Daniel R. Touchette

Economic evaluations of clinical pharmacy services: 2006-2010.

Studies have consistently evidenced the positive clinical, economic, and humanistic benefits of pharmacist‐directed patient care in a variety of settings. Given the vast differences in clinical outcomes associated with evaluated clinical pharmacy services (CPS), more detail as to the nature of the CPS is needed to better understand observed differences in economic outcomes. With the growing trend of outpatient pharmacy services, these economic evaluations serve as viable decision‐making tools in choosing the most effective and cost‐effective pharmacy programs. We previously conducted three systematic reviews to evaluate the economic impact of CPS from 1988 to 2005. In this systematic review, our objectives were to describe and evaluate the quality of economic evaluations of CPS published between 2006 and 2010, with the goal of informing administrators and practitioners as to their cost‐effectiveness. We searched the scientific literature by using the Medline, International Pharmaceutical Abstracts, Embase, and Cumulative Index to Nursing and Allied Health Literature databases to identify studies describing CPS published from 2006 to 2010. Studies meeting our inclusion criteria (original research articles that evaluated CPS and described economic and clinical outcomes) were reviewed by two investigators. Methodology used, economic evaluation type, CPS setting and type, and clinical and economic outcome results were extracted. Results were informally compared with previous systematic reviews. Of 3587 potential studies identified, 25 met inclusion criteria. Common CPS settings were hospital (36%), community (32%), and clinic or hospital‐based ambulatory practices (28%). CPS types were disease state management (48%), general pharmacotherapeutic monitoring (24%), target drug programs (8%), and patient education (4%). Two studies (8%) listed CPS as medication therapy management. Costs were evaluated in 24 studies (96%) and sufficiently described in 13 (52%). Clinical or humanistic outcomes were evaluated in 20 studies (80%) and were sufficiently described in 18 (72%). Control groups were included in 16 (70%) of 23 studies not involving modeling. Study assumptions and limitations were stated and justified in eight studies (32%). Conclusions and recommendations were considered justified and based on results in 24 studies (96%). Eighteen studies (72%) involved full economic evaluation. The mean ± SD study quality score for full economic evaluations (18 studies) was 60.4 ± 22.3 of a possible 100 points. Benefit‐cost ratios from three studies ranged from 1.05:1 to 25.95:1, and incremental cost‐effectiveness ratios of five studies were calculated and reported. Fewer studies documented the economic impact of CPS from 2006–2010 than from 2001–2005, although a higher proportion involved controlled designs and were full economic evaluations. Evaluations of ambulatory practices were increasingly common. CPS were generally considered cost‐effective or provided a good benefit‐cost ratio.

A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension.

ABSTRACTOBJECTIVEEvaluate the effectiveness of collaborative management of hypertension by primary care-pharmacist teams in community-based clinics.STUDY DESIGNA 12-month prospective, single-blind, randomized, controlled trial in the Providence Primary Care Research Network of patients with hypertension and uncontrolled blood pressure.METHODSAs compared to usual primary care, intervention consisted of pharmacy practitioners participating in the active management of hypertension in the primary care office according to established collaborative treatment protocols. At baseline, there was no significant difference in blood pressure between groups. Primary outcome measures were the differences in mean systolic and diastolic blood pressures between arms at study end. Secondary measures included blood pressure goal attainment (<140/90xa0mmHg), hypertension-related knowledge, medication adherence, home blood pressure monitoring, resource utilization, quality of life, and satisfaction.RESULTSA total of 463 subjects were enrolled (nu2009=u2009233 control, nu2009=u2009230 intervention). Subjects receiving the intervention achieved significantly lower systolic (pu2009=u20090.007) and diastolic (pu2009=u20090.002) blood pressures compared to control (137/75xa0mmHg vs. 143/78xa0mmHg). In addition, 62% of intervention subjects achieved target blood pressure compared to 44% of control subjects (pu2009=u20090.003). The intervention group received more total office visits (7.2 vs. 4.9, pu2009<u20090.0001), however had fewer physician visits (3.2 vs. 4.7, pu2009<u20090.0001) compared to control. Intervention subjects were prescribed more antihypertensive medications (2.7 vs. 2.4, pu2009=u20090.02), but did not take more antihypertensive pills per day (2.4 vs. 2.5, pu2009=u20090.87). There were minimal differences between groups in hypertension-related knowledge, medication adherence, quality of life, or satisfaction.CONCLUSIONSPatients randomized to collaborative primary care-pharmacist hypertension management achieved significantly better blood pressure control compared to usual care with no difference in quality of life or satisfaction.

Medication therapy management services: Definitions and outcomes

In the US, the Medicare Modernization Act of 2003 required that Medicare Part D insurers provide medication therapy management (MTM) services (MTMS) to selected beneficiaries, with the goals of providing education, improving adherence, or detecting adverse drug events and medication misuse. These broad goals and variety in MTM programmes available make assessment of these programmes difficult. The objectives of this article are to review the definitions of MTMS proposed by various stakeholders, and to summarize and evaluate the outcomes of MTMS consistent with those that may be offered in Medicare Part D or reimbursed by State Medicaid programmes.MTM programmes are approved by the Centers for Medicare and Medicaid Services (CMS). Pharmacy, medical and insurance organizations have provided guidelines and definitions for MTM programmes, distinguishing them from other types of community pharmacy activities. MTM has been distinguished from disease state management because of the focus on medications and multiple conditions. It differs from patient counselling because it is delivered independent of dispensing and involves collaboration with patients and providers. There is no consensus on the recommended mode of delivery (i.e. face-to-face or by telephone) for MTM.A MEDLINE search was conducted to identify articles published after 2000 using the search terms ‘medication therapy management’ and ‘medication management’. Studies with outcomes evaluating community-based programmes consistent with MTMS, regardless of MTMS reimbursement source, were included in the review. Seven publications describing four MTMS were identified. For each of the identified articles, we describe the study design, service setting, inclusion criteria and outcomes. An additional three surveys describing multiple MTMS were identified and are summarized. Finally, ongoing efforts by CMS to evaluate the success of MTMS in the US are described.To date, there are limited outcomes available for MTMS. The wide variety of MTMS offered means that evaluations of individual programmes are necessary. Despite the potential benefits of MTMS, there are numerous challenges to providing MTMS, including reimbursement, justification of the service and stakeholder acceptance of the services. There remains a need for adequately funded, prospective, controlled studies of MTM programmes using strong designs to advance our knowledge of the effectiveness of various interventions and methods of delivery, and for naturalistic studies assessing the impact of CMS approved MTM programmes.

Impact of Educational Mailing on the Blood Pressure of Primary Care Patients with Mild Hypertension

OBJECTIVE: To assess the effectiveness of mailed hypertension educational materials.DESIGN: Prospective, randomized, controlled single-blind trial.SETTING: Primary care practice-based research network in which 9 clinics located in Portland, Oregon participated.PARTICIPANTS: Patients with mildly uncontrolled hypertension as defined as a last blood pressure of 140 to 159/90 to 99 mmHg from query of an electronic medical record database.INTERVENTIONS: Patients randomized to intervention were mailed 2 educational packets approximately 3 months apart. The first mailer included a letter from each patient’s primary care provider. The mailer included a booklet providing an overview of hypertension and lifestyle modification and a refrigerator magnet noting target blood pressure. The second mailing also included a letter from the patient’s primary care provider, a second educational booklet focused on medication compliance and home blood pressure monitoring, and a blood pressure logbook. The control group consisted of similar patients receiving usual care for hypertension.MEASUREMENTS AND MAIN RESULTS: Patients from each group were randomly selected for invitation to participate in a study visit to measure blood pressure and complete a survey (intervention n=162; control n=150). No significant difference was found in mean blood pressure between intervention and control patients (135/77 mmHg vs 137/77 mmHg; P=.229). Patients in the intervention arm scored higher on a hypertension knowledge quiz (7.48 ± 1.6 vs 7.06 ± 1.6; P=.019), and reported higher satisfaction with several aspects of their care. No significant difference was seen in the prevalence of home blood pressure monitoring ownership or use.CONCLUSIONS: In patients with mildly uncontrolled hypertension, educational mailers did not yield a significant decrease in blood pressure. However, significant improvement in patient knowledge, frequency of home monitoring, and satisfaction with care were demonstrated.

A prescription for improving drug formulary decision making.

Gordon Schiff and colleagues present a new tool and checklist to help formularies make decisions about drug inclusion and to guide rational drug use.

Cost analysis of pancreatic carcinoma treatment

Pancreatic carcinoma is a major health issue and financial burden to society. To improve the quality and efficiency of care delivered, it is essential for health care providers to have a good understanding of the cost of treatment.

Drug errors and related interventions reported by united states clinical pharmacists: The american college of clinical pharmacy practice-based research network medication error detection, amelioration and prevention study

To describe and evaluate drug errors and related clinical pharmacist interventions.

Risk of Hospitalization for Heart Failure Associated with Thiazolidinedione Therapy: A Medicaid Claims–Based Case-Control Study

Study Objectives. To determine, in patients with type 2 diabetes mellitus, whether an association exists between thiazolidinedione therapy or other diabetes therapies and hospital admission for heart failure.

Pharmacist Monitoring of QTc Interval–Prolonging Medications in Critically Ill Medical Patients: A Pilot Study

BACKGROUND: No data exist regarding the value of pharmacist monitoring of drugs associated with QTc interval prolongation. OBJECTIVE: To assess the capability, clinical impact, and economic impact of pharmacists monitoring for drug-induced QTc interval prolongation in critically ill medical adult patients. METHODS: In a prospective, parallel-group study, 149 consecutive medical intensive care unit (ICU) patients prescribed a QTc interval–prolonging drug at the Los Angeles County + University of Southern California Medical Center were assigned on alternating days to an intervention group (clinical pharmacist on physician team monitored drugs using a standardized algorithm) or a standard care group (team without pharmacist using an algorithm). The monitoring algorithm used daily assessments of electrocardiograms and laboratory data to generate pharmacotherapeutic recommendations. The primary endpoint was the frequency of QTc interval prolongation (>500 msec at any time or an increase ≥60 msec over baseline). Secondary endpoints included QTc interval greater than 470 msec in women or greater than 450 msec in men, mean increase in QTc interval at 48 hours, recommendation acceptance rate, and cost of care. RESULTS: QTc interval prolongation occurred less frequently in the intervention group compared with the standard care group (19% vs 39%, respectively; p = 0.006). Incidence of QTc interval greater than 500 msec (13% vs 33%, respectively; p = 0.003) was also lower in the intervention group. Incidence of QTc interval increase of 60 msec or more over baseline (12% vs 21%, respectively; p = 0.12) and increase in QTc interval at 48 hours over baseline (mean ± SD; 6.4 ± 40.8 vs 18.2 ± 42.3 msec, respectively; p = 0.097) were not significantly different between the groups. Algorithm-generated recommendations were accepted 70% of the time by the intervention group physician team. Total cost and cost per day were not significantly different between groups. CONCLUSIONS: In this preliminary study, pharmacist monitoring of QTc interval–prolonging drugs using a simple algorithm was feasible and reduced the risk of QTc interval prolongation. Further studies that monitor other proarrhythmic medications are warranted.

Clinical implications of an accurate problem list on heart failure treatment

CONTEXT: The premise of the problem-oriented medical record is that an accurately defined problem list will directly result in more thorough and efficient patient care. However, little empirical evidence exists demonstrating improved patient outcomes as a result of an adequately structured problem list.OBJECTIVE: To determine the impact of problem list documentation of heart failure on the likelihood that evidence-based pharmacotherapy has been prescribed.DESIGN: Cross-sectional study.SETTING: Community-based primary care clinics in Portland, Oregon.SUBJECTS: Active patients in the network with a left ventricular ejection fraction of 40% or less, with and without heart failure, in their structured problem list.MAIN OUTCOME MEASURES: The proportion of patients prescribed medications with known benefits for systolic dysfunction.RESULTS: In this group of patients with known systolic dysfunction, the likelihood of therapy with either an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker was higher in patients who had heart failure listed on their problem list compared to patients who did not (92.2% vs 76.7%; P<.05). This association remained after statistical adjustment for age, gender, and ejection fraction. Patients with accurate problem list entries were also more likely to receive digoxin (61.1% vs 36.7%; P=.001) and spironolactone (26.7% vs 13.3% P=.025). There were no differences in the use of beta-blockers between the 2 groups.CONCLUSION: Accurate documentation of heart failure on the problem list of patients with known systolic dysfunction is associated with a significant increase in the likelihood of being prescribed medications with known clinical benefit.