Clinical and economic outcomes of medication therapy management services: the Minnesota experience.

OBJECTIVES: To (1) provide medication therapy management (MTM) services to patients, (2) measure the clinical effects associated with the provision of MTM services, (3) measure the percent of patients achieving Healthcare Effectiveness Data and Information Set (HEDIS) goals for hypertension and hyperlipidemia in the MTM services intervention group in relationship to a comparison group who did not receive MTM services, and (4) compare patients' total health expenditures for the year before and after receiving MTM services. DESIGN: Prospective study. SETTING: Six ambulatory clinics in Minnesota from August 1, 2001, to July 31, 2002. PATIENTS: 285 intervention group patients with at least 1 of 12 medical conditions using prestudy health claims; 126 comparison group patients with hypertension and 126 patients with hyperlipidemia were selected among 9 clinics without MTM services for HEDIS analysis. INTERVENTION: MTM services provided by pharmacists to BlueCross BlueShield health plan beneficiaries in collaboration with primary care providers. MAIN OUTCOME MEASURES: Drug therapy problems resolved; percentage of patients' goals of therapy achieved and meeting HEDIS measures for hypertension and hypercholesterolemia. Total health expenditures per person were measured for a 1-year period before and after enrolling patients in MTM services. RESULTS: 637 drug therapy problems were resolved among 285 intervention patients, and the percentage of patients' goals of therapy achieved increased from 76% to 90%. HEDIS measures improved in the intervention group compared with the comparison group for hypertension (71% versus 59%) and cholesterol management (52% versus 30%). Total health expenditures decreased from $11,965 to $8,197 per person (n = 186, P < 0.0001). The reduction in total annual health expenditures exceeded the cost of providing MTM services by more than 12 to 1. CONCLUSION: Patients receiving face-to-face MTM services provided by pharmacists in collaboration with prescribers experienced improved clinical outcomes and lower total health expenditures. Clinical outcomes of MTM services have chronic care improvement and value-based purchasing implications, and economic outcomes support inclusion of MTM services in health plan design.

Drug therapy problems found in ambulatory patient populations in Minnesota and South Australia.

OBJECTIVE: To compare drug therapy problems identified by pharmacists in two patient samples, the Minnesota Sample and the South Australian Sample. METHODS: Two patient samples were selected for this comparison. Both sets of patients received pharmaceutical care services from pharmaceutical care practitioners between March 1999 and February 2000. The two databases were then compared for common drug therapy problems. MAIN OUTCOME MEASURE: Comparison of drug therapy problems in the two samples. RESULTS: Both patient samples included patients who were 40 years of age or older. The Minnesota Sample included 1,598 individual patients, of whom 70% experienced one or more drug therapy problems at some time during their care. The South Australian Sample included a total of 982 patients of whom 90% experienced one or more drug therapy problems at some time during their care. Conditions common to both patient samples include hypertension, diabetes, arthritis, ischemic heart disease, and osteoporosis. Frequently occurring drug therapy problems in the Minnesota Sample included the need for additional drug therapy, dosage too low and non-compliance and in the South Australian Sample included non-compliance, additional drug therapy and ineffective drug therapy. Frequent drug therapy problems associated with medical conditions in the Minnesota Sample included addition of new therapies for conditions such as arthritis, hypertension, hyperlipidemia and allergic rhinitis, while for the South Australian Sample included compliance issues with conditions such as asthma, diabetes mellitus, angina and digestive disorders. Frequent drug therapy problems with associated drug classes in the Minnesota Sample included additional therapy for classes such as salicylates and calcium supplements, while in the South Australian Sample included the need for therapy for pneumococcal vaccines, salicylates, calcium supplements and tetanus vaccines. CONCLUSION: These data demonstrate that this age group has significant drug therapy problems and therefore emphasize the need for pharmaceutical care services in this population. The provision of pharmaceutical care by experienced practitioners can result in improved recognition of the full range of drug therapy problems confronting patients. Analyses such as those presented here provide information to better focus the training of practitioners based on the most frequently encountered health problems and the nature of common drug therapy problems in the community setting.

Consistent standards in medication use: the need to care for patients from research to practice.

OBJECTIVE: To propose adoption of practice standards for pharmacists based on the principles of pharmaceutical care that are parallel to internationally accepted ethical precepts governing clinical research. DATA SOURCES: Relevant literature selected by the authors. SUMMARY: Pharmaceutical care practice standards can create a continuum of high quality care for patients from research through practice and are presented as a rational solution to managing the benefits and risks of medication use. By implementing these practice standards, patients are empowered to become active participants in the treatment process, knowledge of drug effectiveness and safety is increased, and the pharmaceutical care practitioner's responsibilities are delineated. More than a quarter century ago, the research community adopted the ethical principles of respect for persons, beneficence, and justice, as outlined in the Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Under these guidelines, research subjects are considered participants, knowledge of medication efficacy and safety has increased, and investigator responsibilities have been defined. However, these guidelines only apply to the life cycle of a drug before approval by the Food and Drug Administration. Once the product is released for general use, fewer standards are applied. Pharmacy has the opportunity to establish parallel standards for the clinical use of medications in patients by establishing patient care practices in consonance with pharmaceutical care practice. CONCLUSION: Pharmaceutical care practitioners need to apply new practice standards that allow them to contribute meaningfully to appropriate, effective, safe, and convenient drug therapy for all patients. Such pharmaceutical care practice standards could ensure consistent vigilance throughout the life cycle of the drug product and result in rational, appropriate, effective, safe, and convenient drug therapy for all patients.

The impact of pharmaceutical care practice on the practitioner and the patient in the ambulatory practice setting: twenty-five years of experience.

This manuscript reviews 25 years of experience that include developing the practice of pharmaceutical care and initiating new practices. The impact this practice has on practitioners in the ambulatory setting is described as well as data that reflect its clinical and economic impact. There is a great need to prepare new practitioners to provide pharmaceutical care. A focused training program was developed and delivered to over 300 practitioners. The practitioners were prepared by providing direct patient care. They learned the philosophy of pharmaceutical care practice, to identify, resolve and prevent drug therapy problems, to document care using a specially designed software program called the Assurance Pharmaceutical Care program. The practitioners who participated in the training program reported that the average amount of time spent with patients increased three-fold, they now see four times more patients than prior to training, and the number of new patients referred by physicians increased nine-fold as a result of the program. These practitioners have now provided care to more than 25,000 patients in their practices. These data have now been consolidated and analyzed, and a portion of these results is reported here. The clinical and economic outcomes from 2,985 adult patients, who received pharmaceutical care between January, 2000 and December, 2003, are presented. At the first assessment by the pharmaceutical care practitioner, 61% of the patients had one or more drug therapy problems identified and resolved. This resulted in an improvement in the clinical status or maintaining a stable status in 83% of the patients. The health care savings realized from pharmaceutical care were $1,134,162. This represented a benefit to cost ratio of 2:1. Physicians who collaborate with pharmaceutical care practitioners have validated the work of the practitioners, and patients are recognizing the benefits of pharmaceutical care.

Resultados del ejercicio de la atención farmacéutica / The outcomes of Pharmaceutical Care practice

El Programa Certificado de Atención Farmacéutica ofrecido a través del Instituto Peters de Atención Farmacéutica de Minnesota prepara a farmacéuticos para ejercer en Atención Farmacéutica. Describimos esas prácticas y resumimos la atención que esos farmacéuticos han documentado. Proporcionaron atención a 14.357 pacientes durante 45.165 visitas documentadas. Los farmacéuticos identificaron, resolvieron o previnieron 19.140 problemas relacionados con medicamentos (PRM) en esos pacientes ambulatorios. La media de problemas de salud por visita fue de 1,7. La media de tratamientos fue de 2,6. Estos pacientes tuvieron una media de 0,4 PRM por visita. Se identificaron PRM en el 40 por ciento de los pacientes. La indicación inapropiada para el tratamiento representó el 27 por ciento de los problemas identificados y resueltos. El tratamiento inefectivo sumó el 27 por ciento y el tratamiento inseguro el 25 por ciento. El cumplimiento inapropiado se identificó en el 21 por ciento de las situaciones problemáticas. Cuando el farmacéutico resolvió el PRM en colaboración con el médico, el 37 por ciento de las veces se inició un nuevo tratamiento y el 18 por ciento de las dosis de los pacientes se cambiaron. En el 13 por ciento de los casos se cambió un medicamento. Se evitaron visitas innecesarias a la consulta en 193 ocasiones, se redujeron los costes en 177 veces, se evitaron 36 visitas a la sala de urgencias, y se evitaron 14 ingresos hospitalarios. Se documentó un ahorro de 144.626 dólares reflejando un ratio de ahorro: coste de 2:1 por la provisión de Atención Farmacéutica por los farmacéuticos comunitarios. Se documentaron los resultados clínicos del paciente y el 82 por ciento de los pacientes fueron parcialmente mejorados, estables o resueltos después de la evaluación de seguimiento. El 40 por ciento de los resultados de los pacientes mejoraron a lo largo del tiempo, el 50 por ciento permaneció estable, y el 10 por ciento empeoró en su estado. Los resultados indican que el 90 por ciento de los problemas de salud están estables o mejoraron gracias a la provisión de Atención Farmacéutica. Pocos servicios de salud pueden documentar unos resultados positivos y ahorros de esta magnitud (AU)

The Pharmaceutical Care Certificate Program offered through the Peters Institute of Pharmaceutical Care at the University of Minnesota prepares pharmacists to establish pharmaceutical care practices. We describe those practices and summarize the care these pharmacists documented. They provided care for 14,357 patients during 45,165 documented encounters. Pharmacists identified, resolved, and prevented 19, 140 drug therapy problems in these ambulatory patients. The average number of medical conditions per patient encounter was 1.7. The average number of drug therapies was 2.6. These patients had an average of 0.4 drug therapy problems per encounter. Drug therapy problems were identified in 40% of patients. An inappropriate indication for the drug therapy represented 27% of the problems identified and resolved. Ineffective drug therapy accounted for 27%, and unsafe drug therapy accounted for 25%. Inappropriate compliance with the drug therapy regimen was identified in 21% of the problem situations. When the pharmacist resolved drug therapy problems in collaboration with the physician, 37% of the time new drug therapy was initiated, 18% of the patients' dosage regimens were changed. In 13% of the cases drug product was changed. Unnecessary office visits were avoided 193 times, drug costs reduced 177 times, 36 emergency room visits were avoided, and hospital admissions avoided on 14 occasions. Cost savings of $144,626 were documented reflecting a savings: cost ratio of 2:1 for the provision of pharmaceutical care by community pharmacists. Patient clinical outcomes were documented and 82% of the patients were partially improved, improved, stable, or resolved at the follow-up evaluation. 40% of patients' outcomes improved over time, 50% remained the some or stable, and the status of [0% declined. The results indicate that 90% of patient’s conditions are stable or improved through the provision of pharmaceutical care. Few health care services can document positive outcomes and savings of this magnitude (AU)