Publication of the 10th edition of Pharmacotherapy: A Pathophysiologic Approach represents a milestone, in that almost 30 years have passed since publication of the 1st edition. Accordingly, this is a logical time to pause and reflect upon the mission and changes in Pharmacotherapy, health care delivery systems, and our profession. Hopefully, this reflection is not simply an academic exercise, but instead an opportunity to think about what the future may hold and how we might be able to lead the future such that clinical, humanistic, and economic outcomes of our patients are improved.
These are times of unprecedented change in health care. Since publication of the 1st edition, there has been growth and consolidation (through mergers) within health care systems, the pharmaceutical industry, and community pharmacy, especially within chain pharmacy.
Managed health care has become an increasingly stronger influence on how clinicians practice in an effort to ensure delivery of high-quality but cost conscious care. Patient-centered medical homes and accountable care organizations appear to be promising approaches to achieving higher-quality and cost-effective care while improving medication-related outcomes. Pharmacists will need to be integral members of the collaborative teams within patient-centered medical homes in order to maximize these improvements in patient outcomes.
In 2001, the National Academy of Medicine (NAM; formerly the Institute of Medicine) brought to the nation's attention the gap between the excellent care some patients received and the average care that most patients received. They also reported that our health care system is fragmented and uncoordinated, and that more than 43 million people at that time lacked health insurance. They called upon practitioners, health care organizations, and Congress to address these pressing deficiencies. Although some advances have been made, health care remains poorly coordinated, there are variations in quality, and limited progress has been made in integrating team based approaches. Additionally, medication adverse events continue to contribute to poor quality of care and high costs.
Passage of the Affordable Care Act in 2010 expanded access to health insurance coverage, including medications and medication therapy management. About 90% of Americans now have health insurance, but significant problems remain.
In 1985 spending for prescription drugs in the United States was just over $22 billion. IMS Health Holdings Inc. recently estimated that by 2020, that spending will climb to as high as $400 billion. These numbers do not include the ancillary costs of treatment failure, morbidity, and mortality associated with these drug therapies. Today the increasing cost of new drugs is garnering great media and even Congressional attention, as is the escalating costs of old drugs. Calls are being made for manufacturers to provide transparency in pricing and in some cases to justify pricing based on outcomes achieved.
Extensive efforts are now underway to enhance access to and coordinate electronic health records within and between hospitals, physicians' offices, and pharmacies.
As the health care environment has changed, so too has the pharmacy profession. When the 1st edition of Pharmacotherapy was published in 1988, the Board of Pharmacy Specialties (BPS; formerly called the Board of Pharmaceutical Specialties) had not yet approved Pharmacotherapy as a specialty within pharmacy, although they had acknowledged that the petition for approval of the specialty did document a specialist who did exist within the practice of pharmacy and whose expertise could be differentiated from the performance characteristics of those in general practice. BPS approval came later that year and signified that the pharmacotherapy specialist had taken unprecedented responsibilities in the collaborative management of patient-specific pharmacotherapy problems. That same year BPS recognized Nutrition Support as a specialty within pharmacy practice, bringing the number of recognized specialties to three. Since that time, five more specialties have been approved. Today more than 25,000 pharmacists worldwide are BPS certified.
The 2nd edition of Pharmacotherapy came in the early 1990s when pharmaceutical care emerged as the future mission for pharmacy practice. Pharmaceutical care emphasized the pharmacist's role to accept shared responsibility with other health care professionals for patients' drug therapy outcomes. Also of note, pharmacy practice and specialty practice residency programs were beginning to proliferate. The expansion of residencies in the 1990s and growth in demand for pharmacists in community and hospital settings resulted in substantial increases in pharmacist salaries and a pharmacist workforce shortage.
In 2003, President George W. Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act which provided prescription drug benefits (Medicare Part D) to America's seniors starting in 2006.
In 2004, the Joint Commission of Pharmacy Practitioners and the 11 national pharmacy organizations that comprise its membership endorsed a future vision of pharmacy practice as follows:
Pharmacists will be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes.
Over the course of the last 30 years, pharmacy has matured into a clinical profession. Medication management is no longer provided only by pharmacists in tertiary care settings. Although the transformation is not complete, pharmacists provide evidence-based medi-cation management and immunizations in many primary care and community pharmacy settings, and many pharmacists practice col-laboratively with physicians and other health care professionals.
Today, the pace of entry of new drugs onto the market, limited efficacy, and potential toxicity create great complexity in selection and management of optimal medications for individual patients. Even when treatment guidelines are available for many specific diseases, far too many patients continue to receive suboptimal treatment. A 2000 NAM report documented that in the United States adverse drug effects are the sixth leading cause of death. Overuse of antibiotics and underuse of vaccines continue to challenge practitioners involved in delivery and oversight of drug therapy. These are only a few of the critical challenges that we must continue to address to improve the health of our nation. It is increasingly important that all patients have access to the expertise of a clinically trained pharmacist and that all pharmacists ensure that patients receive the most effective, safe, and economical pharmacotherapy. These contributions to patient care must be shared with other health care professionals and the resulting change in clinical outcomes documented to inform health policy decision makers of the value that pharmacists bring to patient care.
When the 1st edition of Pharmacotherapy was published in 1988, the PharmD was not the entry level degree, and 74 U.S. schools and colleges graduated only about 1000 PharmD graduates (in addition to approximately 5300 BS in pharmacy graduates). In 2015, 125 schools and colleges graduated approximately 14,000 first professional degree PharmD graduates, and 273 post-BS PharmD degrees were also conferred. The pharmacy education enterprise continues to grow, but at a slower pace than in the last decade of the 20th century and the first decade of the 21st century.
In the early 1990s, the American Association of Colleges of Pharmacy Commission to Implement Change in Pharmaceutical Education recommended a process to establish entry-level professional doctoral programs designed to produce graduates competent to provide pharmaceutical care upon entry into the pharmacy profession. The Commission also recommended curricular change to emphasize problem solving, communications, and improved practice skills. Responding to this, many colleges of pharmacy enhanced the practice component of the curriculum and are now delivering a significant portion of the curriculum using a problem-based, active learning format. Many schools and colleges are now experimenting with peer teaching and flipped classrooms. Curriculums continue to evolve to ensure that pharmacy students not only have a good grasp of the pharmaceutical sciences and pharmacotherapy, but that they can also think critically, communicate effectively, solve complex problems, and work effectively in teams.
Pharmacy educators recognize that information about prevention, diagnosis, and treatment is emerging more rapidly than ever before, largely due to our increasing knowledge of pharmacogenetics, pharmacogenomics, proteomics, and bioinformatics. This knowledge and information from other basic sciences will enable greater individualization of treatment and eventually precision medicine. It is very difficult to predict the pace of these advances, but relevant information from these disciplines is continuously being incorporated into the pharmacy curriculum.
The 1st edition of Pharmacotherapy included 111 chapters. In response to many of the advances and challenges noted above, the 10th edition includes 144 chapters. Chapters added to the Foundational Issues section include Medication Safety, Cultural Competency, Health Literacy, Pharmacogenetics, Palliative Care, and Clinical Management of Potential Bioterrorism-related Conditions. Several pedagogical features have also been added to facilitate learning. Recognizing a need to provide students and practitioners a mechanism to grow their clinical problem-solving skills, Pharmacotherapy Casebook: A Patient Focused Approach was introduced as a companion textbook in 1997.
Pharmacotherapy has evolved to provide much more information to support provision of medication management in ambulatory and community pharmacy settings, as pharmacy has evolved into a truly clinical profession. The selection of cases for the Casebook, the Clinical Controversies section, and other features in Pharmacotherapy have been critical in expanding this focus.
As stated in the Preface to the 1st edition, the book's purpose was to "provide a basis of principles and information that reflects the breadth and depth of knowledge appropriate for today's pharmacy student and practitioner. The Preface goes on to explain that "the sections on treatment attempt to place drug therapy in its proper perspective with other modalities" and also that "The pathophysiol-ogy sections are the key to imparting a way of thinking for the developing practitioner." Today, 30 years after those precepts were crafted, they are as true for the 10th edition as they were for the first. Each edition of the book provides the scientific knowledge foundation for the clinician who manages the drug therapy of patients. Building on this foundation, the clinician must stay abreast of new developments and advance his/her competence by interpretation and assimilation of new information in the primary literature.
We believe that over the last 30 years Pharmacotherapy has had a critical role in preparing pharmacy students and those already in practice to become medication managers and to define new clinical roles, thus helping to evolve our profession into a truly clinical one.
Pharmacy practitioners, students, teachers, and researchers must accept responsibility to help expand pharmacists' roles as providers of patient focused, comprehensive medication management. This includes providing the highest quality of care in our own practices and increasing awareness of pharmacists' roles and abilities by government, researchers, third-party payers, and the public. It is clear that we also have a responsibility to continue to define new and innovative models for the provision of medication management in all practice settings, including community pharmacies, community health clinics, managed care settings, and physician practices. Pharmacists will be key players in transformation of our medication use systems. Resources, including pharmacists, must be deployed more efficiently and effectively, taking advantage of their full scope of practice and breadth and depth of education and training. Strong leadership will be required to advance both generalist and specialty practices in pharmacy. Patient care of the future will be patient centered and will use a team based approach. Only when we optimize medication use will we be able to make meaningful improvements in the quality of care and decrease the costs of care. We are confident the evolution and maturation of our profession will not only continue, but that it will gain momentum in the years to come.
Barbara G. Wells
Robert L. Talbert
Gary R. Matzke