Evaluation of Academic and Nonacademic Factors of First-Generation Students Transitioning to a Pharmacy Program.

OBJECTIVE: To evaluate the academic transition of first-generation (FG) students to a Doctor of Pharmacy program and the impact of early intervention/outreach. METHODS: The retrospective study evaluated the first semester performance in three classes of student pharmacists (beginning fall 2020, 2021, 2022) at a public university in the mid-South. Student demographics (age, sex, race, relationship status), nonacademic factors (Grit, impostor syndrome, testing anxiety, perceived stress), and academic factors (grade point average, academic probation, early intervention) were assessed. In fall 2022, a required academic meeting was added to the early intervention process after exam one for high-risk students. The data between FG and non-FG students were compared; Mann-Whitney tests for continuous variables and Chi-square tests with risk estimates for categorical variables. RESULTS: There were 152 FG and 274 non-FG students identified over the three classes. A total of 88 (57.9%) FG students represented racial minority groups. More FG students and non-White students were identified for early intervention. First-generation students were more likely to receive two or more grades less than C- and less likely to progress to the spring. No significance was noted with generational status and undergraduate grade point average, academic performance, or nonacademic factors. The required meeting after exam one in fall 2022 resulted in less disparity between FG and non-FG students identified for early intervention for exam two. CONCLUSION: First-generation and non-White students were more likely to struggle when transitioning to the Doctor of Pharmacy curriculum. A proactive, individualized approach incorporated into early intervention procedures is needed to promote academic success and belonging.

Exploring the Relationship Between Imposter Phenomenon and Myers-Briggs Personality Types in Pharmacy Education.

OBJECTIVE: To investigate the relationship between imposter phenomenon (IP) and Myers-Briggs Type Indicator (MBTI) personality types in pharmacy students. METHODS: This was a retrospective, observational study of doctor of pharmacy students who had previously completed MBTI and Clance Imposter Phenomenon Scale (CIPS) assessments. CIPS scores and categories were compared between the 4 MBTI personality type dichotomies using independent samples t tests and chi-square. RESULTS: Mean CIPS score for included pharmacy students (N = 668) was 62.52 (SD 14.82). Clance Imposter Phenomenon Scale scores were significantly higher in students with MBTI of introversion (mean 64.14, SD 14.27), intuition (mean 63.80, SD 15.78), and perceiving (mean 64.38, SD 15.55) as compared to their dichotomous counterparts. No significant difference in mean CIPS scores was found within the thinking/feeling dichotomy. When analyzing IP risk associated with the various MBTI personality dichotomies, introverts were at a 1.8 times greater risk of high/severe IP than extroverts. Additionally, students with perceiving personality types were at a 1.4 times greater risk of high/severe IP than those with judging personality types. CONCLUSION: Our study suggests that pharmacy students with introversion, intuitive, and perceptive personality types exhibit higher CIPS scores, and those with introversion or perceptive personality types are at risk for high/severe IP. Given the common MBTI types and a high degree of IP in pharmacy students, our findings underlie the need for open, targeted discussions about IP and proactively incorporating strategies and resources within a curriculum to support students in normalizing and easing anxiety.

Assessing Student Perceptions of Blended and Online Learning Courses in Pharmacoeconomics, Management, and Leadership.

Objective. Blended learning combines traditional face-to-face education with online instruction. This learner-centered approach has been shown to improve student engagement, critical thinking, and performance outcomes. The objective of this study was to assess and trend student pharmacist perceptions of blended and online learning used to teach pharmacy management, leadership, and economics within a Doctor of Pharmacy (PharmD) curriculum.Methods. Qualitative methods were employed using in-depth, semistructured interviews. Second- and third-year student pharmacists were recruited by purposeful and snowball sampling and interviewed to a point of saturation. The interview guide was based on social cognitive theory. Themes identified through initial deductive thematic analysis were categorized by the three domains of social cognitive theory: cognitive, behavioral, and environmental factors. The coding team additionally analyzed the transcripts using inductive thematic analysis to ensure no themes outside of social cognitive theory were missed.Results. Twenty students were interviewed. Themes reveal perceptions that blended learning facilitated greater understanding of course material, increased motivation among learners, provided more flexibility in workload completion, and was a more enjoyable way to learn compared to traditional didactic instruction. Furthermore, blended learning offered additional distinct advantages over traditional and online-only pedagogies.Conclusion. Student pharmacists perceived blended and online learning positively and acceptable for the delivery of a pharmacy course on management, leadership, and economics over traditional didactic instruction. Blended learning may enhance innovation, leadership, management, and economics content delivery and the student learning experience.

Empowering Student Pharmacists through Social Determinants of Health Activities to Address Patient Outcomes.

The pharmacy education and its educators have to expose the student pharmacists to a plethora of activities regarding health disparities. It is essential for student pharmacists to be introduced to the key elements that comprise the Social Determinants of Health (SDOH) during their didactic curriculum. However, while there have been efforts made in the United States to incorporate the SDOH in the pharmacy curricula, there is limited research on student pharmacists' perspectives of how content in the didactic curriculum prepared them to provide patient care. A quantitative approach was used for this study. For the Class of 2023, activities were added to a skills-based course series and a professional development course series to introduce, apply, and illustrate how SDOH can impact pharmacist-provided care and patient health experiences. As part of the College's assessment plan, a survey is sent to the third-year student pharmacists in January prior to beginning Advanced Pharmacy Practice Experiences (APPEs). The online survey consists of 24 Likert Scale questions with five choices ranging from Strongly Agree to Strongly Disagree and not applicable. Four of the 24 questions pertained to health disparities and SDOH and were evaluated in this study. The responses were analyzed using SPSS for Windows, version 25.0 (IBM Corporation, Armonk, NY, USA). Descriptive statistics were calculated for all variables. Chi-square tests were used for all nominal data and Mann-Whitney test was used for all nonparametric numeric data. A total of 530 student pharmacists completed the survey. The mean age was 26 years and majority of the respondents identified as female (64%). More students strongly agreed that they had the ability to identify and address SDOH to improve access to or the delivery of healthcare in the class of 2023 (51.4%) compared to the class of 2022 (37.8%) and class of 2021 (35.8%). In addition, the mean survey score for the question between the class of 2023 improved significantly compared to the class of 2022 (p = 0.015) and 2021 (p = 0.004). Overall, this study suggests that longitudinal activities involving SDOH can improve student pharmacists' assessment of their abilities to interact with and care for a diverse patient population. The results suggest that the curriculum activities implemented to address a plethora of patients improve student assessment of their abilities to identify and incorporate SDOH in providing patient-centered care.

Changes in Academic Performance after Transitioning to Remote Proctoring: A Before-After Evaluation.

Remote proctoring is often used to ensure testing integrity in a distance education environment but may impact academic performance. This quasi-experimental study aimed to evaluate changes in examination scores after transitioning to remote proctoring during the COVID-19 pandemic. Student pharmacists (n = 384) served as their own controls in this before-after analysis of examination scores with in-person versus remote proctoring. To assess differences in examination scores among students with varying levels of testing anxiety, students were classified into low, moderate, or high testing anxiety groups based on their Cognitive Test Anxiety Scale-Second Edition (CTAS-2) score. Students were also stratified into two groups based on their cumulative grade point average (GPA). After transitioning to remote proctoring, examination scores significantly decreased for first-year (P1) students but significantly increased for second-year (P2) students. When stratified by CTAS-2 score, no significant difference in examination scores was found. When stratified by GPA, no significant difference in examination scores was found for P1 students, but a significant improvement was noted for P2 students with remote proctoring. The results of this study indicate that examination scores do not consistently improve or decline after introducing remote proctoring even when considering a student's GPA and level of testing anxiety.

Examining Preparatory Testing and Other Factors Associated With Performance on the Multistate Pharmacy Jurisprudence Examination.

Objective. To evaluate whether the score on the Pre-Multistate Pharmacy Jurisprudence Examination (Pre-MPJE) predicts pharmacy students' performance on the MPJE, and to determine whether demographics, pre-pharmacy school factors, or pharmacy school factors affect MPJE outcomes.Methods. We performed a retrospective review of pharmacy school graduates' (N = 156) MPJE scores, Pre-MPJE scores, demographics, pre-pharmacy school academic performance factors, and pharmacy school academic performance factors. Bivariate and correlational analyses were conducted along with multiple linear regression models to determine the influence of variables on the MPJE total scaled score.Results. A total of 136 pharmacy school graduates were included, with most being female (59%) and non-Hispanic White students (75%). The score on the Pre-MPJE was not significantly correlated with students' first-attempt MPJE pass-fail outcome or total scaled score. Factors that were correlated with passing the MPJE were a younger age at graduation, a higher pharmacy law course grade, Pharmacy Curriculum Outcomes Assessment (PCOA) examination scores, specifically scaled total scores and scaled scores for content areas 1-4 and final pharmacy school grade point average (GPA). The MPJE total scaled score was correlated with a higher pre-pharmacy school GPA, pharmacy law course grade, PCOA total and content area 1-4 scaled scores, and final pharmacy school GPA. However, regression models found that the greatest variance in MPJE total scaled score was contributed by the pharmacy law course grade. The total scaled score on the PCOA contributed to some variance for all MPJE takers, but only the pharmacy law course grade significantly influenced the in-state MPJE total scaled score.Conclusion. The findings did not show that the Pre-MPJE score was a predictor for passing the MPJE or for the MPJE total scaled score. The most important determinant of the MPJE total scaled score was a student's performance in the pharmacy law course.

Effects of Remote Proctoring on Composite Examination Performance Among Doctor of Pharmacy Students.

Objective. To determine the impact of remote proctoring on the academic performance of Doctor of Pharmacy (PharmD) students.Methods. This was a retrospective, observational study that compared first professional year (P1) and second professional year (P2) pharmacy students' scores on eight composite examinations administered in spring 2020 (n = 387), the final three of which were proctored remotely, to that of a historical cohort of pharmacy students who took the same examinations in spring 2019 (n = 368). To assess whether remote proctoring affected academic performance, spring 2020 scores for examinations 6, 7, and 8 were compared to those of a historical cohort who took the same examinations in person with a proctor present in spring 2019. Academic performance on examinations 1 through 4 was also compared between the two cohorts to evaluate any possible year-to-year variation in academic performance during non-remote circumstances. Mann Whitney tests were used to compare scores between the two cohorts.Results. The median scores of students in the spring 2020 cohort were significantly lower than the scores of the historical cohort on the first composite examination administered to P1 students after the implementation of remote proctoring. In contrast, median scores were significantly higher on two of the three examinations administered to P2 students using remote proctoring.Conclusion. Remote proctoring has minimal impact on pharmacy students' examination performance and its use should be considered to ensure academic honesty and security of testing content in a distance learning environment.

Genetic Variation in CYP2R1 and GC Genes Associated With Vitamin D Deficiency Status.

This cross-sectional study enrolled 180 patients at a private family practice in Virginia. Total serum vitamin D concentrations were obtained weekly from January 30, 2013, through March 30, 2013, in consecutive patients regularly scheduled for laboratory work at the practice. Patients were categorized into 2 groups and analyzed for variant alleles in vitamin D receptor ( VDR; rs2228570), cytochrome P450 2R1 ( CYP2R1; rs10741657), 7-dehydrocholesterol reductase ( DHCR7; rs12785878), and group-specific component ( GC; rs2282679) to determine whether variants of those alleles influenced total serum 25(OH)D concentrations. One-hundred and eighty patients were enrolled, with 40 (22%) being sufficient, 25-hydroxy vitamin D level 25(OH)D ≥ 30 ng/mL, and 140 (78%) being insufficient, 25(OH)D < 30 ng/mL. Of the 4 genes, 2 genes, CYP2R1 (rs10741657) and GC (rs2282679), demonstrated a significant association related to vitamin D status. Subjects with 1 or more variant alleles at rs10741657 were almost 3.7 (odds ratio [OR] 3.67; 95% confidence interval [CI]: 1.35-9.99) times more likely be insufficient in vitamin D and subjects with 1 or more variant alleles at rs2282679 were about half (OR 0.42; 95% CI: 0.18-0.93) as likely to be insufficient in vitamin D. Allelic variations in CYP2R1 (rs10741657) and GC (rs2282679) affect vitamin D levels, but variant alleles on VDR (rs2228570) and DHCR7 (rs12785878) were not correlated with vitamin D deficiency, 25(OH)D < 30 ng/mL.

Management of prediabetes: a comparison of the treatment approaches utilized by a family practice clinic and an internal medicine/endocrinology practice.

PURPOSE: To compare the management of prediabetes between a family practice clinic and internal medicine/endocrinology practice. METHODS: A randomized, retrospective evaluation of the medical history in 168 eligible patients with a diagnosis of prediabetes or abnormal blood glucose (BG) at a family practice clinic (n = 78) and an internal medicine/endocrinology practice (n = 90). RESULTS: The internal medicine/endocrinology practice provided more counseling regarding lifestyle modifications (91.1% vs 76.9%, P = .039), specific physical activity recommendations (26.7% vs 7.7%, P = .003), and recommended more patients receive 150 minutes/week of moderate exercise (8.9% vs 1.3%, P = .038). The family practice clinic provided more written dietary information (16.9% vs 13.3%, P = .044) and specific weight loss goals (20.5% vs 6.7%, P = .015). The internal medicine/endocrinology practice initiated pharmacological therapy in more patients (51.1% vs 3.8%, P< .001) and had a significant decrease in fasting BG from baseline compared to the family practice clinic (-9.0 vs -5.6 mg/dL, P< .001). CONCLUSION: Providers are likely to initiate nonpharmacological therapy but may not provide specific education recommended by the American Diabetes Association. The integration of a multidisciplinary team to provide guideline-based nonpharmacologic counseling may be beneficial in improving outcomes in the management of prediabetes.

Guidelines for resident teaching experiences.

Postgraduate year one (PGY1) and postgraduate year two (PGY2) residencies serve to develop pharmacists into skillful clinicians who provide advanced patient-centered care in various general and specialized areas of pharmacy practice. Pharmacy residencies are a minimum requirement for many clinical pharmacy positions, as well as for positions in academia. The role of clinical pharmacists typically includes teaching, regardless of whether they pursue an academic appointment. Common teaching duties of pharmacist-clinicians include giving continuing education or other invited presentations, providing education to colleagues regarding clinical initiatives, precepting pharmacy students (early and advanced experiences) and residents, and educating other health care professionals. Although ASHP provides accreditation standards for PGY1 and PGY2 residencies, the standards pertaining to teaching or education training are vague. Through the years, teaching certificate programs that develop residents' teaching skills and better prepare residents for a diverse pharmacy job market have increased in popularity; moreover, teaching certificate programs serve as an attractive recruitment tool. However, the consistency of requirements for teaching certificate programs is lacking, and standardization is needed. The Task Force on Residencies developed two sets of guidelines to define teaching experiences within residencies. The first guideline defines the minimum standards for teaching experiences in any residency-training program. The second guideline is for programs offering a teaching certificate program to provide standardization, ensuring similar outcomes and quality on program completion. One of the main differences between the guidelines is the recommendation that residency programs offering a teaching certificate program be affiliated with an academic institution to provide the pedagogy and variety of teaching experiences for the resident. Residency program directors should consider adopting these guidelines to offer consistent teaching experiences. In addition, residents should inquire about the elements of teaching in a program as an aid to selecting the training best suited to their needs.

Impact of obtaining medications from pharmaceutical company assistance programs on therapeutic goals.

BACKGROUND: Limited data exist regarding whether improved access to medications for indigent persons through pharmaceutical company assistance programs (PCAPs) leads to attainment of therapeutic goals. OBJECTIVE: To evaluate the impact of obtaining medications through PCAPs with pharmacist assistance versus prescription insurance on the likelihood of achieving therapeutic goals. METHODS: A retrospective chart review was conducted in a private family practice clinic. Individuals prescribed one or more drugs for the treatment of hypertension, diabetes, or dyslipidemia and receiving medication through a PCAP or prescription insurance were included. Eligible records were reviewed for pertinent laboratory and medication information and to assess achievement of hypertension, diabetic, and dyslipidemia goals. RESULTS: A total of 458 persons were eligible for inclusion: 250 with prescription insurance and 208 using a PCAP. The PCAP group was older, with more females and multiple disease states. There was no significant difference between the groups in reaching hypertension goals; the goals were not predicted by PCAP, presence of diabetes, or class of drug. More PCAP individuals (67.1%) achieved hemoglobin A1C values less than 7% compared with patients in the prescription insurance group (39.6%; p = 0.002). The PCAP group had lower low-density lipoprotein cholesterol (LDL-C) values (95.8 +/- 28.0 mg/dL; mean +/- SD) and higher high-density lipoprotein cholesterol (HDL-C) values (40.8 +/- 12.1 mg/dL) compared with the prescription insurance group (111.8 +/- 37.5 mg/dL; p < 0.001 and 33.7 +/- 13.6 mg/dL; p = 0.011, respectively). Achieving LDL-C goals were significant only for a goal less than 130 mg/dL and less than 160 mg/dL (p = 0.007); diabetes patients were less likely to achieve LDL-C goals compared with those without diabetes in both groups. Enrollment in PCAP was a predictor in reaching diabetic and some dyslipidemia therapeutic goals. CONCLUSIONS: Individuals without prescription insurance and receiving pharmacist and PCAP assistance in obtaining medications were more likely to reach diabetic goals and have better cholesterol values compared with persons with prescription insurance. The presence of prescription insurance alone does not guarantee reaching therapeutic goals; pharmacist involvement with PCAP and obtaining drugs enhances the likelihood of persons achieving therapeutic goals.

Impact of the Medicare modernization act on low-income persons.

BACKGROUND: Low-income Medicare beneficiaries without prescription benefits have high out-of-pocket medication expenses that can discourage adherence to treatment regimens. The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created a temporary drug discount card program and a prescription benefit with low-income provisions to assist with medication expenditures for eligible seniors. OBJECTIVE: To determine the impact of the new drug discount card and prescription benefit on medication expenditures by low-income Medicare recipients who require pharmaceutical company assistance for obtaining medications. DESIGN: Retrospective, nonrandomized evaluation. SETTING: Family practice physicians' office in northern Virginia. PATIENTS: 137 Medicare recipients without prescription coverage who received assistance from pharmaceutical companies for medications. MEASUREMENTS: Patients were stratified into 3 categories according to income, household size, and the federal poverty line (FPL), as defined by the new Medicare act. Participants' long-term oral and inhaled medications, dosages, and instructions for use were obtained. The MMA criteria for low-income provisions were applied for the drug discount program and for the prescription benefit. Medication costs under the new Medicare benefits were compared with those incurred without assistance and with the use of pharmaceutical company programs for the cohort and FPL categories. RESULTS: In all income categories, medication costs were lower after enrollment in all programs than those of patients without assistance. Compared with pharmaceutical company assistance, Medicare drug discount cards resulted in less savings for all income groups. For the prescription benefit, persons with incomes less than 135% of FPL had the greatest benefit because of low-income subsidies. Persons ineligible for low-income subsidies receiving the standard benefit had a smaller reduction in out-of-pocket costs and variable monthly expenditures; they realized a superior savings with pharmaceutical company assistance programs. LIMITATIONS: The generalizability of these findings is limited because the authors used a discount pharmacy to determine drug costs for persons receiving no assistance, could not determine asset criteria for the MMA drug benefit low-income subsidy, and used a selected Medicare population. CONCLUSIONS: In a low-income Medicare population without prescription coverage, pharmaceutical company programs offered considerable savings and were superior to the Medicare drug discount cards. For the Medicare prescription plan, the greatest savings was among those eligible for low-income subsidies. Month-to-month medication costs may vary substantially for persons ineligible for such subsidies, and pharmaceutical company assistance may be a better alternative.

Enhanced antithrombotic effect of warfarin associated with low-dose alcohol consumption.

A 58-year-old Caucasian man was receiving long-term anticoagulation with warfarin for the prevention of ischemic stroke; his international normalized ratio (INR) had been stable. His INR increased when he began consistent, low-dose beer consumption for its perceived cardiovascular protection. After he stopped drinking the alcohol, his anticoagulation control improved and returned to previous levels. Information on the effects of alcohol, particularly beer, is limited in nonalcoholic patients who receive warfarin therapy. This case reveals a potential for low-dose beer consumption to elevate INR. We propose that the increased antithrombotic effect of warfarin involved protein-binding interactions and decreased warfarin metabolism through the cytochrome P450 (CYP) enzyme system. Concurrent administration of aspirin and other drugs that are metabolized through or are inhibitors of the CYP system may have enhanced the interaction that occurred in this patient. Caution should be used whenever warfarin and alcohol in any amount are taken together, especially in patients receiving many drugs, and close monitoring of the INR is warranted.

Early evaluation of hematuria in a patient receiving anticoagulant therapy and detection of malignancy.

A 63-year-old Caucasian man had a painless episode of dark-colored urine while taking warfarin 62.5 mg/week for lone atrial fibrillation in the presence of documented stable anticoagulation. Urinalysis revealed microscopic hematuria. Three weeks later, he had an episode of gross, painless hematuria. Thorough evaluation of the upper and lower urinary tract with renal ultrasound, intravenous pyelography, and cystoscopy revealed poorly differentiated, early-stage, transitional cell carcinoma of the bladder. The patient was not aware of any exposure to carcinogens known to predispose to bladder cancer, nor was he a tobacco user. Early identification of the malignancy allowed for aggressive surgical intervention. Although this patient was considered low risk for the development of bladder cancer and was taking anticoagulants, the presence of hematuria was indicative of underlying pathology. Timely and thorough evaluation of hematuria in patients taking anticoagulants is necessary to identify and treat clinically important pathology.

Accuracy and precision of the CoaguChek S versus laboratory INRs in a clinic.

BACKGROUND: The CoaguChek S is the next-generation coagulation monitor for measuring the international normalized ratio (INR) that replaces the CoaguChek device. Studies are lacking comparing the CoaguChek S with local laboratory INR assessment to ensure its accuracy and precision for monitoring patients on anticoagulation. OBJECTIVE: To evaluate accuracy, precision, and technical ease-of-use of the CoaguChek S compared with laboratory measurements. METHODS: Accuracy was evaluated in 101 patients by parallel assessment of INRs (CoaguChek S and laboratory); precision was evaluated in 31 patients using duplicate INRs from CoaguChek S and laboratory and from liquid quality controls. Accuracy was determined using orthogonal regression, Bland-Altman plot, and clinical applicability (INRs discrepant in categorization of INR goal and resulting in different therapeutic decisions). Precision was examined by comparing mean difference +/- SD between repeated INRs from CoaguChek S and laboratory, coefficient of variation (CV), and coefficient of repeatability (CR). The influence of low and elevated INRs on accuracy and precision was also examined. To assess ease-of-use of the monitor, the number of technical errors was recorded. RESULTS: The CoaguChek S significantly correlated to laboratory measurement (r = 0.93); 16.7% of INRs resulted in discrepant categorization and 24.5% would have required a different therapeutic plan. The CV and CR compared well between CoaguChek S and laboratory (6% vs. 4.9%; 0.455 vs. 0.346, respectively). When subgroups of INR values <4.0 and <3.0 were evaluated, the precision improved with both methods. Precision, based on liquid quality controls, was good (CV 4.6% = low-level; 3.3% = high-level). The CoaguChek S was found to have an error rate of 1.8%. CONCLUSIONS: The CoaguChek S is an accurate and precise alternative to laboratory assessment of the INR at values <4.0; it is an efficient device with a low likelihood of errors during testing.

Effect of stress on international normalized ratio during warfarin therapy.

OBJECTIVE: To discuss the effect of stress on the international normalized ratio (INR) when patients are taking warfarin. CASE SUMMARY: Two patients at a pharmacist-managed anticoagulation clinic who were stable with anticoagulation developed elevated INR values after a stressful event occurred. All other factors known to elevate the INR were unchanged; furthermore, the INR values returned to the prior level of control after resolution of the stressful events. DISCUSSION: Management of anticoagulation with warfarin requires the knowledge of factors that may alter an INR. Many of these factors, such as dietary changes, illnesses, drug interactions, patient compliance, and physical activity, have been described. In spite of this understanding, many patients continue to experience variability in their INR values, suggesting there are other factors that can alter the INR that have not been fully described. The cases presented here demonstrate that stressful events, physical or psychological, can elevate the INR. The mechanism for this occurrence is unknown, but may be related to decreased metabolism of warfarin during stress. CONCLUSIONS: When an unexplained INR value exists, a stressor should be evaluated as a potential cause.

Possible effect of refrigeration of warfarin on the international normalized ratio.

A 43-year-old African-American woman taking warfarin for prevention of ischemic stroke experienced fluctuating international normalized ratio (INR) values over 8.5 months; no cause could be identified. After reading a pharmacy information sheet that accompanied a warfarin refill, she reported that she had been refrigerating her warfarin because her other drugs had been "sticking together." She then was instructed to store her warfarin at room temperature. During the 8.5 months she had been refrigerating her warfarin, 80% of her INR values had been outside her goal range versus 37.5% during 9 months of storage at room temperature. A MEDLINE search and communication with the drug's manufacturer provided no information regarding storage of warfarin outside the temperature range of 59-86 degrees F and resultant changes in potency of the drug. Because of potential fluctuation in anticoagulation control, patients should be reminded to store their warfarin at room temperature.