Showing papers in "Journal of The American Pharmacists Association in 2004"
TL;DR: Little agreement exists among commonly used drug interaction compendia for DDIs that were classified in fall 2001 as having the highest clinical relevance and importance, indicating a concerted effort to identify DDIs of the highestclinical importance is needed to design effective strategies to avoid and manage them.
Abstract: Objective To evaluate the agreement among drug–drug interaction (DDI) compendia as to designation of interactions as having the greatest clinical importance ("major" DDIs). Design Cross-sectional, one-time evaluation. Setting United States in fall 2001. Participants Not applicable. Interventions Major DDIs involving prescription medications likely to be dispensed in the community and ambulatory pharmacy settings were identified as listed in four compendia that provide specific, detailed information about DDIs ( Drug Interaction Facts , Drug Interactions : Analysis and Management , Evaluations of Drug Interactions , and the MicroMedex DRUG - REAX program ). Main Outcome Measure Level of agreement between DDI compendia as assessed by the intraclass correlation coefficient (ICC). Results Overall, 406 major DDIs were listed in one or more of the four compendia. Only 9 (2.2%) of these major DDIs were listed in all four compendia; in fact, the majority of interactions were listed in only one compendium (291 DDIs, 71.7%), despite these interactions being considered of greatest clinical relevance by at least one compendium. The ICC among the compendia was −0.092, indicating low agreement on the classification of major DDIs. Conclusion Little agreement exists among commonly used drug interaction compendia for DDIs that were classified in fall 2001 as having the highest clinical relevance and importance. A concerted effort to identify DDIs of the highest clinical importance is needed to design effective strategies to avoid and manage them.
195 citations
TL;DR: Using an expert panel and a standard evaluation tool, 25 clinically important drug interactions that are likely to occur in the community and ambulatory pharmacy settings and detected by a computerized pharmacy system were identified.
Abstract: Objective To develop a list of clinically important drug–drug interactions (DDIs) likely to be encountered in community and ambulatory pharmacy settings and detected by a computerized pharmacy system. Design Cross-sectional, one-time evaluation. Setting United States in fall 2001. Participants An expert panel comprising two physicians, two clinical pharmacists, and an expert on DDIs. Interventions Systematic review of drug interaction compendia and published literature, ratings (on a 1 to 10 scale) of various clinical aspects of DDIs (e.g., clinical importance, quality and quantity of evidence, causal relationship, risk of morbidity and mortality), and a modified Delphi consensus-building process. Main Outcome Measure Panelists’ opinions about clinical importance of DDIs. Results The expert panel considered 56 DDIs. Of these, 28 had a mean clinical importance score of 8.0 or more. The ratings for clinical importance ranged from 3.2 to 9.6, with a mean ± SD of 7.5 ± 1.5 across the combinations examined. The mean score for the quality of literature suggesting the interaction exists ranged from 1.0 to 9.6, with a mean ± SD of 5.8 ± 2.5. In terms of substantiation of the interactions evaluated, the mean ± SD rating was 6.3 ± 2.2, with a range from 1.4 to 9.2. Through the modified Delphi process, the panel determined that 25 interactions were clinically important. Conclusion Using an expert panel and a standard evaluation tool, 25 clinically important drug interactions that are likely to occur in the community and ambulatory pharmacy settings were identified. Pharmacists should take steps to prevent patients from receiving these interacting medications, and computer software vendors should focus interaction alerts on these and similarly important DDIs.
182 citations
TL;DR: In this paper, the authors describe the nature and extent of patient counseling in community pharmacies and determine whether current counseling practices are influenced by pharmacist and pharmacy characteristics and variations in state regulation of patient care.
Abstract: Objective To describe the nature and extent of patient counseling in community pharmacies and determine whether current counseling practices are influenced by pharmacist and pharmacy characteristics and variations in state regulation of patient counseling. Design Observational, cross-sectional study. Setting 306 community pharmacies in eight states. Participants Trained shoppers (acting as patients). Interventions Three new prescriptions were presented in each pharmacy, and regression techniques were used to analyze the effects of pharmacist age, pharmacy type, and busyness; whether written information was provided; and "intensity" of a state's patient counseling regulation as measured by its scope, stringency, and duration. Main Outcome Measures Whether any or all of these events occurred: pharmacist talked with shopper, oral drug information was given, oral risk information was given, and/or questions were asked to assess shopper understanding; number of informational items mentioned (range 0–7) was also recorded. Results About 63% of the shoppers were given oral drug information (mean = 2.3 items). Shoppers with a younger responsible pharmacist were more likely than other shoppers to receive risk information, a higher number of informational items, and assessment of understanding. While pharmacy type was unrelated to counseling, busyness reduced the odds of any pharmacist talk, oral information-giving, and assessment of understanding. Counseling practices varied significantly according to the intensity of a state's counseling regulation, with frequency of any information provision climbing from 40% to 94% as states' counseling regulations increased in intensity. More intensive regulations also increased the likelihood of any pharmacist talk, any provision of risk information, any assessment of shopper understanding, and amount of oral information given. Conclusion Counseling varied significantly according to intensity of state regulation, pharmacy busyness, and age of responsible pharmacist. These results present important challenges to state boards of pharmacy, pharmacy associations, managers, and individual practitioners who are in a position to improve this important element of patient care.
163 citations
TL;DR: Wanting to spend more time in consultation was most positively associated with role ambiguity, role overload, and role conflict and most negatively associated with job satisfaction, while gender, race, years of experience, marital status, and children also affected work attitudes.
Abstract: Objectives To provide a current profile of pharmacists' attitudes toward worklife and determine how demographic, family, and practice variables influence work attitudes. Design Cross-sectional descriptive survey. Setting Nationwide sample of licensed pharmacists in the United States. Participants 1,737 actively practicing pharmacists. Interventions Mailed survey. Main Outcome Measures Previously validated rating scales were used to measure job satisfaction, job stress, work-home conflict, role overload, role ambiguity, and role conflict. Family variables included the number and age(s) of children and marital status; demographic variables included age, gender, race, years of experience, region, and degree; practice variables included setting, position, work status, and work activities. Results Although 67.2% of pharmacists were satisfied with their job, more than 68% experienced job stress and role overload, and 48% experienced work-home conflict. The levels of role ambiguity, role conflict, and job stress were significantly higher in chain, mass merchandiser, and hospital settings relative to independent settings. Wanting to spend more time in consultation was most positively associated with role ambiguity, role overload, and role conflict and most negatively associated with job satisfaction. Gender, race, years of experience, marital status, and children also affected work attitudes. Conclusion Those interested in the quality of worklife of pharmacists need to develop and implement realistic methods to decrease the role stress that pharmacists continue to face. Unless role stress of pharmacists is lessened, the profession may be endangering not only the physical and mental health of its current and future practitioners, but possibly compromising patient safety as well.
155 citations
TL;DR: CPD is an approach to lifelong learning being discussed as a potential model for pharmacists in the United States and interest in and support for the concept of CPD is growing.
Abstract: Objective To summarize a resource document that explains the concept and components of continuing professional development (CPD) for pharmacists, describes some of the drivers behind the reevaluation of current systems of continuing pharmacy education (CE), defines relevant terms, and outlines some experiences with CPD in selected countries that have already adopted the model. Summary CPD is an approach to lifelong learning being discussed as a potential model for pharmacists in the United States. CPD does not replace CE, but quality-assured CE is an essential component of CPD. Evidence is mounting, however, that traditional methods of CE do not adequately meet the lifelong learning and professional development needs of health care professionals (HCPs) and are not always successful in affecting practice behavior and improving patient outcomes. The Institute of Medicine has concluded that the education and training of HCPs is in need of major overhaul. CPD, which is based on sound principles and adopts educational strategies that have been shown to be effective, potentially offers a quality improvement to the current systems for pharmacist CE. Conclusion Interest in and support for the concept of CPD is growing. Case studies of successful implementation in the United States and other countries now exist. Further discussion on the implications of widespread implementation for pharmacists in the United States is needed.
144 citations
TL;DR: The PCM program improved medication safety during a 9-month follow-up period and no difference was observed between PCM recipients and PCM eligibles who did not receive PCM in health care utilization or charges, even after including reimbursements for PCM.
Abstract: Objective: To test the effect of pharmaceutical case management (PCM) on medication safety and health care utilization. Design: Prospective cohort design with 9-month follow-up period (enrollment from October 1, 2000, through July 1, 2001, with follow-up through July 1, 2002). Setting: Iowa Medicaid program. Participants: 2,211 noninstitutionalized, continuously eligible Iowa Medicaid patients taking four or more chronic medications including at least one agent commonly used in at least 1 of 12 specific diseases who were cared for by pharmacists in 117 pharmacies. Interventions: Reimbursement for PCM services (initial patient assessment, written recommendations to physician, follow-up assessments and communication of progress and new problems to physician). Main Outcome Measures: Use of high-risk medications, Medication
97 citations
TL;DR: Clinical trial data support the value of zinc in reducing the duration and severity of symptoms of the common cold when administered within 24 hours of the onset of common cold symptoms.
Abstract: Objective: To review the laboratory and clinical evidence of the medicinal value of zinc for the treatment of the common cold. Data Sources: Published articles identified through Medline (1980‐2003) using the search terms zinc, rhinovirus, and other pertinent subject headings. Additional sources were identified from the bibliographies of the retrieved articles. Study Selection: By the author. Data Extraction: By the author. Data Synthesis: Human rhinoviruses, by attaching to the nasal epithelium via the intracellular adhesion molecule-1 (ICAM-1) receptor, cause most colds. Ionic zinc, based on its electrical charge, also has an affinity for ICAM-1 receptor sites and may exert an antiviral effect by attaching to the ICAM-1 receptors in the rhinovirus structure and nasal epithelial cells. Clinical tests of zinc for treatment of common colds have been inconsistent, primarily because of study design, blinding, and lozenge contents. Early formulations of lozenges also were unpalatable. In three trials with similar study designs, methodologies, and efficacy assessments, zinc effectively and significantly shortened the duration of the common cold when it was administered within 24 hours of the onset of symptoms. Recent reports of trials with zinc gluconate administered as a nasal gel have supported these findings; in addition, they have shown that treatment with zinc nasal gel is effective in reducing the duration and severity of common cold symptoms in patients with established illness. Conclusion: Clinical trial data support the value of zinc in reducing the duration and severity of symptoms of the common cold when administered within 24 hours of the onset of common cold symptoms. Additional clinical and laboratory evaluations are warranted to further define the role of ionic zinc for the prevention and treatment of the common cold and to elucidate the biochemical
97 citations
TL;DR: Pharmacists can play a useful role in the identification, education, and referral of patients at risk for osteoporosis through pharmacy-based BMD screening and third-party payers are willing to compensate pharmacists for collaborative community health management services.
Abstract: Objective (1) To identify patients at risk for osteoporosis through community pharmacy-based bone mineral density (BMD) screening, to refer at-risk patients to primary care and/or specialty practice physicians, and to follow-up with at-risk patients; (2) to treat and manage osteopenic and osteoporotic patients referred to the pharmacy for medication therapy management services; and (3) to test a payment methodology for pharmacists who deliver community health management services to a population at risk for or diagnosed with osteoporosis. Design Single-cohort observational study. Setting Ukrop's Super Markets, Inc. Grocery and Pharmacy, a 29-store chain with 22 pharmacy locations in Richmond, Virginia. Participants Consumers with one or more known risk factors for osteoporosis in Ukrop's customer service area. Intervention During the initial phase (health promotion and disease prevention) of the project, pharmacy-based osteoporosis screening with referral and follow-up was provided to consumers who responded to Ukrop's screening promotions. The second phase—provision of collaborative community health management services focused on osteoporosis monitoring and management— is ongoing and includes patients who are at risk for or diagnosed with osteoporosis and are covered by a regional payer. Main Outcome Measures Results of screenings; responses of patients and physicians to notifications; and long-term results during collaborative care. Results The pharmacists screened 532 patients and were able to contact 305 of these patients for follow-up interviews 3 to 6months later. The stratification for risk of fracture was 37%, high risk; 33%, moderate risk; and 30%, low risk. A total of 78% of patients indicated that they had no prior knowledge of their risk for future fracture. In the moderate- and high-risk categories, 37% of patients scheduled and completed a physician visit, 19% had a diagnostic scan, and 24% of those patients were initiated on osteoporosis therapy subsequent to the screening. Participating pharmacies received payment for both the osteoporosis screening and the collaborative health management services. Conclusion Pharmacists can play a useful role in the identification, education, and referral of patients at risk for osteoporosis through pharmacy-based BMD screening. Patients are willing to pay for pharmacy-based osteoporosis screening services. Third-party payers are willing to compensate pharmacists for collaborative community health management services.
97 citations
TL;DR: The development of collaboration between pharmacists and physicians is influenced by characteristics of exchanges occurring between them, and continued study of collaborative working relationships between physicians and pharmacists can assist health care practitioners in developing a team-based approach to patient care.
Abstract: Objectives To determine the degree of collaboration in a limited number of pharmacist–physician professional relationships and identify variables important in establishing collaboration between pharmacists and physicians. Design A multicase design, using a personal interview and a mailed survey. Setting Iowa. Participants Pharmacists in 10 community pharmacies and physicians with whom they collaborated. Intervention Two researchers independently judged the stage of collaboration for each case and the level of effect each influence variable had on the development of pharmacist–physician collaboration. Main Outcome Measures Using the Collaborative Working Relationship Model, nine indicators of collaboration were assessed. In addition, influence variables were studied, which included individual, context, and exchange characteristics believed to affect the development of collaborative working relationships between pharmacists and physicians. Results A Perrealt–Leigh reliability index of 0.89 was calculated as an estimate of interrater reliability of the judgments of nine indicators of collaboration. Four pharmacies were rated as having achieved early-stage collaboration, while six pharmacies were at late-stage collaboration. A high level of joint care activities, care communication, and increased accessibility to the physician and to patient information characterized late-stage collaboration. Six variables, labeled as discriminating, helped distinguish between early-stage collaboration and late-stage collaboration: the development of bidirectional communication, caring for mutual patients, the ability to identify a win–win opportunity, adding value to the medical practice, physician convenience, and movement toward balanced dependence between the pharmacist and physician. Conclusion The development of collaboration between pharmacists and physicians is influenced by characteristics of exchanges occurring between them. Continued study of collaborative working relationships between physicians and pharmacists can assist health care practitioners in developing a teambased approach to patient care, improving the ability of pharmacists and physicians to work together to coordinate patient care.
87 citations
TL;DR: Implementation of a specialized service for diabetes in community pharmacy resulted in better diabetes control and health care outcomes for the patient and well-being and the risk of nonadherence were significantly improved in intervention patients.
Abstract: Objective To implement and evaluate a specialized service for type 2 diabetes mellitus in the community pharmacy. Design Parallel group, multisite, control versus intervention, repeated measures design, with three different regions in New South Wales, Australia, used as intervention regions, then matched with control regions as much as possible. Intervention Following training, pharmacists followed a clinical protocol over 9 months, with approximately monthly intervention site visits during which blood glucose readings were downloaded and discussed with the patient, interventions were documented, and goals set with each patient. Main Outcome Measures Quality of life, well-being, risk of nonadherence, and glycosylated hemoglobin (A1C) values at the beginning and end of the study. Blood glucose levels were measured in intervention patients only. Results A total of 106 intervention and 82 control patients completed the study. Patient groups were similar at baseline. Pharmacists delivered 1,459 interventions and blood glucose levels were significantly reduced in all intervention regions. The proportion of patients with A1C values greater than 7% was similar in control sites at baseline (54%) and after 9 months (61%). In intervention sites this proportion was significantly reduced, from 72% at baseline to 53% after 9 months. Well-being and the risk of nonadherence were significantly improved in intervention patients. Conclusion Implementation of a specialized service for diabetes in community pharmacy resulted in better diabetes control and health care outcomes for the patient.
73 citations
TL;DR: Overall, herbal products and dietary supplements promoted for weight loss lack sufficient supporting efficacy and safety data and larger and better-controlled trials are needed before pharmacists should recommend these agents to patients seeking to lose weight.
Abstract: Objective To review the scientific literature on several dietary supplements and herbal products commonly promoted for weight loss. Data Sources Recently published articles and abstracts identified through PubMed (May 1987–May 2003), MEDLINE (January 1966–May 2003), International Pharmaceutical Abstracts (January 1970–May 2003), and Natural Medicines Comprehensive Database (January 1995–May 2003) using the search terms supplement, herbal, weight loss, obesity, overweight, conjugated linoleic acid, ephedra, ephedrine, chromium, Garcinia cambogia, hydroxycitric acid, chitosan, and pyruvate. Study Selection Performed manually by the authors. Data Extraction Performed manually by the authors. Only single-agent, randomized, blinded, controlled studies with sufficient scientific rigor in overweight or obese subjects were included. Data Synthesis Approximately 50 individual supplemental products and hundreds of combination products are promoted for weight loss. As a result, much confusion exists among health care professionals regarding the efficacy and safety of these products. Results for conjugated linoleic acid were positive in three clinical studies, with few adverse effects. Ephedra has been shown to be effective in promoting weight loss, especially when combined with caffeine, but it has a high adverse effect risk profile. The data regarding ephedra and ephedra combinations are conflicting, and many of the studies were poorly designed. Garcinia and chitosan have not shown much promise for weight loss, but little research has been done. Pyruvate has consistently shown positive weight loss effects. Conclusion Overall, herbal products and dietary supplements promoted for weight loss lack sufficient supporting efficacy and safety data. More research is needed to draw definitive conclusions. Conjugated linoleic acid and pyruvate have the best supporting evidence, but larger and better-controlled trials are needed before pharmacists should recommend these agents to patients seeking to lose weight.
TL;DR: The pivotal role played by the platelet in thrombus formation provides the rationale for employing antiplatelet drugs with complementary modes of action (e.g., aspirin, clopidogrel) to prevent atherothrombosis.
Abstract: Objectives To review the pathophysiology of atherothrombosis (atherosclerosis with superimposed platelet-rich thrombus formation) and the measures that can be taken to prevent its clinical sequelae through lifestyle modifications and pharmacotherapy, with emphasis on the role of antiplatelet agents. Data Sources Recent (1995–2003) published scientific literature, as identified by the authors through Medline searches using the terms atherothrombosis, pathophysiology, risk factors, prevention, and reviews on treatment . Study Selection Recent systematic English-language review articles were screened for relevant material. Data Synthesis Atherothrombosis is a generalized and diffuse progressive process affecting multiple vascular beds; its clinical consequences, including acute coronary syndromes (unstable angina, acute myocardial infarction, and sudden cardiac death), ischemic stroke, and peripheral arterial disease, are unpredictable in their time course and potentially life-threatening. Atherothrombosis rather than arterial stenosis appears to account for most of the acute ischemic manifestations of the atherosclerotic process. Interventions that can favorably influence atherosclerotic progression include lifestyle modifications (dietary control, exercise, and smoking cessation) and pharmacotherapy (lipid-lowering, antihypertensive, antiglycemic, and antiplatelet drugs). The pivotal role played by the platelet in thrombus formation provides the rationale for employing antiplatelet drugs with complementary modes of action (e.g., aspirin, clopidogrel) to prevent atherothrombosis. Conclusion Ischemic cerebrovascular, coronary, and peripheral arterial disease can be regarded as diverse manifestations of a common underlying systemic pathology, namely atherothrombosis. Secondary prevention of an ischemic event in an affected arterial bed confers the added benefit of primary prevention against potential ischemic events in other arterial beds.
TL;DR: A variety of drugs and dietary supplements have proven performance-enhancing effects in athletes, however, many of these substances have adverse effects and are banned by various sports-governing organizations.
Abstract: Objective To describe opportunities and obligations for pharmacists regarding doping control in sports, and to present information and resources on drugs and dietary supplements that are popular among athletes for performance enhancement. Data Sources Sports medicine journals and articles in English obtained from Medline (1966 through June 2003) using the search terms doping in sports, drugs in sports, dietary supplements, sports, amphetamine, stimulants, ephedrine, ephedra, caffeine, anabolic steroids, human growth hormone, erythropoietin, darbepoetin, androstenedione, dehydroepiandrosterone, and creatine. Information was also obtained from sports-governing agencies, such as the National Collegiate Athletic Association and the International Olympic Committee. Study Selection Studies and reports that were credible and scientifically sound that evaluated the ergogenic effects of drugs and dietary supplements. Data Extraction By the author. Data Synthesis Pharmacists can participate in doping control programs in a number of ways. Pharmacists also have an obligation when counseling, advising, and treating athletes to help them avoid banned substances. Athletes use a host of drugs for their performance-enhancing effects, many of which are banned by major sports-governing bodies. Myriad dietary supplements are marketed to athletes, claiming to have ergogenic effects. Some of these popular supplements have proven performance-enhancing effects, while others do not. Adverse effects of these drugs and dietary supplements are discussed. Conclusion A variety of drugs and dietary supplements have proven performance-enhancing effects in athletes. However, many of these substances have adverse effects and are banned by various sports-governing organizations. Pharmacists can play a key role in participating in doping control programs, and can prevent athletes from inadvertently consuming a banned substance.
TL;DR: A community pharmacy osteoporosis program had a positive impact on patient health care by influencing lifestyle modifications, increasing use of medications, and encouraging participants to discuss osteoporeosis with their physician.
Abstract: Objective To assess the impact of a community pharmacy-based bone mineral density (BMD) screening and education program and determine the feasibility of providing such a service in community pharmacies. Design Uncontrolled study using convenience sample combined with economic feasibility analysis. Setting Two independent and four chain community pharmacies. Participants Women age 18years and older. Intervention Pharmacy patrons were invited to a free BMD screening. Demographic information was collected, and patients were screened using an ultrasound BMD analyzer. BMD results were reviewed with the participant during an education session and forwarded to primary care providers. Questionnaires were completed at baseline and after 3months. Main Outcome Measures Time spent with each participant, project costs, and willingness to pay for screenings were used to estimate feasibility; questionnaire responses assessed impact of the intervention on participants' health care decisions, lifestyle modifications, and communications with their prescribers about osteoporosis. Results Of the 140 women screened at baseline, 82% indicated the screening was "very useful" for making health care decisions, and 91% believed it encouraged them to talk with their physicians about osteoporosis. At 3months, 11% of patients reported having improved exercise habits, and 30% had increased their calcium and vitamin D intake. A total of 41% of respondents indicated a willingness to pay $20 or more for the BMD screening service. The average screening time was 23minutes. Based on fixed costs of the screening device and materials and variable costs associated with personnel time, a community pharmacy could generate a positive net income with a BMD screening program. Cost of the BMD analyzer could be recovered through revenue generated in 24–35 screening days, depending on the fees charged. Conclusion A community pharmacy osteoporosis program had a positive impact on patient health care by influencing lifestyle modifications, increasing use of medications, and encouraging participants to discuss osteoporosis with their physician. Patients are willing to pay for this service; feasibility varies depending on available resources and patient population served.
TL;DR: Well-described tardive dyskinesia risk factors were common in metoclopramide-associated TD reports and should be considered in meetoclopramside prescribing.
Abstract: Objective To assess risk factors for tardive dyskinesia (TD) in spontaneousreports of metoclopramide and TD and evaluate metoclopramide prescribing patterns before and after withdrawal of cisapride from the market in the United States. Design Retrospective and observational analyses. Setting International metoclopramide adverse event reports and domesticdrug-use data for the continental United States. Patients Users of metoclopramide for 30 days or more who experiencedadverse events reported as TD. Interventions Analyses of the Food and Drug Administration AdverseEvent Reporting System (AERS) and IMS HEALTH data. Main Outcome Measures Pharmacoepidemiological patterns in AERS reports and utilization data from IMS HEALTH. Results The case series comprised 87 reports of primarily older (mean ± SD, 60 ± 22 years) women (67% of all cases). While average metoclopramidedaily dose (33 ± 14 mg) was within recommended product labeling limits,duration of use was considerably longer (753 ± 951 days). Overall, 37% of thereports included concomitant drugs believed to be TD risk factors. Similarly,18% of the reports noted comorbid diseases that are considered risk factors fordevelopment of TD. Metoclopramide utilization decreased following cisapridemarketing in 1993 and increased following cisapride withdrawal in 2000. Themajority (62%) of metoclopramide prescriptions were intended for women.Intended use overall increased with age and was highest in the seventh andeighth decades, with nearly one quarter of all utilization being in persons olderthan 70 years. Conclusion Well-described TD risk factors were common in metoclopramide-associated TD reports. Given the cisapride market withdrawal andassociated increased metoclopramide utilization, the incidence of TD mayincrease accordingly. TD risk factors relative to the intended benefit and durationof use should be considered in metoclopramide prescribing.
TL;DR: Increased awareness among members of the health care community about the prevalence of PAD and benefits associated with risk-factor reduction and antiplatelet therapy could produce substantial decreases in the burden of this disease.
Abstract: Objective To provide an overview of the impact of peripheral arterial disease (PAD) and the steps that can be taken to reduce its burden through greater awareness of the disease, improved diagnosis, and better treatment, with emphasis on the use of antiplatelet agents. Data Sources Recent (1990-2003) published scientific literature, as identified by the author through Medline searches, using the terms peripheral arterial disease, atherothrombosis, pathophysiology, risk factors, treatment, clinical trials, and reviews on treatment. Study selection Recent systematic English-language review articles and reports of controlled randomized clinical trials were screened for inclusion. Data Synthesis PAD is a distinct atherothrombotic syndrome marked by stenosis and occlusion of peripheral arterial beds, typically those in the lower extremities. Symptoms range from intermittent claudication (IC) during exercise to peripheral limb ischemia requiring limb amputation. IC, the most common symptom, is experienced by 2% to 3% of men and 1% to 2% of women aged 60 years and older. Despite its recognition as a major atherothrombotic risk factor, PAD is not widely appreciated by clinicians, and most cases remain undiagnosed. Asymptomatic PAD, as indicated by a reduced ankle brachial systolic pressure index, should alert the health care provider to the presence of diffuse atherothrombotic disease and need for treatment. Risk factors for development and progression of PAD include smoking, hypertension, diabetes, hyperlipidemia, and physical inactivity. The aim of pharmacotherapy is to improve the symptoms of PAD (especially IC), defer onset of limb-threatening ischemia, and improve long-term survival. Successful treatment strategies include risk factor modification, particularly smoking cessation; initiation of regular exercise; control of hypertension, diabetes, and hyperlipidemia; and use of antiplatelet agents to reduce the risk of atherothrombotic events. Available data suggest that aspirin reduces morbidity and mortality in PAD, while clopidogrel reduces the risk of atherothrombotic events such as myocardial infarction and stroke in these patients. Conclusion Increased awareness among members of the health care community about the prevalence of PAD and benefits associated with risk-factor reduction and antiplatelet therapy could produce substantial decreases in the burden of this disease.
TL;DR: The findings suggest that lifetime nonprescribed drug use by pharmacists does not appear to be disproportionate when compared with other groups of HPs, possibly suggesting medication access facilitates drug-associated experiences by HPs.
Abstract: Objectives To assess substance use, misuse, and abuse rates across a representative sample of dentists, nurses, pharmacists, and physicians; compare these rates to available general population data; and determine whether pharmacists report disproportionate unauthorized or illicit substance use. Design Cross-sectional, descriptive self-report survey. Setting A small northeastern state. Participants Stratified random sample of dentists, nurses, pharmacists, and physicians. Interventions Mailed 7-page survey. Main Outcome Measures Demographic characteristics; lifetime, past-year, and month prevalence of substance use; frequency of use; drug-related dysfunctions; drug misuse; and abuse potential. Results Six contacts with participants in the summer 2002 resulted in a 68.7% response rate. More than one half (58.7%) of pharmacists reported using a nonprescribed drug at least once in their lifetime. Though total illicit drug use rates by pharmacists were not noticeably different from those of other health professional (HP) groups, a greater proportion of pharmacists reported lifetime use of minor opiates, anxiolytics, and stimulants. Past-year prevalence of drug use was highest among pharmacists (12.8%). Except for anxiolytics, past-year prevalence of use of most other medications by pharmacists was slightly greater than prevalence of use rates reported by physicians and more prevalent than use rates reported in the general population. As with the other HP groups, pharmacists reported low levels of substance-associated dysfunctions and potential abuse. Conclusion The findings suggest that lifetime nonprescribed drug use by pharmacists does not appear to be disproportionate when compared with other groups of HPs. Specific drug use rates varied across HP groups, possibly suggesting medication access facilitates drug-associated experiences by HPs. Consequently, unauthorized or illicit substance use by HPs, including pharmacists, suggests the need for more intensive educational programs on practitioner impairment.
TL;DR: It is found that splitting cyclobenzaprine 10 mg tablets to achieve 5 mg doses could result in unpredictable dosing and therapeutic response, and the weight variation and calculated dosing variability of tablet fragments upon splitting unscored cyclobenzaprine hydrochloride 10mg tablets varied considerably in weight and estimated drug content.
Abstract: Objective To determine the weight variation and calculated dosing variability of tablet fragments upon splitting unscored cyclobenzaprine hydrochloride 10 mg tablets using two common tablet splitting devices. Design Comparative pharmaceutics study. Setting Pharmacy school laboratory. Participants Not applicable. Interventions Unscored cyclobenzaprine hydrochloride 10 mg tablets from one generic manufacturer were split with a tablet splitter or a kitchen knife by a licensed pharmacist and two doctor of pharmacy students (n = 15 tablets for each method per participant). Main Outcome Measures Fragment weights (FWs) were compared with the theoretical weights (TWs), which were calculated as one half of the mean weight of the tablets used in each part of the experiment; means, relative standard deviations (RSDs), and percentages of TW were also calculated. Results The mean weight before splitting the 45 tablets with the tablet splitter was 136.6 ± 2.1 mg (TW = 68.3 mg). The mean FW after splitting was 67.9 ± 7.9 mg. The RSD of 11.6% corresponded to a range of 69.4% to 130.2% of the TW and an estimated drug content of the split fragments between 3.47 mg and 6.51 mg. The mean weight before splitting the 45 tablets cut with a kitchen knife was 136.6 ± 2.0 mg (TW = 68.3 mg). The mean FW was 68.0 ± 15.7 mg with a RSD of 23.2%, corresponding to a range of 49.9% to 149.5% of the TW and an estimated drug content of the split fragments between 2.49 mg and 7.48 mg. Conclusion Tablet fragments obtained after splitting this generic cyclobenzaprine 10 mg product varied considerably in weight and estimated drug content. Accordingly, splitting cyclobenzaprine 10 mg tablets to achieve 5 mg doses could result in unpredictable dosing and therapeutic response.
TL;DR: In this article, the value of board of pharmaceutical specialties (BPS) certification, particularly as perceived by different stakeholders (pharmacists, employers, government, and academia), and to draw a parallel between specialization and certification in pharmacy and in medicine, was addressed.
Abstract: Objective To address the value of Board of Pharmaceutical Specialties (BPS) certification, particularly as perceived by different stakeholders (pharmacists, employers, government, and academia), and to draw a parallel between specialization and certification in pharmacy and in medicine. Data Sources Electronic databases (Medline, International Pharmaceutical Abstracts, Sociological Abstracts), associations/health care organizations Web sites, outside reports, and clinical pharmacists involved in certification processes. Study Selection Studies and reports that addressed the value of specialty certification were selected by the authors. Data Extraction By the authors. Data Synthesis Pharmacists with specialty certification report enhanced feelings of self-worth, improved competence, and greater marketability. Other values of certification include increased acceptance by health care professionals, salary increases, and job promotions. Employers have acknowledged board-certified pharmacists through public recognition, increase in responsibility, and some types of monetary compensation. In some governmental organizations, certified pharmacists receive salary raises and are granted prescribing authority. However, the overall value of specialty certification in pharmacy as perceived by the public or payers lags behind when compared with the status of specialty certification in medicine. Conclusion Board-certified pharmacists appreciate the value of pharmacy specialty certification, and in a number of organizations and practice settings, board-certified pharmacists are perceived as valuable. Still, unlike board-certified physicians, board-certified pharmacists are not widely recognized outside or even within the pharmacy profession. To address this challenge, board-certified pharmacists ought to market their services to assure that other stakeholders recognize their value.
TL;DR: In this article, the ability of community pharmacists within an anticoagulation clinic to keep international normalized ratios (INRs) within therapeutic ranges and, secondarily, to determine the incidence of bleeding and thromboembolic events and patient satisfaction was evaluated.
Abstract: Objectives To determine the ability of community pharmacists within an anticoagulation clinic to keep international normalized ratios (INRs) within therapeutic ranges and, secondarily, to determine the incidence of bleeding and thromboembolic events and patient satisfaction. Design Retrospective observational study. Setting Eckerd PatientCARE Network in Eckerd pharmacies in Tampa Bay area of Florida. Patients 50 patients taking warfarin and having INR determinations for 6 consecutive months. Interventions Clinical pharmacists monitored patients' anticoagulation status using point-of-care analyzers and making dosage changes as needed under a collaborative agreement. Extensive patient education was provided to patients regarding their anticoagulation. Data were collected from the initial visit through the 6 consecutive months. Patients were surveyed to assess their satisfaction with the clinic. Main Outcome Measures Percentage of INRs within therapeutic range and, secondarily, incidence of bleeding and thromboembolic events and patient satisfaction with the clinic. Results During the 6 months of initial therapy with warfarin, 243 of 435 (56%) INRs were in desired therapeutic ranges. A total of 15 bleeding episodes were reported, of which 10 were minor and 5 were significant. No thromboembolic events were reported. There was a 22% response rate to the survey, in which all statements were rated as above average to excellent. Conclusion Community pharmacists in an anticoagulation clinic effectively manage anticoagulation therapy, as the results of this clinic are similar to those of clinics managed by pharmacists in other settings.
TL;DR: Cancer continues to be a difficult disease to treat, but newly identified cellular targets have resulted in new medications, and these promising agents are giving hope for additional options for patients with various solid tumors.
Abstract: Objective To describe the role of tyrosine kinase (TK) and its subreceptors in the development of cancer and the role of TK inhibitors in cancer treatment. Data Sources Published articles identified through MEDLINE using search terms such as tyrosine kinase, erbB1, erbB2, erbB3, erbB4, epidermal growth factor receptors (EGFR), and EGFR inhibitors. Additional sources were identified from bibliographies in the articles and from Web sites and reports from the National Cancer Institute, American Society of Clinical Oncology, and European Organization for Research and Treatment of Cancer. Data Synthesis Progress in identifying the biochemical and molecular causes of cancer has led to discovery of abnormalities that characterize cancer cells and represent targets for development of drug therapies. TK receptors represent one such target when these are present in elevated quantities and/or aberrant forms. Abnormalities in these cell surface receptors have been correlated with development and progression of cancer, poor response to chemotherapeutic agents, and low survival rates. Several subtypes of TK receptors have been identified, and mutations in these have been associated with neoplasms of the breast, lung, colon, ovaries, and other organs. Approved agents, such as trastuzumab (Herceptin—Genentech) work by blocking a subtype of TK receptors that has been associated with breast cancer growth. Gefitinib (Iressa—AstraZeneca) was recently approved for treatment of non–small-cell lung cancer in patients who have failed treatment with traditional chemotherapeutic agents. Other agents such as cetuximab, erlotinib, and canertinib are in advanced stages of clinical trials and may be available for general clinical use in the next few years. Conclusion Cancer continues to be a difficult disease to treat, but newly identified cellular targets have resulted in new medications, and these promising agents are giving hope for additional options for patients with various solid tumors.
TL;DR: A comprehensive tobacco cessation program is provided that can serve as a model to guide pharmacists in assisting more patients to become tobacco free and live healthier lifestyles and demonstrates that pharmacists are effective providers of tobacco cessation services.
Abstract: Objective To describe an ongoing pharmacist-managed tobacco cessation clinic and assess the long-term effectiveness of the program. Setting Veterans Health Administration (VHA) community-based outpatient clinic in Missoula, Montana. Participants Pharmacy professor/clinical pharmacy specialist, advanced pharmacy practice experience students, and tobacco cessation participants. Practice Description Ongoing, pharmacist-managed tobacco cessation program offered to veterans. Practice Innovation With use of the “Vets without Cigarettes” program developed by the Montana VHA and the most current strategies reported in the literature, the clinical pharmacy specialist and pharmacy students provide tobacco cessation services for Missoula Veterans Affairs Primary Care Center veterans. Activities include a three-session program using the Transtheoretical Model of Change, tobacco cessation pharmacotherapy, behavioral strategies, cognitive techniques, documentation, and follow-up survey. Main Outcome Measure Percentage of veterans contacted reporting tobacco abstinence. Results Follow-up survey results were obtained for 130 (87.8%) of 148 veterans attending one or more sessions of the tobacco cessation class between November 1999 and December 2003. Of the 130 veterans contacted, 54 (41.5%) continued to be tobacco free. Conclusion This program demonstrates that pharmacists are effective providers of tobacco cessation services. Furthermore, a comprehensive tobacco cessation program is provided that can serve as a model to guide pharmacists in assisting more patients to become tobacco free and live healthier lifestyles.
TL;DR: Pharmacists have an opportunity to address barriers to communication with the Spanish-speaking population through use of language-assistance services and educational measures within the profession.
Abstract: Objective To document the types of language-assistance services available in pharmacies and the perceptions of pharmacists regarding the effectiveness of these services, and to measure the attitudes toward counseling Spanish-speaking patients and cultural sensitivity of pharmacists. Design Cross-sectional assessment Setting Metropolitan Atlanta, Ga Participants Registered Georgia pharmacists residing in metropolitan Atlanta. Interventions Mailed survey, with repeat mailing 2 weeks later Main Outcome Measures 38 survey items measuring demographic and practice-site characteristics, types of language-assistance services available with an assessment of the effectiveness of each measured on a nominal scale, and attitudinal items concerning counseling of Spanish-speaking patients and pharmacists' cultural sensitivity using a 5-point Likert-type response scale. Results Of 1,975 questionnaires mailed, 608 were returned, a 30.8% response rate. Nearly two thirds of the pharmacists had recently counseled a Spanish-speaking patient, but only one fourth of those respondents considered their interactions effective. Nearly all pharmacists, 88.0%, worked in pharmacies with language-assistance services. Of seven types of these services, a mean of 2.19 were available in pharmacies, and the majority of pharmacists (84.4% or more) identifying a service considered it to be effective. The pharmacists were neutral about counseling Spanish-speaking patients (mean = 2.94) and indifferent toward other cultures (mean = 3.28); however, they agreed they had a responsibility to counsel Spanish-speaking patients, and they believed that use of language-assistance services would constitute a reasonable effort to counsel these patients. Conclusion Pharmacists have an opportunity to address barriers to communication with the Spanish-speaking population through use of language-assistance services and educational measures within the profession.
TL;DR: Constructs from the Transtheoretical Model of Change were effective in differentiating patients who had discontinued their Avonex treatment versus patients who continued treatment, and likely would be an effective framework for a medication persistency intervention.
Abstract: Objective To delineate factors associated with discontinued use of the multiple sclerosis (MS) medication Avonex (interferon beta-1a—Biogen) as part of an effort to develop an intervention to promote treatment persistency. Design In-depth telephone interviews followed by a 12-page written questionnaire delivered by mail. Setting United States. Participants Of 946 patients with MS who were contacted, 531 (56%) completed questionnaires; 79% of respondents were currently using Avonex for treatment of MS. Main Outcome Measure Discontinuation of Avonex treatment, with analysis based on the theoretical framework of the Transtheoretical Model of Change. Results Four key variables (pros of Avonex use, cons of Avonex use, highest level of education completed, and level of disability) accurately identified 82% of patients who discontinued Avonex use, while also correctly identifying 81% of patients who stayed on the drug. Conclusion Constructs from the Transtheoretical Model of Change were effective in differentiating patients who had discontinued their Avonex treatment versus patients who continued treatment. This behavioral model likely would be an effective framework for a medication persistency intervention.
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TL;DR: In this paper, the authors provide information regarding the most important properties of 28 new therapeutic agents marketed in the United States during 2003, including adalimumab, agalsidase beta, ale- facept, alfuzosin hydrochloride, aprepitant, atazanavir sulfate, atomoxetine hydrochlorides, bortezomib, daptomycin, efalizumab, eletriptan hydrobromide, emtricitabine, enfuvirtide, eplerenone
Abstract: Objectives To provide information regarding the most important properties of the new therapeutic agents marketed in 2003. Data Sources Product labeling supplemented selectively with published studies and drug information reference sources. Study Selection By the author. Data Extraction By the author. Data Synthesis The 28 new therapeutic agents marketed in the United States during 2003 are reviewed in this article: adalimumab, agalsidase beta, ale- facept, alfuzosin hydrochloride, aprepitant, atazanavir sulfate, atomoxetine hydrochloride, bortezomib, daptomycin, efalizumab, eletriptan hydrobromide, emtricitabine, enfuvirtide, eplerenone, gefitinib, icodextrin, laronidase, memantine hydrochloride, mequinol/tretinoin, miglustat, nitazoxanide, omal- izumab, palonosetron hydrochloride, pegvisomant, rosuvastatin calcium, tadalafil, tositumomab and iodine I 131 tositumomab, and vardenafil hydrochloride. Indications and information on dosage and administration for these agents are reviewed, as are the most important pharmacokinetic properties, adverse events, drug interactions, and other precautions. Practical considerations for the use of the new agents are also discussed. When possible, the properties of the new drugs are compared with those of older drugs marketed for the same indications. Conclusion A number of the new therapeutic agents marketed in 2003 have important advantages over older medications. An understanding of the properties of these agents is important for the pharmacist to effectively counsel patients about their use and to serve as a valuable source of information for other health professionals regarding these drugs.
TL;DR: The majority of Vermont community pharmacists were aware of USP MER, however, use was low and barriers to reporting to a common system such as USPMER may differ depending on pharmacy type.
Abstract: Objective To document community pharmacists' awareness and use of the United States Pharmacopeia Medication Errors Reporting (USP MER) program Design Telephone survey Setting Community pharmacies in Vermont Participants One self-identified community pharmacist from each community pharmacy Intervention Each operating community pharmacy in Vermont was contacted by telephone between June 2002 and February 2003 The first individual to self-identify himself or herself as a pharmacist was asked to participate The telephone surveys were conducted using a standard script Main Outcome Measure Survey responses to questions about awareness and use of USP MER Results A pharmacist was contacted in 98% (122/124) of all operating community pharmacies in Vermont Nine (7%) pharmacists refused to participate, leaving 113 pharmacists who responded to the survey Although more than one half of all respondents (70/113; 62%) had heard of USP MER, less than one quarter (24/113; 21%) had ever submitted a report Significantly more pharmacists employed by independent pharmacies had submitted a report, compared with pharmacists from other pharmacy types (chain, supermarket, mass merchandiser; P = 03) Submitting reports through a corporate hierarchy or to a corporate program was the reason most frequently cited by pharmacists for not submitting reports directly to USP MER (37%) Whether corporate reports were forwarded to USP MER is unknown Conclusion The majority of Vermont community pharmacists were aware of USP MER However, use was low Barriers to reporting to a common system such as USP MER may differ depending on pharmacy type Further research to document the barriers to submitting reports is warranted
TL;DR: A positive public health initiative involving community pharmacists had a significant impact on motivating men to see a physician for follow-up care once a potential health risk was identified.
Abstract: Objectives To determine whether community pharmacists using a risk assessment tool could encourage men who were overdue for a physical examination to visit a physician and to calculate the return on investment from the pharmacy perspective for offering a complimentary risk assessment service. Design 12-week, prospective cohort study using convenience sampling among men who visited participating pharmacies. Setting Cross-section of community pharmacies. Patients 382 men aged 25–74 years with potential health risks that were untreated or uncontrolled, or who had not had a physical examination within the past year. Intervention Screening for specific health risks with or without telephone follow-up. Main Outcome Measure Overall male patient response to pharmacist recommendations for follow-up medical care. Results Of 382 men identified by the Men's Health Risk Assessment Tool (MHRAT) as being at risk for 1,194 significant health conditions (mean, 3.1 conditions per patient), 69% had not received a physical examination from a physician for a period ranging from more than 1year to 22.6years. Of men who were recommended to make an appointment, 64% were seen by a physician or were waiting on a scheduled appointment at the end of the study. No differences were seen between the telephone intervention group and the control group in rates of obtaining a physician examination. Conclusion A positive public health initiative involving community pharmacists was demonstrated in this study. Community pharmacists had a significant impact on motivating men to see a physician for follow-up care once a potential health risk was identified. The MHRAT and the pharmacist recommendation or patient education were the motivating factors and not follow-up telephone interventions by the pharmacist. Given community pharmacists' unique accessibility, an enormous opportunity exists for community pharmacists to raise awareness of men's health care and influence men's health behavior.
TL;DR: Atherogenic dyslipidemia represents an important modifiable CAD risk factor and combination therapy with agents that focus on all of the components of the mixed dyslipidsemia that often occurs in persons with diabetes and the metabolic syndrome may be expected to reduce cardiovascular morbidity and mortality.
Abstract: Objective To review the management of dyslipidemia in patients with metabolic syndrome. Data Sources Medline search (2000–2002) conducted for English language articles using the search terms metabolic syndrome , impaired fasting glucose , glucose intolerance , and antilipemic agents ; selective search for clinical trials of lipid therapy conducted in dialogue databases (1990–2002). In addition, current dyslipidemia treatment guidelines reviewed. Study Selection By the author. Data Extraction By the author. Data Synthesis The metabolic syndrome is increasingly recognized as a strong predictor of patient risk for developing coronary artery disease (CAD). It is associated with an atherogenic dyslipidemia characterized by elevated levels of triglycerides, reduced levels of high-density lipoprotein cholesterol (HDL-C) and a preponderance of small dense low-density lipoprotein (LDL) particles. Controlled clinical trials show similar or greater cardiovascular benefits from lipid-modifying therapies in patient subgroups with diabetes, impaired fasting glucose, and metabolic syndrome, compared with overall study populations. Current guidelines recommend intensified lipid management. Therapeutic lifestyle changes, with emphasis on weight loss, are particularly important for patients with metabolic syndrome. Statins are first-line therapy for all patients whose LDL-C levels are above goal. Combination therapy may often be necessary to control all lipid abnormalities adequately. Both niacin and fibrates provide additional benefits, particularly on triglyceride and HDL-C levels. Recent clinical studies show that these agents, in combination with statins, are safe and effective for the treatment of atherogenic dyslipidemia. Conclusion Atherogenic dyslipidemia represents an important modifiable CAD risk factor. Combination therapy with agents that focus on all of the components of the mixed dyslipidemia that often occurs in persons with diabetes and the metabolic syndrome may be expected to reduce cardiovascular morbidity and mortality.
TL;DR: Drug information centers are often overlooked as sources of information about dietary supplements; however, centers have resources that are, by self-assessment, sufficient to respond to dietary supplement information requests.
Abstract: Objective To assess the resources drug information centers are currently using to respond to dietary supplement information requests and to determine the frequency with which drug information centers are used as sources of information on dietary supplements. Design Cross-sectional survey. Setting United States. Participants 116 drug information centers. Interventions Mail survey that collected information on the use of drug information centers for dietary supplement information requests and the dietary supplement-specific resources available at and used in these centers. Main Outcomes Measures Survey responses, evaluated using descriptive statistics. Results Drug information centers received a relatively small number of requests for information related to dietary supplements, and most such requests came from consumers. The centers had a number of resources available to assist in responding to those requests, with Facts and Comparisons' The Review of Natural Products and the print version of Natural Medicines Comprehensive Database being the resources most often at hand. The majority of respondents believed their centers were "usually able" to respond to the requests received. Conclusion Drug information centers are often overlooked as sources of information about dietary supplements; however, centers have resources that are, by self-assessment, sufficient to respond to dietary supplement information requests. Great variation exists among centers in the resources available to address requests, with just two resources, the Review of Natural Products and the print version of Natural Medicines Comprehensive Database , available to more than three-fourths of the respondents.
TL;DR: A case study is presented on the use of buzz marketing by a health system for decreasing antibiotic resistance through lessening of public demand for antibiotics and support of physicians in prescribing the agents appropriately.
Abstract: Objective To (1) discuss buzz marketing, contrast it with traditional forms of promotional communications, and provide guidelines for use and (2) describe a successful buzz-marketing program used by Sentara Healthcare to decrease overuse and inappropriate use of antibiotic medications. Data Sources An English-language-only literature search of ABI Inform, Lexus-Nexus, InfoTrac, and university library databases from 1980 to the present using the keywords buzz, word of mouth, opinion leader, and thought leader. Articles and books were cross referenced for other works of interest. Study Selection Performed by the author for their contribution to an exploratory analysis of this topic. Data Extraction Performed by the author. Data Synthesis Buzz marketing is an indirect communications method that has been used successfully in the promotion of a wide variety of products, services, and ideas. By identifying and cultivating nonmedia opinion leaders, the technique generates word-of-mouth communications between these early adopters of products and services and the early and late majority of people who tend to follow their lead. Opinion leaders can be categorized as ordinary or extraordinary, technical or social, and specialist or generalist, depending on the nature of their communications, expertise, and range of knowledge. Buzz marketing is most useful for ideas that are memorable, produce small changes in behavior that have big effects over time, and have the potential to reach a "tipping point" in terms of momentum among a target population. Pharmacists can use buzz marketing for promoting innovative services such as pharmaceutical care. A case study is presented on the use of buzz marketing by a health system for decreasing antibiotic resistance through lessening of public demand for antibiotics and support of physicians in prescribing the agents appropriately. Conclusion Buzz marketing is a potent force in the promotion of pharmaceuticals and can be used by pharmacists. It works best when patients perceive the benefits of innovations. Providing samples and demonstrations of the innovation will foster positive perceptions. Innovations also spread better when they are compatible with the needs, desires, and preferences of individuals and can be adapted to the unique situation of the adopter.