Barriers to Patient Use of Control Solution for Glucose Meters: Surveys of Patients, Pharmacists, and Providers in a Metropolitan Area.

BACKGROUND: An important factor in controlling diabetes is self-monitoring of blood glucose. Manufacturers of glucose meters recommend routine use of control solution to ensure accuracy. Previous studies have demonstrated that glucose meters vary in accuracy and that patients are not using control solution as recommended. The purpose of this study is to identify potential barriers to control solution use from multiple perspectives including patient, pharmacist, and provider. METHODS: This study was a prospective, observational survey design. First, 25 randomly selected chain and independent pharmacies in the Tulsa metropolitan area were audited for control solution accessibility. These pharmacies were then used to survey pharmacists, via telephone, regarding control solution inventory and perception of importance of use. Next, providers were electronically surveyed on their routine practice recommendations, while 60 patients with diabetes were randomly selected for telephone survey on use and perceptions of control solution. RESULTS: Twenty-five pharmacies were audited and 23 pharmacists, 60 patients, and 29 providers were surveyed. Only 39% of pharmacies stated they supplied control solution, however, only 1 pharmacy visibly stocked it. The only patient factor that appeared to have an impact on control solution usage was having type 1 versus type 2 diabetes (38% vs 15%). Providers are aware of what control solution is (62%), but only half felt it should be routine practice with 44% of those never recommending it. CONCLUSION: This study raises awareness for the need to educate patients, providers, and pharmacists about use of control solution to ensure glucose meter accuracy.

Interventions to improve dissemination and implementation of Hepatitis B vaccination in patients with diabetes.

OBJECTIVE: The purpose of this study was to assess provider awareness of routine vaccinations recommended for patients with diabetes and to determine whether pharmacist-led interventions are associated with increased provider implementation of recommendations for hepatitis B vaccination. METHODS: This study was conducted in 3 phases at 2 outpatient clinics affiliated with an academic institution. In phase 1, adults with diabetes who visited the clinics between January and November 2012 and who were eligible for the hepatitis B vaccine were identified. In phase 2, medical residents were surveyed twice for vaccine recommendations and reasons for (not) recommending the hepatitis B vaccine, specifically. Residents were then provided a pharmacist-led in-service about hepatitis B vaccine recommendations. The third phase was initiated in April 2013, following postintervention observation from December 2012 through March 2013. RESULTS: Forty-eight of 100 (48%) medical residents attended the in-service and completed both surveys, with 77% indicating they did not recommend the hepatitis B vaccine. During phase 1, 1441 patients were identified, 0.6% (n = 8) of whom had received at least the first dose of the series. In phase 3, 946 patients were identified with 1.7% (n = 16) having received at least the first dose (P = 0.007). CONCLUSION: An attempt to disseminate updated recommendations to providers via educational in-service was successful in increasing the percentage of eligible patients vaccinated with the hepatitis B vaccine.

Evaluation of Medication-related Self-care Skills in Patients With Cystic Fibrosis.

BACKGROUND: As the life expectancy of patients with cystic fibrosis (CF) increases, the focus on ensuring success with medication therapies is increasingly important. The ability of patients to autonomously manage medications and related therapies is poorly described in the literature. OBJECTIVE: The goal of this project was to assess the level of medication-related knowledge and self-care skills in patients with CF. METHODS: This project took place in a Cystic Fibrosis Foundation accredited affiliate center. Eighty-nine patients between the ages of 6 and 60 were eligible to participate based on inclusion and exclusion criteria. Pharmacists administered a 16-item questionnaire and detailed medication history during clinic visits from January through May 2014. RESULTS: Forty-five patients 6 to 41 years old participated in the study. The skills most often performed independently were preparing nebulizer treatments (85%) and telling someone if they feel their medicines are causing a problem (89%). Skills least often performed were carrying a medication list (82%) and bringing a medication list to appointments (76%). In respondents 21 years of age and older, less than 75% of respondents were involved with obtaining financial resources, maintaining equipment, carrying a medication list, or rinsing their mouth after using inhaled medicines. Participants were able to provide drug name, dose, and frequency of use for pancreatic enzymes and azithromycin 37% and 24% of the time, respectively. CONCLUSIONS: In the population surveyed, many medication-related skills had not been acquired by early adulthood. Assessing and providing education for medication-related self-care skills at all ages are needed.

Applicability of the Schwartz Equation and the Chronic Kidney Disease in Children Bedside Equation for Estimating Glomerular Filtration Rate in Overweight Children.

STUDY OBJECTIVE: To determine if significant correlations exist between glomerular filtration rate (GFR) prediction equation values, derived by using the original Schwartz equation and the Chronic Kidney Disease in Children (CKiD) bedside equation with a 24-hour urine creatinine clearance (Clcr ) value normalized to a body surface area of 1.73 m(2) in overweight and obese children. DESIGN: Prospective analysis (20 patients) and retrospective analysis (43 patients). SETTING: Pediatric inpatient ward and pediatric nephrology clinic at a comprehensive academic medical center. PATIENTS: Sixty-three pediatric patients (aged 5-17 years), of whom 27 were overweight (body mass index [BMI] at the 85th percentile or higher) and 36 were not overweight (BMI lower than the 85th percentile [controls]) between 2007 and 2012. METHODS AND MAIN RESULTS: Data from the overweight patients were compared with nonoverweight controls. GFR values were calculated by using the original Schwartz equation and the CKiD bedside equation. Each patient's 24-hour urine Clcr value normalized to a body surface area of 1.73 m(2) served as the index value. A Pearson correlation coefficient model was used to determine association between the 24-hour urine Clcr value (index value) with the Schwartz and CKiD GFR estimations. Significant correlation was found to exist between the Schwartz and CKiD bedside GFR estimations relative to the 24-hour urine Clcr in the control subjects (r = 0.85, p<0.0001, and r = 0.85, p<0.0001, respectively). Significant correlation was also found to exist between the Schwartz and CKiD bedside GFR values with the 24-hour urine Clcr value in overweight subjects (r = 0.86, p<0.0001, and r = 0.86, p<0.0001, respectively). The Schwartz equation estimated average GFR 21.75 ml/minute/1.73 m(2) higher than 24-hour urine Clcr (p<0.0001) in overweight children with a kidney disorder. The CKiD bedside GFR estimations were not significantly different compared with 24-hour urine Clcr values for the overweight group with kidney disorder (p=0.85). CONCLUSION: The Schwartz and CKiD bedside estimations of GFR correlated with 24-hour urine Clcr values in both overweight and nonoverweight children. Compared with the Schwartz equation, which tended to overestimate renal function, the CKiD bedside equation appeared to approximate 24-hour urine Clcr more closely in overweight children with kidney disorder.

Evaluation of Adverse Drug Events and Medication Discrepancies in Transitions of Care Between Hospital Discharge and Primary Care Follow-Up.

UNLABELLED: Approximately two-thirds of adverse events posthospital discharge are due to medication-related problems. Medication reconciliation is a strategy to reduce medication errors and improve patient safety. OBJECTIVE: To evaluate adverse drug events (ADEs), potential ADEs (pADEs), and medication discrepancies occurring between hospital discharge and primary care follow-up in an academic family medicine clinic. Adult patients recently discharged from the hospital were seen by a pharmacist for medication reconciliation between September 1, 2011, and November 30, 2012. The pharmacist identified medication discrepancies and pADEs or ADEs from a best possible medication history obtained from the electronic medical record (EMR) and hospital medication list. In 43 study participants, an average of 2.9 ADEs or pADEs was identified (N = 124). The most common ADEs/pADEs identified were nonadherence/underuse (18%), untreated medical problems (15%), and lack of therapeutic monitoring (13%). An average of 3.9 medication discrepancies per participant was identified (N = 171), with 81% of participants experiencing at least 1 discrepancy. The absence of a complete and accurate medication list at hospital discharge is a barrier to comprehensive medication management. Strategies to improve medication management during care transitions are needed in primary care.

Validation of a survey tool assessing effectiveness of an educational intervention on the caring behaviors and referral activities of community pharmacists for migraineurs.

BACKGROUND: Community pharmacists are in an ideal position to ameliorate migraineur under-consulting, under-diagnosis, and under-treatment. Contemporary education/training on developing therapeutic alliances with patients and in advanced pharmacotherapy may further motivate pharmacists to impact the care of migraineurs. OBJECTIVES: The objectives of this study were to assess pharmacists' perceptions of a migraine training program and their self-assessment of subsequent impact on patient care and to develop and assess a tool evaluating the impact of the training program from the patients' perspectives: (1) for patients diagnosed with migraines - identify perceptions of care by pharmacists who have undergone specialty training in migraine vs. pharmacists who have not; and (2) for patients with recurrent headaches and not diagnosed with migraines - identify perceptions of pharmacist effectiveness and thoroughness, after specialty training, to identify a potential migraine diagnosis and referral for advanced care vs. pharmacists that have not undergone specialty training. METHODS: This study employed a mixed method survey design using community pharmacies from the Tulsa, Oklahoma and Pittsburgh, Pennsylvania greater metropolitan areas. Pharmacists from intervention pharmacies received specialty training on migraine and were surveyed on their current practices and about the education program. Approximately 1 month after the training, control and intervention pharmacists were surveyed on current practices. Additionally, patients from both pharmacies were surveyed to assess Migraine Disability Assessment (MIDAS) and pharmacists' delivery of care derived from the Pharmacists' Care of Migraineurs Scale (PCMS). Surveys were handed out for a period of 3-months. RESULTS: There were 16 pharmacists and 61 patients recruited. There was no difference in patient perceptions of pharmacists' care or in patient self-perceptions between migraineurs and recurrent headache sufferers. Ninety-two percent of pharmacists agreed that the program could be transferred to an internet-based educational program. The 14-item patient survey, however, demonstrated good internal consistency reliability, with each question having a Cronbach's alpha 0.80 or higher. CONCLUSIONS: There are few studies evaluating the role and potential impact community pharmacists can have on patients suffering from migraines or recurrent headaches. While no difference was found between the groups, the internal reliability of the survey questions and the need to address needs of migraineurs warrants tool dissemination and a larger-scale study.

Pseudohyperphosphatemia in children treated with liposomal amphotericin B.

PURPOSE: The results of a study to determine the frequency of pseudohyperphosphatemia in a sample of pediatric patients treated with i.v. liposomal amphotericin B are reported. METHODS: A single-site retrospective study was conducted to identify evidence of pseudohyperphosphatemia in the medical records of patients 18 years of age or younger who received at least five doses of amphotericin B liposome; the maximum dose was calculated for each regimen and categorized as either ≤5 or >5 mg/kg/day. The primary objective was to ascertain the rate of pseudohyperphosphatemia (i.e., abnormally high serum phosphate without elevated serum calcium). The secondary objective was to compare rates of pseudohyperphosphatemia at the higher and lower amphotericin B dosage levels. A multivariate generalized estimating equation (GEE) regression model was used to identify potential predictors of pseudohyperphosphatemia. RESULTS: Data were collected on 72 courses of amphotericin B liposome administered during a 13-month period to 47 patients; based on a review of chart notations and clinical data, it was determined that 36 regimens (50%) involved pseudohyperphosphatemia. The GEE model revealed no significant association between pseudohyperphosphatemia and any evaluated variable, including age, weight, duration of therapy, and concurrent use of medications known to alter serum phosphorus. CONCLUSION: In children receiving amphotericin B liposome, half of the regimens were associated with pseudohyperphosphatemia. Although no factors were found to predict pseudohyperphosphatemia, on average, patients who developed the abnormality were significantly older and heavier and received a significantly higher absolute initial dosage of amphotericin B liposome than those who did not develop the condition.

Influence of a systems-based approach to prescribing errors in a pediatric resident clinic.

OBJECTIVE: To measure the difference in prescribing error rates between 2 clinics, 1 with a system in place to reduce errors and 1 with no such system; to determine variables that affect the likelihood of prescription errors. METHODS: This was a retrospective study at 2 university-based general pediatric clinics utilizing the same electronic medical record (EMR) system. Clinic 1 employed pharmacists who provided daily prescription review, provider feedback and education, and EMR customization to decrease errors. Clinic 2 had no systems in place for reducing prescribing errors. Prescriptions written by resident physicians over 2 months were identified and reviewed. RESULTS: A total of 1361 prescriptions were reviewed, 40.7% from clinic 1 and 59.3% from clinic 2. Errors were found in 201 prescriptions (14.8%). Clinics 1 and 2 had error rates of 11% and 17.5%, respectively (P = .0012). The odds of a prescription error at clinic 2 were 1.7 times the odds of a prescription error at clinic 1. Logistic regression identified clinic, nonpediatric resident, liquid dose forms, and younger patient age as significant predictors of prescription errors. Half of the errors could have been prevented with consistent use of a custom medication list within the EMR. CONCLUSIONS: We found 37% fewer prescribing errors in a clinic with systems in place for prescribing error detection and prevention. Pediatric clinics should explore systematic procedures for identifying, resolving, and providing education about prescribing errors to reduce patient risk.

Practice experiences at a single institutional practice site to improve advanced pharmacy practice examination performance.

OBJECTIVE: To determine whether sequential assignment of students to the same facility for institutional practice experiences improves their advanced pharmacy practice experience (APPE) examination scores. DESIGN: Student volunteers were assigned to the same healthcare facility for all institutional introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs). Other students completed institutional IPPEs and APPEs at separate healthcare facilities, ranging from 2 to 4 different facilities per student. APPE examination scores of students assigned to the same facility for all institutional learning experiences were compared with those of students assigned to more than 1 institutional practice site. ASSESSMENT: Holding grade point average constant, students assigned to the same facility for institutional IPPEs and APPEs scored 3 percentage points higher on the APPE institutional examination compared with students assigned to separate facilities for these experiences. CONCLUSION: Assigning students to the same facility for both institutional IPPEs and APPEs positively influenced knowledge-based APPE examination performance.

Assessing student pharmacists' ability to identify drug-related problems in patients within a patient-centered medical home.

OBJECTIVE: To quantify, describe, and categorize patient drug-related problems (DRPs) and recommendations identified by fourth-year (P4) student pharmacists during a live medication reconciliation activity within a patient-centered medical home (PCMH). METHODS: Fourth-year student pharmacists conducted chart reviews, identified and documented DRPs, obtained live medication histories, and immediately provided findings and recommendations to the attending physicians. Documentation of DRPs and recommendations were analyzed retrospectively. RESULTS: Thirty-eight students completed 99 medication reconciliation sessions from June 2011 to October 2012 during their advanced pharmacy practice experience (APPE). The students obtained 676 patient medication histories and identified or intervened on 1308 DRPs. The most common DRPs reported were incomplete medication list and diagnostic/laboratory testing needed. Physicians accepted 1,018 (approximately 78%) recommendations. CONCLUSION: Student pharmacists successfully identified and reduced DRPs through a live medication reconciliation process within an academic-based PCMH model. Their medication history-taking skills improved and medication use was optimized.

Retrievable inferior vena cava filters in trauma patients: factors that influence removal rate and an argument for institutional protocols.

BACKGROUND: Trauma patients at risk for pulmonary embolism, but with contraindications for anticoagulation therapy, often have retrievable inferior vena cava filters (RIVCF) placed. This study evaluated factors associated with the recovery rate of the device (RIVCFs) with the goal of developing an institutional protocol to ensure timely removal. METHODS: This was a case-control study of 88 trauma patients who underwent RIVCF placement at a level 1 trauma center between 2006 and 2010. RESULTS: The overall retrieval rate was 58%, declining from 89% in 2006 to 50% in 2009. Factors independently associated with filter nonretrieval included increasing age, increase in number of providers, comorbidity, hospital discharge from the intensive care unit, and discharge to a long-term acute care facility or skilled nursing facility. In 2010, a protocol was implemented and the retrieval rate increased to 73%. CONCLUSIONS: In a large institution where a number of providers may be responsible for filter management, implementation of a protocol appears to improve retrieval rates.