Implementing lifestyle medicine with medication therapy management services to improve patient-centered health care.

OBJECTIVE: To describe a patient-centered medication therapy management (MTM) program that focuses on lifestyle medicine. SETTING: Community pharmacy in Omaha, NE, from August 2008 to September 2010. PRACTICE DESCRIPTION: Traditional MTM services are combined with lifestyle medicine interventions for employees of a self-insured organization who have dyslipidemia, hypertension, and/or diabetes. Program participants meet one-on-one with a pharmacist 12 times during the first year of the program to ensure proper drug therapy and modify lifestyle behaviors (physical activity, nutrition, weight control, sleep, stress, and alcohol and tobacco use) through individualized programming. PRACTICE INNOVATION: Several patient-centered activities have been developed for the program with an emphasis on modifying lifestyle behaviors in conjunction with medications to manage participants' chronic condition. In addition, a new specialty position in health care is being developed (the ambulatist) that focuses on maintaining the ambulatory status of individuals with chronic medical conditions through appropriate drug therapy, lifestyle medicine, and care coordination. MAIN OUTCOME MEASURES: Biometric data collection and participant survey data at baseline and after 12 months. RESULTS: Pilot data for 15 participants showed improvements in all measurements, including blood cholesterol, low-density lipoprotein cholesterol, blood glucose, body weight, physical activity level, fruit and vegetable intake, risk for myocardial infarction, risk for any cardiovascular disease event, self-reported unhealthy days, and qualitative survey data. CONCLUSION: Pharmacists are in an ideal position to implement lifestyle medicine strategies in combination with MTM services to enhance patient-centered health care in a community pharmacy setting.

Pay-for-performance model of medication therapy management in pharmacy practice.

OBJECTIVE: To use an existing pharmacist-run medication therapy management (MTM)/lifestyle medicine program to propose a new model of reimbursement for pharmacists that is based on pay for performance (P4P) rather than product-based dispensing or fee for service. DATA SOURCES: Specific patient outcomes were collected during a 1-year period from an existing pharmacist-run MTM/lifestyle medicine program as the basis to propose this new model of reimbursement. DATA SYNTHESIS: The proposed model outlines a P4P model of reimbursement for pharmacists that includes both traditional MTM services and patient-centered lifestyle medicine programming. The model uses an all-or-none bundled approach for reimbursement in which the pharmacist is reimbursed at a higher rate if patients achieve all six proposed outcome criteria at 1 year. Pharmacists could earn as much a 43% more income with this model compared with traditional MTM services. This model is an incentive for payers because it is based on patient outcomes and preestablished return on investment models. CONCLUSION: Pharmacist should begin to explore ways they can participate in a high-performance health care system by moving to a P4P model of reimbursement rather than fee-for-service or product-based dispensing reimbursement models. P4P models of reimbursement could be beneficial to the patient, the payer, and the pharmacist.

Lifestyle modifications for patients with hypertension.

OBJECTIVES: To review the lifestyle modification components listed in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) from the National Heart, Lung, and Blood Institute (NHLBI) and discuss how the guidelines can be used by pharmacists in the treatment of patients with hypertension. DATA SOURCES: Published guidelines and abstracts identified through PubMed (May 1987 to April 2007) and Medline (January 1966 to April 2007) using the search terms hypertension, prehypertension, lifestyle modification, nutrition, physical activity, weight loss, weight control, behavior modification, smoking cessation, guidelines, and prevention, as well as the JNC 7 guidelines, NHLBI Obesity Guidelines, and Dietary Guidelines for Americans 2005. DATA SYNTHESIS: Lifestyle modification strategies are recommended in the JNC 7 guidelines for the treatment and prevention of hypertension and cardiovascular disease. The primary strategies discussed are proper nutrition through the Dietary Approaches to Stop Hypertension (DASH) eating plan and sodium restriction, weight reduction, increased physical activity, and moderation of alcohol consumption. Patients with hypertension have been shown to decrease their resting blood pressure considerably by adopting one of more of these strategies. CONCLUSION: Pharmacists are in an ideal setting to care for patients with hypertension by managing their medications and lifestyle behaviors. Doing so provides patients a higher level of clinical care from their pharmacist.

Development and Assessment of an Interprofessional Education Simulation to Promote Collaborative Learning and Practice.

BACKGROUND: We designed an interprofessional education (IPE) clinical simulation that paired nurse practitioner and pharmacy students. The objective was to evaluate the effect on attitudes of interprofessional collaborative learning and practice. METHOD: Perceptions were assessed using the Student Perceptions of Interprofessional Clinical Education-Revised instrument and reflection questions that assessed the simulation's effectiveness in requiring team knowledge and experience from each profession whether the experience improved individual student clinical performance, and how this team approach influenced patient outcomes. RESULTS: Students believed that working with another health profession was educationally beneficial and should be a required experience; they also believed that this collaboration improved patient outcomes and satisfaction. Responses also indicated student ambiguity about their role in interprofessional care, and that clinical rotations were not the ideal setting for first professional interactions with others. CONCLUSION: Students expressed satisfaction and increased awareness of the importance of collaboration to ensure patient safety. Increasing interprofessional education experiences prior to clinical rotations should be considered. [J Nurs Educ. 2018;57(7):426-429.].

Therapeutic lifestyle strategies taught in U.S. Pharmacy Schools.

INTRODUCTION: Several organizations representing pharmacy and other health professions stress the importance of teaching public health topics as part of training future practitioners. The objective of our study was to assess the number of U.S. pharmacy schools that incorporate lifestyle modification topics into their curricula. METHODS: We developed an electronic survey on lifestyle modification topics and sent it to each of the 89 pharmacy schools in the United States. The survey defined lifestyle modification topics as topics that address nutrition, exercise, weight loss, smoking cessation, and alcohol use. RESULTS: Of 89 pharmacy schools contacted, 50 (56%) responded to the survey. Of the 50, four offer at least one required course in a lifestyle modification topic, seven offer at least one elective course, and one offers a required course that incorporates more than one lifestyle modification topic. Five required and nine elective courses were identified from the responses. Nutrition was the most commonly offered required course topic, followed by smoking cessation, exercise, weight loss, and alcohol use. CONCLUSION: Few pharmacy schools are addressing recommendations to promote public health education through formalized didactic courses. More courses on lifestyle modification topics should be offered to pharmacy students, who will be highly accessible to the public as pharmacists and will be able to offer education to enhance public health focused on the prevention of chronic diseases.

Cost of a pharmacist-directed intervention to increase treatment of hypercholesterolemia.

STUDY OBJECTIVE: To evaluate the cost of a pharmacist-directed intervention that prompts physicians to treat hypercholesterolemia more aggressively in patients with coronary heart disease (CHD). METHODS: Health care resource use and CHD outcomes were evaluated for 612 patients with CHD followed for 2 years after an index hospitalization for an ischemic event. After discharge, the physicians of 309 patients who had been admitted from January 1--March 31, 1999, were contacted by telephone and mail concerning lipid profiles and statin therapy. These patients were the intervention group. Controls were 303 patients admitted from October 1--December 31, 1998; their physicians were not contacted. Costs of the physician-prompting intervention, clinic visits, laboratory tests, statin drugs, and CHD outcomes were compared between these two patient groups. RESULTS: The number of clinic visits, laboratory tests, and statins prescribed was significantly greater for the intervention group versus the controls. A significantly higher percentage of patients in the intervention group (55%) than in the control group (18%) achieved their National Cholesterol Education Program target low-density lipoprotein cholesterol level and had significantly better CHD outcomes. The cost of the physician-prompting intervention (pharmacist salaries, postage, telephone calls) was $102,941. For patients in the intervention and control groups, respectively, the cost of statin therapy was $352,365 and $200,087, the cost of clinic visits and laboratory tests $48,097 and $27,367, and the cost of coronary heart disease outcomes, such as myocardial infarction, coronary artery bypass graft, percutaneous transluminal and coronary angioplasty, $1,073,495 and $1,741,220. The total cost was $1,576,898 and $1,968,674, respectively, for patients in the intervention and control groups. Net savings was $1394/patient over the 2-year period. CONCLUSION: A relatively simple physician-prompting intervention involving patients with CHD significantly improved the use of lipid testing and statin therapy. Improved use of statins was associated with better CHD outcomes. As a result, the physician-prompting intervention was associated with cost savings. This intervention should be implemented for patients with CHD discharged after hospitalization for an ischemic event.

Repeated testing to improve skills in a pharmacy practice laboratory course.

OBJECTIVE: To evaluate the impact of repeated simulations and testing on the pharmacy practice skills development of third-year doctor of pharmacy (PharmD) students. DESIGN: A pharmacy practice skills laboratory was redesigned to reinforce skills development and enhance retention. Timed, repeated learning experiences that increased in complexity throughout the semester were used to test student knowledge, skills, and abilities. ASSESSMENT: Over a 5-year period, scores from skills-based activities deemed essential to professional practice and repeated 4 or more times in the course were analyzed. There was a significant improvement in scores on drug utilization reviews and patient counseling simulations despite the increasing difficulty and complexity of the medication problems presented (p <0.001). Students' scores on prescription verification and sterile product verification also improved significantly over 3 assessments (p <0.001), but then plateaued, with less improvement seen in performance on subsequent assessments. CONCLUSION: Providing multiple opportunities for students to conduct or simulate pharmacy practice activities and then test their knowledge and skills improves students' learning and performance.

Development of a Composite Lifestyle Index and Its Relationship to Quality of Life Improvement: The CLI Pilot Study.

An important component to optimal health is quality of life (QOL). Several healthy lifestyle behaviors have independently shown to improve QOL. The simultaneous implementation of multiple lifestyle behaviors is thought to be difficult, and the current literature lacks the assessment of multiple lifestyle behaviors simultaneously with respect to the effect on QOL. This current pilot study sought to develop a method to quantify multiple lifestyle behaviors into a single index value. This value was then measured with QOL for a possible correlation. The results showed that it is possible to convert multiple raw healthy lifestyle data points into a composite value and that an improvement in this value correlates to an improved QOL. After 12 months of participation in a cardiovascular risk reduction program, study participants (N = 35) demonstrated a 37.4% (P < 0.001) improvement in the composite lifestyle index (CLI). The improved CLI demonstrated a correlation with a statistically significant improvement in how participants rated their overall health in 12 months (r = 0.701, P < 0.001) as well as the number of self-reported unhealthy days per month in 12 months (r = -0.480, P = 0.004).

An evidence-based review of fat modifying supplemental weight loss products.

Objective. To review the literature on fat modifying dietary supplements commonly used for weight loss. Methods. Recently published randomized, placebo-controlled trials were identified in PubMed, MEDLINE, International Pharmaceutical Abstracts, Cochrane Database, and Google Scholar using the search terms dietary supplement, herbal, weight loss, obesity, and individual supplement names. Discussion. Data for conjugated linoleic acid (CLA), Garcinia cambogia, chitosan, pyruvate, Irvingia gabonensis, and chia seed for weight loss were identified. CLA, chitosan, pyruvate, and Irvingia gabonensis appeared to be effective in weight loss via fat modifying mechanisms. However, the data on the use of these products is limited. Conclusion. Many obese people use dietary supplements for weight loss. To date, there is little clinical evidence to support their use. More data is necessary to determine the efficacy and safety of these supplements. Healthcare providers should assist patients in weighing the risks and benefits of dietary supplement use for weight loss.

Educational technology use among US colleges and schools of pharmacy.

OBJECTIVE: To develop a searchable database of educational technologies used at schools and colleges of pharmacy. METHODS: A cross-sectional survey design was used to determine what educational technologies were being used and to identify an individual at each institution who could serve as an information resource for peer-to-peer questions. RESULTS: Eighty-nine survey instruments were returned for a response rate of 75.4%. The resulting data illustrated the almost ubiquitous presence of educational technology. The most frequently used technology was course management systems and the least frequently used technology was microblogging. CONCLUSIONS: Educational technology use is trending toward fee-based products for enterprise-level applications and free, open-source products for collaboration and presentation. Educational technology is allowing educators to restructure classroom time for something other than simple transmission of factual information and to adopt an evidence-based approach to instructional innovation and reform.

Impact of statin use on heart failure mortality.

BACKGROUND: There is conflicting data regarding the mortality benefit of statins in patients with heart failure. The objectives of our study were to determine whether statin therapy is associated with decreased all-cause mortality and to assess the effect of incremental duration of therapy. METHODS: We studied 10,510 consecutive patients from the Veterans Affairs health system with a diagnosis of heart failure from January 2002 through December 2006. Mean follow-up was 2.66 years. Statin use and duration of therapy were identified. Veterans were classified into four groups based on duration of statin use during the study period (none, 1-25%, 26-75% and >75% use of statins). Logistic regression was performed to identify the association between incident statin use and all-cause mortality following a diagnosis of heart failure. The Kaplan-Meier method was employed to assess for differences in survival time between the four statin use classifications. RESULTS: Statin use was significantly associated with decreased all-cause mortality following a diagnosis of heart failure after controlling for age, gender, concurrent medications and comorbid diagnoses [χ(3)(2) (N = 10,510) = 1077.82, p < 0.001]. The benefit was seen within a relatively short duration (within 1 year) after starting statins, and in patients with <25% use of statins, there was no mortality benefit. CONCLUSION: Veterans who were not exposed to statin therapy at any time during the study period were 1.56 times more likely to suffer all-cause mortality.

Faculty and student expectations and perceptions of e-mail communication in a campus and distance doctor of pharmacy program.

OBJECTIVE: To examine faculty members' and students' expectations and perceptions of e-mail communication in a dual pathway pharmacy program. METHODS: Three parallel survey instruments were administered to campus students, distance students, and faculty members, respectively. Focus groups with students and faculty were conducted. RESULTS: Faculty members perceived themselves as more accessible and approachable by e-mail than either group of students did. Campus students expected a shorter faculty response time to e-mail and for faculty members to be more available than did distance students. CONCLUSION: E-mail is an effective means of computer-mediated communication between faculty members and students and can be used to promote a sense of community and inclusiveness (ie, immediacy), especially with distant students.

Effectiveness of human anatomy education for pharmacy students via the Internet.

OBJECTIVE: To evaluate the overall effectiveness of a human anatomy course taught to distance-based and campus-based pharmacy students. DESIGN: A retrospective analysis of students' grades and course evaluations from 2003 through 2006 was conducted. ASSESSMENT: No significant differences in student performance by pathway were found for the 2003-2005 academic years (p > 0.05). However, distance-based students' percentage and letter grades were significantly higher in 2006 (p = 0.013 and p = 0.004 respectively). Comparison of course and instructor evaluations showed that students in the distance course held similar or more positive perceptions of the course than their campus peers. CONCLUSIONS: Similar performance by campus and distance students enrolled in a human anatomy suggests that a distance-based course can be used successfully to teach human anatomy to pharmacy students.

Use of a multidisciplinary tool to achieve target outcomes in Native American patients with diabetes: Treat-to-target.

PURPOSE: Our purpose was to test a communication tool used in a multidisciplinary setting to more effectively achieve the recommended goals for glucose, blood pressure, lipids, and prophylactic aspirin use in a Native American population with type 2 diabetes. METHODS: One hundred randomly selected patients were included in this observational, pre-intervention, post-intervention study design. The team began with a chart audit documenting hemoglobin A(1c) (Hgb A(1c)), blood pressure, cholesterol levels, and aspirin use. The intervention included the development of a one page form used to prompt providers to intensify therapy when the patient was not meeting evidence-based goals. The audit was repeated one year later. RESULTS: Analysis of 74 patients completing the study showed a decrease in Hgb A1C from 8.812% pre-intervention to a mean 8.214% post-intervention (p < 0.007). At the time of pre-intervention audit, patients were already at target for blood pressure and no significant further decrease was found. Measures of total cholesterol, triglycerides, and aspirin use showed improvement, but statistical significance was not met. CONCLUSION: The one-page multidisciplinary tool used to intensify therapy significantly improved glucose control. More consistent interaction of the multidisciplinary team is necessary to reach other desired goals.

Using performance-based assessments to evaluate parity between a campus and distance education pathway.

OBJECTIVES: To compare the performance of campus-based students with that of distance students during the first 2 years of a doctor of pharmacy program to evaluate parity between the pathways. METHODS: Twelve cases were created for each year of the program along with performance criteria. The cases were converted into computer-based simulations for programmatic assessment at the end of the 2002-2003 and 2003-2004 school years. All first-professional year (P1) and second-professional year (P2) students participated in the assessments. Overall class means were calculated and used to compare student performances between campus and distance education pathways. RESULTS: Overall scores for the 2003 P1 class were 56.4% for the campus-based students and 62.4% for the distance students, (p = 0.002); overall scores for the 2003 P2 class were 48.8% and 55.5%, respectively (p < 0.0001). The 2004 overall scores for P1 campus and distance students were 59.0% and 65.7%, respectively, (p = 0.001); and for 2004 P2 scores the results were 51.8% and 56.5%, respectively (p = 0.049). CONCLUSIONS: Students receiving their pharmacy education via a distance pathway scored higher on performance-based assessments compared with students receiving their pharmacy education via the traditional campus-based pathway. This indicates that distance students are receiving at least an equivalent curricular experience in the P1 and P2 years compared to that received by campus-based students.

Rhabdomyolysis associated with simvastatin-nefazodone therapy.

Simvastatin is a hydroxymethyl glutaryl coenzyme A reductase inhibitor commonly used to treat patients with hyperlipidemia. It is a safe and effective medication in most patients when used appropriately. A serious side effect known as rhabdomyolysis may rarely occur in patients who take simvastatin, especially at higher doses and with agents that interact and increase the level of simvastatin in the blood. We describe the case of a patient with rhabdomyolysis that occurred after the patient's simvastatin was titrated to 80 mg at approximately the same time that his antidepressant medication was switched to nefazodone. We found only two other similar cases in the literature, both of which were presented as letters to the editor in two different journals. We present this case to add to the literature and to assist practitioners by raising their awareness of this interaction so that it can be monitored.

Student understanding of the relationship between the health professions and the pharmaceutical industry.

BACKGROUND: Pharmaceutical sales representatives and direct-to-consumer advertising may influence physician practices, particularly prescribing. Identifying the relevant knowledge and attitudes students possess about the pharmaceutical industry may help professional curricula address these influences. PURPOSES: To assess knowledge and attitudes toward pharmaceutical industry marketing, ethical principles guiding drug company interactions, pharmaceutical sales representatives as a source of drug information, and confidence level in addressing consumers seeking a prescription from a direct-to-consumer advertisement among senior-level medical, PharmD, and nurse practitioner students. METHODS: A cross-sectional survey design was used to assess student knowledge and attitudes of four domains associated with the pharmaceutical industry. RESULTS: Significant deficiencies were noted in student knowledge of pharmaceutical marketing expenditures, professional ethics regarding interactions with drug companies, and accuracy of drug information from sales representatives. CONCLUSIONS: Health professional students' knowledge and attitudes toward the pharmaceutical industry are formed prior to graduation. Professional curricula must address the influences of sales representatives before postgraduate training.