Fracture risk associated with common medications used in treating type 2 diabetes mellitus.

PURPOSE: Published data on the risk of bone fractures associated with medications used for the treatment of type 2 diabetes mellitus are summarized. SUMMARY: A systematic literature search identified 108 publications on controlled trials and 6 meta-analyses addressing the potential for fractures with the use of 7 commonly used antidiabetic classes: thiazolidinediones (TZDs), sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, biguanides, insulin, and sulfonylureas. Among all the classes of agents evaluated, only TZDs have been clearly linked to significantly increased fracture risk (number needed to harm [NNH], 99 in one meta-analysis and 172 in another meta-analysis) and only in female patients. Interim data from an ongoing large placebo-controlled trial suggest that use of the SGLT2 inhibitor canagliflozin may be associated with an elevated rate of fractures (absolute risk increase, 1.4%; NNH, 71) and decreased total-hip bone mineral density. Published data regarding the other evaluated classes of agents generally show no effect on fracture risk; some evidence suggests a small bone-protective effect with the use of DPP-4 inhibitors. CONCLUSION: In patients with type 2 diabetes mellitus, evidence is strongest that, among antidiabetic drugs, TZDs increase the risk of bone fractures; thus, TZDs should be used with caution in women. Canagliflozin is the only SGLT2 inhibitor linked to an increased fracture rate. Metformin, sulfonylureas, insulin, DPP-4 inhibitors, and GLP-1 agonists appear to have overall neutral effects on bone fractures.

Perceptions of pharmacists as providers of immunizations for adult patients.

Pharmacists have been involved with patient care at the Family Medicine Center, affiliated with the Medical University of South Carolina, for over 20 years. In 1999, to add to existing clinical services, pharmacists administered immunizations (influenza and pneumonia) to over 400 adult patients during clinic visits in designated patient care rooms. A few months after the immunization period, both health care providers and immunized patients were asked to respond to a survey regarding their opinions of pharmacist-administered immunizations. Response rates were 71% for health care providers and 16% for all immunized patients. Most (90%) of the health care respondents felt comfortable with pharmacists providing immunizations and thought it was appropriate for pharmacists to provide this service. However, 35% of the providers did not agree that pharmacists should provide immunizations in local pharmacies. Most (97%) of the immunized patients felt comfortable with their provider but did not recall that a pharmacist had administered the immunization. In addition, 64% questioned the qualifications of a pharmacist to administer immunizations, and only 43% felt comfortable having a community pharmacist administer a vaccine. By extrapolation of these data, one can determine that patients do not regard pharmacists as qualified providers of immunizations. Further study of patient perception of pharmacists in this role is being conducted.

Collaborative drug therapy management by pharmacists--2003.

Since publication of the initial ACCP position statement on CDTM by pharmacists in 1997, the public, government, and much of the health care community at large have come to better appreciate the growing complexity of providing effective and safe drug therapy in today's health care environment. Increased interest in the issues of cost and quality of drug use is evident in the increasing coverage of the issue in the lay press and professional literature. This represents real progress, as well as real opportunity, for pharmacists. It also heightens the potential for a better understanding of the vital role that pharmacists can play in addressing these concerns. The percentage of patients who take several drugs for chronic diseases will continue to increase. Based on current trends, the number of patients who lack adequate access to care, or who receive either suboptimal, inappropriate, or unnecessarily expensive drug therapy for their acute and chronic diseases, will increase. Even as financial and human resources are increasingly strained within the current health care system, costs will continue to rise unless changes are made. Fortunately, qualified pharmacists are prepared, capable, and willing to help address a significant portion of these challenges. The public, many health care providers, some legislators, and a few insurers now recognize that pharmacists, because of their education and training in drug therapy, are well positioned both to accept additional responsibility for patient care and to provide services that make a real difference in health care quality and outcomes. The health care programs administered by the U.S. Public Health Service, the armed forces, and the Veterans Health Administration, as well as 38 states, now support pharmacist participation in CDTM. Pharmacists, working in an interdisciplinary structure with physicians and other health care providers, have demonstrated that they can improve the effectiveness, efficiency, and safety of drug therapy by providing CDTM. It is time to incorporate this valuable professional skill of the contemporary pharmacist as a core component of the delivery of health care services.

Proposed revision to the existing specialty and specialist certification framework for pharmacy practitioners.

Consistent with the American College of Clinical Pharmacy's vision that future clinical pharmacy practitioners who provide direct patient care should be board-certified specialists, a new framework for pharmacist specialty board certification is proposed. This White Paper describes the current and projected needs of the pharmacy profession regarding board certification, provides a rationale for the new framework, and discusses the potential ramifications of changes in the current board-certification process.

First-year residency candidates' experience in various areas of pharmacy practice.

OBJECTIVE: To determine the extent of experience or exposure pharmacy residency candidates had in various areas of hospital pharmacy practice and to identify any candidate-specific variables that correlated with a larger extent of experience. METHODS: Over a 3-year period, a self-assessment survey instrument was administered to 116 postgraduate first-year (PGY1) pharmacy practice residency candidates to evaluate their extent of experience within various areas of hospital pharmacy practice such as patient care activities, drug information, and drug distribution/control. RESULTS: The residency candidates reported the greatest amount of experience in patient counseling, working with pharmacy databases, taking medication histories, pharmacokinetics, and outpatient dispensing procedures. They had less experience with medical emergencies, parenteral nutrition, and intravenous admixture techniques. Overall, there was no correlation between class rank, advanced pharmacy practice experiences, geographic region, or year of interview and the extent of candidates' experience in any specific area of pharmacy. CONCLUSION: PGY1 residency candidates in this sample reported minimal experience in areas necessary for hospital pharmacy practice and this suggests possible deficiencies in the PharmD curriculum. PGY1 residency programs in acute care settings should recognize these educational deficits and assure that residents have exposure to and develop proficiency in critical areas such as medical emergencies, parenteral nutrition, and intravenous admixture techniques.

Pharmacist privileging in a health system: Report of the Qualified Provider Model Ad Hoc Committee.

PURPOSE: The rationale for and steps of pharmacist credentialing and privileging are described. SUMMARY: As pharmacy evolves to include direct patient care, health care organizations are under increasing scrutiny to verify that their pharmacists are not only licensed to practice but are capable providers of direct patient care. Credentialing is a process conducted by a health care organization to review and verify a pharmacist's credentials. Privileging authorizes a pharmacist to perform within a specified scope of practice. The steps in developing a process for pharmacist privileging consist of gathering background information from national, state, and local sources; defining the services a privileged pharmacist may provide; developing policies and procedures; and obtaining approval from the appropriate institutional bodies. An ad hoc committee convened by the American Society of Health-System Pharmacists in 2003 produced two documents, an application for privileging and a general privileging form, that may be used as templates by institutions or individuals developing a pharmacist-privileging process. Barriers to pharmacist privileging may be personal, institutional, and regulatory. CONCLUSION: As pharmacist roles continue to expand, there is increasing need to verify pharmacists' ability to provide direct patient care services. One way to achieve this is for institutions to develop a pharmacist-privileging process that better aligns pharmacists with the methods used to authorize scopes of practice of other types of practitioners.

Assessment of web-based applications for ambulatory care rotations.

BACKGROUND: An interactive Web site was developed to supplement ambulatory care clinical rotations, optimize collaborative efforts of ambulatory care preceptors, and standardize the educational and evaluation experience. OBJECTIVE: To evaluate perceptions of residents and students using an interactive Web site for ambulatory care clinical pharmacy rotations. METHODS: An online anonymous survey comprised of 12 questions using a 5-point Likert scale (1-5, strongly disagree-strongly agree) and 4 open-ended questions was designed. Over a 3-year time frame, each student and resident rotating through the ambulatory care clinical rotation was instructed to complete the survey at the end of the rotation experience. Survey results were compiled and analyzed. RESULTS: Sixty-nine percent (18/26) of residents and 71% (54/76) of students completed the survey. Overall, the Web site was well accepted by all learners. Residents and students differed in opinion on a few aspects of the Web site; however, both appreciated the ease of accessibility and links to additional resources. Inoperable links and outdated quizzes were identified as major weaknesses. CONCLUSIONS: Perceptions of an interactive Web site used during ambulatory care clinical rotations were positive. The survey results reinforce the continued use of this teaching method and will enable preceptors to make appropriate adjustments for future learners.