Pharmacists' role in a smoking-cessation program at a managed health care organization

A smoking-cessation program at a managed health care organization and the involvement of pharmacists are described. Kaiser Permanente Northwest Region is a prepaid group-practice managed health care organization serving more than 380,000 members in Oregon and southwest Washington. A multidepartmental team at Northwest Region designed and implemented a stepped-care approach to smoking cessation in March 1992. The program progresses from advising and helping patients to quit on their own to enrolling patients in a behavioral-modification course to referring them to nicotine-replacement therapy to be given concurrently with the behavioral modification. The program was established with the help of pharmacists, and pharmacists are deeply involved in its operation. They work closely with each patient, the health educator instructing the patient, and the prescribing physician. Pharmacists attend 5 of the 10 behavioral modification/nicotine-replacement course sessions and take responsibility for enrollees throughout the program. Pharmacists prescribe and monitor nicotine-replacement therapy by protocol. They also monitor each patient for the dose-response effect, adverse drug reactions, drug interactions, concurrent medical conditions, and progress and outcome. The physician is informed about any important changes in the patient's status. In 1992, more than 80 courses were held with nearly 1000 participants, and rates of long-term abstinence achieved compare favorably with literature rates for community-based group smoking-cessation programs. Satisfaction of patients, pharmacists, and physicians with the program has been high. Pharmacists at a managed health care organization participate in a smoking-cessation program by helping with behavioral modification, educating patients about nicotine-replacement therapy, and prescribing and monitoring therapy by protocol.     

Computerized monitoring protocols as a pharmaceutical care practice enhancement: a conceptual illustration using diabetes mellitus

OBJECTIVE: To illustrate how a computer system used in an ambulatory care pharmacy setting might enhance care of patients with diabetes by prospectively monitoring and prompting them to seek routine medical care. DATA SOURCES: A MEDLINE search to identify existing works on informatics was conducted. An epidemiology and general medical literature review of diabetes mellitus was also performed via MEDLINE. Additionally, known textbooks on the disease were consulted. CONCLUSIONS: Programming a computer system to prompt pharmacists to remind their patients of necessary medical interventions could save medical resources by warning chronically ill patients not to ignore routine medical care. Also, this would allow the pharmacist to prospectively monitor patient outcomes. By knowing when medical interventions are due and obtaining feedback from patients on the results of the medical contact, pharmacists increase their knowledge about patient outcomes and the rationale behind changes in pharmacotherapy. It is expected that such a system would prevent the inconspicuous development of chronic complications.     

National standards for general practice

A set of standards for Australian general practices has been developed through a 4 year project conducted by The Royal Australian College of General Practitioners. An orderly, iterative process was adopted to ensure comprehensive consultation with general practitioners, other health professionals, consumers and governments. The draft standards were field tested in 199 randomly selected urban and rural practices. Results of this field testing showed that the standards have content validity, that they can be measured reliably and that the practice visit protocol is feasible. The standards are calibrated to define the minimum acceptable features of general practices expected for the mid 1990s. The standards have been adopted by Australian General Practice Accreditation Limited as the basis for a voluntary system of practice accreditation.     

Evaluation of a pharmaceutical care model on diabetes management

PURPOSE: To determine the value of spiral CT during arterial portography (SCTAP) in detecting and localising focal liver lesions we compared the SCTAP findings to those gained by conventional CT during arterial portography (CTAP). MATERIAL AND METHODS: We evaluated a total of CT scans of 128 patients with 162 malignant lesions of the liver. 45 patients underwent SCTAP and 83 patients CTAP. Results of radiological studies were compared with surgical and pathological findings. RESULTS: The overall sensitivity of SCTAP was 93% with a sensitivity of 80% for lesions of less than 1 cm diameter. For CTAP the overall sensitivity was 88%, but the sensitivity for lesions smaller than 1 cm was only 53%. Although with SCTAP examination of hepatic vasculature and liver parenchyma was continuous, we found no advantage in the localisation of lesions to the liver segments compared to CTAP, and the sensitivity of localisation did not correlate with the size of lesions. CONCLUSION: In our study SCTAP turned out to be a reliable radiological method in the preoperative detection of focal liver lesions, with a high overall sensitivity. SCTAP showed improved sensitivity in the detection of small malignant lesions (< 1 cm) in comparison to CTAP.     

Regulating for pharmaceutical care outcomes

Change in cellular reduced glutathione (GSH) level was examined after the addition of 1-10 mM potassium sorbate (SA-K) to cultured rat hepatocytes. The cellular GSH content was decreased to the lowest level at 6 h after the addition of SA-K, and then gradually returned to the normal level except for hepatocytes exposed to 10 mM SA-K. Although the decrease in GSH level was not associated with lactate dehydrogenase (LDH) leakage in hepatocytes exposed to SA-K up to the concentration of 5 mM, cell injury was caused in cells exposed to 10 mM SA-K. When eicosapentaenoic acid was added in conjunction with various concentrations of SA-K to hepatocytes, peroxidation of the fatty acid was accelerated in parallel with the decrease in cellular GSH level. The enhanced lipid peroxidation in the hepatocytes co-exposed to SA-K and eicosapentaenoic acid (EPA) induced the development of cell injury. These results suggest that hepatocytes exposed to SA-K become susceptible to oxidative stress such as lipid peroxidation.     

Pregnant women's perceptions of prenatal care

PROBLEM: To describe pregnant women's perceptions in two specific areas: expectations about prenatal care and satisfaction with prenatal care. METHOD: A focus group technique using a semi-structured interview format. Three focus groups (N = 22) were conducted in the third trimester of pregnancy. Data were transcribed from the taped sessions and studied using content analysis. FINDINGS: Three major dimensions of satisfaction were identified: satisfaction with health care provider(s); satisfaction with support staff; and satisfaction with the prenatal care, including the desire for continuity of provider, clear explanations, and accessible quality care. CONCLUSIONS & IMPLICATIONS FOR NURSING: The provider relationship was identified as having the greatest influence on the women's satisfaction with prenatal care. Satisfaction with prenatal care can be enhanced through positive provider-patient interactions.     

Putting psychiatric nursing standards into clinical practice

1. The nursing service of a 640-bed acute care teaching hospital consistently put standards of care and practice into actual nursing care by implementing a computerized nursing care plan (NCP) system. 2. Staff nurses worked with clinical specialists to write/revise standards for their specialty areas. These facility specific standards of care and practice were incorporated into the computerized NCP system. 3. The result of the computerization was legible NCPs in only a few minutes. These NCPs direct patient care based on generic and specialty nursing practice standards and promote equitable care for all patients.     

Teenagers' perceptions of barriers to prenatal care

A structured interview conducted during the postpartum hospitalization of 184 patients aged 17 years or younger was used to study teenagers' perceptions of barriers to prenatal care. The interview consisted of more than 100 questions on demographic characteristics, family and social support, desire for the pregnancy, perceptions of the importance of prenatal care, practical obstacles to access to health care (such as lack of transportation, day care, etc), financial problems related to care, problems finding time to obtain health care, knowledge of available prenatal care resources, and perceptions of ease or difficulty in the use of existing clinics. Multiple regression analysis using the Kessner index as the criterion variable showed that major factors related to the adequacy of prenatal care received by these teenagers were perceptions of cost barriers, the gestational age at which the teenager discovered she was pregnant, school enrollment status (those in school received poorer care than those who had dropped out), and the degree of social support experienced by the teenager. These findings suggest that specific changes in the health care system are needed to make prenatal care more accessible for pregnant teenagers. These changes would include enhancing community awareness that Medicaid pays for prenatal care, establishing links between prenatal clinics and school health systems, and scheduling prenatal clinics at times more convenient for teenagers.     

Changes in medical students' perceptions of family practice resulting from a required clerkship

BACKGROUND: Career choice research has shown that exposing medical students to family medicine, through a special medical school emphasis or a required clerkship, correlates with an increased rate of selection of family practice. It has been hypothesized that actual exposure to family medicine mitigates the negative stereotypes held by many medical students. METHODS: This study used a qualitative strategy to examine how a family medicine clerkship altered medical students' perceptions and attitudes toward this specialty. A series of 12 focus groups were conducted with the students who had just completed a required family medicine junior core clerkship at our institution. RESULTS: Focus group findings confirmed the existence of negative stereotypes about family practice among medical students and provided additional information on their nature and origins. In addition, student comments indicated that a third-year family medicine clerkship experience dispelled this negative stereotyping and instilled in students a greater respect for and interest in family practice. CONCLUSION: Third-year clerkships can enhance students' perceptions of family practice by dispelling negative stereotypes and by providing medical students with a more accurate portrayal of the nature of this primary care specialty.