Evaluation of anticholinergic burden of medications in older adults.

OBJECTIVES: To calculate and describe the anticholinergic burden of medications in community-dwelling older adults and to identify patient-specific risk factors. DESIGN: Descriptive cross-sectional study. SETTING: Cardinal Health Visiting Pharmacist Program, Columbus, OH, between August 2002 and August 2009. PARTICIPANTS: Community-dwelling adults 65 years or older who were referred through LifeCare Alliance (a provider of home-based senior services). INTERVENTION: Comprehensive medication review records from medication therapy management (MTM) activities were used to calculate the anticholinergic burden using the anticholinergic cognitive burden (ACB) scale for each patient. MAIN OUTCOME MEASURE: Proportion of older adults in the community with a clinically relevant anticholinergic burden (defined as ACB score ≥3). RESULTS: From 341 included records, ACB score was calculated for all patients and an ACB score of 3 or greater was identified in 47.8% (n = 163) of patients. The odds increased significantly as the number of prescription (odds ratio 1.23 [95% CI 1.14-1.32], P < 0.001] and over-the-counter (1.17 [1.02-1.33], P = 0.02] medications increased. The odds also were significantly greater for patients with hypertension (3.01 [1.73-5.21], P < 0.001) and depression (2.6 [1.14-5.9], P = 0.02). CONCLUSION: Nearly one-half of community-dwelling older adults had a clinically relevant ACB score of 3 or greater. The ACB score could be used as a component of MTM services in a variety of practice settings to identify older adults who are at higher risk for potential central and peripheral adverse effects related to cumulative anticholinergic activity of their medications. Additional research to measure the clinical impact of ACB assessment and modification is needed.

Practice-based research network as a research training model for community/ambulatory pharmacy residents.

OBJECTIVE: To describe our experience with a practice-based research training network (PBRTN) in a 1-year residency program. SETTING: Ohio State University in Columbus from 1997 to 2007. PRACTICE DESCRIPTION: The program includes two accredited postgraduate year 1 residencies and one postgraduate year 2 residency. Seven residents, 11 preceptors, and three faculty members participated during the time frame discussed in this article. Practice settings included three community sites and three ambulatory sites. PRACTICE INNOVATION: The PBRTN includes a residency director, a research director, preceptor and resident members, and research faculty. The group works collaboratively to meet training goals. The PBRTN maintains a project timeline, foundational training, and structured research development, implementation, and presentation phases. Each resident submits five required research products: abstract, grant, poster, podium presentation, and research manuscript. MAIN OUTCOME MEASURES: Quantitative measures included the number of abstracts, grants, and peer-reviewed publications over two time periods, one before and one after a deliberate attempt to increase the research focus of the residencies. The ratio of research products to number of residents was used as a measure of productivity. Postresidency career choice and postresidency publications are reported. RESULTS: Over a decade, the program has produced 37 graduates, 50 abstracts, 15 grants, and 12 peer-reviewed publications. The publication-to-resident ratio increased from 0.25 in the pre-emphasis period of 1997-2001 to 0.56 in 2002-2007, after the research focus was intensified. Of graduates, 38% are in faculty positions, with 48 postresidency publications. CONCLUSION: Use of a PBRTN has successfully provided research training and improved research outcomes for the program. This model could be implemented in other residencies.

Improving prescribing practices: A pharmacist-led educational intervention for nurse practitioner students.

BACKGROUND AND PURPOSE: To assess impact of a pharmacist-led educational intervention on family nurse practitioner (FNP) students' prescribing skills, perception of preparedness to prescribe, and perception of pharmacist as collaborator. METHOD: Prospective pre-post assessment of a 14-week educational intervention in an FNP program in the spring semester of 2014. Students participated in an online module of weekly patient cases and prescriptions emphasizing legal requirements, prescription accuracy, and appropriate therapy. A pharmacist facilitator provided formative feedback on students' submissions. Participants completed a matched assessment on prescription writing before and after the module, and a retrospective postsurvey then presurvey to collect perceptions. CONCLUSION: There was significant improvement in performance on error identification and demonstration of prescription elements from preassessment to postassessment (+17%, p < .001). The mean performance on both assessments was less than the 70% passing score. Students reported significant positive changes in perceptions, including all statements regarding their preparedness to prescribe and those addressing willingness to collaborate with pharmacists. IMPLICATIONS FOR PRACTICE: Formative education on prescribing enhanced students' understanding of safe and effective medication use with improved recognition and avoidance of prescribing errors, although it did not result in competency. Exposure to pharmacist expertise in this area may encourage collaboration in practice.

Impact of disease states on the pharmacokinetics and pharmacodynamics of angiotensin-converting enzyme inhibitors.

The pharmacokinetics and pharmacodynamics of angiotensin-converting enzyme inhibitors (ACE) in elderly patients and patients with renal and hepatic impairment were examined, and a role for an AUC/EC50 ratio to guide dosing was evaluated. A Medline and International Pharmaceutical Abstracts search was used to identify human studies and abstracts. Relevant data were evaluated and summarized. Dosing regimens were compared using an AUC/EC50 ratio. Most studies evaluating ACE inhibitors in renal impairment report a strong linear correlation between creatine clearance and drug elimination. AUC and EC50 values for these drugs in elderly subjects appear similar to younger and hypertensive patients. There is increased AUC in some patients with hepatic impairment. Pharmacodynamic data are conflicting. Prolonged ACE inhibition is evident in renal impairment but not necessarily other disease states. ACE inhibitor dosing for hypertension is reasonable based on pharmacokinetics and EC50 values. Further individualization of therapy may improve outcomes, and using the threshold AUC/EC50 ratio may help guide appropriate dosing.

Caring for patients with chronic kidney disease: a joint opinion of the ambulatory care and the nephrology practice and research networks of the American College of Clinical Pharmacy.

An increasing number of patients are developing chronic kidney disease (CKD). Appropriate care for patients with CKD must occur in the earliest stages, preferably before CKD progresses to more severe stages. Therefore, recognition and treatment of CKD and its associated complications must occur in primary care settings. Patients with CKD often have comorbid conditions such as diabetes mellitus, hypertension, and dyslipidemia, creating specific considerations when treating these diseases. Also, these patients have CKD-related conditions, including anemia and renal osteodystrophy, that are not traditionally evaluated and monitored by the primary care practitioner. Collectively, many opportunities exist for pharmacists who practice in the primary care setting to improve the care of patients with CKD.

Pharmacy residents' pursuit of academic positions.

OBJECTIVE: To describe pharmacy residents' interest in and pursuit of academic positions. METHODS: An electronic presurvey and postsurvey were sent to pharmacy residents during the 2011-2012 residency year. The initial survey evaluated residents' job preferences and interest in academia at the beginning of residency, and the follow-up survey focused on job selection and reasons for pursuing or not pursuing positions in academia. RESULTS: Nine hundred thirty-six residents responded to the initial survey and 630 participated in both the initial and follow-up survey. Forty-eight percent of those responding to both surveys strongly considered a career in academia in the initial survey, 28% applied for an academic position, and 7% accepted a position. Second-year postgraduate residents were more likely than first-year postgraduate residents to apply for and be offered a faculty position. CONCLUSION: Pharmacy residents are interested in academia. While increasing interest among residents is encouraging for faculty recruitment, the academy should also encourage and develop adequate training experiences to prepare residents to succeed in these positions.

Effect of phosphate binders on supplemental iron absorption in healthy subjects.

A single-dose, prospective, randomized, four-treatment, four-period crossover study was conducted to determine the acute effect of therapeutically equivalent doses of three commonly used phosphate binders on oral iron absorption. Twenty-three healthy subjects received 65 mg of elemental iron alone and with each phosphate binder (calcium carbonate 3000 mg, calcium acetate 2668 mg, or sevelamer HCl 2821 mg). Area under the change in plasma iron concentration-time curve over 6 hours postdosing was measured. ANOVA was used to assess the statistical significance of differences in iron absorption among the treatments. The relative bioavailability of iron administered with each phosphate binder compared to iron administered alone was estimated. The relative iron bioavailabilities (95% confidence intervals) for the calcium carbonate, calcium acetate, and sevelamer HCI treatments were 0.81 (0.70, 0.94), 0.73 (0.63, 0.85), and 0.90 (0.78, 1.05), respectively. Thus, single doses of both calcium-based phosphate binders significantly reduced single-dose iron absorption, while sevelamer HCl did not.

Student-peer mentoring on a drug information response.

OBJECTIVE: To implement a student peer-mentoring program with a drug information response assignment in an introductory pharmacy practice course. DESIGN: Second-year student pharmacists (P2 mentors) enrolled in an independent study course were randomly assigned first-year student pharmacists (P1 mentees) to mentor on a drug information assignment. The P2 mentors provided feedback to P1 mentees' assignment drafts. The P1 mentees had the opportunity to revise the draft prior to turning in the completed assignment to course faculty members for grading. ASSESSMENT: Both P1 mentees and P2 mentors agreed the mentorship improved their ability to prepare a drug information response (76% and 100%, respectively). A majority of the student pharmacists would choose to be involved in the program again. CONCLUSION: The student peer-mentoring program was successful in improving student pharmacists' perceptions of ability to compose a drug information response.

Bispectral index values, sedation-agitation scores, and plasma Lorazepam concentrations in critically ill surgical patients.

BACKGROUND: Publications on the use of the bispectral index for sedation monitoring in the intensive care unit are increasing. However, few studies have involved correlation of bispectral index with serum drug concentrations. OBJECTIVES: To assess the degree of correlation between bispectral index values, scores on the Sedation-Agitation Scale, and steady-state serum concentrations of lorazepam. METHODS: A prospective open-label study of patients in a surgical intensive care unit who were receiving mechanical ventilation and continuous infusions of lorazepam for more than 24 hours. Bispectral index was measured (BIS-XP, Aspect Medical, Norwood, Massachusetts) to assess patients' sedation. Sensors were applied and values recorded before and after stimulation (endotracheal suctioning). Concomitant plasma samples were obtained to measure lorazepam concentration and scores on the Sedation-Agitation Scale were recorded. RESULTS: Sixteen patients were studied. Correlations between plasma concentrations of lorazepam and measurements of bispectral index for 1, 2, and 3 minutes before endotracheal stimulation were poor (0.21, 0.29, and 0.25, respectively). Correlation of peak values for bispectral index (after stimulation) with plasma concentrations of lorazepam was 0.29. Correlations of scores on the Sedation-Agitation Scale with the aforementioned values for bispectral index were similarly poor. Area under the curve for bispectral index values also correlated poorly with plasma concentration of lorazepam (0.19) and score on the Sedation-Agitation Scale (0.10). CONCLUSIONS: The correlation between bispectral index and score on the Sedation-Agitation Scale was poor. Correlation between bispectral index and plasma concentration of lorazepam was modestly better, but insufficient for clinical utility.

Risk factors and complications of subconjunctival hemorrhages in patients taking warfarin.

OBJECTIVES: The aim of this study was to identify patients with subconjunctival hemorrhage (SCH) on warfarin therapy, to describe risk factors that may contribute to SCH development, and to identify complications related to SCH. METHODS: A retrospective chart review was conducted including patients treated at a university anticoagulation clinic over 2 years (4,334 patient visits). Data collection included patient demographics; international normalized ratios (INRs) before, at time of, and after SCH; risk factors for increased risk of bleeding; patient-reported complications related to SCH; recent changes in medication use; and warfarin dosage adjustments made in response to the event. The data were summarized using descriptive statistics and frequencies described as percentages. RESULTS: Fifteen SCH events were identified at an event rate of 0.35%. Two were excluded because of related surgeries near the time of SCH events. The average patient age was 67.3 years (range, 51 to 82). A total of 76.9% (n = 10) of patients had INRs within the goal range at the appointment before reporting the SCH. A total of 46.2% (n = 6) of patients reported alterations in medication regimens during the month preceding SCH. Various patient conditions were documented that may increase the risk of SCH development. No ophthalmic complications were associated with SCHs. CONCLUSIONS: An SCH event rate of 0.35% was identified. Many factors may have precipitated SCH; however, ophthalmic complications were uncommon.

Assessment of pharmacy faculty members' opinions regarding required postgraduate pharmacy residencies.

PURPOSE: Agreement between pharmacy faculty members and the American College of Clinical Pharmacy (ACCP) recommendations regarding the requirement of residency training to provide direct patient care or attain a position in academia is discussed. METHODS: Faculty members of the American Association of Colleges of Pharmacy participated in a survey administered by an online survey tool. The survey contained a variety of yes/no, multiple choice, and Likert scale questions. Participants were asked to disclose whether they agreed with the ACCP recommendations. Other data collected included faculty demographics, individual awareness of the ACCP position statement, and postgraduate training recommendations before receiving the survey. RESULTS: The survey was sent to 2414 faculty members, and 623 (26%) of those responded. A majority of the respondents (74.8%) identified themselves as pharmacy practice faculty. Of those who replied, 55.6% agreed that one year of residency training should be required to provide direct patient care. Approximately 64% agreed that a postgraduate year 1 residency should be required in order to be appointed as adjunct clinical faculty or preceptor of pharmacy students, while 50.1% agreed that two years of residency training should be required in order to be appointed to rank assistant professor. CONCLUSION: A slight majority of faculty members responding to this survey agreed with recommendations in a 2006 ACCP position statement that proposed requiring residencies for all pharmacy students graduating from pharmacy school in order to attain positions in academia or settings providing direct patient care.

Assessment of factors influencing community pharmacy residents' pursuit of academic positions.

OBJECTIVES: To determine the percentage of residents accepting faculty positions following completion of a community pharmacy residency program (CPRP) and identify influences to pursue/not pursue an academic career. METHODS: CPRP directors and preceptors across the United States were contacted and 53 community pharmacy residents were identified. The residents were invited to participate in surveys at the beginning and end of the 2005-2006 residency year. RESULTS: Forty-five residents (85%) completed the preliminary survey instrument and 40 (75%) completed the follow-up survey instrument. Of these, 36 completed both survey instruments. Initially, 28 (62%) respondents indicated a faculty position as one of their potential job preferences. After completing their residency program, 3 (8%) residents accepted faculty positions; and 3 (8%) others were awaiting offers at follow-up. Reasons for accepting a faculty position were positive teaching experiences and the influence of a mentor or preceptor. Reasons for not pursuing a faculty position included lack of interest, geographic location, disliked teaching experiences, lack of preparedness, and non-competitive salary. CONCLUSION: Many community pharmacy residents consider faculty positions early in their residency but few pursue faculty positions. CPRPs and colleges of pharmacy should work together to enhance residents' experiences to foster interest in academia.

An instructional seminar for online case-based discussions.

OBJECTIVE: To assess a training seminar developed to prepare pharmacy instructors to facilitate online discussions. DESIGN: A 2-part seminar was developed to train faculty members and teaching assistants to facilitate online case-based discussions. A preseminar survey instrument was distributed to potential attendees and a postseminar survey instrument was given to those who attended the seminar. ASSESSMENT: Twenty (91%) instructors completed the preseminar survey instrument. Eleven of these instructors attended at least 1 session of the seminar and indicated that the didactic and/or application portions were either "helpful" or "very helpful." These faculty members and teaching assistants also completed the postseminar survey instrument and conveyed a significant increase in level of comfort in their ability to facilitate online case-based discussions (p=0.004). The 3 most frequently perceived barriers to online teaching remained consistent despite training or teaching experience. CONCLUSIONS: After attending a training seminar and/or facilitating an online case discussion, participants' comfort level in their ability to teach online increased. Further study of the impact of faculty development programs on teaching effectiveness and student satisfaction with online pharmacy education is warranted.

Assessment for chronic kidney disease service in high-risk patients at community health clinics.

BACKGROUND: Chronic kidney disease (CKD) poses significant public health concerns. Early identification and interventions can help prevent or slow progression to end-stage renal disease. OBJECTIVE: To characterize CKD in high-risk indigent patients in a primary care setting and evaluate opportunities for pharmacists to work collaboratively with physicians to improve medication use and CKD patient outcomes. METHODS: Medical records of 200 patients with diabetes mellitus and/or hypertension were reviewed by the clinical pharmacist. Estimated glomerular filtration rate (creatinine clearance [Cl(cr)]) and urinalysis were used to identify and stage CKD according to published guidelines. Glycosylated hemoglobin concentrations and blood pressures were recorded. The pharmacist evaluated medications for possible drug-related problems (DRPs), made therapeutic recommendations, and evaluated the acceptance rate by physicians. RESULTS: One hundred nineteen patients met inclusion criteria, and a total of 68.9% met CKD criteria: stage 1, 16.0%; stage 2, 20.2%; stage 3, 25.2%; stage 4, 1.7%; stage 5, 0.8%; and not stageable, 5.0%. A total of 381 DRPs were identified, averaging 3.2 (1.7) per patient (range 0-11). The number of DRPs correlated with Cl(cr) (r = -0.25; p = 0.007). Therapeutic recommendations included change of drug, dose and/or interval adjustment of the current drug, discontinuation of nonsteroidal antiinflammatory drugs, additional laboratory monitoring, meeting goal blood pressure and glycosylated hemoglobin, adding renoprotective drug and/or low-dose aspirin, and nephrologist referral. Fewer than half (40.9%) of the recommendations were accepted or accepted with modifications, and an approximately equal percentage were not accepted by the physicians. CONCLUSIONS: CKD prevalence was high among the patients evaluated here. New guidelines are available to assist in managing CKD ambulatory patients. Pharmacist collaboration with physicians may optimize CKD screening in high-risk patients and improve medication usage.

Acute renal failure in hospitalized patients: part I.

BACKGROUND: Acute renal failure (ARF) is a common condition in hospitalized patients. Morbidity, mortality, and health resource use are considerable, but the true magnitude of the problem is not well described in the literature. OBJECTIVE: To provide a detailed discussion of the epidemiology, economic costs, and classification of ARF. DATA SOURCES: A MEDLINE search (1996-December 2001) was conducted using the search terms kidney and acute kidney failure: epidemiology, etiology, and drug therapy/drug effects. Bibliographies of selected articles were also examined to include all relevant investigations. Economic data were identified using the terms costs and cost analysis and cost of illness. STUDY SELECTION AND DATA EXTRACTION: Review articles, meta-analyses, and clinical trials describing epidemiology and classification of hospital-acquired ARF were identified. Results from prospective, controlled trials were given priority when available. CONCLUSIONS: ARF occurs in up to 25% of critically ill patients, resulting in significant morbidity and high mortality. Characterization of ARF is difficult due to multiple etiologic factors and variable definitions. Limited cost data describe the extensive economic burden associated with the disorder, although further pharmacoeconomic research is needed. Epidemiology and classification of ARF allow prospective management of at-risk patients.

Acute renal failure in hospitalized patients: part II.

BACKGROUND: Acute renal failure (ARF) is a common condition in hospitalized patients. Research has been unable to identify the optimal target for therapeutic intervention; hence, effective prevention of and/or treatment for ARF remain elusive. OBJECTIVE: To examine the usefulness of current and potential pharmacologic treatments in seriously ill, hospitalized patients. DATA SOURCES: A MEDLINE search (1996-June 2002) was conducted using the search terms kidney (drug effects) and acute kidney failure (drug therapy). Bibliographies of selected articles were also examined to include all relevant investigations. STUDY SELECTION AND DATA EXTRACTION: Review articles, meta-analyses, and clinical trials describing prevention of and treatment for hospital-acquired ARF were identified. Results from prospective, controlled trials were given priority when available. CONCLUSIONS: Appropriate management of ARF includes prospective identification of at-risk patients, fluid administration, and optimal hemodynamic support. Drug treatments, including low-dose dopamine and diuretics, have demonstrated extremely limited benefits and have not been shown to improve patient outcome. Experimental agents influence cellular processes of renal dysfunction and recovery; unfortunately, relatively few drugs show promise for the future.