Enhancing Student Confidence in Diabetes Management Skills through Pharmacist-Run Group Classes in a Community Library.

Purpose: To evaluate student pharmacists' confidence after providing education within diabetes groups in a non-medical community setting. Program Description: Three 8-week diabetes group courses were developed and executed within a local public library. The courses aimed to teach participants with diabetes how to effectively manage their medical condition to prevent future related complications. Student pharmacists were responsible for checking and recording the patients' vitals, assisting in answering questions posed by the participants throughout the session, presenting different medication information each week, and creating a brochure which described the highlights of the specific week's medication class. The student pharmacists were then surveyed regarding their confidence level in providing diabetes education in the future as well as their experience of working within these groups. Summary: Seventeen student pharmacists participated in three 8-week sessions. The majority of the student pharmacists reported increased confidence in being able to provide diabetes education as well as newfound empathy for persons with diabetes on how to manage their medical condition.

Addressing Clinical and Therapeutic Inertia Through Comprehensive Medication Review.

Avoiding clinical and therapeutic inertia, through pharmacist-led medication therapy management, can lead to avoidance of inappropriate medication use and adverse medication events. Clinical and therapeutic inertia are terms that have been used indistinctly. One definition is inertia that appears when clinicians do not initiate or intensify therapy appropriately when therapeutic goals are not reached. Another definition is failure to advance or deintensify treatment, and in a broader sense beyond escalation or deintensification of therapy; definitions include failure to screen, make appropriate referrals, manage risk factors, and complications. Failure of clinicians to address clinical and therapeutic inertia in office or hospital visits can contribute to patients using inappropriate medications, and lead to avoidable serious adverse events. Addressing therapeutic inertia may also be a means to minimize prescription costs and improve quality of life. This case illustrates the importance of identifying and addressing the therapeutic appropriateness of medications for an older person who has been prescribed numerous medications over a long period but now has complaints of dizziness as well as the inability to afford all medications.

Pain Management in Primary Care: A Randomized Controlled Trial of a Computerized Decision Support Tool.

BACKGROUND: Primary care providers manage most patients with chronic pain. Pain is a complex problem, particularly in underserved populations. A technology-enabled, point-of-care decision support tool may improve pain management outcomes. METHODS: We created an electronic health record (EHR)-based decision support tool, the Pain Management Support System-Primary Care (PMSS-PC), and studied the tool-plus-education in 6 Federally Qualified Health Center practices using a randomized, wait-list controlled design. The PMSS-PC generated "best practice alerts," gave clinicians access to a pain assessment template, psychological distress and substance use measures, guidelines for drug and non-drug therapies, and facilitated referrals. Practices were randomly assigned to early vs delayed (after 6 months) implementation of the intervention, including technical support and 6 webinars. The primary outcome was change in worst pain intensity scores after 6 months, assessed on the Brief Pain Inventory-Short Form. Changes in outcomes were compared between the practices using linear multilevel modeling. The EHR provided clinician data on PMSS-PC utilization. RESULTS: The 256 patients in the early implementation practices had significantly improved worst pain (standardized effect size [ES] = -.32) compared with the 272 patients in the delayed implementation practices (ES = -.11). There was very low clinician uptake of the intervention in both conditions. CONCLUSIONS: Early implementation of the PMSS-PC improved worst pain, but this effect cannot be attributed to clinician use of the tool. Further PMSS-PC development is not indicated, but practice-level interventions can improve pain, and studies are needed to identify the determinants of change.

Using Clinical Decision Support Within the Electronic Health Record to Reduce Incorrect Prescribing for Acute Sinusitis.

PURPOSE: Acute sinusitis has viral etiology in more than 90% of cases, but antibiotics are prescribed for more than 80% of adults in the United States. While applications of computer-assisted guidelines have been found effective in reducing inaccurate prescribing for acute respiratory infections, there is a paucity of research focused specifically on the utilization of electronic best practice alerts (BPA) in improving treatment for acute sinusitis. METHODS: This observational cohort study examined prescribing behavior for sinusitis at a single Federally Qualified Health Center 1 year prior and during the first year of implementation of a BPA in the electronic health record (EHR) reminding providers of the recommended treatment of sinusitis. The advisory included a link to national guidelines and a note template was installed to assist providers in documentation. The BPA appeared on the providers' screen when an ICD-9 code of acute or bacterial sinusitis was entered during the patient visit. RESULTS: After adjusting for select patient and provider factors, the computer-assisted guidelines effectively reduced the overall antibiotic prescribing among these patients by 31% (relative risk: 0.69, 95% confidence interval: 0.51-0.95) and reduced incorrect prescribing from 88.5% to 78.7% (P=0.02). CONCLUSIONS: Clinical reminders within the EHR can be an effective tool to reduce inappropriate antibiotic use and improve providers' decisions regarding the correct antibiotic choices for patients with acute sinusitis.

Race and Ethnicity Do Not Clinically Associate with Quality of Life Among Patients with Chronic Severe Pain in a Federally Qualified Health Center.

Objective: Previous research suggests that race/ethnicity predicts health-related quality of life (HRQL) in chronic pain populations but has not examined this in community settings. This study evaluated this association in 522 community-dwelling patients with chronic pain treated at a Federally Qualified Health Center (FQHC). Design: Cross-sectional secondary analysis. Setting: Six practice sites of an FQHC in New York. Subjects: One hundred forty-two non-Hispanic blacks, 121 non-Hispanic whites, 219 Hispanics, and 40 classified as "other" with severe chronic pain. Methods: Patients with chronic severe pain (three or more months with worst pain ≥ 4/10 or T-score > 60.5 on the Patient-Reported Outcomes Measurement Information System pain interference tool) were interviewed as part of a clinical trial. Race/ethnicity and other potential predictors of HRQL were assessed. Results: Mean age was 53.0 years, and 70.1% were women; 62.8% earned less than $10,000 per year, and 22.8% were Spanish-speaking with low acculturation. Mean worst pain during the past week was 8.6/10, and 39.6% used opioids. In multivariate analyses, race/ethnicity was not significantly associated with mental HRQL. Hispanics had significantly lower physical HRQL than non-Hispanic whites or blacks, but this difference was not clinically meaningful (mean T-scores = 33.9 [Hispanics], 35.8 [non-Hispanic whites], and 35.6 [non-Hispanic blacks]). Mental HRQL was predicted by depression, anxiety, pain disability, income, and physical HRQL; physical HRQL was predicted by race/ethnicity, anxiety, pain disability, age, care satisfaction, and mental HRQL. Conclusions: Race/ethnicity does not explain important variation in HRQL reported by diverse patients with chronic pain. Psychological distress, pain disability, age, and socioeconomic status predicted this health outcome. Future studies may clarify modifiers of these associations to guide treatment in FQHC populations.

Implementing a Policy and Protocol on Managing Patients With Hypertensive Urgencies.

BACKGROUND: The use of short-acting agents, such as clonidine, for hypertensive urgency has been shown to worsen outcomes and, therefore, should be avoided in the office. OBJECTIVES: The primary objective was to achieve decreased rates of clonidine orders for immediate treatment of asymptomatic hypertension in the office. The secondary objective was to determine if reduced use leads to a decline in poor outcomes. METHODS: This was an observational cohort study evaluating a protocol and algorithm developed by clinical pharmacists on the appropriate management of hypertensive urgencies. The protocol included the provision of avoiding short-acting antihypertensives (ie, clonidine). Preintervention and postintervention reports were generated to determine the number of times clonidine was ordered in the office. Electronic health charts were also reviewed for documentation of poor outcomes related to clonidine administration within 1 week of the hypertensive urgency visit date. RESULTS: In the preintervention cohort, 106 (17.4%) orders of clonidine were captured compared with 73 (10.6%) in the postintervention group (P = 0.001). Of the patients who were administered clonidine, 7 patients in the preintervention group were advised to go to the emergency department (ED) for additional hypertensive management, 2 of whom were subsequently hospitalized; 9 patients were advised to go to the ED in the postintervention group, and no patient was subsequently hospitalized. No adverse effects were documented from in-office clonidine administration in either cohort of patients. CONCLUSION: The hypertensive urgency protocol and education reduced the number of clonidine orders and hospital admissions. The increase in ED referrals needs further assessment.

Impact of pharmacy student interventions in an urban family medicine clinic.

OBJECTIVES: To determine the number of interventions made by pharmacy students at an urban family medicine clinic and the acceptance rate of these recommendations by the healthcare providers. The secondary objective was to investigate the cost avoidance value of the interventions. METHODS: A prospective, unblinded study was conducted to determine the number and cost avoidance value of clinical interventions made by pharmacy students completing advanced pharmacy practice experiences (APPEs) in an urban family medicine clinic. RESULTS: Eighteen students completed this experience in the 8 months studied. Of the 718 interventions performed, 77% were accepted by physicians, including 58% of the 200 interventions that required immediate action. Projected avoidance was estimated at $61,855. CONCLUSION: The clinical interventions by pharmacy students were generally well received by healthcare providers and resulted in significant cost savings. Pharmacy students can play an important role in a family medicine clinic.

Preventing gaps when switching contraceptives.

Unintended pregnancy can occur when women stop one birth control method before starting another. To prevent gaps in contraception, physicians should ask women regularly about adverse effects, cost, difficulty remembering the next dose, and other issues that affect adherence. Women who want to change contraceptive methods need accurate advice about how to do so. Some contraception transitions require an overlap between the old method and the new method. To switch safely from one contraceptive to another without overlap, women may go directly from the old method to the new method, abstaining from sexual intercourse or using a barrier method, such as condoms or spermicide, for the first seven days.

Effect of a weight-based prescribing method within an electronic health record on prescribing errors.

PURPOSE: The effect of a weight-based prescribing method within the electronic health record (EHR) on the rate of prescribing errors was studied. METHODS: A report was generated listing all patients who received a prescription by a clinic provider for either infants' or children's acetaminophen or ibuprofen from January 1 to July 28, 2005 (preintervention group) and from July 29 to December 30, 2005 (postintervention group). Patients were included if they were 12 years old or younger, had a prescription ordered for infants' or children's acetaminophen or ibuprofen within the EHR, and had a weight documented in the chart on the visit day. The dosing range for acetaminophen was 10-15 mg/kg every four to six hours as needed, and the regimen for ibuprofen was 5-10 mg/kg every six to eight hours as needed. Dosing errors were defined as overdosage of strength, overdosage of regimen, underdosage of strength, under-dosage of regimen, and incomprehensible dosing directions. RESULTS: Totals of 316 and 224 patient visits were analyzed from the preintervention and postintervention groups, respectively. Significantly more medication errors were found in the preintervention group than in the postintervention group (103 versus 46, p = 0.002). Significantly fewer strength overdosing errors occurred in the postintervention group (8.9% versus 4.0%, p = 0.028). CONCLUSION: An automated weight-based dosing calculator integrated into an EHR system in the outpatient setting significantly reduced medication prescribing errors for antipyretics prescribed to pediatric patients. This effect appeared to be strongest for reducing overdose errors.

Risk of fractures with selective serotonin-reuptake inhibitors or tricyclic antidepressants.

OBJECTIVE: To evaluate the literature associating the risk of fracture during antidepressant therapy. DATA SOURCES: Literature was identified via MEDLINE (1970-August 2008) using the search terms selective serotonin-reuptake inhibitors, tricyclic antidepressants, antidepressants, and fracture. Reference citations from publications identified were also reviewed. All articles in English identified from the data sources were evaluated. DATA SYNTHESIS: Selective serotonin-reuptake inhibitors (SSRIs) are generally prescribed over other classes of antidepressants because they are considered to be relatively safer. Recent evidence, however, suggests that SSRIs may be associated with an increased risk of fractures. Thirteen clinical studies were identified in the literature search (7 case controls, 5 prospective cohorts, 1 cross-sectional). Most studies compared SSRIs with tricyclic antidepressants (TCAs) and found similar or greater risk of fracture associated with use of an SSRI. This risk appeared to be highest at the beginning of therapy with TCAs and eventually diminished. SSRI risk tended to increase slightly over time. No risk was seen with other classes of antidepressants. However, the number of patients using antidepressants was low. CONCLUSIONS: There may be a possible correlation with SSRI or TCA use and risk of fracture. Prospective, randomized controlled trials with sufficient patient samples are needed to verify this finding.

Choosing a skeletal muscle relaxant.

Skeletal muscle relaxants are widely used in treating musculoskeletal conditions. However, evidence of their effectiveness consists mainly of studies with poor methodologic design. In addition, these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain. Systematic reviews and meta-analyses support using skeletal muscle relaxants for short-term relief of acute low back pain when nonsteroidal anti-inflammatory drugs or acetaminophen are not effective or tolerated. Comparison studies have not shown one skeletal muscle relaxant to be superior to another. Cyclobenzaprine is the most heavily studied and has been shown to be effective for various musculoskeletal conditions. The sedative properties of tizanidine and cyclobenzaprine may benefit patients with insomnia caused by severe muscle spasms. Methocarbamol and metaxalone are less sedating, although effectiveness evidence is limited. Adverse effects, particularly dizziness and drowsiness, are consistently reported with all skeletal muscle relaxants. The potential adverse effects should be communicated clearly to the patient. Because of limited comparable effectiveness data, choice of agent should be based on side-effect profile, patient preference, abuse potential, and possible drug interactions.

Clinical pharmacology of lubiprostone, a chloride channel activator in defecation disorders.

BACKGROUND: Lubiprostone, a prostaglandin E1 derivative, was approved in January 2006 for the treatment of chronic idiopathic constipation (CIC) in adults and in April 2008 for the treatment of irritable bowel syndrome with constipation (IBS-C) in adult women. OBJECTIVE: To review the pharmacology, efficacy and safety of lubiprostone and recommend its place in therapy for CIC and IBS-C. METHODS: We conducted a literature search using PubMed/Medline (1966-April 2008) using the keywords lubiprostone, chronic constipation, and irritable bowel syndrome. Data provided by the manufacturer and the FDA were also reviewed. CONCLUSION: Available literature for lubiprostone is mostly available in abstract data making it difficult to evaluate the clinical evidence. Although this medication shows promise, more information is needed to determine its place in therapy.

Skeletal muscle relaxants.

Health care providers prescribe skeletal muscle relaxants for a variety of indications. However, the comparative efficacy of these drugs is not well known. Skeletal muscle relaxants consist of both antispasticity and antispasmodic agents, a distinction prescribers often overlook. The antispasticity agents-baclofen, tizanidine, dantrolene, and diazepam-aid in improving muscle hypertonicity and involuntary jerks. Antispasmodic agents, such as cyclobenzaprine, are primarily used to treat musculoskeletal conditions. Much of the evidence from clinical trials regarding skeletal muscle relaxants is limited because of poor methodologic design, insensitive assessment methods, and small numbers of patients. Although trial results seem to support the use of these agents for their respective indications, efficacy data from comparator trials did not particularly favor one skeletal muscle relaxant over another. Therefore, the choice of a skeletal muscle relaxant should be based on its adverse-effect profile, tolerability, and cost.

Demonstrating prescribing competence: a successful pilot of a prescription competency curriculum for family medicine residents.

BACKGROUND: Poor medication prescribing skills among residents have been widely reported. METHODS: We implemented a three-stage prescribing curriculum with eight interns in an urban family medicine residency. Clinical pharmacy faculty delivered two lectures, attended hospital rounds, and coprecepted in clinic. Evaluations were done by a written exam and clinical assessment. RESULTS: All eight interns made at least one prescribing error on the exam. One error was considered potentially fatal. All interns passed on the second attempt and gained prescribing privileges after 6 months. CONCLUSIONS: Our prescribing curriculum was practical and feasible. Further studies will determine whether the intervention improved prescribing habits and reduced clinical errors.

Lubiprostone: a chloride channel activator for treatment of chronic constipation.

OBJECTIVE: To review lubiprostone's pharmacology, pharmacokinetics, efficacy, and safety in the treatment of chronic constipation. DATA SOURCES: A literature search was conducted using PubMed/MEDLINE (1966-January 2007), IngentaConnect, and International Pharmaceutical Abstracts (1977-January 2007). Key words used included lubiprostone, Amitiza, and chronic constipation. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources that were published in English were evaluated. DATA SYNTHESIS: Lubiprostone is a chloride channel activator approved by the Food and Drug Administration for the treatment of chronic constipation. A randomized, double-blind, parallel-group, placebo-controlled study evaluating the effect of lubiprostone on gastric function showed slowed gastric emptying and increased small bowel and colonic transit time. Peak plasma concentration was shown to be around 1.14 hours, with a majority of the drug excreted in the urine within 48 hours. Phase III trials have noted that most patients with chronic constipation have a spontaneous bowel movement within 24 hours after taking lubiprostone. The most common adverse events in these trials were nausea, diarrhea, abdominal pain, and headache. Lubiprostone use has not been studied in the pediatric population. CONCLUSIONS: Lubiprostone may be a reasonable alternative for use in patients who either fail or are intolerant of standard therapy for chronic constipation. Head-to-head comparison studies with conventional therapy are needed to contrast clinical efficacy and safety of this medication.

Effect of bupropion on sexual dysfunction.

OBJECTIVE: To determine the role of bupropion in treatment of sexual dysfunction. DATA SOURCES: Studies and case reports were identified through MEDLINE (1970-July 2005) using search terms bupropion, antidepressants, sexual function, and sexual dysfunction. DATA SYNTHESIS: Bupropion has been shown to have a favorable effect on sexual dysfunction. Several reports and small, short-term trials have examined bupropion as an adjunct or substitute for other antidepressants in sexually dysfunctional patients. Use of bupropion has also been studied in nondepressed patients. Bupropion may be a promising medication for treating sexual dysfunction. However, specific dosing is unclear. CONCLUSIONS: While the studies reviewed here demonstrated some benefit in using bupropion to treat sexual dysfunction, limitations exist. Future studies should be conducted using larger sample sizes.