The pharmacist-physician relationship in the detection of ambulatory medication errors.

BACKGROUND: Expenditures on outpatient prescription drugs have increased enormously in the last decade. Despite this growth in expenditures, prescription medication safety in the ambulatory setting is lacking. Prior research in outpatient care has centered around the physician-patient encounter. What remains unexamined in the ambulatory care literature is the pharmacist's role as interceptor, detector, and reporter of medication errors to the physician. METHODS: Data about the role, responsibilities, and expectations to inform physicians about this subject were collected from pharmacist (N = 30) and patient (N = 31) focus groups conducted between July 2002 and July 2003. Pharmacists in outpatient practices and patients were randomly selected from the state licensure database and the Jackson Metropolitan phonebook, respectively. ANALYSIS: Grounded theory provided the perspective on which data were interpreted. Data patterns were linked using key words and phrases for theme analysis. Arbitration between coders resulted in an inter-rater reliability of 0.85. RESULTS: : Three complementary patterns were identified from the data: 1) patients likely see multiple physicians and only one pharmacist; 2) patients are more likely to report medication errors to the pharmacist than to the physician; and 3) pharmacists are the final interceptors, detecting medication errors before they reach patients. CONCLUSIONS: Ambulatory pharmacists are in a privileged position to gather data regarding adverse responses to prescribed medication or incidents of medication mishaps. The failure of pharmacists to report information back to physicians is a missed opportunity to improve patient safety.

Ethnic and sex differences in the prevalence, treatment, and control of dyslipidemia among hypertensive adults in the GENOA study.

BACKGROUND: Two ethnically different, community-based samples of hypertensive adults were evaluated to determine the prevalence of dyslipidemia and how often dyslipidemia is drug-treated and controlled by such treatment. METHODS: We studied 1286 non-Hispanic black hypertensive subjects from Jackson and 1070 non-Hispanic white hypertensive subjects from Rochester who participated in the Genetic Epidemiology Network of Arteriopathy study. Subjects were categorized according to presence of coronary heart disease and risk factors for coronary heart disease. RESULTS: Prevalence of dyslipidemia was significantly greater among whites than blacks (women, 64.7% vs 49.5%; and men, 78.4% vs 56.7%; P<.001 for both) and among men than women (P

Familial aggregation of hypertension treatment and control in the Genetic Epidemiology Network of Arteriopathy (GENOA) study.

PURPOSE: To assess if the treatment and control of hypertension aggregates in families. METHODS: The Genetic Epidemiology Network of Arteriopathy (GENOA) study enrolled sibships between 1997 and 1999, including 1329 hypertensive non-Hispanic blacks (1057 sibling pairs) from Jackson, Mississippi, 1133 hypertensive non-Hispanic whites (859 sibling pairs) from Rochester, Minnesota, and 752 hypertensive Hispanic whites (627 sibling pairs) from Starr County, Texas. Hypertension awareness and drug treatment were ascertained at examination; control was defined by blood pressure levels <140/90 mm Hg. As a measure of familial aggregation, odds ratios were calculated to assess concordance between sibling pairs in the treatment and control of hypertension. RESULTS: Overall, 90.5% of subjects were aware of their hypertension; 90.6% of those who were aware were treated with antihypertensive drugs and 56.0% of those treated had their hypertension controlled. There was statistically significant sib-sib concordance in the treatment of hypertension (odds ratio [OR] = 1.61; 95% confidence interval [CI]: 1.25 to 2.47; P = 0.003) and in the control of drug-treated hypertension (OR = 1.51; 95% CI: 1.25 to 1.81; P <0.0001). CONCLUSION: These findings suggest that the treatment and control of hypertension aggregates in families.

Ethnicity and unprovoked hypokalemia in the Atherosclerosis Risk in Communities Study.

BACKGROUND: Hypertension is more prevalent in the African American population when compared with the European American population in the United States. Unprovoked hypokalemia may lead to hypertension and is associated with several forms of recognized secondary hypertension. METHODS: We investigated the association of ethnicity with unprovoked hypokalemia in the second Atherosclerosis Risk in Communities (ARIC) study examination. Hypokalemia was defined as serum potassium <3.5 mmol/L. RESULTS: A statistically significant association was detected between ethnicity and unprovoked hypokalemia (odds ratio = 5.3; 95% confidence interval = 3.6, 7.7) with unprovoked hypokalemia more prevalent in African Americans both before and after adjustment for important covariates. The unadjusted prevalence for unprovoked hypokalemia was 2.6% for African Americans and 0.5% for European Americans. CONCLUSIONS: We found that the prevalence of unprovoked hypokalemia for African Americans in the ARIC cohort was more than five times that for European Americans. These data suggest that an increased awareness of hypokalemia and its etiology may be indicated for African Americans.

Phytoestrogens: a viable option?

Estrogen replacement therapy is one of the most commonly prescribed medicines in the United States by traditional medical professionals. Over the past decade, the market for complementary/ alternative therapies for hormone replacement has dramatically increased. Women are seeking more "natural" alternatives to treat menopausal symptoms. Well-designed randomized clinical trials are often lacking, as is the information on efficacy and safety. This article will review several popular herbal therapies for menopausal symptoms including phytoestrogens, black cohosh (Cimicifuga racemosa), dong quai (Angelica sinensis), chast tree (Vitex agnus-castus), and wild Mexican yam. Their use, mechanism of action, and adverse effects are outlined.

Disability examinations: a look at the Social Security Disability Income System.

Disability income protection is an important part of a worker's safety net. U.S. workers who pay into Social Security are eligible for coverage under the federal government, and additional coverage is available in the free market. However, the costs to taxpayers and disability insurance policyholders are high, and a great deal of responsibility rests on the physician providing information on disability issues. A neutral attitude toward a patient requesting disability allows the physician to collect the facts regarding the patient's impairments. A history of the patient's work duties helps the examiner determine the basis for setting limitations or restrictions at work or home. The physician's knowledge base of treatment options assists in determining maximal medical improvement. Records released to the adjudicating body should contain a thorough history, pertinent physical findings, and a review of previous medical records, all of which are to be separated from the opinion of the examiner regarding specific limitations and restrictions. The physician should be aware of symptom magnification and depression as confounders to the patient's perception of disability.

Asthma: a brief overview.

Asthma, a common chronic inflammatory disease of the airways characterized by reversible airway obstruction, is a substantial health problem without regard for age, gender, or ethnicity. Guidelines have been established to provide clinicians with evidence-based recommendations to assist in the diagnosis and management of asthma. This review offers a brief overview of the current understanding of the pathogenesis and definition of asthma, the diagnosis and classification of asthma, and the pharmacologic therapy of asthma in adults. Further studies are required to determine whether the development of new targeted treatments will be effective in the management of asthma.

Hormone replacement therapy and coronary heart disease in women: a review of the evidence.

It is well documented that coronary heart disease (CHD) is the leading cause of death in women-especially postmenopausal women. The role of hormone replacement therapy (HRT) in prevention of CHD has been considered for many years. Early epidemiological studies suggested estrogen to have a potential cardioprotective role, noting that premenopausal women have a decreased risk of developing CHD compared with men. Later observational studies showed decrease of CHD risk in postmenopausal women on HRT. By 1996, estrogen (specifically Premarin) was one of the most dispensed medications in the United States. Major medical organizations such as the American College of Physicians and American College of Obstetricians and Gynecologists widely endorsed and encouraged HRT for CHD risk reduction, along with using HRT for other potential benefits (such as osteoporosis prevention). Unfortunately, recent clinical trials seem to raise more questions than provide definitive proof in the protective role of estrogen in CHD. A review of recent and ongoing observational studies and clinical trials may help guide physicians in their recommendation and discussion of the role of HRT in postmenopausal women. As this article was being prepared for publication, reports from both the Heart and Estrogen/Progestin Replacement Study Follow-up (HERS II) and the Women's Health Initiative (WHI) were published. Both studies concluded that HRT has no role in primary or secondary prevention of CHD in women.

An internist's update on cholesterol management.

Coronary heart disease (CHD) remains the leading cause of death in the United States. It is now well established that cholesterol is an important, reversible risk factor for CHD. This article provides a brief background on classification of the dyslipidemias, then discusses current recommendations for the evaluation and treatment of hyperlipidemia. Other risk factors currently being investigated as they relate to the development of CHD are discussed.

Low back pain.

Low back pain is a very common condition, with about 80% of people suffering from it at some point in their lives. It is usually self-limited, resolving in 4 to 8 weeks in more than 50% of patients, yet the recurrence rate is high, about 85%. Because of the complexity of the bony, muscular ligamentous, and neural elements of the back, a specific anatomic diagnosis often cannot be made. Evaluation should include a careful history and physical examination, paying particular attention to alarm symptoms or "red flags" mentioned in the text. Imaging procedures are usually not necessary because of the lack of specificity and the high rate of early, spontaneous remission. Exceptions to this include history of recent trauma, presence of red flags or chronic unremitting course. Many treatment modalities, including physical therapy, ultrasound, thermal therapy, and local injection have been tried, but most studies are inconclusive as to their effectiveness. Prolonged bed rest is not indicated. Nonsteroidal anti-inflammation agents, judicious use of muscle relaxers, and patient education about the cause and prognosis are justified.

Quality of care in diabetes: understanding the guidelines.

We are in the midst of a global pandemic of diabetes. Despite the increasing burden of the disease, measurements of quality repeatedly show poor adherence to or implementation of current guidelines for diabetes care. This article will provide a brief review of the most significant randomized controlled clinical trials relevant to the current guidelines and then discuss essential treatment goals and the evidence that supports them. Several practical clinical questions related to the implementation of modern diabetes guidelines will be raised and answered. Finally, reasons for the poor quality performance observed will be examined.

Malpractice risk prevention for primary care physicians.

The recent medical malpractice "crisis" has seen skyrocketing liability premiums and increasing fear of liability. Primary care physicians, especially family medicine and internal medicine physicians, have historically experienced low rates of malpractice claims, both in number and amount of payment. This can be attributed to several factors: the esteem held by internal medicine and family medicine physicians in their communities, relatively low numbers of invasive procedures, reluctance of patients to include "their" primary care physician in any potential litigation, and, probably most importantly, the atmosphere of mutual trust and communication between the internist or family physician and the patient. Recent years have seen this trend erased, as insurance industry data suggest primary care physicians presently face significant potential exposure for medical malpractice claims. It is imperative that primary care physicians take steps to insure they are adequately covered in case of a malpractice claim and that they practice aggressive but appropriate risk management to lessen the likelihood of a claim.

Hyperaldosteronism: the internist's hypertensive disease.

Primary aldosteronism (PA) is a disorder typically characterized by resistant hypertension, hypokalemia, alkalosis and suppressed plasma renin activity, and excessive aldosterone production. A true estimate of the prevalence of the disorder is difficult to estimate because its detection is dependent on the awareness of the healthcare provider to the disorder, but it has generally been felt to be a rare occurrence. Its frequency of detection began to change when Hiramatsu suggested calculating the ratio of plasma aldosterone/plasma renin activity as a screening tool for the disorder. He found a ratio greater than 75 as a sensitive indicator for aldosterone-producing adenomas. Using the ratio, several investigators have found prevalence ranging from 3 to 9%. Two major classifications of PA exist: aldosterone-producing adrenal adenoma (APA) and zona glomerulosa hyperplasia (IHA). Distinguishing between these 2 entities is important clinically, because removal of a unilateral aldosterone-producing adenoma may result in correction of elevated blood pressure and hypokalemia. Thus, when evaluating hypertensive patients, PA should be suspected in those with moderate to severe hypertension or with hypertension refractory to standard treatment or in hypertensive patients with disease onset at an early age. The aldosterone-to-renin ratio is an easy, inexpensive, and rapid means of screening for the disorder. The ratio is the screening test of choice, but further confirmatory testing is required to clinch the diagnosis. Frequently employed confirmatory tests include urinary aldosterone excretion on a high-salt diet, aldosterone suppression after a saline infusion, and the fludrocortisone suppression test, which is considered the most sensitive confirmatory maneuver. Both high-resolution CT and MRI scans appear to have similar ability to differentiate between APA and IHA. As with essential hypertension, the goal of treatment is to prevent the long-term sequela of hypertension. The underlying pathology resulting in PA dictates the treatment strategy. The drug of choice is spironolactone. Surgical intervention should be entertained in those patients with PA in whom imaging studies suggest an adenoma.

Identifying barriers to the adoption of new technology in rural hospitals: a case report.

The purpose of this study is to identify barriers to the adoption of new technology in rural settings. Specifically, this paper focuses on identifying and overcoming barriers to the adoption of a medication error reporting system in eight rural hospitals. Prior research has generally focused on barriers to the adoption of new technology in urban areas, medical centers, or large hospitals. The literature has identified six primary barriers to the adoption of new technology: cost, legality, time, fear, usefulness, and complexity. Although our research recognizes these same barriers, the means through which these barriers may be mitigated are different in rural settings. Our research identified three additional barriers to the adoption of new technology that may be specific to rural areas: personnel, physical space, and Internet access. Our outcome variable, in order to demonstrate our success, is the number of reported medication errors.

Improving patient safety through information technology.

Health information technology (HIT) is generally accepted as the solution for the nation's medical error crisis. Although limited studies suggest the importance of using HIT in the process of medication management, research has failed to adequately describe how HIT actually works in capturing medication error data and improving patient safety within a healthcare system.1-3 The aim of our study is to identify essential elements in the adoption of technology within the broader context of system change and workflow modification. Using the adoption of an electronic reporting system to improve patient safety, we examine the role of this technology within process improvement, culture, and workflow.

Lifetime prevalence of migraine and other headaches lasting 4 or more hours: the Atherosclerosis Risk in Communities (ARIC) study.

OBJECTIVES: To evaluate the lifetime prevalence of migraine and other headaches lasting 4 or more hours in a population-based study of older adults. BACKGROUND: Migraine and other headaches not fulfilling migraine criteria are common afflictions. Yet the health and social effects of these conditions have not been fully appreciated, particularly among older adults. METHODS: The study included 12 750 participants in the Atherosclerosis Risk in Communities (ARIC) Study from 4 US communities. Prevalence estimates of a lifetime history of migraine and other headaches lasting 4 or more hours were obtained for race and gender groups. A cross-sectional analysis was done to assess the relationship between headache type, by aura status, and various sociodemographic and health-related indices. RESULTS: Compared to education beyond high school, having completed less than 12 years of education was significantly associated with an increased occurrence of migraine with aura (prevalence odds ratio [POR], 1.47; 95% confidence interval [CI], 1.08 to 2.01). Family income less than $16 000, compared to family income of $75 000 or greater, was significantly associated with migraine with aura (POR, 1.68; 95% CI, 1.07 to 2.64), migraine without aura (POR, 1.56; 95% CI, 1.14 to 2.14), and other headaches with aura (POR, 1.89; 95% CI, 1.14 to 3.13). The prevalence odds ratio was higher in each headache category, particularly for those with an aura, for those with hypertension versus normotension and for those who perceived their general health as poor compared to those whose perception was excellent. CONCLUSIONS: A lifetime history of migraine with aura and other headaches with aura was more common among whites, women, and younger participants. Further investigation of headaches lasting 4 or more hours, particularly by aura status, is warranted.