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Medication management services are a response to a problem. Although the term is relatively new, the problem is not. The problem of medication-related morbidity and mortality has been with us as long as drug therapy has been in use; however, the problem has grown to such a magnitude that something now must be done to address it.

Consider the following scenario:

The next time you are driving down the road and an ambulance goes by with its sirens loudly screaming and its lights brightly flashing—stop and think what you might have done to prevent the victim inside from needing that trip to the hospital. Ask yourself: was there some aspect of his drug therapy that I could have changed in order to prevent the need for that ambulance ride? Probably! Likely!!

In fact, it is very likely that the patient in the ambulance is on the way to a drug-related hospitalization. One in four hospitalizations is due to a drug therapy problem1. What we find even more interesting is that the vast majority of these drug-related hospitalizations are preventable.1–4 Do the math. One out of every six admissions to a hospital is caused by a preventable drug therapy problem. The most common classes of drugs associated with drug-related hospitalizations are cardiovascular agents, anticoagulants, hypoglycemic agents, and anti-inflammatory agents.

In the ambulatory setting, the stories are similar.5 Over 27% of adverse drug events in elderly patients are preventable. In 2006, the drugs most commonly involved include cardiovascular agents, diuretics, analgesics, hypoglycemics, and anticoagulants. That same year, a report describing the over 700,000 patients brought to the emergency department because of a drug-related problem described the drugs most commonly involved.6 The list will sound familiar: warfarin, insulin, nonsteroidal anti-inflammatory drugs, and digoxin.7,8 None of these drug products is new. There is little about their pharmacology that we do not know. In fact, we can measure concentrations and calculate individualized doses of three of the drugs most commonly involved in emergency department visits. These three drugs (warfarin, insulin, and digoxin) have a narrow, but known therapeutic index, yet they are involved in one-third of the emergency departments' adverse drug events in the United States. A large part of the public health burden of adverse drug events is attributable to “older drugs, used poorly.” How much longer are we going to continue to use these very effective drugs “poorly”?

In the patients over 65 years of age, we spend over $201 billion per year due to adverse drug events (50% of which are preventable).9 Over 40% of these patients are readmitted to hospital within 1 year.10,11 This is a substantial opportunity for practitioners who have the skills and knowledge to bring order and a rational approach to the use of medications throughout our health care systems. The impact that we can have on the health of our patients, our friends, and even our families is enormous.

The problem, its causes and its solutions, are multidimensional so it has been difficult to identify a solution that can make a significant difference to the patient and/or the health care system. In fact, little that has been done over the past three decades has improved the situation. In 1991 (2 decades ago), a group from Utah published their findings of 52 hospitalizations due to adverse drug events.12 These events more than doubled the patient's hospital stay. Similarly, most emergency hospitalizations for adverse drug events in older adults are caused by a few commonly used medications (warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents).13 We are old enough to remember the first set of results from the Boston Collaborative Drug Surveillance program over 35 years ago.14 The drugs most often involved in adverse outcomes back then were the same as those being reported today.

It is clear that we need a new practitioner who can apply new practice standards that allow them to contribute meaningfully to appropriate, effective, safe, and convenient drug therapy for all patients. Pharmaceutical care practice standards can create a continuum of high-quality care for patients from research through practice because these standards bring rational solutions to managing the benefits and risks of medication use.15

We remain convinced that medication management services offer a rational solution to this problem. Behind these services is a lengthy history of research, education, and practice, which show that medication management services are a valuable solution to the suffering and pain caused by the inappropriate use of medications. The patient-centered approach, combined with an orderly, logical, rational decision-making process assessing the indication, effectiveness, safety, and adherence of all of a patient's drug therapies has a measurable positive impact on the outcomes of drug therapy.

It is time to make a change. Indeed, positive change is long overdue! This change requires a community of practitioners to stop watching ambulances scurry by and take seriously the philosophy of pharmaceutical care practice, thus accepting the responsibility for the outcomes of drug therapies—good or bad—and to identify, resolve, and prevent drug therapy problems. Only by individual practitioners seeing and providing care for one patient at a time will we finally have the positive impact on overall outcomes of drug therapy that our patients expect and deserve.

This book is written for the purpose of facilitating this change. The book describes medication management services and explains their evolution. The book describes how a practitioner delivers the service and it provides a vision of how these services “fit” into the evolving health care structures. This is accomplished by bringing together medication management services and the professional practice that serves as its foundation, pharmaceutical care practice. The book is organized in the following manner.

Chapter 1 provides an overview of medication management services; what they are, how they developed, why they are needed, the value of the services and how the services are delivered in practice.

Chapter 2 establishes the professional practice of pharmaceutical care as the foundation for medication management services. Chapter 3 explains why the philosophy of pharmaceutical care practice is necessary and why it plays such a significant role in a patient care practice.

Chapter 4 explains the centrality of patient-centeredness to medication management services. Although the term patient-centeredness is used frequently today, we describe the specific meaning it has to a patient's medication experience and adherence behavior.

Chapters 5 through 8 provide a detailed description of how to provide medication management services in a patient-centered manner through the professional practice of pharmaceutical care. Pharmaceutical care is the ethical, clinical, and legal foundation for the delivery of comprehensive medication management services. This section starts with understanding how a patient's medication experience can change our way of thinking about adherence and why the medication experience must be the starting point for any quality medication management service. A quality service includes a comprehensive assessment, a personalized care plan, and timely follow-up evaluations. Chapter 9 explains how this patient care process is best documented.

Chapter 10 describes the skills and knowledge required to prepare qualified practitioners who are able to deliver a patient-centered medication management service.

Chapter 11 changes the focus from the individual practitioner providing pharmaceutical care to how medication management services can be established and managed within the health care system.

Chapter 12 consists of contributed authors from around the world who discuss pharmaceutical care practice and the development of medication management services in each of their geographic areas. The authors explain the local origin of the services and the current adoption level for these services. In addition, there is a discussion of how these services can be disseminated on a large scale in the future, given the cultural, political, and social structures in place.

This book is written for health care practitioners and those involved in the many aspects of our health care systems. The purpose of the book is to provide the basic information necessary to establish, support, deliver and maintain medication management services. Within the context of medication management services drug therapy can be experienced as intended and can achieve the goals of therapy essential to the highest level of optimal clinical outcomes, and directly contribute to improving the patient's quality of life. These goals are well within our reach, now we need both individual and collective resolve to move forward and seize every opportunity to develop and implement medication management services. Patients deserve no less!

Robert J. Cipolle, PharmD
Linda M. Strand, PharmD, PhD, DSc (Hon)
Peter C. Morley, PhD

References

1. Samoy LJ, Zed PJ, Wilbur K, Balen RM, Abu-Laban RB, Roberts M. Drug-related hospitalizations in a tertiary care internal medicine service of a Canadian hospital: a prospective study. Pharmacotherapy. 2006;26(11):1578–1586.

2. Patel KJ, Kedia MS, Bajpai D, Mehta SS, Kshirsagar NA, Gogtay NJ. Evaluation of the prevalence and economic burden of adverse drug reactions presenting to the medical emergency department of a tertiary referral centre: a prospective study. Br J Clin Pharmacol. 2007;7:8.

3. Howard RL, Avery AJ, Slavenburg S, et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol. 2007;63(2):136–147.

4. Leendertse AJ, Egberts AC, Stoker LJ, van den Bemt PM. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med. 2008;168(17):1890–1896.

5. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556–1564.

6. Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755–765.

7. Zhang M, Holman CDJ, Price SD, Sanfilippo FM, Preen DB, Bulsara MK. Comorbidity and repeat admission to hospital for adverse drug reactions in older adults: retrospective cohort study. Br Med J. 2009;338: a2752. doi:10.1136/bmj.a2752.

8. Zhang M, Holman CDJ, Preen DB, Brameld K. Repeat adverse drug reactions causing hospitalization in older Australians: a population-based longitudinal study 1980-2003. Br J Clin Pharmacol. 2006;63(2):163–170.

9. Clark TR. Startling Statistics About Seniors and Medication Use. Alexandria: American Society of Consultant Pharmacists; 2008.

10. Davies EC, Green CF, Mottram DR, Rowe PH, Pirmohamed M. Emergency re-admissions to hospital due to adverse drug reactions within 1 year of the index admission. Br J Clin Pharmacol. 2010;70(5):749–755.

11. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428.

12. Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266(20):2847–2851.

13. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–2012.

14. Miller RR. Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program. Arch Intern Med. 1974;134(2):219–223.

15. Cipolle CL, Cipolle RJ, Strand LM. Consistent standards in medication use: the need to care for patients from research to practice. J Am Pharm Assoc. 2006;46(2):205–212.

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