Pharmacy Division Ramathibodi Hospital


Interesting Articles in 2001 Jan - Jul

May 2001 (Volume 21, Number 5)

Cost-Effectiveness of Ceftazidime by Continuous Infusion Versus Intermittent Infusion for Nosocomial Pneumonia

McNabb JJ, Nightingale CH, Quintiliani R, et al.
Pharmacotherapy. 2001;21:549-555

Nosocomial pneumonia is associated with increased costs and length of stay in hospitalized patients. This prospective, open-label, randomized trial evaluated the cost-effectiveness and efficacy of continuous-infusion ceftazidime compared with intermittent ceftazidime infusion in the treatment of nosocomial pneumonia. Patients were eligible for the study if they had been in the intensive care unit (ICU) for at least 72 hours prior to the diagnosis of suspected bacterial pneumonia. Patients were randomized to receive either ceftazidime 3 g/d by continuous infusion or 1-2 g/d by intermittent infusion (3 times daily). All patients received once-daily intravenous tobramycin.

Data from 35 patients were included in the analysis. Clinical cure was defined as a resolution of all signs and symptoms of pneumonia and a lack of progression of abnormalities on chest x-ray. Four clinical failures occurred; 1 patient had received continuous infusion and 3 had received intermittent infusion. Additional antibiotics were given to these patients, and the expense of the antibiotics was factored into the cost analysis. Pharmacoeconomic analysis revealed that continuous-infusion administration of ceftazidime was the most cost-effective method of delivery in the treatment of nosocomial pneumonia in ICU patients.

Editor's Comment:

Healthcare costs continue to be an important issue in today's medical environment. Pharmacoeconomic studies that take into consideration efficacy as well as costs are important contributions to the literature. This study provides data substantiating a method of antibiotic delivery that differs from the standard of practice and is both cost-effective and therapeutically effective.

The Annals of Pharmacotherapy
May 2001 (Volume 35, Number 5)

Medication Adherence in Elderly Patients Receiving Home Health Services Following Hospital Discharge

Gray SL, Mahoney JE, Blough DK
Ann Pharmacother. 2001;35:539-545

Although risk factors for patient nonadherence to prescribed medications have previously been described, studies evaluating patient nonadherence following hospital discharge have yielded inconsistent results. This study was designed to describe the prevalence of patient over- and underadherence as well as to identify factors associated with those behaviors.

A prospective, cohort study of patients discharged from the hospital and receiving home healthcare services was used to meet the study objectives. Following hospital discharge, a trained clinician met with each patient within 5 days to collect demographic information, conduct a Mini-Mental Status Examination, and assess activities of daily living. To measure compliance, medications were reviewed for agreement with discharge orders and counts of medications were conducted. Patients were interviewed again 2 weeks after discharge to reassess compliance. A total of 147 patients completed the 2-week study period.

Participants in this study were prescribed 9.3 +/- 3.1 medications after hospitalization. Twenty-six patients were identified as having poor cognition; 15 of these patients reported self-administration of medications. Overall mean adherence was 95% +/- 15%. Sixty-four patients (44%) were under- or overadherent with at least 1 of their medications; underadherence was more common than overadherence. The total number of medications and poor cognition contributed to the risk factor for underadherence. Overadherence was associated with cognitive impairment and an educational background of 8th-grade level or less.

Editor's Comment:

Adherence to prescribed medication regimens is a complex issue. Many studies have tried to identify specific risk factors that clinicians can use to identify patients who are at risk for nonadherence. Although this study was small and not without limitations, it confirms earlier findings that the number of medications and cognitive status are risk factors for patient nonadherence. Healthcare professionals can target interventions toward patients with these risk factors to prevent nonadherence. Continued research in this field is needed to add to our understanding of this complex behavior.

Hospital Pharmacy
May 2001 (Volume 36, Number 5)

National Program for Medication Error Reporting and Benchmarking: Experience With MedMARx

Phillips MAS
Hosp Pharm. 2001;36:509-513

Increasing focus on medication errors has led to the development of an Internet-based medication error reporting system. The system is based on a standardized taxonomy for medication errors developed by the National Coordinating Council for Medication Error Reporting and Prevention. This article describes one institution's experience participating in the pilot program for the reporting system.

Prior to participation in the pilot program, the institution had an active multidisciplinary Medication Error Prevention Committee. This committee reviewed errors that had occurred and looked for trends and opportunities for improvement. It also provided staff education and looked for ways to increase reporting of actual errors and potential errors. Increased reporting resulted in an increased amount of time spent on database management and data entry.

Participation in the Internet-based reporting program simplified database management. Local software support needs have been minimal. The author found the program easy to use and responsive to changes. Although actual benchmarking data cannot yet be obtained because of small participation numbers, it is possible to review trends in medication errors from other hospitals. Ninety-five percent of errors reported have not resulted in patient harm but can still be used to direct quality improvement efforts.

Editor's Comment:

In today's day and age, it is no longer acceptable to know only about errors that have occurred in one single institution. Awareness of problems that have occurred nationally will be needed to direct efforts at avoiding situations that could cause patient harm. National databases such as this one will help individual organizations recognize potential problems before they actually occur. Utilizing a program such as this will minimize the workload that relates to database management, providing more manpower to actually evaluate data trends and design system improvements aimed at preventing errors.

Journal of the American Pharmaceutical Association
May/June 2001 (Volume 32, Number 3)

Onset of Illegal Use of Mind-Altering or Potentially Addictive Prescription Drugs Among Pharmacists

Dabney DA
J Am Pharm Assoc. 2001;41:392-400

Unauthorized use of mind-altering or potentially addictive prescription drugs (PAPDs) can be a problem among pharmacists. Studies have been conducted to estimate the prevalence of the problem among practicing pharmacists. In this study, the author attempts to define when these activities occur and what social factors contribute to this type of pharmacist behavior.

Pharmacists were identified using strict criteria from a national pharmacy organization database. Questionnaires were mailed to 2036 pharmacists and were successfully received by 2025. and included questions regarding demographics and career progression, as well as attitudes, understanding, and involvement with PAPDs.

A total of 1016 surveys were returned yielding a response rate of 50.2%. Unauthorized use of PAPDs was reported by 39.5% of the sample at some point in their lives. Moderate use (5-10 lifetime episodes) was reported by 14.2% of pharmacists and 6% reported high use (11 or more lifetime episodes). Diversion from the place of employment was common among the survey respondents indicating unauthorized use of PAPDs; 61.4% reported obtaining the drugs from their place of work. Most of the respondents report that the use of PAPDs occurred after they began their pharmacist training and 88% reported that the episode occurred after they had entered college. Social factors such as peer reinforcement and approval of self-medication also contributed to the unauthorized use of PAPDs.

Editor's Comment:

It is a recognized phenomenon that persons in the medical professions with access to prescription medications are at an increased risk for using those medications illegally. Despite this knowledge, healthcare curricula do not often address this issue and education on the subject is often lacking. This study provides insight into the timing of experimentation with the unauthorized use of prescription medications that indicates a need for educational interventions from the college level forward.

American Journal of Health-System Pharmacy
June 2001 (Volume 58, Number 11)

Changes in Home Care Accreditation: Enhancing Patient Care at Alternative Sites

Rich DS
Am J Health-Syst Pharm. 2001;58:1036-1038

In this commentary, the author discusses the impact of changes affecting the accreditation of home care pharmacies, long-term care pharmacies, and ambulatory care pharmacies. The changes result from the inclusion of freestanding ambulatory infusion centers. Program administered by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As a result, 1 set of standards, rather than 3, will now need to be met during a JCAHO accreditation survey. Changes in the eligibility definitions and reasons for the changes are outlined in this article. Ultimately, JCAHO hopes that the changes will improve patient care and support continued high-quality clinical services.

The Annals of Pharmacotherapy
July/August 2001 (Volume 35, Number 7/8)

Pharmacists' Attitudes Toward Diabetes and Their Involvement in Diabetes Education

Younis WS, Campbell S, Slack MK
Ann Pharmacother. 2001;35:841-845

A tool designed to measure the attitudes of health professionals toward diabetes and therapy for diabetes was introduced in 1989 (Diabetes Attitude Scale [DAS]). Since that time, many studies have been conducted using this tool. Use of the DAS has revealed that the existence of mixed attitudes among health professionals may relay conflicting messages to patients. However, none of these studies included pharmacists. Since pharmacists are important members of the diabetes care team, this study was designed to describe the attitudes of community pharmacists toward diabetes. In addition, the study's purpose included describing the level of involvement of community pharmacists in diabetes patient education and then looking for a link between attitude and involvement.

A cover letter, the survey, and a postage-paid envelope were sent to 749 pharmacists practicing in Arizona. The survey consisted of demographic questions, the DAS, and questions aimed at measuring the pharmacists' involvement in diabetes patient education. Response rate was 31% (229 surveys returned). Ninety-three were included in the study; the remainder were either incomplete or were returned undeliverable.

A significant proportion of the survey respondents had a positive attitude toward diabetes education, P < .01. Pharmacists were in favor of the team approach to care, understood the need for tight glycemic control, and recognized the preference for diabetes education in an outpatient setting (P < .001 for all). Basic diabetes patient education was provided by a majority of respondents (52%). Smaller populations provided either intermediate or advanced patient education (26% and 27%, respectively). A regression analysis revealed a negative correlation between pharmacists' attitudes toward diabetes and its treatment and their involvement in patient education (P < .05).

Editor's Comment

This study suggests that knowledge is not always translated into action. Pharmacists responding to this survey did consider diabetes to be a treatable disease, yet many of them did not provide patient education. Barriers to provision of patient care were not discussed, and it is likely that they would include time, privacy area, and comfort with counseling, as has been identified in other disease management programs. This study is an example of yet one more opportunity begging to be realized for pharmacists who are willing to address their own barriers to diabetes patient education.


Related Resource Center:
-- Diabetes Complications

Hospital Pharmacy
July 2001 (Volume 36, Number 7)

Process Improvements to Decrease Pharmacy Turnaround Time

Kilsdonk GF, Henke LW, Perley DL
Hosp Pharm. 2001;36:750-752

Staffing shortages and low staff morale are issues that face many hospital pharmacy departments. In a 450-bed not-for-profit hospital, these issues had an impact on one of the indicators used in the hospital's quality improvement program: turnaround time for medications. Members of the pharmacy department established turnaround time goals for new routine orders, "now" doses, and "stat" medications.

A new director of pharmacy was hired who interviewed every member of the department individually. Using the information gained during these interviews, the management staff drafted department goals and shared them with staff members during staff meetings. As a result, the drug distribution system within the hospital underwent significant study and modification over the next 18 months. Pharmacy staff decentralized 10 hours a day, 5 days a week, in addition to changes within the pharmacy itself. A Pharmacy-Nursing Committee was formed to improve relations between the 2 departments. Efforts to recruit new pharmacy staff were increased and salary improvements were implemented.

Prior to the improvements, the measurement of pharmacy turnaround times was conducted sporadically. The Pharmacy Department implemented its own internal, continuous measurement. The results of the time studies were plotted and posted for review by staff on a regular basis. Prior to implementation of the process improvement, turnaround time ranged from 80 to 147 minutes. Following implementation of the changes, turnaround time improved, ranging from 26 to 33 minutes.

Editor's Comment

The dramatic results that this department was able to realize with minimal increases in computerization demonstrate the power of communication and involvement. Including members of the organization who actually perform the functions is often the key to getting the most out of improvements in the process. Also, interdepartmental committees and decentralization efforts increase the face-to-face time between pharmacy staff and the staff of other departments, thus leading to improvements in interdepartmental communication.

Journal of the American Pharmaceutical Association
July/August 2001 (Volume 41, Number 4)

Comparison of German St. John's Wort Products According to Hyperforin and Total Hypericin Content

Wurglics M, Westerhoff K, Kaunzinger A, et al.
J Am Pharm Assoc. 2001;41:560-566

The popularity and overall acceptance of using St. John's wort to treat mild-to-moderate depression has increased over the past several years, both in the United States and in Germany. All of the active components of St. John's wort have yet to be identified, although hyperforin has antidepressant activity, and it appears that hypericin also contributes to its effectiveness in the treatment of depression. This study was performed in an attempt to assess the dose-to-dose reproducibility and interchangeability of 8 St. John's wort products currently available in Germany.

Each of the 8 products was tested for hyperforin content via high-performance lipid chromatography and for hypericin content using polarography. Five batches of each product were tested and 10 tablets/capsules from each batch were tested.

The German monograph for St. John's wort states that the hyperforin content should be at least 3%. Only 1 of the 8 products tested had a hyperforin content of 3%. The majority of the remaining products had hyperforin content between 2% and 3%; 1 product tested below 2% and 1 product below 0.2%. The total hypericin content of the samples also differed, ranging from less than 0.2% to greater than 0.3%.

The batch-to-batch differences varied among the tested products. One product had a coefficient of variation (CV) of less than 4%. The majority of the other products tested had a CV of between 20% and 25%, with 1 product having a CV that was 70%. The hypericin content showed less batch-to-batch variability; 7 out of 8 products tested had a CV of less than 20%. Based on the manufacturer's recommended dosing and the tested content of the products, daily doses of hyperforin could range from less than 0.5 mg/day to 16.52 mg/day.

Editor's Comment

Because of strict FDA manufacturing guidelines, healthcare consumers are used to medication dosing that is relatively precise. For many herbal remedies, the precise compound that confers efficacy is unknown, and it is likely that it is a combination of ingredients that are responsible for pharmacologic effects in a specific disease state. Despite the fact that this study was conducted using German-marketed products, this study highlights the need for increased regulation of the herbals market. Patients switching products could experience a relapse or increased adverse effects and be unable to identify the source of the problem. It is important to keep these issues in the lay press to raise patient awareness and to increase the pressure on the government to regulate this industry.


Related Resource Center:
-- Toxicology

Related Articles:
-- Regulatory and Ethical Issues with Dietary Supplements
-- St John's Wort: A Hidden Risk for Transplant Patients
-- Phytopharmaceuticals: Problems, Limitations, and Solutions
-- St John's Wort for Depression
-- Product Definition Deficiencies in Clinical Studies of Herbal Medicines

Journal of Managed Care Pharmacy
July/August 2001 (Volume 7, Number 4)

Evaluating Asthma Medication Use Before and After an Acute Asthma-Related Event

Lee JH, Cassard SD, Dans PE, et al.
J Managed Care Pharm. 2001;7:303-308

In the managed care setting, disease states are often evaluated using pharmacy and medical claims data. Asthma is one of the diseases often targeted in these evaluations. Examinations of these data sets have been used to estimate patient compliance and characterize prescribing behaviors. This study used pharmacy claims data to evaluate the utilization patterns of patients with asthma before and after an emergency room visit or hospitalization for asthma.

This was an observational, retrospective pilot study. Pharmacy claims for beta-2 agonists and inhaled anti-inflammatory medications for patients between the ages of 1 and 60 years enrolled in a preferred provider organization were analyzed. Medical claims for a primary or secondary diagnosis of asthma were used in the analysis. Claims reviewed were submitted over a 21-month period. The acute event was identified as time zero, the pre-event period was designated as the 90 days prior to the event, and the post-event period was designated as the 90 days following the acute event.

A total of 83 members met both the inclusion and exclusion criteria for the study and were included in the analysis. The percentage of patients receiving a prescription for a short-acting beta-agonist was higher in the post-event period (86%) than in the pre-event period (71%). Only 35% of patients evaluated were on an inhaled anti-inflammatory medication following an acute event.

Editor's Comment

The dates included in this study were prior to the release of the updated 1997 guidelines for the management of asthma. These guidelines were instrumental in shifting the focus of asthma management from acute event treatment to the use of chronic anti-inflammatory therapies aimed at preventing acute episodes. It would be interesting to repeat this study now that the guidelines have been in existence for 4 years to determine the impact of the guidelines on the management of asthma. Nonetheless, the study provides reminders that therapy for many chronic diseases is not yet optimal.

Related Resource Center:
-- Asthma Diagnosis and Treatment

July 2001 (Volume 21, Number 7)

Patient-Reported Adherence to Guidelines of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Cheng JWM, Kalis MM, Feifer S
Pharmacotherapy. 2001;21:828-841

Hypertension is linked to significant morbidity and mortality. The prevalence of hypertension increases with advanced age, and many people with hypertension are either unaware of it or have not achieved optimal blood pressure control. The latest guidelines for the management of high blood pressure were released in 1997, the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). This prospective, open-label study was designed to evaluate the impact of the JNC VI guidelines on hypertension management and drug-prescribing patterns.

The study enrolled adult patients who filled prescriptions for antihypertensive agents at community pharmacies in a university-based clerkship training program. Fifth-year pharmacy students collected study data. The hypertensive therapies of the study participants were compared to JNC VI recommendations. Eight hundred twenty-one patients participated in the study. The average patient age was 62 +/- 14 years. Most patients were white and had at least 1 cardiovascular risk factor in addition to hypertension. Prescriptions were paid for by a health maintenance organization, Medicare, or Medicaid in 70% of the patients. Internists managed hypertensive therapy in the majority of patients (71%). Approximately 40% of the patients had completed high school, and close to 40% had either graduated from college or completed graduate studies.

Angiotensin-converting enzyme (ACE) inhibitors, diuretics, beta-blockers, and calcium-channel blockers were the most frequently used antihypertensive agents. Blood pressure was controlled in 61% of participants at the time of the interview. Thirty-seven percent of patients reported always remembering to take their antihypertensive medication. Reasons for noncompliance included forgetfulness, belief that the drugs are unnecessary, and fear of drug dependence. During the study (conducted between September 1998 and December 1999), compliance with JNC VI guidelines decreased from 85% to 64%, P < .05.

Editor's Comment

Hypertension is a significant problem in the United States. The results of this study indicate a concerning number of patients who are not compliant with intended therapies. Cost and education are always important factors to consider in the evaluation of patient compliance. At least 70% of the patients in the study were eligible for some type of help with prescription coverage, but the associated copays can still be troublesome. The majority of patients in this study cited forgetfulness as a reason for noncompliance. Ways to help patients remember to take their medications need to be reinforced with each visit to the physician and pharmacy. As healthcare professionals we need to continue to support our patients and provide them with the education necessary to help them improve their healthcare outcomes.

Full text

Related articles:
-- Medication Adherence

The Consultant Pharmacist
July 2001 (Volume 16, Number 7)

A Retrospective Study of Adverse Drug Reactions Following Administration of Vaccines to Geriatric Nursing Facility Residents

Miller SW, Harris KL
Consult Pharm. 2001;16:664-667

Vaccines offer an effective means of preventing serious morbidity and mortality in the elderly. Despite this knowledge, the geriatric population is not adequately vaccinated. Even patients institutionalized for care do not receive routine vaccinations. The elderly patient is at risk for adverse drug reactions (ADRs) associated with vaccine administration because of altered organ function and multiple drug use. This study was designed to review the incidence and types of ADRs associated with vaccine administration to institutionalized elderly patients.

The study was designed as a retrospective review of residents of nursing facilities. Elderly patients who had received the influenza, pneumococcal pneumonia, tetanus-diphtheria vaccines or any combination of these vaccines were included in the study. A total of 226 patient charts were reviewed over a 1-year period. The Naranjo algorithm was used to score identified ADRs. Two hundred patients met all inclusion criteria and were included in the analysis. The majority of patients received the influenza or pneumococcal vaccine, 88% and 64%, respectively.

In 113 cases (35.4%), a record of postvaccination monitoring was not found. Monitoring was completed more often for influenza vaccine recipients than for recipients of the pneumococcal vaccine (89.7% vs 37.8%). Only 25% of patients had a vaccination record or history included in their medical record. ADRs occurred in 2% of the study population; all of these ADRs occurred in recipients of the influenza vaccine. All reactions were considered possible as defined by the Naranjo scale.

Editor's Comment

Vaccine administration is associated with significant skepticism and fear at all age levels. Vaccines are generally safe and the risk/benefit profile is positive. The appropriate administration of vaccines can serve as an important public health measure. Yet, vaccination rates continue to fall short of the mark in the United States. There continues to be a void in this public health service; pharmacists could be instrumental in the resolution of the problem. Pharmacists can serve as advocates for vaccine administration and aid in the maintenance of much needed patient vaccine histories.

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Related Resource Centers:
-- Medication Errors/Adverse Drug Reactions
-- Toxicology
-- Vaccines: Facing Patients' Concerns

Related Articles:
-- Pharmacists and Immunizations: A National Survey
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