Knowledge and Perceptions of Health Literacy among Pharmacists in Ohio in 2013 and 2021.

BACKGROUND: There is limited existing literature on pharmacists' knowledge of health literacy and the interventions pharmacists use to address limited health literacy. OBJECTIVES: The primary objectives of this study were to evaluate pharmacists' knowledge and perceptions of the impact of limited health literacy on patients and their practice, and to review the techniques used to care for patients. METHODS: We conducted a cross-sectional, web-based survey of registered Ohio pharmacists in 2013 and repeated the survey in 2021. The Nursing Professional Health Literacy Survey was adapted and employed to assess 1) general knowledge; 2) health literacy in the workplace; and 3) demographics. Changes in pharmacists' knowledge and perceptions of health literacy, self-reported use of communication techniques, and methods for assessing a patient's health literacy were evaluated. RESULTS: Response rates were 12.4% (N=62) in 2013 and 3.5% (N=174) in 2021. Awareness of the term health literacy increased, rising from 82.3% to 89.7% (P=0.127). Less than 41% of pharmacists in both cohorts had received formal health literacy training; a regression model indicated that pharmacists with more years of practice were less likely to have had such training (P <0.05). Most pharmacists admitted they never formally assess health literacy (79.0% in 2013 and 81.6% in 2021; P=0.875) but reported often relying on their gut feeling to gauge a patient's health literacy (37.1% in 2013 and 41.4% in 2021; P=0.658)). The percentage of pharmacists who orally reviewed written instructions with patients, used layman's terms, and had patients demonstrate instructions significantly increased (P<0.05) between 2013 and 2021. CONCLUSION: Gaps remain in pharmacists' knowledge and practices related to health literacy. From 2013 to 2021, there were improvements in how pharmacists communicate with patients who have limited health literacy, but no significant change in the methods used to assess health literacy.

Outcomes of an interprofessional SBIRT training program: Knowledge attainment and perceived competence for practice.

Background: One way to address substance misuse is to train health professional students in Screening, Brief Intervention, and Referral to Treatment (SBIRT), an early intervention strategy. This study evaluated a semester-long, 50-hour elective SBIRT training that blended online coursework with interprofessional experiences. Medicine, nursing, pharmacy, and social work students completed an interprofessional standardized patient experience and completed a minimum of two interprofessional SBIRT experiences at community agencies. Methods: We analyzed longitudinal data from 197 students using structural equation modeling to examine gains in knowledge and perceived competence, as well as to test if background variables predicted 30-day application of SBIRT knowledge and skills, 30-day satisfaction' 12-month frequencies of care for performing SBIRT; and number of SBIRT clients/patients served directly. Results: Overall, student SBIRT knowledge and perceived competence both increased by more than a standard deviation during the course. Students who experienced larger gains in perceived competence rated the course significantly higher in terms of relevance and usefulness and, in turn, served significantly more SBIRT clients/patients during the following year. We did not find evidence that intra-individual growth in knowledge impacted the degree to which students ultimately applied SBIRT components. Finally, students who had more previous training and experience related to substance abuse ultimately reported greater application of SBIRT knowledge and skills. Interprofessional differences included: At baseline, medicine students had significantly lower substance abuse education knowledge as compared to the other disciplines. Pharmacy and social work students were more likely to have had previous experience with motivational interviewing. Baseline perceived competence in applying SBIRT was higher in social work and nursing. Upon completion, pharmacy and medicine students had lower satisfaction with the course. Conclusions: These findings suggest that SBIRT courses can increase knowledge and perceived competence; moreover, student background characteristics, work settings, and experiences may have important effects on learning SBIRT.

Interaction between warfarin and nafcillin: case report and review of the literature.

A 39-year-old man with a history of deep vein thrombosis and septic arthritis of the left knee was treated with warfarin and cefazolin. Therapeutic prothrombin times and international normalized ratios (INRs) were maintained with warfarin 32 mg/week for approximately 1 month. When the patient's antibiotic regimen was changed from cefazolin to nafcillin 2 g every 4 hours, his INR declined significantly. His warfarin dosage had to be increased to a maximum of 88 mg/week to achieve a therapeutic INR. After completion of antibiotic therapy with nafcillin, the patient's warfarin requirements slowly declined over several weeks. A maintenance dosage of warfarin 42-48 mg/week was necessary after nafcillin discontinuation. Hepatic cytochrome P450 isoenzyme induction by nafcillin is likely the mechanism of a warfarin-nafcillin interaction. The usual onset of effect is within 1 week after starting nafcillin, and the offset of the effect is usually evident within 4 weeks after nafcillin discontinuation. In patients taking warfarin who are prescribed nafcillin, a 2-4-fold increase in the warfarin dose may be necessary, and clinicians should closely monitor INRs.

Update on the interaction of rifampin and warfarin.

A 79-year-old man with a history of deep vein thrombosis and pulmonary embolism received anticoagulation therapy with warfarin 5 mg daily for 8 months. He was diagnosed with osteomyelitis and underwent partial metatarsal resection of his right foot. After surgery, antibiotics were initiated, including ertapenem sodium 1 g intravenously every 24 hours, vancomycin 1400 mg intravenously every 24 hours, and rifampin 300 mg by mouth twice daily. Achieving a therapeutic level of anticoagulation was difficult despite escalating doses of warfarin, because of the interaction with rifampin. A 5- to 6-fold increase in warfarin dose was prescribed to reach therapeutic international normalized ratios (INRs), but even these increases were insufficient to maintain his INR in the therapeutic range. After rifampin was discontinued, warfarin doses were gradually reduced over the next 2 months. When concurrent warfarin-rifampin therapy is necessary, vigilant monitoring is imperative and significant increases in warfarin doses are likely.

Thrombocytopenia following heparin flush.

A total of 23 patients who developed heparin-induced thrombocytopenia following exposure to heparin solely due to intravascular catheter or filter flush were the subjects of prospective studies of argatroban therapy. Heparin doses were 10-13,000 U, with a mean exposure of 8+/-4 days. Following heparin-induced thrombocytopenia diagnosis and heparin cessation, 13 patients received argatroban (mean dose of 1.8+/-1.1 mg/kg/min for 5.5+/-3.9 days), achieving activated partial thromboplastin times of 63+/-23 seconds, and 10 historical control patients received no direct thrombin inhibitors. Platelet count recovered to a mean of 207+/-153 x 10(9)/L (n=12) after 5.5+/-3.9 days of argatroban therapy and to a mean of 127+/-63 x 10(9)/L (n=8) 5 days after baseline in the control group. A composite end point of death, amputation, or new thrombosis within 37 days occurred in five (38.5%) argatroban-treated patients and four (40%) controls. Death was the most common untoward outcome (approximately 30% of each group). No argatroban-treated patient and two (20%) control patients experienced new thrombosis. Major bleeding was comparable between groups. Heparin-induced thrombocytopenia can occur following minimal heparin exposure, including heparin flushes; in these patients, argatroban provides effective alternative anticoagulation as compared with historical controls.

A literature review of the epidemiology and treatment of acute gout.

BACKGROUND: Gout is the most common cause of inflammatory arthritis in men aged >40 years and is frequently encountered in clinical practice. OBJECTIVE: The goal of this article was to review the published literature on the epidemiology, treatment, and estimated burden of illness of acute gout. METHODS: Articles on gout published in English between 1980 and June 2002 were identified through a MEDLINE search. Relevant clinical studies and review articles were found using the text- and keyword-search term gout alone and in combination with epidemiology, prevalence, incidence, complications, outcome, quality of life, economics, cost, prevention or drug therapy. The reference lists of identified articles, especially review articles, were checked for any additional studies that might have been missed in the original MEDLINE search. RESULTS: The epidemiology of gout in various geographic regions has been well documented. Data suggest that environmental, racial, and hereditary factors may influence the development of gout, and that the prevalence of gout appears to be on the rise worldwide. Evidence from well-designed clinical studies evaluating drug therapies for gout is limited. Therapies for acute gout include corticotropin, corticosteroids, colchicine or, more often, nonsteroidal anti-inflammatory drugs (NSAIDs), which have shown comparable efficacy. A recent study suggests that etoricoxib, a new cyclooxygenase-2-selective inhibitor, may be as effective as and better tolerated than traditional NSAIDs in the treatment of gout. Urate-lowering therapy, prophylactic colchicine, and low-dose NSAIDs are used for the long-term prophylaxis of gout. However, all acute and prophylactic therapies are associated with adverse events. Using an economic model for gout, the annual direct burden of illness for new cases of acute gout can be estimated at 27,378,494 US dollars in the United States. CONCLUSIONS: Gout is an increasingly prevalent condition worldwide and creates a heavy economic burden. Available treatments are generally effective; however, they are not devoid of adverse events. Well-designed, long-term, controlled clinical trials evaluating the comparative efficacy and tolerability of treatments for gout are needed.

Evaluation of online consumer medication information.

BACKGROUND: Millions of Americans search the Internet for health-related information; however, the readability and comprehensiveness of consumer medication information (CMI) on the Internet has not been widely studied. OBJECTIVE: The purpose of this study was to evaluate the readability and comprehensiveness of online CMI. METHODS: The readability and comprehensiveness of consumer drug information found on 3 well-known Web sites (Medline Plus, Yahoo Health, and WebMD) was evaluated; in particular, information related to 10 commonly prescribed medications. Readability was assessed using the Simple Measure of Gobbledygook (SMOG) and Fry Readability Graph (FRG) tools; comprehensiveness of information was evaluated using the Keystone action plan criteria. RESULTS: Using SMOG, the mean reading level of each Web site was 13th grade level or higher. Using the FRG, the mean reading level was 10th grade or higher. Out of the 24 points in the Keystone action plan criteria, information found on each of the Web sites was deemed accurate with mean score of 21, 21, and 19 for Medline Plus, Yahoo Health, and WebMD, respectively. CONCLUSIONS: For the medications reviewed, CMI found on Web sites was accurate when assessed using the Keystone action plan criteria. The readability levels were higher than the recommended sixth grade level.

Fenofibrate potentiates warfarin effects.

OBJECTIVE: To describe 2 patients in whom the initiation of fenofibrate potentiated warfarin's anticoagulant effects. CASE SUMMARY: A 71-year-old white woman and an 80-year-old white woman with multiple medical conditions were both stabilized on long-term warfarin therapy. During the course of anticoagulation, both patients were prescribed fenofibrate and experienced threefold and twofold increases in international normalized ratio (INR), respectively, requiring total weekly warfarin dosage reductions of 30-40%. Before starting fenofibrate therapy, both patients' coagulation values were within the therapeutic range. When interviewed, patients and caregivers denied bleeding, bruising, changes in diet, alcohol ingestion, nonadherence with therapy, or changes in drug regimen except for the addition of fenofibrate. Upon chart review, evaluation of potentially contributory parameters, such as other changes in drug therapy, thyroid function, liver function, and drug-disease interactions, showed that these parameters remained stable and were ruled noncontributory. DISCUSSION: The addition of fenofibrate in 2 patients on stable and therapeutic doses of warfarin increased the anticoagulant response to warfarin. A clear temporal relationship with the addition of fenofibrate and the appearance of the interaction was seen. Fenofibrate is highly protein bound, with the potential to displace warfarin from its binding protein, leading to an enhanced hypoprothrombinemic effect. Fenofibrate is also a mild to moderate inhibitor of CYP2C9, the enzyme responsible for warfarin metabolism. The combination of these effects--displacement of warfarin by fenofibrate coupled with decreased metabolism of warfarin--may increase the anticoagulant response to warfarin. Using the Naranjo probability scale, these interactions were designated as probable. CONCLUSIONS: We suggest serial monitoring of INR and consider an empiric 20% reduction in warfarin dosage when fenofibrate is initiated, with the possibility for a greater warfarin dosage reduction based on INR results.