CoraLynn B. Trewet

Clinical Pharmacists as Key Members of the Patient-Centered Medical Home: An Opinion Statement of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy

The American College of Clinical Pharmacy (ACCP) Ambulatory Care Practice Research Network (PRN) considers the role of clinical pharmacists to be fundamental to the success of the Patient‐Centered Medical Home (PCMH) model. Within the PCMH, pharmacists can improve the health of populations by participating in activities that optimize medication management. Multiple published articles support clinical pharmacist involvement in the PCMH with regard to promotion of team‐based care, enhanced access, care coordination, and improved quality and safety of care. A survey of clinical pharmacist members of ACCP who operate in such a model depict a variety of activities, with some members pioneering new and innovative ways to practice clinical pharmacy. Although this is a significant opportunity for pharmacists in the primary care setting, a unified vision of pharmacy services is needed. It is our hope that with continued efforts focused on obtaining national provider status, clinical pharmacy can use the PCMH model to solidify the future of primary care pharmacy. The following is an opinion statement of the ACCP Ambulatory Care PRN regarding the vital role of clinical pharmacists in the PCMH.

A comprehensive approach to preceptor development.

Objective. To assess the impact of a comprehensive preceptor development program. Design. A comprehensive preceptor development program was designed that included live and recorded online programming, a preceptor manual, a preceptor newsletter, live events (local and regional), and one-on-one practice site visits. Assessment. Over 5,000 evaluations (1,900 pre-implementation and 3,160 post-implementation) of preceptor performance were completed by students. Students rated preceptors higher in items related to providing helpful midpoint and final evaluations after program implementation. Over 1,000 Web-based preceptor development activities were completed by preceptors from 2007 to 2011. Preceptors felt activities enhanced their current knowledge, skills, attitudes, and values, and more than 90% felt the core development activities would improve their current practice. Conclusion. A comprehensive approach to preceptor development that offered a variety of development and training opportunities received positive evaluations from preceptors and resulted in improved student evaluations of preceptors. A comprehensive development program should be made available to preceptors to foster their continuing professional development.

A Leadership Elective Course Developed and Taught by Graduate Students

Objective. To develop and implement a flexible-credit elective course to empower student pharmacists to develop lifelong leadership skills and provide teaching practice opportunities for graduate students. Design. An elective course focusing on leadership development for second- and third-year doctor of pharmacy (PharmD) students was designed and taught by 4 graduate students under the mentorship of 2 faculty members. Student pharmacists could enroll in a 1-, 2-, or 3-credit-hour version of the course. Assessment. Attainment of course objectives was measured using student pharmacist reflection papers and continuing professional development portfolios. Additionally, self-assessments of graduate students and faculty members delivering the course were conducted. In their responses on course evaluations, student pharmacists indicated they found the course a valuable learning experience. Graduate students found course development to be challenging but useful in developing faculty skills. Conclusion. This flexible-credit elective course taught by graduate students was an innovative way to offer formal leadership instruction using limited college resources.

Evaluation of the impact of a continuing professional development worksheet on sustained learning and implementing change after a continuing pharmacy education activity.

BACKGROUND Continuing professional development (CPD) continues to gain acceptance as a model for health care professionals to engage in lifelong learning. Little is known about how CPD participants use the experience to develop learning plans and implement new knowledge into practice. OBJECTIVE The primary objective of this study was to evaluate the effectiveness of instruments designed to guide the pharmacist through a CPD process to plan and participate in continuing professional education activities at a national meeting. METHODS The study was a case-control study of pharmacists randomized from the participants of the 2010 American Pharmacists Association Annual Meeting. The test group (n=47) was instructed to complete CPD planning worksheets designed to facilitate planning of their continuing pharmacy education activities before the meeting. The control group (n=58) did not have instructions beyond the meeting program. Both groups completed 3 surveys assessing components of the CPD processes: 1 before and 2 after the meeting. The surveys focused on confidence in abilities to identify, plan, and evaluate learning as well as implementation of practice change. RESULTS Nearly all the test groups reported successful application of learning (95%) and achieving their designed learning plan (87%). Practice changes were implemented in more than half (60%) of the test groups after using a CPD process to plan their learning activities. There were no significant differences among groups regarding the outcome measures. CONCLUSIONS Participants successfully used a CPD approach to meet their learning plans and achieve meaningful learning outcomes. Integration of CPD components into educational activities may help to promote practice change.

Do ACE Inhibitors/Angiotensin II type 1 receptor antagonists reduce hospitalisations in older patients with heart failure? A propensity analysis.

BackgroundRandomised controlled trials have shown a reduced risk of heart failure (HF) hospitalisation among users of ACE inhibitors (ACEIs) or angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]), but these results have limited generalisability. Some observational studies have also demonstrated reductions in hospitalisation but are potentially affected by non-random treatment selection.ObjectiveTo assess the effect of ACEI/ARB therapy on all-cause and HF-related hospitalisations among older adults using a propensity model to adjust for treatment-selection bias and focusing on consistent medication use as the exposure of interest.MethodsA retrospective cohort study of continuously enrolled, older (age ≥60 years) Kansas Medicaid beneficiaries with HF, using data from May 1999 to April 2000. A propensity analysis was used to identify a comparison group of untreated persons that were otherwise clinically similar to treated persons. The effect of regular ACEI/ARB use on hospitalisations was estimated using multivariable logistic regression models. The HF sample included 887 subjects, of whom 235 (27%) received regular ACEI/ARB therapy. To be considered a regular user of ACEI/ARB therapy (‘treated’), we required evidence that a subject obtained at least 80% of their intended daily supply. The main outcome measure was the effect of regular ACEI/ARB use on all-cause and HF-related hospitalisations.ResultsTreated subjects were matched against an equal number of untreated persons, for a final sample of 470 persons. The mean age of both treated and untreated subjects was 81 years. Regular ACEI/ARB use did not alter the adjusted odds ratio (AOR) of all-cause hospitalisation (AOR = 1.04, 95% CI 0.71, 1.52), which occurred in 40% of the sample, or the odds of an HF-related hospitalisation (AOR =1.01, 95% CI 0.65, 1.57), which occurred in 22.6% of both groups.ConclusionAlthough randomised controlled trials have shown that ACEI/ARB treatment is associated with reduced hospitalisations in patients with HF, this benefit was not observed in our study. Further study of ACEI/ARB outcomes is needed in a larger sample of older subjects with HF.

Pharmacist engagement in medical home practices: Report of the APhA–APPM Medical Home Workgroup

OBJECTIVES To identify factors that have led to successful involvement of pharmacists in patient-centered medical home (PCMH) practices, identify challenges and suggested solutions for pharmacists involved in medical home practices, and disseminate findings. DATA SOURCES In July 2011, the American Pharmacists Association Academy of Pharmacy Practice & Management convened a workgroup of pharmacists currently practicing or conducting research in National Committee for Quality Assurance-accredited PCMH practices. DATA SYNTHESIS A set of guiding questions to explore the early engagement and important process steps of pharmacist engagement with PCMH practices was used to conduct a series of conference calls during an 8-month period. CONCLUSION Based on knowledge gained from early adopters of PCMH, the workgroup identified 10 key findings that it believes are essential to pharmacist integration into PCMH practices.

Clarification of Once-Daily Low-Molecular-Weight Heparin Dosing in Pulmonary Embolism

We appreciate the interest demonstrated by Dr Girard and his colleagues in our work. 1 We agree that we cannot completely rule out a selection bias as a mechanism of our fi ndings and have acknowledged this in the “Limitations” section of our article. Despite robustly adjusting for severity of illness in our multivariable regression model, we cannot exclude residual confounding. The “Monday Effect,” or deferred care for relatively minor pulmonary embolism (PE), as suggested by Dr Girard and colleagues, is an interesting concept and deserves further study. Unfortunately, our data sources do not allow us to make such a determination. The National Inpatient Sample has a variable that indicates whether the admission was on a weekday or weekend but not for specifi c days of the week. However, it is unlikely that this phenomenon is solely responsible for our fi ndings. Delaying care for a potential life-threatening dis ease, by up to . 2 days in some cases, would lead to an increase in severity of illness and by extension mortality on weekdays in at least some such people. This would bias our results toward fi nd ing no differences in mortality between weekends and weekdays. In our article, we did not mean to suggest that delays in inferior vena cava fi lter placement might be the direct cause of observed differences in mortality; indeed, we agree with Dr Girard and colleagues that they are unlikely to be a reliable marker of quality of care in acute PE. Rather, we suggest that differences in timeliness of placement may be a surrogate for delays in other processes of care that possibly affect mortality, for example, delays in achievement of anticoagulation targets or impediments in diagnosis via belated performance of CT scan angiography. The proportion of people receiving inferior vena cava fi lters in our study is consistent with other investigations in the United States. 2 We cannot, however, determine the appropriateness of the indication for such placement. Differences in fi ndings of the Computerized Registry of Patients With VTE (RIETE) and our study may partly arise from the fact that RIETE includes patients with VTE, whereas we restricted our attention to people with PE only.

Lisinopril-Induced Nightmares

Drug‐induced nightmares have been reported in the literature and are a known adverse effect of certain antihypertensive agents such as α‐agonists and β‐blockers. Data are limited, however, on the association of this adverse effect with angiotensin‐converting enzyme (ACE) inhibitors. We describe a 63–year‐old, obese woman, with no history of illicit drug abuse, alcohol abuse, or psychiatric illness, who developed nightmares after starting lisinopril 10 mg/day for blood pressure control. The drug was discontinued, triamterene‐hydrochlorothiazide was started, and her nightmares ceased. One year later, the patient continued to have no complaints of nightmares. At that time, however, her blood pressure was slightly elevated. Triamterene was discontinued, and lisinopril was restarted at a lower dose of 5 mg/day in addition to hydrochlorothiazide 25 mg/day. Her nightmares returned; however, the patient decided to continue taking the lisinopril and tolerate the nightmares. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6) between the patients development of nightmares and lisinopril therapy. The exact mechanism by which ACE inhibitors cause this drug reaction is not known. Clinicians should be aware of this potential adverse effect when monitoring patients receiving ACE inhibitors.

Leukopenia Associated with Paroxetine Use

Objective: To report a case of leukopenia associated with paroxetine treatment. Case Summary: A 44-year-old white female with a history of anemia secondary to heavy menses, anxiety, depression, and current tobacco dependence presented with general symptoms of fatigue and blurred vision. The patients medications at the time of the initial visit were ferrous sulfate 325 mg twice a day and paroxetine 20 mg/day. Three years prior to the initiation of paroxetine, the patients documented white blood cell (WBC) count was 7.4 × 103/μL with normal differential and hemoglobin was 10.5 g/dL; on presentation, laboratory test results were WBC count 1.3 × 103/μL, red blood cell count 1.78 × 106/μL, hemoglobin 4.5 g/dL, hematocrit 15.1%, and platelets 248 × 103/μL. Three months after discontinuation of paroxetine, the patients WBC count was 4.4 × 103/μL. Discussion: Paroxetine and other antidepressants have not been known to cause adverse hematologic effects that can be seen with other antipsychotics, namely, clozapine. The use of the Naranjo probability scale indicated a probable relationship between leukopenia and paroxetine therapy in this patient. Based on a MEDLINE search (February 12, 2007), there are limited data on leukopenia as an adverse event of paroxetine. We found this to be a unique case of leukopenia suspected to be secondary to extended use of low-dose paroxetine. Conclusions: Although leukopenia caused by paroxetine and other medications with serotonergic effects appears to be uncommon, physicians and pharmacists should be aware of this rare but potentially serious adverse event.