Computerized Decision Support Improves Medication Review Effectiveness: An Experiment Evaluating the STRIP Assistant’s Usability

When physicians prescribe medications to patients with certain disease states, there is no way of determining whether the medication that is being prescribed will work for the patient. For example, obtaining adequate control of chronic disease states may involve a process of testing different medications on a patient until one can be deemed as an appropriate treatment option. There are different programs that have been established in the past to provide aid to physicians looking to initiate therapy options on a patient; however, they have not been proven to cause changes in care that lead to clinically significant improvement. For this reason, a new tool referred to as STRIP (Systemic Tool to Reduce Inappropriate prescribing) has been developed to optimize the prescribing process by conducting medication reviews in the primary care setting. This program is a computer-based technology that allows physicians to analyze patients medication histories and preferences to determine the best form of therapy.

In this study, 42 physicians were asked to optimize medical records of patients utilizing multiple medications by both the traditional manner and by the STRIP analysis. Utilization of the STRIP assistance program was linked to an increase in the number of appropriate medication decisions (to 76% from 58% without). Along with this, physicians on average spent more time meeting with patients and discussing treatment options using the program. The only major negative result gathered from the study was the fact that it received a below-average score by physicians examining the usability of the system. Therefore, the STRIP assistance program was determined to be an effective tool for providing medication reviews.

I believe this study is important because it shows how one of the main roles of a pharmacist (providing medication reviews) benefits the overall experience that a patient will have with their medication. I believe having systems like this in place to aid physicians in the process of decision making will allow pharmacists to eventually become more active in the process of prescribing medications. This is something that I think is important due to the amount of knowledge that pharmacists have about medications. Optimization of prescribing methods will not only benefit the health of the individual receiving the medication, but it will also ensure that we are limiting the cost that adverse effects from drugs have on the health care system. I believe that the role of a pharmacist will only continue to expand over the next couple of decades, and as a result, the profession will be more respected by the public.

Challenges to Contraceptive Coverage in the Affordable Care Act

The Affordable Care Act (ACA) has been one of the most highly debated health care changes in recent years, with millions of people both for and against its legislation.  One of the most controversial topics in the act is the  provision that covers contraceptives for women covered by private insurance companies.  Many would argue that this is a long overdue step, and a basic right to women to control their risk of pregnancy.  Although the act has proven beneficial to many women, there are still a number of barriers to accessing appropriate methods of contraceptives for many women.  A recent article published in JAMA attempted to look at the challenges that still remain and explore potential solutions to these problems so that more women are able to have free access to the contraceptives that are best for them.

Under the ACA, women with privately covered health insurance have the right to access FDA approved methods of contraception, sterilization procedures, and counseling without any patient costs.  Already, it has shown to provide free contraceptives to millions of women who may have otherwise struggled to pay for the expenses themselves. However, this does not apply to medicare covered women, follow-up appointments or services, and management of any side effects from the contraceptive methods.  It also failed to cover emergency contraceptives, like Plan B, or any contraceptive methods for men like condoms and vasectomies.  Also, the new provisions are met with resistance from insurance companies who limit the options available without cost sharing, fail to cover contraceptive use with a medical indication besides preventing pregnancy, and fall short on covering many of the procedures and services that surround contraception use.  To compound the issue, there is remarkable confusion about appropriate billing codes by patients and physicians to ensure care coverage, and obtaining coverage for diagnostic costs and out-of-network care.  The article suggests that changes to the act are needed to better define what is covered and what is not billable under certain health care plans.  Also, attention is needed to ensure that insurance companies are compliant with the new laws and clear about their coverage.

This issue is very complex, and no solution to such a multifaceted problem will be quick or simple.  As future pharmacists, it would be beneficial to investigate the problem, its limitations, and ways to use the role of medication expert to help women navigate the system and get the care that they are entitled to.  Anyone who has worked in a community pharmacy understands the struggles with obtaining coverage from private insurance companies, and can sympathize with the barriers that exist to some women to get contraception that they need at a price they can all afford. I am sure there are ways that professionals from the pharmacy field can contribute to solving the gaps in the ACA contraception coverage, any ideas?

 

Article Link

Politi MC, Sonfield A, Madden T. Addressing Challenges to Implementation of the Contraceptive Coverage Guarantee of the Affordable Care Act. JAMA. Published online February 01, 2016. doi:10.1001/jama.2016.0204.

Improving Patients Primary Medication Adherence

Pharmacists across the globe face a key issue in their ability to provide patients with the tools that enable them to adhere to medication regimens. Increasing adherence to prescribed treatment options will help to improve the overall health outcomes of the patients that pharmacist’s are serving.  For this reason, research into the causes for non-adherence and its resulting issues is and will continue to be an area of high importance. The interest that I have in improving medication adherence led me to the article entitled improving Patients Primary Medication Adherence.

This article is focused around a study completed in a French hospital during the months of November 2010 to June 2011. The study, which included patients over the age of 18 that were admitted into the ITD (Infectious and Topical Disease) and the general medicine unit, was developed to determine if incorporating clinical pharmacy activities into the discharge process would decrease the amount of post-discharge adverse effects.  To assess the results of this study, medication adherence was determined by contacting the patients’ community pharmacists 7 days after discharge.  The study did not find a correlation between the rate of re-admittance and/or visits to emergency rooms, but patients who received extra counseling during discharge were more likely to be adherent to newly prescribed medications.  For this reason, the study supported the idea that adherence can be increased by providing discharge counseling sessions to patients.

I feel like this is an important study for us to consider as pharmacists because managing patient adherence to medication regimens is the most important role we play in improving health outcomes.  By improving adherence, we have the ability to lower the risk for serious adverse drug events which can lead to hospitalization.  For this reason, I believe that pharmacists should implement all activities that are proven to increase adherence to maximize the results of treatment options.  This article has left me wondering how similar programs to increase medication adherence can be implemented in community pharmacy settings.

Leguelinel-Blache G, Dubois F, Bouvet S, et al. Improving patient’s primary medication adherence: the value of pharmaceutical counseling. Med. 2015;94(41)

 

Community pharmacist screening for chronic kidney disease

The authors conducted this study as a part of the RxEACH study, which assesses reduction of cardiovascular risk intervention versus usual care as led by pharmacists. This part of the study analyzed pharmacists’ application of the CKD Clinical Pathway criteria (which is an online tool to aid practitioners in diagnosis and management of those with CKD) to screen their patients who are at risk for chronic kidney disease. CKD is defined as a reduction in kidney function with a GFR less than 60 mL/min/1.73m^2 or markers of kidney damage for more than 3 months. Markers of kidney damage includes albuminaria greater than 3 mg/mmol or any abnormalities in urine sediment or renal imaging. The pharmacists systematically identified patient based on their prescriptions (looking for oral hypoglycemic, antihypertensives, lipid-lowering, antiplatelet, and anticoagulants). They also checked the patient’s lab values. Once a patient iss eligible, the patient was screened based on serum creatinine, GFR, and urine albumin-to-creatinine for 12 months. Patients were categorized into the following: no CKD, known CKD, and unrecognized CKD. Of the 720 patients, 60% had known CKD. Forty percent of those with CKD had unrecognized CKD. Overall, the study identified a high number of unrecognized CKD patients, emphasizing the importance of expanding the pharmacist’s role to include laboratory testing and adjusting medication regimens according to those results. Because the study was conducted on patients with a high risk for cardiovascular disease, the results may be higher than in an otherwise healthy population.

Can Pharm J. 2016;149(1):13-17.
I think this study really shows the healthcare world just how important the role of the pharmacist is. We are more than just dispensers. We can optimize a patient’s medication regimen based on the health of their kidneys. Additionally, we can identify patients at risk for chronic kidney disease that a physician may otherwise not have diagnosed. In addition to screening patients for CKD, what other disease may a pharmacist be able to screen for? How can we as student pharmacists advocate for the expansion of the role of the pharmacist to include these screenings at all pharmacy locations?

Safer Use of Medications through Risk Evaluation and Mitigation Strategies

REMs or risk evaluation and mitigation strategies are a baseline of communication between drug and patient. The term itself is relatively new, but pharmacists have been practicing medication education since the beginning of practice. REMs are other wise known as risk minimization action places, because they are proposed to do exactly that. The purpose of REMs is to educate the patient on the medication they are taking to increase therapeutic benefit.

The FDA determines which medications go in certain risk categories and have different guidelines on how to ‘do’ the REMs. Most of the approves REMs are a handout that educates the patient on the medication and usually has some FAQs. Other medications may require verbal counseling to ensure the patient knowledgable on the medication they are about to take. Other high risk medications have iPledge and counseling with the pharmacist.

The goal of REMs is to minimize the risk to our patients and increase their therapeutic outcome through the use of different education strategies. Since pharmacists are at the center of patient and prescriber and patient and drug, it is our responsibility to ensure we are conducting necessary REMs. I believe that pharmacists will continue to play a bigger role in medication safety because of REMs, and that we have the ability to do so. As future pharmacist we need to be sure to give our patients all the information needed and answer any questions about medications to increase our patient’s therapeutic benefit. At my pharmacy, I always have information sheets printing out after the labels. I will be sure to always pass them along to be given to the patient.

 

Hennessy K., Williams K., Bongero D.
J Am Pharm Assoc (2003) 2010;50:556-562. doi:10.1331/JAPhA.2010.10532

Link to Article