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.     

Practice guidelines for community-based parenteral anti-infective therapy

Practice guidelines for community-based parenteral anti-infective therapy (CoPAT) have recently been formulated in several countries. These guidelines emphasize the importance of teamwork and the interdisciplinary nature of CoPAT, and they use similar criteria for patient selection and evaluation, anti-infective agent selection and administration, and clinical monitoring. There are now guidelines or standards addressing the roles and responsibilities of the physician, nurse, and pharmacist in the delivery of CoPAT, and home care standards that address issues such as drug storage and preparation, treatment planning, and monitoring of ongoing care.     

Establishing pharmaceutical care services in an HIV clinic

OBJECTIVE: To present a brief overview of human immunodeficiency virus (HIV) infection and to describe the implementation of pharmaceutical care services for adult patients with HIV infection. SETTING: University hospital clinic. PRACTICE DESCRIPTION: A pharmacist joined a multidisciplinary team serving HIV-infected patients in January 1994. PRACTICE INNOVATION: Current pharmacy services include taking medication histories, educating patients, counseling patients on compliance, monitoring response to therapy, identifying drug-related problems, documenting all interventions, and making therapeutic decisions and formulary choices. The pharmacist also participates in research. INTERVENTIONS: The pharmacist sees patients immediately after their physician appointments. Patients with one or more of the following characteristics are targeted to receive pharmaceutical care: multiple drugs, history of noncompliance, initiation of new drug therapy, recently discharged from hospital or emergency department, identification of potential adverse effects, identification of potential drug-drug interactions, and presence of drug toxicities. CONCLUSION: Pharmacists are uniquely qualified to provide a wide range of pharmaceutical care services to HIV-positive patients. Pharmacy interventions should lead to improved outcomes and decreased costs for a chronic and very expensive disease.     

Clinical implications of cyclins, cyclin-dependent kinases, RB and E2F1 in squamous-cell lung carcinoma

OBJECTIVE: To develop, implement, and assess the outcomes of a system for providing pharmaceutical care to medical progressive care patients. METHODS: A system for providing pharmaceutical care was developed and implemented for an 8-week period beginning in June 1995. Both patient care outcomes and drug therapy cost change from the intervention period were compared with those of an 8-week baseline period. Variables compared included unit length of stay, hospital length of stay, transfers to the intensive care unit, readmissions, and adverse drug reactions requiring treatment. Differences between periods for these variables were assessed by using chi 2 tests and t-tests with alpha set at p less than 0.05. The clinical significance of the interventions were assessed independently by four physicians: two intensivists and two internists. The total drug therapy cost change from the intervention period was calculated as follows: total cost avoidance from individual recommendations subtracted from the total cost incurred from individual recommendations. RESULTS: The pharmacist evaluated 152 patients during the intervention period. A total of 235 pharmacotherapy recommendations were made on 103 patients, of whom 86.4% were accepted. Significantly fewer adverse drug reactions (ADRs) received treatment during the intervention period (p = 0.027). The mean unit length of stay was lower during the intervention period (4.8 +/- 3.7 d) than during the baseline period (6.0 +/- 5.6 d); however, this difference was not significant (p = 0.053). Individual physician assessment of the pharmacists' recommendations revealed that 75.8% were considered somewhat significant, significant, or very significant. The total drug therapy cost change from the intervention period was -$6534.53. The projected annual drug therapy cost reduction from this study is $42,474.45. CONCLUSIONS: The provision of pharmaceutical care to medical progressive care patients was associated with a substantial decrease in drug therapy cost and a decrease in the number of ADRs that required treatment.     

Pharmacist influence on economic and morbidity outcomes in a tertiary care teaching hospital

The influence of pharmacist participation on economic and morbidity outcomes at a tertiary care teaching hospital was studied. Patients admitted to internal medicine wards during a nine-month period were assigned to either a treatment team or a control team. Each team consisted of an attending physician, senior and junior medical residents, and medical students; the treatment team included a pharmacist who reviewed all patient charts, made rounds with the team, and recommended modifications of drug therapy. Pharmacy interaction with the control team was limited to contacting physicians about potentially dangerous orders, answering questions from the medical team, and handling orders for items not on the formulary or otherwise unavailable. After discharge, data from patient records were analyzed for pharmacy costs and total hospital costs and length of stay (as markers of the pharmacist's effect on economics and morbidity, respectively). Analysis of baseline characteristics showed that the two groups of patients were statistically comparable. Treatment team patients who were included in the data analysis (414) had significantly shorter stays (by a mean of 1.3 days) and lower pharmacy and total hospital costs (by a mean of $301 and $1654, respectively) than those included in the control team analysis (453). The direct participation of a pharmacist on a patient care team significantly decreased pharmacy and hospital costs, as well as length of stay, compared with minimal participation of a pharmacist.     

Effect of computer-based alerts on the treatment and outcomes of hospitalized patients

BACKGROUND: Hospital computing systems play an important part in the communication of clinical information to physicians. We sought to determine whether computer-based alerts for hospitalized patients can affect physicians' behavior and improve patients' outcomes. METHODS: We performed a prospective time-series study to determine whether computerized alerts to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic or renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to determine whether such alerts protected renal function. RESULTS: Laboratory data were observed for 20,228 hospitalizations, with documentation of 1573 events (instances of rising creatinine levels during treatment with a nephrotoxic or renally excreted drug). During the intervention period, doses were adjusted or medications discontinued an average of 21.6 hours sooner after such an event (P < .0001). For patients receiving nephrotoxic medications during the intervention period, the relative risk of serious renal impairment was 0.45 (95% confidence interval, 0.22 to 0.94) as compared with the control period, and the mean serum creatinine level was 14.1 mumol/L (0.16 mg/dL) lower on day 3 (P < .01) and 25.6 mumol/L (0.29 mg/dL) lower on day 7 (P < .05) after an event. Forty-four percent of physicians who responded to a questionnaire said that the alerts had been helpful in the care of their patients, whereas 28% found them annoying. Sixty-five percent wished to continue receiving alerts. CONCLUSIONS: Computer-based alerts regarding patients with rising creatinine levels affect physician behavior, prevent serious renal impairment, preserve renal function, and are accepted by clinicians.     

Family pharmacy and family medicine: a viable private practice alliance

The association of the new roles of the family physician and the family pharmacist in a model private practice is described. The pharmacist works closely with the family physician to offer personalized patient education and follow-up for therapeutic effectiveness. He also serves as a consultant to the physician for up-to-date drug information and assists in solving difficult therapeutic problems. Reimbursement for pharmacy services occurs for consultative time as well as by traditional methods. Initial response by the professionals themselves as well as the patients and staff has been very positive. An appropriate physical plant and ongoing communication between physician and pharmacist are mandatory for the success of this model. Some specifics of this practice at its present stage of development are included.     

Post-operative nerve damage and the removal of the mandibular third molar: a matter of common consent

The aim of this study was to seek a consensus regarding written preoperative warning of possible nerve damage for patients having outpatient surgical removal of mandibular third molar teeth with local analgesia in Oral and Maxillofacial surgical units throughout the UK. The person first advising the patient is not always the one undertaking the operative procedure, and confusion concerning consent may arise in such circumstances. Questionnaires were sent to 140 consultants in Oral and Maxillofacial surgery units throughout the UK. Replies were received from 101 consultants. Of these, 29.7% routinely provided patients with a written warning of potential nerve damage. 66.3% routinely provided a verbal warning, and 4% did not routinely provide either a written or verbal warning.     

A knowledge-based alarm system for monitoring cardiac operated patients--assessment of clinical performance

An intelligent alarm system for the postoperative monitoring of cardiac surgery patients, which did not require any manual data entries, was tested in two phases. A clinician monitored at bedside the patients' recovery and verified clinically abnormal physiological states. After the first test with ten patients, the system's rulebase was upgraded and then tested with an additional 15 patients. The alarm system employed two PC/ATs and was programmed to give notice of four pathological states (hyperdynamic state, hypovolemic state, hypoventilation and left ventricular failure) at two levels of urgency (alarm and alert levels). The monitoring lasted 5.4 +/- 1.7 hours per patient (mean +/- S.D.), totalling 134.7 hours. The system alarmed 27 times during the first and 73 times during the second phase of the testing. The sensitivity of the alarms was 100% in both phases, and the specificities increased from 20.0% to 73.9% and from 59.1% to 70.0% for the alarms and the alerts, respectively. This computerized decision support system based exclusively on data available in the automatically collected data base had a low false positive rate and gave early warnings about pathological states in the homogeneous group of adult postoperative cardiac patients.     

Cystic prostatic disease associated with adrenocortical lesions in the ferret (Mustela putorius furo)

CONTEXT: In British Columbia, human immunodeficiency virus (HIV)-infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown. OBJECTIVE: To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users. DESIGN: Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program. SETTING: British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50 x 10(9)/L (500/microL) and/or HIV-1 RNA levels higher than 5000 copies/mL. SUBJECTS: A total of 177 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May 1996. MAIN OUTCOME MEASURES: Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection. RESULTS: After a median of 11 months after first eligibility, only 71 (40%) of 177 patients had received any antiretroviral drugs, primarily double combinations (47/71 [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1 RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-12.37). CONCLUSIONS: Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.     

Role of serological tests in the diagnosis of immune complex disease in infection of ventriculoatrial shunts for hydrocephalus

BACKGROUND: Transdermal drug delivery systems, a relatively recent development, are well accepted by physicians and patients because of reliability and ease of administration. The patch reservoirs, however, contain large quantities of drug, and the potential for considerable toxicity exists if they are used incorrectly. A case is presented of an apparent suicide attempt that involved the use of nicotine transdermal patches. METHODS: This case report involved a patient seen in the emergency department by one of the authors. Data were obtained from the patient's medical record while maintaining confidentiality. RESULTS: The drug overdose was a potentially serious one. The patient recovered fully after an uneventful hospital course. CONCLUSIONS: Transdermal drug delivery systems now deliver many drugs, several of which are quite potent. Intentional or unintentional misuse of the systems can result in toxicity. The physician and pharmacist should carefully instruct each patient in the appropriate use and handling of transdermal drug delivery systems.     

Pharmacist as a provider of oncology ambulatory care services

The services provided by a pharmacist to ambulatory oncology patients is described. The pharmacist takes drug histories, monitors drug therapy, gives patient discharge consultations and acts in cooperation with local physicians and the medical staff in providing chemotherapy to cancer patients for home administration. The pharmacist also provides inservice education and acts as a consultant to the medical, nursing and pharmacy staffs.     

Implementation of a community pharmacy-based influenza vaccination program

OBJECTIVE: To increase accessibility of influenza vaccine in a rural community by establishing a community pharmacy-based influenza vaccination program. SETTING: An independent pharmacy in a rural eastern Iowa community of 5,000 people. PRACTICE DESCRIPTION: Protocols for identification and screening of patients, administration of vaccine, and treatment of emergencies were developed by the pharmacist and approved by the county health department medical director. Administration of vaccine began October 15, 1996, and was completed on December 6, 1996. PRACTICE INNOVATION: Patients were prospectively and retrospectively identified to receive the vaccination. Informed consent was obtained. Vaccine was administered by the pharmacist after screening for contraindications and counseling the patient. Weekly vaccination records were forwarded to the collaborating physician to update patient charts. MAIN OUTCOME MEASUREMENTS: To determine whether accessibility of influenza vaccine in the community was increased through pharmacist administration, the proportion of patients immunized in the pharmacy who were not vaccinated the previous year was determined. RESULTS: The pharmacist administered 343 doses of vaccine. Two-thirds of the immunized patients (67.9%) reported also being immunized the previous year. These patients were generally older (65 years of age +/- 13) than the previously nonimmunized patients (54 years of age +/- 16). However, 60.8% of the patients not immunized the previous year reported either they would not have gone elsewhere for the immunization (45.3%), or were unsure (25.5%). CONCLUSION: The data collected suggest that pharmacist administration of influenza vaccination in a rural community pharmacy increases access and, possibly, immunization rates. This may be especially true among high-risk younger adults who are often overlooked and would not normally have received the immunization.     

Health care triage alternatives and the influence of health insurance, education and race

The relationship between one of Andersen's enabling factors, health insurance status and the choice of a pharmacist as the initial contact in the health care system was examined via telephone surveys. Eighty-seven percent of the sample reported having some form of health insurance. Of all intended health care provider contacts, pharmacists were selected as the initial contact 21% of the time. Logistic regression identified insurance status, education and race as significant (alpha < 0.05) covariates in the model. The odds ratios generated from the logit model indicated that non-whites, persons with less education and no health insurance were more likely to select a pharmacist for triage. The study concluded that uninsured persons were nearly twice as likely to seek pharmacist triage than insured individuals. Pharmacists may be filling an important triage gap for individuals who have limited financial access to traditional sources of physician care.     

Pharmaceutical services in a pediatric oncology day hospital

The role of the pharmacist in a treatment center in which pediatric cancer patients receive intensive chemotherapy with a minimum of inhospital admission time is discussed. Functions of the pharmacist include: preparation and dispensing of oral and parenteral medications; monitoring of physicians' orders; maintaining patient profiles; maintaining investigational drug records; providing drug information; and conducting inservice educational programs.     

The medication information line for the elderly: an 8-year cumulative analysis

OBJECTIVE: To present an 8-year (1985-1992) cumulative analysis of the 12,743 calls received by the Medication Information Line for the Elderly (MILE), a consumer-oriented drug information service. DESIGN: Data on all calls received by MILE were documented using a standard format. Certain calls were selected by the pharmacist for follow-up based on the nature and predicted severity of the inquiry. SETTING: MILE is located within the Faculty of Pharmacy of the University of Manitoba and staffed by experienced, practicing pharmacists. Calls were received from the elderly and their care providers. Calls were initially taken on a local Winnipeg line, although in 1987 a toll-free number was made available to rural Manitoba residents. RESULTS: The majority of the calls received by MILE were from women aged 65 years or older who accessed MILE on their own initiative. Ninety-one percent of the calls were rated as not serious. Only 6% of calls were from outside Winnipeg. Although 94% of the older consumers reported having a regular pharmacist, they commonly never thought of using their pharmacist for inquiries. The drugs cited most often by consumers, nurses, physicians, and dentists were the nonsteroidal antiinflammatory agents, cardiac drugs, diuretics, antihypertensives, benzodiazepines, and antidepressants. The type of inquiries most frequently involved adverse drug reactions, drug interactions, and therapeutic use. The drugs cited and inquiries made by pharmacist callers were more diverse than those of consumers and other healthcare professionals. CONCLUSIONS: Many older drug consumers have medication information needs that are not being met. Since a large proportion of the callers appeared to be self-motivated women, MILE may not be accessing all older consumers in need of information. This analysis also suggests that many older consumers are not aware that the pharmacist is available and capable of providing drug information.