Mark L. Britton

A Review of Pharmacist Contributions to Diabetes Care in the United States

This paper summarizes the outcomes associated with pharmacist involvement in diabetes care in all pharmacy practice settings. Published literature was identified through a search of MEDLINE (1960 to September, week 1, 2008) and International Pharmaceutical Abstracts using the search terms “pharmacist,” “pharmaceutical care,” and “diabetes mellitus.” Only articles reporting clinical or behavior change outcomes were selected for review; papers written outside the United States and citations only in abstract form were not reviewed. The specific data extracted included the following: practice setting, model of care, roles of the pharmacist, study design, number of patients studied, duration of the evaluation, and documented outcomes such as changes in hemoglobin A1c values, adherence to standards of care (lipids, blood pressure, eye exams, foot exams, aspirin use), and changes in quality of life. The greatest improvements in hemoglobin A1c values tend to be observed when pharmacists work in collaborative practice models. Growing evidence demonstrates that pharmacists, working as educators, consultants, or clinicians in partnership with other health care professionals, are able to contribute to improved patient outcomes.

Identification of barriers to appropriate dietary behavior in low-income patients with type 2 diabetes mellitus.

ObjectiveTo identify barriers to appropriate dietary behavior in an urban, low-income population of patients with type 2 diabetes and to examine a new instrument in the identification of these barriers in this population.MethodsA cross-sectional survey was developed, validated, and anonymously administered to low-income adults with type 2 diabetes in an academic family medicine physician group practice with a pharmacist-operated diabetes education and comanagement service. The survey consisted of three key subscales: determinants of food selection, importance of life challenges, and barriers to appropriate eating.ResultsThe survey was administered to 98 patients with a mean age of 51.98 years, a mean duration of diabetes of 9.76 years, and a mean hemoglobin A1c of 7.99%. When asked to rate factors most important in food selection, the highest mean responses were taste (3.97 out of 5) and cost (score of 3.94 out of 5). Barriers that the majority of respondents agreed or strongly agreed were important included: stress causing over-eating or unhealthy food choices, difficulty resisting the temptation to eat unhealthy food, and healthy food being too expensive. The Cronbach’s Alpha for the subscales of food selection, importance of life challenges, and barrier were 0.673, 0.853, and 0.786, respectively.ConclusionsIn a low-income, urban, predominantly African American and Caucasian diabetic population, cost of healthy food, stress-related inappropriate eating, and the temptation to eat unhealthy food were the most frequently reported barriers to healthy eating. Diabetes education programs serving similar populations should evaluate the presence of these barriers. The survey instrument was a reliable measure of the constructs it purported to measure.

The Use of Alternate-Day Lovastatin in Hypercholesterolemic Men

OBJECTIVE: To quantitate the therapeutic effects of alternate-day lovastatin on serum lipoprotein values in a small group of men with primary hypercholesterolemia. DESIGN: Retrospective review of medical, pharmacy, and laboratory records. A paired Students t-test was performed on absolute changes in lipoprotein values with an a priori p value less than or equal to 0.05 being statistically significant. SETTING: A lipid clinic within a tertiary care Department of Veterans Affairs Medical Center. PATIENTS: Twenty men (mean age 62.5 ± 8.3 y) with mean ± SD baseline low-density lipoprotein cholesterol (LDL-C) concentration of 161.3 ± 21.9 mg/dL and triglyceride concentrations below 400 mg/dL. INTERVENTION: All patients had been prescribed lovastatin 20 mg every other day. MAIN OUTCOME MEASURES: The mean absolute and percent changes in lipoprotein values from baseline for patients receiving lovastatin 20 mg every other day and the percentage of patients attaining a target mean LDL-C concentration as defined by the National Cholesterol Education Panel Adult Treatment Panel II guidelines. RESULTS: Mean ± SD total cholesterol and LDL-C were significantly reduced by 32.4 ± 17.8 (14.0% ± 7.8%) and 34.1 ± 14.6 mg/dL (21.5% ± 9.7%), respectively. No significant changes were seen in high- density lipoprotein cholesterol or triglycerides. Four of 20 patients (20%) attained a goal LDL-C concentration. CONCLUSIONS: Lovastatin 20 mg every other day may effectively lower LDL-C in some elderly men, and target LDL-C concentrations may be obtained in some patients.

Assessing the need for diabetes self-management education in the Oklahoma city vietnamese community

IntroductionTo assess the diabetes self-management educational (DSME) needs of the Vietnamese diabetic population in the Oklahoma City metropolitan area.MethodsParticipants in this explorative study included 50 Vietnamese adults with type 1 or type 2 diabetes recruited from the offices of four primary care physicians in the Oklahoma City metropolitan area. Participants completed a culturally sensitive survey focused on their diabetes history, knowledge and need of DSME, and health beliefs. Responses were evaluated using means and frequency analysis.ResultsThe mean age of participants was 62.7±9.1 years. Over 80% of participants were most comfortable speaking and reading Vietnamese, and 62% had never received a high school diploma. Less than 50% of participants reported ever receiving education regarding diabetic complications, nutrition, desirable glycated hemoglobin values, diabetic medications, daily self-care, risk of smoking, or cardiovascular risk associated with diabetes. More than 80% of participants requested more education in all areas of DSME except smoking risk in diabetes, with all participants requesting delivery of this education in Vietnamese.ConclusionDSME is needed and desired in the Vietnamese community of the Oklahoma City metropolitan area. Education should be provided in the Vietnamese language with most targeted to lower literacy levels. Vietnamese diabetes educators should facilitate increased access to DSME knowledge and skills in efforts to improve glycemic control and overall health status for this community.

Practice Experiences at a Single Institutional Practice Site to Improve Advanced Pharmacy Practice Examination Performance

Objective. To determine whether sequential assignment of students to the same facility for institutional practice experiences improves their advanced pharmacy practice experience (APPE) examination scores. Design. Student volunteers were assigned to the same healthcare facility for all institutional introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs). Other students completed institutional IPPEs and APPEs at separate healthcare facilities, ranging from 2 to 4 different facilities per student. APPE examination scores of students assigned to the same facility for all institutional learning experiences were compared with those of students assigned to more than 1 institutional practice site. Assessment. Holding grade point average constant, students assigned to the same facility for institutional IPPEs and APPEs scored 3 percentage points higher on the APPE institutional examination compared with students assigned to separate facilities for these experiences. Conclusion. Assigning students to the same facility for both institutional IPPEs and APPEs positively influenced knowledge-based APPE examination performance.

Assessment of Streams of Knowledge, Skill, and Attitude Development Across the Doctor of Pharmacy Curriculum

Objective. To continue efforts of quality assurance following a 5-year curricular mapping and course peer review process, 18 topics (“streams”) of knowledge, skills, and attitudes were assessed across the doctor of pharmacy (PharmD) curriculum. Design. The curriculum committee merged the 18 topics into 9 streams. Nine ad hoc committees (“stream teams”) of faculty members and preceptors evaluated the content, integration, and assessment for their assigned streams across the 4 professional years. Committees used a reporting tool and curriculum database to complete their reviews. Assessment. After each team presented their findings and recommendations at a faculty retreat, the 45 faculty members were asked to list their top priorities for curriculum improvement. The 5 top priorities identified were: redefinition and clarification of program outcomes; improved coordination of streams across the curriculum; consistent repetition and assessment of math skills throughout the curriculum; focused nonprescription and self-care teaching into an individual course; and improved development of problem solving. Conclusions. This comprehensive assessment enabled the college to identify areas for curriculum improvement that were not readily apparent to the faculty from prior reviews of individual courses.

Incremental Development of an Integrated Assessment Method for the Professional Curriculum

Objective. To incrementally create and embed biannual integrated knowledge and skills examinations into final examinations of the pharmacy practice courses offered in the first 3 years of the pharmacy curriculum that would account for 10% of each course’s final course grade. Design. An ad hoc integrated examination committee was formed and tasked with addressing 4 key questions. Integrated examination committees for the first, second, and third years of the curriculum were established and tasked with identifying the most pertinent skills and knowledge-based content from each required course in the curriculum, developing measurable objectives addressing the pertinent content, and creating or revising multiple-choice and performance-based questions derived from integrated examination objectives. An Integrated Examination Review Committee evaluated all test questions, objectives, and student performance on each question, and revised the objectives and questions as needed for the following year’s iteration. Eight performance objectives for the examinations were measured. Assessment. All 8 performance objectives were achieved. Sixty-four percent of the college’s faculty members participated in the integrated examination process, improving the quality of the examination. The incremental development and implementation of the examinations over a 3-year period minimized the burden on faculty time while engaging them in the process. Student understanding of expectations for knowledge and skill retention in the curriculum also improved. Conclusions. Development of biannual integrated examinations in the first 3 years of the classroom curriculum enhanced the college’s culture of assessment and addressed accreditation guidelines for formative and summative assessment of students’ knowledge and skills. The course will continue to be refined each year.

A Progressive, Collaborative Process to Improve a Curriculum and Define an Assessment Program

Objective. To revise the University of Oklahoma College of Pharmacy’s professional program outcomes and create an assessment map using results from previous peer review and mapping of all professional courses and curricular streams of knowledge, skills, and attitudes (KSAs). Design. After consolidating 15 original program outcomes into 11 more precise outcome statements, defining KSAs for each, and getting faculty approval of them, the committee detailed measurable program expectations upon graduation for each outcome and created an assessment map identifying where KSAs were taught, how they were to be assessed, and the expected ability level (novice, competent, proficient) for each across the curriculum. Assessment. The committee’s work identified deficits, inconsistencies, and disproportionalities in professional program assessment. It recommended assessments to capture student achievement of each outcome, identified performance levels and criteria to measure outcomes progressively in each professional year, and outlined a process to provide students periodic reports on their progress in achieving each outcome. Conclusion. This work establishes a firm foundation for ongoing efforts to measure effectiveness of the professional program, especially in light of Accreditation Council for Pharmacy Education’s (ACPE) revised accreditation standards.

Nafarelin Acetate: A Gonadotropin-Releasing Hormone Agonist for the Treatment of Endometriosis

Nafarelin acetate is a gonadotropin-releasing hormone (GnRH) agonist proven as effective as danazol in treating endometriosis. Its proposed mechanism of action is the desensitization of pituitary GnRH receptors leading to a decrease in gonadotropin release, and ovarian hormone serum concentrations similar to those achieved in postmenopausal women. Nafarelin decreases or ablates the physical symptoms associated with endometriosis, and pregnancy rates following therapy with this drug are comparable to rates observed after danazol therapy. Nafarelin is administered by nasal inhalation and has been generally well tolerated. It is associated with a high incidence of adverse effects but they are rarely severe enough to cause withdrawal from treatment, and those occurring most frequently—hot flashes, vaginal dryness, and decreased libido—are a consequence of the hypoestrogenemia induced by the drug. Increased bone turnover occurs in women on nafarelin but biochemical parameters return to pretreatment concentrations by six months after termination of treatment. This agents place in the therapy of endometriosis will be determined as clinical experience accumulates.