The evolution and assessment of pharmaceutical care: Structure, processes, and outcomes

The evolution of pharmaceutical care is identified through a complete review of the literature published in the American Journal of Health-System Pharmacy, the sole comprehensive publication of institutional pharmacy practice. The evolution is categorized according to characteristics of structure (organizational structure, the role of the pharmacist), process (drug delivery systems, formulary management, acquiring drug products, methods to impact drug therapy decisions), and outcomes (cost of drug delivery, cost of drug acquisition and use, improved safety, improved health outcomes) recorded from the 1950s through the 1990s. While significant progress has been made in implementing basic drug distribution systems, levels of pharmacy involvement with direct patient care is still limited.^ A new practice framework suggests enhanced direct patient care involvement through increase in the efficiency and effectiveness of traditional pharmacy services. Recommendations advance internal and external organizational structure relationships that position pharmacists to fully use their unique skills and knowledge to impact drug therapy decisions and outcomes. Specific strategies facilitate expansion of the breadth and scope of each process component in order to expand the depth of integration of pharmacy and pharmaceutical care within the broad healthcare environment. Economic evaluation methods formally evaluate the impact of both operational and clinical interventions.^ Outcome measurements include specific recommendations and methods to increase efficiency of drug acquisition, emphasizing pharmacists' roles that impact physician prescribing decisions. Effectiveness measures include those that improve safety of drug distribution systems, decrease the potential of adverse drug therapy events, and demonstrate that pharmaceutical care can significantly contribute to improvement in overall health status.^ The implementation of the new framework is modeled on a case study at the M.D. Anderson Cancer Center. The implementation of several new drug distribution methods facilitated the redeployment of personnel from distributive functions to direct patient care activities with significant personnel and drug cost reduction. A cost-benefit analysis illustrates that framework process enhancements produced a benefit-to-cost ratio of 7.9. In addition, measures of effectiveness demonstrated significant levels of safety and enhanced drug therapy outcomes. ^

The utility of rapid participatory appraisal for community assessment, diagnosis, and policy development

The selection of a model to guide the understanding and resolution of community problems is an important issue relating to the foundation of public health practice: assessment, policy development, and assurance. Many assessment models produce a diagnosis of community weaknesses, but fail to promote planning and interventions. Rapid Participatory Appraisal (RPA) is a participatory action research model which regards assessment as the first step in the problem solving process, and claims to achieve assessment and policy development within limited resources of time and money. Literature documenting the fulfillment of these claims, and thereby supporting the utility of the model, is relatively sparse and difficult to obtain. Very few articles discuss the changes resulting from RPA assessments in urban areas, and those that do describe studies conducted outside the U.S.A. ^ This study examines the utility of the RPA model and its underlying theories: systems theory, grounded theory, and principles of participatory change, as illustrated by the case study of a community assessment conducted for the Texas Diabetes Institute (TDI), San Antonio, Texas, and subsequent outcomes. Diabetes has a high prevalence and is a major issue in San Antonio. Faculty and students conducted the assessment by informal collaboration between two nursing and public health assessment courses, providing practical student experiences. The study area was large, and the flexibility of the model tested by its use in contiguous sub-regions, reanalyzing aggregated results for the study area. Official TDI reports, and a mail survey of agency employees, described policy development resulting from community diagnoses revealed by the assessment. ^ The RPA model met the criteria for utility from the perspectives of merit, worth, efficiency, and effectiveness. The RPA model best met the agencies' criteria (merit), met the data needs of TDI in this particular situation (worth), provided valid results within budget, time, and personnel constraints (efficiency), and stimulated policy development by TDI (effectiveness). ^ The RPA model appears to have utility for community assessment, diagnosis, and policy development in circumstances similar to the TDI diabetes study. ^

Association of self-reported physical activity and performance in the physical fitness assessment among Airmen

The U.S. Air Force, as with the other branches of military services, has physical fitness standards imposed on their personnel. These standards ensure a healthy and fit combat force. To meet these standards, Airmen have to maintain a certain level of physical activity in their lifestyle. Objective. This was a cross sectional (prevalence) study to evaluate the association of Airmen's self-reported physical activity and their performance in the Air Force Physical Fitness Assessment in 2007. Methods. The self-reported physical activity data were obtained from the Air Force Web Health Assessment (AF WEB HA), a web-based health questionnaire completed by the Airmen during their annual Preventive Health Assessment. The physical activity levels were categorized as having met or not having met the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) physical activity recommendations. Physical Fitness scores were collected from the Air Force Fitness Management System (AFFMS), a repository of physical fitness test data. Results. There were 49,029 Airmen who answered the AF WEB HA in 2007 and also took their physical fitness test. 94.4% (n = 46,304) of Airmen met the recommended physical activity guidelines and 79.9% (n = 39,178) passed the fitness test. Total Airmen who both met the physical activity recommendations and passed the fitness test was 75.6% (n = 37,088). Airmen who did not meet the activity recommendations and also failed the fitness test totaled 635 or 1.3% of the study group. The Mantel-Haenszel Chi-Square analysis of the data on the activity levels and the physical fitness test relationship was the following χ2 = 18.52, df 1, and p = <0.0001. The Odds Ratio (OR) was 1.22 (95% CI 1.12, 1.34). Conclusion. The study determined that there was a positive association between Airmen's self-reported physical activity and their performance in the physical fitness assessment.^

Cytogenetic assessment of occupational exposure to antineoplastic agents

This study has evaluated the utility of measuring effects of low level occupational exposure of nursing personnel to antineoplastic agents. The effect measured in this study is chromosomal damage in peripheral lymphocytes (chromosomal breakage and micronuclei frequency).^ Using nursing personnel in three exposure classifications (low, moderate and high) and breast cancer patients before and after treatment with antineoplastic agents, a weak but statistically significant association was found between exposure and chromosomal damage. Of special interest was the finding that consistent glove usage was negatively associated with increased chromosomal damage.^ The study also demonstrated a statistically significant association between the two measures of chromosomal damage: chromosomal breakage and micronuclei frequency. This suggests that the micronucleus method is a useful test for studying cytogenetic effects in lymphocytes. ^

An assessment of the relative influence of a vapor recovery system in reducing occupational exposure to volatile organic compounds in high performance liquid chromatography

Occupational exposures to organic solvents, specifically acetonitrile and methanol, have the potential to cause serious long-term health effects. In the laboratory, these solvents are used extensively in protocols involving the use of high performance liquid chromatography (HPLC). Operators of HPLC equipment may be potentially exposed to these organic solvents when local exhaust ventilation is not employed properly or is not available, which can be the case in many settings. The objective of this research was to characterize the various sites of vapor release in the HPLC process and then to determine the relative influence of a novel vapor recovery system on the overall exposure to laboratory personnel. The effectiveness of steps to reduce environmental solvent vapor concentrations was assessed by measuring exposure levels of acetonitrile and methanol before and after installation of the vapor recovery system. With respect to acetonitrile, the concentration was not statistically significant with p=0.938; moreover, exposure after the intervention was actually higher than prior to intervention. With respect to methanol, the concentration was not statistically significant with p=0.278. This indicates that the exposure to methanol after the intervention was not statistically significantly higher or lower than prior to intervention. Thus, installation of the vapor recovery device did not result in statistically significant reduction in exposures in the settings encountered, and acetonitrile actually increased significantly.^

An assessment of post-disaster psychological stress in hazardous waste operations and emergency response (HAZWOPER) workers

Personnel involved in natural or man-made disaster response and recovery efforts may be exposed to a wide variety of physical and mental stressors that can exhibit long-lasting and detrimental psychopathological outcomes. In a disaster situation, huge numbers of "secondary" responders can be involved in contaminant clean-up and debris removal and can be at risk of developing stress-related mental health outcomes. The Occupational Safety and Health Administration (OSHA) worker training hierarchy typically required for response workers, known as "Hazardous Waste Operations and Emergency Response" (HAZWOPER), does not address the mental health and safety concerns of workers. This study focused on the prevalence of traumatic stress experienced by secondary responders that had received or expressed interest in receiving HAZWOPER training through the National Institute of Environmental Health Sciences Worker Education and Training Program (NIEHS WETP). ^ The study involved the modification of two preexisting and validated survey tools to assess secondary responder awareness of physical, mental, and traumatic stressors on mental health and sought to determine if a need existed to include traumatic stress-related mental health education in the current HAZWOPER training regimen. The study evaluated post-traumatic stress disorder (PTSD), resiliency, mental distress, and negative effects within a secondary responder population of 176 respondents. Elevated PTSD levels were seen in the study population as compared to a general responder population (32.9% positive vs. 8%-22.5% positive). Results indicated that HAZWOPER-trained disaster responders were likely to test positive for PTSD, whereas, untrained responders with no disaster experience and responders who possessed either training or disaster experience only were likely to test PTSD negative. A majority (68.75%) of the population tested below the mean resiliency to cope score (80.4) of the average worker population. Results indicated that those who were trained only or who possessed both training and disaster work experience were more likely to have lower resiliency scores than those with no training or experience. There were direct correlations between being PTSD positive and having worked at a disaster site and experiencing mental distress and negative effects. However, HAZWOPER training status does not significantly correlate with mental distress or negative effect. ^ The survey indicated clear support (91% of respondents) for mental health education. The development of a pre- and post-deployment training module is recommended. Such training could provide responders with the necessary knowledge and skills to recognize the symptomology of PTSD, mental stressors, and physical and traumatic stressors, thus empowering them to employ protective strategies or seek professional help if needed. It is further recommended that pre-deployment mental health education be included in the current HAZWOPER 24- and 40-hour course curriculums, as well as, consideration be given towards integrating a stand-alone post-deployment mental health education training course into the current HAZWOPER hierarchy.^