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Pharmacists performance in drug production selection

Also more prevalent in federal hospitals and those location in states with laws
allowing therapeutic interchange. Hospitals gave the following reasons for not
engaging in therapeutic interchange : lack of acceptance by physicians, interference
with physicians right to select the drug, unnecessary risk of civil liability, violation of
laws, and expected benefits do not justify the cost
Therapeutic interchange in managed care organizations
Many managed care oraganizations have embraced therapeutic interchange as a
means of promoting appropriate theraphy and containing cost. In 1992, 23 % of
managed care organizations allowed therapeutic interchange, with staff model
HMOs having the highest prevalence (46%) and independent prac tice associations
(IPAs) having the lowest (17%).
A survey of HMOs conducted by doering and colleagues found that approximately
30% of respondents allowed therapeutic interchange, with the practice being more
prevalent in staff or group model HMOs and less prevalent in IPAs. Policies allowing
therapeutic interchange were found more frequently in HMOs with in house
pharmacies then those using contracted pharmacy services. Physicians knowledge
of patien specific therapeutic interchange was not require by HMO policy in 30% of
the reporting HMOs that allowed the practice to occur.
The Role of the pharmacist in therapeutic interchange
Pharmacists are involved in therapeutic interchange programs at both of the policy
and the practice level. Through their involment in pharmacy and therapeutic
commitees, pharmacist participate in the selection of therapeutic alternatives and
the development of therapeutic interchange guidelines as practicioners,
pharmacists implement therapeutic interchange guidelines. This procces included
assessing patients individually to determine the health and economic impact of
performing therapheutic interchange, informing patients abount the dispensing and
use therapeutic alternatives, and monitoring patient response.
Establishing therapeutic interchange guidelines
In the 1980s, the concept of therapeutic interchange came under attack by the
medical profession. Many of arguments against therapeutic interchange were
based on concerns that interchange might occur without physicians knowledge or
authorization. Recent emphasis on the implementation of therapeutic interchange
guidelines has decreased organized medicines concerns about practice.
The procces use to select therapeutic alternatives is important to ensure quality
patient care, provider and patient acceptance, and positive economic outcome.
Factor to be considered in determining that two or more products are therapeutic
alternatives are listed in table 9.6. the development of a therapeutic interchange

policy should include a thorough evaluation of the products, solicitation of

prescriber support, pharmacy and therapeutic committee review and approval of
therapeutic interchange guidelines, and provider notification of the therapeutic
interchange policy.
The pharmacy and therapeutic interchange procces. It is the cooperative work of
physicians, pharmacists, and other health care professionals on the committee that
determines the therapeutic categories in which therapeutic interchange will occur,
the agents that will be the therapeutic alternatives, the procedure for therapeutic
interchange, and the monitoring of outcomes associated with this procces.
Establishing therapeutic interchange policies through a committee procces
facilitates the attainment of physician authorization for the procces. Often,
physicians admitting patients to hospitals with therapeutic interchange program
before they are allowed to admit patients. When a pharmacist selects and dispenses
a therapeutic alternate, such action must occur within the framework of the
pharmacy and theurapeutics committee guidelines.
To assess the effectiveness of a therapeutic interchange program, there must be a
quality assurance program that measures patient and financial outcomes. If patient
satisfaction and health related quality of life data are available for the population,
the patient perspective may also prove important in deciding whether to continue
with the therapeutic interchange policy as designed.
Performing therapeutic interchange
Achieving optimum patients outcomes should be the pharmacist goal in practicing
therapeutic interchange. When evaluating a patients therapy to determine wheter
a therapeutic alternative is appropriate, pharmacists must asses both patient and
economic factors.
Certain products may require particular caution before a therapeutic interchange is
performed. Variance in the pharmacokinetic profiles of sustain release products
requires that theurapeutic interchange be performed cautiously, if at all, and that
patient response are closely monitored. Care must also be taken when
interchanging oral contraceptive because packaging can differ from one product to
the next, leading to patient confusion and noncompliance. In addition, these product
also have a fairly narrow theurapetics index. Blood levels outside of the normal
range can lead to side effects such as breakthrough bleeding and nausea.
Therapeutic interchange requires particular care in the elderly. Older people, as a
group, exhibit a greater variation in pharmacokinetic and physiologic processes then
younger population ; thus, therapy change require careful monitoring. For some
elderly, particulary those in nursing home, the use of medications that have a liquid
formulation may be important.

Providing provider and patient information

Effective communicatiob between pharmacists and other health care professionals
is very important if a therapeutic interchange program is to be successful. While
therapeutic interchange policies implemented by institutions or pharmacy insurance
plans are usually communicated to the appropriate prescriber, additional prescriber
notification by the pharmacist may be prudent. Such notification may promote
acceptance of the procces and help ensure that the physician has an accurate
record of the patients theraphy, thus preventing confusion as the prescriber
reviews response to the therapy.
It is also important thar pharmacists who practice therapeutic interchange
communicate the practice to patient. For patients beginning theraphy, such
communication will alleviate concerns when a medication with a different name
then the prescribed medication is dispensed. For continuations in therapy, conseling
should focus on explaining the authorization for the interchange and the similarities
of the therapeutic alternative to the prescribed medication. Conseling patients
offers an opportunity to discuss any concerns they may have regarding the
interchange process. Failure to communicate the fact that therapeutic interchange
is occurring could lead to patient mistrust and possible legal action.
As the professional role of the pharmacist expands, drug product selection and
therapeutic interchange will continue to serve as foundation for the provision of
pharmaceutical care. As health care payers seek to contain costs by promoting
generic substitution and therapeutic interchange, pharmacists must assume
responsibility for evaluating the scientific soundness of these policies. As health
practitioners, pharmacists must asses patient response to drug therapy,
communicate with other professionals and patients regarding the intricacies of drug
therapy, and above all, advocate high quality patient care.