Quality assessment and lipid management: considerations for computer databases for tracking patients

Use of electronic technologies to promote community and personal health for individuals unconnected to health care systems

Ensuring health care services for populations outside the mainstream health care system is challenging for all providers. But developing the health care infrastructure to better serve such unconnected individuals is critical to their health care status, to third-party payers, to overall cost savings in public health, and to reducing health disparities. Our increasingly sophisticated electronic technologies offer promising ways to more effectively engage this difficult to reach group and increase its access to health care resources. This process requires developing not only newer technologies but also collaboration between community leaders and health care providers to bring unconnected individuals into formal health care systems. We present three strategies to reach vulnerable groups, outline benefits and challenges, and provide examples of successful programs.

Exposure of Cells to Hydrogen Peroxide Can Increase the Intracellular Accumulation of Drugs

One of the fastest growing areas of scientific research involves aspects of oxidative stress, either causes of or results from. Despite the enormous quantity of literature on the topic, surprisingly, the effects of oxidative stress on the pharmacokinetics of drugs have not been previously investigated. This is an extremely important concern, considering that the degree of oxidative stress that the human body experiences is known to be widely variable. Oxidative stress may be transiently increased, as is the case with some inflammatory episodes, or it may be chronically elevated, as is the case in some disease states, in aging, or with smokers. This report examines the influence of oxidative stress on the pharmacokinetics of model drugs utilizing cells in culture. Specifically, the effect of subtoxic, short-term exposure to hydrogen peroxide was investigated. Low micromolar, single doses of hydrogen peroxide were shown to cause dramatic increases in the apparent intracellular accumulation of model compounds with different physicochemical properties in different cell types. To examine the mechanistic basis for this, we evaluated possible hydrogen peroxide induced changes in cells including (1) intracellular pH, (2) membrane integrity, and (3) membrane fluidity (i.e., lateral membrane diffusion). We found no significant changes in pH or membrane integrity, but results were consistent with changes in hydrogen peroxide mediated reductions in lateral membrane diffusion, which we postulate facilitated the accumulation of the test substrates. Although studies presented here were all done in cell culture systems, we believe the findings could have substantial therapeutic relevance and warrant further investigations, which may provide reasons why drugs often have anomalous pharmacokinetic behavior and disproportionate dose-response relationships in certain patient populations.

Development of a pharmacist-managed lipid clinic

OBJECTIVE

To describe the development of a pharmacist-managed lipid clinic within a primary care medical clinic and review its results after approximately 12 months of operation.

METHODS

A pharmacist-managed lipid clinic was developed at Naval Medical Center San Diego. Administrative background, treatment algorithm development, operational issues, clinical activities, and barriers to the clinic are discussed. For intermediate outcomes, data from patients who had at least 1 intervention by the pharmacist and 1 follow-up lipid panel were analyzed for medication use, changes in lipid parameters, and percent reaching the low-density-lipoprotein (LDL) target goal. Modified National Cholesterol Education Program-Adult Treatment Panel II guidelines were used to determine the LDL goal.

RESULTS

Following approximately 12 months of operation, the clinic received 204 referrals and consisted of 146 active patients. A brief study was conducted to assess clinical outcomes. Of 115 patients who were seen in the clinic and met inclusion criteria, 57% were receiving treatment with a hydroxymethylglutaryl coenzyme A reductase inhibitor (statin) and 17% were receiving fibrates; 17% of the patients were not receiving lipid-lowering medications. Relative to baseline, LDL cholesterol concentrations decreased 20%, high-density-lipoprotein cholesterol increased 11%, and triglycerides decreased 19%. Overall, LDL goals were reached in 77% of the patients. LDL goals were attained by 63%, 79%, and 93% of patients with targets of <100, <130, and <160 mg/dL, respectively. Results are compared with other studies regarding lipid goal attainment.

CONCLUSIONS

A pharmacist-managed lipid clinic can be developed and integrated into a primary care medical clinic. Pharmacists can effectively manage lipid-lowering therapy, helping to achieve LDL goals.