Pharmacy technicians’ attitudes about their roles in Iowa public safety

As the field of pharmacy changes, so do the positions involved.  Pharmacy technicians’ roles are expanding, and this expansion can be easily seen with “tech-check-tech” programs gaining popularity.  This study was developed to review the attitude and perceived importance the pharmacy technicians feel about their work.

During the fall of 2012, 1,000 registered pharmacy technicians in Iowa were sent surveys, and of those 253 pharmacy technicians responded.  The majority of the technicians that responded were in a practice setting.  91.5% of the technicians were female.  About 69% of those who responded had beyond a high school degree, but the numbers decreased the higher the education level (36.6% had some college).

Ambulatory practice technicians, “communicate with third-party payers” and “coordinate written, electronic, and oral communication throughout practice” were ranked highly for importance.  Whereas, hospital and community pharmacy technicians were found to hold “fill/deliver unit dose refills to hospital patients”, and “information systems/dispensing technologies” at a higher level of importance.

The study concludes by stating that for the continuation of the pharmacy profession the pharmacy technician feelings and perceptions must be accounted for in order to support public safety, and improve patient care.

What as future pharmacists can we do to ensure our pharmacy technician team feels appreciated and valued?  As pharmacists in community settings are moving further away from the actual filling of prescriptions and more towards patient counseling, how will this impact a pharmacy technician’s role?

J Am Pharm Assoc. 2015;55(5):493-502. 

Pharmacokinetics of oral and intravenous melatonin in healthy volunteers

Lars Andersen and colleagues created a study to examine the pharmacokinetics of melatonin administered orally, and intravenously.  This was a cohort crossover study in which volunteers were given either 10 mg melatonin orally or 10 mg of intravenous melatonin on two occasions.  Twelve male volunteers with an average age of 27 years old and an average BMI of 23.2 kg/m2.

Some pharmacokinetic parameters were measured for both oral and intravenous routes including half-life, area under curve (AUC), and volume of distribution for intravenous.  The half-life for the oral route was found to be 53.7 minutes, and 39.4 minutes for the intravenous method.  The AUC for the oral melatonin 281,538.3 pg*mL-1*min, and the intravenous melatonin was found to have an AUC 14,179,767.6 pg*mL-1*min.  The volume of distribution was found to be 1.2 L/kg.

The study concluded that the oral melatonin had a very low bioavailability of about 3%.  They commented how other studies they found ranged from 9-33% availability.  The one similarity between the studies they reviewed and this study was that there was high variability between patients.  The low availability was due to the extensive first pass effect from the liver.  The intravenous melatonin was found to be have first order elimination kinetics.  The parameters found with the intravenous study fell within the limits that were predicted based on previous studies.

Studies like this one are very important to help optimize a medications effects.  When examining pharmacokinetic effects do you think that it is important to include both sexes in the volunteer pool?  How does the variable bioavailability affect the results of each patient that takes oral melatonin?

BMC Pharmacol Toxicol. 2016;17:8. 

Modulation of Cell-Mediated Immunity to Suppress High Fat Diet-Induced Obesity and Insulin Resistance

This study was designed to test the effects that cyclosporine A and fingolimod may have on obesity caused by high fat diets and insulin resistance.  This study was conducted in mice that were fed a high fat diet, and that were regularly injected for fifteen weeks with cyclosporine A, fingolimod, or a control.

The study begins by validating its importance due to the large spike in American obesity.  The study reported that 34.9% of American adults are considered obese.  Cyclosporine A is used in organ transplant patients to help prevent the immune system from rejecting the organ.  Fingolimod, on the other hand, is used as a first-line defense in patients experiencing a relapsing form of multiple sclerosis.

Of the mice, those injected with cyclosporine A had an average body weight that was 34% less than the control mice.  Those mice treated with fingolimod were about 16% less in body weight.  They found that the cyclosporine A mice maintained weight gain suppression throughout the entire experiment, while the fingolimod mice had slowed weight gain after week 7.  To rule out the thought that there could be lean mass being lost a body composition analysis was completed using EchoMRI.  It was found that the lean mass of the mice was unaffected, but the cyclosporine A mice had 60.8% less fat mass than the control.  The fingolimod mice had about 22.2% less fat mass than the control mice.

The results of this study were that cyclosporine A and fingolimod both were able to suppress weight gain, improve the mice’s sensitivity to insulin, and reduce their hepatic fat accumulation.  It concluded that this is a promising option that should continue to be looked into and developed.

Pharmacists see countless patients suffering from diabetes type 2 and other weight related conditions.  How would an injection like this affect the way pharmacists discussed lifestyle changes and nutrition expert recommendations?  Do you feel there would be a push from patients to receive the shot rather than make changes similar to the pressure physicians feel to prescribe antibiotics?

 

Pharm Res.  2016;33(2):395-403. 

Influence of the number of daily pills and doses on adherence to antiretroviral treatment: a 7-year study

A seven year retrospective study was conducted to draw a relationship between retroviral medication adherence, and the number of pills patients have to take.  The location was the University Hospital of Salamanca, Spain.  There were two levels of adherence established; greater than or equal to 95%, or less than 95%.  There were 264 patients who were studied.  The mean age was a little over 40 years old, and they had been a part of the antiretroviral treatment (ART) for 5.35 years.

One thing examined in this study is the shift from twice a day, and even three times a day medications to simply once a day medications.  The baseline number of patients who were taking their medications once a day was 10.  By the end of the study, there were 129 patients taking their medication once a day.  Those taking their medication three times a day went from 7 patients to 0 patients.   The average number of pills the patients had to take daily decreased from six to four throughout the study.

The study found that there was no correlation between adherence and the number of pills the patients had to take.  However, the study does clarify that the correlation could be non-existent for the specific setting/type of patients that were examined.  They found that it matters more to patients the frequency of the medications than the number of pills the patient has to take due to the disruption of the patients’ lives when having to take the pills at different times of the day.

Do you believe that there would be no correlation if the medication was treating a less serious diagnosis?  Have you ever found that having to take medications throughout the day interrupted your daily life?

J Clin Pharm Ther. 2016;41(1):34-39. 

A comparison of the Indian Health Service counseling technique with traditional, lecture-style counseling

A non-randomized, observational study at four different community pharmacies in Oregon looks at two different methods of counseling patients.  The first method of counseling was referred to as traditional counseling in which the pharmacist would have a one-sided conversation with the patient by reading/telling the patient important information.  The second method was referred to as the Indian Health Service (IHS) technique.  In this technique, three open ended questions we asked to confirm the patient understood important information about their medication such as; name and purpose, directions and storage, expectations and side effects.  If at any time the patient does not know, the pharmacist clarifies before moving on to the next question.

A total of five hundred patients willing participated between December 2012 and April 2013.  After being counseled by one of the two methods, patients were given questions relating to their medications.  In the IHS group, 71% of the patients were able to answer all three questions correctly.  Whereas, in the traditional group only 33% were able to correctly answer all the questions.  While looking into the incorrect answers it was discovered that about 11.4% of pharmacists did not discuss adverse effects when using the IHS counseling method with their patients.  Those patients counseled using the traditional method were faced with 35.5% of pharmacists not discussing adverse effects with them.  Once those patients who were not counseled about certain points were removed from the data, the percentage of patients who answered all questions correctly moved from 71% with the IHS method to 80%, and 33% with the traditional method to 51.5%.  Time was also assessed, and it was found that the average time it took to counsel traditionally was about 75.3 seconds, compared to the IHS method which took about 128.1 seconds.

In our classes there is a heavy focus on asking open ended questions, and this study validates the importance of open ended questions.  As a pharmacy student do you feel the extra time is worth the increased knowledge of the patient?  How can studies like this one help shape the future of the profession?

J Am Pharm Assoc. 2015;55(5):503-510. 

Effectiveness of a pharmacist-physician collaborative program to manage influenza-like illness

The pharmacist-physician relationship is crucial to the collaborative efforts towards providing the best patient care as soon as possible.  This study is a prospective multicenter cohort study in which pharmacists working under collaborative practice agreements (CPAs) with a licensed physicians were able to administer simple physicals, and point of care rapid influenza diagnostic tests.  There were six overseeing physicians that signed the collaborative practice agreement, and fifty five pharmacies (both chain and independent) in Minnesota, Michigan, and Nebraska that volunteered to be a part of the study.  Those adult patients who showed signs of influenza like illness, and did not have an excluding condition were able to get screened.

There were 121 patients that volunteered for this study, but 45 were excluded due to predetermined exclusion factors.  Of the 76 patients eligible, one was sent to emergency care due to a systolic blood pressure of 83 mmHg.  Only 5 patients at CPA sites tested positive for influenza like illness, and they were given oseltamivir.  After treatment, 78% of all patients in the study were contacted within 48 hours, and reported feeling better.  A large third-party payer was found saying that treatment for upper respiratory tract infections at a physician’s office is on average $130-$180 whereas for emergency care treatment the cost is closer to $510-$635.  One important finding is that 35% of the patients in the study reported not having a primary care provider.

The study mentions that factors such as inconvenience, cost, and treatment delays add to a patient’s dissatisfaction with the health care system.  In the study the average time a pharmacist spent per patient was 10 minutes with a follow-up phone call lasting less than 2 minutes.  It also states that under this CPA model, the pharmacists were able to avoid the patient pressures for prescriptions that physicians often encounter.  The pharmacists were recorded saying that they felt they were able to better guide patients toward effective OTC medications instead of unnecessary prescriptions.  The final conclusion drawn from this study was that more exploration of collaborative models is warranted.

As a patient, would you feel comfortable seeing a pharmacist for treatment of what you believe to be the flu?  How would collaborative practice agreements impact the physician-pharmacist relationship?  Do you feel that a community pharmacist would be able to add this additional service to their day, or what changes to the current community setting would need to be implemented?

J Am Pharm Assoc. 2016;56(1);14-21. 

Minimizing out-of-pocket prescription drug costs for Medicare beneficiaries: Not just ‘a drop in the bucket’

A cross-sectional study was conducted with 621 Medicare beneficiaries to find the relevance four cost minimization techniques have on lowering out-of-pocket prescription medication costs.  The study included people from all different socioeconomic backgrounds.  There were 12 events held during the open enrollment season of 2013 in six cities in northern and central California.  Each appointment was held by a set of trained pharmacy students, and overseen by a licensed pharmacist.  The tools used/helpful programs examined included the Medicare website (Medicare Plan Finder Tool), Low-income Subsidy program, Pharmaceutical Patient Assistance Programs (PAPs), and a 12 point MTM session.

The results found that about 80% of the clients were able to lower their prescription out-of-pocket costs for the upcoming year.  In total, the program found $770,000 in potential annual savings for the clients.  For each patient that underwent the interventions, an annual out-of-pocket savings average was about $1,440, and these savings were a direct result of the four different tools/programs used to reduce prescription costs.  The study concluded that student pharmacists have the potential to improve their clinical, economic, and humanistic outcomes all while saving the geriatric population money on their prescription medications.

It was noted in the study that one limitation was the limited location.  For those working at APPRISE, do you feel compiling the information into a similar study would be beneficial?  Would regional differences between California and Pittsburgh significantly impact the results?

J Am Pharm Assoc. 2014;54(6):604-609.

Potentially inappropriate anticholinergic medication use in older adults with dementia

This was a cross-sectional study done to assess the prevalence of inappropriate anticholinergic medication use in elder dementia patients.  The study used the American Geriatrics Society Beers criteria as guidelines for what medications were considered as potentially inappropriate to use.  This study was published in 2015, however, the data used was from a 2009-2010 national representative health care utilization survey called MEPS.  The MEPS data showed that about 3.78 million adults 65 years old and older were diagnosed with dementia.  Out of those diagnosed with dementia, 1.02 million adults (26.95%) were on potentially inappropriate anticholinergic medications.  The analysis was then further broken down to examine the percentage of patients with dementia over 65 years old who were also diagnosed with either mood disorders (17%) or anxiety (15%).  The conclusion drawn included that those with mood disorders or anxiety had an increased chance of inappropriate anticholinergic medication use, while those 75 to 84 years old had a decreased risk.

The most frequently found medication that could possibly cause inappropriate anticholinergic medication use, according to American Geriatrics Society Beers criteria, was oxybutynin.  Oxybutynin had been found to be the inappropriate medication 16.8% of the time, while solifenacin closely followed at 16.6%.  Some of the other medications often found were paroxetine, tolterodine, promethazine, and cyclobenzaprine.  The geriatric population with dementia already has an increased sensitivity to anticholinergic activity, and therefore this article recommends that anticholinergic medications should be minimized or avoided completely if possible.

Overall, this is an important article because we, as future pharmacists, have to be aware, and stay alert for recommendations such as the avoidance/minimization of the use of anticholinergic medications in dementia patients.  With the geriatric population on the rise, how could studies like this impact pharmacy medication interaction screenings?

J Am Pharm Assoc. 2015;55(6):603-612.