Opioid free treatment algorithm for ED headache management: Effect on revisit rate.

BACKGROUND: The opioid epidemic is a crisis leading to over utilization of resources within emergency departments (EDs). We assessed how implementation of an opioid-free headache and migraine treatment algorithm in the ED impacted patient centered outcomes. METHODS: This was a retrospective review of patients presenting to EDs across a health network with a primary diagnosis of headache or migraine. Two analyses were completed comparing patients presenting before and after implementation of an opioid-free treatment algorithm and patients treated with or without opioids in the ED. The primary outcome was incidence of an ED revisit within thirty days. Secondary outcomes included ED length of stay, admission rate, and incidence of revisit during the entire study period. RESULTS: In total, 2953 patient encounters were included. Incidence of revisit within thirty days was lower in the post- (84/1339, 6.3%) versus pre-algorithm group (133/1614, 8.2%; odds ratio [OR] 0.75, 95% confidence interval [CI] 0.56-0.99; p = 0.049), as was the incidence of revisit within the entire study period (9.2% vs. 12.1%; OR 0.74, CI 0.58-0.93; p = 0.014). In the secondary analysis, patients treated with opioids had a higher incidence of revisit within thirty days (51/335, 15.2%) compared to those not treated with opioids (166/2618, 6.3%). The opioid group also had a higher incidence of admission rates and median ED length of stay. CONCLUSIONS: Opioid use in the ED to treat patients with headaches or migraines may have several negative ramifications including increased risk of revisit, hospital admission, and increased ED length of stay.

A Modified Approach to Setting Curriculum Boundaries in Pharmacy School.

Doctor of Pharmacy department heads are responsible for determining the breadth and depth of content within courses. While the Accreditation Council for Pharmacy Education (ACPE) provides standards for what content, skills, and abilities should be included in PharmD education, the process that schools and colleges use to determine the degree to which these measured outcomes are taught is variable. As new topics and content for instruction are identified, schools and colleges are faced with either extending the PharmD curriculum length, removing other content, or diminishing the depth that other content is covered to make room for new content. To assist with these decisions, the Ebel grid is a tool that can be used to identify the criticality and relevance of encountered topics as well as guide pre-APPE curriculum selection.

Pharmacy Student Anxiety and Success With Objective Structured Clinical Examinations.

Objective. To evaluate whether a relationship exists between the degree of student state-anxiety and pass rates on moderate-to-high stakes objective structured clinical examinations (OSCE). Methods. Third-professional year (P3) students were assessed using the Speilberger State-Trait Anxiety Index (STAI) three weeks prior to their first moderate-to-high stakes OSCEs. Students' OSCE station pass rates, individual station analytical scores, and the overall pass rate for the class were compared with student responses on STAI surveys to measure their association. Results. Seventy-three students (100%) provided consent to participate in the research; 64 (87%) sufficiently completed the STAI survey. Degree of student state-anxiety or train-anxiety was not associated with any of the outcomes assessed in this study. Overall pass rate, individual station pass rates, and station analytical checklist scores were not inversely correlated with state- or trait-anxiety scores. Conclusions. Efforts to assist students in OSCE performance should focus on means other than reducing associated anxiety. Future research in this area should focus on what interventions beyond instruction could be put in place to help students be more successful during OSCEs.

Taste and Smell Disturbance Resulting From Midodrine.

OBJECTIVE: To report a case of dysgeusia and dysosmia following midodrine initiation. METHODS/CASE SUMMARY: A 58-year-old male started midodrine 5 mg tablets 3 times a day for orthostatic hypotension. Two weeks after starting, he began complaining of dysgeusia and dysosmia. He also reported less of an appetite at this time but did not realize it was due to symptoms. He reported his symptoms as tolerable and chose to continue the medicine. At follow-up contact 7 days later, the symptoms were still present but diminishing. MAIN RESULTS/DISCUSSION: Midodrine is used for symptoms of orthostatic hypotension. Dysgeusia and dysosmia are not common adverse events and are not included in the manufacturer's labeling. There is only one other published case report of this reaction. Our patient only admitted to slight appetite suppression, but it may be more profound in some. The reaction may be dose related, but there is not enough information to make this conclusion. PRINCIPAL CONCLUSIONS: Using midodrine may result in dysgeusia and dysosmia. According to this case, both adverse effects may lessen or resolve over time with the use of the medication.

Clinical pharmacists as key members of the patient-centered medical home: an opinion statement of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy.

The American College of Clinical Pharmacy (ACCP) Ambulatory Care Practice Research Network (PRN) considers the role of clinical pharmacists to be fundamental to the success of the Patient-Centered Medical Home (PCMH) model. Within the PCMH, pharmacists can improve the health of populations by participating in activities that optimize medication management. Multiple published articles support clinical pharmacist involvement in the PCMH with regard to promotion of team-based care, enhanced access, care coordination, and improved quality and safety of care. A survey of clinical pharmacist members of ACCP who operate in such a model depict a variety of activities, with some members pioneering new and innovative ways to practice clinical pharmacy. Although this is a significant opportunity for pharmacists in the primary care setting, a unified vision of pharmacy services is needed. It is our hope that with continued efforts focused on obtaining national provider status, clinical pharmacy can use the PCMH model to solidify the future of primary care pharmacy. The following is an opinion statement of the ACCP Ambulatory Care PRN regarding the vital role of clinical pharmacists in the PCMH.

An elective course in information mastery.

OBJECTIVE: To design and implement an elective course in information mastery and assess its impact on students' ability to identify information needs and formulate clinically relevant, evidence-based answers. DESIGN: A semester-long (15-week) elective course was offered to third-year (P3) doctor of pharmacy (PharmD) students that outlined the necessary knowledge and skills for using information mastery in evidence-based practice. ASSESSMENT: Results of a pre- and postcourse survey instrument demonstrated an increase in students' knowledge of information mastery and confidence in and familiarity with the practice of evidence-based medicine in pharmacy. Students who had completed the elective were able to provide higher quality search strategies and evidence-based answers to a clinical question than other P3 students, and P4 students who did not participate in the elective. CONCLUSION: An elective course in information mastery improved students' knowledge and understanding of information mastery as it pertains to practicing evidence-based medicine.

Pharmacist instruction of physical assessment for pharmacy students.

OBJECTIVE: To assess the impact of a change from nurse to pharmacist instructors and a new curriculum intended to encourage students' use of physical assessment skills. DESIGN: Pharmacist faculty members redesigned the physical assessment curriculum to focus on those assessment skills most likely to be performed by practicing pharmacists. The 5 focus areas were general assessment skills, gastrointestinal system, pulmonary system, central and peripheral nervous system, and cardiovascular system. Instructional methods used included prelaboratory assignments, brief introductory lectures, demonstration of assessment techniques, application of techniques with a laboratory partner, and demonstration of competence using a mannequin. ASSESSMENT: A 16-item survey instrument was administered to determine students' perceptions of the revised curriculum. Students who received instruction from pharmacist faculty members used their physical assessment skills more, especially during advanced pharmacy practice experiences (APPEs), than students who received instruction from nurse faculty members. Students instructed by pharmacist faculty members also felt more comfortable with their skills and rated the instruction as more practical. CONCLUSION: A redesigned curriculum and pharmacist-led instruction resulted in improved pharmacy student comfort with and use of physical assessment skills.

Lipid profile changes associated with changing available formulary statins: removing higher potency agents.

OBJECTIVE: To review the fasting lipid panel changes that occurred after removing higher potency statins from a prescription formulary. STUDY DESIGN: Retrospective chart review. METHODS: Researchers compiled data for patients in a medical clinic receiving pharmacy benefits from a particular managed care plan. Patients enrolled in the benefits program at least between June 2006 and June 2007 were evaluated for atorvastatin use before January 1, 2007. After January 1, patients on atorvastatin were prescribed new statins according to the program's preferred drug list. Patients treated with atorvastatin were reviewed for fasting lipid panel results while on atorvastatin; these results then were compared with fasting lipid panels after the formulary change took place. Total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglyceride values were examined for changes. Appropriateness of the replacement statin also was evaluated using statin equivalency charts. RESULTS: Values for total cholesterol, low-density lipoprotein, and triglycerides were not significantly different from baseline to follow-up. High-density lipoprotein values did significantly increase over the study period. Only 34% of statin prescriptions were considered appropriately converted to equipotent or higher potency doses. The mean time to documentation of statin conversion was 2.9 months. CONCLUSIONS: Removing higher potency statins from the formulary did not ignificantly change a population's fasting lipid panel except for a significant increase in high-density lipoprotein. Although multiple factors may have contributed to this effect, the results of this investigation suggest that changing formulary statins will not alter the surrogate lipoprotein markers associated with poor cardiovascular outcomes.

Prevention of type 2 diabetes mellitus with angiotensin-converting-enzyme inhibitors.

PURPOSE: The physiological and clinical data for using angiotensin-converting- enzyme (ACE) inhibitors to prevent new-onset type 2 diabetes mellitus are reviewed. SUMMARY: ACE inhibitors have established their role in hypertension, primary and secondary prevention of cardiovascular events, and prevention of progression to and worsening of renal function. However, their ability to preserve pancreatic function and prevent new-onset diabetes is also coming to the forefront. Secondary analyses of large-scale clinical trials, such as the Captopril Prevention Project, the Heart Outcomes Prevention Evaluation, and the Studies of Left Ventricular Dysfunction trial, are revealing the potential benefits of these agents in diabetes prevention. However, the results of such studies have limited application because they are secondary analyses and, in some cases, were conducted 10 or more years after the original study. Enrollees were evaluated using different diagnostic guidelines for diabetes or not formally evaluated at all. Even in the most recent of the trials, the validity of the results is questionable because researchers coadministered a disease-modifying drug with the ACE inhibitor, potentially blunting the results. While intense lifestyle modifications are still superior in the prevention of new-onset diabetes, patients and providers will continue to investigate new options for preventing the progression of impaired fasting glucose to diabetes, though this delay does not correlate with a decrease in morbidity and mortality. CONCLUSION: ACE inhibitors may preserve pancreatic function and prevent new-onset diabetes, especially for patients who are hypertensive with impaired glucose tolerance. Large studies investigating the effect of ACE inhibitors on the prevention of diabetes as a primary outcome are needed to determine the use for this indication.

Intervention to improve dyslipidemia screening in hospitalized diabetics.

Using an automated method to prospectively identify diabetic patients, we measured the impact of an administrative policy to perform LDL-cholesterol (LDL-c) testing on all diabetics not having the test performed within a specified time period. Automatic testing resulted in significant increases in LDL-c testing rate, and identified a greater proportion of patients who were candidates for statins. Further interventions are needed to increase prescriptions for lipid-lowering therapy.