Impact of the fracture risk assessment on patient and physician behavior in osteoporosis prevention.

OBJECTIVE: To evaluate the impact of a pharmacist-directed osteoporosis screening program utilizing the fracture risk assessment (FRAX) tool on patient and physician behavior. METHODS: Postmenopausal women 45 to 65 years with Achilles T score <-1.0 not receiving bisphosphonate therapy were randomly assigned to a control or intervention group. All participants received a heel ultrasound and pharmacist education on risks of low bone mass. The intervention group received the FRAX and shared their results with their physician. Three months after screening, a telephonic questionnaire was administered to all participants. RESULTS: A total of 749 patients were screened, with 87 meeting the enrollment criteria (43 control and 44 intervention). Physician behavior was not different between the groups with respect to ordering vitamin D levels, prescription medication, or dual-energy x-ray absorptiometry scan. A significant difference in vitamin D supplementation occurred between the 2 groups (P = .024). At follow-up, 72.2% of responding participants increased daily calcium intake and 76.4% started or increased physical activity. CONCLUSION: Physician behavior was not influenced by FRAX results in the intervention group; however, positive patient behavior changes occurred in both groups. Primary prevention efforts conducted through heel ultrasound screening and pharmacist consultation led women to follow-up; however, awareness still needs to be raised of the value of FRAX in osteoporosis prevention.

Development and integration of pharmacist clinical services into the patient-centered medical home.

OBJECTIVES: To describe the development of pharmacist clinical services within a primary care physician practice using a standardized business plan, the extent of clinical pharmacy service integration into the patient-centered medical home (PCMH), and the clinical changes in the pharmacist's patient cohort. SETTING: A two-physician primary care/occupational care practice in Pittsburgh, PA, from May 2007 to December 2011. PRACTICE DESCRIPTION: Pharmacist-led clinic receives physician referrals for medication management, adherence, and disease management services. PRACTICE INNOVATION: Pharmacist practice in a primary care setting with emphasis on integration of clinical services into the medical home model designed by the American Academy of Family Physicians. MAIN OUTCOME MEASURES: Characterization of the patient's pharmacist and services provided by the pharmacist. Glycosylated hemoglobin (A1C), body mass index (BMI), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total cholesterol, triglycerides, and blood pressure. RESULTS: The top five primary referral reasons were diabetes self-management, weight management, medication adherence, hypertension, and dyslipidemia management. Improvements in clinical parameters were demonstrated for lipids and A1C at 1 and 2 years after baseline. Statistically significant improvements in BMI also were observed. CONCLUSION: The pharmacist developed and integrated clinical services into a primary care practice, became an integral member of the clinical team in the two-physician PCMH, and improved patient outcomes.

Management of chronic nonmalignant pain with nonsteroidal antiinflammatory drugs. Joint opinion statement of the Ambulatory Care, Cardiology, and Pain and Palliative Care Practice and Research Networks of the American College of Clinical Pharmacy.

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.

Impact of pharmacist interventions on seeking of medical care by migraineurs.

OBJECTIVES: To determine the impact of a pharmacist-led educational intervention on the seeking of medical care from physicians by patients with migraine and identify barriers to migraine care and lapsing from this care. DESIGN: Prospective, multigroup, quasiexperimental. SETTING: Duquesne University in Pittsburgh, November 2004 through June 2005. PARTICIPANTS: 100 university employees and students. Information from the initial interview was used to divide the patients into four groups: (1) not a migraineur, (2) migraineur who is currently consulting a physician for care of headaches (current consulter), (3) migraineur who has not consulted with a physician for more than 12 months concerning headaches (lapsed consulter), and (4) migraineur who has never consulted a physician regarding headache (never consulter). INTERVENTIONS: Verbal counseling by a pharmacist and written education on migraine, as well as self-administered questionnaires. MAIN OUTCOME MEASURES: Participants' physician consultation rates, perceived barriers to physician consultation, and perceived reasons for lapsing from care. RESULTS: Of the 100 headache sufferers who participated in the study, 82 met International Headache Society criteria for migraine, of whom 22 were never consulters and 20 were lapsed consulters. Cross-tabulation and chi-square statistics did not reveal any statistically significant differences between the never-consulter control and intervention groups for 3-month physician consultation rates or intention to seek consultation during the next 6 months; however, 64% of never consulters contacted their physician or expressed intentions to do so after the intervention. The top three barriers to physician consultation identified were misidentifying migraines as headaches (50%), satisfaction with current treatment (45%), and inconvenience of physician consultation (41%). The top three reasons for lapsing from care were reduced frequency of headache (40%), self-identification of effective therapy (40%), and physician-directed effective therapy (30%). Cross-tabulation and chi-square statistics revealed one significant difference among student/employee groups in their identification of barriers. CONCLUSION: This study identified barriers associated with migraineur physician consultation behavior and reasons for lapses in care. The role of pharmacists in encouraging migraineur physician consultation should be further examined.

A required course in the development, implementation, and evaluation of clinical pharmacy services.

OBJECTIVE: To develop, implement, and assess a required pharmacy practice course to prepare pharmacy students to develop, implement, and evaluate clinical pharmacy services using a business plan model. DESIGN: Course content centered around the process of business planning and pharmacoeconomic evaluations. Selected business planning topics included literature evaluation, mission statement development, market evaluation, policy and procedure development, and marketing strategy. Selected pharmacoeconomic topics included cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, cost-utility analysis, and health-related quality of life (HRQoL). Assessment methods included objective examinations, student participation, performance on a group project, and peer evaluation. ASSESSMENT: One hundred fifty-three students were enrolled in the course. The mean scores on the objective examinations (100 points per examination) ranged from 82 to 85 points, with 25%-35% of students in the class scoring over 90, and 40%-50% of students scoring from 80 to 89. The mean scores on the group project (200 points) and classroom participation (50 points) were 183.5 and 46.1, respectively. The mean score on the peer evaluation was 30.8, with scores ranging from 27.5 to 31.7. CONCLUSION: The course provided pharmacy students with the framework necessary to develop and implement evidence-based disease management programs and to assure efficient, cost-effective utilization of pertinent resources in the provision of patient care.

Development and implementation of a pharmacist-managed university-based wellness center.

OBJECTIVE: To describe the development and implementation of a pharmacist-managed wellness center based on campus within a school of pharmacy. SETTING: Duquesne University Mylan School of Pharmacy, located in Pittsburgh, Pa. PRACTICE DESCRIPTION: University-based employee wellness center, the Academic Research Center for Pharmacy Care, located within a school of pharmacy staffed by clinical practice faculty and student pharmacists. PRACTICE INNOVATION: The campus-based wellness practice integrates public health activities into the pharmacy school curriculum and provides a model that can be adapted for other ambulatory and community practices. INTERVENTIONS: Referral of clients to primary care providers following identification of risk for disease. MAIN OUTCOME MEASURES: Number of screenings; number of clients identified with elevated cholesterol, blood glucose (BG), blood pressure, or weight and referred to primary care providers; and number of student pharmacists participating in wellness experiential rotations. RESULTS: The center conducted more than 19,000 individual screenings on campus, in neighboring communities, and in the western Pennsylvania region from October 2002 through May 2006. During the period July 2005 through May 2006, 16% of those screened required referral for elevated blood pressure (>140/90 mm Hg), 23% required referral for elevated total cholesterol (> 200 mg/dL, the population covers ages 20 to over 70 years), 8% required referral for elevated BG (fasting BG > or =100 mg/dL or nonfasting BG > or =200mg/dL), 43% required referral for low bone density (T-score < or =-1), 21% required referral for abnormal skin findings ranging from dryness to suspicious markings, and 26% required referral for body mass index (> or =30 kg/m2). A total of 70 student pharmacists, divided among two full-time clinical practice faculty, have participated in the wellness clinical rotation since 2004. CONCLUSION: Pharmacists can successfully direct public heath initiatives such as wellness and health promotion programs in an employee-based health center, in the community, and in community pharmacies. Pharmacists are able to identify primary preventive patients for referral to other health care providers.

Equianalgesic dosing of opioids.

The concept of opioid equianalgesia, limitations in current dose conversion systems, equianalgesic dose tables, and computer assisted dose conversions are discussed. Conversions for methadone, fentanyl and hydromorphone are described.

Factors influencing migraineur-consulting behavior in a university population.

OBJECTIVE: The purpose of this study was to identify factors that contribute to treatment-seeking behavior in migraineurs in a large employer population. Specifically, the impact of psychographic variables, such as social support, attitudes toward medication, locus of control, and migraine-associated disability, are considered concomitantly with demographic and disease severity variables. BACKGROUND: Migraine remains an underconsulted condition. Previous explorations of demographic factors and headache characteristics have not adequately predicted migraineur physician-consulting behavior. METHODS: University employees and students experiencing headaches were interviewed by pharmacists to determine whether they suffer from migraine using the International Headache Society (IHS) criteria for migraine. Identified migraineurs were categorized into 3 groups: (1) never-consulter, (2) lapsed-consulter, and (3) current-consulter. Each group was asked to complete an instrument that assesses perceived social support (Headache Social Support Questionnaire), medication attitudes (Beliefs about Medicines Questionnaire), locus of control (Headache-Specific Locus of Control Scale), and migraine-associated disability (Migraine Disability Assessment Questionnaire). Univariate (ANOVA) and multivariate (logistic regression) approaches were used to identify factors associated with migraineur-consulting behavior. RESULTS: A total of 100 subjects participated in the study. Eighty-two participants met IHS criteria for migraine, of whom 22 were never-consulters, 20 were lapsed-consulters, and 40 were current-consulters. The consulter groups differed on scores acquired from the Social Support Active Involvement subscale (P= .04) and the Healthcare Professional Locus of Control subscale (P= .010). The logistic regression procedures confirmed the contributions of social support and healthcare locus of control in predicting migraineur-consulting behavior. CONCLUSION: Results suggest that attitudes concerning the role of healthcare professionals and the presence of a supportive social network have greater influence on migraineur-consulting behavior than do patient demographic characteristics, beliefs about medications, and migraine frequency and severity. With an understanding of the link between psychosocial variables and consulting behavior, healthcare professionals may be able to positively impact migraineur physician consultation rates, drug therapy, and quality of life.