Perceptions of Medicare Part D enrollees about pharmacists and their role as providers of medication therapy management.

OBJECTIVE: To explore the awareness of Medicare Part D enrollees regarding medication therapy management (MTM) and to examine their expectations and perceptions of pharmacists in providing MTM. METHODS: The Internet-based survey consisted of questions on respondent demographics, prescription-related behavior, awareness of MTM, and expectation and perception of pharmacists in usual roles and as MTM providers. Four open-ended questions examined expectations, trust, source of MTM information, and perceived benefit from MTM. RESULTS: The sample of 504 Medicare Part D enrollees from California (mean age 72 years) used an average of 4.3 prescriptions per day. Awareness of MTM was low in this cohort (93% unaware). Trust in the pharmacist was centered on dispensing prescriptions. Expectation of pharmacists also revolved around product (>60%). Approximately 70% of respondents did not believe they needed MTM; however, 58% believed pharmacists were good candidates to provide MTM. Willingness to pay for MTM services was also low (31%). CONCLUSION: Medicare Part D enrollees' expectation and perception of pharmacists revolves around the dispensing function. The public, payers, and policy makers need to be educated to recognize and use pharmacists as cost-effective providers of MTM.

Effect of nesiritide infusion duration on renal function in acutely decompensated heart failure patients.

BACKGROUND: Nesiritide, a synthetic B-type natriuretic peptide, is used for the treatment of patients with acutely decompensated heart failure. Although nesiritide has been reported to worsen renal function, as reflected by significant elevations in serum creatinine (SCr), the impact of infusion duration on renal function has not been evaluated. OBJECTIVE: To investigate the effect of nesiritide infusion duration (< 24 h vs > or = 24 h) on worsening renal function in patients with acutely decompensated heart failure. METHODS: Medical records of hospitalized patients receiving nesiritide were retrospectively reviewed, and 84 consecutive charts of patients with acute decompensated heart failure and available renal function tests were identified for the study. SCr and blood urea nitrogen (BUN) were documented at baseline and during infusion. Worsening renal function was defined as an increase in SCr of 0.5 mg/dL or more or BUN 10 mg/dL or more from baseline. RESULTS: Univariate analysis showed a significant association between nesiritide infusion duration of 24 hours or more (26.1% vs 2.6%; p = 0.003), high diuretic doses (61.5% vs 32.4%; p = 0.045), and baseline SCr (2.0 +/- 0.8 vs 1.5 +/- 0.7 mg/dL; p = 0.04) with increases in SCr of 0.5 mg/dL or more. However, only infusion duration of 24 hours or more was statistically significant on multivariate analysis, after adjusting for baseline SCr (OR 10.46; 95% CI 1.26 to 86.72; p = 0.03). Longer duration of infusion was also a consistent variable in both univariate and multivariate analysis when elevated BUN was evaluated (34.8 vs 2.6%; p < 0.001 and OR 19.73; 95% CI 2.47 to 157.46; p = 0.005, respectively). CONCLUSIONS: Nesiritide infusion of 24 hours or more appears to be significantly associated with elevated markers of worsening renal function in patients with acutely decompensated heart failure compared with infusion of less than 24 hours; however, prospective studies are needed to corroborate this finding.

Decision analysis model evaluating the cost-effectiveness of risperidone, olanzapine and haloperidol in the treatment of schizophrenia.

PURPOSE: To evaluate the cost-effectiveness of three antipsychotic medications (olanzapine, risperidone and haloperidol) in the treatment of schizophrenia using the Positive and Negative Symptom Scale. STUDY DESIGN AND METHODS: A decision analysis model was created to evaluate the cost-effectiveness of two atypical antipsychotics (risperidone and olanzapine) and haloperidol. Outcome probabilities were determined from published clinical trials. The main dependent variable of interest was to compare the incremental cost-effectiveness ratios (ICER) of the atypical antipsychotic with haloperidol, and also to compare the ICER of olanzapine and risperidone. Sensitivity analyses were conducted for olanzapine and risperidone to determine the effects of altering drug cost, efficacy and re-hospitalization rate on total costs. RESULTS: Risperidone and olanzapine were dominant strategies compared with haloperidol (less costly and more effective). Risperidone was also dominant when compared with olanzapine. A one-way sensitivity analysis for efficacy indicated that the efficacy of risperidone would need to decrease by approximately 3% from the base-case in order for olanzapine and risperidone to have equal total costs. In a two-way sensitivity analysis varying both the cost of olanzapine and risperidone, the difference in drug costs between them would have to increase from $2.12 per day to $4.12 per day in order to have equal total costs. In terms of varying re-hospitalization rates, the re-hospitalization rate for risperidone would have to increase from 3% to 33% greater than the re-hospitalization rate for olanzapine in order to have equal total direct costs. CONCLUSION: Based on this decision model, atypical antipsychotics were a dominant strategy over haloperidol primarily because of increased efficacy and lower re-hospitalizations. The ICER indicated that risperidone was dominant over olanzapine because of lower drug costs and increased number of responders, which leads to decreased total costs.

ASHP survey of ambulatory care pharmacy practice in health systems--2004.

PURPOSE: The characteristics of and trends in pharmacy practice in ambulatory care settings across the United States were studied. METHODS: A 2004 national survey of the ambulatory care responsibilities of pharmacists across a spectrum of organizational types (community hospitals, county facilities, Indian Health Services facilities, Veterans Affairs (VA) facilities, teaching institutions, integrated health networks, military facilities, and health maintenance organizations) was conducted and related to organizational features that could promote pharmacist participation. RESULTS: From 1672 deliverable Web-based surveys, 233 organizations reported at least some pharmacist involvement in ambulatory activities, while 475 reported none. Over half of the 228 organizations with some pharmacist involvement reported pharmacists tracking adverse drug reactions (67%), providing written (53%) or oral (52%) information with new prescriptions, and conducting medication management programs (51%). Some 85% reported having at least one clinic with pharmacist involvement. Clinics for anticoagulation services (36%) and oncology services (28%) were most prevalent, followed by primary care or family practice clinics (23%) and diabetes clinics (21%). New survey items found a high prevalence of pharmacist involvement in emergency preparedness programs (90%), medication management services in complex medication situations (63%), and using evidence-based practice guidelines (60%). Of nine enabling factors (factors potentially promoting pharmacist involvement) investigated, participation on multidisciplinary teams and having collaborative practice agreements were significantly associated with pharmacist participation in at least one ambulatory care activity. Having at last one ambulatory care staff pharmacist with advanced training, having at least one residency program, and having collaborative practice agreements were significantly associated with pharmacist participation in at least one clinic or program. Pharmacist participation in ambulatory care activities was not equally distributed across different types of organizations, and VA facilities were notable for the amount and extent of participation. CONCLUSION: Pharmacists' roles and responsibilities in ambulatory care appear to continue to evolve, with VA facilities leading the way.

Prevalence and types of disease management programs in community pharmacies in California.

OBJECTIVES: To (1) evaluate the prevalence and types of disease management (DM) programs provided by independent and chain community pharmacies in the state of California, (2) examine the interest among community pharmacists in establishing programs, and (3) assess perceived barriers to developing a successful DM program in community pharmacy. METHOD: An exploratory telephone survey was conducted from February 2003 to February 2004 to collect data from community (primarily independent and chainstore) pharmacies across California. The survey evaluated existence (or lack of) and types of DM programs in community pharmacies in California. Pharmacies that did not have a DM program were queried on their interest and decisionmaking authority in establishing new programs. Pharmacies that had existing DM programs were sent a follow-up survey to determine the details of the DM programs, including challenges in establishing DM programs, reimbursement issues, and program effectiveness. RESULTS: The sample comprised 1,875 pharmacies, 60 (3.2%) of which had existing DM programs. There were significantly more independent pharmacies (37) with DM programs than chain-store pharmacies (23), P<0.001. There was a statistically significant difference between independent and chain pharmacies in operating hours, number of pharmacist and nonpharmacist staff members per day, and proximity to a clinic or hospital (P<0.05). The most common type of DM program was diabetes, and the second most common type was asthma. Limited time, limited staff, and limited reimbursement were the 3 most commonly reported barriers to establishing new DM programs. About 20% of the sample that did not have a DM program reported interest in developing DM programs, and an equal percentage reported having the decision-making authority to start a program. There were no differences between independent and chain pharmacies on interest (P = 0.234); however, there were significantly more chain pharmacists that did not have the decision-making authority. Of the 18 of 60 pharmacies (30%) that had DM programs and responded to the follow-up survey, 9 respondents (50%) reported monitoring medications as part of their DM program. Fifteen of 18 (83%) perceived lack of reimbursement as a challenge to implementing DM programs. Only 2 pharmacies reported an increase in revenue as a gain from the program, and 2 reported cost savings. Improved patient satisfaction was reported by 16 of 18 respondents (89%) with DM programs, but only 8 (44%) reported that patient satisfaction was being measured. CONCLUSION: The study found that the prevalence of DM programs was very low among California community pharmacies and the interest in developing these programs moderate, attributable to several barriers such as lack of time, lack of reimbursement, and lack of trained personnel. Some of these barriers could be addressed to encourage the development and proliferation of DM programs that would improve patient outcomes and expand practice roles of pharmacists.

Ready, willing, and able to provide MTM services?: A survey of community pharmacists in the USA.

BACKGROUND: Changes in US Medicare legislation could benefit pharmacy's attempt to make medication therapy management (MTM) practice more commonplace; however, little is known about pharmacists' capabilities and preferences to do so. OBJECTIVES: The purpose of this study was to explore US pharmacists' perceived preparedness, willingness, and challenges toward providing MTM services. METHODS: A brief purpose of the survey and its website link were included in the electronic weekly newsletter of the National Community Pharmacists Association (NCPA) in January 2007. The web-based survey consisted of 8 demographic questions, 8 questions examining preparedness and willingness of the respondents regarding MTM, 2 questions regarding reimbursement to pharmacists, and 2 checklists for challenges in establishing MTM services. RESULTS: Most of the 143 respondents indicated that they were aware of MTM, and 92 (65%) reported that they were currently practicing MTM. A majority of the sample agreed that pharmacists should provide MTM and have the ability to do so. Major challenges reported by the sample include the different specification of MTM by each health plan, time, staffing, and reimbursement issues. Respondents selected valid measures of program effectiveness but revealed that they needed help with documentation and billing. Expected reimbursement range was $1-10/minute. CONCLUSION: Community independent pharmacists reported being ready, willing, and able to provide MTM services, but need assistance in the process, that is, standardized MTM protocols, documentation and billing.

Fluoroquinolone-resistant Pseudomonas aeruginosa: risk factors for acquisition and impact on outcomes.

OBJECTIVES: Resistance among Pseudomonas aeruginosa has risen dramatically and parallels the increase in fluoroquinolone (FQ) prescribing in recent years. Risk factors for FQ resistance in P. aeruginosa and its impact on outcomes need to be well characterized. METHODS: A case-control study was carried out on hospitalized adult patients from whom FQ-resistant (case) and FQ-susceptible (control) P. aeruginosa were isolated. RESULTS: A total of 177 patients with positive cultures (91 cases and 86 controls) and 119 with documented infections (65 cases, 54 controls) were included in risk factor and outcomes analysis, respectively. Independent risk factors for FQ resistance were: FQ exposure (OR 12.6, CI 4.95-32), nosocomial acquisition (OR 8.6, CI 3.5-20.7), and diabetes mellitus (OR 6.4, CI 2.1-19.3). An FQ agent was prescribed in 59% of patients receiving an 'antipseudomonal' empirical regimen. Compared with controls, FQ-resistant cases had a median delay to receiving effective therapy of 3.5 days versus 1 day and poorer outcomes: (i) lower complete response rate (45% versus 63%, P=0.04); (ii) longer time to achieve clinical stability (8 days versus 3 days, P=0.005); and (iii) higher infection-related mortality (21% versus 7%; OR = 2.9, 0.9-9.4). Empirical FQ use (OR 4.6, CI 1.5-14.3), FQ resistance (OR 3.6, CI 1.0-13.1), and high APACHE II score (OR 1.1, CI 1.0-1.2) were independent risk factors for increased mortality. CONCLUSIONS: FQ exposure from widespread prescribing is a modifiable risk factor for FQ resistance in P. aeruginosa. FQ empirical therapy for Pseudomonas infections may be associated with significant delays in administering effective therapy resulting in adverse outcomes.