Ambulatory Care Research Research Articles

Clinical Pharmacists as Key Members of the Patient-Centered Medical Home: An Opinion Statement of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy

The American College of Clinical Pharmacy (ACCP) Ambulatory Care Practice Research Network (PRN) considers the role of clinical pharmacists to be fundamental to the success of the Patient-Centered Medical Home (PCMH) model.Within the PCMH, pharmacists can improve the health of populations by participating in activities that optimize medication management. Multiple published articles support clinical pharmacist involvement in the PCMH with regard to promotion of team-based care, enhanced access, care coordination, and improved quality and safety of care. A survey of clinical pharmacist members of ACCP who operate in such a model depict a variety of activities, with some members pioneering new and innovative ways to practice clinical pharmacy. Although this is a significant opportunity for pharmacists in the primary care setting, a unified vision of pharmacy services is needed. It is our hope that with continued efforts focused on obtaining national provider status, clinical pharmacy can use the PCMH model to solidify the future of primary care pharmacy. The following is an opinion statement of the ACCP Ambulatory Care PRN regarding the vital role of clinical pharmacists in the PCMH.

Current trends in outpatient pharmacy services and billing

To provide a summary of community and ambulatory pharmacy practices and billing patterns for medication therapy management (MTM) services and to identify reasons pharmacists report not billing for direct patient care services. Cross-sectional study. United States, February 2011. Members of the American College of Clinical Pharmacy Ambulatory Care Practice and Research Network, American Society of Health-System Pharmacists Ambulatory and Chronic Care Practitioners, and American Pharmacists Association MTM e-community. Online survey. Practice setting, pharmacy services performed, billing technique, and payer, as well as reasons for not billing. MTM services were provided by 287 pharmacists. The most common practice settings included physician office (23.6%), health-system outpatient facility (21.7%), and community pharmacy (20.2%). A total of 149 of 276 pharmacists (54.0%) reported billing for MTM services; 16 of 276 (5.8%) did not know if they were currently billing. Community pharmacists were more likely to bill than all other sites combined (80.5% vs. 53.1%, P < 0.001), and pharmacists with >75% of visits face-to-face were more likely to bill (66.2% vs. 46.6%, P < 0.002). A variety of MTM services are provided in outpatient settings with inconsistent billing techniques and reimbursement. Pharmacists should continue to work toward consistent, sustainable reimbursement to expand MTM services.

Barriers, Enablers, and Incentives for Research Participation: A Report from the Ambulatory Care Research Network (ACRN)

Supported by a supplement to our Clinical and Translational Science Award, we studied the feasibility of implementing clinical research in Northern Manhattan community practices that primarily serve Hispanic patients. We applied a mixed-methods approach (surveys, focus groups, interviews) based on the PRECEDE-PROCEED model to determine the level of interest in clinical research among community clinicians (both practice-based research network [PBRN] members and non-PBRN members), the perceived barriers that hamper participation in clinical research, and the perceived facilitators for conducting research in such practices. Survey and qualitative data indicated strong interest in clinical research among current and potential PBRN members if it was relevant to improving quality of care in their practice or community. They also identified important perceived barriers (lack of time, inadequate training in research methods, lack of collaborators and support staff, institutional review board hurdles, and community distrust of research) and the necessary requirements for overcoming barriers to conducting research in busy clinical settings, which included collaborators, mentors, research support staff, and a trusting patient-clinician relationship. It is feasible to conduct clinical research studies in urban community medical practices if the topics are relevant to the community and appropriate enabling structures and processes are put into place.

Management of Chronic Nonmalignant Pain with Nonsteroidal Antiinflammatory Drugs

Chronic nonmalignant pain is a major burden on the health care system in the United States. Frequently, nonsteroidal antiinflammatory drugs (NSAIDs) are used to assist in the management of various chronic pain syndromes. Although evidence is accumulating on the potential toxicities associated with NSAIDs, clear recommendations are lacking to guide the appropriate use of these drugs. Equivocal data, especially with respect to cardiovascular risk, further confuse a clear treatment pathway when assessing pharmacotherapy. Originally, cyclooxygenase selectivity appeared to be a determining factor in choosing an agent because of the presumed lack of effect on the cardiovascular and gastrointestinal renal systems. This theory, however, was recently dispelled. To provide guidance on the selection of an NSAID for various chronic pain syndromes, members of the Ambulatory Care, Cardiology, and Pain and Palliative Care Practice and Research Networks of the American College of Clinical Pharmacy evaluated evidence-based use of NSAIDs for frequently encountered pain syndromes, with special focus on the adverse effects of this class of agents.

Effects of testosterone and nandrolone on cardiac function: a randomized, placebo‐controlled study

Androgens have striking effects on skeletal muscle, but the effects on human cardiac muscle function are not well defined, neither has the role of metabolic activation (aromatization, 5alpha reduction) of testosterone on cardiac muscle been directly studied. To assess the effects of testosterone and nandrolone, a non-amplifiable and non-aromatizable pure androgen, on cardiac muscle function in healthy young men. Double-blind, randomized, placebo-controlled, three-arm parallel group clinical trial. Ambulatory care research centre. Healthy young men randomized into three groups of 10 men. Weekly intramuscular injections of testosterone (200 mg mixed esters), nandrolone (200 mg nandrolone decanoate) or matching (2 ml arachis oil vehicle) placebo for 4 weeks. Comprehensive measures of cardiac muscle function involving transthoracic cardiac echocardiography measuring myocardial tissue velocity, peak systolic strain and strain rates, and bioimpedance measurement of cardiac output and systematic vascular resistance. Left ventricular (LV) function (LV ejection fraction, LV modified TEI index), right ventricular (RV) function (ejection area, tricuspid annular systolic planar motion, RV modified TEI index) as well as cardiac afterload (mean arterial pressure, systemic vascular resistance) and overall cardiac contractility (stroke volume, cardiac output) were within age- and gender-specific reference ranges and were not significantly (P < 0.05) altered by either androgen or placebo over 4 weeks of treatment. Minor changes remaining within normal range were observed solely within the testosterone group for: increased LV end-systolic diameter (30 +/- 7 vs. 33 +/- 5 mm, P = 0.04) and RV end-systolic area (12.8 +/- 1.3 vs. 14.6 +/- 3.3 cm(2), P = 0.04), reduced LV diastolic septal velocity (Em, 9.5 +/- 2.6 vs. 8.7 +/- 2.0 cm/s, P = 0.006), increased LV filling pressure (E/Em ratio, 7.1 +/- 1.6 vs. 8.3 +/- 1.8, P = 0.02) and shortened PR interval on the electrocardiogram (167 +/- 13 vs. 154 +/- 12, P = 0.03). Four weeks of treatment with testosterone or nandrolone had no beneficial or adverse effects compared with placebo on cardiac function in healthy young men.

New Home for Nation’s Research Hospital

BETHESDA, MD—The Mark O. Hatfield Clinical Research Center at the National Institutes of Health (NIH), which opened to patients in April, is a technological marvel with a human heart. The Hatfield Center adjoins the Warren Grant Magnuson Clinical Center, which opened in 1953. These two buildings, plus an ambulatory care research facility, constitute the NIH Clinical Center. Among federal buildings, the Clinical Center is second in size only to the Pentagon. The $596 million Hatfield Center is named for the Republican senator from Oregon, a longtime champion of government support for biomedical research. Before retiring in 1997, Hatfield helped break ground for the building’s construction. Four patient care wings house 242 inpatient beds and 90 day-hospital stations. Paired around two landscaped courtyards, the wings flank a 7-story glass-enclosed atrium, whose ground floor includes admitting and discharge areas and public services. Two of the patient wings stretch out into laboratory wings that command about one third of the center’s total space. Patient care units and laboratories occupy levels 1, 3, 5, and 7. Levels 2, 4, and 6 and a penthouse above level 7 house mechanical systems, offering workers walk-around room and full access to the floor below for maintenance and remodeling. Hatfield is the first NIH building to incorporate dedicated infrastructure levels. “It is designed to adapt to changes in medicine that have not yet been imagined,” says chief architect Robert Frasca. Two pedestrian bridges connect Hatfield to Magnuson. After the Hatfield building opens, about one third to half of Magnuson will be outfitted with new research laboratories and offices. Some services will remain in Magnuson; other areas will be mothballed pending future remodeling. A new entrance to the NIH campus will speed access to the hospital.

Use of herbal therapies by adults seen in an ambulatory care research setting: an exploratory survey.

To identify and characterize patterns of use of herbal products among patients participating in selected research clinics. Survey of three National Institutes of Health (NIH) ambulatory care research clinics. Convenience sample of 490 adult patients (168 male, 322 female) attending rheumatology, liver, and endocrinology/metabolic research clinics. Of the patients surveyed, 16.7%: (n = 82) reported using herbs. There were no significant sociodemographic differences between herb and nonherb users. Indications for herb use differed among the disease groups; patients in the endocrine and rheumatology clinics were taking herbs predominantly for "energy" or "wellness"; those attending the liver clinic tended to use herbal therapies as treatment for their disease. Mean and median monthly expenditure for herbal products was $30 and $10, respectively. There was a significant positive correlation between number of herbs used and use of other dietary supplements (p < 0.0001). One in six patients in ambulatory clinical research settings may be taking herbal products in addition to prescribed treatment. This figure is lower than in the general population, possibly because the patients may stop using herbs when participating in a research project. Although empirical evidence on the beneficial or adverse effects of herb therapy alone or in combination with drug therapies is limited, clinical researchers should be aware of the potential for confounding clinical trial results.

A framework for selecting outcome measures for ambulatory care research.

Selecting outcome measures must be considered in the context of the application the researcher has in mind, that is, describing the health of a population, predicting health status, or evaluating health outcomes. Most important, the outcome measure selected must be conceptually defensible--it needs to make sense. A general framework for selecting measures is discussed in the context of five critical characteristics: (1) sensibility, (2) reliability, (3) validity, (4) responsiveness, and (5) burden. A commonsense approach to outcome measurement selection weighs the relative importance of each of these characteristics with the framework and application clearly in mind.

Overview of recent literature on undergraduate ambulatory care education and a framework for future planning

This study provides an interpretive overview of ambulatory care undergraduate education from 1979 to 1991 and identifies two major problems for medical education: (1) the difficulties inherent in the transfer of educational techniques from the hospital to the ambulatory care setting; and (2) the misuse of and lack of agreement on definitions of ambulatory care, primary care, and community-oriented primary care. The authors distinguish various types of ambulatory care and examine factors that differentiate ambulatory care and hospital sites for educating medical students, including the setting, program management, curriculum issues, evaluation, cost, faculty time, and space. Based on concepts and issues identified in the study, the authors propose a framework for planning future ambulatory care education and research.

Ambulatory Care Research in the VA: Present Status and Recommendations for the Future

The growth of ambulatory care delivery in the Department of Veterans Affairs (VA) has been accompanied by increasing interest in and need for ambulatory care research. Results from a national survey of academic general internal medicine units suggest that those that share VA and university affiliation tend to be more successful than those that are unaffiliated. The VA must strive to improve the environment for ambulatory care research. Among other things, this will entail providing adequate protected time to ambulatory care faculty and developing a uniform ambulatory care database to facilitate longitudinal, population-based research. Extended fellowships in ambulatory care and faculty development programs for existing staff will be required to create a core of competent investigators. The VA must also provide increased funding to the Health Services Research and Development and Cooperative Studies programs. Special funding programs targeted to key areas such as quality assurance, medical education, and direct patient care should be established. In addition, the VA should seek to develop joint ventures with other funding agencies for innovative ambulatory care initiatives.

Ambulatory care research in the VA

The growth of ambulatory care delivery in the Department of Veterans Affairs (VA) has been accompanied by increasing interest in and need for ambulatory care research. Results from a national survey of academic general internal medicine units suggest that those that share VA and university affiliation tend to be more successful than those that are unaffiliated. The VA must strive to improve the environment for ambulatory care research. Among other things, this will entail providing adequate protected time to ambulatory care faculty and developing a uniform ambulatory care database to facilitate longitudinal, population-based research. Extended fellowships in ambulatory care and faculty development programs for existing staff will be required to create a core of competent investigators. The VA must also provide increased funding to the Health Services Research and Development and Cooperative Studies programs. Special funding programs targeted to key areas such as quality assurance, medical education, and direct patient care should be established. In addition, the VA should seek to develop joint ventures with other funding agencies for innovative ambulatory care initiatives.

Computer use and nursing research. A computerized taxonomy of nursing diagnoses for use in ambulatory care nursing education, practice, and research--Part 1: Development and major headings.

Computer use and nursing research. A computerized taxonomy of nursing diagnoses for use in ambulatory care nursing education, practice, and research--Part 1: Development and major headings.

Data collection, analysis, and interpretation in ambulatory care research: uses of the epidemiologic method.

In summary, in the collection, analysis, and interpretation of study data, individuals planning and analyzing the results of their own investigations or those of others must be particularly careful about the potential pitfalls that may occur. Considerable time and effort beforehand should be given to the type of study design (observational versus randomized trial) to be utilized; the scope of the investigation to be carried out, be it of a small descriptive scale or a large collaborative effort; attention to detail in the development of the data-collection instruments; and extensive training and continued monitoring of the data abstractors. Awareness of these factors should enhance data collection efforts, the quality of the collected data, and any interpretation thereof.

A patient and family number assignment and chart filing system for family physicians.

The Department of Family Medicine and Practice at the University of Wisconsin-Madison has devised and implemented an alpha-numeric system of identifying patient records together with a system of chart filing based on a variation of terminal digit filing. The system provides each patient with a unique identification number. This permanently assigned number is used as part of the medical record (chart) information, as the basis for assigning an account number, as the basis for determining the storage location of the chart in the record room, and as the basis for a family identification number. The number defines the patient's sex and position within the family, and its permanency ensures a capability for conducting both short- and long-term ambulatory care research in the family context.