Background. An objective of pharmaceutical care is for pharmacists to improve patients' health-related quality of life (HRQOL) by optimizing medication therapy. Objectives. The objective of this study was to determine whether ambulatory care clinical pharmacists could affect HRQOL in veterans who were likely to experience a drug-related problem. Research Design. This was a 9-site, randomized, controlled trial involving Veterans Affairs Medical Centers (VAMCs). Patients were eligible if they met ≥3 criteria for being at high risk for drug-related problems. Enrolled patients were randomized to either usual medical care or usual medical care plus clinical pharmacist interventions. HRQOL was measured with the SF-36 questionnaire administered at baseline and at 6 and 12 months. Results. In total, 1,054 patients were enrolled; 523 were randomized to intervention, and 531 to control. After patient age, site, and chronic disease score were controlled for, the only domain that was significantly different between groups over time was the bodily pain scale, which converged to similar values at the end of the study. Patients' rating of the change in health status in the past 12 months was statistically different between groups, intervention patients declining less (−2.4 units) than control subjects (−6.3 units) (P <0.004). This difference was not considered clinically meaningful. However, a dose-response relationship was observed for general health perceptions (P = 0.004), vitality (P = 0.006), and change in health over the past year (P = 0.007). Conclusions. These results suggest that clinical pharmacists had no significant impact on HRQOL as measured by the SF-36 for veterans at high risk for medication-related problems.
Various findings of the Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers (IMPROVE) study are reviewed. Suggestions for future methodologies that will enhance this study are discussed. The IMPROVE study is one of the largest pharmaceutical care studies conducted. Although it was an intervention study that examined global outcomes following management by pharmacists, it was designed as an effectiveness study. Several new practice and research methods were developed, including a method to identify patients at high risk for drug-related problems utilizing pharmacy databases, a method to identify chronic diseases using pharmacy databases, a method to evaluate the structure and process for delivering pharmaceutical care in Veterans Affairs medical centers (VAMCs), and guidelines for providing care to patients in the IMPROVE study. Nine VAMCs participated in the study, and 1054 patients were randomized to either an intervention group (n = 523) or a control group (n = 531). Pharmacists documented a total of 1855 contacts with the intervention group patients and made 3048 therapy-specific interventions over the 12-month study period. There was no meaningful difference in patient satisfaction or quality of life in the two groups. Selected disease-specific indicators found an improved rate of measurement of hemoglobin A1c tests and better control of total and low-density-lipoprotein (LDL) cholesterol levels in the intervention group compared with the control group. Total health care costs increased in both groups over the 12-month period. The mean increase in costs in the intervention group was $1020, which was lower than the control group's value of $1313. The lessons learned from the IMPROVE study suggest to future investigators how to study and measure the effects of clinical pharmacy services on patient outcome.
An ongoing study of the impact of ambulatory care clinical pharmacists on patient outcomes at selected Veterans Affairs medical centers (VAMCs) is described. The IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) study will examine the effects of referring patients at high risk for drug-related problems to a pharmacist-managed monitoring program. Nine study sites from diverse geographic locations and small and large urban areas have been selected. Investigators visited each site to evaluate the structure of care, observe pharmacist-patient interactions, and assess the level and documentation of pharmacists' activities. A coordinating center will collect and process patient-specific data from the study sites to identify high-risk patients. It is expected that 500 intervention patients and 500 control patients from the nine VAMCs will complete all portions of the study. Intervention patients will be scheduled for medication assessments by ambulatory care pharmacists and will be monitored by pharmacists for at least 12 months. The coordinating center will track refill histories for intervention patients. Investigators will assess the activities performed by ambulatory care pharmacists to determine predictors of successful patient outcomes. The two groups will be compared with respect to change from baseline in quality of life and satisfaction with health care providers. A cost-benefit analysis will be undertaken to determine the impact of pharmaceutical care relative to total patient care costs. The main outcome results of the IMPROVE study are expected to be available in 1999. The IMPROVE project will be the first study of the impact of ambulatory care clinical pharmacists on patient outcomes.
Study Objective. To determine if clinical pharmacists could affect economic resource use and humanistic outcomes in an ambulatory, high‐risk population. Design. Prospective, randomized, controlled study. Setting. Nine Veterans Affairs medical centers. Patients. Patients who were at high risk for medication‐related problems. Intervention. Patients were randomized to usual medical care with input from a clinical pharmacist (intervention group) or just usual medical care (control group). Measurements and Main Results. Of 1054 patients enrolled, 523 were randomized to the intervention group and 531 to the control group. The number of clinic visits increased in the intervention group (p=0.003), but there was no difference in clinic costs. Mean increases in total health care costs were $1020 for the intervention group and $1313 for the control group (p=0.06). Conclusion. Including the cost of pharmacist interventions, overall health care expenditures were similar for patients randomized to see a clinical pharmacist versus usual medical care.
Journal Article Development of an antimicrobial formulary for a university teaching hospital system Get access J. Joseph Marr, M.D., J. Joseph Marr, M.D. Senior Vice President Searle Pharmaceuticals, Skokie, IL. At the time this article was written, he was Professor of Medicine and Biochemistry and Director, Division of Infectious Diseases, University of Colorado Health Sciences Center (UCHSC), Denver, CO Search for other works by this author on: Oxford Academic Google Scholar Kenneth F. Baum, Kenneth F. Baum Assistant Professor Department of Medicine UCHSC Search for other works by this author on: Oxford Academic Google Scholar Allen D. Chapman, M.S., Allen D. Chapman, M.S. Pharmacy Section manager Medical Program, Denver. At the time this article was written, he was Director of Pharmacy, University Hospital, Denver, CO Search for other works by this author on: Oxford Academic Google Scholar John M. Douglas, M.D., John M. Douglas, M.D. Assistant Professor Department of Medicine, UCHSA Search for other works by this author on: Oxford Academic Google Scholar Richard T. Ellison, III, M.D., Richard T. Ellison, III, M.D. Assistant Professor Department of Medical Department of Veterans Affairs Medical Center, Denver, and Department of Medical University of Colorado School of Medicine Search for other works by this author on: Oxford Academic Google Scholar Gerry W. Marman, Gerry W. Marman Chief Pharmacy service, Department of Veterans Affairs Medical Center, Denver Search for other works by this author on: Oxford Academic Google Scholar Daniel Perlman, M.D., Daniel Perlman, M.D. Instructor Division of Infectious Diseases, UCHSC Search for other works by this author on: Oxford Academic Google Scholar Harold E. Riley, M.S., Harold E. Riley, M.S. Director of Pharmacy Denver General Hospital Search for other works by this author on: Oxford Academic Google Scholar Charles D. Sintek, M.S., Charles D. Sintek, M.S. Clinical Manager Pharmacy Service Department of Veterans Affairs Medical Center Denver Search for other works by this author on: Oxford Academic Google Scholar Denise A. Woltemath Denise A. Woltemath Manager Pharmacy Department Comprecare, Aurora, CO At the time this article was written, she was Assistant Director, Pharmacy Development, University Hospital, UCHSC Search for other works by this author on: Oxford Academic Google Scholar American Journal of Hospital Pharmacy, Volume 49, Issue 6, 1 June 1992, Pages 1481–1484, https://doi.org/10.1093/ajhp/49.6.1481 Published: 01 June 1992
Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools. The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations.
A piroxicam-warfarin interaction is presented with a discussion of the possible mechanism of action. A 60-year-old white male on warfarin therapy for recurrent pulmonary embolism and deep venous thrombophlebitis showed a decrease in his previously therapeutic and stable prothrombin time when piroxicam was discontinued from his drug regimen. On two rechallenges over a ten-month period, his prothrombin times showed consistent and clinically significant fluctuations as piroxicam was added and deleted from his drug regimen.
