Journal of the American Pharmacists Association Current Issue

Adoption of medication therapy management programs in Minnesota: 2006–11

Larson S, Drake S, Anderson L, et al. — Wed, 01 May 2013 00:00:00 GMT

Objective

To assess the adoption of the Minnesota Department of Human Services (DHS) medication therapy management (MTM) program by patients and pharmacists.

Design

Descriptive nonexperimental study.

Setting

Minnesota DHS MTM program, from 2006 to 2011.

Main outcome measures

Number of claims, providers, and dollars compensated each year from 2006 to 2011, as well as location of claim submissions and percent of eligible patients served in 2011.

Results

During 2011, 76 pharmacists were compensated a total of $210,716 for 2,427 claims. Of these claims, 1,009 were initial visits and 1,418 were follow-up visits. In each of the first 6 years of the program, an increase was seen in number of claims, number of pharmacists submitting claims, and dollars compensated. These increases followed exponential curves for total number of claims and dollars compensated with a declining logarithmic curve for pharmacists. From 2010 to 2011, the number of claims and dollars compensated did not increase as much from 2009 to 2010. However, claims data may still increase for 2011 as a result of late submissions. During 2011, the percentage of eligible patients provided services was estimated to be 5.7% to 7.6%.

Conclusion

The continued increase in use indicates that the program has had a successful beginning and promises to serve many more patients. The small percentage of patients reached should increase with subsequent years. Better strategies to recruit patients and pharmacist providers should increase use of the program.

Minnesota Department of Human Services audit of medication therapy management programs

Smith S, Cell P, Anderson L, et al. — Wed, 01 May 2013 00:00:00 GMT

Objectives

To inform medication therapy management (MTM) providers of findings of the Minnesota Department of Human Services review of claims submitted to Minnesota Health Care Programs (MHCP) for patients receiving MTM services and to discuss the impact of the audit on widespread MTM services and future audits.

Methods

A retrospective review was completed on MTM claims submitted to MHCP from 2008 to 2010. The auditor verified that the Current Procedural Terminology codes billed matched the actual number of medications, conditions, and drug therapy problems assessed during an encounter.

Results

190 claims were reviewed for 57 distinct pharmacies that billed for MTM services from 2008 to 2010, representing 4.5% of all claims submitted. The auditor reported that generally, the documentation within the electronic medical record had the least “up-coding” of all documentation systems. A total of 18 claims were coded at a higher level than appropriate, but only 10 notices were sent out to recover money because the others did not meet the minimum $50 threshold.

Conclusion

The auditor expressed concerns that a number of claims billed at the highest complexity level were only 15 minutes long. Providers will need to be cautious of the conditions that they bill as complex and of how they define drug therapy problems. Everything for which is being billed must be clearly assessed or rationalized in the documentation note. The auditor expressed that overall, documentation was well done; however, many MTM providers are now asking how to internally prepare for future audits.

Characteristics and trends of drug and dietary supplement inquiries by college athletes

Ambrose PJ, Tsourounis C, Uryasz FD, et al. — Wed, 01 May 2013 00:00:00 GMT

Objective

To characterize the types of drug and dietary supplement inquiries submitted to the National Center for Drug Free Sport through the Resource Exchange Center (REC).

Design

Cross-sectional study.

Setting

United States, from July 2009 through June 2010.

Participants

Athletes and athletic personnel associated with the National Collegiate Athletic Association (NCAA).

Intervention

Tabulation and classification of drugs and dietary supplement inquiries.

Main outcome measure

Characteristics and trends of drug and dietary supplement inquiries.

Results

Inquiries for prescription medications for albuterol inhalers, methylphenidate, amphetamines, and prednisone were the most common using a drug lookup function. The most common inquiries for over-the-counter medications included pseudoephedrine, loratadine, cetirizine, and caffeine. Among dietary supplements, inquiries for amino acids/metabolites, vitamins and minerals, and herbal products occurred most frequently. One dietary supplement, N.O.-Xplode (Bio-Engineered Supplements and Nutrition, Inc.), accounted for the majority of individual dietary supplement inquiries. Banned substances accounted for 30% of all inquiries submitted to the REC and 18% of medications searched in a drug lookup database.

Conclusion

Almost 25,000 inquiries were submitted to the REC. Pharmacists can use this information to advise, counsel, and refer NCAA athletes regarding the use of banned and permitted substances. Education programs regarding stimulants, dietary supplements, and the risk of using substances such as animal byproducts are needed, and pharmacists can participate in these programs.

Community pharmacists’ occupational satisfaction and stress: A profession in jeopardy?

Munger MA, Gordon E, Hartman J, et al. — Wed, 01 May 2013 00:00:00 GMT

Objectives

To quantify and model drivers of community pharmacists’ self-reported levels of occupational satisfaction and stress and to identify key segments for possible intervention by the profession.

Design

Descriptive nonexperimental study.

Setting

United States during January to February 2012.

Participants

303 independent and community chain pharmacists.

Intervention

Online survey instrument of previously validated occupational stress and satisfaction attribute batteries.

Results

Participants reported a high level of dissatisfaction with current employment, with more than 50% stating that they were considering quitting their jobs. Dissatisfaction was higher among those with a doctor of pharmacy degree and those employed in community chains. Occupational stress and satisfaction were highly correlated with the intention to search for a new position. Approximately 20% of respondents felt that stress from their employment adversely affected their mental health and well-being, physical health, quality of the work, or relationships with family and friends.

Conclusion

Substantive levels of occupational dissatisfaction and stress exist among pharmacists currently in community practice. These negative attributes are associated with a damaging promotion of community practice—a marker of a negative trajectory in sustaining this practice environment. The results of this study have implications for the health care industry, commercial pharmacy vendors, independent pharmacies, the profession, and academic training institutions as they prepare the pharmacy workforce of the future for potentially dissatisfying and stressful work environments.

Comparing point-of-care A1C and random plasma glucose for screening diabetes in migrant farm workers

Wensil AM, Smith JD, Pound MW, et al. — Wed, 01 May 2013 00:00:00 GMT

Objective

To compare point-of-care (POC) glycosylated hemoglobin (A1C) and random plasma glucose (RPG) as a POC screening tool for prediabetes and diabetes in migrant farm workers of eastern North Carolina.

Design

Prospective, observational, single-center study.

Setting

Federally qualified community health center in eastern North Carolina, from August to October 2011.

Participants

Migrant farm workers 18 years or older who resided in a migrant camp in eastern North Carolina.

Intervention

Diabetes screening using POC A1C and RPG via fingerstick followed by venipuncture A1C and basic metabolic panel in individuals with a positive screening.

Main outcome measures

Positive predictive value (PPV) of POC A1C and RPG, incidence of positive screening, incidence of confirmed diagnosis, concordance rate of the screening tools, and correlation between POC A1C and laboratory A1C.

Results

206 workers participated in the screenings; screening identified 39 individuals with a POC A1C greater than 5.7% and 1 individual with both an RPG of 200 mg/dL or more and a POC A1C greater than 5.7%. Of the 39 individuals found to have a positive screening, 24 presented to Carolina Family Health Centers, Inc., for follow-up venipuncture; however, 1 participant did not have a venipuncture A1C, leaving 23 individuals with complete data. Two participants were diagnosed with diabetes and 17 with prediabetes. POC A1C had a PPV of 82.6%; however, the PPV of RPG could not be calculated due to the number of participants lost to follow-up. POC A1C correlated well with laboratory A1C regardless of time to follow-up.

Conclusion

POC A1C should be considered for diabetes screening in high-risk populations. If the screening had been performed with RPG alone, 38 individuals would have gone undetected. Early identification of individuals with elevated blood glucose will likely decrease the risk of long-term complications.

How does use of a prescription monitoring program change pharmacy practice?

Green TC, Mann MR, Bowman SE, et al. — Wed, 01 May 2013 00:00:00 GMT

Objectives

To assess differences in prescription monitoring program (PMP) use between two states with different PMP accessibility (Connecticut [CT] and Rhode Island [RI]), to explore use of PMPs in pharmacy practice, and to examine associations between PMP use and pharmacists’ responses to suspected diversion or “doctor shopping.”

Design

Descriptive nonexperimental study.

Setting

CT and RI from March through August 2011.

Participants

Licensed pharmacists in CT and RI.

Intervention

Anonymous surveys e-mailed to pharmacists

Main outcome measures

PMP use, use of patient reports in pharmacy practice, and responses to suspected doctor shopping or diversion.

Results

Responses from 294 pharmacists were received (CT: 198; RI: 96). PMP users were more likely to use the PMP to detect drug abuse (CT: 79%; RI: 21.9%; P < 0.01) and doctor shopping (67%; 7%; P < 0.01). When faced with suspicious medication use behavior, PMP users were less likely than nonusers to discuss their concerns with the patient (adjusted odds ratio 0.48 [95% CI 0.25–0.92]) but as likely to contact the provider (0.86 [0.21–3.47]), refer the patient back to the prescriber (1.50 [0.79–2.86]), and refuse to fill the prescription (0.63 [0.30–1.30]). PMP users were less likely to state they were out of stock of the drug (0.27 [0.12–0.60]) compared with nonusers. Pharmacists reported high interest in attending continuing education on safe dispensing (72.8%).

Conclusion

Pharmacists are important participants in the effort to address prescription drug misuse and abuse. Current PMP use with prevailing systems had limited influence on pharmacy practice. Findings point to future research and needed practice and education innovations to improve patient safety and safer opioid dispensing for pharmacists.

Medication adherence program: Adherence challenges and interventions in type 2 diabetes

Odegard P, Carpinito G, Christensen DB. — Wed, 01 May 2013 00:00:00 GMT

Objectives

To describe medication adherence problems for adults with type 2 diabetes and to assess the nature and frequency of pharmacist activities in addressing them and proximate outcomes.

Design

Pre–post analysis.

Setting

Four community chain pharmacies located in Seattle, WA, from April 2008 to October 2009.

Patients

120 patients (mean age >60 years) with type 2 diabetes taking oral diabetes medications and who were 6 or more days late for refills.

Intervention

Pharmacist telephone-initiated adherence support.

Main outcomes measures

Nature and frequency of adherence-related problems and intervention activities and impact on reduction in refill gaps.

Results

The primary adherence challenge was difficulty taking medications (27.1%). Failure to remember doses and forgetting refills were reported by 24.6% and 26.3% of patients at baseline, respectively. Pharmacists provided support through some form of patient education (35.6% of encounters) or other adherence support (40.7%). Pharmacist time averaged slightly greater than 5 minutes per intervention and 12.6 ± 10.7 minutes (mean ± SD) over 12 months, with 3.4 ± 2.4 interventions per patient. Patient-specific education and adherence support by pharmacists and total intervention time were positively correlated, with a modest but significant reduction in refill gaps during 12 months of follow-up.

Conclusion

Not remembering to refill medications was the most commonly reported problem. Patient encounters averaged 4 to 6 minutes for the first visit and 12 to 13 minutes over 12 months. Phone calls by pharmacists to adults who were late for oral diabetes medication refills were effective in identifying adherence-related problems and developing support strategies to promote medication self-management in busy urban community chain pharmacy settings.

Stability of U-500 regular insulin in prefilled syringes

Lull ME, Piacentino JJ, Traina AN. — Wed, 01 May 2013 00:00:00 GMT

Objective

To evaluate the stability of U-500 regular insulin in prefilled syringes stored under refrigeration for up to 28 days.

Methods

U-500 regular insulin was drawn up in 1 mL insulin syringes in a clean, nonsterile environment to emulate conditions of a patient's home. Samples were assayed using a stability-indicating reverse-phase high-performance liquid chromatography method immediately after preparation (day 0) and after 7, 14, 21, and 28 days under refrigeration. Before evaluation, all samples were diluted to a concentration of 40 units/mL in the starting mobile phase. Stability was determined by evaluating the percentage of the initial concentration remaining at each time point.

Results

At least 93.3% of the initial U-500 insulin concentration remained throughout the 28-day study period, with no statistically significant changes in the amount remaining. The percent of initial concentration remained above 97% for the first 21 days of the study.

Conclusion

A prefilled syringe with U-500 regular insulin is stable for at least 28 days when stored under refrigeration. These data are similar to those reported for U-100 regular insulin, indicating that prefilling syringes with U-500 insulin is a safe and effective practice for patients who are unable to accurately draw up their own point-of-care doses.

Caring for visually impaired patients

Orrico KB. — Wed, 01 May 2013 00:00:00 GMT

Objective

To raise pharmacist awareness about the needs and concerns of our patients with visual impairment and to review useful strategies to foster medication adherence.

Summary

As patient-centered pharmacists, we need to understand the challenges faced by our patients with low vision and tailor pharmaceutical care to best fit their needs. Evidence-based best practices in labeling and written communication have been developed by the American Foundation for the Blind in partnership with the American Society of Consultant Pharmacists. These recommendations include the use of specific font styles, minimum font size, and other standards known to enhance usability for those with limited vision. Recent advances in assistive technologies such as audio output and object recognition software can be used to ease the medication-taking process and effectively communicate important drug and safety information in a manner that can be understood by those with low vision. In July 2012, the Prescription Accessible Drug Labeling Promotion Act of 2012 (HR 4087) was signed into law. This new legislation is an addition to the Food and Drug Administration Safety and Innovation Act, which required the development and ultimate implementation by pharmacies of national best practices intended to improve the accessibility of prescription drug labeling for the visually impaired.

Conclusion

As a patient-centered profession, we need to advocate for our patients with special needs by partnering with government and patient groups to support and enact legislation intended to enhance people's ability to adhere to drug therapy.

Spirometry: Tool for pharmacy practitioners to expand direct patient care services

Cawley MJ, Moon J, Reinhold J, et al. — Wed, 01 May 2013 00:00:00 GMT

Abstract

Objectives: To introduce pharmacy practitioners to spirometry testing and provide strategies for integrating this “value-added” tool with other direct patient care pharmacy services. Data sources: Spirometry literature and resources obtained through search strategies including Ovid, PubMed, and Google Scholar. Summary: Pharmacists are distinctive members of the multidisciplinary patient care team and can contribute by performing spirometry services for pulmonary patients. Pharmacists have been largely absent from performing this much needed service, perhaps as a result of lack of training or because this testing may be perceived as irrelevant to the pharmacist scope of practice. However, pharmacists are actively integrated with many aspects of pulmonary patient care, including recommending and adjusting inhaled pharmacological agents, monitoring for potential drug–drug and drug–disease interactions, recommending smoking cessation, assessing patient prescription insurance coverage, and educating patients, caregivers, and health care providers on use of prescribed respiratory delivery devices. Adding quality spirometry services, based on American Thoracic Society guidelines for accuracy, would increase the breadth and depth of services for pharmacy practitioners. Conclusion: Spirometry testing is an added tool for expanding direct patient care pharmacy services. Physician support, appropriate pharmacist training, and understanding of reimbursement of spirometry services are essential in providing quality spirometry testing. Future studies are needed to assess the role of pharmacists in performing spirometry and measuring the performance outcomes of pulmonary patients.

Enhancing pharmacists’ role as oral health advisors

Cohen LA. — Wed, 01 May 2013 00:00:00 GMT

Objective

To examine the expanded role of pharmacists as oral health advisors.

Setting

U.S. community pharmacies.

Practice description

Counseling patients on issues related to oral health.

Practice innovation

The traditional role of pharmacists (i.e., dispensing medications) has evolved to include a broader range of functions associated with primary health care. Pharmacists are important members of the health care team and have an important role in addressing oral health–related problems. The pharmacist role in addressing oral health issues in the United States should be expanded.

Conclusion

Studies are needed to examine the extent of pharmacist training in oral health, the degree to which pharmacists who receive oral health training incorporate it into their practices, and pharmacist interest in relevant continuing education. Data gathered from such studies will be invaluable in developing appropriate training standards, model curricula, and clinical best practices.

Assessing quality in pharmacy education in an era of rapid expansion: Response to Maine and Vlasses

Popovich NG, Robert L. M, Roberts JC, et al. — Wed, 01 May 2013 00:00:00 GMT

We read with interest the article by Maine and Vlasses ¹ in the Jul/Aug 2012 issue of the JAPhA and had the following observations.

Assessing quality in pharmacy education in an era of rapid expansion: Response to Popovich et al.

Maine LL, Vlasses PH. — Wed, 01 May 2013 00:00:00 GMT

We are pleased to have an opportunity to address the critique of our article ¹ by Popovich et al. ² Popovich et al. raise important issues regarding the workforce in pharmacy, the validity of available measures of quality, and the objectivity of two organizations (i.e., Accreditation Council for Pharmacy Education [ACPE] and American Association of Colleges of Pharmacy [AACP]), whose chief executive officers coauthored the original manuscript.

Achieving recognition as patient-centered care providers: We are our own best advocates

Cooke R, Lipowski E, Magness JW. — Wed, 01 May 2013 00:00:00 GMT

Vaccination exemptions: Implications of decline in vaccination rates

Descourouez JL, Hayney MS. — Wed, 01 May 2013 00:00:00 GMT

Vaccines protect individuals to whom they are administered. Unlike other medical interventions, many vaccines also protect people around the immunized individual. Herd protection is defined as the resistance of a group to a disease as a result of the immunity of a large proportion of group members and the consequent lessening of the likelihood of an infected individual coming into contact with a susceptible individual. ¹ Because herd protection depends on high immunization rates in a population, any threat to these high rates must be considered carefully.

Lorcaserin, dimethyl fumarate, and bedaquiline fumarate

Hussar DA, Polyak G. — Wed, 01 May 2013 00:00:00 GMT

Acceptance of pharmacists’ recommendations and outcomes and distance versus local learning

Ried L. — Wed, 01 May 2013 00:00:00 GMT