Making Thesale

SEPTEMBER 2013 america’s TM

Published by the National Community Pharmacists Association PHARMACISTTHE VOICE OF THE COMMUNITY PHARMACIST

Making theSale

Introducing RxWiki • TOC Opportunities • HIT Solutions •

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PHARMACISTTHE VOICE OF THE COMMUNITY PHARMACIST CONTENTS

Features

From the Cover 18 Making the Sale by Chis Linville It's not just what you stock, it's how you show it.

26 Community Pharmacy Goes Digital by Chis Linville NCPA partners with RxWiki to deliver social media and mobile solutions to community pharmacies and patients.

32 Teed Up for a TOC Spike by David D. Pope, PharmD, CDE; and Jason M. VanLandingham, PharmD, BCPS Community pharmacists can get in the game with an expanded role on the transitions of care team.

36 The Solution Is a HIT by Ken Whittemore, Jr., RPh, MBA E-prescribing continues to lead the digital health care transformation. Departments 4 Up Front 26 by B. Douglas Hoey, Pharmacist, MBA For your own good, take charge of Rx benefits in your community.

6 Newswire Health insurance shoppers are coming. Are you ready to help?

America’s Pharmacist Volume 135, No. 9 (ISSN 1093-5401, USPS 535- 12 Adherence—It Only Takes a Minute 410) is published monthly by the National Community Pharmacists As- All aboard the synchronization train. sociation; 100 Daingerfield Road, Alexandria, VA 22314. © 2013 NCPA®. All rights reserved. 14 Foundation Report Postmaster—Send address changes to: America’s Pharmacist, Circula- by Sharlea Leatherwood, PD tion Dept., 100 Daingerfield Road, Alexandria, VA 22314; 703-683-8200; Full slate of convention activities on tap for [email protected]. Periodical postage paid at Alexandria, VA, and other NCPA Foundation. mailing offices. Printed in the USA.

For membership information, email [email protected]. For other information go to www.ncpanet.org.

2 america’s Pharmacist | September 2013 www.americaspharmacist.net Cover: Merchandising for the front end of an independent pharmacy is more complex than simply putting items on a shelf. Products need to do one or all of three things: draw customers in, enhance the store’s image, and/or make the business money.

41 Continuing Education by Stacey Schneider, PharmD; and Thomas Towers, PharmD Preventing osteoporosis within the community setting.

59 Reader Resources NCPA activities and our advertisers.

60 Notes From Capitol Hill by Michael F. Conlan 2012–2013 NCPA state legislative update.

Letters to the Editor—If you would like to comment on an article, email NCPA at [email protected]. Put AP in the subject line and include your phone number. Your letter 32 may be posted on the NCPA website and edited for length and clarity.

CEO B. Douglas Hoey, Alexandria, Va. Associate Director, Design Robert E. Lewis Senior Designer Sarah S. Diab Board of Directors Junior Designer Marianela Guinand President Donnie Calhoun, Anniston, Ala. Senior Director, Business Development Nina Dadgar, [email protected] President-Elect Mark Riley, Little Rock, Ark. Director, Membership Colleen Agan, [email protected] Chairman Bradley Arthur, Buffalo, N.Y. John Sherrer, Marietta, Ga. Keith Hodges, Gloucester, Va. The National Community Pharmacists Association (NCPA®) DeAnn Mullins, Lynn Haven, Fla. represents America’s community pharmacists, including David Smith, Indiana, Pa. the owners of more than 23,000 independent community Bill Osborn, Miami, Okla. pharmacies, pharmacy franchises, and chains. Together they represent an $88.5 Immediate Past President Lonny Wilson, Oklahoma City, Okla. billion health care marketplace, employ more than 300,000 people, including 62,400 pharmacists; and dispense over 40 percent of all retail prescriptions. Visit Officers the NCPA website at www.ncpanet.org. First Vice President Brian Caswell, Baxter Springs, Kan. Second Vice President Michele Belcher, Grants Pass, Ore. America’s Pharmacist annual subscription rates: $50 domestic; $70 foreign; and $15 Third Vice President Hugh Chancy, Hahira, Ga. NCPA members, deducted from annual dues. Fourth Vice President Jeff Carson, San Antonio, Tex. Fifth Vice President Lea Wolsoncroft, Birmingham, Ala. Ask Your Family Pharmacist®

Magazine Staff Editor and VP, Publications Michael F. Conlan, [email protected] Managing Editor Chris Linville America’s Pharmacist is printed on paper that meets Contributing Writers Jeffrey S. Baird, Bill G. Felkey, Mark Jacobs, the SFI standards for sustainable forest management. SFI-00665 Bruce Kneeland

www.americaspharmacist.net September 2013 | america’s Pharmacist 3 Up front

For Your Own Good, Take Charge of Rx Benefits In Your Community

Each fall I usually get a call from bump always just ahead. You have to be able to an NCPA member asking for help offer a path to a better solution without a speed because his or her biggest local bump jolt. employer’s new health plan has in- With that in mind, NCPA is collaborating stituted mandatory mail order or a re- with industry partners to provide the employer stricted pharmacy network. To make with access to a free and unbiased analysis of matters worse, in many cases the their current prescription data and information pharmacy owner is well acquainted on independent, transparent PBMs that align with the person who had made the fateful decision. the interests of patients, employers, and com- When asked how they could shut out their local munity pharmacy. pharmacy, in many cases the decision maker pleads once a pharmacist has met with an em- ignorance. It had never crossed their mind. They had no ployer and chooses to provide the requested intention to harm local businesses and their friend! information, NCPA will work with those industry now, you can help your employer friends with NCPA’s partners to follow up with the employer. new (and free) resource kit, Take Charge of Rx Benefits in concrete business solutions are one of Your Community. It will help you identify key local employ- the best ways to move the needle in achiev- ers and start a conversation about why using local coming more desirable results. That’s why we are munity pharmacy services is in the best interest of their helping to empower independent community business, their employees, and the community. pharmacy owners to be more proactive and The Take Charge of Rx Benefits in Your Community re- effective in helping local health plan sponsors source kit can be accessed through the NCPA Bookstore. avoid PBM plan designs that are not transpar- Think of it as a tool to help prevent a train wreck. Once ent, lack flexibility, and neither maximizes cost the train goes off the rails, it’s nearly impossible to get it savings nor health outcomes. back on track. Take Charge of Rx Benefits in Your Com- Many times the decision to accept a PBM or consul- munity is a resource that gives you the means tant-designed mandatory mail order plan is taken by em- to make a difference locally—for your business ployers innocently or with a lack of information. To make and your community. this work, you have to get out from behind the counter and personally connect with the health insurance plan Best, decision makers in your community. Schedule a breakfast meeting, for example, before your pharmacy opens. But you can’t just talk to employers about the need to improve their plan. They are businessmen and women B. Douglas Hoey, Pharmacist, MBA just like you with the bottom line looming like a speed NCPA Chief Executive Officer

4 america’s Pharmacist | September 2013 www.americaspharmacist.net HEALTHIER VITAMINS FOR ACTIVE CHILDREN

Supplement Facts Serving Size: 1 stickpack (6.1g) Children’s vitamins are usually loaded with things your Servings Per Container: 15

Amount % Daily Value % Daily Value shoppers don’t want for their kids – sugar and arti cial Per Serving < 4 years old > 4 years old Calories < 5 sweeteners,  avors, and colors. Total Carbohydrates < 1 gm * * Sugars 0 gm * * VItamin A (as beta carotene & retinyl palmitate)2500 IU 100% 50% VItamin C (as ascorbic acid) 150 mg 375% 250% ® Vitamin D (as cholecalciferol) 400 IU 100% 100% Volo Vitamins partnered with pediatricians to develop VItamin E (as d-alpha-tocopheryl acetate) 15 IU 150% 50% Thiamin (as thiamin HCI) 1.5 mg 214% 100% a healthier alternative. Each on-the-go VoloPak has a Riboﬂ avin 1.7 mg 213% 100% Niacin (as niacinamide) 2.5 mg 28% 13% Vitamin B6 (as pyridoxine HCI) 2 mg 286% 100% well-rounded mix of vitamins and nutrients, is naturally Folate (as folic acid) 200 mcg 100% 50% Vitamin B12 (as methylcobalamin) 6 mcg 200% 100% Biotin 70 mcg 47% 23%  avored with 17 different fruits, and is sweetened with Pantothenic acid (as D-Calcium 5 mg 100% 50% pantothenate) the stevia herb. Calcium (as calcium lactate) 500 mg 63% 50% Iron (as ferrous fumarate) 8 mg 80% 44% Iodine (as potassium iodide) 75 mcg 107% 50% Magnesium (as magnesium citrate) 8 mg 4% 2% Zinc (as zinc citrate and zinc amino 8 mg 100% 53% acid chelate) You can feel con dent stocking and Selenium (as selenium amino acid 35 mcg * 50% chelate) Copper (as copper chelazome) 0.6 mg 60% 30% recommending pediatrician-approved Potassium (potassium carbonate and 200 mg * 6% potassium bicarbonate) Volo Vitamins to parents who shop in your store. Fruit Blend: Apple, pineapple, orange, 500 mg * * blueberry, grape, grapefruit, plum, raspberry, strawberry, watermelon, lemon, lime, cantaloupe, cherry, papaya, peach, pear Choline (as choline bitartrate) 15 mcg * * Inositol 15 mcg * * Additional Products Launching Fall 2013: PABA (para-aminobenzoic acid) 400 mcg * * Boron (as boron amino acid chelate) 10 mcg * * Volo Energy (Vitamins B and C with organic caffeine) * Daily Value not established. Percent Daily Values based on a 2,000-calorie diet. and Volo Wellness & Immunity Other Ingredients: malic acid, citric acid, silica, natural ﬂ avor, beet color and organic stevia leaf extract. introducing

Volo Vitamins UPCs Mixed Berry 15ct 091037499622 Mixed Berry 30ct 091037499639 Multi-Pack 15ct 091037499646 Multi-Pack 30ct 091037499653 Orange 15ct 091037499608 Orange 30ct 091037499615

Contact your wholesaler to place your order or contact Volo Vitamins directly: 855 VOLO 866 • 855 865 6866 or [email protected] www.volovitamins.com • 229 East 85th Street • PO Box 1614 • New York, NY 10028-1614

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Health Insurance Shoppers Are Coming. Are You Ready to Help?

Oct. 1 is the day up to 25 million uninsured Americans can begin Merchandising Tips for Flu Season shopping for private health insur- By Gabe Trahan ance through the Affordable Care Act’s health insurance marketplaces or exchanges. Some of them may qualify for financial assistance to help pay for their premiums. If they enter your pharmacy looking for answers, could you provide them? Grow your business by helping new and existing customers find the right health insurance. through the insurance marketplaces, individuals without government or employer-provided health insurance can shop for coverage for themselves and their families, or face financial penal- ties. Seven million people are expected to sign up during the Millions of Americans will catch the flu this year and millions more Oct. 1, 2013 to March 31, 2014 will do their best to steer clear of it. Do your customers a great enrollment period. Community service: offer different ways to avoid the flu and find relief. pharmacists should be educated and prepared for the opening of • Minimum Space Needed: Two end-caps; one for flu prevention the marketplaces as both health and one for symptom relief. care professionals and small busi- • Optimum Space Needed: Three end-caps, two for prevention ness owners. and one for relief. Or even better, one 8-foot section with a com- states had the opportunity to bination of the two categories. participate in the federal market- • Must Have: Signs are the most important item that you can dis- place, run their own state-based play! Signs will promote customer awareness and action. marketplaces, or share responsi- Samples: bility in a federal-state partnership. • Prevention Messages: Avoid the Flu!—Start Fighting the Sixteen states and the District of Flu Now, Wash Your Hands Often! Wipe Down House- Columbia opted to run their own hold Surfaces! Protect You and Your Continued on page 8 ➦ exchanges, Continued on page 8 ➦

6 america’s Pharmacist | September 2013 www.americaspharmacist.net NCPA booth 901 & 907 Visit us at

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©2013, J M SMITH CORPORATION. QS/1 and RxCare Plus are registered trademarks of the J M Smith Corporation. plans and all others next year Continued from page 6 ➦ must offer coverage to individuals Family from the Flu—(next to toothbrushes and wipes) with pre-existing health conditions Throw Away Those Germs! and cannot charge more based • Symptom Relief Messages: Flu Symptom Relief Center— on health or gender. The coverage Flu Relief, It’s Smart to Have it on Hand!—Buy Now and will begin Jan. 1, 2014. Hope You Never Need It—No one likes to shop when they As we go to press, exchange have the flu! provisions of the Affordable Care • Products for Prevention End-Cap: Eye‐catching sign, hand Act, including the individual man- sanitizers, CDC‐approved mask, disposable gloves, disinfect- date, continue to be hotly contest- ing wipes, toothbrushes, antiviral facial tissues, disinfectant ed. Assuming there are no more sprays and surface cleansers, antibacterial soap, homeopathic changes, the addition of millions immune boosters, time-release vitamin C, and germ-fighting of newly insured Americans will mouth wash. likely generate many questions for • Products for Relief End-Cap: Offer a selection of flu symp- community pharmacists. Ben- tom relief formulations in tablets, gel‐caps, powder mix, liquid, efit from the patient-pharmacist lozenges, and nasal spray. Stock daytime, nighttime and relationship by promoting yourself combination day and nighttime relief. Display fever reducing as an educational source for pa- medication in the forms of acetaminophen and ibuprofen for tients. NCPA will continue to work adults and children and NEVER RUN OUT. Have a wide choice diligently to keep you up to date of thermometers on hand. on the insurance marketplace • Just a Few Brand Names to Choose From: Dayquil, Nyquil, implementation and to provide Mucinex, Delsym, Contac, Robitussin, Theraflu, Alka‐Seltzer you with helpful resources. For Plus, Triaminic, Tylenol, Motrin, Advil, Zicam, Airborne and the most current information and private label. member resources including com- • Checkout Counters: Impulse display should stock hand sani- munity pharmacy specific FAQ’s, tizers along with a larger poster suggesting flu prevention tips. please login to the members-only (http://www.cdc.gov/flu/freeresources/index.htm). section of www.ncpanet.org.

Gabe Trahan is NCPA’s senior director of store operations and market- Attention Annual ing. He uses more than 30 years of front-end merchandising experi- Convention Attendees, ence to help NCPA members increase store traffic and improve profits. Visit (www.ncpanet.org) and click on Front-End Overhaul. Watch Devotees the videos, read the tips, and view two galleries of photo examples by Use the hashtag #NCPA2013 on Gabe. Follow him on Twitter @NCPAGabe for additional tips. Twitter, Facebook, and Google+ to share your stories and photos from this year’s Annual Continued from page 6 ➦ creating ship. For a complete breakdown Convention and Trade Exposition specialized websites and call cen- of marketplace by state, please and to follow the latest news and ters and controlling which quali- visit the NCPA website. updates from the Convention fied health plans participate in It is estimated that 90 per- floor. Don’t forget to follow NCPA their individual market. The federal cent of uninsured Americans can on Twitter (@commpharmacy), facilitated marketplaces will oper- receive government subsidies to like us on Facebook (facebook. ate in 27 states, and seven states help pay their premiums through com/commpharmacy), and add will share the responsibility of the expanded Medicaid, Children’s us to your circles on Google+ exchange with the federal govern- Health Insurance Plan, or cost (ncpanet.org/googleplus). ment under a state-based partner- sharing in the marketplace. These Continued on page 10 ➦

8 america’s Pharmacist | September 2013 www.americaspharmacist.net Bio-Oil® is a skincare oil that helps improve the appearance of scars, stretch marks and uneven skin tone. It contains natural oils, vitamins and the breakthrough ingredient PurCellin Oil™. For comprehensive product information and results of clinical trials, please visit bio-oilusa.com. Bio-Oil is the No.1 selling scar and stretch mark product in 11 countries. $11.99 (2fl.oz.). synergy between our two organiza- ye on PBMs tions became obvious.” Email your recent example of a problem you or a patient has had npsc’s business model helps with a PBM to [email protected], or fax it to 703-683-3619. We may edit it for length and clarity. its participating pharmacies “be more competitive in the challeng- Usually items in this space come from pharma- ing marketplace,” said NCPA Ecists. Here is one from a patient’s point of view: CEO B. Douglas Hoey, Pharma- “I tried mail order. When I received a bad order of insulin pen needles cist, MBA. “As a result, their pa- (missing the actual needles), the mail order pharmacy would not help tients receive better services. We me. Told me to complain to needle manufacturer. Would not send me believe the partnership between more needles. The doctor got me through a three-week waiting period before I could get another refill. So mail order was fine and saved me on NCPA and NPSC will be mutually cost until I had a problem. No savings is worth that problem of no meds beneficial.” and no help from mail order pharmacy.” Growing Number of Lawmakers Challenge THE AUDIT ADVISOR Medicare Home Audits on Albuterol Substitutions Delivery Ban NCPA has endorsed the Diabetic Q: In my last audit, why was I cited for “misfills” when substituting albuterol Testing Supply Access Act (H.R. inhalers? 2845), legislation recently intro- A: The three Food and Drug Administration approved albuterol inhalers on the duced by Rep. Peter Welch (D- market today are Proventil HFA, ProAir HFA, and Ventolin HFA—all of which Vt.), that would allow independent are brand name and have no FDA-approved generics. While these products all community pharmacies to provide contain albuterol sulfate and are considered to be therapeutically equivalent by same-day delivery services of dia- most health care professionals, they are NOT considered ‘interchangeable’ by betes testing supplies to Medicare the FDA and require prescriber approval. Many prescription benefit programs “prefer” one brand over another and stipulate that pharmacists make clinical beneficiaries who are homebound notations on the prescription if a substitution has been authorized. or in long-term-care or assisted living facilities. While we disagree with these audit chargebacks, PAAS recommends that phar- More than 40 members of macies document substitution approvals on the hard copy prescription in the Congress led by Welch and Rep. form of a clinical note that includes: your initials, the date, who you spoke with Aaron Schock (R-Ill.) also wrote and what information was discussed. Medicare in May questioning the delivery prohibition. "Now that By Mark Jacobs, RPh, PAAS National, the Pharmacy Audit Assistance Service. For retail and mail order suppliers more information call 888-870-7227 toll free. receive the same level of reim- bursements, we believe there is no further reason to prohibit Northeast Pharmacy “The commitment to join our home delivery by retail pharma- Services Corporation organizations on behalf of our cies," they asserted. "We ask pharmacy owners strengthens that you expeditiously consider Enrolls Members in NCPA the future of their businesses,” allowing small retail pharmacies Northeast Pharmacy Services Cor- said NPSC’s President and CEO, to continue home delivery and poration (NPSC) has signed up Patricia Monaco, MBA. “NCPA not prevent these crucial face-to- the approximately 250 indepen- has been expanding its impact face counseling and adherence dent community pharmacies that it in Washington, D.C. and growing services from being available to serves in New England in NCPA. its support for local efforts. The Medicare patients."

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13-DOUG-37_DL_Pharmacy_FINAL.indd 1 3/6/13 12:57 PM ADHERENCE—IT ONLY TAKES A MINUTE

All Aboard the Synchronization Train

here’s an old saying that you can either get on chronization program. This is one program the train or get run over by it. The same could you shouldn’t try to tackle on your own, and it be said about providing medication synchroni- can be a great empowerment opportunity for a zation services to your patients. These once- staff member. groundbreaking services may soon become the DO test the program out with a few T‘new norm’ in pharmacy. Will your pharmacy be on the patients first. When first launching a sync pro- synchronization train or left at the station? gram, it’s helpful to try it with several patients Independent pharmacists have always been the to work out the kinks and fine tune the proce- conductors when it comes to leading the way in patient dures. Instead of starting with your train wreck care, including pioneering the concept of medication patients, try it with a few loyal ones who don’t synchronization. But with changes to the nation’s health mind being a guinea pig. care system underway, other pharmacy providers are DO engage your front-line staff. Hold not far behind. Several of the large pharmacy chains a staff in-service to educate them about your are currently piloting synchronization programs, many pharmacy’s sync program. Then, ask your of them in preparation for changes to the Medicare Part cashiers to ask every patient if they have heard D program that will make synchronization more com- about your sync program when they’re checking mon in 2014. Beginning in January, Part D beneficiaries out. A simple “have you heard about our new who would like the convenience of synchronized refills Simplify My Meds program?” Rotate it with other can request them and receive a prorated copay to programs and services you are offering. These cover their short fills. front-line employees are your best marketers! If you’re not providing medication synchronization DO look for ways to distinguish your services at your pharmacy, what are you waiting for? sync patients from your non-sync patients. Nearly 1,000 of your colleagues already have imple- One owner shared with us that he uses color- mented medication synchronization programs and are coded baskets to help organize his phar- providing synchronization to more than 25,000 patients macy’s prescription orders. Blue baskets are nationwide. Whether you’re thinking about rolling out for sync patients, pink baskets are for patients such a program, or need a tune-up to get back on track, in the waiting area, and white baskets are for consider this month’s column your pharmacy’s map to other prescriptions to be filled that day. By launching a successful medication synchronization pro- using a different-colored basket for the sync gram and moving full steam ahead to healthier patients patients, his staff is able to easily identify these and a healthier bottom line. special orders. DO utilize free tools and resources to help DO leverage your pharmacy manage- you establish your medication synchronization ment software. Look for ways to identify non- program. NCPA members can sign up for Simplify My adherent patients, identify your sync patients Meds™, a free turnkey program that helps you get your and/or group your sync patients using your phar- program up and running. Learn more at www.ncpanet. macy’s technology. This will make it much easier org/smm. when it comes to filling these prescriptions. DO designate a technician or staff pharmacist consider these tips your pharmacy’s ticket to run the daily operations of your medication syn- to medication synchronization success!

12 america’s Pharmacist | September 2013 www.americaspharmacist.net

Foundation report

Full Slate of Convention Activities On Tap for NCPA Foundation By Sharlea Leatherwood, PD

he NCPA Foundation is hosting the Sunrise will take place in the Exhibit Hall Oct. 14-15. Breakfast at the 2013 NCPA Annual Conven- Items available include popular electronic gad- tion and Trade Exposition in Orlando. The gets, travel packages, gourmet cuisine, art, and breakfast, sponsored by Cardinal Health, is celebrity memorabilia. Tuesday, Oct. 15 from 6:30–8 a.m. Seating is Tlimited, so be sure to register by Sept. 15. Email ncpaF@ Bone Marrow Donor Drive ncpanet.org for the event registration form, or to find out The foundation is continuing its partnership details for donating a door prize. with DKMS Americas in the fight against blood cancers. More than 1,000 individuals have been Fundraising Auction added to the National Bone Marrow Registry The NCPA Foundation annuaol fundraising silent auction from donor drives con- Continued on page 16 ➦

NCPA Foundation: 2013 Scholarship Winners Scholarship Recipients: The NCPA Foundation and Partners in Pharmacy are awarding educational aid to the following high achieving NCPA student members:

Tahlia Rae Aarstad, University of Washington Kara Piechowski, West Virginia University Abayomi Adewodu, Hampton University Zachary Steven Post, West Virginia University Nathan Kyle Beattie, SW Oklahoma State University Elizabeth Rankos, Washington State University Sabrina Caico, University of Saint Joseph Josephine Richardson, Harding University Abby Cooper, Harding University Boopathy Sivaraman, Auburn University Ravi K. Davuluri, University of Texas, Austin Lucas Smith, University of Colorado-Skaggs Ashlie Margaret Decker, Ohio State University Megan Elizabeth Sneller, Texas Tech University Margaret Ann DeLeo, Massachusetts College Health Sciences Center of Pharmacy & Health Sciences—Boston Tyler Staten, Harding University Mary Nicole Dimaano, University of Colorado-Skaggs Matthew D. Talbot, University of Rhode Island Lindsey Feuz, University At Buffalo Heather Taylor, University of Arkansas for Medical Sciences Lisa Garza, Washington State University Andrea Nicole Van Deusen, Ohio State University Lauren Hammond, Regis University Tiffany R. VanMaanen, South Carolina College of Pharmacy Kourtney Maisog, University of Kansas Tadeh Vartanian, University of Southern California Erin Pao-ju Marten, University of Colorado Lydia B. Watkin, Philadelphia College of Pharmacy Amanda Martin, University of Houston Holly Wilkerson, Harding University Samantha Mattison, University at Buffalo John Louis Woods II, Mercer University College of Teresa Ng, West Virginia University Pharmacy/Health Sciences Aimee Patterson, Auburn University

Scholarship sponsors (as of 8/14/13): Apotex, McKesson Foundation, and Rochester Drug Cooperative

14 america’s Pharmacist | September 2013 www.americaspharmacist.net Fundraising Auction 2013 NCPA ANNUAL CONVENTION AND TRADE EXPOSITION ORLANDO, FLA. Exhibit Hall, October 12–15, 2013

Don’t miss the National Community Pharmacists Association Foundation’s fundraising auction in the Exhibit Hall.

You’ll be sure to find a GREAT item for yourself—or even a gift for a co-worker, friend, or spouse!

Proceeds from the auction support disaster relief aid to community pharmacy owners, scholarships to pharmacy students, pharmacy school outreach nationwide, research/programs to improve the success of independent pharmacy and patient care, and community-based health awareness programs.

Auction items include: • Electronics • Travel packages • Gourmet cuisine • Pharmacy memorabilia • Celebrity memorabilia • Sports memorabilia • And More!

Look for signs in the Exhibit Hall to direct you to the auction.

Please email [email protected] if you need more information.

National Community Pharmacists Association Foundation 100 Daingerfield Rd, Alexandria, VA 22314, 800-544-7447 Continued from page 14 ➦ ducted at independent pharmacies. For more details, please email [email protected].

Legacy Society Members Individuals who remember the NCPA Foundation through a gift of $10,000 or more or in their estate planning are part of the foundation’s Legacy Society. The newest inductee is Tony Welder. Other Legacy Society members are Ed Berg, Donnie R. Calhoun, David Elm, Holly W. and Mike Henry, Sharlea and Gary Leatherwood, Forrest “Woody” Pack, Nancy Pruitt, Betty Schutte, Andrew Stout, and Charles and Becky West. Please visit www.ncpafoundation.org to learn and-comers realize their dreams of pharmacy more about the Legacy Society or to make a donation. ownership. The foundation’s and Partners in Pharmacy (PIP) scholarship programs help Awards Ceremony NCPA student members with a demonstrated During the NCPA Foundation Awards Ceremony at the interest in community pharmacy ownership off- NCPA Convention, scholarship and award recipients, set growing tuition costs. This year, the founda- distinguished pharmacy leaders, volunteers, and corpo- tion and PIP are awarding more than $65,000 in rate partners will be recognized. The ceremony is Sunday, educational aid to high-achieving students. The Oct. 13 from 3:30 – 5 p.m. Please email ncpaF@ncpanet. McKesson Foundation is a major supporter of org for more details. the NCPA foundation’s scholarship program.

Scholarship Program Sharlea Leatherwood, PD, is NCPA Foundation president The NCPA Foundation takes great pride in helping up- and was NCPA president in 2003–2004.

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Left: Combined floor displays can be an effective merchandising tool. Making theSale

It's not just what you stock, it's how you show it

By Chris Linville Category Sizes Photos by Gabe Trahan With over-the-counter products, manufacturers are battling for real estate, and line extensions have been proliferating, Trahan says. “When there’s a fight for space, what happens is that Merchandising for the front end of an independent many times that space is not filled with exciting new pharmacy is more complex than simply putting product items,” he says. “In fact usually it’s an item that has been on a shelf. It’s knowing where to place it, how to display reinvented into a different size, different shape, different it, how to price it, and how to promote it. color, or different taste.” Products need to do one or all of three things: draw To give an example, Trahan says he was in a store customers in, enhance the store’s image, and/or make the that had 20 different sizes of Pepto-Bismol. business money. “Let’s face it, if you are a customer and need a Pepto- “If it doesn’t do one of those three things, you have to Bismol, you are tickled that there’s three to choose from,” wonder why it’s there,” says Gabe Trahan. As NCPA’s senior he says. “If they can get 20 of their products on the shelf, director of store operations and marketing, he brings more they are squeezing out any other new items or competi- than 37 years of front-end merchandising experience to tion. Line extensions aren’t necessarily bad, but it doesn’t help NCPA members increase store traffic and improve mean they are going to bring more sales. More choices profits. And he has plenty of opinions on how to do so. do not equate to more sales.” “Years ago the theory was, stack it high, and watch it What Trahan urges merchandisers to do is look at fly,” Trahan says. “That’s not necessarily true for indepen- their sales reports. dent pharmacy anymore. We no longer merchandise our “They should ask themselves, ‘Am I filling up the product with aisle space that’s only 3-foot wide. We no shelves with items that customers are looking for?’” he longer use the tallest fixture that we can buy. Today we says. “If I’m filling up the shelves with more choices of need to make aisles 5-foot wide whenever possible. And the same product, I may want to revisit that to make make them no higher than 60 inches for fixtures. If it’s room for other products, or cross-merchandising to 72 inches tall it looks like a canyon.” bring me the additional sale.”

www.americaspharmacist.net September 2013 | america’s Pharmacist 19 Trahan says effective merchandisers will look at their dent will do, and what some merchandisers will do, is to store as if it’s an apartment complex. Each shelf is a floor try milk the old item to get whatever they can.” in the apartment building. On that shelf are different But Trahan says that can be a costly proposition. apartments that are being leased. “Time is not on your side,” he says. “Every minute “Think of yourself as a landlord,” he says. “You of the day, even when you are sleeping at night, you are rented an apartment to Pepto-Bismol Maximum Cherry paying rent for your building. That doesn’t go away. So 16 ounces, but it has only paid the rent once every three you have an old bottle of Jean Naté on your shelf, taking years. But over on the street waiting to move in is a new up six inches of space, and the box is turning from blue to tenant who looks like it’s going to pay the rent on time, yellow, and you still think, ‘I paid for that, I’m going to get every month. something for it.’ Well, no you’re not. What you are getting “As a landlord, you would say to Mr. Pepto-Bismol is a freeloader that’s not going to make you money.” Maximum Cherry 16 ounces, ‘You’re either moving to Trahan’s advice is to “stop the bleeding. Donate it. the basement or you are moving out. Because I have Give it away. Do whatever you have to do. Go 50 [per- somebody who is going to pay the rent.’ That’s the way cent] off for a short time. If it doesn’t sell at 50 off, think you have to look at it. Let’s make sure that the tenants about that. Do you think people will jump all over it if who live in your valuable real estate [shelves] deserve to it’s 60 percent off? Meanwhile, the clock is ticking and be there, fill the needs of your customers, and hopefully the rent is not being paid.” making you money.” Don’t Cap Sales Dumping Underperformers End-caps are typically a prime spot for impulse sales in Trahan says that in his visits to independent pharmacies, he a retail setting. Trahan says that independents tend to sees a reluctance to get rid of underperforming products. struggle to successfully market end-caps because they are “I guess it’s human nature—we paid for something, difficult to stock. and we’d like to get our money back,” he says. “It goes “A merchandiser will often try to make an end-cap back to the apartment theory. If Jean Naté Body Splash with what he or she has in the store,” Trahan says. “Most is sitting in an apartment not paying its rent, you don’t stores don’t have more than six of any item on their hope that someday it will get the money to pay you. After shelves. Most people have three or four. It’s hard to make a while you get the message and you throw them out a full-looking themed end-cap with an anemic inventory.” and say, ‘I’ll take the loss, but now I’m starting to make Trahan stresses that an end-cap “has to be stunning, money because I have a new tenant.’ What an indepen- it has to be full, it has to have a theme, and it must be

Product Position to Create Companion and Impulse Sales Braces Compression Hosiery Shoes

Foot Hot & Cold or Wound Care First Aid

Pain Relief Kleenex Cough & Cold

Antacid & Laxatives Vitamins

Mens Oral Hygiene Eye & Ear

Soap & Body Wash Deodorant Feminine

Hair Care Skin Care

20 america’s Pharmacist | September 2013 www.americaspharmacist.net Before After

In the “before” photo (top left), valuable space at eye level features the wrong items. Pretzels in a tin and single serve chocolates have less than $1 value each. The most expensive chocolates are positioned in poor “below knee level” and are jammed into shelving. In the “after” photo, valuable eye level space now shows the most expensive 2-pound chocolates while sharing the next premium merchandising space with 1-pound boxes. The less expensive candy is now relocated to the slanted base shelf. exciting and grab people’s attention.” wholesaler might have Listerine with a free toothpaste Planning a theme is the first step in developing a taped to it, and Advil with 30-count free. So that’s an successful end-cap. It could be bone density, heart sup- exciting end-cap. Now you look as big as the chains.” port, skin protection, or summer fun, to name several. Trahan also says an easy way to make an end-cap Once you determine the theme, it has to look full. look full is to simply use smaller shelves. Trahan suggests that independents call their whole- “With the exception of a base shelf end-cap, shelving saler and ask them what they have. He says floor displays does not have to be more than 10 inches deep,” he says. “You are effective. “You can take [product out of] a floor can even go with an 8-inch deep shelf on the top. Look for display and build an exciting end-cap,” he says. product that you already have, and don’t hesitate to create Wholesalers often have bonus sizes that they are an end-cap out of a few picked over floor displays.” looking to move out of their warehouse. “Lots of times Trahan says that when featuring products on an end these bonus sizes and ‘buy one get one free’ are not cap, smaller items should have no less than three facings, always well known to independent retailers,” Trahan three deep each, and should appear on two adjacent says. “They are just sitting there, so it doesn’t hurt to call shelves for a total of six facings of 18 of the item. (Facing and say, ‘Hey, what do you have for bonus sizes?’ A good is the amount of the same item that appears on the front

www.americaspharmacist.net September 2013 | america’s Pharmacist 21 But Trahan says that if you are in a small community, it is more important to change your displays. “People will tell me they don’t have time,” he says. “I understand that. Just move the display. You don’t have to reinvent it, just move it. Tear it down and put it back up in another spot.” Trahan says that moving a display brings new life into it. As many of the same customers come in frequently, they might start ignoring displays if they stay in the same location. “A good merchandiser has to literally grab the customer and shake them,” he says. “And the only way you can do that is with a compelling display, fresh and new.” When Trahan was a store manager, he took the greeting cards off the end-caps of the greeting card fixtures and created end-caps with everything from gifts, candies, candles, clothing, maple syrup, reading glasses, body lotions & crèmes, body and bath items, massage oils, toys, and handbags. He was pleasantly surprised at how successful it was. Decorating end-caps is one of Trahan’s pet peeves. “It gets in the way of product, and makes customers have to move it, which is a step they don’t want to take,” he says. “It would actually be the last thing I would consider.

Decorations on end-caps get in the way of product and can make I’ve run into a large number of merchandisers who think a bad end-cap even worse. wrapping or decorating an end-cap makes a bad end-cap better. It’s sort of like putting gold hubcaps on a 1971 Ford Pinto. When you’re done it’s still a 1971 Ford Pinto and edge of a shelf.) Larger items should have no less than when you are done wrapping, it’s still a bad end-cap.” two facing, two deep, and on two adjacent shelves. He also says that slanting bottom shelves will give smaller Size Does Matter items a better exposure. Another trend Trahan notices among some independents is a fascination with large spaces. When Stay Fresh owners tell him they have an opportunity to acquire a Trahan says that it’s important for displays to be changed 7,000-square-foot store, his first question is, “What are frequently to keep them from becoming stale. “Frequent- you going to put in it?” ly” can be interpreted in different ways, but he says once Trahan’s message is that independent pharmacists every two weeks is optimum. Years ago Trahan managed have to be realistic about what they can sell in their space. a chain of 14 retail pharmacies and understands that “Don’t buy the store and then try to fill it up,” he staff is busy and might be resistant. says. “Plan what you are going to specialize in, what you “I had all of our managers date the back of the are going to offer, then look for the space. Many times displays with a piece of masking tape,” he says. “They merchandisers have a bigger challenge of making a profit were great people, but inevitably I would say, ‘How long in a large store than they will a tight store of 2,000 square has this end-cap been up?’ They would say it was put up feet. When you have a large store, the merchandiser is two weeks ago. And we’d look and it was five weeks. They taxed, asking. ‘How am I going to have every square foot weren’t lying or being deceitful; it’s because time flies.” make me money?’”

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Finally, a program that gives you the Make plans today to attend! know-how and tools to build store traffic and profit: FRIDAY, OCTOBER 11, 2013 Walt Disney World Swan and Dolphin Resort n Eye-catching curb appeal to bring in Orlando, Florida new customers Held in conjunction with n Merchandise floor plans and cross NCPA’s Annual Convention and Trade Exposition merchandising ideas to increase sales

n Effective inventory management tools NCPA Member Fee: $350 Non-Member Fee: $450 n Private label profit drivers

n Proven and effective marketing guides that Get more information and sign up at: set your pharmacy apart from the competition www.ncpanet.org/index.php/events/ front-end-profit-building-seminar n Popular gifts, seasonal items and cards that bring customers into your store for more than prescriptions

n Tools, examples and networking to make “Loved the class – it was very informative. every square foot of your front-end real I have never seen merchandising put together estate profitable in such an easy to understand model. Keep up the good work!!! I still have a lot to learn.” Jason Callicoat, Paris Apothecary, Paris TX.

FrontEnd_June2013.indd 1 8/15/13 10:06 AM FRONT-END PROFIT BUILDING SEMINAR

Trahan says there is a reason that 5,000–7,000- square-foot facilities tend to be available on the market: How Not to Merchandise “Who’s going to rent them?” Gabe Trahan, NCPA’s senior director of store The 2,000-3,000 square-foot-spaces are more desir- operations and marketing, formerly managed a Connect Your Front End able; thus they don’t become available as often. Trahan tells chain of independent pharmacies. One year for a story of a trip to El Paso, Texas, to illustrate his point. an Easter promotion he purchased 1,632 bags of with your bottom line “I rented a car and was offered an upgrade to an jelly beans. Each store created a compelling sign, SUV for a cheaper rate,” he says. “It was tempting, but a colorful display and the jelly beans were priced then it’s 107 degrees outside, and I don’t need a big four- at two bags for $1. Each store was told to offer free samples of the Jelly beans at every register. wheel-drive. And I was going to pay a lot more in gas. “How could we fail?” Trahan says. “It was “That’s the same with leasing a 7,000 square-foot- easy; I had forgotten to taste the jelly beans. store. Yes, by square footage you are getting it for less They were awful; chewing the bag would have money than a 2,000-square-foot space, but now that been a better choice. Thank goodness I discov- square foot is going to cost you money because you have ered a store that was doing pretty well with them. merchandise sitting there. And you have to buy more fix- I asked what they were doing special, they said, ‘We are making sure nobody puts them in their tures and pay to heat or cool the space. Most businesses mouth.’ We sold about a third, and gave a num- are looking for smaller stores. There’s a fight for those. ber of people refunds.” There’s not so much for 7,000 square feet.” If you want some of those jelly beans, Trahan says he has plenty. Merchandise to the Right Hemisphere “I have some in my basement; they are next Obviously, signage is a key aspect of selling. “A compel- to my case of Smurfs. I’ll send you some; they are 12 years old, but trust me they are just as ling sign will sell more product than what we think good as the day they were made. (Even the mice would be a well-merchandised display without a sign,” brought them back.)” -CL Trahan says. Take FIJI Water, for example. Get a bottle and read the label. It says, ‘Never Touched by Human Hands. The “The right dwells on how great this will be when I own Finally, a program that gives you the Make plans today to attend! Purest Water on Earth.’ it. So the right hemisphere looks at FIJI Water and sees know-how and tools to build store traffic When making a sign for FIJI Water, Trahan says that the slogan: ‘Purest Water on Earth, isn’t that what you and profit: FRIDAY, OCTOBER 11, 2013 the average merchandiser who hasn’t studied the art of want?’ Of course! But the left says, ‘$4.99 for water, are Walt Disney World Swan and Dolphin Resort sign making will say, “FIJI Water, $4.99 for 16 ounces.” you crazy?’ n Eye-catching curb appeal to bring in Orlando, Florida “Well, we know that [price]. If you put a sticker on “So never invite the left hemisphere into the conver- new customers Held in conjunction with that says $4.99, you haven’t romanced the item. sation.” n Merchandise floor plans and cross NCPA’s Annual Convention and Trade Exposition This is where merchandising to the correct side of Trahan says if a merchandiser insists on listing a merchandising ideas to increase sales the brain comes into play. The left side is more analytical, price, to use the word “only.” understanding words and science, and controlling speech. “That gets their right brain hemisphere tickled,” he NCPA Member Fee: $350 n Effective inventory management tools The right hemisphere of the brain, on the other says. “Without ‘only,’ only your left hemisphere is think- Non-Member Fee: $450 n Private label profit drivers hand, “is the party animal. It allows you to have emo- ing about it. You’re not saying it’s on sale, you are just tion,” Trahan says. “If I can’t sing happy birthday, it saying ‘Only’.” n Proven and effective marketing guides that Get more information and sign up at: means my right hemisphere has been damaged. That’s No matter how a merchandiser displays product, set your pharmacy apart from the competition www.ncpanet.org/index.php/events/ why some people can sing, but stutter [when speaking]. builds end-caps, or designs signs, in the end Trahan says front-end-profit-building-seminar n Popular gifts, seasonal items and cards that The right and left hemispheres do separate jobs.” that “independent pharmacists need stores to be warm, So, when making a sign, Trahan says that you need wide, comfortable, and open. They need to draw custom- bring customers into your store for more to attract the right hemisphere and keep the left out of ers in and be appealing.” than prescriptions the decision making. A good merchandiser will say “FIJI n Tools, examples and networking to make “Loved the class – it was very informative. Water: Purest Water on Earth.” every square foot of your front-end real I have never seen merchandising put together “The left hemisphere dwells on the price,” he says. Chris Linville is managing editor of America’s Pharmacist. estate profitable in such an easy to understand model. Keep up the good work!!! I still have a lot to learn.” www.americaspharmacist.net September 2013 | america’s Pharmacist 25 Jason Callicoat, Paris Apothecary, Paris TX.

FrontEnd_June2013.indd 1 8/15/13 10:06 AM NCPA partners with RxWiki to deliver social media and mobile solutions to community pharmacies and patients

By Chris Linville Community Pharmacy GoesDigital

Donald Hackett and Lou Scalpati have been in the health care universe for almost 25 years. During that time, they’ve seen a lot of things change within the eHealth “With pharmacists becoming more involved in market. With their latest venture, RxWiki, Inc., Hackett the delivery and management of patient care, there is and Scalpati are coming full circle on one trend they a valuable opportunity for greater collaboration with believe is here to stay—digitally connecting patients to patients to improve overall health outcomes,” says NCPA their pharmacist. president and pharmacy owner Donnie Calhoun, RPh. RxWiki is the culmination of years of innova- “The strategic goal of this partnership is to empower tive technology development, a keen understanding community pharmacists with world-class medication in- of the ever-evolving eHealth landscape, and strategic formation and digital solutions to better engage patients timing. Now, NCPA members can take advantage of within the pharmacy and from any digital device,” says this technology as the association has partnered with Hackett, RxWiki chairman and CEO. RxWiki. Through this strategic relationship, NCPA will incorporate RxWiki’s Digital Pharmacist™ offering as Digital Solutions a new, cost-free benefit for its members. The Digital In describing RxWiki’s capabilities, Hackett says, “As Pharmacist suite includes website, social media, and health care delivery shifts toward an age of accountable mobile solutions for pharmacists to deliver medication care, RxWiki‘s solutions are supporting community information to patients. pharmacists’ transition into a new role as the ‘primary-

www.americaspharmacist.net September 2013 | america’s Pharmacist 27 ing directions to our store. That digital visibility translates to new patients coming through our pharmacy’s front door.” Kent Lambrecht, owner of Vail Valley Pharmacy, Edwards, Colo., says he heard about RxWiki's Digital Pharmacist solutions from Andy Berg (RxWiki’s director of network membership), who had done a rotation at Valley while a pharmacy school student. “As pharmacists continue to play a more active role in patient care, it has become important for our pharmacy to keep patients and customers engaged through several mediums,” Lambrecht says. “Social media in particular has proved to be a powerful tool to attract and connect with patients. RxWiki's solutions have definitely enhanced Vail Valley Pharmacy's digital presence and given me and my staff a valuable opportunity to interact with patients outside of the pharmacy.” Bill Osborn, PharmD, president of Osborn Drugs, Inc., Miami, Okla., says his pharmacy has had a Face- book page for about five years, and RxWiki has helped enhance its online profile. “We found RxWiki through NCPA and were asked Facebook is a tool that can help independents level the to be a beta site,” he says. “It has been great to have a playing field. source of suitable content that will not direct patients to mail order promotion or other content not showing community pharmacy properly.” care-pharmacist.’ In partnering with NCPA, RxWiki will While having a website is certainly important, have the opportunity to connect thousands of communi- Osborn says that Facebook is more flexible and “so ty pharmacies and their patients to timely, trusted medi- much easier to maintain.” He also points out that the cation information and digital tools to improve patient adaptability and versatility of social media can help level medication management. New solutions must leverage the playing field with larger organizations such as chains. innovative technologies to create work-flow efficiencies In fact, he says the personal touch that pharmacists can that reduce costs and improve patient outcomes.” deliver through social media is a valuable asset for inde- RxWiki’s digital solutions enable community pendents. Osborn says that Osborn Drugs has divided pharmacists on any scale to connect and engage with pa- its social media offerings into three primary categories: tients on Facebook, Twitter, and Google+. Additionally, health care, gifts, and local staff news. patients will be able to leave the pharmacy with a mobile Osborn says that he knows other independent app customized for their needs. pharmacists might be taking a wait-and-see approach to “RxWiki’s Digital Pharmacist program has deliv- find out how things shake out, but in his opinion, with ered measurable results for my pharmacy,” says Mark younger people (and plenty of older ones) being com- Newberry, PharmD, owner of Tarrytown Pharmacy in pletely immersed in mobile technology, being proactive Austin, Texas, who tested the program earlier this year. is a must. “Within the first two months, Tarrytown Pharmacy’s “A lot of these people will be our future customers, Facebook audience more than doubled, our customer and some already are,” he says. “We need to stay on top reviews on Google+ earned us a ranking of excellent, of the newest technology trends to enhance health care and we received more than 300 online requests for driv- because customers will expect that from us.”

28 america’s Pharmacist | September 2013 www.americaspharmacist.net RxWiki Digital Pharmacist Solutions

The following is a brief overview of the options available to independent community pharmacists through RxWiki’s Digital Pharmacist program. These tools are free for NCPA members.

• Social Media: With RxWiki’s social media solutions, pharmacists can share the latest health and medication news directly on their social media channels. RxWiki creates and customize social properties for each pharmacy on Google+, Facebook, and Twitter. Each social page is automatically updated with timely, trusted RxWiki content. RxWiki also op- timizes each pharmacist’s page’s settings, language and keywords to maximize visibility on each social channel.

• Mobile: RxWiki’s custom mobile apps are branded for each pharmacy. Patients can access the news that’s important to them, at any time, with customizable health and medication news feeds delivered to their smartphones. Each custom app also includes a click-to-call feature that routes patients directly to a specific pharmacy.

• Website: Website tools enable pharmacists to share RxWiki content from their pharmacy websites. RxWiki’s Active News feature keeps website content fresh with the latest medication and health news syndicated on pharmacists’ websites. Pharmacies can also integrate RxWiki’s Search widget to enable patients to search RxWiki content directly from their website.

The RxWiki Evolution down the industry’s silos of fragmented, non-communi- In the early 1990s, Hackett and Scalpati (RxWiki chief cating apps. technology officer) launched the first eRx network with When Hackett and Scalpati started RxWiki, the fax machines. They then connected pharmacists, doctors, big question was how the company would leverage its and hospitals with the first e-prescribing app. A few years platforms and health content to change the way doctors, later, the two launched one of the first digital health pharmacists, and patients communicate. They knew that communities on AOL with former U.S. Surgeon General today’s low health literacy rates had been largely due to C. Everett Koop, which featured the first drug interaction both the quality of and patients’ ability to access medica- app on the Internet. tion information and health news. With each of these ventures, Hackett and Scalpati The ACA has created an opportunity for RxWiki to saw that patients were interested in digitally connecting change the rules of the game. with health care providers. Since those early days, they’ve The first part of this evolution equation is content. seen the digital evolution continue, from small online RxWiki’s patient-centric publishing model focuses on forums to widely popular social networks. transparency, velocity, and accessibility. The company’s goal They say that the health industry, however, has been is to deliver trusted, multimedia medication news within largely unreceptive to IT-based disruptions. The behav- minutes, not weeks, of when new research is released. iors of the major players have, in large part, remained the RxWiki’s digital medication encyclopedia is cre- same despite a rapidly evolving technology landscape. ated for patients, by pharmacists. From patient-centric But the Affordable Care Act (ACA) has opened the medication news to Food and Drug Administration door to change. It has served as a tipping point to break alerts and manufacturer updates, RxWiki’s pharmacist-

www.americaspharmacist.net September 2013 | america’s Pharmacist 29 Twitter provides independent pharmacists with a quick and easy way to get their message to the public.

created-and-edited content is written in positive, neutral support pharmacists as they transition into their new language targeted at an eighth-grade reading level. role of “primary-care-pharmacist.” RxWiki also publishes video news and information seg- RxWiki embraces the power of social media and mo- ments. These concise and effective videos are integrated bile devices to share its content with patients and bring within relevant text to provide patients with a versatile pharmacists into the digital conversation. Social media, multimedia experience. All medication information is in particular, has developed into a space where RxWiki available to consumers at no cost via websites, social brings pharmacists and patients together to communi- media, mobile, and print platforms. cate and collaborate. On-demand accessibility to information and interac- Distribution Options tion via social media and digital devices has made it possible The second part of the equation is distribution, which is for RxWiki to not only connect a national network of phar- rooted heavily in the company’s technological capabili- macists and their patients but also connect both parties with ties. The ACA created a demand for patient education engaging medication information that empowers patients to and engagement in an effort to improve patient out- play a more active, informed role in their health. comes while also reducing overall health care costs. The RxWiki Digital Pharmacist solutions also serve Among health care providers, pharmacists are often as marketing tools for pharmacies, enabling pharmacists the lowest cost operators. As a result, pharmacists have to boost their online presence, increase brand awareness, moved away from product-based business models to attract new customers, and strengthen relationships with become more involved in the delivery and management existing patients to build loyalty. of patient care. To learn more about these solutions and how to enroll, RxWiki is building out the technology and infra- please visit http://www.ncpanet.org/digitalpharmacist. structure that will continue to support the needs of patients and pharmacists as the industry evolves. The company has developed this suite of digital solutions to Chris Linville is managing editor of America’s Pharmacist.

30 america’s Pharmacist | September 2013 www.americaspharmacist.net MAKE PLANS TODAY TO ATTEND!

Opportunities in Compounding: Niche Exploration of the Nutrition and Pain Management Markets

Saturday, October 12 The maturing population brings big opportunities 8 am – 4:30 pm for the community pharmacy, and none are more Walt Disney World Swan and Dolphin Hotel potentially successful than nutrition and pain management. Nutrition counseling helps you to This program is sponsored by an unrestricted educational grant reach out to patients as a trusted healthcare resource from PCCA. All proceeds will be donated to NCPA’s Foundation. helping them to improve their health and wellness. Pain management covers the gamut from exercise Members Fee: $350 recovery to arthritis and injury and at one time or ½ day morning: $200 another touches every patient. The key take-away of ½ day afternoon: $200 this program is strong guidance on how to best manage and market your services to ensure the best outcome Non-members Fee: $450 ½ day morning: $225 for your patients and practice. ½ day afternoon: $225 Take away expertise in clinical, Held in conjunction with NCPA’s 115th Annual Convention counseling, operations and marketing aspects for your practice!

For more information on this program as well as other programs scheduled at the convention, please go to http://www.ncpanet.org/index.php/2013-pre-convention-programming Teed Up for a TOC Spike Community pharmacists can get in the game with an expanded role on the transitions of care team

By David D. Pope, PharmD, CDE; and Jason M. VanLandingham, PharmD, BCPS

32 america’s Pharmacist | September 2013 www.americaspharmacist.net If you’ve ever played volleyball, you know that the best have just been wasted by all the health care professionals way to score a point is to bump, set, and spike the ball. involved? Unfortunately, this scenario is all too common. You simply defend the ball with a bump, and then set it In response, the Centers for Medicare & Medicaid up for an eye-popping spike. It’s a great feeling to spike Services (CMS) now financially penalizes hospitals for all- the ball, but it’s utterly dependent on the setup shot by cause readmissions within 30 days for heart failure, pneu- your teammate. A perfectly placed ball from the setter monia, and MI patients. Therefore, hospitals (including position allows you to place all of your power into the hospital pharmacists) have created several initiatives that ball, ensuring a point each time. Likewise, in the case of have improved TOC, including notable programs such as transitions of care (TOC) planning, pharmacists have Project RED (Re-Engineered Discharge) at Boston Uni- been set up with an awesome opportunity to set them- versity Medical Center. In one study at Einstein Medical selves up for the ‘spike’ of a generation. Center in Philadelphia, pharmacists successfully reduced all-cause readmissions via pharmacist-led interven- Bump tions. The readmission rate in the control group was 21.4 According to a January 2013 study, almost one in every percent while only 10.6 percent in the intervention group. four heart failure patients will return to the hospital with- Studies representing every type of setting consistently in the first 30 days of discharge. Of those returning, 61 show that community pharmacist involvement improves percent are actually re-admitted within the first 15 days. readmission rates. With a financial and patient outcome Other disease states, such as pneumonia and myocardial incentive to improve readmission rates, accountable care infarction (MI), boast similar numbers. Additionally, 20 organizations (ACOs), health systems, and other health percent of prescriptions written in the hospital are never care entities are now actively partnering with community filled. While there are a myriad of reasons the patient pharmacists to improve TOC. may be readmitted, community pharmacists have proven themselves to be a powerful force in both improving Spike outcomes and reducing overall health care costs through Assisting patients leaving the hospital isn’t new for any transitions of care planning. Health care providers from community pharmacy. For years, many independent every arena have joined the chorus singing the need for pharmacists have gone beyond filling prescriptions to an improved process for discharging hospital patients. provide services to patients leaving the hospital. From diabetes education to impromptu medication reconciliation Set services, partnering with their patients has been a core Community pharmacists understand the typical scenario essential of the DNA of a community pharmacist. Patrick that presents itself: A patient is admitted to the hospital, Devereux, PharmD, CDE, owner and pharmacist at Fam- upon which a hospital staff member (most likely not a ily Medical Services (FMS) Pharmacy, Bessemer, Ala., has pharmacist, physician, or registered nurse due to staffing been working with patients who are discharged from his restraints) asks the patient which medications they are local hospital. Devereux meets with patients within hours taking. The patient is then switched to medication alter- of discharge, performs medication reconciliation, and natives, which are on the hospital formulary. Upon dis- more. As a pioneer in the TOC model, Devereux simply charge, the patient brings new prescriptions to the retail relies on increased prescription volume to sustain the ser- pharmacy, where the pharmacist discovers the formulary vice. Pharmacists such as Devereux have inspired others medications prescribed in the hospital are not covered to do the same in their communities as well. Several bar- under the patient’s plan. Therefore, the pharmacist riers exist, however, that inhibit community pharmacists contacts the hospitalist to address the issue, to which the from partnering with health care entities. hospitalist informs the pharmacist to call their primary care physician instead. Finally, when the family physician Barrier #1: The community pharmacy lacks a simple way is asked about the medication issue, the physician explains to ascertain lab values and diagnoses. he wasn’t even aware of the patient being admitted to There is an ever-increasing effort to develop health in- the hospital! How much time and how many resources formation exchanges (HIEs) to improve the level of care

www.americaspharmacist.net September 2013 | america’s Pharmacist 33 Imagine, for example, using video-based communication (such as FaceTime) in a roundtable discussion with others on the health care team before discharge. The community pharmacist would effectively be able to inform the team regarding previous medication history, at the community pharmacy. While several barriers exist immediately check for drug interactions with discharged in this particular area, a well-informed pharmacist can medications, discuss insurance formularies, and ensure more easily identify issues quickly and in a cost-effective clinical guidelines are met before the patient is dis- manner. Should the pharmacist be forced to infer disease charged. Not to mention saving the patient, hospitalist, states from prescriptions? Could the pharmacist be more community physician, and pharmacist time and energy. effective in properly dosing medications if lab values were known? Could potential medication errors be averted? Barrier #3: Payment models have yet to be fully defined. Lack of access to an HIE is not an absolute barrier to pro- In January of 2013, new HCPCS codes were introduced viding quality care. Imagine how effective a pharmacist covering transitions of care management. These codes could be, however, when armed with critical patient data. (99496, 99495) represent a powerful new way for pharmacists to be a part of a team of HCPs that work Barrier #2: Communication with health care professionals together to improve outcomes and lower readmission can be difficult. rates. While a recognized Medicare provider must bill Similar to barrier #1, pharmacist communication must these codes, it does not preclude pharmacists from improve with prescribers to improve readmission rates. performing the service and acting as an extension of the E-prescription pathways such as Surescripts are now provider. This model also leaves open the opportunity offering the first forms of this type of clinical messag- to use a variety of communication methods, including ing. Consider, however, the typical hospital discharge electronic methods. Ultimately, pharmacists should be planning meeting. The physician, medical residents, able to bill for this cost-saving service. As integral mem- social worker, hospital pharmacist, and other health care bers of the solution to improving the health of America, providers (HCPs) are typically present. Unfortunately, it’s imperative that pharmacists receive provider status, the only HCPs that aren’t present are the only ones who which would effectively allow pharmacists to directly bill will see the patient again: the family practice physician for the transitions of care management service. and the community pharmacist. By developing a plan in which the aforementioned team includes the community Prepare and Engage pharmacist and family practice physician—before pre- In light of the weight of countless studies that prove the scriptions are written—many of the inherent issues with effectiveness of the community pharmacist in regards to the discharge process may be avoided. TOC, how can the typical pharmacy owner prepare and

34 america’s Pharmacist | September 2013 www.americaspharmacist.net Business Plan How many patients would you expect to see from this clinic or hospital? How will you meet with them? How much of a pharmacist’s time will it take? Would the hospital or physician be willing to partner with you to act as a contractor for transition of care management billing? Define a specific financial model that will be sustainable. While you will certainly acquire new patients and fill engage to participate in TOC? First, look at the Hawaii additional prescriptions with this service, make your Community Pharmacist Association’s (HCPA) model. This TOC program self-sufficient. Find ways to incorporate grouping of independent pharmacists recently received your current offerings to chronic care patients, such as a $14 million grant from CMS to further expand its in- adherence packaging and the Simplify My Meds® novative TOC practice. According to Dr. Karen Pellegrin (www.ncpanet.org/smm) refill synchronization program. at the University of Hawaii, pharmacists are required to These programs will not only help your patients take go through their training and use workflow tools for stan- their medications, but it will also serve as selling points dardization. Pharmacists call the patient within 24 hours to potential hospital partners. of discharge and then home visits typically occur within It may take ingenuity to overcome the inherent three days. Weekly visits are also provided as needed. barriers to independent community pharmacist involve- “Physicians have been thrilled for the support and ment. However, if there were ever a problem that the have been extremely supportive of the pharmacist,” Pel- clinical community pharmacist can assist with, it’s dis- legrin says. charge planning. The community pharmacist stands in Practices such as these show that TOC models can the gap routinely for these patients, offering medication be flexible to meet the demands and resources of the screenings and in-depth counseling services. Many phar- hospital, community pharmacists, and even the patient. macists go a step beyond medications by even partnering For example, one-on-one meetings combined with with their patients to assist them with lifestyle modifica- electronic communication may work well in some areas, tions, such as teaching them healthy eating, exercise, and while home visits may be necessary in others. If you are monitoring tips. a community pharmacist, consider the hospitals and If you’re a pharmacist, call your local hospital and physician groups that surround you. Are there any spe- let them know you want to be a part of the solution for cific departments that you would consider working with? discharge planning. If they are a part of an ACO, sched- Heart failure clinics within the hospital are a great place ule a meeting to find a way to be a part of it. Let’s face to start. Before you contact hospital administration, it …they need you. If you’re a hospital administrator or develop two separate plans: clinical and business. physician, know that there are myriads of clinical pharmacists in the field that are ready to partner with you. Clinical Plan The ball has been set, so it’s up to you to spike it! Your clinical plan will vary depending on the specific group of patients you will be working with (such as heart failure). Consider how you will develop the program. You may David D. Pope, PharmD, CDE, is chief of innovation at need to develop a checklist to ensure patients are following CreativePharmacist.com. He can be reached at david@ disease-based guidelines. You’ll also need to identify a docu- CreativePharmacist.com or 706-210-9087. Share your TOC story: mentation system to record and report in a consistent man- creativepharmacist.com/blog. ner. Have a plan in place to easily and effectively communicate with the provider to make changes quick and simple for Jason M. VanLandingham, PharmD, BCPS, is an oncology phar- the patient and physician. Consider patient-specific pieces macist at Georgia Regents University Cancer Center in Augusta, will you need, such as medication action plans. Ga. He can be reached at [email protected].

www.americaspharmacist.net September 2013 | america’s Pharmacist 35 E-prescribing continues to lead the E-prescribing has come a long way in the past decade, and community pharmacies have been consistently digital health care transformation leading the way. The National Community Pharmacists Association and the National Association of Chain Drug By Ken Whittemore, Jr., RPh, MBA Stores founded Surescripts in 2001 to enable the electronic routing of prescriptions between providers and pharmacies, laying the foundation for the widespread Over the past year, questions have been raised about the adoption of e-prescribing. Today more than one half of pace of adoption of electronic health records (EHRs) and all prescriptions are sent electronically and, as of the end whether investments in health information technology of 2012, 93 percent of community pharmacies routed (HIT) are truly having an impact on improving care and prescriptions electronically. reducing costs. As a former community pharmacist myself and a member of the HIT industry for more than a decade, Not an Overnight Success I would suggest that the role of pharmacists in implement- This success didn’t happen overnight. In fact, despite ing and promoting the digital transformation of our health the publicized patient safety and quality benefits of e- care system is one of the greatest, most under-appreciated prescribing, prescriber adoption remained low through success stories in HIT. This is evidenced most clearly by the the mid-2000s, and the trends suggested a long uphill fact that e-prescribing has become the first widely adopted struggle. By 2007, just six percent of prescribers nation- and used HIT transaction set on a national basis. wide had adopted electronic prescribing. By 2008, physi-

36 america’s Pharmacist | September 2013 www.americaspharmacist.net cian adoption of EHRs was still less than 10 percent, but community pharmacies were clearly responding and taking a leadership role with more than 46,000 community pharmacies (72 percent) having adopted e-prescribing. Independent pharmacists in particular have con- cies, as reported through the Surescripts Independent tinued to drive considerable adoption and utilization of Pharmacy Line (IPL), a customer service hotline reserved e-prescribing. In 2012, 74 percent of all new pharmacies for independent pharmacies. In 2012, we witnessed a 40 connecting to the Surescripts network were independent percent decline in the number of support cases logged pharmacies, increasing the total number of indepen- to the IPL. The IPL can be reached via phone, email or dently owned and operated pharmacies engaged in fax (http://www.surescripts.com/support/independent- e-prescribing from 10,000 in early 2009 to 19,000 by the pharmacy-help-line). end of 2012. Independent pharmacy adoption is critical to the Thanks to the leadership of community pharmacists, success of electronic prescribing and has been a health e-prescriptions are quickly becoming a part of standard care policy objective at the federal, state, and local levels. pharmacy workflow. In 2012, e-prescribing transactions While government programs have increased physician increased to the point that one out of every three pre- adoption of HIT, the intent of these programs is not scriptions received by an independent pharmacist was an adoption for adoption’s sake. Instead, the purpose is to e-prescription. And as e-prescribing has matured, fewer leverage the digitization, interoperability, and decision issues are being reported affecting independent pharma- support capabilities of EHRs to facilitate improvements

www.americaspharmacist.net September 2013 | america’s Pharmacist 37 in quality, care communication, patient safety, and prescriptions, while creating efficiencies for pharmacies reduced costs. Unfortunately, broad scale adoption and and prescribers. Solving any one of these challenges is use of EHRs is still new enough that it has been difficult a significant contribution to improving our health care to decisively prove out the values of EHRs. Thankfully, e- system, and taken altogether, e-prescribing is projected prescribing once again leads the way, providing a wealth to result in $140 to $240 billion in health care savings of peer-reviewed studies that can serve as an example of and improved health outcomes over the next 10 years. the transformative potential of HIT. Work to Be Done Improving Adherence But our work is not done. E-prescribing has quickly Consider the challenge of medication adherence: the become widely adopted, but we must focus on continual World Health Organization estimates that as many as improvements. Additionally, pharmacists are uniquely half of all patients do not adhere fully to their prescribed poised to leverage their technological capabilities and medication treatments, and that medication non-adher- role as trusted clinicians to once again lead the health ence leads to 125,000 preventable deaths and billions of care industry to the next stage of transformation. dollars in preventable health care costs annually. Already, Surescripts has broadened the horizons of phar- According to two recent studies (one published by macy HIT by beginning to enable the pharmacy industry Surescripts), physician adoption of e-prescribing helps to electronically deliver immunization notification improve patient primary adherence by 10 percent. Un- messages from pharmacies to primary care providers like with paper prescriptions, which can wind up being and state registries, driving the adoption of electronic misplaced or forgotten, e-prescriptions always make it prescribing of controlled substances (EPCS), and more. to the pharmacy. In fact, previous studies have suggested In developing programs to speed up progress, the that between 25 to 28 percent of paper prescriptions industry should consider the successes achieved in e-pre- never made it to the pharmacy. Now that they are being scribing and leverage pharmacists and other non-physi- e-prescribed, pharmacists have visibility to all prescrip- cians as key health care providers and technology leaders. tions and are able to proactively address primary medica- All stakeholders should be invited to inform and guide tion non-adherence. Given the influence of pharmacists the development of industry standards to ensure quality, in improving medication adherence (as NCPA recently governance, certification, and versioning. Together, we demonstrated with the release of Medication Adherence can work to promote the benefits of HIT and encourage in America: A National Report Card), e-prescribing is a investment in technologies that have direct benefits to pa- perfect example of how technology can provide more tients and providers. And we must remain committed to complete and actionable information to the right pro- investing in continual improvement and develop results- vider at the right time to improve health care. based (not process-based) drivers that allow for flexibility The increase in e-prescribing has yielded tremen- in meeting necessary requirements. Looking forward, we dous benefits for pharmacies, patients, physicians, and applaud the work of community pharmacists to spur the the health care system as a whole. Along with improving adoption of HIT, and we hope other stakeholders begin first-fill medication adherence by increasing pharma- to catch up to the pharmacy industry soon. cists’ visibility into the prescription writing process, e-prescribing removes the problem of illegible physician handwriting, decreases adverse drug events (ADEs), Ken Whittemore, Jr., RPh, MBA, is the senior vice president of and increases formulary compliance and use of generic professional and regulatory affairs for Surescripts.

38 america’s Pharmacist | September 2013 www.americaspharmacist.net Make sure you plan a sale that will get you the best return on the investment you have made in your pharmacy. Take advantage of a panel of experts: lawyer, accountant, banker, investment counselor. They will focus specifically on the issues of importance as you prepare to sell. This program is designed to help you with the process:

• Planning and preparation for retirement

• Cleaning up (normalizing) your books

• Sellers checklist – The details of a sale

• Contracts and the legalities

• Accounting guidelines for sale Make plans today to attend! • The banker’s perspective – valuation Saturday, October 12, 2013 • Should I do this myself or rely on a broker – Walt Disney World Swan and Dolphin Resort tools for a decision Orlando, Florida NCPA Member Fee: $350 • Ask the experts panel Non-Member Fee: $450

Held in conjunction with NCPA’s Annual Convention and Trade Exposition

More information & sign up – www.ncpanet.org/preconvention

Selling_Pharmacy_AP_Aug2013.indd 1 8/14/13 3:23 PM Introducing our newest benefit, NCPA’s Digital Pharmacist SOLUTION

— Forbes’ technology and medicine contributor John Nosta calls it a “Health Care Game Changer!” The Digital Pharmacist Solution delivers consumer- focused, health-related articles to your pharmacy’s social media sites and website and a mobile app. No presence on social media? RxWiki will create pages for you and update them on a regular basis with content. All free for NCPA members.

And don’t forget… • Simplify My Meds, NCPA’s medication synch program with over 1,000 pharmacies participating. • Dispose My Meds, NCPA’s drug take back program with over 1,500 pharmacies participating • NCPA’s communications including our monthly journal, America’s Pharmacist, weekly communications, e-News and Executive Update • A team of experts working on the national and state levels to support independent pharmacy

NCPA… providing our members with cutting-edge solutions, legislative and regulatory support, and timely communications.

Go to www.ncpanet.org or call 1-800-544-7447 for more information and to join today. continuing education

Preventing Osteoporosis Within the Community Setting by Stacey Schneider, PharmD; and Thomas Towers, PharmD

pon successful completion of this porosis-related fracture in their lifetime. Although osteo- activity the pharmacist will be able to: porosis is less frequent in African Americans, those with 1. Discuss the most recent National osteoporosis have the same fracture risk as Caucasians. Osteoporosis Foundation Guide- The prevalence of osteoporosis is expected to increase lines for the Prevention and Treat- as the population increases. U ment of Osteoporosis. With increasing demands to reduce health care 2. Counsel a woman on proper methods to pre- spending and improve patient outcomes, the intent of this vent the risks of developing osteoporosis. article is to review the current practice recommendations 3. Understand the available treatment options for for the treatment and prevention of osteoporosis. This the prevention and treatment of osteoporosis. will enhance pharmacists’ knowledge and increase their 4. Discuss current practice trends in the commu- confidence when treating this patient population. nity pharmacy to establish patient programs to educate women about osteoporosis. Overview of the NOF Clinicians Guide 5. Apply clinical knowledge of osteoporosis to a on Osteoporosis specific clinical case. The National Osteoporosis Foundation (NOF) guidelines are a source of information for determining risk factors, Upon successful completion of this activity, the diagnosing and evaluating the treatment of osteoporosis pharmacy technician will be able to: in men age 50 and older and postmenopausal women 1. Discuss the most recent National Osteoporo- Achieving optimal levels of bone mass at a young sis Foundation Guidelines for the Prevention age would account for a logical approach to building and Treatment of Osteoporosis. stronger bones later in life; peak bone mass occurs at 2. Understand the available treatment options for 18-25 years of age. Bone mass is influenced by factors the prevention and treatment of osteoporosis. such as genetics, nutrition, endocrine status, and physi- 3. Discuss current trends in the patient education cal activity. Bone growth and bone resorption are always programs. in some form of continuous balance, thus routine screen- 4. Identify patients who are at-risk for osteoporosis ing of individuals at high risk for osteoporosis may reduce or fractures and refer them to the pharmacist for incidence of osteoporosis-related fracture. Osteoporosis counseling occurs when the rate of bone resorption is greater than the rate of bone formation and is defined as bone that is An estimated 10 million Americans have osteo- 2.5 standard deviations less dense (T-score -2.5) than a porosis. An additional 34 million people in the young adult reference population. United States have osteopenia, which increases there are a wide variety of factors that influence the their risk for osteoporosis. It is estimated that risk of osteoporosis (Table 1 and 1A). The patient’s lifestyle one in two women and one in four men older choices, family history, disease states, and use of certain than 50 years of age will experience an osteo- medications are part of the risk assessment process.

www.americaspharmacist.net September 2013 | america’s Pharmacist 41 Table 1. Conditions, Diseases and Medications That A large number of osteoporotic fractures are Cause or Contribute to Osteoporosis and Fractures attributed to falls. Therefore, it is important to determine an individual’s risk for falls. Table 2 lists Lifestyle Factors Low calcium intake Vitamin D insufficiency factors that can increase an individual’s risk for Falling falling. Helping patients understand their person- Excess vitamin A Aluminum (in antacids) al risk factors is an excellent way to begin coun- High salt intake seling individuals on ways to reduce their risks High caffeine intake Alcohol (3 or more drinks/day) for developing osteoporosis. Several of these risk Smoking (active or passive) factors have been included in the World Health Inadequate physical activity Immobilization Organization (WHO) 10-year fracture risk model Decreased physical activity (Table 3). These risk factors put patients at an Thinness increased risk for fracture regardless of bone Genetics Factors Cystic fibrosis mineral density (BMD). These risk factors can be Homocystinuria Parental history of hip fracture combined with BMD measurements and used to Porhyria assess an individuals’ risk of future fractures. Idiopathic hypercalciuria Glycogen storage disease Hypogonadal States Androgen insensitivity Universal Recommendations Anorexia nervosa and bulimia for All Patients Premature ovarian failure Athletic amenorrhea Appropriate Calcium Intake Hyperprolactinemia In public lay media, there are conflicting re- Panhypopituitarism ports of the benefits and risks of calcium and Turner’s & Klinefelter’s syndromes vitamin D supplementation. However, accord- Endocrine Disorders Adrenal insufficiency Cushing’s syndrome ing to the Institute of Medicine of the National Diabetes mellitus Academies Practices, most reports in the media Thyrotoxicosis Hyperparathyroidism that showed negative benefits from increased Gastrointestinal Factors Celiac disease Gastric bypass Table 2: Risk Factors for Falls GI surgery Environmental Lack of assistive devices in the Inflammatory bowel disease bathrooms Malabsorption Loose throw rugs Pancreatic disease Low level lighting Obstacles in the walking path Hematologic Disorders Hemophilia Slippery outdoor conditions Leukemia and lymphomas Multiple myeloma Medical Age Sickle cell disease Anxiety and agitation Arrhythmias Rheumatic and Rheumatoid arthritis Dehydration Autoimmune Disease Ankylosing spondylitis Depression Lupus Female gender Impaired transfer and mobility Table 1A. Medications Associated With Osteoporosis Malnutrition Medication causing oversedation Medications Orthostatic hypotension Poor vision and use of bifocals • Anticoagulants (heparin) Previous falls • Anticonvulsants Reduced problem solving • Aromatase inhibitors or mental acuity • Barbiturates Urgent urinary incontinence • Cancer chemotherapeutic drugs • Cyclosporine A and tacrolimus Neuro and Kyphosis • Depo-dedroxyprogresterone musculoskeletal Poor balance • Glucocorticoids ( mg/d of prednisone or equivalent for  3 mo) Weak muscles • Gonadotrophin releasing hormone agonist • Lithium Other risk factors Fear of falling

42 america’s Pharmacist | September 2013 www.americaspharmacist.net Table 3: Risk Factors Included in the WHO mately 600 to 700 mg of dietary calcium daily. Patients Fracture Risk Assessment Model may be advised to increase their dietary calcium intake by increasing the consumption of milk, cheese, yogurt, Uncontrolled Current age risk factors Gender or fortified cereals before beginning dietary calcium Current smoking status supplements. Tables 4 and 4A include some non-dairy Alcohol intake (3 or more drinks/day) Low body mass index (kg/m2) and dairy food sources and their calcium and caloric Disease states Rheumatoid arthritis contents, respectively. This becomes useful for patients Secondary osteoporosis trying to determine how to obtain additional calcium A prior osteoporosis risk factor (including morphometric vertebral in their diet. Heath care providers should help patients fractures) evaluate what their current daily intake is before seeking Diagnostic Parental history of hip fracture supplements. When diet is not sufficient alone for meet- Femoral neck BMD ing the body’s needs of calcium intake, supplements Medications Oral glucocorticoids  5mg/day of may be administered. The amount of elemental calcium prednisone for  3 months (ever) in over-the-counter supplements varies by the salt form; calcium intake are considered inconclusive. The Table 4B lists calcium salts and elemental calcium found NOF recommends intake of at least 1,000 mg to in each type. Pharmacists should know their calcium 1,200 mg per day of dietary calcium, which may supplement inventory and be a knowledgeable resource include the elemental intake from supplemental for patients who may require assistance selecting an nutrients. Intake in excess of 1,200 to 1,500 mg appropriate supplement. Price and bioavailability are per day may increase the risk of developing important factors. kidney stones, cardiovascular disease, and stroke, and has limited benefits. Consequently, Appropriate Vitamin D Intake there is no benefit to increasing intake above the The NOF now recommends an intake of 800 to 1000 maximum recommended dose. international units (IU) of vitamin D (dietary or combined the average person consumes approxi- dietary and supplement) per day for adults age 50 or older.

Table 4: Amount of Elemental Calcium Calcium Product Calcium Content Approximate Elemental Calcium Calcium carbonate 400 mg (20 mEq) per g 40%

Calcium chloride 270 mg (13.5 mEq) per g 27%

Calcium acetate 253 mg (12.7 mEq) per g 25%

Calcium citrate 211 mg (10.6 mEq) per g 21%

Calcium lactate 130 mg (6.5 mEq) per g 13%

Calcium gluconate 90 mg (4.5 mEq) per g 9%

Table 4a: Non-Dairy Food Sources of Calcium Food, Standard Amount Calcium (mg) Calories Fortified ready-to-eat cereals (various), 1 oz 236-1043 88-106

Soy beverage, calcium fortified, 1 cup 368 98

Sardines, Atlantic, in oil, drained, 3 oz 325 177

Pink salmon, canned, with bone, 3 oz 181 118

Soybeans, green, cooked, ½ cup 130 127

Turnip greens, cooked from frozen, ½ cup 124 24

www.americaspharmacist.net September 2013 | america’s Pharmacist 43 Table 4B: Dairy Food Sources of Calcium known as ergocalciferol, is derived from diet and supplements. Vitamin D3, also known as Food, Standard Amount Per serving (mg) cholecalciferol, is synthesized in the skin and is Yogurt, plain, low fat, 8 ounces 415 also present in foods. Both ergocalciferol and Orange juice, calcium-fortified, 6 ounces 378 cholecalciferol must be converted in the liver to

Mozzarella, part skim, 1.5 ounces 333 calcidiol, where it is delivered to the kidney to be converted to calcitriol, the active metabolite Cheddar cheese, 1.5 ounces 306 of vitamin D. Those who have hepatic or renal Cottage cheese, 1% milk fat, 1 cup unpacked 138 disease will face challenges with conversion to the active metabolite. Pharmacists prepar- The previous recommendation of 400 IU/day has been ing a therapy recommendation should review shown to produce insufficient vitamin D levels in individu- the patient’s past medical history for cues to als at risk for developing osteoporosis. Without vitamin D, determine if one of the vitamin D analogues only 10–15 percent of dietary calcium is absorbed. Studies (ergocalciferol or cholecalciferol) appropriate. have shown that elderly women, who received 1,200 mg of Patients requiring calcium supplements in ad- calcium with 800 IU/day of vitamin D, had fewer vertebral dition to vitamin D supplements may find useful and nonvertebral fractures. Fracture occurrence has been combination products sold over the counter. shown to decrease when serum vitamin D levels are main- tained at a level of at least 30 ng/ml. Lifestyle Changes Falling has also been shown to correlate with an Along with educating patients on the adequate insufficient vitamin D level. A study conducted by Broe et intake of calcium and vitamin D, pharmacists al showed that higher doses of vitamin D reduced the risk should make recommendations to decrease the of falls in nursing home residents. This study was con- risk for developing osteoporosis. These would ducted in 124 patients and gave doses of vitamin D rang- include encouraging regular weight-bearing and ing from 200 IU/day to 800 IU/day compared to placebo. muscle-strengthening exercises such as walk- The participants who were given the 800 IU/day dose of ing, stair climbing, dancing, or T’ai chi. Water vitamin D were shown to have a 72 percent reduction in aerobics and swimming, while low-impact, fall rate as compared to the other groups. are not considered weight-bearing. Strength A safe upper limit for vitamin D intake was determined building exercises combined with cardiovas- to be 2,000 IU per day in 1997 and no longer coincides with cular activity produce the best results. Regular current guidelines. New evidence indicates higher intakes weight-bearing and muscle-strengthening are safe in elderly patients and may be required especially exercises also decrease a patient’s risk for falls, in those patients who are vitamin D deficient, due to mal- thereby lessening a patients risk for fractures. absorption or renal insufficiency. Patients who are house- Advise patients to seek physician evaluation bound with limited sun exposure are also at risk of vitamin prior to starting a new exercise regimen. Exces- D deficiency. In practice, pharmacists may see off-label sive alcohol intake should be avoided because prescriptions for high-dose ergocalciferol once weekly. The it can prevent proper absorption of calcium goal of therapy is to obtain the average adult’s serum vita- and vitamin D and inhibit osteoblast activity. min D concentration of 30 ng/ml or higher and should be Additionally, excessive alcohol intake should monitored periodically until adequate levels are reached. be avoided because it impairs judgment and Patients may be counseled to increase their intake of food coordination which could lead to falls. Pharma- sources with vitamin D to aid in reaching their target serum cists should encourage smoking cessation as level of vitamin D. These would include foods such as vita- it is valuable not only to bone health but also to min D-fortified milk, cereals, liver, egg yolks, and salmon. overall health. Smoking decreases the produc- Many patients may wonder about the difference tion of new estrogen and decreases circulating between vitamin D2 and vitamin D3. Vitamin D2, also amounts of estrogen already present in the

44 america’s Pharmacist | September 2013 www.americaspharmacist.net body. Because estrogen works with calcium macy setting should be aware of the correct counseling and vitamin D to build bone mass, smoking one points. Oral tablet formulations of both alendronate and pack per day can lead to a loss of bone mass. risedronate are required to be taken on an empty stom- Identifying individuals with impaired vision and ach, first thing in the morning with eight ounces of water. ensuring patient’s homes are safe are addition- these drugs should not be administered at the same al key factors in eliminating the risk for falls. time as other medications. Patients should wait at least 30 minutes before other food, drink or medication. The Pharmacologic Therapy patient should remain upright during this time period. Patients requiring pharmacologic therapy for Ibandronate follows the same principles except pa- osteoporosis have several options available. tients must wait 60 minutes before eating or taking other Those products with a Food and Drug Admin- medications. Patients who receive zoledronic acid will do istration (FDA) indication to treat osteoporosis so in a clinic setting. Patients who ask questions about include bisphosphonates, calcitonin, estrogen zoledronic acid because they have trouble remembering and hormone therapy (ET/HT), estrogen agonist to take oral bisphosphonates should be made aware of and antagonist, a parathyroid hormone analog the risk of the possibility of an acute phase reaction and and a receptor activator of nuclear factor kap- know that the incidences decreases with each adminis- pa-B ligand (RANKL) inhibitor. These medica- tration. To avoid this reaction, pre-medication with acet- tions have mainly been studied in women with aminophen as well as during the 72 hours following the postmenopausal osteoporosis. Consequently, infusion helps. While each bisphosphonate has slightly there is limited to nonexistent data to sup- different indications, comparative effectiveness research port applicability with glucocorticoid-induced finds they are all effective treatment for reducing the risk osteoporosis. There have likewise been few of hip and vertebral fractures in postmenopausal women studies conducted in men. The NOF guidelines with osteoporosis. also state that pharmacotherapy may decrease Another option for treatment is calcitonin (Miacalcin) fractures in patients with osteopenia, but the which is a naturally occurring hormone whose function is evidence is not as compelling. to regulate serum calcium levels in the body. Similar to Bisphosphonates include alendronate bisphosphonates, calcitonin directly inhibits osteoclast (Fosamax, Binosto or Fosamax Plus D), iban- activity, decreases bone resorption, and lowers serum dronate (Boniva), risedronate (Actonel, Atelvia, calcium levels. Adequate calcium and vitamin D intake is or Actonel with Calcium), and zoledronic acid still recommended with calcitonin therapy. It is approved (Reclast). These prescription medications work for the treatment of osteoporosis in women who are five or by inhibiting osteoclast-mediated bone resorp- more years postmenopausal. Since given daily as an intra- tion. Side effects of alendronate, ibandronate, nasal spray, side effects can include local irritation, rhinitis and risedronate include swallowing difficulties, and nausea. This drug should not be used in patients with gastric ulcers, and osteonecrosis of the jaw an allergy to salmon. (especially with intravenous administration). Various estrogen and estrogen receptor-mediated Zoledronic acid, only available in an injectable therapies are available for patients. When a woman enters formulation, is administered intravenously every menopause, a decline in serum estrogen levels leads to one to two years. Administration generally takes an overproduction of RANKL, causing an activation of place in the clinic to monitor and manage an osteoclasts leading to decreasing bone mass. Although acute phase reaction which includes headache, extensive research has been done on hormone replace- joint pain, muscle pain, and fever; acetamino- ment therapy in women showing positive benefits, several phen may be used as pretreatment to avoid concerns arose from the Women’s Health Initiative trial. reduce the risk of this reaction. Since bisphos- Early data found that there was an increase in myocar- phonates are the cornerstone of pharmacologic dial infarction, stroke, pulmonary embolism, deep vein treatment, pharmacists in a community phar- thrombosis and breast cancer in women taking estrogen

www.americaspharmacist.net September 2013 | america’s Pharmacist 45 and progesterone. Subsequent analysis of the Women’s tion is given in a physician’s office once every Health Initiative trial showed that cardiovascular disease six months as a subcutaneous injection. did not increase in women starting treatment within 10 lifestyle modifications should be initiated years of menopause. However, the FDA recommends that before beginning any pharmacotherapy regimen. for the prevention of osteoporosis approved non-estrogen When pharmacotherapy is indicated, selection treatments should be considered first. of the agent should be patient-specific and take raloxifene (Evista) is an estrogen agonist and an- into consideration FDA-approved indications and tagonist, and is formerly known as a selective estrogen the severity of the patient’s condition. receptor modulator (SERM). The FDA has approved its practitioners need to evaluate various fac- use for prevention and for treatment in postmenopausal tors for each medication, including side effect women who have osteoporosis. Raloxifene also has an profiles, administration, associated fracture risk, indication for reducing the risk of breast cancer; however, efficacy, and other safety concerns to determine it does not reduce the risk of coronary heart disease. Pa- which medication is best for each patient. In tients should be advised of the side effects of increased very severe osteoporosis, patients may use two possible hot flashes, leg cramps and/or muscle spasms. agents to increase BMD. Sequential therapy teriparatide (Forteo) is a recombinant human para- of a bone-building agent followed by one that thyroid hormone derivative and was the first drug that inhibits resorption is preferred to concomitant has been shown to cause new bone formation. It is FDA use. The NOF Clinician’s Guide cites active approved to treat osteoporosis in patients at high risk for bone loss in women on hormone replacement fracture and who meet one of the following three crite- therapy or raloxifene as possible situations, but ria: postmenopausal women, men with hypogonadal or studies that study specific combinations and idiopathic osteoporosis, and patients with glucocorticoid support concomitant therapy are lacking. induced osteoporosis. Safety and efficacy have not been shown beyond two years of treatment. As such, NOF The Pharmacist's Role guidelines recommend against its use after a two year Clinical Impact time period. After two years alternate therapy to maintain Why should osteoporosis be a concern in the bone mineral density should be initiated. Patients should community setting? Osteoporosis is a silent be advised of the side effects which include leg cramps disease with symptoms that are usually unrec- and dizziness. Teriperatide comes with a black box warn- ognized until a fracture occurs. These fractures ing for osteosarcoma; benefits of treatment must out- are common and place an enormous economic weigh the risk. and personal burden on society. Osteoporosis- denosumab (Prolia) is a RANKL inhibitor approved related fractures cause more than 432,000 for treatment of postmenopausal women with osteoporo- hospital admissions, almost 2.6 million medical sis who have a high risk of fractures. Other indications are office visits and about 180,000 nursing home for men with osteoporosis, men receiving anti-androgen admissions annually in the United States. The therapy for prostate cancer, and women receiving aro- cost to the health care system associated with matase inhibitor therapy for breast cancer. It is the first osteoporosis-related fractures was estimated at biologic drug to treat bone loss caused by osteoporosis. $17 billion in 2005. Due to the aging population, It is a monoclonal antibody that binds to the RANKL pro- the Surgeon General estimates that the number tein preventing it from binding to the osteoclast-activating of hip fractures and their associated cost could RANK receptor. The most commonly reported side effects double or triple by 2040. associated with the drug include pain in the back, arms the most common fractures are those of and legs, muscle and bone pain, high cholesterol levels, the spine, hip, and wrists. It has been estimated and urinary tract infections. A medication guide explains that approximately one in five patients 50 years the risks for hypocalcemia, infection, skin problems, jaw of age or older with a hip fracture will die within bone problems and atypical femur fracture. This medica- one year following the fracture. Approximately

46 america’s Pharmacist | September 2013 www.americaspharmacist.net Table 5: Classification of Osteoporosis by T-scores Normal BMD is within 1 standard deviation of a young normal adult (t  -1)

Low bone mass (Osteopenia) BMD is between 1 and 2.5 standard deviation below that of a young normal adult (-2.5  t  -1)

Osteoporosis BMD is 2.5 standard deviations or more below that of a normal adult (t  -2.5)

20 percent of hip fracture patients will require care providers are encouraged to use this list to identify long-term nursing home care, and only 40 patients using a drug on the list and suggest more ap- percent will fully regain their pre-fracture level of propriate options; this may decrease a patients risk for independence. Fractures may be followed by fractures due to falls. Included on this list are some long complications such as chronic pain, disability or and short-acting benzodiazepines, tricyclic antidepres- even death. Psychological symptoms are also sants, and barbiturates. common after a fracture; these include depression and loss of self-esteem due in part to Screening for Osteoporosis physical limitation and lifestyle changes. Phar- At this point, we have reviewed the basis of prevention, macists in the community can aid in decreas- risk assessment and treatment as recommended by the ing this economic burden on society and are a NOF guidelines for osteoporosis. The next step would key resource to help patients understand the be recognizing how to evaluate patients and determine pharmacologic and non-pharmacologic treat- the need to refer for medical follow-up. Patients who ment of osteoporosis. Pharmacists can also have risk factors and conditions predisposing them to help increase patient awareness of their risks by osteoporosis should be considered for screening; refer to performing community screenings and educat- tables 1, 1A, 2, and 3. Once their individual risk has been ing patients about their risk factors for develop- established, a referral to a physician may be required. A ing osteoporosis. physician may then determine the next appropriate steps. pharmacists may be better able to rec- diagnosis of osteoporosis is based on clinical evalu- ognize medications which increase the risk ation and BMD measurement obtained from a bone scan of developing osteoporosis. As highlighted in or the occurrence of an adult hip or vertebral fracture Table 1A, there are several medications that can without major trauma. A BMD is expressed in terms of increase the risk of osteoporosis. For example, two norms. The first being the patient’s Z-score, which the use of corticosteroids can decrease intes- compares their BMD to peers of the same age, sex, and tinal absorption of calcium and phosphorus, ethnicity. The second norm is the patient’s T-score, which leading to increased urinary excretion and inhi- compares their BMD to that of a same sex, younger bition of osteoblast activity. Other examples in- “normal” individual. The T-score can be a valuable predic- clude agents such as loop diuretics, aluminum tor of fracture risk. The WHO has defined osteoporosis containing antacids, and tetracycline, which can based on BMD using T-scores for a bone scan of the decrease calcium absorption. Anticonvulsants, spine, hip, or forearm. The classifications of bone density which increase catabolism of vitamin D, can based on the T-score can be found in Table 5. Dual-ener- lead to decreased calcium absorption. Discuss- gy x-ray absorptiometry (DEXA) of the hip and spine can ing medications that can potentially affect a provide the confirmatory diagnosis and can predict the patients’ risk of osteoporosis with the patient likelihood of future fracture risk. Thus, patient awareness or health care provider can decrease the risk of their BMD can decrease the likelihood of a fracture if of osteoporosis. Table 1A includes additional steps are taken to alleviate risk factors. medications that can increase a patient’s risk several technologies have been developed to esti- for osteoporosis. The Beers Criteria lists medi- mate a T-score without using a DEXA scan. These densi- cations that have been determined to be poten- tometers are capable of predicting both site-specific and tially inappropriate for use in the elderly. Health overall fracture risk and can be used as a guide to help

www.americaspharmacist.net September 2013 | america’s Pharmacist 47 patients know when they should seek further information probability of a major osteoporotic fracture. about osteoporosis from their physician. Quantitative These calculators take into consideration other ultrasound densitometry and may be useful to a com- risk factors that traditional BMD tests don’t munity pharmacist for screening purposes; other tech- consider, such as weight, height, age, sex, nologies include peripheral energy x-ray absorptiometry previous fracture, smoking status, corticosteroid and quantitative computed tomography. Any abnormal use, and secondary osteoporosis. Secondary findings should be reported to a primary care physician osteoporosis may be iatrogenic or a compli- and confirmed with an axial DEXA scan. cation of certain medical conditions. Medical the peripheral DXA (pDEXA) scan can be performed conditions may include rheumatoid arthritis, on the forearm, finger, or heel. This is used to predict ver- some cancers, hormone imbalances, or kidney tebral and overall fracture risk in postmenopausal women. failure. In this case, both the underlying issue Although peripheral scans are convenient, they are not causing the osteoporosis and the osteoporosis recommended for monitoring BMD once a diagnosis of itself need to be addressed. Using the FRAX or osteoporosis has been established FORE tool will allow the clinician to get a more the quantitative computed tomography (QCT) complete picture of the patients’ fracture risk measures bone density, bone strength and bone struc- and decide if there are any underlying condi- ture at the spine and the hip. It also includes a peripheral tions that need to be treated. FRAX is intended measurement of the tibia, hip, and spine. One drawback for postmenopausal women and men age 50 of the QCT is that it is associated with higher amounts of and older. This tool is not intended to be used radiation exposure than DEXA scan and pDEXA. in younger adults and children, however it has Finally, the quantitative ultrasound densitometry been validated in men and women from age (QUS) can be used to measure BMD indirectly based on 40-90 years of age. a bone’s ability to deaden sound waves. Measurements are made at the heel, tibia, patella, and other peripheral Literature Review sites. QUS does not expose individuals to radiation be- Assessment of Women’s Knowledge cause it uses ultrasound technology. of Osteoporosis BMD testing is recommended by the NOF for the fol- There seems to be a lack of knowledge about lowing populations: the risk factors associated with developing os- • Women age 65 and older and men age 70 and older, teoporosis and preventing fractures in women regardless of clinical risk factors. who are at risk. There may not be enough • Adults who have a facture after the age of 50. information or access to this information to en- • Younger postmenopausal women, women in the sure women are properly educated on ways to menopausal transition and men age 50 to 69 with decrease their risks for developing this disease. clinical risk factors for fracture (e.g. low body weight, Alinger et al. performed a study to assess previous fracture, high-risk medications). women’s knowledge of osteoporosis. The re- • Adults with a condition (e.g., rheumatoid arthritis) or searchers developed a 25-question quiz known taking a medication (e.g., glucocorticoids in a daily as the Facts on Osteoporosis Quiz (FOOQ) dose equal to, or greater than 5 mg prednisone or where higher scores correlated to an estab- equivalent for three or more months) associated with lished knowledge of osteoporosis. Questions low bone mass or bone loss. included assessing women’s knowledge of os- In much the same way that a pharmacist might teoporosis based on exercise, caffeine intake, calculate a Framingham Score to determine a patient’s risk factors, and epidemiologic factors. On aver- long-term risk for cardiovascular disease, the WHO and age, participants scored a 16 (standard devia- the Foundation for Osteoporisis Research and Education tion 4.87; range of 1 to 25). Only half of the 24 (FORE) offer 10-year fracture risk calculators to determine participants responded to 64 percent or more of the 10-year probability of a hip fracture and/or the 10-year the questions correctly. A qualitative analysis re-

48 america’s Pharmacist | September 2013 www.americaspharmacist.net vealed that the women participating in the study pharmacists and some made follow up appointments had insufficient knowledge of proper calcium with their physician. Overall, 61 percent of participants intake, alcohol use, caffeine intake, and those reported a positive change in perception of the services specific populations who are at risk for develop- provided by the pharmacist in the workplace. This small ing osteoporosis. Also, there was no difference study demonstrates that pharmacists are able to have a found based on women’s knowledge of osteo- positive impact on disease risk reduction. porosis as related to their current menopausal status or their age. The authors concluded that Screening of Osteoporosis in the the majority of women they surveyed did not Underserved Communities have the adequate knowledge about osteopo- Summers et al. evaluated the impact pharmacists have rosis and the associated risk factors. on osteoporosis counseling after a BMD screening and peters et al. evaluated how pharmacists assessed patient perception of community health screen- could deliver osteoporosis education and ings for osteoporosis performed by a pharmacist. A screening outside of the pharmacy and in the screening took place at urban retail pharmacies for three workplace. The authors had three objectives for days and was offered to any woman who requested a this study. They set out to determine if par- scan. Subjects were given a verbally administered risk ticipants would make lifestyle changes if they factor assessment that documented age, race, meno- were educated on how to decrease the risk of pausal status, family history, personal history, calcium osteoporosis, what influenced their decision to intake, current medications, and assessed for symptoms discuss osteoporosis risks with their primary associated with osteoporosis or osteoporosis related care provider, and their perception of phar- fractures. After assessing subjects, a peripheral DEXA macist services relating to osteoporosis. The scan was performed on those subjects that consented for study involved 38 teachers between the ages enrollment in the study. Following the scan, a 10-minute of 28–65 (mean age 47.5 years) at six different counseling session was conducted with a pharmacist or schools. Pharmacists provided a 20-minute supervised pharmacist interns to discuss the scan results presentation on osteoporosis and discussed and answer any questions. Although studied subjects prevention strategies. Using ultrasound den- received their T-scores, diagnosis was not established. sitometry, participants were provided with At three and six months, the patients were telephoned to T-scores. Those found to be at an increased risk assess if contact with their primary care physician had for developing osteosporosis were encouraged occurred, if they had obtained primary care physician to discuss their findings with their primary care recommendations, if suggested lifestyle changes had provider. A survey via electronic mail or tele- occurred, or if there was any change in previous reported phone follow-up was conducted at six weeks behavior or medications. following the initial presentation to assess life- By the six-month point, 52 of 102 patients discussed style changes, the perception of pharmacist’s their findings with their primary care physician. It was services, and if communication was conducted found that of the subjects who discussed their results with their health care provider after the screen- with their primary care providers; 14.8 percent increased ing. Results showed that 65.8 percent of par- calcium through supplements or diet, 9.2 percent con- ticipants made one or more lifestyle changes. tinued their current osteoporosis regimen, 7.4 percent The most significant change was the number of of subjects obtained prescription treatment, and 11.1 participants who increased their calcium intake. percent received an additional BMD scan. Most of the Of the respondents, 36.8 percent showed an subjects (90.2 percent) reported an increased under- increase in dietary calcium, and 42.1 percent standing of the risk factors associated with osteoporosis reported an increase in supplemental calcium. and found the session with the pharmacist or supervised Those who were found to be at an increased pharmacist intern(s) useful. Similarly, 87.2 percent of risk, discussed treatment options with their patients responded that the conveniences of the commu-

www.americaspharmacist.net September 2013 | america’s Pharmacist 49 nity location increased their likelihood of having a bone community pharmacy screenings in these set- scan performed. This study, which took place in an urban tings would be beneficial. retail community pharmacy, helps individuals with access challenges. By using community-based screening in their Value of Osteoporosis Screening local pharmacy, patients were able to increase awareness in the Community of osteoporosis risk factors, allowing physicians to sug- It’s important that patients recognize a need gest and implement treatments. for osteoporosis screening in the community. nauton et al. performed a study in six rural com- Screening services such as blood pressure munity pharmacies attempting to assess the impact of monitoring, blood glucose testing, hemoglobin providing osteoporosis screenings for patients who were A1c testing, and immunization administration at least 65 years of age and had limited access to BMD have become valued services within a commu- testing. Limited access was defined as those subjects nity pharmacy. Each service has demonstrated who resided at a distance of greater than approximately a benefit to everyone involved. Implementation 27 miles from an axial DEXA unit for osteoporosis testing. of osteoporosis screening by a community The authors assessed women’s knowledge of osteoporo- pharmacy must ensure that there is value sis by administering a questionnaire that focused on risk associated with service. Some key questions factors that contribute to osteoporosis. The pharmacist need to be answered: Is the out-of-pocket fee assessed each subject’s risk factors for osteoporosis, to the individual reasonable? What research is including smoking status, alcohol intake, medical his- available to suggest what people will pay? Will tory, medication history, and demographic information. insurance companies reimburse the patient or Subjects were further assessed to estimate their calcium the pharmacy for screenings in this environ- intake. Upon completion of the questionnaires, subjects ment? Will other medical professionals sup- were provided with educational material on osteoporosis, port the screenings done by a pharmacist is BMD interpretations, risk factors, diet, and the importance this setting? Lata et al. looked at evaluating of physical activity. After completion of a BMD scan using women’s information sources about osteoporo- a ultrasound densitometer, subjects were referred to their sis screening, what monetary value they would practitioner for further evaluation if the estimated T-score place on services, and how clinician’s would re- was less than or equal to -1.0 or were greater than -1 with spond to peripheral bone mass measurement risk factors. As a result of the bone scans, 58 percent results. In four rural Midwestern independent of women were referred to their primary care physician community pharmacies, 194 women age 50 for further assessment, of which 34 percent started drug or older completed a questionnaire to assess therapy for osteoporosis (6 percent indicated starting an their knowledge about osteoporosis, frequency oral bisphosphonates, 30 percent began taking calcium of visits to her primary care physician, knowl- supplements, and 6 percent began taking vitamin D edge about BMD testing, and the monetary supplements). Lifestyle changes were reported to have value they would equate with receiving a BMD been made by 67 percent of women who received the scan. After the questionnaire was completed, screening, and 46 percent responded they were willing subjects received a bone density scan using to pay a median of $16 (range $4–$80) for the services a peripheral instantaneous x-ray imager (PIXI), provided by a pharmacist. The authors concluded that and their results were sent to their primary care screening provided by a pharmacist in rural areas is a provider. In addition, local area physicians were useful method for identifying and discussing measures to surveyed to determine if they had received prevent osteoporosis. bone density testing from these patients and if As in the previous study, this study showed particu- the information was useful. This was done as lar benefits to patients in rural locales which are less a means to assess if patients were discuss- likely to obtain preventive health services than urban ing their results with their practitioners. These residents. Further analysis on the cost/benefit ratio of practitioners were also asked if they would

50 america’s Pharmacist | September 2013 www.americaspharmacist.net consider having their patients screened in a “very useful” for making health care decisions and 91 community pharmacy using a bone density percent planned speak with their primary provider about testing method. Of the participants, 93 percent the results. A second survey was sent three months of women stated they were willing to pay an av- later to determine if they had in fact spoken to their pri- erage of $25 for the screening, with 31 percent mary care provider, made any lifestyle changes, or any willing to pay up to $50 for the session. Of the changes to their medication had occured. The results clinicians surveyed, 72 percent stated that the of this second questionnaire showed that 42 percent screening data was useful. Approximately 51 of women did speak to their health care provider. Other percent of those health care providers went on positive results indicated that 11 percent increased their to state that they would support a pharmacy- exercise, 25 percent increased calcium and vitamin D based bone density testing for patients in their intake, and six subjects started taking osteoporosis practice. This would be helpful to increase medication. Overall, 41 percent of patients agreed that participants in the screening since a majority of they would pay $20 for the services provided. To put it in those who were involved found out about the perspective, it is important to determine if such an event screening either through in-store advertisement is actually feasable in a pharmacy. To cover the cost of or through a family member or friend and not an ultrasound densitometer, it could take a pharmacy 50 through referral by their physician. This study weeks and they would need to do 21 scans at $25 per suggests community pharmacy can play a week, or 15 scans at $30 per week. more active role in increasing women’s knowledge of osteoporosis screening and provide Implementation of Services valuable data to physicians. By providing this Although the need for osteoporosis screening is evident, service, community pharmacies can increase community pharmacists may have concerns about how physician and patient awareness about the to design and implement such a process. Johnson et benefits of screening for osteoporosis. al. conducted a study in northwest Iowa in an attempt to cerulli et al. conducted a study that create a model for community pharmacies to implement involved a group of women with a mean age an osteoporosis screening program. Letters were sent of 61 to determine economically feasibility of to regional pharmacies in 17 counties outlining project providing BMD screenings and education pro- details and request their participation. Five pharmacies grams to women to reduce the likelihood of os- responded and entered the study. Each site was required teoporosis. The study took place at four chain to select a project leader who would attend or watch a and two independent pharmacies. Women videotape of a grant-sponsored continuing education who were at least 18 years of age were en- program on osteoporosis. Pharmacists received training couraged to participate in the study and were on how to operate an ultrasound densitometer. Pharma- provided their bone density using ultrasound cists were also required to participate in a continuing densitometry. Patients were given their T-score education program that covered an overview of diagno- and their potential risk factors were reviewed sis, preventative and treatment strategies, and to height- with the pharmacist. Each participant was en awareness about osteoporosis. Advanced pharmacy encouraged to discuss their results with their practice experience rotation (APPE) students assisted in primary care provider and it was reinforced screening and educating patients on risk factors associ- that the test results did not constitute a diag- ated with osteoporosis. nosis. After the study, participants received a on the screening day, background information 13-item questionnaire to evaluate their opinion obtained for each patient included, age, height, weight, of the value of services provided, their willing- ethnicity, medication history, calcium, and alcohol intake. ness to pay, and if they planned to discuss the Based on this information a risk factors analysis was results with their doctor. The results showed performed for each patient. Subjects were also asked that 82 percent of women found the screening how they were made aware of the screening program.

www.americaspharmacist.net September 2013 | america’s Pharmacist 51 Case Study A 67-year-old patient comes to your pharmacy and tells you she just came from her physician and has been diagnosed with osteopenia. She is very disturbed by this diagnosis and tells you she takes no other medication and has been very healthy her entire life. The only medication she takes is Tylenol PM on a nightly basis to help her sleep. Her physician has recommended she buy OTC calcium supplementation to begin taking to prevent the development of osteoporosis. Upon further conversation, you learn she is lactose intolerant and refuses to use supplements and would prefer to obtain the required amount of calcium in her diet. She is asking for your recommendation on a dietary plan.

Case Questions: 1. What is the proper amount of calcium this patient should receive on a daily basis? 2. recommend a diet that would allow her to obtain this amount of calcium? 3. Are there any other recommendations you could make that would help delay the onset of osteoporosis in this patient?

Answers: 1. this patient should receive at least 1,200 mg/day of calcium. 2. A diet may consist of a combination of foods but here is one example: Two ounces of fortified cereals would provide approximately 500 mg of calcium. Soy milk could be used on cereal. One cup of a soy beverage would provide approximately 360 mg of calcium. One cup of cooked green soy beans would provide approximately 250 mg of calcium. Three ounces of canned pink salmon would provide approximately 180 mg of calcium per day. This would be an example of some foods to add to her diet with on a daily basis to ensure the minimum of 1,200 mg/day. 3. other recommendations would be to discontinue the use of Tylenol PM. Diphenhydramine in the elderly is known to increase the risk of falling. If she is having difficulties falling asleep she should be referred to her physician for another recommendation. Also, it would be advisable to begin weight bearing exercises which may include Tai- Chi, dancing, walking, or other aerobic activity. It is also necessary to ensure the patient is taking the proper amount of Vitamin D (800-1000 IU per day)

After completing all forms, the patients were given a modifications were initiated. Overall, results bone scan. A printed report of the T-score was proved to of the study showed that at three months, 37 the pharmacist to discuss with the patient. Each par- percent of participants contacted their health ticipant also received a copy of their informed consent care provider about the results and 5 percent and a copy of their risk score to share with their health- received an additional DEXA scan. Of the par- care provider. It was made clear to the patient that the ticipants, 50 percent began increasing calcium screening was not a diagnostic test for osteoporosis and intake and 21 percent increased the amount further assessments from their primary care provider of weight bearing activity. At the six-month would be required. Screening took a total of 15 minutes survey interval, 24 percent of patients spoke to per participant. In total, pharmacists were paid $20 from primary care providers and 7 percent received grant funded money and $10 from each patient who a DEXA scan. Lifestyle modifications at six participated in the osteoporosis screening. months showed that 56 percent of patients As a follow-up, participants were telephoned at starting calcium and 43 percent of patients three and six months to see if they had discussed the began weight bearing exercises. Based on the results with their primary care provider and if lifestyle positive impact they made, participating phar-

52 america’s Pharmacist | September 2013 www.americaspharmacist.net macists wanted to continue to offer the screen- either a verbal or written referral to a physician for con- ings, but they were limited by personal support firmation and diagnosis. All participants, regardless of and screening equipment. However, this study risk stratification, received follow-up phone calls three to did make efficient use of pharmacist interns six months after the screening to assess the outcomes and showed they may be a useful resource for of the referral. those pharmacies hosting students. the study found that 78 percent of participants some studies have been able to illustrate had no prior knowledge of their risk factors. Of the 532 that a pharmacist and physician agreement participants screened, 29 percent of them contacted a can increase awareness of osteoporosis in the primary care provider and 16 percent of them received community. In one study know as Project Im- a DEXA scan. Follow-ups showed that 19 percent of PACT (Improve Persistence and Compliance participants started a prescription medication for osteo- and Therapy): Osteoporosis, the researchers porosis, 30 percent made lifestyle changes (including aimed to identify at-risk patients in the com- calcium supplementation), 26 percent were initiated on munity and refer these patients to their respec- vitamin D, and 26 percent of patients were initiated on tive physician(s). This study was conducted weight bearing exercises. Researchers stated that all at a supermarket chain that involved 22 participants were willing to pay the screening fee out of local area pharmacies and was done during pocket. The authors estimated that 500 patients would women’s health month. Prior to initiation of the require screening to account for the cost of the screen- study, pharmacists received a training certifi- ing device used in the in the study. cate in osteoporosis and received education this study showed that there can be collaboration on operation of a ultrasound densitometer. between pharmacists and physicians to promote the Promotion was conducted via marketing in awareness and screening of osteoporosis in the commu- local newspapers, the supermarket website, nity setting by pharmacists. The authors concluded that in-store signs and shelf talkers, printouts on when pharmacists become involved in a collaborative the store receipt, direct mail and live segments screening and education program, although at times it on the local news networks. Study participants may be difficult to initiate, at-risk patients can be identi- were targeted if they had at least one risk fied and referred for appropriate treatments to minimize factor for osteoporosis, not including the fact negative outcomes associated with osteoporosis. that they were female. The screening process was offered for a $25 fee. Screening occurred Suggestions for Further Outreach at five sites on a weekly basis for almost 1.5 Establishing the need and benefit for screening in years. Local physicians were recruited to community pharmacy is evident by the trials discussed provide training to area pharmacists about previously. It is clear that pharmacists can make an different diagnosis and treatments associated impact in delaying the onset of osteoporosis either with osteoporosis. Additionally, the physi- through education of their patients or through an actual cian performed a DEXA scan on each of the referral to a physician. Even if doing a screening in pharmacists who participated. In exchange for your pharmacy setting is not feasible, some counseling the educational experience, the pharmacist points can be discussed with your patients to decrease referred some of the high-risk patients to this osteoporosis risk factors. Pharmacist counseling should specialist. Risk stratification was predeter- not only identify risk factors, it should help patients mined based on the reported T-scores from understand which risk factors are modifiable and make the Densitometer. Those participants who plans to manage risks for developing osteoporosis, falls were considered at moderate or high risk was and fractures. defined as T-scores between -1 to 0 and less As previously stated, NOF guidelines do not recom- than or equal to -1, respectively. All partici- mend hormone replacement as a monotherapy (es- pants who were within this range received trogen or progestin replacement) for the treatment or

www.americaspharmacist.net September 2013 | america’s Pharmacist 53 prevention of osteoporosis. Patients should be advised Conclusions to discuss the risks and benefits for hormone replace- This activity reviewed valuable information from ment therapy with their physicians. Many factors are the NOF guidelines to enhance understanding involved in assessing the risk versus benefit of being initi- and encourage pharmacists make recommen- ated on hormone therapy. At a minimum, the community dations to patients to prevent and treat osteo- pharmacist can make a postmenopausal woman aware porosis. The literature has been examined to of her risk for developing osteoporosis and educate deem the value of community pharmacist based her about ways to decrease this risk. Other interven- screening clinics and has shown that there is tions can be made in all patient populations. Encourage an apparent need in the community to increase inactive patients to perform regular weight bearing and the awareness of osteoporosis risk factors and muscle-strengthening exercises. By performing such complications. Studies have shown it may be routine activities, the patient may notice an increase in easier or more convenient for the patient to agility, posture, balance, and strength, which would help have access to a pharmacist especially in rural alleviate the risk of falling. Knowing your patient popula- settings. Pharmacists play a key role in not only tion and their specific limitations and needs can allow for assessing patient risk factors and giving sug- successful patient centered counseling. Leverage your gestions to eliminate those risk factors, but also patient relationships to tailor a plan to reduce their long- helping a patient best manage their osteoporo- term risks for this silent disease. sis medication regimens. Based on this infor- community pharmacists should talk to patients about mation, it is evident that a pharmacist can be the necessity of smoking cessation. As discussed previ- a key player in the prevention and detection of ously, consumption of tobacco products over a long peri- osteoporosis. od of time can adversely affect bone status. It is estimated that on average, cigarette smokers reach menopause 1–2 years earlier compared to their counterparts. With early Stacey Schneider, PharmD, is assistant professor onset of menopause, patients may experience osteo- of pharmacy practice at Northeast Ohio Medical porosis and other comorbidities earlier than expected. University in Rootstown, Ohio. Non-prescription nicotine replacement options are a good place to start. Shelf cards might encourage patients to ask Thomas Towers, PharmD, is a clinical pharmacy questions about picking a quit date, or they could com- specialist in the neonatal intensive care unit at pare the cost of a pack-a-day cigarette habit to the cost North Florida Regional Medical Center in Gaines- of patches, gum or lozenges. Pharmacists may choose ville, Fla. to investigate options for continuing education or hosting and facilitating a support group. there are many areas where a pharmacist can help a patient to reduce their risk of falls. Encouraging annual eye exams is an effective way to reduce the incidence of falls, along with improving home safety. Pharmacists can point out common fall risks such as loose rugs, slippery surfaces (especially icy patches outdoors, the tub and bathroom floor), inadequate lighting and stairs with no handrail. Patients who have a significant risk for falling may be advised to consider a hip protector. Some patients may also require assistance with household chores, meal planning, or other activities of daily living. Pharma- cists can be a valuable source of information for patients with these special needs.

54 america’s Pharmacist | September 2013 www.americaspharmacist.net

Preventing Osteoporosis Within the Community Setting Sept. 2, 2013 (expires Sept. 2, 2016) • Activity Type: Knowledge-based To earn continuing education credit: ACPE Program 207-000-13-009-H01-P; 207-000-13-009-H01-T FREE ONLINE CE To take advantage of free CE for A score of 70 percent is required to successfully complete this program, go to the CE Center of Pharmacist eLink the CE quiz. If a passing score is not achieved, one free (www.pharmacistelink.com) by clicking on the CE tab to take a test on the material of this article. You will receive reexamination is permitted. immediate online test results. (Please note: you must achieve a passing score of 70% on the activities post-test Answer sheet for your use below and will receive 2 opportunities to successfully pass the a b c d e a b c d e post-test). NCPA will submit your CEUs to the CPE Monitor 1. q q q q q 11. q q q q q system. Please allow 6 weeks for the upload of your CEUs 2. q q q q q 12. q q q q q prior to checking your CPE Monitor transcript. If you do 3. q q q q q 13. q q q q q not already have a CPE Monitor e-Profile DI , please go to 4. q q q q q 14. q q q q q www.cpemonitor.net to register. 5. q q q q q 15. q q q q q 6. q q q q q 16. q q q q q NCPA® is accredited by the Accreditation Council for Pharmacy Education as a pro- 7. q q q q q 17. q q q q q vider of continuing pharmacy education. NCPA has assigned 1.5 contact hours (0.15 8. q q q q q 18. q q q q q CEU) of continuing education credit to this article. Eligibility to receive continuing 9. q q q q q 19. q q q q q education credit for this article expires three years from the month published. 10. q q q q q 20. q q q q q

CONTINUING EDUCATION QUIZ 3. Which of the following is true about factors that affect Select the correct answer. bone mass? a. Bone growth only occurs during adolescence. 1. A Which of the following facts is true about b. Peak bone mass is achieved at the age of 35 in the prevalence of osteoporosis? women and men. a. An estimated 10 million Americans have c. Bone mass is influenced by factors such as genetics, osteoporosis. nutrition, endocrine status, and physical activity. b. It is estimated that one in two women and d. Osteoporosis occurs when the net bone resorption oc- men will experience an osteoporosis related curs less frequently then bone formation. fracture in their lifetime. c. An estimated 40 million Americans have 4. Which of the following is NOT a factor that affects the osteopenia. risk of developing osteoporosis? d. Osteoporosis is more frequent in African a. Excessive Vitamin A Americans than Caucasians. b. High salt intake c. Athletic amenorrhea 2. The cost to the health care system associat- d. Osteoarthritis ed with osteoporosis-related fractures has been estimated at which of the following for 2005? 5. Which of the following is NOT a medication associated a. $25 billion with the risk of developing osteoporosis? b. $50 million a. Exemestane (Aromasin) c. $17 billion b. Heparin d. $40 million c. Phenytoin d. Methylprednisolone 6-day taper (Medrol Dosepak)

www.americaspharmacist.net September 2013 | america’s Pharmacist 55

6. Which of the following is true about calcium intakes of 11. Which of the following medications proven for greater than 1,200-1,500 mg of calcium per day? treatment of osteoporosis can cause side effects a. Increased risk for kidney stones which include local irritation, rhinitis, and nausea? b. Increased risk for diarrhea a. Evista c. Increased risk for GI upset b. Boniva d. Increased risk for magnesium deficiency c. Calcitonin d. Alendronate 7. A T-score of -2 in a 25-year-old female would indicate which of the following? 12. Which of the following medications has only a. Osteoporosis been approved for women who are five years b. Osteopenia or more post-menopausal in the treatment of c. Normal bone osteoporosis? d. The results cannot be applied to a female a. Evista in this age group. b. Boniva c. Calcitonin 8. What is the recommendation for daily vitamin D intake d. Alendronate in adults aged greater than 50 years old to support bone health and muscle formation? 13. Which of the following densitometry tech- a. 200 IU/d nologies can provide confirmatory diagnosis of b. 400 IU/d osteoporosis? c. 800 IU/d a. DEXA d. 1,200 IU/d b. p DEXA c. Q CT 9. Studies have shown that fracture occurrence decreas- d. Q US es when vitamin D levels where are at least which of the following levels? 14. Which of the following densitometry tech- a. 25 ng/ml nologies is associated with higher amounts b. 30 ng/ml of radiation exposure as compared to other c. 20 ng/ml devices available for use in the community d. 15 ng/ml pharmacy setting? a. DXA 10. A patient approaches you and tells you they will be b. p DXA receiving zoledronic acid for the first time in her physi- c. Q CT cian’s office. The patient has read about possible flu-like d. Q US symptoms occurring after the administration of the medication. Which of the following recommendations would be 15. Bone mineral density testing is recom- appropriate for you to tell her? mended by the NOF for which of the following? a. Take an 81 mg baby aspirin one hour prior to adminis- a. All women age 35 and older tration to help relieve the symptoms. b. All men age 65 and older b. Take 500 mg of acetaminophen one hour prior to ad- c. All women age 65 and older ministration to help relieve the symptoms. d. All men age 35 and older c. Take 400 mg of ibuprofen one hour prior to administration to help relieve the symptoms. d. Take 12.5 mg of diphyenhydramine one hour prior to administration to help relieve the symptoms.

56 america’s Pharmacist | AugustSeptember 2011 2013 www.americaspharmacist.net

16. Which patient should be recommended for 19. A pharmacist is qualified to do all of the BMD testing? following in order to educate a patient about a. A patient who has been on prednisone 1mg osteoporosis in the community setting except per day for one month which of the following? b. A patient who is 25 years old and currently a. Recommend routine eye exams to improve smoking vision to decrease falling c. A post-menopausal woman age 45 who has b. Independently diagnose osteoporosis and a family history of osteoporosis initiate appropriate bisphosphonate therapy d. A patient who is 39 years old who does not c. Help a smoker pick a quit date and discuss take any calcium supplementation behavior modification for greater success d. Recommend physical activity to aid in 17. Which of the following is NOT true about muscle strengthening. using a fracture risk calculator? a. This tool was established to determine the 20. All of the following would be good sugges- 10-year probability of a hip fracture and/or tions to implement a community run pharmacist the 10-year probability of a major osteopo- clinic except which of the following? rotic fracture. a. Utilize technicians to design advertising ma- b. The score takes into consideration many terials to announce the screening event. other risk factors which include weight, b. Utilize technicians perform a heel ultrasound height, age, sex, previous fracture, smoking scan and discuss the results with the patient. status, corticosteroid use, and secondary c. Utilize pharmacy students to perform a heel osteoporosis that a simple bone scan is not ultrasound scan and discuss the results with capable of factoring into the bone mineral the patient under pharmacist supervision. density measurement. d. Physician area detailing to allow physicians c. Using this tool will allow the clinician to get a to know about the services your pharmacy is more complete picture of the patients’ risk of offering in order to recruit patients. developing a fracture. d. This assessment is valid for those who are receiving treatment for osteoporosis.

18. Which of the following activities would NOT help to decrease a patient’s risk for developing osteoporosis? a. Tai Chi b. Walking c. Dancing d. Swimming

www.americaspharmacist.net September 2013 | america’s Pharmacist 57 Making the Grade: Practical Strategies for Improving Medication Adherence

You don’t see bumper stickers proclaiming “My Child is a ‘C’ Student.” While good grades aren’t everything, when it comes to medication adherence, anything less than an A deserves attention. Unfortunately, recent research has revealed that Americans with chronic disease earn a troubling C+ when it comes to taking their medications correctly. This lackluster grade translates to an estimated $105 billion annually in avoid- Luncheon Symposium able health care costs in the United States.

Sunday, October 13th This special symposium will show you why non-adherence has become such a large part of the health care discussion and how community 11:30 a.m. – 1:30 p.m. pharmacies are stepping in to offer solutions to this nationwide epidemic. Southern Hemisphere 2 You’ll get an up-close look at three pharmacy practices just like yours to see how they are pioneering unique new approaches to traditional (Seating is limited and will be provided adherence services in ways that are both beneficial to their patients and on a first-come, first-served basis) profitable to their pharmacy. Discover what initiatives are underway at the local and national level, and how you can leverage these programs to help earn your patients (and your pharmacy) a spot on the dean’s list.

Learning Objectives: 1. Discuss the reasons that patients may not be adherent to their prescription regimen. 2. Understand how and to what extent non-adherence results in avoid- able costs in the healthcare system. 3. Explain how pharmacist-provided interventions can improve a patient’s adherence to therapy. 4. Relate effective best practices for adherence programs in independent pharmacies.

For full program information, please go to www.ncpanet.org.

NCPA’s 115th Annual Convention and Trade Exposition | October 13-17, 2013 | Orlando, FL Reader Resources NCPA activities and our advertisers

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60 america’s Pharmacist | September 2013 www.americaspharmacist.net About Orlando, FL A world-renowned destination, Orlando is the October 12-16, 2013 place to make all of your vacation dreams come Register now at www.ncpanet.org true. Of course, it is beloved for its theme parks: Walt Disney World, Universal Studios Florida, SeaWorld Orlando, and many others. But it also beckons with world-class resorts, shopping opportunities for every budget, all-season golf courses, and some of the most enticing dining opportunities on the planet. Less known but equally inviting are the downtown sections of Orlando itself and many nearby towns in Central Florida— places that celebrate public art and take pride in offering a myriad of cultural opportunities. There is something for everyone in Orlando.

Keynote Speaker William Jefferson “Bill” Clinton served as the 42nd President of the United States from 1993 to 2001. Inaugurated at age 46, he was the third-youngest president. After leaving the White House, President Clinton established the William J. Clinton Foun- dation with the mission to improve global health, strengthen economies, promote healthier child- hoods, and protect the environment by fostering partnerships among governments, businesses, nongovernmental organizations (NGOs), and private citizens to turn good intentions into measurable results.

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National Community Pharmacists Association 115th Annual Convention and Trade Exposition