History And Evolution Of Pharmaceutical Care (PC)

Pharmaceutical care is one of the evolved practices of pharmacy. It did not start today. There has been a series of reformations to the practice that gave birth to pharmaceutical care. The history and evolution of pharmacy practice in the United States of America (USA) has greatly influenced what we see today of the profession. Pharmacy practice in the USA as of today is representative of the most advanced in the world and documents exist to trace its history. The profession of pharmacy has undergone a series of changes in terms of philosophy and practice as it seeks to meet the dynamics of societal expectations and changes in the legal/regulatory standards, as well as technology of health care provision.

Evolution of pharmaceutical care

It is worthy to note that pharmacy practice is greatly influenced by academics. So the history and evolution of pharmaceutical care is interwoven in the history of teaching of the profession.

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Over the years, the practice has been divided into various fields. However, the two most important are the hospital and community pharmacy. This makes it difficult to have a single historic story.

History And Evolution Of Pharmacy Practice

Apothecary Model

Apothecary, as a profession, can be dated back at least to 2600 BC to ancient Babylon. Apothecary made patent medicines according to their own recipe (ingredients), prescribed, and sold them from their own dispensaries. Patients came to the pharmacist for the medication itself and for medical advice and guidance on its selection and use. They also sold the medicines they prepared wholesale to other medical practitioners.

The Middle Ages: Arabic Contributions

From the 9th - 13th centuries, Arabic books told of Greek and East Asian culture. Included medicine and other science predominantly of Islamic society. Pharmacist - historian Sami K. Hamrneh characterized 4 main types of drug-oriented contributions by Islamic literature;

1. Formularies and compendiums

a. A collection of formulas or recipes for medications, which included instructions for formulation and therapeutic uses

i. Compilation of work in the 850s called “The Apothecary Shop”

2. Herbals and Books

a. Strong influence by the Greco-Romans and added on by Islamic travelers and field workers

i. By 11th century Al-Biruni recognized pharmacy as a separate branch of healing

b. Materia medica mentions 1800 botanical drugs, 145 mineral drugs, and 130 drugs from animal sources

3. Toxicology Treatises

a. Helped to describe toxic substances and their actions, symptoms, and antidotes

4. Diet and Drug Therapy in Relation to Human Ecology

a. The biggest attention amongst the time

i. Central concept:

1. Sick person requires different ways of living compared to a healthy individual

2. Importance of unpolluted air for health

The Middle Ages: European World (500 CE to 1500 CE)

Between 1231-1240, German Emperor Frederick II issued an edict for the profession of pharmacy. Three regulations were created to establish pharmacy as an independent branch of governmentally supervised health service;

1. Separation of pharmaceutical profession from medical profession

2. Official supervision of pharmaceutical practice

3. Obligation by oath to prepare drugs reliably and in a uniform, suitable quality.

Soda Fountain Era

The apothecary era lasted for years. However, for it to survive, it must evolve to meet social needs. professions exist because of the social need for them; every profession consciously makes efforts to meet the social needs, or else, it goes into oblivion. Pharmacy being an international profession, is part of this social evolutionary process. So come along the soda fountain era. This was the period between 1920 and 1949.

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First, the sale and consumption of “medicinal” alcohol was allowed and this created a legal loophole which many pharmacists and physicians exploited. Second, soda fountains became very popular destinations for those seeking alcohol-alternatives. Neither was considered a “professional” activity, but both were surely profitable. Traditional prescription compounding and dispensing became a minor part of pharmacy operations in the 1920s and 1930s. Although 75% of prescriptions still required some compounding, less than 1% of pharmacies had more than 50% of their sales from prescription drugs.

Compounding Model

This lasted for a very short time in 1945. The industrial revolution saw massive production of ingredients that only need compounding. Pharmacists then moved to compounding the mixing of medicines already manufactured according to prescription and guiding patients on self-care.

Distribution Model

Laws confined community pharmacists to dispensing. Community pharmacy became a channel of distribution for the pharmaceutical industry. Hospital pharmacists functioned primarily in a support role for the management of drug products. distribution, management, large-volume compounding, teaching of nurses, and participation in Pharmacy and Therapeutics Committee. Emphasis was on the product not the patient.

Clinical Pharmacy Model

Originating in the USA during 1960, this model was patient oriented. Community pharmacists resumed providing drug information by way of advice and medication counseling, providing consultations on generic substitution and non-prescription drug use. Pharmacists performed clinical functions such as:

a. Interpreting, questioning, and validating drug orders;

b. Monitoring patients' drug therapy;

c. Managing selected drug therapies (e.g. aminoglycosides, heparin, aminophylline, parenteral nutrition);

d. Detecting and reporting drug allergies and adverse drug reactions;

e. Providing drug-use education;

f. Answering drug information requests;

g. Conducting patient reviews;

h. Participating in patient care rounds;

i. Performing drug use review and patient Care audits; and performing drug therapy research.

Traditional drug dispensing was flawed because it was;

1. Focus on dispensing the medicine

2. Patient’s education and counselling concentrate on technical advice.

3. No monitoring of the outcomes of drug treatment.

4. Drug related problems would emerge if the patient tells them about them.

5. No responsibility for the drug treatment.

Pharmaceutical Care Model

Pharmaceutical care model came to correct the anomaly with the clinical pharmacy model. The final major change to pharmacy education in the last 100 years was the transition from the five-year, entry-level B.S. degree with the optional post-graduate PharmD training to the PharmD becoming the entry level degree in many countries. The 1980s witnessed major changes to the philosophy of pharmacy practice of pharmacy. Hepler and Strand’s definition of pharmaceutical care placed patient care at the center of pharmacy practice:

Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life. These outcomes are (1) cure of a disease, (2) elimination or reduction of a patient’s symptomatology, (3) arresting or slowing of a disease process, or (4) preventing a disease or symptomatology.

To achieve these ends, pharmacists cooperate with patients and with other health care professionals in designing, implementing, and monitoring a care plan aimed at preventing and resolving drug-related problems (DRPs). This in turn involves three major functions namely: identifying potential and actual drug related problems; resolving actual drug related problems; and preventing potential drug related problems.

The new role requires pharmacists to apply a higher level of drug knowledge, clinical skill and independent judgment to their work and to accept the burden of responsibility. Pharmaceutical care thus emphasizes the role of pharmacists in two broad areas which are medicines management and health promotion.

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Also growing during the 1990s was the new role of pharmacists as immunizers. This came with some restrictions that have gradually been lifted over the years.

Total Pharmacy Care Model

Holland and Nimmo (1999) have proposed this model of pharmacy practice using a reductionist and subjective interpretation of events. Total pharmacy care (TPC) is the delivery of a comprehensive range of services that result in the maximum possible contribution to the health care of a nation's population within the limits of the health care delivery structure. A systems view of the amalgamation of existing pharmacy practice models was proposed. Pharmacy's evolution is traceable as a series of stages. The stages in pharmacy's evolution have been manufacturing pharmacy, compounding, distribution, clinical pharmacy, and pharmaceutical care. Good pharmacy practice (GPP) represents an international attempt to unite various conceptualizations of practice, including pharmaceutical care. GPP in turn provides a foundation for a model to explain current and changing practice, the total pharmacy care (TPC) model.

TPC combines five existing practice models: drug information, self-care, clinical pharmacy, pharmaceutical care, and distribution. TPC, as the sum of these models, asserts that there will be an ongoing need for all five existing models of practice, that the proportion of pharmacists employing each model will reflect the needs of a given health care environment at a given time, and that if changes in health care provide more opportunities for pharmaceutical care, pharmacists will shift increasingly toward that type of practice.

1. Drug information practice model. The tasks are to provide general advice to health care consumers on health matters in group settings, contribute the pharmacy perspective to the design and delivery of public wellness campaigns, contribute the pharmacy perspective to formulary decisions, educate prescribers about their individual prescribing patterns, evaluate patterns of medication use, evaluate materials promoting medication use, evaluate and disseminate drug information, provide education-related educational programs for other health care professionals, and provide patient-specific drug information.

2. Self-care practice model. The tasks are to provide general advice to health care consumers on health care matters in individual settings, assess the individual’s need, recommend safe and efficacious products, and make needed referrals.

3. Clinical pharmacy practice model. The task is to contribute to the physician’s therapeutic management of a patient by providing one or more clinical services, such as drug information, pharmacokinetic dosing, or taking a drug history or by modifying or designing, recommending, monitoring, and evaluating the patient’s pharmacotherapy.

4. Pharmaceutical care practice model. The tasks are to assume responsibility, on the patient care team, for modifying or designing, recommending, monitoring, and evaluating a patient’s pharmacotherapy, and to ensure the outcomes of the pharmacotherapy provided.

5. Distributive practice model. The tasks are to ensure the integrity of a prescription; ensure that a prescription is appropriate for the individual and that it meets therapeutic, social, legal, and economic requirements; secure medications and ensure the quality and accuracy of medications dispensed; counsel patients on medication use; and document professional activities.

The evolution of pharmacy practice is still going on, and no single practice model can best explain the observed practices in different parts of the world. However, the system of drug use wherein pharmacists share responsibility for optimizing outcomes of drug therapy with other health care professionals represents the accepted professional ideal for pharmacy.