Primary care process

The main process (Fig. 1.1) for the care of a patient is normally the Primary care process (the patient handles their own drugs)—or the community care process (the patient gets help from community nurses at home or at a nursing home). All other processes such as hospital care (secondary/tertiary care) and the pharmacy process must support the main patient process. For improvement we must focus on patient safety and reduce drug-related problems. This means correct prescription and correct use (follow-up, documentation and communication) from the supportive process to the main process. 

Fig. 1.1 Time scale of the patient medication processes. Main (primary care) and some important supportive processes...

Many alcohol-dependent patients manage their withdrawal outside of the hospital when they have only mild symptoms and are in generally good health. Very often these patients will visit their primary care physician, seeking a short course of benzodiazepines (such as diazepam or chlordiazepoxide) for a few days, as well as some prescription-strength vitamins and thiamine to assist in their withdrawal and recovery. It is critical that a responsible adult monitors these patients around the clock to be sure that they are not developing confusion, unstable blood pressure, or other vital signs and to provide essential support for the detoxification process. 

The patient s insurance plan will often dictate the referral options. Even if the patient pays out of pocket for the therapist s services, he or she is unlikely to pay privately for medication evaluation and management. Physician charges are usually more expensive than psychotherapy charges, and appointments with physicians— regardless of whether they are psychiatrists or primary care doctors—are usually paid for by the patient s insurance. Thus, a therapist can usually start the referral process by asking whether the patient has previously seen a primary care physician or psychiatrist whose fees are paid by the patient s insurance. If the patient is comfortable with Dr. X, and the therapist is comfortable with Dr. X, the initial referral decision is made. 

The Early Use of Existing Preventive Strategies for Stroke (EXPRESS) study aimed to determine the effect of more rapid treatment after TIA and minor stroke in patients who were treated in a specialist neurovascular cUnic (Rothwell et al. 2007) within OXVASC. In a prospective, population-based, sequential comparison study, the effect on the process of care and outcome of either urgent access and immediate treatment in a dedicated neurovascular clinic or an appointment-based access and routine treatment initiated in primary care were compared for all patients with TIA or minor stroke who did not need hospital admission. The primary outcome was the risk of stroke during the 90 days after first seeking medical attention. 

Complex secondary reactions can follow the primary photochemical process of quinine leading to dark reactions, which occur after exposure of the quinine solution has ceased. For this reason, the absorbance should be measured immediately after exposure. The user must carefully control the variables that can affect the quinine actinometry system in order to obtain reproducible results. One should take into account that the calibration factor stated in the ICH guideline may only be valid at 25°C. 

This theory was proposed by Knox [39] following a series of careful kinetic and analytical studies of the oxidation of ethane [40], propane [41], and isobutane [42] in the early stages of reaction (<1% fuel consumption). For these lower alkanes, he found that at this stage of the reaction 75—80 % of the alkane consumed appeared in the products as the conjugate alkene both at low temperature (ca. 300 °C) and at high temperature (ca. 450 °C). He concluded, therefore, that the primary oxidation process for alkyl radicals is the same at both temperatures, viz. 

Reaction (lA) is the other major primary initiation process, particularly above 1000 K. Kinetic data have been available for a number of years, partly because /cia is relatively easy to measure because secondary initiation is effectively absent. Nevertheless, the systems used are invariably complex and care is necessary in abstracting /cia- Tsang [47,48] has used a single-pulse shock-tube with considerable success by use of an approach whereby relative rate constants are obtained with one known accurately as a reference. Baldwin, Walker and Drewery [34] have shown that Eia can... 

The application form in Appendix 1 also requests data on whether the clinical pharmacist is board certified in pharmacotherapy or another specialty. Board certification should be considered strongly desirable, if not required. At the present time, the most appropriate specialty certification process for ambulatory or primary care pharmacists would be certification in pharmacotherapy. This would be analogous to physician certification in the broad-based specialty of family practice. Board certification in pharmacy will be increasingly important and it... 

Performing quality assurance evaluations of specific pharmacists performance does not measure patient outcomes, but rather, the process of delivering care. However, providing an acceptable or ideal process (or standard of care) should, by implication, create an environment conducive to better patient outcomes. However, to move from evaluating process to evaluating outcome, other specific tools must be used (see below). Appendix 2 is an example of a quality assurance form that might be used in a pharmacist-managed primary care clinic. 

Primary care providers, patients, and health care administrators are interested in HRQL outcomes because they are a method to measure the impact of therapy on the disease process. Hospital administrators and other policy makers have a high stake in these issues because payers are beginning to use HRQL data in their reimbursement policies. 

If pharmacists were providing primary care for hypertensive patients and wanted to compare the results of an intervention, they should first provide interventions based upon established therapeutic guidelines for treating hypertension such as those outlined by the Fifth Joint National Committee on Detection, Evaluation, and Treatment of Hypertension (JNC-V). With each patient encounter, they would collect the data in Appendix 2. These two procedures would ensure that the pharmacist is providing an appropriate process of care. 

Appendix 2 Evaluating process of care Example quality assurance in primary care... 

Handling UKCPA conference communications and the adjudication process requires a scrupulous process to make it work for members. UKCPA has developed a housestyle and is a transparent process of adjudication and feedback to assure the final quality of work presented and published. This applies equally to the adjudication process for the four industry sponsored awards, AstraZeneca Travelling Fellowship Award, the four GlaxoSmithKline Poster Awards, the Pharmacia Pharma-coeconomics Award and the Wyeth Education and Training Award. New awards for 2002 are Unichem Com-munity/Primary Care Pharmacy Award, Napp Palliative Care Award and the Merck Pharmaceuticals for Medicines Management Award. 

Evaluation of each individual woman is essential in determining the appropriateness of perimenopausal and postmenopausal hormone therapy, and collaboration between a woman and her primary care provider in the decision-making process is essential. The benefits and risks of hormone therapy should be reassessed annually. 

The mechanism by which phosphates, e.g. the disodium salts of glycerol-1-phosphate and glycerol-2-phosphate, undergo photoinduced hydrolysis has been the subject of a careful study. The mechanism of the primary photochemical processes still remains a mystery. 

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