Effectiveness of clinical pharmacist interventions in a hemodialysis unit

Many patients with end-stage renal disease are treated with a complex pharmacotherapeutic regimen that requires constant and thorough monitoring. The role of a clinical pharmacist in contributing to the care of patients receiving long-term hemodialysis in an outpatient dialysis unit was assessed. Therapeutic interventions provided routinely by the clinical pharmacist were recorded and then categorized and evaluated by two independent clinical pharmacists with expertise in nephrology pharmacotherapeutics. Of the 205 interventions recorded, 97.6% were initiated by the clinical pharmacist and 91.7% were accepted by the medical team; 80.9% were judged to have primarily affected the quality of care. The purposes of interventions were drug selection in 32.2% of cases, drug discontinuation in 19.0%, dose selection in 24.4%, and therapeutic monitoring in 24.4%. Most interventions were initiated in response to abnormal laboratory test results. When the interventions were ranked according to clinical significance, 34.6% were involved with the preservation of major organ function and 62.4% with improvement of the quality of care to acceptable standards. Of all the interventions accepted by the medical team, 90.5% resulted in positive patient outcome; 7.9% resulted in no observable change or had no effect on outcome. The results demonstrate the potential influence and effectiveness of clinical pharmacy interventions on the drug therapy of patients receiving long-term hemodialysis.     

Impact of pharmacist interventions on medication management by the elderly: a review of the literature

OBJECTIVE: To review the impact of pharmacist interventions designed to assist older people in managing their medication regimens. DATA SOURCES: A computer search of literature published between 1975 and 1990 was conducted using MEDLINE. References were also identified from the bibliographies of pertinent articles. STUDY SELECTION: Studies included in the review were those evaluating pharmacist interventions that were designed to assist in medication management by people over 65 years of age. Only nine studies were identified by these criteria. Interventions that have not been evaluated are discussed briefly. The studies included were chosen by consensus of the authors. DATA EXTRACTION: A data extraction form was used to summarize the information in each study. RESULTS: This was a qualitative review. Some studies evaluating the effects of short verbal medication counseling episodes showed positive benefits; others showed no benefit. Written medication information, some memory devices, and audiovisual techniques have also been found to be of limited use. Self-medication programs for hospitalized elderly people need to be evaluated. CONCLUSIONS: This review identified the lack of published evaluations of pharmacist interventions in medication management by elderly people. Well-designed studies need to be performed to determine the effects of individualized advice and counseling. The cost-effectiveness of such interventions should be assessed, with consideration of long-term outcomes, such as readmission rates to the hospital and cost savings accruing from increased duration of independent living.     

Effect of pharmacist interventions on medication use and cost in hospitalized patients with or without HIV infection

Pharmacotherapeutic interventions and drug acquisition costs in HIV-positive and HIV-negative patients on a hospital medical service were studied. In November and December 1995, HIV-positive and HIV-negative patients were randomly selected and matched on the basis of admission date. Pharmacotherapeutic interventions were recorded by a pharmacist until the time of discharge. Drug acquisition costs were obtained through records of medications ordered. The two patient groups were compared with respect to length of stay (LOS), number and cost of medications, and number of interventions. HIV-positive patients had significantly more medication orders and required more interventions than HIV-negative patients. Mean LOS was not significantly different. HIV status and number of medications were significantly associated with requiring five or more interventions. Drug acquisition costs were significantly higher in the HIV-positive group. The mean pharmacist-attributed cost saving per patient was $134 for HIV-positive patients and $27 for HIV-negative patients. HIV-positive patients required more interventions and consumed more medication resources than HIV-negative patients. Pharmacist interventions produced drug acquisition cost savings for both groups, with more savings being realized for positive patients.     

Collaboration in capitated care: Challenges for psychology.

This article highlights the mutual dependence of disciplines in capitated care systems, with a focus on a sample program at Kaiser Permanente. Challenges for psychology are discussed as they relate to intradiscipline issues, relationships with other psychosocial care disciplines, and broad health care systems issues. The author suggests that psychology's future in capitated care will rest on skills in research, program development, and specialty practice areas (e.g., clinical health psychology, clinical neuropsychology) and encourages advocacy for the elimination of mind–body dualism in health care policy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cardiac surgical education in the managed care capitated environment

OBJECTIVE: To determine the effects of the androgenic anabolic steroid nandrolone decanoate on uterine endometrium and myometrium and on the mammary gland of female cynomolgus macaques by using morphologic, histomorphometric, and histopathologic determinations. DESIGN: Histologic and histomorphometric measurements were performed on uteri and mammary glands that were collected at necropsy from animals that had been used in a long-term experiment to examine the effects of nandrolone decanoate on bone and coronary arteries. The animals were surgically postmenopausal cynomolgus macaques randomized into four treatment groups: (a) intact sham ovariectomized (sham; n = 12), (b) ovariectomized (OVX; n = 15), (c) ovariectomized + nandrolone decanoate for 2 years (OVX + ND; n = 14), and (d) ovariectomized + nandrolone decanoate for 1 year, beginning 1 year after ovariectomy (OVX + NDdelay; n = 11). Intramuscular injections of nandrolone decanoate (25 mg every 3 weeks) were given to the two nandrolone-treated groups of animals (OVX + ND and OVX + NDdelay): one starting 3 weeks after ovariectomy and continuing for 2 years and the other group 1 year after ovariectomy. The sham and OVX groups were given an intramuscular injection of sterile vehicle every 3 weeks. RESULTS: Nandrolone treatment was moderately uterotropic in all treated versus ovariectomized animals. Changes induced were an increase in uterine weight, endometrial thickness, and glandular area, and a high incidence of mucometra. Glandular architecture was altered by nandrolone treatment such that glands extended into the myometrium (producing an adenomyosis-like lesion). Mammary gland changes were mild and equivocal. CONCLUSION: Nandrolone induced pathologic changes in ovariectomized monkeys similar to adenomyosis in the uterus.     

Lease contract in a consumer goods shop

Dneprodzerzhinsk Industrial Institute. Dnepropetrovsk Metallurgical Plant. Translated from Metallurg, No. 6, pp. 21–23, June, 1990.     

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.     

On a contract model for treatment.

Finds serious problems with the suggestion by R. K. Schwitzgebel (1975) that a contract be used to define the rights and liabilities between patient and therapist in an institutional setting and notes that the courts are better at defining such ground rules. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A practical method of adjusting for risk in the prospective costs of capitated systems

Increasingly, providers of health services and medical groups are required to negotiate with managed care organizations and evaluate the adequacy of capitation rates. An intelligent assessment of the rate of payment requires an accurate projection of the costs per member per month that have been adjusted for the risk present in the insured population. This article develops a practical model for incorporating risk in forecasts of the full cost per member per month.     

Combination drug therapy in hypertension: a rational approach for the pharmacist

Knowledge of precise head kinematics during whiplash trauma is important for identifying possible injury mechanisms and their prevention. This study reports a comprehensive data set describing head kinematic response to horizontal accelerations simulating whiplash. Seven isolated fresh human cervical spine specimens (C0 to T1 or C7), each carrying a surrogate head designed to represent a 50th percentile human head, were mounted on the sled and subjected to incremental trauma by horizontal sled accelerations of 2.5, 4.5, 6.5, 8.5, and 10.5 g. Sled and head kinematics were measured with potentiometers and accelerometers. The incremental sled accelerations resulted in average (standard deviations) sled velocity changes (delta V) ranging from 5.8 (0.2) to 15.8 (0.2) km/h. Generally, all the peak head kinematic parameters increased with increasing sled acceleration, except for the peak head angular displacement, which decreased. In the initial phase of a whiplash trauma, the head translated posteriorly with respect to T1, without rotation. In the later phase, the head rotated backwards, but much less than its physiological limit. Maximum head rotation of 31.5 (23.9) degrees occurred in a 2.5 g trauma class, and this was less than the maximum physiological head extension of 55.1 (13.3) degrees. Head kinematics expressed in the T1 or shoulder coordinate system is better suited to study potential neck injury in whiplash.     

The cost-effectiveness of a clinical pharmacist intervention among elderly outpatients

We report the close correlation between changes in serum immunoreactive vascular endothelial growth factor 165 (iVEGF165) levels and metastatic tumor burden measured by computed tomography scan before treatment, during the antitumor response, and during early progression in a patient treated with ex vivo gene therapy for renal cell carcinoma. With the researcher blinded to outcome, iVEGF levels were measured in archived serum samples from a patient with metastatic renal cell carcinoma who demonstrated a 7-month partial remission to treatment with autologous, irradiated human GM-CSF gene transduced tumor vaccine. Although a spontaneous regression could not be formally excluded in this patient, the appearance of 20 new pulmonary metastases on computed tomography scan after nephrectomy and before vaccination indicates that if spontaneous regression occurred, it took place at the start of vaccine treatment.