The Evolution of Drug Therapy

Pharmacists, the Elderly and the Changing Health

The Canadian Pharmacists Association (CPhA) represents the interests of Canada’s pharmacists in every practice setting. Our members include community, hospital, consultant, government and industrial pharmacists. The CPhA represents the Canadian pharmacist, not the pharmaceutical industry, not pharmacies, but the profession of pharmacist, wherever pharmacists work.

In addition to advocacy on behalf of pharmacists, CPhA publishes drug and therapeutic information. CPhA is Canada's primary source of prescription and nonprescription drug information – unbiased, critical and comprehensive in a variety of publications and soon in electronic media.

Editor’s Note: We wish to thank the Canadian Pharmacists Association for their contribution of the three-article series, which concludes with the following paper. The information has been insightful and educational, and we are pleased to have been able to present its forwardthinking discussions to our readership.

Our rapidly evolving health care system needs urgent attention to ensure quality, affordable care in the future. Some aspects of health care costs are quickly growing beyond our reach. There are a variety of reasons for this growth. One is our ageing population that requires more care involving medications. Another is the release on the market of expensive new medications. These two factors combine to cause us to spend more on drugs. However the proper use of medications can save considerable costs in other areas of health care. We can keep people healthier and spend less on hospital care or intensive care in long-term care facilities if we manage these resources well.

Medications are a cost effective therapy when used well. Yet despite a growing understanding of this, there is solid evidence pointing to significant waste, inappropriate prescribing, under-treatment of chronic disease and non-adherence to therapy.

Proper care is required to ensure that medications work and that patients get the most from them. Pharmacists, as medication experts, can contribute significantly to improving patient outcomes by delivering care that considers all aspects of drug therapy. There is a growing body of evidence to support this, yet the current system sets up barriers to prevent pharmacists from providing such care.

A pharmacist whose skills and professionalism are fully engaged in optimizing drug therapies might take on duties such as:

• home visits to support elder care
• full medication reviews
• academic detailing to support better prescribing practices by physicians
• providing education and support around management of chronic conditions
• participation in primary health care teams, at first contact or at the beginning of therapy, to advise on prescribing

This paper will look at ways to better integrate pharmacists to achieve positive outcomes. A Snapshot of the Profession and the Practice of Pharmacy in Canada Canadian pharmacists have a minimum of five years of university education, which includes complex courses in pharmacology, microbiology, physiology and anatomy, and applied and clinical healthcare. Pharmacy is the only health profession whose education and knowledge base centres entirely on medications and their use.

Pharmacists practice in many settings, but are found primarily in two: community and hospital, with the majority of pharmacists practicing in community pharmacies.

Community pharmacists tend to be closely tied to the dispensing process, with responsibility for the drug therapy of many patients. Because they are so accessible, they frequently provide over-the-counter (OTC) drug and health advice to patients and drug therapy information to physicians.

Pharmacies are situated in all parts of the country – urban and rural. In some smaller communities in Canada, patients have immediate access to a pharmacist, but not to a physician. Community pharmacists’ main interaction with other health care providers is with physicians.

In hospitals and other institutions, such as long-term care facilities, pharmacists’ primary role is providing therapeutic advice rather than dispensing medications. In these settings, pharmacists are considered essential members of multidisciplinary teams. Besides ensuring the safe supply of drugs to their patients, they provide drug and therapy information and participate in activities such as drug utilization audits.

As pharmacists in institutional settings have redesigned their practice, so too will community pharmacists. Advances in drug and other therapies have contributed to both the increasing complexity of healthcare, as well as the capacity to receive such care outside of the acute care hospital, often in the primary care setting.

We anticipate that the future of primary care pharmacy in Canada will be a hybrid of hospital and community based practice, as it is in Britain. The primary care pharmacist will still be responsible for the dispensing of medications, but because of their unique skills, knowledge and accessibility, they will fully participate in patient care.

The Evolving Landscape

The realities of shifting demographics, availability of new expensive drug therapies and the availability of less public money all combine to necessitate changes to the way we deliver health care. Our choices are limited to how we direct this evolution to ensure we arrive at workable approaches to delivering higher quality care. That there needs to be better collaboration between health care providers is widely accepted. In The Future of Health Care in Canada - Final Report, Commissioner Romanow specifically points to a greater role for pharmacists as a means to achieving better patient outcomes:

“...pharmacists can play an increasingly important role as part of the primary health care team, working with patients to ensure they are using medications appropriately and providing information to both physicians and patients, monitor patients’ use of drugs and provide better information and communication on prescription drugs.”

The benefit to prescribers of better integration of pharmacists is easy access to quality drug and prescribing information. Patients gain by having a dedicated professional to work with them to make sure their medication works properly and is the best fit from all the medications available.

The Evolving Landscape: The Barriers

The role most people associate with a pharmacist is that of medication dispenser. Unless the system moves beyond this lone association, the potential benefits derived from fully engaging pharmacists’ expertise will be missed. Pharmacists have a more important role meeting the needs of their patients as the medication management expert.

CPhA defines medication management as a strategy that attempts to use drug therapy more efficiently to achieve definite outcomes that improve a patient's quality of life. Medication management in primary health care requires a reorientation of pharmacists and other providers toward effective drug therapy outcomes. It is a set of relationships and decisions through which primary health care practitioners and their patients work together to design, implement and monitor a therapeutic plan that will produce specific drug therapy outcomes.

Increased drug expenditures, combined with health care reforms and a growing recognition of the positive impact pharmacists can have on patient care, has lead to a dramatic increase in the demand for pharmacists and their services. While the community pharmacist may be the most accessible health care provider for the public, in reality, they are often the provider furthest removed from the rest of the health care team. There are multiple barriers to providing fully integrated care.

One major barrier for pharmacists is the lack of access to the full patient record. Community pharmacists have inadequate access to the diagnosis, medical and drug history, laboratory values and drug history of their patients, which is not the case in the hospital or long-term care setting. The information is critical to optimizing the role of the pharmacist in primary health care.

The lack of electronic health records integrated with pharmacy information systems (and also electronic hospital records) is a barrier to communication and collaboration between the pharmacist and the rest of the primary health care team. Community pharmacists must have access to their patients’ full medical records. They must also be able to order and monitor laboratory and other diagnostic tests as independent providers. Otherwise, pharmacists are being asked to make decisions and provide care without adequate - and in some cases, any information.

There are other barriers to implementing change. For pharmacists, these include:

• Outdated compensation schemes. Generally speaking, in the community setting, pharmacists are currently paid a fee for each prescription dispensed. This fee for service model of payment discourages collaboration with other providers and the expansion of medication management.
• Professional shortages. There is a shortage of pharmacists in Canada that is having an impact on patient care in both the community and hospital setting.
• Necessary changes to legislation and practice models. Governments must implement changes so pharmacies can become health consultation centres, either through public or private initiatives, allowing the pharmacist’s role to be more of a consulting nature. They must be given the “authority” to provide services such as physical assessment and the immunization of patients.

Removing the Barriers

CPhA has led ongoing efforts to educate stakeholders about the need to incorporate pharmacists more fully into the system. These discussions include looking at a variety of new payment models, coordinating and encouraging research, working with various agencies on broad research projects, such as Human Resources Development Canada, that will allow us to understand issues like demographics and training practices that contribute to or, on the other hand, might ease pharmacist shortages.

CPhA and provincial pharmacists’ associations have been advocating to governments for changes in public health management from the ground up so that pharmacists are viewed as a necessary player on primary health care teams. CPhA has lobbied in support of the creation of the new Public Health Agency, we supported the creation of the new National Health Council and worked to ensure that a pharmacist was part of the Council. We actively participate in various coalition activities ranging from committees that make recommendations on more effective patient safety measures to lobbying jointly with the Canadian Medical Association, the Canadian Healthcare Association and the Canadian Nurses Association for better funding of the health care system in order to meet shared objectives. Where legislative challenges exist we lobby in conjunction with our provincial counterparts for a better interpretation of the regulations that might prohibit pharmacists from participating in better patient care. From the pharmacists’ perspective, we have created continuing education courses to support pharmacists in their efforts to achieve better patient care models. We conduct research in a variety of areas to ensure that our practice models are effective and to ensure that we contribute to the body of evidence that supports a better and more effective role for pharmacists.

The Evidence of the Value of the Pharmacist

The benefits of clinical pharmacy services have been proven in a number of clinical trials that have shown that pharmacists can play a key role in disease management models for anticoagulation treatment, hypertension, cholesterol management, asthma, and other chronic conditions.

Community pharmacists working in partnership with patients and physicians had a major beneficial impact on cholesterol risk management, according to the results of a Canadian study. The purpose of the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP) was to evaluate the efficacy of a program of intervention by community pharmacists to improve the cholesterol management in patients at high risk of cardiovascular events. A total of 675 patients were enrolled from 54 community pharmacies. Patients received either usual care or intervention by a pharmacist.

The study was stopped early due to the overwhelming benefit seen in the intervention group. The study demonstrated the value of the pharmacist in improving disease and drug therapy management.

The BC Community Asthma Study demonstrated that an enhanced pharmacist-based asthma education program based on the principles of medication management (responsibility for outcomes and increased patient involvement) significantly improved clinical and economic outcomes in patients. The study showed that pharmacists can improve the quality of life for their patients with asthma.

In a British study, pharmacists conducted medication reviews with elderly patients to identify potentially appropriate repeat prescriptions. The study indicated that pharmacists can effectively and safely manage repeat prescriptions while reducing costs and not adversely affecting the workload of physicians. Review by a pharmacist resulted in more drug changes and lower prescription costs. There was a slight decrease in mortality among patients who were assigned to the pharmacists’ intervention group.

Other studies have confirmed the important role of pharmacists in primary care settings. An American study compared pharmacist managed anti-coagulation services to usual medical care. Patients cared for by pharmacists had fewer emergency room visits and hospitalizations. There was improved patient safety and decreased overall costs to the health care system. Another American study conducted in a medically underserved rural area of the country concluded that medication management as provided by pharmacists improved the quality of prescribing, enhanced disease management and patient safety, improved medication compliance without adversely affecting quality of life.

Conclusion

By incorporating the pharmacist in all aspects of care, patients will receive better health care and the system will spend less money to provide that better care.

The evidence is there; it’s time to act. The challenge now is twofold:

1. Governments must take the pharmacists’ proven professional services and develop policies and programs that incorporate them into multidisciplinary primary health care settings as a standard of care.
2. All health care providers must work together in a spirit of cooperation as models of collaboration are developed. Otherwise, energy is wasted on the debate and not focused on supporting the evolution of a system that works in the best interest of patients.