MEDLINE Abstracts: Pharmacists and Disease State Management
MEDLINE Abstracts: Pharmacists and Disease State Management
Holden J, Holden K
J Clin Pharm Ther. 2000 Feb;25(1):49-54
Objective: To compare pharmacist- with general practitioner-managed anticoagulation in the community. Design: Included in the study were all patients who had been managed by general practitioners (GPs) and subsequently referred to the pharmacist-led outreach service within Gateshead & South Tyneside Health Authority. A retrospective analysis was carried out recording individual international normalized ratio (INR) estimations, the time interval between successive tests and whether the result resided within the prescribed therapeutic range. These values were derived for both the GP- and pharmacist-managed elements of care. Subjects: Fifty-one patients who met the inclusion criteria identified from eight practices had been successively treated by GPs and then by pharmacists. Eighteen patients (35.3%) had a diagnosis of non-rheumatic atrial fibrillation, 10 (19.6%) had thromboembolic disease and 13 (25.5%) had valvular disease.
Results: In total, 1782 INR results were analysed. GPs were responsible for 1075 (60.3%) of these estimations and pharmacists for the remaining 707 (39.7%). Of the GP-monitored results the patient-mean proportion of estimates that resided within the prescribed therapeutic range was 0.6 (SD = 0. 21, n = 51) compared with pharmacist management where patients showed a mean in range proportion of 0.7 (SD = 0.18, n = 51, P = 0. 03). The mean inter-test interval was 28.6 days (SD = 8.65, n = 51) for GPs compared with 34.1 days (SD = 12.3, n = 51, P = 0.01) for pharmacists. The weighted INR index for GPs was 17.2 (SD = 7.93, n = 51) compared with 24.7 (SD = 13.15, n = 51, P < 0.001) for pharmacists.
Conclusion: There is no apparent detriment to INR control when pharmacist management is compared with that of GPs. The overall proportion of INR estimations within the prescribed range is greater for pharmacists than for GPs and the interval between tests is longer for pharmacists compared with GPs.
Ellis SL, Billups SJ, Malone DC, et al
Pharmacotherapy. 2000 Apr;20(4):429-435
The purpose of this study was to describe and evaluate the activities and interventions provided by ambulatory care clinical pharmacists during the IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) study. A total of 523 patients were randomized into the intervention arm at nine Veterans Affairs medical centers if they were considered to be at high risk for drug-related problems. Patients randomized to the control group had no interventions and they are not reported. Using a standard form, pharmacists were asked to document the length of visit, method of contact, medical conditions addressed, and drug-related problems addressed and resolved during each contact. Seventy-eight ambulatory care clinical pharmacists documented 1855 contacts over 12 months, an average of 3.54 +/- 2.31/patient. The length of visits was 15 minutes or more for 73% of contacts. In-person contacts accounted for 1421 visits (76.6%), with the remainder being telephone contacts. During each contact the average number of drug-related problems addressed and resolved were 1.64 +/- 1.16 and 1.14 +/- 0.98, respectively. More drug-related problems were addressed and resolved when visits were 15 minutes or longer (p=0.001) and when the contact was in person (p=0.001). These data may provide information to clinical pharmacists developing pharmacy-managed clinics for patients at high risk for drug-related problems. The information may be a benchmark for types of interventions that can be made, as well as the time commitments required to make them.
Turner CJ, Parfrey P, Ryan K, Miller R, Brown A
Am J Health Syst Pharm. 2000 Apr 15;57(8):747-752
The predictive value of digoxin and furosemide treatment for identifying patients receiving treatment for congestive heart failure (CHF), the use of angiotensin-converting-enzyme (ACE) inhibitors in this population, and the ability of a pharmacist outreach program to address underutilization of ACE inhibitors were studied. All physicians and owner-managers of community pharmacies on Newfoundland's Avalon Peninsula were asked to participate in the study. Pharmacists who agreed to participate were asked to list patients of the participating physicians with prescriptions for (1) furosemide and digoxin with and without an ACE inhibitor or angiotensin II-receptor inhibitor and (2) an ACE inhibitor. Physicians were visited by a pharmacist and asked whether each of their patients receiving digoxin and furosemide was being treated for CHF and to identify further cases of CHF among their patients receiving an ACE inhibitor. Intervention-group physicians received academic detailing on the use and dosage of ACE inhibitors and angiotensin II-receptor inhibitors for CHF. Both groups were reinterviewed after three months to establish what if any changes in therapy had occurred for each patient discussed during the first visit. The positive predictive value of digoxin and furosemide treatment for identifying patients receiving treatment for CHF was 94%. Seventy-six percent of patients identified by physicians as CHF patients who were taking digoxin and furosemide were treated with an ACE inhibitor. Thirty-six percent of patients treated with an ACE inhibitor for CHF received the targeted dosage. Four physicians stated that the outreach visit influenced their prescribing, but there was no significant difference in ACE inhibitor prescribing between the intervention and control groups. A pharmacist outreach program involving the use of prescription records and academic detailing did not affect prescribing or dosages of ACE inhibitors but demonstrated value as a quality assurance tool.
Holden J, Holden K
J Clin Pharm Ther. 2000 Feb;25(1):49-54
Objective: To compare pharmacist- with general practitioner-managed anticoagulation in the community. Design: Included in the study were all patients who had been managed by general practitioners (GPs) and subsequently referred to the pharmacist-led outreach service within Gateshead & South Tyneside Health Authority. A retrospective analysis was carried out recording individual international normalized ratio (INR) estimations, the time interval between successive tests and whether the result resided within the prescribed therapeutic range. These values were derived for both the GP- and pharmacist-managed elements of care. Subjects: Fifty-one patients who met the inclusion criteria identified from eight practices had been successively treated by GPs and then by pharmacists. Eighteen patients (35.3%) had a diagnosis of non-rheumatic atrial fibrillation, 10 (19.6%) had thromboembolic disease and 13 (25.5%) had valvular disease.
Results: In total, 1782 INR results were analysed. GPs were responsible for 1075 (60.3%) of these estimations and pharmacists for the remaining 707 (39.7%). Of the GP-monitored results the patient-mean proportion of estimates that resided within the prescribed therapeutic range was 0.6 (SD = 0. 21, n = 51) compared with pharmacist management where patients showed a mean in range proportion of 0.7 (SD = 0.18, n = 51, P = 0. 03). The mean inter-test interval was 28.6 days (SD = 8.65, n = 51) for GPs compared with 34.1 days (SD = 12.3, n = 51, P = 0.01) for pharmacists. The weighted INR index for GPs was 17.2 (SD = 7.93, n = 51) compared with 24.7 (SD = 13.15, n = 51, P < 0.001) for pharmacists.
Conclusion: There is no apparent detriment to INR control when pharmacist management is compared with that of GPs. The overall proportion of INR estimations within the prescribed range is greater for pharmacists than for GPs and the interval between tests is longer for pharmacists compared with GPs.
Ellis SL, Billups SJ, Malone DC, et al
Pharmacotherapy. 2000 Apr;20(4):429-435
The purpose of this study was to describe and evaluate the activities and interventions provided by ambulatory care clinical pharmacists during the IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) study. A total of 523 patients were randomized into the intervention arm at nine Veterans Affairs medical centers if they were considered to be at high risk for drug-related problems. Patients randomized to the control group had no interventions and they are not reported. Using a standard form, pharmacists were asked to document the length of visit, method of contact, medical conditions addressed, and drug-related problems addressed and resolved during each contact. Seventy-eight ambulatory care clinical pharmacists documented 1855 contacts over 12 months, an average of 3.54 +/- 2.31/patient. The length of visits was 15 minutes or more for 73% of contacts. In-person contacts accounted for 1421 visits (76.6%), with the remainder being telephone contacts. During each contact the average number of drug-related problems addressed and resolved were 1.64 +/- 1.16 and 1.14 +/- 0.98, respectively. More drug-related problems were addressed and resolved when visits were 15 minutes or longer (p=0.001) and when the contact was in person (p=0.001). These data may provide information to clinical pharmacists developing pharmacy-managed clinics for patients at high risk for drug-related problems. The information may be a benchmark for types of interventions that can be made, as well as the time commitments required to make them.
Turner CJ, Parfrey P, Ryan K, Miller R, Brown A
Am J Health Syst Pharm. 2000 Apr 15;57(8):747-752
The predictive value of digoxin and furosemide treatment for identifying patients receiving treatment for congestive heart failure (CHF), the use of angiotensin-converting-enzyme (ACE) inhibitors in this population, and the ability of a pharmacist outreach program to address underutilization of ACE inhibitors were studied. All physicians and owner-managers of community pharmacies on Newfoundland's Avalon Peninsula were asked to participate in the study. Pharmacists who agreed to participate were asked to list patients of the participating physicians with prescriptions for (1) furosemide and digoxin with and without an ACE inhibitor or angiotensin II-receptor inhibitor and (2) an ACE inhibitor. Physicians were visited by a pharmacist and asked whether each of their patients receiving digoxin and furosemide was being treated for CHF and to identify further cases of CHF among their patients receiving an ACE inhibitor. Intervention-group physicians received academic detailing on the use and dosage of ACE inhibitors and angiotensin II-receptor inhibitors for CHF. Both groups were reinterviewed after three months to establish what if any changes in therapy had occurred for each patient discussed during the first visit. The positive predictive value of digoxin and furosemide treatment for identifying patients receiving treatment for CHF was 94%. Seventy-six percent of patients identified by physicians as CHF patients who were taking digoxin and furosemide were treated with an ACE inhibitor. Thirty-six percent of patients treated with an ACE inhibitor for CHF received the targeted dosage. Four physicians stated that the outreach visit influenced their prescribing, but there was no significant difference in ACE inhibitor prescribing between the intervention and control groups. A pharmacist outreach program involving the use of prescription records and academic detailing did not affect prescribing or dosages of ACE inhibitors but demonstrated value as a quality assurance tool.
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