Objective To review current literature reporting outcomes associated with utilization of the Medication Regimen Complexity Index (MRCI) with older adults in an outpatient setting. Data sources The National Library of Medicine via PubMed, International Pharmaceutical Abstracts, and the Cochrane Database were used to identify clinical trials evaluating outcomes associated with utilization of the MRCI. The medical subject heading terms "geriatrics" and "medication adherence" were used in combination with key terms "medication regimen complexity index" and "medication complexity." Study selection/data extraction Seventy-five articles met the search criteria and were reviewed. Studies were included if they had MRCI-related outcomes and were performed in patients 60 years of age and older in an outpatient setting. Eleven articles met the stated criteria. Data synthesis Higher MRCI scores may be associated with increased mortality rates, medication nonadherence, and unplanned hospitalizations; however, when compared with medication number, MRCI did not better predict increased medication nonadherence and unplanned hospitalizations. Conclusion The MRCI is a useful tool to determine medication complexity; however, current literature is limited by its observational design. Also, MRCI does not take into account potential factors such as high-risk medications and comorbid conditions, which may affect MRCI scores; therefore, additional trials are warranted before suggesting pharmacists implement this tool in their everyday practice.
This case reports on a patient whose International Normalized Ratio (INR) increased after ingestion of cranberry sauce while stabilized on warfarin. It is followed by a review of the published literature on the potential interaction between the two.An 85-year-old woman on chronic warfarin therapy for atrial fibrillation experienced INR elevations of two- to three-fold after two separate ingestions of cranberry sauce. In each case, her INR values decreased after withholding three to four doses and resuming a similar maintenance dose of warfarin. Although the majority of the pharmacokinetic and pharmacodynamic studies did not find a significant interaction between cranberry and warfarin, several case reports indicate that cranberry products may increase INR values in patients on warfarin. Practitioners should consider cranberry usage as a potential contributor in the evaluation of supratherapeutic INR values in patients on warfarin.
Hypoglycemia in the older population is a significant problem accounting for increased hospitalizations, emergency room visits, health care costs, and decreased quality of life. Older patients are more susceptible to hypoglycemia because of the increased prevalence of comorbidities requiring multiple medications, age-related physiologic changes, and a progressive decline in health. Older patients are less likely to present with symptoms of hypoglycemia and symptoms may frequently appear at a lower threshold of blood glucose than in younger patients. Consequently, preventing and treating hyperglycemia in older patients can be challenging. If mismanaged, the impact of hypoglycemia in these patients can lead to acute and chronic negative outcomes. Insulin and sulfonylureas should be closely monitored, and deprescribing should be routinely considered in older patients at high risk for hypoglycemia.
Objective: The objective was to utilize an Objective Structured Clinical Examination (OSCE) for assessment of pharmacy residents. Innovation: Post-graduate year 1 (PGY1) and post-graduate year 2 (PGY2) pharmacy residents completing multiple, local residency programs were invited to participate in an OSCE. A total of eight PGY1 residents and one PGY2 resident completed the OSCE. American Society of Health-System Pharmacists (ASHP) residency program goals were aligned for each case, which were originally developed for a fourth-year pharmacy student OSCE. Station design included outpatient and inpatient settings with patient and physician interactions. Median communication and clinical skills scores were evaluated. Critical Analysis: The OSCE allows for assessment of all residents on common scenarios. Pharmacy residents met competency requirements and demonstrated excellent communication skills. The OSCE was able to evaluate both physician-pharmacist communication and patient-pharmacist communication. Baseline performance related to the ASHP goals and objectives was not completed; however, the OSCE could highlight resident strengths and weaknesses in communication and clinical skills. The OSCE could simulate independent practice, may reduce bias, and could provide an evaluation of the resident by a patient. However, the OSCE incurs higher resource utilization, specifically monetary and time, than other assessment methods. Next Steps: The pilot study results provide a beginning for further study of OSCEs for pharmacy residents. Further study should include surveying the residency directors about use of the OSCE, a comparison of performance between the OSCE and preceptor evaluations of residents on ASHP goals and objectives, and an evaluation of OSCE implementation at different time points within the residency. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties Type: Note
H ealth care teams with a focus on patientcentered coordinated care can assist patients to make changes in health. These changes can lead to improved outcomes associated with chronic disease, such as diabetes, as demonstrated in several studies. 1-3 Barcelo and colleagues 1 compared an intensive diabetes program to usual care and the effect on A1C in 10 clinics in Mexico for a total of 307 patients. The program included training of the health care providers, cross-consultations with specialists, and case managers. The intervention group's A1C lowered from 8.4% to 7.9% (P < .01) compared to the usual care group's A1C lowering from 8.7% to 8.6% (P = .80). 1 Janson and colleagues 2 created an interprofessional team of primary care internal medicine residents, nurse practitioner students, and pharmacy students to improve the care of 384 patients with type 2 diabetes. The team received training on how to work in interprofessional teams and the Improving Chronic Illness Care (ICIC) model. The patients who received care from the interprofessional team received improved quality of care with more assessments and visits than the patients who received routine care provided by the internal medicine residents. There was a statistically significant difference in frequency of A1C assessments comparing the patients receiving care from the interprofessional team versus the internal medicine residents (79% vs 67%, P = .01). 2 Taylor and colleagues 3 created a crew management resource intervention to improve adherence to evidence-based diabetes standards of care and patient outcomes. The intervention included standardized communication methods with daily briefings and checklist development utilized for 619patients. Statistically significant improvement in adherence to diabetes process measures was found (75.23% to 82.09%, P < .001). There was an improvement seen in patient outcomes, but it was not statistically significant (42.96% to 45.34%, P = .079). 3
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