Pharmacy Sites Research Articles

Attrition of Canadian Internet pharmacy websites: what are the implications?

BackgroundThe unavailability of Internet pharmacy websites may impact a consumer’s drug purchases and health care.ObjectiveTo address the issue of attrition, a defined set of Canadian Internet pharmacy websites was examined at three separate time intervals.MethodsIn February to March 2006, 117 distinct, fully functional “Canadian Internet pharmacy” websites were located using the advanced search options of Google and the uniform resource locator (URL) for each website was recorded. To determine website attrition, each of the 117 websites obtained and recorded from the previous study was revisited at two later periods of time within a 4-year period.ResultsAfter approximately 4 years and 5 months, only 59 (50.4%) sites were found in the original state. Thirty-four sites (29.1%) had moved to a new URL address and were not functioning as the original Internet pharmacy. For 24 sites (20.5%) the viewer was redirected to another Canadian Internet pharmacy site.ConclusionOf concern for patients if Internet pharmacy sites were suddenly inaccessible would be the disruption of continuity of care.

Adaptation of the health literacy universal precautions toolkit for rheumatology and cardiology – Applications for pharmacy professionals to improve self-management and outcomes in patients with chronic disease

Over a decade of research in health literacy has provided evidence of strong links between literacy skills of patients and health outcomes. At the same time, numerous studies have yielded insight into efficacious action that health providers can take to mitigate the negative effects of limited literacy. This small study focuses on the adaptation, review and use of two new health literacy toolkits for health professionals who work with patients with two of the most prevalent chronic conditions, arthritis and cardiovascular disease. Pharmacists have a key role in communicating with patients and caregivers about various aspects of disease self-management, which frequently includes appropriate use of medications. Participating pharmacists and staff offered suggestions that helped shape revisions and reported positive experiences with brown bag events, suggestions for approaches with patients managing chronic diseases, and with concrete examples related to several medicines [such as Warfarin(©)] as well as to common problems [such as inability to afford needed medicine]. Although not yet tested in community pharmacy sites, these publically available toolkits can inform professionals and staff and offer insights for communication improvement.

Dextromethorphan Abuse: A Literature Review

Objective: To review dextromethorphan abuse patterns from 2002–2012 and emphasize the pharmacist's role in prevention, education, and sales surveillance. Data Sources: A literature search was conducted through PubMed (2002-November 2012), EMBASE (2002-November 2012), and International Pharmaceutical Abstracts (2002-November 2012), using the search term dextromethorphan abuse. The Drug Enforcement Administration and National Association of Boards of Pharmacy websites were searched for dextromethorphan abuse and legislative updates. The search was limited to a 10-year period to identify the most current case reports and studies. Study Selection and Data Extraction: The limits used were studies/case reports evaluating humans and published in the English language. Only studies and case reports that assessed dextromethorphan abuse were included in the review. Eight studies and 9 case reports met the inclusion criteria. Data Synthesis: Case reports and studies demonstrate that there are patterns associated with dextromethor phan abuse. A study using data reported to the National Poison Data System identified Coricidin as the most (65.5%) commonly abused dextromethorphan product until 2006; its abuse has decreased since that time (p < 0.0001). The most common abuse effects and toxicities cited in studies and case reports include agitation, confusion, central nervous system depression, tachycardia, hypertension, lethargy, psychosis, hallucinations, mydriasis, dizziness, and cardiotoxicity. One study identified that 96% of samples tested positive for other substances in addition to dextromethorphan. Coingestion of other substances is also common among dextromethorphan abusers. Conclusions: Case reports and studies demonstrate that there are patterns associated with dextromethorphan abuse. It is difficult to identify dextromethorphan as the causative agent of abuse effects because of coingestion of other substances. Studies should examine the pharmacist's role and the association between dextromethorphan sales restrictions and abuse patterns.

The trend toward self-diagnosis

Do-it-yourself diagnosis is becoming easier than ever as more self-test kits appear on pharmacy shelves and websites. The kits claim to diagnose everything from prostate cancer to Alzheimer disease and menopause. But many health organizations warn consumers to use the kits with caution, claiming

Bar-code-assisted medication administration: A method for predicting repackaging resource needs

Results of a study at two hospitals to validate and test systems for bar-code-assisted medication administration (BCMA) are reported, including data on bar-code scanning failures and BCMA-related staff resource needs. To prepare for BCMA implementation, pharmacy inventories at the two study sites were characterized by scanning product bar codes with a handheld device. The custom database built to house BCMA data was programmed to match National Drug Code (NDC) information on package labels with NDC information in the BCMA database. The data collected during inventory scanning were used (1) to quantify and address failed bar-code scans, (2) to predict the number of products that would require repackaging and relabeling to ensure accurate bedside scans, and (3) to estimate full-time equivalent (FTE) staff resources for BCMA-related repackaging work. During inventory assessment, scanning failures occurred with about 12.5% of products at the two pharmacy sites, mainly due to the absence of a bar-code label (49-53% of failed scans) or the inability to identify NDCs within the package bar code (38-46% of failed scans). It was determined that 8-10% of products inventoried at the two sites would require repackaging before dispensing, with associated technician resource needs estimated at 0.3-0.5 unit of FTE labor. The results of inventory scanning revealed that most failed scans were attributable to the lack of a bar code on some products or problems with NDC recognition by the BCMA database. After those problems were addressed, a three-month pilot test on one patient care unit indicated an overall scanning success rate of >96%.

The Role of Pharmacists in Patient Safety: An Analysis of Patient-Pharmacist Interactions in Community Pharmacy Consultations

This research was developed in order to identify factors contributing to medication non-adherence in congestive heart failure patients. In a pilot study completed at a community pharmacy in a small midwestern town, pharmacists completed paper surveys regarding their consultations with congestive heart failure patients. Information noted by the pharmacists included patient questions, drug-related problems discovered, patient gender, refill versus new prescription, and patient age. Questions asked most frequently involved cost or financial concerns (15.4% of patients, n = 4) and dosage amount (11.5% of patients, n = 3). All patients obtaining a new prescription had questions as compared to 42.9% of patients (n = 11) refilling a prescription. Future developments may include surveys seeking more descriptive accounts of consultations, researcher interviews with pharmacists, and extension of the study to additional pharmacy sites.

Detecting Fake Medical Web Sites Using Recursive Trust Labeling

Fake medical Web sites have become increasingly prevalent. Consequently, much of the health-related information and advice available online is inaccurate and/or misleading. Scores of medical institution Web sites are for organizations that do not exist and more than 90% of online pharmacy Web sites are fraudulent. In addition to monetary losses exacted on unsuspecting users, these fake medical Web sites have severe public safety ramifications. According to a World Health Organization report, approximately half the drugs sold on the Web are counterfeit, resulting in thousands of deaths. In this study, we propose an adaptive learning algorithm called recursive trust labeling (RTL). RTL uses underlying content and graph-based classifiers, coupled with a recursive labeling mechanism, for enhanced detection of fake medical Web sites. The proposed method was evaluated on a test bed encompassing nearly 100 million links between 930,000 Web sites, including 1,000 known legitimate and fake medical sites. The experimental results revealed that RTL was able to significantly improve fake medical Web site detection performance over 19 comparison content and graph-based methods, various meta-learning techniques, and existing adaptive learning approaches, with an overall accuracy of over 94%. Moreover, RTL was able to attain high performance levels even when the training dataset composed of as little as 30 Web sites. With the increased popularity of eHealth and Health 2.0, the results have important implications for online trust, security, and public safety.

IMPACT on campus

IMPACT on campus

Synthetic Cathinones (Bath Salts): Legal Status and Patterns of Abuse

To review the current legal status and patterns of abuse of bath salts. A literature search was conducted through MEDLINE (1950-December 2011), PubMed (1966-December 2011), EMBASE (1966-December 2011), and International Pharmaceutical Abstracts (1970-December 2011) using the search terms bath salts, mephedrone, and methylenedioxypyrovalerone to identify articles on the legal status of bath salts and on studies focusing on patterns of abuse of bath salts. The GovTrack.us Web site was searched to determine the status of federal bills regarding bath salts. The National Association of Boards of Pharmacy and Drug Enforcement Administration Web sites and the Federal Register were also examined to identify legislation on bath salts. Case reports and studies regarding bath salts were examined. Federal laws involving bath salts were also evaluated. The Department of Justice issued a final order in the Federal Register, temporarily placing the 3 synthetic stimulants, mephedrone, methylenedioxypyrovalerone, and methylone, under Schedule I of the Controlled Substances Act. Literature evaluated included case reports, retrospective studies, surveys, toxicology data, and chemical analyses studies. Information in the literature demonstrated that bath salts are highly abused, and common adverse effects include hypertension, tachycardia, and psychiatric symptoms. Psychoactive substances recently sold as bath salts have been placed in Schedule I of the Controlled Substances Act. Pharmacists can play an important role in raising awareness on the dangers of bath salts abuse through patient counseling and community outreach programs. The evidence on legal status and patterns of abuse clearly demonstrates that bath salts contain dangerous substances that should be permanently controlled.

Do remote community telepharmacies have higher medication error rates than traditional community pharmacies? Evidence from the North Dakota Telepharmacy Project

ObjectiveTo evaluate the differences in medication dispensing errors between remote telepharmacy sites (pharmacist not physically present) and standard community pharmacy sites (pharmacist physically present and no telepharmacy technology; comparison group). DesignPilot, cross-sectional, comparison study. SettingNorth Dakota from January 2005 to September 2008. ParticipantsPharmacy staff at 14 remote telepharmacy sites and 8 comparison community pharmacies. InterventionThe Pharmacy Quality Commitment (PQC) reporting system was incorporated into the North Dakota Telepharmacy Project. A session was conducted to train pharmacists and technicians on use of the PQC system. A quality-related event (QRE) was defined as either a near miss (i.e., mistake caught before reaching patient; pharmacy discovery), or an error (i.e., mistake discovered after patient received medication; patient discovery). Main outcome measureQREs for prescriptions. ResultsDuring a 45-month period, the remote telepharmacy group reported 47,078 prescriptions and 631 QREs compared with 123,346 prescriptions and 1,002 QREs in the standard pharmacy group. Results for near misses (pharmacy discovery) and errors (patient discovery) for the remote and comparison sites were 553 and 887 and 78 and 125, respectively. Percentage of “where the mistake was caught” (i.e., pharmacist check) for the remote and comparison sites were 58% and 69%, respectively. ConclusionThis study reported a lower overall rate (1.0%) and a slight difference in medication dispensing error rates between remote telepharmacy sites (1.3%) and comparison sites (0.8%). Both rates are comparable with nationally reported levels (1.7% error rate for 50 pharmacies).

Extended adherence support by community pharmacists for patients with hypertension: a randomised controlled trial

Abstract Objective To determine the effects of a patient-centred intervention by community pharmacists on adherence to treatment for hypertension. Study design Randomised controlled trial. Method Randomisation was at pharmacy level. Pharmacists in the intervention group used a structured, brief questioning protocol to identify patients' medication-related problems and their information needs relating to hypertension and its treatment. Advice, information and referral to the general practitioner (GP) were provided by the pharmacist, based on patients' responses. Pharmacists in the control group provided usual care. The intervention was delivered three times at approximately two-month intervals. Blood pressure measurements were collected retrospectively from GP medical records. Patients completed feedback questionnaires at baseline and post-study. The questionnaire comprised a self-reported adherence measure and explored satisfaction with pharmaceutical services. Setting Twenty community pharmacy sites (11 intervention and nine controls) in one health authority area in England. Outcome measures Control of blood pressure; patient satisfaction with pharmaceutical services; self-reported adherence. Results In total, 180 patients (101 intervention and 79 control) from 43 general medical practices completed the trial. Patients whose blood pressure was uncontrolled prior to the study were more likely to become controlled in the intervention group (P<0.05). Most of the effect on self-reported adherence was seen after the first intervention. Patient satisfaction was high prior to the study and was increased in the intervention group after the study. The increase was statistically significant for five items relating to communication between pharmacist and patient. Conclusion A simple intervention delivered by community pharmacists produces positive effects on blood pressure control, self-reported adherence and on patient satisfaction with pharmaceutical services.

Rural pharmacy in Canada: pharmacist training, workforce capacity and research partnerships

Objectives. To characterize rural health care and pharmacy recruitment and retention issues explored in Canadian pharmacy strategic guidelines and Canadian Faculties of Pharmacy curricula; compare the availability of pharmacy workforce across Canadian jurisdictions; and identify models for potential collaborations between universities and rural pharmacies in the North.Methods. Review of Canadian pharmacy strategic documents, Canadian Faculty of Pharmacy websites, Canadian pharmacy workforce data and relevant literature based on the search terms to identify university– rural community pharmacy initiatives.Results. Three recent Canadian pharmacy strategic documents do not directly address issues related to rural and northern pharmacy practice, with recruitment and retention mentioned only in Canadian Pharmacists Association documents. Few Canadian Faculties of Pharmacy provide curricula on rural and northern health care issues or discuss rural recruitment and retention during training, with barriers to experiential rural practicums impeding placements. An innovative new partnership between the University of Waterloo School of Pharmacy and Gateway Rural Health Research Institute has the potential to enhance rural education, pharmacy services and community-based research. The number of pharmacists per 100,000 population in northern regions of British Columbia and the territories is low when compared with other Canadian provinces. In Australia, a model of university–rural pharmacy collaboration has been developed that may have the potential to inform future Canadian initiatives.Conclusions. Development of a coordinated, multifaceted approach involving universities, pharmacy professional associations and community-based research organizations in rural and northern regions of the country has the potential to enhance pharmacist education, practice recruitment, practice retention and community-based health outcomes research.

Web vulnerability study of online pharmacy sites

Consumers are increasingly using online pharmacies, but these sites may not provide an adequate level of security with the consumers’ personal data. There is a gap in this research addressing the problems of security vulnerabilities in this industry. The objective is to identify the level of web application security vulnerabilities in online pharmacies and the common types of flaws, thus expanding on prior studies. Technical, managerial and legal recommendations on how to mitigate security issues are presented. The proposed four-step method first consists of choosing an online testing tool. The next steps involve choosing a list of 60 online pharmacy sites to test, and then running the software analysis to compile a list of flaws. Finally, an in-depth analysis is performed on the types of web application vulnerabilities. The majority of sites had serious vulnerabilities, with the majority of flaws being cross-site scripting or old versions of software that have not been updated. A method is proposed for the securing of web pharmacy sites, using a multi-phased approach of technical and managerial techniques together with a thorough understanding of national legal requirements for securing systems.

Adalimumab Pricing and Market Exclusivity for Biologics

To the Editor: In our Perspective article about market exclusivity for biologics (Nov. 12, 2009, issue),1 the table provided the cost to consumers for adalimumab for the treatment of Crohn's disease, for which the approved dose is an induction of 160 mg, followed by 80 mg 2 weeks later, and then 40 mg every other week for a year. The value of $50,933 was derived from a publicly available listing in 2009 on Drugstore.com, a widely used Internet pharmacy site, where the product was described as “1 box = two 20 mg/0.4 mL syringes” and the price per box was . . .

Navy takes telepharmacy worldwide

The Navy Bureau of Medicine’s investment in telepharmacy is giving isolated Navy pharmacy technicians real-time access to a pharmacist—in some cases, for the first time ever. Navy Medicine’s telepharmacy project was undertaken to meet the Joint Commission’s requirements for prospective pharmacist review of outpatient prescriptions, said Lieutenant Commander Marc Young, program manager for the project. The telepharmacy system, by ScriptPro of Mission, Kansas, provides an audio-and-video link between pharmacist-staffed sites and remote pharmacies. Through the link, a pharmacist can view the original prescription and critical dispensing steps, speak with the pharmacy technician, and counsel patients when they pick up medications. Telepharmacy was examined as an alternative to other options for Joint Commission compliance, including hiring pharmacists to staff all Navy pharmacy sites. Young said the Navy competes with the private sector to hire pharmacists, and both are affected by the current shortage of pharmacists. As of May, the Navy had...

111th Annual Meeting of the American Association of Colleges of Pharmacy, Seattle, Washington, July 10–14, 2010

111th Annual Meeting of the American Association of Colleges of Pharmacy, Seattle, Washington, July 10–14, 2010

Patient (PT) understanding of venous thromboembolism (VTE) risks associated with lenalidomide (Len) and thalidomide (Thal), previous clots, and current prophylaxis.

e16512 Background: PTs takingLen and Thal alone or in combination with high dose dexamethasone are at risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). PT and provider awareness of VTE and optimal means of prevention is relatively unknown. This ongoing cross-sectional survey assessed the following objectives: 1) PT understanding of VTE risk associated with Len and Thal, 2) previous history of VTE among these PTs, and 3) current prophylaxis. Methods: A novel collaboration was developed between the specialty service demonstration outpatient pharmacy site (Walgreens Pharmacy) at Northwestern, and the Research on Adverse Drug Events and Reports (RADAR) team. A survey was developed and administered to PTs who filled a prescription for Len or Thal between July 2009 and December 2009. This pharmacy is the primary on-site location for outpatient prescriptions associated with the NCI-designated Robert H. Lurie Comprehensive Cancer Center at Northwestern. Results: A total of 23 PTs met eligibility requirements; 74% consented (14 = Len, 3 = Thal). Indications included: multiple myeloma (12), myelodysplastic syndrome (3), plasma cell lymphoma (1) and unspecified (1). Mean age= 64 (95% CI 59-70), 71% male. The proportion indicating awareness of increased clot risk while on Len or Thal was 82% (57%-96%). However, only 47% reported physician recommendation of prophylaxis and only 3 were on low molecular weight heparin or warfarin. The majority of PTs with prophylaxis were on aspirin alone (5/8). Three PTs reported history of clots (DVT = 1, PE = 1, PE and DVT = 1); all of these reported no current prophylaxis. Conclusions: In this patient subset, there is a significant discordance between PT-physician awareness of VTE risk and VTE prophylaxis. Althoughthemajority of PTs were aware of increased clot risk, less than half reported physician recommendation of prophylaxis. Further work to identify new thrombosis incidence and optimal means of prophylaxis is needed. If prophylaxis options prove to be effective, both patient education and provider awareness stand as areas of potential improvement. No significant financial relationships to disclose.

Value of community pharmacy residency programs: College of pharmacy and practice site perspectives

ObjectivesTo describe and compare perceptions of key informants representing U.S. colleges/schools of pharmacy and community pharmacy practice sites regarding (1) value associated with community pharmacy residency programs (CPRPs) and (2) barriers to offering CPRPs. DesignDescriptive, nonexperimental, cross-sectional study. SettingUnited States, June 13, 2009, through July 13, 2009. Participants554 respondents to a Web-based survey. InterventionKey informants representing the following four organizational groups were surveyed: (1) colleges/schools of pharmacy participating in CPRPs, (2) colleges/schools of pharmacy not participating in CPRPs, (3) CPRP community pharmacy practice sites, and (4) non-CPRP community pharmacy practice sites. Main outcome measuresValue of CPRPs to participating pharmacies, value of CPRPs to participating colleges/schools of pharmacy, and barriers to offering CPRPs. ResultsOverall, 267 key informants from colleges/schools of pharmacy and 287 key informants from pharmacy practice sites responded to the survey (n = 554 total respondents). Of these, 334 responders provided data that were usable for analysis. The most important types of value to the respondents were altruistic in nature (e.g., pharmacy education development, pharmacy profession development, community engagement). However, barriers to offering CPRPs were more practical and included challenges related to accreditation and operational issues. Further, evidence indicated that (1) lack of leadership, (2) lack of revenue generated from such programs, and (3) the cost of reimbursement for residents may be fundamental, multidimensional barriers to implementing CPRPs. ConclusionGuidelines for starting and continuing CPRPs, “industry norms” that would require CPRP training for certain types of employment, and creation of models for patient care revenue would help develop and position CPRPs in the future.

Complications After Self-Injection of Hyaluronic Acid and Phosphatidylcholine for Aesthetic Purposes

Various types of dermal fillers have been developed for soft tissue augmentation, including hyaluronic acid products, which have been approved by regulatory agencies in Europe, the United States, and elsewhere. Phosphatidylcholine (PPC) injection has attracted attention for its application in the treatment of cellulite, weight loss, and skin rejuvenation. Because the public can now buy PPC and similar products from various online pharmacy websites without the involvement of a clinician, there is potential for misuse. The authors discuss two cases of complications experienced by patients after self-injection of hyaluronic acid and PPC for aesthetic purposes.

Pharmacy Characteristics Associated With the Provision of Drug Therapy Services in Nonmetropolitan Community Pharmacies

Higher prevalence of chronic diseases and reduced access to other health professionals in rural areas suggest that rural Medicare enrollees will benefit from pharmacist-provided drug therapy services (DTS). The purpose of this study was to describe non-metropolitan community pharmacy sites in Wisconsin, the provision of DTS at these sites, and to identify factors associated with provision of DTS. A cross-sectional, descriptive survey design was used to collect primary data in 2005. The manager/owner listed for each of the 279 non-metropolitan community pharmacy sites in Wisconsin was surveyed using an 8-page instrument. The 7 drug therapy services that key informants were asked to report on included 6 disease state management (DSM) programs and medication therapy management services (MTMS). Descriptive statistics were calculated for variables describing the pharmacy sites and how DTS were provided. Logistic regression was performed, with any drug therapy service provision as the dependent variable and 8 independent variables. The response rate to the survey was 44%. Overall, 31% of the respondent pharmacies offered MTMS and 31% offered DSM programs. Higher service orientation, location in a more rural area, and lower workload per pharmacist were significantly positively related to provision of any DTS. Conducted 4 months prior to the implementation of Medicare Part D, the results serve as a baseline against which the effects of Part D on MTMS provision may be evaluated. The negative association of pharmacist workload with pharmacy provision of DTS, coupled with the current pharmacist shortage, has important implications for patients' access to these services in rural areas.