Debra J. Barnette

Evaluation of hypertensive patients after care provided by community pharmacists in a rural setting.

We evaluated blood pressure control, quality of life, quality of care, and satisfaction of patients who were monitored by specially trained community pharmacists in a group medical practice. After participating in an intensive skill development program, pharmacists performed in an interdisciplinary team in a rural clinic. The primary objective was assessed by evaluating outcome variables at 6 months compared with baseline in 25 patients randomly assigned to a study group. A control group of 26 patients was also evaluated to determine if outcome variables remained constant from baseline to 6 months. Systolic blood pressure was reduced in the study group (151 mm Hg baseline, 140 mm Hg at 6 mo, p<0.001) and diastolic blood pressure was significantly lower at 2, 4, and 5 months compared with baseline. Ratings from a blinded peer review panel indicated significant improvement in the appropriateness of the blood pressure regimen, going from 8.7 ± 4.7 to 10.9 ± 4.5 in the study group (p<0.01), but they did not change in the control group. Several quality of life scores improved significantly in the study group after 6 months (p<0.05). These included physical functioning (61.6 vs 70.7), physical role limitations (56.8 vs 72.8), and bodily pain (60.0 vs 71.7) at baseline and 6 months, respectively. There were no significant changes in the control group. Patient satisfaction scores were consistently higher in the study group at the end of the study. Our results indicate that when community pharmacists in a clinic setting are trained and included as members of the primary care team, significant improvements in blood pressure control, quality of life, and patient satisfaction can be achieved.

Clinical and Economic Impact of Ambulatory Care Clinical Pharmacists in Management of Dyslipidemia in Older Adults: The IMPROVE Study

We examined the impact of ambulatory care clinical pharmacist interventions on clinical and economic outcomes of 208 patients with dyslipidemia and 229 controls treated at nine Veterans Affairs medical centers. This was a randomized, controlled trial involving patients at high risk of drug‐related problems. Only those with dyslipidemia are reported here. In addition to usual medical care, clinical pharmacists were responsible for providing pharmaceutical care for patients in the intervention group. The control group did not receive pharmaceutical care. Seventy‐two percent of the intervention group and 70% of controls required secondary prevention according to the National Cholesterol Education Program guidelines. Significantly more patients in the intervention group had a fasting lipid profile compared with controls (p=0.021). The absolute change in total cholesterol (17.7 vs 7.4 mg/dl, p=0.028) and low‐density lipoprotein (23.4 vs 12.8 mg/dl, p=0.042) was greater in the intervention than in the control group. There were no differences in patients achieving goal lipid values or in overall costs despite increased visits to pharmacists. Ambulatory care clinical pharmacists can significantly improve dyslipidemia in a practice setting designed to manage many medical and drug‐related problems.

An economic analysis of a randomized, controlled, multicenter study of clinical pharmacist interventions for high-risk veterans: The IMPROVE study

Study Objective. To determine if clinical pharmacists could affect economic resource use and humanistic outcomes in an ambulatory, high‐risk population.

Can clinical pharmacists affect SF-36 scores in veterans at high risk for medication-related problems?

Background.An objective of pharmaceutical care is for pharmacists to improve patients’ health-related quality of life (HRQOL) by optimizing medication therapy. Objectives.The objective of this study was to determine whether ambulatory care clinical pharmacists could affect HRQOL in veterans who were likely to experience a drug-related problem. Research Design. This was a 9-site, randomized, controlled trial involving Veterans Affairs Medical Centers (VAMCs). Patients were eligible if they met ≥3 criteria for being at high risk for drug-related problems. Enrolled patients were randomized to either usual medical care or usual medical care plus clinical pharmacist interventions. HRQOL was measured with the SF-36 questionnaire administered at baseline and at 6 and 12 months. Results.In total, 1,054 patients were enrolled; 523 were randomized to intervention, and 531 to control. After patient age, site, and chronic disease score were controlled for, the only domain that was significantly different between groups over time was the bodily pain scale, which converged to similar values at the end of the study. Patients’ rating of the change in health status in the past 12 months was statistically different between groups, intervention patients declining less (−2.4 units) than control subjects (−6.3 units) (P <0.004). This difference was not considered clinically meaningful. However, a dose-response relationship was observed for general health perceptions (P = 0.004), vitality (P = 0.006), and change in health over the past year (P = 0.007). Conclusions.These results suggest that clinical pharmacists had no significant impact on HRQOL as measured by the SF-36 for veterans at high risk for medication-related problems.

Postabsorption Concentration Peaks with Brand‐Name and Generic Verapamil: A Double‐Blind, Crossover Study in Elderly Hypertensive Patients

The pharmacokinetic actions, bioequivalence, and cardiovascular effects of two verapamil products were studied in a randomized, double‐blind, crossover study in eight elderly hypertensive patients (median age, 69.5 years; range, 60–79 years) given brand‐name or generic immediate‐release verapamil in 120‐mg twice‐daily doses for 14 days. Blood pressures, heart rates, P—R intervals, and serum concentrations of R‐/S‐verapamil and norverapamil were measured multiple times in patients during the last day of each therapy. Median blood pressure decreased more with generic verapamil than with the brand‐name drug, with the largest difference occurring at 0.5 hours (137/74 mmHg versus 144.5/80.5 mmHg; P = 0.05 and 0.091, respectively). Pharmacokinetic parameters were not different for the two products (P < 0.10). However, the generic product, compared with the brand‐name drug, had mean area under the concentration—time curve (time 0 to 12 hours) ratios (90% CI) of 1.09 (0.78–1.52), 1.16 (0.87–1.55) and 1.11 (0.81–1.52) for R‐, S‐, and total verapamil. Seventy concentration peaks (31 with the brand‐name drug, 39 with the generic drug) appeared between 8 and 24 hours. Median percentages of increase of these peaks, compared with those of previous concentrations, were 48.3% and 36.3% for brand‐name and generic drugs, respectively. Fifty of the 70 peaks (71%) were associated with a stereospecific concentration peak of norverapamil and, temporally, with meals. Our findings suggest that whereas the two verapamil products may not be bioequivalent by Food and Drug Administration criteria, the observed differences in effects were not clinically significant in this elderly population. Multiple concentration peaks after absorption were observed in all patients with both verapamil products and were perhaps related to enterohepatic recirculation.

Short-term outcomes of an employer-sponsored diabetes management program at an ambulatory care pharmacy clinic

PURPOSE The impact of a collaborative, employer-sponsored diabetes management program on glycemic control and other clinical endpoints over 6-12 months is reported. METHODS In a retrospective, chart-based evaluation, glycosylated hemoglobin (HbA(1c)) and related health status indicators were assessed among first-year enrollees in the Healthy Outcome Partnership for Employees (HOPE) with Diabetes Program, an ongoing program sponsored by the Wake Forest Baptist Health (WFBH) system. Diabetes management services were provided by pharmacists in collaboration with providers inside and outside the WFBH system. The primary endpoint was the mean change in HbA(1c) during follow-up averaging 8.2 months; secondary endpoints included changes in blood pressure, cholesterol, and triglyceride levels. RESULTS Among the 98 patients included in the data analysis (75.5% women, 72.4% Caucasian), the mean HbA(1c) value decreased significantly during the study period (from 7.8% to 7.1%, p < 0.01); the proportion of patients at the recommended goal of an HbA(1c) of ≤7.0% rose from 40.8% to 56.1% (p < 0.01). HOPE Program enrollees also experienced significant improvements in mean triglyceride, total cholesterol, and blood pressure values (p < 0.05 for all). A subgroup of patients with initially poor glycemic control (HbA(1c) of ≥8.0%) had a mean HbA(1c) reduction of 1.7 percentage points during the study (p < 0.01), suggesting that the greatest benefits occurred in the highest-risk patients. CONCLUSION Among patients seen for at least six months at an employer-sponsored ambulatory care diabetes clinic managed by pharmacists, significant improvements from baseline in clinical end-points including HbA(1c) and blood pressure were demonstrated.