Characteristics of High-Performing Interprofessional Health Care Teams Involving Student Pharmacists

Objective. To identify key themes of interprofessional models of care that offer experiential education opportunities for pharmacy learners. Methods. Six pharmacists from four Area Health Education Centers in North Carolina participated in individual, 60-minute interviews. Using two pre-established frameworks, the data were analyzed qualitatively by two members of the research team to identify the characteristics of interdisciplinary care teams. Results. At the level of the organization or health care system, the theme of appropriate resources and procedures emerged. At the level of the team, the themes of appropriate resources and procedures, communication, appropriate skill mix, climate, quality and outcomes of care, and respecting and understanding roles emerged. At the level of the individual, the themes of communication, respecting and understanding roles, and individual characteristics emerged. Three themes identified in a previous study failed to emerge in the interviews: leadership and management; personal rewards, training and development; and clarity of vision. Conclusion. Although a growing body of evidence highlights the importance of designing practice models to achieve interdisciplinary care that is patient-centered and effective, capacity to support learners and effectively educate them in the principles and practices of team-based care is limited. This study provides critical insight into characterizations of interprofessional models that integrate pharmacy learners. Further research is needed to better understand the barriers to designing and implementing IPE in experiential settings.

Identifying the Presence of Cognitive Apprenticeship in the Layered Learning Practice Model

Objective. To identify the presence of cognitive apprenticeship themes in the layered learning practice model (LLPM). Methods. Attending pharmacists who had implemented an LLPM completed an individual 90-minute face-to-face semi-structured interview. Three researchers independently reviewed transcripts to identify cognitive apprenticeship themes according to the framework's dimensions and sub-dimensions. Results. Of 25 eligible attending pharmacists, 24 (96%) agreed to participate. All core dimensions of the cognitive apprenticeship framework emerged during the interviews; however, preceptors varied in how they used the framework in the training of pharmacy learners at different levels. This variability was especially apparent within the sub-dimensions of the content and method domains. Conclusion. This study demonstrates that all four cognitive apprenticeship principles are being used in the clinical environments operationalizing the LLPM. These findings suggest that cognitive apprenticeship is an applicable and relevant educational framework when engaging multiple learners in clinical education environments.

The layered learning practice model: Lessons learned from implementation

PURPOSE

Pharmacists' views about the implementation, benefits, and attributes of a layered learning practice model (LLPM) were examined.

METHODS

Eligible and willing attending pharmacists at the same institution that had implemented an LLPM completed an individual, 90-minute, face-to-face interview using a structured interview guide developed by the interdisciplinary study team. Interviews were digitally recorded and transcribed verbatim without personal identifiers. Three researchers independently reviewed preliminary findings to reach consensus on emerging themes. In cases where thematic coding diverged, the researchers discussed their analyses until consensus was reached.

RESULTS

Of 25 eligible attending pharmacists, 24 (96%) agreed to participate. The sample was drawn from both acute and ambulatory care practice settings and all clinical specialty areas. Attending pharmacists described several experiences implementing the LLPM and perceived benefits of the model. Attending pharmacists identified seven key attributes for hospital and health-system pharmacy departments that are needed to design and implement effective LLPMs: shared leadership, a systematic approach, good communication, flexibility for attending pharmacists, adequate resources, commitment, and evaluation. Participants also highlighted several potential challenges and obstacles for organizations to consider before implementing an LLPM.

CONCLUSION

According to attending pharmacists involved in an LLPM, successful implementation of an LLPM required shared leadership, a systematic approach, communication, flexibility, resources, commitment, and a process for evaluation.

Cognitive apprenticeship in health sciences education: a qualitative review

Cognitive apprenticeship theory emphasizes the process of making expert thinking "visible" to students and fostering the cognitive and meta-cognitive processes required for expertise. The purpose of this review was to evaluate the use of cognitive apprenticeship theory with the primary aim of understanding how and to what extent the theory has been applied to the design, implementation, and analysis of education in the health sciences. The initial search yielded 149 articles, with 45 excluded because they contained the term "cognitive apprenticeship" only in reference list. The remaining 104 articles were categorized using a theory talk coding scheme. An in depth qualitative synthesis and review was conducted for the 26 articles falling into the major theory talk category. Application of cognitive apprenticeship theory tended to focus on the methods dimension (e.g., coaching, mentoring, scaffolding), with some consideration for the content and sociology dimensions. Cognitive apprenticeship was applied in various disciplines (e.g., nursing, medicine, veterinary) and educational settings (e.g., clinical, simulations, online). Health sciences education researchers often used cognitive apprenticeship to inform instructional design and instrument development. Major recommendations from the literature included consideration for contextual influences, providing faculty development, and expanding application of the theory to improve instructional design and student outcomes. This body of research provides critical insight into cognitive apprenticeship theory and extends our understanding of how to develop expert thinking in health sciences students. New research directions should apply the theory into additional aspects of health sciences educational research, such as classroom learning and interprofessional education.

Exploring the Requisite Skills and Competencies of Pharmacists Needed for Success in an Evolving Health Care Environment

Objective. To identify and describe the core competencies and skills considered essential for success of pharmacists in today's rapidly evolving health care environment. Methods. Six breakout groups of 15-20 preceptors, pharmacists, and partners engaged in a facilitated discussion about the qualities and characteristics relevant to the success of a pharmacy graduate. Data were analyzed using qualitative methods. Peer-debriefing, multiple coders, and member-checking were used to promote trustworthiness of findings. Results. Eight overarching themes were identified: critical thinking and problem solving; collaboration across networks and leading by influence; agility and adaptability; initiative and entrepreneurialism; effective oral and written communication; accessing and analyzing information; curiosity and imagination; and self-awareness. Conclusion. This study is an important step toward understanding how to best prepare pharmacy students for the emerging health care needs of society.

Improved Organizational Outcomes Associated With Incorporation of Early Clinical Experiences for Second-Year Student Pharmacists at an Academic Medical Center

Purpose:

To assess the feasibility of engaging second professional year student pharmacists in the medication reconciliation process on hospital and health system pharmacy practice outcomes.

Methods:

Student pharmacists in their second professional year in the Doctor of Pharmacy degree program at our institution were randomly selected from volunteers to participate. Each participant completed training prior to completing three 5-hour evening shifts. Organizational metrics, student pharmacist perception regarding quality of interactions with health care professionals, and pharmacist perceptions were collected.

Results:

A total of 83 medication histories were performed on complex medical patients (57.0 ± 19.2 years, 51% female, 65% Caucasian, 12 ± 6 medications); of those, 93% were completed within 24 hours of hospital admission. Second professional student pharmacists completed on average 1.9 ± 0.6 medication histories per shift (range 1-3). Student pharmacists identified 0.9 medication-related problems per patient in collaboration with a pharmacist preceptor. Student pharmacists believed the quality of their interactions with health care professionals in the Student Medication and Reconciliation Team (SMART) program was good or excellent. The program has been well received by clinical pharmacists involved in its design and implementation.

Conclusion:

This study provides evidence that second professional year student pharmacists can assist pharmacy departments in the care of medically complex patients upon hospital admission.

Primary Prevention of Coronary Heart Disease in the Elderly

OBJECTIVE:

To review relevant literature supporting the use of antihypertensive agents, lipid-lowering agents (i.e., statins), and aspirin therapy for the primary prevention of coronary heart disease (CHD) in an elderly patient population (age ≥65 y).

DATA SOURCES:

A MEDLINE search (1988–January 2003) was conducted.

STUDY SELECTION AND DATA EXTRACTION:

Primary and tertiary literature involving the uses of antihypertensives, statins, and aspirin therapy in the elderly were reviewed.

DATA SYNTHESIS:

Mortality due to CHD in the US population has decreased 40–50% over the last 30 years; however, CHD remains the leading cause of morbidity and mortality in elderly persons. As the population continues to age, the number of older adults eligible for primary prevention will rise. The American Heart Association clinical practice guidelines for the primary prevention of CHD were updated in 2002; however, they are based on findings from clinical trials that enrolled predominantly middle-aged white men. The recommendations for elderly individuals are predominantly extrapolated from subgroup analyses of randomized clinical trials or cohort studies. This literature suggests that elderly persons are candidates for primary prevention measures and experience reductions in coronary events when treated with appropriate therapies.

CONCLUSIONS:

Data suggest that use of antihypertensives, statins, and aspirin therapy in the elderly appears effective to an extent similar to, and often greater than, that observed in younger patients. We believe these agents should be prescribed to all appropriate high-risk elderly patients. Ongoing and future studies will more clearly elucidate the benefits of primary prevention therapy, particularly in persons ≥75 years of age.

A Study of Layered Learning in Oncology

Objective. To explore use of pharmacy learners as a means to expand pharmacy services in a layered learning practice model (LLPM), to examine whether an LLPM environment precludes achievement of knowledge-based learning objectives, and to explore learner perception of the experience. Design. An acute care oncology pharmacy practice experience was redesigned to support the LLPM. Specifically, the redesign focused on micro discussion, standardized feedback (eg, rubrics), and cooperative learning to enhance educational gain through performing clinical activities. Assessment. Posttest scores evaluating knowledge-based learning objectives increased in mean percentage compared to pretest values. Learners viewed the newly designed practice experience positively with respect to perceived knowledge attainment, improved clinical time management skills, contributions to patient care, and development of clinical and self-management skills. A fifth theme among students, comfort with learning, was also noted. Conclusion. Layered learning in an oncology practice experience was well-received by pharmacy learners. Data suggest a practice experience in the LLPM environment does not preclude achieving knowledge-based learning objectives and supports further studies of the LLPM.

Early Clinical Experiences for Second-Year Student Pharmacists at an Academic Medical Center

OBJECTIVE

To examine student outcomes associated with the Student Medication and Reconciliation Team (SMART) program, which was designed to provide second-year student pharmacists at the University of North Carolina (UNC) Eshelman School of Pharmacy direct patient care experience at UNC Medical Center.

DESIGN

Twenty-two second-year student pharmacists were randomly selected from volunteers, given program training, and scheduled for three 5-hour evening shifts in 2013-2014. Pre/post surveys and reflection statements were collected from 19 students. Data were analyzed with a mixed methods approach.

ASSESSMENT

Survey results revealed an increase in student self-efficacy (p<0.05) and positive perceptions of SMART. Qualitative findings suggest the program provided opportunities for students to develop strategies for practice, promoted an appreciation for the various roles pharmacists play in health care, and fostered an appreciation for the complexity of real-world practice.

CONCLUSION

Early clinical experiences can enhance student learning and development while fostering an appreciation for pharmacy practice.

Student Perceptions of a Flipped Pharmacotherapy Course

OBJECTIVE

To evaluate student perception of the flipped classroom redesign of a required pharmacotherapy course.

DESIGN

Key foundational content was packaged into interactive, text-based online modules for self-paced learning prior to class. Class time was used for active and applied-but primarily case-based-learning.

ASSESSMENT

For students with a strong preference for traditional lecture learning, the perception of the learning experience was negatively affected by the flipped course design. Module length and time required to complete preclass preparation were the most frequently cited impediments to learning. Students desired instructor-directed reinforcement of independently acquired knowledge to connect foundational knowledge and its application.

CONCLUSION

This study illustrates the challenges and highlights the importance of designing courses to effectively balance time requirements and connect preclass and in-class learning activities. It underscores the crucial role of the instructor in bridging the gap between material learned as independent study and its application.

Student experiences across multiple flipped courses in a single curriculum

CONTEXT

The flipped classroom approach has garnered significant attention in health professions education, which has resulted in calls for curriculum-wide implementations of the model. However, research to support the development of evidence-based guidelines for large-scale flipped classroom implementations is lacking.

OBJECTIVES

This study was designed to examine how students experience the flipped classroom model of learning in multiple courses within a single curriculum, as well as to identify specific elements of flipped learning that students perceive as beneficial or challenging.

METHODS

A qualitative analysis of students' comments (n = 6010) from mid-course and end-of-course evaluations of 10 flipped courses (in 2012-2014) was conducted. Common and recurring themes were identified through systematic iterative coding and sorting using the constant comparison method. Multiple coders, agreement through consensus and member checking were utilised to ensure the trustworthiness of findings.

RESULTS

Several themes emerged from the analysis: (i) the perceived advantages of flipped learning coupled with concerns about implementation; (ii) the benefits of pre-class learning and factors that negatively affect these benefits, such as quality and quantity of learning materials, as well as overall increase in workload, especially in the context of multiple concurrent flipped courses; (iii) the role of the instructor in the flipped learning environment, particularly in engaging students in active learning and ensuring instructional alignment, and (iv) the need for assessments that emphasise the application of knowledge and critical thinking skills.

CONCLUSIONS

Analysis of data from 10 flipped courses provided insight into common patterns of student learning experiences specific to the flipped learning model within a single curriculum. The study points to the challenges associated with scaling the implementation of the flipped classroom across multiple courses. Several core elements critical to the effective design and implementation of the flipped classroom model are identified.

Patterns of medication adherence and health care utilization among patients with chronic disease who were enrolled in a pharmacy assistance program

BACKGROUND

Poor medication adherence due to high drug costs is a barrier to optimal health outcomes among low-income uninsured patients with chronic conditions. Charitable pharmacy assistance programs provide medications to such patients, but little is known about the utilization patterns of program participants.

METHODS

We used a retrospective cohort design to investigate 6-month outcomes for participants in the University of North Carolina (UNC) Health Care Pharmacy Assistance Program (PAP) who received medications indicated for hypertension, diabetes, and/or hyperlipidemia from 2009 through 2011. Logistic regression was used to analyze predictors of medication adherence and to evaluate the association between adherence and use of emergency and inpatient care.

RESULTS

The 3 study cohorts included 866 patients receiving antihypertensive agents, 265 patients receiving oral glucose-lowering agents, and 455 patients receiving statins. When assessed 6 months after program enrollment, 52%, 45%, and 38% of patients in these 3 groups, respectively, were at least 80% adherent to treatment. Adherent patients in all cohorts had lower odds of requiring inpatient or emergency department care, but the decrease was only statistically significant among those taking antihypertensive agents (odds ratio for hospitalization = 0.58; 95% confidence interval, 0.39-0.87).

LIMITATIONS

Selection bias and inability to capture utilization data from sources other than UNC Health Care may have biased results.

CONCLUSION

Approximately 50% of PAP participants were adherent to chronic disease medications. Adherence to such therapies among patients who are receiving financial assistance with medications may reduce their need for costly health care services. Future research should assess the long-term ability of pharmacy assistance programs to promote medication adherence and should examine alternative strategies for improving adherence and health outcomes among low-income uninsured patients.

The University of North Carolina's Health Care Pharmacy Assistance Progam

BACKGROUND

UNC Health Care has a Pharmacy Assistance Program (PAP) that provides financial assistance to uninsured patients in North Carolina who need prescription medications. Despite significant investment in the program, little is known about the patients accessing it or the specific health care services they use. Our objectives were to describe the PAP population, to examine their use of prescription medications and health services, and to characterize changes in prescription medication use and expenditures from 2009 through 2011.

METHODS

We used a repeated cross-sectional study design, merging prescription claims with health records from Carolina Data Warehouse for Health, to measure use of prescription medications and use of inpatient, outpatient, and emergency department care by PAP participants. Prescription claims were grouped into therapeutic categories. We generated descriptive statistics for key variables to examine health service utilization from 2009 through 2011.

RESULTS

From 2009 through 2011, PAP served 7,180 patients from 81 counties in North Carolina. PAP users received a mean of 23 prescriptions, at an average cost of $754 per recipient per year. An average of $2.93 million per year was spent on the program, with an 8% rise in spending from 2009 to 2011. Inpatient care and emergency department care were utilized by 30% and 31% of PAP users, respectively, and there was minimal change in these rates over 3 years.

LIMITATIONS

Data were limited to medications dispensed through PAP and to health services provided by UNC Health Care.

CONCLUSIONS

With the state's decision to not expand Medicaid, PAP will continue to be an important resource for North Carolina's low income citizens.

Enhancing Quality in Psychiatry with Psychiatrists (EQUIPP)--results from a pilot study

OBJECTIVES

To pilot a pharmacist-led, patient centered medication management program.

DESIGN

Prospective, single arm trial.

SETTING

Academic geriatric psychiatry outpatient clinic.

PARTICIPANTS

Outpatients at least 65 years old, proxy available if demented, and on two or more psychiatric medications.

INTERVENTION

A clinical pharmacist completed a baseline medication review and made evidence-based recommendations that were implemented by the pharmacist after discussion with the physician. The pharmacist made a minimum of monthly contact for 6 months to review medications and related issues.

MEASUREMENTS

The primary outcome was the change in number of medication related problems over time (3 and 6 months) as defined by a predetermined classification system.

RESULTS

The mean age of the 27 patients was 75 years, 10 of whom required a proxy to participate. On average, patients had nine chronic conditions and were taking 14 medications. The mean number (SD; range) of medication related problems at baseline was 4.1 (2.2; 0-8) and at 3 and 6 months were 3.6 (2.4, 0-9) and 3.4 (2.1; 0-8), respectively. Most follow-up problems were new (80% and 89% at 3 and 6 months, respectively).

CONCLUSION

Using a pharmacist to deliver a medication management program was feasible and addressed existing problems. New problems, however, developed over a short interval (3-6 months), suggesting that ongoing intervention is required.

A renaissance in pharmacy education at the University of North Carolina at Chapel Hill

The UNC Eshelman School of Pharmacy is transforming its doctor of pharmacy program to emphasize active engagement of students in the classroom, foster scientific inquiry and innovation, and immerse students in patient care early in their education. The admissions process is also being reengineered.

The flipped classroom: a course redesign to foster learning and engagement in a health professions school

Recent calls for educational reform highlight ongoing concerns about the ability of current curricula to equip aspiring health care professionals with the skills for success. Whereas a wide range of proposed solutions attempt to address apparent deficiencies in current educational models, a growing body of literature consistently points to the need to rethink the traditional in-class, lecture-based course model. One such proposal is the flipped classroom, in which content is offloaded for students to learn on their own, and class time is dedicated to engaging students in student-centered learning activities, like problem-based learning and inquiry-oriented strategies. In 2012, the authors flipped a required first-year pharmaceutics course at the University of North Carolina Eshelman School of Pharmacy. They offloaded all lectures to self-paced online videos and used class time to engage students in active learning exercises. In this article, the authors describe the philosophy and methodology used to redesign the Basic Pharmaceutics II course and outline the research they conducted to investigate the resulting outcomes. This article is intended to serve as a guide to instructors and educational programs seeking to develop, implement, and evaluate innovative and practical strategies to transform students' learning experience. As class attendance, students' learning, and the perceived value of this model all increased following participation in the flipped classroom, the authors conclude that this approach warrants careful consideration as educators aim to enhance learning, improve outcomes, and fully equip students to address 21st-century health care needs.

A roadmap for educational research in pharmacy

Educational research must play a critical role in informing practice and policy within pharmacy education. Understanding the educational environment and its impact on students, faculty members, and other stakeholders is imperative for improving outcomes and preparing pharmacy students to meet the needs of 21st century health care. To aid in the design and implementation of meaningful educational research within colleges and schools of pharmacy, this roadmap addresses philosophy and educational language; guidelines for the conduct of educational research; research design, including 4 approaches to defining, collecting, and analyzing educational data; measurement issues; ethical considerations; resources and tools; and the value of educational research in guiding curricular transformation.

Pharmacy student engagement, performance, and perception in a flipped satellite classroom

OBJECTIVE

To determine whether "flipping" a traditional basic pharmaceutics course delivered synchronously to 2 satellite campuses would improve student academic performance, engagement, and perception.

DESIGN

In 2012, the basic pharmaceutics course was flipped and delivered to 22 satellite students on 2 different campuses. Twenty-five condensed, recorded course lectures were placed on the course Web site for students to watch prior to class. Scheduled class periods were dedicated to participating in active-learning exercises. Students also completed 2 course projects, 3 midterm examinations, 8 graded quizzes, and a cumulative and comprehensive final examination.

ASSESSMENT

Results of a survey administered at the beginning and end of the flipped course in 2012 revealed an increase in students' support for learning content prior to class and using class time for more applied learning (p=0.01) and in the belief that learning key foundational content prior to coming to class greatly enhanced in-class learning (p=0.001). Significantly more students preferred the flipped classroom format after completing the course (89.5%) than before completing the course (34.6%). Course evaluation responses and final examination performance did not differ significantly for 2011 when the course was taught using a traditional format and the 2012 flipped-course format. Qualitative findings suggested that the flipped classroom promoted student empowerment, development, and engagement.

CONCLUSION

The flipped pharmacy classroom can enhance the quality of satellite students' experiences in a basic pharmaceutics course through thoughtful course design, enriched dialogue, and promotion of learner autonomy.

Individualized medication assessment and planning: optimizing medication use in older adults in the primary care setting

STUDY OBJECTIVE

To test the feasibility and effectiveness of an individualized Medication Assessment and Planning (iMAP) program integrated within a primary care practice on the number and prevalence of medication-related problems (MRPs) and acute health services utilization, defined as combined hospitalizations and emergency department visits.

DESIGN

Six-month, prospective, observational pilot study.

SETTING

Community-based primary care medical practice.

PATIENTS

Convenience sample of 64 patients aged 65 years and older who were taking at least five medications.

INTERVENTION

Each patient was enrolled in the iMAP program-a collaborative, multifaceted intervention facilitated by a clinical pharmacist whereby patients receive comprehensive medication therapy management at baseline and 3 and 6 months as part of routine clinical care.

MEASUREMENTS AND MAIN RESULTS

MRPs were assessed and recommendations proposed using the previously published MRP classification tool; physician acceptance of recommendations served to validate the assessments. There was a significant reduction in mean number of MRPs/patient (4.2 at baseline vs 1.0 at 6 mo, p<0.0001) when adjusted for number of medications, race, and pharmacist. The prevalence of MRPs at 6 months compared with baseline was also significant (p<0.0008). Acute health services utilization was assessed by medical record abstraction. The 64 patients experienced a rate of 8.3 events/100 person-months (64 total events) during the 12-month prestudy period. During the 6-month study period, the same patients experienced 5.4 events/100 person-months (20 total events). Thus, we noted a reduction in acute health services utilization of 35%. Physicians were enthusiastically supportive of iMAP.

CONCLUSION

iMAP has the potential to address a significant and timely issue affecting older adults and primary care practices: the burden of managing and continuously monitoring multiple medications in medically complex older adults. A more rigorous evaluation of iMAP is warranted and planned to demonstrate sustained effectiveness and cost-benefit.

Completeness of prescription information in US commercial claims databases

PURPOSE

Pharmacy commercial claims databases are widely used for pharmacoepidemiologic research. However, concerns have been raised that these databases may not fully capture claims for generic medications as a result of patients filling outside the context of their insurance. This has implications for many research activities and quality improvement programs. We sought to estimate the percentage of missing prescriptions in US commercial claims data using a novel design.

METHODS

Using a large US commercial insurance database, we examined the completeness of warfarin prescription claims among patients with atrial fibrillation receiving regular medical follow-up and testing to manage warfarin dosing. We examined 14 different 6-month cross sections. Each cross section was treated independently to identify patients with at least two outpatient diagnoses of atrial fibrillation, two international normalized ratio tests, and one pharmacy claim. Trends in the percentage of patients with prescription claims for generic and branded warfarin were compared by year and 6-month periods using chi-square tests and generalized linear models adjusting for patient characteristics.

RESULTS

Out of 111 170 patients, the percentage of patients with any warfarin drug decreased slightly from 91.7% (95% CI: 91.0, 92.4) in early 2003 to 87.1% (95% CI: 86.7-87.6) in late 2009 (χ(2)  = 93.8, p < 0.0001). Over the same interval, the proportion of patients with generic warfarin exposure appearing increased significantly, whereas the proportion of patients with branded warfarin exposure decreased significantly.

CONCLUSIONS

Our study supports the possibility that some prescriptions may not be captured in US commercial insurance databases.

Understanding pharmacists' experiences with advice-giving in the community pharmacy setting: a focus group study

OBJECTIVE

To examine the experiences of community pharmacists providing advice about symptoms and complementary and alternative medicines (CAM).

METHODS

Ten licensed pharmacists and 21 student pharmacists working in community settings participated in 4 focus groups to discuss: patients' questions about symptoms and CAM, comfort level providing advice, and factors prompting physician referrals. Focus group recordings were transcribed verbatim and interpreted using thematic text analysis.

RESULTS

Pharmacists' dual role as advisors and medical liaisons emerged as primary themes. Participants reported that patients often seek their advice about self-care of symptoms to delay physician visits. Participants were comfortable giving advice; lack of medical history decreased their comfort level. Most were uncomfortable recommending CAM because of the lack of regulation and evidence. Participants suggested that pharmacy curricula expand training on symptom triage, pharmacist-patient communication, and CAM to prepare graduates for employment in community settings.

CONCLUSION

Student and licensed pharmacists of this study voiced that they are often asked for advice on symptom management, but reported needing training to help provide appropriate advice to patients.

PRACTICE IMPLICATIONS

The findings suggest that training strategies could help pharmacists appropriately triage and advise patients seeking self-care advice for their symptoms in the community setting.

Design of a medication therapy management program for Medicare beneficiaries: qualitative findings from patients and physicians

BACKGROUND

The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals.

OBJECTIVES

We conducted focus groups with older adults and primary care physicians to explore (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from patient and provider perspectives.

METHODS

Five focus groups (4 with older adults, 1 with physicians) were conducted by a trained moderator using a semistructured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification.

RESULTS

Twenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe that the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist access to the medical record, and a mutually trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM.

CONCLUSIONS

This study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include being comprehensive and addressing all medication-related needs over time. The clinical pharmacist's ability to build trusting relationships with patients and providers is essential.

Development and testing of a tool for assessing and resolving medication-related problems in older adults in an ambulatory care setting: the individualized medication assessment and planning (iMAP) tool

BACKGROUND

Medication is one of the most important interventions for improving the health of older adults, yet it has great potential for causing harm. Clinical pharmacists are well positioned to engage in medication assessment and planning. The Individualized Medication Assessment and Planning (iMAP) tool was developed to aid clinical pharmacists in documenting medication-related problems (MRPs) and associated recommendations.

OBJECTIVE

The purpose of our study was to assess the reliability and usability of the iMAP tool in classifying MRPs and associated recommendations in older adults in the ambulatory care setting.

METHODS

Three cases, representative of older adults seen in an outpatient setting, were developed. Pilot testing was conducted and a "gold standard" key developed. Eight eligible pharmacists consented to participate in the study. They were instructed to read each case, make an assessment of MRPs, formulate a plan, and document the information using the iMAP tool. Inter-rater reliability was assessed for each case, comparing the pharmacists' identified MRPs and recommendations to the gold standard. Consistency of categorization across reviewers was assessed using the κ statistic or percent agreement.

RESULTS

The mean κ across the 8 pharmacists in classifying MRPs compared with the gold standard was 0.74 (range, 0.54-1.00) for case 1 and 0.68 (range, 0.36-1.00) for case 2, indicating substantial agreement. For case 3, percent agreement was 63% (range, 40%-100%). The mean κ across the 8 pharmacists when classifying recommendations compared with the gold standard was 0.87 (range, 0.58-1.00) for case 1 and 0.88 (range, 0.75-1.00) for case 2, indicating almost perfect agreement. For case 3, percent agreement was 68% (range, 40%-100%). Clinical pharmacists found the iMAP tool easy to use.

CONCLUSIONS

The iMAP tool provides a reliable and standardized approach for clinical pharmacists to use in the ambulatory care setting to classify MRPs and associated recommendations. Future studies will explore the predictive validity of the tool on clinical outcomes such as health care utilization.

Implementation of a community pharmacy-based falls prevention program

BACKGROUND

Falls are the leading cause of fatal and nonfatal unintentional injury among older adults in the United States. Multifaceted falls prevention programs, which have been reported to reduce the risk for falls among older adults, usually include a medication review and modification component. Based on a literature search, no randomized trials that have examined the effectiveness of this component have been published.

OBJECTIVE

The aim of this article was to report on a retrospective process evaluation of data from a randomized, controlled trial conducted to examine the effectiveness of a medication review intervention, delivered through community pharmacies, on the rate of falls among community-dwelling older adults.

METHODS

Patients were recruited through 32 pharmacies in North Carolina. Participants were community-dwelling older adults at high risk for falls based on age (≥ 65 years), number of concurrent medications (≥ 4), and medication classes (emphasis on CNS-active agents). The process evaluation measured the recruitment of patients into the study, the process through which the intervention was delivered, the extent to which patients implemented the recommendations for intervention, and the acceptance of pharmacists' recommendations by prescribing physicians.

RESULTS

Of the 7793 patients contacted for study participation, 981 (12.6%) responded to the initial inquiry. A total of 801 (81.7%) participated in an eligibility interview, of whom 342 (42.7%) were eligible. Baseline data collection was completed in 186 of eligible patients (54.4%), who were randomly assigned to the intervention group (n = 93) or the control group (n = 93). Pharmacists delivered a medication review to 73 of the patients (78.5%) in the intervention group, with 41 recommendations for changes in medication, of which 10 (24.4%) were implemented. Of the 31 prescribing physicians contacted with pharmacists' recommendations, 14 (45.2%) responded, and 10 (32.3%) authorized the changes.

CONCLUSIONS

Based on the findings from the present study, coordination of care between community pharmacists and prescribers needs to be improved for the realization of potential beneficial effects of medication management on falls prevention.

Racial disparities in quality of medication use in older adults: findings from a longitudinal study

BACKGROUND

The quality of medication use in older adults is suboptimal, with a large percentage of individuals not receiving recommended care. Most efforts to evaluate the quality of medication use target high-risk drugs, appropriate treatment of prevalent chronic disease states, or a set of predefined quality indicators of medication use rather than the patient. It is also suggested that racial differences in the quality of medication use may exist in older adults.

OBJECTIVE

This study was conducted to determine the prevalence, number, and types of medication-related problems in older adults, examining the impact of race on quality medication use.

METHODS

This was a prospective cohort study involving in-home interviews and medical record reviews of community-residing older adults, stratified by race, conducted 3 times over 1 year. No intervention to address medication-related problems was performed. The quality of medication use was reported as medication-related problems by clinical pharmacists.

RESULTS

Of the 200 participants (100 blacks, 100 whites), mean age was 78.3 (whites) and 75.5 (blacks), and the majority of patients were female. Although whites used more medications than blacks (mean, 11.6 vs 9.7; P < 0.01), blacks had more medication-related problems per person than whites (mean, 6.3 vs 4.9; P < 0.01). All patients had at least 1 medication-related problem. Common problems at baseline, 6 months, and 12 months for both whites and blacks were undertreatment, suboptimal drug use, suboptimal dosing, nonadherence, and less costly alternative available. Blacks had significantly higher rates of nonadherence than whites (68% vs 42%; P < 0.01). Over the 12-month study, the number of medication-related problems not only persisted but increased (adjusted P = 0.0168).

CONCLUSIONS

Medication-related problems were prevalent in both black and white older adults and persisted over 1 year. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in the quality of medication use in older adults and the impact of race on specific medication-related problems.

Impact of enhanced pharmacologic care on the prevention of falls: a randomized controlled trial

BACKGROUND

Falls are the leading cause of both fatal and nonfatal injuries among older adults in the United States. Medications that affect the central nervous system are known to increase the risk of falling.

OBJECTIVE

The purpose of this study was to assess the effects of a community pharmacy-based falls-prevention program targeting high-risk older adults on the rates of recurrent falls, injurious falls, and filling prescriptions for medications that have been associated with an increased risk of falling.

METHODS

This was a randomized controlled trial of participants recruited through a community pharmacy chain in North Carolina. The 2-year study consisted of a 1-year "look-back" period before randomization and a 1-year follow-up period after randomization. Patients were eligible to participate if they were ≥65 years of age, had fallen at least once during the 1-year period preceding enrollment, and were taking medications associated with an increased risk of falling. Medications classified as high risk included benzodiazepines, antidepressants, anticonvulsants, sedative hypnotics, opioid analgesics, antipsychotics, and skeletal muscle relaxants. Participants were assigned to either the intervention arm or the control arm; participants in the intervention arm were invited to attend a face-to-face medication consultation conducted by a community pharmacy resident, whereas those in the control arm received no medication consultation. The primary end point was the rate of recurrent falls during the 1-year followup period. Secondary end points were the total number of prescriptions for high-risk medications filled during the follow-up period and either discontinued use or a reduction in the dosage of a high-risk medication during the follow-up period.

RESULTS

One hundred eighty-six patients (132 women, 54 men; 88.7% white) were enrolled. Intention-to-treat (ITT) analyses revealed no significant differences in the rates of recurrent falls, injurious falls, or filling prescriptions for high-risk medications. However, 13 patients in the intervention group either discontinued use of a high-risk medication or had the dosage reduced during the follow-up period, compared with 5 patients in the control group (χ(2) = 3.94; P < 0.05). As-treated analyses revealed numeric reductions in the rates of falls (rate ratio [RR] = 0.76; 95% CI, 0.53-1.09), injurious falls (RR= 0.67; 95% CI, 0.43-1.05), and filling prescriptions for high-risk medications (RR= 0.85; 95% CI, 0.72-1.03) after receipt of the intervention, but the differences were not statistically significant.

CONCLUSIONS

Results of this study support the feasibility of using community pharmacies to deliver a falls-prevention program targeting high-risk older adults. Although the ITT analyses revealed no significant reduction in the rate of recurrent falls, injurious falls, or overall use of high-risk medications, individuals in the intervention group were more likely than those in the control group to discontinue use of a high-risk medication or have the dosage reduced during the 1-year follow-up period. More work is needed to evaluate the intervention using a larger sample size that provides greater power to detect clinically meaningful effects of reduction in the use of high-risk medications on preventing or reducing falls in the high-risk population.

Racial disparities in the quality of medication use in older adults: baseline findings from a longitudinal study

BACKGROUND

Medication-related problems are prevalent in older adults and adversely affect the quality of care. It has been suggested that racial differences exist in medication use. Most efforts to evaluate the quality of medication use target specific drugs or disease states, or a set of pre-defined quality indicators, rather than the patient.

OBJECTIVE

We conducted a prospective cohort study to determine the prevalence and types of medication-related problems in older adults, examining the impact of race on quality medication use.

METHODS

In-home interviews and medical record reviews of 200 (100 white, 100 black) older adults were conducted three times over 1 year. The quality of medication use was measured using a clinical pharmacist's assessment of quality and the Assessing Care of Vulnerable Elders quality indicators. We used logistic and negative binomial regression models to analyze the two primary endpoints of prevalence and number of medication-related problems.

RESULTS

Mean age was 78.3 (whites) and 75.5 (blacks), with the majority being female. Although whites used more medications than blacks (11.6 versus 9.7; p < 0.01), blacks had more medication-related problems per person than whites (6.2 versus 4.9; p < 0.01). All patients had at least one medication-related problem; undertreatment, suboptimal drug, suboptimal dosing, and nonadherence were most prevalent. Blacks had significantly higher rates of nonadherence than whites (68% versus 42%; p < 0.01).

CONCLUSION

Medication-related problems are prevalent in community-residing older adults. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in quality medication use.

Development of student professionalism

In late 2007, the American College of Clinical Pharmacy (ACCP) charged their National StuNet Advisory Committee to formulate tenets of professionalism, with the primary goal of introducing students to essential attitudes and behaviors of professionalism. The committee's list of tenets served as a working document for the development of this White Paper. This collaborative effort of the ACCP Board of Regents and the National StuNet Advisory Committee sought to complement other published documents addressing student professionalism. The purpose of this White Paper is to enhance student understanding of professionalism, emphasizing the importance of the covenantal or "fiducial" relationship between the patient and the pharmacist. This fiducial relationship is the essence of professionalism and is a relationship between the patient and the pharmacist built on trust. This White Paper also outlines the traits of professionalism, which were developed after an extensive review of the literature on professionalism in medicine and pharmacy. The traits of professionalism identified here are responsibility, commitment to excellence, respect for others, honesty and integrity, and care and compassion. It is from these traits that student actions and behaviors should emanate. Students, pharmacy practitioners, and faculty have a responsibility to each other, to society as a whole, and to individual patients whom they serve to ensure that their words and actions uphold the highest standards of professional behavior.

Analysis of Binary Adherence Data in the Setting of Polypharmacy: A Comparison of Different Approaches

Older community dwelling adults often take multiple medications for numerous chronic diseases. Non-adherence to these medications can have a large public health impact. Therefore, the measurement and modeling of medication adherence in the setting of polypharmacy is an important area of research. We apply a variety of different modeling techniques (standard linear regression; weighted linear regression; adjusted linear regression; naïve logistic regression; beta-binomial (BB) regression; generalized estimating equations (GEE)) to binary medication adherence data from a study in a North Carolina based population of older adults, where each medication an individual was taking was classified as adherent or non-adherent. In addition, through simulation we compare these different methods based on Type I error rates, bias, power, empirical 95% coverage, and goodness of fit. We find that estimation and inference using GEE is robust to a wide variety of scenarios and we recommend using this in the setting of polypharmacy when adherence is dichotomously measured for multiple medications per person.

Measuring the quality of medication use in older adults

The quality of health care in the United States continues to fall short of expectations. A contributing factor is the suboptimal use of medications, a problem that is causing significant morbidity and mortality and costing the healthcare industry billions of dollars each year. Older adults are especially vulnerable to suboptimal quality medication use because of their concurrent medical conditions, multiple medications, and the physiological effects of aging on the use of drug therapy. In addition, older adults and their caregivers are often responsible for managing complex medication regimens. Efforts to measure the quality of medication use in older adults have traditionally focused on inappropriate medications and doses, select indicators of medication appropriateness, or diseases rather than the unique medication needs of individual patients. The goal is to move toward a measure that can account for the complexities of an individual's medication regimen and that is responsive to individual patient values and needs. The purpose of this article is to discuss the benefits and limitations of current strategies to measure the quality of medication use in older adults and, using a case study, illustrate the variations in quality measurement using existing measures. The article concludes with recommendations for moving toward a more-comprehensive approach to measuring the quality of medication use in older adults.

The quality of medication use in older adults: methods of a longitudinal study

BACKGROUND

The quality of medication use in older adults is a recurring problem of substantial concern. Efforts to both measure and improve the quality of medication use often define quality too narrowly and fall short of addressing the complexity of an older adult's medication regimen.

OBJECTIVES

In an effort to more comprehensively define the quality of medication use in older adults, we conducted a prospective cohort study to: (1) describe the quality of medication use in community-dwelling older adults at baseline, examining differences between whites and blacks; (2) examine the effect of race on medication-related problems; and (3) assess the change in quality medication use between whites and blacks over time. This paper presents the research design and methods of this longitudinal study.

METHODS

We interviewed white and black community-dwelling older adults (aged > or =60 years) 3 times over 1 year (baseline, 6, and 12 months). We oversampled blacks so that we could estimate racial differences in the quality of medication use. We collected information on the quality of medication use, relying on a clinical pharmacist's assessment of quality and the Assessing Care of Vulnerable Elders quality indicators. We also collected data on demographic characteristics, health literacy, functional status, and participant-reported drug therapy concerns.

RESULTS

Four hundred thirty-five older adults were assessed for inclusion; 200 older adults (100 white, 100 black) were enrolled in the study and completed a baseline visit. Of the 200, 92% completed the 6-month visit (n = 183) and 88% completed the 12-month visit (n = 176). We present baseline demographic characteristics for the 200 older adults enrolled in the study.

CONCLUSION

This longitudinal study is an initial step toward developing more comprehensive, patient-centered measures and interventions to address the quality of medication use in older adults.

Methodology of an ongoing, randomized controlled trial to prevent falls through enhanced pharmaceutical care

BACKGROUND

Falls are the leading cause of both fatal and nonfatal injuries among adults aged > or =65 years in the United States. Past research suggests that individuals taking multiple medications are at increased risk of falls. Central nervous system-active drugs in particular have been associated with increased risk.

OBJECTIVE

The goal of this research was to describe the design of a study evaluating the effectiveness of a community pharmacy-based falls prevention program. Also presented are the algorithms used to identify high-risk patients based on their prescription profile records and to deliver the experimental intervention.

METHODS

The study is a randomized controlled trial. The target population was community-dwelling older adults (aged > or =65 years) at high risk for future falls because: (1) they had experienced > or =1 fall within the 12-month period preceding study enrollment; (2) they were currently using > or =4 chronic prescription medications; and (3) they were taking > or =1 of the high-risk medications targeted by the intervention. Participants were recruited using pharmacy prescription profile records. Individuals in the intervention group received a face-to-face medication consultation provided by a community pharmacy resident. Identification of drug therapy problems and therapeutic recommendations was guided by a series of algorithms developed for this study. All participants were followed up for 24 months. The primary study end points were: (1) time to first fall; and (2) proportion of participants who experienced > or =1 fall during the first year of follow-up.

RESULTS

Participant enrollment began in September 2005 and was completed in August 2007. A total of 186 individuals were enrolled in the study (mean [SD] age, 74.8 [6.9] years; 132 women, 54 men), and 67 have completed the first year of follow-up.

CONCLUSIONS

The study is using a rigorous randomized controlled research design, which will enhance the internal validity of its findings. Results of the study, which will be reported after the completion of follow-up data collection activities, will enable us to assess the effects of the intervention on both medication use and the incidence of falls. If the intervention is found to be effective, it will provide a resource for community pharmacists working with older adults at high risk of medication-related falls.

Geographic Information System mapping as a tool to assess nonresponse bias in survey research

BACKGROUND

Surveys are a useful tool for assessing professional practice patterns, although declining response rates have caused concern over external validity. This is particularly relevant to Web-based surveys, where response rates traditionally have been lower than with paper mail surveys. In a 2005 survey of North Carolina community pharmacy managers using a Web-based data collection instrument, we achieved an overall response rate of 23%.

OBJECTIVE

To explore nonresponse bias using accepted methods and to test whether Geographic Information System mapping is a useful tool for assessing response bias.

METHODS

Cross-sectional survey of 1593 community pharmacy managers in North Carolina using a Web-based tool. Nonresponse bias was assessed quantitatively by comparing early responders with late responders (ie, wave analysis) and by comparing respondents with nonrespondents with regard to known pharmacy, pharmacist, and population characteristics. Significant variables from these analyses were then mapped using ArcGIS 9.1.

RESULTS

Pharmacy type was identified as a predictor of response, with independent pharmacies less likely to respond than chain pharmacies (odds ratio 0.75; 95% confidence interval 0.59-0.95). This conclusion was consistent in the wave analysis and the analysis of known population characteristics. Other county-level variables such as the number of physicians per capita, income, and the percentage of residents eligible for Medicaid showed trends but were not statistically significant (P<.1). Geographic Information System mapping was able to descriptively illustrate nonresponse bias for pharmacy type but trends were more difficult to detect for statistically insignificant trends.

CONCLUSION

The best way to avoid nonresponse bias is to improve response rates. When this is not possible, Geographic Information System mapping has some utility for assessing nonresponse bias, and for aggregating known population characteristics based on location. It is most useful in conjunction with other accepted techniques such as wave analysis and analysis of known population characteristics.

Medication therapy management services in North Carolina community pharmacies: current practice patterns and projected demand

OBJECTIVE

To evaluate the types of cognitive services offered and the number of patients being served in community pharmacies, determine the number of pharmacies that plan to offer medication therapy management (MTM) services under the Medicare Part D prescription drug benefit, and assess whether current and expected practices will meet the potential needs of enrollees.

DESIGN

Cross-sectional study.

SETTING

North Carolina in January 2005.

PARTICIPANTS

1,593 community pharmacy managers.

INTERVENTIONS

Survey using a Web-based tool.

MAIN OUTCOME MEASURES

Provision of cognitive services and number of patients for whom services are provided.

RESULTS

A total of 262 (16%) pharmacy managers provided usable responses. Approximately 42% of respondents (n = 110) indicated that they provide some type of cognitive service. Comprehensive MTM services, or services consistent with the professionwide consensus definition, were provided by 31% of respondents (n = 81). Independent pharmacies were more likely to offer some type of service compared with chain pharmacies (58% versus 31%, respectively; P < .001). Pharmacy managers with a doctor of pharmacy degree were less likely than pharmacy managers with a bachelor's degree to offer services in their pharmacies (P = .02), and pharmacies with pharmacists on staff who had received certificate training were more likely to offer cognitive services (P = .03). Of all respondents, 28% (n = 73) indicated that they planned to offer MTM services under the Medicare Part D prescription drug benefit.

CONCLUSION

Comparing these results with those of a 1999 survey of North Carolina pharmacists that used some of the same items, the percentage of community pharmacies that provide cognitive services has increased in the intervening years but remains low. Among the services being offered in 2005, most were focused on patient education and training, coordinating and integrating care, and medication regimen reviews. Implementation of MTM services under the Medicare Part D prescription drug benefit should hasten the development and offering of these services in community pharmacies.

Self-reported medication use in community-residing older adults: A pilot study

BACKGROUND

Older adults (ie, those aged > or = 65 years) are at increased risk of developing drug therapy problems, which may lead to poor health outcomes and decreased quality of life.

OBJECTIVE

The primary goal of this pilot study was to evaluate and report medication use and potential drug therapy problems in older adults who received Eldercare program assistance through the Orange County Department on Aging in North Carolina.

METHODS

Between May and July 2002, subjects were consecutively sampled from a registry of adults aged > or = 60 years enrolled in the Eldercare program. To be eligible for the study, individuals had to be receiving the services of the Eldercare program, speak English, and reside independently in the community of Orange County. The older adults were contacted by the program director to determine interest in participating in the study. If interested, the individual was contacted by a trained pharmacy doctoral student to verify study eligibility and arrange a home visit. At the home visit, information was collected via self-report on medication use and medical history. Nonadherence, potentially inappropriate prescribing, health literacy, and functional capacity were also assessed. All home visits were conducted between May and July 2002.

RESULTS

A total of 100 subjects were interviewed. The mean (SD) age of respondents was 77.5 (8.7) years; 85% were women, 66% were white, 34% black, and 70% lived alone. The mean (SD) number of prescription medications used per patient was 9.6 (4.1). Adequate health literacy, defined as a score > or = 23 (range of possible scores, 0-36) on the Short Test of Functional Health Literacy in Adults, was documented in only 35% of individuals. Twenty-five percent of the sample (25/100) had reduced functional capacity when evaluated on the Functional Activities Questionnaire, with total scores > or = 10 (range of possible scores, 10-30) indicative of reduced functional ability. Rates of nonadherence, defined as a score of 0 to 3 on the 4-item Morisky instrument, were 53%. When evaluating inappropriate prescribing based on the Beers criteria, 34% of individuals used > or = 1 potentially inappropriate medication. In bivariate analyses, there was a statistically significant relationship between race and number of medications (P < 0.002), adherence (P < 0.001), health literacy status (P < 0.001), and functional capacity (P < 0.027). No differences were noted when examining the effects of age on the same variables.

CONCLUSIONS

In this study, older adults residing independently in the community were responsible for managing and taking a considerable number of medications on a daily basis. In addition, inadequate health literacy, poor adherence, and potentially inappropriate medication use were prevalent in this sample. The results also suggest that race may have played an important role in the risk of developing medication-related problems.

Outcomes from an Outpatient Smoking-Cessation Clinic

STUDY OBJECTIVES

To determine the success of an outpatient smoking-cessation clinic by assessing smoking abstinence rates and factors associated with lower abstinence rates. We also sought to determine whether smoking abstinence rates differed among various smoking-cessation products.

METHODS

Patients were referred by primary care providers to a pharmacist-managed smoking-cessation clinic. Patients received tailored behavioral counseling, educational materials, and drug therapy consisting of sustained-release (SR) bupropion; nicotine patch, inhaler, or nasal spray; or combination therapy. Patients were monitored by phone or clinic visit for 6 months, if possible. Outcomes assessed were abstinence (both point prevalence and continuous abstinence) and adverse effects. Patients lost to follow-up were assumed to be smoking.

RESULTS

Over 2 years, 198 patients were enrolled in the program. At the initial visit, 35.4% received the patch, 32.8% bupropion SR, 18.2% a combination of patch plus inhaler, 9.6% inhaler alone, and fewer than 5% other therapies. At 6 weeks, a statistically significant difference was observed in continuous abstinence rates between the nicotine patch versus bupropion SR groups (22.9% vs 7.7%, p=0.02) and between the combination patch-inhaler versus bupropion SR groups (25% vs 7.7%, p=0.02). However, this difference was not significant beyond the 6-week visit. A trend toward higher abstinence rates was noted at 6 weeks in the nicotine patch-inhaler versus the other treatment groups, possibly suggesting the need for more intense treatment regimens with combination therapy. Point prevalence abstinence rates after 12 weeks were 18.6%, 15.4%, 22.2% and 21.1% respectively, for the patch, bupropion SR, patchinhaler, and inhaler alone treatment groups. The corresponding continuous abstinence rates were 10.0%, 3.1%, 11.1%, and 10.5%.

CONCLUSION

Although statistically significant differences between products were noted at 6 weeks, no sustained difference in smoking abstinence rates was observed between products. At 6 months, point prevalence and continuous abstinence rates were small, but the decline in success noted over time and the limited overall success rates are consistent with rates for the United States. Our findings suggest that when smokers are assisted in quitting, initial contact as well as follow-up evaluation and monitoring must be intense and sustained to increase the likelihood of successful abstinence. Tobacco dependence is clearly a chronic condition warranting repeated treatment and monitoring until continuous abstinence is achieved.

Secondary prevention of coronary heart disease in the elderly

OBJECTIVE

To review relevant literature supporting the use of aspirin, beta-blockers, lipid-lowering agents, and angiotensin-converting enzyme (ACE) inhibitors for the secondary prevention of coronary heart disease (CHD) in an elderly patient population aged >/=65 years.

DATA SOURCES

A MEDLINE search (1990-May 2003) was conducted using the key terms coronary heart disease, secondary prevention and elderly.

STUDY SELECTION AND DATA EXTRACTION

Primary and tertiary literature relating to the use of aspirin, beta-blockers, lipid-lowering agents, and ACE inhibitors in the elderly were reviewed.

DATA SYNTHESIS

CHD is the leading cause of morbidity and mortality in persons >/=65 years of age, and the use of pharmacologic agents has created a considerable opportunity for reducing recurrent events in those with established disease. This, combined with the aging of the US population, is creating an increase in the number of older adults eligible for secondary prevention. In 2002, the American Heart Association issued a scientific statement on the benefits of specific secondary prevention risk factor interventions in older adults. This article reviews pertinent findings from this statement, along with additional data supporting the use of pharmacologic agents for the secondary prevention of CHD in the elderly.

CONCLUSIONS

Data suggest that use of aspirin, beta-blockers, lipid-lowering agents, and ACE inhibitors are effective in secondary prevention of CHD in individuals aged >/=65 years. This benefit is similar to, and often greater than, that observed in younger patients. We believe that these agents should be prescribed for all elderly patients without contraindications. Ongoing studies and future clinical trials will more clearly elucidate the benefits of secondary prevention of CHD, particularly in persons >/=75 years of age, to determine the magnitude of benefits that can be achieved in this population.

Evidence for the cardioprotective effects of omega-3 Fatty acids

OBJECTIVE

To review available literature regarding the cardiovascular effects of marine-derived Omega-3 fatty acids and evaluate the benefit of these fatty acids in the prevention of coronary heart disease.

DATA SOURCES

Biomedical literature accessed through a MEDLINE search (1966-April 2002). Search terms included fish oil, omega-3 fatty acid, sudden death, hypertriglyceridemia, myocardial infarction, and mortality.

DATA SYNTHESIS

Following an early 1970's observational investigation that Omega-3 fatty acids may reduce the occurrence of myocardial infarction-related deaths in Greenland Eskimos, additional trials have been conducted that support this finding. Epidemiologic and clinical trial data suggest that Omega-3 fatty acids may reduce the risk of cardiovascular-related death by 29-52%. In addition, the risk of sudden cardiac death was found to be reduced by 45-81%. Possible mechanisms for these beneficial effects include antiarrhythmic properties, improved endothelial function, antiinflammatory action, and reductions in serum triglyceride concentrations. Omega-3 Fatty acids are fairly well tolerated; potential adverse effects include bloating and gastrointestinal distress, "fishy taste" in the mouth, hyperglycemia, increased risk of bleeding, and a slight increase in low-density-lipoprotein cholesterol.

CONCLUSIONS

Omega-3 Fatty acids may be beneficial and should be considered in patients with documented coronary heart disease. They may be particularly beneficial for patients with risk factors for sudden cardiac death.

Asthma exacerbation after administration of nicotine nasal spray for smoking cessation

A 58-year-old man experienced an asthma exacerbation after administration of nicotine nasal spray for smoking cessation. His medical history was significant for asthma, chronic obstructive pulmonary disease, hypertension, and tobacco use when he was prescribed nicotine nasal spray for smoking cessation in an outpatient setting. Within the first 3 days of administering the spray, he developed wheezing, coughing, and significant shortness of breath, which required hospitalization. The patient was hospitalized for 48 hours and discharged with a diagnosis of asthma exacerbation probably related to administration of nicotine nasal spray. Prudent administration of nicotine nasal spray is recommended in patients with underlying respiratory disease. Patients should be counseled on the potential adverse effects of treatment and proper administration techniques in order to minimize these effects.

Health literacy: a review

Illiteracy has become an increasingly important problem, especially as it relates to health care. A national survey found that almost half of the adult population has deficiencies in reading or computation skills. Literacy is defined as the basic ability to read and speak English, whereas functional health literacy is the ability to read, understand, and act on health information. Up to 48% of English-speaking patients do not have adequate functional health literacy. The consequences of inadequate health literacy include poorer health status, lack of knowledge about medical care and medical conditions, decreased comprehension of medical information, lack of understanding and use of preventive services, poorer self-reported health, poorer compliance rates, increased hospitalizations, and increased health care costs. The medical community must acknowledge this issue and develop strategies to ensure that patients receive assistance in overcoming the barriers that limit their ability to function adequately in the health care environment.

Use of Bupropion SR in a Pharmacist-Managed Outpatient Smoking-Cessation Program

We administered bupropion sustained-release (SR) in a pharmacist-managed outpatient smoking-cessation program. Patients were referred to the program by their primary care physician. All patients completed initial visit questionnaires, received behavioral counseling by a clinical pharmacist, and were provided educational materials on smoking cessation. Seventy-one patients received bupropion SR for treatment of nicotine dependence and were followed for 6 months. Point prevalence abstinence rates were 28.2% and 25.4% at 8 weeks and 6 months, respectively. The trend was toward lower cessation rates in patients with a documented psychiatric diagnosis at 6 months (p=0.064). Bupropion SR was fairly well tolerated, with the most common adverse effects being dry mouth and bad taste. The agent appears to have better success for smoking cessation in patients free of psychiatric comorbidities, but further research is required to support this finding.

Genetic discrimination in health insurance: an overview and analysis of the issues

The problem of genetic discrimination in health insurance will increase as genetic knowledge expands and the number of genetic tests proliferates. Unless appropriate legislative protections are developed and enforced, a consequence of the genetic revolution may be that more people are put at risk for losing their health insurance. The current situation requires people to make difficult choices about taking tests that could save or prolong their lives. Unless these people believe that they and their families will be adequately protected from discrimination and from the possibility of losing or being denied health insurance, many will choose not to be tested for genetic conditions or predisposition to disease. Solutions to this problem require continuing research and debate and the creation of new policies and laws that protect the people while maintaining the economic viability of insurance companies. This article explores the problem of genetic discrimination as it relates to health insurance in the United States. The goal of this article is to assist nurses and other health care professionals to better understand the important and complex issues and concepts related to genetics, genetic testing, and genetic discrimination in health insurance.

Eradication ofHelicobacter pylori in the Treatment of Peptic Ulcer Disease

Helicobacter pylori is responsible for the majority of cases of peptic ulcer disease. Peptic ulcer disease should no longer be regarded as a “chronic, recurring, lifelong disease, but rather a curable infection.” Treatment and eradication of H. pylori infection in patients with peptic ulcer disease has been shown to resolve the chronic inflammation present and prevent further ulcer relapse. Despite the vast amount of literature on H. pylori infection in peptic ulcer disease, the diagnosis and management of this common infection have become increasingly straightforward. This article will summarize the role of H. pylori in patients with peptic ulcer disease and will address the current clinical practice guidelines for diagnosis and treatment of H. pylori in the subset of patients.

Pontine acetylcholine release is regulated by muscarinic autoreceptors

Acetylcholine (ACh) in the medial pontine reticular formation (mPRF) originates from the laterodorsal and pedunculopontine tegmental (LDT/PPT) nuclei and contributes to generating rapid eye movement (REM) sleep. The mechanisms controlling mPRF ACh levels are incompletely understood. This study tested the hypothesis that mPRF ACh release is regulated, in part, by muscarinic autoreceptors. The mPRF of intact, halothane-anesthetized cats was dialyzed with Ringer's solution (control) or Ringer's containing the muscarinic antagonist scopolamine, Scopolamine caused a dose-dependent increase in mPRF ACh release and a concomitant decrease in the number of halothane-induced cortical EEG spindles. These data suggest that presynaptic muscarinic receptors, presumed to reside on cholinergic LDT/PPT terminals in the mPRF, play a role in regulating mPRF ACh release, REM sleep and EEG spindles.