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The Official Publication of the Georgia Pharmacy Association

April 2009

GPhA Convention: Opportunities for Phun and Pharmacy Education! June 20-24, 2009 Volume 31, Number 4

www.gpha.org


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Call or e-mail TODAY to schedule a time to discuss your health insurance needs.

Trevor Miller – Director of Insurance Services 404.419.8107 or e-mail at tmiller@gpha.org Georgia Pharmacy Association Members Take Advantage of Premium Discounts Up to 30% on Individual Disability Insurance Have you protected your most valuable asset? Many people realize the need to insure personal belongings like cars and homes, but often they neglect to insure what provides their lifestyle and financial well-being - their income! The risk of disability exists and the financial impact of a long-term disability (90 days or more) can have a devastating impact on individuals, families and businesses. During the course of your career, you are 3½ times more likely to be injured and need disability coverage than you are to die. (Health Insurance Association of America, 2000) As a member of the Georgia Pharmacy Association, you can help protect your most valuable asset and receive premium discounts up to 30% on high-quality Individual Disability Income Insurance from Principal Life Insurance Company.

For more information visit www.gphainsurance.com. * Association Program subject to state approval. Policy forms HH 750, HH 702, HH 703. This is a general summary only. Additional guidelines apply. Disability insurance has limitations and exclusions. For costs and details of coverage, contact your Principal Life financial representative.

The Georgia Pharmacy Journal

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16

Departments

GPhA Convention Registration Information June 20­24, 2009 Ponte Vedra Beach, Florida Sawgrass Golf Resort and Spa, A Marriott Resort FEATURE ARTICLES

7 8 12 19 20

7 9 11 11 17 18 22 24 25 30

Eggs & Issues Save the Date 2009 Spring Region Meetings New Members GPhA Members in the News Pharmacy-Based Immunization Delivery BLS Healthcare Provider Course Pharmacy Schools in the News Pharmacy School Alumni Dinner Information Journal CE GPhA Board of Directors

Advertisers

Meeting with U.S. Representative Nathan Deal GPhA’s Legislative Affairs Information & Resources Action Plan for Implementation of the JCPP Future Vison of Pharmacy Practice

2 2 5 8 10 15 15 21 31 32

The Insurance Trust Principal Financial Group PharmStaff GoodSense AIP Meeting Announcement Toliver and Gainer Michael T. Tarrant Pharmacists Mutual Companies Bowl of Hygeia The Insurance Trust

Being a Well Person VIP Day at the Capitol: February 18, 2009

COLUMNS

4 6

President’s Message Editorial

For an up­to­date calendar of events, log onto

www.gpha.org.

The Georgia Pharmacy Journal

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PRESIDENT’S MESSAGE Robert Bowles, Jr. , R.Ph., CDM, CFts GPhA President

Plan Now to Attend the GPhA Convention, June 20-24, 2009 ow is the time to make plans to attend GPhA’s Annual Convention at the Sawgrass Golf Resort and Spa, a Marriott Resort at Ponte Vedra Beach, Florida. This will be a great time to visit with old friends, make new friends, and take part in an incredible learning experience with continuing education opportunities and events that are being planning with pharmacists from every practice setting in mind.

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GPhA’s CE Committee, chaired by Jonathan Marquess, Pharm.D., CDE, CDM, met in September and then again in January to develop goals and ideas for CE programs that might be provided at our convention. Last Beach Club available to guests of the Sawgrass Golf Resort and Spa, A Marriott Resort. fall, a Convention Planning Committee Convention Planning Committee in developing was appointed, chaired by Liza Chapman, Pharm.D. programming that will meet the needs of the different Members of this committee are Josh Kinsey, Pharm.D.; practice settings in our membership. Rusty Lee, R.Ph. CGP, FASCP, LNHA; Pam Marquess, Pharm.D.; Mary Meredith, R.Ph.; Debbie Initially, the Convention Planning Committee submitted Nowlin, R.Ph.; and Sharon Sherrer, Pharm.D., CDM. a “needs survey” to the GPhA membership. The Staff support has been provided by Ruth Ann McGehee committee received very positive feedback and numerous and Mary Ellen Chapman. These two ladies provide topics that were of interest to them. Some of the tremendous insights into this process. This list of information that was provided to the committee was individuals represents a diversity of practice settings. The about CE programming that is required each year for CE Committee has been a valuable resource for the The Georgia Pharmacy Journal

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CE programs representing all practice settings ranging from diabetes education to new drug updates and pharmacy ownership. I hope that each of you is using our website and taking Ballroom at the Sawgrass Golf Resort and Spa. advantage of all of license renewal in other states, the information that is available at certifications that require this site. Certainly, our website has maintenance CE, speaker taken on a new light under the suggestions, and possible funding direction of Kelly McLendon, sources. The Convention Planning GPhA’s Director of Public Affairs. Committee is focused on trying to She continues to amaze with her provide appropriate and current insights. It is important to take time programs, (i.e., immunization NOW and go to www.gpha.org to training for pharmacists along with register for the GPhA Convention at BCLS certification.) There will be Sawgrass Golf Resort and Spa at

YOU’VE FOUND IT!

Ponte Vedra Beach, Florida, June 20–24, 2009. As CE programs are finalized, they will be posted to the GPhA website. Georgia Pharmacy Foundation’s Annual Golf Tournament will be held again this year at the Convention. Since the Henderson Scholarship and Pruitt Scholarship are both fully funded, all proceeds from the 2009 Foundation Golf Tournament will go to scholarships this year. We need people to sponsor holes for this golf tournament. Remember, ALL of the proceeds from the golf tournament will go for scholarships this year. Please contact Regena Banks, the Georgia Pharmacy Foundation Director, at 404.419.8121 to sponsor a hole at the golf tournament. This year’s convention will be a memorable one with many new and exciting opportunities. Get Involved! Get Excited! Go to www.gpha.org to register for this year’s convention.

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April 2009


EXECUTIVE VICE PRESIDENT’S EDITORIAL Jim Bracewell Executive Vice President / CEO

GPhA’s Eggs & Issues Event In Our Nation’s Capitol n May 11-12, 2009, GPhA will have a private breakfast in Washington, D.C., with the U.S. Congressmen from Georgia to discuss pharmacy healthcare issues. This opportunity is a 24 hour investment of time for the future of the pharmacy profession.

These discussions will not happen if pharmacists choose not to attend these events on May 11-12, 2009. Stay home and complain or go to Washington, D.C. and do something to improve the future of community pharmacy in Georgia.

O

No one knows how many pharmacists it will take going to Washington, D.C., to demonstrate to the Georgia congressional delegation that action is needed on pharmacy issues , but one thing is for certain: if enough pharmacists speak their minds and share their concerns their voices will be heard, and will facilitate change.

Delta has a flight to Reagan National Airport in Washington, D.C. for $74 each way and for members of GPhA’s Academy of Independent Pharmacy. GPhA has reserved rooms at no cost to the member at the Embassy Suites Hotel in Alexandria, VA, and long as there are 2 people per room.

What a year GPhA is having in the Georgia Legislature in 2009! What a celebration of the power of grassroots efforts!

The schedule of events includes, dinner Monday night at Joe Thiemann’s Restaurant for a briefing on the pertinent federal issues that effect pharmacy. The next morning members will board the Metrorail to the Rayburn Congressional Office Building for the opportunity to discuss pharmacy issues with Georgia congressmen at a private breakfast just for GPhA members and the Georgia congressmen. Each congressman will have a round table to sit and hear personally from the pharmacists from back home in his district.

What changes can GPhA members make if pharmacists apply that same commitment to changing things in Washington, D.C.? Georgia Pharmacy Association’s Eggs & Issues Breakfast Tuesday, May 12, 2009 Rayburn Congressional Office Building-Washington, D.C.

What will be the outcome of this venture? Pharmacy will be better off because pharmacists will have the opportunity to discuss exempting pharmacy from DME certification and discuss AMP and its effect on the practice of pharmacy with your congressman.

Register on the GPhA website www.gpha.org or call Verouschka Betancourt-Whigham at 404.419.8102 at GPhA’s Academy of Independent Pharmacy. Pharmacists + Eggs + Issues = Results.

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SG AP Vh E A T UH PE D ADTAET E

Become a part of GPhA’s grassroots team and support your profession!

May 12, 2009 Eggs and Issues Breakfast Washington, D.C. Sign up online at www.gpha.org.

How Many Pharmacists Does It Take To Persuade A US Congressman? U.S. Congressman Nathan Deal said he would co-sponsor HB 616 to remove pharmacists from the DME Certification requirement. The congressman also said he supports a remedy to AMP and will work to help pharmacy find a solution. To reinforce the need for these changes, pharmacists should consider attending GPhA’s Eggs & Issues Breakfast in Washington, D.C. on May 12, 2009 to meet Georiga congressmen and discuss these important pharmacy issues. The Georgia Pharmacy Journal

February 23, 2009, GPhA’s Academy of Independent Pharmacy members met with U.S. Rep. Nathan Deal. From left to right in the back: Steve Adams, R.Ph., Congressman Nathan Deal, Ron Cain, R.Ph., Barry Breaden, R.Ph., Allison Layne, C.Ph.T., Jim Bracewell, GPhA’s EVP and CEO, Cleve Brown, R.Ph., Wayne Gee, R.Ph.; in the front: Tim Short, R.Ph., Jeff Lurey, R.Ph., Laird Miller, R.Ph.

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GPhA’s Legislative Affairs Information & Resources by Stuart Griffin, Director of Governmental Affairs - sgriffin@gpha.org 1,900 members are receiving the weekly Pharm-O-Grams that are sent to via e-mail each Friday during the legislative session. For those who do not receive these weekly updates, here is an update of our three top legislative priorities as of March 16, 2009. To receiving breaking news from GPhA and weekly legislative updates, subscribe to the Pharm-O-Gram at the GPhA website at : www.gpha.org , or send an email to Kelly McLendon at kmclendon@gpha.org

legislation that could affect the practice of pharmacy in Georgia. Having access to the weekly Pharm-O-Gram allows you to see the progress being made and helps you get involved in the process as a member. The Pharm-O-Gram is a very important resource to the GPhA members to keep them updated on the latest happenings at the Georgia State Capitol, but there is another resource GPhA members should learn to access and take advantage of. This resource is the Georgia General Assembly website: www.legis. state.ga.us.

Priority #1: HB 217 – Immunization Protocol – Rep. Jimmy Pruett HB 217 authorizes the use of influenza vaccine orders for patients and provides for influenza vaccine protocol agreements between physicians and pharmacists.

While visiting the General Assembly website you can find your legislators and read their biographies and also find out the best way to contact them. The website also gives you access to all legislation, past and present, that is being debated. You can see if your legislator voted on certain pieces of legislation that are important to pharmacy and you can find the dates and times of important legislative committee meetings where pharmacy legislation may be discussed. During the Legislative Session you can access a live feed of the General Assembly. This is just the beginning of what you can access on the General Assembly’s website. I encourage all of you to visit the site and explore everything that is offered.

HB 217 has passed the House of Representatives and is waiting to be heard in the Senate Health and Human Services Committee. Priority #2: SB 123 – Pharmacy Benefits Manager Regulation – Sen. Lee Hawkins SB 123 provides for regulation and licensure of pharmacy benefits managers by the Commissioner of Insurance. This bill requires the PBM to hold a surety bond, requires they do not engage in the practice of medicine and requires the PBM adhere to the ‘Pharmacy Audit Bill of Rights.’

These two resources are valuable to your involvement with the association. Please feel free to use me as a resource anytime you have a question about GPhA legislative affairs.

SB 123 has passed the Senate and has passed the House Insurance Committee and is now waiting to be heard by the Rules Committee before it can be voted on by the House of Representatives. Priority #3: HB 614 – Prescription Drug Monitoring – Rep. Sharon Cooper HB 614 enacts the “Georgia Prescription Monitoring Program Act.” This bill provides for the establishment of a program for the monitoring of prescribing and dispensing Schedule II, III, IV, or V controlled substances by the Georgia Drugs and Narcotics Agency. HB 614 has passed the House of Representatives and is waiting to be read and referred to a Senate committee. The legislation above represents the Georgia Pharmacy Association’s top three priorities for the 2009 Legislative Session. Currently, GPhA is tracking 20 other pieces of

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GPhA 2009 Spring Region Meetings State Pharmacy Law 2009 Update

Sharon Sherrer, Pharm.D., CDM, Chairman, 2008-2009 Robert Bowles, R.Ph., CDM, President, 2008-2009 Eddie Madden, R.Ph., President-Elect, 2008-2009 Dale Coker, R.Ph., First Vice President, 2008-2009 Jack Dunn, R.Ph., Second Vice President, 2008-2009 Jim Bracewell, Executive Vice President

Schedule of Spring 2009 Region Meetings For additional information and to RSVP go to www.gpha.org April 21, 2009 - 7:00-9:00 p.m. April 21, 2009 - 6:00-9:00 p.m. April 21, 2009 - 6:30-9:00 p.m. April 23, 2009 - 6:30-9:00 p.m. April 23, 2009 - 6:00-9:00 p.m. April 23, 2009 - 7:00-9:00 p.m. April 28, 2009 - 6:30-9:00 p.m. April 28, 2009 - 6:00-9:00 p.m. April 28, 2009 - 6:30-9:00 p.m. April 30, 2009 - 6:30-9:00 p.m. April 30, 2009 - 6:30-9:00 p.m. April 30, 2009 - 6:00-9:00 p.m.

Holiday Inn Tellus NWGA Sci. Museum Columbus Reg. Med. Center The Village at Moore Village Griffin Country Club Carey Hilliard’s Restaurant TBA Cadwaller’s Cafe Healy Point Country Club Stonebridge Country Club Mercer University Provino’s Italian Restaurant

Region 8 - Waycross Region 7 - White Region 3 - Columbus Region 12 - Dublin Region 4 - Griffin Region 1 - Savannah Region 10 - TBD Region 11 - Augusta Region 6 - Macon Region 2 - Albany Region 5 - Atlanta Region 9 - Canton

Larry Batten Pam Marquess Renee Adamson Ken Eiland Bill McLeer Alex Tucker Chris Thurmond Marshall Frost Bobby Moody Alex Tucker Shobhna Butler Alissa Rich

For details about the Continuing Education Program at the Spring Region Meetings and to RSVP for this event visit www.gpha.org or call GPhA at 404.231.5074. The Georgia Pharmacy Association is accredited by the Accreditation Council of Pharmacy eduction as a provider of continuing pharmacy education.

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AIP Spring Meeting April 25-26, 2009

Sea Palms Resort, St. Simons Island, GA Come relax in the lush oasis that is Sea Palms Resort. Take a walk under ancient live oaks, where the ocean air mixes with a soft marsh breeze. Bike on the beach, play golf, tennis or just relax on your balcony overlooking the island's natural beauty. Sea Palms Resort offers the perfect setting for our AIP Spring Meeting.

AIP members and non-members are welcome to come and enjoy this networking and learning opportunity. Saturday, April 25, 2009 7:00 am – 8:00 am – 8:00 am – 9:45 am –

Registration/Continental Breakfast How to Prepare a Business Plan/Loan Package for a Community Pharmacy (.15 CEU) Richard Allen Jackson, Ph.D.

8:45 am – 9:00 am Break 9:45 am – 10:00 am Break 10:00 am – 11:45 am – Financial Analysis and Planning to Increase Valuation for Community Pharmacy (.15 CEU) Richard Allen Jackson, Ph.D.

10:45 am – 11:00 am 4:00 pm – 7:00 pm – Sunday, April 26, 2009 7:00 am – 8:00 am – 8:00 am – 9:00 am –

Break Cocktail Reception with exhibiting AIP Partners

Registration/Continental Breakfast Community Pharmacy Valuation and Junior Partnership Establishment (.1 CEU) Richard Allen Jackson, Ph.D. 9:00 am – 9:10 am Break 9:10 am – 10:10 am – Legal Documentation in the Transfer of Ownership (.1 CEU) - Richard Allen Jackson, Ph.D. 10:10 am – 10:20 am - Break 10:20 am – 11:20 am – Financial Planning Rx: After the Sale, Now What? (.1 CEU) - Michael E. Tarrant 11:20 am – 11:30 am - Break 11:30 am – 11:45 am - AIP Business Meeting

Please call 1.800.841.6268 for reservations (Ask for the AIP room block) Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. For complete details of the CPE programs, please visit www.gpha.org.

Registration: (For Planning Purposes Please Fill Out and Return) Member’s Name: __________________________Nickname (for badge): _______________________________ GA R.Ph. License No:___________ Pharmacy Name: ______________________________________________ Address: ______________________________________________________________________________ Phone:(____)____________ Fax:(____)_____________ E-mail Address: _____________________________ Please circle the following: GPhA™ Member? Yes No AIP Member? Yes No If no, there is a $25.00 charge Please return this form with a check or call 404.237.8435 to give a credit card. **If Spouse/Guest is attending please print his/her name: _____________________________________________ Nickname (for badge): ____________________________ Is the above guest a member of GPhA? Yes____ No ____

Please Fax Registration to 404.237.8435 The Georgia Pharmacy Journal

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Welcome to GPhA! The following is a list of new members who have joined Georgia’s premier professional pharmacy association! E. Carman, Marietta William M. Flatau, J.D., Macon Kimberly Marie Kopp, C.Ph.T., Waverly Hall James Robert Potts, R.Ph., Las Vegas, NV James Isaac Rogers, Pharm.D., Chester

Domenick A. Serra, R.Ph., Eatonton Adam James Snyder, Pharm.D., Atlanta Kristen Whelchel, Pharm.D., Macon Julie M. Wickman, Pharm.D., Suwanee William Wrenn, Watkinsville

GPhA MEMBERS IN THE NEWS Sally Huston, Ph.D. , Assistant Professor at the University of Georgia College of Pharmacy has been named a grant reviewer for the Health Resources and Services Administration of the U.S. Department of Health and Human Services. Huston also gave a presentation at the 2009 Mental Health Pharmacotherapy symposium on Ethics and Pharmacogenomics. Bill Atkins, R.Ph., was presented with a framed copy of the Georgia Pharmacy Association’s Resolution honoring his service to the profession of pharmacy at GPhA’s VIP Day at the Capitol on February 18, 2009.

Bill Atkins, R.Ph., receiving the resolution honoring his many years of service to the profession of pharmacy.

The Georgia Pharmacy Journal

Charlie Hildebrand, Jr., R.Ph. was honored for his contributions to GPhA’s Governmental Affairs program by presenting him with the Bobby Parham Good Government Award at GPhA’s VIP Day at the Capitol on February 18, 2009. Wayne Oliver, J.D., GPhA’s former Director of Governmental Affairs, who attended VIP Day to share this honor with Charlie said, “He should be the poster child for volunteerism and certainly deserves the recognition and award Charlie’s dedication really set the bar for GPhA’s governmental affairs program. Now, under Neal’s leadership, that spirit of volunteer involvement in GPhA’s governmental affairs program which Charlie inspired, continues forward today.”

Azza El-Remessy, R.Ph., Assistant Professor at the University of Georgia College of Pharmacy presented “Oxidative stress alters growth factor signaling in diabetic retinopathy” at the Vision Discovery Institute at he Medical College of Georgia. If you have an item that you would like included in the GPhA Members in the News section of The Georgia Pharmacy Journal please email the item to Kelly McLendon at kmclendon@gpha.org or fax it to her attention at 404.237.8435.

Charlie Hildebrand, Jr., R.Ph., receiving GPhA’s Bobby Parham Good Government Award.

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Feature Article

Action Plan for Implementation of the JCPP Future Vision of Pharmacy Practice Project Summary time to success in achieving the vision were identified:

Background The concept of “optimal medication therapy” implies that the use of medicines occurs within a system that assures the highest likelihood of achieving desired clinical, humanistic and economic outcomes. However, significant gaps exist between the goal of optimal drug therapy and the current state of medication use in the United States. This public health crisis calls for significant changes in our medication use system and in how key healthcare resources are deployed. One such resource is the nation’s pharmacists.

Practice Model: Articulate a practice model for the profession that is consistent with the Future Vision of Pharmacy Practice.

Payment Policy: Align payment systems with the pharmacy practice model envisioned by the Joint Commission of Pharmacy Practitioners. Transition from a payment system based mainly on product-based reimbursement to one that includes appropriate payment for professional services and management of the Pharmacy organizations, pharmacy education, and many medication use system. individual pharmacists have responded by redefining pharmacy’s professional mission and how pharmacists’ Communications: Help transform pharmacy by building services benefit patients and society. Evolutionary change widespread stakeholder understanding of, support for, and will not suffice if pharmacy as a whole is to provide much commitment to the practice roles and responsibilities of needed leadership in meeting society’s need for an optimal pharmacists and the new economic foundation for the medication use system. A broadly supported, strategically profession as articulated by the JCPP Future Vision of driven plan must be implemented to address the most Pharmacy Practice. critical barriers that currently prevent patients and the healthcare system from realizing the maximum benefit Articulation of a desired pharmacy practice model from pharmacists’ unique knowledge, skills, and describes not only those patient care services provided by professional capabilities. pharmacists, but must assure that such services are widely and consistently available in all patient care settings. The An important first step was the articulation of a Future practice model must be financially viable and economically Vision of Pharmacy Practice by the Joint Commission of feasible. Payment policy reform is critical. Patients, private Pharmacy Practitioners (JCPP): and government payers, and the other health professions must understand and demand the medication therapy Pharmacists will be the health care professionals responsible for management and other patient care services of providing patient care that ensures optimal medication therapy pharmacists. outcomes.

The Action Plan

The JCPP vision statement further describes pharmacy practice and how pharmacy will benefit patients and society in 2015. To facilitate achieving this vision, JCPP undertook the effort to develop a strategically driven implementation plan. Three Critical Areas deemed most important at this The Georgia Pharmacy Journal

This Action Plan is designed to focus effort on those issues felt most critical for success. It is possible that one or more of the action steps recommended may not align fully with current policy of one or more of the organizations that participated in the development of this Action Plan. If so, 12

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its inclusion should not be taken to mean that organization has officially endorsed the recommended policy. The plan developers have outlined suggested courses of action likely to achieve their respective Critical Success Factors, and thereby facilitate achieving the JCPP Future Vision of Pharmacy Practice. It is expected that further discussions to resolve these possible areas of nonalignment will take place as part of efforts to implement the recommended strategies.

by pharmacists in all practice settings that optimize the therapeutic outcomes of patients of all ages.

Although some practices or individual pharmacists may opt to emphasize one or two of these areas over the other(s) based on location or patient population served, the model as articulated is independent of practice site or patient care setting. These practice responsibilities are equally applicable to the hospital, community pharmacy, nursing home, clinic, physician’s office, or wherever else a pharmacist may choose to practice. The model describes the set of services that patients can expect to receive from the pharmacists and other personnel that comprise the practice when they have a pharmacy encounter.

Critical Area II: Payment Policy—Current payment policy for pharmacy services is driven by product-based reimbursement (i.e., payment for the drug product and the act of dispensing it). Current payment policy generally is not aligned with all three elements of the proposed practice model. As only one example of this misalignment, a pharmacist’s activities to simplify a patient’s complex drug therapy regimen may actually decrease his/her revenue if it results in the patient taking fewer medications, even though the patient and payer would benefit.

Dissemination of the JCPP-envisioned practice model will occur best through a combination of practitioners’ desire to reengineer their practices (voluntary uptake), societal demand, regulatory pull through, and peer pressure (business competition). Certainly, example practices exist today that embody the JCPP vision. The goal is to move from the current state where these practices may be Critical Area I: Practice Model—Three broad areas considered “centers of excellence” to one where the JCPP comprise the proposed practice model: vision is considered the standard of practice. This Critical Area is focused on widely promulgating a new vision of ● medication therapy management that pharmacy practice. It is focused on developing pharmacy’s achieves optimal patient outcomes; capacity to provide the described services. Nine Key ● appropriate, safe, accurate, and efficient Elements that characterize viable business models for the access to and use of medications; and delivery of medication therapy management and other ● services that promote wellness, health patient care services by pharmacists in any practice setting improvement, and disease prevention. were identified.

The Plan focuses on activities to “transition from a Recognizing that this practice occurs in a “structured payment system based mainly on product-based system across a continuum of care” conveys that pharmacy reimbursement to one that includes appropriate payment is not only integrated into the broader healthcare system, for professional services and management of the but that pharmacy itself represents a system of care with medication use system.” Although there is a need to defined links and relationships between practitioners in address the payment system for provision of drug product, different practice settings. One of pharmacy’s that important task is not addressed within the proposed responsibilities is to assure the continuity of medication Action Plans. therapy as patients move among these settings. As noted earlier, some practices or individual pharmacists Reference is made throughout this document to may opt to emphasize one or two elements of the practice pharmacists’ “medication therapy management services.” model over the other(s) based on location or patient As used here, the term is not meant to be limited to population served. For example, a pharmacist practicing in Medication Therapy Management Services as defined by an ambulatory clinic or physician office may focus on Medicare Part D Instead, “medication therapy enhancing patients’ wellness and medication therapy management” refers to those patient care services provided outcomes and may not be directly involved in dispensingThe Georgia Pharmacy Journal

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related activities. Payment policy for pharmacy services management of my medication therapy. I have heard of this must be able to make this economically viable. health benefit called “medication therapy management” and know where to get it. I know that health screenings or As payers increasingly adopt the concepts of value-based immunization services are available at my pharmacy. purchasing, these pay-for-performance systems must identify and be based on “pharmacist-sensitive” outcomes 2. Understanding - I understand why it’s important that a (i.e., patient outcomes that pharmacists are able to impact). pharmacist help manage my medication therapy. I The recommended Action Plans focus on private and understand how pharmacists contribute to my overall government payers respectively. It is understood that those health by providing services like health education, disease who pay for healthcare usually will pay only for what the screening, and immunizations. patient (consumer) values and demands. Efforts identified within the Plan to solidify and organize consumer demand 3. Support - I have experienced personal benefit from the for pharmacists’ medication therapy management and medication therapy management and other patient care other patient care services is the necessary third element of services provided by pharmacists. These benefits are of a comprehensive effort to implement the JCPP Future value to me. Vision of Pharmacy Practice. 4. Commitment - I value these services to such an extent Demand for quality patient care services provided by that I consider them essential. pharmacists, and for the management of safe and efficient medication distribution systems, aligns the financial incentives 5. Action - Because of their importance and value to me, I of patients, payers, and providers and sustains the JCPP- expect and demand that pharmacists’ medication therapy management and other patient care services are available to envisioned pharmacy practice model. me and are provided consistently in all healthcare settings; Critical Area III: Communications—The Plan and that these services are covered by my health insurance recommends activities to create demand for pharmacists’ benefits. medication therapy management and other patient care The recommended Action Plans outline a series of steps to services among a variety of stakeholders, including: implement strategic communications plans to create ● patients, families, and lay care givers; demand for pharmacists’ medication therapy management ● physicians and other health professionals; and other patient care services. It must be stressed, ● payers and policy makers; however, that creating such demand must begin at the level ● corporate employers of pharmacists; and of the individual pharmacist and pharmacy. It must be part ● individual pharmacists themselves. of every patient-pharmacist or physician-pharmacist encounter. A person cannot be expected to truly value and The Plan identifies a single over statement of strategic demand something that s/he has never experienced. These intent: Create demand among patients, care givers, and communications plans will be of little use if the pharmacist other health professionals for pharmacists’ medication services for which they are designed to create demand are therapy management and other patient care services. not routinely and consistently available across the continuum of patient care. The recommended Action Plans are built around a fivestep communications process of building: Patients and other stakeholders understand, use, and consider essential the medication therapy management and other patient care services of pharmacists. The following describe what selected aspects of pharmacy Example Patient Knowledge, Attitudes, Behaviors practice and healthcare will look like when this desired future state has been achieved: 1. Awareness - I am aware that pharmacists can help with The Georgia Pharmacy Journal

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decisions about their health care. ● Purchasing decisions for pharmacy services are based on the ability of the practice to achieve desired medication therapy outcomes, rather than mainly on the cost of the drug product. ● Patients, payers, and healthcare systems expect pharmacists to provide medication therapy management. Pharmacists hold shared accountability with patients and other health professions for the desired outcomes of medication use.

It is the standard of care for pharmacists to work cooperatively with other healthcare professionals to provide or oversee: medication therapy management that achieves optimal patient outcomes; appropriate, safe, accurate, and efficient access to and use of medications; and services that promote wellness, health improvement, and disease prevention. ● Pharmacists’ medication therapy management and other patient care responsibilities are covered services in all health benefits programs. Pharmacists are paid fairly for their professional services and management of the medication use system. ● Pharmacists are widely recognized as the primary and most trusted source for unbiased information and advice regarding the safe, appropriate, and costeffective use of medications. ● Patients, payers, and other healthcare professionals recognize pharmacists as the medication use specialists. ● Patients are active participants in making

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The Georgia Pharmacy Journal

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April 2009


GPhA Convention June 20-24, 2009 Sawgrass Golf Resort and Spa, Ponte Vedra Beach, Florida Register Online Today for...

Preserving the Triad GPhA’s 2009 Convention will be held at the Sawgrass Golf Resort and Spa in June. This is a favorite venue of GPhA members. With quick access to the gorgeous beach, a spacious and luxurious hotel and spa, and delicious food, we are assured a relaxing and educational convention. GPhA offers an “early bird” convention rate through the end of April. Hotel rooms fill quickly so make your reservations now and plan to attend the 2009 Convention. Register online at www.gpha.org or call 404.231.5074 to receive a paper registration form. GPhA Registration Type GPhA Member GPhA Member with Spouse or Guest and Student Sponsorship GPhA Member with Spouse or Guest GPhA Member with Student Sponsorship Spouse or Guest Only Registration (Does Not Include CE) GPhA Non-Member GPhA Non-Member with Spouse or Guest and Student Sponsorship GPhA Non-Member with Spouse or Guest GPhA Non-Member with Student Sponsorship

Early Bird $295 $660 $535 $420 $240 $470 $835 $710 $595

Sawgrass Golf Resort and Spa, A Marriott Resort For Resort Reservations call: 1.800.457.4653 & indictate you are attending the GPhA convention. Room Block Expires 5/15/2009 so make your reservations today! Single or Double Room $179 Island Green Villa Suite (1 Bedroom and Full Kitchen) $199 Island Green Villa Suite (2 Bedroom and Full Kitchen) $378 Rates include Parking (a $10 per day value) and Internet Access (a $12.95 per day value).

5/1-6/1 $320 $710 $585 $445 $265 $495 $885 $760 $620

After 6/1 $345 $735 $610 $470 $265 $520 $910 $645 $645

Convention Registration Fee: includes admittance to CE Sessions, Sunday Opening Dinner, All Refreshments, Exhibits and Entertainment, President’s Reception, Awards Banquet, Coffee/Dessert Reception.

Tentative GPhA Annual Convention Programming HIV/AIDS: The Pharmacists Perspective Marketing for Compounding Program New Drug Update 2009 Medicare Diabetes Screening Project Medication Errors Managing and Monitoring Diabetes Execution - The Art of Turning Pharmacy Vision Into Reality Pharmacy Law Update *APhA Pharmacy-Based Immunization Delivery Program *BLS Healthcare Provider Course *additional fee applies Additional details on the tentative programs will be posted to www.gpha.org as they become available. The Georgia Pharmacy Association is accredited by the Accreditation Council of Pharmacy eduction as a provider of continuing pharmacy education. These activities are eligible for ACPE credit; see final CPE activity announcement for specific details.

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Pharmacy-Based Immunization Delivery Saturday, June 20, 2009 (7:30 AM - 6:00 PM) Hosted by: GPhA Each participant must be CPR or BCLS certified in order for the certificate of achievement to be valid. Visit www.gpha.org for details regarding the BLS Healthcare provider course that will be offered at the convention in June. To register For this event visit www.gpha.org. Registration for these event can be found on the convention registration page. For more information about this program including Continuing education details visit www.gpha.org. Registration for this event closes May 20, 2009, to allow adequate time to complete the home study. No exception will be made. Course hand books with contain materials for both the self study component and the live seminar will be mailed upon receipt of payment. The GPhA reserves the right to cancel the Pharmacy-Based Immunization Program if fewer than 20 participants are registered by May 20, 2009. Pharmacy-Based Immunization Delivery is an innovative and interactive training program that teaches pharmacists the skills necessary to become a primary source for vaccine information and administration. The program teaches the basics of immunology and focuses on practice implementation and legal/regulatory issues. The purpose of this educational program: 1. Provide comprehensive immunization education and training 2. Provide pharmacists with the knowledge, skills, and resources necessary to establish and promote a successful immunization service 3. Teach pharmacists to identify at-risk patient populations needing immunizations 4. Teach pharmacists to administer immunizations in compliance with legal and regulatory standards The American Pharmacists Association and the Georgia Pharmacy Association are accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Pharmacy-Based Immunization Delivery: A Certificate Program for Pharmacists was developed by the American Pharmacists Association, and is supported inpart by an educational grant from VaxServe.

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BLS Healthcare Provider Course Monday, June 22, 2009 (1:00 p.m. - 3:00 p.m.) Hosted by: GPhA BLS for Healthcare Provider card is issued upon successful completion of the course. The card is valid for a period of 2 years.

Course Description: The BLS Healthcare Provider Course is designed to provide a wide variety of healthcare professionals the ability to recognize several life-threatening emergencies, provide CPR, use an AED, and relieve choking in a safe, timely and effective manner. The course is intended for certified or noncertified, licensed or nonlicensed healthcare professionals. Course Length: Approximately 2 hours Intended Audience: Healthcare providers such as physicians, pharmacists, nurses, paramedics, emergency medical technicians, respiratory therapists, physical and occupational therapists, physician's assistants, residents or fellows, or medical or nursing students in training, aides, medical or nursing assistants, police officers, and other allied health personnel. Instructor: Linda Bell, MSN, ARNP, EMT-P Task Force Chairman for NE Florida #3 AHA ECC Family Nurse Practitioner Programs Coordinator for Consultant Services, AHA Training Center for BLS, ACLS, PALS, NRP programs Contact information: For information contact Mary Ellen Chapman at mechapman@gpha.org or 404.419.8126 Registration fee: $60.00 per person Please be advised that this program is subject to cancellation if the required minimum number of registrants is not met by May 20, 2009. Register for this program at www.gpha.org.

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Pharmacy News

Being a Well Person by Trevor Miller, Director of Insurance Services - tmiller@gpha.org

Definition of Wellness

What is the definition of wellness? More than ever before, we hear this word in the news, on billboards, in conversation and even at work. Interestingly, there is no universally-accepted definition of wellness. There is, however, a set of common characteristics seen in most thoughtful attempts at a definition of wellness. We generally see a reference to a “state of well-being,” which is vague, to say the least. Also frequently seen is a “state of acceptance or satisfaction with our present condition.” The truth is wellness is a tough word to define. Charles B. Corbin, a Professor Emeritus in the Dept. of Exercise and Wellness of Arizona State University, gives us this definition of wellness: “Wellness is a multidimensional state of being describing the existence of positive health in an individual as exemplified by quality of life and a sense of well-being.” Wellness is an active process of becoming aware of and making choices toward a more successful existence. ●

Process means that improvement is always possible.

Dimensions of Wellness

If wellness is multidimensional, what are the dimensions of wellness? The most commonly described subdimensions are the following: 1. Social Wellness 2. Occupational Wellness 3. Spiritual Wellness 4. Physical Wellness 5. Intellectual Wellness 6. Emotional Wellness 7. Environmental Wellness 8. Financial Wellness 9. Mental Wellness 10. Medical Wellness Vocational Wellness and Environmental Wellness are not personal in nature, but a person's working and physical environments are factors that influence personal wellness. Research is necessary to clearly establish the relationship among the sub-dimensions. While the exact dimensions of wellness could be debated, there is believe that the ones listed here make up a good list.

Ultimately, the dimensions of wellness all fall into two Aware means that we are continuously seeking broader categories, being mental and physical. This is critical to note, as the mental or emotional component is more information about how we can improve. often overlooked as focus on such main staples as physical Choice means that we consider a variety of fitness and chronic disease risk factors. In order to achieve a state of wellness in our own lives or try to guide others to options and select those in our best interest. it, we must pay due diligence to each of the dimensions. We may not all be Success is determined by each individual to be physically fit or free from their collection of life accomplishments. disease; we can, however, strive for increased wellness by working with what we’ve been dealt.

Source - National Wellness Institute The Georgia Pharmacy Journal

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Feature Article

VIP Day at the Capitol: February 18, 2009 n February 18, 2009, 260 pharmacists gathered at the Georgia State Capitol in Atlanta to speak out on behalf of their profession. On the morning of the festivities GPhA hosted a breakfast at the Sloppy Floyd Building where our guest speaker, Senator Don Balfour (RGwinnett) spoke about the challenges of legislating during tough financial times , and Stuart Griffin, GPhA’s Director of Government Affairs, briefed attendees about pharmacy legislation.

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GPhA also took time during the breakfast to honor Senator Lee Hawkins as GPhA’s 2009 Legislator of the Year, Bill Atkins, R.Ph., for his contribution to the profession of pharmacy during his career; and Charlie Hildebrand, Jr., R.Ph., for his commitment to the GPhA Governmental Affairs program by honoring him with the Bobby Parham Good Government Award. After bestowing these honors and have breakfast the pharmacists and students moved to the Capitol where they had time to meet with their legislators and discuss pharmacy legislation.

The Georgia Pharmacy Journal

Senator Lee Hawkins receiving GPhA’s 2009 Legislator of the Year Award from Robert Bowles, GPhA’s President.

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GEORGIA PHARMACY SCHOOLS’ NEWS

Mercer University College of Pharmacy and Health Sciences News At the close of each session, the residents are encouraged to ask questions of the students which may or may not be related to the session at hand. Questions have ranged from personal issues with medication regimens to the reasons behind African-Americans being at higher risk for diabetes and hypertension. This open question and answer session provides a non-threatening environment for the residents to ask a variety of healthcare related questions and hopefully builds trust in the community allowing for improved communication with other healthcare providers.

lifton Sanctuary is a homeless shelter located in the Lake Claire neighborhood of Atlanta, Georgia, which was established initially as an emergency shelter in 1979 by the Clifton Presbyterian Church. In 2003, Clifton Sanctuary made the transition to a full time shelter with traditional housing provisions and serves homeless men over the age of 40 years. Clifton Sanctuary provides its residents with basic health care requirements (Medicaid applications, HIV/TB screenings etc), clothing and laundry facilities as well as food and shelter. Additional services offered through Clifton Sanctuary include job training seminars and arts/crafts sessions.

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A basic service noted to be missing from the Clifton Sanctuary regimen was the maintenance of healthcare as the residents were transitioning out of the shelter. Education on basic chronic disease states and instruction on monitoring chronic diseases is essential for proper management and/or prevention. The Special Populations Committee of Mercer University APhA meets with the residents of Clifton on a monthly basis to discuss various diseases and perform screenings. Presentations with the men have included basic overviews of chronic diseases such as hypertension and diabetes; covered disease state contraindications with such medications as ephedrine-based products, non-steroidal anti-inflammatory drugs, and sugar content in cough syrups; and discussions of various overthe-counter products which can be used to provide self-care. Each session students also instruct the men on assessment of blood pressure and blood glucose using personal supplies provided by the shelter. The values are then discussed and the men are provided copies of their results for their records. Mercer University College of Pharmacy and Health Sciences Students at the Clifton Sanctuary in Atlanta, Georgia

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GEORGIA PHARMACY SCHOOLS’ NEWS

University of Georgia College of Pharmacy News: VA Clinic offers unique residency in ambulatory care he collaboration between UGA and the VA clinic provides a distinctive training environment for the resident by combining clinical practice with the development of teaching skills, according to Dr. Beth Phillips, a clinical associate professor at the College and director of the PGY2 Ambulatory Care Residency program.

“For me there are certain parallels between the two residency experiences that I enjoy,” said Guffey. “Both work with patients in an outpatient setting, and both provide the opportunity to educate patients about disease state management and therapeutic life style changes. I spent a lot of time talking with patients during the community pharmacy residency about the same illnesses that I now manage in an ambulatory care setting.”

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“Our residency goals and outcomes are the same as with any specialized second-year residency,” she said. “In the pharmacotherapy clinic, we provide disease state management, optimize medication usage, and educate patients about managing their diseases, whether that might be diabetes, hypertension, chronic obstructive pulmonary disease or hyperlipidemia.”

“An important difference with this residency is the ability to actually develop relationships with patients in the clinic as a result of providing continued care,” he added, “And I especially like the experience of working in the VA system with its broad scope of practice for pharmacists.” The VA clinic also offers a unique opportunity for clinical research, another important component of the second-year residency program, said Phillips.

One of the distinguishing aspects of the VA residency program is that the VA works under a progressive scope of practice and allows prescriptive authority for pharmacists. Here pharmacists can write prescriptions and even change dosage or add medications as indicated for the disease. Additionally they can order lab tests related to the disease states they are managing.

“Since the VA operates as a closed system, all patient records are stored in a main data base. As we work with our patients, we can easily access their files to determine their medical history and medication usage and adherence,” she noted. “Many of our patients are more than 50 years old and have complex disease states; most have multiple diseases.”

“Needless to say, this type of practice greatly enhances the educational opportunities for our resident,” added Phillips, who joined the College faculty in 2007 after working for 11 years as a clinical pharmacist and faculty member at the University of Iowa and directed the PGY1 and PGY2 Ambulatory Care Residency programs at the University of Iowa Hospitals and Clinics.

Guffey’s project centers on disease state outcomes in patients referred to the pharmacotherapy clinic. He notes whether the patients meet the guideline-driven goals established for certain diseases based on risk factors and medical history; whether the services provided by the clinic impact medication adherence; and whether patients have shown improvement even if the goals have not been met. A final component looks at patient satisfaction with pharmaceutical services and care. Guffey will present his findings at the annual Southeastern Residency Conference this spring.

Another advantage of practicing in this environment is that medications are provided to all patients. Prescriptions are sent to a central mail order processing facility in Charleston, S.C., and patients receive their medications in the mail in about 10 days. “No medications are actually dispensed from the clinic,” said Phillips. “Acute care needs for chronic patients are handled by Athens Regional Medical Center and Hodgsons Pharmacy.”

The College of Pharmacy currently has eight residents in addition to Guffey – six in first-year hospital residencies at Phoebe Putney Memorial Hospital in Albany and at the Medical College of Georgia in Augusta; one in a first-year community practice residency in Athens; and one in a second-year pediatric residency at MCG. Another first-year community practice residency is planned for Fall 2009 in Augusta.

Josh Guffey is the first resident to participate in the new 12month program. His decision to undertake an ambulatory care residency was unique in that his first-year residency was spent in a community pharmacy setting rather than in a hospital, which is the customary practice site prior to undergoing the more specialized second-year residency.

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Mercer University College of Pharmacy and Health Sciences Alumni Dinner Monday, June 22, 2009 at Tento Churrascaria, Brazilian Steak House 528 North First Street, Jacksonville Beach, FL 32250, 904.246.1580 7:30 p.m. I will attend the Alumni Dinner for alumni spouses and friends of Mercer University’s College of Pharmacy and Health Sciences. Please make ______ reservations at $35.00 per person, and there will be a cash bar available. _______ Yes, I would like to sponsor ______ student(s) for the alumni dinner at $35.00 each. Name: ______________________________________________ Name of spouse and/or guest(s): Address: City:

Class/Year:

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_____________________________________________________

______________________________________________________________________

_____________________ State: ___________

Zip code:

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Work Phone: _________________________ Home Phone: __________________________ Mail registration form with check, payable to Mercer University, before June 12, 2009, to Sharon Lim Harle, Mercer University Office of Alumni Services, 3001 Mercer University Drive, Atlanta, GA 30341. For more information please call 678.547.6420 or 800.837.2905, or email lim_s@mercer.edu.

University of Georgia College of Pharmacy Alumni Dinner Buffet Monday, June 22, 2009 at the Magnolia Terrace at Sawgrass Plantation 7:30 p.m. I will attend the Alumni Dinner for alumni spouses and friends of Univeristy of Georgia College of Pharmacy. Please make ______ reservations at $35.00 per person, and there will be a cash bar available. _______ Yes, I would like to sponsor ______ student(s) for the alumni dinner at $35.00 each. Name: ______________________________________________ Name of spouse and/or guest(s): Address: City:

Class/Year:

________________

_____________________________________________________

______________________________________________________________________

_____________________ State: ___________

Zip code:

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Work Phone: _________________________ Home Phone: __________________________ Mail registration form with check, payable to UGA Foundation, before June 19, 2009, to Sheila Roberson, Director of Alumni and Public Relations, University of Georgia, College of Pharmacy, Athens, GA 30602. For more information please call 706.542.5303. The Georgia Pharmacy Journal

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Thomas A. Gossel, R.Ph., Ph.D. Professor Emeritus Ohio Northern University Ada, Ohio

J. Richard Wuest, R.Ph., Pharm.D. Professor Emeritus University of Cincinnati Cincinnati, Ohio

Gossel

Wuest

Hemorrhagic Stroke: Prevention and Treatment Goals.

The goal of this lesson is to discuss hemorrhagic stroke with focus on its clinical characteristics and treatment.

Objectives. At the conclusion of

this lesson, successful participants should be able to: 1. recognize epidemiologic information and clinical characteristics relevant to hemorrhagic stroke; 2. identify symptomatology that characterizes hemorrhagic stroke and the principles that govern clinical confirmation and management; and 3. select from a list specific therapeutic measures that are reported to modify signs and symptoms of hemorrhagic stroke.

Background

Every year in the United States, 700,000 persons suffer from stroke, and 200,000 of these events are recurrent. Approximately 270,000 persons die each year in the United States because of stroke, ranking it third in mortality behind heart disease and cancer. Hemorrhagic stroke (intracranial hemorrhage) accounts for approximately 13 percent of all strokes. Hemorrhagic stroke not only has a high case fatality, but also limited treatment options and a poor, most often disabling, outcome. Stroke leads to more long-term disability than any other disease process, and

burdens the U.S. healthcare system by a reported $57.9 billion each year.

Subarachnoid Hemorrhage

Epidemiology. Subarachnoid hemorrhage (SAH) accounts for 21,000 to 22,000 strokes each year in the United States, affecting young adults predominantly. The risk for women is 1.6 times that of men, and the risk for African-Americans is 2.1 times that of whites. The average mortality rate is 51 percent. Approximately one-third of survivors require lifelong care. Most deaths occur within two weeks after the event, with 10 percent occurring before the patient reaches a medical facility and 25 percent within 24 hours after the stroke. Overall, SAH accounts for 5 percent of deaths from stroke, but for 27 percent of all stroke-related years of potential life lost before age 65. One-half to two-thirds of survivors report a decrease in their quality of life. A number of risk factors for SAH have been identified. Hypertension, a well established risk factor for ischemic stroke, is less well characterized as a risk factor in SAH. Pathogenesis. Nontraumatic SAH is a neurologic emergency characterized by bleeding into spaces surrounding the brain that are normally filled with

cerebrospinal fluid (CSF). Recall that the brain and spinal cord are covered by three layers of connective tissue, termed the meninges, and encased in bone. The outer layer of the meninges is the dura mater, the middle layer the arachnoid, and the inner layer the pia mater. The arachnoid is a thin, delicate membrane. Separating the arachnoid from the pia mater is the sub-arachnoid space that contains CSF, which serves to cushion the brain and spinal cord. Bleeding into the subarachnoid space initiates a series of events that lead to spasms of the cerebral blood vessels. Spasm can significantly constrict these vessels, resulting in diminished cerebral blood flow. Blood flow is inversely proportional to the fourth power of the radius, so small changes in the vessel size can produce deleterious effects. If blood flow is reduced below the critical level needed to maintain membrane integrity, cerebral ischemia with edema formation and infarction may follow. Regional cerebral edema further compromises local blood flow causing further ischemia despite an overall normal intracranial pressure. The principal causes of SAH are rupture of aneurysms and arteriovenous malformations (AV anomalies). Trauma can also cause subarachnoid bleeding. Ruptured aneurysms are the cause in 85 percent of patients.

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Saccular Aneurysms. Saccular (“berry”) aneurysms are thin-walled outpouchings that protrude from arteries. They gradually enlarge and can ultimately rupture. Multiple aneurysms are found in about 15 percent of affected persons. Since the incidence of aneurysmal SAH is approximately one in 10,000, it is clear that most saccular aneurysms do not rupture. Surgical morbidity far exceeds these percentages. Following rupture, rebleeding is an early and devastating complication. Intracranial aneurysms, unless giant (greater than 1.5 cm in diameter), are usually asymptomatic. An estimated 5 to 15 percent of cases of stroke are related to ruptured intracranial aneurysms. Clinical Characteristics and Confirmation. SAH should be suspected in persons complaining of a sudden onset of severe headache along with nausea and vomiting, neck pain or stiffness, photophobia and loss of consciousness. The classic symptom is a rapidly developing, severe headache. Patients typically describe it as the “worst headache of my life” or “like a hammer blow.” In three out of four patients, onset occurs within a few seconds. It is the only symptom in about a third of patients. Headache from SAH is usually diffuse. Prodromal (warning) headaches may precede the actual SAH by several weeks in over 40 percent of cases. It is however, not the severity, but the suddenness of onset, which is the characteristic feature of SAH, a feature that patients may fail to mention because it is the severity of pain for which they seek medical attention. SAH is believed to be misdiagnosed in up to half of persons being evaluated for the first time. The most common incorrect diagnoses are migraine and tension-type headache. Arterial pressure is often elevated and body temperature increased, especially during the first few days after bleeding since sub-arachnoid blood products produce chemical meningitis. Nearly half of all victims experience transient changes in mental status. A number of neurologic complications can occur if a patient does not die immediately after a SAH. Some result from blood in the subarachnoid space.

Other complications include rebleeding from the same aneurysm, cerebral vasospasm and its resulting ischemia leading to reduced blood supply, hydrocephalus (excessive accumulation of fluid in the cerebral area) from blockage of CSF outflow, and seizures. Non-neurologic complications include cardiac and electrolyte abnormalities. Survivors of SAH may experience chronically disabling problems. More than half report problems with memory, mood or neuropsychological function. These deficits result in impairment of social roles, even in an absence of apparent physical disability. Up to twothirds of survivors return to work by one year after a SAH. Treatment. Patients with SAH should be evaluated and treated on an emergency basis. Following stabilization, they should ideally be transferred to a center with a dedicated neurologic critical care unit to optimize care. The primary goals of treatment are prevention of rebleeding, prevention and management of vasospasm, and treatment of accompanying medical and neurologic complications. Medical management of a ruptured aneurysm is intended to reduce the risk of rebleeding and cerebral vasospasm and to prevent other medical complications before and after surgical intervention. The patient is provided general support including bed rest, gentle sedation as needed, analgesics for headache and stool softeners to minimize straining. Glucocorticoids may help reduce the headache and neck stiffness and/or pain caused by blood in the subarachnoid space. There is no solid evidence that they reduce cerebral edema, are neuroprotective or reduce vascular injury in SAH; their routine use is therefore not recommended. Hypertension, if present, should be treated but not aggressively since elevated blood pressure may be a normal compensatory mechanism, especially in a chronically hypertensive patient. At present, there is no conclusive evidence whether modifying blood pressure in acute SAH benefits the patient.

The calcium channel antagonist nimodipine (Nimotop) has an established role in decreasing vasospasm in all grades of SAH. A review concluded that calcium channel antagonists decrease the proportion of patients with poor outcome and ischemic neurological deficits after aneurysmal SAH. The results relating to poor outcome depend on one large trial, but against the background of the potentially devastating consequences of vaso-spasm, the use of nimodipine is indicated in all patients with non-traumatic SAH and should be started as soon as the diagnosis is made. A dose of 60 mg should be given every four hours orally or via a nasogastric tube. Nimotop carries a boxed warning to not administer the drug intravenously or by other parenteral routes because deaths and serious life threatening adverse events have occurred when the contents of the capsules have been injected parenterally. Blood pressure should be kept in the “high-normal” range in attempt to maintain cerebral perfusion pressure. If hypotension occurs, the dosage regimen may be changed to 30 mg every two hours.

Primary Hemorrhage

Intracerebral

Nontraumatic intracerebral hemorrhage (ICH; within the brain substance) occurs mainly as a result of chronic, poorly controlled hypertension; spontaneous ICH refers to those cases that occur in the absence of trauma. A ruptured vascular malformation is responsible less often. Despite evidence that ICH is more than twice as deadly as SAH, clinical and laboratory research continues to focus primarily on SAH. Unlike the declining mortality with SAH due to improvements in surgical and critical care techniques, morbidity and mortality with ICH have remained relatively unchanged over the past several decades. Epidemiology. Primary ICH is one of the most devastating forms of stroke, and is responsible for about 80 percent of all intracranial hemorrhages in the United States, affecting approximately 67,000 Americans each year. ICH has the distinction of having the highest mortality rate of all types of stroke.

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Morbidity and mortality associated with ICH are dismal, with 30-day mortality ranging between 30 and 40 percent in hospital-based studies to as high as 52 percent in community-based studies. The annual mortality rate following 30day survival was 8 percent per year for five years in one community-based study with almost half of all later deaths attributed to complications of the original hemorrhage. Only 21 to 28 percent of patients with ICH could live independently after six months. The risk for primary ICH is estimated to be about twice as high in AfricanAmerican, Hispanic and Japanese populations than in Caucasians. The reason for the large discrepancy among populations is unclear. Alcohol consumption and low serum cholesterol levels have been theorized to account for some differences in the Japanese population. There is a slight predominance of men with ICH versus women. Pathogenesis. ICH is bleeding that occurs directly into the brain parenchyma (the functional tissue, as opposed to connective tissue). It is differentiated from intraventricular hemorrhage and SAH, which involve bleeding into the brain’s ventricular system and subarachnoid space, respectively. ICH is classified as primary (unrelated to congenital or acquired lesions), secondary (directly related to congenital or acquired conditions), and/or spontaneous (not secondary to trauma or surgery). ICH typically consists of a large area of hemorrhaged blood that clots. Most hemorrhages occur at or near bifurcations of arteries (the point at which a vessel divides into two branches). The blood is slowly removed over the next several weeks by phagocytosis, and after several months, only a small collapsed cavity may remain. Large hemorrhages typically rupture into the ventricles with bleeding into the subarachnoid space. It is believed that the initial hemorrhage encircles intact neural tissue, which causes neurologic deterioration attributed to the development of cerebral edema. This appears within hours secondary to the clot releasing plasma

proteins into the underlying white matter. Later, delayed thrombin formation may contribute to neural toxicity directly or through damage to the blood-brain-barrier indirectly with subsequent worsening of edema. Peak edema occurs three to seven days following the hemorrhage along with lysis of erythrocytes. Both hemoglobin and its degradation products have been implicated in neural toxicity. The importance of cerebral edema in ICH has been supported by evidence suggesting that patients with a larger amount of cerebral edema relative to the initial hemorrhage volume have a very poor prognosis. Evidence from serial contrast computed tomography (CT) scans show that hematomas can continue to expand over many hours and is the natural course of disease progression. Bleeding may cease when the lesion gets to a size sufficient to produce increased tissue compression (tamponade). Hypertension is the most important risk factor for ICH especially in persons younger than 55 years of age. It is estimated that approximately 25 percent of ICH events would be prevented if all hypertensive patients received adequate antihypertensive therapy to maintain normal pressure. Smoking, excessive chronic alcohol consumption (more than two drinks/day), and cocaine use (especially in persons older than 45 years) also increases the risk. It is unknown why cholesterol levels less than 160 mg/dL increase the risk. Warfarin anticoagulation remains a highly effective therapy for prevention of thromboembolic stroke in persons with atrial fibrillation. Anticoagulation to an International Normalized Ratio (INR) of 2.5 to 4.5 has been associated with risk of ICH of approximately 1 percent per year for stroke-prone patients. On the other hand, this rate is nearly 10 times greater than the risk of hemorrhage in a matched group of persons who have not undergone anticoagulation. When such hemorrhages occur, the fatality rate averages 60 percent. Predictors are advanced age, prior ischemic stroke, hypertension, and intensity of anticoagulation therapy.

ICH is the most feared complication of thrombolytic therapy used in acute myocardial infarction or stroke. When a recombinant tissue plasminogen activator (rt-PA) (e.g., alteplase/Activase) is administered within three hours after onset of ischemic stroke symptoms, the ICH rate is 6.5 percent, compared with 0.5 percent in placebo patients. Half of the individuals who sustain these hemorrhages die. The overall benefit of rt-PA therapy in appropriate patients with ischemic stroke is more than counterbalanced by the risk of hemorrhage. Clinical Manifestations and Confirmation. Although not associated with exertion, ICH usually occurs when the patient is awake and sometimes when stressed. The classic presentation is sudden onset of a focal neurologic deficit that progresses over minutes to hours with accompanying headache, nausea and vomiting, elevated blood pressure and decreased consciousness. The neurologic abnormalities are similar to those caused by ischemic stroke since destruction of neural tissue is the root cause of the dysfunction that results from either entity. Specific signs and symptoms are determined by the location of the lesion. Since the site of ICH often differs from ischemic stroke, characteristic patterns of neurologic loss may be more frequently associated with ICH than with ischemic stroke. Hemorrhages may continue to enlarge over several hours as bleeding continues. Ischemic lesions, on the other hand, usually do not change in size following vascular occlusion. As a result, hemorrhages characteristically cause increasing loss of neurologic function with time until a plateau is reached, whereas ischemic strokes may remain static or fluctuate after the early phases of the stroke. About one-fourth of patients who initially are alert may show subsequent deterioration in their level of consciousness after an ICH. ICH in each of the four typical locations within the brain produces characteristic findings (Table 1). ICH often cannot be confirmed based on clinical findings alone. The test of choice for assessing the type of stroke is CT.

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Table 1 Clinical features of intrecerebral hemorrahage Symptom Unconsciousness Sensory change Pupils Size Reaction Response to nutrition Ocular bobbing Gait lost Vomitting

Site of Hemorrhage Putamen Thalamus Later Later Yes Yes

Pons Early Yes

Cerebellum Late Late

Normal Yes Yes No No Occasional

Small Yes or No No Sometimes Yes Often

Normal Yes Yes or No Sometimes Yes Severe

Small Yes or No Yes No No Occasional

Adapted from Zivin JA. Textbook of Medicine, 22 ed. Philadelphia:Saunders;2004:2298-2305. Head CT provides substantial information including the size and location of the hemorrhage, and the presence of intraventricular, subarachnoid or subdural blood. It differentiates ICH from nonhemorrhagic cerebral infarctions and may reveal underlying structural abnormality. Magnetic resonance imaging (MRI) is sensitive for ICH; it is useful for dating hemorrhages and identifying small vascular lesions that may be missed with conventional CT. MRI is limited in early detection of ICH, time required to obtain imaging and by the limited ability to monitor patients while in the scanner. Treatment. No surgical or medical treatment has proved effective, although an estimated 7,000 surgeries to remove hemorrhaged blood are performed in the United States each year. Supportive treatment is the usual means to manage acute ICH, with early care given to maintenance of airway, oxygenation and nutrition, and treatment of secondary complications. Clinical trials of corticosteroids, glycerol and hemodilution (increasing plasma volume in relation to erythrocytes), have not demonstrated benefit. Corticosteroids, in fact, may increase the risk of infectious complications. There is no accepted means for management of increased intracranial pressure. Hyperventilation, neuromuscular paralysis and osmotherapy (treatment by the intravenous injection of hypertonic

solutions to produce dehydration) are without significant benefit. Fluid management should maintain a normal volume (euvolemia). Seizures should be treated despite a lack of data from randomized trials, since they can be particularly harmful for critically ill patients. Maintenance of normal body temperature is desirable and fever should be aggressively treated with acetaminophen or cooling blankets since fever may accelerate tissue destruction. Prognosis. Most early deaths result from the direct neurologic consequences of the hemorrhage. The severity of bleeding (e.g., size, extension into ventricles) and level of neurologic function are the best predictors of poor outcomes. Long-term prognosis for various degrees of recovery is similar or better than that of cerebral infarctions of comparable severity. The risk of recurrent ICH has not been well studied, but the risk of at least one rebleed may be as high as 25 percent over the next several years. The risk of ICH can be reduced by appropriate treatment although there is no specific therapy. Control of mild to moderate hypertension decreases the risk of hemorrhagic stroke by one-third to onehalf.

Summary and Conclusions

All patients with suspected stroke require rapid assessment and intervention. Assessment aims to establish the diagnosis of stroke and its etiological subtypes, and to estimate the prognosis for complications, recurrent events, survival and handicap. Intervention strives to reverse any ongoing brain hemorrhage or ischemia, lessen the risk of complications and recurrent stroke, and optimize physiological homeostasis and rehabilitation. The content of this lesson was developed by the Ohio Pharmacists Foundation, UPN: 129-000-08-012-H01-P. Participants should not seek credit for duplicate content.

Volume XXVI, No. 12

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dâ|Ê

Hemorrhagic Stroke: Prevention and Treatment 1. Most deaths from subarachnoid hemorrhage (SAH) occur within: a. two minutes. c. two days. b. two hours. d. two weeks.

7. The bleeding associated with ICH occurs directly into the brain parenchyma which is: a. connective tissue. c. interstitial tissue. b. functional tissue. d. mesenteric tissue.

2. The arachnoid is the thin, delicate membrane that constitutes which of the following layers of the meninges? a. Inner b. Middle c. Outer

8. The most important risk factor for ICH, especially in persons younger than 55 years of age, is: a. hyperkalemia. c. hypertension. b. hyperlipidemia. d. hyperthrombosis.

3. The principal causes of SAH are arteriovenous malformations and rupture of: a. aneurysms. c. arterioles. b. plaque. d. granulomas.

9. The root cause of the dysfunction that results from either ICH or ischemic stroke is: a. destruction of neural tissue. b. initiation of arterial fibrillation. c. precipitation of ventricular techycardia. d. rupture of atherosclerotic plaque.

4. The classic symptom of SAH is severe: a. cramping. c. headache. b. depression. d. syncope.

10. Which of the following has been proven to be effective in treating ICH? a. Medical treatment only b. Surgical treatment only c. Both medical and surgical treatment d. Neither medical nor surgical treatment

5. General support for patients experiencing an SAH include all of the following EXCEPT: a. antiemetics. c. sedatives. b. analgesics. d. stool softeners 6. Spontaneous intracerebral hemorrhage (ICH) refers to those cases that occur in the absence of: a. syncope. c. thromboembolism. b. symptoms. d. trauma.

1. Select one correct answer per question and circle the appropriate The Georgia Pharmacy Association is letter below using blue or black ink (no red ink or pencil). accredited by the Accreditation Council 2. Members submit $4, Non-members must include $10 to cover the for Pharmacy Education as a provider of cost of grading and issuing statements of credit. Please send check or continuing pharmacy education. money order only. Note: GPhA Members will receive priority in Hemorrhagic Stoke: Prevention and Treatment processing CE. Statements of credit for GPhA members will be mailed Volume XXVI, No. 12 This lesson is a Knowledge Based CPE Activity and is targeted to pharmacists in all practice settings. GPhA Code J09-04 Program Number: 142-999-09-004-H01-P CE Hours: 1.5 (0.15 CEUs) Release Date: 4/5/2009 Expiration: 12/15/2011

within four weeks of receipt of the course quiz.

1. 2. 3. 4. 5.

A A A A A

B B B B B

C C C C C

D D D D

6. 7. 8 9. 10.

A A A A A

B B B B B

C C C C C

D D D D D

Mail completed quiz to: GPhA, 50 Lenox Pointe NE, Atlanta, GA 30324 A passing grade of 70% is required for each examination. A person who fails the exam may resubmit the quiz only once at no additional charge. Please check here if you are indicating a change of address ______

Phone # __________________

Name _____________________________________________ License Number(s) and State(s) ____________ Address _______________________________________________________________________________ City ______________________________________________________ State __________ Zip __________ How long did this program take to complete? _____________________________________________________

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2008 - 2009 GPhA BOARD OF DIRECTORS

The Georgia Pharmacy Journal Editor:

Jim Bracewell jbracewell@gpha.org

Managing Editor & Designer:

Kelly McLendon kmclendon@gpha.org

The Georgia Pharmacy Journal® (GPJ) is the official publication of the Georgia Pharmacy Association, Inc. (GPhA). Copyright © 2009, Georgia Pharmacy Association, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording or information storage retrieval systems, without prior written permission from the publisher and managing editor. All views expressed in bylined articles are the opinions of the author and do not necessarily express the views or policies of the editors, officers or members of the Georgia Pharmacy Association.

ARTICLES AND ARTWORK Those who are interested in writing for this publication are encouraged to request the official GPJ Guidelines for Writers. Artists or photographers wishing to submit artwork for use on the cover should call, write or e-mail the editorial offices as listed above.

SUBSCRIPTIONS AND CHANGE OF ADDRESS The Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is distributed as a regular membership service, paid for through allocation of membership dues. Subscription rate for non-members is $50.00 per year domestic and $10.00 per single copy; international rates $65.00 per year and $20.00 single copy. Subscriptions are not available for non-GPhA member pharmacists licensed and practicing in Georgia. The Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is published monthly by the GPhA, 50 Lenox Pointe NE, Atlanta, GA 30324. Periodicals postage paid at Atlanta, GA and additional offices. POSTMASTER: Send address changes to The Georgia Pharmacy Journal®, 50 Lenox Pointe, NE, Atlanta, GA 30324.

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April 2009


2008 Recipients of the “Bowl of Hygeia” Award

Rick Stephens Alabama

Ron J. Miller Alaska

Stephen Nathenson Arizona

Rob Richardson Arkansas

Jeffrey Shinoda California

Thomas L. Stock Colorado

Thomas Buckley Connecticut

John Murphy Delaware

Michael Kim District of Colombia

Theresa Tolle Florida

Michael Farmer Georgia

Byron Yoshino Hawaii

Stanley Gibson Idaho

Om Dhingra Illinois

Daniel Degnan Indiana

Leman Olson Iowa

Geraldine Liebert Kansas

Charles D. Peterson Kentucky

Allen Cassidy Louisiana

Maureen Burke Maine

Stephen L. Disharoon Maryland

Karen Ryle Massachusetts

Willie Flounory Michigan

Gary Raines Minnesota

Keith Guy Mississippi

Dennis Bond Missouri

John A. Fitzgerald Montana

Robert Marshall Nebraska

Paul Oesterman Nevada

Brenda McBride New Hampshire-

Frederick Trinkley New Jersey

Debra Herman New Mexico

John Navarra New York

Fred Eckel North Carolina

Patricia Churchhill North Dakota

Jerry Marlowe Ohio

Don Coody Oklahoma

David Widen Oregon

Coleen Kayden Pennsylvania

Blanca I. Vazquez Puerto Rico

Scott Campell Rhode Island

Pam Whitmire South Carolina

Julie Meintsma South Dakota

Martha Shepard Tennessee

OC Houston Texas

Joel Jolley Utah

The “Bowl of Hygeia”

Keith Hodges Virginia

Richard Kuch Washington

Susan Meredith West Virginia

James Fuhs Wisconsin

James Carder Wyoming

Wyeth Pharmaceuticals takes great pride in continuing the “Bowl of Hygeia” Award Program developed by the A. H. Robins Company to recognize pharmacists across the nation for outstanding service to their communities. Selected through their respective professional pharmacy associations, each of these dedicated individuals has made uniquely personal contributions to a strong, healthy community which richly deserves both congratulations and our thanks for their high example.

Wyeth Pharmaceuticals, Philadelphia, Pennsylvania

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*2008 recipient awarded in 2009

April 2009


Georgia Pharmacy Journal速 50 Lenox Pointe, N.E. Atlanta, Georgia 30324

The Georgia Pharmacy Journal: April 2009  
The Georgia Pharmacy Journal: April 2009  

June 20-24, 2009 www.gpha.org Volume 31, Number 4 The Official Publication of the Georgia Pharmacy Association April 2009

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