Pharmacist Prescribing in Pediatric and Neonatal Acute Care: An Observational Study.

OBJECTIVE: The intent of this project was to objectively describe the frequency of pharmacist prescribing in acute care pediatrics and neonatology and to determine the medications most often prescribed by pharmacists practicing in a jurisdiction that permits pharmacists' prescribing. METHODS: This was a subgroup analysis of a retrospective observational study using prescribing data from an electronic medical record system used in 5 acute care hospitals (1 pediatric, 4 primarily adult but with pediatric and neonatal units) within Calgary, Alberta, Canada. RESULTS: Considering orders for pediatric or neonatal patients only, there was a mean (SD) of 126 (226) prescriptions per pharmacist per year, with a wide range (1-1101 per year). Considering only the 9 clinical pharmacist full-time equivalents (FTEs) assigned to pediatrics and/or neonatology (i.e., not including dispensary pharmacist FTE), this represents 572 prescriptions per clinical pharmacist FTE per year (726 in pediatrics and 380 in neonatology). The most common medication classes on pediatric units included anti-infective agents, central nervous system agents, and gastrointestinal agents. In NICUs, blood formation, coagulation and thrombosis agents (mainly iron), electrolytes, caloric and water balance agents (primarily sodium supplements), and vitamins were also commonly prescribed by pharmacists. CONCLUSIONS: As the scope of pharmacy practice expands to include prescribing, health team leadership can use these data to support incorporation of this role into practice. Prescribing pharmacists can ensure appropriate use of many medications used in acutely ill infants and children, potentially improving efficiency and quality of care.

Hospital pharmacists understanding of available health literacy assessment tools and their perceived barriers for incorporation in patient education - a survey study.

BACKGROUND: Patients with low health literacy experience difficulty in understanding their medications leading to worse health outcomes. Pharmacists need to use formal assessment tools to be able to identify these patients, so they can better tailor their patient education. The objective of the study was to characterize hospital pharmacists understanding of health literacy and their use of screening and counselling strategies before and after completion of an educational module and to identify barriers that hospital pharmacists perceive to exist that prevent them from using health literacy tools. METHODS: Pharmacists in three health authorities were administered a pre-survey and then given access to an online 11 min educational video. The post-survey was distributed 1 month later. Descriptive statistics were used to quantify survey responses with comparisons made between pre and post responses. The main outcome measure was pharmacists' understanding of health literacy and their current practice related to health literacy. RESULTS: There were 131 respondents for the pre-survey and 39 for the post-survey. In the pre-module survey, 84% of pharmacists felt they understood what health literacy was, but only 53% currently assessed patients for their health literacy status and 40% were aware of what strategies to use in low health literacy patients. Lack of time (74%) was the biggest barrier in assessing patients' health literacy. In the post-module survey, 87% felt they understood what health literacy was and 64% incorporated health literacy status evaluation into their clinical practice. The educational module was helpful to the clinical practice of 74% of respondents. CONCLUSION: As health literacy can affect a patient's ability to adhere to their medications it is important for pharmacists to assess this in their patients. While pharmacists self-reported a high degree of understanding of health literacy, they are not regularly assessing their patients' health literacy status and are unaware of what strategies to use for low literacy patients.

CAPABLE: Calgary zone usage of Additional Prescribing Authorization By pharmacists in an inpatient setting: review of the prescribing Landscape and Environment.

BACKGROUND: In Alberta, Canada, pharmacists have been granted the ability to prescribe most medications independently after completing an additional authorization process. While there are data to support the use of pharmacists' prescribing in the community setting, little is known about its use in the inpatient hospital setting. OBJECTIVES: To describe the prescribing patterns of pharmacists in an inpatient setting including the percentage of pharmacists using their prescribing authority, the care areas where prescribing occurred, and the frequency of prescribing. Secondary objectives included describing the medications prescribed, and to determine if pharmacists are documenting their prescribing interventions. METHODS: A descriptive, retrospective, cross-sectional study of medications ordered by pharmacists through the electronic order entry system in Calgary, Alberta, Canada. Prescriptions were examined in the context of how often each pharmacist prescribed, the medications prescribed, and an audit of documentation practices was performed using patient charts. RESULTS: A total of 64,293 orders from 172 pharmacists were included in the analysis, of which 51% (n = 32,681) were discontinuation orders. It was found that 90% of pharmacists used their prescribing authority, ordering a median of 11.3 prescriptions monthly (interquartile range 4.3-32.8). Clinical areas with the most overall prescribing included critical care (854.8), oncology and palliative care (463.0), and surgery (409.3) prescriptions per pharmacist Full-Time Equivalent per year. CONCLUSIONS: This study demonstrates a broad range of prescribing from pharmacists within acute care practice and a wide variety of medication prescribed. Future areas for research include barriers and enablers to pharmacist prescribing and examination of where prescribing pharmacists have the greatest value.

The construct validity of the health utilities index mark 3 in assessing health status in lung transplantation.

PURPOSE: To assess the cross-sectional construct validity of the Health Utilities Index Mark 3 (HUI3) in lung transplantation. METHODS: Two hundred and thirteen patients (103 pre-transplant and 110 post-transplant) with mean age 53 years old (SD 13) were recruited during a randomized controlled clinical trial at the out-patient clinic in a tertiary institution. At baseline, patients self-completed measures that included the HUI3, EuroQol EQ-5D, Hospital Anxiety and Depression Scale (HADS) and socio-demographic questionnaire. Six-minute walk test scores and forced expiratory volume in 1 second data were collected from patient's medical records. A priori hypotheses were formulated by members of the transplant team about the expected degree of association between the measures. Correlation coefficients of < 0.1 were considered as negligible, 0.1 to < 0.3 as small, 0.3 to < 0.5 as medium, and ≥ 0.5 as large. RESULTS: Of the ninety predictions made, forty three were correct but in 31 the correlation was slightly lower than predicted and in 7 the correlations were much higher than predicted. In 48% of the cases, predicted and observed associations were in agreement. Predictions of associations were off by one category in 42% of the cases; in 10% of the cases the predictions were off by two categories. CONCLUSIONS: This is the first study providing evidence of cross-sectional construct validity of HUI3 in lung transplantation. Results indicate that the HUI3 was able to capture the burden of lung disease before transplantation and that post-transplant patients enjoyed higher health-related quality of life than pre-transplant patients.

An international survey of cytomegalovirus management practices in lung transplantation.

BACKGROUND: Cytomegalovirus (CMV) is an important infection in lung transplant recipients. Center-to-center variation in preventive and treatment strategies is unknown. METHODS: An electronic survey was sent to 102 lung transplant programs registered with the International Society of Heart and Lung Transplantation and United Network for Organ Sharing. RESULTS: Fifty-nine (58%) programs responded to the survey. For CMV prevention (D+/R-), 56 of the 59 (94.9%) programs used prophylaxis and two (3.4%) of them used preemptive therapy. For R+ patients, 86.4% used prophylaxis and 13.6% used preemptive strategy. Duration of prophylaxis was extremely variable ranging from 3 months to indefinite. Adjunctive prophylactic strategies included routine viral monitoring (51% D+/R-; 44% R+) and CMV immunoglobulin (32% D+/R-; 14% R+). The medication used for prophylaxis was valganciclovir with approximately half starting with intravenous ganciclovir. 9 of the 59 (15.2%) centers reported using specific CMV prophylaxis in D-/R- patients. Methods for viral monitoring included peripheral blood polymerase chain reaction, antigenemia, bronchoalveolar lavage viral culture, and bronchoalveolar lavage polymerase chain reaction. For treatment of CMV viremia, valganciclovir or intravenous ganciclovir were used. A total of 47.5% of centers routinely decreased immunosuppression at the time of viremia. Secondary antiviral prophylaxis was used routinely by 36 of the 59 (61%) centers. CONCLUSIONS: Although prophylaxis is the most commonly used preventive strategy, significant variation exists in the way it is implemented. Specifically, duration of prophylaxis is extremely variable. Uniform international guidelines would be of value in this population.

The use of patient-reported outcomes becomes standard practice in the routine clinical care of lung-heart transplant patients.

OBJECTIVE: To assess the use of patient-reported outcome (PROs) measures in the routine clinical care of lung-heart transplant patients. We assessed whether the addition of PROs in routine clinical care affected the duration of the consultation and patient's and clinician's views. METHOD: Consecutive lung-heart transplant patients visiting the outpatient clinic, University of Alberta Hospital, completed the Chronic Respiratory Questionnaire (CRQ) and the Health Utilities Index (HUI) on touchscreen computers. Information on the patient's responses was made available to the members of the transplant team prior to the encounter with the patient. The duration of clinical encounters was noted. At the end of every visit, clinicians completed a questionnaire on the usefulness of having PRO information available. After 6 months patients completed a survey of their experiences. RESULTS: The final patient sample consisted of 172 patients with a mean (SD) age of 52 (13.3) years old; 47% were female; 68% were organ recipients and 32% candidates. The transplant team, comprising four pulmunologists, two nurses, and one pharmacist had an average of 9 years of practical experience in pulmunology. The mean duration of patient-clinician encounters in minutes was 15.15 (4.52). Ninety-eight percent of patients indicated that they would be happy to complete the CRQ and HUI at every clinic visit. Ninety-one percent of the assessments completed by clinicians showed complete satisfaction with the use of PROs in routine practice. Further, the clinicians developed guidelines for the use of PRO information in clinical practice. CONCLUSIONS: The incorporation of PRO measures in the routine clinical care of lung-heart transplant patients resulted in a reduction of the duration of patient-clinician encounters. The experience was well accepted by patients and clinicians. We conclude that the routine use of PROs in lung-heart transplant patients has become standard practice.

Adverse effects of antiretrovirals in HIV-infected pregnant women.

BACKGROUND: Current guidelines for the use of antiretroviral (ARV) therapy during pregnancy recommend that women be offered treatment with combination ARV therapy used in nonpregnant HIV-infected individuals. It is unclear whether the risk of ARV-related adverse drug reactions (ADRs) is increased during pregnancy. OBJECTIVE: To evaluate the frequency and severity of ADRs likely caused by ARV therapy in pregnant women who are HIV-positive. METHODS: A retrospective analysis of HIV-infected women who received ARV therapy during pregnancy and delivered between January 1997 and February 2006 was conducted. Incidence of maternal ADRs was determined through evaluation of laboratory findings, documented physical examinations, and patient self-reports. An AIDS Clinical Trials Group severity grading scale was applied to the ADRs. Cause-effect relationship was adjudicated based on the Naranjo probability scale and, if causality was found, that information was included. RESULTS: There were 103 women who accounted for 133 pregnancies that resulted in deliveries. Of the 111 pregnancies in which treatment was received, regimens included 26 nucleoside reverse transcriptase inhibitor monotherapy, 40 nonnucleoside reverse transcriptase inhibitor (NNRTI)-based, 44 protease inhibitor (PI)-based, and 1 PI/NNRTI combination therapy. Ninety-eight ADRs were documented in 49 pregnancies. The most common ADRs were gastrointestinal (n = 48), followed by central nervous system symptoms (n = 15), anemia (n = 15), elevated liver/pancreatic enzyme levels (n = 11), and cutaneous reactions (n = 8). Severe ADRs included elevations in liver/pancreatic enzymes (n = 3), nausea and vomiting (n = 3), and anemia (n = 2). Seven women required a change in therapy due to an ADR. CONCLUSIONS: Approximately 7 ADRs were reported for every 10 pregnancies in this cohort. Most ADRs were mild to moderate. Short exposure times in most women (second and third trimester) may have accounted for the lack of long-term toxicities. Although ADRs did not pose a major barrier to use of ARVs in pregnancy, close monitoring of pregnant women receiving ARV therapy continues to be warranted.

Monitoring of mycophenolate mofetil in orthotopic heart transplant recipients--a systematic review.

BACKGROUND: Recent attention has focused on individualizing mycophenolate mofetil therapy via monitoring of mycophenolic acid (MPA) levels to overcome interpatient variability in MPA exposure when standard doses are administered. To our knowledge, no systematic review of the pharmacokinetic data in orthotopic heart transplant recipients has been published to date. OBJECTIVE: The study aimed to systematically review published studies on the MPA target concentration that is effective at preventing rejection in cardiac transplant patients. METHODOLOGY: A search of MEDLINE (January 1996 to July 2008) and EMBASE (January 1980 to July 2008) was conducted for articles describing the relationship between rejection and MPA concentration. RESULTS: The literature search yielded 7 citations for inclusion: 1 prospective, randomized controlled study (level I); 2 prospective, nonrandomized controlled studies (level II-1); 1 well-designed cohort study (level II-2); 2 retrospective cohort studies (level II-3); and 1 case report (level III). CONCLUSIONS: The relationship between MPA levels and rejection cannot be clearly defined based on available evidence. Preliminary evidence suggests limited sampling strategies may be a better predictor of rejection than a single-time point model. Further studies must be conducted on the relationship between the MPA area under the curve, the risk of rejection, and adverse effects to appreciate the value of such strategies.

Prenatal screening and perinatal HIV transmission in Northern Alberta, 1999-2006.

OBJECTIVES: We evaluated the effectiveness of a program that includes routine opt-out prenatal HIV screening, combination antiretroviral therapy (ART), and a multidisciplinary team in preventing perinatal HIV transmission. METHODS: A retrospective analysis was performed on HIV-infected pregnant women in northern Alberta, Canada, who delivered between January 1, 1999, and February 28, 2006. RESULTS: Ninety-eight women had 113 deliveries. Forty-three percent were diagnosed with HIV infection through prenatal screening. Approximately 60% of HIV-infected pregnant women were Aboriginal, with 45% reporting alcohol use and 42% illicit drug use during pregnancy. The use of combination ART during pregnancy increased throughout the study period; 89% or more received combination ART from 2004 through 2006. Only 1 of the 111 infants (0.9%) was confirmed to be HIV infected, and that infant was born to a woman with no prenatal care. CONCLUSIONS: High rates of HIV testing using an opt-out approach, combined with efforts by a multidisciplinary team, resulted in a low rate of perinatal HIV transmission in our cohort. The added value of retesting high-risk women late in pregnancy or with rapid HIV tests at the time of delivery should be explored.