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Background: Drug therapy problems, adverse drug events (ADEs), and symptom burden are high among adults with disabilities. Objective: To compare the effects of a modified medication therapy management (MTM) program within a self-efficacy workshop versus the workshop alone or usual care on symptom burden among adults with activity limitations. Methods: Three-group randomized controlled trial among adults (age 40 and older) with self-reported activity limitations in community practice. Interventions: 8 weekly Living Well With a Disability (LWD) 2-hour workshop sessions with and without a collaborative medication management (CMM) module. Primary outcome: mean number of moderate to very severe symptoms from a list of 11 physical and mental symptoms. Process measures: changes in medication regimens and self-reported ADEs. Analysis: general linear mixed models (continuous outcomes) and generalized estimating equations (categorical outcomes). Results: Participants had high symptom burden, low physical health, and took many medications. There was a significant increase in ADE reporting in the LWD + CMM group relative to the other 2 groups (Study group × Time P = .014), and there were significantly more changes in medication regimens in the LWD + CMM group ( P = .013 LWD only vs LWD + CMM). The oldest third of participants had significantly fewer mean symptoms but received more intense CMM. There was no difference between the LWD-only, LWD + CMM, and usual care groups in symptom burden over time. Conclusion: Pharmacist MTM practices and MTM guidelines may need to be modified to affect symptom burden in a population with physical activity limitations.

Background Pharmacists in various settings have been effective in initiating diabetes treatment. Patients with diabetes require ongoing disease management, and community pharmacists are in a strategic position to provide such extended care. Little is known, however, about the effects of community pharmacist–provided interventions beyond the initial treatment period. Objective To evaluate the effect of community pharmacist–provided extended diabetes care service on primary clinical outcomes, including hemoglobin A1c (A1C), low-density lipoprotein cholesterol (LDL-C), and blood pressure, and on patients' reported self-care activities. Methods A randomized controlled trial was conducted in patients with diabetes. Participants had already completed at least 2 diabetes education sessions at a local diabetes education center. Nine specially trained pharmacists administered interventions during up to 4 quarterly visits per patient. Interventions included discussing medications, clinical goals, and self-care activities with patients and recommending medication changes to physicians when appropriate. The main outcome measures were 12-month changes in A1C, LDL-C, blood pressure, and self-report of self-care activities. Results Seventy-eight patients participated in the study (36 intervention, 42 control); 66 were included in the final analysis (31 intervention, 35 control). Compared with changes in the control group, patients who received interventions significantly increased the number of days per week that they engaged in a set of diet and diabetes self-care activities (1.25 and 0.73 more days/wk, respectively). The mean 12-month changes for A1C, LDL-C, and blood pressure were not significantly different between the 2 study groups. Conclusions Although pharmacist-provided interventions did not demonstrate statistically significant improvements in clinical outcomes over the study period, study results did show that pharmacists were effective at increasing the number of days that patients spent engaging in healthy diet and diabetes self-care activities. Addressing lifestyle and self-care behaviors can be a beneficial component of a pharmacist-provided extended diabetes care service.

Background: Adverse drug events (ADEs) occur in older adults. ADEs occur in up to 6.5% of all hospitalized patients and outpatients, and about 28% of these events are preventable. The proportion of outpatients with an ADE ranges from 5% to 35%, depending on the exact definition used. There is a critical need to examine the risk factors associated with having an ADE to increase awareness about medication safety among older adults. Objective: To quantify the association between risk factors such as the number of pharmacies used by patients and their concern and necessity beliefs about medicines, and self-reported ADEs. Methods: A cross-sectional Internet survey was administered by Harris Interactive. Harris Interactive asked individuals from their online panel who were 65 years of age or older, US residents, and enrolled in Medicare to complete the survey. A convenience sample of 1220 anonymous surveys was obtained. Multiple logistic regression analysis was performed. The dependent variable was self-reported ADEs, defined as the patient's visiting a physician to report an unwanted reaction or medicine problem in the past year. Independent variables included sociodemographics, self-rated health, number of medications, sum of symptoms experienced, concern and necessity beliefs about medicines, number of pharmacies, and whether subjects skipped doses of their medications to save money or stopped taking the drugs due to cost. Results: Eighteen percent of respondents reported an ADE. ADEs were related to being female (OR 1.56; 95% CI 1.05 to 2.33), number of pharmacies (OR 3.40; 95% CI 1.56 to 7.41), number of symptoms experienced (OR 3.39; 95% CI 1.87 to 6.14), concern beliefs about medicines (OR 1.14; 95% CI 1.08 to 1.20), and having a graduate academic degree (OR 2.17; 95% CI 1.41 to 3.36). Conclusions: The number of pharmacies, concern beliefs about medicines, and number of symptoms experienced in the past month were associated with self-reported ADEs. Discussing patients’ beliefs about their drug therapy with them is likely to affect their expectations and interpretation of symptoms, as well as future attributions regarding drug therapy.

Objective: To describe the state of community pharmacy, including patient care services, in the US. Findings: Chain pharmacies, including traditional chains, mass merchandisers, and supermarkets, comprise more than 50% of community pharmacies in the US. Dispensing of drugs remains the primary focus, yet the incidence of patients being counseled on medications appears to be increasing. More than 25% of independent community pharmacy owners report providing some patient clinical care services, such as medication counseling and chronic disease management. Most insurance programs pay pharmacists only for dispensing services, yet there are a growing number of public and private initiatives that reimburse pharmacists for cognitive services. Clinical care opportunities exist in the new Medicare prescription drug benefit plan, as it requires medication therapy management services for specific enrollees. Discussion: The private market approach to healthcare delivery in the US, including pharmacy services, precludes national and statewide strategies to change the basic business model. To date, most pharmacies remain focused on dispensing prescriptions. With lower dispensing fees and higher operating costs, community pharmacies are focused on increasing productivity and efficiency through technology and technicians. Pharmacists remain challenged to establish the value of their nondispensing-related pharmaceutical care services in the private sector. As the cost of suboptimal drug therapy becomes more evident, medication therapy management may become a required pharmacy benefit in private drug insurance plans. Pharmacy school curricula, as well as national and state pharmacy associations, continually work to train and promote community pharmacists for these roles. Practice research is driven primarily by interested academics and, to a lesser degree, by pharmacy associations. Conclusions: Efficient dispensing of prescriptions is the primary focus of community pharmacies in the US. Some well designed practice-based research has been conducted, but there is no national research agenda or infrastructure. Reimbursement for cognitive services remains an infrequent, but growing, activity.

BACKGROUND Medication reviews may be an important strategy to improve medication use, especially for individuals receiving many drugs. OBJECTIVE To describe the types of medication issues and recommendations identified in the Iowa Priority Brown Bag Medication Reviews, compare individuals with medication issues with those without medication issues, and describe Iowa Priority enrollees’ experiences with and satisfaction of the review. METHODS A retrospective review of enrollment forms and medication review records and a survey of Iowa Priority members were conducted in 2002. Subjects were Medicare-eligible individuals who joined the Iowa Priority Prescription Savings Program. Frequency distributions and descriptive statistics were calculated. Analysis using t-test and χ2 test determined differences between individuals with and without issues regarding use of drug therapy. RESULTS Almost 13% of Iowa Priority enrollees received a review. There were 1167 individuals with 2123 medication issues identified. Nonprescription medications accounted for one-third of drug interactions and >40% of duplications. People with issues had poorer health, more chronic conditions, and took more drugs than people without medication issues. One-third of survey respondents discussed the review with their physicians, and 17.7% reported medication changes. Satisfaction with the review was good; however, only 24% were likely to have received an annual review. CONCLUSIONS Iowa Priority Brown Bag Medication Reviews showed that individuals with fair/poor health, higher numbers of medications, and more chronic conditions were likely to have medication issues. Reviews generated discussions between physicians and patients, produced some medication changes, and helped individuals save money.

INTRODUCTION: La fiabilite de l'index d'adequation therapeutique (MAI) de Hanlon a ete demontree dans des services selectionnes de consultations externes, ou le dossier du patient etait facilement accessible. Toutefois, son utilisation en milieu hospitalier pour des patients âges ambulatoires, ou les donnees du patient peuvent etre limitees, n'a pas ete examinee. OBJECTIF: Evaluer l'utilite d'un index MAI modifie dans le cadre d'une pharmacie hospitaliere par l'evaluation de la fiabilite inter-evaluateurs, en utilisant trois echelles d'evaluation differentes. METHODES: Deux evaluateurs, pharmaciens hospitaliers entraines a ces methodes, ont evalue 160 traitements (prescrits et non prescrits) par l'interrogatoire de 32 patients âges ambulatoires. Ils ont egalement recueilli les donnees medicales actuelles et passees en utilisant un formulaire standardise. Un score MAI cumule, un pourcentage de concordance, le kappa, la concordance positive ou negative et le coefficient de correlation intra-classe ont ete calcules pour chaque critere en utilisant trois echelles d'evaluation. Un test t apparie, avec 95% d'intervalle de confiance, a ete utilise pour tester la fiabilite interevaluateurs. RESULTATS: Les statistiques K ont ete superieures a 0.75 pour l'indication et l'efficacite (correlation excellente) et bonnes pour les autres criteres (0.41-0.66) en utilisant l'echelle de Hanlon. Les coefficients infra-classe (0.82, 0.86, 0.87) et le K total (0.65, 0.66, 0.61) ont ete similaires pour les trois echelles d'evaluation. CONCLUSIONS: Cette etude suggere que l'index MAI modifie a la possibilite de detecter si un traitement est approprie ou non dans les services de pharmacie hospitaliere. Toutefois il existe des limitations. Etant donne que le MAI a le plus de donnees clinimetriques et psychometriques valides les etudes doivent etre poussees plus loin pour en augmenter la fiabilite et en permettre la generalisation.

OBJECTIVE: To determine the efficacy of a program of intervention by pharmacists on lipid risk management in patients at high risk for cardiovascular events. METHODS: Randomized, multicenter (44 sites in Alberta and Saskatchewan) study of community pharmacist intervention versus usual care in 1000 patients. Patients are those at high risk of vascular events (existing atherosclerotic vascular disease, or diabetes with ≥1 other risk factor). After obtaining consent, the pharmacist calls the Project Office to randomize. Patients allocated to intervention receive a brochure and education about cardiovascular risk factors. Pharmacists also complete a physician contact form, which lists the patient's risk factors, medications, and any recommendations. A point-of-care cholesterol test is performed, the result is discussed with the patient, and it is entered on the contact form. If appropriate, the patient is asked to see his or her primary care physician for further assessment and/or treatment, and the form is faxed to the physician. Patients are followed up at two, four, eight, 12, and 16 weeks. During follow-up visits, pharmacists provide educational reinforcement and check for primary end point occurrence. Patients allocated to usual care receive the brochure only, with minimal follow-up. The primary end point is a composite of measurement of a complete lipid panel by the physician, or addition or modification of lipid-lowering drug therapy. Substudies will evaluate economics (third-party payer and pharmacy manager perspective), patient satisfaction, and quality of life. CONCLUSIONS: SCRIP (Study of Cardiovascular Risk Intervention by Pharmacists) is a unique ongoing trial that is evaluating a community pharmacist intervention designed to optimize cholesterol risk management in patients at high risk for cardiovascular events.

OBJECTIVE:To develop a categorization scheme for grouping various nonsteroidal antiinflammatory drugs (NSAIDs) by relative safety; to develop a method to quantify the appropriateness of the initial and subsequent choices of NSAID therapy; to assess whether NSAID prescribing was consistent with the developed criteria; to examine the cost of inappropriate, acute NSAID use as defined by the established criteria.DESIGN:Retrospective drug utilization review focusing on NSAIDs.SETTING/PARTICIPANTS:Members aged age⩾18 years of a 40 000-person southeastern Michigan health maintenance organizationMAIN OUTCOME MEASURES:(1) Appropriateness of therapy using a four-level safety classification system for the NSAIDs developed by a consensus process; criteria based on safety under the assumption that any particular NSAID is equally likely to be effective when dosed appropriately; (2) evaluation of progression of NSAID therapy using the NSAID Therapy Progression Formula.RESULTS:For acute patients, almost half of the prescriptions were for ibuprofen and 33 percent were for naproxen. Ibuprofen usage accounted for 16 percent of total NSAID cost and naproxen agents accounted for over 50 percent of that cost. Potential cost savings of approximately $82 000 probably would have occurred had a 50 percent interchange rate for ibuprofen been acceptable. For chronic patients, 85 percent were treated with one or two NSAIDs; treatments were of reasonable high quality when compared by safety profiles. There was low use of ibuprofen in patients who only received one NSAID.CONCLUSIONS:NSAID usage assessment in a large population was achieved by developing a classification and scoring system based on NSAID safety; in this population, prescribing patterns were generally consistent with established criteria; however, when considering cost, improvement in initial NSAID selection for acute patients was possible.