Survey of bisphosphonate regimen preferences in an urban community health center.

OBJECTIVE: to determine patient preference for bisphosphonate therapy based on dosage form and dosing schedule. DESIGN: prospective telephone survey. SETTING: urban community health center. PATIENTS, PARTICIPANTS: all patients who were seen in the osteoporosis clinic during the 22-month time period were contacted. Patients were excluded if they could not complete the survey in English, had difficulty hearing, had cognitive impairment, or were unable to be reached by telephone. INTERVENTIONS: patients were asked which route and frequency of bisphosphonate therapy was preferred, convenient, and easiest to remember. MAIN OUTCOME MEASURE(S): patient-reported preference for route and frequency of bisphosphonate administration. RESULTS: ninety patients were included in the final analysis. Preference for bisphosphonate therapy illustrated that equal numbers of respondents preferred either once-monthly or once-yearly regimens (24.4% for each, n = 22). One-third of respondents (n = 30) indicated that a once-yearly infusion was the most convenient method of administration. The survey revealed no strong association of which regimen was easiest to remember. CONCLUSION: the majority of patients preferred once-monthly or less frequent dosing schedules. Clinicians may consider discussing patient preferences during initiation and throughout therapy.

Denosumab in osteoporosis and oncology.

OBJECTIVE: To review the pharmacology, pharmacokinetics, pharmacodynamics, safety, efficacy, and use of denosumab in osteoporosis, breast cancer, prostate cancer, and multiple myeloma. DATA SOURCES: Studies and abstracts were identified through MEDLINE and International Pharmaceutical Abstracts (1966-July 2009). Key search terms include denosumab, AMG-162, and receptor activator of nuclear factor-kappaB ligand system. Information available in abstract form was retrieved from major oncology and bone metabolism meetings. Additional data were obtained from the manufacturer. STUDY SELECTION AND DATA EXTRACTION: All available studies in humans were included except for studies in rheumatoid arthritis and giant cell tumor of the bone. DATA SYNTHESIS: In patients with osteoporosis, denosumab significantly reduces bone resorption and fractures. Studies of denosumab in the prevention and treatment of osteoporosis have demonstrated significantly increased bone mineral density and reduced bone turnover markers. Studies of denosumab versus placebo in the treatment of osteoporosis have demonstrated reductions in vertebral, hip, and nonvertebral fractures. In oncology, positive results from clinical trials in patients receiving endocrine therapy for breast and prostate cancer demonstrated decreases in bone loss and skeletal-related events. Denosumab seems to be at least as effective in reducing bone turnover markers as intravenous bisphosphonates in the oncology setting. The most common adverse effects in patients with osteoporosis were arthralgia, nasopharyngitis, back pain, and headache. The most common adverse effects in patients with cancer were infection, pain in the extremities, arthralgia, bone pain, fatigue, and pain. Serious adverse effects include infections requiring hospitalization. CONCLUSIONS: Denosumab has documented efficacy and safety in patients with osteoporosis, breast cancer, and prostate cancer. Additional clinical trial data are needed to more completely establish the effectiveness of denosumab in the treatment of osteoporosis and neoplastic disease as well as its cost-effectiveness and long-term safety.

An elective course on landmark trials to improve pharmacy students' literature evaluation and therapeutic application skills.

OBJECTIVES: To determine the impact of a landmark trials elective course on pharmacy students' attitudes toward evidence-based medicine, students' comfort with technical concepts used in drug literature, and students' perceptions of accessibility of PubMed from home computers. DESIGN: An elective course which gave third-year pharmacy students the opportunity to discuss landmark trials in primary care and reinforced skills in applying evidence from the primary literature to support therapeutic recommendations was design and implemented. The impact of the course was evaluated via a pre- and postcourse questionnaire administered during 3 consecutive course offerings. ASSESSMENT: Overall, students had positive attitudes toward evidence-based medicine before taking the course (97.5% positive or somewhat positive) and these attitudes were unchanged postcourse (p = 0.74). Though 97.6% (n = 40) of students had Internet access at home, only 68.3% (n = 28) indicated having PubMed access at home. The course increased self-assessed comfort with technical concepts used in literature evaluation including random assignment (p < 0.01), placebo-controlled (p < 0.01), and intention-to-treat (p = 0.02). CONCLUSION: An elective course on landmark trials allowed third-year pharmacy students to increase their comfort level with literature evaluation and reinforced their positive attitudes toward the use of evidence-based medicine in pharmacy practice.

International Normalized Ratio values in group versus individual appointments in a pharmacist-managed anticoagulation clinic.

PURPOSE: The clinical effectiveness of a group-visit model versus individual point-of-care visits is compared by International Normalized Ratio (INR) monitoring in a pharmacist-managed anticoagulation clinic. METHODS: This study was a prospective, randomized, repeated-measures, two-group, intention-to-treat comparison and survey at a pharmacist-managed anticoagulation clinic in a managed-care ambulatory care setting. Patients were eligible for this study if they were taking warfarin therapy for at least 30 days, had a goal INR range, and provided consent. At a routine point-of-care visit, eligible patients were randomly invited to participate in group visits. The number of visits and INR values were documented prospectively for both groups during the 16-week study period. RESULTS: Of the 45 patients who consented and enrolled in group visits, 28 patients participated for the 16-week study period. The control group included 108 patients seen by a pharmacist for individual anticoagulation appointments. No significant difference in the percentage of INR values within the therapeutic range was detected between patients in the group-visit model versus patients receiving individual visits (59% versus 56.6%, respectively; p = 0.536). Seventy-three percent of INR values for patients who attended group visits were within +/- 0.2 of the desired INR range compared with 71.9% of those in the control group ( p = 0.994). In addition, 79% of group-visit patients were within the therapeutic range at their last clinic visit compared with 67% of patients who attended individual appointments (p = 0.225). Group visits were preferred by 51% (n = 38) of patients who completed the satisfaction survey. Of the 92 patients who declined group-visit participation, 36% indicated that the time of day that group visits were offered was inconvenient. There were no thromboembolic or hemorrhagic events documented in either group during the study period. CONCLUSION: Group visits in a pharmacist-managed anticoagulation clinic may provide a safe and effective alternative to individual appointments.

ACCP white paper: Essential components of a faculty development program for pharmacy practice faculty.

Prospective, ongoing faculty development programs are important in the initial orientation and short- and long-term development of faculty in higher education. Pharmacy practice faculty are likely to benefit from a comprehensive faculty development program due to the complex nature of their positions, incomplete training in select areas, and multiple demands on their time. The need for faculty development programs is supported by the increased need for pharmacy practice faculty due to the increased number of colleges and schools of pharmacy, expanding enrollment in existing colleges and schools, and loss of existing senior faculty to retirement or other opportunities within or outside the academy. This White Paper describes a comprehensive faculty development program that is designed to enhance the satisfaction, retention, and productivity of new and existing pharmacy practice faculty. A comprehensive faculty development program will facilitate growth throughout a faculty member's career in pertinent areas. The structure of such a program includes an orientation program to provide an overview of responsibilities and abilities, a mentoring program to provide one-on-one guidance from a mentor, and a sustained faculty development program to provide targeted development based on individual and career needs. The content areas to be covered in each component include the institution (e.g., culture, structure, roles, responsibilities), student-related activities, teaching abilities, scholarship and research abilities, practice abilities and the practice site, and professional abilities (e.g., leadership, career planning, balancing responsibilities). A general framework for a comprehensive pharmacy practice faculty development program is provided to guide each college, school, department, and division in the design and delivery of a program that meets the needs and desires of the institution and its faculty.

Improving effectiveness in communicating risk to patients.

OBJECTIVE: To review approaches and tools that pharmacists may use in communicating evidence of risk to older patients and their caregivers. DATA SOURCES: Relevant publications related to tools to communicate evidence to patients were identified through a systematic MEDLINE and Internet search engines using key words: evidence-based medicine/practice, patient, and risk communication. Additional articles were identified through use of the PubMed "related articles" feature and a review of citations of previously identified articles. STUDY SELECTION AND DATA EXTRACTION: Relevant English language publications were reviewed, with particular focus on articles about older adults. DATA SYNTHESIS: Communicating evidence from clinical trials to patients remains a challenge because of patient- and clinician-related barriers. Communicating with older adults faces additional challenges: perceptions of patient involvement in care and uncertainty of drug benefit-to-risk ratio because of the potential increase in adverse events. This is especially true in this population because of their multiple medical conditions. To actively involve patients in health care decisions, an ordered approach to teaching risks and benefits can be valuable. Evidence presented as a general risk estimate should be reinforced with specific numbers to depict patient-specific risk. Understanding may be strengthened with visual aids such as risk ladders or perspective scales. Each step in the process serves as a framework and should consider patients' individual values and beliefs. CONCLUSIONS: For patients to fully understand medications' risks and benefits, clinicians must use a systematic approach to present data from clinical trials and reinforce patients' comprehension using visual aids. Ultimately, these approaches and tools aim to support patient involvement in health care decisions.

Improving adherence--sharing experiences.

Nonadherence is a significant concern for practitioners. Adherence rates have been estimated at 50%, demonstrating the need for information regarding interventions to improve adherence. Patient education through creative analogies or stories may help overcome barriers related to patient misconceptions. There is a need for individual clinicians to have a forum for sharing successful strategies used in patient adherence on an individual level. An electronic column for clinicians to share innovative approaches may fill this need.

Pharmacy residents' attitudes toward pharmaceutical industry promotion.

PURPOSE: The attitudes of pharmacy residents toward pharmaceutical industry promotion and the perceived effects of such promotion on the knowledge and professional practice of the residents were studied. METHODS: A questionnaire study of current postgraduate year 1 and postgraduate year 2 pharmacy residents was conducted. Questions were adapted from instruments used in studies of medical student or physician attitudes regarding the pharmaceutical industry. The questionnaire requested demographic information about the resident, information regarding the resident's exposure to specific types of pharmaceutical company-related activities, and the resident's perception of whether the residency program or department had policies or guidelines regarding interactions with the pharmaceutical industry. Questions investigated the attitudes toward pharmaceutical industry promotion and the perceived influence of pharmaceutical industry promotion on the professional knowledge and behavior of the residents. RESULTS: Responses were received from 496 pharmacy residents. Nearly all (89%) residents agreed that pharmaceutical company-sponsored educational events enhance knowledge. Almost half (43%) of the respondents reported that information from educational events influences therapeutic recommendations. One quarter (26%) of the pharmacy residents indicated prior training regarding pharmacist-industry interactions, and most (60%) residents indicated that their institution's residencies or departments have policies regarding interactions with the pharmaceutical industry. CONCLUSION: Most surveyed pharmacy residents believed that educational events sponsored by pharmaceutical companies enhance knowledge. Respondents whose institutions had policies or who had received training about such events were less likely than other respondents to perceive an influence of the events on their knowledge and behavior.

Chief resident in pharmacy residency programs.

PURPOSE: The frequency of chief resident positions in pharmacy residency programs and the roles and responsibilities of such chief residents are described. METHODS: A Web-based questionnaire was developed to determine the current state and interest of residency program directors (RPDs) in chief residency programs within pharmacy residency training. RPDs were identified through directories of the American Society of Health-System Pharmacists and the American College of Clinical Pharmacy. RESULTS: Of the 892 surveys distributed, 34 were returned as undeliverable and 335 responses were received (effective response rate, 39.0%). Over one quarter of respondents (28.4%) had a chief resident, resident-in-charge, or other leadership position for residents at their institution. Institutions with existing chief resident programs had larger programs. Common duties of the chief resident included serving as a liaison between residents and the RPD (91.4%), coordinating resident meetings (87.1%), coordinating educational programming (45.2%), and managing residents' schedules (44.1%). RPDs indicated interest in training programs designed to develop management skills and enhance leadership potential (72.7%). Of those RPDs whose institutions did not off er a chief resident position, 22% expressed interest in developing such a position. Programs with four or more residents were more likely to be interested in developing a chief residency program than those with smaller programs (34.3% versus 13.2%, p < 0.001). CONCLUSION: The majority of RPDs stated that their residency programs do not currently have a chief resident position. Programs with a greater number of pharmacy residents were more likely to have a current chief resident position or interest in establishing a chief resident position.

Update in handheld electronic resources for evidence-based practice in the community setting.

OBJECTIVE: To provide an update on the handheld electronic resources for evidence-based practice (EBP) in the community setting. DATA SOURCES: Electronic resources for EBP in the community setting were identified by compiling the commonly used, well-established resources and by searching MEDLINE and other Internet sites. Search terms included evidence-based medicine, evidence-based practice, resources, and abstraction. Only sources available for personal digital assistants were included. DATA EXTRACTION: Three databases were identified that provided abstraction and evaluation of the medical literature for the handheld platform. Content, features, ease of use, system requirements, and costs of each resource were evaluated. DATA SYNTHESIS: FIRSTConsult, InfoRetriever, and UpToDate were evaluated, and the utility of each in the community pharmacy setting was evaluated by tracking a clinically relevant example through each system. FIRSTConsult provides evidence-based information organized by diagnosis but is not searchable on the handheld platform. InfoRetriever focuses on searchable evidence-based summaries, while UpToDate includes comprehensive topic reviews. The latter 2 platforms have large system memory requirements. All 3 sources provide evidence-based abstraction of the medical literature for the PDA platform, convenient for use at the point of care in community pharmacy. CONCLUSIONS: While users may select a particular resource based on unique features, each provides evidence-based abstraction of the medical literature that is a practical approach to EBP in the community pharmacy setting.

Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation.

STUDY OBJECTIVE: To determine the effect of access to ambulatory anticoagulation management services (AMS) on the rate of warfarin use in patients with atrial fibrillation. DESIGN: Retrospective medical record review. SETTING: Two ambulatory care clinics in the same managed care system: one with and one without access to pharmacist-managed AMS. PATIENTS: One hundred seventy-eight patients with atrial fibrillation diagnosed between June 2000 and June 2001. MEASUREMENTS AND MAIN RESULTS: Warfarin use was assessed overall and by contraindications and risk factors for stroke. Independent predictors of therapy were identified. The overall rate of warfarin use in atrial fibrillation was higher in the clinic with access to AMS than in the clinic without access (77.9% vs 61.7%, p=0.03). In patients with no known contraindications, warfarin use increased by 20.2% with access to AMS versus no access (80.2% vs 60.0%, p=0.023). Patients aged 65 years or older with one or more risk factors for stroke and no contraindications were more likely to receive warfarin in the clinic with access to AMS than in the clinic without access (85.1% vs 53.8%, p=0.001). Access to AMS was an independent predictor of warfarin use (odds ratio 2.19, 95% confidence interval [CI] 1.05-4.56). Female sex was an independent negative predictor of warfarin use (odds ratio 0.48, 95% CI 0.24-0.96). CONCLUSION: In the managed care setting, use of warfarin for stroke prophylaxis in patients with atrial fibrillation was higher in the ambulatory care clinic with access to pharmacist-managed AMS than in the clinic without access.