Community Pharmacist Telephonic Medication Reviews with Uncontrolled Asthma Patients: A Pilot Study

This study reports the process of telephonic medication reviews conducted by community pharmacists for patients with asthma. The study occurred at an independent community chain in association with a Missouri Medicaid consulting group. Participants were identified utilizing claims data and met the National Quality Forum criteria for uncontrolled moderate-to-severe persistent asthma. A pharmacist performed the initial encounter via telephone which included a knowledge questionnaire, symptom control assessment, and medication review. Pharmacists identified drug-related problems (DRPs) and faxed recommendations to patients’ primary care providers (PCPs). Thirty days later, pharmacists called to follow up with the patients and faxed PCPs to resolve any outstanding DRPs, new DRPs, or recommendations. Questionnaire scores and symptom control assessments were compared and analyzed utilizing a paired t-test, Chi-squared test, or Fisher’s exact test. The number and categories of DRPs, recommendations made by pharmacists, and intervention time were reported. Fourteen participants completed initial encounters with twelve completing follow-up. The majority answered ‘yes’ to at least one symptom control assessment question indicating partially controlled to uncontrolled asthma. The average knowledge assessment score was 5.17 out of 7 initially and 5.42 for the follow-up. Pharmacists identified 43 DRPs and made 41 recommendations with a mean intervention time of 65 min.

Community Pharmacist-Provided Wellness and Monitoring Services in an Employee Wellness Program: A Four-Year Summary

Objective: To assess the clinical outcomes of participants of an employee wellness program during four years of service implementation. Methods: A prospective cohort study was conducted at 15 independent community pharmacy chain locations in northwest and central Missouri. A total of 200 participants were enrolled in an employee wellness program, and the program included five monitoring groups-cholesterol, blood pressure, blood glucose, weight, and healthy participant groups. Participants selected a pharmacist wellness coordinator and wellness appointments were conducted, consisting of education, goal-setting, and monitoring through physical assessment and point of care testing. The primary outcome measures were total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG), body mass index (BMI), and waist circumference (WC). The secondary outcome measures were the proportion of patients who achieved the clinical value goals at baseline versus 48 months. The primary outcome measures among data collection time points were compared using one-way analysis of variance (ANOVA) tests, and the secondary outcomes were compared between baseline and 48 months by Chi-square or Fisher's exact tests. One-way ANOVA post hoc tests were also performed using least significant difference, to further identify which time points differed from each other. Results: At baseline, there were 134 patients in the cholesterol monitoring group, 129 in the weight monitoring group, 117 in the blood pressure monitoring group, 46 in the blood glucose monitoring group, and 26 in the healthy participant monitoring group. For patients in the blood pressure monitoring group, compared with baseline, there was a significant decrease in DBP at months 12, 24, 36, and 48, and a significant increase in the proportion of patients achieving blood pressure goals at 48 months. For patients in the blood glucose monitoring group, compared with baseline, there was a significant decrease in FBG at months 12, 24, 36, and 48, and a significant increase in the proportion of patients achieving blood glucose goals at 48 months. Conclusions: Pharmacist-led wellness visits provided to employee wellness patients in a community pharmacy may lead to improvements in BP and FBG values.

Genomic Investigation of a Mycobacterium tuberculosis Outbreak Involving Prison and Community Cases in Florida, United States

We used whole-genome sequencing to investigate a tuberculosis outbreak involving U.S.-born persons in the prison system and both U.S.- and foreign-born persons in the community in Florida over a 7-year period (2009-2015). Genotyping by spacer oligonucleotide typing and 24-locus mycobacterial interspersed repetitive unit-variable number tandem repeat suggested that the outbreak might be clonal in origin. However, contact tracing could not link the two populations. Through a multidisciplinary approach, we showed that the cluster involved distinct bacterial transmission networks segregated by country of birth. The source strain is of foreign origin and circulated in the local Florida community for more than 20 years before introduction into the prison system. We also identified novel transmission links involving foreign and U.S.-born cases not discovered during contact investigation. Our data highlight the potential for spread of strains originating from outside the United States into U.S. "high-risk" populations, such as prisoners, with subsequent movement back to the general community.

Physicians' Preferences for Communication of Pharmacist-Provided Medication Therapy Management in Community Pharmacy

OBJECTIVES

(1) To identify physicians' preferences in regard to pharmacist-provided medication therapy management (MTM) communication in the community pharmacy setting; (2) to identify physicians' perceived barriers to communicating with a pharmacist regarding MTM; and (3) to determine whether Missouri physicians feel MTM is beneficial for their patients.

METHODS

A cross-sectional prospective survey study of 2021 family and general practice physicians registered with MO HealthNet, Missouri's Medicaid program.

RESULTS

The majority (52.8%) of physicians preferred MTM data to be communicated via fax. Most physicians who provided care to patients in long-term care (LTC) facilities (81.0%) preferred to be contacted at their practice location as opposed to the LTC facility. The greatest barriers to communication were lack of time and inefficient communication practices. Improved/enhanced communication was the most common suggestion for improvement in the MTM process. Approximately 67% of respondents reported MTM as beneficial or somewhat beneficial for their patients.

CONCLUSIONS

Survey respondents saw value in the MTM services offered by pharmacists. However, pharmacists should use the identified preferences and barriers to improve their currently utilized communication practices in hopes of increasing acceptance of recommendations. Ultimately, this may assist MTM providers in working collaboratively with patients' physicians.

Falsely incompatible B-cell flow cytometry crossmatch after pronase treatment: a case report

This report presents a falsely incompatible B cell crossmatch by flow cytometry in a lung transplant recipient. The patient was a 35-year-old Caucasian male with end-stage lung disease secondary to cystic fibrosis whose pretransplantation serologic workup did not disclose the presence of anti-HLA class II antibodies by single antigen bead testing. Unexpectedly, crossmatch of recipient sera with pronase-treated donor lymphocytes resulted in antibody binding to B cells only. The positive reactivity was reproducible in pronase-treated autologous B cells. Recipient sera did not react with nontreated donor or autologous lymphocytes. Herein, we describe our approach to this unexpected crossmatch result and consider the implications of false-positive crossmatch results on transplantation.

Examining the Effect of a Medication Synchronization or an Education Program on Health Outcomes of Hypertensive Patients in a Community Pharmacy Setting

Objective: To examine the effect of a medication synchronization or education program on hypertensive health outcomes. Methods: This study used a design of randomized controlled trial lasting four months taking place within a family-owned community pharmacy chain in a U.S. Midwestern state. A total of 302 hypertensive patients were randomized into 3 study groups - control, medication synchronization, and education. Interventions included management of medication refills through a medication synchronization program for the medication synchronization group, and monthly hypertension (HTN) education for the education group. Outcome measures included systolic blood pressure (SBP), diastolic blood pressure (DBP), percentage of patients at blood pressure (BP) goal, self-rated change in medication adherence, and patients' HTN knowledge. Results: All groups had significant decline of SBP from baseline; however the final analysis showed no significant SBP differences among study groups. The proportion of patients achieving BP goals in both the control (p=0.005) and education (p=0.019) groups increased at Month 4. Changes in self-reported adherence were not significant for any groups. All groups showed positive changes on HTN knowledge questions with the education group showing the greatest change. Conclusion: Compared to the control group, there was no difference in the primary outcomes. However, this study demonstrated that educational materials written at an appropriate level and presented by community pharmacists to patients may have been associated with an increase in HTN knowledge and a significant increase in the proportion of patients achieving their BP goal. These educational interventions had a greater impact on helping patients achieve their blood pressure goals than medication synchronization. This may indicate that further intervention is needed to impact adherence aside from ensuring that patients have their medication on hand. Taking the time to educate patients about hypertension led to self-reported positive change with being more careful about taking medications and with not forgetting to take medications when they felt better.   Type: Original Research

Implementation of a financially incentivized weight loss competition into an already established employee wellness program

Objective: To assess improvement in clinical outcomes and patient satisfaction of a financially incentivized weight loss competition adjunct to a currently established pharmacist-directed employee wellness program. Design: Retrospective, cohort, pilot study Setting: 6 independent community pharmacy chain locations, two long-term care pharmacies, and a pharmacy corporate office in northwest and central Missouri, from January 2013 to April 2013. Participants: 24 benefit-eligible patients employed by the self- insured pharmacy chain. Intervention: A financially incentivized weight loss competition focusing on healthy lifestyle practices was implemented at nine pharmacy locations over an eight week period. Main outcome measure(s): Change from baseline in mean total cholesterol, serum triglycerides, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP), weight, and body mass index (BMI). Patient satisfaction was also assessed after completion. Results:24 patients completed the competition. The average weight loss among all participants was 10 ± 7.3 pounds. A mean decrease in serum triglycerides was significant at 36.9 mg/dL per participant (p Conclusion: The implementation of a financially incentivized weight loss competition provided significant short-term weight loss to a patient population that was already enrolled in an established pharmacist-directed employee wellness program and had not shown clinical improvement prior to the intervention. Overall the patients were satisfied, felt healthier, and agreed to continue following the recommendations of the program.   Type: Original Research

Defending against violence in hospitals

The authors examine the rise of violence in the healthcare setting and present some practical methods for identifying high-risk individuals and reducing the incidence of violence. Some commonsense strategies are presented to help healthcare security professionals combat workplace violence.

The future of medication information practice: a consensus

OBJECTIVE

To analyze the current practice of drug information and develop a strategic plan for a "valued" specialty of medication information practice.

DATA SOURCES

The Consortium for the Advancement of Medication Information, Policy, and Research (CAMIPR) met in June 1994 to initiate a strategic plan for a future of medication information practice. A multidimensional situation analysis and strategic planning process was conducted and the results are discussed.

RECOMMENDATIONS

Trends in health care (e.g., healthcare reform, managed care) will impact the future of medication information practice, and the medication information specialist must evolve with society's values. Medication information practice must transform and attention will likely focus on medication policy research/ development and information systems. However, new skills, resources, and relationships must be developed to facilitate this evolution. In addition, interest in the practice of drug information has declined. Strategies are presented to enhance the "value" and "image" of future medication information practice.

Hospital violence

The author discusses the problem of healthcare violence, including factors that contribute to it, how to identify high-risk individuals, the socioeconomic impact of assault injuries, violence associated with prisoners as patients, and psychiatric ward violence. He also provides an outline of emergency department security survey procedures, as well as guidelines for improving hospital security.

Using pharmacist clinical intervention data for quality improvement of medication use and physician assessment

BACKGROUND

Patient-specific intervention data are often used for drug usage evaluation (DUE), but their use in physician assessment is less often discussed. In response to the quality assurance department's request, the pharmacy department at the Medical College of Georgia (Augusta) developed a database and a reporting system that supports quality assessment of the medical staff, identifies housestaff education needs, and directs efforts for improvement in medication use. THE REPORTING SYSTEM: In 1991 the comprehensive, concurrent screening of drug therapy by pharmacists formed the foundation of the hospital's DUE program. Each month information from the pharmacy database is sorted with use of a spreadsheet software program to generate medical department-level reports and for use in physician reappointment. Identified performance deficiencies can be used to educate individual prescribers and to develop educational programs for the department or specialty areas. Feedback from the medical staff assessment is useful for pharmacist education, such as identifying newly reported indications and dosage regimens.

RESULTS

During the first six months after all pharmacists began participating in the reporting program, a mean of 224 interventions were recorded monthly. For the period January through June 1994, 400-550 interventions were recorded monthly. System improvements in medication during the first year of implementation included hospitalwide guidelines for parenteral potassium and phosphate dosing and administration and a renewed focus on patient allergies.

CONCLUSION

Emphasis for use of intervention data has shifted from identifying "problem" persons to improving performance by identifying topics for corrective education and redesigning systems to promote positive patient outcomes.

The role of nondepolarizing neuromuscular blocking agents in mechanically ventilated patients

Prolonged use of the nondepolarizing neuromuscular blocking agents in the critical care setting has greatly increased in the recent past. Accompanying the increased use of these agents are numerous accounts of long-lasting adverse outcomes such as muscular atrophy and neuropathy that can be attributed to pharmacologic paralysis. There has been a financial impact on hospitals as well. Responding to these facts, the medical staff at the Medical College of Georgia Hospital and Clinics recently approved guidelines for the use of nondepolarizing neuromuscular blocking agents in the intensive care setting. These guidelines recommend clinical indications for these agents and dosing ranges reflecting current medical opinion.

A prospective study of patient-controlled analgesia. Impact on overall hospital course

Previous studies have shown that patient-controlled analgesia (PCA) provides effective pain control in the postoperative patient. To determine the impact of PCA technology on the overall hospital course, we designed a randomized controlled study comparing patients receiving analgesia using PCA infusion (Abbott Lifecare, Abbott Laboratories; Chicago, IL) with patients receiving analgesia by traditional intramuscular or intravenous methods. All patients had undergone elective cholecystectomy. Sixty-nine patients completed the study, 35 received traditional postoperative analgesia, and 34 received analgesia using the PCA infuser. Comparison of both groups demonstrated no significant difference in postoperative bowel activity with both groups receiving liquids on the first postoperative day. There was no significant difference between the two groups with respect to postoperative length of stay (3.4 days for PCA vs 3.6 days for traditional). Patients demonstrated a wide range of analgesic requirement in the first 24 hours but the average of the total analgesic required was higher in the PCA group (average, 29.5 mg) than the traditional group (22.8 mg). Urinary complications occurred more commonly in the group of patients receiving traditional analgesia than in the group of patients receiving analgesia with the PCA device. When compared with patients receiving analgesia by traditional methods, patients receiving the PCA infusion required more analgesia with fewer urinary complications and similar postoperative length of stay.

The influence of fibronectin administration on the incidence of sepsis and septic mortality in severely injured patients. The Medical College of Georgia Fibronectin Research Group

Eighty-five trauma patients between the ages of 18 and 55, with American College of Surgeon's (ACOS) trauma scores greater than or equal to 7 were entered into a double-blind, randomized, placebo-controlled study to assess the efficacy of prophylactic fibronectin (Fn) administration on clinical course, sepsis development, and septic mortality. Patients were randomized on admission to receive purified human virus-inactivated Fn or placebo control (human serum albumin, HSA). Fn or HSA was administered on a daily basis if and when the patient was Fn deficient (less than 75% normal). When a Fn deficiency was not evident, the patient received saline. Seventy one patients developed Fn deficiencies during their initial clinical course: 36 received Fn, 35 received HSA. Fourteen patients did not develop a Fn deficiency after trauma and thus received only saline. Analysis of admission data demonstrated no significant differences between the three groups with respect to extent of injury (injury severity score, ACOS trauma score) or physiologic assessments of organ function (serum creatinine, bilirubin, lactic acid). On day 1 after trauma, Fn levels were shown to correlate with other plasma proteins and cellular components (range of r values, 0.24 to 0.75; all p less than 0.05), but not with organ function parameters. Eighteen of 85 patients became septic as judged by clinical criteria. Ten of these patients had received Fn (10 of 36), five had received HSA (5 of 35), and three had received only saline (3 of 14) before the development of sepsis (differences not significant). When septic, nine of 17 patients developed Fn deficiencies. Six patients received Fn while septic, three received albumin, and eight received saline. Seven patients died: 5 of 6 Fn patients, 1 saline, and 1 HSA recipient. Our data suggest that exogenous Fn repletion in states of deficiency does not alter clinical course, the development of sepsis, or septic mortality.

Two critical psychological components of ski racing: fun and feelings

The concepts of having fun and being aware of feeling states are presented as two critical factors in ski racing. First, the positive motivational characteristics of 'fun' are outlined. It is suggested that fun is not only a concept for young athletes but elite ones as well. Preliminary data based on a questionnaire, completed by the United States Alpine Ski Team and approximately 150 ski coaches, are represented. Second, the discussion on feelings refers to the mental programming of tactile sensations and determining one's emotional arousal (feeling state) prior to, and during, competition. Practical suggestions are made with regard to the psychological states and their effects on ski racing.

Drug interactions in surgical patients

Drug interactions, defined as when the administration of a single substance (drug, nutrient, or tobacco) modifies the response to a drug, occur relatively frequently in surgical patients and may result in increased morbidity and lengthened hospital stay. Drug interactions also account for some instances of drug ineffectiveness or exaggerated pharmacologic response. There are many types of drug interactions. However, most of them are related to altered drug pharmacokinetic properties, where there are alterations in drug absorption, distribution, metabolism, or elimination; or altered drug pharmacodynamic actions, where two agents may have synergistic, additive, or antagonistic pharmacologic effects. The term, drug interaction, usually refers to pairs of drug substances administered concurrently, but more than two agents may be involved. When patients are taking a large number of different medications, there may be multiple drug interactions with additive or antagonistic effects, the overall effects of which are difficult to predict. There are hundreds of reported drug interactions, and some may be of important clinical consequence. In surgical patients, the majority of drug interactions involve histamine-2 blockers (particularly cimetidine), digoxin, warfarin, or a variety of agents that may be administered during anesthesia. Recognition of the potential for adverse drug interactions is of primary importance in minimizing their effects. Usually, potentially interacting drugs may be administered concurrently as long as appropriate patient or laboratory assessments are performed. For some agents, such as digoxin or theophylline, serum drug concentrations may aid in the avoidance of adverse drug interactions.

A Psychological Study of Health, Injury, and Performance in Athletes on the US Alpine Ski Team

In brief: We assessed life events, depression, and general well-being (health concerns, energy, life satisfaction, cheerfulness, tension, and emotional control) in 73 members of the US Alpine Ski Team. We compared these psychological factors with subsequent surveys of general health, illness, and athletic performance and found that psychological status (especially general well-being) was associated with subsequent health problems, injuries, and performance levels. These findings indicate that coaches and sports medicine specialists must be sensitive to psychological disorders in elite athletes and provide appropriate clinical assessment and treatment.

Potential drug interactions in surgical patients

The incidence and frequency of potentially serious drug interactions were evaluated in hospitalized surgical patients. Drug profiles of patients on the general surgical service of a tertiary-care teaching hospital were retrospectively reviewed for two six-month periods to determine how often drugs that are known for major interactions were prescribed concurrently. Interactions were studied that were relatively well documented and potentially harmful to the patients. A total of 1825 patient profiles were reviewed (21,888 patient days). At least one potential drug interaction was found in 17% of the patients. Interactions were found to occur at the rate of 1 for every 59 patient days. Digoxin and cimetidine were the potential interacting drugs in almost 90% of the cases. Hospitalized surgical patients require close monitoring because they frequently receive potentially interacting drugs.

Evaluation of pharmacy and therapeutics committee drug evaluation reports

Pharmacy and therapeutics (P & T) committee drug evaluation reports prepared by pharmacies and drug information centers (DICs) and product package inserts were compared with standard guidelines to evaluate their quality. Letters were sent to 143 hospital pharmacies asking them to submit a previously prepared drug evaluation report on temazepam, moxalactam disodium, or atenolol. The reports and package inserts for these three drugs were evaluated by the presence of 40 elements derived from the published ASHP guidelines for drug evaluation report preparation. Responses were obtained from 124 (87%) pharmacies; however, only 80 reports (60 DIC-prepared and 20 pharmacy-prepared) were received. The reports contained a mean of 28 of the 40 (70%) possible elements. The most frequently omitted elements were AHFS number, potential unlabeled uses, drug-drug interactions, drug-disease-laboratory test interactions, risk and benefit data, prevention and treatment of side effects, comparisons with established treatment, and disadvantages of the drug under consideration. Although the reports prepared by the DICs and pharmacies contained the same amount of information, the DIC-prepared reports included data more frequently on supply sources, therapeutic indications, approved labeling, comparison with established treatment, bioavailability and pharmacokinetics, and recommendations. Most of the reports contained more elements than the corresponding package inserts. The product package inserts did not contain the comparative elements required for P & T committee decisions. Both the pharmacy- and DIC-prepared reports failed to contain all 40 elements recommended in the standard guidelines, suggesting the need for more thorough reports.