Self-care, including self-medication with over-the-counter (OTC) drugs, facilitates the public’s increased willingness to assume greater responsibility for their own health. Direct consultation with pharmacists provides efficient professional guidance for safe and appropriate OTC use.
The purpose of this study was to characterize patient perceptions of pharmacists and use of nonprescription therapy in an ambulatory care population in Qatar.
Patients having prescriptions filled at one organization’s private medical clinics during two distinct two-week periods were invited to participate in a short verbal questionnaire. Awareness of pharmacist roles in guiding OTC drug selection was assessed, as were patient preferences for OTC indications. Attitudes towards pharmacist and nurse drug knowledge and comfort with direct dispensing were also evaluated.
Five hundred seventy patients participated representing 29 countries. Most respondents were men (92.1%) with mean age of 38.3 years. Almost 1 in 7 did not know medical complaints could be assessed by a pharmacist (15.3%) and 1 in 5 (21.9%) were unaware pharmacists could directly supply OTC therapy. The majority (85.3%) would be interested in this service. In general, respondents were more comfortable with medication and related advice supplied by pharmacists as opposed to nursing professionals.
Patients were familiar with the roles of pharmacists as they pertain to self-medication with OTC therapy and described the desire to use such a service within this Qatar ambulatory health care setting.
patient; self-medication; over-the-counter; pharmacist; Qatar
The purpose of this study was to investigate the physicians’ perceptions, and expectations of their experiences with the pharmacists at Hamad Medical Corporation (HMC) in Qatar.
A cross-sectional study was conducted at HMC between January and March 2006 using a validated questionnaire. The self-administered questionnaire was distributed to 500 physicians who were working at HMC comprising Hamad General Hospital, Women’s Hospital, Rumaila Hospital, Al-Amal Hospital, Al Khor Hospital, and primary health centers. The questionnaire was composed of four parts, investigating the physicians’ expectations, experiences, and perceptions of the pharmacists.
A total of 205 questionnaires were completed (response rate 41%). A total of 183 physicians (89%) expected the pharmacist to educate patients about safe and appropriate use of drugs, whereas 118 (57%) expected the pharmacist to be available for health-care team consultation during bedside rounds. The indices of physicians showing how comfortable they were with pharmacists, and their expectations of pharmacists, were 61% and 65%, respectively, whereas the index on experience of physicians with pharmacists was lower (15%).
Physicians were comfortable with pharmacists and had high expectations of pharmacists in performing their duties. However, physicians reported a poor experience with pharmacists, who infrequently informed them about the effectiveness of alternative drugs, patients experiencing problems with prescribed medications, and who took personal responsibility to resolve any drug-related problem.
hospital pharmacists; perceptions; expectations; experience; physicians; Qatar
To assess the public’s attitudes towards the community pharmacist’s role in Qatar, to investigate the public’s use of community pharmacy, and to determine the public’s views of and satisfaction with community pharmacy services currently provided in Qatar.
Materials and methods
Three community pharmacies in Qatar were randomly selected as study sites. Patients 16 years of age and over who were able to communicate in English or Arabic were randomly approached and anonymously interviewed using a multipart pretested survey.
Over 5 weeks, 58 patients were interviewed (60% response rate). A total of 45% of respondents perceived community pharmacists as having a good balance between health and business matters. The physician was considered the first person to contact to answer drug- related questions by 50% of respondents. Most patients agreed that the community pharmacist should provide them with the medication directions of use (93%) and advise them about the treatment of minor ailments (79%); however, more than 70% didn’t expect the community pharmacist to monitor their health progress or to perform any health screening. Half of the participants (52%) reported visiting the pharmacy at least monthly. The top factor that affected a patient’s choice of any pharmacy was pharmacy location (90%). When asked about their views about community pharmacy services in Qatar, only 37% agreed that the pharmacist gave them sufficient time to discuss their problem and was knowledgeable enough to answer their questions.
This pilot study suggested that the public has a poor understanding of the community pharmacist’s role in monitoring drug therapy, performing health screening, and providing drug information. Several issues of concern were raised including insufficient pharmacist– patient contact time and unsatisfactory pharmacist knowledge. To advance pharmacy practice in Qatar, efforts may be warranted to address identified issues and to promote the community pharmacist’s role in drug therapy monitoring, drug information provision, and health screening.
pharmacist; public; attitudes; Qatar
To characterize prescribing error interventions documented by pharmacists in four pharmacies in a primary health care service in Qatar.
The study was conducted in a primary health care service in the State of Qatar in the period from January to March 2008. Pharmacists in four clinics within the service used online, integrated health care software to document all clinical interventions made. Documented information included: patient’s age and gender, drug therapy details, the intervention’s details, its category, and its outcome. Interventions were categorized according to the Pharmaceutical Care Network Europe Classification of drug-related problems (DRP).
The number of patients who had their prescriptions intercepted were 589 (0.71% of the total 82,800 prescriptions received). The intercepted prescriptions generated 890 DRP-related interventions (an average of 1.9% DRPs identified across the four clinics). Fifty-four percent of all interventions were classified as drug choice problems, and 42% had safety problems (dose too high, potential significant interaction). The prescriber accepted the intervention in 53% of all interventions, and the treatment was changed accordingly. Interventions as a result of transcription errors, legality and formulary issues were eliminated from this study through the use of computerized physician order entry (CPOE).
Documenting and analyzing interventions should be a routine activity in pharmacy practice setting in primary health care services. Educational outreach visits and other strategies can improve prescribing practices and enhance patient safety.
pharmacists; interventions; prescribing errors
Pharmacists can improve patient outcomes in institutional and pharmacy settings, but little is known about their effectiveness as consultants to primary care physicians. We examined whether an intervention by a specially trained pharmacist could reduce the number of daily medication units taken by elderly patients, as well as costs and health care use.
We conducted a randomized controlled trial in family practices in 24 sites in Ontario. We randomly allocated 48 randomly selected family physicians (69.6% participation rate) to the intervention or the control arm, along with 889 (69.5% participation rate) of their randomly selected community-dwelling, elderly patients who were taking 5 or more medications daily. In the intervention group, pharmacists conducted face-to-face medication reviews with the patients and then gave written recommendations to the physicians to resolve any drug-related problems. Process outcomes included the number of drug-related problems identified among the senior citizens in the intervention arm and the proportion of recommendations implemented by the physicians.
After 5 months, seniors in the intervention and control groups were taking a mean of 12.4 and 12.2 medication units per day respectively (p = 0.50). There were no statistically significant differences in health care use or costs between groups. A mean of 2.5 drug-related problems per senior was identified in the intervention arm. Physicians implemented or attempted to implement 72.3% (790/1093) of the recommendations.
The intervention did not have a significant effect on patient outcomes. However, physicians were receptive to the recommendations to resolve drug-related problems, suggesting that collaboration between physicians and pharmacists is feasible.
To investigate older patient, pharmacist, and physician perspectives about what information is essential to impart to patients receiving new medication prescriptions and who should provide the information.
Qualitative focus group discussions.
Senior centers, retail pharmacies, and primary care physician offices.
Forty-two patients aged 65 and older, 13 pharmacists, and 17 physicians participated in eight focus groups.
Qualitative analysis of transcribed focus group interviews and consensus through iterative review by multidisciplinary auditors.
Patient, pharmacist, and physician groups all affirmed the importance of discussing medication directions and side effects and said that physicians should educate about side effects and that pharmacists could adequately counsel about certain important issues. However, there was substantial disagreement between groups about which provider could communicate which critical elements of medication-related information. Some pharmacists felt that they were best equipped to discuss medication-related issues but acknowledged that many patients want physicians to do this. Physicians tended to believe that they should provide most new-medication education for patients. Patients had mixed preferences. Patients aged 80 and older listed fewer critical topics of discussion than younger patients.
Patients, pharmacists, and physicians have incongruent beliefs about who should provide essential medication-related information. Differing expectations could lead to overlapping, inefficient efforts that result in communication deficiencies when patients receive a new medication. Collaborative efforts to ensure that patients receive complete information about new medications could be explored.
provider–patient communication; physician–patient communication; prescription medication; older patients; qualitative focus group interviews
Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia.
We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients’ adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors.
Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was −0.2 mmol/L (95% confidence interval [CI] −0.3 to −0.1), and the adjusted reduction was −0.05 (95% CI −0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34).
Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.
To determine if there is improvement in medication management when pharmacists and family physicians collaborate to prescribe medication renewals requested by fax.
Prospective, non-randomized controlled trial.
W est Winds Primary Health Centre, an interdisciplinary health centre that includes an academic family medicine practice, located in Saskatoon, Sask.
All patients whose pharmacies faxed the health centre requesting prescription renewals between October 2007 and February 2008 were selected to participate in the study.
Medication renewal requests were forwarded to the pharmacist (who works in the clinic part-time) on days when he was working (intervention group). The pharmacist assessed drug-therapy issues that might preclude safe and effective prescribing of the medication. The pharmacist and physician then made a collaborative decision to authorize the requested medication or to request additional interventions first (eg, perform laboratory tests). When the pharmacist was not working, the physicians managed the renewal requests independently (control group).
MAIN OUTCOME MEASURES
Medication renewals authorized with no recommendations, medication-related problems identified, new monitoring tests ordered, and new appointments scheduled with health providers.
A total of 181 renewal requests were included (94 in the control group and 87 in the intervention group). The control group had significantly more requests authorized with no recommendations (75.5% vs 52.9%, P = .001). Those in the intervention group had significantly more medication-related problems identified (26 vs 10, P = .031); medication changes made (24 vs 10, P = .044); and new appointments scheduled with their family physicians (31 vs 21, P = .049).
There is an improvement in medication management when a pharmacist collaborates with family physicians to prescribe medication renewals. The collaborative model created significantly more activity with each renewal request (ie, identification of medication-related problems, medication changes, and new appointments), which reflects an improvement in the process of care.
Today there are significant gaps between reaching the goal of “optimal medication therapy” and the current state of medication use in the United States. Pharmacists are highly accessible and well-trained—yet often underutilized—key health care professionals who can move us closer toward achieving better medication therapy outcomes for patients. Diabetes medication management programs led by pharmacists are described. This is consistent with the “medical home” concept of care that promotes primary care providers working collaboratively to coordinate patient-centered care. Pharmacists utilize their clinical expertise in monitoring and managing diabetes medication plans to positively impact health outcomes and empower patients to actively manage their health. In addition, pharmacists can serve as a resource to other health care providers and payers to assure safe, appropriate, cost-effective diabetes medication use.
collaborative drug-therapy management; diabetes management; medication therapy management; pharmacists; role of pharmacists
Medication-related problems are a serious concern in Australian primary care. Pharmacist interventions have been shown to be effective in identifying and resolving these problems. Collaborative general practitioner-pharmacist services currently available in Australia are limited and underused. Limitations include geographical isolation of pharmacists and lack of communication and access to patient information. Co-location of pharmacists within the general practice clinics is a possible solution. There have been no studies in the Australian setting exploring the role of pharmacists within general practice clinics.
The aim of this study is to develop and test a multifaceted practice pharmacist role in primary care practices to improve the quality use of medicines by patients and clinic staff.
This is a multi-centre, prospective intervention study with a pre-post design and a qualitative component. A practice pharmacist will be located in each of two clinics and provide short and long patient consultations, drug information services and quality assurance activities. Patients receiving long consultation with a pharmacist will be followed up at 3 and 6 months. Based on sample size calculations, at least 50 patients will be recruited for long patient consultations across both sites. Outcome measures include the number, type and severity of medication-related problems identified and resolved; medication adherence; and patient satisfaction. Brief structured interviews will be conducted with patients participating in the study to evaluate their experiences with the service. Staff collaboration and satisfaction with the service will be assessed.
This intervention has the potential to optimise medication use in primary care clinics leading to better health outcomes. This study will provide data about the effectiveness of the proposed model for pharmacist involvement in Australian general practice clinics, that will be useful to guide further research and development in this area.
Australian New Zealand Clinical Trials Registry: ACTRN12612000742875
Pharmacists; Primary healthcare; General practice; Multidisciplinary; Family practice
Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration.
To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration.
A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification.
On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential.
The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.
Pharmacists; Physicians; Collaborative working relationships; Pharmacist-physician collaborative index; Community
Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations.
Inner-city academic general internal medicine practice.
Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 × 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls.
Data Extraction/Collection Methods
Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires.
During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed.
Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease.
medical decision making; guidelines; quality improvement
To assess Croatian community pharmacists' patient care competencies using the General Level Framework (GLF).
The competencies of 100 community pharmacists working in 38 community pharmacies were evaluated using an adapted version of the GLF.
Pharmacists demonstrated the best performance in the competency areas drug specific issues and provision of drug products; the poorest performance was in the competency areas evaluation of outcomes and monitoring drug therapy. Pharmacists' behavior varied the most in the following areas: ensuring that the prescription is legal, prioritization of medication management problems, and identification of drug-drug interactions.
Competencies were identified that need to be developed to improve pharmacist interventions in community settings. This study provides the first data on pharmacists' performance in Croatia and serves as a starting point for future studies and actions.
competency; pharmacist; General Level Framework; Croatia; community pharmacy
The family physician's relationship with the community pharmacist has tended to be biased. The physician sees the pharmacist simply as a dispenser of drugs. Physicians and pharmacists are usually physically separated, lessening their chances of a collaborative working relationship. Family physicians' traditional sources of drug information include journals, colleagues and drug company literature. However, when they have some form of regular interaction with a pharmacist, physicians tend to see the pharmacist as a main source of drug information. The proper use of medication involves three critical relationships: doctor/patient, doctor/pharmacist, and pharmacist/patient. The doctor/pharmacist relationship has several components: individual consultations, regular team meetings, and establishment of a limited formulary for physicians and residents. There is evidence that compliance is improved when the pharmacist is involved in patient education.
Pharmacist; family physician; primary care
To analyze clinical pharmacist interventions in the intensive care units (ICUs) setting of a tertiary care Indian hospital and to assess the pharmacoeconomic impact on drug-related problems (DRPs).
Materials and Methods:
A postgraduate clinical pharmacist reviewed drug prescriptions over a period of 7 months. Whenever a DRP is identified, it was discussed with a physician and appropriate suggestions were provided, later it was documented on a preprepared form. Clinical significance of each intervention was graded based on the predicted clinical outcome. Acceptance of the interventions is entirely at the discretion of the medical staff. Each intervention was analyzed with respect to potential cost saving and/or additional cost incurred to existing drug therapy. An independent clinical panel was convened, and all the interventions made by the intervening pharmacist were critically reviewed for potential cost savings.
The intervening pharmacist made 117 recommendations, of which 94% was accepted by the medical professionals. The most frequent DRP identified was overdose (24%). The total net cost savings made was Rs. 77260.13 (USD 1796.73). This corresponds with Rs. 965.75 per patient and an annualized savings of Rs. 135205.22.
Clinical pharmacist interventions had a significant impact on the cost of drug therapy and the patient outcome in intensive care settings of our hospital.
Cost savings; drug-related problems; intensive care units; interventions; pharmacist
Cancer drugs are high risk drugs and medication errors in their prescribing, preparation and administration have serious consequences, including death. The importance of a multidisciplinary approach and the benefits of pharmacists’ contribution to cancer treatment to minimise risk have been established. However, the impact of services provided by pharmacists to cancer patient care is poorly studied. This study explored the clinical interventions made by pharmacists in dispensing of chemotherapy doses, and evaluated pharmacists’ contribution to patient care.
Pharmacists at the Chemotherapy Preparation Unit at a tertiary cancer centre in London were shadowed by two research pharmacists during the clinical screening of chemotherapy prescriptions and release of prepared drugs. An expert panel of pharmacy staff rated the clinical significance of the recorded interventions.
Twenty-one pharmacists’ interventions were recorded during the screening or releasing of 130 prescriptions or drugs. “Drug and therapy” (38%), “clerical” (22%) and “dose, frequency and duration” (19%) related problems most often required an intervention, identifying areas in chemotherapy prescribing that need improvement. The proposed recommendations were implemented in 86% of the cases. Many recorded interventions (48%) were ranked to have had a “very significant” influence on patient care.
Clinical interventions made by pharmacists had a significant impact on patient care. The integration of pharmacists’ technical and clinical roles into dispensing of chemotherapy doses is required for providing high-quality cancer services.
pharmacy; cancer; chemotherapy; drug compounding; medication errors
To explore the best interventions and working patterns of clinical pharmacists in pediatrics and to determine the effectiveness of clinical pharmacists in pediatrics.
We conducted a randomized controlled trial of 160 pediatric patients with nerve system disease, respiratory system disease or digestive system disease, who were randomly allocated into two groups, with 80 in each group. Interventions by clinical pharmacists in the experimental group included answering questions of physicians and nurses, giving advice on treating patients, checking prescriptions and patient counseling at discharge. In the control group, patients were treated without clinical pharmacist interventions.
Of the 109 interventions provided by clinical pharmacists during 4 months, 47 were consultations for physicians and nurses, 31 were suggestions of treatment, with 30 accepted by physicians (96.77%) and 31 were medical errors found in 641 prescriptions. Five adverse drug reactions were submitted to the adverse drug reaction monitoring network, with three in the experimental group and two in the control group. The average length of stay (LOS) for patients with respiratory system diseases in the experimental group was 6.45 days, in comparison with 10.83 days in the control group, which was statistically different (p value<0.05); Average drug compliance rate in the experimental group was 81.41%, in comparison with 70.17% of the control group, which was statistically different (p value<0.05). Cost of drugs and hospitalization and rate of readmission in two weeks after discharge in the two groups were not statistically different.
Participation by clinical pharmacists in the pharmacotherapy of pediatric patients can reduce LOS of patients with respiratory system disease and improve compliance rate through discharge education, showing no significant effects on prevention of ADR, reduction of cost of drugs and hospitalization and readmission rate in two weeks.
Chinese Clinical Trial Registry ChiCTR-TRC-10001081
To measure physicians’ experiences with opioid-related adverse events and their perceived level of confidence in their opioid prescribing skills and practices.
The province of Ontario.
A total of 1000 primary care physicians randomly selected from the College of Physicians and Surgeons of Ontario registration database.
Main outcome measures
Opioid-related adverse events and concerns (eg, number of patients, type of opioid, cause of the event or concern); physicians’ confidence, comfort, and satisfaction with opioid prescribing; physicians’ opinions on strategies to optimize their prescribing; and physicians’ perspectives of their interactions with pharmacists and nurses.
The response rate was close to 66%, for a total of 658 participants. Almost all respondents reported prescribing opioids for chronic pain in the past 3 months. Eighty-six percent of respondents reported being confident in their prescribing of opioids, but 42% of respondents indicated that at least 1 patient had experienced an adverse event related to opioids in the past year, usually involving oxycodone, and 16.3% of respondents did not know if their patients had experienced any opioid-related adverse events. The most commonly cited factors leading to adverse events were that the patient took more than prescribed, the prescribed dose was too high, or the patient took alcohol or sedating drugs with the opioids. Most physicians had concerns about the opioid use of 1 or more of their patients; concerns included running out of opioids early, minimal access to pain and addiction treatment, and addiction and overdose. The reported number of physicians’ patients taking opioids was positively associated with their confidence and comfort levels in opioid prescribing and negatively associated with their belief that many patients become addicted to opioids.
Most physicians have encountered opioid-related adverse events. Comprehensive strategies are required to promote safe prescribing of opioids, including guidelines and comprehensive office-system materials.
To measure agreement between advanced pharmacy practice experience students using a guided interview process and experienced clinical pharmacists using standard practices to identify drug therapy problems.
Student pharmacists enrolled in an advanced pharmacy practice experience (APPE) and clinical pharmacists conducted medication therapy management interviews to identify drug therapy problems in elderly patients recruited from the community. Student pharmacists used a guided interview tool, while clinical pharmacists' interviews were conducted using their usual and customary practices. Student pharmacists also were surveyed to determine their perceptions of the interview tool.
Fair to moderate agreement was observed on student and clinical pharmacists' identification of 4 of 7 drug therapy problems. Of those, agreement was significantly higher than chance for 3 drug therapy problems (adverse drug reaction, dosage too high, and needs additional drug therapy) and not significant for 1 (unnecessary drug therapy). Students strongly agreed that the interview tool was useful but agreed less strongly on recommending its use in practice.
The guided interview process served as a useful teaching aid to assist student pharmacists to identify drug therapy problems.
guided interview; drug therapy; advanced pharmacy practice experience; interview; medication therapy management
To assess the effect of a physician and pharmacist teamwork approach to uncontrolled hypertension in a medical resident teaching clinic, for patients who failed to meet the recommended goals of the fifth Joint National Commission on Detection, Evaluation and Treatment of High Blood Pressure.
Physician and pharmacist teamwork can improve the rate of meeting national blood pressure goals in patients with previously uncontrolled hypertension.
A single-blinded randomized controlled trial lasting 6 months.
A primary care outpatient teaching clinic.
A sample of 95 adult hypertensive patients who failed to meet national blood pressure goals based on three consecutive visits over a 6-month period.
Patients were randomly assigned to a control arm of standard medical care or to an intervention arm in which a physician and pharmacist worked together as a team.
At study completion, the percentage of patients achieving national goals due to intervention was more than double the percentage in the control arm (55% vs 20%, p < .001). Systolic blood pressure declined 23 mm Hg in the intervention arm versus 11 mm Hg in the control arm (p < .01). Diastolic blood pressure declined 14 and 3 mm Hg in the intervention and control arms, respectively (p < .001). The intervention worked equally as well in men and women and demonstrated noticeable promise in a minority of mixed-ancestry Hawaiians in whom hypertension is of special concern.
Patients who fail to achieve national blood pressure goals under standard outpatient medical care may benefit from a program that includes a physician and pharmacist teamwork approach.
blood pressure; coronary heart disease; risk factor; pharmacist; ambulatory care
In recent years, the focus of pharmacists as traditional drug dispensers has shifted to more active and participative role in risk assessment, risk management, and other medication related consultation activities. Pharmacy profession is evolving steadily in the United Arab Emirates (UAE). Pharmacists in UAE are so much occupied in their administrative and managerial duties that dispensing is mostly attended to by pharmacy technicians. Pharmacist-led patient counseling is limited to the dosage and frequency of medications and rarely adverse reactions and drug interactions with other medications. Therefore we decided to perform quantitative questionnaires study to explore the role of pharmacist in patient counseling in UAE, the evaluation of pharmacist's opinion on patient counseling and the potential determinants of personal consultation. Results show the frequency and nature of inquiries received by pharmacist. Five to twenty inquires per month are received from patient, most of them related to drug prescription and dose recommendation. Thirty nine percent of pharmacists received inquiries from doctors, most of them related to the dose and mode of action. Ninty two percent of the pharmacists agreed that patient counseling is their professional responsibility. About 82% of pharmacists agreed that counseling will increase their sales and enhance the reputation of their pharmacies. Seventy percent of pharmacists mentioned that they need to undergo training for effective counseling while 46% of pharmacists felt that more staff in the pharmacies would have a positive influence on patient compliance to medication therapies and patient safety. The potential determinants of personal consultation show that 52% of participants trusted pharmacist and 55% considered the pharmacist as a friend. Forty eight percent of participants visited the pharmacy for medical recommendation while 30% for drug compounding, 72% agreed that pharmacist conducts full instruction while 31% agreed about full investigation. In conclusion, reorganization of the pharmacist's activities may improve pharmaceutical consultations. Pharmacists must be exposed to recent trends in drug therapy, dosage forms, dosage, adverse effects and interaction. This will go a long way in providing rational use of drugs to the patients and improve their quality of life.
Attitudes and behaviors; community pharmacists; patient counseling; patient information leaflets; personal consultation
Pharmacist-physician co-management of hypertension has been shown to improve office blood pressures (BP). We sought to describe the effect of such a model on 24-hour ambulatory BPs.
We performed a prospective, cluster-randomised controlled clinical trial in 179 patients with uncontrolled hypertension from five primary care clinics in Iowa City, Iowa. Patients were randomized by clinic to receive pharmacist-physician collaborative management of hypertension (intervention) or usual care (control) for a 9-month period. In the intervention group, pharmacists helped patients identify barriers to BP control, counselled on lifestyle and dietary modifications, and adjusted antihypertensive therapy in collaboration with the patient’s primary care provider. Patients were seen by pharmacists a minimum every 2 months. Ambulatory BP was obtained at baseline and study end.
Baseline and end of study ambulatory BP profiles were evaluated for 175 patients. Ambulatory BPs were reduced to a greater extent in the intervention compared to control group (daytime ΔSBP [SD] 15.2[11.5] vs 5.5[13.5], p<0.001; nighttime ΔSBP [SD] 12.2[14.8] vs 3.4[13.3], p<0.001; 24-hour ΔSBP [SD] 14.1[11.3] vs 5.5[12.5], p<0.001). More patients in the intervention group had BP controlled at the end of the study (75% vs 50.7%, p<0.001) as defined by overall 24-hour ambulatory BP monitoring.
Pharmacist-physician collaborative management of hypertension achieved consistent and significantly greater reduction in 24-hour BP and a high rate of BP control.
Ambulatory blood pressure monitoring; pharmacist/physician collaboration; blood pressure; hypertension management; cardiovascular risk; team-based care
To evaluate blood pressure (BP) control following discontinuation of a physician\pharmacist collaborative intervention.
BP was previously measured at baseline and at the end of a 9-month cluster-randomized intervention trial. This study abstracted medical record data for mean BP and BP control at 18 months (9 months after the discontinuation of the intervention) and at 27 months (18 months after discontinuation of the intervention).
Five primary care medical offices operated by a university health system.
Subjects with hypertension who were enrolled in a previous controlled trial and who consented to have data abstracted for an additional 18 months following the end of that study.
A physician\pharmacist collaborative intervention to improve BP control was withdrawn after 9 months and BP and the change in BPs following withdrawal of the intervention were evaluated.
A research nurse measured BP during the 9-month interventional study. BP values were then abstracted from the medical record for the 18 month period after the end of that study.
104 patients had BP values at all 4 time periods. At baseline, systolic BP (SBP) was 152.5 ± 9.5 and 150.1 ± 9.6 mm Hg in the intervention and control groups, respectively (p=0.22). At 9 months, SBP decreased to 124.5 ± 10.7 and 132.0 ± 15.1 mm Hg (p=0.0038 between groups) and BP was controlled in 78.5% and 48.7% in the intervention and control groups, respectively (p=0.0017). By 18 months, SBP had deteriorated to 131.0 ± 12.2 and 143.3 ± 17.5 mm Hg (p<0.001) and BP control rates deteriorated to 53.9% and 30.8% in the intervention and control groups, respectively (p=0.02). By 27 months, SBP was 131.3 ± 13.0 and 141.2 ± 15.8 mm Hg (p=0.0008) and BP control was 55.3% and 35.9% in the intervention and control groups, respectively (p=0.05).
This study found a sustained effect on BP control up to 18 months following discontinuation of a pharmacist intervention. However, BP control deteriorated at a similar rate in both the intervention and control group but remained significantly higher in the intervention group. This study suggests that continued interventions by pharmacists may be necessary to maintain high rates of BP control, especially in those patients who lose BP control.
hypertension management; clinical trial; pharmacist management; team-care; blood pressure control
The beneficial outcomes of oral anticoagulation therapy are dependent upon achieving and maintaining an optimal INR therapeutic range. There is growing evidence that better outcomes are achieved when anticoagulation is managed by a pharmacist with expertise in anticoagulation management rather than usual care by family physicians. This study compared a pharmacist managed anticoagulation program (PC) to usual physician care (UC) in a family medicine clinic.
A retrospective cohort study was carried out in a family medicine clinic which included a clinical pharmacist. In 2006, the pharmacist assumed anticoagulation management. For a 17-month period, the PC group (n = 112) of patients on warfarin were compared to the UC patients (n = 81) for a similar period prior to 2006. The primary outcome was the percentage of time patients' INR was in the therapeutic range (TTR). Secondary outcomes were the percentage of time in therapeutic range within ± 0.3 units of the recommended range (expanded TTR) and percentage of time the INR was >5.0 or <1.5.
The baseline characteristics were similar between the groups. Fifty-five percent of the PC group was male with a mean age of 67 years; 51% of the UC group was male with a mean age of 71 years. The most common indications for warfarin in both groups were atrial fibrillation, mechanical heart valves and deep vein thrombosis. The TTR was 73% for PC and 65% for UC (p < 0.0001). The expanded TTR for PC was 91% and 85% for UC (p < 0.0001). The percentage of time INR values were <1.5 was 0.7% for PC patients and 1.9% for UC patients (p < 0.0001), and >5 were 0.3% for PC patients and 0.1% for UC (p < 0.0001).
The pharmacist-managed anticoagulation program within a family practice clinic compared to usual care by the physicians achieved significantly better INR control as measured by the percentage of time patients' INR values were kept in both the therapeutic and expanded range. Based on the results of this study, a collaborative family practice clinic using pharmacists and physicians may be an effective model for anticoagulation management with these results verified in future prospective randomized studies.
With the initiatives by the National Institutes of Health and the Food and Drug Administration, pharmacogenomics has now moved from the laboratory to the patient bedside. Over 100 drug-products now contain pharmacogenomic information as part of their labeling. Many of these are commonly used in the pediatric population. Direct-to-consumer genetic test kits also require intervention and guidance from healthcare professionals. This increased trend towards personalized medicine mandates that healthcare professionals develop a working knowledge about pharmacogenomics and its application towards patient care. Because pharmacogenomic testing can provide patient-specific predictors for response to and safety of medications, pharmacists are positioned to play an active role in pharmacogenomic testing, clinical interpretation of results, and recommendations for individualization of drug therapy. Opportunities for pharmacists exist in both inpatient and outpatient settings, such as pharmacist-managed clinical pharmacogenomics consultation services and educating patients and families about pharmacogenomic testing. In addition to clinical roles, pharmacists may also be involved in genetically-influenced drug discovery and development. Given the potential for genetic and age-dependent factors to influence drug selection and dosing, pediatric pharmacists should be involved in the development of dosing recommendations and interprofessional practice guidelines regarding pharmacogenomic testing in pediatric patients. Opportunities to become knowledgeable and competent in pharmacogenomics span from coursework as part of the pharmacy curriculum to postgraduate education (e.g., residencies, fellowships, continuing education). However, there exists a need for additional postgraduate learning opportunities for practicing pharmacists. As a result, the Pediatric Pharmacy Advocacy Group (PPAG) acknowledges a need for increased education of both student and practicing pharmacists, with consideration of special patient populations, such as infants and children. PPAG endorses and advocates for the involvement of pediatric pharmacists in pharmacogenomic testing and in using those results to provide safe and effective medication use in pediatric patients of all ages. Additionally, PPAG strongly encourages pediatric pharmacists to take responsibility for educating patients and their families about the importance of pharmacogenomic testing and its role in the safe and effective use of medications.
pediatrics; personalized medicine; pharmacist; pharmacogenomics; testing