Determining essential elements and functionalities for a patient record system in community pharmacy.

BACKGROUND: As community-based pharmacy continues to evolve from a focus on product distribution to a practice focused on patient care, a key requirement is for pharmacists to document their patient care activities. Some community-based pharmacies are working to routinely use the Pharmacist eCare Plan standard in documenting their new care activities. OBJECTIVES: With the need for a robust patient record in community-based pharmacies, the purpose of this study was to identify key elements and functionalities for a community-based pharmacy patient record. METHODS: An expert panel of 26 individuals participated in 3 rounds of surveys using an online Delphi method to develop consensus about the key data elements and functionalities for a pharmacy patient record system. RESULTS: A total of 46 items reached consensus: 16 as essential elements for a longitudinal pharmacy patient record, 7 as essential elements for a patient encounter, and 23 functionalities for a pharmacy patient record system. A rubric was developed to assess community-based pharmacy patient record systems. CONCLUSION: The functionalities can support pharmacists in fully adopting a standard care process and providing and documenting patient care, while coordinating and improving communication with patients, providers, and payers. Pharmacists are encouraged to use the rubric in evaluating software for their practices.

Pharmacist-community-based organization collaboration to address health-related social needs.

BACKGROUND: Community-based organizations (CBOs) help address community issues, including health-related social needs (HRSNs). Community pharmacies are positioned to collaborate with CBOs to help their patients identify and address HRSNs to optimize medication use. OBJECTIVES: To develop and evaluate 2 models of community pharmacy-CBO collaboration to address HRSNs facing patients taking medications. METHODS: Two different pharmacy-CBO models were studied. The CBO-initiated model had 2 CBOs assess and refer clients to a community pharmacy to address HRSN-related medication concerns. In the pharmacy-initiated model, pharmacists screened patients for HRSNs, addressed those related to medication costs and referred patients to a CBO for other HRSNs. Documented HRSNs were extracted and analyzed. Participating pharmacy and CBO staff were interviewed. The interview recordings were transcribed and coded, using rapid qualitative analyses. RESULTS: The CBO-initiated model screened 23 clients with 17 receiving a comprehensive medication review. In the pharmacy-initiated model, 39 patients were screened for HRSNs with 6 patients having medication costs issues addressed at the pharmacy and 23 patients being referred to the CBO. The most common HRSNs were high stress levels (43%), lack of confidence filling out forms (36%), feeling overwhelmed (34%), and inability to get food (27%). Patient-related themes from interviews were patient willingness to participate in the service, obstacles patients faced in obtaining medication therapy, and establishing patient trust. Pharmacy-related and CBO-related themes included fitting new activities into workflow, importance of time management and good communication, and establishing relationships between pharmacy and CBO personnel. CONCLUSION: Both pharmacy-CBO models effectively identified clients in need of medication management services or patients with HRSNs affecting medication optimization. Limited trust between the patient and the party to which they were referred was an obstacle to successful referral. Developing pharmacy and CBO personal relationships is a vital key in planning and coordinating these pharmacy-CBO collaboration models.

A taxonomy for community pharmacy patient care services reported in Pharmacist eCare Plans.

BACKGROUND: Pharmacies belonging to the Community Pharmacy Enhanced Service Networks (CPESN) are transforming their practices with support of the Flip the Pharmacy initiative. These pharmacies are submitting eCare plans that describe care that they have provided to patients. OBJECTIVES: The objectives of this study were (1) To develop a taxonomy for services reported by community pharmacies participating in year 1 of the Flip the Pharmacy initiative and (2) to illustrate the use of the taxonomy for hypertension-related services. METHODS: A retrospective observational study design was used. The analyzed data were extracted from eCare plans submitted by participating pharmacies during the first year of the Flip the Pharmacy initiative (October 1, 2019-September 30, 2020). Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) codes submitted for encounter reason and for procedures were sorted into categories based on similarity of terminology in the SNOMED-CT code labels. All SNOMED-CT codes in the encounter reasons that had blood pressure or hypertension in their labels were mapped to taxonomy categories. Descriptive statistics were calculated for all variables. RESULTS: A total of 368,297 eCare plans reporting 1,049,061 SNOMED-CT procedures were submitted for 133,210 patients by 526 pharmacies. Seven categories of community pharmacy patient care services were identified: medication synchronization, medication review, monitoring, immunizations, patient education, adherence, and recommendations. Over half of the encounter reasons (63.5%) and procedures (56.2%) were for medication synchronization. Both medication review and monitoring accounted for about 10% of the encounters, and medication review made up over 30% of procedures. A total of 18,307 encounters were related to hypertension. Of these, monitoring was the most frequent, with 11,285 encounters (61.6%) encounters, followed by patient education, with 5173 encounters (28.3%). CONCLUSION: CPESN pharmacies are delivering a wide range of patient care services. This taxonomy provides a concise way to organize and report services being delivered by community pharmacies.

Use of medication regimen complexity to target services in the community.

BACKGROUND: In the community, successful medication therapy depends on patients managing complex medication regimens. To assist, pharmacists can sort patients on the basis of their regimen complexity and then tailor care appropriately. OBJECTIVES: Objectives were to (1) develop a medication regimen complexity score and assess its reliability and validity, (2) design and implement a Less Complex program to tailor medication management services to the complexity of medication regimens, and (3) evaluate the impact that a Less Complex program had on identification and resolution of medication-related problems (MRPs). METHODS: Patients in the Less Complex program were stratified into complexity categories on the basis of Iowa Medication Complexity Scores (IMECSs) to receive pharmacy services tailored to their complexity category. Types and numbers of MRPs identified and associated pharmacist interventions were extracted. Frequencies and descriptive statistics were calculated. To assess the reliability and validity of the IMECS, a stratified random sample of 125 patients was drawn. For each of these patients, baseline and end of 9-month scores for IMECS were compared with Medication Regimen Complexity Index (MRCI) scores using paired t tests. RESULTS: A total of 661 patients had both baseline and post-IMECSs. The mean IMECS for the sample of 661 patients decreased from 28.6 at baseline to 27.3 during the postperiod. For the stratified sample (n = 113), the MRCI showed a nonsignificant change from baseline to the end of treatment period, whereas the IMECS showed a statistically significant decrease from baseline to the end of treatment period. A total of 10,535 MRPs and 10,482 interventions were documented during the 9-month treatment period for 1019 patients. CONCLUSION: Evidence supported initial reliability and validity of the IMECS. The Less Complex program identified and addressed many MRPs by matching patient complexity to service type. Future work is needed to evaluate a similar approach in other pharmacies.

Pharmacy performance while providing continuous medication monitoring.

OBJECTIVES: The aim of this work was to assess the effects of continuous medication monitoring (CoMM) on: 1) total costs of care; 2) proportion of days covered (PDC) rates; and 3) use of high-risk medications by older patients. DESIGN: Cohort design. SETTING AND PARTICIPANTS: A reimbursed CoMM program was implemented in a community pharmacy to manage problems with medications being dispensed to beneficiaries of a commercial insurer. Pharmacists assessed medications being dispensed, interacted with patients in the pharmacy, and documented their actions. Claims data compared the pharmacy performance for 3 study groups after 12 months of CoMM: group 1, patients with prescriptions dispensed only at the study pharmacy; group 2, patients with prescriptions dispensed from the study pharmacy and other pharmacies; and group 3, patients with no prescriptions dispensed by the study pharmacy. For the analyses, individuals in group 1 (CoMM-only group) were matched with those in group 2 and group 3 by age band, gender, risk category, and utilization band. MAIN OUTCOME MEASURES: The variables of interest were per-member per-month total health care costs, medication adherence (PDC), and the use of high-risk medications in older adults. RESULTS: At 12 months, per-member per-month total costs of care were significantly lower (P < 0.05) for group 1 versus group 2 ($309 difference) and for group 1 versus group 3 ($298 difference). At 12 months the average PDC for group 1 was significantly higher than for group 2 (3.8% difference) and group 3 (2.6% difference). No significant differences were found in the use of high-risk medications. CONCLUSION: A CoMM program in a community pharmacy was associated with lower total costs of care and better medication adherence. Paying pharmacists to proactively address the safety, effectiveness, and adherence of medications at the time of dispensing can support optimization of medication therapy.

A survey of pharmacists' preparedness for provider status implementation.

OBJECTIVES: 1) To measure pharmacists' preparedness for the implementation of provider status; and 2) to measure pharmacists' perceived stakeholder readiness for provider status implementation. METHODS: An anonymous 24-item electronic survey was sent to a convenience sample of approximately 1500 licensed Iowa pharmacists. They were contacted by means of their membership in the Iowa Pharmacists Association, 1 of 6 regional associations; Drake University and University of Iowa faculty listservs; and the University of Iowa alumni office. Pharmacists received initial contact through e-mail, private groups on social media, or respective organizations' websites requesting participation. Respondents' confidence to provide clinical skills and perceived preparedness for provider status implementation were measured. RESULTS: One hundred thirty-two pharmacists completed the survey. Participants perceived high confidence in themselves to serve as providers and low confidence in the preparedness of payers to support pharmacist provider status. Participants reported feeling most confident in obtaining a medication history and past medical history and least confident in obtaining vital signs and providing point-of-care testing. CONCLUSION: If provider status for pharmacists becomes law, Iowa pharmacists should expand on initiatives in collaboration with stakeholders to make a smoother transition into provider status. Iowa pharmacists may benefit from educational programming focused on delivering components of clinical services, such as measuring vital signs and point-of-care testing. Future research can be conducted to explain pharmacists' confidence levels as well as intentions to implement provider status services.

Exploring relationships among pharmacy service use, patronage motives, and patient satisfaction.

OBJECTIVES: To describe and identify significant relationships among pharmacy service use, general and service-specific patient satisfaction, pharmacy patronage motives, and marketing awareness in a service-oriented, independent community pharmacy. DESIGN: Cross-sectional study. SETTING: Midwest United States during May through July 2011. PARTICIPANTS: Stratified random sample of 500 participants. INTERVENTION: Self-reported questionnaire mailed to participants. MAIN OUTCOME MEASURES: Patient satisfaction, pharmacy service use, patronage motives, marketing awareness, and demographics. RESULTS: Study participants were mostly satisfied with the pharmacy services on global and service-specific measures. Patronage motives of relationships, pharmacy atmosphere, and quality previous experience were associated with increased pharmacy service use at the study pharmacy, while a unique service patronage motivation was associated with decreased pharmacy service use at the study pharmacy. Participants citing pharmacy atmosphere and personnel competency as patronage motives did not use pharmacies other than the study pharmacy more often, whereas participants citing unique services as a patronage motive used pharmacies other than the study pharmacy more often. Direct marketing awareness increased pharmacy service awareness but not use. CONCLUSION: Offering unique services may not be enough to bring in patients loyal to all services provided in a pharmacy. Pharmacists should focus on developing strong relationships with patients and conveying competence when delivering appropriate, quality pharmacy services in a professional pharmacy atmosphere.

Three-year financial analysis of pharmacy services at an independent community pharmacy.

OBJECTIVE: To assess the financial performance of pharmacy services including vaccinations, cholesterol screenings, medication therapy management (MTM), adherence management services, employee health fairs, and compounding services provided by an independent community pharmacy. METHODS: Three years (2008-10) of pharmacy records were examined to determine the total revenue and costs of each service. Costs included products, materials, labor, marketing, overhead, equipment, reference materials, and fax/phone usage. Costs were allocated to each service using accepted principles (e.g., time for labor). Depending on the service, the total revenue was calculated by multiplying the frequency of the service by the revenue per patient or by adding the total revenue received. A sensitivity analysis was conducted for the adherence management services to account for average dispensing net profit. RESULTS: 7 of 11 pharmacy services showed a net profit each year. Those services include influenza and herpes zoster immunization services, MTM, two adherence management services, employee health fairs, and prescription compounding services. The services that realized a net loss included the pneumococcal immunization service, cholesterol screenings, and two adherence management services. The sensitivity analysis showed that all adherence services had a net gain when average dispensing net profit was included. CONCLUSION: Most of the pharmacist services had an annual positive net gain. It seems likely that these services can be sustained. Further cost management, such as reducing labor costs, could improve the viability of services with net losses. However, even with greater efficiency, external factors such as competition and reimbursement challenge the sustainability of these services.

Retrospective financial analysis of medication therapy management services from the pharmacy's perspective.

OBJECTIVE: To determine the net financial gain or loss for medication therapy management (MTM) services provided to patients by an independent community pharmacy during 16 months of operation. DESIGN: Retrospective study. SETTING: Independent community pharmacy in Iowa City, IA, from September 1, 2006, to December 31, 2007. PATIENTS: Patients receiving MTM services during the specified period who had proper documentation of reimbursement for the services. INTERVENTION: MTM services were provided to the patient and documented by the pharmacist or student pharmacist. MAIN OUTCOME MEASURE: Net financial gains or losses for providing MTM services. Sensitivity analyses included costs that might be incurred under various conditions of operation. RESULTS: 103 initial and 88 follow-up MTM visits were conducted during a 16-month time period. The total cost for these services to the pharmacy was $11,191.72. Total revenue from these services was $11,195.00; therefore, the pharmacy experienced a net financial gain of $3.28. Sensitivity analyses were conducted, revealing the net gain/loss to the pharmacy if a student pharmacist was used and the net gain/loss if the pharmacist needed extra training to provide the services. Using a student pharmacist resulted in a net gain of $6,308.48, while extra training for the pharmacist resulted in a net loss of $1,602.72. CONCLUSION: The MTM service programs showed a positive financial gain after 16 months of operation, which should encourage pharmacists to incorporate these services into their practice.

Community pharmacist-provided extended diabetes care.

BACKGROUND: Pharmacists in various settings have been effective in initiating diabetes treatment. Patients with diabetes require ongoing disease management, and community pharmacists are in a strategic position to provide such extended care. Little is known, however, about the effects of community pharmacist-provided interventions beyond the initial treatment period. OBJECTIVE: To evaluate the effect of community pharmacist-provided extended diabetes care service on primary clinical outcomes, including hemoglobin A(1c) (A1C), low-density lipoprotein cholesterol (LDL-C), and blood pressure, and on patients' reported self-care activities. METHODS: A randomized controlled trial was conducted in patients with diabetes. Participants had already completed at least 2 diabetes education sessions at a local diabetes education center. Nine specially trained pharmacists administered interventions during up to 4 quarterly visits per patient. Interventions included discussing medications, clinical goals, and self-care activities with patients and recommending medication changes to physicians when appropriate. The main outcome measures were 12-month changes in A1C, LDL-C, blood pressure, and self-report of self-care activities. RESULTS: Seventy-eight patients participated in the study (36 intervention, 42 control); 66 were included in the final analysis (31 intervention, 35 control). Compared with changes in the control group, patients who received interventions significantly increased the number of days per week that they engaged in a set of diet and diabetes self-care activities (1.25 and 0.73 more days/wk, respectively). The mean 12-month changes for A1C, LDL-C, and blood pressure were not significantly different between the 2 study groups. CONCLUSIONS: Although pharmacist-provided interventions did not demonstrate statistically significant improvements in clinical outcomes over the study period, study results did show that pharmacists were effective at increasing the number of days that patients spent engaging in healthy diet and diabetes self-care activities. Addressing lifestyle and self-care behaviors can be a beneficial component of a pharmacist-provided extended diabetes care service.

Retrospective financial analysis of a herpes zoster vaccination program from an independent community pharmacy perspective.

OBJECTIVE: To determine the net financial gain or loss for herpes zoster vaccination services provided to patients from the perspective of an independent community pharmacy. DESIGN: Retrospective review of pharmacy records over the program's initial 11-month period. SETTING: Independent community pharmacy in Iowa City, IA. PARTICIPANTS: Patients received immunization with the herpes zoster vaccine from a certified pharmacist. INTERVENTION: Herpes zoster vaccination services were provided to the patient and documented by the pharmacist. MAIN OUTCOME MEASURE: Net financial gains or losses were calculated for the herpes zoster vaccination program. Sensitivity analyses were based on costs that might be incurred during program start-up. RESULTS: 478 patients received zoster vaccination services over the initial 11-month period. A net financial gain for the herpes zoster vaccination program was achieved, with a net profit of $15.02, or 8.15%, per vaccination. CONCLUSION: Revenues for this vaccination program exceeded its costs from the independent community pharmacy perspective.

Identifying patients at risk of cardiovascular disease: a pharmacist-managed screening event for union workers and their dependents.

OBJECTIVE: To describe a pharmacist-managed health screening as a tool to identify patients who were at risk for cardiovascular disease (CVD). DESIGN: Descriptive nonexperimental study. SETTING: A community pharmacy, a health benefit consulting company, and two local unions of plumbers and electricians in the Quad Cities area (Mid-Mississippi Valley) in fall 2006. PATIENTS: Union members and their dependents who received any one of the following pharmacist-managed screening services: systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, and high-density lipoprotein (HDL). INTERVENTION: Pharmacist-managed CVD risk screening program coordinated by a health benefit consulting company. MAIN OUTCOME MEASURES: Risk levels of CVD according to SBP, DBP, total cholesterol, and HDL. RESULTS: 452 patients 20 years of age or older were screened. A total of 137 participants (45.2%) had an SBP of 140 mm Hg or more and 73 (24.1%) a DBP of 90 mm Hg or more. Among patients who checked their total cholesterol or HDL, 81 (24.0%) had high total cholesterol and 55 (16.4%) low HDL. CONCLUSION: A pharmacist-managed health screening program was a tool to identify patients at risk of CVD. At-risk individuals could be potential participants in a cardiovascular risk management service.

Feasibility of a Coordinated Human Papillomavirus (HPV) Vaccination Program between a Medical Clinic and a Community Pharmacy.

Human papillomavirus (HPV) vaccination coverage could be enhanced by community pharmacies working with medical clinics to coordinate completion of the HPV vaccination series. The objective for this study was to assess the feasibility of a coordinated model of HPV vaccine delivery in which a clinic gives the first dose and refers patients to a partnering community pharmacy to receive subsequent doses. A medical clinic-community pharmacy team was established in a Midwestern state to develop and operate a coordinated care model for HPV vaccinations. Under the coordinated model, the clinic identified patients needing HPV vaccination(s), administered the first dose and described the option to complete the vaccination series at the pharmacy. Interested patients then had an information sheet faxed and electronic prescriptions sent to the pharmacy. The pharmacy contacted the patients to schedule administration of 2nd and 3rd doses of the HPV vaccine. Over a 12-month period, 51 patients were referred to the pharmacy by the clinic. Of these, 23 patients received a total of 25 vaccinations. Clinic and pharmacy personnel mostly rated the coordinated program favorably. An initial study of a coordinated HPV vaccination program between a medical clinic and a community pharmacy supported patients getting HPV vaccinations.

Community pharmacist assessment of 10-year risk of coronary heart disease for union workers and their dependents.

OBJECTIVE: To determine 10-year coronary heart disease (CHD) risk for union workers and their dependents in a pharmacist-managed health screening program. METHODS: Two local unions of plumbers and electricians contracted with a community pharmacy to provide health screening services for union workers and their dependents. Patients chose any one or any combination of three clinical tests: blood pressure, total cholesterol, and HDL cholesterol. At the end of the screening, which took approximately 35 minutes, the participants received brief patient education from pharmacists and a printout of their results. Pharmacists provided the services based on their in-store screening experience and, before the screening, received training on 10-year CHD risk calculation and guidelines regarding cholesterol treatment. Framingham scoring was applied to calculate 10-year CHD risk for participants who chose all three clinical tests. RESULTS: 265 patients (55.8% men, average age 57.7 years) participated in the screening program. Frequency of cardiovascular disease (CVD) risk factors ranged from 25.5% (diastolic blood pressure) to 52.5% (total cholesterol). Using Framingham scoring, 10-year CHD risk was calculated for 226 patients, with 119 (52.7%) patients having less than 10% risk with zero to one CVD risk factor, 73 (32.3%) having 10% to 20% risk with two or more CVD risk factors, and 34 (15%) having greater than 20% risk with two or more risk factors. CONCLUSION: Pharmacists provided intermediate- and high-risk participants with guideline-based recommendations such as referring them to physicians for further assessment, therapeutic lifestyle changes, and medication treatment. Community pharmacists were able to identify individuals with intermediate or high 10-year CHD risk. Based on 10-year CHD risk assessment, further pharmacist-managed interventions, such as a cardiovascular risk management program, can be conducted.

Medication-Related Problems Identified Through Continuous Medication Monitoring.

Community pharmacists performing Continuous Medication Monitoring (CoMM) systematically monitor each new prescription and refill dispensed for medication-related problems. The objectives for this study were to describe medication-related problems identified through CoMM and drug classes involved in problems. This 12-month pilot study used dispensing and clinical records from a single independent U.S. community pharmacy. Clinical records contain medication-related problems documented by the pharmacists. Problems identified for patients filling at least one prescription at the pharmacy and having at least one medication-related problem during the study period were included. A total of 8439 medication-related problems were identified for 1566 patients, an average of 5.4 problems per patient. Over 63% of problems were nonadherence. The drug class most often involved in problems was the central nervous system and analgesic class. Community pharmacists performing CoMM identified medication-related problems that might otherwise have gone undetected.

Continuous Medication Monitoring (CoMM): A foundational model to support the clinical work of community pharmacists.

BACKGROUND: Under the Continuous Medication Monitoring (CoMM) approach, community pharmacists prevent, identify, resolve, and document drug therapy problems during the dispensing process. OBJECTIVE: To describe the patients receiving CoMM interventions and the pattern of delivery of CoMM interventions. METHODS: Pharmacy dispensing and clinical records were reviewed for patients filling at least one prescription and receiving at least one continuous medication monitoring intervention at a community pharmacy from April 2014 through March 2015. The proportion of patients receiving an intervention type and the number of interventions per patient were computed. RESULTS: Nearly 2500 patients received 16,986 continuous medication monitoring interventions over the year. The average age of the patients receiving the interventions was 59.1 years, and they filled an average of 8.0 unique medications. An average of 6.8 interventions was delivered to each patient. About half (49.7%) of interventions addressed drug therapy problems. The pharmacists delivered 3.0 patient counseling and education and 3.4 drug therapy problem interventions per patient on average. CONCLUSION: There are many opportunities to improve patients' medication use that can be identified and addressed under a Continuous Medication Monitoring model. Movement to this model of practice is desirable, but changes are needed to facilitate the shift.

Osteoporosis risk screening for women in a community pharmacy.

OBJECTIVES: To describe the development, implementation, and financial aspects of a sustainable osteoporosis screening service in a community pharmacy and report osteoporosis risk factors for women screened during the 48 months in which the screening service was in operation. SETTING: An independent community pharmacy (Main at Locust Pharmacy Clinic) in Davenport, Iowa, beginning in 1999. PRACTICE DESCRIPTION: The osteoporosis screening service was provided by a staff pharmacist, a pharmacy resident, or a combination of a pharmacist and a resident. The service included use of the Hologic Sahara Bone Sonometer at the heel and education of the patient. Patient education consisted of a discussion of screening results, an overview of osteoporosis, and recommendations to address risk factors. PRACTICE INNOVATION: For patients who received osteoporosis screening, an overall cumulative risk score and a cumulative modifiable risk score were calculated. Patients were identified as having high (T-score or=0) risk. An analysis was performed to determine the net financial gain or loss of osteoporosis screening. INTERVENTION: Osteoporosis screening service. MAIN OUTCOME MEASURES: T-score, overall cumulative risk score, cumulative modifiable risk score, and net financial gain of service. RESULTS: A total of 444 women received the osteoporosis screening service during 48 months. More than 90% of the women had an overall cumulative risk score of at least 3, and 83.3% had at least one modifiable risk factor. According to the bone density tests, about 58% of the women were at high risk for osteoporosis and 25.7% were at moderate risk. The service had a net gain if provided by a pharmacist ($4,823.72), a resident ($8,153.72), or a combination of a pharmacist and a resident ($6,488.72). CONCLUSION: This pharmacy-based osteoporosis screening service effectively identified patients at risk for osteoporosis and was sustainable for 48 months. Other community pharmacies are encouraged to offer similar services.

Informal learning processes in support of clinical service delivery in a service-oriented community pharmacy.

The evolving health care system necessitates pharmacy organizations' adjustments by delivering new services and establishing inter-organizational relationships. One approach supporting pharmacy organizations in making changes may be informal learning by technicians, pharmacists, and pharmacy owners. Informal learning is characterized by a four-step cycle including intent to learn, action, feedback, and reflection. This framework helps explain individual and organizational factors that influence learning processes within an organization as well as the individual and organizational outcomes of those learning processes. A case study of an Iowa independent community pharmacy with years of experience in offering patient care services was made. Nine semi-structured interviews with pharmacy personnel revealed initial evidence in support of the informal learning model in practice. Future research could investigate more fully the informal learning model in delivery of patient care services in community pharmacies.

Increased thyroid-stimulating hormone levels associated with concomitant administration of levothyroxine and raloxifene.

A 47-year-old Caucasian woman had a 3.5-year history of primary hypothyroidism treated with levothyroxine. Her levothyroxine dosage of 0.05 mg/day had been stable for the past 15 months. She was then prescribed raloxifene for prevention of osteoporosis secondary to early menopause. During the next 30 months, her levothyroxine dosage had to be gradually increased. The patient had been taking levothyroxine and raloxifene at the same time each day on an empty stomach. During the months of her levothyroxine dosage changes, however, she separated administration of levothyroxine and raloxifene by 12 hours; the patient then became hyperthyroid. Eventually, her levothyroxine needs decreased, and she returned to the same levothyroxine dosage she had taken before separating administration of the two drugs. These findings suggest that raloxifene decreased the absorption of levothyroxine when the two agents were coadministered. Assessment of causality using the Naranjo adverse drug reaction probability scale resulted in a possible association for this adverse event. Another published case report provides findings similar to our patient's experience. The possibility of a malabsorption interaction between levothyroxine and raloxifene is significant, as hypothyroidism is common among postmenopausal women-the same population that is the target of osteoporosis therapy with agents such as raloxifene. The mechanism by which raloxifene decreases levothyroxine absorption is unknown. Further investigation of this potential interaction is warranted. Until then, clinicians should be alert to the potential for an interaction between raloxifene and levothyroxine.

Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy.

OBJECTIVE: The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them. METHODS: In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patient's physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations. RESULTS: Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%). CONCLUSION: The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.