Inter- and intra-subject variability in gabapentin absorption and absolute bioavailability.

UNLABELLED: Gabapentin (GBP) is a non-metabolized, non-plasma protein bound, renally excreted antiepileptic drug that is actively absorbed via the system L amino acid transporter. Previous studies have demonstrated that gabapentin displays dose-dependent absorption. OBJECTIVES: These studies were conducted to determine inter- and intra-subject variability of gabapentin absorption. Two prospective clinical studies in healthy adult volunteers were conducted. Coefficient of variation (CV) was used to express variability of gabapentin absorption. METHODS: Study A: 400-mg single dose, randomized, cross-over study to assess bioavailability of four different gabapentin formulations (n=20, 9 males, 11 females; mean age and weight 41 years, 75.1 kg). Plasma was serially collected up to 48 h and bioavailability (F) calculated post-dose to determine concentration-time curves (AUC). All four formulations were bioequivalent, thus repeated measures analysis was performed to assess inter-and intra-subject variability. Study B: 600-mg single dose study (n=50, 15 males, 35 females; mean age and weight 31.1 years, 72.7 kg) was conducted to determine inter-subject variability in gabapentin F. Urine was collected over 48 h and bioavailability (F) calculated. Urine and plasma gabapentin concentrations were measured by HPLC-UV. RESULTS: Study A: Overall mean (CV) of GBP AUC values was 34.1+/-24 ug/h per ml. Inter-subject CV for AUC was 22.5% and intra-subject CV was 12.1%. Study B: Overall mean (SD) GBP F was 49.3+/-13.6%. Inter-subject CV of F was 27.6%. DISCUSSION: The inter-subject variability in gabapentin absorption is substantially less than that of the inter-subject variability. This indicates that one would expect a wide range in gabapentin absorption between subjects; however, a much smaller variability within a subject. The within subject variability of gabapentin is small enough that plasma drug monitoring may be used to assess gabapentin absorption for a given subject and the benefit of dose individualization.

Staffing and the cost of clinical and hospital pharmacy services in United States hospitals.

A survey was mailed to pharmacy directors at all United States acute care medical-surgical hospitals that related to staffing and cost components of hospital pharmacies and clinical services. Cost information was evaluated as both unadjusted and adjusted for severity of illness using the Health Care Financing Administration's Medicare case mix index (CMI). Unadjusted drug costs/occupied bed/year were $13,350+/-6927, a 36% increase over 1992 and a 112% increase over 1989, with statistically significant differences observed by geographic region, hospital size, hospital ownership, and drug delivery system. Annual median pharmacist salary costs/patient associated with centrally based clinical pharmacy services were drug use evaluation $111, in-service education $20, drug information $117, poison information $24, and clinical research $35. Annual median pharmacist salary costs/patient associated with patient-specific clinical services were drug therapy monitoring $5, pharmacokinetic consultation $8, patient counseling $6, medical rounds $4, admission drug histories $7, and drug therapy protocol management (prescribing) $9. Drug costs continue to increase at double-digit rates. Substantial differences exist among various regions of the country with salary and specific cost components. Registered nursing staffing is increasing at twice the rate of pharmacists staffing increases.

Health care professional staffing, hospital characteristics, and hospital mortality rates.

To evaluate associations among hospital characteristics, staffing levels of health care professionals, and mortality rates in 3763 United States hospitals, a data base was constructed from the American Hospital Association's Abridged Guide to the Health Care Field and hospital Medicare mortality rates from the Health Care Financing Administration. A multivariate regression analysis controlling for severity of illness was employed to determine the associations. Hospital characteristics associated with lower mortality were occupancy rate and private nonprofit and private for-profit ownership. Mortality rates decreased as staffing level per occupied bed increased for medical residents, registered nurses, registered pharmacists, medical technologists, and total hospital personnel. Mortality rates increased as staffing level per occupied bed increased for hospital administrators and licensed practical-vocational nurses. To our knowledge, this is the first study to show that pharmacists were associated with lower mortality rates.

Clinical pharmacy services in hospitals educating pharmacy students.

In 1995 we conducted a national survey of 1102 acute care hospitals in the United States to determine types of clinical pharmacy services, patient-focused care, and pharmaceutical care used to educate and train pharmacy students, and compared outcomes with surveys in 1989 and 1992. Clinical pharmacy services offered in 50% or more of Pharm.D.-affiliated hospitals (core services) were drug-use evaluation, in-service education, pharmacokinetic consultations, adverse drug reaction management, drug therapy monitoring, protocol management (most common for aminoglycosides, nutrition, antibiotics, heparin, warfarin, theophylline), nutrition team, and drug counseling. Comprehensive pharmaceutical care programs were established in 64%, 42%, and 33% of Pharm.D., B.S., and nonteaching hospitals, respectively. Patient-focused care programs were beginning or established in 77%, 71%, and 60%, respectively. Pharmacists served as care team leaders in 23% of hospitals affiliated with a college of pharmacy. Most common ambulatory care clinics were oncology, anticoagulation, diabetes, geriatrics, refill, and infectious diseases/HIV. For-profit hospitals rarely provided education for pharmacy students. Thus patient-focused and comprehensive pharmaceutical care programs exist according to a hospital's academic program affiliation with Pharm.D. or B.S. degree program.

Gabapentin bioavailability: effect of dose and frequency of administration in adult patients with epilepsy.

UNLABELLED: Gabapentin (GBP) is a non-metabolized antiepileptic drug that is eliminated by renal excretion and displays saturable, dose dependent absorption. The recommended dosing schedule for GBP is t.i.d. At large daily doses, oral bioavailability (F) may be improved by giving the daily dose more frequently. OBJECTIVE: To evaluate whether switching GBP dosage regimen from t.i.d. to q.i.d. results in increased oral bioavailability. METHODS: This study consisted of two parts; a computer simulated pharmacokinetic model and a clinical pharmacokinetic study in nine adult epileptic patients receiving 3600 mg/day and 11 receiving 4800 mg/day. All patients were evaluated during both t.i.d. and q.i.d. regimens. F were determined by calculation of percent of dose excreted unchanged using steady-state 24-h urine collections and were compared using a paired t-test. RESULTS: At 3600 mg/day, mean F following t.i.d. and q.i.d. dosing were 38.7+/-22.1% and 40.0+/-18.9%, respectively (P=0.738). At 4800 mg/day, mean F following t.i.d. and q.i.d. dosing were 29.2+/-16.2% and 35.6+/-17.6%, respectively (P=0.006). DISCUSSION: Good agreement was observed between values from this study and predicted values based on the pharmacokinetic model. Improved GBP F at doses of 3600 mg/day was not achieved with more frequent drug administration, and thus is not warranted. At 4800 mg/day, a 22% increase in F was observed with more frequent drug dosing. CONCLUSION: GBP F may be significantly increased by q.i.d. versus t.i.d. dosing, depending upon dose level. This increase in F however must be balanced against the inconvenience of more frequent dosing. Therapeutic drug level monitoring may aid in the evaluation of such pharmacokinetic maneuvers.

Gabapentin absorption: effect of mixing with foods of varying macronutrient composition.

OBJECTIVE: To compare the oral absorption profile of gabapentin following administration of the contents of opened capsules that were mixed with food vehicles of varied macronutrient (protein) composition. DESIGN: An unblinded, randomized, single-dose, four-way crossover pharmacokinetic study in nine healthy adult men and women volunteers. METHODS: Following an overnight fast, a single 600-mg dose of gabapentin (2 x 300-mg Neurontin capsules) was given either as an intact capsule swallowed with 120 mL of tap water (control, phase I), or after capsule contents were opened and mixed with; 4 oz. of applesauce (phase II), 120 mL of orange juice (phase III), or 4 oz. of fat-free chocolate pudding (phase IV). Subjects fasted for 4 hours following drug ingestion. Serial venous blood samples were obtained over 24 hours to determine gabapentin serum concentrations. Pharmacokinetic variables including AUC, maximum serum concentration (Cmax), and time to maximum serum concentration (tmax) were calculated by using standard noncompartmental methods. Subjects served as their own controls, and were randomly crossed over following a minimum 7-day washout period. Statistical analysis was performed by using ANOVA and Student's t-test where appropriate. RESULTS: No statistically significant differences in any kinetic variable were found between any study arm. A trend was noted for a modest increase in both Cmax and AUC in phase IV (chocolate pudding) compared with control (+18.6% and +13.2%, respectively). In a comparison of protein (phase IV) versus nonprotein phases (phases I-III), gabapentin AUC was 26% greater (47.28+/-14.65 vs. 37.43+/-9.78 microg/mL x h; p = 0.03), and Cmax was 32% higher (4.72+/-1.04 vs. 3.56+/-0.92 microg/mL; p = 0.003). CONCLUSIONS: Opening and mixing the contents of gabapentin capsules does not significantly impair drug absorption. This may be a viable administration option for patients who are unable to swallow intact capsules. Dietary macronutrient composition (i.e., protein) may favorably influence gabapentin oral absorption.

1995 National Clinical Pharmacy Services Study.

To determine the extent of hospital-based clinical pharmacy services in 1995, we surveyed 1109 United States acute care, general, medical-surgical, and pediatric hospitals with 50 or more licensed beds. Fifteen clinical pharmacy services were assessed to determine pharmacists' specific patient care responsibilities. The percentage of hospitals offering services grew between 1992 and 1995: pharmacokinetic consultations (16% increase), drug therapy protocol management (15%), drug therapy monitoring (8%), drug counseling (13%), and parenteral-enteral nutrition team (6%). All other services increased 0-5%. Pharmacists conducted clinical research in 14% of hospitals, averaging 6.3+/-22.1 protocols/department annually; total budget $96,219+/-$262,026. Patient-focused care predominated in 20% of hospitals, although most pharmacists reported to directors of pharmacy through traditional pharmacy department channels. Clinical pharmacy services continue to expand, with pharmacists providing higher-level direct patient care activities related to drug therapy management and monitoring.

Effect of lamotrigine on carbamazepine epoxide/carbamazepine serum concentration ratios in adult patients with epilepsy.

Although lamotrigine (LTG) appears to have a low propensity to cause pharmacokinetic interactions with other medications, it has been suggested that LTG may interfere with the elimination of carbamazepine 10,11-epoxide (CBZE), the active metabolite of carbamazepine (CBZ). Evidence for this pharmacokinetic interaction is inconclusive and conflicting, however. We evaluated CBZ apparent oral clearance and the steady-state CBZE/CBZ serum concentration ratios in nine patients (30.8 +/- 7.7 years) with epilepsy prior to and following the initiation of adjunctive treatment with LTG. Overall, CBZ oral clearance was unchanged following the introduction of LTG (5.58 +/- 1.60 vs. 5.81 +/- 1.74 1/h, P = 0.630). Likewise, CBZE to CBZ serum concentration ratios were not significantly different (0.241 +/- 0.082 vs. 0.232 +/- 0.082, P = 0.782). These observations suggest that the addition of LTG did not result in a significant pharmacokinetic interaction involving either CBZ or CBZE.

Diet- and valproate-induced transient hyperammonemia: effect of L-carnitine.

Hyperammonemia is an adverse effect of valproate (VPA) treatment. In particular, transient hyperammonemia has been reported to occur in VPA-treated patients after protein-rich meals. This phenomenon may occur secondary to a VPA-mediated carnitine insufficiency. We sought to confirm that protein ingestion would result in transient hyperammonemia and to determine whether supplementation with L-carnitine would prevent this effect. We studied the effect of consumption of a standardized protein-rich meal (45 g protein) before (phase I) and after (phase II) administration of L-carnitine 50 mg/kg/day for 7 days in 11 epileptic children (13.3 +/- 2.3 years of age) receiving VPA. Venous blood was obtained during fasting (baseline) and at 2 and 4 hours after the protein-rich meal for analysis of ammonia (NH3), and VPA concentrations. Mean VPA trough concentrations did not differ significantly at any time. After protein ingestion, 2-hour NH3 concentration increased by 86% (P < .05) from baseline in phase I as compared with a 38% increase in phase II. In both phases I and II, 4-hour NH3 concentrations decreased toward baseline values. We conclude that (1) modest protein ingestion can result in significant transient increases in NH3 in VPA-treated children, (2) significant increases may occur in patients with normal fasting NH3 concentrations, (3) these increases can be significantly attenuated by L-carnitine supplementation, and (4) these changes do not appear to be related to changes in VPA concentration.

Evaluation of carbamazepine and carbamazepine-epoxide protein binding in patients undergoing epilepsy surgery.

Carbamazepine (CBZ) serum concentrations increase after epilepsy surgery. A possible mechanism may be acute changes in protein binding, specifically those involving the acute phase reactant alpha(1)-acid glycoprotein (AAG). We prospectively evaluated 16 adults (11 receiving CBZ) with epilepsy (mean age 30 +/- 9.9 years, 8 women and 8 men) undergoing temporal lobe resections and characterized AAG, albumin, CBZ, and CBZ-epoxide (CBZ-E) free fractions over time. AAG, ALB, CBZ, and CBZ-E free fractions were determined before surgery (baseline) and on postoperative days 1-5, 14, and 30. AAG was measured with a radial immunodiffusion assay method, CBZ and CBZ-E serum concentrations were determined by high-performance liquid chromatography (HPLC). Free fractions of CBZ and CBZ-E were calculated as the ratio of unbound (determined after ultracentrifugation) to total serum drug concentrations. Statistical analysis included analysis of variance (ANOVA) and Student's t test for paired data when appropriate, with significance assigned at p<0.05. All data are mean +/- SD. AAG concentrations increased significantly from baseline 61.9 +/- 21.3 mg/dl), peaking at postoperative day 3 (116.8 +/- 20.6 mg/gl) and decreasing to baseline levels between days 14 and 30. CBZ serum concentrations were significantly increased in the immediate postoperative period (day 3), but albumin concentrations and CBZ and CBZ-E free fractions did not differ significantly between baseline and the postoperative time points. Temporal lobe resection results in an acute phase reaction which is manifested in part by significant changes in AAG. Although CBZ and CBZ-E total serum concentrations increased significantly in the immediate postoperative period, epilepsy surgery did not appear to result in significant overall changes in drug binding to plasma proteins.

Effect of a high-protein meal on gabapentin pharmacokinetics.

The anticonvulsant gabapentin is transported across biological membranes via the L-amino acid transport system (System-L). Absorption of gabapentin is saturable, and in-vitro data have previously demonstrated that both L-leucine and L-phenylalanine may compete with the intestinal transport of gabapentin. The purpose of this study therefore was to determine whether a high-protein meal would interfere with gabapentin absorption. Ten healthy volunteers received in a randomized, cross-over design, a single 600-mg dose of gabapentin in the fasting state and after a high-protein meal consisting of 80 gm total protein (4.1 g phenylalanine, 8.2 g leucine and 4.2 g isoleucine), 52 g carbohydrate, and 9 g fat. Plasma gabapentin concentrations were measured by HPLC at baseline, 0.25, 0.5, 0.75, 1, 1.5, 2, 2.5, 3, 3.5, 4, 5, 6, 8, 12, 24, 30 h. Calculated pharmacokinetic parameters included Cmax' Tmax' AUC and T1/2. In addition, a pharmacodynamic assessment (using visual analog scales) of gabapentin-related adverse effects was performed at 2 h post drug ingestion and was compared between study phases. Statistical analysis included Student's t-test for paired data, with significance assigned at P < 0.05. Cmax was significantly increased by 36% (3.87 +/- 1.15 vs 5.28 +/- .97 micrograms/ml, P = 0.002), and Tmax tended to be shorter (3.9 +/- 1.8 vs 2.8 +/- .35 h, P = 0.10), after the high-protein meal. Although AUC was increased by 11%, this did not achieve statistical significance. Despite significantly higher plasma concentrations at 2 h, subjects reported significantly fewer adverse effects after the high-protein meal. Potential mechanisms to explain these unexpected findings may be that the large amino acid load delivered with the high-protein meal enhanced gabapentin absorption via trans-stimulation, the process by which acutely increased intestinal luminal amino acid concentrations result in an acute up regulation in System-L activity. Conversely, the decrease in perceived adverse CNS effects of gabapentin following the high-protein meal may reflect CNS competition for System-L transport.

Relationship between valproic acid dosage, plasma concentration and clearance in adult monotherapy patients with epilepsy.

Significant variability has been reported in the plasma concentration-dose relationship for the anticonvulsant compound valproic acid (VPA). Several factors may contribute to this observed variability, including heterogeneous patient populations of children and adults, polytherapy, and timing of plasma concentration sampling. To optimally determine the relationship between trough VPA plasma concentration and dose, we evaluated a homogeneous group of adult ambulatory patients with epilepsy receiving VPA monotherapy. Furthermore, we sought to evaluate whether a relationship existed between VPA dosage and plasma clearance for both total and unbound or free drug. Steady-state trough plasma concentrations were determined in thirty-two patients. Mean VPA dose was 22.8 +/- 10.3 mg/kg/day. Mean total and unbound VPA plasma concentrations were 97.9 +/- 34.9 and 13.2 +/- 10.6 micrograms/ml, respectively. Significant correlations between VPA dose and total and unbound plasma concentrations were found (r = 0.82 and r = 0.85, P < or = 0.001, respectively). Significant relationships were also observed between VPA dose and clearance. A positive correlation was noted for dose and total plasma clearance (r = 0.61, P < or = 0.001), while an inverse correlation existed between dose and unbound VPA plasma clearance (r = -0.51, P < 0.01). Although a statistically significant correlation does exist between VPA dosage and both total and unbound plasma concentrations, significant interpatient variability still remains even under 'optimal' therapeutic drug monitoring conditions.

Cost of pharmaceutical services in U.S. hospitals in 1992.

The results of a 1992 national survey of hospital-based pharmaceutical services are reported and compared with data collected during a similar survey in 1989. A questionnaire was mailed to pharmacy directors at all 3756 medical-surgical hospitals in the United States that had 50 or more licensed beds. Cost results were evaluated both as unadjusted data and as data adjusted for severity of illness with the case mix index. The response rate was 43% (1597 usable responses). Mean +/- S.D. unadjusted medication costs per occupied bed were $9850 +/- 4744 (a 46% increase over 1989 costs); significant differences were observed for geographic region, hospital ownership, drug delivery system, and pharmacy director's education. Mean +/- S.D. unadjusted total pharmacy costs per occupied bed were $16,550 +/- 6,249 (a 40% increase over 1989 costs); significant differences were observed for geographic region, hospital ownership, drug delivery system, and pharmacy director's education. Other mean +/- S.D. unadjusted pharmacy cost components were as follows: injectable solution costs, $2627 +/- 2191 (a 38% increase over 1989 costs); inventory costs, $2029 +/- 2593 (70% increase); pharmacist salary costs per occupied bed, $2997 +/- 1267 (33% increase); pharmacy technician costs per occupied bed, $995 +/- 876 (24% increase); pharmacist salary costs per full-time equivalent (FTE), $43,791 +/- 12,206 (14% increase); pharmacy technician salary costs per FTE, $18,953 +/- 6,154 (15% increase); and pharmacy staff development costs per occupied bed, $45 +/- 41 (29% increase). Pharmacist salary costs associated with centrally based clinical pharmacy services ranged from a high of $361 per occupied bed per year for drug-use evaluation to a low of $15 per occupied bed per year for inservice education. Pharmacist salary costs for patient-specific pharmaceutical services ranged from $3 per patient for medical rounds to $8 per patient for cardiopulmonary resuscitation team participation and drug protocol management. A 1992 survey provided comprehensive data on the cost structure of hospital-based pharmaceutical services and a basis for comparison with 1989 cost data.

An assessment of recent pharmacy graduates' knowledge and competency, professional practice functions, and involvement in pharmacy teaching programs.

STUDY OBJECTIVES: To determine self-evaluated professional knowledge and competency, functions, demographic information, lifelong learning, degree and training status, practice sites, involvement in pharmacy teaching programs, and salary for recent pharmacy graduates. DESIGN: A survey of recent Bachelor of Science (B.S.) pharmacy graduates of the University of Wisconsin School of Pharmacy. MEASUREMENTS AND MAIN RESULTS: A total of 371 B.S. pharmacy graduates (55% response rate) provided information. Graduates who had an advanced degree or training (from many programs) after completing their B.S. pharmacy degree, and those who were teaching in pharmacy programs generally had higher self-rated levels of knowledge and competencies. Hospital pharmacists spent less of their work time in dispensing activities (33.82% +/- 30.39%) than community pharmacists (61.04% +/- 19.97%; t = 8.78, df = 288, p < 0.001); community pharmacists spent twice as much of their work time counseling and educating patients (16.65% +/- 10.47% vs 7.13% +/- 7.39%; t = 9.06, df = 288, p < 0.001). The amount of time pharmacists spent in dispensing functions had a negative association with knowledge and competencies in the sections on pharmacokinetic and disease process (r = -0.277, p < 0.01), patient communications (r = -0.272, p < 0.01), and administrative and economic aspects of practice (r = -0.210, p < 0.01) for all respondents. Pharmacists reported that they spent 13.78 +/- 14.06 hours per month outside work in professional lifelong learning. There was a negative association between the time pharmacists spent dispensing and the time they spent in professional lifelong learning (r = -0.239, p < 0.001), and a positive relationship between the time spent in such learning and the time providing information to prescribers and other health care professionals (r = 0.214, p < 0.001), monitoring patients (r = 0.216, p < 0.001), and performing primary care activities (r = 0.176, p < 0.001). Graduates reported a mean yearly salary of $46,879 +/- $8183. More hospital pharmacists were involved in teaching (48, 37%) than those practicing in a community setting (19, 12%). CONCLUSIONS: Practice site, advanced degree or training, lifelong learning, involvement in teaching programs, and time spent in various professional functions were associated with pharmacists' self-rated knowledge and competencies.

Hospital and pharmacy characteristics associated with mortality rates in United States hospitals.

We attempted to determine hospital and pharmacy characteristics associated with mortality rates in 4864 United States hospitals. Data were obtained from the Health Care Financing Administration, the American Hospital Association, and the National Clinical Pharmacy Services survey. Univariate and multivariate regression models were used to determine which hospital characteristics were associated with mortality. A similar regression analysis was performed on 718 hospitals for which detailed pharmacy information was available. In a multivariate regression model, some characteristics of 4864 hospitals associated with reduced mortality rates were high-technology index (R2 = 0.09, p < 0.001), severity of illness (R2 = 0.048, p < 0.001), number of hospital beds (R2 = 0.016, p < 0.001), and medical personnel (R2 = 0.012, p < 0.001). This analysis accounted for 41% of the mortality rate variance. For the 718 hospitals and pharmacies, some of these characteristics were high-technology index (R2 = 0.157, p < 0.001), severity of illness (R2 = 0.07, p < 0.001), number of pharmacists/average daily census (R2 = 0.021, p < 0.001), and combined hospitalwide clinical pharmacy services (R2 = 0.016, p < 0.01). The results of this analysis were similar to those in the only other large study in this area, but that excluded pharmacy characteristics. This is the first study to show a statistically significant association between pharmacist and pharmacy variables and reduced hospital mortality rates.

Valproate-mediated disturbances of hemostasis: relationship to dose and plasma concentration.

Valproic acid (VPA) may cause impaired platelet function, thrombocytopenia and, occasionally, severe bleeding. Controversy exists both as to the mechanism of this alteration in hemostasis and as to whether these adverse effects are either dose-related or idiosyncratic. Previous investigations have focused primarily on pediatric patients who commonly were receiving multiple anticonvulsant medications. We evaluated a cohort of 27 adult patients with epilepsy who were receiving VPA monotherapy and compared them with age-matched controls to determine whether a correlation exists between platelet count, function, bleeding time, levels of von Willebrand's factor antigen, and VPA dose or plasma concentration. VPA patients had significantly lower platelet counts and longer bleeding times than did controls (p < 0.05). Platelet count was inversely correlated to VPA dose and both free and total VPA concentration (p < 0.01). There was no significant difference in levels of von Willebrand's factor antigen between patients and controls. We assessed platelet aggregation by measurement of whole-blood platelet aggregation and release with agonists including adenosine diphosphate, thrombin, collagen, arachidonic acid, and ristocetin. VPA patients had significant decreases in platelet aggregation values compared with controls. There were significant differences in collagen, arachidonic acid, and adenosine diphosphate release and aggregation between groups that correlated to both VPA dose (p < 0.01) and concentration (p < 0.05). Prolongation of bleeding time was significantly correlated to both VPA dose and concentration. Our data suggest a significant relationship between impaired platelet function and both VPA dose and plasma concentration.

1992 National Clinical Pharmacy Services Study.

STUDY OBJECTIVE: To determine the extent of hospital-based clinical pharmacy services in 1992. DESIGN: National survey with trend comparison to 1989. SETTING: All 1597 United States acute care, general medical-surgical and pediatric hospitals with 50 or more licensed beds and one or more full-time pharmacists (43% of all U.S. hospitals). MEASUREMENTS AND MAIN RESULTS: Fourteen clinical pharmacy services, carefully defined to indicate pharmacist proactive or concurrent patient care provision, were assessed to determine pharmacists' specific patient care responsibilities. The percentage of hospitals offering each of the services increased from 1989 to 1992, with greatest growth in management of adverse drug reactions (22% increase), pharmacokinetic consultations (14%), and drug therapy protocols (12%). The mean percentage of patients actually receiving clinical pharmacy services ranged from 0.2% for pharmacist participation on the cardiac arrest team to 36.1% for daily monitoring of drug therapy. Pharmacists conducted clinical research in 13% of all hospitals, averaging 3.9 +/- 4.3 protocols per year with a total budget of $79,765 +/- $128,641. CONCLUSIONS: Clinical pharmacy services continue to expand; however, even the most common direct patient care service is provided to a small number of inpatients.

Evaluation of recent pharmacy graduates' practice patterns, professional lifelong learning, pharmacy organization memberships, and salary.

OBJECTIVES: To document information on recent bachelor of science (B.S.) pharmacy graduates' practice patterns, professional lifelong learning (PLL) methods, pharmacy organization memberships, and salary. The association between advanced training and education on PLL methods, pharmacy organization membership, and salary are explored. DATA SOURCES: Pertinent literature was identified by MEDLINE searches (1966-1992). STUDY DESIGN: The results of a Fall 1991 survey of recent B.S. pharmacy graduates (n = 371) of the University of Wisconsin School of Pharmacy are reported (55 percent response rate). RESULTS: Hospital pharmacists devoted more time to PLL outside of work (18.00 +/- 17.89 h/mo) than community pharmacists (9.93 +/- 8.76 h/mo), t = 5.02, degrees of freedom (df) = 289, p < 0.001. Graduates who had completed an advanced degree program, residency, or fellowship (advanced degree/training [ADT]) spent more time in PLL (17.76 +/- 10.63 h/mo) compared with graduates who had only obtained a B.S. degree (10.63 +/- 8.56 h/mo), t = 3.80, df = 311, p < 0.001. Graduates who had ADT were more likely to belong to multiple pharmacy organizations (2.14 +/- 1.38 organizations) than hospital pharmacists (1.61 +/- 1.27 organizations) and community pharmacists (1.11 +/- 1.06 organizations). Of the pharmacists who graduated in 1989 and 1990 (one to two years postgraduation), 55 percent belonged to the American Pharmaceutical Association. This declined to 19 percent of the graduates from 1984 and 1985 (six to seven years postgraduation), a 62 percent decline in membership. Membership in the American Society of Hospital Pharmacists (ASHP) was held by 19 percent of graduates one to two years after graduation; and 34 percent of graduates belonged to ASHP six to seven years after graduation, an 81 percent increase. Graduates with ADT (compared with graduates with the B.S. degree only) showed the strongest correlation of membership affiliation, which was about equal with ASHP (phi = 0.32) and ACCP (phi = 0.33). Although pharmacists changed their individual pharmacy organization memberships during the first seven years after graduation, there was no evidence of a decline in overall interest in pharmacy organization membership. Pharmacists who had completed ADT had an annual mean salary of $51,112 +/- $10,012; those pharmacists who did not complete an ADT program had an annual mean salary of $46,440 +/- $7802, a difference of $4672 per year. Hospital pharmacists who had obtained ADT had an annual mean salary of $51,840 +/- $9765; B.S. pharmacists without ADT in hospital practice had an annual mean salary of $43,603 +/- $8192, a difference of $8237 per year. CONCLUSIONS: Pharmacists' PLL methods, organization memberships, and salaries varied significantly by their practice site and the completion of an ADT program.

Ambulatory pharmacy services affiliated with acute care hospitals.

The extent to which hospital-based pharmacists provide ambulatory clinical pharmacy services in the United States is unknown. We evaluated pharmacists' activities in hospital-affiliated ambulatory clinics and home health services. A questionnaire was mailed to directors of pharmacy in one-half of the United States acute care general medical-surgical hospitals with 50 or more licensed beds. The survey response rate was 56% (n = 1174). In 19% of hospitals, pharmacists provided patient care (nondispensing activities) in ambulatory clinics. The most common clinics with pharmacist involvement were diabetes (10% of hospitals), oncology (9%), cardiology (6%), and geriatrics, infectious disease, and pain (4% each). Nondispensing roles varied by clinic type; prescribing by protocol was performed in 57% of anticoagulation clinics and 7% of diabetes clinics. Home health care services, with pharmacists' activity extending beyond providing drugs, were offered by 28% of the hospitals. Thirty-six percent of the hospitals operated one or more outpatient pharmacies. A statistically significant association was observed between hospitals' inpatient clinical pharmacy services (as assessed by the pharmaceutical care index) and the involvement of pharmacists in both ambulatory clinics and home health care services.