Part I

Introduction
1
PHARMACEUTICAL CARE,
INTRODUCTION
Defining an activity like care in itself is difficult and on an international level it becomes
hazardous. The concept of care is strongly influenced by national care concepts and local
circumstances in health care practice.
This chapter deals with issues surrounding health systems and the definitions of
pharmaceutical care. The place of pharmaceutical care within a general health system is
defined and the scope on pharmacy and pharmaceutical care is used for explaining the
development of different definitions. Different linguistic and cultural influences on the
construct of the definition are given.

1.1THE CHALLENGES OF DEFINING PHARMACEUTICAL CARE

*
ON AN INTERNATIONAL LEVEL
Looking at the literature, pharmaceutical care is a way of dealing with patients and their
medication. It is a concept that deals with the way people should receive and use medication
and should receive instructions for the use of medicines. It also deals with responsibilities,
medication surveillance, counselling and outcomes of care. In some countries the concept
also deals with the way people should obtain information about disease states and lifestyle
issues. In exceptional cases even purchasing medicines by a pharmacy is considered to be part
of the concept.
Observations of, and communications with, researchers in the field of pharmacy practice
in different countries in Europe, Australia, New Zealand, and in the USA reveal many
differences in the interpretation of the concept of pharmaceutical care and its outcomes.
The different interpretations sometimes prohibit the exchange and comparison of the
results of pharmaceutical care and pharmacy practice research. The differences are a result
of international cultural factors in pharmacy practice (see also Chapter 8), linguistic
difficulties, the national and social environment in which health care is provided and
different interpretations of the terms ‘managed care’ and ‘disease management’. Also
different approaches towards outcomes may lead to misunderstandings. All these factors
have contributed to a continuous development of the concept of pharmaceutical care
internationally. The questions of how and why different definitions have developed and why
the original American definition of pharmaceutical care1 has been and perhaps should be
further reshaped in other countries are discussed.

———
*
A slightly adapted version of this chapter has been accepted for publication in the December 1999 issue of the
International Journal for Pharmacy Practice as: van Mil JWF, McElnay J, de Jong-van den Berg LTW, Tromp ThFJ.
The Challenges of defining pharmaceutical care on an international level.

Pharmaceutical Care, Theory, Research, and Practice 19

To be able to outline the place and function of pharmaceutical care, the terms managed
care, disease management and pharmaceutical care will first be described, before identifying
elements that might influence the concept and the definition of pharmaceutical care at a
national level.

1.1.1 Sources of information

Initially a literature search was performed using Medline Silver Platter, from 1985 to 1993,
using the keywords ‘pharmaceutical care’ as text in title and/or abstract and appropriate
articles including definitions of the subject or discussions around the definition were
selected. For the period between 1993 and 1999 additional searches were performed in a
similar way. These latter searches did not offer important new viewpoints.
Although a large number of articles dealt with the elements, which might or might not be
part of the pharmaceutical care concept, the number of articles discussing its definition is
limited especially in Europe. Furthermore literature descriptions reflected the ideal situation
rather than reality. Therefore the content of this chapter is also influenced by discussions
with representatives of the international academic and professional pharmaceutical
community, such as researchers united within the Pharmaceutical Care Network Europe
Foundation (PCNE)2 and peers meeting during the conferences of the International
Pharmaceutical Federation (FIP). The results of a questionnaire survey on international
pharmacy are also used. This questionnaire was compiled in 1997 in co-operation with the
community pharmacy section of FIP. Information was obtained from the pharmaceutical
societies of 31 different countries (response rate was 68%, see chapter 8). Most section
member countries in Asia and Eastern Europe did not reply. South Africa is not represented
in the FIP community pharmacy section.
Although the results of the survey have not yet been published, one of the questions in
the questionnaire specifically asked for the definition of pharmaceutical care used
nationally. Other information was obtained from the Internet, especially the PharmCare
discussion list Pharmweb.

1.1.2 Pharmaceutical Care, Disease Management and Managed Care

In the European world of healthcare and pharmacy, the terms managed care, disease
management and pharmaceutical care often seem to be used without much distinction.
From discussions with peers it appears that many activities are labelled as managed care
(especially in Switzerland) or disease management (sometimes in The Netherlands or
Germany), where pharmaceutical care probably would be more appropriate. In the USA,
where the terminology originated, there is a much clearer distinction between those terms.

Pharmaceutical Care, Theory, Research, and Practice 20

 ……… (playing consumer advocate), who are we to withhold information about medication which someone else
is taking? It is the right of the consumer to be fully informed about side effect etc. It is not our job to "filter"
what the consumer is told, it is our job to interpret that information. As Janne Graham (Consumer Health
Forum) would say, if you provide adequate directions on the pack label, give them the CPI and then the
consumer throws all the info away, takes an overdose and dies, well that is the right of the consumer! They
can accept or reject whatever we advise or provide, that is their decision. If we withhold information because
we think the consumer may become scared, not use the medication or may not understand the info, then we
are playing God. Remember that it is a pharmacist’s duty of care to ensure the "safe and effective use of
medication". If a pharmacist provides the info and counselling for that duty of care and the consumer
decides to do something else, well that’s their decision, the pharmacist has fulfilled all his/her responsibilities.
Remember also, that although we may quite rightly feel that some CPI is rubbish, we must work with it
because it does hold a certain legal status now. I believe that the content should be altered, and lets work to
bring those changes about for all our sakes!

Mr Kim Bessell, President

Pharmaceutical Society of Australia (SA Branch)

Citation 1-1 Statement on position of patient in care†

There is a major difference between these different forms of care in a sense that the drivers
and the subjects of the processes differ. Managed care, disease management and professional
care (e.g. pharmaceutical care) are concepts, which are initiated by groups with specific
interests. Many definitions have been advanced to indicate the differences between these
forms of care or care activities, but none of them seems to be appropriate. One of the
confusing examples of such definitions can be found in a Dutch article by de Smet et al.3.
They define managed care as a framework and disease management as a process. But
others see disease management as a framework for which the processes still must be defined
in the form of protocols for the health care professionals. On the other hand, during a FIP-
meeting in Germany, managed care was defined as a process4.
Table1-2 Actors in care

CONCEPT Patient Pharmacist Physician Insurer

Pharmaceutical Care ++ I + +/-

Disease management + + I +

Managed Care +/- +/- + I

I = Initiator/driving force
+/- = Maybe important
+ = Important
++ = Very important
———
†
(Published with consent from the author)

Pharmaceutical Care, Theory, Research, and Practice 21

The different parties in health care, being the patient, professionals, insurance companies
and the health care industry, obviously have different approaches. The different parties have
developed methods, systems and concepts. However, the role of the patient in these
developments often seems to be rudimentary.
In the different concepts, systems or methods, functions are assigned to the different other
parties in the field. Table 2-1 best illustrates this.
Managed Care is a market-driven framework for the provision of health-care, originally
developed in the United States5. ‘Health-care management’ could be another term for this.
The Managed Care Organisation (MCO), or a large employer initiates and controls the
framework through a managed care plan either offered by a Health Maintenance
Organisation (HMO) or by directly hiring health care professionals though a Preferred
Provider Organisation (PPO). The physician plays the central role, within a large
administrative organisation6. The role of the patient and his/her influence on the system is
often almost absent. Pharmacists discussions on different internet platforms (the
Pharmaceutical Care Discussion Group and the Pharmacy Mail Exchange), suggest that
managed care’s main purpose is reducing costs and providing care to a level which is just
acceptable to society7.
Managed care is the principal driving force behind health care in the USA. In Europe the
influence of managed care on health care systems is limited although the UK National
Health System could be seen as one large HMO.
In Disease Management the physician is the initiator of a framework which controls the
treatment of specific diseases. Often the HMO drives the physicians’ actions through a
disease management programme. The role of the pharmacist and patient is usually
acknowledged but the individual patient has no direct influence on the content of the care
provided.
The pharmacists’ role in disease management has become increasingly clear. Munroe et al.
state that pharmacists have the unique expertise that is vital to ensuring the maximum
benefit of pharmacotherapy to be able to deliver improved patient outcomes and lower
costs8. Pharmaceutical care has some of the characteristics of disease management in the
sense that attention is being paid to the patient and protocols are sometimes being used
when disease specific pharmaceutical care is to be delivered. But the concept of disease
management is usually only applied to groups of patients with ‘expensive’ diseases, certainly
in Europe9.
In Pharmaceutical Care the individual patient is the main subject and usually the
pharmacist is the initiator and driving force of the process. Depending on the interpretation
of the definition, the latter need not always be the case. By identifying, resolving, and
preventing undertreatment, overtreatment or inappropriate treatment, pharmacists can
prevent or reverse many adverse drug-therapy related events and also have an economic
impact10. These activities can be protocollised to a certain extend. Sometimes the insurers
seem to be interested in the concept, but distance themselves from it. Usually the profession
itself supports the development of the concept through their professional organisations.

Pharmaceutical Care, Theory, Research, and Practice 22

Pharmaceutical care is a form of professional care like nursing care or medical care, and
therefore the core roles of the patient and the provider are vital.

MANAGED
CARE
Increasing Patient role

DISEASE
MANAGE-
MENT

Hospital
care
Nursing Physicians’
care Pharmac. Other care care
Care forms

Figure 1-3 Relationships between care in a health system

1.1.3 Defining Pharmaceutical Care

In the complex field of care, as outlined above, it is necessary to define pharmaceutical care.
One can regard the activities in a (community) pharmacy as separated into supportive
pharmaceutical actions, (carried out in the back-office) and clinically oriented activities
(disease or case oriented). In addition to these activities pharmaceutical care, aimed at the
individual patient, can be carried out at the counter or in the consultation room. Figure 1-4
shows the relationships of those activities.

Pharmaceutical Care, Theory, Research, and Practice 23

 Patient contact Individual patient
oriented
Pharmaceutical care

Physician contact Disease/case

Clinical Pharmacy oriented

Back Office Supportive pharmaceutical actions Logistics oriented

Figure 1-4 Pharmacy activities

Depending on the time and the country of origin, different definitions of pharmaceutical
care are in use. In the United States, for example, the definitions have developed into their
current form, starting in 1976, and since then pharmaceutical care has been often redefined.
However, in the FIP questionnaire, which was evaluated at the University of Groningen. 6
out of the 30 responding countries indicated in that they use the Hepler and Strand (1990) 1
definition as their current working definition. Twelve countries did not give a definition of
pharmaceutical care (including the USA) and 12 countries gave their own description or
definition, which was in all cases significantly different from the Hepler and Strand
definition. All definitions and descriptions have the same intent, namely care for individual
patients.
A message on the PharmCare discussion list also suggests that a community level
provision of pharmaceutical care is possible, especially in developing countries. In this case
pharmaceutical care would focus on developing standard treatment guidelines, effective
supervision of dispensing and effective use of support personnel11. Although these activities
are extremely useful in certain circumstances, this structural group-approach is not
common and currently is not regarded as pharmaceutical care according to all published
definitions.

The American definitions

Clinical pharmacists generated the first definition for pharmaceutical care in the US, not
unexpectedly if we look at the history of the pharmacy profession in that country. Mikeal et
al. described pharmaceutical care in 1975 as ‘The care that a given patient requires and
receives which assures safe and rational drug usage’12. In the following years the term
pharmaceutical care has been used a number of times for all actions which are needed for
compounding and dispensing medicines. Brodie et al. were the first to give a more complete
definition of pharmaceutical care in 1980. They stated: ‘Pharmaceutical care includes the
determination of the drug needs for a given individual and the provision not only of the
drugs required but also of the necessary services (before, during or after treatment) to assure

Pharmaceutical Care, Theory, Research, and Practice 24

optimally safe and effective therapy. It includes a feedback mechanism as a means of
facilitating continuity of care by those who provide it’13.
In this definition for the first time a possible feedback-mechanism was suggested, a
principle that Hepler later used in the work following his joint definition with Strand14. It
also placed pharmaceutical care in a sociological context in which the role of the patient and
his or her needs became important.
In 1987 Hepler formulated his first definition, in which the commitment to the patient
became apparent: ‘a convenantal relationship between a patient and a pharmacist in which
the pharmacist performs drug-use-control functions (with appropriate knowledge and skill)
governed by awareness of and commitment to the patients’ interest’15. It is interesting to
note that Hepler at the time of formulating this definition seemed to suggest that only a
pharmacist could provide pharmaceutical care. This viewpoint is less clear in the widely
accepted definition published in1990, which Hepler formulated together with Strand. That
definition is the current cornerstone of many parties working in the field of pharmaceutical
care, in hospital as well as in community pharmacy: ‘pharmaceutical care is the responsible
provision of drug therapy for the purpose of achieving definite outcomes which improve a
patient’s Quality of Life’1.
Strand, in 1992, published a new definition together with Cipolle and Morley, in which the
patients’ central position in the process receives even more emphasis. ‘Pharmaceutical Care
is that component of pharmacy practice which entails the direct interaction of the
pharmacist with the patient for the purpose of caring for that patient’s drug-related needs’16.
In her address delivered when receiving the Remington Medal in 1997, Strand redefined
pharmaceutical care as: ‘A practice for which the practitioner takes responsibility for a
patient’s drug therapy needs and is held accountable for this commitment’17. It seems like
Strand’s approach has become more humanistic while Hepler’s approach remains more
process orientated in nature. Others, like Munroe, see pharmaceutical care as a service
during which the clinical and psychosocial effects of drug therapy on a patient are
systematically and continuously monitored i.e. a more clinical approach18, which still can be
recognised in the Australian interpretation of pharmaceutical care.
In summary, currently in the US there seems to be three approaches to pharmaceutical care:
a process oriented one (Hepler), a humanistic one (Strand) and a clinical one (Munroe).

The Dutch definition, an example

When pharmaceutical care started to develop in The Netherlands in the beginning of the
1990s, the definition was formulated as follows: ‘Pharmaceutical care (Farmaceutische
Patiëntenzorg, FPZ) is the structured, intensive care by the pharmacist for an optimal
pharmacotherapy in which the patient and his condition are the primary concern. The aim
is to obtain optimal Health Related Quality of Life’19.
Some typical Dutch aspects of community pharmacy practice are inherent to this definition
e.g. continuity of care, protocols or critical pathways, documentation, high quality
communication with patients, providing drug information, medication surveillance and
communication with other professionals. These aspects therefore are not explicit in the
definition. The new aspect for Dutch pharmacy was that the care now became targeted

Pharmaceutical Care, Theory, Research, and Practice 25

directly at the individual, whereas before it was more of a technical professional approach
originating from clinical pharmacy.
In 1998 the WINAp, the scientific Institute for Dutch Pharmacists, redefined
pharmaceutical care as ‘the care of the pharmacy team for the individual patient in the field
of pharmacotherapy, aimed at improving the quality of life’. In this definition the role of the
whole pharmacy team, pharmacist and assistant-pharmacists, is stressed and pharmaceutical
care also became a possible activity when there was no current pharmacotherapy involved,
thus including disease prevention or merely providing advice on drug related issues.
In both definitions the patient plays the central role and it is also clear that from the
Dutch viewpoint pharmaceutical care is a practice philosophy solely for the pharmacy
profession.

1.1.4 Language and cultural differences

Whenever someone comes up with a definition, be it for an object or a concept, words and
meaning of words in a language play an important role. But the problem is not only
linguistic. The framework of reference in which a definition is constructed is also important.
This framework can be societal, as seen by any observer, but also professional as seen by
practitioners close to the subject defined.

Language differences
As words may have slightly different meanings in different languages, translating definitions
becomes a hazardous activity. The English word ‘care’ and the Dutch word ‘zorg’, as far as
we can judge, have approximately the same meaning in the health care environment being
personal and emotional care combined with professionalism and quality. But words like
‘soin’ (French), ‘Fürsorg’(German), or ‘omsorg’ (Scandinavian languages)‡ have a different
meaning, with much more emphasis on the intrinsic emotional aspect. That is why the
French would rather speak about ‘suivi pharmaceutique’ (meaning a pharmaceutical follow
up) and the Germans speak of ‘Betreuung’ (meaning coaching). The Scandinavian countries
have not found a more suitable word and tend to use the English expression.
An essential word like the English word ‘outcome’, which is used in the definition of
Hepler and Strand, cannot be translated into the Dutch ‘uitkomst’ or ‘resultaat’. It is a
concept that covers both Dutch words.
The language difficulties noted above are one of the reasons why certain countries cannot
adapt or translate the basic definition of Hepler and Strand.

Influence of health systems

In describing an activity like pharmaceutical care, the meaning of the words ‘pharmacy’,
’pharmaceutical’ and ‘care’ must be interpreted with regard to the health system of the
country of origin.
For the word pharmacy, an American will have the image of a shop where you can buy
health related substances but also all kinds of other commodities like food, cigarettes,
———
‡
Personal information Dr. Hanne Herborg, Danmarks Apoteksforenings Kursusenjendom and Dr. Christian
Berg, Norske Apotekerforening

Pharmaceutical Care, Theory, Research, and Practice 26

detergents, photo equipment etc., and somewhere in the back of this store you can go with
your prescription. The British will have images, which depend not only on national but also
regional differences. Someone who lives in a city may have the image of, for instance, a
department store with mainly beauty-related products and a counter where you can buy
OTC products or present a prescription for dispensing. Someone from a village in Great
Britain has the image of the place to go for prescription medicines, a limited set of other
health care products and perhaps veterinary products. In The Netherlands a pharmacy is the
place where you usually only go to have your prescriptions filled, and perhaps purchase self
care pharmaceutical products. The only common feature of the meaning of the word
‘pharmacy’ is therefore a place where you can go to have your prescription filled and where
you can buy self care products. All other features are different between the countries
mentioned.
Depending on the country, community pharmacies serve anywhere between 1500-18000
patients and the generated income in some countries depends heavily on the turnover from
related products, rather than drugs. Pharmaceutical Care is the concept of a patient
orientated activity in this broad range of pharmacies with a variation of driving forces.

Professional differences
If Dutch pharmacists describe Pharmaceutical Care from a professional viewpoint, they will
relate to the pharmacy practice in their country. Since in The Netherlands professional
aspects like medication surveillance, keeping medication records and giving patient-
information leaflets are common practice in all community pharmacies, those activities are
an implicit part of the definition. In Denmark and Sweden, where keeping medication
records is largely prohibited because of privacy laws, certain activities which are standard
practice in Dutch pharmacies are hard to conceive and their interpretation of the same
definition will therefore show a conceptual difference. In Norway keeping medication
records is now common practice in community pharmacies but medication surveillance by
computer is not, and the provision of patient information leaflets is restricted to ‘group’
leaflets of the type used in The Netherlands about 10 years ago§.
In most western countries the licensed team-members in a pharmacy fill and dispense the
prescriptions. There is, however, an amazing difference in the amounts of prescriptions the
team-members handle per day. According to the results of the FIP questionnaire, each
licensed team-member in a pharmacy in Luxembourg fill on average 130 prescriptions per
day, in Spain 107, in the USA 70, but in The Netherlands only 32. Although it is unclear how
a prescription is interpreted (the total prescription or the numbers of different medicines on
it), this suggests a difference in the professional content of the work of licensed team-
members (mostly pharmacists).
Another major professional difference in The Netherlands, when compared with
countries world-wide, is that the assistant-pharmacist** also may provide patients with
prescription medicines, even when no pharmacist is on the premises. This is unthinkable in

———
§
Personal information Swan Apotheke, Tromso
**
A Dutch assistant pharmacist receives a 3 year non-university education in preparing and dispensing medicines

Pharmaceutical Care, Theory, Research, and Practice 27

other countries, where a pharmacist always must be present during opening hours and
supervise the pharmacist-assistants.
Additionally a pharmacist does not always have an academic degree. In most Scandinavian
countries there are two types of so-called pharmacists, but with a different background. One
is the university-educated person, the other is the prescriptionist (reseptar), who has not
received a full academic pharmacy education but also is called a pharmacist. In a country
like Brazil there even are two kinds of pharmacists with a different university education
(three or five years after highschool).
The relationships between professionals, especially the physician and pharmacist, also are
very different in different countries. In the United Kingdom and the United States it is quite
customary for hospital pharmacists to attend the wards-rounds, but according to the FIP
questionnaire, communication in the community setting is much less well developed
although there have been advances in this area. In the Dutch setting the regular
pharmacotherapeutic consultation meetings or the drug-formulary committees in hospitals
between pharmacists and physicians ensure a reasonable easy communication between those
two professions. In Germany and Switzerland the controversies between pharmacists and
doctors about dispensing rights and professional responsibilities make relationships difficult
but such relationships are slowly starting to improve as a result of developing
communication between the professions††.

What outcomes?
The concept of outcomes of pharmaceutical care, usually meaning final outcomes, may lead
to confusion as well. The major fields of outcome in care a threefold: economic outcomes,
clinical outcomes and humanistic outcomes (quality of life and satisfaction) 20.
The word ‘outcomes’ was deliberately not used in the Dutch definition because of
conceptual difficulties, but also because there may be a potential conflict when outcomes are
used in the double sense of Heplers’ definition, e.g. ‘definite outcomes which improve the
patients’ Quality of Life (HRQL)’. Certain desirable outcomes in a pharmaceutical sense may
sometimes conflict with that main outcome of care i.e. to obtain an optimal Health Related
Quality of Life. Nevertheless the outcome might be worth pursuing. This can be easily
explained by the example of benzodiazepine use in an elderly population. As an outcome in
general, decreased use of benzodiazepines in the elderly would be a possible target for a
pharmaceutical care intervention, because elderly people in general should preferably not
use this class of drugs21. Although in the long term HRQL may improve as a group effect in
elderly patient if benzodiazepine use is discontinued, certainly not all elderly patients will
benefit this way if examined at an individual level. That also explains why in both Dutch
definitions, the ‘individual patient’ is mentioned.
Additionally economic outcomes may conflict with health status or quality of life. If all
three types of final outcomes are to be taken into account, which one has priority? In the
Dutch definition therefore an explicit choice has been made for the field of quality of life as
(final) outcome, which needs to improve under the influence of the provided care.

———
††
Personal information Dr. Martin Schultz, ABDA, Frankfurt

Pharmaceutical Care, Theory, Research, and Practice 28

1.2 C O N C L U S I O N A N D R E C O M M E N D A T I O N S
The concept of pharmaceutical care is part of health care. There are essential differences
between the concepts of pharmaceutical care, disease management or managed care,
although there are also some relationships. The main difference can be found in the extent
of influence of the patient on the process or concept of care and the initiator of the care
concept. In some countries conceptual differences are overlooked and this leads to a
confusing use of the terminology. From pharmaceutical care through disease management
to managed care there is a decreasing chance for the patient to influence his/her own
treatment. However, pharmaceutical care can be, and often is, part of disease management
while managed care uses disease management strategies to control costs.
There are different definitions and interpretations of the term ‘Pharmaceutical Care’.
When defining pharmaceutical care, at least the culture, the language, and the pharmacy
practice in the country of origin have to be taken into account. Even after 20 years of
evolution of the definition of pharmaceutical care in different cultures, it is not absolutely
clear whether pharmaceutical care is a service that could be provided by different health-
care providers who have been trained, or a practice philosophy for pharmacy. The current
different approaches in the USA by Strand and Hepler illustrate that differences in opinion
can even be found within one country i.e. a process approach (Hepler) versus a humanistic
approach (Strand). It is therefore amazing that the Hepler and Strand definition (1990) is so
often used in other countries, apparently without taking into account the existence of
differences in culture, language and the professional context. It is clear from the issues raised
in this chapter that authors and presenters should include their working definition of
pharmaceutical care when presenting or writing about the concept. A Cochrane review22 in
1997 reached the same conclusion, based upon articles by Rupp et al. and Ilersich et al.23,24.
Social and culturally bound activities like pharmaceutical care need rephrasing, depending
on factors in the country of origin and the health care system developments over time.
When literally translating definitions, one must also take conceptual language differences
into account.

1.3 R E F E R E N C E S TO C HAPTER 1
1
Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47:533-43
2
van Mil JWF, Tromp ThFJ.The Pharmaceutical Care Network Europe (PCNE). Int Pharm J 1997;11:10-1
3
De Smet PAGM, van der Vaart FL, de Blaey CJ.Een WINAp visie op ‘managed care’ en ‘disease management’ [A
WINAp vision on managed care and disease management]. Pharm Wbl 1997;132:1759-60.
4
Tromp TFJ, van Mil JWF, de Smet PAGM. De uitdagingen van ‘Managed Care’ [The challenges of managed care].
Pharm Wbl 1996;131:278-281
5
Hughes EFX. The ascendancy of management: National health care reform, managed competition and its
implications for physician executives. In: New leadership in the Health Care Management: The physician executive
II, American College of physician executives, Tampa FL, 1994, p 1-18
6
Inglehart JK. Physicians and the growth of managed care. N Engl J Med 1994;331:1167-71
7
Internet. Pharmacy Mail Exchange (PME). Managed Care. Posted 13-12-1995 by J. Max

Pharmaceutical Care, Theory, Research, and Practice 29

8
Munroe WP, Dalmady-Israel C. The Community Pharmacist’s Role in Disease Management. Drug Benefit Trends
1997;9:74-7. Can also be found on http://www.medscape.com
9
de Gier JJ.‘Pharmaceutical Care’ staat of valt met goede richtlijnen.[Pharmaceutical care is kept upright with good
guidelines] Pharm Wbl 1997;132:1727-8
10
Fincham JE. Pharmaceutical Care Studies; A Review and update. Drug Benefit Trends 1998;10:41-45
11
Internet. PharmCare mailing list. Re: Pharmaceutical Care and Health Care. Posted 22/6/99 by Dr. A. Gray
12
Mikael RL, Brown TR, Lazarus HL, Vinson MC. Quality of pharmaceutical care in hospitals. Am J Hosp Pharm
1975;32:567-74
13
Brodie DC, Parish PA, Poston JW. Societal needs for drugs and drug-related services. Am J Pharm Educ 1980;44:276-8
14
Hepler CD. pharmaceutical care Plan (Therapeutic Outcome Monitoring). In: C.D. Hepler. Introduction to
pharmaceutical care in the Elderly. Proceedings of the section of Community Pharmacists, World Congress of
Pharmacy and Pharmaceutical Sciences in Lisbon, International Pharmaceutical Federation. 1994, The Hague. 3-7.
15
Hepler CD. The third wave in pharmaceutical education and the clinical movement. Am J Pharm Ed 1987;51:369-85
16
Strand LM, Cipolle RJ, Morley PC. Pharmaceutical Care: an introduction. Kalamazoo, MI: Upjohn Company 1992
17
Anonymous. A pharmacy pioneer. Int Pharm J 11;1997:69
18
Munroe WP, Dalmady-Israel C. The community pharmacist’s role in disease management and managed care. Int
Pharm J 1998;12(suppl II)
19
van Mil JWF, Tromp TFJ, de Jong-van den Berg LTW. ‘Pharmaceutical Care’ de zorg van de apotheker
[Pharmaceutical care, the care of the pharmacist]. Pharm Wbl 1993;128:1243-7
20
Kozma CM, Reeder CE, Schulz RM. Economic, Clinical and Humanistic outcomes. A planning model for
Pharmacoeconomic research. Clin Therap 1993;15:1121-32
21
Shorr RI, Robin DW. Rational use of benzodiazepines in the elderly. Drugs & Aging 1994;4:9-20
22
Bero LA, Mays NB, Barjesteh K, Bond C. Expanding the roles of outpatient pharmacists: effects on health services
utilisation, costs, and patient outcomes (Cochrane Review). In: The Cochrane
Library, Issue 2, 1999. Oxford: Update Software.
23
Rupp MT, Kreling DH. The impact of pharmaceutical care on patient outcomes: What do we know? Proceedings of
the American Pharmaceutical Association Conference on patient outcomes of pharmaceutical interventions: A
scientific Foundation for the Future. Washington D.C. 13-15 November 1994. Page 53-65
24
Ilersich AL, Arlen RR, Ozolins TRS, Einarson TR, Mann JL, Segal HJ. Quality of reporting in clinical pharmacy
research. American Journal of Pharmaceutical Research 1990;54:126-31.

Pharmaceutical Care, Theory, Research, and Practice 30