Teaching clinicians about drugs--50 years later, whose job is it?

Impact and feasibility of a pharmacist-delivered pharmacotherapy rotation on pediatric resident education

Pharmacotherapy training for pediatric residents is an important part of their overall education. Limited data exist describing formal engagement of clinical pharmacists in residency training. The objective of this study was to evaluate a novel pharmacotherapy rotation for learner gains and program feasibility. We designed a novel pharmacotherapy rotation (PTR) involving a pharmacist preceptor, pediatric resident, and final-year pharmacy students in the pediatric intensive care unit (PICU). Rotation objectives and content were based on learning gaps identified in a review of the resident curriculum. Data from PTRs completed 2014-2020 were used to evaluate PTR impact on residents' knowledge and confidence in pharmacotherapy decision-making, and interprofessional valuing. We also addressed PTR feasibility for long-term and for adoption by others. Measures for demographic, knowledge, and confidence measures were administered to intervention and control groups. Measures for interprofessional valuing and post-PTR feedback were administered only to the intervention group. Pre-post gains were greater for intervention residents (n = 7) than for control (n = 10), (knowledge: p = 0.02, confidence: p < 0.0001). Interprofessional valuing gain for the intervention group was significant (p = 0.004). Few PTR changes have been necessary since initial implementation. Residents provided high ratings of PTR experiences and specific value-added benefits. Designing an inter-professional PTR within the existing PICU and pharmacy rotation enhanced feasibility, curriculum consistency, and flexibility to optimize inter-professional learning.Participation in the PTR enhanced resident pharmacotherapy knowledge and decision-making, and engagement in interprofessional practice. Next steps include expanding the PTR to other settings and specialties with further evaluation study.

Learning from our mistakes: using key opportunities to remove the perverse incentives that help drive antibiotic resistance

Introduction: Governments need to do far more to help curb the emergence and transmission of antibiotic resistance and help protect the efficacy of any new antibiotics that come to the market. Industry is an important stakeholder that must be brought on-board such efforts given its influence on the direction and scale of antibiotic sales. Financial incentives supporting industry R&D of novel antibiotics should structurally remove the drivers of superfluous sales and encourage access to newer antibiotics where infections are otherwise resistant to treatment. Indeed, the use of public money provides an important opportunity to prioritize these public health goals within market structures such that we both adequately reward industry for their efforts and prolong antibiotic efficacy for as long as possible.Areas covered: This work discusses possible financial 'pull' incentives that fully delink the reward paid to the developer from unit sales, examining their primary advantages and limitations.Expert opinion: Pharmaceutical companies need to be rewarded generously for their efforts to develop new, badly needed antibiotics. But the current marketplace does not provide a sustained financial lure and its reliance on unit-sales for profitability jeopardizes the efficacy of antibiotics both new and old. Fully delinked models can make antibiotic R&D more financially appealing and create a market environment that is far less threatening to public health.

Post-marketing research and its outcome for novel anticancer agents approved by both the FDA and EMA between 2005 and 2010: A cross-sectional study

Post-marketing research in oncology has rarely been described. We aimed to characterize post-marketing trials for a consistent set of anticancer agents over a long period. We performed a cross-sectional analysis of post-marketing trials registered at ClinicalTrials.gov through September 2014 for novel anticancer agents approved by both the US Food and Drug Administration and the European Medicines Agency between 2005 and 2010. All relevant post-marketing trials were classified according to indication, primary outcome, starting date, sponsors, and planned enrollment. Supplemental indications were retrieved from regulatory documents and publication rate was assessed by two different methods. Ten novel anticancer agents were eligible: five were indicated for hematologic malignancies and the remaining five for solid cancers (three for kidney cancer). We identified 2,345 post-marketing trials; 1,362 (58.1%) targeted an indication other than the originally approved one. We observed extreme variations among drugs in both number of post-marketing trials (range 8-530) and overall population to be enrolled per trial (1-8,381). Post-marketing trials assessed almost all types of cancers, the three most frequently studied cancers being leukemia, kidney cancer and myeloma. In all, 6.6% of post-marketing trials had a clinical endpoint as a primary outcome, and 35.9% and 54.1% had a safety or surrogate endpoint, respectively, as a primary outcome. Nine drugs obtained approval for supplemental indications. The publication rate at 10 years was 12.3 to 26.1% depending on the analysis method. In conclusion, we found that post-marketing research in oncology is highly heterogeneous and the publication rate of launched trials is low.

Drug information by public health and regulatory institutions: Results of an 8-country survey in Europe

PURPOSE

To evaluate the framework of drug information produced by public health and regulatory institutions in Europe.

MATERIALS AND METHODS

We carried out a short survey asking editors of ISDB bulletins of the European region to indicate the main sources of drug information provided by public health and regulatory authorities in their countries, the specific kind of information produced and their opinions about strengths and weaknesses of such information. The availability of evaluations about the added therapeutic value of drugs and of tools facilitating the implementation of such information were particularly addressed and checked on the websites of those institutions.

RESULTS

Answers pertaining to eight countries were available. Regulatory information and safety alerts are generally available, but just UK and Germany stand out by showing quite an advanced framework of evidence-based, comparative drug information for health professionals, decision-makers and for the general public. National plans to implement evidence-based drug information seem lacking.

CONCLUSION

More efforts are warranted to develop sharp formats to make evidence-based drug information easier to access, understand and put in context, showing the place in therapy of medicines and their added therapeutic value. Harmonization of different sources, also at European level, would be important to favor their access and limit dispersion. Appropriate tools and specific plans are then necessary to favor implementation of information materials.

Public perception of pharmacists: Film and television portrayals from 1970 to 2013

OBJECTIVES

To determine the percentage of pharmacists portrayed in a positive, negative, or neutral light in films and television shows available in the United States from January 1970 to July 2013. Secondary objectives were to evaluate pharmacist characters as heroes, villains, or victims; assess pharmacist characters' demographics; and determine the presence of pharmacist characters in medical-themed television shows.

DESIGN

Retrospective, observational, descriptive study.

SETTING

A review of available U.S. film and television from January 1970 to July 2013 at an academic institution.

PARTICIPANTS

214 television episodes or films that contained at least one pharmacist portrayal.

INTERVENTION

Electronic inquiries requesting submissions of known pharmacist portrayals were distributed to pharmacy professionals in national and state-affiliated pharmacy organizations and to faculty, staff, and students at the University of South Carolina. Electronic databases and search engines (Internet Movie Database [IMDb], Bing, and Google) were consulted and used to further research possible pharmacist portrayals. The study investigators developed an algorithm incorporating social norms, common pharmacist practices, and viewer perceptions to determine positive, negative, or neutral status for each pharmacist portrayal.

MAIN OUTCOME MEASURES

Year and genre of media, demographics of identified pharmacist characters, portrayal status of identified pharmacist characters, and number of pharmacist characters and appearances per each television show reviewed.

RESULTS

In the films and television shows reviewed, there were 231 pharmacist portrayals, with 160 unique pharmacist characters. Of the 231 portrayals, 145 (63%) were negative, 30 (13%) were positive, and 56 (24%) were neutral. Of the 160 unique characters, 121 (76%) were male, 120 (75%) were Caucasian, and 86 (54%) were younger than 50 years old. The name of the character was provided for 70 (44%) of the pharmacists portrayed.

CONCLUSION

The portrayal of pharmacists in U.S. film and television is primarily negative. Pharmacists and pharmacy organizations are encouraged to be vocal proponents of the profession and educate trainees on the importance of an enhanced public perception.

A statewide controlled trial intervention to reduce use of unproven or ineffective breast cancer care

BACKGROUND

Challenged by public opinion, peers and the Congressional Budget Office, medical specialty societies have begun to develop "Top Five" lists of expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The extent to which these lists have influenced the behavior of physicians or patients, however, remains unknown.

METHODS

We partner with a statewide consortium of health systems to examine the effectiveness of two interventions: (i) "basic" public reporting and (ii) an "enhanced" intervention, augmenting public reporting with a smart phone-based application that gives providers just-in-time information, decision-making tools, and personalized patient education materials to support reductions in the use of eight breast cancer interventions targeted by Choosing Wisely® or oncology society guidelines. Our aims are: (1) to examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states; (2) to examine the effectiveness of the enhanced intervention relative to the basic intervention; and (3) to simulate cost savings forthcoming from nationwide implementation of both interventions.

DISCUSSION

The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system for influencing provider behavior that may be easily exportable to other states, and potentially also to large healthcare systems. Findings will be further relevant to the ACO environment, which is expected to provide financial disincentives for ineffective or unproven care.

TRIAL REGISTRATION

ClinicalTrials.gov number pending.

A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care

Background

Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year.

Methods

We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years.

Findings

We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later.

Interpretation

Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population.

Trial Registration

International Standard Randomised Controlled Trials Register ISRCTN61233866

Awareness and Perceptions of Vermont’s Prescribed Product Gift Ban and Disclosure Law by Prescribers and Pharmacists

Purpose:

Vermont law strictly regulates the interactions between pharmaceutical manufacturers and health care providers, including gifts, meals, and medication samples. The purpose of this study was to describe providers’ awareness and perceptions of current requirements.

Methods:

An online survey was completed by Vermont providers, including prescribers and pharmacists. The survey asked providers about their awareness of 15 different legal requirements and about their level of agreement with these requirements.

Results:

Four hundred and eleven providers completed the survey (61% male, mean age 52 years, and 71% physicians). Awareness of the 15 requirements ranged from 28.4% to 93.8%. Most providers agreed or had no strong opinions. Responses at significance levels of P < .001 were noted in 8 of 15 requirements when perceptions were stratified by providers who had any interactions with pharmaceutical representatives in the past year (N = 227, 55.4%) versus providers who reported no interactions (N = 183; 44.6%).

Conclusions:

A high proportion of Vermont providers are unaware of the current law. Most agreed or had no strong opinions about the requirements; however, at least a quarter disagreed with banning small gifts and meals. Having any interaction with pharmaceutical representatives changed how providers perceived the requirements. These data may be useful for other states considering similar laws.

Can access limits on sales representatives to physicians affect clinical prescription decisions? A study of recent events with diabetes and lipid drugs

The authors explored to what extent important medical decisions by practitioners can be influenced by pharmaceutical representatives and, in particular, whether restricting such access could delay appropriate changes in clinical practice. Medical practices were divided into four categories based on the degree of sales representative access to clinicians: very low, low, medium, and high from a database compiled by ZS Associates called AccessMonitor (Evanston, IL) used extensively by many pharmaceutical companies. Clinical decisions of 58,647 to 72,114 physicians were statistically analyzed using prescription data from IMS Health (Danbury, CT) in three critical areas: an innovative drug for type 2 diabetes (sitagliptin), an older diabetes drug with a new Food and Drug Administration-required black box warning for cardiovascular safety (rosiglitazone), and a combination lipid therapy that had reported negative outcomes in a clinical trial (simvastatin+ezetimbe). For the uptake of the new diabetes agent, the authors found that physicians with very low access to representatives had the lowest adoption of this new therapy and took 1.4 and 4.6 times longer to adopt than physicians in the low- and medium-access restriction categories, respectively. In responding to the black box warning for rosiglitazone, the authors found that physicians with very low access were 4.0 times slower to reduce their use of this treatment than those with low access. Likewise, there was significantly less response in terms of changing prescribing to the negative news with the lipid therapy for physicians in more access-restricted offices. Overall, cardiologists were the most responsive to information changes relative to primary care physicians. These findings emphasize that limiting access to pharmaceutical representatives can have the unintended effect of reducing appropriate responses to negative information about drugs just as much as responses to positive information about innovative drugs.

The cultural divide: exploring communication barriers between scientists and clinicians

Despite remarkable advances in basic biomedical science that have led to improved patient care, there is a wide and persistent gap in the abilities of researchers and clinicians to understand and appreciate each other. In this Editorial, the authors, a scientist and a clinician, discuss the rift between practitioners of laboratory research and clinical medicine. Using their first-hand experience and numerous interviews throughout the United States, they explore the causes of this 'cultural divide'. Members of both professions use advanced problem-solving skills and typically embark on their career paths with a deeply felt sense of purpose. Nonetheless, differences in classroom education, professional training environments, reward mechanisms and sources of drive contribute to obstacles that inhibit communication, mutual respect and productive collaboration. More than a sociological curiosity, the cultural divide is a significant barrier to the bench-to-bedside goals of translational medicine. Understanding its roots is the first step towards bridging the gap.

Fostering the use of clozapine in the severely mentally ill through academic detailing

Academic detailing is an educational program in which independent researchers and clinicians evaluate available literature to develop up-to-date, unbiased, evidence-based recommendations for a given therapeutic area. Pharmacists, nurses, and physicians trained as academic detailers then disseminate this information to providers. This is one means to foster the greater use of clozapine in patients with treatment-resistant schizophrenia. The Veterans Health Administration (VHA) Academic Detailing Service meets with mental health providers at each facility to identify barriers and healthcare systems solutions, provide feedback about prescribing and patterns of care, and develop and distribute educational materials to improve veteran health outcomes. Preliminary results include a reduction in polypharmacy antipsychotic use from 17% of patients on antipsychotics to 12.2% of patients (p&lt;0.001). Although there was a numeric increase clozapine new starts in the 5-month interim analysis, the increase was not significant in this analysis. Analysis for 12-month data is underway. The early success of this program demonstrates there may be opportunity for this type of educational intervention in the Veterans Affairs Healthcare System.

[Justification to health managers: cost-benefit of osteoporosis management]

Medicines are strictly regulated and controlled until they reach the patients. Once in the market, the mechanisms governing their use are very complex due to the large number of actors playing different roles. It is necessary to extend an evaluation culture among all involved and to make economic analysis a structured part of decisions made by physicians and health managers. Since physicians occupy a central place in this market of medicines, it is necessary that they assume their responsibility by actively participating in this evaluation.