Reimagining Medication Adherence: A Novel Holistic Model for Hypertension Therapy

Purpose

Patients' adherence to the prescribed therapy is influenced by several personal and social factors. However, existing studies have mostly focused on individual aspects. We took a holistic approach to develop a higher-level impact factor model.

Patients and Methods

In this independent, non-interventional, cross-sectional and anonymous study design the pharmacist recruited patients who entered the pharmacy and handed in a prescription for a blood pressure medication. The patients received a paper questionnaire with a stamped return envelope to volunteer participation. A total of 476 patients in Germany who reported having at least high normal blood pressure according to the Global Hypertension Practice Guidelines were surveyed. In this study, each patient received an average of 2.49 antihypertensive prescriptions and 7.9% of all patients received a fixed-dose combination. Partial least squares structural equation modeling was performed for model analytics since it enables robust analysis of complex relationships.

Results

Emotional attitude, behavioral control, and therapy satisfaction directly explained 65% of therapy adherence. The predictive power of the out-of-sample model for the Q2-statistic was significant. The patient's overall therapy satisfaction determined medication adherence. The medication scheme's complexity also influenced the adherence levels. Therapy satisfaction was significantly shaped by the complexity of the medication scheme, behavioral control, and emotional attitude. The results demonstrated the superior performance of fixed-dose combinations against combinations of mono-agents according to the adherence level. Additionally, patient-physician and patient-pharmacist relationships influenced behavioral control of medication therapy execution. According to the A14-scale to measure the level of adherence, 49.6% of patients were classified as adherent and the remainder as non-adherent.

Conclusion

The results enable healthcare stakeholders to target attractive variables for intervention to achieve maximum effectiveness. Moreover, the proven predictive power of the model framework enables clinicians to make predictions about the adherence levels of their hypertensive patients.

Expanding oncology pharmacist teams: Justifying the return on investment

Oncology pharmacists are an integral member of the cancer care multi-disciplinary team. Despite the role being previously well defined, responsibilities continue to expand. Position justification for pharmacists is a challenge with prerequisites to optimize efficient processes, promote quality and reduce overall costs. Initiation and implementation of new oncology pharmacist services requires a clear description of value to the organization and a strong understanding of workflows. Position justifications must be data-driven and unique to the organization's need and should include physician or key stakeholder support, quality initiatives, cost-savings initiatives, and revenue-generating roles. The cases and examples described serve as a reference for individuals, teams, or organizations pursuing the value of a financial investment of an oncology pharmacist to expand or initiate new pharmacy services.

Perceptions of clinical pharmacy specialists' contributions in mental health clinical teams

Introduction

Mental health (MH) clinical pharmacy specialists (CPS) are increasingly functioning as integral providers in MH care teams. MH providers may delegate many medication management tasks to the CPS. As there is a shortage of primary care and specialist MH providers, CPS are increasingly being utilized in MH care clinics. We assess provider and CPS perceptions of the contributions of CPS to MH clinical teams in the Veterans Health Administration.

Methods

We examined the roles and functions of CPS in MH clinics through surveys (n = 374) and semistructured interviews (n = 16) with MH CPS and other members of MH clinical teams (psychiatrists, nurse practitioners, registered nurses, social workers) to gain insight into how CPS were integrated in these settings. We assessed perceptions of CPS contributions to MH teams, interactions between CPS and other providers, and challenges of integrating CPS into MH clinical teams.

Results

Contributions of CPS in MH were received positively by clinical team members. Clinical pharmacy specialists providing comprehensive medication management were especially valuable in the management of clozapine. The knowledge and training of CPS reassured providers who frequently referred to them with questions about medication and medication therapy management. MH CPS were also perceived to be received well by patients.

Discussion

The integration of MH CPS into MH teams was well received by team members and patients alike. The MH CPS have become important members of the MH team and are widely viewed as being able to improve access, quality, and workflow.

Evaluation of a Pharmacists' Patient Care Process Approach for Hypertension

INTRODUCTION

An estimated 116 million American adults (47.3%) have hypertension. Most adults with hypertension do not have it controlled-3 in 4 (92.1 million) U.S. adults with hypertension have a blood pressure ≥130/80 mmHg. The Pharmacists' Patient Care Process is a standardized patient-centered approach to the provision of pharmacist care that is done in collaboration with other healthcare providers. Through the Michigan Medicine Hypertension Pharmacists' Program, pharmacists use the Pharmacists' Patient Care Process to provide hypertension management services in collaboration with physicians in primary care and community pharmacy settings. In 2019, the impact of Michigan Medicine Hypertension Pharmacists' Program patient participation on blood pressure control was evaluated.

METHODS

Propensity scoring was used to match patients in the intervention group with patients in the comparison group and regression analyses were then conducted to compare the 2 groups on key patient outcomes. Negative binomial regression was used to examine the number of days with blood pressure under control. The findings presented in this brief are part of a larger multimethod evaluation.

RESULTS

More patients in the intervention group than in the comparison group achieved blood pressure control at 3 months (66.3% vs 42.4%) and 6 months (69.1% vs 56.5%). The intervention group experienced more days with blood pressure under control within a 3-month (18.6 vs 9.5 days) and 6-month period (57.0 vs 37.4 days) than the comparison group did.

CONCLUSIONS

Findings support the effectiveness of the Michigan Medicine Hypertension Pharmacists' Program approach to implementing the Pharmacists' Patient Care Process to improve blood pressure control.

Comprehensive medication review service by embedded pharmacists in primary care: Innovations and impact

BACKGROUND

Primary care may offer innovations in delivering comprehensive medication reviews (CMRs).

OBJECTIVES

This study aimed to (1) describe innovations to improve delivery and impact of CMR, (2) quantify CMR completion rates and patient satisfaction, and (3) characterize medication changes and impact on medication costs.

PRACTICE DESCRIPTION

Board-certified ambulatory care pharmacists with collaborative practice agreements embedded in primary care provided CMRs in 5 clinics for eligible university prescription plan retirees.

PRACTICE INNOVATION

Innovations included (1) physician review of potential CMR recipient list, (2) use of trained student pharmacists to recruit and set up CMR visits, (3) use of clinical information in a standardized CMR 2-visit approach by embedded pharmacists, and (4) enrollment into disease management programs or referrals to other providers.

EVALUATION METHODS

Data from a retrospective cohort were collected. The CMR completion rate and therapeutic interventions were documented. Prescription fill data were available for 6 months before and after the CMR. An anonymous survey assessed patient satisfaction. Frequencies and descriptive statistics characterized completion rate, interventions, and patient satisfaction. The median cost to the plan of deleted versus added medications and per member per month total drug costs before and after the CMR were compared.

RESULTS

Among 729 beneficiaries screened, 489 were eligible and 223 (46%) received a CMR. There were 388 medication interventions: the most common intervention was to delete medications (41.0%). One in 4 was enrolled into the pharmacists' disease management programs. Individuals reported 4.68 (SD 0.67) of 5 for helpfulness of the CMR. The ratio of median costs for medication deletions versus additions was $1.46 vs. $1.00.

CONCLUSION

Innovations to deliver CMRs capitalized on well-established physician-pharmacist relationships and nonpharmacist personnel to recruit and prepare the intake. Almost half of eligible beneficiaries received a CMR, and the CMRs were impactful for patients and payers. The most prevalent intervention was to discontinue medications for efficacy reasons.

Impact of a novel project management course sequence on innovative thinking in pharmacy students

BACKGROUND

As healthcare continues to become more complex, pharmacist innovators have worked to advance the profession and expand the role of the pharmacist on the healthcare team. Accreditation standards for schools of pharmacy recognize the importance of developing future pharmacist innovators capable of making positive change in the profession, but there are limited resources available on how to best instill innovative thinking in student pharmacists.

EDUCATIONAL ACTIVITY

A two-semester elective course sequence was created for third-year doctor of pharmacy students requiring completion of a longitudinal quality improvement project at a partnering health system. Students collaborated with key stakeholders to design a project plan and charter, identify deliverables, and deliver project results. Innovative thinking was assessed using a mixed methods approach including questionnaires with forced choice and open response items, focus group data, and semi-structured interviews. Each questionnaire item mapped specifically to an element of a validated model for employee innovation. From the beginning to the end of the course sequence, there were significant improvements in student-perceived project management self-efficacy and innovative thinking.

CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY

Student learning outcomes and the course structure mapped closely with a validated model of innovative behavior, demonstrating the effectiveness of utilizing project management to instill innovative thinking in student pharmacists. These findings support the concept that innovative thinking can be taught in pharmacy didactic curricula by situating students in the environment of real-world pharmacy practice.

Reducing Primary Care Provider Burnout With Pharmacist-Delivered Comprehensive Medication Management

Primary care physicians have among the highest rates of burnout of any medical specialty in the United States. Team-based care is an organizational approach to meet the increasing demands on the primary care system, including the well-being of its providers. Physicians report that pharmacist-delivered comprehensive medication management improves patient care efficiency, decreases workload and provides additional work-based social support, among other benefits. Physician perspectives as well as resources for implementing physician-pharmacist collaborations are discussed.

Reducing Emergency Department Visits Among Patients With Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams

BACKGROUND

Pharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency department (ED) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care.

OBJECTIVE

The objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ED and hospital use for patients with diabetes.

DESIGN

This was a quasi-experimental study with a comparator group.

SUBJECTS

The analytic sample included patients with diabetes with uncontrolled cardiovascular risk factors (A1C >9%, blood pressure >140/90 mm Hg, low-density lipoprotein-cholesterol >130 mg/dL) who had 1 or more visits in either a UCMyRx (648 patients, 14 practices) or usual care practice (1944 patients, 14 practices).

MEASURES

Our outcomes were ED and hospitalization rates as measured before and after the consultations between UCMyRx and usual care. Our predictor variable was the pharmacist consultation. Poisson generalized estimating equations model was used to estimate the adjusted predicted change in utilization before and after the pharmacist consultation. The Average Treatment Effect on the Treated was estimated.

RESULTS

In models adjusted, the adjusted mean predicted number of emergency department visits/month during the year before the consultation was 0.09 among UCMyRx patients. During the year after initiating the care with the pharmacists, this rate decreased to an adjusted mean monthly rate of 0.07, with an Average Treatment Effect on the Treated=0.021 (P=0.035), a predicted reduction of 21% in emergency department visits associated with the clinical pharmacist consults. There was a nonsignificant predicted 3.2% reduction in hospitalizations over time for patients in the UCMyRx program.

CONCLUSION

Clinical pharmacists are an important addition to clinical care teams in primary care practices and significantly decreased utilization of the ED among patients with poorly controlled diabetes.

Pharmacists providing care in statewide physician organizations: findings from the Michigan Pharmacists Transforming Care and Quality Collaborative

BACKGROUND: Clinical services provided by pharmacists embedded in practices can improve patient outcomes within the primary care setting. Little is known about whether physician organizations (POs) will retain the services of clinical pharmacists after outside funding for a statewide implementation program is ended. OBJECTIVE: To evaluate a statewide program, Michigan Pharmacists Transforming Care and Quality (MPTCQ), that incorporated pharmacists within 17 POs. METHODS: A descriptive study was conducted using data collected from June 2016 to September 2018 from primary care clinical pharmacist encounters in POs participating in MPTCQ. Process outcomes included the number of participating POs, patient encounters, and average visits per patient. Analyses at the encounter level were stratified by 2 encounter types: disease state management (DSM) or comprehensive medication review (CMR). Separately by encounter type, pharmacist effect was described by the number, type, and reasons for medication changes, as well as medication adherence and cost barriers found and addressed. Clinical outcomes included hemoglobin A1c and blood pressure change. Sustainability and patient satisfaction of pharmacists providing clinical services are reported. RESULTS: Across 17 POs, 27 pharmacists participated in the MPTCQ program. Pharmacists completed 24,523 patient encounters for DSM with 5,942 patients, with an average of 5 visits per patient with diabetes and 2 visits for hypertension. Pharmacists made 15,153 therapeutic medication changes during visits for diabetes and hypertension, with approximately 70% related to efficacy. Pharmacists completed 4,203 CMR visits for 3,092 patients. During CMR visits, 1,296 therapeutic medication changes were recommended. Problems with medication cost were identified in 13% of CMR visits. Blood pressure and A1c levels decreased in patients managed by pharmacists. In 157 patients surveyed, 87% rated their pharmacists' care as excellent. Sixteen POs retained their pharmacists at the end of funding. CONCLUSIONS: A statewide provider-payer partnership successfully integrated and retained primary care pharmacists within POs. Pharmacists in the MPTCQ program contributed to improvements in disease control by changing medications to improve patient clinical outcomes. DISCLOSURES: Support for MPTCQ was provided by Blue Cross and Blue Shield of Michigan (BCBSM) as part of the BCBSM Value Partnerships program. Coe was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR002241. Although BCBSM and MPTCQ work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have no conflicts of interest to report.

Understanding the Feasibility, Acceptability, and Efficacy of a Clinical Pharmacist-led Mobile Approach (BPTrack) to Hypertension Management: Mixed Methods Pilot Study

BACKGROUND

Hypertension is a prevalent and costly burden in the United States. Clinical pharmacists within care teams provide effective management of hypertension, as does home blood pressure monitoring; however, concerns about data quality and latency are widespread. One approach to close the gap between clinical pharmacist intervention and home blood pressure monitoring is the use of mobile health (mHealth) technology.

OBJECTIVE

We sought to investigate the feasibility, acceptability, and preliminary effectiveness of BPTrack, a clinical pharmacist-led intervention that incorporates patient- and clinician-facing apps to make electronically collected, patient-generated data available to providers in real time for hypertension management. The patient app also included customizable daily medication reminders and educational messages. Additionally, this study sought to understand barriers to adoption and areas for improvement identified by key stakeholders, so more widespread use of such interventions may be achieved.

METHODS

We conducted a mixed methods pilot study of BPTrack, to improve blood pressure control in patients with uncontrolled hypertension through a 12-week pre-post intervention. All patients were recruited from a primary care setting where they worked with a clinical pharmacist for hypertension management. Participants completed a baseline visit, then spent 12 weeks utilizing BPTrack before returning to the clinic for follow-up. Collected data from patient participants included surveys pre- and postintervention, clinical measures (for establishing effectiveness, with the primary outcome being a change in blood pressure and the secondary outcome being a change in medication adherence), utilization of the BPTrack app, interviews at follow-up, and chart review. We also conducted interviews with key stakeholders.

RESULTS

A total of 15 patient participants were included (13 remained through follow-up for an 86.7% retention rate) in a single group, pre-post assessment pilot study. Data supported the hypothesis that BPTrack was feasible and acceptable for use by patient and provider participants and was effective at reducing patient blood pressure. At the 12-week follow-up, patients exhibited significant reductions in both systolic blood pressure (baseline mean 137.3 mm Hg, SD 11.1 mm Hg; follow-up mean 131.0 mm Hg, SD 9.9 mm Hg; P=.02) and diastolic blood pressure (baseline mean 89.4 mm Hg, SD 7.7 mm Hg; follow-up mean 82.5 mm Hg, SD 8.2 mm Hg; P<.001). On average, patients uploaded at least one blood pressure measurement on 75% (SD 25%) of study days. No improvements in medication adherence were noted. Interview data revealed areas of improvement and refinement for the patient experience. Furthermore, stakeholders require integration into the electronic health record and a modified clinical workflow for BPTrack to be truly useful; however, both patients and stakeholders perceived benefits of BPTrack when used within the context of a clinical relationship.

CONCLUSIONS

Results demonstrate that a pharmacist-led mHealth intervention promoting home blood pressure monitoring and clinical pharmacist management of hypertension can be effective at reducing blood pressure in primary care patients with uncontrolled hypertension. Our data also support the feasibility and acceptability of these types of interventions for patients and providers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02898584; https://clinicaltrials.gov/ct2/show/NCT02898584.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.8059.

Association between polypharmacy and health-related quality of life among US adults with cardiometabolic risk factors

PURPOSE

There are known associations between cardiometabolic risk factors and polypharmacy; however, there is no evidence about how polypharmacy among adults with cardiometabolic risk factors impacts their health-related quality of life (HRQoL). The main objective of this study was to assess the association between polypharmacy and HRQoL among adults with cardiometabolic risk factors living in the USA.

METHODS

Individuals age ≥ 18 years with at least one of the three cardiometabolic risk factors (diabetes, hyperlipidemia, and hypertension) were identified from the Medical Expenditure Panel Survey 2015 data. We defined polypharmacy as use of at least five classes of prescription medications. Physical component summary (PCS) and mental component summary (MCS) were obtained from the 12-item Short-Form Health Survey version 2 to measure HRQoL. We conducted adjusted ordinary least-square regressions to determine the association between polypharmacy and HRQoL.

RESULTS

We identified 7621 (weighted N = 80 million) adults with at least one cardiometabolic risk factors of whom 46.9% reported polypharmacy. Polypharmacy was noted in 29.7% of those with hypertension, whereas 82.4% of those with all the three cardiometabolic risk factors had polypharmacy. The unadjusted mean PCS and MCS scores for those with polypharmacy were lower than those without polypharmacy. In the multivariable regressions, we found that adults with polypharmacy had significantly lower PCS scores (β = - 4.27, p < 0.0001) compared to those without polypharmacy, while the MCS scores between those with and without polypharmacy were no longer significantly different.

CONCLUSION

Surveillance of use of concurrent prescription medications is warranted so as to improve physical functioning in this vulnerable group.

Partnering With Pharmacists to Reduce Cardiovascular Risk in Outpatient Settings

See Article Martınez-Mardones et al.

Applying Contemporary Management Principles to Implementing and Evaluating Value-Added Pharmacist Services

Value-added pharmacy services encompass traditional and emerging services provided by pharmacists to individual and entire populations of persons increasingly under the auspices of a public health mandate. The success of value-added pharmacy services is enhanced when they are carried out and assessed using appropriate theory-based paradigms. Many of the more important management theories for pharmacy services consider the “servicescape” of these services recognizing the uniqueness of each patient and service encounter that vary based upon health needs and myriad other factors. In addition, implementation science principles help ensure the financial viability and sustainability of these services. This commentary reviews some of the foundational management theories and provides a number of examples of these theories that have been applied successfully resulting in a greater prevalence and scope of value-added services being offered.

Clinical and Economic Benefits of Pharmacist Involvement in a Community Hospital-Affiliated Patient-Centered Medical Home

BACKGROUND

The primary goals of an accountable care organization (ACO) are to reduce health care spending and increase quality of care. Within an ACO, pharmacists have a unique opportunity to help carry out these goals within patient-centered medical homes (PCMHs). Pharmacy presence is increasing in these integrated care models, but the pharmacist's role and benefit is still being defined.

OBJECTIVE

To exhibit the clinical and economic benefit of pharmacist involvement in ACOs and PCMHs as documented by clinical interventions (CIs) and drug cost reductions.

METHODS

This is a retrospective quality improvement study. All interventions made by the pharmacist during the study period were documented using TAV Health. The interventions were then analyzed. Specific identified endpoints included the total number of documented interventions and number of CIs from each category, transition of care (TOC) medication reconciliations performed, discrepancies identified during TOC medication reconciliation, and cost savings generated from generic and therapeutic alternative use. CI categories were collaborative drug therapy management, medication therapy management (MTM), medication reconciliation, patient and provider education, and drug cost management.

RESULTS

During the study period (October 2016-March 2017), a pharmacist was in clinic 8 hours per week. Sixty-three patients were included in the study. There were 283 CIs documented, with a majority of the interventions associated with MTM or cost management (94 and 88 CIs, respectively). There were 37 education CIs, 36 TOC medication reconciliations performed, and 28 collaborative drug therapy management CIs. From the 36 TOC medication reconciliations, 240 medication discrepancies were found, with a majority associated with medication omission. A cost savings of $118,409 was gained from generic and therapeutic alternative substitutions.

CONCLUSIONS

Clinical benefit of pharmacy services was demonstrated through documented CIs. Pharmacists can have a dramatic and quantitative effect on reducing drug costs by recommending less expensive generic or therapeutic alternatives. Documenting CIs allows pharmacists to provide valuable evidence of avoided drug misadventures and identification of medication discrepancies. Such evidence supports an elevated quality of care.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose. Study concept and design were contributed by Tate and Hopper, along with Bergeron. Tate collected and interpreted the data, as well wrote the manuscript, which was revised by all the authors.

Oncology Pharmacist Opportunities: Closing the Gap in Quality Care

PURPOSE

ASCO has worked to facilitate the improvement in quality oncology care via the development of the Quality Oncology Practice Initiative (QOPI). The extent to which the ASCO QOPI identifies areas in which pharmacists may enhance care is not known. These findings are important, as pharmacists are an integral part of the care team, providing direct clinical care in addition to medication use guidelines and practice-based policies. In addition, high-performing practices may receive reimbursement from the Centers for Medicare and Medicaid Services.

METHODS

Three pharmacists reviewed 200 QOPI measures for potential pharmacist involvement. We used the Hematology/Oncology Pharmacy Association Scope of Practice document and a validated summary of services provided by board-certified oncology pharmacists to identify which practice domains and pharmacy services would best fit the care provided by the selected QOPI measures.

RESULTS

A total of 177 QOPI measures were analyzed. Potential areas of pharmacist impact were identified in 67 (38%) of the included metrics. Measures largely related to optimizing drug therapy through the development and implementation of pharmacy guidelines. Patient counseling and symptom management are services that best described the majority of QOPI measures deemed actionable by a pharmacist. We also found that several QOPI measures pharmacists can intervene upon overlap with metrics currently assessed for reimbursement via the Centers for Medicare and Medicaid Services Merit-Based Incentive Payment System.

CONCLUSION

Oncology pharmacists are uniquely positioned to improve the quality of care provided to patients with cancer within the team-based setting.

Utilizing Consumer Health Informatics to Support Management of Hypertension by Clinical Pharmacists in Primary Care: Study Protocol

BACKGROUND

Hypertension (HTN) is a major public health concern in the United States given its wide prevalence, high cost, and poor rates of control. Multiple strategies to counter this growing epidemic have been studied, and home blood pressure (BP) monitoring, mobile health (mHealth) interventions, and referrals to clinical pharmacists for BP management have all shown potential to be effective intervention strategies.

OBJECTIVE

The purpose of this study is to establish feasibility and acceptability of BPTrack, a clinical pharmacist-led mHealth intervention that aims to improve BP control by supporting home BP monitoring and medication adherence among patients with uncontrolled HTN. BPTrack is an intervention that makes home-monitored BP data available to clinical pharmacists for use in HTN management. Secondarily, this study seeks to understand barriers to adoption of this intervention, as well as points of improvement among key stakeholders, so that larger scale dissemination of the intervention may be achieved and more rigorous research can be conducted.

METHODS

This study is recruiting up to 25 individuals who have poorly controlled HTN from a Family Medicine clinic affiliated with a large Midwestern academic medical center. Patient participants complete a baseline visit, including installation and instructions on how to use BPTrack. Patient participants are then asked to follow the BP monitoring protocol for a period of 12 weeks, and subsequently complete a follow-up visit at the conclusion of the study period.

RESULTS

The recruitment period for the pilot study began in November 2016, and data collection is expected to conclude in late-2017.

CONCLUSIONS

This pilot study seeks to document the feasibility and acceptability of a clinical pharmacist-led mHealth approach to managing HTN within a primary care setting. Through our 12-week pilot study, we expect to lend support for this approach, and lay the foundation for translating this approach into wider-scale implementation. This mHealth intervention seeks to leverage the multidisciplinary care team already in place within primary care, and to improve health outcomes for patients with uncontrolled HTN.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02898584; https://clinicaltrials.gov/ct2/show/NCT02898584 (Archived by WebCite® at http://www.webcitation.org/6u3wTGbe6).

Improving Ambulatory Care Resident Training: Preparing for Opportunities to Treat Mental Illness in the Primary Care Setting

PURPOSE

The development of an outpatient psychiatry clinical practice learning experience for PGY2 ambulatory care pharmacy residents in preparation for the treatment of psychiatric disorders in the primary care setting is described.

SUMMARY

With the increased prevalence of psychiatric disorders, significant mortality, and limited access to care, integration of mental health treatment into the primary care setting is necessary to improve patient outcomes. Given the majority of mental health treatment occurs in the primary care setting, pharmacists in patient-centered medical homes (PCMHs) are in a unique position with direct access to patients to effectively manage these illnesses. However, the increased need for pharmacist education and training in psychiatry has prompted a large, Midwestern academic health system to develop an outpatient psychiatry learning experience for PGY2 (Postgraduate Year 2) ambulatory care pharmacy residents in 2015. The goal of this learning experience is to introduce the PGY2 ambulatory care residents to the role and impact of psychiatric clinical pharmacists and to orient the residents to the basics of psychiatric pharmacotherapy to be applied to their future practice in the primary care setting.

CONCLUSION

The development of an outpatient psychiatry learning experience for PGY2 ambulatory care pharmacy residents will allow for more integrated and comprehensive care for patients with psychiatric conditions, many of whom are treated and managed in the PCMH setting.

Pharmacist home visits: A 1-year experience from a community pharmacy

OBJECTIVE

To provide experience on the methods and costs for delivering a large-scale community pharmacist home visit service.

SETTING

Independent urban community pharmacy, Buffalo, NY.

PRACTICE DESCRIPTION

Mobile Pharmacy Solutions provides traditional community pharmacy walk-in service and a suite of clinically oriented services, including outbound adherence calls linked to home delivery, payment planning, medication refill synchronization, adherence packaging, and pharmacist home visits. Pharmacist daily staffing included three dispensing pharmacists, one residency-trained pharmacist, and two postgraduate year 1 community pharmacy residents.

PRACTICE INNOVATION

A large-scale community pharmacy home visit service delivered over a 1-year period.

EVALUATION

Pharmacist time and cost to administer the home visit service as well as home visit request sources and description of patient demographics.

RESULTS

A total of 172 visits were conducted (137 initial, 35 follow-up). Patients who received a home visit averaged 9.8 ± 5.2 medications and 3.0 ± 1.6 chronic disease states. On average, a home visit required 2.0 ± 0.8 hours, which included travel time. The percentages of visits completed by pharmacists and residents were 60% and 40%, respectively. The amounts of time to complete a visit were similar. Average home visit cost including pharmacist time and travel was $119 ($147 for a pharmacist, $77 for a resident).

CONCLUSION

In this community pharmacy-based home visit service, costs are an important factor, with each pharmacist visit requiring 2 hours to complete. This experience provides a blueprint and real-world perspective for community pharmacies endeavoring to implement a home visit service and sets a foundation for future prospective trials to evaluate the impact of the service on important indicators of health and cost.

Exploring Electronic Medical Record and Self-Administered Medication Risk Screening Tools in a Primary Care Clinic

BACKGROUND

Electronic medical record (EMR) screening for indicators of medication risk could improve efficiency in identifying primary care clinic patients in need of clinical pharmacist care compared with patient self-reporting.

OBJECTIVES

To (a) compare the performance of an EMR medication risk assessment questionnaire (MRAQ) with a self-administered (SA) MRAQ and (b) explore each tool's ability to predict indicators of health behavior, health status, and health care utilization.

METHODS

A prospective cohort study was conducted with 143 adults who attended an academic family medicine center and were taking ≥ 2 medications. All participants completed the 10-item SA-MRAQ, Morisky Medication Adherence Scale, Chew's health literacy screener, Stanford Health Distress Scale, and SF-36 overall rating of health. A blinded investigator completed the EMR-MRAQ and a chart review to ascertain 6 months of health care utilization. Outcome measures included the following: (a) scores from the 5- and 10-item SA-MRAQs and 5-item EMR-MRAQ; (b) sensitivity and specificity to determine the accuracy of the 5-item EMR versus the 5-item SA risk scores; (c) correlations between risk assessments and health behavior/status scales; and (d) area under the receiver operator curve to determine how well a high-risk score predicted health care utilization.

RESULTS

The 5-item SA-MRAQ, the 5-item EMR-MRAQ, and the 10-item SA-MRAQ categorized 52.9% (55/104), 69.2% (99/143), and 17.6% (18/102) of participants as high risk, respectively. For the 104 participants who completed both 5-item MRAQ tools, the EMR-MRAQ had a sensitivity of 81.8% and specificity of 49.0% in detecting a high-risk SA-MRAQ score. Both 5-item risk assessments showed weak correlations with health distress and overall health, while the 10-item SA-MRAQ additionally showed weak correlations with medication adherence. The EMR-MRAQ was most effective in predicting all-cause emergency room visits/hospitalization (c-statistic = 0.69; 95% CI=0.57-0.81) and high clinic utilization (≥ 4 visits per 6 months; c-statistic = 0.77; 95% CI = 0.69-0.85). The EMR-MRAQ had high sensitivities but low specificities for these health care utilization outcomes, respectively (82.6% and 33.3%; 88.9% and 42.7%).

CONCLUSIONS

This pilot study suggests that EMR-MRAQ screening has high sensitivity but low specificity in comparison with self-reporting and was able to discriminate between those who would and would not experience health care utilization outcomes. These results justify further development and validation of an automated EMR-based tool to predict patient-important consequences of medication-related problems.

DISCLOSURES

This work was funded by the Canadian Society of Hospital Pharmacists Research and Education Foundation, which had no role in the analysis or interpretation of data or the decision to submit the manuscript for publication. The authors have no conflict of interests, potential or otherwise, to report. Makowsky had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Makowsky and Cor. Makowsky and Wong collected the data, and data interpretation was performed by Makowsky, Cor, and Wong. The manuscript was written by Makowsky and was critically reviewed for intellectual content by Makowsky, Cor, and Wong.

Implementation and impact of a chronic kidney disease elective for second-year pharmacy students

BACKGROUND AND PURPOSE

Pharmacists can make a great impact on the management of chronic kidney disease (CKD), which is a highly prevalent and costly disorder. This article describes the implementation and impact of a CKD elective course for second-year pharmacy students, which aimed to expose students to CKD and enhance their ability to care for these patients.

EDUCATIONAL ACTIVITY AND SETTING

Topics associated with CKD were covered in a fifteen-week, three credit hour course. Various active-learning techniques were utilized, including student presentations of pharmacotherapy and primary literature, team-based learning though patient case discussions, and interactions with standardized and actual patients. Surveys designed to assess students' career goals and level of confidence with assessing primary literature, delivering presentations to peers, working as members of a team, and communicating with patients were administered at the beginning and end of the course.

FINDINGS

Twenty-three students (100%) participated in the initial survey, and nineteen (86.4%) participated in the final survey. Students gave more positive responses on the final survey that they were considering a career in ambulatory care (P=0.03), planning to pursue a career in ambulatory care (P=0.02), considering a career in kidney disease management (P=0.02), and planning to pursue a career in kidney disease management (P=0.0498). Students also felt more confident in their ability to assess primary literature (P=0.005) and deliver presentations to their peers (P=0.02).

SUMMARY

Courses such as this can expose students to new and unique career paths and help them develop key skills to promote a successful and fulfilling pharmacy career.

Health care professionals' perceptions of a community based 'virtual ward' medicines management service: A qualitative study

This article describes a qualitative research study using focus groups to explore the views and experiences of a medicines management team (MMT) on the service they deliver within a 'Virtual Ward' (VW); and those of the wider multidisciplinary team of healthcare professionals on the service provided by the MMT. Several themes emerged from the focus groups, including impact on patients and carers, team working and issues and challenges. A dedicated MMT was seen as a positive contribution to the VW, which potentially increased the quality of patient care, and appeared to be a positive experience for both the MM and wider multidisciplinary team.

Development and Implementation of Clinical Pharmacist Services Within an Integrated Medical Group

Background:

In 2012, pharmacists were integrated into a medical group to provide direct patient care, drug information activities, and health care provider education. The medical group encompasses 40 primary care and 60 specialty offices in Virginia.

Objective:

To describe the development and implementation of clinical pharmacist services integrated within a medical group.

Methods:

Pharmacists’ roles and responsibilities, type and number of patient encounters, and identification of strategies to facilitate implementation are described.

Results:

From June 2012 to December 2014, pharmacists had 809 patient encounters, which included patient-centered education, medication consults, Medicare annual wellness visits, senior care visits, and comprehensive medication reviews. Pharmacists addressed 403 drug information requests from nurse navigators, providers, and administrators. Pharmacists also have roles in risk management, quality improvement initiatives, and operations that benefit the medical group. Strategies to facilitate implementation include working with organizational leadership, identifying a physician champion, and establishing credibility by being responsive to practice needs and responding to requests in a timely manner to build trust within the health care team.

Conclusion:

Integration of pharmacists within health care teams involves more than direct patient care activities. Pharmacists should be involved at the organizational level to have a broader impact on patient and practice levels.

Maintenance of Clinical Endpoints After Discharge from a Pharmacist-Managed Risk Reduction Clinic at a Veterans Affairs Medical Center

BACKGROUND

Diabetes, dyslipidemia, and hypertension are complex chronic disease states that often require close monitoring and frequent follow-up to achieve and maintain therapeutic control as determined by hemoglobin A1c (A1c), low-density lipoprotein (LDL), and blood pressure (BP). At the Charles George Veterans Affairs Medical Center (CGVAMC), physicians may refer their patients to the on-site pharmacist-managed Risk Reduction Clinic (RRC). Patients are discharged from the RRC once patient-specific therapeutic goals have been met for diabetes, dyslipidemia, and/or hypertension. This study investigated the change in A1c, LDL, and systolic blood pressure (SBP) after discharge from the CGVAMC RRC.

OBJECTIVES

To investigate (a) how clinical endpoints for diabetes, dyslipidemia, and hypertension change after discharge from the pharmacist-managed RRC at the CGVAMC; (b) the factors associated with worsening of monitoring parameters; and (c) the frequency of reconsultation to the RRC.

METHODS

In this single-center retrospective quality management study, patients were included if they had a completed consultation to the CGVAMC RRC between August 11, 2008, and January 1, 2011, for the management of type 2 diabetes, dyslipidemia, and/or hypertension. Patients were included if they were discharged from the RRC prior to October 1, 2011, due to goal attainment. Furthermore, it was required that patients have A1c, LDL, and SBP measurements, as applicable based on diagnoses, at least yearly during the first 2 years following discharge. Patients were excluded if they were discharged for any reason other than goal attainment or if they were followed by a specialty clinic related to the RRC, including the Diabetes PharmD, Diabetes MD, MIDAS (group diabetes), or MAGIC (group dyslipidemia) clinics. Data collection included patient demographics; date of and indication for consultation to the RRC; date of first RRC visit; date of discharge from the RRC; number of visits to the RRC; A1c, LDL, SBP, and weight at consultation to the RRC, at discharge, and during the 2 years following discharge from the RRC; and date of and indication for reconsultation to the RRC, as applicable. Two-tailed paired t-tests were used to compare A1c, LDL, and SBP at discharge from the RRC to A1c, LDL, and SBP during the follow-up period. Two-tailed unpaired t-tests were performed to determine which variables were associated with changes in the monitoring parameters after discharge from the RRC.

RESULTS

One hundred forty-nine patients were included in this study. For all patients with a diagnosis of diabetes (N = 82), A1c rose from 6.49% to 6.79% (P < 0.001) during the first year and to 7.04% (P < 0.001) during the second year following discharge. For patients diagnosed with dyslipidemia (N = 137), LDL rose after discharge from 81.5 mg/dL to 90.8 mg/dL (P < 0.001) and to 90.9 mg/dL (P < 0.001), respectively. For patients diagnosed with hypertension (N = 132), SBP rose from 126.2 mm Hg to 131.5 mm Hg (P < 0.001) and to 133.9 mm Hg (P < 0.001), respectively. An increase in A1c after discharge was associated with lower discharge A1c (P = 0.014), higher consultation weight (P = 0.009), and higher discharge weight (P = 0.042). A rise in LDL was correlated to higher consultation LDL (P = 0.006), while higher SBP was associated with lower discharge SBP (P < 0.001). Twelve percent of patients were reconsulted to the RRC.

CONCLUSIONS

A1c, LDL, and SBP rose after discharge from the pharmacist-managed risk reduction clinic, but these changes may not have been clinically significant based on the low reconsultation rate and values remaining close to generally accepted therapeutic goals. Patients likely to benefit from extending RRC services past goal attainment include those with higher A1c and LDL at the time of consultation and those with higher weight. As a result of this study, recommendations have been made to consider following up every 3-4 months for 2-3 additional visits for patients with baseline A1c > 8% and LDL > 115 mg/dL and those with weight > 220 pounds prior to discharging them from the CGVAMC RRC. Furthermore, we believe that all patients could benefit from extending follow-up to 6 months for 1-2 additional visits or as needed after their therapeutic goals have been reached.

Adherence to the 2013 Blood Cholesterol Guidelines in Patients With Diabetes at a PCMH: Comparison of Physician Only and Combination Physician/Pharmacist Visits

PURPOSE

The purpose of this study is to assess adherence to the 2013 blood cholesterol guideline in a population with diabetes based on the atherosclerotic cardiovascular (ASCVD) risk.

METHODS

Patients with diabetes were assessed to see whether they received the appropriate intensity statin therapy via chart review. Patients seen by a physician or pharmacist at CommUnityCare, a PCMH, from December 2013 to October 2014 were included in this retrospective study. The ASCVD risks were calculated to determine if the patients received appropriate intensity statin.

RESULTS

A total of 583 patients met the inclusion criteria; there were 475 in the physician only group and 108 with additional pharmacist visits. Statin therapy was prescribed in 71% of patients in the physician group and 88% of patients in the pharmacist/physician group. The appropriate intensity statin was prescribed in 32% of patients in the physician group and 35% of patients in the pharmacist/physician group. The appropriate intensity statin in statin naïve patients was prescribed in 45% of the physician group and 50% of patients in the pharmacist/physician group.

CONCLUSION

The proportion of patients prescribed an appropriate intensity statin did not differ between patients managed by physicians alone compared to those managed by pharmacists and physicians. Overall adherence to the 2013 blood cholesterol guidelines was 33%, and this measure can be used as a baseline assessment of current adherence with the guidelines.

Patient care delivery and integration: stimulating advancement of ambulatory care pharmacy practice in an era of healthcare reform

PURPOSE

This article discusses how to plan and implement an ambulatory care pharmacist service, how to integrate a hospital- or health-system-based service with the mission and operations of the institution, and how to help the institution meet its challenges related to quality improvement, continuity of care, and financial sustainability.

SUMMARY

The steps in implementing an ambulatory care pharmacist service include (1) conducting a needs assessment, (2) aligning plans for the service with the mission and goals of the parent institution, (3) collaborating with patients and physicians, (4) standardizing the patient care process, (5) proposing the service, (6) attaining the necessary resources, (7) identifying stakeholders, (8) identifying applicable quality standards, (9) defining competency standards, (10) planning for service payment, and (11) monitoring outcomes. Ambulatory care pharmacists have current opportunities to become engaged with patient-centered medical homes, accountable care organizations, preventive and wellness programs, and continuity of care initiatives. Common barriers to the advancement of ambulatory care pharmacist services include lack of complete access to patient information, inadequate information technology, and lack of payment.

CONCLUSION

Ambulatory care pharmacy practitioners must assertively promote appropriate medication use, provide patient-centered care, pursue integration with the patient care team, and seek appropriate recognition and compensation for the services they provide.

Quality improvement in healthcare delivery utilizing the patient-centered medical home model

Despite the fact that the United States dedicates so much of its resources to healthcare, the current healthcare delivery system still faces significant quality challenges. The lack of effective communication and coordination of care services across the continuum of care poses disadvantages for those requiring long-term management of their chronic conditions. This is why the new transformation in healthcare known as the patient-centered medical home (PCMH) can help restore confidence in our population that the healthcare services they receive is of the utmost quality and will effectively enhance their quality of life. Healthcare using the PCMH model is delivered with the patient at the center of the transformation and by reinvigorating primary care. The PCMH model strives to deliver effective quality care while attempting to reduce costs. In order to relieve some of our healthcare system distresses, organizations can modify their delivery of care to be patient centered. Enhanced coordination of services, better provider access, self-management, and a team-based approach to care represent some of the key principles of the PCMH model. Patients that can most benefit are those that require long-term management of their conditions such as chronic disease and behavioral health patient populations. The PCMH is a feasible option for delivery reform as pilot studies have documented successful outcomes. Controversy about the lack of a medical neighborhood has created concern about the overall sustainability of the medical home. The medical home can stand independently and continuously provide enhanced care services as a movement toward higher quality care while organizations and government policy assess what types of incentives to put into place for the full collaboration and coordination of care in the healthcare system.

Effectiveness of diabetes interventions in the patient-centered medical home

The patient-centered medical home (PCMH) is an innovative care model for the provision of primary care that is being rapidly adopted in the U.S. with the support of federal agencies and professional organizations. Its goal is to provide comprehensive, patient-centered care with increased access, quality, and efficiency. Diabetes, as a common, costly, chronic disease that requires ongoing management by patients and providers, is a condition that is frequently monitored as a test case in PCMH implementations. While in theory a PCMH care model that supports patient engagement and between-visit care may help improve diabetes care delivery and outcomes, the success of this approach may depend largely upon the specific strategies used and implementation approach. The cost-effectiveness of diabetes care in the PCMH model is not yet clear. Interventions have been most effective and most cost-effective for those with the poorest diabetes management at baseline.

Educational and career goals of pharmacy students upon graduation

OBJECTIVE

To assess the doctor of pharmacy (PharmD) students' desire to obtain additional degrees after graduation.

METHODS

During the spring 2011 semester, an anonymous 14-question survey instrument was administered to students across all 6 years of the PharmD program to evaluate their interest in obtaining an additional degree after graduation. Demographic data was also collected and analyzed from this convenience sample.

RESULTS

Approximately 34% of the respondents (n=1,239) indicated a desire to seek an additional degree. Of the additional degrees offered in the survey instrument, more than one-third of the students expressed interest in the master of business administration (MBA). Also, 79% of those respondents were willing to take summer courses to achieve a dual or additional degree.

CONCLUSION

Pharmacy students are interested in obtaining an additional degree(s) after graduation and are willing to complete summer courses to achieve their career goals.

Clinical pharmacists as key members of the patient-centered medical home: an opinion statement of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy

The American College of Clinical Pharmacy (ACCP) Ambulatory Care Practice Research Network (PRN) considers the role of clinical pharmacists to be fundamental to the success of the Patient-Centered Medical Home (PCMH) model. Within the PCMH, pharmacists can improve the health of populations by participating in activities that optimize medication management. Multiple published articles support clinical pharmacist involvement in the PCMH with regard to promotion of team-based care, enhanced access, care coordination, and improved quality and safety of care. A survey of clinical pharmacist members of ACCP who operate in such a model depict a variety of activities, with some members pioneering new and innovative ways to practice clinical pharmacy. Although this is a significant opportunity for pharmacists in the primary care setting, a unified vision of pharmacy services is needed. It is our hope that with continued efforts focused on obtaining national provider status, clinical pharmacy can use the PCMH model to solidify the future of primary care pharmacy. The following is an opinion statement of the ACCP Ambulatory Care PRN regarding the vital role of clinical pharmacists in the PCMH.