Interprofessional objective structured teaching exercise (iOSTE) to train preceptors.

BACKGROUND AND PURPOSE: Interprofessional education (IPE) is important in the education of all health care students, yet limited IPE training has been provided to preceptors who train these students in the clinical setting. Simulation using the standardized student model has been used to train health care preceptors in medicine. To our knowledge, there are no reports utilizing interprofessional objective structured teaching exercises (iOSTE) to train pharmacy preceptors. The primary objectives of this pilot study were to evaluate the effects of iOSTE on the pharmacy preceptors' perceived importance of the Interprofessional Education Collaborative (IPEC) core competencies and confidence in precepting interprofessional students. Additionally, data were collected regarding pharmacy preceptors' prior experiences in simulation and debriefing. EDUCATIONAL ACTIVITY AND SETTING: Preceptors (n=23) participated in an iOSTE and debriefed with trained standardized nursing and pharmacy students caring for a trained standardized asthma patient. FINDINGS: Pre- versus post-iOSTE survey data showed statistically significant improvements in all self-confidence related items, including the following abilities: precept students from different disciplines (p=0.004), facilitate a simulation activity (p=0.001), conduct the debriefing process (p<0.001), and discuss with students the IPE core competencies (p=0.001). Additionally, responses to post-iOSTE survey questions assessing the learning activity showed high ratings (median=5, interquartile range=4 to 5). Pharmacy preceptors increased their teaching ability and confidence level in communicating with students from other health care professions. SUMMARY: These findings indicate that iOSTE is a useful and well-received method for preceptor development.

Interprofessional education accreditation standards in the USA: a comparative analysis.

Interprofessional education (IPE) and interprofessional collaborative practice (IPCP) will play a prominent role in the future of health professions' education and healthcare delivery in the USA and internationally. To assess the accreditation mandate for IPE in the USA, content analysis of IPE-related accreditation statements for all practice-level degrees in dentistry, medicine, nursing, occupational therapy, pharmacy, physical therapy, physician assistant, psychology, public health and social work was performed. Eighteen keywords were used to locate potentially relevant IPE statements within each accreditation document. Identified statements were independently categorized by each author into one of three mutually exclusive categories: accountable, non-accountable or non-applicable (κ = 0.79; 95% CI 0.69-0.89). Eighteen of 21 accreditation documents analyzed contained applicable IPE statements. The Commission on Collegiate Nursing Education and Accreditation Council for Pharmacy Education documents contained 77% (46/60) of accountable IPE statements. Two-thirds (14/21) of documents contained two or fewer accountable IPE statements. Statement categorization using inductive methodology identified four IPE student competency and organizational structure/process domains, respectively. Collectively, US health professions' graduates are not required to complete IPE and, therefore, may not be prepared for IPCP. US accrediting bodies are encouraged to collaborate to create a common IPE accreditation standard.

Achieving equivalent academic performance between campuses using a distributed education model.

OBJECTIVES: To demonstrate that students in competency-based anatomy and pharmaceutical calculations courses performed similarly whether enrolled in the classes through distance education or face-to-face lectures. METHODS: Student outcomes data including module examination scores, final course grades, and student demographics data were collected, merged, and analyzed. RESULTS: Mean module examination final scores and final course grades did not significantly differ between students at the lecture site and students at the remote site. CONCLUSIONS: The competency-based anatomy and pharmaceutical calculations courses, whether remote or at the lecture site, provided equitable learning opportunities and roughly equivalent learning outcomes for students.

Assessment of manual blood pressure and heart rate measurement skills of pharmacy students: a follow-up investigation.

OBJECTIVES: To evaluate the impact of a laboratory course on the manual blood pressure (BP) and heart rate (HR) measurement skills of pharmacy students. METHODS: After 1 lecture and 1 laboratory session on vital sign technique, pharmacy students enrolled in a patient assessment laboratory course were randomly paired with a classmate and manually measured the classmate's BP and HR. Within 2 minutes, the BP and HR were measured by an Omron 711-AC automatic monitor. The same assessment procedures with manual and automatic measurements were repeated near the end of the laboratory course. Student skills were also evaluated through direct observation by faculty members. RESULTS: Student and machine measurements of systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR significantly correlated at the final assessment (r = 0.92, 0.83, and 0.91 respectively; p < 0.001 for each. The proportion of student and device values agreeing to within 5 units (mmHg and beats-per-minute) at baseline versus at the final assessment significantly improved from 38% to 67% for SBP, 51% to 77% for DBP, and 52% to 79% for HR (p < 0.001 for each). The percentage of students correctly performing all 13 AHA endorsed steps for BP measurement improved significantly from 4.6% to 75.6% (p < 0.001). CONCLUSIONS: Significant improvement and the attainment of competency in manual vital signs measurement were demonstrated by pharmacy students after 11 weeks of skill rehearsal in a laboratory course.

2006 national clinical pharmacy services survey: clinical pharmacy services, collaborative drug management, medication errors, and pharmacy technology.

STUDY OBJECTIVE: To determine the extent of 15 hospital-based clinical pharmacy services, 51 different drugs managed under protocol by pharmacists, medication errors, and pharmacy technology in United States hospitals. DESIGN: A survey was mailed, as well as sent electronically, to pharmacists in 2893 hospitals. RESULTS: A total of 1125 surveys were returned (38.9% response rate). The 1125 hospitals had 14,315,506 patients admitted, which represented 45.7% of the 31,324,496 admissions to all U.S. hospitals in 2006. The proportion of clinical pharmacy services provided by Veterans Affairs (VA) hospitals was higher compared with non-VA hospitals. In all hospitals, the clinical pharmacy services with the greatest growth from 1989-2006 were pharmacist-provided admission drug histories (300% increase), pharmacist participation on medical rounds (292.3% increase), drug protocol management (208% increase), pharmacist-conducted clinical research (166.7% increase), pharmacist-provided drug information (150% increase), and pharmacist-provided pharmacokinetic consultation (117.5% increase). A total of 864 hospitals (76.8%) had pharmacists providing drug protocol management (collaborative drug management). Pharmacists managed a mean +/- SD of 9.18 +/- 10.23 different drugs/hospital (7932 protocols). Drugs commonly managed included aminoglycosides (64.4% of hospitals), vancomycin (63.8%), warfarin (37.8%), low-molecular-weight heparins (32.7%), unfractionated heparin (30.0%), fluoroquinolones (30.0%), antiparkinsonian drugs (22.8%), proton pump inhibitors (22.7%), human immunodeficiency virus drugs (21.9%), and cephalosporins (19.7%). The mean number of medication errors reported/hospital increased by 151.4% between 1995 and 2006. The percentage of patients who experienced a medication error increased from 4.7% to 6.5% between 1995 and 2006 (a 38.3% increase). A total of 220 hospitals (19.6%) had computerized prescriber order entry systems, 263 (23.4%) had bar coding for drug administration, and 439 (39.0%) used robotics for dispensing. CONCLUSION: This study provides continuing evidence of the growth and value of clinical pharmacy services and clinical pharmacists in our nation's hospitals. These data will guide hospital pharmacy directors and clinical coordinators in allocating resources to optimally meet their patients' needs.

Clinical and economic outcomes of pharmacist-managed antimicrobial prophylaxis in surgical patients.

PURPOSE: The associations between pharmacist-managed antimicrobial prophylaxis in Medicare patients who had surgical codes indicative of the need for antimicrobial prophylaxis and the major health care outcomes of death rate, length of stay, Medicare charges, drug charges, laboratory charges, and complications were explored. METHODS: Pharmacist management of antimicrobial prophylaxis was evaluated in 242,704 Medicare patients from 860 [corrected] hospitals. RESULTS: Patients who developed a surgical-site infection (SSI) had a 331.58% increased risk of death compared with patients who did not develop an SSI (chi2 = 743.471; df = 1; p < 0.0001; odds ratio [OR], 3.62; 95% confidence interval [CI], 3.28-3.99). Patients who developed an SSI also had a 167.16% increase in length of stay, 136.49% increase in total Medicare charges, 245.96% increase in drug charges, and 187.14% increase in laboratory charges. In hospitals without pharmacist-managed antimicrobial prophylaxis, death rates were 52.06% higher (105 excess deaths; p < 0.0001; OR, 1.54; 95% CI, 1.46-1.63), length of stay was 10.21% higher (167,941 excess patient days, p < 0.0001), mean +/- S.D. total Medicare charges were 3.10% higher ($980 +/- $1,109 more per patient) ($182,113,400 excess total Medicare charges, p < 0.0001), mean +/- S.D. drug charges were 7.24% higher ($292 +/- $492 more per patient) ($54,262,360 excess drug charges, p = 0.005), mean +/- S.D. laboratory charges were 2.72% higher ($74 +/- $151 more per patient) ($13,751,420 excess laboratory charges, p = 0.0056), and SSIs were 34.30% higher (chi2 = 95.48; df = 1; p < 0.0001; OR, 1.52; 95% CI, 1.40-1.66). CONCLUSION: The provision of pharmacist-managed antimicrobial prophylaxis was associated with significant improvement in clinical and economic outcomes for Medicare patients with a surgical code indicative of the need for antimicrobial prophylaxis.

Evaluation of pharmacy students' blood pressure and heart rate measurement skills after completion of a patient assessment course.

OBJECTIVES: To evaluate pharmacy students' skills at measuring brachial artery blood pressure and radial heart rate at the completion of a patient assessment course in the second-professional year of a doctor of pharmacy (PharmD) program. METHODS: Students enrolled in a required patient assessment laboratory course (n = 83) participated in this study. Each student was randomly matched with a classmate and manually measured the classmate's blood pressure by auscultation of the brachial artery and heart rate by palpation of the radial pulse. RESULTS: The student-device absolute disagreement was 6.5 +/- 4.8 mmHg for systolic blood pressure (SBP), 6.2 +/- 4.5 mmHg for diastolic blood pressure (DBP), and 5.3 +/- 4.0 beats per minute (BPM) for heart rate. Student and machine measurements of SBP, DBP, and HR significantly correlated. CONCLUSIONS: Pharmacy students in the second-professional year of a PharmD program demonstrated competence in but not mastery of manual blood pressure and heart rate measurement. These skills need further refinement during third- and fourth-professional year APPEs.

Clinical pharmacy services, pharmacy staffing, and hospital mortality rates.

OBJECTIVE: To determine if hospital-based clinical pharmacy services and pharmacy staffing continue to be associated with mortality rates. METHODS: A database was constructed from 1998 MedPAR, American Hospital Association's Annual Survey of Hospitals, and National Clinical Pharmacy Services databases, consisting of data from 2,836,991 patients in 885 hospitals. Data from hospitals that had 14 clinical pharmacy services were compared with data from hospitals that did not have these services; levels of hospital pharmacist staffing were also compared. A multiple regression analysis, controlling for severity of illness, was used. RESULTS: Seven clinical pharmacy services were associated with reduced mortality rates: pharmacist-provided drug use evaluation (4491 reduced deaths, p=0.016), pharmacist-provided in-service education (10,660 reduced deaths, p=0.037), pharmacist-provided adverse drug reaction management (14,518 reduced deaths, p=0.012), pharmacist-provided drug protocol management (18,401 reduced deaths, p=0.017), pharmacist participation on the cardiopulmonary resuscitation team (12,880 reduced deaths, p=0.009), pharmacist participation on medical rounds (11,093 reduced deaths, p=0.021), and pharmacist-provided admission drug histories (3988 reduced deaths, p=0.001). Two staffing variables, number of pharmacy administrators/100 occupied beds (p=0.037) and number of clinical pharmacists/100 occupied beds (p=0.023), were also associated with reduced mortality rates. CONCLUSION: The number of clinical pharmacy services and staffing variables associated with reduced mortality rates increased from two in 1989 to nine in 1998. The impact of clinical pharmacy on mortality rates mandates consideration of a core set of clinical pharmacy services to be offered in United States hospitals. These results have important implications for health care in general, as well as for our profession and discipline.

Early implementation of medicare part D in urban and rural nursing facilities.

OBJECTIVE: To determine if differences occurred in the early implementation of Medicare Part D (prescription drug program) between urban and rural nursing facilities. DESIGN: Nursing facility demographic data, obtained from the Nursing Facility Compare Medicare Web site, were used to create matched pairs of rural and urban facilities. On-site interviews were conducted in June and July 2006 with one designated representative from each nursing facility. Details for each prescription drug plan (PDP), identified by the facility representatives, were obtained from the PDP's Web site. SETTING: A prospective pilot field study of rural and urban nursing facilities was created from among 40 facilities in the 26-county Texas Panhandle. Five rural/urban nursing facilities of identical ownership and of similar perceived quality (number of cited deficiencies) and staffing (total nursing staff time per resident) were used for the pilot study. PARTICIPANTS: Nursing facility employees charged with overseeing Part D implementation and trained interviewers. INTERVENTION: None. MAIN OUTCOME MEASURES: Number of PDPs per nursing facility and distribution of persons providing enrollment decision support. RESULTS: Rural facilities used more PDPs (7.4 +/- 3.9) than did urban facilities (4.6 +/- 3.8, NSS). Independent samples Student's t-test determined that there was a significant difference in the average number of drugs per resident. Rural residents received fewer medications (8.2 +/- 1.9) than urban residents (11.2 +/- 2.2; P = 0.049, t = 2.32). CONCLUSIONS: These early findings suggest that rural nursing facilities interact with more PDPs than urban facilities and that Medicare Part D enrollment decisions are more likely to be aided by family members in rural facilities than in urban nursing facilities.

Clinical and economic outcomes of pharmacist-managed antiepileptic drug therapy.

This study explores the associations between pharmacist-managed antiepileptic drug therapy in hospitalized Medicare patients and diagnoses indicating the need for these drugs. It also explores the following major heath care outcomes: death rate, hospital length of stay (LOS), Medicare charges, drug charges, laboratory charges, complications, and adverse drug reactions. Data were drawn from the 1998 MedPAR and 1998 National Clinical Pharmacy Services databases. Pharmacist-managed antiepileptic drug therapy was evaluated in a study population of 9380 Medicare patients with diagnosed epilepsy or seizure disorders treated in 794 United States hospitals. This population was derived from the 38,311 hospitalized Medicare patients with epilepsy or seizure disorders (MedPAR). In hospitals without pharmacist-managed antiepileptic drug therapy, death rates were 120.61% higher, with 374 excess deaths (chi(2)=5.983, df=1, p=0.014, odds ratio [OR]=1.553, 95% confidence interval [CI] 1.102-2.189). Hospital LOS was 14.68% higher, with 8069 patient-days (Mann-Whitney U test [U]=3833132, p=0.0009); total Medicare charges were 11.19% higher, with 14,372,550 dollars in excess total charges (U=3644199, p=0.0003); per-patient drug charges were $115 +/- $92 higher (p=NS); laboratory charges were 32.24% higher, with 5,664,970 dollars in excess charges; and aspiration pneumonia rate was 54.61% higher (chi(2)=5.848, df=1, p=0.015, OR=1.233, 95% CI 1.081-1.901). Although the frequencies of other complications and adverse effects were higher, these differences were not statistically significant compared with hospitals with pharmacist-managed antiepileptic drug therapy. Clinical and economic outcomes were improved among hospitalized Medicare patients whose antiepileptic drug therapy was managed by pharmacists.

Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals.

Adverse drug reactions (ADRs) were examined in 1,960,059 hospitalized Medicare patients in 584 United States hospitals in 1998. A database was constructed from the MedPAR database and the National Clinical Pharmacy Services survey. The 584 hospitals were selected because they provided specific information on 14 clinical pharmacy services and on pharmacy staffing; they also had functional ADR reporting systems. The study population consisted of 35,193 Medicare patients who experienced an ADR (rate of 1.8%). Of the 14 clinical pharmacy services, 12 were associated with reduced ADR rates. The most significant reductions occurred in hospitals offering pharmacist-provided admission drug histories (odds ratio [OR] 1.864, 95% confidence interval [CI] 1.765-1.968), drug protocol management (OR 1.365, 95% CI 1.335-1.395), and ADR management (OR 1.360, 95% CI 1.328-1.392). Multivariate analysis, performed to further evaluate these findings, showed that nine variables were associated with ADR rate: pharmacist-provided in-service education (slope -0.469, p=0.018), drug information (slope -0.488, p=0.005), ADR management (slope -0.424, p=0.021), drug protocol management (slope -0.732, p=0.002), participation on the total parenteral nutrition team (slope 0.384, p=0.04), participation on the cardiopulmonary resuscitation team (slope -0.506, p=0.008), medical round participation (slope -0.422, p=0.037), admission drug histories (slope -0.712, p=0.008), and increased clinical pharmacist staffing (slope -4.345, p=0.009). As clinical pharmacist staffing increased from the 20th to the 100th percentile (from 0.93+/-0.77/100 to 5.16+/-4.11/100 occupied beds), ADRs decreased by 47.88%. In hospitals without pharmacist-provided ADR management, the following increases were noted: mean number of ADRs/100 admissions by 34.90% (OR 1.360, 95% CI 1.328-1.392), length of stay 13.64% (Mann-Whitney U test [U]=11047367, p=0.017), death rate 53.64% (OR 1.574, 95% CI 1.423-1.731), total Medicare charges 6.88% (U=111298871, p=0.018), and drug charges 8.16% (U=108979074, p<0.001). Patients in hospitals without pharmacist-provided ADR management had an excess of 4266 ADRs, 443 deaths, 85,554 patient-days, $11,745,342 in total Medicare charges, and $1,857,744 in drug charges. The implications of these findings are significant for our health care system, especially considering that the study population represented 15.55% of 12,261,737 Medicare patients and 5.71% of the 34,345,436 patients admitted to all U.S. hospitals.

Screening tests for intended medication adherence among the elderly.

BACKGROUND: Medication nonadherence is increasingly recognized as a cause of preventable adverse events, hospitalizations, and poor healthcare outcomes. While comprehensive medication adherence assessment for the elderly is likely to identify and prevent drug-related problems, it is time consuming for patient and healthcare providers alike. OBJECTIVE: To identify screening tools to predict elderly patients' intended medication adherence that are suitable for primary-care settings and community pharmacies. METHODS: This study evaluated 57 English-speaking persons aged 65 years and older who were from diverse socioeconomic backgrounds. Intended adherence was quantified, and the relationships to demographic, medical history, socioeconomic, and literacy variables were determined. RESULTS: In a multivariate analysis with the composite MedTake Test (a quantitative measure of each subject's intent to adhere to prescribed oral medications) as the dependent variable, independent predictors of intended adherence included: age, car ownership in the last 10 years, receipt of food assistance in the last 10 years, number of over-the-counter (OTC) medicines, and REALM (Rapid Estimate of Adult Literacy in Medicine). The strongest predictor was the REALM word-recognition pronunciation test (beta = 0.666; R2 = 0.271; p < 0.001). CONCLUSIONS: We observed that the REALM word-recognition pronunciation test, along with age, number of OTC drugs, and 2 socioeconomic questions, predicted the intent of seniors to correctly take their own prescribed oral medications.

Adverse drug reactions in United States hospitals.

Adverse drug reactions (ADRs) were examined in 8,208,960 hospitalized Medicare patients in 1998. A database was constructed from the 1998 MedPAR database. The study population was composed of 141,398 Medicare patients who experienced an ADR (rate of 1.73%). The most common drug classes associated with ADRs were cardiotonic glycosides, adrenal corticosteroids, antineoplastic agents, anticoagulants, and analgesics. The most common associated diagnoses were hypertension, congestive heart failure, atrial fibrillation, volume depletion disorders, and atherosclerotic heart disease. In patients who experienced an ADR, death rates were 19.18% higher with 1971 excess deaths (odds ratio 1.208, 95% confidence interval 1.184-1.234), and length of hospital stay was 8.25% higher with 77,769 excess patient-days (Mann-Whitney U test [U]=200078720610, p<0.0001). Charges for patients with an ADR were increased as follows: total Medicare 19.86% (339,496,598 US dollars, U=200,089,611,739, p<0.0001), drugs 9.15% (24,744,650 US dollars, U=208,719,928,502, p<0.0001), and laboratory charges 2.82% (6,221,512 US dollars, U=195,143,498,450, p<0.0001). We developed a list of high-risk diagnoses and drug classes to help pharmacists target patients who are more likely to experience ADRs. This is the first study to evaluate the ADRs in a large population of hospitalized Medicare patients. These findings will enable pharmacists to develop better management programs for ADRs.

Management of age-related osteoporosis and prevention of associated fractures.

Osteoporosis and related fractures are a significant concern for the global community. As the population continues to age, morbidity and mortality from fractures due to low bone mineral density (BMD) will likely continue to increase. Efforts should be made to screen those at risk for osteoporosis, identify and address various risk factors for falls and associated fractures, ensure adequate calcium and vitamin D intake, and institute pharmacological therapy to increase BMD when indicated. Agents which increase BMD and have been shown to decrease fractures, particularly at the hip, should be considered preferentially over those for which only BMD data are available. Drugs which have been shown to decrease the risk of age-related osteoporotic fractures include oral bisphosphonates (alendronate, ibandronate, and risedronate), intranasal calcitonin, estrogen receptor stimulators (eg, estrogen, selective estrogen receptor modulators [raloxifene]), parathyroid hormone (teriparatide), sodium fluoride, and strontium ranelate. Data are beginning to emerge supporting various combination therapies (eg, bisphosphonate plus an estrogen receptor stimulator), though more data are needed to identify combinations which are most effective and confer added fracture protection. In addition, further research is needed to identify ideal regimens in special populations such as nursing home patients and men.