Review of Objective Structured Clinical Examination Practices Within Pharmacy Programs Throughout the United States.

OBJECTIVE: To update the description of current objective structured clinical examination (OSCE) practices within pharmacy schools in the United States and identify barriers to OSCE implementation and expansion. METHODS: A survey was deployed to all accredited Doctor of Pharmacy programs within the United States. The survey was designed to collect information regarding the curricular mapping of OSCEs, OSCE design, OSCE delivery, assessment of OSCE performance, and barriers to OSCE implementation and expansion. RESULTS: Of the 135 US-accredited programs identified, 109 (81%) programs completed the survey. In total, 93 (85%) programs reported using OSCEs to assess students; however, implementation throughout the curriculum and current practices varied by institution. Most programs place OSCEs within specific courses (96%), with the applied skills coursework being the most used (80%). The most common number of OSCEs that occur throughout a curriculum is 6 (18%), however, 20 (22%) programs execute 10 or more OSCEs throughout their curriculum. Forty (43%) programs use OSCEs as high-stakes assessments where poor performance could prevent a student from progressing to advanced pharmacy practice experiences. Of the responding programs, over half (56%) use teaching objective structured examinations to enhance learning. Common barriers to OSCE expansion exist and are related to resource utilization. CONCLUSION: Significant expansion of OSCE development and implementation has occurred over the last decade. There is substantial variability in implementation and utilization among programs. Although standards of best practice for OSCEs exist for other health professions, best practices in pharmacy education have not been widely accepted or adopted.

Adherence to antihyperlipidemic medication and lipid control in diabetic Veterans Affairs patients with psychotic disorders.

BACKGROUND: Medication adherence for chronic medical illnesses has been studied extensively, but there is limited data evaluating medication adherence for comorbid medical illnesses in a psychiatric population. Furthermore, only one study has evaluated both medication adherence and clinical outcomes between the two populations. Examining medication adherence rates and clinical outcomes are important as chronic medical illnesses occur commonly in psychiatric patients, can be drug-induced, and have negative long-term consequences. OBJECTIVES: To compare antihyperlipidemic medication adherence and lipid control between individuals with psychotic disorders and those without a psychiatric illness. METHODS: This was a retrospective medical record review of 124 subjects with hyperlipidemia and diabetes (62 subjects with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched individuals without a psychiatric illness) receiving medical and psychiatric care through the Veterans Affairs Medical Center during 2008. Cumulative mean gap ratio (CMGR) was used to determine adherence. Lipid values were utilized to compare lipid control between groups. RESULTS: A significant difference in CMGR was detected. Subjects with psychotic disorders were without antihyperlipidemic therapy for 44 days compared with 62 days for the nonpsychiatric comparison group (P = 0.034). Antipsychotic adherent subjects (≥80% adherent) were more likely to adhere to their antihyperlipidemic medication (P = 0.0007). There were no significant differences between the groups for lipid control. CONCLUSION: Antihyperlipidemic medication adherence differed with the psychotic disorder group having fewer days without drug therapy. However, there was no significant difference in lipid control between subjects with a psychotic disorder and those without a psychiatric illness.

Implementation and evaluation of activities to foster a sense of community among pharmacy students.

INTRODUCTION: The purpose of this study was to investigate the association of a series of team-based instructional activities on students' sense of community for pharmacy students assigned to the main and distance program sites. MATERIALS AND METHODS: In conjunction with a teaching objective structured clinical examination (OSCE) conducted at the program's distance site, several team-based sense of community activities were completed. The classroom and school community inventory (CSCI) was adapted and administered to students prior to and following all learning activities to measure course and program sense of community. RESULTS: Pre- and post-surveys were completed by 116 students. Course and program sense of community significantly increased among students at the distance site (p = 0.007 and p = 0.008, respectively). No significant changes were found for students assigned to the main site. CONCLUSION: For programs with multiple sites, activities designed to enhance sense of community and conducted at the distance site are effective for students assigned to the distance site.

Maintenance of low-density lipoprotein goal with step-down pravastatin therapy.

STUDY OBJECTIVE: To determine whether patients who had achieved their National Cholesterol Education Program (NCEP)-derived goals for low-density lipoprotein (LDL) cholesterol with pravastatin would benefit from step-down therapy. DESIGN: Prospective, randomized, open-label study SETTING: Kansas City Veterans Affairs Medical Center. PATIENTS: One hundred four men who were taking pravastatin once/day and had maintained their NCEP-defined LDL goal for at least 3 months. INTERVENTION: Fifty-three patients were randomized to group 1, for which the dosing frequency was changed from daily to every other day, and 51 patients were randomized to group 2, for which the daily dose was halved. MEASUREMENTS AND MAIN RESULTS: Fasting lipid profiles and hepatic transaminase levels were analyzed at baseline, 2 months, and 4 months. Lifestyle, concomitant drug therapy, adverse events, weight, and compliance were noted at baseline and month 4. Thirty-one patients (58%) from group 1 and 22 patients (43%) from group 2 did not remain at their LDL goal after step-down pravastatin therapy Mean LDL at study end was 113 mg/dl for group 1 and 104 mg/dl for group 2 (p=0.04). CONCLUSION: More than half (51%) of the patients enrolled did not remain at their LDL goal with step-down pravastatin therapy Therefore, we do not recommend a step-down approach for patients who have achieved their LDL goals. If a clinician decides, however, to attempt dosage reduction, the preferred regimen appears to be to halve the current dose once/day (vs administering the current dose every other day). A fasting lipid profile should be evaluated at 2 months and 4 months after step-down therapy begins to ensure that desired outcomes are achieved.

A clinical comparison of calculated versus direct measurement of low-density lipoprotein cholesterol level.

STUDY OBJECTIVES: To determine if, and to what extent, the low-density lipoprotein cholesterol (LDL) level is underestimated when it is calculated by the Friedewald formula compared with the LDL level measured by a direct method. A secondary objective was to determine and compare the percentages of patients meeting LDL goal using each of these two methods. DESIGN: Retrospective chart review. SETTING: Kansas City Veterans Affairs Medical Center. SUBJECTS: Patients aged 18 years or older and whose laboratory results reflected a complete lipid profile for 1 year. MEASUREMENT AND MAIN RESULTS: Calculated LDL level (C-LDL) was derived using the Friedewald formula and was compared with Wako method-derived direct LDL level (D-LDL) to ascertain whether a positive correlation existed. The absolute difference between the methods for each sample was determined and compared overall and for various subgroups. The number of patient samples achieving National Cholesterol Education Program-defined LDL goal was determined and compared for both methods. A total of 20,224 lipid profiles were generated and 19,343 were included in the analysis. A strong correlation was found between D-LDL and C-LDL (r = 0.94). The absolute difference between the two methods demonstrated an underestimation of C-LDL of 19.5 +/- 11.8 mg/dl. The degree of underestimation increased as the triglyceride level increased (p < 0.05). Age within the fifth and sixth decades resulted in significantly higher differences compared with age in the eighth decade or greater (p < 0.05). Female sex and elevated body mass index also resulted in increased discrepancies between the two methods (p < 0.05 for both). Seventy-six percent of the lipid profiles were derived from patients with coronary heart disease (CHD) or a CHD risk equivalent. Approximately one half of these patients met their LDL goal when LDL level was measured versus calculated (p < 0.0001). CONCLUSION: When compared with D-LDL, an underestimation of approximately 20 mg/dl was found with C-LDL, resulting in a loss of LDL goal attainment for half of the patients with CHD or a CHD risk equivalent.

Clinical efficacy, tolerability, and cost savings associated with the use of open-label metronidazole plus ceftriaxone once daily compared with ticarcillin/clavulanate every 6 hours as empiric treatment for diabetic lower-extremity infections in older males.

BACKGROUND: Patients with diabetes mellitus, particularly those with poor glucose control, commonly experience various medical complications related to the disease (eg, renal impairment, decreased peripheral vascular circulation, suppressed immune function). Infections of the lower extremities can range from superficial cellulitis to ulcerative, deep soft-tissue infections to osteomyelitis that necessitates some degree of amputation. OBJECTIVE: This study compared the efficacy, tolerability, and cost differences associated with the use of metronidazole plus ceftriaxone (MTZ/CTX) given once daily with those of ticarcillin/clavulanate potassium (T/C) given every 6 hours in hospitalized older males with diabetic lower-extremity infections. METHODS: This prospective, open-label study was conducted at a Veterans Affairs Medical Center. Male patients with diabetes and a lower-extremity infection were randomized to receive MTZ/CTX 1 g once daily or T/C 3.1 g every 6 hours. Treatment success was determined at 96 hours or on discontinuation of antibiotic. Success was measured in terms of body temperature <38.3 degrees C (100.6 degrees F), normalization of the finger-stick blood sugar concentration, improvement in wound staging, or a white blood cell count <10,000 cells/mm3. Medication acquisition costs per treatment arm were calculated and compared. RESULTS: Seventy patients were enrolled in the study (36 MTZ/CTX, 34 T/C). The study population had a mean (SD) age of 63.8 (10.8) years, a duration of diabetes of 12.4 (9.1) years, 0.5 (0.7) diabetes-related comorbidities, and an initial creatinine clearance of 67.1 (26.0) mL/min. There were no significant differences between groups at randomization. At 96 hours, treatment success was achieved in 31 (86%) patients in the MTZ/CTX group, compared with 28 (82%) patients in the T/C group (P=NS). Twenty-six patients were considered successfully treated on the final day of therapy in both the MTZ/CTX group (72%) and the T/C group (76%) (P=NS). There were no significant differences in primary or secondary measures of success between the 2 groups. No single or multiple baseline factors predicted treatment success or failure. No patient experienced adverse events considered related to study medication. MTZ/CTX was associated with savings of $61.06 per hospital admission, or $2198.05 for all patients who received this combination. CONCLUSION: In this population of older males, once-daily MTZ/CTX was as well tolerated and effective as T/C in the treatment of diabetic lower-extremity infections and was associated with reduced institutional costs.

Admission variables predictive of academic struggle in a PharmD program.

Objective. To characterize and describe admission variables predictive of poor grade attainment by students in 2 pathways to a doctor of pharmacy (PharmD) program.Methods. A retrospective analysis of course grades of PharmD students admitted from 2000 to 2009 (N= 1,019) in the traditional degree pathway ("1 plus 5" degree program) and the provisional pathway (admitted directly from high school) was performed.Results. Four hundred three grades of D or less were earned by 183 (18%) students. There were more grades of D or less in the first pharmacy year. Receipt of an unsatisfactory grade was associated with all Pharmacy College Admission Test (PCAT) subcategory scores, PCAT composite score, cumulative prepharmacy coursework hours, prepharmacy grade point average (GPA), prepharmacy science and math GPA, and interview score for accepted students in the traditional pathway. For students in the provisional pathway, PCAT-quantitative analysis, PCAT composite score, prepharmacy cumulative GPA, prepharmacy science and math GPA, English American College Testing (ACT) score, and composite ACT score predicted poor grades. Conclusion. Admissions committees should heed PCAT scores and GPAs, regardless of program pathway, while progression committees should focus on early program coursework when designing strategies to optimize retention.

Medication adherence and glycemic control in patients with psychotic disorders in the Veterans Affairs healthcare system.

OBJECTIVE: To compare antihyperglycemic medication adherence and glycemic control between individuals with schizophrenia and related psychotic disorders and a nonpsychiatric comparison group. METHODS: This was a retrospective medical record review. A total of 124 subjects with diabetes (62 patients with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched patients without a psychiatric illness) receiving their medical and psychiatric care exclusively through the Kansas City Veterans Affairs healthcare system during 2008 were included in the study. Adherence to antihyperglycemic and antipsychotic medication was determined by refill records obtained through the computerized patient record system to calculate the cumulative mean gap ratio. Hemoglobin A1C values were utilized to compare glycemic control between groups and compared to glycemic goals established by diabetes treatment guidelines. RESULTS: Antihyperglycemic medication adherence was poor for both groups as approximately 60% of the psychotic disorder group and 75% of the nonpsychiatric comparison group were without antihyperglycemic medication for greater than 30 days during the 12-month period but adherence did not differ between the groups (p=0.182). Antipsychotic adherent subjects (≥80% adherent) were more likely to be adherent to their antihyperglycemic medication (p=0.0003). There were no significant differences between groups in glycemic control. CONCLUSIONS: Antihyperglycemic medication adherence and glycemic control was less than optimal for both groups. There were no significant differences in antihyperglycemic medication adherence and glycemic control between patients with a psychotic disorder and those without a psychiatric illness.

Irbesartan substitution for valsartan or losartan in treating hypertension.

OBJECTIVE: To determine whether subjects whose therapy was converted from losartan or valsartan to irbesartan maintained equivalent blood pressure measurements, determine the safety and tolerability of irbesartan in the veteran population, and assess the number of subjects attaining their goal blood pressure before and after conversion. METHODS: A retrospective review of medical records for subjects whose antihypertensive was converted to irbesartan was conducted. Demographic data were collected, and subjects' past medical histories were used to determine their goal blood pressure. Blood pressures were compared at baseline, 2 weeks, and 2 months after conversion to determine efficacy, and adverse effect occurrence was compared between visits to assess safety. RESULTS: Conversion was attempted in 79 subjects; 72 met the criteria for review. Mean baseline, 2-week, and 2-month blood pressures for all subjects were 143/74, 139/72, and 139/73 mm Hg, respectively (p values NS). The number of subjects achieving their goal blood pressure at each assessment visit was similar: 37.5% at baseline, 43.4% at 2 weeks, and 31.9% at 2 months. Thirteen of the 72 subjects discontinued irbesartan due to adverse events. CONCLUSIONS: Irbesartan is an appropriate substitution for valsartan or losartan.