In the first study, the investigators explored the relationship of professional staffing levels and inpatient mortality at 3,763 hospitals—about 78% of the entire U.S. hospital census. They found that mortality was lower in hospitals with higher levels of staffing by pharmacists, medical residents, registered nurses, and medical technologists. Staffing consisting of more licensed practical-vocational nurses and hospital administrators was associated with increased mortality (Pharmacother 1999;19:130–8).
In their second study, the Texas Tech team found a significant association between provision of four clinical pharmacy services and reduced inpatient mortality. Specifically, provision of clinical research services was estimated to have prevented 21,125 inpatient deaths per year; drug information services, 10,463 deaths; pharmacist participation on cardiopulmonary resuscitation teams, 5,047 deaths; and medication history-taking at admission, 3,843 deaths (Pharmacother 1999;19:556–64).
"During the last 15 years, cost reduction efforts and downsizing have reduced professional staffing and eliminated some of the services that [pharmacists] perform in many of our nation’s hospitals," lead investigator C. A. Bond, PharmD, wrote. "These studies indicate that the indiscriminate reduction of professional staff or replacement of professionals with less-qualified individuals (technicians, licensed practical-vocational nurses, etc.) may seriously affect patient care and mortality rates."
A safer method of delivering the medical benefits of marijuana might help allay the concerns of groups such as the American Medical Association and the Institute of Medicine, which have called for expanded clinical use of and research on medical use of the drug but caution against use of smoked marijuana because of its adverse respiratory effects and potential for abuse.
Dronabinol, the capsule form of THC, has been widely used for treatment of chemotherapy-induced nausea and AIDS wasting syndrome since its approval by the Food and Drug Administration (FDA) in 1985. However, dronabinol’s effectiveness is limited by inconsistent oral absorption and bioavailability. "Taken orally, the drug first gets routed to the liver, where it is metabolized before it ever has a chance to exert its therapeutic effect," Mahmoud ElSohly, MD, the inventor of the new suppository, commented in a press release.
ElSohly’s investigative suppository contains dronabinol hemisuccinate, a semisynthetic form of THC that is readily absorbed into the bloodstream via the intestines. The suppository does not produce the psychological "high" associated with smoking marijuana, making abuse highly unlikely, he said.
After promising results in preliminary animal and human studies, ElSohly is working to gain pharmaceutical industry support for additional studies necessary to pave the way for filing a New Drug Application with the FDA. The new suppository could come on the market within two to three years, he predicted.
Those were the compelling questions explored by Dartmouth Medical School professors Lisa Schwartz, MD, and Steven Woloshin, MD, in a recent article on the potential implications of changes in disease definitions proposed by the National Institutes of Health; the Joint National Committee (JNC) on Detection, Evaluation and Treatment of High Blood Pressure; and other expert panels. Their broad conclusion: Lower diagnostic thresholds, while defensible from a strictly clinical and patient care standpoint, might do more harm than good in the grand scheme of things.
In its most recent guidelines, the JNC, for example, recommended that the diagnostic threshold for "hypertension requiring treatment" be revised downward from the current threshold of systolic blood pressure >lt;160 mm Hg or diastolic >lt;100 mm Hg. Under the JNC’s proposed new definition (systolic BP >lt;140 or diastolic BP >lt;90 mm Hg), the number of Americans with "treatable hypertension" would increase by 13 million—a 35% increase.
Adoption of the proposed lower diagnostic thresholds would boost the estimated prevalence of diabetes, obesity, and hypercholesterolemia by 14%, 42%, and 86%, respectively.
All told, the four definitional changes would increase the population of Americans considered "diseased" by more than 87.3 million, Schwartz and Woloshin noted (Effective Clin Pract 1999;2:76–85). This might be undesirable for several reasons, they contend.
First, supporting evidence for the proposed definitional changes is "incomplete." As an example, the authors cited recent clinical research indicating that treatment of mild diastolic hypertension (diastolic BP of 90–109 mm Hg) yields a small reduction in stroke rates but no change in overall coronary events or all-cause mortality.
Second, Schwartz and Woloshin argued in their report, heightened efforts to identify and treat millions of "new" patients might hinder efforts to treat existing patient populations—efforts that are widely considered to be inadequate in many cases. "Rather than lowering thresholds to identify more patients with milder disease, it may make more sense to identify patients who meet the old disease criteria and focus efforts on more adequately treating their disease," they said.
Third, the authors noted, treatment of newly identified patients would result in an increase in adverse medication effects (e.g., cardiac valvular abnormalities with use of dexfenfluramine/fenfluramine for obesity, hypoglycemia due to use of diabetes medications). "If the benefit of treatment is small, untoward effects may overwhelm the benefits, and the new diagnostic criteria could actually result in net harm."
Finally, the authors noted, regardless of whether newly identified patients received treatment, simply labeling them with a diagnosis would have "potentially important physical and psychological consequences." For example, "In a nation already obsessed with weight and body image and in which eating disorders (e.g., anorexia nervosa and bulimia) are prevalent, labeling half of the population ‘overweight’ . . . may be traumatic."
The report presents the findings of a recent survey of a large sample of American adults, community pharmacists, and physicians. The findings suggest that consumer trust and confidence in pharmacists has increased substantially over the past two decades. In the current survey, 61% of consumers said they have "complete confidence" in their pharmacist, up from 54% in a comparable 1978 survey. Independent pharmacies were generally rated higher than chain pharmacies (70% versus 50% overall approval).
In one of the most impressive survey findings, 46% of respondents said they respect pharmacists’ medication advice as much as that of physicians—up from 17% in 1978.
On the issue of compliance counseling, the survey findings indicated that consumers 35 to 49 years old are the age group most interested in counseling, while those 65 and over are the least interested. "Perhaps this relative indifference of people over 65 reflects their much greater familiarity and experience with the drugs they use," speculated the author of the report, Schering executive Jack Robbins, PhD. "It may be that the elderly feel they don’t need a brush-up session on how to use a drug they have been taking successfully for months or years. This desire for self-sufficiency is admirable. But it can become self-defeating at an age when illness and injury are especially prevalent."
Roughly two-thirds of patients and physicians surveyed said pharmacists do a good job providing medication information verbally; about 80% of both groups said pharmacists do a good job providing written information.
Pharmacists were not nearly as commendatory in their estimation of physicians’ counseling performance. Only 18% said physicians do a good job providing verbal instructions, and only 15% said physicians are effective in providing written information. In Robbins’ view, these findings suggest that pharmacists may be failing to take full advantage of an important counseling ally. "Pharmacists are rejecting the judgment of more than half of their customers, who think doctors are more competent or consider the two professions equally capable," he wrote. "More important, if patients start believing them, pharmacists may be downgrading a strong if largely unrecognized asset" in the counseling arena.
The report concluded with an upbeat prediction about pharmacists’ future patient care roles: "In the new century and the new millennium we are entering, disease management is likely to become the dominant style of health care delivery, integrating the best principles of pharmacy and medicine in a comprehensive manner along the entire continuum of care."
The Prevention of Falls in the Elderly Trial (PROFET), led by researchers at the University of London Hospital, enrolled 397 community-dwelling seniors receiving emergency department treatment after a first fall. All subjects received a complete medical evaluation while in the hospital, followed by an occupational therapy evaluation in their homes; specific environmental causes and risk factors were identified and corrected when possible. At one-year follow-up, seniors participating in the program were about 60% less likely than those in a control group receiving usual care to have experienced another fall, the investigators reported (Lancet 1999;353:93–7).
A team of researchers at the University of California, San Francisco, conducted a comprehensive analysis of nurse staffing information gleaned from the federal On-Line Survey Certification and Reporting (OSCAR) database for 1991–95. They found that average registered nurse, licensed vocational nurse, and licensed practical nurse staffing levels each rose slightly during the study period. However, average combined staffing levels increased only 7%—far lower than the rate of increase recommended in a recent Institute of Medicine report.
The data analysis indicated that the total nurse time spent with patients at U.S. nursing facilities averaged 72 minutes per resident per day in 1995, with the majority of care provided by nursing assistants.
A group of investigators led by a psychiatrist at Toronto Hospital studied the association of marital cohesiveness and blood pressure among 205 married men and women (age range, 20-65 years) who were diagnosed with but not yet receiving treatment for essential hypertension. Study subjects were asked to rate their marriage on five activities indicating marital cohesiveness: engaging in outside interests together, stimulating exchange of ideas, laughing together, having calm discussions, and working together on a project.
Ambulatory monitors were used to record subjects’ blood pressure status at 15-minute intervals during the day and hourly at night over a 24-hour period.
After controlling for job strain and other psychosocial variables, the investigators documented a consistent mean blood pressure elevation of 6 mm Hg among 14 men and women who scored lowest on the marital cohesiveness indicators (Am J Hypertens 1999;12:227 -30). "These findings may be regarded as an initial step in the development of a ‘marital strain’ construct in relation to hypertension," they concluded.
David K. Buerger
Managing Editor