Evaluation of Interprofessional Team Disclosure of a Medical Error to a Simulated Patient.

Objective. To evaluate the impact of an Interprofessional Communication Skills Workshop on pharmacy student confidence and proficiency in disclosing medical errors to patients. Pharmacy student behavior was also compared to that of other health professions' students on the team. Design. Students from up to four different health professions participated in a simulation as part of an interprofessional team. Teams were evaluated with a validated rubric postsimulation on how well they handled the disclosure of an error to the patient. Individually, each student provided anonymous feedback and self-reflected on their abilities via a Likert-scale evaluation tool. A comparison of pharmacy students who completed the workshop (active group) vs all others who did not (control group) was completed and analyzed. Assessment. The majority of students felt they had adequate training related to communication issues that cause medication errors. However, fewer students believed that they knew how to report such an error to a patient or within a health system. Pharmacy students who completed the workshop were significantly more comfortable explicitly stating the error disclosure to a patient and/or caregiver and were more likely to apologize and respond to questions forthrightly (p<0.05). Conclusions. This data affirms the need to devote more time to training students on communicating with patients about the occurrence of medical errors and how to report these errors. Educators should be encouraged to incorporate such training within interprofessional education curricula.

Roles of the pharmacist in the use of safe and highly effective long-acting reversible contraception: an opinion of the women's health practice and research network of the American College of Clinical Pharmacy.

The U.S. population continues to experience an alarmingly high rate of unintended pregnancies that have an impact on individual families and society alike. Lack of effective contraception accounts for most unintended pregnancies, along with incorrect use of contraceptives. The most common reversible contraceptive method used in the United States is the oral contraceptive pill, which has significant failure and discontinuation rates. Use of long-acting reversible contraceptive (LARC) methods has been increasing in recent years after efforts to educate providers and patients. Women are more likely to use LARC methods when barriers such as access and cost are removed. An uptake in the use of LARC methods would allow for markedly reduced contraception failure rates and higher user satisfaction and thus higher continuation rates than those seen with current contraception use. Promoting the use of LARC methods is an important strategy in improving both individual and public health outcomes by reducing unintended pregnancies. The pharmacist's role in family planning is expanding and can contribute to these efforts. Although knowledge regarding LARC has not been studied among pharmacists, a knowledge deficit exists among health care professionals in general. Thus pharmacist education and training should include LARC methods along with other contraceptives. The American College of Clinical Pharmacy Women's Health Practice and Research Network advocates for the pharmacist's role in the use of safe and highly effective LARC methods. These roles include educating patients, informing providers, facilitating access by providing referrals, and modifying institutional procedures to encourage provision of LARC methods.

Updates in hormonal emergency contraception.

In recent years, there have been many updates in hormonal emergency contraception. Levonorgestrel emergency contraception has been available for several years to prevent pregnancy when used within 72 hours after unprotected intercourse or contraceptive failure, and it was recently approved for nonprescription status for patients aged 17 years or older. Current research suggests that the primary mechanism of action is delaying ovulation. Ulipristal is the newest emergency contraception, available by prescription only, approved for use up to 120 hours after unprotected intercourse or contraceptive failure. The primary mechanism of action is delaying ovulation. When compared with levonorgestrel emergency contraception, ulipristal was proven noninferior in preventing pregnancy. Evidence suggests that ulipristal does not lose efficacy from 72-120 hours; however, more studies are warranted to support this claim. Many misconceptions and controversies about hormonal emergency contraception still exist. Research does not support that increased access to emergency contraception increases sexual risk-taking behavior. Several studies suggest that health care providers, including pharmacists, could benefit from increased education about emergency contraception. It is important for pharmacists to remain up-to-date on the most recent hormonal emergency contraception products and information, as pharmacists remain a major point of access to emergency contraception.

Osteoporosis treatment: an evidence-based approach.

Osteoporosis is a disease that results in decreased bone mass and quality of bone, which may lead to fracture. Clinicians need to counsel individuals on appropriate intake of calcium and vitamin D, increasing weight-bearing exercise, limiting alcohol and caffeine, and avoiding smoking. A variety of nonhormonal pharmacological options are available for prevention and treatment of osteoporosis, including bisphosphonates, calcitonin (Miacalcin®), raloxifene (Evista®), teriparatide (Forteo®), and denosumab (Prolia®). The National Osteoporosis Foundation and the American Association of Clinical Endocrinologists have recently published new guidelines, and it is important for clinicians to be familiar with the evidence behind each of these treatment modalities. It is paramount for nurses to make evidence-based, cost-effective decisions about pharmacological therapy based on individual patient-specific factors.

Evaluation of compliance with osteoporosis treatment guidelines after initiation of a pharmacist-run osteoporosis service at a family medicine clinic.

BACKGROUND: Osteoporosis affects more than 10 million Americans, and fracture complications are devastating to patients and society. Despite the availability of guidelines and performance measures, osteoporosis is not optimally managed. Pharmacists have been pivotal in management of other disease states, and a multidisciplinary approach to osteoporosis management may improve patient outcomes. OBJECTIVE: To establish a pharmacist-run osteoporosis service at a family medicine clinic and to evaluate short-term compliance with osteoporosis treatment guidelines before and after initiation of the service. METHODS: A pharmacist-run osteoporosis service was established in October 2008. Adults with the diagnosis of osteoporosis before initiation of the service were included in evaluation of short-term compliance with treatment guidelines, including appropriate dual-energy X-ray absorptiometry (DEXA) scan frequency, pharmacotherapy, calcium and vitamin D supplementation, and nonpharmacologic education. Of 42 referred patients, 22 were eligible for inclusion. A retrospective chart review was conducted, and patients served as their own controls, with data from before and after establishment of the service evaluated. RESULTS: Of the 22 patients evaluated, 8 (36%) received DEXA scans at the appropriate frequency before the service was established, versus 18 (82%) after the service was initiated. Seven (32%) patients were taking appropriate pharmacotherapy before the service, versus 17 (77%) after the service. Nine (41%) patients were taking calcium and vitamin D before the service, versus 22 (100%) after the service. Three (33%) of these patients were taking the appropriate dose and salt of calcium before the service, versus 20 (91%) after the service. Five (56%) of the 9 patients were taking the appropriate vitamin D dose before the service, versus 21 (95%) after the service. No patient had documented nonpharmacologic education prior to the service, compared with all patients after the service. All differences were significant (p < 0.05). CONCLUSIONS: A pharmacist-run osteoporosis service significantly improved short-term compliance with guidelines, including appropriate DEXA scan frequency, pharmacotherapy, calcium and vitamin D supplementation, and nonpharmacologic education.

A method for educating patients and documenting smoking status in an electronic medical record.

BACKGROUND: Published evidence demonstrates benefit from pharmacist smoking cessation interventions; however, there is limited research evaluating the impact of a template within an electronic medical record used at pharmacy disease state management visits. OBJECTIVE: To determine the rates of smoking cessation and movement along the transtheoretical model of change after implementation of a template into existing pharmacy-related progress notes within the electronic medical record. METHODS: Patients who were routinely followed by clinical pharmacists for anticoagulation and diabetes mellitus education at 3 clinics at the Medical University of South Carolina were included. At each visit, the pharmacist would document patient smoking information in a newly designed template within the existing progress note. In addition, pharmacists would educate patients on the benefits of smoking cessation and pharmacologic options that may be available to them. Data were collected between April 2007 and March 2008. Baseline demographic data and smoking cessation rates and products were compared using descriptive statistics. The McNemar chi(2) test was used to compare the groups of patients achieving smoking cessation pre- and postintervention. RESULTS: Of the 90 current smokers, 38 (42%) achieved smoking cessation postintervention. Movement along the transtheoretical model of change was also seen, with 52 (58%) patients progressing to at least the next stage. Thirty-four patients in the contemplation/preparation stage and 4 patients in the precontemplation stage moved to the action or maintenance stage by the end of the study period (p = 0.03). A variety of pharmacologic therapies were used in individuals who stopped smoking, although varenicline was most common. Thirty-nine percent of the patients used no medications to achieve cessation. CONCLUSIONS: Incorporating a smoking cessation template into existing progress notes and providing education during existing pharmacy referral visits is a simple and effective method to assist patients in achieving smoking cessation.

Compliance with osteoporosis treatment guidelines in postmenopausal women.

BACKGROUND: Osteoporosis continues to be poorly managed despite compelling statistics indicating increased morbidity and mortality associated with fractures. Guideline compliance in individual practices must be evaluated to implement improvements in the care of patients with this disease state. OBJECTIVE: To evaluate compliance with osteoporosis treatment guidelines by physicians and patients at 2 family medicine clinics affiliated with a large university teaching hospital. METHODS: Postmenopausal women 65 years of age or older with the ICD-9 diagnosis code 733.0 for osteoporosis during the study period between July 2006 and July 2007 were identified through the family medicine electronic medical record (EMR). Of 133 patients, 113 were eligible for inclusion. A retrospective chart review was conducted and prospective voluntary telephone surveys were administered. The EMR of each eligible patient was examined for presence of a baseline dual-energy X-ray absorptiometry (DXA) scan as well as appropriate follow-up DXA monitoring, appropriateness of osteoporosis pharmacotherapy, calcium and vitamin D supplementation, and fracture history. The telephone survey was used to assess the patients' calcium use, nonpharmacologic recommendations received, and fracture incidence after diagnosis of osteoporosis. RESULTS: Of 113 patients diagnosed with osteoporosis, 68 of 82 (82.9%) had appropriate baseline DXA scans; however, only 9 (13.2%) of these 68 patients had appropriate follow-up scans every 2 years thereafter. Sixty-five (57.5%) patients were on Food and Drug Administration-approved, guideline-endorsed pharmacotherapy for osteoporosis. Thirty-five (70%) of the 50 participants in the telephone survey reported taking calcium regularly, and 41 (82%) patients recalled receiving some nonpharmacologic advice. Thirteen (26%) patients reported a fracture after diagnosis. CONCLUSIONS: Osteoporosis care can be measurably improved at these clinics with use of baseline and appropriate follow-up DXA scans, increasing the number of patients who receive pharmacotherapy, and providing ongoing reinforcement of nonpharmacologic measures whereby bone health may be maintained.

Extended- and continuous-cycle oral contraceptives.

Five new oral contraceptives, classified as extended- or continuous-cycle oral contraceptives, have been approved by the United States Food and Drug Administration. These agents have various combinations of estrogen and progestin, and different effects on the length of women's menstrual cycles. Usually they shorten the duration of menses, decrease the frequency of menses to 4 times/year, or completely eliminate menses. These new oral contraceptives are given in the following regimens: 24 days followed by placebo for 4 days (24/4), 84 days followed by placebo for 7 days (84/7), or continuously (without placebo). These agents contain ethinyl estradiol 20 microg-drospirenone 3 mg (24/4); ethinyl estradiol 20 microg-norethindrone 1 mg (24/4); ethinyl estradiol 30 microg-levonorgestrel 150 microg (84/7); ethinyl estradiol 30 microg-levonorgestrel 150 microg (84/7) with very low-dose ethinyl estradiol (10 microg/day) for 7 days; and ethinyl estradiol 20 microg-levonorgestrel 90 microg continuously. Clinical trials have demonstrated that extended- and continuous-cycle oral contraceptives are as effective in preventing pregnancy as traditional oral contraceptives. These new agents also have similar adverse effects; however, the only significantly different adverse effect compared with traditional oral contraceptives in clinical trials was change in bleeding pattern. These oral contraceptives are associated with more breakthrough bleeding and spotting than the traditional pills. Long-term effects on efficacy and safety are not known, as these new products generally have been used for only 1-2 years. Extended- and continuous-cycle oral contraceptives are a new option for women desiring decreased menses or for whom decreased menses may alleviate symptoms of coexisting medical conditions.

Life after the women's health initiative: evaluation of postmenopausal symptoms and use of alternative therapies after discontinuation of hormone therapy.

STUDY OBJECTIVE: To determine the number of women who have menopausal symptoms after discontinuing hormone therapy, to determine how many of these women subsequently require nonhormonal alternatives to manage their symptoms, and to assess the effectiveness of those therapies. DESIGN: One-year retrospective study. SETTING: Department of Family Medicine outpatient clinic at a university medical center. PATIENTS: From 378 postmenopausal women who discontinued hormone therapy between August 1, 2002, and August 31, 2003, we randomly selected 78 using electronic medical records to provide a sample with a 95% confidence interval and a 10% margin of error. MEASUREMENTS AND MAIN RESULTS: Reasons why the women discontinued therapy and any nonhormonal alternative therapies that they may have used to manage subsequent menopausal symptoms were recorded. The primary investigator contacted the 78 women to complete a telephone survey. In most women, at least one menopausal symptom recurred. Vasomotor symptoms (hot flashes) were most common and occurred in 41 (53%) women. In addition, 59 (76%) women reported using nonhormonal alternative therapies, and 40 (68%) of this group deemed the alternatives helpful. CONCLUSION: We strongly believe that health care providers, including pharmacists, must continue to communicate with and educate women regarding treatment options for menopausal symptoms. Clinical pharmacists are ideally suited to contribute to ongoing research in this area.

Parathyroid hormone (1-84) and treatment of osteoporosis.

OBJECTIVE: To present the chemistry, pharmacology, and pharmacokinetics of parathyroid hormone (PTH) (1-84) and review the available clinical trials that evaluate its efficacy and safety; clinical applicability of this agent and its relationship to other Food and Drug Administration (FDA)-approved medications for treatment of osteoporosis are also discussed. DATA SOURCES: A MEDLINE search (1996-December 2004) was completed, along with a review of information obtained from the manufacturer, NPS Pharmaceuticals. Key search terms included parathyroid hormone, PTH (1-84), and ALX 111. STUDY SELECTION AND DATA EXTRACTION: Studies were selected based on their relevance and availability. Pertinent information, including objectives, design, demographics, outcomes, adverse events, dosing strategies, and therapeutic controversies, was extracted. DATA SYNTHESIS: PTH (1-84) is being developed for treatment of osteoporosis. Recent studies have shown that, when administered intermittently as a subcutaneous injection, PTH (1-84) produces an increase in bone mineral density and prevents vertebral fractures. The fact that this agent contains the C-terminal region of PTH may differentiate it from PTH (1-34), teriparatide, which is approved by the FDA for treatment of osteoporosis. Further trials are necessary to determine the role of PTH (1-84) in combination with other treatments for osteoporosis and/or the order in which PTH (1-84) is given with these other agents. There are currently no comparative trials with other osteoporosis treatment modalities. CONCLUSIONS: PTH (1-84), when given intermittently as a subcutaneous injection, appears to be a safe and efficacious treatment option for osteoporosis. Further trials are needed to determine its specific place in therapy compared with other treatment options.

Azithromycin and warfarin interaction.

A 57-year-old Caucasian woman came to the clinic with symptoms of an upper respiratory tract infection. She was treated with a 5-day course of oral azithromycin 500 mg on day 1, then 250 mg/day for 4 days. During this period, the patient decreased her cigarette smoking from 1 pack/day to 1 pack every 3 days. No additional confounding variables were present. Two days after the completion of therapy, her international normalized ratio (INR) was 8.32. Six case reports documented in the literature have suggested an azithromycin-warfarin interaction with a resultant increase in INR. Many confounding variables existed in each of these cases, such as hepatic dysfunction, poor appetite, and concomitant drugs that resulted in an increased anticoagulant response. We report a case that involved only one potential confounding variable. Continued documentation of azithromycin-warfarin interactions is valuable considering no mention of this drug interaction exists in most tertiary references and in the package insert for azithromycin, the demonstration that no drug interaction occurred in a retrospective review of 52 cases, and the widespread use of azithromycin in the community. Clinicians should be mindful when prescribing azithromycin in combination with warfarin, and INR values should be monitored.