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PubMed2004

Glycosylated hemoglobin, cardiovascular, and renal outcomes in a pharmacist-managed clinic.

BACKGROUND: Pharmacists' responsibilities in caring for patients with diabetes mellitus are expanding. However, few data are available to support pharmacists optimizing therapy and improving outcomes in these patients. OBJECTIVE: To determine the effect of a clinical pharmacist-directed diabetes management clinic on glycemic control and cardiovascular and renal parameters in patients with type 2 diabetes. METHODS: A nonrandomized, prospective study was conducted in 70 Veterans Affairs patients. Patients met with the pharmacist every 6-8 weeks for approximately 30 minutes for education, medication counseling, monitoring, and management. The primary endpoint was the impact of 9-12 months of participation in the clinic on glycosylated hemoglobin (HbA1C). Secondarily, we evaluated body weight, total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides, systolic and diastolic blood pressure, and level of microalbuminuria. All comparisons were made using a paired t-test at a significance level of p < or = 0.05. RESULTS: HbA1C significantly decreased from 10.3% +/- 2.2% at baseline to 6.9% +/- 1.1% (mean +/- SD) during the 9- to 12-month evaluation period (p < 0.001). The secondary endpoints including systolic (p < 0.001) and diastolic (p < 0.001) blood pressure, total cholesterol (p < 0.001), LDL-C (p < 0.001), triglycerides (p = 0.006), and level of microalbuminuria (p < 0.001) also were reduced at 9-12 months. CONCLUSIONS: This study demonstrated that a clinical pharmacist can effectively care for patients with diabetes referred by their primary care provider because of poor glycemic control.

Aged↗
PubMed2000

Effect of a clinical pharmacist-managed lipid clinic on achieving National Cholesterol Education Program low-density lipoprotein goals.

Despite national guidelines for treatment of hyperlipidemia, significant numbers of individuals with coronary artery disease are not treated to their National Cholesterol Education Program (NCEP) low-density lipoprotein (LDL) goals. The potential benefits of a clinical pharmacist-managed lipid clinic would be to improve rates of success in achieving these goals, improve drug adherence and compliance with therapy, and reduce cardiovascular events. All patients who had a documented history of coronary artery disease and were under the care of one cardiologist were treated in the pharmacist-managed lipid clinic. A second cardiologist provided usual care to a group of patients with coronary artery disease who served as controls. Patients in each arm were followed for a minimum of 6 months. A protocol for therapy changes in clinic patients was developed by the clinical pharmacist and approved by the cardiologist. At the end of 6 months, 69% of patients in the pharmacist-managed clinic achieved their LDL goal, compared with 50% of controls. Compliance with laboratory tests and drug regimens also improved in clinic patients. Compliance with lipid panels went from 8% 2 months before to 89% 2 months after the start of the study. At the end of 6 months compliance with laboratory work and refills was 80%. Thus the clinical pharmacist-managed clinic was highly successful in achieving NCEP goals for secondary prevention.

Adult↗
PubMed2001

Use of point-of-service health status assessments by community pharmacists to identify and resolve drug-related problems in patients with musculoskeletal disorders.

STUDY OBJECTIVE: To determine whether community pharmacists can use point-of-service health status assessments to identify and resolve drug-related problems (DRPs) in ambulatory patients with selected musculoskeletal (MSK) disorders. DESIGN: Twelve-month, prospective, multicenter demonstration project. SETTING: Twelve independent community pharmacies in eastern Iowa. PATIENTS: Ambulatory patients with self-reported diagnosis of osteoarthritis, rheumatoid arthritis, or low back pain. MEASUREMENTS: During quarterly pharmacy visits for 1 year, patients used touch-screen computers to report their health status. Patients answered questions on the Short Form-36 (SF-36) general health survey, as well as questions assessing limitations associated with their MSK condition. Pharmacists used this data in interviewing patients to assess for DRPs. MAIN RESULTS: The study enrolled 461 patients, of whom 388 returned for the 12-month visit. During this 1-year period, community pharmacists identified 926 cumulative DRPs. Patients with no DRPs had significantly higher physical component summary scores on the SF-36 (p<0.05) than patients with more than one DRP at baseline (36.2 vs 31.6), 6 months (39.2 vs 33.3), and 12 months (40.1 vs 35.4). At 12 months, actions performed by pharmacists led to resolution or improvement of 70.7% of DRPs. CONCLUSION: Drug-related problems are numerous in community-dwelling patients with MSK disorders and correspond to decreased physical health status. Community pharmacists can use patient-reported measures of health status to identify DRPs and initiate processes to resolve them.

Adult↗
PubMed2005

Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoagulation service.

STUDY OBJECTIVE: To compare adverse events related to anticoagulation in patients assigned to a pharmacist-managed anticoagulation service versus those receiving usual care. DESIGN: Retrospective cohort analysis. SETTING: Three hundred-bed community hospital. PATIENTS: Four hundred twenty patients referred for anticoagulation management. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were the number of adverse events requiring patient hospitalization and the number of patients experiencing such events. Secondary outcomes were the median length of hospital stay/admission and the total number of hospital days. The total numbers of adverse events requiring hospitalization were three for the pharmacist-managed group and 14 for the usual care group (p=0.0153). The number of patients experiencing an adverse event requiring hospitalization was also lower for the pharmacist-managed group than for the usual care group (3 vs 10, p = 0.0962). The median length of hospital stay associated with each adverse event was not significantly different between the two groups; however, the total number of hospital days accrued was higher in the usual care group. CONCLUSION: At 6 months after discontinuation of the pharmacist-managed anticoagulation service, the frequency of adverse events increased significantly, resulting in both an increased number of hospitalizations and an increased number of hospital days accrued. This coordinated anticoagulation program using a pharmacist reduced warfarin-related complications.

Age Factors↗
PubMed2006

Design and implementation of an educational partnership between community pharmacists and consumer educators in mental health care.

OBJECTIVE: To design and implement an interactive education program to improve the skill and confidence of community pharmacists in providing pharmaceutical services to people with mental illnesses. DESIGN: A literature review was conducted and key stakeholders were consulted to design a partnership that involved community pharmacists and consumer educators. The partnership was designed so that all participants shared equal status. This facilitated mutual recognition of each others' skills. ASSESSMENT: Four 2-hour training sessions were conducted over a 2-week period in March 2005. Seven pharmacists, 5 consumer educators, and 1 caregiver educator participated in the partnership. Pharmacists indicated that their participation caused them to reflect on their own medication counseling techniques. Consumer educators reported that speaking about their experiences aided their recovery. CONCLUSION: Developing a better understanding and improved communication between community pharmacists and people with mental illnesses is an important aspect of facilitating a concordant approach to patient counseling. Implementing mental health education programs utilizing consumer educators in pharmacy schools is a promising area for further research.

Community Participation↗
PubMed1993

Pharmacist monitoring of drug therapy in patients with abnormal serum creatinine levels.

Because of possibly drug-related adverse events that occurred in renal patients, a program was developed to routinely monitor renal patients to ensure that all prescribed drugs and dosages conformed to standard clearance-adjusted regimens. Summary laboratory reports were surveyed daily, patients with abnormally elevated serum creatinine values were noted, and reviews of patients' medication profiles and orders were performed at least daily. The pharmacist was made responsible for judging if renally-eliminated drugs were used appropriately. If the pharmacist deemed that a change was needed, the prescribing physician was contacted by telephone or in person. From January 1990 through December 1992, a total of 627 patients with renal impairment were monitored. Among these patients, 233 changes in drug therapy were implemented as a direct result of pharmacist assessment and subsequent physician contact. The most common changes were dosage decreases. Medications requiring changes most often were antimicrobial agents, accounting for 55% of all interventions. A retrospective assessment of interventional efficacy, performed through focused evaluation of 20 randomly selected cases, revealed no direct evidence of either therapeutic failure or drug toxicity in patients for whom pharmacist-directed changes were made. Pharmacist monitoring can have a beneficial influence on the care of renal patients.

Colorado↗
PubMed1995

Pharmaceutical care role model in psychiatry--pharmacist prescribing.

Pharmacist's expanded roles in a mental health clinic are described. A needs assessment identified problems which could be solved by expanding the pharmacist's scope of practice. Pharmacy, psychiatry, and medical center administration approved the pharmacist's psychiatric prescribing privileges and the authority to order appropriate laboratory tests, which provides the mechanism of solving the problems identified. Psychiatry's acceptance of pharmacists in this new role is demonstrated by the continued expansion of this program. By the end of a 4-year period, pharmacists were seeing 46% of all psychiatric medication visits. A description of the privileges, roles, and process is provided.

California↗
PubMed1995

Economic impact and clinical benefits of pharmacist involvement on surgical wards.

A one-year pilot project was performed to assess the economic and clinical benefit of pharmacist involvement on the surgical wards of a 600-bed tertiary care, teaching hospital. A total of 405 recommendations were collected with a physician acceptance rate of 90%. From these recommendations, 1416 patient follow-ups were performed to document outcome. The total documented cost avoidance of the pharmacists' activities was $33,265.58. The total annual drug expenditure for the department of surgery declined by $59,662 representing a 9% decrease over the previous year with the greatest decline involving antimicrobials which decreased by $52,587 compared with the previous year. Most of the cost-avoidance in this area was attributable to antimicrobial selection and dosing adjustment in renal impairment. Pharmacist-directed pharmacokinetic monitoring of aminoglycosides resulted in a clinical success rate of 93.8% for treatment regimens and a 6.2% incidence of nephrotoxicity. Housestaff education aimed at improving prescribing practices were identified and provided for select agents including midazolam, ketorolac, vancomycin and aminoglycosides. As well, select recommendations were documented which illustrated the benefit to patient care of pharmacist involvement. Pharmacist involvement on the surgery services produced both financial and clinical benefits.

Canada↗
PubMed1982

Use of the countersuit by pharmacists who have been groundlessly sued for malpractice.

Attorneys for patients who have been injured by adverse reactions to drugs often name as defendants the prescribing physician, the drug manufacturer, and the pharmacist. In many jurisdictions neither the law of warranty nor the law of strict liability will support a cause of action against a pharmacist who has done nothing more than correctly dispense a drug which was correctly prescribed. If the lawsuit against the pharmacist can be shown to have been filed for no other reason than to coerce a nuisance settlement or just to be cautious, the pharmacist may have available a remedy in the form of a countersuit. Malicious prosecution is one cause of action which might be maintainable as a countersuit. The elements of the cause of action are: 1) the initiation of a lawsuit; 2) lack of probable cause; 3) malice; 4) termination in favor of the pharmacist; and 5) damages. Lack of probable cause and malice are interrelated and are the two most difficult elements to prove. Abuse of process is another possible cause of action. The elements are: 1) an illegal, improper, or perverted use of the process; 2) an ulterior motive or purpose; and 3) damages. Other causes of action which have been considered by attorneys for groundlessly sued health professionals are barratry, defamation, attorney negligence, prima facie tort, and violation of a disciplinary rule.

Drug-Related Side Effects and Adverse Reactions↗
PubMed1985

Hiring patterns for non-faculty clinical staff pharmacist positions in institutions greater than 500 beds.

A survey was mailed to 150 randomly-selected hospitals greater than 500 beds to determine: 1) the type of pharmacists currently in non-faculty clinical staff positions; and 2) to assess the hiring philosophy toward such positions. Seventy-two surveys were used to tabulate results. Fifty-eight per cent of the non-faculty clinical positions in the institutions surveyed are held by BS pharmacists. Top preference if rehiring was an advanced degree PharmD or an entry level PharmD with a specialized residency. However, BS pharmacists with clinical experience also ranked high in preference, showing a definite competition with advanced degree pharmacists. Personality and experience seem to become important factors. MS graduates ranked very low, unless their degree was accompanied by a specialized residency. Implications of the survey results are discussed in respect to graduating pharmacy students, academe, and pharmacists currently in the work force.

Education, Pharmacy↗
PubMedDate not supplied

Tools used to help community pharmacists implement comprehensive pharmaceutical care.

OBJECTIVE: To describe the tools and processes used in the practice enhancement program (PEP) of the Pharmaceutical Care Research and Education Project to enable community pharmacists to acquire the necessary skills, knowledge, and attitudes to deliver comprehensive pharmaceutical care to elderly ambulatory patients. SETTING: Independent community pharmacies in Alberta. PRACTICE DESCRIPTION: The PEP was designed to allow self-directed learning in a problem-based environment. The intent was for pharmacists to apply the knowledge they gained to improve drug therapy outcomes. PRACTICE INNOVATION: As a systematic approach to providing care, several tools were adapted to help pharmacists execute tasks required by the nine steps of the pharmaceutical care process proposed by Helper and Strand. These tools and processes facilitated (1) self-directed learning about diseases and drugs, (2) acquisition of relevant patient data, (3) a consistent and stepwise approach to the identification and resolution of drug-related problems, (4) documentation of care provided, and (5) continuity of care. RESULTS: To help pharmacists in the PEP acquire the necessary competency to provide pharmaceutical care, they were required to use the tools and processes described herein to work up and resolve patient problems. Initially, patient problems were presented as paper cases covering a range of acute and chronic problems, including topics applicable to geriatric patients. This was followed by a practicum phase wherein patient problems represented individuals from among their clientele. CONCLUSION: The tools and processes used in the project increased community pharmacists' competency for providing pharmaceutical care, by helping them develop the needed skills, knowledge, and attitudes.

Aged↗
PubMedDate not supplied

Pharmacist involvement in Healthy People 2010.

OBJECTIVES: To review opportunities through which pharmacists can help the United States achieve its public health goals as expressed in Healthy People 2010, a document issued by the federal government that expresses the areas of focus for Americans in the first decade of the 21st century. SUMMARY: Healthy People 2010 provides general goals for 10 leading health indicators (such as tobacco use, over-weight and obesity, and immunizations), and these are then further subdivided into 28 focus areas, many of them with quantifiable goals (such as, "Reduce hospitalization rates for three ambulatory care-sensitive conditions--pediatric asthma, uncontrolled diabetes, and immunization-preventable pneumonia and influenza."). As health care professionals, pharmacists have the responsibility to help the country meet these goals. Ideas for increased pharmacist involvement are described in the article, including the conduct of screening programs and provision of specialized services that focus on such areas as hypertension, diabetes, asthma, patient education, smoking cessation, or general medication management. Pharmacists can build their efforts in these and similar areas by collaborating with physicians and other appropriate professionals, identifying target patients who have obtained services at the pharmacy, contacting patients in at-risk populations within the pharmacy's patient base and/or the community, choosing and monitoring an objective of interest, and maintaining efforts for sustained time periods. CONCLUSION: The message of Healthy People 2010 is that the health of the individual is closely linked to the health of the community and hence the health of the nation. Pharmacists, uniquely positioned as the most accessible health care providers in the community, can dedicate their considerable strengths toward using Healthy People 2010 as a tool to organize their own efforts and motivate their patients.

Adult↗
PubMed1991

Physician opinion of pharmacist-initiated change from injectable to oral administration of histamine H2-receptor antagonists.

Physicians' knowledge of dosage and cost differences between injectable and oral histamine H2-receptor antagonists (HRAs) and attitudes toward pharmacist-initiated route conversion of HRAs were assessed. A questionnaire was mailed to 491 physicians two months before implementation of a hospital program that allowed pharmacists to use preapproved guidelines to directly change the route of HRA administration. A similar questionnaire was sent to 488 physicians after five months of program operation. The response rate was 36.0% and 37.5% for the first and second surveys, respectively. In both surveys, almost half of the respondents gave incorrect answers or did not know whether dosage should be altered when HRA route is changed, and about 60% underestimated the relative cost of injectable HRAs. Among respondents who were aware of the program, 28% preferred direct pharmacist intervention; 15% of respondents who were unaware of the program had the same preference. Physicians generally responded positively to statements regarding the acceptability of the program and thought that the pharmacist's role in route conversion was appropriate. Many physicians were ignorant of differences in dosage and cost between injectable and oral HRAs. They generally supported allowing pharmacists to change the route of HRA administration from injectable to oral.

Administration, Oral↗
PubMed1990

Monitoring mutagenicity in urine and peripheral blood lymphocytes of pharmacists occupationally exposed to anticancer drugs.

Two approaches to mutagenicity monitoring were compared for estimation of possible absorption of cytotoxic drugs by a group of six pharmacists at Auckland Hospital. Blood samples were taken before and after a three week duty roster, from age and sex matched negative controls, and from a matched group of patients on chemotherapy. Peripheral blood lymphocytes were fixed, stained and analysed for sister chromatid exchange (SCE). Urine samples were collected from the pharmacists on the morning following their last day on cytotoxic dispensing duty, as well as from positive and negative controls. Samples were concentrated and analysed for mutagenicity in the bacterial Ames test. Comparison of negative control groups with the pharmacists using either of these test measures gave no evidence for significant absorption of cytotoxics by the pharmacist group as a whole, although values for the positive control groups were raised significantly in a similar comparison. The value for SCE of one pharmacist however, was elevated in the second sample (after three weeks dispensing duty) when compared with the first sample (before duty) and the urine analysis also suggested that this individual might have absorbed some mutagens. The results permit a comparison of these techniques as a means of ongoing monitoring of similar populations within New Zealand.

Antineoplastic Agents↗
PubMed1984

Justifying additional pharmacist staff in an era of cost reductions.

A proposal is described that justified adding one full-time equivalent (FTE) pharmacist in a 125-bed community hospital that already employed in its pharmacy department 2.5 FTE pharmacists and 5.2 FTE other personnel. The administrative steps taken included identifying the need for an additional staff member and documenting the cost effectiveness of various clinical activities. Literature references were used to justify the proposed ratio of pharmacists to technicians; to show the results of deficiencies in supervision, motivation, and scheduling; and to demonstrate the cost effectiveness of serum concentration monitoring, formulary review, and patient discharge-medication consultations. Results of formulary review, drug-use audits, dosing guidelines, and serum concentration monitoring performed by the pharmacy department were included in the proposal. Prospective drug-use reviews, computerized pharmacokinetic dose determinations, additional educational programs, and tighter purchasing policies were identified as other cost-saving activities that could be performed with an additional pharmacist. A 12-page proposal was submitted in July 1983 to the hospital administrator and the budget review committee, and the additional staff position was approved. The key to maintaining the new pharmacist position will be the continual documentation of cost-saving activities within the department.

Budgets↗
PubMed1981

Liability of the pharmacist as a therapeutic consultant.

The legal implications of pharmacists serving as therapeutic consultants to other health professionals are discussed. The legal view of the consultant relationship and the relative liability exposure of the primary practitioner and the consultant are reviewed. The pharmacist's liability when serving as a therapeutic consultant is considered in light of the high standard of care that would probably be used in evaluating the pharmacist's performance. Other legal issues considered include potential criminal liability of the pharmacist, whether responses should be in writing, impact of charging for therapeutic consultation services, and coverage for such activities under professional liability insurance policies. By being aware of the legal implications in these areas, pharmacists may limit their liability exposure to an acceptable level.

Pharmaceutical Services↗
PubMed1994

Certification program in antineoplastic drug preparation for pharmacy technicians and pharmacists.

A formal training program for technicians who prepare cytotoxic agents and pharmacists who check the doses is described. To handle an overwhelming workload in an oncology satellite pharmacy and to enable the pharmacists there to increase their clinical involvement, a program was developed to train technicians to prepare antineoplastic doses and pharmacists to check the technicians' work. The program consists of two days of classroom instruction, three weeks of hands-on training, and a written examination. In addition to handling and preparation of antineoplastic drugs, other topics related to oncology are covered to give the participants a better understanding of cancer and its treatment. The technicians must complete a refresher program annually. From 1991 to 1993, 15 pharmacists and 14 technicians and pharmacy students completed the program. The technicians have taken on additional responsibilities in the satellite pharmacy, including managing the inventory of oncology drugs. Implementation of a comprehensive cancer chemotherapy training class for technicians and pharmacists has benefited the pharmacy in terms of labor and inventory control.

Antineoplastic Agents↗
PubMed2006

Role of pharmacist counseling in preventing adverse drug events after hospitalization.

BACKGROUND: Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs. METHODS: We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs. RESULTS: Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization. CONCLUSIONS: Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.

Directive Counseling↗