Class of 2012 Abstract / Specific Aims: To assess physician approval of the MTM services provided. Specifically, to compare cost saving, guideline adherence, and safety concern interventions. Methods: A retrospective analysis of pharmacist interventions was performed using the MMC database for 2008. Data were collected on the type of intervention and approval by physicians. Physician specialty was also collected from state medical boards. Descriptive statistics were used to generate frequencies of approvals. Chi-square tests were used to compare physician approval by intervention type. Main Results: Pharmacists initiated 1,563 interventions that were faxed to physicians for approval. Of these interventions, cost saving, guideline adherence, and safety concerns were 33.2, 58.3, and 8.5 percent, respectively. Interventions primarily targeted diabetes (38.6%), cardiovascular disease (28.8%), gastroesophageal reflux disease (13.1%), and respiratory disease (8.4%). Physician approval for cost saving, guideline adherence, and safety concerns were 58.0, 44.4, and 41.0 percent, respectively. Approval for cost saving was greater than guideline adherence (58.0% versus 41.0%, P<0.001) and safety concerns (58.0% versus 44.4%, P=0.005). Approval among primary care physicians (PCP) compared to specialty physicians was greater for both cost saving (60.6% versus 50.7%, P=0.046) and guideline adherence (43.2% versus 36.2%, P=0.045) interventions. Conclusions: Results of this investigation provide evidence that there are differences in the types of MTM interventions that physicians will approve. In an effort to improve patient outcomes, this finding suggests a potential to increase overall physician approval of pharmacist-initiated MTM interventions in the areas of guideline adherence and safety concerns. Results further suggest that lower approval by specialists compared to PCPs may call for alternative methods to better reach these providers.

Two possible variables of the McKenzie/Stoughton blanching assay, namely amount applied to the test site and occlusion time have been investigated. Subsequently, two topical steroid preparations, Synalar cream (0,025% fluocinolone acetonide) and Betnovate cream (0,1% betamethasone 17- valerate) were extemporaneously diluted with five and six placebo bases respectively. Taking cognizance of the two possible variables, these diluted preparations were assessed in vivo using a modified version of the McKenzie/Stoughton blanching assay for blanching activity over a 14 month period. It was found that the base E45, which is slightly alkali, had the greatest effect on both preparations. In the case of betamethasone 17-valerate this base caused the conversion to the less active isomer, betamethasone 21-valerate whereas at the end of the 14 month test period it was found that the Synalar/E45 dilution contained no fluocinolone acetonide. Quantitative analysis of all the diluted preparations by high performance liquid chromatography using a reverse-phase system was performed. The data obtained from the systematic studies of the effects of varying concentrations and occlusion times were presented at the Eleventh National Congress of the South African Pharmacological Society

The current world-wide interest in transdermal drug delivery makes the prospect of valid in vitro diffusion cell methodology highly attractive. A new laboratory diffusion cell has been designed and constructed based on theoretical principles and practical permeation reports surveyed in recent literature, and has been applied to the monitoring of betamethasone 17-valerate permeation. The cell performance has been validated with respect to hydrodynamic mixing efficiency and temperature of the receptor phase. The steady-state permeation of this corticosteroid has been monitored through various synthetic and animal membranes in order to select the most appropriate media for in vitro study. The permeation of betamethasone 17-valerate has been monitored from various types of commercial and extemporaneously prepared semisolid topical formulation (cream, lotion, ointment and scalp application), through silicone membrane, human and weanling pig stratum corneum, and full thickness hairless mouse skin, and these in vitro results have been compared to data from in vivo blanching assays, using the same formulations, in an attempt to correlate the findings. This experimental methodology has necessitated the development of ancillary analytical techniques. A column-switching high-performance liquid chromatographic method has been developed for the rapid on-line clean-up and analysis of betamethasone 17-valerate contained in the various topical formulations, which minimizes sample handling and extraction procedures. The method has been modified for the analysis of this corticosteroid in the isopropyl myristate receptor phase used in the in vitro permeation experiments, and scintillation counting of tritium-labelled water has been used to verify the integrity of the animal membranes. The comparison of in vitro permeation and in vivo blanching results indicate good correlation of the data in certain instances. The closest correlations have been observed when the human stratum corneum has been used in vitro and these results are compared to data from the occluded mode of the blanching assay. The results of the porcine and murine media have also correlated with the human in vivo data, whereas the silicone membrane appears applicable only in certain in vitro experiments. The results indicate that valid, comparative percutaneous absorption data may be obtained in vitro by using a well designed, validated diffusion cell system.

The rapidly growing interest in the potential use of topical drug delivery formulations has resulted in increased use of the skin as a vital port for drug delivery. Extensive research has been conducted in designing vehicles capable of delivering a desired amount of drug to a specific site, to produce the desired pharmacological response. Rooperol tetra-acetate is a lipophilic, cytotoxic drug with the potential for use in the treatment of solar keratosis. For effective pharmacological action, delivery of the drug to the epidermal/dermal junction of the skin is required. A study of the topical penetration properties of rooperol tetra-acetate from different topical bases, each possessing different physico-chemical properties, was performed. The assessment involved a comparison of the diffusion properties under occlusive and non occlusive conditions when the drug was formulated into a gel, Cetomacrogol Cream B.P. (oil-inwater), Simple Ointment B.P. and an extemporaneously prepared water-in-oil topical cream. The in vitro experiments were conducted using polydimethylsiloxane and rat membrane mounted in a Franz diffusion cell. The topical permeation kinetics of rooperol tetra-acetate were determined by exploring the release characteristics of the active ingredient from the vehicles formulated and the permeability properties of the drug through the membranes employed. Further studies involved investigating the utilization of supersaturated systems intended to increase the thermodynamic activity of the drug when formulated into a propylene glycol/water vehicle (with and without polymer). To measure the release of rooperol tetra-acetate into the skin from a topical base it was necessary to, firstly, develop a suitable quantitative method for the analysis of the active drug in the aqueous receptor phase of in vitro diffusion cells. The second stage of product development was the design of an effective delivery system to facilitate the release of the diffusant from its base. A high performance liquid chromatographic method was utilized for the identification and quantification of the active drug. As validation is an important aspect in the development and subsequent utilization of an analytical procedure, the developed HPLC technique was validated by determining the precision, accuracy, range, limit of quantitation and sensitivity of the system. Lastly, the stability of rooperol tetra-acetate at elevated temperatures was assessed and a stability profile of the drug was generated for the three-month period of analysis. The results obtained following chromatographic analysis of the receptor phase sampled during the diffusion experiments indicate that the gel and oil-in-water formulations most effectively promoted the diffusion of rooperol tetra-acetate across polydimethylsiloxane membrane. The water-in-oil system exhibited lower flux rates and the ointment showed the least drug release. Occlusion of the topical vehicle increased the diffusitivity of the permeant from all formulations analysed. The permeation assessment results of the supersaturated systems showed enhanced diffusion of rooperol tetra-acetate across polydimethylsiloxane and rat membrane. The high thermodynamic activity existing in supersaturated systems most effectively increased the driving force for drug diffusion resulting in enhanced percutaneous penetration of rooperol tetra-acetate beyond the release and transport limitations of saturated solutions. These results provide the basis on which an effective topical drug delivery vehicle may be designed for this new drug entity.

Class of 2017 Abstract / Objectives: To evaluate the perceptions of the pharmacy staff on prescription errors, efficiency, and difficulty of use before and after implementation of a new pharmacy computer system. Subjects: Employees of El Rio Community Health Center outpatient pharmacies located at the Congress, Northwest, and El Pueblo Clinics. Methods: This study was of a retrospective pre-post design. A 5-question survey on error rates and workflow efficiency was distributed to pharmacists and technicians 6 months after a new computer system had been implemented. Participants of the study included employees of El Rio Community Health Center outpatient pharmacies who were employed with El Rio during the time of transition between the old and new computer systems. Results: Questionnaire responses were completed by 10 (41.7%) technicians and 6 (66.7%) pharmacists at three El Rio Clinics. There was an increase in perceived efficiency between the new (Liberty) (n=17, 94.4%) and old (QS1) (n=11, 61.1%) computer systems (p<0.05). There were no significant differences in perceived difficulty of use, most common types of errors, error rates, and time to fix detected errors. Conclusions: While there were no significant differences between Liberty and QS1 in perceived difficulty of use, most common types of errors, error rates, and time to correct detected errors, there was a significant difference in the perceived efficiency, which may have beneficial implications.

Tuberculosis (TB) is an infectious disease and nonadherence to medication can lead to new cases, multi-drug resistant TB, or potential death. Additionally, healthcare professionals and individuals with TB’s knowledge of the disease and medication adherence are crucial for successful completion of medication therapy. Patient education is one of the most important aspects of care provided in healthcare settings (CDC, 1994). TB tends to disproportionally affect minority and economically disadvantaged patient populations. The purpose of this mixed method study was to explore the relationship between spirituality, knowledge, and TB medication adherence among African Americans and Haitians. The primary research question was: What is the relationship between spirituality, knowledge and TB medication adherence among African Americans and Haitians? Quantitative data were gathered from 33 questionnaires and analyzed by two ANOVAs and four chi square analyses. The null hypothesis was not rejected; there was not a statistically significant relationship between spirituality and TB medication adherence (p =.208) among the study’s African Americans and Haitians. Qualitative data concerning participants’ knowledge of TB, gathered from 16 individual interviews further informed this analysis. Secondary research questions examined the role of spirituality, knowledge of TB and medication adherence among African Americans and Haitians. Four common themes emerged across both groups to answer the secondary research questions. Interviews revealed the themes: (a) God is in control, (b) stigmatization of TB, (c) lack of knowledge, and (d) fear of death. The theme lack of knowledge about TB was found to contribute to stigmatization of TB patients. However, in this study stigma and lack of knowledge were related to initial denial of symptoms and delayed diagnosis, but not found to be related to TB medication adherence. This study could help adult educators and health educators enhance their educational interventions, develop a better understanding of adult learning, resulting in early diagnosis and treatment ultimately decreasing transmission of TB, drug resistance, and potential death. Educators should be aware that TB patients’ spirituality may be an important part of how they cope with having TB. A larger scale study, conducted at multiple locations should be conducted to extend the findings of this small scale exploratory study. Further studies should be done to better determine what patient, healthcare provider and health care system factors might mediate relationships that may exist between lack of knowledge of TB, stigma and TB medication adherence.

Class of 2017 Abstract / Objectives: To first educate undergraduates involved in social sororities about prescription stimulant medications and to evaluate the effectiveness of an educational intervention in influencing the attitudes and beliefs regarding prescription stimulant medication use of undergraduates involved in a social sorority. Methods: The intervention, an educational session, was presented to undergraduates involved in social sororities. Questionnaire that included demographic data of gender, age, ethnicity, race, undergraduate year, grade point average, type of member, history of an attention-deficit/hyperactivity disorder (ADHD) diagnosis, and previous or current non-medical use of prescription stimulants were collected. The participants’ beliefs on nine statements regarding prescription stimulants were queried pre- and post-intervention using a four-point Likert scale ranging from strongly disagree to strongly agree. To analyze change in attitudes and beliefs, Mann-Whitney test was used. Results: One hundred sixty-three sorority members participated in the study. The average age of participants was 19 years with the majority of respondents identifying as an active sorority member (81%) and in their first year of undergraduate study (69%). There was a statistically significant change in beliefs regarding the safety (p < 0.01) and health risks (p = 0.02) associated with prescription stimulants. There was no significant difference in topics relating to addiction, legality, emotional and academic outcomes from the use of prescription stimulants. Conclusions: The education session was effective in changing participants’ beliefs on safety and health risks of nonmedical use of prescription stimulants.

Class of 2008 Abstract / Objectives: The purpose of this study was to identify how community pharmacies have integrated medication therapy management (MTM) programs into their workflow and specifically determine the changes that were made in order to deliver such services. Methods: This was a descriptive study on the implementation of MTM programs in community pharmacies. Pharmacy managers associated with Cardinal Health, Medicine Shoppe International, United Drugs, the Iowa Pharmacy Association (IPA) and 10 additional selected pharmacists were invited to take an online survey regarding MTM program implementation in their pharmacy. Exclusion criteria were those pharmacists that did not provide any MTM services from January 2006 through December 2007. The primary dependent variables included time spent training, time to complete clinical pharmacy program sessions, scheduling and implementing clinical pharmacy sessions, staffing, and cost for additional equipment. Data analysis included percents and frequencies for categorical variables addressed in the internet survey. Results: Pharmacists that participated in this survey were mostly male (82%) and had been practicing for greater than 10 years. Only 3 out of 17 participants were female and all were a part of the group practicing for less than 10 years. The majority of participants in both groups completed 0-2 MTM sessions per week (p=0.65). In order to complete these sessions, the hiring of additional staff was not required (82%) nor was the purchase of additional equipment (70%). Conclusions: The implementation of MTM programs in community pharmacies requires little to no additional time or money. With this data, more pharmacists should be inclined to provide MTM sessions.

Class of 2009 Abstract / Objectives: This study utilized a prescription claims database to retrospectively assess the relationship between adherence rates with a mood stabilizer in bipolar type I patients for: gender, age, psychiatric hospitalization rates, cost of services, and concomitant psychotropic medications. Methods: Adult patients with bipolar type I disorder (N=149; F=92 and M=57) who received at least two prescriptions of a mood stabilizer (i.e., carbamazepine, lamotrigine, lithium, oxcarbazepine, and valproic acid) during a 3-month intake period were included. Adherence to the mood stabilizer was retrospectively analyzed using high: >75% (> 274 days) vs. low: < 75% (< 274 days) supply of a mood stabilizer during 12-months. Results: Only 35.6% of the patients (N=53) met the criteria for > 75% adherence and 11.4% (N=17) met the criteria for > 90% adherence. There was a trend toward women having more days supply of a mood stabilizer compared to men (p=0.08) and older patients having a higher adherence rate with a mood stabilizer (p=0.06). The high adherence group had greater prescription costs (p<0.001) and total cost per year (R2=0.34, p=0.064) and more concomitant medications (p=0.04) than the low adherence group. Overall, there were no significant differences between the high and low adherence groups for mean hospital days, inpatient costs, and total cost of care. Among those patients that were hospitalized there was a negative correlation between adherence and inpatient cost (R2=0.49, p=0.024). Conclusions: Our findings suggest that patients with bipolar type I disorder demonstrate poor medication adherence with a mood stabilizer and that adherence rates based on a prescription claims database using two adherence categories may not be a predictive factor for psychiatric hospitalizations or cost of care.

Background: Type 2 Diabetes is a chronic metabolic condition which occurs as a result of insufficient insulin production and insulin resistance. This results in less glucose uptake by muscle and fat cells, allowing blood glucose levels to rise in the body. Higher blood glucose levels place patients at an increased risk of diabetes-related complications. The treatment is characterised by the initiation, switching and intensification of antidiabetic medications. The goal for patients with diabetes is to maintain glycaemic control, with blood glucose levels (HbA1c) between 6.5-7.0%(48-53mmol/mol). International guidelines recommend prescribing of metformin at initiation but there is no consensus on optimal agents in a combination regimen. The aim of this thesis was to assess the drug utilisation patterns of first-line therapies and the impact of this pathway on second-line regimens. This entailed: (i.) observing the prescribing of the first-line therapy, (ii.) characterising the medication-taking process of the first-line therapy and effectiveness of the regimens, and (iii.) determining the most effective second-line regimen in delaying the onset of microvascular complications. Methods: Patients with type 2 diabetes, prescribed a first-line antidiabetic regimen, were identified from the Clinical Practice Research Datalink (a large UK anonymised primary care database) between 01/01/05 and 31/12/09, were followed-up until 31/12/12. A multinomial logistic regression model was used to assess the relationship between patient characteristics and the choice of first-line agent. Adherence to first-line therapy was estimated using the Medication Possession Ratio calculation, expressing the percentage of days covered by a drug supply. To assess the factors influencing achievement of glycaemic goals from the first-line therapy, a logistic regression analysis was performed. To investigate second-line regimens, a Marginal Structural Cox model was implemented to explore the causal relationships between the time to development of microvascular complications and the second-line regimens. Results: Of the 72,429 individuals diagnosed with type 2 diabetes, 44,838 started therapy with an antidiabetic medication regimen. Metformin and sulphonylureas were the most frequently prescribed agents at initiation (82.9% and 9.8%,respectively). Deviations from metformin were associated with patients presenting with higher HbA1c levels, lower BMI values and had concurrent prescriptions (immunosuppressants and oral corticosteroids). Achieving glycaemic control, to the target of 6.5% (48mmol/mol), was only met in 22.7% of patients. Characteristics of the patient, choice of first-line agent and medical support influenced the effectiveness of the treatments. Patients at the greatest risk of failing to achieve the target glycaemic goal from therapy had HbA1c levels>8.0% (64mmol/mol) and a BMI≥25kg/m2. Adherence was significantly associated with greater lowering of HbA1c levels but these reductions did not guarantee reaching the ideal glycaemic target. Intensification of the monotherapy to a dual therapy regimen was observed in 30.2% of patients in a mean time of 2 years. The most frequently prescribed second-line regimens consisted of metformin/sulphonylurea (SU) (74.5%), metformin/thiazolidinediones(TZD) (11.3%) and metformin/DPP-4 inhibitors (14.2%). Metformin/SU was the most effective dual therapy regimen for delaying the onset of microvascular diagnoses. The rate of development of these events was significantly higher for the DPP-4 combination in comparison to the SU combination with a hazard ratio of 1.85 (95% CI: 1.53,2.24). A TZD combination resulted in a non-significant increase of 19% in the rate of development compared to the SU combination (HR 1.19; 95% CI: 0.98,1.47). Metformin/SU resulted in the greatest lowering in HbA1c levels (-3.3%; 12mmol/mol) in comparison to the DPP-4 and TZD regimens. Conclusions: It is unlikely that patients starting first-line therapy with high HbA1c levels will be able to reduce blood glucose levels sufficiently on a monotherapy regimen. It is important for practitioners to consider a faster uptake of a dual therapy regimen (metformin/SU) to prevent sustained suboptimal glycaemic control and reduce the risk of future complications. Other important considerations in the optimal treatment pathway would be to provide more frequent support from health professionals; this may help to highlight inadequate drug regimens, offer management of risk factors and provide education. These aspects may help patients to achieve better control of their condition, with the aim of reducing the risk of diabetes-related complications; which, severely impact patient quality of life and NHS costs and resources.