Welcome back! This is the sixth post in a series exploring the various problems posed by medication nonadherence. So far, we’ve discussed the scope of the problem and its impact, as well as a few ways that physicians and can tackle this growing challenge using both market based solutions and strategic remedies. Today, we turn our attention to the men and women on the front lines, the people literally put the medication in the patient’s hands: pharmacists.
Pharmacists are the linchpin of today’s medication management. When things go awry— drug shortages, medication contamination, prescription abuse, or dispensing errors—it is to the pharmacist that people look to for solutions. Pharmacists also must juggle the sometimes competing interests of patients, providers, insurers, and health care institutions. In this article, we examine some of the stresses facing pharmacy practitioners today, and see how the role of the pharmacist is evolving to meet these demands.
“I think pharmacists are probably the most accessible health care providers to patients, and they are readily available in the community as well as in hospitals,” said Maimonides Medical Center Director of Pharmacy Fred Cassera. “Although I think we are underutilized, we are becoming more directly involved with patient-care activities.”
These direct interactions between pharmacists and patients may have beneficial effects on medication adherence, persistence, physiological outcomes, and costs. For example, both in-person consultations and phone calls from pharmacists improved patient adherence for diabetes medications and medications for concomitant illnesses.
Pharmacist services may go beyond education and counseling, to include training patients on injection techniques—for example, helping diabetics to overcome their fears and become better at self-management. Community pharmacy retailers, such as CVS Caremark and Walgreens, offer in-store medication counseling services as well as reminder phone calls to patients who are late in refilling prescriptions. Pharmacists in CVS Caremark’s Pharmacy Advisor program also may suggest other medications from which patients may benefit, such as statins or antihypertensives.
Hospital pharmacists have been expanding their services, too. For instance, said Mr. Cassera, Maimonides offers a discharge medication prescription program. As part of it, a pharmacist will consider the appropriateness of prescribed drugs, the medication regimen, duplicate medicines, costs, and affordability.
Pharmacists at Maimonides also perform medication reviews upon patient admission. Mr. Cassera said that electronic health records have made the process easier, allowing pharmacists to see previous episodes of care, interventions, medication history, and dosing changes—and to communicate with prescribers. Through the Brooklyn Health Insurance Exchange (BHIX), Maimonides pharmacists can access a patient’s medical history from ambulatory clinics and other health care facilities as well.
Another role that pharmacists play is in delivering enhanced counseling services known as medication therapy management (MTM). This includes annual one-on-one comprehensive medication reviews (CMRs), quarterly targeted medication reviews, creation of personal medication lists, and medication-related action plans. Sometimes, pharmacists may be asked by patients to confer with their physicians about medication-related problems.
On another front, pharmacists are taking more responsibilities under collaborative drug therapy management (CDTM) initiatives. According to the Alliance for Pharmaceutical Care, CDTM “is a team approach to health care delivery whereby a pharmacist and prescriber establish written guidelines or protocols authorizing the pharmacist to initiate, modify, or continue drug therapy for a specific patient.” CDTM empowers pharmacists to implement, modify, and manage a drug regimen, and to order and evaluate relevant laboratory tests. CDTM became law in May 2011 after decades of lobbying by pharmacist professional organizations.
“Pharmacists are integral members of the clinical team,” said Paula Ioannides, Vice President of Risk Management and Regulatory Affairs at Maimonides Medical Center. “They are often the final opportunity for a patient to get information and ask questions about drugs being prescribed to them.”
When it comes to medication adherence, the critical role played by pharmacists is never more clear than when a popular drug is in short supply.
Drug shortages can have severe ramifications for patients, physicians, and health care systems. An Associated Press report related 15 deaths to drug shortages in the 15 months preceding September 2011. A 2012 survey of 206 oncologists found that 40 percent believed a patient had died sooner as a result of a drug shortage, and 48 percent thought shortages had led to some tumor recurrences in the previous year.
When a drug is in short supply, pharmacists hasten to act. “Dealing with medication shortages can consume a great deal of our resources and concerns,” said Mr. Cassera. “Whenever there is a shortage, we must work with clinicians to come up with a safe alternative and anticipate any vulnerability or area in which an error can be made due to the substitutions being put into place. We mitigate potential errors by creating new labeling, changing order sets in the computer systems, sending out alerts, and educating providers and patients.”
Whether they are speaking directly with patients, working with doctors and nurses to devise appropriate treatment plans, or consulting with other healthcare agencies on behalf of their patients, pharmacists play a critical role in the effort to improve medication adherence. In the coming years, their importance will only grow.