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PubMed2005

Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of case management by a clinical pharmacist on glycemic control and preventive measures in patients with type 2 diabetes mellitus. STUDY DESIGN: Randomized controlled trial in a university-affiliated primary care internal medicine clinic. METHODS: We recruited 80 patients with poorly controlled type 2 diabetes mellitus. A clinical pharmacist provided evaluation and modification of pharmacotherapy, self-management diabetes education, and reinforcement of diabetes complications screening processes through clinic visits and telephone follow-up. The main clinical outcome was hemoglobin A1C (HbA1C) level; process measures included HbA1C and low-density lipoprotein measurement, retinal examination, urine microalbumin testing (or use of angiotensin-converting enzyme inhibitors), and monofilament screening for diabetic neuropathy. RESULTS: Patients in the intervention and control groups were similar in age, sex, mean HbA1C levels (10.1% and 10.2%, respectively; P = .65), and current treatment regimens at baseline. Patients who received case management by the clinical pharmacist achieved greater reduction in HbA1C levels than those in the control group (2.1% vs 0.9%, P = .03). Three of the 5 process measures were conducted more frequently in the intervention group than the control group, including low-density lipoprotein measurement (100.0% vs 85.7%, P = .02), retinal examination (97.3% vs 74.3%), and monofilament foot screening (92.3% vs 62.9%). CONCLUSIONS: Proactive diabetes case management by a pharmacist substantially improved glycemic control and diabetes process-of-care measures. This approach, integrated with and based in the primary care setting, was an effective and efficient approach to improving care, especially for those with poor glycemic control at baseline.

Blood Glucose↗

PubMed2005

Pharmacists and prescribing rights: review of international developments.

PURPOSE: Continuity of care, equitable access, and quality and safety are major foci in health services management. The introduction of limited prescribing rights to pharmacists has the potential to reduce fragmentation within the health system, optimise medication management, improve continuity of patient care and improve patient access to medication. RESULTS: Eight models for pharmacists' prescribing have been implemented internationally, varying in their dependency on protocols, formularies and collaboration with physicians. These have also been described using terms such as Supplementary Prescribing and Patient Group Directions. CONCLUSION: Issues relating to practical implementation of pharmacists' prescribing include negotiation of national health policy, pharmacists' training and accreditation, liability, reimbursement and documentation.

Drug Prescriptions↗

PubMed2005

Effect of diabetes drug counseling by pharmacist, diabetic disease booklet and special medication containers on glycemic control of type 2 diabetes mellitus: a randomized controlled trial.

BACKGROUND: type 2 diabetes mellitus continues to increase in prevalence worldwide. Many factors have been cited as contributing to compliance, such as family and social support, education, number of tablets per dose, frequency of administration and health care provider communication. Toward these goals, the present study was developed to measure the effect offactors on glycemic control such as diabetes education by pharmacists, a diabetes disease booklet and special medication containers. MATERIAL AND METHOD: A total of 360 volunteers with type 2 DM patients were recruited, participants were simple randomized to control 180 and intervention 180 patients. Which intervention categorized to 4 groups; all intervention groups received diabetes drug counseling by a pharmacist, one group received plus a diabetes booklet, one received plus special medical containers and the last group received all of them. The interventions were done at the 1st time of visit. Both the control and intervention groups were monitored for fasting plasma glucose and HbA1c at 0, 3, 6 months and glycemic level in both groups was compared. RESULTS: After 3 months, mean fasting plasma glucose and HbA1c decreased wiih the intervention group vs. control group (152.36 +/- 39.73 to 131.52 +/- 35.22 mg%) and (150.16 +/- 41.78 to 153.98 +/- 47.95 mg%) respectively; (p < 0.001). HbA1c level 8.16 +/- 1.44 to 7.72 +/- 1.26 vs 8.01 +/- 1.51 to 8.38 +/- 1.46 respectively; (p < 0.001). After 6 months, mean fasting plasma glucose and HbA1c decreased with the intervention group vs. control group (152.36 +/- 39.73 to 145.20 +/- 46.07 mg%) and (150.16 +/- 41.78 to 159.16 +/- 54.90 mg%) respectively; (p < 0.013). HbA1c level 8.16 +/- 1.44 to 7.91 +/- 1.27 vs. 8.01 +/- 1.51 to 8.80 +/- 1.36 respectively; (p < 0.001). The most favorable glycemic outcome was the group that received all of the interventions; mean FPG was reduced from 147.46 +/- 36.07 to 125.38 +/- 31.12 mg% (p < 0.000) in 1nd visit (3 months later) and still reducing effect on the 2nd visit (6 month later) mean FPG from 147.46 +/- 36.07 to 130.21 +/- 33.96 mg% (p < 0.016) also the same way in HbA 1c level. The group that received only drug counseling by pharmacist had no significant reduction in FPG and HbA1c. (p > 0.05). CONCLUSION: Drug counseling by a pharmacist has little beneficial effect on diabetes management outcome compared to the diabetes booklet and special drug container. To improve glycemic control of type 2 DM is to integrate self-management in daily life, wide a variety of education, drug taken behavior and health care provider available communication produce improvement in patient management and is somewhat better when used in combination.

Adult↗

PubMed2006

[The role of the pharmacist in patient education].

Interdisciplinary programs promoting therapeutic education rarely involve the pharmacist, though his major contribution in the health care system and his multiple competencies are of a big help towards patients treatment adherence. As a regular patients confident, specially for those who require a long term treatment, the pharmacist deserves a better acknowledgment for his therapeutic reinforcement's contribution. A research work has been done in the field of therapeutic education to inscribe pharmacist's engagement in this topic. Instruments have been worked out to measure and to estimate relevant competencies used by pharmacists when answering patients needs. More open minded discussions and better rearrangement in the pharmacy in order to respect patients intimacy would contribute to enhance his competencies which are largely appreciated by the public.

Humans↗

PubMed1991

Alternative work schedules for female pharmacists.

The impact of the increased proportion of women in pharmacy is discussed, and two leadership positions for which part-time work schedules were implemented are described. Issues associated with the increased representation of women include pharmacist shortages, loss of future leaders, decreased staff productivity related to inadequate day-care services, and a reduced earning potential of pharmacists. Many of these problems can be addressed by altering benefit packages and work schedules to enable employees to raise children while continuing to work. Specific strategies include legislation, day-care programs, flex time and flex scheduling, telecommuting, and the creation of alternative work schedules or permanent part-time positions. At the University of Michigan, a part-time position that combines faculty and clinical responsibilities has been in place since 1988. At The Washington Hospital Center, one of the three assistant director of pharmacy positions is part-time. The women in both positions have met or exceeded job performance requirements while raising a family. Issues raised by the increasing number of female pharmacists must be addressed by the profession. Part-time work schedules are one strategy for enabling female pharmacists to meet both their family and career responsibilities.

District of Columbia↗

PubMed1990

The pharmacist's role in thrombolytic therapy.

The pharmacist's role in the administration, appropriate use, and evaluation of thrombolytic agents is discussed. Thrombolytic drugs have been shown to be efficacious when given early in the development of an acute myocardial infarction (AMI). If the drug is to be reconstituted in a central area, there must be immediate response from the pharmacy. If reconstitution is not the pharmacist's responsibility, the pharmacist should still play a role in establishing guidelines for patient selection, drug reconstitution, patient-specific dosing regimens, and concomitant therapy. Pharmacists must also participate in drug-use evaluation. The three thrombolytic agents currently available for the management of AMI are streptokinase, alteplase, and anistreplase. Dosing and reconstitution guidelines for each of these agents are given, and current investigations concerning optimum regimens are summarized. Some of the relative contraindications now used in patient selection need to be examined. It is possible that certain patient subgroups excluded in some trials may benefit from thrombolytic agents. Future clinical trials will provide guidance for the use of thrombolytic agents in these populations. The advent of thrombolytic therapy offers pharmacy an opportunity to expand its role in the drug-use process and to ensure the appropriate use of these agents.

Fibrinolytic Agents↗

PubMed1990

Pharmacist intervention program focused on i.v. ranitidine therapy.

A staff pharmacist intervention program designed to modify inappropriate dosage intervals for i.v. ranitidine and promote timely conversion to oral therapy is described. Records of patients who were receiving i.v. ranitidine were reviewed for eight weeks to determine whether the dosage interval was appropriate and whether they began receiving oral ranitidine within 24 hours of an order for an oral diet or other oral medications. Pharmacists were then asked to determine the proper i.v. ranitidine dosage interval based on creatinine clearance and the oral dosage that would be appropriate when i.v. therapy was no longer indicated. The information was used to complete an intervention form that was placed in the patient's chart. During the baseline phase the i.v. dosage interval was inappropriate for 49 of 139 patients; 617 i.v. doses costing $4214 were administered to 62 patients for whom oral therapy was indicated; conversion to oral therapy occurred appropriately for 39 of 68 patients (57%). In the intervention phase 138 patients received i.v. ranitidine. Pharmacists made 51 recommendations for adjusting the i.v. dosage interval, and 18 were implemented within 24 hours. All six recommendations to convert immediately to oral therapy were also implemented within 24 hours. A total of 280 inappropriate i.v. doses costing $1912 were given to 30 patients for whom oral therapy was indicated. Conversion to oral therapy occurred appropriately for 53 of 76 patients (70%). A simple program of monitoring and intervention by staff pharmacists when i.v. ranitidine therapy is begun can save money and promote the appropriate use of this drug.

Adolescent↗

PubMed1989

Laboratory tests recommended by pharmacists in a skilled-nursing facility.

The types of laboratory tests recommended by pharmacists in a 185-bed skilled-nursing facility, the rate of physician acceptance of the recommendations, the reasons for and costs of the tests, and the outcomes of the tests were determined. Patients for whom laboratory tests had been recommended by a pharmacist from 1982 to 1987 were identified; this information had been taken from patients' charts during routine review by a pharmacist and entered into a computer database. The following information was recorded: type of laboratory test recommended, physician response to the recommendation, cost of the test, and outcome of the test. The investigator determined reasons for the recommendations by using the Department of Health and Human Services list of apparent irregularities that, if present, could indicate problems with drug therapy. During the study period, pharmacists requested 99 tests for 63 patients; physicians ordered 87 (87.9%) of those tests. Tests done most frequently were the SMA-6 (serum concentrations of sodium, potassium, chloride, glucose, blood urea nitrogen, and carbon dioxide), serum concentrations of various drugs, and anticoagulation studies. The reasons given most frequently for requesting the tests were routine monitoring, the most recent results being more than six months old, suspected drug toxicity or drug-drug interactions, and the need for information to determine whether drug therapy should continue. Results of 36 of the tests prompted a change in drug therapy, whereas 56 tests indicated that the current therapy was appropriate and safe.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic Tests, Routine↗

PubMed1989

Nurse-pharmacist collaboration in clinical nursing education.

Collaboration between nurses and pharmacists is an approach to enhancing nursing students' education in pharmacology and improving nurses' and pharmacists' understanding of complementary roles and expertise. This paper describes a collaborative model used by the authors to teach pharmacologic concepts to nursing students in the clinical area. This approach included individual pharmacist-nursing student conferences and a clinical conference led jointly by a nurse educator and a pharmacist. The reactions of participants in these collaborative educational efforts have been overwhelmingly favorable.

Education, Nursing↗

PubMed1987

Effect of clinical pharmacists on drug prescribing in a primary-care clinic.

The effect of clinical pharmacy services on prescribing patterns and drug costs for nonsteroidal anti-inflammatory drugs (NSAIDs) and salicylates in a primary-care clinic operated by a health-maintenance organization (HMO) was studied. Two pharmacists provided clinical services to a randomly selected cluster of family practice physicians in the HMO for six months. A second family practice cluster served as a control group. The pharmacists alerted prescribers to the availability of low-cost alternatives (such as ibuprofen and salicylates) and reviewed the medication profiles of patients receiving high-cost NSAIDs. Data were collected for both physician clusters for nine months before and six months after the pharmacists' intervention. Changes in the mean numbers of prescriptions for ibuprofen and piroxicam per 1000 enrollees per physician in the baseline and evaluation periods were not significantly different between the two groups. Significantly more prescriptions for salicylates were written by physicians in the intervention group than in the control group during the evaluation period. Annualized mean drug ingredient costs per enrollee and per prescription for NSAIDS and salicylates decreased during the evaluation period in both groups, but these differences were not significant. In relatively unstructured interactions with physicians and nurses, clinical pharmacists were not able to reduce the costs associated with NSAIDs but did have a modest effect on altering salicylate prescribing patterns. This clinical pharmacy program was not economically self-sustaining during the first six months of operation, since operating costs exceeded anticipated savings.

Ambulatory Care↗

PubMed1986

Pharmacist interventions to improve prescribing of vancomycin and tobramycin.

The effect of clinical pharmacist interventions that promoted the use of nafcillin rather than vancomycin and of gentamicin rather than tobramycin, when appropriate, was evaluated. Physician information sheets and criteria describing appropriate use of the target drugs vancomycin and tobramycin were developed by a clinical pharmacist and infectious disease physicians. When drugs were prescribed for indications that did not meet the established criteria, the clinical pharmacist either contacted the prescribing physician or left the sheet in the patient's chart if the physician was not available. The average use of the target drugs and their alternatives was evaluated monthly during two six-month study periods and compared with the average use of these drugs during a three-month period before the target-drug programs were initiated. Throughout the 12-month study, on a per-patient basis, nafcillin use increased 31% while vancomycin use decreased 27% compared with the reference period; gentamicin use increased 21% while tobramycin use decreased 12% during the same period. These changes in use resulted in a net decrease in drug expenditures of $161,396. Approximately 0.5 full-time equivalent was spent on the program, and the return on investment for the service was greater than 10 to 1. Clinical pharmacist interventions through target-drug programs were effective in improving the appropriateness of vancomycin and tobramycin prescribing based on literature-derived criteria. The effects achieved by these interventions may decrease with time, and ongoing drug-use monitoring and physician education are necessary.

Anti-Bacterial Agents↗

PubMed1986

Effect of pharmacist interventions on drug therapy costs in a surgical intensive-care unit.

The effect of interventions by a clinical pharmacist on the cost of drug therapy in a 14-bed surgical intensive-care unit (SICU) was evaluated. The SICU pharmacist provides both distributive and clinical services from a modified satellite pharmacy five days each week. During a 13-week study period that comprised 65 days, the pharmacist documented all interventions that resulted in a discontinuation of or change in drug therapy, all nonformulary-drug requests, the detection and avoidance of problems related to drug therapy, and the enrollment of patients in investigational drug studies (for which the pharmacy department received monetary remuneration). The effect of these interventions on the costs of drug therapy was calculated using drug acquisition costs and, for i.v. preparations, the cost of the i.v. fluid and the cost of preparing and checking the product. A total of 332 interventions during the study period represented $18,030 in potential cost avoidance, which would extrapolate to an annual cost avoidance of $72,122. The majority of interventions involved discontinuations of or changes in drug therapy, most often involving antimicrobials. This pharmacist had a positive impact on the cost of drug therapy in the SICU.

Costs and Cost Analysis↗

PubMed1985

Retrospective evaluation of a pharmacist-managed warfarin anticoagulation clinic.

The effectiveness of a pharmacist-managed warfarin anticoagulation clinic in maintaining therapeutic prothrombin times and preventing hospitalizations secondary to inadequate control of anticoagulation was evaluated. Patients who had received warfarin sodium for at least one year before being referred to the anticoagulation clinic were studied using retrospective chart reviews. Clinical pharmacists provided patient education, monitored patients for hemorrhagic and thromboembolic complications, and adjusted warfarin sodium dosage to maintain therapeutic prothrombin times. The patients' primary physicians retained responsibility for overall care and were consulted by pharmacists regarding complications of anticoagulation and patient unreliability. The percentage of patients requiring hospitalization (39% versus 4%) and the percentage of prothrombin times outside the therapeutic range (35.8% versus 14.4%) were significantly higher during the preclinic phase (before referral to the clinic) than during the clinic phase. Eight patients were hospitalized for hemorrhagic complications and four for thromboembolism during the preclinic phase; only one hospitalization for hemorrhage occurred during the clinic phase. The warfarin anticoagulation clinic staffed by specially trained pharmacists provided improved therapy compared with treatment received by patients before their referral to the clinic.

Adult↗

PubMed1985

Pharmacists' perceptions of mental health care, psychiatrists, and mentally ill patients.

The attitudes of hospital pharmacists in Texas toward mental health care, psychiatrists, and mentally ill patients were evaluated. The pretested survey instrument contained 33 statements, which the respondents graded on a five-step Likert scale. These questionnaires were mailed to a random sample of 300 pharmacists. In general, the 170 respondents perceived psychiatrists and mentally ill patients in a positive manner. The psychiatrist was viewed as a true professional with legitimate expertise, and mentally ill patients were considered to be basically similar to normal individuals, generally rational, nondangerous, and without blame for their disease. The pharmacists showed more negative attitudes toward hospitals for mentally ill patients. They supported statements that depicted mental hospitals as understaffed, too drug oriented, and at times insensitive to individual needs. The surveyed hospital pharmacists generally demonstrated healthy, unprejudiced views toward psychiatrists and mentally ill patients; however, their attitudes toward mental hospitals were skewed in the negative direction.

Attitude of Health Personnel↗

PubMed1985

Pharmacist-directed heparin therapy using a standard dosing and monitoring protocol.

Use of a protocol for pharmacist determination of heparin sodium dosages administered by continuous i.v. infusion was evaluated by retrospective chart review in a California hospital. Charts of adult medical-surgical patients who received heparin infusions between June 1982 and December 1983 were reviewed for the following information: patient sex, age, and reason for receiving heparin; times, dates, numbers, and values of coagulation tests before and during heparin therapy; times, dates, and values of prothrombin time determinations during conversion to warfarin therapy; and times, number, and costs of heparin infusions. Charts were divided into two groups: those of patients for whom physicians prescribed heparin doses empirically and those of patients for whom physicians requested heparin dosing by the pharmacy department. Data were evaluated for 62 patients in the physician-dosed group and 26 patients in the pharmacy protocol group. Pulmonary embolism was the reason for heparin therapy in 34% of the physician-dosed patients and only 15% of the pharmacist-dosed patients. Pharmacists using the protocol ordered fewer anticoagulation tests and fewer heparin infusions per patient. Time from the start of heparin therapy to therapeutic anticoagulation was shorter in patients whose heparin dose was determined by the protocol, and values in the therapeutic range were achieved in a greater percentage of these patients than in the empirically dosed patients. Pharmacists using a standard dosing protocol effectively initiated and maintained heparin therapy that compared favorably with physician-dosed empiric therapy.

Adolescent↗

PubMed1978

The hospital pharmacist: master or victim of the environment?

The results of an investigation into role perceptions and expectations of hospital pharmacists are reported. The Locus of Control Scale which taps a personality attribute associated with beliefs about personal control over the environment was administered to 443 practitioners and students. It was found that hospital pharmacists are significantly more internal (masters rather than victims of the environment) than pharmacy students, other students and the general population. Implications of this finding are discussed in light of changing roles of pharmacists in the delivery of health care and the evaluation of pharmacy education. It is suggested that hospital pharmacists are well suited to the role of change agent, but that certain cautions are indicated in selecting strategies for change.

Attitude of Health Personnel↗

PubMed1978

Harvey A. K. Whitney Lecture: Patient accountability--pharmacists' future.

A philosophy of pharmacy practice is expressed, centering on service and accountability to the patient. To attain the goal of comprehensive pharmaceutical services, one must consider the factors of the environment and the characteristics of individual pharmacists. Aspects of the environment include support by the hospital administration and medical staff, and team cooperation among pharmacists and among all health professionals. Individual motivation to perform must be based on service to the patient. It is suggested that economic justification of pharmaceutical services should be a major goal of pharmacy organizations. The problem of employment opportunities for young pharmacists is discussed. The future of pharmacy practice is bright if pharmacists center their activity around the patient and become accountable for patient services.

Attitude of Health Personnel↗

PubMed1984

Capitation payment for pharmacy services. I. Impact on drug use and pharmacist dispensing behavior.

Results of a two-county pilot study in Iowa revealed that capitation may have significant advantages over fee-for-service (FFS) reimbursement in the Medicaid drug program. Consequently, the capitation program was expanded to 32 counties on April 1, 1981 and continued through December 31, 1981. Another 32 counties were used as part of a before:after/experimental:control design. Pharmacists were paid 80% of projected drug expenditures in advance based on the types of Medicaid eligibles who chose them as their providers. The remaining 20% was withheld in an escrow account to be used for supplemental, emergency, and bonus payments. Pharmacists who participated in this experiment were guaranteed that their gross profits on Medicaid prescriptions would remain at least equal to what they would have been if they had remained under the current FFS payment system. Major differences in drug use levels and pharmacist dispensing behavior under capitation financing were observed in the pilot study. However, no such changes associated with payment type were noted in the expanded program. Relative to these findings, a discussion of pharmacist attitudes is presented.

Attitude of Health Personnel↗