Showing papers in "Journal of the American Pharmaceutical Association in 1999"
TL;DR: Despite longstanding efforts and the expansion of managed care, primary care providers remain in short supply in rural areas, especially ZIP code-based HPSAs, and it is logical to use other available providers and combinations to increase health care access.
Abstract: Objective To determine the rural distribution of primary care providers (primary care physicians, physician assistants, nurse practitioners, and nurse midwives) and pharmacists. Design Five-digit ZIP code mapping to study the availability of primary care providers and pharmacists, alone and in combinations, in rural areas and ZIP code-based health professional shortage areas (HPSAs). National averages for annual physician visits for hypertension, asthma, and diabetes were used to estimate the sufficiency of the rural physician supply. Setting Rural areas of the United States. Results In rural areas, all providers were present in lower densities than national averages, particularly in HPSAs. The primary care physician supply was insufficient to meet national averages for office visits for hypertension, asthma, and diabetes. Among available providers, the most prevalent co-presence was primary care physician with pharmacist. HPSAs showed very low physician density (1 per 22,122), and the most prevalent providers were pharmacists. States varied widely in provider density. Conclusion Despite longstanding efforts and the expansion of managed care, primary care providers remain in short supply in rural areas, especially ZIP code-based HPSAs. Making the best use of available providers should be encouraged. The continued shortfall of primary care providers in rural areas, particularly HPSAs, makes it logical to use other available providers and combinations to increase health care access. Pharmacists could increase care for patients with conditions treated with medications. Other available providers, based on skills and work site, could also offset shortages.
110 citations
TL;DR: This model offers an effective and efficient mechanism for providing pharmaceutical care, for patients with diabetes, and measures the rate at which physicians implemented therapy recommendations made by community pharmacists.
Abstract: Primary Objective: Evaluate the effects of a point-of-dispensing (POD) pharmaceutical care model on outcomes of self-monitored blood glucose (SMBG) results, 5MBG frequency, and medication adherence rates for patients with diabetes. Secondary Objective: Measure the rate at which physicians implemented therapy recommendations made by community pharmacists. Design: 12-month, noncrossover, single-group trial. Setting: Two independent community pharmacies in Richmond, Va Patients: 101 patients were initially identified as potential participants; of the 82 that elected to participate in the study, 62 (760/0) completed the first 6 months and 52 (63%) completed the entire 12-month study period. Intervention: This pharmaceutical care program was integrated into the dispensing function: subjective and objective data related to diabetes care were gathered with each prescription refill. Recommendations were made to patients and their physicians. Main Outcome Measures: 5MBG values and frequency at baseline, 6, and 12 months. Diabetic medication adherence rates for 1 year before and during participation were evaluated. Community pharmacist recommendations and implementation status were followed over the 12-month period. Results: Average morning blood glucose values (n = 27) decreased from 178.6 mg/dL to 159.3 mg/dL, from baseline to 6 months, respectively (p = .07). Blood glucose values (n = 23) at baseline and 12 months decreased from 179.0 mg/dL to 149.7 mg/dL, respectively (p Conclusion: This model offers an effective and efficient mechanism for providing pharmaceutical care, for patients with diabetes.
107 citations
TL;DR: Because of their extensive drug knowledge and frequent access to patients, pharmacists are uniquely positioned to educate patients and other health care professionals about the dangers of acquaintance rape drugs and methods to reduce their risk of becoming victims.
Abstract: Objective To describe gamma-hydroxybutyrate (GHB), flunitrazepam, and ketamine and their purported uses to facilitate acquaintance rape. Patient presentation characteristics, treatment regimens, processes to detect the presence of the medications by toxicology screening, and methods to avoid exposure are discussed. Data Sources MEDLINE search from 1985 to 1998; additional references found within the articles; information obtained from the Internet. Study Selection Clinical trials, reviews, and press releases concerning the use of GHB, flunitrazepam, and ketamine to facilitate acquaintance rape. Trials and reviews describing clinical effects, adverse effects, pharmacokinetics/pharmacodynamics, and usage trends were evaluated. Literature judged to be pertinent by the author was included in the discussion. Data Extraction/Data Synthesis Reports of the use of GHB, flunitrazepam, and ketamine in acquaintance rape appear in the medical literature and lay press. Many health care professionals may not be familiar with these medications, and information about caring for patients under their influence is limited. Victims lose their ability to ward off attackers, develop amnesia, and are unreliable witnesses. Because symptoms caused by these agents mimic those of alcohol, not all victims are screened for their presence. Legislative efforts to further limit the use of or access to GHB, flunitrazepam, and ketamine have been initiated at the state and federal levels. Pharmacists should know the symptoms of exposure to the three agents; they should understand treatment regimens, methods to detect the presence of these and other drugs that may have been used in a sexual assault, and techniques individuals can use to avoid becoming victims of drug-assisted acquaintance rape. Conclusion Because of their extensive drug knowledge and frequent access to patients, pharmacists are uniquely positioned to educate patients and other health care professionals about the dangers of acquaintance rape drugs and methods to reduce their risk of becoming victims.
94 citations
TL;DR: Patients may be less able to judge the technical quality of the care they receive, but they do judge their social interaction with the pharmacist, and Pharmacy professionals must increase patients' awareness of the value of pharmaceutical care services and make it important to their judgment of satisfaction.
Abstract: Objective: To explore the relationships between patients' satisfaction and (1) the level of pharmaceutical care services received, (2) patients' perceptions of the personal attention paid to them by the pharmacist, and (3) patients' perceptions of the pharmacist's ability to help them manage their asthma and prevent asthma-related problems. Design: Exploratory study using mail or telephone survey methods. Patients or Other Participants: Asthma patients (n = 250) enrolled in one of two Florida managed care organizations. Main Outcome Measures: Predictor variables were level of pharmaceutical care and patients' perceptions of personal attention and their pharmacist's ability to help them control their asthma. Outcome variable was patients' overall satisfaction with the care they received from their pharmacist. Results: The direct causal effects of level of care (standardized regression coefficient, (3 = 0.07) and patients' perception of pharmacists' ability to help (p = 0.01) on satisfaction were nonsignificant. Only personal attention had a significant direct path coefficient to patient satisfaction ((3 = 0.63). Although the level of care was associated with patient satisfaction (r= 0.32), its direct effect was not significant because of its joint association (r = 0.27) with personal attention. Patients' satisfaction was associated with the level of pharmaceutical care and their perception of the pharmacist's ability to help them with their asthma. However, personal attention from the pharmacist was most influential. Conclusion: Patients may be less able to judge the technical quality of the care they receive, but they do judge their social interaction with the pharmacist. Pharmacy professionals must increase patients' awareness of the value of pharmaceutical care services and make it important to their judgment of satisfaction.
75 citations
TL;DR: The effects of job stress on job turnover intention were mediated through career commitment, met expectations, organizational commitment, and job satisfaction, and an increase in the mean level of job satisfaction and organizational commitment decreased the likelihood ofJob turnover intention.
Abstract: Objective: The hypothesis for this study was that career commitment mediates the effects of job stress on several work-related attitudes of pharmacists. The effects of job stress, career commitment, met expectations, job satisfaction, and organizational commitment on job turnover intention were also investigated. Design: Cross-sectional mail survey. Setting: Nationwide sample of licensed pharmacy practitioners in the United States. Participants: 1,088 respondents (full- or part-time chain, independent, or hospital pharmacists) to a previous study. Main Outcome Measures: Rating scales measured each of the study variables. Demographic information was also collected. Data analyses included descriptive statistics, confirmatory factor analysis, and structural equation modeling with latent variables. Interventions: None. Results: Responses were received from 653 pharmacists out of 921 contacted (71%). The effects of job stress on job turnover intention were mediated through career commitment, met expectations, organizational commitment, and job satisfaction. Career commitment positively affected met expectations (β = 0.35), and met expectations positively affected organizational commitment (β = 0.66) and job satisfaction (β= 0.78). An increase in the mean level of job satisfaction and organizational commitment decreased the likelihood of job turnover intention. Independent pharmacy owners tended to have the most positive attitudes toward work. Conclusion: Strategies should be developed to increase the career commitment of pharmacists. Increased commitment can reduce the negative effects of job stress and improve work-related attitudes.
68 citations
TL;DR: From the pharmacist's perspective, important quality-of-worklife issues include job and career satisfaction, turnover intention, and patient care concerns are found in all practice settings.
Abstract: Objective To examine the quality of worklife of pharmacists across practice environments. Design Written survey mailed to a stratified random sample of pharmacists. Participants 2,014 pharmacist-members of the American Pharmaceutical Association (APhA) residing in the United States. Main Outcome Measures Work-related attitudes including job satisfaction, career satisfaction, organizational commitment, turnover intention, likelihood of voting for a union, and patient care issues. Results Usable surveys were returned by 1,199 practicing APhA members (60% response rate). Overall, work-related attitudes were generally positive. However, clear differences were identified in quality-of-worklife perceptions associated with practice setting, area of primary responsibility, and several demographic variables. Some quality-of-worklife concerns were found in all practice settings. While a majority of respondents indicated that they would not vote for a union at their place of employment if given the opportunity, 43% of staff employee pharmacists (who would likely be targeted in any union campaign) indicated that they would definitely or probably vote for a union. Conclusion From the pharmacist's perspective, important quality-of-worklife issues include job and career satisfaction, turnover intention, and patient care concerns. The data provide a point of departure for future dialogue, action, and research aimed at understanding and enhancing the quality of pharmacists' worklife.
62 citations
TL;DR: While creatine may enhance the performance of high-intensity, short-duration exercise, it is not useful in endurance sports and consumers should balance the quality of information supporting the use of creatine with the known and theoretical risks of using the product, including possible renal dysfunction.
Abstract: Objective: To provide an overview of the data on the efficacy and safety of the nutritional supplement creatine Data Sources: Human studies in English in MEDLINE, Current Contents, BIOSIS, Science Citation Index, and the popular media (including a LEXIS-NEXIS search and information from the World Wide Web and lay media) for 1966 to July 1999 using the search terms creatine, creatine supplement#, creatine monophosphate, and creatine NOT kinase. Data Synthesis: Creatine use is common among professional athletes. Its use has spread to college athletes, recreational athletes, and even children. Most creatine supplement regimens include a loading dose of 20 to 30 grams divided in 4 equal doses for 5 to 7 days, followed by a 2 gram per day maintenance dose. The increased creatine in the muscle may allow larger stores of phosphocreatine to build, and provide extra energy in the form of adenosine triphosphate. Despite the many clinical trials, high-quality research is lacking. Laboratory investigations of endurance isotonic exercises, strength and endurance during isotonic exercises, isokinetic torque, isometric force, and ergometer performance have yielded roughly an equal number of published studies showing a positive effect or lack of effect. Field studies (i.e., on subjects participating in sports activities) are less impressive than laboratory studies. Performance was more often improved for short-duration, high-intensity activities. Reports have linked creatine to weight gain, cramping, dehydration, diarrhea, and dizziness. Creatine may decrease renal function, but only two case reports of this effect have been published. Creatine appears to be well tolerated in short-term trials. Conclusion: While creatine may enhance the performance of high-intensity, short-duration exercise, it is not useful in endurance sports. Because commercially marketed creatine products do not meet the same quality control standards of pharmaceuticals, there is always a concern of impurities or doses higher or lower than those on the labeling. Consumers should balance the quality of information supporting the use of creatine with the known and theoretical risks of using the product, including possible renal dysfunction.
55 citations
TL;DR: General satisfaction with pharmacy services is high, but patients' perceived benefit and satisfaction with cognitive services is lower, and increased public awareness of pharmacists' capabilities and a more proactive approach to providing cognitive services are needed.
Abstract: Objective To determine whether patients targeted to receive intervention from an asthma management program reported receiving more services and had greater perceived benefit and satisfaction with those services compared with asthma patients not targeted by the program. Design Mailed survey. Setting Community pharmacy. Patients 471 community-based patients receiving asthma medications from 44 intervention pharmacies and 1,164 patients from 46 usual care (control) pharmacies. Main Outcome Measures Five-point agreement scale measuring asthma services received, perceived value of the services, and satisfaction. Results Usable surveys were received from 39.0% of intervention patients and 42.4% of controls. There were no statistically significant differences between groups in the frequency of provision of listed services. Approximately 60% of respondents from both groups received written materials on asthma medications and 54% received inhaler counseling; both were rated high for perceived benefit. Fewer than 20% reported being counseled about asthma triggers. Fewer than 5% reported pharmacists talking to physicians on their behalf. General satisfaction with pharmacy services was high (78.2% agree or strongly agree), but not statistically different between groups. More than 65% believed that pharmacists spend enough time counseling patients. Several comments indicated that patients did not expect or ask for information because they were unaware that services were available and/or they had already been counseled by their physician. Responses to the statement "my asthma is better controlled because of help given to me by the pharmacist" were equivocal and not different between groups. Conclusion Overall, there were few differences between groups. General satisfaction with pharmacy services is high, but patients' perceived benefit and satisfaction with cognitive services is lower. Increased public awareness of pharmacists' capabilities and a more proactive approach to providing cognitive services is needed.
54 citations
TL;DR: Self-reported rates of patient counseling concerning asthma medications in the community pharmacy setting are low and adequately address neither the educational needs of patients nor the recommendations of the National Asthma Education and Prevention Program.
Abstract: Objective To assess the level of expectation and satisfaction of patients with asthma regarding the counseling provided by community pharmacists, and to identify the counseling information patients consider important in helping them manage their asthma. Design Mailed survey. Participants: 208 patients seen in the University of Utah Asthma Clinic for at least 3 months, age 18 years or older, and on at least 1 asthma medication. Main Outcome Measures: Frequency of pharmacist-provided asthma medication counseling, patients' perception of the importance of counseling, and their satisfaction with counseling. Results: Response rate was 55% (106 of 194 surveys returned). The majority of patients (> 90%) indicated that their community pharmacist "never" or "sometimes" discussed the management of their asthma with them. Frequency of counseling in three predefined areas of asthma education (role of medications, inhaler technique, and prevention of asthma attacks) was 1.91, 1.72, and 1.31, respectively (1=never, 4=always). Most patients (76%) considered these areas of counseling to be important for the management of their asthma. Most patients (62%) were "somewhat" to "pretty" satisfied with the type and amount of asthma counseling provided by their pharmacist. Counseling sessions averaged less than 3 minutes. Only 25% of patients would be willing to pay an additional amount for pharmaceutical care. Conclusion: Self-reported rates of patient counseling concerning asthma medications in the community pharmacy setting are low and adequately address neither the educational needs of patients nor the recommendations of the National Asthma Education and Prevention Program.
44 citations
TL;DR: A balanced middle ground must be found regarding the benefits of MPD and its abuse potential and education of clinicians, patients, and family members is key in ensuring that MPD is used appropriately.
Abstract: OBJECTIVE To address the question of the significant increase in methylphenidate (MPD) prescriptions being written and to make recommendations for health care providers involved in providing care for patients with attention deficit hyperactivity disorder (ADHD) and their families. DATA SOURCES Medline search 1966-1998 for professional articles using the following search terms--methylphenidate, children, adolescents, abuse; Internet search using MPD, Ritalin, and ADHD; and Paper Chase search using methylphenidate. DATA EXTRACTION The available literature regarding potential abuse or diversion of MPD consists of case reports, review articles, newspaper articles, and a Drug Enforcement Administration (DEA) publication. All available literature sources were used. DATA SYNTHESIS Although the media and DEA report significant abuse and diversion of prescribed MPD, a review of the available literature did not reveal data to substantiate these claims. Nonetheless, there are reasons to suspect that abuse and diversion occur. A potential contributing factor to abuse is the reported similarities in pharmacodynamics and pharmacokinetics between MPD and cocaine. Recommendations are made to decrease the possibility of abuse and diversion of prescribed MPD. CONCLUSION A balanced middle ground must be found regarding the benefits of MPD and its abuse potential. Education of clinicians, patients, and family members is key in ensuring that MPD is used appropriately.
42 citations
TL;DR: Performance of CS was strongly affected by payment and other situational factors, including practice setting and volume of prescriptions dispensed, according to the Washington State Cognitive Activities and Reimbursement Effectiveness Project.
Abstract: Objective: To determine the frequency and severity of sexual harassment in the pharmacy workplace for both male and female pharmacists, and to identify: (1) instigators, (2) places of occurrence, and (3) pharmacists' responses. Design: Prospective randomized trial. Community pharmacies were randomized to a documentation-and-payment group (study group) and a documentation-only group (control). Participating pharmacies and pharmacists were surveyed by mail, and responses were linked to a documented CS database. Setting: Community pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents. Participants: 200 community pharmacies and their pharmacists (110 study, 90 control) participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project. Interventions: Payment for CS. All participants documented CS. Study group pharmacies billed Medicaid for services performed in identifying and resolving drug therapy-related problems. Main Outcome Measures: Documentation of CS. Results: Documentation of CS was more likely if the pharmacist was an owner or manager, if documentation was not perceived as burdensome, and if the pharmacy had a low ratio of prescription to total sales. Higher documentation rates were associated with study group status, lower pharmacy prescription volume as a percentage of total sales, and a higher percentage of prescriptions billed to Medicaid. Among pharmacists, two setting variables-medical center location and rural location-were associated with higher documentation rates. Conclusion: Performance of CS was strongly affected by payment and other situational factors, including practice setting and volume of prescriptions dispensed. Pharmacies and pharmacists were also more likely to perform CS if the target patient population represented a relatively large percentage of that pharmacy's patient clientele.J Am Pharm Assoc. 1999;39:640–9.
TL;DR: Amlodipine was stable in two suspensions when stored in plastic prescription bottles for 91 days at 4 degrees C or 56 days at 25 degrees C, and these formulations may be considered for pediatric or elderly patients who are unable to swallow tablets.
Abstract: Objective: To determine the stability of amlodipine besylate in two liquid dosage forms under refrigeration and at room temperature. Design: Commercially available amlodipine tablets (Norvasc-Pfizer) were used to prepare two suspensions: one in extemporaneously prepared 1% methylcellulose in syrup (1:1), and another in equal volumes of commercially available OraPlus/OraSweet. Each suspension containing amlodipine 1 mg/mL was stored in 10 plastic prescription bottles; 5 were stored at 4°C and 5 at 25°C. Samples were collected immediately after preparation (day 0) and on days 7, 14,28,42,56,70, and 91. Amlodipine concentration was measured by stability-indicating HPLC method (n = 15). Setting: Research laboratory at Children's Hospital. Main Outcome Measures: Physical and chemical stability (> 90% of the initial concentration) of amlodipine in the two extemporaneously prepared suspensions during storage in plastic prescription bottles at 4°C and 25°C. Results: Observed mean concentrations exceeded 90% of the initial concentrations in both suspensions for 91 days at 4°C and 56 days at 25°C. No noticeable change in physical appearance or odor was observed; pH changed slightly in the methylcellulose-containing formulation stored at 25°C. Conclusion: Amlodipine was stable in two suspensions when stored in plastic prescription bottles for 91 days at 4°C or 56 days at 25°C. These formulations may be considered for pediatric or elderly patients who are unable to swallow tablets. The liquid dosage form would also permit accurate administration of amlodipine doses to infants and young children based on their body weight.
TL;DR: Pharmacotherapy is currently the most common treatment modality for insomnia, but long-term use of hypnotic agents can become complicated by drug tolerance, dependence, or rebound insomnia.
Abstract: Objective
To review current issues in the pharmacologic and nonpharmacologic management of insomnia.
TL;DR: Community pharmacies can effectively implement an anticoagulation education and monitoring program using fingerstick capillary whole blood testing, and this pilot study shows that this process can be effective.
Abstract: Objective: To determine the process for establishing community pharmacy-based anticoagulation education and monitoring programs using fingerstick capillary whole blood testing. Design: Pilot community-based intervention study using convenience sample of patients. Setting: Three community pharmacies with pre-established health education centers and laboratories certified for moderate complexity. Participants: 26 patients were referred to the clinics by 2 primary care physicians for each pharmacy, most with a diagnosis of atrial-fibrillation. Intervention: Patient assessment, including adherence to prescribed regimens; changes in medication use, including prescription and nonprescription medications, vitamins, health foods, and nutrition supplements; changes in diet and ethanol consumption; assessment of adverse experiences; and needed changes in warfarin dosage. Main Outcome Measures: Percentage of international normalized ratio (INR) values within therapeutic range, major bleeding events, and thrombotic events. Results: A total of 21 patient charts were available for analysis. More than 80% of patients had INR values within their targeted range (i 0.2) 60% or more of the time, comparable with values reported for anticoagulation clinics. Of the 235 INR values obtained during the study, 75% were within the individualized targeted therapeutic range (e.g., 2 to 3 ± 0.2). One patient experienced a major bleeding event related to an underlying cancer. None of the patients experienced a thrombotic event. Conclusion: Community pharmacies can effectively implement an anticoagulation education and monitoring program.
TL;DR: Although the PCCP was successful in preparing pharmacists to perform the pharmaceutical care components covered in the program, time seems to be one of the major barriers for their actual implementation into practice.
Abstract: Objective: To measure the effects of a Pharmaceutical Care Certificate Program (PCCP) in community pharmacists. Design: This study compared the effects of the PCCP over time using a repeated measures design. Setting: Retail, independent, and managed care pharmacy. Participants: 36 pharmacists who participated in the PCCP. Interventions: PCCP, which was developed to train pharmacists in (1) practice reengineering, (2) components of pharmaceutical care, and (3) drug therapy management of disease states. Main Outcome Measures: (1) pharmacist job functions, (2) pharmaceutical care job functions, (3) pharmaceutical care components, (4) pharmacist-perceived barriers to providing pharmaceutical care, and (5) proposed solutions for overcoming barriers. Results: When comparing pharmacists at baseline and after 1 year, pharmacists after 1 year felt significantly better prepared to perform all pharmaceutical care components. Conclusion: Although the PCCP was successful in preparing pharmacists to perform the pharmaceutical care components covered in the program, time seems to be one of the major barriers for their actual implementation into practice. One proposed solution is the development of partnerships between pharmacists and schools of pharmacy.
TL;DR: Reconstituted gemcitabine as the hydrochloride salt in the original vials is chemically stable at room temperature for 35 days but may develop crystals when stored at 4 degrees C but does not redissolve upon warming to room temperature.
Abstract: Objective To evaluate the physical and chemical stability of gemcitabine hydrochloride (Gemzar-Eli Lilly and Company) solutions in a variety of solution concentrations, packaging, and storage conditions. Design: Controlled experimental trial. Design Controlled experimental trial. Setting Laboratory Interventions Test conditions included (1) reconstituted gemcitabine at a concentration of 38 mg/mL as the hydrochloride salt in 0.9% sodium chloride or sterile water for injection in the original 200 mg and 1 gram vials; (2) reconstituted gemcitabine 38 mg/mL as the hydrochloride salt in 0.9% sodium chloride injection packaged in plastic syringes; (3) diluted gemcitabine at concentrations of 0.1 and 10 mg/mL as the hydrochloride salt in polyvinyl chloride (PVC) minibags of 0.9% sodium chloride injection and 5% dextrose injection; and (4) gemcitabine 0.1, 10, and 38 mg/mL as the hydrochloride salt in 5% dextrose in water and 0.9% sodium chloride injection as simulated ambulatory infusions at 32°C. Test samples of gemcitabine hydrochloride were prepared in the concentrations,solutions, and packaging required. Main Outcome Measures Physical and chemical stability based on drug concentrations initially and after 1,3, and 7 days of storage at 32°C and after 1, 7, 14, 21, and 35 days of storage at 4°C and 23°C Results The reconstituted solutions at a gemcitabine concentration of 38 mg/mL as the hydrochloride salt in the original vials occasionally exhibited large crystal formation when stored at 4°C for 14 days or more. These crystals did not redissolve upon warming to room temperature. All other samples were physically stable throughout the study. Little or no change in particulate burden or the presence of haze were found. Gemcitabine as the hydrochloride salt in the solutions tested was found to be chemically stable at all concentrations and temperatures tested that did not exhibit crystallization. Little or no loss of gemcitabine occurred in any of the samples throughout the entire study period. However, refrigerated vials that developed crystals also exhibited losses of 20% to 35% in gemcitabine content. Exposure to or protection from light did not alter the stability of gemcitabine as the hydrochloride salt in the solutions tested. Conclusion Reconstituted gemcitabine as the hydrochloride salt in the original vials is chemically stable at room temperature for 35 days but may develop crystals when stored at 4 °C. The crystals do not redissolve upon warming. Gemcitabine prepared as intravenous admixtures of 0.1 and 10 mg/mL as the hydrochloride salt in 5% dextrose injection and 0.9% sodium chloride injection in PVC bags and as a solution of 38 mg/miln 0.9% sodium chloride injection packaged in plastic syringes is physically and chemically stable for at least 35 days at 4 °C and 23 °C. Gemcitabine as the hydrochloride salt is stable for at least 7 days at concentrations of 0.1, 10, and 38 mg/miln 5% dextrose injection and 0.9% sodium chloride injection stored at 32 °C during simulated ambulatory infusion.
TL;DR: For all result categories except "add drug therapy," the extrapolated cost savings in the paid group exceeded the savings estimated from the nonpaid group, sometimes by a considerable amount.
Abstract: OBJECTIVE: To determine the changes in drug costs associated with drug therapy changes resulting from pharmacists' cognitive services (CS) provided to Medicaid recipients during a 1-year period following the documented CS. DESIGN: A study-control group analysis of documented pharmacists' CS interventions linked to Medicaid prescription claims. Each CS resulting in a drug therapy change was linked to an index prescription claim and all refills for the same drug within 365 days. The drug cost change associated with the CS was calculated as the difference between the estimated cost of the prescription as originally written less the actual cost to Medicaid for the stream of refills dispensed. SETTING: Pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents. PARTICIPANTS: Approximately 200 community pharmacies participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project. Pharmacies were randomly assigned to a group that was paid a fee for each CS provided or a group that was not paid. INTERVENTION: Payment for CS. MAIN OUTCOME MEASURES: Downstream drug costs associated with CS resulting in a drug therapy change. RESULTS: CS resulting in drug therapy changes accounted for 5,417 out of 20,240 (27%) documented CS in the CARE Project. Of the 2,002 CS records analyzed in this study, 76% indicated a change in the prescribed drug or drug regimen, 9% indicated that a drug was added, 5% indicated that a current drug was discontinued, and 10% indicated that an originally prescribed drug was never dispensed. Only 9% involved generic substitution; all other changes would have necessitated prior prescriber approval. Overall, CS resulting in a drug therapy change generated a mean drug cost savings of $13.05 per CS intervention. There were no significant differences in average savings per intervention between the paid and nonpaid groups. CONCLUSION: For all result categories except "add drug therapy," the extrapolated cost savings in the paid group exceeded the savings estimated from the nonpaid group, sometimes by a considerable amount. At the payment rate used in this study, paying for CS that result in a drug therapy change (except add drug therapy) is estimated to save an additional $10 per 1,000 prescriptions dispensed. Those CS that result in addition of drug therapy are estimated to add an incremental cost of about $13 per 1,000 prescriptions. A sensitivity analysis revealed that a higher intervention rate would lead to a higher potential savings. This finding suggests that efforts to encourage CS interventions may lead to greater savings.
TL;DR: Some products showed evidence of poor formulation and/or poor quality control as indicated by excessive friability, failure to disintegrate and dissolve, and excessive variation in hardness.
Abstract: Objective To evaluate and compare the quality of a sample of melatonin products, as measured by the United States Pharmacopeial Convention (USP) General Tests and Assays for Nutritional Supplements (other than Microbial Limits) and certain other tests. Design Five immediate-release, two sublingual, and two controlled-release products were randomly gathered from a health food store, groceries, and pharmacies in the Baltimore–Washington metropolitan area. Main Outcome Measures Weight variation, disintegration (not applicable for controlled-release products), and drug dissolution, based on USP standards. Twelve-hour dissolution profiles were obtained from the controlled-release products. All tablets were also evaluated for friability following the USP procedure and for hardness following unofficial procedures. Results All products passed the weight variation test. Two products showed excessive friability. Three immediate-release products failed both the disintegration and the dissolution tests. One of the three products demonstrated a threefold difference in hardness. One controlled-release product released 90% of melatonin in four hours in the dissolution test; the other released 90% of its content in 12 hours. Conclusion Some products showed evidence of poor formulation and/or poor quality control as indicated by excessive friability, failure to disintegrate and dissolve, and excessive variation in hardness. In vitro release profiles of the two controlled-release products were substantially different. The poor quality of some supplements should be a concern to consumers and health care providers.
TL;DR: Pharmacists who follow these guidelines for billing third party payers for pharmaceutical care services should notice an increase in the number of paid claims.
Abstract: Objective To describe the steps pharmacists must complete when seeking compensation from third party payers for pharmaceutical care services. Data Source Government publications; professional publications, including manuals and newsletters; authors' personal experience. Data Synthesis Pharmacists in increasing numbers are meeting with success in getting reimbursed by third party payers for patient care activities. However, many pharmacists remain reluctant to seek compensation because they do not understand the steps involved. Preparatory steps include obtaining a provider/supplier number, procuring appropriate claim forms, developing data collection and documentation systems, establishing professional fees, creating a marketing plan, and developing an accounting system. To bill for specific patient care services, pharmacists need to collect the patient's insurance information, obtain a statement of medical necessity from the patient's physician, complete the appropriate claim form accurately, and submit the claim with supporting documentation to the insurer. Although many claims from pharmacists are rejected initially, pharmacists who work with third party payers to understand the reasons for denial of payment often receive compensation when claims are resubmitted. Conclusion Pharmacists who follow these guidelines for billing third party payers for pharmaceutical care services should notice an increase in the number of paid claims.
TL;DR: Assessment of knowledge and practice patterns of primary care physicians relating to the detection and treatment of diabetic nephropathy and the benefits of angiotensin-converting enzyme inhibitors demonstrated a unique opportunity for pharmacists to become educators to physicians in their community.
Abstract: Objective: To assess the knowledge and practice patterns of primary care physicians relating to the detection and treatment of diabetic nephropathy and to compare these findings with current standards of care. Design: National survey. Participants: 1,000 randomly selected physicians Setting: Primary care. Intervention: Mailed questionnaire consisting of a six-page "Diabetes Survey." Results: Among the 1,000 primary care physicians, 950 were considered eligible for the survey. Sufficiently completed surveys were returned by 216 physicians, yielding an adjusted response rate of 22%. In general, patients with type 1 diabetes were monitored more intensively than those with type 2 diabetes. Primary care physicians were more likely to monitor patients for overt proteinuria (86%) than microalbuminuria (58%). Of the physicians who claimed to monitor patients for microalbuminuria, 39% chose inappropriate methods for detection, which lowers the percentage of physicians who correctly monitored for microalbuminuria to 37%. More than 95% of the respondents were aware of the benefits of angiotensin-converting enzyme inhibitors (ACEls) in delaying the progression of diabetic nephropathy. Patients with proteinuria (86%) were more likely to be treated with an ACEI than were patients with microalbuminuria (79%). If a patient presented with proteinuria but without hypertension, the use of ACEls fell to 75%. Rates of referral to a nephrologist were low at early stages of the disease (3% to 11%) and remained relatively low (28%) at later stages, even when serum creatinine was greater than 3 mg/dL. Conclusion: Further efforts directed toward education of primary care physicians about diabetic nephropathy have the potential to improve the care of patients with this disorder. These findings demonstrate a unique opportunity for pharmacists to become educators to physicians in their community.
TL;DR: A system for documentation and payment of pharmacists' CS to Medicaid recipients was implemented successfully and relatively easily in community pharmacies.
Abstract: Objective: To determine the changes in drug costs associated with drug therapy changes resulting from pharmacists' cognitive services (CS) provided to Medicaid recipients during a 1-year period following the documented CS. Design: A study-control group analysis of documented pharmacists' CS interventions linked to Medicaid prescription claims. Each CS resulting in a drug therapy change was linked to an index prescription claim and all refills for the same drug within 365 days. The drug cost change associated with the CS was calculated as the difference between the estimated cost of the prescription as originally written less the actual cost to Medicaid for the stream of refills dispensed. Setting: Pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents. Participants: Approximately 200 community pharmacies participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project. Pharmacies were randomly assigned to a group that was paid a fee for each CS provided or a group that was not paid. Interventions: Payment for CS. Main Outcome Measures: Downstream drug costs associated with CS resulting in a drug therapy change. Results: CS resulting in drug therapy changes accounted for 5,417 out of 20,240 (27%) documented CS in the CARE Project. Of the 2,002 CS records analyzed in this study, 76% indicated a change in the prescribed drug or drug regimen, 9% indicated that a drug was added, 5% indicated that a current drug was discontinued, and 10% indicated that an originally prescribed drug was never dispensed. Only 9% involved generic substitution; all other changes would have necessitated prior prescriber approval. Overall, CS resulting in a drug therapy change generated a mean drug cost savings of $13.05 per CS intervention. There were no significant differences in average savings per intervention between the paid and nonpaid groups. Conclusion: For all result categories except "add drug therapy," the extrapolated cost savings in the paid group exceeded the savings estimated from the nonpaid group, sometimes by a considerable amount. At the payment rate used in this study, paying for CS that result in a drug therapy change (except add drug therapy) is estimated to save an additional $10 per 1,000 prescriptions dispensed. Those CS that result in addition of drug therapy are estimated to add an incremental cost of about $13 per 1,000 prescriptions. A sensitivity analysis revealed that a higher intervention rate would lead to a higher potential savings. This finding suggests that efforts to encourage CS interventions may lead to greater savings.
TL;DR: Pharmacists can assist in the prevention of HIV transmission through nonprescription needle sales to IDUs, and this role can be promoted through education of pharmacists and development of referral systems for IDUs.
Abstract: Objective To determine louisiana pharmacy managers' attitudes and practices regarding needle and syringe sales to suspected injection drug users (IDUs) without prescriptions, and to assess which factors affect their decisions to sell nonprescription needles and syringes. Design Cross-sectional mail survey. Setting The six most populous cities of Louisiana. Participants Pharmacy managers with active permits not affiliated with large hospitals or institutions. Main Outcome Measures Selling nonprescription needles to suspected IDUs, willingness to sell nonprescription needles to suspected IDUs, and reasons for not selling nonprescription needles to suspected IDUs. Results Approximately one-fourth of the respondents reported that they had sold needles and syringes to suspected IDUs without a prescription. The most frequently cited reason for not selling was fear of increasing drug use; however, many of these pharmacists reported that they would conduct a sale if the customer had a referral from an agency or clinic. Conclusion Pharmacists can assist in the prevention of HIV transmission through nonprescription needle sales to IDUs. This role can be promoted through education of pharmacists and development of referral systems for IDUs.
TL;DR: In this paper, the authors identify and measure intergender and interethnic differences in preferences and expectations of pharmacy students, focusing on similarities and differences in expected sources of job satisfaction and dissatisfaction.
Abstract: Objectives To identify and measure intergender and interethnic differences in preferences and expectations of pharmacy students. Design Two-part survey. One part addressed systematic variations in work-related expectations and preferences between the sexes and among ethnic minorities that may result from cumulative disadvantage or attitudinal traits; the other part focused on similarities and differences in expected sources of job satisfaction and dissatisfaction. Setting College of Pharmacy, Nova Southeastern University. Participants 171 students enrolled in their final semester of didactic training (that is, immediately before rotations or internship). Interventions Not applicable. Main Outcome Measures Significance of intergender and interethnic disparities was determined using t tests. Results No significant intergender disparities were detected in income expectations, anticipated level of job satisfaction, estimated time from graduation to passing the Board exam or working, or in preferred or expected sector of first job. African American students expected to earn lower levels of income, experience less satisfaction in their first job as a pharmacist, and work longer hours. Hispanic and Asian American students exhibited less confidence in their ability to pass the Board exam and in the allocative function of the job market. Salary and ability to help patients were the two sources of job satisfaction anticipated most frequently, whereas work overload ranked first among the anticipated sources of job dissatisfaction. Conclusion The rapidly changing gender composition of the profession has altered traditional intergender differences in outlook and attitudinal traits, contributing to the disappearance of intergender disparities identified in previous research. However, significant interethnic differences in preferences and expectations suggest the presence of cumulative disadvantage among minorities.
TL;DR: The tools and processes used in the practice enhancement program of the Pharmaceutical Care Research and Education Project increased community pharmacists' competency for providing pharmaceutical care, by helping them develop the needed skills, knowledge, and attitudes.
Abstract: Objective: To describe the tools and processes used in the practice enhancement program (PEP) of the Pharmaceutical Care Research and Education Project to enable community pharmacists to acquire the necessary skills, knowledge, and attitudes to deliver comprehensive pharmaceutical care to elderly ambulatory patients Setting: Independent community pharmacies in Alberta Practice Description: The PEP was designed to allow self-directed learning in a problem-based environment The intent was for pharmacists to apply the knowledge they gained to improve drug therapy outcomes Practice Innovation: As a systematic approach to providing care, several tools were adapted to help pharmacists execute tasks required by the nine steps of the pharmaceutical care process proposed by Hepler and Strand These tools and processes facilitated (1) self-directed learning about diseases and drugs, (2) acquisition of relevant patient data, (3) a consistent and stepwise approach to the identification and resolution of drug-related problems, (4) documentation of care provided, and (5) continuity of care Results: To help pharmacists in the PEP acquire the necessary competency to provide pharmaceutical care, they were required to use the tools and processes described herein to work up and resolve patient problems Initially, patient problems were presented as paper cases covering a range of acute and chronic problems, including topics applicable to geriatric patients This was followed by a practicum phase wherein patient problems represented individuals from among their clientele Conclusion: The tools and processes used in the project increased community pharmacists' competency for providing pharmaceutical care, by helping them develop the needed skills, knowledge, and attitudes
TL;DR: Physicians desire pharmacist involvement in specific areas of care for patients with epilepsy, and the feasibility of implementing the Pharmacist Note and similar programs appears promising, however, pharmacists identified barriers to implementation, and these barriers need to be addressed.
Abstract: Objective To obtain primary care physicians' and community pharmacists' opinions of the Pharmacist Note, a model epilepsy patient profile maintained by the pharmacist and transmitted to the physician as needed, and the information it contains. Design A cross-sectional descriptive study design was used for collecting and analyzing data. Separate surveys were developed and mailed to physicians and pharmacists. Participants 554 primary care physicians and 114 community pharmacists in Ohio who interact regularly with epilepsy patients. Main Outcome Measures: Pharmacist and physician opinions on the Pharmacist Note program. Results Physicians ranked seizure frequency as their most useful piece of information, followed by medication compliance and drug interaction screening. For medication profile and drug interaction screening, most physicians currently use themselves as their primary source of information, although a significant number would prefer to use pharmacists as information sources in these areas (p Conclusion Physicians desire pharmacist involvement in specific areas of care for patients with epilepsy, and the feasibility of implementing the Pharmacist Note and similar programs appears promising. However, pharmacists identified barriers to implementation, and these barriers need to be addressed if this type of program is to be successful.
TL;DR: This study provides a baseline for evaluating the impact of training programs or other alterations in the practice environment on pharmacists' work-related behaviors and is useful in helping grocery chain management better understand how pharmacy personnel are currently being utilized.
Abstract: Objective To measure grocery chain pharmacists' work-related behaviors to assess the impact of a Pharmaceutical Care Certificate Program (PCCP) and other future interventions intended to alter pharmacists' practice behaviors. Design This study used multidimensional work sampling (MWS), a work measurement methodology that breaks “work” into three components: activity (what was done), contact (with whom the activity was performed), and function (the purpose or objective of the activity). Pharmacists were signaled at random intervals during the workday by a random signal generator. A selection was made from a list of items in each of the three dimensions of work to form an activity-contact-function combination code that described the work-related behavior at that point in time. Setting and Participants Pharmacists in 15 grocery chain stores in the Indianapolis area; 20 pharmacists were enrolled in Purdue University's PCCP and 10 served as controls. Data were collected for a period of six weeks during April through June 1997 before the beginning of the PCCP program. Main Outcome Measures Pharmacists' work-related behaviors. Results Writing/keyboarding was the most frequently recorded activity (22%), followed by one-to-one meetings (21.6%), and drug preparation (18%). Pharmacists spent most of their time working alone (62.9%), while a smaller but still substantial proportion of time was spent interacting with patients (17.9%). The most frequently recorded purpose (i.e., function) of pharmacists' activities was drug distribution (23.9%), followed by personal time (12.4%), receiving or transferring a medication order (10.2%), and patient counseling (6.6%). Out of a possible 1,760 activity-contact-function combinations, 10 accounted for 46.3% of all reported observations, with “Prepare drug-Self-Drug distribution” representing the most frequently recorded activity-contact-function combination (15.7%). Conclusion MWS is useful in helping grocery chain management better understand how pharmacy personnel are currently being utilized. This study provides a baseline for evaluating the impact of training programs or other alterations in the practice environment on pharmacists' work-related behaviors.
TL;DR: Antidepressants, especially extended-release venlafaxine, may be considered first-line therapy for GAD and buspirone may be indicated in individuals with histories of chemical dependency who have failed or could not tolerate antidepressants.
Abstract: Objective: To review the epidemiology, etiology, clinical presentation, diagnosis, clinical course, and treatment of generalized anxiety disorder (GAD). Data Sources: Controlled studies conducted in humans and published in English as identified through a MEDLINE search of the years 1975-1999 using the search terms generalized anxiety disorder, treatment, epidemiology, outcomes. Study Selection: Not applicable. Data Extraction: By the author. Data Synthesis: GAD is now a clearly identified psychiatric illness. Patients often suffer from this disorder from childhood into adult years. Treatment includes benzodiazepines, buspirone, and extended-release venlafaxine. The nonbenzodiazepines have a longer time to onset of therapeutic effects but are equivalent to benzodiazepines by the third or fourth week of treatment. All agents have a favorable side effect profile with cautions exercised in the use of benzodiazepines and chemical dependency. Long-term outcome may be better with nonbenzodiazepine agents. Buspirone efficacy studies have not been performed in patients diagnosed with GAD using current criteria. The most extensively studied antidepressant is extended-release venlafaxine, which has been effective in acute and long-term studies. In comparison with buspirone and placebo, extended-release venlafaxine demonstrated equal to greater efficacy. Conclusion: Antidepressants, especially extended-release venlafaxine, may be considered first-line therapy for GAD. Buspirone may be indicated in individuals with histories of chemical dependency who have failed or could not tolerate antidepressants. While benzodiazepines have faster onset of effect, their use should be limited to short-term situations because of the possibility of dependence.