Drug Therapy Recommendations Research Articles

Implementation of personalized medicine services in community pharmacies: Perceptions of independent community pharmacists

ObjectivesTo evaluate the perceptions of independent community pharmacists within a regional independent community pharmacy cooperative on implementing personalized medicine services at their pharmacies and to gauge the pharmacists’ self-reported knowledge of pharmacogenomic principles. DesignDescriptive, exploratory, nonexperimental study. SettingAmerican Pharmacy Services Corporation (APSC), 2011–12. ParticipantsPharmacists (n = 101) affiliated with the independent pharmacies of APSC. InterventionSingle-mode survey. Main outcome measuresIndependent community pharmacists’ interest in implementing personalized medicine services, perceived readiness to provide such services, and perceived barriers to implementation. Results101 completed surveys were returned for data analysis. The majority of pharmacists surveyed (75%) expressed interest in offering personalized medicine services. When asked to describe their knowledge of pharmacogenomics and readiness to implement such services, more than 50% said they were not knowledgeable on the subject and would not currently be comfortable making drug therapy recommendations to physicians or confident counseling patients based on results of genetic screenings without further training and education. Respondents identified cost of providing the service, reimbursement issues, current knowledge of pharmacogenomics, and time to devote to the program as the greatest barriers to implementing personalized medicine services. ConclusionThe majority of independent community pharmacists are interested in incorporating personalized medicine services into their practices, but they require further education before this is possible. Future initiatives should focus on the development of comprehensive education programs to further train pharmacists for provision of these services.

Gründe von Änderungen der medikamentösen Therapie nach Krankenhausentlassung – eine qualitative Studie aus Sichtweise von Hausärzten und Patienten

After discharge from hospital there is often change of medication regimen. Usually, the main results of the inpatient stay and the subsequent treatment recommendations are summarised in a "discharge letter". Based on this, the general practitioner decides on how to proceed taking the individual aspects of his/her patient into consideration. The aim of the study is to trace changes of medication and suggested therapy in the discharge letter, from the GP through to the patient and the reasons/influencing factors for any changes in medication undertaken or retained. A prospective qualitative study with successively selected patients, who were put on a new long-term medication, at discharge after a stay in a hospital internal medicine unit was undertaken. Semi-structured interviews were conducted with the patients 4-6 weeks after hospital discharge. Subsequently, interviews were conducted with the patient's GP on details of current medication. The interviews were recorded electronically, based on the consensus method and evaluated with respect to changes in medication and influencing factors. In order to detect discrepancies in drug therapy, discharge letters were included in the analysis. A total of 34 patients and their GPs were interviewed. Few changes of medication changes were registered; however, these were more frequent in the weeks after hospital discharge. Drug therapy recommendations were modified by GPs for different medical or non-medical reasons. Non-medical reasons identified included economic, health policy constraints, personal conviction or non-adhrence of the patient. Reasons for a change in medication by the patient included, questioning of the need for taking the drug, incompatibility, fears and a lack of knowledge about the medication. The data demonstrate that the transition from inpatient to outpatient care is a sensitive interface. The data do not allow quantitative estimation of the magnitude of this phenomenon. In this study, the reasons for the modification of the drug demonstrated that these findings could be the basis for further studies or the development of interventions for preventing unwanted medication changes.

Assessing the Potential of E-mail for Communicating Drug Therapy Recommendations to Physicians in Patients With Heart Failure and Ventricular-Assist Devices

Purpose: This project explores electronic mail (e-mail) as a potential medium for pharmacists to communicate pharmacotherapy interventions to prescribers. Methods: This retrospective descriptive analysis was conducted at an urban, academic teaching hospital. The pharmacist attempted a drug therapy intervention via e-mail when unable to make face-to-face contact with the attending physician. Eligible patients for this project were admitted to the advanced heart failure (HF) team between December 1, 2010, and July 31, 2011, and had at least 1 attempted e-mail intervention. The primary outcome was the number of accepted interventions, while the secondary end point was the time until a physician e-mail response. Results: A total of 51 e-mail interventions were attempted on 29 patients (mean age = 53, 24% caucasian, 59% male, 69% left ventricular-assist device [VAD]). Overall, of the total 51 interventions,44 (86.3%) were accepted. The average time to a physician e-mail response was 41 minutes. Initiation of drug therapy and changing dose and route or frequency accounted for the most frequent intervention (33%). The most common drug classes involved in the e-mail interventions were angiotensin-converting enzyme inhibitors (15.7%), loop diuretics (9.8%), and antiplatelet agents (7.8%). Conclusion: Clinical pharmacists with well-established physician relationships can effectively implement timely drug therapy recommendations using e-mail communications in patients with advanced HF or VADs.

Embodying the principles of clinical pharmacy

Recently my technician was upset about a call she received from a pharmacy benefi t manager (PBM) who wanted to know why we were fi lling a 30-day supply for a patient who had been getting a 90-day supply from another pharmacy. She explained that the patient, who has an intellectual disability, was referred to our pharmacy for assistance with medication adherence and specialized compliance packaging due to his nonadherence history and past challenges in managing his medications.

Recognizing pharmacists as members of the team

Recognizing pharmacists as members of the team

Strengthening the bones in primary biliary cirrhosis

Strengthening the bones in primary biliary cirrhosis

Newly Diagnosed Immune Thrombocytopenia: Update on Diagnosis and Management

Immune thrombocytopenia (ITP) continues to intrigue pediatricians and hematologists alike. Patients can have a dramatic presentation with wide-spread bleeds over a few days. There is an aura and fear of intra-cranial hemorrhage that drives the physician to recommend and the patient's family to accept drug treatment. Difference of opinion among physicians in the recommendations for treatment is not uncommon, even though recent evidence-based guidelines recommend a conservative, observation-based approach for the majority of patients with newly diagnosed childhood ITP. It is important to note that a specific 'platelet cut-off count', is no longer suggested as an indication by itself to recommend drug therapy. The manuscript is an update on newly diagnosed ITP in children. Recent changes in definitions and recommendations for treatment are highlighted. Pros and cons of 1st line drugs, including corticosteroids, intravenous immunoglobulin and anti-D are listed. Adjunctive therapies for the management of epistaxis and menorrhagia are described. Role of splenic artery embolization and emergency splenectomy in the backdrop of severe thrombocytopenia is discussed. Realistic case scenarios, common errors and frequently asked questions are included for a practical and easy reading.

Discrepancies between two lipid-lowering guidelines for CVD prevention in seemingly healthy individuals-case study Lebanon.

In deciding on optimal interventions for cardiovascular disease (CVD) prevention, more than one set of guidelines are available. The aim of the study was to assess the agreement between the European Society of Cardiology (ESC) 2011 Guidelines for CVD Prevention and the Canadian Cardiovascular Society (CCS) 2009 Guidelines in recommending lipid lowering interventions in a seemingly healthy cohort of Lebanese persons. A nationally representative cohort of Lebanon was identified according to the World Health Organization (WHO) Steps Criteria. From this cohort, a group of 283 adult individuals not known to have chronic illnesses was selected. Using the algorithms present in each guideline, lipid lowering recommendations for each individual were determined. Agreement between the two guideline recommendations was determined using the Kappa test. As per ESC, 3.9% of the participants required immediate drug therapy, 15.5% should be considered for drug therapy, and 80.1% required lifestyle intervention. As per the CCS, however, 19.4% required drug therapy. The overall level of agreement between the ESC and CCS for recommending lipid lowering was moderate (Kappa 0.77), and better in males (Kappa 0.82). In contrast, 37.5% of females recommended drug therapy as per the CCS guidelines would not be per the ESC guidelines (Kappa 0.63). Significant discrepancies exist in recommendations for lipid-lowering therapy between CCS and ESC guidelines when applied to Lebanese individuals, particularly for women. Local healthcare authorities and the WHO should attend to this issue in order to unify treatment approaches and limit disparities in care.

What Types of Nursing Facilities Are More Likely to Adopt a Pharmacist's Medication Review Recommendations?

Few studies in the literature have analyzed the determinants of pharmacist drug therapy recommendations in nursing facility settings, and those that have focus primarily on accepted/rejected recommendations by disease state. To identify the set of nursing facility characteristics that are more likely to adopt a pharmacist's medication review recommendations. Cross-sectional, retrospective methods are used to examine 53 licensed nursing facilities receiving medication review services from a small independent consultant pharmacist practice with no ties to vendor pharmacy functions. Nursing facilities in rural areas of central and western Minnesota in 2008. Medication review services. The number of recommendations made and accepted, which are aggregated to the level of the nursing facility. Poisson regression analysis is used to identify those nursing facility characteristics that predict total recommendations and total accepted recommendations. Data obtained from Medicare's Web site on each nursing facility's operating characteristics and quality indicators serve as covariates. At the 5% level, patient census (positively), greater certified nursing assistant staffing hours (positively), multisite facilities (positively), resident residency councils (negatively), and greater perceptions of registered nurse quality (negatively) predict a greater number of recommendations. Patient census (positively), greater licensed practical nurse staffing (negatively), having residency councils (negatively), and greater perceptions of registered nurse quality (negatively) significantly predict the number of accepted and implemented recommendations. Institutional specific factors, most notably, quality-of-care indicators, may affect a nursing facility's acceptance of a pharmacist's drug therapy review.

Pharmacy innovation across the nation

Pharmacy innovation across the nation

Retracted Publications in the Drug Literature

Recent studies have suggested an increase in the number of retracted scientific publications. It is unclear how broadly the issue of misleading and fraudulent publications pertains to retractions of drug therapy studies. Therefore, we sought to determine the trends and factors associated with retracted publications in drug therapy literature. A PubMed search was conducted to identify retracted drug therapy articles published from 2000-2011. Articles were grouped according to reason for retraction, which was classified as scientific misconduct or error. Scientific misconduct was further divided into data fabrication, data falsification, questions of data veracity, unethical author conduct, and plagiarism. Error was defined as duplicate publication, scientific mistake, journal error, or unstated reasons. Additional data were extracted from the retracted articles, including type of article, funding source, author information, therapeutic area, and retraction issue. A total of 742 retractions were identified from 2000-2011 in the general biomedical literature, and 102 drug studies met our inclusion criteria. Of these, 73 articles (72%) were retracted for a reason classified as scientific misconduct, whereas 29 articles (28%) were retracted for error. Among the 73 articles classified as scientific misconduct, those classified as unethical author conduct (32 articles [44%]) and data fabrication (24 articles [33%]) constituted the majority. The median time from publication of the original article to retraction was 31 months (range 1-130). Fifty percent of retracted articles did not state a funding source, whereas pharmaceutical manufacturer funding accounted for only 13 articles (13%) analyzed. Many retractions were due to repeat offenses by a small number of authors, with nearly 40% of the retracted studies associated with two individuals. We found that a greater proportion of drug therapy articles were retracted for reasons of misconduct and fraud compared with other biomedical studies. It is important for health care practitioners to monitor the literature for retractions so that recommendations for drug therapy and patient management may be modified accordingly.

Drugs in Pediatric Ischemic Stroke

Traditionally, drug therapy for pediatric ischemic stroke has been extrapolated from adult guidelines and studies. This approach is not optimal due to important differences between adult and pediatric stroke (e.g. etiologies, maturation changes in hemostasis). Research in pediatric stroke is increasing, and pediatric specific management guidelines have recently become available. This manuscript summarizes available drug therapy recommendations for pediatric ischemic stroke. Both acute management and secondary stroke prevention are discussed, including antiplatelet, anticoagulant, and thrombolytic drugs. When relevant, recommendations from adult ischemic stroke guidelines and data from pediatric stroke studies are incorporated.

Managing atrial fibrillation in the CRT patient: Controversy or consensus?

The cumulative incidence of new onset atrial fibrillation (AF) in patients undergoing cardiac resynchronization therapy (CRT) is substantial, exceeding 25% in multiple recent studies. Although AF patients undergoing CRT show improved echocardiographic parameters, functional status, and quality of life in, they benefit to a lesser degree than do patients in normal sinus rhythm. They also exhibit a trend toward increased mortality. Understanding the barriers to response from CRT among AF patients is critical to addressing the needs of growing populations of patients with AF and HF. Foremost among these are suboptimal biventricular pacing, often characterized by fusion or pseudo-fusion complexes, leading to inefficient CRT delivery. Furthermore, AF increases the risk of inappropriate shocks, which lead to substantial psychiatric morbidity, increased risk of heart failure hospitalization, and may also increase mortality. Assiduous rate control is reasonable for all AF patients receiving CRT, but there is a paucity of data regarding specific antiarrhythmic drug therapy recommendations. For patients with permanent AF and severe symptoms, atrioventricular junction ablation appears effective in improving response by ensuring biventricular capture and reducing implantable cardioverter-defibrillator shock burden in selected patients. Catheter-based techniques such as pulmonary vein isolation appear more attractive and in the future may offer further advantages and lower risks, particularly for patients with paroxysmal AF.

Pediatric Pneumonia Guidelines Summary

guidelines were published by the Infectious Disease Society of America and the Pediatric Infectious Disease Society.1 Within these guidelines is a wealth of information regarding the diagnosis, siteof-care decisions, treatment, and prevention of pediatric community-acquired pneumonia (PCAP). While guidelines cannot replace clinical judgment, they do provide evidence-based recommendations with the potential to adapt to patient-specific situations. This article focuses specifically on the drug therapy and new immunization recommendations.

Quality of Care for Myocardial Infarction at Academic and Nonacademic Hospitals

BackgroundWhether academic hospitals provide better quality of care for patients with acute myocardial infarction is widely debated. The aim of this study was to compare processes of care and mortality between academic and nonacademic hospitals in the contemporary era of acute myocardial infarction management. MethodsWe analyzed the original data from a prospective cohort study of 3059 patients, including 1714 with ST-segment elevation and 1345 with non-ST-segment elevation myocardial infarction, enrolled at 39 and 183 academic and nonacademic hospitals, respectively, in France. ResultsUnadjusted 1-year mortality for academic and nonacademic hospitals was 10% versus 15% for patients with ST-segment elevation myocardial infarction (P=.01) and 13% versus 14% for patients with non-ST-segment elevation myocardial infarction (P=.75). Patients treated in academic or nonacademic hospitals with percutaneous coronary intervention capability were more likely to receive reperfusion and recommended drug therapies than those treated in nonacademic hospitals without percutaneous coronary intervention capability. After adjusting for baseline characteristics, the hazards of death associated with admission to nonacademic hospitals with and without percutaneous coronary intervention capability relative to academic hospitals were 1.13 (95% confidence interval [CI], 0.79-1.62) and 1.65 (95% CI, 1.09-2.49) for those with ST-segment elevation myocardial infarction and 0.95 (95% CI, 0.66-1.36) and 1.06 (95% CI, 0.72-1.58) for those with non-ST-segment elevation myocardial infarction, respectively. Further adjustment for receipt of acute reperfusion and recommended drug therapies eliminated all differences in mortality between the study groups. ConclusionAdmission to academic hospitals was associated with a more frequent use of recommended therapies, conveying a survival advantage for patients with ST-segment elevation myocardial infarction.

Pharmacist’s role in a Parkinson’s disease and movement disorders clinic

The expanding role of a clinical pharmacist at a Veterans Affairs (VA) out-patient clinic for patients with Parkinson's disease (PD) and movement disorders is described. San Francisco VA Medical Center added a clinical pharmacist to the multi-disciplinary team serving patients at an outpatient clinic operated by its Parkinson's Disease Research, Education and Clinical Center (PADRECC). During the first six months after joining the clinic team, the pharmacist met with 131 patients and made a total of 69 drug therapy recommendations that were implemented by neurologists, clinical nurse specialists, and other PADRECC providers. The results of a retrospective chart review suggested that in about 21% of the cases evaluated, the pharmacist's recommendations contributed to an improved medical outcome or the resolution of a medical problem. Anonymous surveys indicated that clinic providers (n = 33) and patients (n = 20) were satisfied with the pharmacist's services. Using a five-point Likert scale (scores ranged from 1 for "strongly disagree" to 5 for "strongly agree") that they had more time to devote to other clinic responsibilities with the pharmacist present in the clinic (mean score, 4.79); patients indicated that they had an improved understanding of their medications after speaking with the pharmacist (mean score, 4.88). A clinical pharmacist's regular involvement in an outpatient PD and movement disorders clinic has been well received by patients and clinic providers. The study results suggest that the pharmacist has made important contributions in areas such as therapeutic problem solving and medication education while freeing up providers for other responsibilities.

Recommended drug therapy for inflammatory bowel disease

AbstractInflammatory bowel disease is a chronic condition of unclear aetiology that can greatly impact on the lives of those affected. Our Drug review discusses the currently available treatments and their properties, followed by sources of further information. Copyright © 2012 Wiley Interface Ltd

Pharmacotherapy for imported parasitic diseases with drugs reserved by the government

Parasitic diseases are widely distributed throughout the world. Recently, travel abroad and migration from abroad are increasing in Korea. Therefore, it is necessary to appropriately control imported parasitic disease. The drugs for the treatment of the parasitic diseases that can be imported from abroad are reserved by the government. To guide proper treatment of parasitic diseases, recommended chemotherapy focused on these reserved drugs has been introduced. The diseases reviewed in this article include malaria, babesiosis, toxoplasmosis, leishmaniasis, Chagas disease, African sleeping sickness, filariasis, angiostrongyliasis, and fascioliasis. Because most of the parasitic diseases produce severe illness or fatal results, rapid and accurate diagnosis is important and following fully the recommended therapy is needed. The recommended drug therapy changes from time to time due to various factors, so always recognizing and applying the latest therapy and is very important.

Implementing a Pharmacist-Led Medication Management Pilot to Improve Care Transitions

Purpose: The purpose of this project was to design and pilot a pharmacist-led process to address medication management across the continuum of care within a large integrated health-system.
 Summary: A care transitions pilot took place within a health-system which included a 150-bed community hospital. The pilot process expanded the pharmacist's medication management responsibilities to include providing discharge medication reconciliation, a patient-friendly discharge medication list, discharge medication education, and medication therapy management (MTM) follow-up.
 Adult patients with a predicted diagnosis-related group (DRG) of congestive heart failure or chronic obstructive pulmonary disease admitted to the medical-surgical and intensive care units who utilized a primary care provider within the health-system were included in the pilot. Forty patients met the inclusion criteria and thirty-four (85%) received an intervention from an inpatient or MTM pharmacist. Within this group of patients, 88 drug therapy problems (2.6 per patient) were identified and 75% of the drug therapy recommendations made by the pharmacist were accepted by the care provider. The 30-day all-cause readmission rates for the intervention and comparison groups were 30.5% and 35.9%, respectively. The number of patients receiving follow-up care varied with 10 (25%) receiving MTM follow-up, 26 (65%) completing a primary care visit after their first hospital discharge, and 23 (58%) receiving a home care visit.
 Conclusion: Implementation of a pharmacist-led medication management pilot across the continuum of care resulted in an improvement in the quality of care transitions within the health-system through increased identification and resolution of drug therapy problems and MTM follow-up. The lessons learned from the implementation of this pilot will be used to further refine pharmacy care transitions programs across the health-system.
 
 Type: Original Research

Evolution of the Therapeutic Profile over a Three Year- Period in Heart Failure Patients

Background: Recent studies have shown that recommended drugs for the treatment of chronic heart failure (CHF) are under-prescribed in daily practice. This gap between guidelines and clinical practice is even more pronounced in developing countries, including Romania. Aim: To compare the characteristics and the modality of treatment of patients with CHF discharged from a General Romanian Hospital in 2009, with those of an analogous patient population observed three years earlier, in 2006. Methods: There were studied two cohorts of patients (from 2006-415 patients, 67.08±10.59 years old vs from 2009-500 patients, aged 67.31±11.27 years) admitted in the Rehabilitation Hospital-Cardiology Department with a diagnosis of CHF class NYHA II-IV. The mean LVEF was 56.09±14.83% in 2006 and 58.91±15.41% in 2009. In all patients recommended drug therapy was compared with the recommendations made by the ESC 2005 and 2008 guidelines, respectively. Results: Inhibitors of the Renin-Angiotensin System were prescribed to the great majority of patients, the percentage being 74.4% in 2006 vs 77.20 % in 2009. A decrease of ACEI (71.3% vs 65.2%; p<0.01) and an important increase of ARB's use (3.1% vs 12.20% p<0.01) were registered. Beta-blockers use increased (51.8% vs 69.2%), prescription of loop diuretics and aldosterone antagonists' slightly decreased (89.4% vs 85%, 80.2% vs 67.8%). Digoxin was less used in 2009 (57.10% vs 42.60 %) even though the percentage of patients with atrial fibrillation was no different between the two years. The use of antiplatelet drugs increased (32.23% vs 56.5 %). Conclusions: There was an improvement in guidelines adherence over a three-year period in Romania. Renin- angiotensin inhibitors, beta-blockers and diuretics are used according to the guidelines recommendations, yet antiplatelets remain underused.