Pharmacist hypertension management using an electronic health record-based approach

OBJECTIVES

To evaluate the impact of the chronic medication optimization pharmacist (CMOP) program on blood pressure (BP) control and time to goal compared with usual care in the ambulatory care setting.

STUDY DESIGN

This was a retrospective cohort study that included patients from June 2018 to June 2020 who were seen in an ambulatory care clinic for hypertension management.

METHODS

Patients aged 18 to 80 years were divided into 2 cohorts based on hypertension management by usual care or the CMOP program. Patients were enrolled in the CMOP program either by referral or identification via a data analytics tool. The primary outcome assessed the proportion of patients within BP goal (< 140/90 mm Hg) at 3 months. Secondary outcomes assessed the proportion of patients within goal at 6 months, time and number of visits to goal, and adherence (CMOP cohort only).

RESULTS

The primary end point demonstrated a greater proportion of patients within goal in the CMOP cohort compared with usual care (69.4% vs 42.3%; P < .001). The CMOP cohort also displayed a greater proportion of patients achieving goal within 6 months (75.7% vs 60.4%; P = .014) and faster time to goal (42.99 vs 63.12 days; P = .002), but more visits (1.67 vs 1.18; P = .001). Lastly, adherence improved from 50.4% to 72.1% in the patients with a documented adherence assessment in the pharmacist group (P = .03).

CONCLUSIONS

The pharmacist intervention improved BP control in a primarily African American patient population compared with usual care. Future studies should assess the sustainability of this intervention.

Comprehensive medication reviews: Optimal delivery setting and recommendations for quality assessment

OBJECTIVES

To propose a metric evaluating the quality of comprehensive medication reviews (CMRs), and to discuss the optimal setting for CMR delivery.

SUMMARY

First, we provide a current assessment of the quality of CMRs performed in community, payer, and health system/clinic settings, with recommended opportunities for improvement. Thereafter, a companion metric for CMR quality is discussed, because this is critical to ensuring that patients are not just receiving CMR services, but that CMRs reflect evidence-based recommendations supporting optimal patient outcomes.

CONCLUSION

Based on the data currently available, accessibility to electronic medical records would enhance patient-specific recommendations to optimize CMR delivery and patient outcomes. Future studies may help to identify additional factors, such as pharmacist-physician collaboration in clinic and use of evidence-based recommendations, that can further enhance CMR quality.

Evolution of interdisciplinary geriatric transitions of care on readmission rates

OBJECTIVES

To evaluate the effect of an interdisciplinary transitions of care (TOC) service on readmission rates in a geriatric population.

STUDY DESIGN

Single-center retrospective cohort study of adults 60 years or older discharged from an academic medical center.

METHODS

From July 1, 2013, to February 21, 2016, a total of 4626 patients discharged from 1 hospital, including inpatient, emergency department, observation, and short-stay units, were included. Cases were scheduled for a TOC service with the interdisciplinary team. Controls received usual care at other sites. All-cause 14-, 30-, and 90-day readmission rates between propensity score-matched study groups were evaluated by intention-to-treat (ITT), per-protocol (PP), and as-treated methods.

RESULTS

During the study period, 513 patients were scheduled for at least 1 component of the TOC intervention (ITT group). Of those patients, 215 completed all scheduled visits (PP group). Readmission rate after 30 days demonstrated no difference in the ITT group compared with the control group (12.8% vs 10.7%; P = .215), although it was significantly lower in the PP group in comparison with the control group (12.8% vs 7.9%; P = .042).

CONCLUSIONS

An interdisciplinary team based in a patient-centered medical home improved readmission rates for all patients who completed the intervention (PP group).

Role of feed water biodegradable substrate concentration on biofouling: Biofilm characteristics, membrane performance and cleanability

Biofouling severely impacts operational performance of membrane systems increasing the cost of water production. Understanding the effect of critical parameters of feed water such as biodegradable substrate concentration on the developed biofilm characteristics enables development of more effective biofouling control strategies. In this study, the effect of substrate concentration on the biofilm characteristics was examined using membrane fouling simulators (MFSs). A feed channel pressure drop (PD) increase of 200 mbar was used as a benchmark to study the developed biofilm. The amount and characteristics of the formed biofilm were analysed in relation to membrane performance indicators: feed channel pressure drop and permeate flux. The effect of the characteristics of the biofilm developed at three substrate concentrations on the removal efficiency of the different biofilms was evaluated applying acid/base cleaning. Results showed that a higher feed water substrate concentration caused a higher biomass amount, a faster PD increase, but a lower permeate flux decline. The permeate flux decline was affected by the spatial location and the physical characteristics of the biofilm rather than the total amount of biofilm. The slower growing biofilm developed at the lowest substrate concentration was harder to remove by NaOH/HCl cleanings than the biofilm developed at the higher substrate concentrations. Effective biofilm removal is essential to prevent a fast biofilm regrowth after cleaning. While substrate limitation is a generally accepted biofouling control strategy delaying biofouling, development of advanced cleaning methods to remove biofilms formed under substrate limited conditions is of paramount importance.

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.

Effect of water temperature on biofouling development in reverse osmosis membrane systems

Understanding the factors that determine the spatial and temporal biofilm development is a key to formulate effective control strategies in reverse osmosis membrane systems for desalination and wastewater reuse. In this study, biofilm development was investigated at different water temperatures (10, 20, and 30 °C) inside a membrane fouling simulator (MFS) flow cell. The MFS studies were done at the same crossflow velocity with the same type of membrane and spacer materials, and the same feed water type and nutrient concentration, differing only in water temperature. Spatially resolved biofilm parameters such as oxygen decrease rate, biovolume, biofilm spatial distribution, thickness and composition were measured using in-situ imaging techniques. Pressure drop (PD) increase in time was used as a benchmark as to when to stop the experiments. Biofilm measurements were performed daily, and experiments were stopped once the average PD increased to 40 mbar/cm. The results of the biofouling study showed that with increasing feed water temperature (i) the biofilm activity developed faster, (ii) the pressure drop increased faster, while (iii) the biofilm thickness decreased. At an average pressure drop increase of 40 mbar/cm over the MFS for the different feed water temperatures, different biofilm activities, structures, and quantities were found, indicating that diagnosis of biofouling of membranes operated at different or varying (seasonal) feed water temperatures may be challenging. Membrane installations with a high temperature feed water are more susceptible to biofouling than installations fed with low temperature feed water.

Elevated International Normalized Ratio values in a patient receiving warfarin and ceftaroline

PURPOSE

The case of a patient whose International Normalized Ratio (INR) became elevated due to a probable interaction between ceftaroline and warfarin is reported.

SUMMARY

A 65-year-old African-American man developed an INR of >18.0 after completing 12 days of ceftaroline therapy for the treatment of cellulitis while taking warfarin therapy. The patient was on warfarin due to his history of deep vein thrombosis of a lower extremity and pulmonary embolism, and his INR was consistently therapeutic for approximately 2 years before ceftaroline therapy. The patient reported no known drug allergies, had no history of adverse drug reactions, and had no recent changes in medications or diet. Phytonadione was administered, and the patient's INR began to decrease, returning to a therapeutic range of 2.30 after approximately 48 hours, at which time warfarin was restarted. After six days of hospitalization, the patient was discharged on his previous regimen of warfarin 7.5 mg orally once daily, with a therapeutic INR of 2.11. His cellulitis had resolved, so no further antibiotic therapy was warranted. To determine the likelihood of the drug interaction between warfarin and ceftaroline in this patient, the Drug Interaction Probability Scale of Horn and colleagues was applied and yielded a score of 6, indicating a probable likelihood of an interaction. Rechallenge was not attempted, as the patient's cellulitis had resolved and there were no evident signs or symptoms of infection.

CONCLUSION

A 65-year-old man experienced an increase in INR values after the addition of ceftaroline to his medication regimen.

Early non-destructive biofouling detection and spatial distribution: Application of oxygen sensing optodes

Biofouling is a serious problem in reverse osmosis/nanofiltration (RO/NF) applications, reducing membrane performance. Early detection of biofouling plays an essential role in an adequate anti-biofouling strategy. Presently, fouling of membrane filtration systems is mainly determined by measuring changes in pressure drop, which is not exclusively linked to biofouling. Non-destructive imaging of oxygen concentrations (i) is specific for biological activity of biofilms and (ii) may enable earlier detection of biofilm accumulation than pressure drop. The objective of this study was to test whether transparent luminescent planar O2 optodes, in combination with a simple imaging system, can be used for early non-destructive biofouling detection. This biofouling detection is done by mapping the two-dimensional distribution of O2 concentrations and O2 decrease rates inside a membrane fouling simulator (MFS). Results show that at an early stage, biofouling development was detected by the oxygen sensing optodes while no significant increase in pressure drop was yet observed. Additionally, optodes could detect spatial heterogeneities in biofouling distribution at a micro scale. Biofilm development started mainly at the feed spacer crossings. The spatial and quantitative information on biological activity will lead to better understanding of the biofouling processes, contributing to the development of more effective biofouling control strategies.