Clinical pharmacist intervention and the proportion of diabetes patients attaining prevention objectives in a multispecialty medical group.

BACKGROUND: Clinical practice recommendations from American Diabetes Association (ADA) include specific prevention goals intended to reduce the risk of diabetic complications. The Healthy People 2010 (HP2010) initiative, updated to Healthy People 2020, proposes similar objectives for improvement of clinical measures and outcomes in patients with diabetes. Clinical pharmacists are gaining an increasing role in providing diabetes management services, including collaborative practice in medical groups. OBJECTIVE: To compare the rates of attainment of diabetes prevention goals described by the ADA 2009 guidelines and the HP2010 initiative for patients receiving clinical pharmacist interventions in a collaborative practice diabetes clinic versus patients receiving usual care. METHODS: The setting is a primary care clinic affiliated with a 140-physician multispecialty medical group in the upper Midwest. Diabetes patients were identified from electronic medical records by ICD-9-CM diagnosis codes 250.00 through 250.99 for dates of service in the 12-month period from January 1, 2007, through December 31, 2007. Study subjects had to be aged 18 years or older and have at least 2 visits to a primary care physician (PCP) or the pharmacist-managed diabetes clinic during 2007. Descriptive statistics and chi-square analysis were utilized. RESULTS: Of 7,068 patients at least 18 years of age with at least 1 diabetes diagnosis code for a medical encounter in 2007, 1,298 (18.4%) had a least 1 visit in the pharmacist-managed diabetes clinic, and 321 patients (4.5%) had 2 or more visits. These 321 patients were compared with 321 patients stratified by gender and randomly selected from 3,022 patients who had at least 2 visits with a PCP and no visits in the pharmacist-managed diabetes clinic in 2007. Nine of the 14 HP2010 objectives (64.3%) were attained in the intervention group compared with 7 of 14 (50.0%) in the usual care group. For patients with hypertension at baseline, 44.6% (120/269) in the intervention group versus 48.0% (123/256) in the usual care group achieved goal blood pressure (P = 0.430). The low-density lipoprotein (LDLC) goal ( less than 100 milligrams per deciliter) was achieved in 76.0% of patients in the intervention group (244/321) versus 59.2% (190/321) in usual care (P less than 0.001). Fewer patients in the intervention group achieved hemoglobin A1c less than 7% (50.8%, n =163/321) compared with usual care (71.0%, n = 228/321, P less than 0.001). The proportions of patients with influenza and pneumococcal vaccinations were higher in the intervention group versus the usual care group for 3 of 4 comparisons by age, but neither group met the target goals. CONCLUSIONS: Patients who were seen by the clinical pharmacists met more of the preventive care objectives recommended by the ADA 2009 and HP2010 initiatives; however, more patients in usual care met the A1c goal compared with pharmacist-managed patients. The absence of baseline values for A1c, blood pressure, and LDL-C prevented longitudinal assessment of the effects of this clinical pharmacist intervention.

Insulin glargine and cancer risk: an opinion statement of the Endocrine and Metabolism Practice and Research Network of the American College of Clinical Pharmacy.

Diabetes mellitus has reached epidemic proportions worldwide, eliciting extensive research on both the disease process and its treatment. Regardless of diabetes type, the progressive nature of the disease makes insulin the long-term mainstay of diabetes management. Recently, the insulin analog glargine was reported in several epidemiologic studies to be associated with an increased risk of cancer. Inconsistent study results and media attention have caused much angst and concern to health care professionals and the general population. A clear understanding of the current evidence is needed to adequately develop a patient-oriented risk:benefit assessment. Members of the Endocrine and Metabolism Practice and Research Network of the American College of Clinical Pharmacy evaluated available evidence to provide guidance and discussion on the risk of cancer with insulin glargine use. We believe the current link between insulin glargine and cancer is tenuous but merits further evaluation. An independent analysis of all available glargine clinical trial data should be performed, and a vigorous postmarketing safety study of glargine should be conducted. Until more substantial data are available, however, neither the choice of initial insulin therapy nor insulin maintenance regimens should be influenced by the current information linking insulin glargine to cancer.

Effect of postgraduate training on job and career satisfaction among health-system pharmacists.

PURPOSE: The effect of postgraduate training on job and career satisfaction among health-system pharmacists was evaluated. METHODS: A mail-based questionnaire was sent to a random sample of pharmacist members of the American Society of Health-System Pharmacists. Previously validated questions for job and career satisfaction among pharmacists were utilized. The questionnaire was designed to obtain information regarding general employment, work environment, job satisfaction, career satisfaction, postgraduate training, and demographic characteristics. Pharmacists who had completed either a pharmacy residency or fellowship were classified as having postgraduate training. Questionnaires returned within two months of the original mailing date were included in the analysis. Responses from pharmacists who were retired, employed in a nonpharmacy career, or unemployed were excluded. Data were analyzed using SPSS software. RESULTS: Of the 2499 questionnaires mailed, 36 were undeliverable; 1058 were completed, yielding a response rate of 43%. Of these, 48 were excluded, resulting in 1010 questionnaires suitable for analysis. Approximately 37% of respondents indicated completion of postgraduate training. The most common practice setting was a community, not-for-profit hospital (40.9%). Overall, 90.7% of respondents indicated they were either satisfied or highly satisfied with their current employment. Approximately 45% of pharmacists with postgraduate training indicated they were highly satisfied with their employment, compared with 32.7% of pharmacists without postgraduate training (p < 0.001). CONCLUSION: Pharmacists who completed postgraduate training were more satisfied with their job than those who did not complete such training.

Didactic migraine education in US doctor of pharmacy programs.

OBJECTIVE: To compare didactic migraine education in doctor of pharmacy (PharmD) programs in the United States with the Headache Consortium's evidence-based migraine treatment recommendations. METHODS: A self-administered survey instrument was mailed to all 90 Accreditation Council for Pharmacy Education (ACPE) approved PharmD programs in the United States. RESULTS: Seventy-seven programs responded (86%) and 69 useable survey instruments were analyzed. Fifty-five percent of programs discussed the Consortium's guidelines, 49% discussed the selection of nonprescription versus prescription agents, 45% recommended a butalbital-containing product as migraine treatment, and 20% educated students about tools for assessing migraine-related debilitation. At least 50% of programs taught information consistent with the remaining Consortium recommendations. CONCLUSION: Approximately half of the PharmD programs teach concepts about migraine headache treatment consistent with the US Headache Consortium's recommendations.

Aldose reductase inhibitors in the treatment of diabetic peripheral neuropathy: a review.

PURPOSE: The purpose of this article was to examine how aldose reductase (AR) inhibitors are used in the prevention and treatment of peripheral neuropathy in diabetes, specifically focusing on efficacy. METHODS: Medline searches were used to identify clinical trials investigating AR inhibitors and their proposed mechanism of action, efficacy, and adverse effects. Additionally, the references of the articles returned by the Medline search were examined for pertinent publications. RESULTS: Three AR inhibitors were selected for review. Modest improvements in the preservation and restoration of nerve conduction velocities were reported in the studies. Additionally, patients reported improvements in the subjective symptoms associated with diabetic peripheral neuropathy. Adverse effects for the studied agents were minimal or not reported. CONCLUSIONS: Given the mechanism by which diabetic peripheral neuropathy can result, targeting the polyol pathway as a method of treatment appears promising, yet the efficacy of newer AR inhibitors is still to be proven. Currently, these agents are not marketed in the United States. As newer studies emerge, diabetes educators will learn more about their efficacy and safety in preventing and treating diabetic peripheral neuropathy.

Topiramate for migraine prevention.

Migraine is a costly, recurrent condition that affects 28 million individuals in the United States yet remains underdiagnosed and undertreated. In 2004, the U.S. Food and Drug Administration approved topiramate for the prevention of migraine in adults, joining three other agents with this indication: divalproex sodium, propranolol, and timolol. We evaluated the role of topiramate in the treatment of migraine based on published literature and our clinical experiences. A qualitative systematic search of the literature from January 1966-December 2004 was conducted by using MEDLINE, and other pertinent literature was reviewed. Three large, randomized, placebo-controlled trials of topiramate for migraine prevention in individuals experiencing 3-12 attacks/month have been published, as have several small studies and a comparator trial with propranolol. Based on the results of these studies, 100 mg/day is the optimum topiramate dosage in terms of efficacy and tolerability. Using that dosage, the number of migraine attacks/month decreased by approximately two. Several other secondary outcome measures were also significantly reduced including the number of days/month with migraine and the use of acute treatment/attack. Suboptimal efficacy was shown with 50 mg/day, whereas 200 mg/day caused considerably more tolerability issues. Paresthesia was dose related and the most common cause of attrition. Cognitive dysfunction and weight loss were also commonly reported. The reduction by two migraines/month demonstrated with topiramate in clinical trials is similar to the published results for other preventive agents, though most of those studies were small, antiquated, and poorly designed. In contrast, the topiramate trials enrolled a larger number of patients and closely adhered to the International Headache Society research recommendations, strengthening the quality of results. Topiramate 100 mg/day is an effective option in adults who require migraine prophylaxis. Although the published efficacy results of the various migraine preventive agents are comparable, the superior study design of the topiramate trials warrants consideration of topiramate as an agent of choice for migraine prevention. Future studies of any preventive agent should include more refined quality-of-life outcomes.