Kimberly M. Crosby

Evaluation of a hypertension medication therapy management program in patients with diabetes.

OBJECTIVE To evaluate the effect of a 9-month community pharmacy-based medication therapy management (MTM) program on quality of care in patients with diabetes and hypertension. DESIGN Randomized controlled trial. SETTING Tulsa, OK, between November 2005 and July 2007. PATIENTS 52 patients with diabetes and hypertension who were enrolled in a managed care organization. INTERVENTION During monthly visits, intervention group participants received MTM services for hypertension and diabetes management. MAIN OUTCOME MEASURES Systolic blood pressure (SBP), percentage at goal blood pressure (<130/80 mm Hg), and antihypertensive medication adherence. RESULTS The mean intervention group SBP decreased 17.32 mm Hg, whereas the mean control group SBP level increased 2.73 mm Hg (P = 0.003). The percentage of patients at goal blood pressure increased from 16.0% to 48.0% in the intervention group and decreased from 20.0% to 6.67% in the control group. Intervention group participants were 12.92 times more likely than control group participants to achieve goal blood pressure (P = 0.021). Although the mean adherence rate in the intervention group increased 7.0% while remaining fairly constant in the control group (-0.7%), this group difference was not statistically significant. CONCLUSION A community pharmacy-based hypertension MTM program was effective in improving blood pressure control among managed care enrollees with diabetes and hypertension. Community pharmacists are strategically positioned to provide MTM services and effectively communicate with providers to improve quality of care for patients.

Cardiovascular disease and non-steroidal anti-inflammatory drug prescribing in the midst of evolving guidelines.

RATIONALE, AIMS AND OBJECTIVES Responding to safety concerns, the American Heart Association (AHA) published guidelines for non-steroidal anti-inflammatory drug (NSAID) use in patients with pre-existing cardiovascular disease (CVD) during 2005 and revised them in 2007. In the revision, a stepped approach to pain management recommended non-selective NSAIDs over highly selective NSAIDs. This research evaluated NSAID prescribing during and after guideline dissemination. METHOD A cross-sectional sample of 8666 adult, community-based practice visits with one NSAID prescription representing approximately 305 million visits from the National Ambulatory Medical Care Survey (NAMCS) from 2005 to 2010 was studied. Multivariable logistic regression controlling for patient, provider and visit characteristics assessed the associations between diagnosis of CVD and NSAID type prescribed during each calendar year. Visits were stratified by arthritis diagnosis to model short-term/intermittent and long-term NSAID use. RESULTS Approximately one-third (36.8%) of visits involving a NSAID prescription included at least one of four diagnoses for CVD (i.e. hypertension, congestive heart failure, ischaemic heart disease or cerebrovascular disease). Visits involving a CVD diagnosis had increased odds of a prescription for celecoxib, a highly selective NSAIDs, overall [adjusted odds ratio (AOR) = 1.29, 95% confidence interval (CI): 1.06-1.57] and in the subgroup of visits without an arthritis diagnosis (AOR = 1.45, 95% CI: 1.11-1.89). Results were not statistically significant for visits with an arthritis diagnosis (AOR = 1.10, 95% CI: 0.47-2.57). When analysed by year, the relationship was statistically significant in 2005 and 2006, but not statistically significant in each subsequent year. CONCLUSION National prescribing trends suggest partial implementation of AHA guidelines for NSAID prescribing in CVD from 2005 to 2010.

Evaluation of a diabetes management program using selected HEDIS measures

OBJECTIVE To evaluate the efficacy of a community-based, pharmacist-directed diabetes management program among managed care organization enrollees using National Committee for Quality Assurance (NCQA)-Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. DESIGN Randomized controlled trial. SETTING Regional community pharmacy chain in Tulsa, OK, from November 2005 to July 2007. PATIENTS 52 participants with diabetes and hypertension who were enrolled in a managed care organization. INTERVENTION Diabetes management versus standard care. MAIN OUTCOME MEASURES Comprehensive diabetes care measures of glycosylated hemoglobin (A1C <7.0%), blood pressure (<130/80 mm Hg), and low-density lipoprotein (LDL) cholesterol (<100 mg/dL). A composite research outcome of success was created by determining whether a participant achieved two of the three HEDIS goals at the end of 9 months. RESULTS 46.7% of intervention group participants achieved the A1C goal, while 9.1% of control group participants achieved the goal ( P < 0.002). More than one-half (53.3%) of intervention participants achieved the blood pressure goal compared with 22.7% of control participants ( P < 0.02). Among control group participants, 50% achieved the LDL cholesterol goal compared with 46.67% of intervention group participants. The odds of the intervention group attaining the composite goal were 5.87 times greater than the control group. CONCLUSION A community pharmacy-based diabetes management program was effective in achieving A1C and blood pressure goals measured by NCQA-HEDIS performance standards. Program participants were statistically significantly more likely to achieve two of three HEDIS standards during a 9-month period.

Impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic

OBJECTIVES To determine the rate of prescribing errors in a family medicine clinic and the subsequent impact of pharmacist-led educational and error notification interventions on prescribing errors. DESIGN Single site, pre-post study design. SETTING An outpatient academic family medicine clinic serving pediatric and adult populations in Oklahoma from March 1, 2011, through April 30, 2012. PARTICIPANTS 24 resident physicians who prescribed medications during routine outpatient visits. INTERVENTION A prescribing educational program, audit and feedback methods, and weekly newsletter. MAIN OUTCOMES MEASURE Percentage of prescription errors and physician error rate before and after intervention among pediatric and adult populations. RESULTS During the two assessment periods, 24 resident physicians wrote 2,753 prescriptions for 394 pediatric and 899 adult patients. The overall percentage of prescription errors decreased from 18.6% during March 2011 to 14.5% during April 2012 (P = 0.004). Errors were more commonly seen with prescriptions written for pediatric patients (24.9%) than for adult patients (13.9%) (P = 0.001). Individual physician error rates ranged from 5% to 36% (mean ± SD 16.5% ± 8.1). Physicians committed significantly fewer prescribing errors during the postintervention assessment period (14.9%) than during the preintervention assessment period (20.9%) (P = 0.002). Controlling for time, pediatric prescription error rates among physicians who participated in the educational intervention were 36% lower than the error rates among physicians who did not participate (rate ratio 0.64 [95% CI 0.45, 0.91], P = 0.01). CONCLUSION The pharmacist-led educational program was effective in reducing pediatric prescribing errors among resident physicians in a family medicine clinic.

Consequences of Undocumented Medication Use

Obtaining complete medication histories is imperative to treating patients effectively and avoiding unintended medication consequences. Health care providers (HCPs) receive training and learn skills to help elicit complete medical information, including but not limited to medication use, but the system falls short in some instances (1,2). In these instances, undocumented medication use can complicate patients’ treatment. Examples encompass confounding of the differential diagnosis and unforeseen medication interactions. The potential for unintended medication consequences can be increased by omissions in reporting usage of herbal, homeopathic, or over-the-counter (OTC) treatments. Although warnings about the risks of self-medicating, such as possible variability of medication effects from one person to another, date back for decades, this practice has become increasingly common (3,4). Self-medication through the use of old prescriptions or OTC products has the potential to pose problems, but self-medication via prescription sharing with other individuals—often family members or friends—is especially problematic. This practice can be dangerous because it can remain undetected for long periods of time and may be accompanied by a wide range of effects. Prescription medications are intended to be used under the supervision of licensed HCPs. The sharing of prescription medications among individuals removes pharmacists and other HCPs from the medication use process, resulting in the loss of education and instruction regarding the safe use of medications and increasing the potential for adverse effects (5,6). A survey distributed to patients in community pharmacies in New Zealand showed that, among prescription sharers, about half of prescription borrowers received written instructions with the medication, and about half of prescription lenders gave verbal instructions with the medication (7). That leaves many individuals with no instructions at all, and those who do receive instructions cannot be certain that they have received correct information because the source is not …