Consultant Pharmacist Forum

Marketing Specialized Services in Diabetes Care

Successful management of a chronic disease such as diabetes hinges on teaching patients how to take control of their condition through proper self-care practices. Effective self-care must incorporate changes in lifestyle, including changes in diet, exercise, and smoking cessation. Individuals must be empowered to take an active role in the management of their diabetes. If lifestyle changes and the implementation of self-care practices are to be successful, the guidance of a health educator is paramount.

With adequate training, the pharmacist is in a key position to play the role of health educator, at a cost-effective price to the health care system. This is because pharmacists see their patients with diabetes more frequently than any other health care provider, about two or three times monthly.¹ By following established standards of care, the pharmacist can have a significant impact on the outcome of diabetes management.²

To emphasize this fact, a project was performed at a midwestern intermediate-volume chain pharmacy (average 272 prescriptions per day). The objectives of this project were two-fold: to establish that a retail pharmacy can increase prescription sales by increasing the diabetes customer base as a direct result of marketing specialized services in diabetes care, and to establish that this increase in sales in the diabetes patient base can occur when the overall prescription volume of the store is declining. The latter objective will establish the basis for the discussion on disease management and marketing of the same to increase the pharmacy customer base and prescription volume.

One pharmacist at this pharmacy had attained the status of Certified Diabetes Educator and had successfully marketed the pharmacy's services to the lay community and health care professionals for two years prior to the measurement of sales trends. Marketing consisted of focus groups of patients with diabetes and health care professionals, direct marketing to health care professionals with price lists and available cognitive services, presentations on diabetes care, newspaper advertising, and in-store promotions.

Health care professionals included diabetes educators and endocrinologists involved in caring for patients with diabetes. Referrals were made to the pharmacy based on the reputation of the pharmacy for providing valuable cognitive services, such as blood glucose monitor training, data management, and drug regimen review.

Data were collected from January 1, 1994, to June 24, 1994, and were compared to data collected from January 1, 1995, to June 24, 1995. Data did not include sales of over-the-counter diabetes products or the expected increase in sales of other products due to increased store traffic. At the time of measurement of data, the pharmacy was providing cognitive services in diabetes health education. All patients with diabetes were coded in the computer to separate them from the pharmacy customer base as a whole. Reports were run on prescription volume and sales for the entire customer base and then compared to reports run for the diabetes-specific customer base.

Total diabetes prescription volume increased from 2,118 prescriptions in 1994 to 2,558 prescriptions in 1995, representing a 20.8% increase in prescription volume. The total pharmacy prescription volume actually decreased by 2.7% over the course of the study. Sales from diabetes prescriptions increased from $78,797 in 1994 to $90,393 in 1995. This increase represents a 14.7% jump in diabetes prescription sales compared to a 0.31% decrease in total pharmacy prescription sales for the same time period.

In the above data, as pharmacy prescription volume and sales are heading downward, there is an increase in prescription volume and sales to patients with diabetes. Thus, it is clear that prescription sales to this group can be increased, even in pharmacies with shrinking prescription volume, simply by marketing specialized services for patients with diabetes. More studies should be done to verify this finding and its applicability to other markets.

Prescription sales can be increased in this patient population by marketing specialized services to referring providers. It naturally follows that this concept can be applied to other patient populations and disease states. In essence, the goal would be to market in more than one area of disease management in order to grow the entire pharmacy prescription volume.

Other areas of disease management that have potential for pharmacist involvement are asthma management, hypertension, hyperlipidemias, and hormonal replacement therapies.

With the arrival of disease management into this era of managed care, there can be significant benefits to patients with diabetes and other chronic diseases and the pharmacy programs choosing to participate. It is generally believed that a pharmacy program that can establish itself as a provider of disease management programs, produce positive patient outcomes, and save insurers significant health care expenditures will be the provider of choice. Pharmacists have an opportunity to forge a new path in the delivery of health care for years to come.

Alan Lukazewski, RPh, CDE, FASCP
Pharmacy Corporation of America
Madison, Wisconsin

1. Campbell RK. Diabetes Supplement. US Pharm 1992: Nov.
2. Diabetes Control and Comparison Trials. N Eng J Med 1993: Sept.

Pharmacists' Role in the Management of Occupational Exposure to HIV

Potential exposure to HIV in the workplace is a frightening occurrence for any health care worker. Regardless of how knowledgeable people are about infection control procedures, initial reactions may be clouded by panic and fear. Irrational behavior, like washing the site of exposure with undiluted bleach, is not an appropriate course of action. Numerous questions race through one's mind after an exposure, questions that pharmacists can help answer. Pharmacists can provide invaluable assistance to other health care workers by ensuring that timely treatment is obtained.

Most health care facilities have infection control policies outlining what to do in the event of occupational exposure to HIV. The policy should closely follow guidelines issued by the Centers for Disease Control and Prevention (CDC). Since these guidelines may change before the policy at your worksite has been updated, staying abreast of CDC recommendations is crucial to providing the best outcome for each exposure case. A pharmacist's knowledge can also be useful in developing and maintaining infection control policies concerning occupational exposure to HIV, and other communicable viral diseases.

Employees should be informed that the pharmacist is a resource for information regarding treatment following potential exposure to HIV. Potential exposure affects a large cross-section of workers, and pharmacists can provide employee training. There is a tendency to forget that departments other than nursing have increased risk of HIV exposure, including employees in housekeeping who handle trash and soiled laundry.

Training and prevention minimize accidental exposure to HIV, but every health care worker should realize there is always some risk. Knowing what to do following a potential exposure is critical. Naturally, the risk of infection after an exposure depends on several factors, including the type of exposure, the amount of virus in the patient's blood at the time of exposure, and whether post-exposure treatment is taken.

The most commonly reported occupational exposures result from needlestick injuries. Of the 52 documented cases of occupational-acquired HIV infection received by the CDC as of December 1996, 45 were due to needlestick injuries or cuts, and the majority of those cases involved blood contact.

Current CDC guidelines recommend washing needlestick sites and cuts with soap and water, not caustic agents like bleach. Splashes to the nose, mouth, or skin should be flushed with water. Eyes should be irrigated with clean water, saline, or sterile irrigants. Immediately after proper cleansing, the exposure site should be reported to the person or department responsible for tracking and managing potential exposures. Whether it is infection control or employee health, reporting the exposure is usually mandatory. Once reported, the employee will be faced with a decision: pursue post-exposure treatment, or simply do nothing.

Whether or not to start drug treatment for a potential HIV exposure is a weighty question, but there is little time for debate or contemplation after an exposure occurs. Treatment should be initiated one to two hours after the exposure for optimal outcome. Each exposure involves its own unique variable, and the risk of infection from the incident must be weighed against the risk of side effects from drugs used to prevent infection.

Follow up and treatment decisions can be quite complicated. Treatment decisions must be based on the likelihood that the source is HIV positive. If the status of the source person is known to be negative, the possibility of recent exposure must be considered as well. Seroconversion to positive HIV serology generally takes place at 6 to 12 weeks following the established transmission event. The median interval is 63 days.

The employee's decision should be made in conjunction with counseling from a pharmacist. A calm, rational approach will go a long way in reassuring a distraught exposure victim. The short window of time to aid the individual demands knowledge and empathy. Confidentiality is of the utmost importance and should be reinforced by counseling the individual in an area that offers privacy.

The CDC currently recommends triple-drug therapy for post-exposure HIV prophylaxis. The three agents are summarized in Table 1.

Table 1. Triple Drug Therapy

Drug	Strength	Dosage	Side Effects and Special Consideration
Retrovir (zidovudine)	200 mg	every four hours	Similar for each agent: GI problems, nausea, vomiting, diarrhea, pancreatitis, headache, fatigue, jaundice, kidney stones
Epivir (lamivudine)	150 mg	twice a day
Crixivan (indinavir)	800 mg	three times a day

The optimal length of therapy is unknown. However, current CDC recommendations advocate a minimum of four weeks. Blood tests, including complete blood cell counts and liver and kidney function tests, must be performed to monitor for drug toxicity. Ideally, the tests should be performed both before and two weeks after initiating treatment.

Pregnant health care workers should consult their physician prior to starting treatment, since no studies have been done to test the effects of these drugs in pregnant women. There is, however, limited data showing that zidovudine, taken in the second and third trimester, has not caused any serious side effects in mothers or teratogenicity in infants.

Monitoring for potential infection involves performing an HIV antibody test as soon as possible after exposure, then at 6 weeks, 12 weeks, and 6 months after the exposure.

Treatment does not guarantee infection will be prevented. None of the drugs recommended by the CDC for post-exposure treatment are FDA-approved for HIV prophylaxis. However, there is a study showing a 79% reduction in transmission rates when zidovudine prophylaxis was used. Individuals should be told to seek immediate medical attention if they experience sudden or severe flu-like symptoms such as fever, muscle aches, fatigue, malaise, or swollen glands.

Advise the individual to abstain from sexual intercourse for 6 to 12 weeks after exposure, or, if abstinence is unlikely, to use a latex condom. They should prevent others from coming into contact with their body fluids, and nursing mothers should not breast feed infants in order to prevent possible transmission through breast milk.

Advance planning is needed to coordinate all the details involved in managing occupational HIV exposures. Pharmacists have a prime opportunity to take the lead in managing each facet of this issue. Working with other disciplines, develop a plan at your worksite or build from a plan that may already exist. Identify potential problems that may impede a person from obtaining treatment within two hours after exposure. For example, since the recommended drugs for post exposure treatment can only be obtained with a doctor's order, how will a night shift employee get a doctor's order; even if they obtain a doctor's order, how will they get the medication if the pharmacy is not open 24 hours?

At our government-run facility, the employee health physician handles the prescriptions for exposures during the day, and the on-call evening and night physicians are available for all other times. When the pharmacy closes at 5:00 p.m., we have prepackaged "needlestick" medication kits available in a pharmacy nightbox that nursing staff can access, and there is an on-call pharmacist available as well.

It is important to make employees aware of additional information sources like the CDC National AIDS Hotline (800-342-2437), and the AIDS Treatment Information Service (800-933-4313). To track occupational exposures on a nationwide basis, there is also a voluntary HIV Postexposure Prophylaxis Registry (888-737-4448), which is completely confidential.

Walter L. Fava, RPh
St. Elizabeths Hospital
Washington, D.C.

Subject: PRN Nifedipine Alternatives

The following discussion was excerpted from the "Clinical Topics" Conference Room on ASCP's Web page. (To get to the ASCP Conference Rooms, select Consult Net from the ASCP homepage at www.ascp.com.)

Richard Marasco, PharmD,
United Pharmacy Services, Inc.
Lilburn, GA

With all the concern about the use of p.r.n. nifedipine for rapid reduction of blood pressure, I still have physicians using it. I have been able to discontinue some orders and get some physicians to start routine therapy with an ACE inhibitor or clonidine instead. I was wondering: What other alternatives are being used out there?

Spencer Klaassen, PharmD, Independent Consultant
Ottumwa, IA

We are really struggling with this issue after being able to "prove" that one myocardial infarction and one cerebrovascular accident were due to rapid reduction of blood pressure. We are going back to focusing on target organ damage instead of the blood pressure. We are trying to inservice the nursing home staff on what target organ damage is. Our long-term plan is to use the nursing staff to identify patients with end-organ damage and send those patients directly to the emergency room for admission to an acute bed. Other patients are to be given an extra dose of their regularly scheduled medication to bring the blood pressure down gradually. I feel the main goal is to get nurses to understand that nobody dies from a single elevation in blood pressure. It is the long-term effects of consistent hypertension that cause death. I am hoping to drive this point home to help nurses understand and to prevent pages to the geriatricians and internists at two a.m. about a blood pressure of 180/100 mm Hg. A good review is found in the BCPS II review guide.

Todd King, PharmD,
Neil Medical Group
Lillington, NC

I agree that educating the nursing staff on the significance of sustained hypertension versus isolated elevations is very important. However, many physicians will often give these orders to prevent after-hours calls and I see them as very reluctant to discontinue the orders or change to another medication. In these cases, I have recommended to just give the nifedipine capsule whole and not puncture the capsule. This allows for less rapid onset, but will still bring the blood pressure down in 15 to 30 minutes.

In cases where the physician is insistent on using a p.r.n. medication, I will sometimes recommend p.r.n. clonidine or captopril (watch out in the dehydrated resident) and these seem to work well. The end point is assessment of the blood pressure, if p.r.n. drugs are needed frequently, then naturally a routine medication may be needed. But if the elevations are periodic in nature, then looking at underlying causes is very important. It could be diet, exercise, hydration status, other medications (p.r.n. NSAIDs), etc. After those two issues are evaluated, the use of p.r.n. antihypertensive medications should be minimal.

Marie Gardner, PharmD,
University of Arizona
College of Pharmacy
Tuscon, AZ

We have converted everyone to clonidine 0.1 mg and it seems to work fine. I don't know what to do when physicians don't listen. It's frustrating. Contacting the medical director may help.

Richard Marasco, PharmD,
United Pharmacy Services, Inc.
Lilburn, GA

Unless the problem physician is the medical director!

Paul Sovcik, PharmD, BCPS,
University of Illinois at Chicago
Chicago, IL

You may want to persuade your physicians with references. The best ones for this topic are: Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive pseudoemergencies? JAMA 1996;276:1328-31. The accompanying editorial is also great (page 1342). Also, look at: Acute reduction of blood pressure in asymptomatic individuals, an idea whose time has come-and gone. Arch Inter Med 1989;149.