Although there are no perfect solutions to the problem of dangerous drug interactions, there are steps HMOs and health care professionals can take to minimize risk. The American Pharmaceutical Association is observing National Pharmacy Week, Oct. 1824, by encouraging better consumer communication with physicians and pharmacists to reduce that risk. And APhA is using the occasion to promote pharmaceutical care as a way to prevent errors at the professional level.
Sometimes even the best-laid treatment plans can crash upon a pharmacy counter, where dangerous even deadly combinations of prescription drugs are too often dispensed.
Pharmacists filling prescriptions don't want to make errors, Michael Cohen, president of the Institute for Safe Medication Practices, an advocacy group in Warminster, Pa., concedes. "But," he asks, "when the system puts them in a position of having to fill over two hundred prescriptions in a shift with numerous telephone interruptions and no chance to go to the bathroom, do you really believe that they're not going to make an error at some point?"
Of course, other variables come into play as well. In the past 18 months, for instance, the Food and Drug Administration has removed diet drugs, pain killers and antihypertensives from shelves because they interacted negatively with other drugs, making some people sick and killing others.
Most health care professionals agree that it's nearly impossible to create a formulary without some potential for unsafe drug interactions. However, HMOs can greatly minimize risks by:
Tim Birner, director of pharmacy for Harvard Pilgrim Health Care in Boston, thinks that preventing adverse drug interactions begins with the pharmacy and therapeutics committee, which should outline criteria a patient must meet to be eligible for a drug that is coming onto the formulary.
"Who are the perfect candidates?" asks Birner. "We don't want to try to sell this drug to everybody."
Pharmacy guidelines were created to prevent serious avoidable toxicity in patients receiving multiple medications, points out Robert Fontana, M.D., gastroenterologist and assistant professor of internal medicine at the University of Michigan in Ann Arbor. But, he says, "I am concerned that formulary managers may create too many detailed rules and guidelines that can impair care. From my own experience, pharmacy and formulary committees can excessively restrict the availability of effective medications [in the name of] safety concerns, resulting in delay in treatment and prolonged hospitalization."
Many of these problems can be prevented further up the line, where medical decision making takes place. Wherever you find the risk, that's where you'll find a growing acceptance of the concept of pharmaceutical care.
As independent practice associations, large medical groups and physician practice management companies take on more risk from managed care organizations, consultant pharmacy is growing in stature. In California, the rule of thumb, according to one observer, is that any practice with more than 50,000 covered lives needs a pharmacist on staff to keep track of formularies, and to educate physicians about medications and drug interactions.
Although responsibility often rests with pharmacists and physicians for harmful drug interactions, it may someday shift to the managed care company, says Alan Lyles, Ph.D., assistant professor of health policy and management at Johns Hopkins University.
"If a plan takes a premium to provide comprehensive services, there is an expectation of performance of duty that will grow to include that," he says.