Evaluation of clinical pharmacy interventions in a Veterans Affairs medical center primary care clinic.

PURPOSE: The development of an electronic tool to quantify and characterize the interventions made by clinical pharmacy specialists (CPSs) in a primary care setting is described. SUMMARY: An electronic clinical tool was developed to document the clinical pharmacy interventions made by CPSs at the Veterans Affairs Medical Center in West Palm Beach, Florida. The tool, embedded into the electronic medical record, utilizes a novel reminder dialogue to complete pharmacotherapy visit encounters and allows CPSs to document interventions made during patient care visits. Interventions are documented using specific electronic health factors so that the type and number of interventions made for both disease-specific and other pharmacotherapy interventions can be tracked. These interventions were assessed and analyzed to evaluate the impact of CPSs in the primary care setting. From February 2011 through January 2012, a total of 16,494 pharmacotherapy interventions (therapeutic changes and goals attained) were recorded. The average numbers of interventions documented per patient encounter were 0.96 for the management of diabetes mellitus, hypertension, dyslipidemia, and heart failure and 1.36 for non-disease-specific interventions, independent of those interventions being made by the primary physician or other members of the primary care team. CONCLUSION: A clinical reminder tool developed to quantify and characterize the interventions provided by CPSs found that for every visit with a CPS, approximately one disease-specific intervention and one additional pharmacotherapy intervention were made, independent of those interventions being made by the primary physician or other members of the primary care team.

The effect of acetaminophen on the international normalized ratio in patients stabilized on warfarin therapy.

STUDY OBJECTIVE: To determine whether an interaction exists between acetaminophen and warfarin that alters the international normalized ratio (INR). DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Anticoagulation clinic at a Veterans Affairs Medical Center. PATIENTS: Thirty-six adult patients receiving warfarin with stable INRs, defined as two consecutive INRs at least 3 weeks apart that were within the therapeutic range. INTERVENTION: Patients were randomly assigned to receive acetaminophen 1 g twice/day along with matching placebo twice/day (12 patients), acetaminophen 1 g 4 times/day (12 patients), or matching placebo 4 times/day (12 patients) for 4 weeks. MEASUREMENTS AND MAIN RESULTS: The primary end point was the difference in mean INR between groups at weekly intervals. Secondary end points were the percentages of patients in each group with supratherapeutic (INR > or = 0.3 above the upper limit of their therapeutic range) or subtherapeutic (INR > or = 0.2 or 0.3 below the lower limit of their respective therapeutic range of 2.0-3.0 or 2.5-3.5) INRs, and the difference in mean serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels between groups at biweekly intervals. Slow enrollment and a preliminary observation that 15 patients experienced an elevated INR prompted early termination of the study. At week 2, the group receiving acetaminophen 2 g/day had a significantly higher mean INR versus the placebo group (p=0.01). At weeks 1, 2, and 3, the acetaminophen 4-g/day group had significantly higher mean INRs compared with those in the placebo group (p=0.04, p=0.01, p=0.01, respectively). In addition, 13 (54%) of 24 patients in the acetaminophen groups combined exceeded the upper limit of their therapeutic range by 0.3 or greater compared with only 2 (17%) of 12 patients in the placebo group. No statistically significant differences in serum ALT or AST levels between either acetaminophen group versus the placebo group were found at week 4; however, there was a statistically significant increase in mean ALT level at week 2 in the acetaminophen 4-g/day group versus the placebo group. CONCLUSION: These findings support the existence of a clinically significant interaction between warfarin and daily use of acetaminophen 2-4 g, necessitating close monitoring of patients who receive this drug combination. Whether this interaction occurs when acetaminophen is taken in lower doses or is used sporadically requires further study.

Effect of splitting simvastatin tablets for control of low-density lipoprotein cholesterol.

The efficacy, safety, and economics of a voluntary conversion from whole simvastatin tablets to split tablets in 6 Veterans Affairs medical centers were retrospectively evaluated in 3,787 patients who received a consistent daily dose (5 to 40 mg) of simvastatin in 1999. Baseline and final low-density lipoprotein cholesterol levels and average change from baseline were not significantly different between groups (p >0.05), nor were the incidence of transaminase increases (p >0.05) or measurements of patient compliance (p = 0.07). Widespread implementation of this initiative resulted in a cost avoidance of >$1.2 million in the 6 medical centers and $10.3 million across the Veterans Affairs medical system in 1999, with >$46 million avoided in 2003.

Metformin monitoring and change in serum creatinine levels in patients undergoing radiologic procedures involving administration of intravenous contrast media.

STUDY OBJECTIVES: To evaluate the prevalence and magnitude of serum creatinine level elevations in patients receiving metformin who underwent radiologic procedures involving administration of intravenous contrast media, and to evaluate the efficacy of an electronic consultation in promoting timely evaluation of renal function after the procedure. DESIGN: Retrospective evaluation. SETTING: Veterans Affairs Medical Center. PATIENTS: Ninety-seven patients receiving metformin who underwent a radiologic procedure involving administration of intravenous contrast media over a 27-month period. MEASUREMENTS AND MAIN RESULTS: Ninety-seven patients underwent a total of 111 radiologic procedures with documented administration of intravenous contrast dye. Average time from procedure to laboratory follow-up, excluding one patient, was 2.62+/-1.56 days. Average serum creatinine levels before and after the procedure were 1.10+/-0.19 and 1.13+/-0.23 mg/dl, respectively (p>0.05). Four patients developed contrast material-associated nephropathy. An additional four patients with borderline serum creatinine levels at baseline (1.4 mg/dl) had a serum creatinine level of 1.5 mg/dl or greater after the procedure. CONCLUSION: Our results indicated that electronic consultations result in timely evaluation of serum creatinine levels in patients receiving metformin who undergo a radiologic procedure involving intravenous contrast material. Also, the study suggests that nearly 4% of patients with diabetes mellitus and normal renal function may develop contrast material-associated nephropathy [corrected] with nonionic contrast material. In addition, about 8% of patients with diabetes treated with metformin (with baseline serum creatinine levels < 1.5 mg/dl) who undergo a procedure with nonionic intravenous contrast material acquire an increased risk (serum creatinine > or = 1.5 mg/dl) of lactic acidosis. These findings support the recommendations of the Food and Drug Administration regarding metformin monitoring in patients undergoing radiologic procedures involving administration of intravenous contrast media.

Optimizing drug therapy in patients with cardiovascular disease: the impact of pharmacist-managed pharmacotherapy clinics in a primary care setting.

We evaluated the effectiveness of pharmacist-managed pharmacotherapy clinics in implementing and maximizing therapy with agents known to reduce the morbidity and mortality associated with cardiovascular disease. This was a retrospective chart review of 150 patients who were treated for coronary artery disease in primary care clinics. Appropriate treatment of hypercholesterolemia occurred in 96% of patients referred to a clinical pharmacy specialist, compared with 68% of those followed by primary care providers alone (p<0.0001). Eighty-five percent and 50%, respectively, achieved goal low-density lipoprotein (LDL) values below 105 mg/dl (p<0.0001). Appropriate therapy with aspirin or other antiplatelet or anticoagulant drugs was prescribed in 97% and 92%, respectively (p=0.146). As appropriate therapy with these agents was high in both groups, the ability to detect a difference between groups was limited. Among patients with an ejection fraction below 40%, appropriate therapy with an angiotensin-converting enzyme inhibitor or acceptable alternative was 89% and 69%, respectively (p<0.05). Twenty-seven cardiac events were documented in the clinical pharmacy group, versus 22 in the primary care group (p=0.475). Despite the relatively high percentage of patients reaching goal LDL in the primary care group, referral to clinical pharmacy specialists resulted in statistically significant increases in the number of patients appropriately treated for hypercholesterolemia and achieving goal LDL.