Development and Implementation of Clinical Pharmacist Services Within an Integrated Medical Group.

BACKGROUND: In 2012, pharmacists were integrated into a medical group to provide direct patient care, drug information activities, and health care provider education. The medical group encompasses 40 primary care and 60 specialty offices in Virginia. OBJECTIVE: To describe the development and implementation of clinical pharmacist services integrated within a medical group. METHODS: Pharmacists' roles and responsibilities, type and number of patient encounters, and identification of strategies to facilitate implementation are described. RESULTS: From June 2012 to December 2014, pharmacists had 809 patient encounters, which included patient-centered education, medication consults, Medicare annual wellness visits, senior care visits, and comprehensive medication reviews. Pharmacists addressed 403 drug information requests from nurse navigators, providers, and administrators. Pharmacists also have roles in risk management, quality improvement initiatives, and operations that benefit the medical group. Strategies to facilitate implementation include working with organizational leadership, identifying a physician champion, and establishing credibility by being responsive to practice needs and responding to requests in a timely manner to build trust within the health care team. CONCLUSION: Integration of pharmacists within health care teams involves more than direct patient care activities. Pharmacists should be involved at the organizational level to have a broader impact on patient and practice levels.

A 68-year-old woman with multiple NSAID-induced adverse effects.

Common comorbid conditions such as atrial fibrillation, hypertension, congestive heart failure, and osteoarthritis put geriatric patients at risk for toxicity while using nonsteroidal anti-inflammatory drugs (NSAIDs). Concomitant medications also can contribute to complications associated with NSAID therapy. However, NSAID therapy is widely used for pain management in this patient population. This case describes a 68-year-old patient, with a history of hypertension and osteoarthritis, who presented with multiple NSAID-induced adverse effects. Upon admission to the hospital, this patient was found to have renal and hepatic failure, fluid overload, and electrocardiogram changes, most likely as a result of excessive naproxen ingestion. This patient also was taking hydrochlorothiazide and had not had any laboratory values drawn to monitor her medication regimen. Subsequently, she required hemodialysis and a long hospital course. Her hepatic failure, fluid overload, and electrocardiogram changes resolved with treatment. Multiple health care providers could have detected problems with this patient's pain management. Adverse events associated with NSAIDs can be prevented with patient monitoring and education. Health care providers also need education to learn how to optimize the pain management of their geriatric patients. Recommendations for preventing NSAID-induced adverse effects and for optimizing pain management are presented.

Nonhormonal alternatives for the treatment of hot flashes.

OBJECTIVE: To review the literature on clonidine, venlafaxine, selective serotonin reuptake inhibitors, and gabapentin for the treatment of hot flashes. DATA SOURCES: A MEDLINE search (January 1966-July 2003) was conducted to identify English-language literature available on the treatment of hot flashes that focused on clonidine, venlafaxine, selective serotonin reuptake inhibitors, and gabapentin. These articles, relevant abstracts, and additional references listed in articles were used to collect pertinent data. STUDY SELECTION: All controlled and uncontrolled trials were reviewed. DATA SYNTHESIS: In women unable or unwilling to take hormonal therapies, several nonhormonal alternatives have been evaluated in small controlled and uncontrolled trials. Oral and transdermal formulations of clonidine are moderately effective in reducing hot flashes. Results of studies evaluating venlafaxine, paroxetine, and gabapentin suggest greater reductions in hot-flash frequency and severity compared with those of clonidine. Fluoxetine appears to display a modest benefit compared with paroxetine, although no comparative trials have been conducted. Most women studied in these trials had a history of breast cancer, and many were taking concurrent tamoxifen. All of these agents were fairly well tolerated. CONCLUSIONS: Clonidine, venlafaxine, paroxetine, fluoxetine, and gabapentin are nonhormonal agents that have demonstrated efficacy in small controlled and uncontrolled trials in reducing hot flashes and should be considered in patients unwilling or unable to take hormonal therapies.

Newer insulin therapies for management of type 1 and type 2 diabetes mellitus.

OBJECTIVE: To provide an overview of type 1 and type 2 diabetes mellitus and review newer insulin therapies used to manage patients with diabetes. DATA SOURCES: A MEDLINE search covering articles published from 1985 to March 2003 was conducted to identify English-language literature available on the management of diabetes, specifically focusing on the newer insulin products insulin glargine and insulin aspart, and any other novel insulin therapies (Medical Subject Headings [MeSH] search terms used were: diabetes, insulin, insulin aspart, insulin glargine, inhaled insulin, intranasal insulin, oral insulin). These articles, abstracts, and data provided by the pharmaceutical manufacturers were reviewed to collect pertinent data. Additional references were obtained from the bibliographies of those publications. STUDY SELECTION: Human studies presenting safety or efficacy information on newer insulin formulations. DATA EXTRACTION: Specific insulin formulations were reviewed with regard to background information, pharmacokinetic data, relevant clinical studies, U.S. Food and Drug Administration-approved indications, dosing and administration, adverse effects, storage, cost, and role in therapy. DATA SYNTHESIS: Insulin therapy is essential in the management of patients with type 1 diabetes, as well as in many patients with type 2 diabetes. No single insulin product currently on the U.S. market mimics natural endogenous insulin secretion. Problems encountered with traditional insulin products include variable absorption, peaks leading to hypoglycemic events, troughs leading to inadequate duration of response, and difficulty accurately timing injections in relation to meals. Insulin analogs such as insulin glargine and insulin aspart have been synthesized in an effort to overcome those difficulties. Novel insulin formulations (oral, intranasal, and inhaled) are also in various stages of investigation. CONCLUSION: Insulin glargine and insulin aspart are two of the newest insulin products approved for managing diabetes mellitus. Clinical trials have shown that these agents may offer certain clinical benefits and conveniences for patients. These advantages, however, must be weighed against the increased cost of insulin glargine and insulin aspart relative to traditional insulins.

Utilization and outcomes of Missouri Medicaid's EHR: CyberAccess.

CyberAccess is MO HealthNet's web-based electronic health record solution. Our objective is to characterize the utilization of CyberAccess by physicians caring for MO HealthNet recipients. Our results demonstrate that the CyberAccess EHR solution for MO HealthNet has been a highly utilized tool in the care of its recipients.