Improving the Quality of Medications Use: The Case for Medication Management Systems

The quality of drug therapy is a major contributor to overall quality of health care. Drug therapy can increase quality, as when it stops a life-threatening infection. Medication use, however, also can cause toxicity, side effects or other adverse events. These are, in effect, new medical problems. They may lower quality of life and require additional expense to correct. Common examples include digoxin overdose or bleeding from warfarin or non-steroidal antiinflammatory drugs (NSAIDS) like ibuprofen or aspirin. Medication use can also fail to achieve the intended therapeutic effect, allowing a disease to continue or worsen. Finally, medications may not be ordered or many not be taken when needed. This has the same effect as treatment failure, as when a patient with asthma misuses his medications until he has a life-threatening crisis. Expenditures for prescription drugs outside hospitals represent about 12% of total expenditures for personal health care goods and services. This is substantial, but the quality of medications use can greatly affect expenditures for many other goods and services, the “other 88%”. The need for more effective management of medications use is clear. The usual, very unsystematic, ambulatory care medications use processes found in North America and Western Europe do not provide consistently acceptable quality of drug therapy. Drug therapy in hospitals is not much better. This is evidenced by many research studies showing that preventable drug-related patient injury is prevalent in many health care organizations. The corresponding cost of correcting such patient injuries is staggering. The causes and preventives of many drug-related patient injuries are known. The money spent on correcting injuries (or compensating victims when injuries cannot be corrected) could be better spent on systems that would prevent them. The case for constructing well-functioning medications use systems is also clear. First, little evidence supports the effectiveness of intuitively appealing interventions like prescribing improvement or adherence improvement programs. On the contrary, some well-meant prescribing restrictions have been associated with lower overall quality of medications use. Increasing patient adherence as an end in itself is illogical and may occasionally exacerbate some adverse drug effects. There is substantial evidence, however, that systematizing medications use improves outcomes, often at lower total cost of care. Despite the evidence of a problem and a possible solution, the road to medications management has turned out to be rough and long. In the past 20 years, systematic medications management has not become a de facto standard for the safe and effective use of medicines. Passage of Medicare Part D and the requirement for Medication Therapy Management (MTM) certainly was a step toward that goal. The MTM requirement officially recognized the need for