OBJECTIVE To summarize the start-up experience with patients identified as eligible during the first four quarters of the Iowa Pharmaceutical Case Management (PCM) program and to characterize the extent of the services proved by pharmacists in the program. DESIGN Prospective pharmaceutical care intervention project. SETTING One hundred seventeen community pharmacies in Iowa. PATIENTS Medicaid patients at high risk for drug-related problems based on using 4 or more nontopical medications and having 1 of 12 specific disease states. INTERVENTION To become eligible to provide PCM services, licensed pharmacists had to undergo training and submit five care plans to the Iowa Department of Human Services. Community pharmacists were provided names of newly eligible patients each calendar quarter for 1 year. For each patient, pharmacists were asked to indicate by fax whether they had met with the patient, performed a written work-up of the patient, sent recommendations to the patient's physician, and whether the physician replied. When pharmacists were unable to provide the service, they were asked to state the reason. Both the pharmacist and the physician receive $75 for the initial assessment, with additional payments after each follow-up visit performed. MAIN OUTCOME MEASURES An intensity score and the percentage of eligible patients for whom all steps were completed were calculated for each pharmacy. RESULTS Fax survey results were returned for 2,834 (96.7%) of the 2,931 patients eligible for PCM services. Pharmacists met with 943 (33.3%), worked up 763 (26.9%), sent recommendations to physicians for 500 (17.6%), and received replies from physicians for 327 (11.5%) patients. Pharmacists were unable to provide PCM services for 1,891 (66.7%) patients. The primary reasons given for this inability to provide services were patient access issues for 438(23.2%) patients, pharmacy staffing or start-up issues for 419(22.2%) patients, or no reason specified for 575(30.4%) patients. A PCM intensity score was developed to represent the scope of services provided and the number of patients served. A higher intensity score indicated pharmacies that provided PCM to more patients and/or that offered higher levels of care (e.g., provided a written set of recommendations to the physician rather than simply assessing the patient without preparing or sending recommendations). Future evaluations will determine the validity of the score on the basis of patient outcomes. CONCLUSION Some pharmacies implemented PCM services very effectively. However, 40% to 60% of the pharmacies provided little or no PCM services within 3 months of notification of patient eligibility. Future investigations will evaluate the quality of prescribing and quality of life for patients who received PCM services.
Adalimumab joins free existing biologic agents for the treatment of RA. Its place among these therapeutic options is unclear until head-to-head studies are performed with adalimumab and other biologic DMARDs. Adalimumab is currently in clinical trials for additional therapeutic uses, namely Crohn's disease and coronary artery disease.
Using sterile triploid salmon is of interest to fish farmers as a means to mitigate interbreeding between farmed and wild fish, prevent pre-harvest maturation and offer potential for faster growth. We investigated within the same experiment whether growth, deformity and cataract prevalence in diploid and triploid Atlantic salmon post-smolts (8 full-sib families) were influenced by isolated- or mixed-ploidy rearing during 12 months of sea water grow-out in tanks until harvest. Diploids attained significantly higher harvest weights than triploids in both treatments (+ 6.7% isolated, + 26.3% mixed). Triploid harvest weight was 29.6% lower under mixed ploidy rearing than their isolated triploid siblings. A similar effect was also observed in diploids (12% lower harvest weight). Family had a significant effect on harvest weight in both ploidy. However, family harvest weight in triploids showed a linear relationship between isolated and mixed rearing (r2 = 0.76), while a non-linear relationship was found between diploids reared in isolation or mixed populations (r2 = 0.88). Furthermore diploid family weight correlated positively with triploid weight in isolation (r2 = 0.65), but a non-significant relationship was observed under mixed rearing (r2 = 0.49). Diploids had a significantly higher condition (K) factor at harvest than triploids in both treatments, while triploid K factor was significantly reduced by mixed rearing with diploids. Triploids had a significantly higher incidence of cataract than diploids in both treatments (60.9–77.3% vs. 21.7–47.2%, severity ≥ 1). However, severity of cataract was greater in both triploids (2.43) and diploids (1.44) grown in isolation than those grown in a mixed ploidy population (triploid 2.17; diploid 1.09). Triploids had a significantly higher prevalence of visible deformity than diploids (18.1 vs. 7.2%), however, triploids grown in isolation had significantly higher prevalence than triploids under mixed rearing (30.4 vs. 5.8%). Collectively, the results provide clear evidence that triploids perform very differently when reared in the presence or absence of diploid conspecifics. Furthermore, observations of reduced deformity and cataract in the slower growing mixed populations support the hypothesis that such malformations are in part a function of higher growth rate. The results of this study also indicate that care should be taken when designing conventional common garden experiments to evaluate family performance between ploidy as interactions between ploidy may influence growth traits, although family effects appear to remain consistent.
Lucie Kutikova, PhD, RPh, is senior health outcomes research scientist, Global Economic Affairs, Eli Lilly and Company, Indianapolis, Ind. At the time of this study Kutikova was a graduate student, Health Science Administration, Department of Pharmacy Practice and Pharmacoeconomics, College of Pharmacy, University of Tennessee–Memphis. Pamala J. Reed, DrPH, MPH, is assistant professor, Department of Pharmacy Practice and Pharmacoeconomics, College of Pharmacy, University of Tennessee–Memphis.
OBJECTIVE 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, overweight 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.
OBJECTIVES:To measure dispensing accuracy rates in 50 pharmacies located in 6 cities across the United States and describe the nature and frequency of the errors detected.DESIGN:Cross-sectional descriptive study.SETTINGS:Chain, independent, and health-system pharmacies (located in hospitals or managed care organizations).PARTICIPANTS:Pharmacy staff at randomly selected pharmacies in each city who accepted an invitation to participate.INTERVENTION:Observation by a pharmacist in each pharmacy for 1 day, with a goal of inspecting 100 prescriptions for dispensing errors (defined as any deviation from the prescriber's order).MAIN OUTCOME MEASURE:Dispensing errors on new and refill prescriptions.RESULTS:Data were collected between July 2000 and April 2001. The overall dispensing accuracy rate was 98.3% (77 errors among 4,481 prescriptions; range, 87.2%-100.0%; 95.0% confidence interval, +/- 0.4%). Accuracy rates did not differ significantly by pharmacy type or city. Of the 77 identified errors, 5 (6.5%) were judged to be clinically important.CONCLUSION:Dispensing errors are a problem on a national level, at a rate of about 4 errors per day in a pharmacy filling 250 prescriptions daily. An estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year.
OBJECTIVE To assess the persistence of outcomes for up to 5 years following the initiation of community-based pharmaceutical care services (PCS) for patients with diabetes. DESIGN Quasi-experimental, longitudinal pre-post cohort study. SETTING Twelve community pharmacies in Asheville, N.C. PATIENTS AND OTHER PARTICIPANTS Patients with diabetes covered by self-insured employers' health plans. Community pharmacists trained in a diabetes certificate program and reimbursed for PCS. INTERVENTIONS Education by certified diabetes educators, long-term community pharmacist follow-up using scheduled consultations, clinical assessment, goal setting, monitoring, and collaborative drug therapy management with physicians. MAIN OUTCOME MEASURES Changes in glycosylated hemoglobin (A1c) and serum lipid concentrations and changes in diabetes-related and total medical utilization and costs over time. RESULTS Mean A1c decreased at all follow-ups, with more than 50% of patients demonstrating improvements at each time. The number of patients with optimal A1c values (< 7 %) also increased at each follow-up. More than 50% showed improvements in lipid levels at every measurement. Multivariate logistic regressions suggested that patients with higher baseline A1c values or higher baseline costs were most likely to improve or have lower costs, respectively. Costs shifted from inpatient and outpatient physician services to prescriptions, which increased significantly at every follow-up. Total mean direct medical costs decreased by $1,200 to $1,872 per patient per year compared with baseline. Days of sick time decreased every year (1997-2001) for one employer group, with estimated increases in productivity estimated at $18,000 annually. CONCLUSION Patients with diabetes who received ongoing PCS maintained improvement in A1c over time, and employers experienced a decline in mean total direct medical costs.
OBJECTIVETo provide information regarding the most important properties of the new therapeutic agents marketed in 2002.DATA SOURCESPublished studies, drug information reference sources, and product labeling.DATA SYNTHESISIn 2002, 26 new therapeutic agents were marketed. The indications and information on dosage and administration for the new agents are reviewed, as are the most important pharmacokinetic properties, adverse events, drug interactions, and other precautions. Practical considerations for the use of the new agents are also discussed. Where possible, the properties of the new drugs are compared with those of other drugs marketed for the same indications.CONCLUSIONA number of the new therapeutic agents marketed in 2002 have important advantages over older medications. An understanding of the properties of these agents is important for the pharmacist to effectively counsel patients about their use and to serve as a valuable source of information for other health professionals regarding these drugs.
OBJECTIVES To develop guidelines for the documentation elements that need to be included in any record of pharmacist-provided care to allow the quality of the care to be assessed and to describe the use of these guidelines to improve the quality of pharmacist documentation. DESIGN An initial list of 85 potential documentation elements, developed through a review of the literature, was validated by a group of pharmacy practitioners. Then, through three rounds of a Delphi process and a group meeting, a panel of experts reached consensus on a refined list of 27 documentation data elements. RESULTS The documentation elements were formatted into a one-page Tool for Evaluation of Documentation (TED). The TED is a checklist for assessing the completeness of the documentation of pharmacist-provided care. CONCLUSION The TED and the consensus-building methodology used in the development of this tool can serve as cornerstones of a quality assessment process for documentation of pharmacist-provided care, enable further assessment of the quality of care, and, ultimately, be used to measure the impact of pharmacist-provided care on patient outcomes. Our results should provide guidance both to pharmacists providing care and to organizations that assess the quality of that care.
Objectives: To assess short-term clinical, economic, and humanistic outcomes of pharmaceutical care services (PCS) for patients with diabetes in community pharmacies. Design: Intention-to-treat, pre-post cohort-with-comparison group study. Setting: Twelve community pharmacies in Asheville, N.C. Patients and Other Participants: Eighty-five patients with diabetes who were employees, dependents, or retirees from two self-insured employers; community pharmacists who completed a diabetes certificate program and received reimbursement for PCS. Interventions: Patients scheduled consultations with pharmacists over 7 to 9 months. Pharmacists provided education, self-monitored blood glucose (SMBG) meter training, clinical assessment, patient monitoring, follow-up, and referral. Group 1 patients began receiving PCS in March 1997, and group 2 patients began in March 1999. Main Outcome Measures: Change from baseline in the two employer groups in glycosylated hemoglobin (A1c) values, serum lipid concentrations, health-related quality of life (HRQOL), satisfaction with pharmacy services, and health care utilization and costs. Results: Patients used SMBG meters at home, stored all readings, and brought their meters with them to 87% of the 317 PCS visits (3.7 visits per patient). Patients' A1c concentrations were significantly reduced, and their satisfaction with pharmacy services improved significantly. Patients experienced no change in HRQOL. From the payers' perspective, there was a significant $52 per patient per month increase in diabetes costs for both groups, with PCS fees and diabetes prescriptions accounting for most of the increase. In contrast, both groups experienced a nonsignificant but economically important 29% decrease in nondiabetes costs and a 16% decrease in all-diagnosis costs. Conclusion: A clear temporal relationship was found between PCS and improved A1c, improved patient satisfaction with pharmacy services, and decreased all-diagnosis costs. Findings from this study demonstrate that pharmacists provided effective cognitive services and refute the idea that pharmacists must be certified diabetes educators to help patients with diabetes improve clinical outcomes.
OBJECTIVES:To identify individuals in schools of pharmacy in the United States who are responsible for covering the topic of pain management in courses for doctor of pharmacy students and to describe how and at what depth pain management is covered in pharmacy school curricula.DESIGN:One-time qualitative assessment.SETTING:Schools of pharmacy in the United States. PARTICIPANTS Twenty-eight faculty members with the rank of professor, associate professor, or assistant professor who had been employed in their current positions for at least 2 years and who were directly involved in preparing and teaching didactic courses that address pain management.INTERVENTION:In-depth telephone interviews.MAIN OUTCOME MEASURES:Qualitative responses to open-ended interview questions.RESULTS:While pain management was included in the curricula of all 28 schools of pharmacy, it was generally covered in a fragmented way, usually as part of presentations on diseases with pain as a prominent feature (e.g., cancer pain addressed during oncology lectures) or as part of discussions of analgesics. Only two schools offered stand-alone courses in pain management, and both of those courses were electives that were taken by an average of 15 students per year. Three-fourths of respondents believed that pain was being given too little emphasis in their schools' curricula. Palliative care and the use of medications in the treatment of cancer pain was not presented in a standardized manner, and respondents were unsure of how the subject was covered in pharmacy law classes. Instruction about the diagnosis of pain, patient assessment, and physical examination was reported as "minimal" by most respondents. Respondents perceived a need for a single, complete reference and teaching resource that would address the entire spectrum of pain management as it applies to pharmacy.CONCLUSION:The topic of pain management is poorly presented and inadequately developed in the curricula of many U.S. schools of pharmacy.
