMedicineList/COCExecutiveSummary.aspx. [Last cited on 2013 Nov 10]. |
|12.||Scope of Contemporary Pharmacy Practice: Roles, Responsibilities, and Functions of Pharmacists and Pharmacy Technicians. Washington, DC: Council on Credentialing in Pharmacy; 2009. Available from: https://www.accp.com/docs/positions/misc/CCPwpScope_Pharmacy_Practice_2-2009.pdf. [Last cited on 2013 Feb 11]. |
|13.||Smith J, Picton C, Dayan M. Now or never: Shaping pharmacy for the future. The report of the commission on future models of care delivered through pharmacy. Royal Pharmaceutical Society; 2013. Available from: http://www.rpharms.com/promoting-pharmacy-pdfs/moc-report-full.pdf. [Last cited on 2014 Feb 06]. |
[Figure 1], [Figure 2]