CPS Utilization Differences between Patients Living in Rural and Urban Areas

In this study the utilization of clinical pharmacy services (CPS) was examined and compared between people living in urban and rural areas. They also looked at what kinds of sites the patients were receiving their primary care from whether it be medical centers, urban community based outpatient clinics (CBOC) or rural CBOC were all kept track of.

Patients taking medications regularly and receiving primary care services at the veteran’s health administration (VHA), other medical centers, and CBOCs (urban and rural) were evaluated for their likelihood of CPS utilization. The site at which the patients received their primary care would be classified as either rural or urban. In addition this study looked at these sites in different regions of the United States attempting to see if any disparity was present (or more prevalent) in one U.S. region than another. The researchers in this investigation looked at how many CPSs were utilized by patients in each group in 2011. Specific CPS encounters were also evaluated such as “the patient was being seen in regards to anticoagulation medication,” etc. as well as mode of delivery as some of the patients would be counseled over a video form of communication.

The results showed that patients were more likely to make CPS visits if they were visiting an urban clinic. Overall patients living in rural areas were 35% less likely to receive a CPS than patients living in an urban area. This stayed true across regions throughout the U.S. There were a few possible explanations for this besides that of geography and ease with which commuting may have come to the patient. Proposed explanations included the availability of pharmacists in areas close to these community outpatient clinics. Physicians operating in areas close to large medical centers will be more likely to refer a patient to a pharmacist for CPS than a physician in a small town in a rural area – where there may be fairly reduced access to clinical pharmacists. Also it is likely that the patients living in rural areas may choose to go to urban medical centers anyway since they are in need of a greater variety of medical services.

This study illustrated the disparity between rural and urban living patients in terms of access to CPS. A proposed solution to this problem acknowledged by the authors of this article is the implementation of Telehealth services which accounted for almost one half of the documented CPS encounters counted in the study. Another solution is the implementation of patient-aligned care teams (PACT). In this system one pharmacist is assigned to 3-5 primary care providers covering an overall panel of 5,000 patients. These proposed improvements will themselves require research in determining their effectiveness in reduction in geographical disparity in terms of CPS access.

Reference

Patterson B, Kaboli P, Tubbs T, Alexander B, Lund B. Rural access to clinical pharmacies. Journ Am Pharm Assoc. 2014; 54(5): 518-25

Journ Am Pharm Assoc. 2014; 54(5): 518-25

Pharmacist Role in Counseling on Preconception Health

As accessible health care providers, pharmacists have a unique opportunity to improve preconception health in women which can lead to overall improved pregnancy outcomes. If women are thinking about conceiving a baby, it is important that they are counseled on prenatal supplementation and vaccinations. The information that a pharmacist can provide can help the woman make informed decisions about their lifestyle.

Screening for immunizations for measles, mumps, rubella, varicella, human papillomavirus, hepatitis A, and hepatitis B should all be recommended for women thinking about conceiving since they may have harmful effects on the developing fetus after conception. Not all vaccinations are off limits however. Inactivated influenza virus and tetanus, diphtheria, and pertussis vaccinations are recommended) even if the woman is pregnant (regardless of trimester) and should not pose a risk to the fetus. Moreover, contraction of influenza may cause problems for the baby. Influenza contraction in the first trimester gives rise to higher incidence of schizophrenia in the child. Contraction of the virus in the second and third trimesters poses more risk for the mother as breathing is impaired and the fetus is applying pressure on the mother’s diaphragm and lungs.

Counseling the woman on supplementation of folic acid may also lead to improved pregnancy outcomes as this B vitamin has been shown to improve optimal birth outcomes and neural tube development. Deficiency of this vitamin may result in spina bifida, a condition in which the spine does not close properly which can result in paralysis or mental retardation. It can also result in anencephaly or the case in which the brain does not form altogether. Since these events occur in the developing fetus within the first 28 days, it is important that the woman supplements this ahead of time.

Pharmacists have a role in helping educate people about medication day to day. However this role may be all the more important when discussing good preconception habits with women. This is a situation that there is a good chance that they have not been in before and since the development of the fetus is so fragile, it is important to make sure that they are getting all of the information correct in order to improve the likelihood of optimal birth outcomes.

Reference

El-Ibiary S, Raney E, Moos M. The pharmacist’s role in preconception health. J Am Pharm Assoc. 2014; 54(5): 288-303

J Am Pharm Assoc. 2014; 54(5): 288-303

Use of Fenugreek in Maintenance of Type II Diabetes Mellitus

As the industry in production of these natural supplements grows, there are more questions being raised about their effectiveness and different uses. Since there is not a ton of literature that supports their efficacy, it is difficult on the part of the pharmacist to recommend these with any sort of confidence. Here fenugreek was evaluated for its use in assisting with maintenance of type II diabetes mellitus (T2DM).

Fenugreek has already been used in foreign countries in patients with uncontrolled blood glucose levels. It is thought to work by delaying gastric emptying, slow carbohydrate absorption, and act to increase insulin sensitivity in tissues. The fenugreek seeds increase glucose dependent insulin secretion. It does have issues with blood thinning and may cause hypokalemia. It may decrease the absorption of some medications since it is rich in fiber, thus its use should be spaced out by at least 2 hours from other medications.

There have been mixed results regarding its effectiveness in treatment of T2DM. One study showed a significant decrease in A1C of 1.13% in use of the supplement over time while it did not show any effect on fasting blood glucose level. Another study did show a decrease in fasting levels of -0.96 mmol/L and 2 hour levels of -2.19 mmol/L. This study also showed a decrease in A1C of 0.85%.

Fenugreek was showed to be a supplement that may have some use in the maintenance of T2DM. However, there are definitely some reasons why not to recommend its use for this indication. The issue with its interference with the absorption of other orally administered medications could prove to be problematic in its usefulness since many of antidiabetic medications must be taken before meals. More studies are needed to determine its place in T2DM therapy but due to its ability to lower blood sugar, this should be encouraging to the scientific community to investigate more of these herbal supplements in an attempt to determine if they may have a place in modern medicine.

Reference

Smith J, Clinard V. Natural products for the management of type 2 diabetes mellitus and comorbid conditions. J Am Pharm Assoc. 2014; 54(5): 304-21

J Am Pharm Assoc. 2014; 54(5):304-21

Thiazide Diuretics in Treatment of Osteoporosis

The study discussed looked at the ability of thiazide diuretics to increase bone density. This is not an FDA labelled use but in theory the mechanism of action of the drug corresponds to increased calcium reabsorption (in the process of increasing sodium and water excretion). LaCroix and colleagues looked at its use in this manner.

The study looked at 205 women and 115 men all between the ages of 60 and 79 who were not antihypertensive nor did they have osteoporosis. A double blind study in which participants received a daily dose of 12.5 mg hydrochlorothiazide (HCTZ), 25 mg HCTZ or a placebo was used to evaluate this. They were to take their assigned medication once by mouth daily for three years. They would check in with monthly appointments to have their blood pressure monitored since the medication of course has an effect on lowering blood pressure. Also every 6 they would have their bone densities examined using an x-ray densitometer.

The results of this study showed a slight (but significant) difference in the change in bone density in the 25 mg group and the placebo group after 36 months. There was a greater reduction in bone density in the group that was taking the placebo than the other two groups, while there was not a significant difference in the reduction in bone density between the group taking the higher dose of HCTZ than the group taking the lower dose. While the 25 mg group had seen a 0.61% increase in bone density, the placebo group had seen 0.32% decrease in bone density.

The results of this study showed that hydrochlorothiazide could assist in slowing the reduction in bone density in older patients. It may not do this in a way that would make this medication an appropriate monotherapy; however it may have a place a adjunctive therapy alongside calcium/vitamin D supplementation and in more serious cases bisphosphonates.

Reference

LaCroix A, Ott S, Ichikawa L, et al. Low-dose hydrochlorothiazide and preservation of bone mineral. Ann Intern Med. 2000;133(7):516-26.

Ann Intern Med. 2000;133(&):516-26

Opioid Overdose Prevention

Here the role of the pharmacist as a key agent in the prevention of opioid overdose is discussed. Through counselling patients on points about safe opioid use and overdose prevention the pharmacists can stop some of these events from occurring at the time of pick up by the patient. These points may include disclaimers about dangerous drug cocktails such as combining benzodiazepines with opioids (as other drugs are found in the systems of most of those who die by opioid overdose. In addition to this the pharmacist can educate both the patients and the providers about naloxone, which in the case of most of the overdoses could prevent death as there is usually a witness to the overdose. Abuse deterrent formulas that prevent the snorting or injecting of these medications can also be considered here.

It should also be noted that pharmacists have a unique opportunity to identify patients as having a high risk factor for opioid overdose. These patients should especially be counselled on such points.

Although a pharmacist may not know everything about the patients that come into their pharmacies it is not uncommon for some information to be disclosed about previous struggles with these drugs since the pharmacist may see the patients much more frequently than the physicians. There are also clear records of drug dispensing from the particular pharmacy that the pharmacist works at that can allow the pharmacist to draw inferences about the patient’s use of these drugs. Furthermore, 49 states have a prescription drug monitoring program that allows the pharmacist to have access to information pertaining to prescriptions filled at multiple pharmacies.

Through educating patients on the risks associated with opioid dependence and overdose, pharmacists can play a part in reducing the number of these preventable injuries and deaths.

Reference

Bratberg J, McLaughlin B, Brewster S. Opioid overdose prevention. J Am Pharm Assoc. 2015; 55(5): 470-77.

J Am Pharm Assoc. 2015; 55(5): 470-477

New Drugs Used to Treat Hepatitis C

A little over two years ago two antiviral drugs were developed. Sofosbuvir and ledipasvir were combined in a formulation for an antiviral medication that is indicated in treating hepatitis C virus (HCV) genotype 1. HCV is known to exist in 6 major genotypes numbered as such. Last fall the drug was approved for treatment of HCV genotypes 4, 5, and 61.

Currently the third drug from this class is to enter the market. Daclatasvir dihydrochloride is a drug in this new class of antiviral medications which work by inhibiting Hepatitis C virus (HCV) NS5A, a protein that is required for viral replication. Only the third drug to be marketed in this class, daclatasvir is indicated alongside sofosbuvir to treat patients with chronic HCV genotype 3. This is the first proposed drug regimen used to treat HCV genotype 3 that does not contain another antiviral drug called ribavirin, a guanosine analog1.

The daclatasvir/sofosbuvir combination has shown to be effective in treating the virus as it exhibited a 98% sustained virologic response (SVR) in a 24 week trial in which the drug was administered to patients who had not been treated for the condition before. The drug has reduced effects in patients with cirrhosis of the liver (which is a common hindrance for other HCV drugs) as they showed a 58% SVR. Patients who had undergone treatment in the past had slightly different outcomes (92% in those without cirrhosis and 69% in those who did)1 Previous drug regimen had shown to have SVR rates ranging from 65-80% in patients without cirrhosis2. Thus, the effectiveness of the NS5A inhibitors may be the future of first line drug therapy in treating HCV.

References:

  1. Hussar, Daniel A., and Joellen Friedman. “Ceftazidime Pentahydrate/avibactam Sodium, Isavuconazonium Sulfate, and Daclatasvir Dihydrochloride.” J Am Pharm Assoc. 56.1 (2016): 100-03. Web.

    Journ Am Pharm Assoc. 2016; 56(1): 100-103

  2. Spach D. Treatment of HCV genoype 3. Hepatitis C Online. University of Washington, 27 Jan. 2016. Web. 9 Feb. 2016.

Novel and Expanded Role for the Pharmacy Technician

A CMS Health Care Innovations Award – funded care transitions program known as SafeMed has the goal of reducing hospital readmissions and overall healthcare cost through the optimization of drug therapy. In particular they focus on adherence to drug therapy in addition to the efficiency of the drug regimens being undertaken by patients who are taking multiple chronic conditions – much like what we would expect in a patient who is eligible for MTM services.

Hospital readmissions are common in these patients who have an abrupt transition from extensive medical oversight to being unmonitored in their homes. Here, SafeMed decided to expand the role of their pharmacy technicians having them follow up with these patients by giving the patients phone calls after they return home from their hospital stays. These technicians were put through a training program with teachings provided by a pharmacist with expertise in MTM and through their basic understanding of MTM services they were appointed to a role of identification of some drug therapy problems. The idea here is not to have a technician assume the role of a pharmacist but rather be a less expensive extra set of eyes which could help draw attention to problems that could then be more promptly resolved by the pharmacist.

More time would be needed to draw conclusions about the clinical outcomes surrounding this program. However, an increase in DTP pharmacist interventions did result from this method which intuitively should result in more effective outpatient treatment and less hospital readmissions resulting in less medical expenses, a parameter which is to be measured in follow up studying of this method. In addition, they aim to improve the education of these technicians which can provide a very useful arm for the pharmacists helping them spot the patients who could use their expertise most.

Reference

Bailey J. SafeMed: using pharmacy technicians in a novel role as community health workers to improve transitions of care.” J Am Pharm Assoc. 2016; 56(1): 73-81.

J Am Pharm Assoc. 2016; 56(1): 73-81

New Drug to Prevent Heart Failure

In the event of a myocardial infarction or another related episode concerning one’s cardiovascular health, it is common for an angiotensin converting enzyme inhibitor to be prescribed in addition to a beta adrenergic blocker, and a diuretic or aldosterone antagonist. In place of an ACE inhibitor an angiotensin II receptor blocker (ARB) may be prescribed. However, a new class of drug is being studied that may become an additional team player in the fight against cardiovascular disease.

Sacubitril is a prodrug which is converted to LBQ657 by esterases in the body. This metabolite is a neprilysin inhibitor. Neprilysin is an endopeptidase that can degrade peptides that are responsible for regulating actions in the blood vessels. This can lead to vasoconstriction and increased sodium retention. Thus, sacubitril would work to reduce vasoconstriction and sodium retention.

So far the formulation of this drug has been only in a form coupled with valsartan; it has not been administered as the single drug, sacubitril. It was administered to 8,400 patients with symptomatic heart failure and a left ventricle ejection of 40% or lower. The patients involved had been treated with an ACE inhibitor and a beta adrenergic blocker for at least 4 weeks. Many of the patients were also taking a diuretic. The rate of cardiovascular deaths for those taking sacubitril was 13.3% which was considered significantly lower than that of those taking the ACE inhibitor, enalapril, which was 16.5%.

Thus there is reason to believe that sacubitril, and other drugs from this class of neprilysin inhibitors, may account for a new model of first line drug therapy in the treatment of cardiovascular disease.

Reference

Hussar D, Abdelsayed M. Sacubitril/valsartan, ivabradine hydrochloride, alirocumab, and evolocumab. Journ Am Pharm Assoc. 2015; 55(6): 674-78.

J Am Pharm Assoc. 2016; 55(6): 674-678