Relationship between patient and disease characteristics, and health-related quality of life in adults with asthma.

The purpose of this study was to examine relationships between patient- and disease-related variables and health-related quality of life (HQL). This cross-sectional study surveyed adults with asthma enrolled in a managed care organization (MCO). Data were obtained from a mailed questionnaire and the MCO's patient and claims databases. The Asthma Quality of Life Questionnaire (AQLQ) and the SF-36 instruments were used. The behavioral Model of Health Services Utilization was used to characterize independent variables and their relationships to HQL. Independent variables included predisposing (age, gender, education, race, number of comorbidities, years with asthma, social support, health-belief questions); enabling (income, number of metered dose inhaler (MDI) instructors, perceived inconvenience of accessing the physician); and illness level (perceived and symptom-derived asthma severity). Multivariate linear regression models were developed to examine the relationships between the independent variables and the domain and summary scores of the AQLQ and the SF-36. The survey response rate was 63% (n=603). for the AQLQ, symptom-derived severity perceived severity education level, and the health-belief factor Barriers were significant in all five models. Symptom-derived severity had consistently higher standardized regression coefficients than perceived severity Barriers had the highest coefficient in all but the Symptoms domain model. Number of Comorbidities was significant in all eight domain and two summary score SF-36 models. Symptom-derived and/or perceived severity were also significant in all but the Mental Health domain model. Other frequently significant variables included the health-belief factor Barriers and Yearly Household Income. When assessing HQL of a population, such as this group of patients with asthma, one must consider patient and disease variables that may influence the results.

Compliance from self-reported versus pharmacy claims data with metered-dose inhalers.

OBJECTIVE: To determine how well self-reported compliance with metered-dose inhalers (MDIs) agrees with compliance determined from pharmacy claims data. Additional analyses were conducted to establish phychmetric properties of the questionnaire. METHODS: A cross-sectional survey was performed of all adult enrollees with asthma of a managed care organization. The overall return rate was 63.4% (696/1098). Patents with persistent asthma and at least one prescription claim for a controller MDI during the four months preceding the survey were included. Pharmacy claims data were used to calculate a compliance ratio. Self-reported compliance was based on a four-item questionnaire. The primary end points were the percent-agreement and the overall correlation between the two measures. The questionnaire's internal reliability and construct validity were assessed using Cronbach's alpha and Pearson's correlations, respectively. Mean item response scores for compliant patients were compared with scores of noncompliant patients using the Student's t-test. RESULTS: One hundred questionnaire respondents met the study criteria. The mean +/- SD compliance ratio was 0.52+/-0.27, the mean +/- SD self-reported compliance score was 4.07+/-1.0. The overall percent agreement and correlation between self-reported compliance score and the compliance ratio were 75.5% and r = 0.348 (p = 0.01), respectively. The percent agreement was highest (85%) when noncompliant patients (by compliance ratio <0.8) reported being noncompliant (questionnaire score <5). Cronbach's alpha was 0.86. CONCLUSIONS: This study demonstrated a moderate correlation between self-reported asthma compliance and the compliance ratio determined using claims data. The questionnaire may be useful as a screening tool to detect noncompliant behavior in populations or individual patients with asthma.

Perceived symptoms and health-related quality of life reported by uncomplicated hypertensive patients compared to normal controls.

OBJECTIVES: This study compared the prevalence and intensity of symptoms and the health-related quality of life (HQL) of patients taking antihypertensive medications and patients without disease. METHODS: This cross-sectional study used surveys mailed to patient's homes. All consecutive patients over age 30 years attending either a general medicine or hypertension clinic during 3 months were eligible (n = 437). Hypertension group (HTN-G) patients were diagnosed with primary hypertension, prescribed antihypertensive medications, and had no other symptomatic conditions or drug therapies. Control group (CNTL-G) patients were seen in the general medicine clinic and had no chronic symptomatic conditions or drug therapies. Measures included the Symptom Distress Checklist (SDC, list of 51 symptoms, frequency, and level of distress), the Medical Outcomes Study Short Form-36 (SF-36), medications, blood pressures, and other data obtained from medical records and patient self-report. RESULTS: A total of 222 patients responded (46% CNTL-G, 55% HTN-G). HTN-G patients were somewhat older (59.0 +/- 11.2 vs 48.5 +/- 11.7 years, P = 0.001) and had a higher percent of minorities (24.8% vs 13.5%, P = 0.02), but otherwise similar. After adjusting for age and race differences, HTN-G patients reported significantly more symptoms (8.8 +/- 7.8 vs 4.7 +/- 4.8, P = 0.001) and related distress (32.2 +/- 4.2 vs 12.0 +/- 18.2, P = 0.001) as well as lower scores (reduced HQL) for most of the SF-36 domains. In general, hypertensive patients had more physical, but not mental symptoms than control patients. CONCLUSIONS: Hypertensive patients receiving antihypertensive medications have more symptoms and lower HQL. Differences were detected by both a brief, general HQL instrument and a detailed, disease-specific instrument. Routine screening of treated hypertensive patients using a brief HQL questionnaire to detect physical symptoms may prove feasible and useful.

Pharmacists' understanding of patient education on metered-dose inhaler technique.

OBJECTIVE: To assess pharmacists' attitudes, beliefs, and knowledge about assessing and educating patients regarding metered-dose inhaler (MDI) technique; to determine frequency of MDI assessment and teaching behavior; and to assess the effect of an asthma pharmaceutical care educational program on the same variables six months later. DESIGN: Questionnaire completed before and six months after the educational intervention. SETTING: Pharmacies based in clinics owned by a healthcare system located in communities of a large metropolitan area. MAIN OUTCOMES MEASURES: Pharmacists' self-reported frequency of assessment and education; attitudes and beliefs about assessing and educating patients using MDIs; and knowledge of MDI technique. RESULTS: The survey response rate was 53.7% (n = 39) for baseline and 43% (n = 32) for follow-up. Most pharmacists (85.4% at baseline, 87.5% at follow-up; p = 0.79) indicated that they educate patients receiving new MDI prescriptions. In addition, 47.4% at baseline and 68.8% at follow-up indicated they educate patients using inhalers for three months (p = 0.07). Only 21.1% at baseline and 18.8% at follow-up (p = 0.81) indicated that they follow up with long-term users. The mean +/- SD MDI technique knowledge score (steps correct out of 9 possible) at baseline was 7.2 +/- 1.1 and 7.5 +/- 1.3 at follow-up (p = 0.29). Significant changes in level of agreement with some beliefs/attitudes were observed, including the importance of frequently assessing/educating patients, confidence and comfort when assessing/educating patients, and that assessing/educating patients is not the role of only the physician. Respondents continued to acknowledge that MDI education and assessment are important to improving and maintaining control of disease. However, the respondents thought that barriers exist that inhibit this activity, such as not enough time for education and assessment. CONCLUSIONS: Pharmacists reported they frequently educate patients and assess MDI technique for new prescriptions but not very often for patients recently started, as well as for long-term users. Six months after an educational program, attitudes and beliefs toward this activity were either not changed or, in some, improved. Pharmacists perceive that there is not enough time to assess and educate patients who use MDIs.

Assessing metered-dose inhaler technique: comparison of observation vs. patient self-report.

The purpose of this study was to develop and determine the validity of a patient-completed questionnaire that assesses metered-dose inhaler (MDI) technique. Self-reported MDI technique was compared to observed technique. The questionnaire included nine steps for MDI use, with two to three response choices for each step. A total of 159 patients were studied. Direct observation revealed that greater than 82% of patients exhibited inadequate technique (more than two out of nine steps incorrect). The mean percentage agreement between the questionnaire and observation was 77.4%. Questionnaire results where in higher agreement with observation when patients performed correct MDI technique.

Michigan Medicaid recipients' perceptions of medication counseling as required by OBRA '90.

OBJECTIVE: To assess pharmacist counseling under OBRA '90 from the Medicaid recipient's perspective. Specifically, the study was designed to (1) assess pharmacists' compliance with counseling requirements, (2) assess recipients' level of satisfaction with the information provided during counseling and whether the information provided increased their comfort level in taking medication correctly, and (3) determine relationships between variables associated with pharmacist counseling and recipient satisfaction and comfort level. DESIGN: Cross-sectional telephone survey of Medicaid recipients. Medicaid recipient or caregiver was the unit of measure. SETTING: Michigan. PATIENTS: 408 recipients who received new prescriptions during a one-week period in November 1995. INTERVENTIONS: Telephone survey. MAIN OUTCOME MEASURE: Recipients' perception of whether an offer to counsel was made. RESULTS: Only 104 (25.5%) recipients indicated that someone offered counseling for their new prescription, and only 62 (15.2%) recipients indicated they knew of the requirement; 163 (40.0%) indicated someone offered counseled them. Counseled recipients were satisfied with the amount, quality, and way the information was presented, and were more likely to assign a higher level of importance to pharmacist counseling. The majority of respondents indicated high levels of comfort in using their medications safely, with those who were counseled expressing a higher level of comfort. CONCLUSION: From the perspective of the Medicaid recipient, pharmacies are failing to offer counseling for most new prescriptions. The results indicate that counseling improves measures of recipient comfort in using medications safely and enhances the level of importance patients assign to pharmacist counseling.

Pharmacists' ability to influence outcomes of hypertension therapy.

We measured the impact of pharmaceutical care on outcomes of antihypertensive therapy for patients with elevated baseline blood pressures who were attending an urban university-affiliated internal medicine clinic. The intervention group received education about hypertension, drug and nondrug management, and assistance to enhance compliance. The pharmacist made recommendations to physicians regarding pharmacotherapy. The control group received no such education, and interventions relating to pharmacotherapy were only physician initiated. Over an average follow-up of 5 months, significant-decreases in mean blood pressures were noted for the intervention group from baseline to final assessment (156.5/144.5 mm Hg systolic, p = 0.001; 91.6/86.9 mm Hg diastolic, p = 0.01), with insignificant changes in mean pressures in the control group (153.7/151.0 mm Hg systolic, p = 0.48; 90.4/87.8 mm Hg diastolic, p = 0.29). Comparing the groups, the change in diastolic pressures was insignificant (4.7 vs 2.6 mm Hg intervention vs control, p = 0.49), but the change in systolic pressure was more impressive (12.0 vs 2.7 mm Hg, respectively, p = 0.05). There was no significant difference in SF-36 Health Survey scores between groups. A significant decrease (p = 0.03) in the SF-36 physical functioning domain was seen in the intervention group, but no other significant changes in health-related quality of life scores. Pharmaceutical care contributed to improved blood pressure control in these patients.

Clinical interventions provided by doctor of pharmacy students.

OBJECTIVE: To assess the types, perceived benefit, and cost impact of the interactions provided by two-year post-B.S. Pharm.D. students on clerkship rotations. DESIGN: Information was obtained through voluntary reporting by students on a standardized data collection form. Cost analysis and peer review were performed on a subset of interventions. SETTING: The setting of the study included hospital clerkship sites (general medicine and specialty rotations) and an ambulatory care site (general medicine). PARTICIPANTS: Six second-year Pharm.D. students. RESULTS: Reports that were completed totaled 951, including 612 intervention, 335 information, and 4 unknown events. Most events were drug related and student initiated. Follow-up was predominantly to physicians. Intervention events primarily involved changes in drug therapy regimens (63.5 percent), changes in dose (29.5 percent), and identification of potential adverse drug reactions (7 percent). Acceptance rate of recommendations was 78.7 percent. Antibiotics, cardiovascular agents, and central nervous system drugs accounted for 55.5 percent of all interventions. Almost 80 percent of disease states encountered included cardiovascular, infectious, neurologic, pulmonary, gastrointestinal, and endocrine diseases. Overall, peer review scores tended to show a positive impact, with physician scoring higher than pharmacy faculty scoring. Medication-related costs were reduced modestly by accepted student interventions. CONCLUSIONS: This study demonstrates substantial clinical involvement of two-year post-B.S. Pharm.D. students on clerkships. The results indicate that the curriculum of Pharm.D. programs should emphasize cardiology, infectious disease, neurology, and gerontology.

Hypotension and bradycardia possibly associated with intraocular injection of acetylcholine.

Topically applied drugs are an important part of the pharmacologic management of cataract extraction and lens implant surgery. Acetylcholine facilitates this procedure via its miotic effect on the ciliary body of the eye. Systemic effects can occur with topically administered ophthalmic medications. Acetylcholine has been implicated in several cases of systemic cholinergic effects, such as hypotension, bradycardia, and bronchospasm, following intraocular administration. The patients we present experienced profound hypotension and bradycardia occurring up to 45 minutes after intraocular injection of acetylcholine. Both patients were over 90 years of age and had a history of first-degree atrioventricular block. As cataract surgery and lens implantation become more prevalent in the older ambulatory segment of the geriatric population, healthcare professionals should be aware that these patients may be more sensitive to the pharmacologic effects of medication used during surgery. Monitoring for adverse effects must be performed intraoperatively and several hours postoperatively. Additionally, patients with known conduction abnormalities prior to surgery should be monitored closely and proper emergency equipment and personnel should be available. Pharmacists who investigate adverse drug reactions should consider ophthalmic medications as potential causes for unexplained or suspected adverse drug reactions.

Clinical use and toxicity of high-dose tobramycin in patients with pseudomonal endocarditis.

The effects and toxicity of tobramycin were assessed in 26 patients receiving high-dose (approximately 8 mg/kg/d) therapy for pseudomonal endocarditis or conventional-dose (approximately 3 mg/kg/d) therapy for various systemic Gram-negative infections. Patients in the high-dose group received an average of 29.5 g of drug over 49 days and the dosage was adjusted to maintain peak serum concentrations of 15-20 mg/l. In the conventional-dose group, patients received an average of 8.6 g of tobramycin over 26.7 days and the dosage was adjusted to achieve peak concentrations of 4-10 mg/l. Clinical evidence of acute renal failure was not apparent in any patient. Five of seven patients in the high-dose group, for whom audiologic data was available, exhibited loss of hearing sensitivity in the high frequency range, but no patients sustained significant reduction in hearing in the conversational frequency range. Patients receiving high-dose tobramycin do not appear to be at greater risk for development of nephrotoxicity than do patients receiving conventional-dose therapy.