An instrument to evaluate pharmacists' patient counseling on herbal and dietary supplements

OBJECTIVE

To develop a measure of pharmacists' patient counseling on herbal and dietary supplements.

METHODS

A systematic process was used for item generation, testing, and validation of a measure of pharmacists counseling on herbal and dietary supplements. Because a pharmacist-patient encounter may or may not identify an indication for taking an herb or dietary supplement, the instrument was bifurcated into 2 distinct components: (1) patient counseling in general; and (2) patient counseling related to herbal and dietary supplements.

RESULTS

The instrument demonstrated high reliability and desirable construct validity. After adjusting for item difficulty, we found that pharmacists tended to provide more general patient counseling than counseling related to herbal and dietary supplements.

CONCLUSION

This instrument can be applied to assess the quality of counseling provided by pharmacists and pharmacy students, and the outcomes of pharmacist and pharmacy student education on herbal and dietary supplements.

The Team Education and Adherence Monitoring (TEAM) trial: pharmacy interventions to improve hypertension control in blacks

Recent studies suggest that involving pharmacists is an effective strategy for improving patient adherence and blood pressure (BP) control. To date, few controlled studies have tested the cost-effectiveness of specific models for improving patient adherence and BP control in community pharmacies, where most Americans obtain prescriptions. We hypothesized that a team model of adherence monitoring and intervention in corporately owned community pharmacies can improve patient adherence, prescribing, and BP control among hypertensive black patients. The Team Education and Adherence Monitoring (TEAM) Trial is a randomized controlled trial testing a multistep intervention for improving adherence monitoring and intervention in 28 corporately owned community pharmacies. Patients in the 14 control pharmacies received "usual care," and patients in the 14 intervention pharmacies received TEAM Care by trained pharmacists and pharmacy technicians working with patients and physicians. Data collectors screened 1250 patients and enrolled 597 hypertensive black patients. The primary end points were the proportion of patients achieving BP control and reductions in systolic and diastolic BP measured after 6 and 12 months. Secondary end points were changes in adherence monitoring and intervention, patient adherence and barriers to adherence, prescribing, and cost-effectiveness. Researchers also will examine potential covariates and barriers to change. Involving pharmacists is a potentially powerful means of improving BP control in blacks. Pharmacists are in an excellent position to monitor patients between clinic visits and to provide useful information to patients and physicians.

Neighborhood geographical factors and the presence of advanced community pharmacy practice sites in Greater Chicago

OBJECTIVES

To determine the availability of experiential learning opportunities in culturally diverse areas and to identify opportunities and barriers to attract and sustain sites for the University of Illinois at Chicago College of Pharmacy.

METHODS

Utilizing variables of census tract income, racial/ethnicity composition and crime index, data analyses included descriptive statistics and multivariate logistic regression. Faculty members involved in experiential education were interviewed to identify other factors influencing site placement and selection for community-based advanced pharmacy practice experiences (APPEs).

RESULTS

Median family income and Asian population were significantly higher and black population was significantly lower in census tracts with community APPE sites than in census tracts without APPE sites (p < 0.05). No significant differences were found in the population variables of white and Latino populations and crime index. The Asian population variable was the only significant predictor of an APPE site (p = 0.0148) when controlling for other variables. Distance from the College, pharmacy staffing issues, goodwill, influence of district and corporate managers, and strategic initiatives were critical considerations in site establishment and overall sustainability.

CONCLUSION

Advanced community pharmacy practice sites were fairly well distributed across metropolitan Chicago, indicating that exposure to diverse populations during the advanced community practice experiences parallels with strategic College objectives of expanding and diversifying experiential sites to enhance pharmacy students' abilities to meet emerging patient care challenges and opportunities.

An online debate series for first-year pharmacy students

OBJECTIVES

This article describes an online debate series that was developed as a new component to an introductory core course for first-professional year pharmacy students. Objectives were to facilitate the group process, introduce controversial issues related to the US healthcare system, improve critical thinking and communication skills, enable students' ability to analyze and evaluate evidence, help develop skills in formulating written arguments, and encourage tolerance of diverse points of view.

DESIGN

One hundred sixty-two students were assigned to 40 teams (half assigned to argue as "Pros" and half as "Cons") and paired into 20 debating groups. The paired teams posted 3 arguments in an online forum alternatively over a 12-week period. The winning teams were determined by a panel of 3 judges.

ASSESSMENT

Feedback from the judges was posted online and summarized in an in-class discussion. Thematic analysis of qualitative data from students and faculty members demonstrated the effectiveness of the online debate component in helping students work together in a group, learn alternative sides of complex issues, and write persuasive arguments.

CONCLUSION

This novel online-debate forum was a feasible teaching and learning strategy, which helped pharmacy students improve their communication skills and critical thinking, expanded their scope of knowledge, and provided a platform for group process.

Trend and area variation in amphetamine prescription usage among children and adolescents in Michigan

The increased use of stimulant medications for children and teenagers is an ongoing issue of professional and public concern. Unlike methylphenidate, the growth of prescriptions and patterns of utilization of amphetamines for pediatric populations have not been well documented. The study objectives were to describe the trends of amphetamine prescription utilization among pediatric age groups in Michigan and to compare area variations. A population-based computerized data set from the state of Michigan was used to extract all outpatient prescriptions for Schedule II amphetamines dispensed from 1990 to 1997. The prescribing rates by age groups and by counties were computed with the projected population size of corresponding years, and mapped and analyzed with spatial statistical methods. Counties that did not conform to the global spatial dependence pattern in the prescription rate were identified using Moran scatter plot. A total of 236,661 outpatient prescriptions for amphetamines were dispensed in Michigan during the time frame, including less than 1% for methamphetamine, 24.5% for amphetamine, and 74.8% for dextroamphetamine. The prescribing rate was highest among children 10-14 years old (380 prescriptions per 10,000 people) in 1997, followed by children 5-9 years old (253 prescriptions per 10,000). Over the 8-year period, the prescribing rates of amphetamines increased significantly, ranging from 380% for children 2-4 years to 817% for teenagers older than 14 years. The rates among counties ranged from 60 to 1648 per 10,000 children 5-14 years old, with the highest prescribing rates in the northwestern regions of Michigan. Although spatial dependence explained 36% of the variance, the area variations that are unaccounted for are still considerable. In conclusion, there were substantial increases and unexplained area variations in amphetamine usage in Michigan during the study period. Both phenomena require awareness and evaluation from researchers, policy makers, clinicians, and the public.

Potential access and revealed access to pain management medications

The area configuration of healthcare resources, such as the number of hospitals per hundred thousand population, has often been used in healthcare planning and policy making to estimate the global access (potential access) of health services to a local population. However, the actual utilization of the "available" healthcare resources (revealed access) is usually much more limited. The objectives of this study were to examine the availability of healthcare resources by measuring the potential access and the revealed access for outpatients who need to access pharmacies to fill prescriptions of Schedule II (CII) opioids for pain management, and to explore the difference between rural and urban residents in these two types of access. About 191,700 prescriptions for CII opioids dispensed in 1997 in the state of Michigan, USA were analyzed. Revealed accessibility was measured by the distance between the paired zip codes of the pharmacy and the patient listed on each prescription. Potential accessibility was measured by the distance from a patient's zip code to that of the nearest community pharmacy that could dispense the opioid prescriptions. The analyses on revealed access showed that 50% of the CII prescriptions were dispensed by pharmacies located within a 5-mile radius of patients' residences, 75% of prescriptions were dispensed within about a 10-mile radius, and 90% were within 20 miles. If patients were free to access the nearest pharmacy for dispensing (a hypothetical situation under potential access), the median, 75th percentile, and 90th percentile distances could reduce to 2, 3, and 5 miles, respectively. Similar differences between revealed and potential access were observed in both rural and urban areas and for every major opioid drug group. We conclude that policymakers should recognize the discrepancy between potential and revealed accessibility and move beyond only considering area configuration of healthcare resources to evaluating and improving access to care.

Systems factors in the reporting of serious medication errors in hospitals

Underreporting of medication errors poses a threat to quality improvement initiatives. Hospital risk management programs encourage medication error reporting for effective management of systems failures. This study involved a survey of 156 medical-surgical hospitals in the United States to evaluate systems factors associated with the reporting of serious medication errors. Prior to controlling for bed size, a multivariate logistic regression model showed increased reporting of medication errors in hospitals with 24-h pharmacy services, presumably because of better error reporting systems. When number of occupied beds was included, the final model demonstrated bed size to be the only statistically significant factor. Increased reporting rates for serious medication errors warrant further evaluation, but higher error reporting may paradoxically indicate improved error surveillance. Results suggest that increased availability of pharmacist services results in opportunities for more diligent systematic efforts in detecting and reporting medication errors, which should lead to improved patient safety.

Pharmaceutical services in rural hospitals in Illinois--2001

The results of a survey characterizing pharmaceutical services in rural hospitals in Illinois are reported and compared with results of a similar survey conducted in 1991. A questionnaire was developed and mailed to pharmacy directors at rural hospitals in Illinois to obtain information about product-related services, the use of technology, clinical pharmacy services, and human resources data (including vacancies) for 2001. Of the 71 surveys that were mailed, 47 pharmacy directors (66%) responded. Respondent hospitals were smaller compared with those responding in 1991 (mean average daily census, 41.0 versus 51.2, respectively). As in 1991, nearly all respondents reported the provision of unit dose services and complete and comprehensive i.v. admixture programs (100% and 83%, respectively, for 2001). Three respondents (6%) reported having a cleanroom facility. The most commonly used technology reported was nursing-unit-based automated drug dispensing cabinets (35%). Nearly all hospitals reported providing drug therapy monitoring, patient education and counseling, pharmacokinetic consultations, and nutritional support. Consistent with national reports, staffing levels and vacancies increased between 1991 and 2001. In 2001, the mean number of full-time equivalents was 7.1, with a pharmacist to technician ratio of 1.0:1.08 and a ratio of pharmacists to occupied beds of 1.0:22.6. The overall vacancy rate was 8%, with a vacancy rate of 14% and 5% for pharmacists and pharmacy technicians, respectively. A 2001 survey of pharmacy departments in rural hospitals in Illinois showed progression in the provision of distributive and clinical pharmacy services since 1991. Employee vacancy rates in pharmacy departments were high in 2001, especially among pharmacist positions, but were lower than those reported for the general population of hospitals.

Internet pharmacy: issues of access, quality, costs, and regulation

Internet pharmacy has been the focus of heightened interest over the past 3 years since the first major Web site was introduced in the United States. This paper addresses issues pertaining to Internet pharmacies that sell prescriptions and other products to consumers at the retail level. The Internet pharmacy industry has shifted rapidly in the short time span. This paper begins with a summary of historical considerations and the shifting organization of Internet pharmacy. The advantages and disadvantages of online pharmacy practice are listed. Issues of access, quality, and cost are described. The challenges in regulation at the state and federal levels are presented. Advice to consumers is offered regarding the use of Internet pharmacy sites for purchasing prescription drug products.

National survey of stress ulcer prophylaxis

OBJECTIVE

To determine the rationale for using stress ulcer prophylaxis (SUP) among clinicians; to assess criteria used to define failure of SUP; and to evaluate the decision-making process in the selection of a prophylactic agent.

DESIGN

A cross-sectional national mail survey.

SETTING

Random sample of the members of the Society of Critical Care Medicine who identified anesthesiology, surgery, or internal medicine as their primary specialty area.

PATIENTS

None.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Questionnaires consisting of multiple-choice and short-answer questions were sent to a simple random sample of 1,268 physicians to assess the current practice of SUP. A total of 328 usable questions were returned, resulting in a response rate of 26%. All percentages reported in the results are based on the total number of responses. The risk factors for SUP that were most commonly identified were burns (91%), shock (90%), and sepsis (88%). These were also risk factors for which the respondents most commonly started SUP. Histamine-2-receptor (H2)-antagonists as a class, were the most commonly used prophylactic agents (67%). The most commonly used agents for SUP were ranitidine (31%), famotidine (24%), sucralfate (24%), and cimetidine (12%). Most respondents selected ranitidine for ease of administration, famotidine because of formulary availability, sucralfate for a better side effects profile, and cimetidine for cost-effectiveness. Eighty-two percent of respondents considered the presence of bright red blood in the nasogastric tube as failure of SUP. In cases where SUP failed, most respondents would add a second agent from a different therapeutic class. Of those respondents who used an H2-antagonist initially, 48% would add sucralfate, 36% would add antacid, and 13% would add omeprazole. Of those respondents who used sucralfate, 77% would add an H2-antagonist when SUP failed. For those respondents who would switch to another agent when the H2-antagonist failed, 52% would change to omeprazole, whereas 67% would change to an H2-antagonist when sucralfate failed. Only eight respondents would discontinue SUP when risk factors were resolved. Most respondents would discontinue SUP when the patient was no longer in the "nothing by mouth" status (28%), started on enteral feeding (23%), or discharged from the intensive care unit (21%). The mean duration of SUP was 6.3+/-4.5 (SD) days.

CONCLUSIONS

This survey highlighted the lack of consensus in the use of SUP. Many patients receive SUP for an extended period, without clear-cut indications or documented benefit. The cost of unwarranted SUP in patients with low risk of stress ulcer gastrointestinal bleeding is prohibitive. Treatment algorithms or protocols for SUP based on prescribing patterns, hospital formulary restrictions, and cost-analysis should be considered for each institution to guide critical care physicians on the proper use of SUP therapies.

Survey of hospital systems and common serious medication errors

The Institute for Safe Medication Practices and the University of Illinois at Chicago, College of Pharmacy, undertook a hospital survey of medical-surgical hospitals to determine systems-oriented factors that allow the highest level of medication safety. The study incorporated a peer-reviewed and pretested questionnaire, which focused on critical information necessary to yield quality data for comparison. Through analysis, it was shown that over one third of all medication errors reported in the survey involve just six categories--allergies, insulin, heparin, opiates, PCA devices, and potassium concentrates.

Staff attitudes about the use of robots in pharmacy before implementation of a robotic dispensing system

Hospital pharmacy staff members at a Mid-western university medical center were surveyed to determine their attitudes about the use of robots in pharmacy dispensing before a robotic system was implemented. A questionnaire seeking attitudes about the use of robots in pharmacy was distributed to 147 pharmacy staff (pharmacy managers, pharmacist practitioners, pharmacotherapists, pharmacy residents and fellows, pharmacy technicians, and salaried pharmacy students). Attitudinal items were scored on a 5-point scale ranging from very favorable to very unfavorable. The response rate was 75%. Overall, staff expressed favorable attitudes in terms of job security, professional impact, and general robotics orientation. Pharmacy managers and pharmacotherapists were the most likely to report feeling secure about their jobs; pharmacy technicians and salaried pharmacy students were slightly less positive. Favorable attitudes about the professional impact of the robotic system were demonstrated by all groups except pharmacist practitioners and pharmacy technicians. Attitudes about management issues were unfavorable; pharmacist practitioners demonstrated the least favorable attitudes. In general, responses to semantic-differential statements reflected favorable attitudes; where there were differences, pharmacy technicians showed the least positive and pharmacy managers the most positive attitudes. Respondents reported that pharmacist practitioners would be most positively affected and pharmacy technicians most negatively affected by robotic dispensing. Almost half of the respondents who provided general comments indicated that they needed more information about the use of robots. Pharmacy staff had generally favorable attitudes about the use of robots in pharmacy.

Health outcomes variables important to patients in the treatment of erectile dysfunction

PURPOSE

Erectile dysfunction is underreported and the rate of noncompliance with therapy is high. The National Institutes of Health Consensus Conference on Impotence endorsed the need for outcomes research of the various approaches to treatment. The purpose of our exploratory study was to begin that process through identification of erectile dysfunction treatment outcomes variables that are important to men.

MATERIALS AND METHODS

The study format consisted of focus group meetings. The goal of the discussions was to identify variables that are important to men when choosing among and judging the success of treatment modalities for erectile dysfunction. After discussion participants were individually asked to identify the 10 variables that they considered important and rank the 5 most important variables. An importance score reflecting group consensus was calculated for each variable.

RESULTS

Success and negative outcomes were identified as the 2 most important outcomes variables for all treatment modalities. Participants defined success in several ways. The most important measures of success were cure, pleasure and partner satisfaction. Negative outcome was defined as negative consequences associated with treatment.

CONCLUSIONS

The focus group discussion assisted in identifying and defining outcomes variables important to patients with erectile dysfunction. We believe that understanding issues and outcomes important to such patients is necessary to increase compliance with treatment and, thereby, increase the success of treatment of this widespread condition.

Efficacy of 3-hydroxy-3-methylglutaryl coenzyme a reductase inhibitors in the treatment of patients with hypercholesterolemia: a meta-analysis of clinical trials

Recent studies have documented the long-term impact of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors on mortality and morbidity related to coronary heart disease, establishing the link between lowering cholesterol levels and reducing cardiac events. Our study was a comparative literature review and meta-analysis of the efficacy of four HMG-CoA reductase inhibitors-fluvastatin, lovastatin, pravastatin, and simvastatin-used in the treatment of patients with hypercholesterolemia. The data sources for our meta-analysis of the efficacy of these cholesterol-lowering agents were 52 randomized, double-masked clinical trials with at least 25 patients per treatment arm. The results showed all four agents to be effective in reducing blood cholesterol levels. We computed summary efficacy estimates for all published dose strengths for the four agents. Fluvastatin 20 mg/d reduced low-density lipoprotein cholesterol (LDL-C) levels by 21.0% and total cholesterol (total-C) levels by 16.4%; fluvastatin 40 mg/d reduced these levels by 23.1% and 17.7%, respectively. Lovastatin 20 mg/d reduced LDL-C levels by 24.9% and total-C levels by 17.7%; lovastatin 80 mg/d reduced these levels by 39.8% and 29.2%, respectively. Pravastatin 10 mg/d reduced LDL-C levels by 19.3% and total-C levels by 14.0%; pravastatin 80 mg/d reduced these levels by 37.7% and 28.7%, respectively. Simvastatin 2.5 mg/d reduced LDL-C levels by 22.9% and total-C levels by 15.7%; simvastatin 40 mg/d reduced these levels by 40.7% and 29.7%, respectively. The results of our meta-analysis can be used in conjunction with treatment objectives and comparative cost-effectiveness data for these agents to decide appropriate therapeutic alternatives for individual patients.

National survey of once-daily dosing of aminoglycoside antibiotics

To evaluate the scope of once-daily dosing of intravenous aminoglycoside antibiotics, a questionnaire was designed and mailed to a random sample of pharmacy directors at 500 acute care hospitals in the United States. The response rate was 68.4%. Nineteen percent of the respondents reported use of once-daily dosing of aminoglycosides. Affiliation with a pharmacy residency program and the presence of a pharmacokinetic consultation service by the pharmacy department were associated with this practice (p < 0.05). No other statistically significant differences were found. Reported indications, contraindications, and dosing were consistent with those found in the literature. The profession of pharmacy, as demonstrated by pharmacy residency programs and pharmacokinetic consultation services, appears to have been instrumental in implementing this method of dosing aminoglycosides.

ASHP national survey of pharmaceutical services in federal hospitals--1993

The results of a national mail survey of pharmaceutical services in federal hospitals conducted by ASHP from May to July 1993 are reported. Mailing lists were compiled of all Air Force, Army, Navy, Public Health Service, and Department of Veterans Affairs (VA) hospitals, as well as some federal prison hospitals. Questionnaires were mailed to each chief of pharmacy. The adjusted gross population size was 326. The net response rate was 76%. Complete unit dose drug distribution was offered by 85% of respondents, and 83% offered complete, comprehensive i.v. admixture programs. About half of the pharmacies provided decentralized services. Over 99% provided services to ambulatory care patients. A computerized pharmacy system was present in 99% of the departments. More than 95% of hospitals participated in adverse drug reaction, medication error management, and drug-use-evaluation programs. A total of 93% provided drug therapy monitoring, and 89% provided patient education. About 70% provided written documentation of pharmacist interventions in the medical records, and 57% participated in drug research. A total of 42% provided pharmacist-managed drug clinics, 41% participated in drug management of medical emergencies, 30% provided written medication histories, and 30% provided drug therapy management planning. Pharmacokinetic consultations were provided by 64% of departments. About 90% had a well-controlled formulary system and prescribing restrictions. Therapeutic interchange was practiced by 64%. Diversified pharmaceutical services included telephone or mail-in refill services (80%), mail-out pharmaceutical services (58%), and services to long-term-care facilities (49%). A total of 70% of the hospitals were affiliated with a pharmacy school. The first ASHP national survey of pharmaceutical services in federal hospitals showed that comprehensive distributive and clinical services were offered by most of the facilities.

Evaluating the performance of clinical pharmacy faculty: putting the ACCP template to use

The responsibilities of clinical faculty members are often multifaceted and may include direct patient care, didactic and experiential teaching, research, and administrative duties. Specialization, poorly defined standards of care, and lack of direct supervision have traditionally made performance evaluation difficult. We implemented a method to evaluate clinical faculty as they carried out patient care activities using a revised template for the evaluation of a clinical pharmacist developed by the American College of Clinical Pharmacy Clinical Practice Affairs Committee. In addition, it allows individuals to report and evaluate their own performance in the areas of patient care, instructional activity, university and public service, research and scholarly activities, and administrative duties. Teaching evaluations from clerkship students and residents are also submitted and assessed during the annual interview. To determine the usefulness of the evaluation, including the template, we surveyed the opinions of clinical faculty (nontenured) at four primary practice sites (response rate 92%). Mean scores for responses suggested agreement with statements as to the merits of the evaluation system; however, there was some variation among practice sites. Incorporating the template into a broad evaluation system was effective in facilitating improved job performance and career development. Adaptation of the template may be practice site dependent and should be coordinated by a participative approach. Additional assessment may be facilitated by physician, nurse, or peer evaluation.