Pharmacy education and practice in 13 Middle Eastern countries.

The Arab world has influenced the art and science of pharmacy for centuries. Pharmacy education and practice is continuing to evolve in the Arabic-speaking traditional Middle East countries, although relatively little information has been published in the English press. Our goal was to provide a high-level synopsis of conditions in this region. We selected 13 countries for review. Information was obtained by reviewing the available published literature and individual university and program web sites, as well as contacting program or country representatives. Seventy-eight active pharmacy schools in 12 countries were identified. At least 14,000 students (over 75% from Egypt) are admitted into baccalaureate degree programs every year. The 5-year baccalaureate degree remains the first professional degree to practice. While changes in pharmacy education have been relatively rapid over the past decade, the advancement of pharmacy practice, particularly in the private sector, appears to be slower. Hospital pharmacists often possess an advanced degree and tend to have a higher level of practice compared to that of community pharmacists. Despite the adversities that face academics and practitioners alike, there is a strong desire to advance the science and practice of pharmacy in the Middle East.

Documenting drug-related problems with personal digital assistants in a multisite health system.

PURPOSE: A scalable, multiuser, personal digital assistant (PDA)-based documentation tool for pharmacist collection of data on drug-related problems (DRPs) is described. SUMMARY: A PDA-based tool for documenting DRPs and pharmacist interventions was developed with database software. Data fields were based on the pharmaceutical care model. PDA synchronization stations were configured to transmit encrypted data from three hospital sites to a central server. Pharmacists in a multisite health care organization were trained to use the documentation tool. Data were analyzed with commercially available software. Users' opinions about the tool were solicited in a survey. Twenty-eight PDAs containing a 15-field database were issued to 39 pharmacists in 31 service areas. Data were successfully transmitted from all hospital sites over the existing corporate local area network. During a two-month period, 5084 DRPs were documented; 90% of them were resolved at the time of data entry. The most frequent types of DRPs were the need to add a drug (31%) and the ordering of an unnecessary drug (15%). Most pharmacists reported that the tool was easy to use, was well integrated with the workflow, and required less than 30 minutes per day for documenting DRPs. CONCLUSION: A PDA-based documentation tool was successfully used in a multisite health care organization to collect data on DRPs and document pharmacist interventions.

The impact of a pharmacist-managed dosage form conversion service on ciprofloxacin usage at a major Canadian teaching hospital: a pre- and post-intervention study.

BACKGROUND: Despite cost containment efforts, parenteral (IV) ciprofloxacin appears to be overutilized at Vancouver General Hospital. In November 2003, the Pharmacist-managed intravenous to oral (IV-PO) Dosage Form Conversion Service was implemented, enabling autonomous pharmacist-initiated dosage form conversion for ciprofloxacin. This study evaluates characteristics of ciprofloxacin use prior to and following implementation of this conversion service. METHODS: This was a single-centre, two-phase (pre/post), unblinded study. Phase I occurred between November 12, 2002 and November 11, 2003 (365 days), and Phase II between November 12, 2003 and March 11, 2004 (120 days). All patients receiving ciprofloxacin IV during these periods were reviewed. The primary endpoint was IV:PO ciprofloxacin use ratio. Secondary endpoints were total number of ciprofloxacin doses, proportion of inappropriate IV ciprofloxacin doses, cost of therapy between phases, and estimated cost avoidance with the intervention. RESULTS: Two hundred ciprofloxacin IV treatment courses were evaluated (100 per phase). The IV:PO ciprofloxacin use ratio was 3.03 (Phase I) vs. 3.48 (Phase II). Total number of doses and ratio of IV to total doses across phases were similar (p = 0.2830). IV-PO ciprofloxacin conversion occurred in 27/100 (27%) of IV courses in Phase I and 23/100 (23%) in Phase II. Proportion of inappropriate ciprofloxacin IV doses decreased between Phases I and II (244/521 (47%) vs. 201/554 (36%) (p = 0.0005), respectively). Furthermore, the proportion of pharmacist-preventable inappropriate ciprofloxacin IV doses was reduced between Phases I and II (114/244 (47%) vs. 65/201 (32%) (p = 0.0026). Proportional cost avoidance associated with total inappropriate IV use was 7,172 Can dollars/16,517 Can dollars (43%) (in Canadian dollars) in Phase I vs. 6,012 Can dollars/17,919 Can dollars (34%) in Phase II (p = 0.001). Similarly, proportional cost avoidance associated with pharmacist-preventable inappropriate IV doses was reduced from 3,367 Can dollars/16,517 Can dollars (20%) in Phase I to 1,975 Can dollars/17,919 Can dollars (11%) in Phase II (p = 0.001). CONCLUSION: While overall utilization of ciprofloxacin remained unchanged and the proportion of IV to total doses was stable during the study period, the proportion of inappropriate IV doses and its associated costs appear to have declined subsequent to implementation of a Pharmacist-managed IV-PO Dosage Form Conversion Service. Such a program may be a beneficial adjunct in facilitating appropriate and cost-effective usage of ciprofloxacin.

Willingness to pay to assess patient preferences for therapy in a Canadian setting.

BACKGROUND: Adult outpatient parenteral antibiotic therapy (OPAT) programs have been reported in the literature for over 20 years, however there are no published reports quantifying preference for treatment location of patients referred to an OPAT program. The purpose of this study was to elicit treatment location preferences and willingness to pay (WTP) from patients referred to an OPAT program. METHODS: A multidisciplinary, single centre, prospective study at a 1000-bed Canadian adult tertiary care teaching hospital. This study involved a WTP questionnaire that was administered over a 9-month study period. Eligible and consenting patients referred to the OPAT program were asked to state their preference for treatment location and WTP for a hypothetical treatment scenario involving intravenous antibiotic therapy. Multiple linear regression analysis was performed to determine predictors of WTP. RESULTS: Of 131 eligible patients, 91 completed the WTP questionnaire. The majority of participants were males, married, in their sixth decade of life and had a secondary school education or greater. The majority of participants were retired or they were employed with annual household incomes less than 60,000 dollars. Osteomyelitis was the most common type of infection for which parenteral therapy was required. Of those 87 patients who indicated a preference, 77 (89%) patients preferred treatment at home, 10 (11%) patients preferred treatment in hospital. Seventy-one (82%) of these patients provided interpretable WTP responses. Of these 71 patients, 64 preferred treatment at home with a median WTP of 490 dollars CDN (mean 949 dollars, range 20 to 6250 dollars) and 7 preferred treatment in the hospital with a median WTP of 500 dollars CDN (mean 1123 dollars, range 10 to 3000 dollars). Tests for differences in means and medians revealed no differences between WTP values between the treatment locations. The total WTP for the seven patients who preferred hospital treatment was 7,859 dollars versus 60,712 dollars for the 64 patients who preferred home treatment. Income and treatment location preference were independent predictors of WTP. CONCLUSION: This study reveals that treatment at home is preferred by adult inpatients receiving intravenous antibiotic therapy that are referred to our OPAT program. Income and treatment location appear to be independently associated with their willingness to pay.

Pharmacist computer skills and needs assessment survey.

BACKGROUND: To use technology effectively for the advancement of patient care, pharmacists must possess a variety of computer skills. We recently introduced a novel applied informatics program in this Canadian hospital clinical service unit to enhance the informatics skills of our members. OBJECTIVE: This study was conducted to gain a better understanding of the baseline computer skills and needs of our hospital pharmacists immediately prior to the implementation of an applied informatics program. METHODS: In May 2001, an 84-question written survey was distributed by mail to 106 practicing hospital pharmacists in our multi-site, 1500-bed, acute-adult-tertiary care Canadian teaching hospital in Vancouver, British Columbia. RESULTS: Fifty-eight surveys (55% of total) were returned within the two-week study period. The survey responses reflected the opinions of licensed BSc and PharmD hospital pharmacists with a broad range of pharmacy practice experience. Most respondents had home access to personal computers, and regularly used computers in the work environment for drug distribution, information management, and communication purposes. Few respondents reported experience with handheld computers. Software use experience varied according to application. Although patient-care information software and e-mail were commonly used, experience with spreadsheet, statistical, and presentation software was negligible. The respondents were familiar with Internet search engines, and these were reported to be the most common method of seeking clinical information online. Although many respondents rated themselves as being generally computer literate and not particularly anxious about using computers, the majority believed they required more training to reach their desired level of computer literacy. Lack of familiarity with computer-related terms was prevalent. Self-reported basic computer skill was typically at a moderate level, and varied depending on the task. Specifically, respondents rated their ability to manipulate files, use software help features, and install software as low, but rated their ability to access and navigate the Internet as high. Respondents were generally aware of what online resources were available to them and Clinical Pharmacology was the most commonly employed reference. In terms of anticipated needs, most pharmacists believed they needed to upgrade their computer skills. Medical database and Internet searching skills were identified as those in greatest need of improvement. CONCLUSIONS: Most pharmacists believed they needed to upgrade their computer skills. Medical database and Internet searching skills were identified as those in greatest need of improvement for the purposes of improving practice effectiveness.

Industry sponsorship and authorship of clinical trials over 20 years.

BACKGROUND: The pharmaceutical industry has become a major source of funding for biomedical research. Our general observation is that pharmaceutical industry employees are appearing with increasing frequency as coauthors of clinical trial publications. OBJECTIVE: To characterize clinical trial funding, reporting, and sources; investigate author-industry affiliation; and describe clinical outcome trends over time. METHODS: We reviewed 500 randomly selected clinical trials published in 5 influential medical journals over a 20-year period (1981-2000). RESULTS: Of the 500 clinical trials reviewed, 181 (36%) involved pharmaceutical industry as an independent (n = 104) or joint (n = 77) sponsor and 180 (36%) involved a peer-review funding source; the balance (139; 28%) lacked any declared sponsorship. The percentage of industry-sponsored clinical trials increased to 62% during 1997-2000. The percentage of nonprofit sponsored clinical trials remained constant over time, while the percentage of those without funding declaration declined. Reported author affiliation with industry increased to 66% of clinical trials sponsored only by industry. An increase in the percentage of clinical trials with reported author-industry affiliation was observed for all journals. Regardless of funding source, the majority of clinical trials reported clinical outcomes that favored the study drug. CONCLUSIONS: Pharmaceutical industry-sponsored and mixed-funding clinical trials are common, and the relative incidence of published trials with these declared funding sources in the 5 journals reviewed has increased. Industry employees are appearing as coauthors of clinical trial publications with increasing frequency.

Point of care use of a personal digital assistant for patient consultation management: experience of an intravenous resource nurse team in a major Canadian teaching hospital.

The development and integration of a personal digital assistant (PDA)-based point-of-care database into an intravenous resource nurse (IVRN) consultation service for the purposes of consultation management and service characterization are described. The IVRN team provides a consultation service 7 days a week in this 1000-bed tertiary adult care teaching hospital. No simple, reliable method for documenting IVRN patient care activity and facilitating IVRN-initiated patient follow-up evaluation was available. Implementation of a PDA database with exportability of data to statistical analysis software was undertaken in July 2001. A Palm IIIXE PDA was purchased and a three-table, 13-field database was developed using HanDBase software. During the 7-month period of data collection, the IVRN team recorded 4868 consultations for 40 patient care areas. Full analysis of service characteristics was conducted using SPSS 10.0 software. Team members adopted the new technology with few problems, and the authors now can efficiently track and analyze the services provided by their IVRN team.

Selecting antibacterials for outpatient parenteral antimicrobial therapy : pharmacokinetic-pharmacodynamic considerations.

Some infectious diseases require management with parenteral therapy, although the patient may not need hospitalisation. Consequently, the administration of intravenous antimicrobials in a home or infusion clinic setting has now become commonplace. Outpatient parenteral antimicrobial therapy (OPAT) is considered safe, therapeutically effective and economical. A broad range of infections can be successfully managed with OPAT, although this form of treatment is unnecessary when oral therapy can be used. Many antimicrobials can be employed for OPAT and the choice of agent(s) and regimen should be based upon sound clinical and microbiological evidence. Assessments of cost and convenience should be made subsequent to these primary treatment outcome determinants. When designing an OPAT treatment regimen, the pharmacokinetic and pharmacodynamic characteristics of the individual agents should also be considered. Pharmacokinetics (PK) is the study of the time course of absorption, distribution, metabolism and elimination of drugs (what the body does to the drug). Clinical pharmacokinetic monitoring has been used to overcome the pharmacokinetic variability of antimicrobials and enable individualised dosing regimens that attain desirable antimicrobial serum concentrations. Pharmacodynamics (PD) is the study of the relationship between the serum concentration of a drug and the clinical response observed in a patient (what the drug does to the body). By combining pharmacokinetic properties (peak [C(max)] or trough [C(min)] serum concentrations, half-life, area under the curve) and pharmacodynamic properties (susceptibility results, minimum inhibitory concentrations [MIC] or minimum bactericidal concentrations [MBC], bactericidal or bacteriostatic killing, post-antibiotic effects), unique PK/PD parameters or indices (t > MIC, C(max)/MIC, AUC(24)/MIC) can be defined. Depending on the killing characteristics of a given class of antimicrobials (concentration-dependent or time-dependent), specific PK/PD parameters may predict in vitro bacterial eradication rates and correlate with in vivo microbiologic and clinical cures. An understanding of these principles will enable the clinician to vary dosing schemes and design individualised dosing regimens to achieve optimal PK/PD parameters and potentially improve patient outcomes. This paper will review basic principles of useful PK/PD parameters for various classes of antimicrobials as they may relate to OPAT. In summary, OPAT has become an important treatment option for the management of infectious diseases in the community setting. To optimise treatment course outcomes, pharmacokinetic and pharmacodynamic properties of the individual agents should be carefully considered when designing OPAT treatment regimens.

Quality-of-life assessment in an outpatient parenteral antibiotic program.

OBJECTIVE: To measure changes and to identify predictors of change of health-related quality of life (HRQoL) for enrollees into an outpatient parenteral antibiotic therapy (OPAT) program. METHODS: A multidisciplinary, single-center, prospective investigation was conducted at a 1000-bed Canadian adult tertiary-care teaching hospital. Over a 15-month study period, consenting patients who were enrolled in the OPAT program completed paired Short Form-36 (SF-36) questionnaires within 48 hours prior to discharge from the hospital and again 26-30 days after discharge. Sociodemographic data and clinical variables were also collected for the purpose of determining potential predictors of change in quality of life. RESULTS: During the study period, 134 patients were enrolled in the OPAT program and 82 completed the paired SF-36 questionnaires. Study participants experienced a significant improvement in 3 SF-36 domains (physical functioning, bodily pain, role emotional) and the mental component summary scale (MCS) scores when they were transferred from the hospital to home setting. The SF-36 scores for all domains and summary scales were lower than the Canadian population average (all p < 0.001). Multiple linear-regression analysis revealed that infectious disease diagnosis and baseline physical component summary scale (PCS) scores were predictors of the change in the PCS score when patients transferred from the hospital to the home setting. Length of hospital stay and baseline MCS scores were predictors of the change in MCS scores when patients transferred from the hospital to the home setting. CONCLUSIONS: This study reveals that some domains in HRQoL appear to improve 4 weeks after discharge for adults enrolled in an OPAT program and that there are different predictors for changes in physical and mental health.

An infusion program resource nurse consult service: our experience in a major Canadian teaching hospital.

Infusion resource teams are comprised of nurses specially trained and experienced in infusion therapy. Our multidisciplinary team provides clinical, educational, and research support to a 1000-bed Canadian tertiary hospital. To characterize the infusion resource nurse service, 789 recorded consults for 250 patients during a 12-month period study were reviewed. Noncritical medicine and surgical wards accounted for a similar number of consults, with the highest volume (31% of total consults) being generated by the general and vascular surgery wards. Vein status was visible and either "fair" or "good" in approximately half of all consults, but 39% of consults were visible and "poor." Most consults (81% of total) resulted in the initiation of peripheral intravenous catheters into an area of nonflexion in an upper extremity and successful peripheral catheter initiations were accomplished in 96% of all cases. Our multidisciplinary infusion program approach to vascular access support appears to be a well-utilized and an effective resource for this hospital.

Patterns of use and patients' attitudes toward complementary medications: a survey of adult general medicine patients at a major Canadian teaching hospital.

OBJECTIVE: To characterize the preadmission and hospital utilization of, and patients' attitudes toward, complementary medications. PATIENTS AND METHODS: Patient survey data were collected at an acute care hospital over a four-month period for 85 patients who had been admitted to the general medicine wards. Patient information about complementary medicine use and opinions were obtained through patient interviews. Patient demographic information including age, sex, ethnic background, level of education and annual household income were gathered. Patients were eligible to participate in the survey if they were on a general medicine ward on any given interview day. Patients were excluded if they were absent from their room, were sleeping, spoke no English and had no translator present, were occupied by other health care staff or friends and family on days of interviewing, or did not consent. Logistical regression was used to identify predictive factors for complementary medicine use. RESULTS: Eighty-five of 105 patients (81%) consented to complete the survey. The mean patient age was 55 years (range 19 to 91), and 45 respondents (53%) were male. About one-third of patients surveyed reported having previously visited a practitioner of natural medicine. Thirty-three patients (39%) interviewed indicated that they had used complementary medications at some time in their lives. One in six respondents (17%) reported using a complementary medicine immediately before admission to the hospital, although only two patients (3%) reported using a complementary medicine while in hospital. The most commonly reported products of use were echinacea, garlic pills and ginseng. Five patients (15%) indicated that their pharmacists were aware of their complementary medicine use, while 17 patients (52%) stated that their family doctors were aware. The majority of patients indicated they were satisfied with the information provided to them from various sources. Other data collected revealed that almost one-half would choose to take a complementary medicine for the ailment that brought them into the hospital. Univariate analysis indicated that age was a significant negative predictor for complementary medication use. CONCLUSIONS: The use of complementary medications on general medicine wards appears to be low; however, preadmission use of complementary medications appears common. The present study results suggest that use of complementary medications may go unreported; therefore, all health care providers should be aware of and knowledgeable about the potential self-administration of complementary medications by their patients.