Peer review of presentations through examination software.

BACKGROUND AND PURPOSE: Peer evaluations are often utilized to allow student pharmacists practice in giving and receiving feedback. In a small class setting, these can easily be completed and feedback distributed quickly. However, in the larger class setting, reviewing and disseminating peer feedback can be quite cumbersome, especially if using paper format. The purpose of this educational activity was to create a process for peer evaluations that allows for efficient collection and dissemination of peer feedback of presentations of student pharmacists and describe the student experience with this new format. EDUCATIONAL ACTIVITY AND SETTING: In Research Topics in Pharmacy II, an electronic peer-evaluation tool was created using electronic examination software to collect and distribute this peer review in a timely fashion during and after each class session. At the completion of this course, a survey was distributed to collect student pharmacists' perception of this electronic peer-review process. FINDINGS: A total of 63 of 91 students (69%) completed the survey. The majority of the students (98.4%) "strongly agreed" or "agreed" the peer-evaluation items made it easy to provide feedback to their peers and 79% preferred this electronic method of feedback vs. paper format. Overall, 93.6% of student pharmacists felt they were more engaged during the presentations as a result of providing electronic feedback. SUMMARY: Maximizing our resources by creating an electronic peer evaluation with our current examination software, allowed for an efficient means of obtaining and disseminating peer review that was timely and well-received by students.

Medication Simulation Affects Health Provider Students' Attitudes About Adherence and Concordance.

INTRODUCTION: Assisting polypharmacy patients with complex health regimens is a part of health provider responsibilities. The concepts of adherence and concordance contrast the traditional emphasis on patient compliance. However, health provider students may not be able to empathize with polypharmacy patients. The purpose of this study was to measure the effect of a medication simulation on medical, nursing, and pharmacy students' beliefs about adherence and concordance. METHODS: A prospective, quasi-experimental, pretest, and posttest design was used with institutional review board approval. The participants (N = 62) took four simulated medications (varied dosing schedules) for 1 week. Attitudes toward adherence and concordance were assessed before and after the intervention. RESULTS: Subjects averaged 24.6 years (SD = 4.32), 72.6% female, and 79% white. Most were medical students (n = 33, 53%), followed by nursing (n = 21, 34%) and pharmacy students (n = 8, 13%). There were significant changes [t(61) = 3.92, P < 0.001] in beliefs about adherence from time 1 (mean = 25.13, SD = 5.77) to time 2 (mean = 22.05, SD = 6.06), and about concordance (mean = 41.85, SD = 5.58 time 1) to (mean = 44.29, SD = 6.32 time 2) [t(61) = 3.31, P < 0.05], for the entire group. Most students (84%) predicted that they would be able to take four medications correctly for 1 week. Fifty-eight students (94%) found that adherence was 'much harder' or 'a little harder' than anticipated. Most (89%) felt that the simulation will impact their patient care. CONCLUSIONS: Participation in a medication simulation exercise affected health provider students' attitudes toward adherence and concordant behaviors. These experiences may influence future patient interactions.

Medication discrepancy rates among Medicaid recipients at hospital discharge.

OBJECTIVES: To compare the rate of discrepancies per patient for medications changed during hospitalization in patients with and without prescription provider comments at hospital discharge. Secondary objectives included comparing 35-day readmission rates, describing the overall medication discrepancy rate stratified by age group and type of discrepancy, collecting average number of medication changes, and reporting percentage change in admission medications at discharge. METHODS: This single-center prospective cohort included NC Medicaid recipients discharged from East Carolina University Family Medicine service from November 1, 2015, to January 31, 2016. Patients were assigned to a group based on presence or absence of provider comments on discharge prescriptions. Outpatient pharmacy claims were compared with the discharge summary to identify medication discrepancies. Medication discrepancy rates between groups were to be compared by means of independent-samples t test. Medication discrepancy rates were compared according to 35-day readmission status, age group, and type of discrepancy by means of independent-samples t tests and analysis of variance. Descriptive statistics were used for other secondary outcomes. RESULTS: Of 118 patients included, only 1 had provider comments. Therefore, a medication discrepancy rate comparison was not performed. Patients had a mean of 4 medication changes made to their regimen and 21.3% change in admission medications. Sixty-one percent of patients had at least 1 medication discrepancy, with an overall rate of 1.19. Patients readmitted within 35 days had a significantly greater medication discrepancy rate than those not readmitted (1.63 vs. 1.05, respectively; P = 0.044). Patients 18-49 years of age had the highest discrepancy rate and those older than 80 years of age the lowest (1.58 and 0.50, respectively). New or changed discharge medication not filled accounted for 69% of discrepancies. CONCLUSION: Although medication discrepancies were common, use of provider comments was rare. Future studies should address more effective ways to communicate pertinent information to community pharmacists and methods to improve adherence in obtaining new medications.

Evaluation of Changes in Citalopram Prescribing Patterns Following a US Food and Drug Administration Alert: A Retrospective Cohort Study.

OBJECTIVE: The US Food and Drug Administration (FDA) issued a warning stating that patients older than 60 years are not recommended to receive doses of citalopram exceeding 20 mg daily due to concerns of corrected QT (QTc) prolongation. The purpose of this study is to assess the impact of the FDA warning on prescribing patterns of citalopram in patients 60 years of age and older. METHOD: This is a retrospective cohort study of hospitalized patients 60 years of age and older prescribed citalopram from October 24, 2010, to August 24, 2011 and from November 24, 2011, to September 24, 2012. Records were examined for the presence of baseline risk factors for QTc prolongation and torsades de pointes. RESULTS: The issuance of an FDA warning was not associated with an observable change in prescribing patterns of citalopram. A total of 98.8% of patients had at least 1 risk factor for QTc prolongation. No significant difference in the total number of risk factors was seen between groups (P = .915). No differences were seen in risk factors prewarning and postwarning, except a higher percentage had left ventricular hypertrophy (P = .001) or history of syncope (P = .043) prior to the warning. More subjects were prescribed concomitant proarrhythmic medications (P = .009) after the FDA warning was issued. Similar percentages of each group were receiving daily dosages > 20 mg of citalopram (P = .600). CONCLUSIONS: The issuance of an FDA warning did not produce observable changes in prescribing patterns of citalopram. Modifiable risk factors and optimal dosing may be targets of interventions aimed at promoting safer use of citalopram.

Treatment of osteoporosis: current state of the art.

Osteoporosis can be treated with medications and lifestyle changes, including avoiding a sedentary lifestyle, alcohol, and smoking. We will identify medications that protect against hip fractures in addition to vertebral fractures, and explore new evidence of adverse effects and risks. Bisphosphonates are used as first-line treatment. We will discuss the latest osteoporosis medications, drug interactions, potential bone protective effects of other drug classes, and the evidence of exercise and kyphoplasty.

Bullous pemphigoid: corticosteroid treatment and adverse effects in long-term care patients.

Bullous pemphigoid (BP) is the most common autoimmune bullous disease. It primarily presents in elderly patients older than 70 years of age. The presentation can vary with localized or generalized disease that variably affects mucosal tissue. Therapy primarily consists of administration of topical and systemic corticosteroids. Topical corticosteroids are effective with less adverse effects compared with systemic steroids. Other therapies, such as steroid-sparing agents and plasma exchanges, have been recommended and studied to some degree, but these require more evidence before they can be routinely recommended. A 68-year-old African-American female resident of a nursing facility develops a rash and is evaluated at a dermatology clinic. Since the resident has many medications and concomitant diseases, the physician at first suspected a drug rash. On subsequent visits, the resident undergoes multiple punch biopsies and is diagnosed with BP. Treatment is initiated with topical steroids, systemic steroids, and oral minocycline. On a follow-up visit, the resident is showing improvement of her BP. However, the resident's hypertension and hyperglycemia are now uncontrolled as a result of the discontinuation of hydrochlorothiazide and the initiation of steroid therapy. This case highlights the dangers of corticosteroids in patients, especially the elderly, who have multiple comorbidities.

Documenting the use of calcium supplements with oral bisphosphonates.

OBJECTIVE: Patients receiving an oral bisphosphonate for treatment of osteopenia or osteoporosis without adequate calcium intake are not optimally treated. Physicians prescribing bisphosphonates may not consistently document calcium supplementation recommendations. DESIGN: This is a retrospective chart review of osteoporotic or osteopenic outpatients with an active prescription for an oral bisphosphonate. This cross-sectional study was designed to determine the point prevalence of calcium supplementation recommendations by physicians. SETTING: Academic family medicine outpatient clinics. PATIENTS: Of the 1,229 patients with osteoporosis or osteopenia, 425 patients had an active prescription for an oral bisphosphonate and were included in the study. INTERVENTIONS: The active/inactive medication list and physician clinic notes in the electronic medical record were reviewed for documentation regarding calcium. MAIN OUTCOME MEASURES: The primary endpoint was the percentage of patients on bisphosphonates also receiving calcium. The secondary endpoint was the identification of demographic characteristics associated with lower use of calcium. RESULTS: The patient sample was 94% female, 69% white, with a mean body mass index of 27, and mean age of 72 years. Of the 425 patients, 387 (91.1%) were taking calcium or had a documented recommendation for calcium supplementation. Of the demographic characteristics evaluated, only age was statistically significantly different, with an average age of 76 years in the calcium group and 66 years of age in the noncalcium group. CONCLUSION: In this study, 91% of outpatients who were prescribed a bisphosphonate also were taking calcium or had it recommended to them. The only statistically significant difference between groups was greater age for those who received calcium.

Reasons for bisphosphonate exclusion in patients treated for osteoporosis.

OBJECTIVE: Inadequate treatment is a concern in management of osteoporosis because of its negative impact on fracture risk, health care costs, and quality of life. Bisphosphonates are the most effective drug class at decreasing hip and spine fractures. The purpose of the study was to discover reasons for exclusion of bisphosphonates in the treatment of patients with osteoporosis. DESIGN: A cross-sectional study of electronic medical records. SETTING: Academic family medicine outpatient clinics. PATIENTS: Subset of patients older than 25 years of age who had a diagnosis of osteoporosis and were not on bisphosphonate treatment on December 31, 2007. OUTCOMES: The primary endpoint was the reason patients were not on bisphosphonate therapy. Secondary endpoints included the length of previous bisphosphonate therapy and the number of patients receiving other prescription treatments for osteoporosis. RESULTS: Of 698 patients with osteoporosis, 418 (60%) were not treated with a bisphosphonate. Patients were 91.6% female and 76.4% white, with a mean age of 77.5 ± 13.5 years. Of the random sample of 191 patients, 17 (8.9%) patients did not have an identifiable reason for bisphosphonate exclusion. The most common reasons were gastrointestinal (GI) diagnosis (28%), low functional status (24%), and poor renal function (12%). Almost half (44.5%) of patients were previously on a bisphosphonate, with an average use of 20.7 ± 17.7 months. Only 2.6% of patients received osteoporosis treatment other than a bisphosphonate. CONCLUSION: Even though 60% of patients were not prescribed a bisphosphonate, 91.1% had a reason for exclusion. With GI reasons most common, parenteral forms of bisphosphonates recently approved for osteoporosis may increase use.

Medication nonadherence secondary to drug-induced memory loss.

Overactive bladder (OAB) is a common condition in the elderly. Treatments for OAB include nonpharmacological or behavioral therapy, pharmacological therapy, and surgical therapy. Antimuscarinic agents are the current pharmacological treatment for OAB and are known to cause memory impairment. A 66-year-old female presented with memory loss secondary to the administration of oxybutynin, which resulted in medication nonadherence. Upon review of her medications, the pharmacist recommended discontinuing the oxybutynin because of the anticholinergic effects on cognition. At a three-week follow-up visit, the patient reported an improvement in memory and medication adherence. Pharmacists can play a vital role in recognizing drug-induced side effects and educating patients in an effort to improve medication adherence.

Nursing home medication administration cost minimization analysis.

OBJECTIVES: To assess the time it takes nurses to administer medications in the nursing home setting, to calculate nursing cost of medication administration, and to determine whether using extended-release products are justified by decreasing nursing costs. DESIGN: Cost-minimization analysis using observational data from a time-motion analysis. SETTING: Two 150-bed nursing homes in rural eastern North Carolina. PARTICIPANTS: Nurses working during first and second shifts. MEASUREMENTS: Nurses were timed as they each administered medications to 12 patients. The mean time required to administer each dosage form was calculated. The cost of nursing time was based on the average nursing staff salary of $20.45 per hour as reported by the directors of nursing. Time and cost to dispense one more medication during an existing medication pass and an additional medication pass are calculated. RESULTS: The time to administer an additional dose of an oral medication to one patient was 45.01 seconds during an already scheduled medication pass and 63.05 seconds during a new medication pass. The cost of adding an oral medication once a day for a patient will cost $7.67 per month if administered at the same time as other medications or $10.74 per month if a new medication pass is required. The administration of other dosage forms, such as crushed, percutaneous enteroscopic gastrostomy, injection, and patch was more time involved and, thus, costlier. Formulas are provided to calculate medication administration cost based on local salary. CONCLUSIONS: Nursing time and costs for medication administration in the nursing home are great and should be considered when selecting a product. This may justify the selection of higher cost extended-release products.