Identifying and Resolving Drug-Related Issues through the Iowa Medicaid Case Management Program

Presenter: William R. Doucette, Ph.D.

Institution: University of Iowa

Co-Authors: Randal P McDonough, Pharm.D., Barry Carter, Pharm.D., Elizabeth A. Chrischilles, Ph.D., and Donald Klepser, M.B.A.

Introduction: Drug therapy can present safety issues for ambulatory patients taking multiple medications. Iowa Medicaid has initiated a pharmaceutical case management (PCM) program in which community pharmacists and physicians work together to manage the drug therapy for ambulatory patients taking at least four chronic medications. The objective of this study was to describe the drug-related issues identified at one pharmacy during the first year of the PCM program. After an initial assessment, pharmacists make written recommendations to the patient’s physician. Recommendations that are accepted by the physician constitute an action plan, which can be modified through follow-up actions.

Methods: Data were abstracted from pharmacy records for 153 patients who had at least one documented PCM visit during the first year of the PCM program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, pharmacist recommendations, and physician acceptance of recommendations. Frequencies and descriptive statistics were calculated for the variables.

Results: The patients had an average age of 54.2 (SD=19.3) years and about 74 percent were female. They were taking a mean of 9.3 (SD=4.5) medications and had 6.2 (SD=2.9) medical conditions at enrollment. During the twelve months, a total of 901 drug-related issues were classified into nine categories: inappropriate compliance (25.8%), needs additional therapy (22.2%), wrong drug (13.5%), unnecessary drug therapy (12.6%), adverse drug reaction (10.9%), dosage too low (9.4%), dosage too high (5.2%), drug duplication (0.3%), and drug interaction (0.1%). Physicians accepted 323 of the 672 (48.1%) recommendations made by pharmacists regarding the drug-related issues. Specifically, pursuant to a pharmacist’s recommendation physicians changed dosage 87 times (49.7%), added a medication 74 times (42.1%), changed to a different medication 84 times (50.6%), and stopped a medication 74 times (50.3%).

Discussion: These findings show that medication safety for ambulatory patients taking multiple medications can be improved through collaboration between physicians and pharmacists. Because these patients often visit multiple physicians, a community pharmacist may have a more complete view of a patient’s drug therapy than an individual physician. However, community pharmacists often are lacking information that physicians have such as diagnoses and medical history. By working together, physicians and pharmacists can improve the safety of patients taking multiple medications. Further study of physician-pharmacist coordinated care models such as the PCM program is needed. Also, physicians and pharmacists likely would benefit from continuing education that contains joint case work-ups in which both types of practitioners bring their clinical perspectives and expertise to the discussion.