Geer Mohammad Ishaq* Ph.D., Mir Javed Iqbal* B.Pharm., Parvaiz A. Koul** M.D.
*Deptt. of Pharmaceutical Sciences, University of Kashmir
**Deptt. of Internal and Pulmonary Medicine, SKIMS, Srinagar
Pharmaceutical Care is a patient-centered, outcome-oriented pharmacy practice that requires the qualified pharmacist to work in concert with the patient and the patient's other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective. The goal of Pharmaceutical Care is to optimize the patient's health-related quality of life and achieve positive clinical outcomes. The pharmacist in the contemporary template is one who provides a vital connect between the health sciences and the pharmaceutical world. Their work in the medical field has become multifaceted, extending from the manufacturing of quality medicines, to the delivery of pharmaceutical care to patients. Pharmaceutical care entails the work of addressing a patient's medication related needs. The involvement of the pharmacist in India in this regard has been somewhat restricted, contrary to trends in developed countries. While seeking medical help, people think of a doctor or a nurse or a medical technician, but seldom does a pharmacist come to mind. This needs correction. Nowadays medicine options have multiplied manifold thus raising the complexity of therapies. Pharmacists have a unique role to play in evaluating these options. Within the team of healthcare professionals, trained pharmacists would have the knowledge and skills to prevent, detect, monitor, and resolve medicine related problems. As the public demands more information on medicines and their effects, to make more informed decisions, pharmacists will have to take on a more pro-active role in patient counseling1.
Defining Pharmaceutical Care
Hepler and Strand2 defined Pharmaceutical care in 1990 as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. These outcomes include cure of disease; elimination or reduction of a patient's symptomatology; arresting or slowing a disease process; or preventing a disease or symptomatology. Thus Pharmaceutical Care involves four major functions by a pharmacy practitioner on behalf of the patient viz., identifying potential and actual drug-related problems; addressing needs and resolving actual drug related problems; preventing potential drug-related problems and optimizing patient therapy outcomes.
Of late Cipolle and his colleagues3 have redefined Pharmaceutical Care as “a practice in which the pharmacy practitioner takes responsibility for a patient’s drug-related needs and is held accountable for this commitment”. The pharmaceutical care practitioner assures that all of a patient's drug therapy is used appropriately for each medical condition; the most effective drug therapy available is used; the safest drug therapy possible is used, and the patient is able and willing to take the medication as intended. The Pharmacotherapy Workup is the rational thought process that is used by pharmaceutical care practitioners to make drug therapy decisions.
Definition given by Cipolle et al has three components viz. a philosophy of practice; a patient care process, and a practice management system. Most major pharmacy organizations in developed countries e.g., the American Pharmaceutical Association (AphA)4 and the American Society of Health- System Pharmacists5 have since adopted the pharmaceutical care philosophy. ASHP believes that, to ensure proper coordination of patients’ medication therapies, health care systems must be designed to enable, foster, and facilitate communication and collaboration among health care providers.
More recently, in the year 2009, International Pharmaceutical Federation (FIP)6 defined Pharmaceutical Care as, “the responsible provision of pharmacotherapy for the purpose of achieving definite outcomes that improve or maintain a patient’s quality of life. It is a collaborative process that aims to prevent or identify and solve medicinal product and health-related problems. This is a continuous quality improvement process for the use of medicinal products”. Thus Pharmaceutical Care management is a modern approach towards providing seamless and integrated health care through collaboration with pharmacy practitioners.
What is it all about?
Pharmaceutical care is a ground-breaking concept in the practice of pharmacy which emerged in 1990s. It stipulates that all practitioners should assume responsibility for the outcomes of drug therapy in their patients. It encompasses a variety of services and functions – some new to pharmacy, others traditional – which are determined and provided by the pharmacists serving individual patients. The concept of pharmaceutical care also includes emotional commitment to the welfare of patients as individuals who require and deserve pharmacists’ compassion, concern and trust. However, pharmacists often fail to accept responsibility for this extent of care. As a result, they may not adequately document, monitor and review the care given. Accepting such responsibility is essential to the practice of pharmaceutical care7.
Over the past four decades there has been a trend for pharmacy practice to move away from its original focus on medicine supply towards a more inclusive focus on patient care. The role of the pharmacist has evolved from that of a compounder and supplier of pharmaceutical products towards that of a provider of services and information and ultimately that of a provider of patient care. Increasingly, the pharmacist’s task is to ensure that a patient’s drug therapy is appropriately indicated, the most effective available, the safest possible, and convenient for the patient. By taking direct responsibility for individual patient’s medicine-related needs, pharmacists can make a unique contribution to the outcome of drug therapy and to their patients’ quality of life.
The practice of pharmaceutical care is new, in contrast to what pharmacists have been doing for years. Because pharmacists often fail to assume responsibility for this care, they may not adequately document, monitor and review the care given. Accepting such responsibility is essential to the practice of pharmaceutical care. In order to fulfill this obligation, the pharmacist needs to be able to assume many different functions. The concept of the seven-star pharmacist, introduced by WHO and taken up by FIP in 2000 in its policy statement on Good Pharmacy Practice, sees the pharmacist as a caregiver, communicator, decision-maker, teacher, life-long learner, leader and manager8.
What are its objectives?
Main objectives of Pharmaceutical Care revolve around four areas of drug therapy management viz., Indication, Effectiveness, Safety and Compliance to drug therapy and include:
To evaluate drug related needs of the patients
To identify actual and potential drug-related problems among the patients.
To resolve the actual drug-related problems and prevent potential problems from becoming actual problems.
To work with physicians and patients in designing, implementing and monitoring
an appropriate care plan.
To make suggestions for any interventions about drug use, whenever required.
To offer education and counseling services to patients with a view to
optimize therapeutic outcome.
Global Scenario
Pharmaceutical care started in the nineties in the United States and has rapidly extended in many other countries. The present meaning of pharmaceutical care evolved from a term, defined in 1975 by Mikeal et al10 as a subset of medical care, using an analogous definitional format as medical care. It was Brodie11, who developed this concept by including in it the drug needs for a given patient and the provision, not only of the required drugs but also of the services needed for safe and effective therapy, in an environment of changing societal purpose of pharmacy12 and in 1990, Hepler and Strand2 defined pharmaceutical care as “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life”
Pharmaceutical care is a generalist practice which has evolved from many years of research that can be applied in all settings: community, hospital, long-term care, and the clinic. It can be used to care for all types of patients with all types of diseases taking any type of drug therapy. Pharmaceutical Care practitioner is not intended to replace the physician, the dispensing pharmacist, nurse or any other health care practitioner. Rather, the pharmacy practitioner is a new patient care provider within the health care system2.
The principal elements of pharmaceutical care are9 that it is medication related; it is care that is directly provided to the patient; it is provided to produce definite outcomes; these outcomes are intended to improve the patient’s quality of life; and the provider accepts personal responsibility for the outcomes.
The Pharmaceutical care is a much needed service as it has direct impact on quality of healthcare and supports audit of outcome of the treatments. One huge study in America involving approximately 1000 hospitals showed that as the number of clinical pharmacists per occupied bed increased mortality, drug costs, total costs of care and length of stay were reduced13. The adoption of Pharmaceutical Care Practice in clinical and community setting is the need of the hour. There is a tremendous scope for the upcoming pharmacists to practice the profession which not only ensures efficacy but also safety of therapy. The benefits of pharmaceutical care have been illustrated in a number of studies worldwide.
Indian Scenario
India is a country with significant problems in medication use, but until recently Indian pharmacists have not been properly educated for a patient-care role14. Clinical Pharmacy on the whole has so far remained neglected within India and there has been resistance on part of the medical professionals to accept the fact that pharmacists too have a clinical role. There has also been reluctance on part of pharmacists themselves towards assuming such clinical role and responsibilities. However this dismal scenario has started undergoing promising changes in the recent past. Many hospitals across India have of late initiated clinical pharmacy and pharmaceutical care services and this step has already started showing positive results. In a six-month long, prospective, open-label study conducted at three primary health centers of a southern Indian district of Tamil Nadu to evaluate the impact of pharmaceutical care on the clinical outcomes of patients enrolled in a pharmacist-coordinated diabetes management program, effective improvement was seen in the clinical outcome and health-related quality of life of diabetes patients in rural India15. Association of Community Pharmacists of India also took an initiative to establish Pharmaceutical Care Clinic at Chinchwad, Pune, first of its kind in India in the year 200916. In another study that was conducted on 115 patients admitted in General Medicine ward of a 1700 bedded tertiary care teaching hospital in South India, to identify and resolve drug-therapy related problems through pharmaceutical care, it was demonstrated that a pharmacist can identify drug related problems and other pharmaceutical care related issues and resolve them by his timely interventions, thereby playing a pivotal role in promoting patient care17.
Status in J&K
Clinical Pharmacy on the whole is in its infancy in the state of Jammu and Kashmir and the concept of Pharmaceutical Care is completely new to most of the physicians, nurses and even pharmacists presently working at the government health facilities. As a result of the patient overload of physicians and some other reasons, they are not in a position to offer detailed counseling, patient education and pharmaceutical care services on individual basis to all their patients. Therefore it is for the trained pharmacy practitioners to step in and fill the void by offering such services with a view to achieve definite therapeutic outcomes that improve a patient’s quality of life. Overall goal is to optimize the therapeutic outcome management and decrease the burden of five D’s viz, death, disease, disability, discomfort and dissatisfaction among patients. Clinical, economic and humanistic outcomes will also shift towards the positive side as a result of these integrated and seamless healthcare services rendered by a pharmacy practitioner.
Therefore need of the hour is to design, implement and monitor models aimed at providing Pharmaceutical Care services to our patients at primary, secondary and tertiary care level so that there is a transition in the focus of the qualified and pharmacists from bench side to bed side and from product to patient for the greater benefit of the patients at large. Pharmaceutical Care being a patient-oriented service will pave way for pharmacist involvement in providing patient education and counseling services, monitoring drug therapy and suggesting interventions wherever required, reporting ADRs and drug interactions, supplying drug information to physicians and nurses, conducting drug-utilization evaluation studies, preparing monographs and hospital formularies and in providing poison control services. Ultimate aim of all these services is only one and that is to optimize the clinical outcomes and thereby improve patient’s health-related quality of life.
REFERENCES:
1. Excerpts from the speech delivered by her Excellency the president of India, Shrimati Pratibha Devi singh Patil at the inauguration of the National Seminar on Recent Trends in Pharmacy Education and Practice, held at New Delhi on 9th of July 2010. (Accessed at http://presidentofindia.nic.in/sp090710.html, retrieved on 28.05.2011)
2. Hepler C,Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47:533-43.
3. Cipolle RJ,Strand LM,Morley PC.Pharmaceutical Care Practice.McGraw-Hill,New York. 1998.
4. American Pharmaceutical Association.An AphA White Paper on the Role of the Pharmacist in Comprehensive Medication Use Management: The Delivery of Pharmaceutical Care. American Pharmaceutical Association, Washington, DC, 1992.
5. American Society of Hospital Pharmacists. ASHP statement on phamaceutical care. Am J Hosp Pharm 1993;50:1720-23.
6.International Pharmaceutical Federation FIP Statement of professional standards- pharmaceutical care http://www.fip.org (retrieved September 1,2009).
7.Developing Pharmacy Practice-A focus on patient care. FIP Handbook 2006 Edition WHO/PSM/PAR/2006.5
8.The role of the pharmacist in the health care system.Preparing the future pharmacist: Curricular development.Report of a third WHO Consultative Group on the role of the pharmacist,Vancouver,Canada, 27–29 August 1997. Geneva: World Health Organization; 1997.WHO/PHARM/97/599.Availableat:http://www.who.int/medicinedocs/
9.Medication therapy and patient care: organization and delivery of services-guidelines. ASHP guidelines on a standardized method for Pharmaceutical Care,Pharmacist-conducted patient education and counseling and documenting pharmaceutical care in patient medical records. (Retrieved from http://www.ashp.org/Import/PRACTICEANDPOLICY/PolicyPositionsGuidelinesBestPractices/BrowsebyTopic/MedicationTherapyandPatientCare.aspx Accessed on 28.05.2011)
10.Mikeal RL,Brown TR,Lazarus HL,Vinson C.Quality of Pharmaceutical care in hospitals. Am J Hosp Pharm 1975;32:567-74
11.Brodie DC.Drug Use Control: keystone to pharmaceutical service.Drug Intell Clin Pharm 1967;1:63-65.
12.Brodie DC. Pharmacy’s societal purpose. Am J Hosp Pharm 1981;38:1893-986.
13.Bond C A, Raehl C L,Franke t.Interrelationships among mortality rates, drug costs, total costs of care and length of stay in United States hospital, summary and recommendations for clinical pharmacy services and staffing. Pharmacotherapy 2001;21:129-41
14.Parthasarthi G, Ramesh M, Hansen KN, Nagavi BG. Clinical pharmacy in a South Indian teaching hospital. Ann Pharmacotherapy 2002; 36(5): 927-32.
15.Arun KP, Murugan R, Kanna MR, Rajalakshmi S, Kalaiselvi R, Komathi V. The impact of pharmaceutical care on the clinical outcome of diabetes mellitus among a rural patient population. Int J Diabetes Dev Ctries 2008; 28(1): 15-18.
16.Inauguration of Pharmaceutical Care Clinic for patient safety and therapeutic efficacy For chronic diseases management, drug information and pharmacoeconomics. Intl Journ Comm Pharm 2009; 2(3):1-4.
17.Kannan G, Janardhan V, Rani V, Thennarasu P, Kumar A, Reddy UM. Pharmaceutical care in the general medicine ward of a tertiary care hospital in South India. J Pharmacy Res 2011; 4(5): 1467-69.
