What is ‘pharmaceutical care’ in 2013?
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- van Mil, J.W.F. & Fernandez-Llimos, F. Int J Clin Pharm (2013) 35: 1. doi:10.1007/s11096-012-9728-x
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Since 1990, the question ‘What is pharmaceutical care’ was usually answered with Hepler and Strand’s definition: “Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life” . Nonetheless, already since 1990 some debate existed about different elements in this definition, and also different understandings on how this definition links in with the professional mission of the pharmacist.
In further statements, consensus meetings, or position papers, attempts were made to clarify the controversies around the definition. More than 20 years should be enough to analyse the definition and its different elements in depth, and (why not) even the term. But questions still remain. In this joint editorial, we cannot provide solutions but we can formulate some questions that may help in the clarification process.
Does “the responsible provision of drug therapy” mean that pharmaceutical care is necessarily associated with the provision, (or dispensing) of drugs (medicines)? When the term medication therapy management (MTM) was introduced in the US as a substitute for the term pharmaceutical care, a consensus group stated in the definition that MTM services “are independent of, but can occur in conjunction with, the provision of a medication product” . This could mean that medication therapy management is not identical to pharmaceutical care, or we should consider provision of drug therapy not as identical to the provision of a medication product. Otherwise the introduction of a new term was not necessary, or indeed undesirable. And this leads to another question: is the provision of drug therapy than something pharmacists do?
Does “the purpose of achieving definite outcomes” limit the process of pharmaceutical care to outcome oriented activities only? Or, in other words, following Donadedian’s SPO paradigm , should we consider that services focused on improving the use of medicines, obviously with the ultimate aim of improving health outcomes (but not immediately directed to them), are part of ‘pharmaceutical care’? This would exclude services devoted to, for instance, improving patients’ medication adherence or medication-related health literacy, which most probably improve the outcomes as well, but indirectly.
Does the aim to “improve a patient’s quality of life” mean that pharmaceutical care is not implemented to improve clinical or economic outcomes, following Kozma’s ECHO model , or does the definition refer to the remote aim? We should keep in mind that improving clinical aspects may sometimes improve (or maintain) humanistic outcomes, like quality of life, but not necessarily. Care may also prolong life, even when it does not affect its quality. Improving economic outcomes might sometimes even imply that the humanistic outcomes are neglected.
And then, should ‘pharmaceutical care’ always be associated with the existence of medicine treatment in a given patient? Should we therefore perhaps exclude educational activities or health promotion activities performed by pharmacists from the scope of the ‘pharmaceutical care’? Are other pharmacist activities that are not necessarily associated with medicines parts of the concept, like smoking cessation programs, condom use promotion, needle exchange, or disease screenings? In other words, is it care by the pharmacist, or care around pharmaceuticals.
Thus, we finally reach the last point where we wonder, is pharmaceutical care a ‘pharmacist-only’ activity? This question could be split into two different elements for the discussion: may or can other (medical) professionals provide ‘pharmaceutical care’ services? This is a question that we already asked in 2003, and has still not been resolved . Should we consider the term ‘pharmacist care’ as an alternative or an equivalent? The latter term also appeared in studies published in major medical journals , or in some recent articles in pharmacy journals . This is not a simple word change, because ‘pharmaceutical’ is usually associated with the medicinal product and not with the professional. This same issue led in 2002 to the name change of the American Pharmaceutical Association to American Pharmacists Association .
Using dictionaries or on-line thesauruses does not help us to solve this part of the terminology problem. The main biomedical thesaurus, the MeSH database, defines ‘nursing care’ as “Care given to patients by nursing service personnel”. But it defines ‘dental care’ as “The total of dental diagnostic, preventive, and restorative services provided to meet the needs of a patient”. Unfortunately, ‘pharmaceutical care’ was never considered for inclusion in this controlled vocabulary dictionary, in spite of several requests.
Accepting the challenge to answer the above questions may help us to have a clearer picture of what pharmaceutical care actually is, anno 2013.