Authored by Abdul Kader Mohiuddin*
Abstract
Pharmacy practice has changed significantly lately. The professionals have the chance to contribute straightforwardly to patient consideration so as to lessen morbimortality identified with medication use, promoting wellbeing and preventing diseases. Healthcare organizations worldwide are under substantial pressure from increasing patient demand. Unfortunately, a cure is not always possible particularly in this era of chronic complications, and the role of physicians has become limited to controlling and palliating symptoms. The increasing population of patients with long-term conditions are associated with high levels of morbidity, healthcare costs and GP workloads. Clinical pharmacy took over an aspect of medical care that had been partially abandoned by physicians. Overburdened by patient loads and the explosion of new drugs, physicians turned to pharmacists more and more for drug information, especially within institutional settings. Once relegated to counting and pouring, pharmacists headed institutional reviews of drug utilization and served as consultants to all types of health-care facilities. In addition, when clinical pharmacists are active members of the care team, they enhance proficiency by: Providing critical input on medicine use and dosing. Working with patients to solve problems with their medications and improve compliance.
Keywords: Chronic care; Pharmacy intervention; Diabetes care; CVD prevention; Inflammatory bowel disease
Abbreviations: AACP: American Association of Colleges of Pharmacy; ACPE: Accreditation Council for Pharmacy Education; IDF: International Diabetes Federation; HbA1c: Hemoglobin A1c; IHD: Ischemic Heart Disease; MI: Myocardial Infarction; CHD: Coronary Heart Disease; DALY: Disability- Adjusted Life Year; QoL: Quality of Life; DRPs: Drug Related Problems; IBD: Inflammatory bowel disease; HRT: Hormone replacement therapy; BMD: Bone-Mineral Density; COPD: Chronic Obstructive Pulmonary Disease; LDL-C: LDL cholesterol; GERD: Gastroesophageal Reflux Disease; OSA: Obstructive Sleep Apnea; SCH: Subclinical Hypothyroidism; NAMI: National Alliance on Mental Illness; MDD: Major Depressive Disorder; NMHS: National Mental Health Survey; ABS: Australian Bureau of Statistics; NSMHWB: National Survey of Mental Health and Wellbeing; CHD: Coronary Heart Disease; MH: Mental Health; ADT: Antidepressant Drug Treatment; CANMAT: Canadian Network for Mood and Anxiety Treatments; PES: Psychiatric Emergency Services; DALY: Disability-Adjusted Life Year; DRPs: Drug-Related Problems; VLW: Value of Lost Economic Welfare; ALS: Amyotrophic Lateral Sclerosis; SNRIs: Serotonin and Norepinephrine Reuptake Inhibitors; TCAs: Tricyclic Antidepressants; ASPs: Antimicrobial Stewardship Programs; ESRD: End-Stage Renal Disease; CKD: Chronic Kidney Disease; MSM: Men who have Sex with Men; NSCLC: Non-small-cell lung cancer; ELISA: Enzyme-Linked Immunosorbent Assay; LLS: Leukemia & Lymphoma Society; ALL: Acute Lymphoblastic Leukemia; AML: Acute Myeloid Leukemia; CML: Chronic Myeloid Leukemia; NRT: Nicotine Replacement Therapy; ADT: Androgen Deprivation Therapy; PSA: Prostate Specific Antigen; DRE: Digital Rectal Examination; PSA: Prostate Specific Antigen; FOBT: Fecal Occult Blood Testing; GLOBOCAN: Global Cancer Incidence, Mortality and Prevalence
Background
Clinical pharmacology is a professional discipline that combines basic pharmacology and clinical medicine. A clinical pharmacist offers invaluable support in the development of a final prescription with better patient management and enhanced safety [1]. Its development began in the early 1950s, primarily as a result of the efforts of Harry Gold. Pharmacist rounding with inpatient hospital services has been traced to the University of Kentucky in 1957 [1,2]. Drug therapy was becoming much more complex. Graham Calder pioneered a new role for pharmacists on hospital wards in Aberdeen [3]. The role of clinical pharmacists underwent significant changes from the 1960s through 1990s as their participation in direct patient care enhanced. In the early 1970s, federal funding assisted with greatly expanding clinical pharmacy faculty in Colleges of Pharmacy [4]. Pharmacy education debated where clinical pharmacy fit within pharmacy training. The AACP spearheaded an effort to examine this issue. Till then, two full generations of pharmacists have been educated and trained after the general adoption of the aims of clinical pharmacy [4,5]. ACPE has revised the standards for colleges and schools of pharmacy several times since 2000. ACPE Standards 2016 go into effect July 1, 2016. To some extent, pharmacy took over an aspect of medical care that had been partially abandoned by physicians [6]. Overburdened by patient loads and the explosion of new drugs, physicians turned to pharmacists more and more for drug information, especially within institutional settings. A clinical pharmacist often has a somewhat different approach to the use of drugs and may give valuable supplementary information about for example interactions, during the physician’s decision-making process concerning potential changes of and the follow-up of the medication [7,8]. The concept of pharmaceutical care accentuates the pharmacists’ responsibility to pursue the best possible patient outcomes of therapeutic regimen [9]. They possess in-depth knowledge of medications that is integrated with a foundational understanding of the biomedical, pharmaceutical, socio-behavioral, and clinical sciences [10]. To achieve desired therapeutic goals, the clinical pharmacists follow evidence-based therapeutic guidelines, evolving sciences, emerging technologies, and relevant legal, ethical, social, cultural, economic, and professional precept [11- 13]. In accordance, clinical pharmacists assume responsibility and accountability for managing medication therapy in direct patient care settings, whether practicing independently or in consultation or collaboration with other health care professionals [14,15]. Their functions encompass comprehensive medication management (ie, prescribing, monitoring, and adjustment of medications), nonpharmacologic guidance, and coordination of care. Interdisciplinary collaboration allows pharmacists opportunities to provide direct patient care or consultations by telecommunication in many different clinical environments, including disease management, primary care, or specialty care [16-19]. Pharmacists may manage chronic or acute illnesses associated with endocrine, cardiovascular, respiratory, gastrointestinal, or other systems [20]. Clinical pharmacist researchers generate, disseminate, and apply new knowledge that contributes to improved HRQoL [21-24]. Within the system of health care, clinical pharmacists are experts in the therapeutic use of medications. They consistently provide medication therapy evaluations and endorsements to patients and allied health professionals (AHPs) [25,26]. Clinical pharmacists are a primary source of scientifically accurate/logical information and advice regarding the safe, appropriate, and cost-effective use of medications [27,28]. They obtain medical and medication history, check medication errors including prescription, dispensing and administration errors, identify drug interactions, monitor ADR, suggest individualization of dosage regimen, provide patient counseling, etc. [29-35]. They also provide information about the use of drugs and medical devices like inhaler, insulin pen, eye drops, nasal sprays, etc. [36]. Participation of a clinical pharmacist in ward/ICU rounds and clinical discussions helps to identify, prevent or reduce drug interaction and ADR [29], [37-39] (Figure 1).
Introduction
Population aging has increased the burden of chronic diseases globally. There are both ethical and practical imperatives to address health inequity issues related to chronic disease management for persons with social complexity, existing programs often do not appropriately address the needs of these individuals. This leads to low levels of participation in programs, suboptimal chronic disease management, and higher health-care utilization [40]. Unlike acute conditions, chronic diseases require consistent care and management outside of the healthcare setting, in the community or primary care setting, in terms of medication, lifestyle management, and health behavior modification [41-45]. It is typically a multi-component intervention that includes medication therapy review, patient medication education, medication monitoring, immunizations, disease self-care and support, and/or prescribing authority. Patients who take voluminous medications due to chronic disease have a high risk of drug duplication, interaction, or ADRS, which could result in extended hospital stays and higher costs [46]. To increase the safety and effectiveness of therapeutics, these patients must have specific needs met, with regards to appropriate medication use [47]. Studies have shown that integrating pharmacists into ambulatory clinics can improve chronic disease management and optimal use of medications [48]. Furthermore, pharmacist involvement in patient care may help to curtail inappropriate drug use, specifically in the elderly. A study in Canada saw the proportion of patients receiving an inappropriate medication drop significantly after medication review and optimization by a team that included a pharmacist [49]. Compared to usual care, pharmacist-led care was associated with similar incidences or rates of office, urgent care or ED visits, and hospitalizations and medication adherence, increased the number or dose of medications received and improved study-selected glycemic, blood pressure, and lipid goal attainment [50]. Another recent study shows telehealth-based chronic disease management program including clinical pharmacy specialists imparted statistically significant improvements in diabetes and hypertension outcomes along with clinically significant improvements in the areas of lipid management and tobacco cessation [51].
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