Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations: A Report from the Accountable Care Organization Research Network, Services, and Education

BACKGROUND

The accountable care organization (ACO) is an innovative health care delivery model centered on value-based care. ACOs consisting of primary care providers are increasingly becoming commonplace in practice; however, medication management remains suboptimal.

PROGRAM DESCRIPTION

As experts in medication management, pharmacists perform direct patient care and assist in the transition from one provider to another, which places them in an ideal position to manage multiple aspects of patient care. Pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits. Although pharmacists have become key team members of interdisciplinary teams within traditional care settings, their role has often been overlooked in the primary care-based ACO. In 2015, Nova Southeastern University College of Pharmacy founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED), a team of pharmacy practice faculty dedicated to using innovative approaches to patient care, while providing unique learning experiences for pharmacy students by partnering with ACOs in the South Florida region. Five opportunities are presented for pharmacists to improve medication use specifically in primary care-based ACOs: medication therapy management, annual wellness visits, chronic disease state management, chronic care management, and transitions of care.

OBSERVATIONS

Several challenges and barriers that prevent the full integration of pharmacists into primary care-based ACOs include lack of awareness of pharmacist roles in primary care; complex laws and regulations surrounding clinical protocols, such as collaborative practice agreements; provider status that allows compensation for pharmacist services; and limited access to medical records. By understanding and maximizing the role of pharmacists, several opportunities exist to better manage the medication-use process in value-based care settings.

IMPLICATIONS/RECOMMENDATIONS

As more organizations realize benefits and overcome barriers to the integration of pharmacists into patient care, programs involve pharmacists will become an increasingly common approach to improve outcomes and reduce the total cost of care and will improve the financial viability of primary care-based ACOs.

DISCLOSURES

No outside funding supported this research. The authors report no conflicts of interest related to this manuscript. Study concept and design were contributed by Joseph, Hale, and Eltaki, with assistance from the other authors. Prados and Jones took the lead in data collection and data interpretation and analysis, with assistance from the other authors. The manuscript was written primarily by Joseph and Hale, along with the other authors, and revised primarily by Seamon and Gernant, along with the other authors.

Electronic Journals and Medical Headline Sites

This bimonthly column will keep readers up-to-date on the Internet as a source of drug information. Examples of using the Internet to answer inquiries and prepare for committee meetings will be taken from the authors' experiences at a drug information center. A list of reliable web sites—and some examples of sites that have not been useful—will be included in each column.

Role of Residency Interview Preparatory Activities as a Determinant on Pharmacy Residency Match Rates

Purpose:

Different strategies have been implemented to assist students in securing residency positions. The purpose of this study was to explore the impact of student participation in residency preparation activities on match rates.

Methods:

A retrospective observational study was conducted to explore the effect of participation in residency preparation activities and grade point average (GPA) on residency match rate. Match rates for students participating in the Residency Interview Preparation Seminar (RIPS) or mock interviews (ie, intervention group) were compared with students who participated in neither activity (ie, control group).

Results:

A total of 118 individuals were included in the comparison. Forty-eight students participated in RIPS (n = 29) or mock interviews (n = 19), while 70 students were in the control group. The intervention group had a statistically larger proportion of students securing residency than the control group (81% vs 57%; P = .009). Match rates between students enrolled in RIPS versus those in the mock interview group were not significant. No statistically significant differences were observed based on GPA.

Conclusion:

Students receiving additional preparation prior to interviews when seeking postdoctoral training were significantly more likely to obtain a residency position. In academic settings with limited resources, mock interviews may be preferred over comprehensive preparatory courses.

Portable ultrasound in disaster triage: a focused review

Ultrasound technology has become ubiquitous in modern medicine. Its applications span the assessment of life-threatening trauma or hemodynamic conditions, to elective procedures such as image-guided peripheral nerve blocks. Sonographers have utilized ultrasound techniques in the pre-hospital setting, emergency departments, operating rooms, intensive care units, outpatient clinics, as well as during mass casualty and disaster management. Currently available ultrasound devices are more affordable, portable, and feature user-friendly interfaces, making them well suited for use in the demanding situation of a mass casualty incident (MCI) or disaster triage. We have reviewed the existing literature regarding the application of sonology in MCI and disaster scenarios, focusing on the most promising and practical ultrasound-based paradigms applicable in these settings.

Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies

Given the increasing complexity of both the modern health care environment and the overall patient population, reduction of medical errors is a high priority task for health policy makers and medical/surgical community alike. The problem of retained surgical foreign bodies (RSFB) has existed ever since the humans first performed surgical procedures. Retained surgical foreign bodies continue to be a significant problem with an incidence between 0.3 and 1.0 per 1,000 abdominal operations. Retained surgical foreign bodies have the potential to cause harm to the patient and carry profound professional and medico-legal consequences to surgical trainees, surgical practitioners, hospitals, and health systems. Currently, there are no known methods of entirely eliminating the occurrence of RSFB. In this manuscript, the authors discuss the available evidence with regards to risk factors associated with RSFB as well as methods of minimizing the incidence of RSFB. Modern technological advances designed to decrease the incidence of RSFB (radio-frequency tagging of surgical sponges) and improved perioperative patient processing (multiple 'checks and balances' and better provider-to-provider communication) are reviewed. The authors also explore the relationship between RSFB and surgical training with emphasis on education in early recognition, prevention, and focus on team-oriented training strategies.

Evaluation of State Schedule II Controlled Substance Laws

Background:

States have the authority to mandate laws that are more stringent than federal law, which often results in important differences in prescribing and dispensing patterns throughout the country.

Objective:

To evaluate schedule II controlled substance laws in all 50 states, the District of Columbia, and Puerto Rico to identify important differences.

Methods:

The current state laws and regulations regarding controlled substances were evaluated using the following criteria: whether prescription expirations dates are mandated, whether partial fills are permitted, whether changes can be made to prescriptions after consulting with a physician, whether maximum days' supplies are mandated, and whether pharmacists can dispense emergency oral prescriptions.

Results:

Thirty-nine states and Puerto Rico (77%) mandate prescription expiration dates. Partial filling is permitted in all states, the District of Columbia, and Puerto Rico (100%). All 50 states and the District of Columbia (98%) permit pharmacists to make prescription changes after consulting with the physician. Nine states (17%) have mandated maximum days' supplies that a physician may prescribe. All 50 states, the District of Columbia, and Puerto Rico (100%) permit pharmacists to dispense drugs in an emergency situation with verbal prescription.

Conclusions:

Pharmacists should be aware that differences exist among the states, the District of Columbia, and Puerto Rico regarding Schedule II controlled substance laws. Understanding these differences is fundamental to the profession.

Medical marijuana and the developing role of the pharmacist

PURPOSE

The pharmacology, therapeutic uses, safety, drug-drug interactions, and drug-disease interactions of medical marijuana are reviewed, and the legal issues related to its use and the implications of medical marijuana for the pharmacist are presented.

SUMMARY

Marijuana contains more than 460 active chemicals and over 60 unique cannabinoids. The legal landscape surrounding marijuana is surprisingly complex and unsettled. In the United States, 11 states and several municipalities have legalized medical marijuana. Another state provides legislation that allows patients to claim a defense of medical necessity. Nevertheless, patients using medical marijuana may never interact with a pharmacist. Marijuana is a Schedule I controlled substance and its use is illegal under federal law. Marijuana has a number of purported therapeutic uses with a broad range of supporting evidence. There are five general indications for medical marijuana: (1) severe nausea and vomiting associated with cancer chemotherapy or other causes, (2) weight loss associated with debilitating illnesses, including HIV infection and cancer, (3) spasticity secondary to neurologic diseases, such as multiple sclerosis, (4) pain syndromes, and (5) other uses, such as for glaucoma. Marijuana is associated with adverse psychiatric, cardiovascular, respiratory, and immunologic events. Moreover, marijuana may interact with a number of prescription drugs and concomitant disease states.

CONCLUSION

Several states have legalized the use of marijuana for chronic and debilitating medication conditions. Pharmacists need to understand the complex legal framework surrounding this issue so that they can protect themselves and better serve their patients.

Clinical decision support tools: analysis of online drug information databases

Background

Online drug information databases are used to assist in enhancing clinical decision support. However, the choice of which online database to consult, purchase or subscribe to is likely made based on subjective elements such as history of use, familiarity, or availability during professional training. The purpose of this study was to evaluate clinical decision support tools for drug information by systematically comparing the most commonly used online drug information databases.

Methods

Five commercially available and two freely available online drug information databases were evaluated according to scope (presence or absence of answer), completeness (the comprehensiveness of the answers), and ease of use. Additionally, a composite score integrating all three criteria was utilized. Fifteen weighted categories comprised of 158 questions were used to conduct the analysis. Descriptive statistics and Chi-square were used to summarize the evaluation components and make comparisons between databases. Scheffe's multiple comparison procedure was used to determine statistically different scope and completeness scores. The composite score was subjected to sensitivity analysis to investigate the effect of the choice of percentages for scope and completeness.

Results

The rankings for the databases from highest to lowest, based on composite scores were Clinical Pharmacology, Micromedex, Lexi-Comp Online, Facts & Comparisons 4.0, Epocrates Online Premium, RxList.com, and Epocrates Online Free. Differences in scope produced three statistical groupings with Group 1 (best) performers being: Clinical Pharmacology, Micromedex, Facts & Comparisons 4.0, Lexi-Comp Online, Group 2: Epocrates Premium and RxList.com and Group 3: Epocrates Free (p < 0.05). Completeness scores were similarly stratified. Collapsing the databases into two groups by access (subscription or free), showed the subscription databases performed better than the free databases in the measured criteria (p < 0.001).

Conclusion

Online drug information databases, which belong to clinical decision support, vary in their ability to answer questions across a range of categories.

The legal status of medical marijuana

OBJECTIVE

To review the legal status of medical marijuana in the US.

DATA SOURCES

Relevant publications were located using LexisNexis (1982-October 2006), WestLaw (1996-October 2006), BNA Health Law Reporter (1996-October 2006), MEDLINE (1996-October 2006), EMBASE (1980-October 2006), International Pharmaceutical Abstracts (1970-October 2006), and an Internet search targeting government sites using the key words medical marijuana.

STUDY SELECTION AND DATA EXTRACTION

Federal and state medical marijuana laws were examined. Relevant cannabinoid-based drug products were reviewed. Federal and State Supreme Court and Appeal level cases involving medical marijuana were evaluated.

DATA SYNTHESIS

Marijuana is regulated as a Schedule I controlled substance and its use is prohibited under federal law. Dronabinol and nabilone are synthetic cannabinoids approved by the Food and Drug Administration and Sativex is a cannabis-based extract being evaluated in Phase III trials. The federal government sponsors a single patient compassionate use Investigational New Drug Application program providing medical marijuana for a small number of patients. Eleven states permit marijuana use for medical purposes and one state provides a defense of medical necessity. Employers do not have to provide workplace accommodations for employees using medical marijuana and can terminate them at will. Healthcare providers have First Amendment constitutional protections that allow them to discuss marijuana with patients.

CONCLUSIONS

Until the Supreme Court rules directly on the constitutionality of state medical marijuana laws, a conflict remains. Marijuana use remains illegal under federal law and states assume their medical marijuana laws to be constitutional.

Statin Withdrawal: Clinical Implications and Molecular Mechanisms

Retrospective analyses of data from the Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM), the National Registry of Myocardial Infarction 4, and the Global Registry of Acute Coronary Events (GRACE) trials revealed that the benefits of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) on acute coronary outcomes are rapidly lost and outcomes worsened if statins are discontinued during a patient's hospitalization for an acute coronary syndrome. Withdrawal of statin therapy in the first 24 hours of hospitalization for non-ST-elevation myocardial infarction increased the hospital morbidity and mortality rate versus continued therapy (11.9% vs 5.7%, p<0.01). Data from the Treating New Targets (TNT) study, however, suggested that short-term discontinuation of statin therapy in patients with stable cardiac conditions may not substantially increase the risk of acute coronary syndromes. In patients with acute coronary syndromes who discontinue statins, the rapid increase in risk of an event may result not only from the lost benefits from the therapy, but also from rebound inhibition of vascular protective substances and activation of vascular deleterious substances. Statins inhibit cholesterol synthesis in vascular cells. By reducing levels of isoprenoid intermediates, statins increase the production of nitric oxide and downregulate angiotensin II AT(1) receptors, endothelin-1, vascular inflammatory adhesion molecules, and inflammatory cytokines. These benefits are rapidly lost and often transiently reversed when statins are acutely discontinued. Acute removal of pleiotropic effects and rebound vascular dysfunction may be more important in an acute coronary event, where inflammation promotes rupture of atherosclerotic plaques and inflammatory and prothrombosis markers are present in high concentration, than in stable chronic vascular disease. In the absence of data from randomized controlled trials, current information suggests that statin therapy should be continued, and possibly boosted, during hospitalization for an acute coronary syndrome. Because statins are discontinued during the early hospitalization of many patients, practitioners must ensure that statins are not omitted, unless contraindicated, from the treatment of patients with acute coronary syndromes.

Ephedra: yesterday, DSHEA, and tomorrow--a ten year perspective on the Dietary Supplement Health and Education Act of 1994

The Dietary Supplement Heath and Education Act of 1994 (DSHEA) established the regulatory framework for dietary supplements in the United States, triggering the growth of a multi-billion dollar industry. Ephedra is a dietary supplement used for weight loss. However, due to its sympathomimetic activity, it has caused stroke, cardiac arrhythmia, and death. Accordingly, the Food and Drug Administration (FDA) has prohibited its sale in the United States since April 12, 2004. Consequently, numerous other dietary supplements are attempting to fill the marketing void. An evaluation of these products demonstrates a general lack of efficacy and safety data. Thus, in the ten years since the passage of DSHEA, the dietary supplement industry remains controversial and a concern for consumer safety.

Evaluation of drug information databases for personal digital assistants

PURPOSE

Core and supplemental drug information databases available for use with personal digital assistants (PDAs) were evaluated.

METHODS

Ten core (or standalone) databases, six drug interaction analyzers, and three dietary supplement databases used with the Palm and Pocket PC operating systems were selected for study. The databases were rated for scope (the absence or presence of an answer to a drug information question), completeness (the comprehensiveness of an answer), and ease of use (the number of hypertext links needed to reach the desired answer). A total of 14 weighted categories, consisting of 146 and 30 drug questions for the core and supplemental databases, respectively, were used to determine the overall scores.

RESULTS

The best overall performers were, in order of total scores, Lexi-Drugs Platinum, Tarascon Pocket Pharmacopoeia, ePocrates Rx Pro, and Clinical Pharmacology OnHand. The databases with the lowest composite scores were Triple i Prescribing Guide and A2Z Drugs.

CONCLUSION

Drug information databases for PDAs varied in scope, completeness, and ease of use. The results may help clinicians find the most appropriate product for their practice setting.

Disease State Organization Web Sites

This bimonthly column will keep readers up-to-date on the Internet as a source of drug information. Examples of using the Internet to answer inquiries and prepare for committee meetings will be taken from the authors' experiences at a drug information center. A list of reliable web sites—as well as some examples of sites that have not been useful—will be included in each column.

Clinical Trial Web Sites

This bimonthly column will keep readers up-to-date on the Internet as a source of drug information. Examples of using the Internet to answer inquiries and prepare for committee meetings will be taken from the authors' experiences at a drug information center. A list of reliable web sites—as well as some examples of sites that have not been useful—will be included in each column.

Pharmaceutical Manufacturers' Web Sites

This bimonthly column will keep readers up-to-date on the Internet as a source of drug information. Examples of using the Internet to answer inquiries and prepare for committee meetings will be taken from the authors' experiences at a drug information center. A list of reliable web sites–as well as some examples of sites that have not been useful–will be included in each column.

CD40-activated human B cells: an alternative source of highly efficient antigen presenting cells to generate autologous antigen-specific T cells for adoptive immunotherapy

Multiple clinical trials have shown the efficacy of adoptively transferred allogeneic antigen-specific T cells for the treatment of viral infections and relapsed hematologic malignancies. In contrast, the therapeutic potential of autologous antigen-specific T cells has yet to be established since it has been technically difficult to generate sufficient numbers of these T cells, ex vivo. A major obstacle to the success of this objective derives from our inability to simply and rapidly isolate and/or expand large numbers of highly efficient antigen presenting cells (APCs) for repetitive stimulations of antigen-specific T cells in vitro. We show that autologous CD40-activated B cells represent a readily available source of highly efficient APC that appear to have several important advantages over other APCs for ex vivo T cell expansion including: (a) methodological simplicity necessary to generate continuously large numbers of APCs from just 50 cm3 of peripheral blood without loss of APC function; (b) capacity to induce high peak T cell proliferation and interferon-gamma production without IL-10 production; (c) ease in cryopreservation; and (d) markedly reduced cost. We, therefore, contend that CD40-activated B cells are an alternative source of highly efficient APCs with which to generate antigen-specific T cells ex vivo for autologous adoptive immunotherapy.

Ex vivo generation of human anti-pre-B leukemia-specific autologous cytolytic T cells

In contrast to other neoplasms, antigen-specific autologous cytolytic T cells have not been detected in patients with human pre-B-cell leukemias. The absence of efficient B7 family (B7-1/CD80; B7-2/CD86) -mediated costimulation has been shown to be a major defect in tumor cells' capacity to function as antigen-presenting cells. We show here the generation of autologous anti-pre-B-cell leukemia-specific cytolytic T-cell lines from the marrows of 10 of 15 patients with pre-B-cell malignancies. T-cell costimulation via CD28 is an absolute requirement for the generation of these autologous cytolytic T cells (CTL). Although costimulation could be delivered by either bystander B7 transfectants or professional antigen-presenting cells (indirect costimulation), optimal priming and CTL expansion required that the costimulatory signal was expressed by the tumor cell (direct costimulation). These anti-pre-B-cell leukemia-specific CTL lysed both unstimulated and CD40-stimulated tumor cells from each patient studied but did not lyse either K562 or CD40-stimulated allogeneic B cells. Cytolysis was mediated by the induction of tumor cell apoptosis by CD8+ T cells via the perforin-granzyme pathway. Although we were able to generate anti-leukemia-specific CTL from the bone marrow, we were unable to generate such CTL from the peripheral blood of these patients. These studies show that antigen-specific CTL can be generated from the bone marrow of patients with pre-B-cell leukemias and these findings should facilitate the design of adoptive T-cell-mediated immunotherapy trials for the treatment of patients with B-cell precursor malignancies.

Autologous tumor infiltrating T cells cytotoxic for follicular lymphoma cells can be expanded in vitro

Follicular lymphomas (FLs) rarely induce clinically significant T-cell-mediated responses. We showed that freshly isolated tumor infiltrating T cells (T-TILs) lack tumor-specific cytotoxicity. Stimulation of these T cells with FL cells in the presence of interleukin-2 (IL-2) and/or costimulation via CD28 does not lead to T-cell activation and expansion. In contrast, when stimulated with FL cells preactivated via CD40, autologous T-TILs can be expanded by the addition of exogenous IL-2. These T cells can be further expanded in vitro by the addition of exogenous IL-4, IL-7, or interferon-gamma, but not IL-12. Once activated, these T cells showed FL-directed cytotoxicity in four of five patients tested. We concluded that autologous cytotoxic anti-FL-specific T cells exist, but can only be detected in vitro under optimized conditions for T-cell stimulation and expansion. This suggests that their frequency in vivo is either very low or that the microenvironment does not provide the necessary signals to activate these T cells. This model system allows dissection of the requisite conditions for activation and expansion of lymphoma-directed cytotoxicity and may permit expansion of previously activated cytotoxic T cells for adoptive transfer.

Pre-B acute lymphoblastic leukemia cells may induce T-cell anergy to alloantigen

Even if neoplastic cells express tumor associated antigens they still may fail to function as antigen presenting cells (APC) if they lack expression of one or more molecules critical for the induction of productive immunity. These cellular defects can be repaired by physiologic activation, transfection, or fusion of tumor cells with professional APC. Although such defects can be repaired, antitumor specific T cells may still fail to respond in vivo if they may have been tolerized. Here, human pre-B cell acute lymphoblastic leukemia (pre-B ALL) was used as a model to determine if primary human tumor cells can function as alloantigen presenting cells (alloAPC) or alternatively whether they induce anergy. In the present report, we show that pre-B cell ALL express alloantigen and adhesion molecules but uniformly lack B7-1 (CD80) and only a subset express B7-2 (CD86). Pre-B ALL cells are inefficient or ineffective alloAPC and those cases that lack expression of B7-1 and B7-2 also induce alloantigen specific T-cell unresponsiveness. Under these circumstances, T-cell unresponsiveness could be prevented by physiologic activation of tumor cells via CD40, cross-linking CD28, or signaling through the common gamma chain of the interleukin-2 receptor on T cells. Taken together, these results suggest that pre-B ALL may be incapable of inducing clinically significant T-cell-mediated antileukemia responses. This defect may be not only due to their inability to function as APC, but also due to their potential to induce tolerance. Attempts to induce clinically significant antitumor immune responses may then require not only mechanisms to repair the antigen presenting capacity of the tumor cells, but also reversal of tolerance.

Follicular lymphomas can be induced to present alloantigen efficiently: a conceptual model to improve their tumor immunogenicity

In the tumor-bearing host, T cells invariably fail to induce a clinically significant antitumor immune response. Although model systems support the existence of tumor peptide antigens, the molecular interactions critical for antigen presentation by the tumor cell remain unresolved. Here, we demonstrate that human follicular lymphoma cells are highly inefficient at presenting alloantigen despite their strong expression of major histocompatibility complex and low-to-intermediate expression of some adhesion and B7 costimulatory molecules. Activation of follicular lymphoma cells via CD40 induces or up-regulates both adhesion and B7 costimulatory molecules essential to repair this defect. More importantly, once primed, alloreactive T cells efficiently recognize unstimulated follicular lymphoma cells. Thus, correction of defective tumor immunity requires not only expression of major histocompatibility complex but also sufficient expression of multiple adhesion and costimulatory molecules.