Craig A. Pedersen

Evaluation of Community Pharmacy Service Mix: Evidence from the 2004 National Pharmacist Workforce Study

OBJECTIVES To describe the mix of pharmacy services being offered in different types of community pharmacy practices and to identify factors associated with a community pharmacy offering pharmacy services. DESIGN Cross-sectional study. SETTING Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies). PARTICIPANTS Pharmacists practicing full-time or part-time who worked in community pharmacies and responded to the 2004 National Pharmacist Workforce Survey. INTERVENTION Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists. MAIN OUTCOME MEASURES Type and frequency of pharmacy services being offered in a community pharmacy, including dispensing and product-related services (e.g., specialty compounding), and pharmacist care services (e.g., immunizations, smoking cessation, health screening, medication therapy management, wellness screening, nutritional support, and disease management services). RESULTS Four pharmacist care services were reported as being offered at more than 10% of community pharmacy practices: immunizations, smoking cessation, health screening, and diabetes management. The number of pharmacist care services offered at a community pharmacy was positively associated with having at least three pharmacists on duty, innovativeness of the pharmacy, status as an independent pharmacy, and status as a supermarket pharmacy. More than one half of the community pharmacy practices did not offer any of the eight pharmacist care services included in a pharmacy service index. CONCLUSION Pharmacy services were reported at relatively few community pharmacies, and were associated with pharmacy innovativeness, pharmacist staffing levels, and pharmacy setting. Some community pharmacies are offering pharmacy services as part of their business strategy, while others are dedicated to dispensing services. Continued study of pharmacy service availability in community pharmacies is needed to improve our understanding of our capacity to deliver such services, including medication therapy management services.

Impact of medication packaging on adherence and treatment outcomes in older ambulatory patients

OBJECTIVE To evaluate medication adherence and treatment outcomes in elderly outpatients using daily-dose blister packaging (Pill Calendar) compared with medications packaged in bottles of loose tablets. DESIGN Randomized controlled trial. SETTING Ambulatory care clinics at Ohio State University Medical Center, Columbus; University of Arizona Health Science Center, Tucson; and Riverside Methodist Hospital Family Medicine Clinic, Columbus, Ohio, from July 1, 2002, to December 31, 2004. PATIENTS 85 individuals 65 years of age or older being treated with lisinopril for hypertension. INTERVENTION Patients were randomly assigned to receive lisinopril in either daily-dose blister packaging (Pill Calendar) or traditional bottles of loose tablets. MAIN OUTCOME MEASURES Adherence was assessed by prescription refill regularity and medication possession ratio (MPR). Treatment outcome and use of medical services were assessed by medical record review of blood pressure and morbidity associated with poorly controlled hypertension. RESULTS Patients receiving lisinopril in the daily-dose blister packaging (Pill Calendar) refilled their prescriptions on time more often (P = 0.01), had higher MPRs (P = 0.04), and had lower diastolic blood pressure (P = 0.01) than patients who had their medications packaged in traditional bottles of loose tablets. CONCLUSION Providing medications in a package that identifies the day each dose is intended to be taken and provides information on proper self-administration can improve treatment regimen adherence and treatment outcomes in elderly patients.

Pharmacist Participation in the Workforce: 1990, 2000, and 2004

OBJECTIVE To examine work variables for licensed pharmacists for 1990, 2000, and 2004. DESIGN Three cross-sectional, descriptive studies. SETTING United States. PARTICIPANTS Licensed pharmacists: 1,623 in 1990; 2,092 in 2000; and 1,564 in 2004. These numbers of usable responses to the three respective surveys represented 54.0%, 42.7%, and 33.8% of those receiving surveys. INTERVENTION Mailed survey from the 2004 National Pharmacist Workforce Survey; data from the national studies of the pharmacist workforce conducted in 1990 and 2000. MAIN OUTCOME MEASURES Characteristics of pharmacists; work setting, work position and age distribution of actively practicing pharmacists. Work status of licensed pharmacists; proportion actively practicing pharmacy. Proportion of pharmacists working part-time overall and by age group, weekly hours worked by actively practicing pharmacists, and full-time equivalents (FTEs) by age group. Proportion of pharmacists with secondary pharmacy employment; work setting, hours worked, and weeks worked in secondary pharmacy employment. RESULTS In each year studied, more than 86% of licensed pharmacists were actively practicing pharmacy. In 2004, the largest proportion of actively practicing women pharmacists was between the ages of 31 and 45, and the largest proportion of actively practicing men pharmacists was between the ages of 46 and 60. Across the survey years, the proportion of all actively practicing pharmacists working part-time increased, and the proportion of women working part-time was at least double that of men except in 2004. In 2004, the FTE contribution for women was 0.81 and 0.91 for men. CONCLUSION The decrease in FTE contributions by all pharmacists and the aging of the male pharmacist population raise concerns about the adequacy of current and future pharmacist supply. As the demand for pharmacists continues to evolve, pharmacy must continue to monitor the pharmacist workforce to show how pharmacists react to changes to better inform projections of the pharmacist workforce.

Organizational factors influencing pharmacy practice change.

BACKGROUND Some pharmacists have changed the focus of their practice from solely dispensing. Emerging services they have added include medication therapy management and other pharmacy services. OBJECTIVE To assess the effect of entrepreneurial orientation, resource adequacy, and pharmacy staffing on pharmacy practice change. METHODS A total of 1847 licensed U.S. pharmacists received 2 mail surveys as part of a larger national pharmacist survey. The core survey collected information about practice setting, prescription volume, and staffing. The supplemental survey assessed how the pharmacy had changed over the past 2 years to enable the delivery of pharmacy services. The amount of change was assessed by 12 items, which were summed to provide an aggregate change index. Five variables from organizational change literature were assessed as influences on practice change: proactiveness, risk taking, autonomy, work ethic, and adequacy of resources. In addition, the associations of pharmacist and technician staffing with practice change were assessed. A multiple linear regression analysis was performed with the aggregate change index as the dependent variable and the 7 potential influences on change as the independent variables. RESULTS Four hundred usable surveys were analyzed. At least some level of practice change was reported in 60% of pharmacies surveyed. The linear regression analysis of the model was significant (P<.001) with an R-square value of 0.276. Significant influences on change were 2 dimensions of entrepreneurial orientation-proactiveness and autonomy-as well as adequacy of resources and pharmacy technician staffing. CONCLUSIONS Many pharmacies reported that some aspects of their practice have changed, such as collecting patient information and documenting care. Few reported changes in asking patients to pay for pharmacy services. These findings support previous results, which show that the capacity for organizational change can be augmented by increasing proactiveness, autonomy among employees, and the availability of adequate and appropriate resources.

Physician adherence to the national asthma prescribing guidelines: evidence from national outpatient survey data in the United States.

BACKGROUND The Expert Panel 2 Guidelines for the Diagnosis and Management of Asthma (EPR-2 guidelines) were developed to improve medication prescribing for patients with persistent asthma and to control acute exacerbations of asthma. In addition, these guidelines also encourage physician-provided asthma education. Little is known about prescribing adherence to EPR-2 guidelines. OBJECTIVES To examine physician adherence to EPR-2 asthma medication prescribing guidelines and determine patient and physician factors associated with prescribing of asthma medications. METHODS This study was a cross-sectional retrospective analysis of National Ambulatory Medical Care Survey physician visit survey data from 1998 through 2004. Data were extracted on all patients with an International Classification of Diseases, Ninth Revision (ICD-9) code for asthma (493.XX) and reason for visit as asthma. The unit of analysis was individual patient visit. The dependent variables in analyses were specific type of drug class. The independent variables were various patient and physician factors. Logistic regression analysis was used to evaluate study objectives. RESULTS Asthma patients in 2002 had 3.3 times more odds of being prescribed controller medications compared with asthma patients in 1998. Findings in 2004 were not significant. Elderly patients had 54% less odds of receiving controller medication compared with those in the 35- to 64-year-old age group. Patients in the other race category are 40% as likely to receive controller asthma medication compared with white patients. Physicians in 2002 had 6.3 times more odds of prescribing long-acting beta-agonists compared with those in 1998. Physicians without ownership stake in their practice had 1.9 times more odds of providing asthma education to their patients compared with those who owned their practice. CONCLUSION Physician prescribing of asthma pharmacotherapy does not adequately comply with EPR-2 treatment guidelines.

Potential Adverse Drug Events in an Indigent and Homeless Geriatric Population

OBJECTIVE: To identify potential adverse drug events (ADEs) in a geriatric ambulatory population using the modified Beers criteria. METHODS: This is a cross-sectional study of an indigent and homeless geriatric population served by a network of six primary healthcare clinics with clinical pharmacy services. Medical records of patients ≥65 years old visiting the clinics between December 1999 and April 2000 were retrospectively reviewed by a clinical pharmacist. Medications meeting the modified Beers criteria were evaluated for the most common drug classes involved, severity potential, and dose or disease state restrictions. Following the identification of medications meeting Beers criteria, the pharmacist left a written recommendation regarding use of alternative drugs or doses in the medical record. Physician acceptance of pharmacy recommendations was also evaluated. RESULTS: Medical records of 146 patients (71.9% women, average age 72.6 ± 6.7 y) were reviewed. Overall, 52 patients (35.6%) had 70 medications with the potential for causing an ADE based on the modified Beers criteria. The most commonly identified medication classes were narcotic analgesics (20.0%), antihypertensives (20.0%), and antihistamines (14.3%). Fifteen of these medications (21.4%) had a high severity potential. Identified medications met the following modified Beers criteria: 41.4% were inappropriate in a specific disease state, 38.6% were inappropriate for the elderly, 10.0% exceeded maximum dosage guidelines, and 10.0% were inappropriate for both the elderly and the patients disease state. Approximately 60% of pharmacy recommendations were accepted by physicians. CONCLUSIONS: The modified Beers criteria are a useful tool for reviewing medical records to identify potential ADEs in an ambulatory geriatric population.

Practice-based research network as a research training model for community/ambulatory pharmacy residents

OBJECTIVE To describe our experience with a practice-based research training network (PBRTN) in a 1-year residency program. SETTING Ohio State University in Columbus from 1997 to 2007. PRACTICE DESCRIPTION The program includes two accredited postgraduate year 1 residencies and one postgraduate year 2 residency. Seven residents, 11 preceptors, and three faculty members participated during the time frame discussed in this article. Practice settings included three community sites and three ambulatory sites. PRACTICE INNOVATION The PBRTN includes a residency director, a research director, preceptor and resident members, and research faculty. The group works collaboratively to meet training goals. The PBRTN maintains a project timeline, foundational training, and structured research development, implementation, and presentation phases. Each resident submits five required research products: abstract, grant, poster, podium presentation, and research manuscript. MAIN OUTCOME MEASURES Quantitative measures included the number of abstracts, grants, and peer-reviewed publications over two time periods, one before and one after a deliberate attempt to increase the research focus of the residencies. The ratio of research products to number of residents was used as a measure of productivity. Postresidency career choice and postresidency publications are reported. RESULTS Over a decade, the program has produced 37 graduates, 50 abstracts, 15 grants, and 12 peer-reviewed publications. The publication-to-resident ratio increased from 0.25 in the pre-emphasis period of 1997-2001 to 0.56 in 2002-2007, after the research focus was intensified. Of graduates, 38% are in faculty positions, with 48 postresidency publications. CONCLUSION Use of a PBRTN has successfully provided research training and improved research outcomes for the program. This model could be implemented in other residencies.

Evaluation of board certification in nutrition support pharmacy.

BACKGROUND Credentialing of healthcare professionals is a topic that has received increasing attention. The Board of Pharmaceutical Specialties (BPS) has recognized nutrition support pharmacy as a specialty for more than 10 years. There has recently been concern about the decline in the number of pharmacists seeking board certification or recertification as specialists in nutrition support and changes in the job responsibilities of nutrition support pharmacists. These factors have resulted in a need to evaluate the current system of certification of nutrition support pharmacists. METHODS A national survey was developed and sent to pharmacist members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and members of the Home Care Section of the American Society of Health-System Pharmacists (ASHP). The objectives of this study were to describe the activities of nutrition support pharmacists, determine the benefits and barriers to board certification, and assess the current system of certification. RESULTS Two hundred and fifty-eight of 486 surveys were returned for an overall response rate of 53%. There has been a decrease in the amount of professional time devoted to nutrition support activities. The most highly ranked benefit to certification was peer recognition. The most highly ranked barrier to certification was the examination cost. CONCLUSIONS There is satisfaction with the current system; however, alternative methods were supported if the current method cannot sustain itself There is a need to evaluate the cost of the examination and increase marketing efforts to candidates for whom the examination is intended.

Asthma Pharmacotherapy Prescribing in the Ambulatory Population of the United States: Evidence of Nonadherence to National Guidelines and Implications for Elderly People

OBJECTIVES: To examine the level of physician adherence to the Expert Panel Report 2 (EPR‐2) pharmacotherapy guidelines of the asthma population, specifically in the elderly ambulatory patient population of the United States.

Assessment of pharmacy faculty members' opinions regarding required postgraduate pharmacy residencies.

PURPOSE Agreement between pharmacy faculty members and the American College of Clinical Pharmacy (ACCP) recommendations regarding the requirement of residency training to provide direct patient care or attain a position in academia is discussed. METHODS Faculty members of the American Association of Colleges of Pharmacy participated in a survey administered by an online survey tool. The survey contained a variety of yes/no, multiple choice, and Likert scale questions. Participants were asked to disclose whether they agreed with the ACCP recommendations. Other data collected included faculty demographics, individual awareness of the ACCP position statement, and postgraduate training recommendations before receiving the survey. RESULTS The survey was sent to 2414 faculty members, and 623 (26%) of those responded. A majority of the respondents (74.8%) identified themselves as pharmacy practice faculty. Of those who replied, 55.6% agreed that one year of residency training should be required to provide direct patient care. Approximately 64% agreed that a postgraduate year 1 residency should be required in order to be appointed as adjunct clinical faculty or preceptor of pharmacy students, while 50.1% agreed that two years of residency training should be required in order to be appointed to rank assistant professor. CONCLUSION A slight majority of faculty members responding to this survey agreed with recommendations in a 2006 ACCP position statement that proposed requiring residencies for all pharmacy students graduating from pharmacy school in order to attain positions in academia or settings providing direct patient care.