Effects of testosterone and progressive resistance exercise on vascular function in older men.

The cardiovascular effects of testosterone (T) are controversial. Low T has been associated with accelerated vascular aging, characterized by large elastic artery stiffening (decreased compliance), intimal-medial thickening (IMT), and endothelial dysfunction. Endurance exercise improves vascular function, but resistance training may increase arterial stiffness. We sought to determine whether T supplementation improved markers of vascular aging in men with low-normal T and whether T supplementation prevented arterial stiffness with resistance exercise. We studied 160 community-dwelling older men (66 ± 5 yr) with low-normal baseline total T levels (200-350 ng/dl). Participants were randomized to transdermal T gel targeting either a lower (400-550 ng/dl) or higher (600-1,000 ng/dl) T range or to placebo gel and to either progressive resistance training (PRT) or to no exercise for 12 mo. Carotid artery stiffness (arterial compliance) and carotid IMT were measured at baseline, 6 mo, and 12 mo. Endothelial function (brachial artery flow-mediated dilation) was measured in a subset (n = 86). Changes in carotid artery compliance, IMT, and endothelial function with either the lower or higher range of T supplementation were not different from placebo at 6 or 12 mo. There were no differences between PRT and no PRT groups, alone or with T supplementation, in changes in any of the vascular measures at either time point. Supplementation of T and PRT in older men with low-normal levels do not appear to improve or harm vascular function.NEW & NOTEWORTHY Increased promotion and prescription of testosterone (T) to aging men has raised concerns about potential adverse cardiovascular effects. We show that in older men with T levels in the low-normal range, 12 mo of T supplementation with or without resistance exercise did not improve or harm vascular function.

Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic.

PURPOSE: The implementation and delivery of a pharmacist-led chronic care management (CCM) service in a geriatric primary care clinic are described. METHODS: A CCM service was provided March 1 through December 31, 2016, at the University of Colorado Hospital Seniors Clinic ("Seniors Clinic"). The electronic health record (EHR) team for the University of Colorado Health system developed a patient registry through EPIC Healthy Planet (Epic Systems Corp., Verona, WI) to identify patients at the Seniors Clinic eligible for CCM services. The EHR team constructed a note type and documentation template within the EHR to ensure documentation of all necessary components for billing and to allow individual clinical staff to document the time spent providing CCM care. RESULTS: Overall, 36 elderly patients enrolled in the pharmacist-provided CCM service over the 10 months. Clinical pharmacists spent a total of 156-849 minutes per month providing CCM services, with a mean outreach time of 45.4 minutes per patient. The clinical pharmacists submitted 95 claims, and all but 5 were paid. The total amount reimbursed from the health plans during the 10 months was $2,775.02. CONCLUSION: Medicare patients were successfully enrolled in a CCM service in a geriatrics primary care clinic led by clinical pharmacists and medical providers. The CCM services were more time-consuming than the allotted 20 minutes per patient per month with the CCM Current Procedural Terminology code used during this study.

Blood pressure control rates measured in specialty vs primary care practices within a large integrated health system.

Blood pressure measurement is a diagnostic test and a key component of assessing and managing hypertension, a major contributor to cardiovascular risk. Based on real-world clinical observations within a large, university-based, accountable care organization, we sought to assess whether blood pressure control results varied by the assessment setting, primary care versus specialty. We studied the most recent outpatient measurement for patients with hypertension during the 2016 calendar year and categorized each as being performed in a primary care or specialty setting, and as being controlled (<140/90 mm Hg) or uncontrolled. Among the 86 512 patients identified, the 43 364 whose most recent blood pressure measurement was in a specialty setting were significantly less likely to be controlled compared to the 43 148 whose most recent measurement was in primary care (63% vs 68%, respectively, OR = 0.83 [0.80-0.85]). For the 27 955 patients who had measurements performed in both settings during the year, the control rates based upon their most recent specialty and primary care measurements were 63% and 71%, respectively (OR = 0.62, 0.60-0.65). For the subsets of patients whose measurements in each setting were within 30 or within seven days of each other, the odds of control in the specialty versus primary care setting were 0.63 (0.58-0.75) and 0.65 (0.57-0.75), respectively. Health systems should weigh the value of performing blood pressure measurement in specialty settings that do not manage this condition, taking into consideration the resources required to perform it and the potential negative consequences of inaccurate measurements.

Expansion of clinical pharmacist positions through sustainable funding.

PURPOSE: Expansion of clinical pharmacist positions through sustainable funding is described. SUMMARY: The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences was awarded a 2-year program grant to establish an integrated clinical pharmacy program for underserved residents in family health centers in northeastern Colorado. The grant enabled the hiring of 2 bilingual, full-time, board-certified, postgraduate year 2-trained clinical pharmacists to initiate comprehensive clinical pharmacy services. Clinical pharmacy services for diabetes, hypertension, and dyslipidemia management were provided during direct patient care visits using collaborative drug therapy management protocols to facilitate comprehensive medication management. Initial visits lasted 1 hour, and follow-up visits lasted 30 minutes. In addition, clinical pharmacists provided point-of-care consultations for patients seeing other healthcare providers. All patient encounters and consultations were documented in the electronic health record. Success of the clinical pharmacy program was evaluated based on the achievement of goal blood pressure values, glycosylated hemoglobin values, and low-density-lipoprotein cholesterol levels. Pharmacists' involvement in patient care activities led to improvements in all of these clinical outcomes. This coincided with unique funding opportunities with regional accountable care organizations that sought to demonstrate improved patient care in an expansion population. As a result, 2 grant-funded clinical pharmacist positions in 2 community health clinics were converted into 4 faculty positions in 5 community health centers funded by regional accountable care organizations. CONCLUSION: Collaboration with accountable care organizations resulted in the successful funding of ambulatory care clinical pharmacy services. These services resulted in improved chronic disease control and provider satisfaction.

Clinic-Level Population Health Intervention by PGY2 Ambulatory Care Pharmacy Residents to Optimize Medication Management in a Self-Insured Employer Health Plan Population.

BACKGROUND: Postgraduate year 2 ambulatory care pharmacy residents (PGY2 residents) may be able to improve healthcare quality by providing clinical pharmacy services provided to self-insured employer health plan patients. The objectives of this study are to describe this care delivery in a family medicine clinic, and to identify patients most likely to benefit from the service. METHODS: From October 1, 2014 till June 30, 2015, comprehensive medication review was completed by PGY2 residents for patients insured by CU Anthem at the University of Colorado Westminster Family Medicine. For patients with medication-related problems (MRPs), a note was sent to the provider before the patient visit. Patient characteristics were compared in those who received a clinical pharmacy note with those who did not. RESULTS: Sixty-eight MRPs were identified in 39 notes; 40 (58.8%) recommendations were implemented. The following Clinical Pharmacy Priority (CP2) score criteria were identified more frequently in patients with MRPs: age ≥65 years, diagnosis of diabetes, hypertension, chronic obstructive pulmonary disease, cardiovascular disease, blood pressure ≥140/90, hemoglobin A1c >7.9%, and ≥6 items on the medication list. CONCLUSION: PGY2 residents identified and resolved numerous clinically relevant MRPs. Patient-specific criteria can be utilized to target self-insured employer health plan patients who are likely to have clinically relevant MRPs.

Curriculum renewal: Alignment of introductory pharmacy practice experiences with didactic course content.

BACKGROUND AND PURPOSE: The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) used the opportunity of curriculum renewal to integrate knowledge and skills learned from didactic courses into the introductory pharmacy practice experiences (IPPEs) occurring simultaneously. This paper describes and evaluates the meaningful application of course content into IPPEs, and evaluates the success using qualitative feedback. EDUCATIONAL ACTIVITY AND SETTING: Students entering the renewed curriculum starting in fall 2012 were provided a list of pharmacy skills and activities from didactic course directors that reinforced course content for that semester. The skills and activities were to be completed during the students' IPPE visits in the community or health systems settings, depending on the program year and semester. FINDINGS: Students successfully completed course assignments during their IPPE course program. Not all activities could be completed as designed, and many required modification, including simulated experiences. Feedback from faculty and preceptor members of the school's experiential education committee demonstrated that these activities were valuable and improved learning of course material, but were challenging to implement. DISCUSSION AND SUMMARY: A renewed curriculum that mapped course assignments for completion in experiential settings was successfully established, after some modifications. The program was modified at regular intervals to improve the ability of preceptors to complete these activities in their individual practice environment. A balance between the school providing guidance on what activities students should perform and allowing unstructured independent learning with the preceptor is needed for an optimal experience.

Pharmacy student perspectives regarding curricular renewal with experiential alignment.

BACKGROUND AND PURPOSE: To evaluate pharmacy students' ability to perform and perspectives regarding a purposeful mapping of curricular content into experiential settings for application. EDUCATIONAL ACTIVITY AND SETTING: Students were given a list of activities developed by their curricular course directors that were to be completed during their introductory pharmacy practice experiences (IPPEs). Students were tasked with completing each assignment at their community or health system pharmacy site, and verify completion with their preceptor. Students were surveyed regarding their completion of these activities, who the tasks were performed on, and the value students perceived from the exercises. FINDINGS: Students ranked that the curricular mapping to experiential courses were successful. Average student responses reflected that the activities had value and positively impacted their learning. Many students struggled to find specific patient examples to complete the activities the way the course designed them. Changes to the structure of these activities was necessary for student success. DISCUSSION AND SUMMARY: Students felt that the curricular mapping of assignments into IPPEs was meaningful and improved their learning. Not all students were able to complete assignments as described.

Design and activity evaluation of an Advanced-Introductory Pharmacy Practice Experience (aIPPE) course for assessment of student APPE-readiness.

BACKGROUND AND PURPOSE: The newly implemented Advanced-Introductory Pharmacy Practice Experience (aIPPE) course at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences was designed to assess student readiness for Advanced Pharmacy Practice Experience (APPE) and provide formative feedback regarding skills and abilities needed to be successful during subsequent coursework and practice experiences. EDUCATIONAL ACTIVITY AND SETTING: The aIPPE is a full-time, six week (240hours) direct patient care rotation occurring in the spring semester of the third-professional year following a longitudinal integrated IPPE program. Required aIPPE course elements mimic the activities and expectations students should anticipate encountering during APPE training. FINDINGS: All students participating in the initial aIPPE course offering were described as APPE-Ready. Students and preceptors described the aIPPE course as successful in achieving the primary outcome of preparing students for improved downstream performance. SUMMARY: The aIPPE provided students opportunities to demonstrate readiness to enter advanced pharmacy practice experience.

ACCP Clinical Pharmacist Competencies.

The purpose of the American College of Clinical Pharmacy (ACCP) is to advance human health by extending the frontiers of clinical pharmacy. Consistent with this mission and its core values, ACCP is committed to ensuring that clinical pharmacists possess the knowledge, skills, attitudes, and behaviors necessary to deliver comprehensive medication management (CMM) in team-based, direct patient care environments. These components form the basis for the core competencies of a clinical pharmacist and reflect the competencies of other direct patient care providers. This paper is an update to a previous ACCP document and includes the expectation that clinical pharmacists be competent in six essential domains: direct patient care, pharmacotherapy knowledge, systems-based care and population health, communication, professionalism, and continuing professional development. Although these domains align with the competencies of physician providers, they are specifically designed to better reflect the clinical pharmacy expertise required to provide CMM in patient-centered, team-based settings. Clinical pharmacists must be prepared to complete the education and training needed to achieve these competencies and must commit to ongoing efforts to maintain competence through ongoing professional development. Collaboration among stakeholders will be needed to ensure that these competencies guide clinical pharmacists' professional development and evaluation by educational institutions, postgraduate training programs, professional societies, and employers.

Effect of an Advanced Pharmacy Practice Experience on Medication Therapy Management Services in a Centralized Retail Pharmacy Program.

BACKGROUND: Medication therapy management (MTM) delivery is increasingly important in managed care. Successful delivery positively affects patient health and improves Centers for Medicare & Medicaid Services star ratings, a measure of health plan quality. As MTM services continue to grow, there is an increased need for efficient and effective care models. The primary objectives of this project were to describe the delivery of MTM services by fourth-year Advanced Pharmacy Practice Experience (APPE) students in a centralized retail pharmacy system and to evaluate and quantify the clinical and financial contributions of the students. The secondary objective was to describe the engagement needed to complete comprehensive medication reviews (CMRs) and targeted interventions. PROGRAM DESCRIPTION: From May 2015 to December 2015, thirty-five APPE students from the University of Colorado Skaggs School of Pharmacy provided MTM services at Albertsons Companies using the OutcomesMTM and Mirixa platforms. Students delivered patient care services by phone at the central office and provided face-to-face visits at pharmacies in the region. With implementation of the MTM APPE in 2015, the team consisted of 2 MTM pharmacists and pharmacy students, as compared with 1 MTM pharmacist in 2014. The number of CMRs and targeted interventions completed and the estimated additional revenue generated during the 2015 time period were compared with those completed from May through December 2014. The patient and provider engagement needed to complete the CMRs and targeted interventions was summarized. OBSERVATIONS: 125 CMRs and 1,918 targeted interventions were billed in 2015, compared with 13 CMRs and 767 targeted interventions in 2014. An estimated $16,575-$49,272 of additional revenue was generated in 2015. To complete the interventions in 2015, the team engaged in 1,714 CMR opportunities and 4,686 targeted intervention opportunities. IMPLICATIONS/RECOMMENDATIONS: In this MTM rotation, students provided real-life care to patients, resulting in financial and clinical contributions. This model of education and care delivery can be replicated in the community pharmacy or managed care setting. APPE students are an important component of this model of care delivery, particularly when considering the level of patient engagement needed to complete MTM interventions. DISCLOSURES: No outside funding supported this research. The authors have no conflicts of interest to disclose related to this work. All authors contributed to study concept and design. Rodgers collected the data, and data interpretation was performed by Vande Griend, along with Rodgers and Nuffer. The manuscript was written and revised primarily by Vande Griend, along with Nuffer and Rodgers. This project was presented at the Pharmacy Quality Alliance Annual Meeting in Arlington, Virginia, in May 2016.

Establishment and Implementation of a Required Medication Therapy Management Advanced Pharmacy Practice Experience.

Objective. To develop a community pharmacy-based medication therapy management (MTM) advanced pharmacy practice experience (APPE) that provides students with skills and knowledge to deliver entry-level pharmacy MTM services. Design. The University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences (SSPPS) partnered with three community pharmacy chains to establish this three-week, required MTM APPE. Students completed the American Pharmacists Association MTM Certificate Course prior to entering the APPE. Students were expected to spend 90% or more of their time at this experience working on MTM interventions, using store MTM platforms. Assessment. All 151 students successfully completed this MTM APPE, and each received a passing evaluation from their preceptor. Preceptor evaluations of students averaged above four (entry-level practice) on a five-point Likert scale. The majority of students reported engagement in MTM services for more than 80% of the time on site. Students' self-reporting of their ability to perform MTM interventions improved after participation in the APPE. Conclusion. The SSPPS successfully implemented a required MTM APPE, preparing students for entry-level delivery of MTM services.

Assessment of blood pressure in patients with hypertension aged 60-79 years before and after the publication of the 2014 Eighth Joint National Committee report.

OBJECTIVES: In late 2013, the Joint National Committee (JNC 8) published hypertension treatment recommendations endorsing a goal blood pressure (BP) of < 150/90 mmHg starting at age 60 years. This was in contrast to other cardiovascular groups recommending age 80 years for this BP goal. This study examined mean BP in patients from age 60 years to 79 years with hypertension before and after publication of the JNC 8 recommendations. METHODS: This retrospective cohort study examined mean BP and number of antihypertensives for a period of 1 year before and after the release of the JNC 8 report. Patients aged 60-79 years with hypertension receiving care at a University of Colorado Hospital primary care clinic were included. Patients with diabetes, chronic kidney disease, or kidney transplant were excluded. A total of 150 BP measurements were included in each of the before and after time frames. The primary outcomes were change in mean BP and number of antihypertensives. RESULTS: A total of 171 patients met the criteria and were included in the study. Most had BPs in both the before and after time frames. Mean BP values were similar in the before and after groups (130.2/75.9 mmHg versus 131.5/76.6, respectively; p = 0.27/p = 0.46). Mean number of antihypertensives were similar in the before and after groups (1.95 versus 1.93, respectively; p = 0.79). CONCLUSIONS: Over 1 year at an academic health system, new recommendations from the JNC 8 did not affect mean BP or number of antihypertensives in older patients with hypertension. A similar investigation after more time or in patients with newly diagnosed hypertension may help determine the full impact.

Prioritization of patients for comprehensive medication review by a clinical pharmacist in family medicine.

BACKGROUND: This pilot study describes and evaluates the clinical pharmacy priority (CP2) score. We hypothesize that patients with high CP2 scores are more likely to receive a medication recommendation after comprehensive medication review (CMR) than patients with lower scores. Prioritization of patients for CMR by a clinical pharmacist in family medicine could enhance the provision of interprofessional care within the patient-centered medical home. METHODS: The CP2 score was developed collaboratively by the research team and is derived from 11 patient-specific factors extracted from the electronic health record. To evaluate the utility of the score, CMR was performed prospectively by a clinical pharmacist for patients with appointments between October 1 and December 31, 2012, at 2 University of Colorado family medicine clinics. RESULTS: CMR was performed for 1107 patient appointments. Of these, 101 were identified as having received a medication recommendation from the clinical pharmacist. For patients with a CP2 score of 0 to 2, 2 of 588 charts (0.3%) reviewed received a recommendation (level 1). The proportion increased to 37 of 358 (10.3%) for scores of 3 to 7 (level 2), 40 of 119 (33.6%) for scores of 8 to 10 (level 3), and 22 of 42 (52.4%) for scores of ≥11 (level 4). Compared with CP2 scores in level 1, patient appointments were more likely to receive a medication recommendation after CMR in level 2 (relative risk [RR], 30.4; 95% confidence interval [CI], 7.4-125.3), in level 3 (RR, 98.8; 95% CI, 24.2-403.3), and in level 4 (RR, 154; 95% CI, 37.5-632.8). CONCLUSIONS: Patients with higher CP2 scores were more likely to receive a medication recommendation after CMR by a clinical pharmacist than patients with lower scores. The CP2 score could be used by clinical pharmacists in family medicine to enhance the efficient and effective delivery of interprofessional care.

Statins for the primary prevention of cardiovascular disease in the elderly.

OBJECTIVE: The objective is to review the evidence evaluating the efficacy of statin therapy for primary prevention of cardiovascular (CV) disease in the elderly. DATA SOURCES: A literature search of MEDLINE and PubMed (1966-January 2013) using the terms HMG-CoA reductase inhibitor, statin, primary prevention, elderly, and geriatrics was performed. The search was limited to clinical trials, meta-analyses, and subanalyses, including primary prevention patients. Bibliographies of selected articles were examined to identify additional clinical trials. STUDY SELECTION: Fourteen clinical trials, subanalyses, and meta-analyses were reviewed. A total of seven clinical trials and subanalyses evaluating statin therapy versus placebo in the elderly primary prevention patients with a primary endpoint of hard coronary heart disease were included. DATA EXTRACTION: Data collected from the clinical trials and subanalyses included number of elderly patients randomized, therapy, duration of follow-up, and the incidence of coronary events. DATA SYNTHESIS: The average annual rates of first CV event increases as patients age. There is strong evidence that supports the use of statins for secondary prevention; although primary prevention, specifically in the elderly, is less defined. This paper reviews the literature specifically for primary prevention, for which the results have shown a trend toward decreased first occurrence of coronary heart disease with statin therapy in elderly patients. CONCLUSION: Statin therapy should be considered as a primary prevention therapy against coronary disease for elderly patients. Evidence-based clinical benefits are seen in this patient population. However, clinical judgment and consideration of comorbidities that may impact life expectancy should be assessed to determine appropriateness for individual patients.

Patient-level medication regimen complexity in older adults with depression.

PURPOSE: Polypharmacy and medication adherence are well known challenges facing older adults. Medication regimen complexity increases the demands of self-care in the home. Some medication regimens may be more complex than others, especially when dosage form, frequency of dosing, and additional usage directions are included in complexity along with the number of medications In older adults with depression, it is unknown what features of their medications most influence their medication regimen complexity. METHODS: A sample cohort of 100 adults ≥65 years old with a diagnosis of depression was randomly selected from electronic medical records (EMR) in ambulatory clinics at the University of Colorado (CU) and University of San Diego (SD). Demographic, medical history, and medication-related information was extracted from the EMR. Complexity was determined using the Medication Regimen Complexity Index (MRCI). IRB approval was obtained. FINDINGS: The cohort mean age was 74.3 years (SD) and 79.7 years (CU). The mean unweighted Charlson comorbidity index for 1.0 (SD) and 1.8 (CU). The mean number of medications was 7.1 and 8.0, with 1.1 and 1.2 depression meds, 5.4 and 4.3 non-depression prescription meds, and 0.6 and 2.4 OTC meds for the SD and CU cohorts, respectively. 66% of SD adults and 70% of CU adults took six or more meds. Individual MRCI scores were on average 17.62 (SD) and 19.36 (CU). Dosing frequency contributed to 57-58% of the MRCI score, with patients facing an average of 7-8 unique dosing frequencies in their regimen. In both cohorts, there was an average of 3 additional directions added to the regimens to clarify dosing. IMPLICATIONS: As expected, in our older adult cohorts with depression the majority of patients took multiple medications. Using a standardized instrument, we characterized the regimen complexity and found that it was increasingly complex due to numerous dosing forms, frequencies and additional directions for use. Patient-level medication regimen complexity should go beyond depression medication to encompass the patient's entire regimen for opportunities to reduce complexity and improve ease of self-care.

Unnecessary lipid-lowering drugs in an outpatient geriatric clinic.

OBJECTIVES: Identify the number of patients in the University of Colorado Seniors Clinic who were prescribed a nonstatin lipid-lowering therapy and describe a pharmacist intervention that can reduce the unnecessary use of these agents. SETTING: Outpatient geriatrics clinic in a university health system. PRACTICE DESCRIPTION: The University of Colorado Seniors Clinic provides outpatient care for ambulatory patients 75 years of age or older. In 2012, there were 2,000 active patients, with 7,000 clinic visits. PRACTICE INNOVATION: All patients prescribed extended-release niacin, ezetimibe, fenofibrate, gemfibrozil, or prescription omega-3-acid ethyl esters were identified. Extended-release niacin, ezetimibe, fenofibrate, and gemfibrozil were deemed necessary if the patient was intolerant to statin therapy or could not attain the cholesterol goal with the maximum tolerated dose of a statin. Fenofibrate, gemfibrozil, and prescription omega-3-acid ethyl esters were considered necessary if the patient had a history of triglycerides above 500 mg/dL. If a pharmacist deemed the medication unnecessary, a note was placed in the medical record and discussed face-to-face with the provider. MAIN OUTCOME MEASURE(S): The number of patients and types of drugs that were prescribed and discontinued; the cost savings to the health system. RESULTS: Fifty-five patients were prescribed a potentially unnecessary lipid-lowering drug. Twenty-three drugs were discontinued, for an estimated $38,660.40 in cost savings. CONCLUSIONS: A low percentage of patients were prescribed a nonstatin lipid-lowering agent in this population. However, more than half were deemed unnecessary and were stopped, resulting in significant savings and health benefits. Applying this on a larger scale could result in significant savings and improved health.

An off-site clinical pharmacy service in family medicine: development and 1-year outcomes.

BACKGROUND AND OBJECTIVES: Clinical pharmacists are a part of integrated health care teams and provide clinical medication recommendations for family physicians. On-site clinical pharmacy services are common in family medicine. This model may not be the most effective or efficient way to provide clinical pharmacy services in a small practice or in a remote location. The objectives of this study were to describe the development of an off-site clinical pharmacy service and to describe the 1-year clinical impact of this service. METHODS: The University of Colorado Park Meadows Family Medicine Clinic is located approximately 15 miles from the Anschutz Medical Campus. In July 2011, a clinical pharmacist implemented clinical pharmacy services with the goal of providing medication expertise primarily using an off-site model. The clinical pharmacist prospectively screened patients with appointments and provided medication recommendations in the electronic medical record for providers to consider at the patient appointment. RESULTS: For the first 12 months, the clinical pharmacist spent 118 hours providing the clinical pharmacy service. A total of 315 medication recommendations were made for 123 patients; 69.8% were implemented. Forty-nine vaccinations were administered, and 24 potentially dangerous major drug-drug interactions were identified and resolved. Thirty-one unnecessary high-cost drugs were discontinued, resulting in estimated annual savings of $52,215.36. CONCLUSIONS: Our data indicate that clinical pharmacy services can be implemented for smaller remote family clinics using an offsite model. Within this model, clinical pharmacy interventions optimized medication use, managed serious drug interactions, and resulted in cost avoidance.

Quetiapine for insomnia: A review of the literature.

PURPOSE: The safety and efficacy of quetiapine for the treatment of insomnia in adults are reviewed. SUMMARY: Quetiapine was developed for the treatment of psychiatric disorders, but its antagonism of histamine H1- and serotonin type 2A receptors has the added effect of causing sedation. As such, quetiapine is widely used off-label as a treatment for insomnia. Due to quetiapine's potential adverse effects, guidelines for the treatment of insomnia have recommended the drug's use only in patients with specific comorbid psychiatric disorders. The use of quetiapine for the treatment of insomnia in the absence of comorbid conditions has been evaluated in only two clinical trials of 31 patients in total, and very few studies have evaluated quetiapine use in patients with insomnia and other comorbidities. No trials have been conducted comparing quetiapine with an active control (e.g., zolpidem); the data that exist compare quetiapine to a placebo or there is no comparison and all patients are treated with quetiapine. Very few studies have evaluated quetiapine's efficacy in the treatment of insomnia using sleep objective testing, another limitation of the available data on quetiapine. CONCLUSION: Robust studies evaluating the safety and efficacy of quetiapine for the treatment of insomnia are lacking. Given its limited efficacy data, its adverse-effect profile, and the availability of agents approved by the Food and Drug Administration for the treatment of insomnia, quetiapine's benefit in the treatment of insomnia has not been proven to outweigh potential risks, even in patients with a comorbid labeled indication for quetiapine.

Glycemic targets and medication limitations for type 2 diabetes mellitus in the older adult.

OBJECTIVE: To review the optimal management of type 2 diabetes mellitus (T2DM) in the older adult. DATA SOURCES: A PubMed search was completed to identify publications in the English language from 1947 to 2013 using combinations of the search terms: geriatrics, aged, diabetes mellitus, and type 2 diabetes mellitus. References of articles were also reviewed for inclusion if not identified in the PubMed search. STUDY SELECTION AND DATA EXTRACTION: Original studies, clinical reviews, and guidelines were identified and evaluated for clinical relevance. DATA SYNTHESIS: Although the number of older adults with T2DM is growing, evidence for the treatment of T2DM in this population is lacking. Barriers such as polypharmacy, comorbid conditions, economic limitations, cognitive impairment, and increased risk of hypoglycemia may limit optimal glycemic control in older adults. Several organizations provide recommendations for glycemic targets and recommend using standard glycemic goals in most healthy older adults. However, less stringent goals are necessary in certain older populations such as those patients with limited life expectancy and severe hypoglycemia. In general, glycemic goals should be individualized in older patients. Age-related pharmacokinetic and pharmacodynamic changes, comorbid conditions, adverse drug reactions, ease of medication administration, and cost of medications necessitate the need to individualize pharmacologic therapy. CONCLUSION: Glycemic targets and medication use for T2DM should be individualized in older adults.

Evaluation of type 2 diabetes mellitus medication management and control in older adults.

OBJECTIVES: The primary aims of this study were to characterize glycemic control and pharmacologic management in older patients and to compare glycemic control and pharmacological management in patients 65 to 79 years of age ("young-old") with those 80 to 89 years of age ("old-old"). We hypothesized that patients 80 to 89 years of age would be prescribed fewer medications and would have higher A1c values compared with younger patients. DESIGN: Retrospective medical record review. SETTING: This study was conducted in outpatient clinics within a university hospital setting. PATIENTS, PARTICIPANTS: This study included 400 adults 65 to 89 years of age with a diagnosis of type 2 diabetes mellitus and at least one A1c measurement over 12 months. MAIN OUTCOME MEASURES: A1c measurements and diabetes mellitus medications were assessed in these patients. RESULTS: The overall mean A1c was similar in the young-old compared with the old-old (7.1 ± 1.1% vs. 7.0 ± 1.1%; P = NS). There was no difference between groups for any of the A1c ranges studied. Fewer diabetes medications were prescribed in the old-old compared with the young-old (P = 0.003). In the young-old compared with the old-old, metformin (51.0% vs. 33.0%; P < 0.01), glucagon-like peptide-1 agonists (6.7% vs. 0%; P < 0.01), insulin glargine/detemir (24.7% vs. 13.0%; P < 0.05), and short-acting insulin (15.0% vs. 7.0%; P < 0.05) were more frequently prescribed. CONCLUSION: Our results indicate that glycemic control was similar between the young-old and old-old. However, the old-old required fewer diabetic medications for this same level of glycemic control.