A Pilot Study to Assess Patient Adherence to New Chronic Medications Following the Use of a Novel Adherence Tool and Individualized Counseling.

Background: Medication nonadherence leads to an increase in morbidity and mortality. In the United States, it results in an annual estimated cost of $290 billion in patients with chronic diseases. Several adherence screening tools are available for use, but none have been adopted for widespread use. Objective: Examine the impact of using a novel 3-item adherence tool (The Adherence Estimator) and individualized patient counseling on medication adherence, as determined by rate of initial prescription fill. Methods: This prospective, descriptive study enrolled patients discharged home from an inpatient adult family medicine service who received a prescription for at least one new chronic medication. Patients completed the Adherence Estimator survey for each new medication prescribed. All patients received counseling from a pharmacist or student pharmacist. Date of initial fill was determined by contacting the dispensing pharmacy. Results: The survey was completed for 79 medications. The rate of first fill for medications identified as low, medium, and high risk for nonadherence was 76.5% (n = 28), 71.4% (n = 20), and 94% (n = 17), respectively. Conclusions: The brevity of The Adherence Estimator and the ease of scoring allow the possibility of adoption for widespread clinical use. The survey permits immediate results that allow the clinician to tailor medication counseling toward the 3 most common predictors of nonadherence. The rate of first fill for medications classified as high risk was improved following administration of the tool and targeted medication counseling, 94% in our population compared to predicted probability of adherence of <32%. Several factors, including targeted counseling or study/tool limitations, could account for these results. Consideration should be given to revising the statements in the tool to a lower reading level. This screening tool provides significant advantages over available tools; however, further research is needed to determine the most appropriate population and setting for use of this tool.

Acquired Thrombophilia.

Acquired thrombophilia is associated with an increased risk of venous thromboembolism (VTE). Antiphospholipid syndrome (APS) is the most prevalent acquired thrombophilia and is associated with both venous and arterial thromboses. Human immunodeficiency virus (HIV) is another form of acquired thrombophilia. Risk factors associated with VTE in this population include those related to the disease itself, host factors, and the pharmacotherapy for HIV. A significant proportion of VTE events occur in patients with malignancies. There is an increase in mortality associated with patients having cancer who experience VTE when compared to patients having cancer without VTE. Combination oral contraceptive (COC) use infers risk of thromboembolic events. The risk is dependent upon the presence of an underlying inherited thrombophilia, the estrogen dose, and generation of progestin. Patients at highest risk of VTE include those receiving high-dose estrogen and fourth-generation, progesterone-containing contraceptives. With the exception of APS, thrombophilia status does not alter the acute treatment of an initial VTE in nonpregnant patients.

Pregnancy-Related Venous Thromboembolism.

Pregnancy is associated with an increased risk of venous thromboembolism (VTE), with a reported incidence ranging from 0.49 to 2 events per 1000 deliveries. Risk factors include advanced maternal age, obesity, smoking, and cesarian section. Women with a history of previous VTE are at a 4-fold higher risk of recurrent thromboembolic events during subsequent pregnancies. Additionally, the presence of concomitant thrombophilia, particularly factor V Leiden (homozygosity), prothrombin gene mutation (homozygosity), or antiphospholipid syndrome (APS), increases the risk of pregnancy-related VTE. Low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) are the drugs of choice for anticoagulation during pregnancy. LMWH is preferred due to ease of use and lower rates of adverse events. Women with high thromboembolic risk particularly those with a family history of VTE should receive antepartum thromboprophylaxis. Women with low thromboembolic risk or previous VTE caused by a transient risk factor (ie, provoked), who have no family history of VTE, may undergo antepartum surveillance. Postpartum anticoagulation can be considered in women with both high and low thromboembolic risk.

Inherited Thrombophilia.

Thrombophilia alters normal hemostasis, shifting the balance in favor of thrombus formation. Inherited conditions include factor V Leiden (FVL), prothrombin G20210A mutation, deficiencies in natural anticoagulants (antithrombin [AT], protein C, and protein S), hyperhomocysteinemia, and elevations in clotting factors (factors VIII and XI). Although FVL and prothrombin mutation are common disorders, deficiencies in the natural anticoagulants are rare. The risk of initial thrombosis conferred by inherited thrombophilia varies with the highest risk in those homozygous for either FVL or prothrombin mutation, or with AT deficiency. In the nonpregnant patient, the presence of a thrombophilia does not affect treatment of an acute event. Although vitamin B supplementation has been shown to decrease the levels of homocysteine, the treatment has failed to show a benefit in thrombus prevention and is therefore not recommended.

Thrombophilia Screening.

Although controversial, screening for thrombophilia has become common. Testing for antiphospholipid antibodies is indicated in order to guide treatment decisions if there is clinical suspicion for antiphospholipid syndrome. The utility of identifying other thrombophilias in symptomatic venous thromboembolism (VTE) is questionable, as the risk of recurrence does not appear to be increased by an appreciable degree with the most common disorders (heterozygosity for factor V Leiden or prothrombin mutation). Although recurrence appears to be increased in those with homozygous or multiple abnormalities and potentially deficiencies in natural anticoagulants, screening to detect these conditions is difficult to justify based on their rarity. The American College of Chest Physicians' current guidelines note the increased risk of recurrence with idiopathic, proximal events regardless of thrombophilia status. They suggest duration of anticoagulation therapy be based on location and provoking factors rather than whether or not the individual has a thrombophilia. Because routine prophylaxis in asymptomatic individuals with thrombophilia is not recommended, screening of asymptomatic family members is difficult to justify. Screening prior to prescribing combination oral contraceptives is not cost effective, may result in unwanted pregnancies, and may have little effect on the overall rate of VTE.

Assessing the impact of mobile technology on order verification during pharmacist participation in patient rounds.

PURPOSE: Pharmacists' use of mobile technology (MT) to verify medication orders placed during their participation in medical rounds is investigated. METHODS: A retrospective observational study was conducted at a large academic medical center to assess the impact of MT on the average time to pharmacist verification of medication orders written by general medicine staff during pharmacist participation in patient rounds. A total of 260 medication orders for 129 patients were evaluated: 146 orders processed over a one-month period during which rounding pharmacists verified orders using stationary computer terminals on patient care units and 114 orders processed using an MT device. The primary endpoint was the average time to pharmacist verification for all medication orders; average verification times for orders for specific medication classes (analgesics, antibiotics, antidiabetes drugs, and antihypertensives) were also evaluated. RESULTS: Overall, the average time to order verification was significantly lower with the use of the MT device compared with non-MT-assisted order verification (7.5 minutes versus 38.9 minutes, p < 0.001), with significant (p < 0.001) time benefits favoring MT-assisted verification for all order subsets within the evaluated medication classes. Challenges posed by the use of MT-assisted order verification included the selected device's relatively small keyboard and the frequent loss of network connections as the pharmacist moved from floor to floor within the hospital. CONCLUSION: Clinical pharmacists' use of an MT device to verify medication orders written during patient care rounds can significantly decrease the average time required for order verification relative to the use of stationary computer terminals.

Indacaterol: a novel long-acting ß(2) -agonist.

Bronchodilator drugs are the foundation for the treatment of chronic obstructive pulmonary disease. The principal inhaled bronchodilator treatments used are ß(2) -agonists and anticholinergics, either alone or in combination. Currently available ß(2) -agonists are of either short duration and used multiple times/day, or of long duration, which requires twice-daily administration. Indacaterol is considered an ultra-long-acting ß(2) -agonist and was recently approved for use in the United States. Its duration of action is approximately 24 hours, allowing for once-daily administration. Cough was the most commonly reported adverse effect with use of indacaterol. Cough usually occurred within 15 seconds of inhalation of the drug, lasted around 6 seconds, was not associated with bronchospasm, and did not cause discontinuation of the drug. Otherwise, the drug's safety profile was similar to that of other bronchodilators. Based on similar improvement in spirometric measurements compared with other bronchodilator drugs and the convenience of its once-daily dosing, indacaterol may be beneficial in the management of mild-to-moderate chronic obstructive pulmonary disease, either alone or in combination with anticholinergic drugs administered once/day.

Psychiatric diagnoses as contemporaneous risk factors for suicide attempts among adolescents and young adults: developmental changes.

The purpose of this prospective, naturalistic study was to examine the relationships between suicide attempts and contemporaneous psychiatric disorders, and developmental changes in these relationships from adolescence to young adulthood. The sample consisted of 180 adolescents, 12-19 years of age at hospitalization, repeatedly assessed for up to 13 years (n = 1,825 assessments). Semistructured psychiatric diagnostic instruments were administered at repeated assessments to assess psychiatric disorders and suicide attempts. After controlling for demographic variables and prehospitalization suicide attempts, most contemporaneous psychiatric disorders (major depressive disorder [MDD], dysthymic disorder, generalized anxiety disorder [GAD], panic disorder, attention-deficit/hyperactivity disorder [AD/HD], conduct disorder, and substance use disorder [SUD]) were related to increased risk of attempts. The relationship between suicide attempts and MDD, GAD, AD/HD, and SUD strengthened as participants got older. MDD, dysthymic disorder, GAD, and panic disorder were more commonly associated with repeat than 1st-time suicide attempts. In sum, most major psychiatric disorders are associated with increased risk for suicide attempts, but the strength of the relationships between these disorders and attempts changes over the course of development.