Showing papers in "Journal of the American Pharmaceutical Association in 1998"

Part 2. Clinical and Economic Outcomes in the Hypertension and COPD Arms of a Multicenter Outcomes Study

Abstract: Objective To evaluate the impact of pharmaceutical care on selected clinical and economic outcomes in patients with hypertension chronic obstructive pulmonary disease (COPD) in ambulatory care settings. Design Clinic patients with hypertension or COPD were radomly assigned to a treatment group (pharmaceutical care) or a control group (traditional pharmacy care) over a six·month period. Clircal pharmacists and pharmacy residents conducted the protocols. There were 133 evaluable patients (63 treatment and 70 control) in the hypertension study arm and 98 evaluable patients (43 treatment and 55 control) in the COPD study arm. Setting 10 Departments of Veerans Affairs medical centers and 1 academic medical center. Interventions Patient-centered pharmaceutical care model (employing stadardized care) implemented by clinical pharmacy residents. Main Outcome Measures Patient knowledge, medication compliance, and health resource use. Results The hypertension treatment group had a significantly greater reduction in systolic blood pressure from visit 1 to visit 5 than did the control group. In the COPD study arm, trends were positive in the treatment group for patient ratings of symptom interference with activities and dyspnea measures. There was a significant difference between the hypertension treatment and control group for compliance. There were no significant changes in compliance scores in the COPD study arm. Mean number of hospitalization and other health care provider visits was higher for the hypertension control group. For patients with COPD, hospitalizations increased in the control group, and the number of other health care provider visits was higher in the control group. Conclusion Pharmacists' participation in a pharmaceutical care program resulted in disease state improvement in ambulatory patients with hypertension and COPD.

Part 3. Humanistic Outcomes in the Hypertension and COPD Arms of a Multicenter Outcomes Study

Abstract: Objective To evaluate the effects of pharmaceutical care on selected humanistic outcomes in patients with hypertension or chronic obstructive pulmonary disease (COPD). Design Clinic patients with hypertension or COPD were randomly assigned to a treatment group (pharmaceutical care) or a control group (traditional pharmacy care) over a six-month period. Clinical pharmacists and pharmacy residents conducted the protocols. There were 133 evaluable patients (63 treatment, 70 control) in the hypertension study arm and 98 evaluable patients (43 treatment, 55 control) in the COPD study arm. The Pharmaceutical Care Questionnaire evaluated patient satisfaction with care. Tests specific to the disease states assessed disease and disease management knowledge. Quality of life (QOL) was evaluated using the Health Status Questionnaire 2.0 (HSQ 2.0) in the COPD arm; in the hypertension arm, the Hypertension/Lipid TyPE Specification Form 5.1 was used. Setting Ambulatory care centers of 10 Department of Veterans Affairs (DVA) medical centers and 1 university medical center. Interventions Patient-centered pharmaceutical care model (employing standardized care) implemented by clinical pharmacy residents. Main Outcome Measures Satisfaction with pharmaceutical care, disease and disease management knowledge, and QOL. Results Statistically significant differences in most satisfaction items were found, with treatment patients expressing greater satisfaction. Treatment groups in both arms strongly agreed that pharmacists helped them with confidence in use of their medication and understanding of their illness, gave complete explanations about their medications, made them feel that their care was a priority, and followed up on their questions and concerns. In the hypertension arm, treatment patients demonstrated significant increases in knowledge scores. Trends in QOL were positive for both hypertension groups, with a significant decrease found in number of treatment patients reporting problems with sexual function. In the COPD arm, improvement trends were significantly stronger for treatment patients. Conclusion Although patients were not dissatisfied with traditional pharmacy care, they were more satisfied overall with the pharmaceutical care model.

Obstacles to the Implementation of Pharmaceutical Care in the Community Setting

Abstract: Objective: To describe the obstacles to the implementation of pharmaceutical care in the community setting based on the experience and informal observations of the authors in their work with community practitioners. Summary: Various obstacles impede the implementation of pharmaceutical care in community practice. These obstacles can be grouped into six categories: pharmacists' attitudes, lack of advanced practice skills, resource-related constraints, system-related constraints, intraprofessional obstacles, and academic/educational obstacles. Pharmacists should identify those obstacles that are relevant to their practice and develop strategies to overcome them. By understanding the obstacles, pharmacists, pharmacy organizations, and colleges of pharmacy can work together to find solutions and accelerate the community practitioner's successful conversion to pharmaceutical care. Conclusion: Although these obstacles may seem overwhelming to the community practitioner, commitment and proper planning will help to lessen their effects. Overcoming certain of these obstacles will require the involvement of pharmacy organizations and colleges of pharmacy. It is the responsibility of all pharmacy professionals to develop the skills, tools, and knowledge to overcome any obstacle to the success of pharmaceutical care.

Community Pharmacists as Patient Advocates: Physician Attitudes

Abstract: Objectives To assess physician attitudes toward community pharmacists acting as patient advocates with respect to drug-related matters, and to correlate physician attitudes with physician characteristics and physician–pharmacist interactions. Setting State of Utah. Participants Physicians in family practice, internal medicine, pediatrics, and psychiatry. Interventions Mail survey. Main Outcome Measures Physician attitudes toward community pharmacists performing 15 patient advocacy activities, as well as physician–pharmacist interaction and respondent demographics. Results Favorable attitudes were identified for pharmacists monitoring drug use, counseling patients, advising physicians, contacting physicians to discuss patients' pharmacotherapy, and recording over-the-counter product use in patient profiles. Attitudes were less favorable toward pharmacists helping patients manage adverse drug reactions, suggesting drug regimen alterations, providing health screening services, selecting drugs by a protocol, discussing therapeutic equivalents with patients, and changing dosage forms to better suit patient needs. Physician age was negatively correlated with attitude toward a pharmacist aiding a physician in selecting a drug to be prescribed. The helpfulness of physician–pharmacist interactions was positively correlated with physician attitudes. Conclusion From the physician's perspective, the most appropriate areas for expansion of the community pharmacist's role into patient advocacy are in monitoring pharmacotherapy, assisting physicians in coordinating pharmacotherapy, and providing patients with medication information. Physician resistance is more likely in areas where community pharmacists assume a more autonomous role in patient care.

Pharmacy Staff Interventions in a Medical Center Hematology–Oncology Service

Abstract: Objectives Many pharmaceutical care efforts remain undocumented, resulting in underestimation of the importance of the pharmacy staff interventions and missed opportunities to find new directions for quality improvement. The purpose of this project was to document and analyze the pharmaceutical care interventions of the staff of a hematology-oncology pharmacy. Design Interventions were self-reported by pharmacy staff members. The data collection period was October 1, 1995, to May 31,1996. Intervention analysis consisted of types of interventions performed, categories of personnel performing interventions, intervention acceptance rate by staff physicians, and medication cost avoidance. Participants This project was performed by the Hematology-Oncology Pharmacy Service, Department of Pharmacy, Walter Reed Army Medical Center, Washington, D.C. Setting Walter Reed Army Medical Center, Washington, DC, a 1,000-bed teaching and research institution of the U.S. Army Medical Department. Results Pharmacy staff report, ed 503 interventions. The leading categories of interventions were clinical consultations (167), correction of prescribing errors (85), and I patient treatment procedures (65). The interventions were primarily initiated by oncology pharmacists and residents (68.8%) and oncology pharmacy technicians (30.6%). The intervention acceptance rate was 97%. Medication cost avoidance was $23,091. Conclusion A significant amount of pharmaceutical care was documented by the hematology-oncology pharmacy staff, with both oncology pharmacists and oncology pharmacy technicians making key contributions. The pharmacy staff's interventions had a high rate of acceptance by the medical and nursing staffs, and resulted in significant medication cost avoidance.

Michigan Medicaid recipients' perceptions of medication counseling as required by OBRA '90.

Abstract: Objective To assess pharmacist counseling under OBRA '90 from the Medicaid recipient's perspective. Specifically, the study was designed to (1) assess pharmacists' compliance with counseling requirements, (2) assess recipients' level of satisfaction with the information provided during counseling and whether the information provided increased their comfort level in taking medication correctly, and (3) determine relationships between variables associated with pharmacist counseling and recipient satisfaction and comfort level. Design Cross-sectional telephone survey of Medicaid recipients. Medicaid recipient or caregiver was the unit of measure. Setting Michigan. Patients 408 recipients who received new prescriptions during a one-week period in November 1995. Interventions: Telephone survey. Main Outcome Measure Recipients' perception of whether an offer to counsel was made. Results Only 104 (25.5%) recipients indicated that someone offered counseling for their new prescription, and only 62 (15.2%) recipients indicated they knew olthe requirement; 163 (40.0%) indicated someone counseled them. Counseled recipients were satisfied with the amount, quality, and way the information was presented, and were more likely to assign a higher level of importance to pharmacist counseling. The majority of respondents indicated high levels of comfort in using their medications safely, with those who were counseled expressing a higher level of comfort. Conclusion From the perspective of the Medicaid recipient, pharmacies are failing to offer counseling for most new prescriptions. The results indicate that counseling improves measures of recipient comfort in using medications safely and enhances the level of importance patients assign to pharmacist counseling.

A model for improving medication use in home health care patients.

Abstract: Objectives (1) To develop a model for the identification and resolution of problems associated with suboptimal medication use in elderly patients receiving home health care; (2) To select the most important identifiable problems and develop structured procedures for their resolution. Design Expert panel review, problem selection, and development of a problem resolution model and guidelines. Setting Home health care. Participants A panel with expertise in home health nursing, pharmacy, clinical pharmacology, gerontology, pharmacoepidemiology, and health services research. Interventions A list of potential problems associated with the most frequently used classes of drugs was compiled for review by the panel. Problems that were controversial or that could not be identified in the home care setting were excluded. Panel members individually ranked the remainder. Detailed procedures for identification and resolution of the 15 top-ranking problems were developed. Main Outcome Measures Not applicable. Results Potential medication problems were defined by both drug use and symptoms or clinical signs associated with specific adverse effects, to ensure that clinically relevant problems would be identified. The model developed for problem assessment and resolution was centered on the drug utilization review (DUR) coordinator and the attending home health nurse. Following guidelines developed by the panel, the DUR coordinator advises the home health nurse about identified problems and how to resolve them. One of these practitioners, usually the nurse, then contacts the attending physician to explain their concerns, offer potential solutions, and request instructions. Conclusion A potentially useful model for the identification and resolution of medication problems in the home health care setting was developed. This model is currently being evaluated in a randomized controlled trial.

Update on Treatment of Rheumatoid Arthritis

Abstract: Objective: To review current treatment of rheumatoid arthritis (RA), as well as recent advances. Data Sources: MEDLINE search from 1990 to 1998 for human studies using search terms "rheumatoid arthritis"; "cyclooxygenase inhibitors" combined with "anti-inflammatory agents, nonsteroidal"; "tumor necrosis factor" limited to "antagonists and inhibitors"; "isoxazoles." Data Synthesis: RA is a chronic inflammatory disease characterized by symmetrical joint involvement, usually of the small joints of the hands and feet. Although the hallmark of the disease is inflammation of joints, other organ systems—including the eyes, blood vessels, lungs, and car-diopulmonary system—may also be involved. Treatment of RA requires both drug and non drug approaches. Current drug therapy consists of combinations of nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs). Corticosteroids are also used either for short-term treatment during initiation of therapy, in bursts during acute disease flares, or chronically in low doses. A number of promising new agents are in development. NSAIDs with preferential inhibition of cyclooxygenase II may offer a better safety profile than existing agents. Leflunomide and biological agents such as etanercept may provide benefit for patients who fail to achieve adequate response from conventional therapy. Conclusion: Traditional approaches to treatment of RA include NSAIDs combined with DMARDs. New agents just reaching the market represent important advances and have the potential to make a positive impact on treatment of RA.

Part 1. Development, Implementation, and Evaluation of a Multicenter Pharmaceutical Care Outcomes Study

Abstract: Objectives To: (1) develop a pharmaceutical care multicenter outcomes research project using clinical pharmacy residents and preceptors; (2) develop two research protocols to document pharmacists' impact on clinical, economic, and humanistic outcomes of therapy; (3) develop and implement a data collection process and methodology for outcomes research; (4) evaluate the effectiveness of the multicenter outcomes research process; and (5) prepare clinical pharmacy preceptors and residents to conduct outcomes research. Design and Setting Two research protocols were developed, each a randomized, parallel, open-label evaluation of patients at 10 Department of Veterans Affairs and 1 university medical center. One protocol focused on patients with chronic obstructive pulmonary disease (COPD) and the other on patients with hypertension. The study evaluated pharmacists' management of these two patient groups. Patients and Other Participants 133 patients with hypertension and 98 patients with COPD; 33 pharmacy directors and preceptors; 45 pharmacy residents. Main Outcome Measures Clinical, economic, and humanistic outcomes of pharmacists' interventions. The processes of developing a multicenter outcomes study were evaluated, including the data collection process. Results The two study protocols and an educational program for study participants were developed. A data collection process was developed and implemented, with the paper process being successful and the computer data collection process not implemented due to time constraints. Overall, the multicenter outcomes research process was successful. Conclusion The study provides a framework of processes and sites for the future development of other outcomes research studies. Clinical, economic, and humanistic outcomes are reported in Parts 2 and 3.

How Pharmacists Respond to On-Line Real-Time OUR Alerts

Abstract: Objective To quantify the type and frequency of drug utilization review (OUR) alerts sent by one claims processor to pharmacists; identify how pharmacists respond to these on-line, real-time DUR messages; and quantify the interventions taken by these pharmacists as a result of these alerts. Design Retrospective analysis of Medicaid claims from July 1, 1995, through June 30, 1996. Setting: State of Delaware. Participants 55,000 Medicaid recipients served by 170 participating pharmacies and 2,000 physicians. Interventions All on-line OUR alerts sent to pharmacists and the pharmacists' responses were categorized by alert type and analyzed by drug class. Main Outcome Measures Pharmacists' response (dispensed prescription, contacted prescriber, talked with patient, consulted own reference sources) and drug classes. Results During the study period, 807,017 claims generated 83,260 OUR alerts involving 73,554 (9.1%) prescriptions. Prescriptions were not dispensed in 20.9% of cases because of the OUR message. Prescriptions were dispensed 17.7% of the time after the pharmacist contacted the prescriber, in 20.6% of cases after the pharmacist talked with the patient, and 37.2% of the time after reviewing internal resources. Action taken by pharmacists varied among and within OUR criteria categories. Specific examples of alerts generate.d in high-frequency and high-profile areas are reviewed, some of which generated inconsistent responses. Conclusion Among Delaware Medicaid providers, drug alerts resulted in pharmacists not dispensing prescriptions in a surprising percentage of situations. Pharmacists' responses varied according to the drug class involved and the type of alert received.

Use of Alternative Therapies and Their Impact on Compliance: Perceptions of Community Pharmacists in Texas

Abstract: Objective To assess community pharmacists' experiences with the use of alternative therapies by their patients with chronic illnesses. Design Mail survey. Setting State of Texas. Participants 142 community independent and chain pharmacists. Main Outcome Measures Pharmacists' recollections about patients' use of alternative therapies. Results Pharmacists estimated that 17% of their patients with chronic illnesses used some form of alternative therapy. A majority (66.9%) indicated that they have patients who used some type of alternative therapy for chronic conditions and that a majority (59.7%) of these patients consulted with them regarding those therapies. However, in only 11.1% of these cases did pharmacists document alternative therapy use in patients' pharmacy records. Pharmacists reported that 25.9% of these patients who use alternative therapies for chronic conditions were not compliant with their prescribed medication regimen. One-third (33.1%) of respondents indicated they knew of no patients who used alternative therapies, and 35.9% had never asked. Conclusion Pharmacists need information on patients' use of alternative therapies for chronic illnesses to make valid therapy decisions and to monitor outcomes. Future research should identify actions that pharmacists take to address drug-related problems among alternative therapy users and assess the impact of these actions on drug therapy-related outcomes.

Analysis of the Medical Use of Marijuana and its Societal Implications

Abstract: Objective To review the pharmacology, therapeutics, adverse effects, and societal implications of the medical use of marijuana. Data Sources MEDLINE and manual searches of English-language marijuana literature, supplemented with interviews of scientists currently conducting cannabinoid research. Search terms included pain OR palliative care AND cannabis or ALL marijuana ; cachexia OR appetite OR appetite stimulants ; muscle spasticity OR spasm ; immune system and cannabis ; nausea and vomiting and cancer and cannabis . MEDLINE search terms: cannabis OR marijuana smoking OR marijuana abuse ; all glaucoma ; multiple sclerosis AND ( cannabis OR marijuana smoking OR marijuana abuse . Study Selection Studies on pharmacology, risks, and medical potential of 1 marijuana. Data Extraction Not applicable. Data Synthesis The most prominent effects of marijuana are mediated by receptors in the brain. Acute intoxication is characterized by euphoria, loss of short-term memory, stimulation of the senses, and impaired linear thinking. Depersonalization and panic attacks are adverse effects. Increased heart rate and reddened conjunctivae are common physical effects. Chronic, high doses may cause subtle impairment of cognitive abilities that are appear to be long-term, but of unknown duration. Marijuana may be a risk factor for individuals with underlying mental illness. It causes dependence, but compared with cocaine, alcohol, heroin, and nicotine, marijuana has little addictive power and produces only mild withdrawal symptoms. Marijuana shows clinical promise for glaucoma, nausea and vomiting, analgesia, spasticity, multiple sclerosis, and AIDS wasting syndrome. Conclusion As a recreational drug, marijuana poses dangers, particularly to social and emotional development during adolescence and young adulthood. As a medical drug, marijuana should be available for patients who do not adequately respond to currently available therapies.

Providing Pharmaceutical Care in a Physician Office

Abstract: Objective To develop a physician office–based pharmaceutical care practice and evaluate the impact on the participating physicians, their staff, and patients. Setting Internal medicine physician office. Practice Description Two physicians and two nurses practice in a medical office complex in a rural setting in eastern Washington. Practice Innovation Development of an experimental pharmaceutical care program in which a registered pharmacist works in a physician office to evaluate the medication needs of patients and to provide pharmaceutical care and medication information to health professionals and patients. Main Outcome Measures Functions and interventions performed by the pharmacist; types of disease states in patients that were confronted by the pharmacist; summary of time spent with patients; and attitudes of physicians and patients concerning the pharmacist interventions. Results 660 pharmacist interventions or functions occurred during the seven months of the project. Of 107 recommendations to the physicians concerning changes in therapy, 89 were accepted. Patients suffered from 53 different disease states that were evaluated by the pharmacist. The pharmacist spent from less than 5 minutes to more than an hour with individual patients, 5 to 15minutes with the majority of patients. Both patients and physicians were impressed with the service and strongly desired to have it continued. Conclusion There is a career opportunity for pharmacists to provide pharmaceutical care in the setting of a physician office practice. Many of the barriers to providing pharmaceutical care can be eliminated or diminished in this setting.

Consumer Attitudes, Behaviors, and Perceptions About Pharmacies, Pharmacists, and Pharmaceutical Care

Abstract: Objective: To determine the kinds of pharmacy services consumers in the United States currently use, what other services they might be seeking, and the value they place on pharmaceutical care services. Design: Telephone survey of random sample of 1,200 households located throughout the continental United States, chosen by random-digit dialing. Participants: 984 consumers in July and August 1996. Results: Respondents were most commonly between the ages of 35 and 54 (43.9%). Most respondents (77%) had all or part of the cost of their prescriptions paid by insurance. Consumers rarely used more than one (72%) or two (24%) pharmacies on a regular basis. A total of 81% of consumers indicated that they are "always" provided with information on new prescriptions. Two services were rated highest in not meeting respondents' needs: mail or telephone reminders (70%) and calls to determine the effectiveness of filled prescriptions (69%). More than two-thirds of consumers were favorably receptive to the pharmaceutical care concept; however, demand for pharmaceutical care declined dramatically when hypothetical out-of-pocket costs were proposed. Conclusion: Consumers use few characteristics other than location to discriminate between pharmacies. Consumers are receptive toward the pharmaceutical care concept. The revenue potential of such a service depends on its acceptance by the "prescription-insured" population.

Important features of blood glucose meters.

Abstract: Objective To provide an overview of several blood glucose meters that will enhance practicing pharmacists' knowledge and under-standing of these devices to allow education of the patient with diabetes. Data Sources Original and review articles, blood glucose meter package inserts and manuals. Data Synthesis Careful blood glucose control is essential to prevent long-term complications of diabetes. Newer blood glucose meters have a broad variety of features, including small size, extended memory capacity, blood glucose manipulation techniques, and computer downloading capabilities. The decision to choose a blood glucose meter should be based on a number of criteria, including the patient's needs, ease of use, and affordability. Conclusion Pharmacists must position themselves to differentiate among the numerous blood glucose meters available on the market and make appropriate recommendations based on patient-specific needs.

Sale of Tobacco Products in Pharmacies: Results and Implications of an Empirical Study

Abstract: Objective To provide national-level data concerning the percentage of pharmacies selling tobacco products, examine relationships between selling practices and pharmacy characteristic variables, and explore perceptions of conflicts between tobacco-selling activity and professional and personal values and the potential effects of such conflicts. Design, Setting, Participants Data were collected from a geographically stratified systematic random sample of 899 pharmacies. Multiple mailings were sent to the attention of the pharmacy manager. A random sample of nonrespondents was also contacted by telephone, urging participation. Main Outcome Measures Whether the pharmacy currently sold cigarettes and/or smokeless tobacco products, and if so, whether these practices differed from what respondents' personal or professional values tell them to do. Scales designed to measure job satisfaction, job-induced tension, and propensity to leave were also included. Results Slightly more than half (50.5%) of the pharmacies sold cigarettes and 35.4% sold smokeless tobacco products. Independents were less likely than chain pharmacies to sell tobacco products. For those respondents working in pharmacies where tobacco products were sold, 47.6% responded that this practice differs from what their personal values tell them to do and 63.9% replied that this practice differs from what their professional values tell them to do. Even when controlling for pharmacy type, respondents working in pharmacies that sold tobacco products had significantly lower levels of global job satisfaction, higher levels of job-induced tension, and a higher propensity to leave than did respondents working in pharmacies that did not. Conclusion Decision makers in pharmacies where tobacco products are still sold should take a serious look at the justification for the continued availability of tobacco products in an environment that has a goal of promoting health.

The Role of Pharmacy in the Management of Patients with Temporomandibular Disorders and Orofacial Pain

Abstract: Objective To provide information regarding the current understanding of the etiology and treatment, both nonpharmacologic and, pharmacologic, of orofacial pain conditions including temporomandibular disorders (TMDs). This review briefly discusses the etiology and pathophysiology underlying the development of TMDs, generally accepted non pharmacologic methods of treatment, and the most common current pharmacologic management approaches. Data Sources Current medical literature and the authors' clinical experiences. Data Synthesis TMDs encompass a number of diagnostic subgroups that involve the masticatory musculature, the temporomandibular joint(s), and associated structures. More than 10 million individuals in the United States are affected by TMDs. Most current pharmacologiC management approaches in the treatment of orofacial pain conditions, including TMDs, involve the use of antidepressants, anticonvulsants, muscle relaxants, corticosteroids, and nonsteroidal anti-inflammatory drugs. Conclusion Inclusion of pharmacists who are knowledgeable in the non pharmacologic and pharmacologic treatment approaches on the TMD management team would improve therapeutic monitoring, follow-up, and outcomes in these patients.

Osteoporosis in Women: Prevention and Treatment

Abstract: Objective To review osteoporosis, its pathophysiology, lifestyle and dietary factors that influence osteoporosis, and treatments to prevent and treat the disease in women. Data Sources MEDLINE using the search term osteoporosis and individual therapies and inventions for 1974–1998. Study Selection English-language studies in humans were reviewed. Prospective clinical trial data were selected when available; epidemiologic data were used when prospective clinical trials were not available. Data Synthesis Pharmacists should initiate discussions with women of all ages to help prevent, recognize, and treat osteoporosis. Assessing and modifying calcium, vitamin D, caffeine, alcohol, and phosphate intake, increasing exercise, and minimizing falls can help prevent osteoporosis and fractures. The risks and benefits of hormone replacement therapy should be presented to women so they can make an informed decision. Hormone replacement therapy is the treatment of choice for preventing and treating osteoporosis; it also reduces cardiovascular morbidity and mortality. The benefits must be put into the proper perspective with adverse effects, events such as vaginal bleeding and the risk of breast cancer, that prevent women from taking estrogen. As not every woman is willing or able to take estrogen, alternative should be discussed. Raloxifene prevents osteoporosis, has beneficial lipid effects, and does not stimulate breast or endometrial tissue Alendronate is a safe and effective for the prevention and treatment of osteoporosis when administered properly. Calcitonin is approved for treatment of osteoporosis and provides analgesic effects for fractures. Conclusion Pharmacists should initiate discussions with women of all ages to help prevent, recognize, and treat osteoporosis. Assessing and modifying calcium and vitamin D, caffeine, alcohol and phosphate intake, increasing exercise, and minimizing falls can help prevent osteoporosis and fractures.

Situational Factors as Determinants of Community Pharmacists' Clinical Decision Making Behavior

Abstract: Objective To examine the relative contribution of two work-related pressures, workload and perceived normative beliefs of significant others, to community pharmacists' clinical decision making behavior. Design Systematic random sample design. Setting A large southeastern city. Participants 450 independent and chain community pharmacists identified from the state board of pharmacy list of licensed community pharmacists. Interventions A mailed questionnaire asking about community pharmacists' workload pressures and the perceived beliefs of their patients and employers (significant others) approving or disapproving of them providing pharmaceutical care. Main Outcome Measures Clinical decision making behavior, as measured using a subset of the Behavioral Pharmaceutical Care Scale. Results Response rate was 31.8%. Workload was not significantly related to clinical decision making. After controlling for social desirability and workload, perceived normative beliefs of significant others was highly significant; it accounted for 7.6% of the variance associated with clinical decision making behavior. Conclusion Workload pressures did not appear to influence the provision of pharmaceutical care. Community pharmacists' perceived normative beliefs about their patients' and employer's approval or disapproval of the provision of pharmaceutical care should be further examined within the larger context of the pharmacy organization's climate.

Costs of Implementing Pharmaceutical Care in Community Pharmacies

Abstract: Objective: To estimate the costs and benefits to community pharmacies of converting a traditional practice into one based on pharmaceutical care. Setting: Community-based ambulatory care pharmacies. Practice Description: Community pharmacy. Practice Innovation: Pharmaceutical care. Main Outcome Measures: Costs incurred and revenues received. Design: Twenty-five community pharmacies that had made the transition from traditional practice to one based on pharmaceutical care returned a survey providing data on the costs and revenues associated with the transition. Results: Mean total cost of making the conversion for the 25 pharmacies was $36,207. The largest cost component associated with the transition was personnel, which had a mean cost of $16,512 per pharmacy. Mean revenues received for pharmaceutical care by these 25 pharmacies was $3,687, mainly for disease management services. Pharmacies that spent more on the conversions, and used brochures and physician detailing as well as consultants and franchises, tended to be more successful in generating revenues from pharmaceutical care. Conclusion: Most pharmacies that have made the conversion to pharmaceutical care have not experienced an increase in profits as a result of that conversion. More effort needs to be directed toward improving the flow of revenues obtained from providing pharmaceutical care.

Hormone Replacement Therapy and Breast Cancer: Revisiting the Issues

Abstract: Objective To assess current ideas about the benefits and risks of estrogen and hormone replacement therapy (ERT/HRT) in post·menopausal women. Data Sources MEDLINE searches, supplemented by various texts, of the literature on HRT, ERT, and selective estrogen receptor modulators (SERMs): tamoxifen, toremifene, and raloxifene. Data Synthesis HRT is primarily used for improving quality of life in women suffering from vasomotor symptoms associated with menopause. HRT is beneficial in postmenopausal women for preventing cardiovascular disease, osteoporosis, and Alzheimer's disease. Review of meta-analyses of clinical trials showed that ERT/HRT ever·users (patients who have ever used ERT/HRT) did not have an increased risk of breast cancer, but current users did have an increased risk, with some studies reporting increasing risk with duration of ERT. No relationship was found between dose or the addition of progestin to ERT and increased breast cancer risk. Overall breast cancer mortality rates associated with HRT were decreased in current users. In general, HRT does not increase the risk of breast cancer in women with a family history of the disease, compared with those without a family history. New HRT strategies that could potentially prevent breast cancer are now being developed. The SERMs tamoxifen and toremifene appear to have positive clinical effects on bone and serum lipids; they are currently being investigated for use as breast cancer chemopreventive agents. Raloxifene, a new SERM used for the prevention of osteoporosis, is an alternative for women who cannot tolerate HRT. Unfortunately, these SERMS have anti-estrogenic effects and thus cause vasomotor adverse effects such as hot flashes and vaginal dryness. In addition, SERMs do not protect against heart disease or prevent osteoporosis as well as does HRT. Conclusion Presently, SERMs will not become first-line HRT, as the positive effects of ERT/HRT may out·weigh any potentially increased risk of breast cancer. The development of new agents with pharmacodynamic profiles similar to that of ERT/HRT but lacking its adverse effects would be greatly beneficial for postmenopausal women.

Smoking cessation: Part 2--Pharmacologic approaches.

Abstract: Objective To present the concept of nicotine-replacement therapy (NRT) and the pharmacologic approaches, nonprescription and prescription, to smoking cessation. Data Sources Current clinical literature. Data Synthesis NRT can be delivered through a number of different nicotine-containing dosage forms (e.g., gum, patch, nasal spray, oral inhaler). The Agency for Health Care Policy and Research (AHCPR) recommends using the nicotine patches for routine clinical practice and the American Psychiatric Association (APA) recommends the use of the patches and gum as initial pharmacotherapies for smoking cessation. There are no comparative studies indicating the superiority of one form or another at relieving nicotine withdrawal symptoms. Of the other pharmacologic agents used for smoking cessation, bupropion hydrochloride demonstrates the most promise. Conclusion The pharmacist can assist the consumer with the selection of an OTC smoking cessation product and serve as an informational resource to consumers and physicians desiring information on prescription drug products for smoking cessation.

Medication Use During the Perinatal Period

Abstract: Objective To briefly describe the drug therapy administered during the perinatal period of pregnancy for common maternal and fetal complications, and to identify those agents that should not be used for these conditions. Data Sources References were obtained from an ongoing literature search of peer-reviewed obstetric and gynecologic journals and other selected medical and pharmacy journals available in the English language. Primary search vehicle was a weekly review of the tables of contents of nearly 1,300 medical journals provided by Reference Update (Institute of Scientific Information, Philadelphia). MEDLINE searches were also conducted using key terms for each subtopic. Study Selection Specific references were selected for each topic based on the adequacy of their study design, patient population, and a recent publication date. Reviews were used if a large number of primary references would have been required to adequately describe the topic. Data Extraction Most references reflected the current opinions expressed in the Educational (Technical) Bulletin and Committee Opinion series published by the American College of Obstetricians and Gynecologists. Recent, well-conducted studies that arrived at different conclusions were also included. Data Synthesis Data obtained from each reference reflected the conclusions of the authors based on their research or an analysis of the research of others on the appropriate use of the drug(s) for the specific condition being treated. Conclusion Drug therapy during the perinatal period is frequently required and can be beneficial for the mother, fetus, and newborn. Many complications previously associated with severe morbidity and mortality, such as infections, premature rupture of membranes, preterm labor, hypertension, maternal pain during labor, and postpartum hemorrhage, are now controlled with appropriate pharmacologic therapy. All health professionals who provide services to pregnant women should be knowledgeable in this drug therapy.

Alcohol Use, Drug Use, and Sexual Activity among Pharmacy Students at Three Institutions

Abstract: Objective To determine alcohol and drug use and sexual activity among pharmacy students at three colleges of pharmacy. Design and Setting A survey to obtain self-reported information on alcohol and drug use, and sexual activity was administered to professional pharmacy students at the University of Iowa (UI), Massachusetts College of Pharmacy, and Texas Southern University. Main Outcome Measures Information on sexual activity and condom use, alcohol and drug consumption, and the effect of alcohol on unintended sexual activity. Results 848 students (50% response rate) completed the survey. Alcohol use was high at all three institutions, and most students had consumed five or more drinks on one or more occasions within the last three months. The extent of drug use among pharmacy students was similar to that reported in other college students. The majority of students were sexually active. More men than women reported having been sexually active with one or more partners. Most students reported having had sexual intercourse without a condom. Significant numbers of students had engaged in unintended sex after alcohol use, especially at UI (χ 2 = 12.6, p = 0.002). Sexual contact and drinking were strongly correlated (Pearson r = 0.31, p = 0.0001). Conclusion Alcohol consumption among pharmacy students was high. Heavy drinking (five or more drinks on one occasion) was associated with unintended sexual contact. Given low condom use and increased sexual contact, pharmacy students are at an increased risk for HIV infection. Strategies should be developed to reduce alcohol intake and unprotected sexual activity among pharmacy students.