Questions elderly patients have about on-going therapy: a pilot study to assist in communication with physicians.

PURPOSE OF THE STUDY: This pilot study examined the prevalence and types of questions elderly patients have about their current drug therapy. It also evaluated the effectiveness of a brief intervention to prepare patients to ask questions about drug therapy during medical visits. DESIGN AND METHODS: The research used a posttest-only experimental design. Forty-five elderly patients seen at a primary care clinic during a one-month period consented to participate and completed the study. After consent, subjects were randomly assigned to intervention and control conditions. A brief interview with intervention group subjects conducted by a medical student assigned to the clinic as part of a summer research experience helped subjects formulate questions they had about current therapy before they went into medical visits. Patient-physician visits were audiotaped and patient questions about medications and health care were tallied. RESULTS: Subjects in the intervention group were significantly more likely to ask questions of providers than were subjects in the control group. Intervention group subjects were found to ask a wider variety of medication-related questions than were control group subjects, including questions related to proper use, problems perceived with medications, and effectiveness of treatment. IMPLICATIONS: Assisting patients to formulate questions before medical visits results in an increased likelihood that patients will ask questions and will ask a wider variety of questions during the medical visit.

Patients' perceptions of the benefits of pharmaceutical care.

OBJECTIVE: To investigate patients' perceptions of the benefits of regular participation in pharmaceutical care services. DESIGN: Written survey of a convenience sample. SETTING: Pharmacist-run anticoagulation clinic in a Veterans Administration Medical Center. PATIENTS: 154 patients who had regularly scheduled appointments in the clinic. INTERVENTIONS: Patients were asked to complete a written survey. The survey was read to those who had trouble reading it. MAIN OUTCOME MEASURES: Patients' perceptions about the benefit of services provided in the clinic and the relationship between those services and reduced risks of medication-related problems. RESULTS: All components of anticoagulant-related pharmaceutical care were rated as at least fairly beneficial. Monitoring of warfarin blood levels and information on the appropriate use of warfarin were rated highest. The perceived benefits of the pharmaceutical care components were associated with patients' perceptions of the extent to which pharmaceutical care reduced their risk of experiencing blood clots or warfarin-related problems. Patients also perceived that their risk of developing blood clots or bleeding problems would be higher if they did not regularly visit the anticoagulation clinic. CONCLUSION: Patients' perceptions of the benefits of pharmaceutical care were associated with the perceived threat reduction capacity of the pharmacist's services. Pharmaceutical care providers may be able to enhance patient participation in their services by educating patients on the risks of medication-related problems and how frequent monitoring of key clinical indicators may help reduce those risks.

Relationship between quality of life, social support and disease-related factors in HIV-infected persons in Venezuela.

This study examines the relationships among health-related quality of life (HRQL), social support, sociodemographic factors and disease-related factors in persons infected with the human immunodeficiency virus (HIV) living in Venezuela. A sample of 118 HIV-infected persons living in Caracas, Venezuela, was surveyed using a written questionnaire that included a Spanish translation of the Interpersonal Support Evaluation List (ISEL) developed for this study, the Medical Outcomes Study Short Form-36 (SF-36) and a symptom inventory. All three instruments showed good internal consistency reliability. Multiple regression analyses were used to model SF-36 sub-scale scores as a function of symptoms, social support, HIV-status and use of antiretroviral drugs. The models explained between 16 and 39% of the variance in the different HRQL domains. Controlling for other variables in the model, level of symptomatology was significantly associated with all HRQL domains except social functioning and role-emotional scores. Social support was significantly associated with all HRQL domains except physical functioning and bodily pain. The use of antiretroviral drugs was significantly associated with social functioning. The study indicates the importance of social support to the quality of life of HIV-infected individuals in this culture.

Issues related to using a short-form of the Center for Epidemiological Studies-Depression Scale.

The study examined the reliability and validity, including the factor structure, of a 10-item abbreviated version of the Center for Epidemiological Studies-Depression (CES-Depression) scale when administered as part of a mail questionnaire. It also examined patterns of nonresponse to items and the effects of imputation of data for missing items on the factor structure of the inventory. A problem of missing data has been reported even with interview administration of the CES-Depression. Researchers have varied considerably in the amount of imputation used to replace missing datapoints. In this study, factor structures varied when items were imputed. In addition, those subjects with complete data were compared with those with up to two imputed datapoints. Those subjects with imputed data were more likely to be female, have lower functional status scores, lower self-reported health status, more advanced age, and a greater number of depressive symptoms than those with no missing data. While the estimate of coefficient alpha of .78 indicated the inventory was reliable, the effects of missing data on construct validity were problematic.

The Medication Attribution Scale: perceived effects of antiretrovirals and quality of life.

This report describes the development and validation of an instrument to assess the attributions human immunodeficiency virus (HIV)-infected persons who are currently taking antiretrovirals make about the effects of these medications. The specific limitations in functioning that the subjects attributed to the effects of medication were assessed. The scores on a ten-item instrument were found to have high internal consistency reliability and to be related to beliefs about the benefits and barriers to taking antiretrovirals. The attribution that the use of antiretrovirals had contributed to an increase in depressive symptoms was related to reports of having temporarily discontinued use of antiretrovirals during the preceding month. The summated score on the Medication Attribution Scale (MAS) and other subscale scores were not found to predict self-reported intentional alterations of treatment regimens. Multiple regression analyses indicated that negative attributions about the effects of medications contributed to the amount of variance in quality of life explained over and above that explained by perceived health status and level of symptomology.

Perceived access to care and medication use among ambulatory elderly in Rio de Janeiro, Brazil.

This study examined physician and non-physician prescribed medication use of a growing segment of Brazilian society--the elderly. Personal interviews were conducted with 436 subjects in a stratified random sampling of elderly respondents to the previously completed 1990 Brazilian Old Age Survey (BOAS). The BOAS sample had been stratified according to the socioeconomic status (SES) of three communities within Rio de Janeiro. This study focused on medication use of these subjects as a function of the predisposing, enabling, and need variables which have been found in previous research to predict other types of health services utilization (HSU). The enabling variables of access to care were measured as patient perceived availability, affordability, and acceptability of both medical and pharmacy services. ANOVA results found differences among the different communities in perceived availability and affordability of medical and pharmacy services and acceptability of pharmacy services. Subjects from Santa Cruz, the lowest SES area, consistently reported lesser availability of services, more difficulties with affordability but greater perceived acceptability of pharmacy services than those from the highest SES area. Multivariate regressions modeling both prescribed and non-prescribed medication use for the three areas found that the access-oriented HSU framework was much more effective in explaining the variance in medication use for the lowest SES area (45% and 48% for prescribed and non-prescribed use, respectively) than for the highest SES area where only 16% and 18% of prescribed and non-prescribed medication use was explained.

Psychosocial aspects of antiretroviral medication use among HIV patients.

This study examines variables related to alteration of antiretroviral medication regimens by HIV infected persons, independent of medical advice. Perceived severity, susceptibility, benefits/barriers, cues to action, and locus of control were included in the analyses. Of 99 subjects, 37 reported discontinuing antiretrovirals on their own initiative and 36 subjects ('fiddlers') reported recent alterations in their medication regimens. Subjects who reported greater perceived barriers and pessimism and less faith in the ability of antiretrovirals to protect them from AIDS related illness were more likely to discontinue drug therapy. Fiddlers were more pessimistic and perceived more barriers to drug therapy than compliers, who believed more in the benefits of antiretrovirals. Fiddlers were significantly more internally oriented than were discontinuers. Compliers were the most optimistic about the effect of antiretrovirals. Even though compliers were more symptomatic than discontinuers, they reported their health status to be better than did discontinuers.

Role orientation and community pharmacists' participation in a project to improve patient care.

Community pharmacists are being assigned increased responsibility in assuring the appropriateness and effectiveness of drug therapy. This increased responsibility is reflected in recently passed legislation (OBRA '90) in the United States that requires pharmacists to counsel patients about prescriptions received and to engage in prospective drug use review for Medicaid recipients. The potential impact of this legislation is unclear due to a dearth of research evaluating the effects of community pharmacists' activities on medication use. In addition, there is little research on pharmacists' willingness to assume increased responsibility. Research that would demonstrate the effectiveness of community pharmacists in improving therapeutic outcomes is hampered by problems inherent in conducting experimentally designed research in field settings. This paper examines two issues of concern in such studies--namely, the extent to which those who agree to participate in a demonstration project differ from those who decline to participate and the extent to which differential dropout from treatment and control conditions compromise the comparability of the two groups. Specifically, this report examines pharmacist characteristics related to participation in a demonstration project to improve the care of elderly patients. Community pharmacists in Florida who had earlier been asked to participate in a demonstration project (N = 418) were sent mail questionnaires to assess their attitudinal, demographic and employment characteristics. In particular, researchers were interested in the role orientation of pharmacists in regard to patient counseling and physician consultation, satisfaction with current jobs and career choices, employment settings and treatment vs control group assignment as predictors of participation in the research project. Demographic characteristics were also examined as possible predictors of participation.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of an education program for community pharmacists on detecting drug-related problems in elderly patients.

Community pharmacists are in a position to assume increased responsibility for preventing and resolving drug-related problems in ambulatory patients. Such an expanded role is mandated under provisions of the Omnibus Budget Reconciliation Act of 1990. The need for pharmacist oversight of drug therapy may be most acute in elderly patients. This study reports on a program to teach community pharmacists a process of assessing drug therapy of elderly patients and intervening to correct problems. Community pharmacists (N = 102) were assigned to treatment and control conditions. Both groups targeted patients meeting criteria and enrolled them into the study. Treatment group pharmacists, who participated in a training program, also assessed the medication use of enrolled patients to identify and resolve medication-related problems. Patients (N = 762) were telephoned by researchers 1 month after enrollment for an interview. Comparisons between treatment and control group patients were made on reports of pharmacist activities, knowledge of regimens, compliance, and potential drug therapy problems, such as interactions and side effects. Treatment patients were more likely to report that pharmacists provided information and assessed for problems than were control patients. These differences were maintained on 3-month follow-up questionnaires. No differences were found on the odds that patients indicated misunderstanding of regimens, non-compliance, or potential therapeutic problems.

Multidimensional work sampling to evaluate the effects of computerization in an outpatient pharmacy.

The effectiveness of multidimensional work sampling versus direct observation in evaluating the effects of computerization in an outpatient pharmacy was studied. A direct-entry, self-reporting method of multidimensional work sampling was used to measure and compare the relative times spent on various tasks before and after computerization in the outpatient pharmacy of a 475-bed teaching hospital. Analysis of variance was used to evaluate differences in the types of functions performed, differences in functions among the five employees (two pharmacists, one pharmacy intern, and two technicians), and differences in functions on a week-to-week basis. Data obtained by multidimensional work sampling were compared with data obtained by direct observation to determine the level of agreement between the two methods. Also, a time clock method was used to measure and compare the time required for prescription processing before and after computerization. After computerization, the percentage of time spent on some clerical tasks decreased by 26.7%, but this decrease was offset by a significant increase of 27.7% in the percentage of time spent entering information into the computer. Time spent on clinical tasks did not change significantly. A significant difference among employees was found in the percentage of time spent on clinical functions. The differences in time spent on clinical or clerical functions from week to week were not significant. The time to process a set of prescriptions increased after computerization, primarily because of the time needed to enter information into the computer. However, computerization enabled the generation of patient profiles. Multidimensional work sampling is an accurate method of work measurement that may be more useful than direct observation in capturing clinical functions.

Work measurement in pharmacy research.

The applicability of various methods of work measurement to pharmacy research is discussed, and studies that have used these methods are reviewed. Methods of work measurement include subjective evaluation, direct time study, work sampling, statistical data, and pre-determined data. Subjective evaluation lacks precision in its estimates but may be useful in formulating hypotheses. Direct time study is most appropriate for readily observable, highly repetitive tasks that can be divided into short segments, although it has been used for longer and more variable activities. Work sampling is the most frequent method of work measurement used in pharmacy research, but few studies reported doing any check of measurement reliability or validity. Multidimensional work sampling and other forms of direct-entry, self-reporting work sampling may be useful in measuring the more complex and unobservable tasks of pharmacists such as clinical activities. By developing an understanding of the purposes and applications of measurement techniques, hospital pharmacists can choose the most appropriate method for their research setting and purpose.

Development and validation of an instrument to measure pharmacists' satisfaction with their jobs and careers.

The development and validation of a survey questionnaire measuring pharmacists' satisfaction with their jobs and careers is outlined. The instrument was part of a 1983 study which surveyed pharmacists licensed and residing in Florida. The use of the pilot survey to arrive at a final survey instrument is outlined. Reliability of the instrument is assessed with tests of internal consistency reliability. Validity is judged through a test of concurrent validity utilizing the Job Descriptive Index, a standardized measure of job satisfaction. The delineation of this process is intended to aid other researchers in the development and validation of their surveys of job satisfaction and similar attitudinal measures.

Drug product selection: the Florida experience revisited.

The comparison of drug product selection rates determined approximately one year and four years after passage of Florida's Drug Product Selection (DPS) Law indicates very little change in the product selection and brand interchange behaviors of Florida pharmacists. Lack of adequate guidelines from the state and the liability concerns of pharmacists appeared to limit an expected increase in the state DPS rate.

An evaluation of the education of hospital pharmacy directors.

The education received by hospital pharmacy directors was evaluated by the 1981 survey responses of the directors of pharmacy practicing in hospitals with over 300 beds. A total of 657 out of 1,531 (42.9 percent) usable questionnaires were returned. Directors ranked the following academic areas in decreasing order of importance to them; personnel and financial management, computers, hospital organization, clinical pharmacy practice, traditional pharmacy practice, and statistics. Directors with MBA degrees perceived themselves to be stronger in these same academic areas than did directors with MS, PharmD, and BS degrees. Only directors with MBA and MS degrees believed they had been adequately prepared through their academic programs for their administrative role as director. Recommendations for changes in the education received by future hospital pharmacy directors are included in this paper.

Predicting success of pharmacy students in basic science and clinical clerkship courses.

A number of studies on the ability of admissions variables to predict success in pharmacy schools have examined only success in the first professional year, which typically consists primarily of basic science courses. This study examined not only grades in basic science courses but also performance on clinical clerkships, for two classes of students. It also examined the ability of various personality variables to predict performance in clinical and basic science coursework. Previous grade point average (GPA) was the best single predictor of performance. In one class, the personality variable of Responsibility best predicted clinical clerkship performance. However, it only accounted for 13 percent of the variance in clerkship grades. Pharmacy College Admission Test (PCAT) Biology and PCAT Verbal Ability scores added to the predictive ability of previous GPA in one class, but none of the PCAT scales entered a prediction equation for the other class. The limitations on our ability to predict, with any consistency, academic performance in pharmacy school is discussed.

Effects of time lapse between sputum collection and culturing on isolation of clinically significant fungi.

A retrospective study of 34,314 sputum specimens received by a reference laboratory over a 10-year period demonstrated that clinically significant fungi could be isolated even after long periods of delay between collecting and culturing. As a result of this study, it should be stressed that although immediate culturing for fungi is the ideal, specimens should not be rejected because of delays in transport.

Physician and pharmacy student expectations of pharmacy practice.

This study was initiated to examine the attitudes of some of the future health care providers, family practice residents, toward various ambulatory pharmacy services. Pharmacy students were then asked to predict what the resident attitudes would be and the results were compared. This project addressed the following questions: (i) What are the expectations of family practice residents of what today's pharmacists should be doing? and (ii) How accurately can pharmacy students judge what the responses of the residents will be? The survey results indicated that the family practice residents' perceptions of certain pharmacist behaviors rated significantly higher than how the pharmacy students thought they would respond. Such behaviors included: (i) maintain and review patient profiles; (ii) counsel patients; (iii) take medication/allergy histories; (iv) provide therapeutic information to physicians; and (v) stock a wide variety of generic drugs. Most of these behaviors reflect direct involvement of the pharmacist in disseminating information to the patient and/or physician. Other expanded roles of the pharmacist such as triage, refill determination, reimbursement for consultation services, and chronic care management were given low priority.

Accuracy of copper-reduction and glucose-oxidase tests for various glucose concentrations.

Three glucose-oxidase (Diastix) and two copper-reduction (Clinitest) urine tests for glucose were compared to determine the differences in accuracy for various concentrations of glucose. Fifty volunteers were assigned on a random basis to one of five urine-testing methods and to a testing order for eight glucose samples. The samples were assayed spectrophotometrically to verify the actual concentrations of glucose, ranging form 0.1 to 20.0%. Scale points were assigned to correspond to the different glucose concentrations. The deviation of the volunteers' determinations above or below the actual concentrations were recorded as error points. A one-way analysis was conducted on the error points to determine it there were significant differences among the five testing methods. Significant differences were found among the five testing methods (p less than 0.01). The five-drop Clinitest method was significantly less accurate than the 1:5 Diastix and the two-drop Clinitest methods. Significant differences were found among the five testing methods at low and medium glucose concentrations but not at the high concentrations. In the glucose concentration range of 0.1-0.25%, the Diastix method with no dilution was significantly less accurate (p less than 0.01) than the two-drop Clinitest method. In the 0.5-1.25% range, the two-drop Clinitest was more accurate than Diastix 1:5, 1:10, and five-drop Clinitest. Overall, the two-drop Clinitest procedure was most accurate, particularly at the lower concentrations of glucose.

Interactions between Histoplasma capsulatum and macrophages from normal and treated mice: comparison of the mycelial and yeast phases in alveolar and peritoneal macrophages.

Interactions between macrophages (alveolar and peritoneal) from normal, vaccinated (with heat-killed yeast cells), and Mycobacterium bovis BCG-treated mice and the mycelial and yeast phases of Histoplasma capsulatum were observed. Phagocytosis of microconidia, small hyphal fragments, and yeast cells occurred 4 to 6 h after the infection of macrophage cultures. Conversion to the yeast phase began at 6 to 7 h and was complete after a 72-h incubation at 37 degrees C. Macrophages surrounded and adhered to macroconidia and large hyphal elements. More macrophages (65 to 68%) from BCG-treated mice contained fungi at 24 h than did macrophages from normal or vaccinated mice. Although there was no increase in the number of fungi in macrophages from vaccinated mice, only the macrophages from BCG-treated mice contained fewer fungi after 48 h of infection with the mycelial phase of H. capsulatum. Fungal growth was not inhibited in any of the macrophage cultures when infected with the yeast phase. The macrophages infected with yeast cells were destroyed after 48 to 72 h in the culture. Only BCG-treated macrophages survived infection with the mycelial phase, whereas macrophages from normal and vaccinated mice were destroyed by the infection.