Beth Bryles Phillips

Instruments Assessing Capacity to Manage Medications

Objective: To review literature on instruments available for assessing the physical and cognitive ability to take medications as prescribed, which serve as a way to rule out reasons for nonadherence. Data Sources: A PubMed search (1950–February 2008) was conducted to identity relevant articles. Additional references were obtained from cross-referencing the bibliographies of selected articles. Only journals containing English-language articles were selected for review. Study Selection and Data Extraction: Articles that described a simulated assessment of medication management were obtained, irrespective of whether the assessment also contained data about medication adherence or was focused on older adults. Data Synthesis: Fifteen instruments were identified. Six instruments required 5 minutes or less to administer. 5 required 6–30 minutes, and 4 had no administration time data reported. A possible advantage of 3 of the instruments is that they use a subjects own medications and may therefore provide a more authentic assessment. Only 2 instruments have been tested by subjects other than the drug developers and only one has been used in 2 different populations, thereby affording soma insight into generalizability. These studies have used a variety of other validated surveys/assessments to provide an indication of construct validity, including neuropsychological batteries, caregiver reports, prospective outcomes, instrumental activities of daily living, and levels of care. One instrument determined whether Individuals could tell if refills existed, whom to contact, and resources to obtain medications. Three assessed numeracy literacy. Conclusions: Five instruments that measure medication management capacity should be compared for potential further use, including Beckmans tasks, due to their brevity and assessment of numeracy literacy; the Medication Management Ability Assessment, Drug Regimen Unassisted Grading Scale, and Hopkins Medication Schedule because of the evidence supporting their use; and the Medication Management Instrument for Deficiencies In the Elderly because it includes an assessment of the patients knowledge of how to obtain more medications. No brief tool is available for the primary care setting to identify individuals with medication management problems or to guide the type and amount of support required to manage medications.

Rosiglitazone, Myocardial Ischemic Risk, and Recent Regulatory Actions:

Objective: To review the evidence surrounding rosiglitazone and ischemic cardiovascular risk and discuss the Food and Drug Administration (FDA) decision to revise safety information and restrict access to the drug. Data Sources: A literature search was conducted through MEDLINE (1950-January 2012), PubMed (1966-January 2012), and International Pharmaceutical Abstracts (1970-December 2011) using the search terms rosiglitazone and cardiovascular risk. Regulatory documents from the FDA and the Center for Drug Evaluation and Research, as well as reference citations from publications identified, were reviewed. Study Selection and Data Extraction: All articles in English identified from the data sources were evaluated for inclusion. Data Synthesis: Literature regarding rosiglitazone and ischemic cardiovascular risk has shown inconsistent results. Meta-analyses by the FDA, GlaxoSmithKline, and several independent research groups suggest an increased risk for myocardial infarction (MI), while others have not. Long-term, controlled trials not designed to evaluate cardiovascular outcomes did not find a significant increase in cardiovascular events and had low event rates overall. The RECORD (Rosiglitazone Evaluated for Cardiovascular Outcomes In Oral Agent Combination Therapy for Type 2 Diabetes) trial is the only prospective randomized trial to date designed to evaluate cardiovascular outcomes of rosiglitazone; the results were limited because of issues with study design and event adjudication. The only direct comparisons between rosiglitazone and pioglitazone are observational studies in which pioglitazone had a more favorable MI risk profile. Conclusions: Data involving rosiglitazone and an association with ischemic cardiovascular risk have yielded variable results. The FDA made the decision to restrict access to rosiglitazone in September 2010 by requiring GlaxoSmithKline to submit a risk evaluation and mitigation strategy (REMS). Drug labeling was revised in February 2011, and the rosiglitazone REMS program took full effect in November 2011.

Safety and Efficacy of Allopurinol in Chronic Kidney Disease

Objective: To review the evidence surrounding the use of allopurinol in chronic kidney disease (CKD) and discuss safety and efficacy considerations of such use. Data Sources: A literature search was conducted through MEDLINE (1950-July 2013), PubMed (1965-July 2013), and International Pharmaceutical Abstracts (1970-July 2013) using the search terms allopurinol and kidney or renal. In addition, reference citations from publications identified were reviewed. Study Selection and Data Extraction: All articles in English identified from the data sources were evaluated for inclusion. Data Synthesis: Gout management with allopurinol in patients with CKD can be challenging because of the risk of adverse events and uncertain efficacy. Not all gout treatment guidelines provide recommendations for allopurinol use specifically in patients with CKD. Literature regarding the safety and efficacy of dosing allopurinol in CKD has shown inconsistent results and is based primarily on retrospective, case cohort or observational data. Some trials have demonstrated an increased risk of allopurinol-induced adverse reactions in patients with CKD, whereas others have not confirmed renal insufficiency as a risk factor. More CKD patients achieved a target uric acid level in studies where the allopurinol dose was titrated to effect as compared with those studies in which patients were given renally adjusted or untitrated allopurinol doses. Conclusions: Studies evaluating allopurinol use in patients with CKD have reported inconsistent findings relative to safety and efficacy. Providers should be aware of the potential risk of allopurinol hypersensitivity syndrome as well as the need for reducing the initiation dose and gradual titration of allopurinol to safely achieve a target serum urate level in this population.

An Elective Course on Postgraduate Residency Training

Objective. To develop, implement, and assess the impact of an elective course for pharmacy students on postgraduate pharmacy residency training. Design. An elective course on residency training was developed using short lectures, group discussions, and active-learning strategies, such as small-group exercises, mock match, and mock interview. Assessment. Students were asked to self-assess their understanding and abilities related to residency training at the beginning and end of the semester based on course objectives. The median post-semester responses increased for all objectives compared to baseline (p<0.05). Conclusion. A residency elective using a variety of teaching methods increased student knowledge and confidence in their skills regarding residency training.

Academic pharmacy and patient-centered health care: a model to prepare the next generation of pharmacists.

OBJECTIVEnTo provide evidence regarding existing partnerships between academic pharmacy and primary care that focus on training practitioners in patient-centered health care (PCHC).nnnDATA SOURCESnThe report of the 2009-10 American Association of Colleges of Pharmacy Professional Affairs Committee identified 25 current U.S.-based examples of PCHC that incorporate the training and preparation of both student pharmacists and pharmacy residents.nnnSUMMARYnThe most frequently reported health care delivery model was an ambulatory care clinic followed by a Department of Veterans Affairs or military hospital clinic. Pharmacists worked alongside a variety of other health care providers in these settings. Collaboration occurred most commonly with family and internal medicine physicians but also with specialists such as psychiatrists, obstetricians/gynecologists, hematologists/oncologists, and other health care providers (e.g., nurses, physician assistants, dieticians, social workers).nnnCONCLUSIONnIn light of the increasing demand for primary care services, pharmacists documented ability to address these needs and the resulting benefits to patients, providers, and systems in these models, developing strategies for promoting pharmacist integration into PCHC is essential. Academic pharmacy provides a valuable platform for this integration through its expert faculty clinician involvement in care and practice-based research and student pharmacist and pharmacy residency training.

Report of the 2009-2010 Professional Affairs Committee: pharmacist integration in primary care and the role of academic pharmacy.

According to the Bylaws of the AACP, the Professional Affairs Committee is to study: issues associated with professional practice as they relate to pharmaceutical education, and to establish and improve working relationships with all other organizations in the field of health affairs. The Committee is also encouraged to address related agenda items relevant to its Bylaws charge and to identify issues for consideration by subsequent committees, task forces, commissions, or other groups. COMMITTEE CHARGE President Jeffrey Baldwin charged the 2009-10 American Association of Colleges of Pharmacy (AACP) Standing Committees to consider the role of the pharmacist in primary healthcare and identify the public policy, workforce, education and advocacy issues associated with advancing pharmacists contributions to systems of primary care. The Argus Commission, Advocacy and Professional Affairs standing committees focused on the pharmacists role in primary care. How will/do pharmacists integrate their unique expertise as medication use specialists into primary care delivery to improve patients lives? Their work is grounded in the Institute of Medicine definition for primary care and the Joint Commission of Pharmacy Practitioners (JCPP) Vision Statement for Pharmacy Practice 2015: * Primary care is the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community; (1) * Pharmacists will be the healthcare professionals responsible for providing patient care that ensures optimal medication therapy outcomes, (2) Specifically, the 2009-10 Professional Affairs Committee is charged to: * Examine the evidence for pharmacists integration in primary care practice in the community in the context of partnership with patients and healthcare service providers. * Provide analysis of current and potential care delivery models. BACKGROUND Healthcare reform is a topic at the forefront of concern for Congress, the public and healthcare professionals. The primary care workforce is comprised of a diverse complement of health professionals with direct patient care provided by allopathic and osteopathic physicians, nurse practitioners, physician assistants, and registered nurses. Pharmacists are among the health professionals with growing responsibilities in the provision of patient care services within the primary care environment. (3) Others include social workers, medical assistants, and nutritionists. An adequate supply of all healthcare professionals will be required to meet the future demand for services and many recent publications reflect a growing concern for the workforce supply fulfilling this demand. (4) It is important that pharmacists are considered in legislation related to the future of the health professions workforce and future healthcare policy. To determine how pharmacists may influence healthcare reform, a critical review of the evidence of pharmacists involvement in primary care service delivery is necessary. In the early 1990s, the concept of pharmaceutical care emerged and took hold. (5) Healthcare reform, as pressing then as it is now, embraced pharmacists offering pharmaceutical care as the most vital contribution pharmacists could make in primary care to produce positive patient outcomes. Providing pharmaceutical care meant that pharmacists should enter into a partnership with patients, be accountable for drug therapy outcomes along with other healthcare providers, manage drug therapy, and coordinate the continuum of drug therapy. (6) Several barriers to providing pharmaceutical care were identified, including lack of continuity between institutional and community pharmacy practice settings, lack of technology allowing pharmacists to take a greater responsibility for drug therapy outcomes and the lack of reimbursement for provision of pharmaceutical care. …

Implementation of a pharmacy residency in a Veterans Affairs community-based outpatient clinic.

PURPOSEnThe implementation of an innovative ambulatory care pharmacy residency program at a Veterans Affairs (VA) outpatient clinic is described.nnnSUMMARYnCommunity-based outpatient clinics (CBOCs) are a largely underutilized resource for pharmacy residency training. Through a collaboration of the University of Georgia College of Pharmacy in Athens and Charlie Norwood VA Medical Center in Augusta, a postgraduate year 2 (PGY2) pharmacy residency program was established at the CBOC in Athens. The program graduated its first resident in 2009; components of training included (1) disease state management at an anticoagulation clinic and a newly created disease state-focused pharmacotherapy clinic, (2) participation in the planning and implementation of a new lipid management service, (3) a variety of didactic, laboratory, and experiential teaching activities at the college of pharmacy, and (4) management experiences such as completing requests for nonformulary medications, management of drug shortages, adverse drug reaction reporting, and participation in meetings of local and regional VA pharmacy and therapeutics committees. The demonstrated value of the ongoing program led to position upgrades for two CBOC clinical pharmacists and the addition of a clinical faculty member, enabling the program to offer additional learning experiences and preceptorship opportunities.nnnCONCLUSIONnA PGY2 ambulatory care residency program established in a CBOC provided a novel practice setting for the resident, helped improve patient care and pharmacy student education, and assisted in the professional development of preceptors and providers at the training site.

Evaluation of anticoagulation in patients with antiphospholipid syndrome

PURPOSEnThe quality of anticoagulation therapy in patients with antiphospholipid syndrome (APS) was evaluated.nnnSUMMARYnThe high risk of unnecessary anticoagulation and recent changes in the recommended International Normalized Ratio (INR) target range prompted a performance-improvement initiative to improve the care of patients with APS within the University of Iowa Hospitals and Clinics internal medicine and family medicine anticoagulation clinics. Twenty-three patients with an initial diagnosis of APS were evaluated through chart review to determine the anticoagulation indication, occurrence of thromboembolic events, and INR target range. Confirmation of APS diagnosis was made using Sapporo criteria. Recommendations were made to the patients physicians for confirmatory APS testing and changes in the anticoagulation regimen. INR target ranges were 2.0-3.0, 2.5-3.5, and 2.5-3.0 for 57%, 39%, and 4% of patients, respectively. Only 6 (26%) of the 23 patients met Sapporo criteria for a definite diagnosis of APS. Of the 17 patients (74%) who did not meet these criteria, 8 (47%) had another indication for indefinite anticoagulation. Repeat APS testing was indicated for 7 patients, 5 of whom met Sapporo criteria for APS. A lower target INR range of 2.0-3.0 was determined appropriate for 6 (26%) of the 23 patients evaluated.nnnCONCLUSIONnA majority of patients with an initial diagnosis of APS did not meet criteria for a definite diagnosis of APS. Of those patients, approximately half had another indication for long-term anticoagulation, and one third were receiving warfarin dosages based on an INR target range that was higher than clinically indicated.

Impact of a Community Pharmacist on Patient Knowledge of NPMs

Background: Nonprescription medications (NPMs) account for more than 100,000 products for approximately 450 ailments. It has been estimated that 59% of the American population self-medicates with NPMs. A recent survey found that patients are deficient in reading drug labels and identifying active ingredients and that they are exceeding the recommended daily dose of NPMs. Objective: To evaluate the impact of one-on-one pharmacist counseling sessions on patients knowledge of NPMs, looking at specific patient populations. Methods: We conducted a randomized prospective intervention trial. Patients over the age of 18 years taking blood pressure and/or diabetes medications were randomized into control and intervention groups. All patients received baseline preintervention surveys. Patients in the intervention group completed a postintervention survey after a 20-minute NPM counseling session, while patients in the control group completed the postintervention survey without completing a counseling session. t-Test and descriptive analyses were used to evaluate results from the presurvey and postintervention survey to evaluate the impact of a community pharmacist, delineate NPM use in the past 6 months, and reflect the opinions and attitudes toward use and safety of NPMs. Results: Patient NPM knowledge improved after a counseling session with a community pharmacist. Drug facts label knowledge scores improved (4.8 vs 5.4; p = 0.02) and basic drug knowledge scores improved (3.9 vs 6.3; p = 0.02) compared with baseline analysis in the intervention group. Patients in the intervention group scored significantly higher compared with the control group on the overall knowledge postintervention survey (11.8 vs 9; p = 0.01). Conclusions: Pharmacists can significantly impact the NPM knowledge of patients by dedicating a short amount of scheduled time to educating patients about appropriate use of medications.

Impact of Multi-Modal Methods to Teach Advanced Cardiovascular Life Support (ACLS) Principles in the Core Doctor of Pharmacy Curriculum

The 2016 Accreditation Council for Pharmacy Education Accreditation Standards place clear expectations on the production of “practice ready” graduates. Advanced cardiovascular life support (ACLS) is an integrated, team‐based approach to optimizing patient outcomes in acute cardiovascular events. Foundational knowledge and skill with ACLS principles will support graduate pharmacists as essential members of the health care team.