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Medication therapy management - private medical / pharmaceutical consultation

Medication therapy management, or MTM, is one of the oldest private medical consultation services provided by US and UK pharmacists since early 90s’. The main purpose of the MTM method is providing a detailed medical recommendation to the patient with regard to his / her drug record in the following areas:

1) providing a list of any possible harmful or unwanted side effects (of grade moderate and above)for all the drugs / food supplements taken by the patient.

2) revealing any potential DDI (drug - drug interactions) which may interfere with the patients’ treatment or harm him / her in some way.

3) same as 2 but with regard to DFI (drug - food interactions), some food types may interfere with the absorption , metabolism or excretion of certain medicines.

4) double checking the patients’ dosage regimen, because sometimes unintentional mistakes may be made.

5) correcting the dosages of the drugs taken by the patient according to his / her renal and liver function, due to the fact that most drug undergo metabolism and excretion via those pathways.

6) searching the patients’ medical record for any diseases diagnosed which have no active treatment prescribed.

7) the opposite of the 6 - searching for any obsolete medical treatment which is not “attached” to any diagnosis.

8) and last but not least - search for a therapeutic duplications - in the majority of cases two medicines of the same group for the same indication do not provide addition treatment benefit but do provide additional side effects typical for the drug type used.

How does it work

The working plan includes two consultation sessions. Before the first session (which can be either personal or via phone / internet video or audio conference) any relevant information is transferred to the consulting pharmacist. The information must include all of the following for maximum efficiency:
* A personal medical record which contains all the diseases diagnosed up to the present day and all the medical interventions performed (i.e. surgery, chemotherapy e.t.c.).

* Most recently performed lab test results - blood, urine e.t.c. - the more info provided here will aid great to the pharmacist.

* A detailed list of all the drugs taken by the patients (vitamins, minerals and other food supplements included) with all the instructions of how and when taking them, as the patients remembers.

The first sessions is the information gathering session. During the session course two sets of information are obtained. There is an objective information, and that is exactly the 3 things that were mentioned a few lines above. There is also a subjective information which is provided by the patient directly. Subjective information may include anything “not standard” that the patient want to tell. Examples may be of the following type: “I have difficulty falling asleep”, “I go to the toilet a lot”, “I have burning sensations in the morning” e.t.c. The importance of subjective information must not be underrated! Like small pieces of a large puzzle may by themselves look like “just lines and colors”, together they help revealing a whole picture, here too all the information bits provided by the patient may look irrelevant or unrelated to him / her - but for the consulting pharmacist it may provide another cue to some DDI or a potential drug caused side effect. Next there is a deep heuristic analysis of all the info provided to the pharmacist during which all the possible optimizations to the patient’ treatment plan are considered. By the end of the analytical phase a second session is scheduled. The second session is the recommendation session during which the patient gets two forms. The first form is intended for the patient him / herself and contains a detailed list of any recommended changes with regard to the patients’ medicinal treatment. The list also contains all the recommended food supplements that may benefit the patient specific condition (for example q10 and statins taken IS a recommended combination). Another issue that may appear in this list is a recommendation of certain types of physical activity which may specifically benefit the patients’ condition. All the info provided in the recommendation section comes with simple but detailed explanation of the reason for the change recommendation. The second form is optional and provided on request by the patient. This form is essentially the same as the first one, but is intended for primary care physician. In it all the recommended changes for the patient, provided with a detailed medical/ chemical and physiological basis rather than with a simple explanation. At this point a note must be taken, that the final decision with regard to the patient treatment will be made at the primary care physician level. The purpose of the MTM service is providing an insight for the patient and for the physician from a point of view of a pharmacologist rather than a doctor, and by that optimizing the medical treatment of the patient to a greater extent than it would be in the case of doctor only.

Why MTM ?

Some people may ask themselves: “why do I need that ? I already have a doctor, he’ll cure me”. The answer to this question is the result of many meta analyses performed in the US and EU during the 90s’ and the early 2000s’. The conclusion of the analyses was that pharmacist intervention to the patients’ medicinal treatment reduced therapeutic mistakes (drug and drug prescription related), lowered the secondary hospitalization incidence (and here worth to mention that almost 30% of the hospitalizations are due initial therapeutic mistake or an initial incorrect therapeutic medicinal regimen), raised the life quality of patients and their compliance to the prescribed drugs. In some cases it is also possible to reduce the amount of money spent on the drugs each month which benefits not only the patient but also the healthcare system itself.

Pharmacist, being the ultimate expert in the field of applied pharmacology and pharmacotherapy has much greater chance to discover DDIs, DFIs, and trace / relate a subjectively reported condition to some drug (as a possible side effect of the named drug) than any physician. This means no disrespect for any doctor who may be a great specialist in his / her area of specialization, but not necessarily specialize in other specialization areas of medicine to the same extent (a skilled cardiologist is not a skilled neurologist and vice versa - otherwise the science of medicine would not be subdivided into areas of speciality).

Another thing worth mentioning is the time factor. The healthcare system has too few doctors for too many patients. The median time “provided” by the system for each patient for physician attendance purpose is 5-7 minutes. During this time the physician must hear the patient, establish the CORRECT diagnosis, think of a CORRECT treatment for the established diagnosis and at the same time deal with all the bureaucracy (different forms, lab results, notes from and to other doctors e.t.c.). All this must be done without a single mistake and with the mentioned above time frame. It is known for a long time that the more stressful conditions are superimposed on an individual, the more chance the individual has to “collapse”, and here the consequence for a doctor may be losing his / her license and possibly dealing with lawsuit, but more important for the patient it can be dangerous and in certain cases life threatening (as already mentioned 30% of the hospitalizations are due therapeutic mistakes). Again it must be emphasized that the purpose of the MTM service is not to steal doctor authority, but to help the physicians with the temporal and professional burden they have to deal with everyday, in order to reach mutual goal - helping the patients.

Last thing that has to be said is about bureaucracy and how it can increase the chance for a therapeutic mistake. Imagine the following scenario: a patient (who has high cholesterol, type 2 diabetes with neuropathy and hypertension) admitted to the hospital with MI. In the hospital all the needed procedures are performed, and the patient is released to continue his / her treatment in an ambulatory fashion. During the ambulatory phase the patient goes (more or less in the following order) to: cardiologist, diabetes clinic, perhaps neurologist, a nutrition specialist and finally to a primary care physician. All this chain of events if of course accompanied with a large amount of forms, notes e.t.c. Now the question to be asked is, what is the chance for the initial info (from the hospital) to be delivered to the case manager (primary care physician) accurately, in the same form and without a single mistake or a deviation? And what is the chance that the neurologist will take in account the reason which was the basis of the treatment chosen for the patient by the cardiologist and won’t change it according to his / her own logic as a neurologist? The chance for some degree of mistake is high and the only element that will be harmed in most cases is the patient.

MTM, who can benefit most from it ?

* elderly people. (60y +)

* people who take more than 5 drugs simultaneously and / or have 3 or more chronic diseases.

* people who were release to an ambulatory treatment phase from a hospital with “renewed” list of conditions and medications.

* people whose’ conditions (insomnia, frequent urination e.t.c.) may originate in medicinal side effects.

* people who want to improve their life quality via optimization of their pharmacological, nutritional and physiological routine.

* and last but no less important - people who wish to reduce their monthly spent money on medications.


Best regards and wishing you a long healthy life