Clinical career ladders: Thomas Jefferson University Hospital.

The clinical career ladder program developed for pharmacists at Thomas Jefferson University Hospital, a 700-bed teaching hospital, is described. A task force was assembled to develop a clinical career ladder that would parallel the managerial advancement track in terms of rewards and recognition. The task force created separate lists of competencies for staff and clinical pharmacists and ranked the competencies according to their complexity and the number of years most pharmacists would need to achieve them. Separate pathways were established for staff and clinical pharmacists: staff pharmacist I, II, and III and clinical pharmacist I, II, and III. A salary scale designed to provide meaningful salary increases between levels was established. Nearly all pharmacists who are hired begin at level I and are allowed to apply for promotion to level II within six months. Opportunities for promotion occur twice annually. Pharmacists who have received an overall rating of effective or outstanding at the most recent performance appraisal may submit documented evidence that they have gained the knowledge and skills required at the higher level. A promotions review board evaluates each application and informs the director of pharmacy as to whether the applicant meets the criteria for promotion. Response to the program has been favorable, as indicated by the number of pharmacists who have applied for promotion and the quality of their applications. A carefully planned clinical career ladder program was well received by pharmacists, who responded by acquiring the knowledge and skills necessary for promotion.

Pharmacy component of a hospital end-product cost-accounting system.

Determination of pharmacy department standard costs for providing drug products to patients at Thomas Jefferson University Hospital in Philadelphia is described. The hospital is implementing a cost-accounting system (CAS) that uses software developed at the New England Medical Center, Boston. The pharmacy identified nine categories of intermediate products on the basis of labor consumption. Standard labor times for each product category are based on measurement or estimation of time for each task in the preparation and distribution of a dose. Variable-labor standard time was determined by adjusting the cumulative time for the tasks to account for nonproductive time and nonroutine activities, and a variable-labor standard cost for each category was calculated. The standard cost per dose included the costs of labor and supplies (variable and fixed) and equipment; this standard cost plus the acquisition cost of a drug line item is the total intermediate product cost. Because the CAS is based on the hospital's patient charges, clinical pharmacy services are excluded. Intermediate products that substantially affect end-product costs (costs per patient case) will be identified for inclusion in CAS reports. The CAS will give a more accurate picture of resource consumption, enabling managers to focus their efforts to improve efficiency and productivity and reduce supply use; it could also improve the accuracy of the budgeting process. The CAS will support hospital administration decisions about marketing end products and department managers' decisions about controlling intermediate-product costs.

Current issues in the management of hypertension.

Major trials evaluating antihypertensive therapy are reviewed, and the current issues surrounding the choice of therapy in mild and isolated systolic hypertension are discussed. Several major trials have shown that patients with mild hypertension benefit from therapy. These results have prompted widespread use of antihypertensive agents; however, there are still no clear guidelines on when drug therapy should be initiated. Only the Hypertension Detection and Follow-up Program has shown significant decreases in coronary heart disease (CHD) related deaths. Thiazide diuretics are recommended as agents of first choice in the stepped-care approach to the management of uncomplicated mild to moderate hypertension. The Multiple Risk Factor Intervention Trial evaluated the effects of modifying several cardiovascular risk factors in more than 12,000 high-risk men. It failed to document significant differences in CHD-related mortality in patients who received special care as compared with those who received usual care. Concerns have been raised about the contribution of antihypertensive therapy, particularly diuretics, to the lack of differences in therapeutic outcomes. There is renewed interest in lipid alterations secondary to antihypertensive agents and the effect of diuretic-induced hypokalemia. Antihypertensive therapy should be instituted with an individualized assessment of the potential benefits of therapy relative to the short- and long-term risks of treatment.

Verapamil (Isoptin, Knoll; Calan, Searle).

Verapamil is a calcium antagonist that is pharmacologically different from other currently marketed antiarrhythmics. It is used for the acute treatment of PSVT and atrial fibrillation and flutter. It appears to be more effective than beta-adrenergic blocking agents in the treatment of PSVT. Approximately 80 percent of patients with PSVT will convert to normal sinus rhythm after verapamil 0.075-0.15 mg/kg. Atrial fibrillation and flutter seldom convert to sinus rhythm with verapamil, but it successfully reduces the ventricular rate in 90 percent of these patients. Verapamil is useful for the rapid conversion of PSVT to normal sinus rhythm and for the rapid control of ventricular rate in atrial fibrillation and flutter before other antiarrhythmics have taken effect. Because of its short plasma half-life, other agents or cardioversion can be used if verapamil is unsuccessful. The use of verapamil in the treatment of classical and variant angina, hypertrophic cardiomyopathy, and hypertension is being evaluated. Mild reduction in blood pressure and heart rate may occur with verapamil therapy. Caution must be exercised when verapamil is administered to patients with sinus node disease, advanced AV block, concomitant beta-adrenergic blocking agents, and digitalis intoxication.

Diagnosis and treatment of Prinzmetal's variant angina.

The presentation, diagnosis (including provocative testing), and therapy of Prinzmetal's variant angina are reviewed. Prinzmetal's variant angina (PVA) is a form of angina caused by coronary-artery vasospasm (CAS) and is not associated with exertion. It is diagnosed by history, electrocardiogram, or coronary-artery angiography. Provocative tests, such as the cold-pressor test or intravenous ergonovine maleate, are sometimes used to aid diagnosis of PVA. Nitrates, adrenergic - blocking agents, and calcium-channel blocking agents can be used in treating PVA. Nitroglycerin and isosorbide dinitrate effectively relieve CAS. However, long-term prospective studies on the use of these drugs for PVA are lacking in the literature. Studies on treating PVA with adrenergic-blocking agents have been equivocol, with some studies reporting improvement and some reporting worsening. Calcium-channel blocking agents are promising drugs for PVA. Nifedipine is generally considered the prototype of this class for antianginal activity. It is administered orally in PVA patients and is effective. Side effects are mild and do not usually require termination of therapy. Verapamil hydrochloride, the prototype calcium-channel blocking agent for arrhythmias, is effective for PVA, but only 10-20% of an orally administered dose reaches systemic circulation because of the first-pass effect. Other calcium-channel blockers, including perhexilene maleate, diltiazem hydrochloride, prenylamine, and lidoflazine, have been tested in a few CAS patients with some success; adverse effects and toxicities limit the use of some of them, especially perhexilene. Therapy, using combinations of nitrates, adrenergic-blocking agents, and calcium-channel blocking agents, is needed in some patients. Dosing guidelines for all drugs are given in the paper. Treatment of PVA should begin with oral nitrates. Calcium-channel blocking agents are indicated in the patient who has failed to respond or is intolerant to maximum doses of nitrates given in various forms.