Maqual R. Graham

A Clinical Comparison of Calculated versus Direct Measurement of Low-Density Lipoprotein Cholesterol Level

Study Objectives. To determine if, and to what extent, the low‐density lipoprotein cholesterol (LDL) level is underestimated when it is calculated by the Friedewald formula compared with the LDL level measured by a direct method. A secondary objective was to determine and compare the percentages of patients meeting LDL goal using each of these two methods.

Admission Variables Predictive of Academic Struggle in a PharmD Program

Objective. To characterize and describe admission variables predictive of poor grade attainment by students in 2 pathways to a doctor of pharmacy (PharmD) program. Methods. A retrospective analysis of course grades of PharmD students admitted from 2000 to 2009 (N= 1,019) in the traditional degree pathway (“1 plus 5” degree program) and the provisional pathway (admitted directly from high school) was performed. Results. Four hundred three grades of D or less were earned by 183 (18%) students. There were more grades of D or less in the first pharmacy year. Receipt of an unsatisfactory grade was associated with all Pharmacy College Admission Test (PCAT) subcategory scores, PCAT composite score, cumulative prepharmacy coursework hours, prepharmacy grade point average (GPA), prepharmacy science and math GPA, and interview score for accepted students in the traditional pathway. For students in the provisional pathway, PCAT-quantitative analysis, PCAT composite score, prepharmacy cumulative GPA, prepharmacy science and math GPA, English American College Testing (ACT) score, and composite ACT score predicted poor grades. Conclusion. Admissions committees should heed PCAT scores and GPAs, regardless of program pathway, while progression committees should focus on early program coursework when designing strategies to optimize retention.

Use of Online Modules to Enhance Knowledge and Skills Application During an Introductory Pharmacy Practice Experience

Objectives. To implement and assess the effectiveness of online instructional modules to increase the consistency of learning outcomes related to students’ patient-care practice knowledge and their skills application and confidence across introductory pharmacy practice experience (IPPE) sites. Design. Twenty online modules were created to provide uniform delivery of instructional content that complemented classroom instruction and to introduce students to common pharmacy-practice skills in the patient-care arena. Assessment. Quantitative data were collected by means of a survey and pre- and post-module quizzes, which were completed by students to assess knowledge. More than 85% of students applied the IPPE skills. During the course, students’ confidence increased significantly in all areas. For all but 1 of the 13 competencies, more than 70% of students agreed or strongly agreed that the competencies were met. Conclusions. Online instructional modules in patient care can effectively increase students’ knowledge, skills application, and confidence, and improve the consistency of achieving outcomes for instructional content and activities across diverse practice settings.

Adherence to Antihyperlipidemic Medication and Lipid Control in Diabetic Veterans Affairs Patients with Psychotic Disorders

BACKGROUND Medication adherence for chronic medical illnesses has been studied extensively, but there is limited data evaluating medication adherence for comorbid medical illnesses in a psychiatric population. Furthermore, only one study has evaluated both medication adherence and clinical outcomes between the two populations. Examining medication adherence rates and clinical outcomes are important as chronic medical illnesses occur commonly in psychiatric patients, can be drug-induced, and have negative long-term consequences. OBJECTIVES To compare antihyperlipidemic medication adherence and lipid control between individuals with psychotic disorders and those without a psychiatric illness. METHODS This was a retrospective medical record review of 124 subjects with hyperlipidemia and diabetes (62 subjects with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched individuals without a psychiatric illness) receiving medical and psychiatric care through the Veterans Affairs Medical Center during 2008. Cumulative mean gap ratio (CMGR) was used to determine adherence. Lipid values were utilized to compare lipid control between groups. RESULTS A significant difference in CMGR was detected. Subjects with psychotic disorders were without antihyperlipidemic therapy for 44 days compared with 62 days for the nonpsychiatric comparison group (P = 0.034). Antipsychotic adherent subjects (≥80% adherent) were more likely to adhere to their antihyperlipidemic medication (P = 0.0007). There were no significant differences between the groups for lipid control. CONCLUSION Antihyperlipidemic medication adherence differed with the psychotic disorder group having fewer days without drug therapy. However, there was no significant difference in lipid control between subjects with a psychotic disorder and those without a psychiatric illness.

Medication adherence and glycemic control in patients with psychotic disorders in the Veterans Affairs healthcare system

Objective To compare antihyperglycemic medication adherence and glycemic control between individuals with schizophrenia and related psychotic disorders and a nonpsychiatric comparison group. Methods This was a retrospective medical record review. A total of 124 subjects with diabetes (62 patients with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched patients without a psychiatric illness) receiving their medical and psychiatric care exclusively through the Kansas City Veterans Affairs healthcare system during 2008 were included in the study. Adherence to antihyperglycemic and antipsychotic medication was determined by refill records obtained through the computerized patient record system to calculate the cumulative mean gap ratio. Hemoglobin A1C values were utilized to compare glycemic control between groups and compared to glycemic goals established by diabetes treatment guidelines. Results Antihyperglycemic medication adherence was poor for both groups as approximately 60% of the psychotic disorder group and 75% of the nonpsychiatric comparison group were without antihyperglycemic medication for greater than 30 days during the 12-month period but adherence did not differ between the groups (p=0.182). Antipsychotic adherent subjects (≥80% adherent) were more likely to be adherent to their antihyperglycemic medication (p=0.0003). There were no significant differences between groups in glycemic control. Conclusions Antihyperglycemic medication adherence and glycemic control was less than optimal for both groups. There were no significant differences in antihyperglycemic medication adherence and glycemic control between patients with a psychotic disorder and those without a psychiatric illness.

Maintenance of Low-Density Lipoprotein Goal with Step-Down Pravastatin Therapy

Study Objective. To determine whether patients who had achieved their National Cholesterol Education Program (NCEP)‐derived goals for low‐density lipoprotein (LDL) cholesterol with pravastatin would benefit from step‐down therapy.

Characterization of Medication Discrepancies Occurring at the Time of Discharge From an Adult State Psychiatric Inpatient Facility

Purpose To retrospectively measure the frequency of medication discrepancies occurring at hospital discharge and to characterize these discrepancies. Methods All consecutive discharges from an adult state psychiatric hospital with a length of stay ≥2 days were retrospectively evaluated for medication discrepancies occurring at the time of discharge. The content of the handwritten discharge plan was compared to the medication administration record from the last day of admission to identify medication discharge discrepancies. The primary endpoint was to determine the number of patients with a medication discharge discrepancy (MDD). Secondary objectives were to characterize the MDD by type of discrepancy and medication class (psychiatric vs nonpsychiatric). Results From October 1, 2008 to December 31, 2008, 205 patients were screened for eligibility; 163 patients were included. Thirty-eight patients (23.3%) had at least 1 MDD, with 10 (26.3%) of these patients having >1 MDD (range, 2-6). Characterization of the MDDs determined that 63.2% of the discrepancies occurred because a scheduled medication was omitted on the discharge plan whereas 36.8% were due to a dosing discrepancy. MDDs occurred at a similar rate for both classes of medications (ie, psychiatric and nonpsychiatric), but omission discrepancies occurred more commonly with nonpsychiatric medications and dosing discrepancies occurred more commonly with psychiatric medications. Conclusions Medication discrepancies occur commonly on hospital discharge. Understanding the frequency and types of MDDs occurring at this interface of care can assist in the development of more effective and targeted medication reconciliation procedures.

Effectiveness of an Amiodarone Protocol and Management Clinic in Improving Adherence to Amiodarone Monitoring Guidelines

Objective: To determine whether adherence to suggested monitoring parameters improved as a result of the development and implementation of an amiodarone protocol and management clinic. Adverse effects from amiodarone therapy were also evaluated to ascertain whether the Amiodarone Management Clinic (AMC) better identified adverse events as a result of improved monitoring. Methods: A retrospective review of charts of patients with an active amiodarone prescription was conducted. Patients were identified as enrolled in the AMC (intervention) or as receiving standard medical care (control) by nonpharmacist practitioners. Compliance with recommended monitoring parameters, including the presence of interacting medications and associated drug concentration or international normalized ratio (INR), was assessed for all patients and then compared between groups. Type and frequency of adverse effects were determined for both groups. Results: Two hundred twenty-five charts were reviewed; 154 and 71 patients were assigned to the intervention and control groups, respectively. One hundred one (66%) patients in the intervention group were considered compliant with thyroid function monitoring compared with 26 patients (37%) in the control group (p < 0.0001). One hundred six (69%) and 27 (38%) patients in the intervention and control groups, respectively, were deemed compliant with liver function monitoring (p < 0.0001). Intervention patients taking warfarin were more likely to have blood drawn for INR assessment; however, there was no difference in values between groups. Seventy-six patients had a documented adverse effect from amiodarone, 68 of whom were from the intervention group (p < 0.0001). Conclusions: Many patients receiving amiodarone are not managed according to published guidelines. Implementation of a pharmacist-managed protocol and clinic significantly improved compliance with 2 of the 3 parameters needing continuous monitoring. Although more adverse effects were documented for intervention patients, it is unclear whether the AMC actually improved the event detection rate.

A Comparison of Orlistat Use in a Veteran Population: A Pharmacist-Managed Pharmacotherapy Weight-Loss Clinic versus Standard Medical Care

Objective: To determine whether a pharmacist-managed pharmacotherapy weight-loss clinic using orlistat is beneficial in promoting weight loss and reducing cardiovascular risk. Methods: A retrospective review of the records of all veterans receiving orlistat was conducted. Patients were assigned to 1 of 2 treatment groups: those enrolled in the pharmacist-managed pharmacotherapy weight-loss clinic (intervention) or those receiving standard medical care (control). Changes in weight and body mass index (BMI) at 6 months were compared with baseline measures. Treatment success, defined as a weight loss of ≥5% of initial body weight, was determined. The impact of weight loss on cardiovascular risk factor reduction was compared within each group. The prevalence of adverse drug reactions was also assessed and compared. Results: Forty-seven patients were included in the analysis: 18 and 29 in the intervention and control groups, respectively. Intervention patients lost a mean ± SD of 5.0 ± 6.0 kg by 6 months compared with 2.2 ± 4.7 kg for the controls (p = 0.109). BMI significantly decreased for all patients independent of group assignment (intervention, p = 0.006; control, p = 0.026), yet a between-group comparison revealed no difference (p = 0.140). Five patients (28%) in the intervention group were considered treatment successes versus 4 (14%) in the control group; however, this was not a significant difference (p = 0.274). Total cholesterol and glycosylated hemoglobin were significantly decreased in intervention patients, while control patients demonstrated significant improvement only in total cholesterol. There was no difference in adverse reaction occurrence between groups (p = 0.995). Conclusions: Patients enrolled in the pharmacist-managed pharmacotherapy weight-loss clinic lost twice as much weight, and twice as many were considered treatment successes compared with control patients. Intervention patients demonstrated improvement in several cardiovascular risk factors.

Evaluation of a Pharmacist-Managed Anticoagulation Clinic

Background Anticoagulation therapy is important in the prevention and treatment of cardioembolic events. Warfarin is frequently used but requires continual monitoring to ensure safety and efficacy. The target time in therapeutic range (TTR) is not always achieved. Objectives The objectives for this study were to determine the TTR for a pharmacist-managed anticoagulation clinic and identify reasons for sub- and supratherapeutic international normalized ratio (INR) values. Methods Medical records for subjects prescribed warfarin were reviewed. Demographic and relevant clinical information was assessed. INR measurements were extracted for subjects enrolled. The TTR was calculated, and the cause for sub- or supratherapeutic values was determined when possible. Results One hundred twenty-six subjects were included in this retrospective study. The calculated TTR was 51%. The cause for more than 65% of the sub- and supratherapeutic INR values could not be determined. One subject incurred a clot and 6 subjects suffered a bleed. No deaths occurred. Age was the only factor that correlated with a supratherapeutic INR value (r = −0.179, P = .045). Conclusion Pharmacists in the anticoagulation clinic are effectively managing patients who are taking warfarin by frequently maintaining INR values near or within the recommended therapeutic range. Very few negative outcomes occurred during the time of study.