Accountable care organizations: impact on pharmacy.

The Patient Protection and Affordable Care Act (PPACA) has considerably transformed the approaches being used to deliver health care in the United States. It was enacted to expand health insurance access, improve funding for health professions education, and reform patient care delivery. The traditional fee-for-service payment system has been criticized for overspending and providing substandard quality of care. The Accountable Care Organization (ACO) was developed as a payment reform mechanism to slow rising health care costs and improve quality. Under this concept, networks of clinicians and hospitals share responsibility for a population of patients and are held accountable for the financial and clinical outcomes. Due to high rates of medication misuse, nonadherence to therapeutic medication regimens, and preventable adverse drug events, pharmacists are in an ideal position to manage drug therapy and reduce health care expenditures; as such, they may be valuable assets to the ACO team. This article discusses the role of the pharmacist in the era of ACOs specifically and health care reform globally. It outlines pharmacy-related quality of care measures, medication therapy management (MTM) programs (which may provide the foundation for pharmacist involvement in ACOs), and pharmacist functions in patient-centered medical homes (through which ACO services may be organized). The article concludes with a description of successful ACO models that have incorporated pharmacists into their programs.

Shared trauma, resilience, and growth: A roadmap toward transcultural conceptualization.

Objective: Countless communities worldwide are exposed directly and subsequently to the effects of massive-scale collective stressors, from natural disasters to human-caused. In contexts of collective adversity, health care providers who are also members of these communities share and interdependently affect the range of responses their patients have. We aim to conceptualize this spectrum, termed shared trauma, shared resilience, and shared growth. Method: In this metasynthesis, we review the literature on these underacknowledged dynamics globally. We include prior conceptualizations of direct and indirect trauma, collective trauma, cultural context, and the COVID-19 pandemic toward clearer conceptualization of shared mental health in global collective stressor contexts. Results: Most trauma and resilience research focuses on prevailing concepts and measures with questionable cross-cultural applicability. These works usually center on acute, highly distressing threats to physical safety at the individual level. The scarce literature on shared trauma describes it as a rare phenomenon, entailing conflicting messages of narrative accounts within contexts of few cultures with medium to high degrees of individualism. There has been little consideration of other non-Western and indigenous communities with more collectivist values and collective trauma histories. There is limited understanding of these concepts as they pertain to the vast majority of cultures. As a result, shared trauma, resilience, and growth have been poorly conceptualized, differentiated, or empirically researched. Conclusions: We propose uniquely inclusive models of shared trauma, resilience, and growth. These models reflect the cumulative effects and interplay of direct to indirect, acute to chronic, individual to collective, and historic to transgenerational factors influenced by cultural context. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Oral glutamine for the prevention of chemotherapy-induced peripheral neuropathy.

OBJECTIVE: To evaluate the role of glutamine in the reduction of peripheral neuropathy associated with neurotoxic chemotherapy. DATA SOURCES: Relevant literature was accessed through PubMed (1990-May 2008), using the search terms glutamine, chemotherapy, peripheral neuropathy, neurotoxicity, safety, paclitaxel, platinum compounds, and vinca alkaloids. References in the identified articles were also reviewed for pertinent information. STUDY SELECTION AND DATA EXTRACTION: Studies evaluating the role of oral glutamine for prevention and treatment of chemotherapy-induced peripheral neuropathy (CIPN) were included. Studies regarding the role of glutamine in the reduction of other radiation- and chemotherapy-related toxicities, such as mucositis, cardiotoxicity, diarrhea, and cachexia, were excluded. DATA SYNTHESIS: CIPN is a significant adverse effect associated with neurotoxic chemotherapy, particularly with taxanes, platinum compounds, and vinca alkaloids. There is no standard therapy for the treatment of this dose-limiting reaction. Glutamine is a nonessential amino acid that is thought to have a neuroprotective role, possibly due to the upregulation of nerve growth factor. Two studies revealed that oral glutamine was effective in reducing peripheral neuropathy associated with high-dose paclitaxel, as evidenced by a reduction in numbness, dysesthesias, and motor weakness, as well as a smaller loss of vibratory sensation. Another study found that glutamine effectively reduced peripheral neuropathy in patients with colorectal cancer being treated with oxaliplatin, thereby decreasing the need for an oxaliplatin dose reduction. However, data are limited by small sample sizes in these studies and the lack of placebo-controlled, randomized clinical trials. CONCLUSIONS: Larger, well-designed, placebo-controlled trials assessing both safety and efficacy of oral glutamine are warranted before this agent can be definitively recommended for the prevention of CIPN in patients treated with high-dose paclitaxel or oxaliplatin.

Clinical response at Day 3 of therapy and economic outcomes in hospitalized patients with acute bacterial skin and skin structure infection (ABSSSI).

OBJECTIVE: The FDA recently issued guidance for the types of infections that should be included in trials to support an indication for antibacterial treatment. The latest FDA guidance recommends assessing response to drug therapy at 48 to 72 hours as the primary endpoint in clinical trials. This study evaluated clinical and economic outcomes among acute bacterial skin and skin structure infections (ABSSSI) patients hospitalized at a 3000-bed healthcare system in New Jersey. RESEARCH DESIGN AND METHODS: In this retrospective cohort analysis, adult ABSSSI patients hospitalized between July 2010 and December 2011 were stratified based on infection type: cellulitis/erysipelas and major cutaneous abscess, wound infection, and all ABSSSI. Initial antibiotic therapy was assessed by individual agent, regimen, and MRSA coverage. Day 3 response to initial antibiotic therapy was evaluated based on temperature and lesion cessation outcomes; clinical response rates were assessed by initial therapy and pathogen for each cohort. The impact of response on length of stay (LOS), cost of care, and antibiotic treatment duration were also evaluated. RESULTS: Commonly used antibiotics included vancomycin, cefazolin, piperacillin-tazobactam, and ampicillin-sulbactam; over 40% of patients received empiric therapy with activity against MRSA. Clinical non-response to initial antimicrobial therapy at Day 3 was 39.9%, 30.3%, and 60.7%, for all ABSSSI, cellulitis/abscess, and wound infection patients, respectively. The cost of care among non-responders was over 1.5 times that of responders (p < 0.0001). Non-response to initial therapy was associated with a 3.7 day increase in duration of antibiotic treatment (p < 0.0001). CONCLUSIONS: Results of this study demonstrate that a significant percentage of ABSSSI patients, particularly those with wound infection, were not achieving clinical response at Day 3 of therapy. Failure to respond to drug therapy is associated with substantial increases in LOS, antibiotic treatment duration, and cost of care. LIMITATIONS: This had the inherent limitations associated with a retrospective chart review; because data was initially collected for clinical rather than research purposes, certain information may have been absent, incomplete, or missed by data abstractors.