Darin C. Ramsey

Primary Care Monitoring of Long-Term Opioid Therapy among Veterans with Chronic Pain

OBJECTIVE To characterize long-term opioid prescribing and monitoring practices in primary care. DESIGN Retrospective medical record review. SETTING Primary care clinics associated with a large Veterans Affairs (VA) medical center. PATIENTS Adult patients who filled ≥6 prescriptions for opioid medications from the outpatient VA pharmacy between May 1, 2006 and April 30, 2007. OUTCOME MEASURES Indicators of potential opioid misuse, documentation of guideline-recommended opioid-monitoring processes. RESULTS Ninety-six patients (57%) received a long-acting opioid, 122 (72%) received a short-acting opioid, and 50 (30%) received two different opioids. Indicators of some form of potential opioid misuse were present in the medical records of 55 (33%) patients. Of the seven guideline-recommended opioid-monitoring practices we examined, the mean number documented within 6 months was 1.7 (standard deviation [SD] 1.5). Pain reassessment was the most frequently documented process (N = 105, 52%), and use of an opioid treatment agreement was the least frequent (N = 19, 11%). Patients with indicators of potential opioid misuse had more documented opioid-monitoring processes than those without potential misuse indicators (2.4 vs 1.3, P < 0.001). After adjustment, potential opioid misuse was positively associated with the number of documented guideline-recommended processes (mean = 1.0 additional process, 95% confidence interval [CI] 0.4, 1.5). CONCLUSIONS Guideline-recommended opioid management practices were infrequently documented overall but were documented more often for higher risk patients who had indicators of potential opioid misuse. The relationship between guideline-concordant opioid management and high-quality care has not been established, so our findings should not be interpreted as evidence of poor quality opioid management. Research is needed to determine optimal methods of monitoring opioid therapy in primary care.

Effectiveness of a hypertension care management program provided by clinical pharmacists for veterans.

Study Objective. To evaluate the effectiveness of a hypertension care management program provided by clinical pharmacists.

Redesign of a statewide teaching certificate program for pharmacy residents.

Objectives. To identify and assess changes made to the Indiana Pharmacy Resident Teaching Certificate program over 10 years to adapt to the growing number and changing needs of pharmacy educators in the next generation. Design. In 2011, all resident program participants and directors were sent an electronic survey instrument designed to assess the perceived value of each program component. Assessment. Since 2003, the number of program participants has tripled, and the program has expanded to include additional core requirements and continuing education. Participants generally agreed that the speakers, seminar topics, seminar video recordings, and seminar offerings during the fall semester were program strengths. The program redesign included availability of online registration; a 2-day conference format; retention of those seminars perceived to be most important, according to survey results; implementation of a registration fee; electronic teaching portfolio submission; and establishment of teaching mentors. Conclusion. With the growing number of residents and residency programs, pharmacy teaching certificate programs must accommodate more participants while continuing to provide quality instruction, faculty mentorship, and opportunities for classroom presentations and student precepting. The Indiana Pharmacy Resident Teaching Certificate program has successfully evolved over the last 10 years to meet these challenges by implementing successful programmatic changes in response to residency program director and past program participant feedback.

Evaluation of Pharmacist Care for Hypertension in the Veterans Affairs Patient-centered Medical Home: A Retrospective Case-control Study

OBJECTIVE The study objective was to evaluate a pharmacist hypertension care management program within the patient-centered medical home. METHODS This was a retrospective case-control study. Cases included all patients with hypertension who were referred to the care management program, and controls included patients with hypertension who were not referred to the program during the same 1-year period. Each case was matched to a maximum of 3 controls on the basis of primary care physician, age ±5 years, gender, diagnoses of diabetes and kidney disease, baseline systolic blood pressure ±10 mm Hg, and number of unique antihypertensive medications. Pharmacists provided a hypertension care management program under an approved scope of practice that allowed pharmacists to meet individually with patients, adjust medications, and provide patient education. Primary outcomes were systolic blood pressure and diastolic blood pressure at 6 and 12 months. Multivariate regression models compared each blood pressure end point between cases and controls adjusting for age, comorbidities, baseline blood pressure, and baseline number of blood pressure medications. RESULTS A total of 573 patients were referred to the hypertension program; 86% (465/543) had at least 1 matched control and were included as cases in the analyses; 3:1 matching was achieved in 90% (418/465) of cases. At baseline, cases and controls did not differ with respect to age, gender, race, or comorbidity; baseline blood pressure was higher (139.9/80.0 mm Hg vs 136.7/78.2 mm Hg, P ≤ .0002) in the cases compared with controls. Multivariate regression modeling identified significantly lower systolic blood pressure for the cases compared with controls at both 6 and 12 months (6-month risk ratio [RR], 9.7; 95% confidence interval [CI], 2.7-35.3; 12-month RR, 20.3; 95% CI, 4.1-99.2; P < .01 for both comparisons). Diastolic blood pressure was significantly lower at 12 months (RR, 2.9; 95% CI, 1.2-7.1; P < .01) but not at 6 months (RR, 1.0; 95% CI, 0.31-3.4; P = .9) for the cases compared with controls. CONCLUSIONS Patients who were referred to the pharmacist hypertension care management program had a significant improvement in most blood pressure outcomes. This program may be an effective method of improving blood pressure control among patients in a medical home model of primary care.

Teaching Certificate Program Participants’ Perceptions of Mentor-Mentee Relationships

Objective. To assess teaching certificate program (TCP) participants’ perceptions of mentor-mentee relationships. Methods. A 15-item survey instrument was administered to all 2014-2015 participants of the Indiana Pharmacy Teaching Certificate (IPTeC) program. Results. One hundred percent of IPTeC program participants (83/83) responded to the survey. The majority of participants indicated that having a professional mentor was either very important (52%) or important (47%) to their professional development and preferred to choose their own professional mentor (53%). Mentor characteristics rated as highly important by mentees included having similar clinical practice interests (82%), having similar research interests (66%), and being available to meet face-to-face (90%). Age, race, and gender of the mentor were not rated by mentees as important. Conclusion. Teaching certificate program participants place high importance on having a professional mentor. Mentorship of pharmacists completing TCPs should be a priority for current pharmacy faculty members so adequate guidance is available to future pharmacy educators.

Implementing mentoring into a pharmacy teaching and learning curriculum

Recent recommendations for standardization of postgraduate pharmacy experiences in education include the implementation of a mentoring program.[1][1],[2][2] The Indiana Pharmacy Teaching Certificate (IPTeC) program emphasizes the importance of the mentor–mentee relationship in developing

Survey of pharmacist-managed primary care clinics using healthcare failure mode and effect analysis

Objective The primary objective was to expand upon results of a previously piloted patient perception survey with Healthcare Failure Mode and Effect Analysis (HFMEA), to identify areas within pharmacist-managed clinics needing improvement. Methods The survey was adapted for use in pharmacist-managed clinics. Patients completed the survey following regularly scheduled pharmacist appointments. Data were analyzed with a method adapted from HFMEA. Product scores could range from five to 25. A product of five indicates that pharmacists are doing a good job on the items that patients place the most value on, while a product score of 25 indicates that pharmacists are doing a poor job. A score greater than or equal to ten was used to identify areas for improvement. Results Seventy-one patients completed surveys. Thirteen components were assessed and no item achieved a mean product greater than or equal to ten. The survey item with the highest mean product pertained to discussion of potential medication side effects (mean: 7.06; interquartile range: 5-10). Analysis of each survey item found that all survey items had multiple individual responses that provided a product score of greater than or equal to ten. The survey items most frequently listed in the overall population as being most valued were “Told you the name of each of your medicines and what they are used for”, “Answered your questions fully,” and “Explained what your medicines do”. Conclusions Educational components provided during pharmacist-managed clinic appointments are aligned with patients’ needs and are successfully incorporating the components that patients value highly in a patient-healthcare provider interaction. The HFMEA model can be an important teaching tool to identify specific processes in need of improvement and to help enhance pharmacists’ self-efficacy, which may further improve patient care.