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?
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
. 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
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
) 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
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
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
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
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
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.
describes the skills and knowledge required to prepare qualified
practitioners who are able to deliver a patient-centered medication
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,
Linda M. Strand, PharmD, PhD, DSc (Hon)
Peter C. Morley,
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.
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.
Howard RL, Avery AJ, Slavenburg S, et al. Which drugs cause preventable
admissions to hospital? A systematic review. Br J Clin Pharmacol.
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
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory
care. N Engl J Med.
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.
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.
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.
9. Clark TR. Startling Statistics About Seniors and
Alexandria: American Society of Consultant Pharmacists;
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.
11. Jencks SF, Williams
MV, Coleman EA. Rehospitalizations among patients in the Medicare
fee-for-service program. N Engl J Med.
12. Classen DC, Pestotnik SL, Evans RS, Burke JP.
Computerized surveillance of adverse drug events in hospital patients. JAMA.
13. Budnitz DS,
Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse
drug events in older Americans. N Engl J Med.
14. Miller RR. Hospital admissions due to adverse drug
reactions: a report from the Boston Collaborative Drug Surveillance Program.
Arch Intern Med.
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