The Clinical Pharmacy Specialists' Role in Antihypertensive Management Surrounding Bariatric Surgery in a Veterans Affairs Population

BACKGROUND

No guidelines exist for de-escalating antihypertensive medications surrounding bariatric surgery. This study analyzed clinical pharmacy specialist (CPS) management of antihypertensive medications in patients undergoing bariatric surgery at a Veterans Affairs medical center.

OBJECTIVES

The primary objective was to describe the CPS role in antihypertensive management surrounding bariatric surgery through evaluation of number of CPS encounters, number and type of antihypertensive medications and medication interventions by CPSs and all other providers, over 5 time periods between a pre-operative assessment and up to 6 months post-operatively.

METHODS

Electronic medical records of patients taking antihypertensive medication who underwent bariatric surgery between 1/1/2014 and 2/27/2018, had primary care through our facility, and at least 1 encounter with a CPS were reviewed.

RESULTS

Forty patients were included out of 221 screened. There were 109 total medication interventions in 37 patients. CPSs provided 60 medication interventions (55% of total interventions) in 26 patients. Mean antihypertensive agents per patient was 2.18 at baseline versus 0.95 at 6-months post-operative. Dihydropyridine calcium channel blockers had the highest discontinuation rate. Thiazide diuretics were most commonly discontinued prior to surgery and angiotensin converting enzyme inhibitors were discontinued more steadily over the study duration. Nineteen patients (48.7%) had blood pressure <140/90 mmHg and were off all antihypertensive medications at the final CPS encounter.

CONCLUSION

The results of this small study support the role of CPSs in antihypertensive medication management surrounding bariatric surgery.

Collaborative hypertension case management by registered nurses and clinical pharmacy specialists within the Patient Aligned Care Teams (PACT) model

BACKGROUND

Clinical Pharmacy Specialists (CPSs) and Registered Nurses (RNs) are integrally involved in the Patient Aligned Care Teams (PACT) model, especially as physician extenders in the management of chronic disease states. CPSs may be an alternative to physicians as a supporting prescriber for RN case management (RNCM) of poorly controlled hypertension.

OBJECTIVE

To compare CPS-directed versus physician-directed RNCM for patients with poorly controlled hypertension.

DESIGN

Non-randomized, retrospective comparison of a natural experiment.

SETTING

A large Midwestern Veterans Affairs (VA) medical center.

INTERVENTION

Utilizing CPSs as alternatives to physicians for directing RNCM of poorly controlled hypertension.

PATIENTS

All 126 patients attended RNCM appointments for poorly controlled hypertension between 20 September 2011 and 31 October 2011 with either CPS or physician involvement in the clinical decision making. Patients were excluded if both a CPS and a physician were involved in the index visit, or they were enrolled in Home Based Primary Care, or if they displayed non-adherence to the plan.

MAIN MEASURES

All data were obtained from review of electronic medical records. Outcomes included whether a patient received medication intensification at the index visit, and as the main measure, blood pressures between the index and next consecutive visit.

KEY RESULTS

All patients had medication intensification. Patients receiving CPS-directed RNCM had greater decreases in systolic blood pressure compared to those receiving physician-directed RNCM (14 ± 13 mmHg versus 10 ± 11 mmHg; p = 0.04). After adjusting for the time between visits, initial systolic blood pressure, and prior stroke, provider type was no longer significant (p = 0.24). Change in diastolic blood pressure and attainment of blood pressure < 140/90 mm Hg were similar between groups (p = 0.93, p = 0.91, respectively).

CONCLUSIONS

CPS-directed and physician-directed RNCM for hypertension demonstrated similar blood pressure reduction. These results support the utilization of CPSs as prescribers to support RNCM for chronic diseases.

Effect of sulfonylurea dose escalation on hemoglobin A1c in Veterans Affairs patients with type 2 diabetes

Sulfonylureas are often titrated to maximum doses despite evidence that their efficacy plateaus above half-maximum doses. The aim of this study was to determine the impact of doubling the dose of glyburide and glipizide to high doses on hemoglobin A1c (HbA1c) in Veterans Affairs patients with type 2 diabetes. A retrospective review of 131 patient cases with prescriptions for high-dose glyburide or glipizide from July 1 through December 18, 2008, was conducted. Three dosage groups were examined: glyburide 5 mg twice daily increased to 10 mg twice daily (GLYB), glipizide 5 mg twice daily increased to 10 mg twice daily (GLIPA), and glipizide 10 mg twice daily increased to 20 mg twice daily (GLIPB). Each patient served as his or her own control; HbA1c after at least 75 days on each dose was compared. There was a statistically significant decrease in HbA1c in GLIPA only (mean ± SD 8.0 ± 1.0 vs. 7.6 ± 1.0%, P = 0.03). No significant change in HbA1c was detected in GLYB (8.1 ± 1.1 vs. 8.1 ± 1.3%, P = 0.80) and the evaluation of GLIPB (8.6 ± 1.7 vs. 8.2 ± 1.1%, P = 0.41) was not adequately powered due to the small sample size. In this small retrospective study, increasing glipizide, but not glyburide, from 5 mg to 10 mg twice daily significantly decreased HbA1c in patients with diabetes.

Are women in early pregnancy following the national pyramid recommendations?

Appropriate nutrition in pregnancy is fundamental for maternal and fetal health, and the long-term physiological wellbeing of the offspring. We aimed to determine whether a sample of pregnant women met the national guidelines for healthy eating during pregnancy, and to examine if compliance differs when analysed by Body Mass Index (BMI) category. Subjects completed a 24-hr dietary recall, and had their BMI calculated. The mean age was 27.8 years. The mean BMI was 25.1 kg/m2, with 32 (31.7%) subjects overweight and 14 (13.9%) obese based on BMI category. Although the majority of subjects thought that they had a healthy diet, less than half met the recommended guidelines for each individual food group with achievement of the dairy group being particularly low. Achievement of food group recommendations was not influenced by BMI category. Public health messages on healthy eating guidelines need to be clearly communicated to pregnant women.

Vitamine D analogue-based therapies for psoriasis

Topical vitamin D3 analogues are a mainstay of treatment in mild to moderate plaque psoriasis. Vitamin D3 analogues exert their effect in psoriasis via binding nuclear vitamin D3 receptors on genes involved in cellular proliferation, differentiation and inflammation. Currently available synthetic vitamin D3 analogues include calcipotriol, maxacalcitol, tacalcitol and calcitriol. These agents are only minimally systemically absorbed and therefore have few systemic side effects. Local irritation is the most frequently noted side effect and can be managed by combining vitamin D3 analogues with other topical or systemic therapies, such as topical corticosteroids or narrow-band UVB phototherapy. The use of a vitamin D agent helps improve the efficacy of topical corticosteroids for psoriasis and helps minimize the potential for adverse events associated with topical corticosteroid treatment. Care should be taken when combining with other topical therapies due to potential inactivation of either agent. Topical vitamin D3 analogues can be a cost-effective addition to a psoriasis treatment regimen, especially when compliance is encouraged by the tolerability of these agents and more costly systemic agents are avoided.

Health behaviour models: a framework for studying adherence in children with atopic dermatitis

Atopic dermatitis (AD) is a common problem of childhood causing considerable distress. Effective topical treatments exist, yet poor adherence often results in poor outcomes. A framework is needed to better understand adherence behaviour. To provide a basis for this framework, we reviewed established models used to describe health behaviour. Structural elements of these models informed the development of an adherence model for AD that can be used to complement empirical AD treatment trials. Health behaviour models provide a means to describe factors that affect adherence and that can mediate the effects of different adherence interventions. Models of adherence behaviour are important for promoting better treatment outcomes for children with AD and their families. These models provide a means to identify new targets to improve adherence and a guide for refining adherence interventions.

Investigating the relationship between the practice of pharmaceutical care, construed external image, organizational identification, and job turnover intention of community pharmacists

BACKGROUND

Pharmacy employers are being challenged to recruit and retain qualified employees.

OBJECTIVES

Our study hypothesized that pharmacists who practice pharmaceutical care have an attractive construed external image (how employees think outsiders view their organization), which strengthens their organizational identification (perceptions of oneness with or belongingness to the organization) and decreases job turnover intention (thoughts of quitting/searching for another job).

METHODS

A 7-page questionnaire was mailed to the homes of a random sample of 759 licensed pharmacists practicing in the United States. Participants had the option of returning the completed survey via postal mail or a Web site. The study variables were measured with previously validated scales. Structural equation modeling with latent variables evaluated the hypothesized relationships. Several demographic variables were included.

RESULTS

Responses were received from 252 subjects (33%); 121 were community pharmacists. As hypothesized, organizational identification and job turnover intention were significantly related (B=-0.24) as well as construed external image and organizational identification (B=0.41). The practice of pharmaceutical care and construed external image were not significantly correlated (B=0.10). Although not hypothesized, construed external image was directly related to job turnover intention (B=-0.25). The effects of the practice of pharmaceutical care on job turnover intention were mediated through organizational identification. Position had significant effects.

CONCLUSIONS

One additional benefit to the practice of pharmaceutical care may be strengthened organizational identification. Pharmacists' perception of the image of their employer may increase organizational identification and decrease job turnover intention. An understanding of the organizational identification of pharmacists would be useful in decreasing job turnover intention. Given the current demand for pharmacists, this is a worthwhile endeavor. Future research should focus on other predictors of construed external image and ways to enhance organizational identification. Encouraging the practice of pharmaceutical care may be 1 such way.

An examination of the influence of eating location on the diets of Irish children

OBJECTIVES

To examine the influence of eating location on the quality of the diets of Irish children and to compare intakes at home with intakes at other people's homes and intakes outside the home, and to compare intakes at various locations outside the home.

DESIGN

Food intake was measured using a 7-day weighed diary in 594 children from the Republic of Ireland (aged 5-12 years). Details of where the food was prepared or obtained were also recorded.

RESULTS

Eighty-nine per cent of all eating occasions occurred at home; < 6% occurred at both other people's homes and outside the home (takeaway, restaurant, shop, other). The percentage of food energy from fat was above the recommended 35% at other people's homes and outside the home, specifically at takeaways and restaurants. Fibre and micronutrient intakes (per 10 MJ) were significantly higher at home than at the other locations (P < 0.05). Within the 'out' locations, fibre and micronutrient intakes were generally higher at restaurants and lower at shops. High consumers of foods outside the home had a statistically significant, but relatively small decline in nutrient intakes compared with non- or low consumers. Chips and processed potatoes, meat products, savouries, sugars and confectionery, and savoury snacks made the greatest contribution to foods consumed outside the home.

CONCLUSIONS

The main focus of nutrition policies to improve the diets of Irish children should be the home environment rather than the food service sector. However, guidelines could call for better food choices outside the home to improve nutrient intakes.

Prevalence of overweight and obesity in Irish school children, using four different definitions

OBJECTIVE

To determine the prevalence of overweight and obesity in Irish children using four different weight-for-height methods and to examine secular trends from previous national data.

DESIGN

A cross-sectional survey. Weight and height were measured according to standard procedures and used to determine the prevalence of overweight and obesity using four weight-for-height methods of assessment, actual relative weight, the Centers for Disease Control and Prevention body mass index (BMI) for age charts for boys and girls, the BMI reference curves for the UK 1990 and the International Obesity Task Force age- and sex-specific BMI cutoffs.

SETTING

The survey was carried out between 2003 and 2004 in the Republic of Ireland.

SUBJECTS

Random representative sample of 596 children aged 5-12 years.

RESULTS

The prevalence of overweight and obesity in Irish children is high, but varies considerably with each method. The prevalence of obesity in boys ranged from 4.1 to 11.2 % and in girls from 9.3 to 16.3%. Between 1990 and 2005, depending on the method used, there was a two-to-fourfold increase in obesity in children aged 8-12 years.

CONCLUSION

It is evident given the variation displayed in the prevalence of obesity when using the different methods, that there is a discernible need for a single definition to identify the obese child in Ireland. The findings show a high prevalence of overweight and obesity in Irish school children and the increase in the prevalence of obesity over the last 15 years highlights this growing public health issue.

Safety of outpatient dalteparin therapy in veterans with mechanical heart valves

STUDY OBJECTIVES

To determine the rate of bleeding and thromboembolic events within 1 month of outpatient dalteparin therapy in veterans with mechanical heart valves, to evaluate potential risk factors associated with these events, and to examine the prescribing patterns of dalteparin in this patient population.

DESIGN

Single-center retrospective electronic chart review.

SETTING

Large, academically affiliated Veterans Affairs hospital.

SUBJECTS

Thirty-eight men with mechanical heart valves who received outpatient prescriptions for dalteparin from October 1, 1998-June 30, 2003.

MEASUREMENTS AND MAIN RESULTS

Charts were reviewed for thromboembolic and bleeding events. Demographic, clinical, and drug utilization variables were assessed. The associations of adverse events with potential risk factors, indication for dalteparin therapy, and prescribing clinic were analyzed. Sixty-four dalteparin regimens were evaluated. No thromboembolic events were reported in any case within 1 month after receiving dalteparin for thromboembolic prophylaxis during warfarin interruption for periprocedural anticoagulation or for anticoagulation during an unintentional subtherapeutic international normalized ratio. Bleeding events occurred in 15 (23%) of the 64 regimens. Most bleeding events resolved spontaneously and without intervention. No potential risk factors for bleeding were identified.

CONCLUSION

Dalteparin appeared to be a safe, effective means of short-term thromboembolic prophylaxis in this population of ambulatory male veterans with mechanical heart valves. Large, randomized, controlled, prospective trials are warranted.

Drug-induced esophageal injuries and dysphagia

OBJECTIVE

To review and analyze medical literature documenting drug-induced esophageal injury and dysphagia and to formulate strategies to enhance pharmacists' prevention, detection, and treatment of these iatrogenic complications.

DATA SOURCES

A MEDLINE search (1966-April 2002) was conducted to identify primary and secondary literature using variable combinations of the following search terms: pill-induced, drug-induced, or iatrogenic with esophageal injury, esophageal damage, or dysphagia. Bibliographies were also reviewed to identify additional relevant references.

STUDY SELECTION AND DATA EXTRACTION

All case reports, reviews, and clinical studies relating to drug-induced esophageal injury or swallowing dysfunction were evaluated.

DATA SYNTHESIS

Drug-induced esophageal injury may be under-recognized. Several drugs have been associated with physical or chemically mediated injuries. Risk factors for injury have been identified and preventive and treatment strategies have been successful in limiting esophageal injury. Drug-induced dysphagia can have serious complications and is most often associated with typical neuroleptics such as haloperidol.

CONCLUSIONS

Pharmacists can play a pivotal role in proactively identifying situations where there is a higher likelihood of drug-induced esophageal injury or dysphagia. They can recommend preventive strategies to promote safe medication use, help identify iatrogenic complications when they occur, and assist in formulation of appropriate treatment strategies.