A survey exploring the barriers and drivers to leader and leadership development of the pharmacy workforce

INTRODUCTION

Leadership is an essential but under-researched domain in advanced pharmacy practice.

AIM

To describe pharmacist leadership training experience and ascertain perceptions of barriers/drivers for leadership development.

METHODS

Online survey at a UK tertiary-care organization. Questions related to leadership competencies, personal qualities, barriers, and drivers, with Likert scale responses options, were analysed using Microsoft Excel®.

RESULTS

Thirty-nine pharmacists responded. Three quarters reported no formal leadership training. Many identified leadership development as essential for career progression. Main driver was a manager or peer support. Barriers included workload, being undervalued, and lack of strategic opportunities.

CONCLUSION

Our findings can inform educators and organizations in developing future strategies.

Patient's and Consultant's Views and Perceptions on Switching from an Originator Biologic to Biosimilar Medication: A Qualitative Study

The aim of this study was to describe the opinions of patients undergoing treatment with originator biologics and medical consultants managing their conditions and identify the barriers and enablers to transitioning from originator biologics to equivalent biosimilars. This study was undertaken prior to biosimilar switching at a large teaching hospital in the United Kingdom. Five gastroenterology, rheumatology, and dermatology consultants were interviewed. Two focus groups were conducted with patients prescribed infliximab (n = 2) and etanercept originators (n = 7). Four main themes emerged, as follows: (1) 'Benefit to the NHS'; (2) 'Evidence for efficacy and safety'; (3) 'Team roles'; and (4) 'Effective communication during switching', with sub-themes such as (4a) 'What patients want to know' and (4b) 'How it should be communicated'. Recognition of the ability to save NHS money was an enabler for both patients and consultants, with patients wanting to be reassured that the money saved would be used to benefit other patients. Consultants did not always believe that biosimilars had similar efficacy as the originators or that the manufacturing standards were the same. Effective interventions to address these concerns are required. Offering patients the opportunity to revert back to their originator if necessary was seen as an enabler, as was the provision of readily available mechanisms for reporting suspected adverse events resulting from switching. The role of pharmacy in the process of switching from originator biologics to biosimilars can range from educating consultants regarding the safety and efficacy of biosimilars, explaining the rationale for switching patients, and providing a route for reporting adverse events.

Evaluation of an e-Learning Program for Community Pharmacists for Dispensing Emicizumab (Hemlibra) in France: Nationwide Cross-Sectional Study

BACKGROUND

Since June 2021, patients with hemophilia A with antifactor VIII inhibitors and those with severe hemophilia A without antifactor VIII inhibitors treated with Hemlibra have had to choose between a community or hospital pharmacy. The French reference center for hemophilia developed the HEMOPHAR e-learning program for community pharmacists for dispensing emicizumab.

OBJECTIVE

This study aims to evaluate the efficiency and safety of this new care pathway by assessing the HEMOPHAR e-learning program.

METHODS

The methodology is based on Kirkpatrick's model for evaluating the immediate reaction of trained community pharmacists (level 1), their level of acquired knowledge (level 2), and their professional practice after 3 months of dispensation (level 3).

RESULTS

The HEMOPHAR e-learning program reached a large audience, with 67% (337/502) of the eligible community pharmacists following it. The immediate reaction was overall satisfying. High rates of engagement were reported with 63.5% (214/337) to 73.3% (247/337) of completed training modules, along with high rates of success with quizzes of 61.5% (174/337) to 95.7% (244/337). We observed that 83.9% (193/230) of the community pharmacists needed less than 2 attempts to pass the quiz of the module related to professional practice, while the other quizzes required more attempts. Advice on compliance and drug interactions were most frequently provided to patients by the community pharmacists.

CONCLUSIONS

This study suggests ways to improve the training of community pharmacists and to optimize coordination with treatment centers. This study also reports on the feasibility of switching to a community pharmacy in a secure pharmaceutical circuit, including in the context of a rare bleeding disease.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05449197; https://clinicaltrials.gov/study/NCT05449197.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/43091.

Training student pharmacists to administer long-acting injectable medications

Objective/Process

In June of 2022, the State of Maryland Board of Pharmacy issued regulations permitting pharmacist administration of maintenance injectable medications. Subsequently, the University of Maryland School of Pharmacy created a laboratory to train student pharmacists based on these regulations on administering long-acting maintenance injections. This training included a review of regulations, reconstitution and administration of medications, and education for patients and caregivers on long-acting injectable medications. This is the first training the authors are aware of incorporating both reconstitution and administration of these medications. The objective of this paper is to describe the laboratory details and future directions of the training course.

Results/Conclusions

The first training laboratory trained 94 student pharmacists in the administration technique of long-acting injectable medications. The program has been adapted for practicing pharmacists and other healthcare providers. Thus far, more than 300 practitioners have participated in the learning lab.

Pharmacotherapeutic Considerations in the Treatment of Nontuberculous Mycobacterial Infections: A Primer for Clinicians

Nontuberculous mycobacteria (NTM) can cause a variety of infections, including serious pulmonary disease. Treatment encompasses polypharmacy, with a targeted regimen of 2-5 active medications, depending on site of infection, species, and clinical characteristics. Medications may include oral, intravenous, and inhalational routes. Medication acquisition can be challenging for numerous reasons, including investigational status, limited distribution models, and insurance prior authorization. Additionally, monitoring and managing adverse reactions and drug interactions is a unique skill set. While NTM is primarily medically managed, clinicians may not be familiar with the intricacies of medication selection, procurement, and monitoring. This review offers insights into the pharmacotherapeutic considerations of this highly complex disease state, including regimen design, medication acquisition, safety monitoring, relevant drug-drug interactions, and adverse drug reactions.

Medication Management Through Collaborative Practice for Children With Medical Complexity: A Prospective Case Series

OBJECTIVE

Care coordination for children and youth with special health care needs and medical complexity (CYSHCN-CMC), especially medication management, is difficult for providers, parents/caregivers, and -patients. This report describes the creation of a clinical pharmacotherapy practice in a pediatric long-term care facility (pLTCF), application of standard operating procedures to guide comprehensive medication management (CMM), and establishment of a collaborative practice agreement (CPA) to guide drug therapy.

METHODS

In a prospective case series, 102 patients characterized as CYSHCN-CMC were included in this pLTCF quality improvement project during a 9-month period.

RESULTS

Pharmacists identified, prevented, or resolved 1355 drug therapy problems (DTP) with an average of 13 interventions per patient. The patients averaged 9.5 complex chronic medical conditions with a -median length of stay of 2815 days (7.7 years). The most common medications discontinued due to pharmacist assessment and recommendation included diphenhydramine, albuterol, sodium phosphate enema, ipratropium, and metoclopramide. The average number of medications per patient was reduced from 23 to 20. A pharmacoeconomic analysis of 244 of the interventions revealed a monthly direct cost savings of $44,304 ($434 per patient per month) and monthly cost avoidance of $48,835 ($479 per patient per month). Twenty-eight ED visits/admissions and 61 clinic and urgent care visits were avoided. Hospital -readmissions were reduced by 44%. Pharmacist recommendations had a 98% acceptance rate.

CONCLUSIONS

Use of a CPA to conduct CMM in CYSHCN-CMC decreased medication burden, resolved, and prevented adverse events, reduced health care-related costs, reduced hospital readmissions and was well-accepted and implemented collaboratively with pLTCF providers.

The Impact of the COVID-19 Pandemic on the Transplant Pharmacist Workforce

Background: The COVID-19 pandemic has placed an unprecedented strain on the US healthcare system, greatly impacting transplant centers. Objective: The purpose of this survey was to evaluate the impact of the COVID-19 pandemic on the transplant pharmacist workforce. Methods: A survey was disseminated electronically to assess the impact of the COVID-19 pandemic on the transplant pharmacist workforce. Respondents were asked to give background regarding transplant center, patient, population, and departmental staffing. Results: There were 67 total respondents from 56 transplant centers. In response to the COVID-19 pandemic, 55% of centers reported stopping non-life saving transplants, and a majority (89%) stopped living donor transplants altogether. The banning of caregivers on-site during education, reduction of bedside education teaching, and cancelling of group teaching classes occurred at 46%, 40%, and 22% of centers, respectively. Consequently, 42% of pharmacists surveyed felt that their confidence in patient and caregiver's understanding of medications had decreased since these changes have been implemented. Conclusions: Pharmacist perception of patient and caregiver understanding of transplant medications has decreased since before the COVID-19 pandemic. As health systems strategize resource allocation throughout the pandemic, the importance of patient education must be prioritized to sustain and improve transplant outcomes.

Transplant Pharmacists' Experience With Telehealth During the COVID-19 Pandemic

Background: The adoption of telehealth became a necessity for healthcare organizations during the COVID-19 pandemic. Transplant pharmacists are integral members of the multi-disciplinary care team who quickly adapted application of these technologies to ensure continuity of care. Objective: To assess transplant pharmacists' experience with telehealth during the COVID-19 pandemic. Methods: A 23-question online survey was developed to assess transplant pharmacists' experience with telehealth during the COVID-19 pandemic. Results: Forty-five pharmacists responded to the survey from a broad range of transplant centers. The majority of respondents indicated infrequent use of telehealth (98%) before the COVID-19 pandemic, but this was significantly changed during the pandemic with only 9% reporting infrequent use. Pharmacists anticipated a decrease in future use, but 91% of respondents stated they would like to continue utilization of telehealth in their practice post-pandemic. Conclusions: The adoption of telehealth during COVID-19 was widespread and has the potential to facilitate continuity of care. Though pharmacists anticipated a decrease in future use, a majority favored continued utilization of telehealth in their practice.

Pharmacist-Managed Diabetic Retinopathy in Hispanic/LatinX Population

There are three major microvascular complications of diabetes, retinopathy, nephropathy, and neuropathy, among which diabetic retinopathy (DR) is the most common. Several studies suggest that the Hispanic/LatinX population exhibit the highest cases of both diabetes and DR. Strategies aimed at reducing risk factors that could minimize the likelihood of DR development or progression could be beneficial. This retrospective study assessed DR in the Hispanic/LatinX population in pharmacist-managed cardiovascular risk reduction services. A chart review was conducted for 60 individuals who visited clinics led by both a pharmacist and a primary care physician (intervention group) and 178 individuals who saw physicians only (control group). Demographics, metabolic parameters, DR severity, and pharmacist appointment data were collected. The highest benefit of pharmacist intervention was observed in terms of a greater but insignificant decrease in HbA1c; however, there was no benefit of pharmacist's intervention on DR in general, likely due to the longer duration of diabetes and higher HbA1c at the beginning of the study. When the DR progression was examined based on the frequency of pharmacy visits, individuals who met a pharmacist more than two times per year showed more stable and lesser worsening of DR. Overall, our studies suggest that pharmacist intervention could benefit retinopathy outcome; however, well-known determinants of DR such as good glycemic control and duration of diabetes still play a critical role, in addition to challenges in receiving healthcare by the Hispanic/LatinX population. Future strategies in a prospective manner could help retinopathy outcomes in these at-risk patient populations.

Economic evaluation of clinical pharmacy service using integrated health system in tertiary care hospital

BACKGROUND

Clinical pharmacy services are the specialized practices of pharmacists to provide pharmaceutical care. All these activities are documented as pharmacist interventions to avoid medication errors which occur during prescribing, dispensing, and administration. The purpose of this study is to conduct an economic analysis of the pharmacist interventions using integrated health system.

RESEARCH DESIGN AND METHODS

A retrospective study was conducted in a tertiary care hospital. Pharmacist interventions were analyzed by an independent pharmacist. Cost-saving and cost avoidance analyses were carried out for drug-related interventions. Economic analysis was performed and tabulated both in PKR and USD.

RESULTS

Out of 1330 interventions, 1250 (95%) interventions were accepted and changed the prescription upon the physician-pharmacist consultation while 71 (5%) were not accepted. Interventions related to prescribing and duplication errors were the highest of all (30 and 29% respectively). Pharmacist interventions were recorded with a 95% acceptance rate. Cost analysis showed that pharmacist interventions saved around 105,115.88 US dollars.

CONCLUSION

Clinical pharmacy services provided by integrated health system are a cost saving program. The cost saved per intervention for our study is around USD 37 which is more than another similar study which quoted USD 30.35 per intervention.

Views of the Pharmacists' Role in HPV Vaccinations: A Qualitative Study in Tennessee

The Human Papillomavirus (HPV) is a frequently occurring sexually transmitted infection in adults and is associated with various cancers that can affect both males and females. Recently, the Advisory Committee on Immunization Practices (ACIP) expanded its recommendations for the HPV vaccine to include patients aged 27-45 years with shared clinical decision-making. A commonly reported obstacle to receiving the HPV vaccine among adults is a lack of healthcare provider recommendations. Considering the suboptimal HPV vaccine coverage figures and noting that the vast majority of hesitancy research has been conducted among children and adolescents, limited research is available on the adult perception of HPV vaccination in pharmacies. This study focuses on understanding adults' opinions and perceptions regarding the role of pharmacists in the uptake of the HPV vaccine and awareness of its availability in the pharmacy setting.

METHODS

After receiving approval from the Institutional Review Board (IRB), the qualitative study was initiated using virtual focus groups (FGs). Concepts from the Transtheoretical Model, the Health Belief Model, and the Social Cognitive Theory guided the study design. The corpus of data was collected in 2021 and 2022 by two researchers, and a third party transcribed the FGs to avoid any biases. The data were analyzed using Braun and Clarke's Thematic Analysis.

RESULTS

Out of 35 subjects that participated in six FGDs, most identified as female, with ages ranging from 18 to 45 years. The following four themes emerged: (1) HPV vaccine awareness; (2) stigmas leading to reduced education and vaccination rates; (3) education preferences; (4) follow-up in vaccination series reminders and preferences.

CONCLUSION

Participants' views of the HPV vaccine and the ability to receive the vaccine in a pharmacy are influenced by a myriad of factors. Common factors include improved awareness, preferences for educational modalities, avoiding stigmas associated with HPV vaccination, combating gender-focused biases, and preferences for the location of vaccination. These barriers provide opportunities for pharmacists to promote and enhance vaccine uptake.

Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500.

Assessment of Knowledge and Attitudes of Physicians and Pharmacists on Probiotics: A Cross-Sectional Survey

Objectives

Probiotics have been gaining increased attention from the public recently, which originates concerns about their rationale use among healthcare professionals. Although there is evidence on the efficacy and safety of probiotics in certain gastrointestinal disorders, it is important to identify healthcare professionals' opinions on probiotics. This study aimed to identify the opinions of pharmacists and physicians on the use of probiotics.

Materials and Methods

This cross-sectional study was conducted between November, 2017 and August, 2018 among pharmacists and physicians practicing in Ankara, Türkiye. An electronic survey was designed and sent to the participants via e-mail.

Results

A total of 361 pharmacists (74.5% female) and 356 physicians (42.4% female) participated in the study. Approximately two-thirds of pharmacists and physicians were familiar with the mechanism of action and indications of probiotics. Most pharmacists and physicians recommended probiotics to be used in gastrointestinal system disorders (99.7% and 97.7%). Other areas that probiotics are commonly recommended was genitourinary system (29.3%) by pharmacists and dermatological symptoms (15.1%) by phycisians, respectively. Considering patient advice regarding the probiotics, pharmacists (63.3%) seemed to receive more requests compared to physicians (30.9%); and with regard to the probiotic recommendation, 70.7% and 38.2% of pharmacists and physicians, respectively, indicated that they have no concerns, but 61% of physicians have concerns on reimbursement policy when prescribing.

Conclusion

Pharmacists and physicians are healthcare providers commonly asked about probiotics by patients. Therefore, it is important to address healthcare professionals' concerns and increase their knowledge of the use of probiotics for different health conditions. Given that probiotic products can be purchased without a prescription, healthcare professionals in primary care settings should be more vigilant about the rational use of probiotics.

Identifying metrics and designing measurable outcomes in the electronic health record to evaluate pharmacist intervention in an oral chemotherapy program

INTRODUCTION

Due to the increased utilization of oral anticancer agents, pharmacist-led oral anticancer programs have emerged to meet the needs of oral anticancer management. Currently, at Froedtert & MCW, there is a lack of established tools to collect metrics which demonstrate the value of a pharmacist-led oral anticancer program.

METHODS

The purpose of this project is to establish metrics that reflect the interventions pharmacists are performing, and second, to develop a documentation tool which can reliably extract discrete data on the identified metrics.

RESULTS

Eight of the 10 desired metrics were included in the documentation tool. Two questionnaires were created to allow for easy data retrieval of the metrics. The "initial" questionnaire focuses on interventions made at the time of starting an oral anticancer agent, while the "follow-up" questionnaire focuses on interventions made during the subsequent monitoring. The introduction of the questionnaire tool was well received by end users and did not add to the pharmacist's overall workload.

CONCLUSIONS

By establishing metrics that reflect pharmacist interventions in a pharmacist-led oral anticancer program and creating a documentation tool to collect discrete data related to those metrics from the electronic health record, we at Froedtert & MCW are better able describe the workload of the ambulatory oncology pharmacists with regard to their interventions and monitoring of oral anticancer agents. This data will be used to establish differences in pharmacist workload between clinics, justify pharmacist resources, and provide a snapshot of the patient population served as part of the oral anticancer program.

Development of a Continuous Glucose Monitoring Service by Clinical Pharmacists in a Medically Underserved Population

Background: Continuous glucose monitoring (CGM) is an evolving technology that provides a wealth of information to aid in managing diabetes. Professional CGM (ProCGM) is recommended when personal CGM is not desired or available. Patients in medically underserved areas may have limited access to personal CGM devices, thus ProCGM devices can be used for short-term monitoring and medication adjustment. Clinical pharmacists are well-positioned to help set up and establish personal and professional CGM management services. Objectives: To determine the effect of ProCGM in patients with persistently uncontrolled type 2 diabetes in a medically underserved population (MUP). Methods: Pre-post intervention analysis of a single cohort of patients in a public health center. Patients with persistently uncontrolled (A1c > 9%) and taking at least one daily dose of insulin were included. Included participants wore a ProCGM sensor and met with the clinical pharmacist at least once for ProCGM data interpretation and education. The primary analysis evaluated patients who achieved an A1c <9% 1-6 months after intervention. The change in A1c was also evaluated. Participants completed a pre- and post-survey about their experience. Results: Twenty-two patients were included in the final analysis. Ten patients achieved an A1c <9% (45%). The mean A1c pre- and post-ProCGM was 11.0% and 9.8% respectively, with a decrease of -1.2% (p=0.055) overall and a decrease of -1.7% for patients who wore the sensor for at least 10 days (p=0.012; n=15). Using the CGM data 91% of participants had a change to their medication regimen and 45% achieved an A1c <9%. Six participants experienced hypoglycemia per the CGM report, but only two were aware of it. After reviewing their glucose report with the pharmacist, 95% of the respondents agreed or strongly agreed to feeling more knowledgeable about blood sugar patterns after reviewing the report with a pharmacist. Conclusion: Almost half of the patients in the study achieved an A1c <9%. This study demonstrated glycemic benefit in patients in a MUP who wore a ProCGM for at least 10 days and met with a clinical pharmacist. Data from ProCGM enabled patients to better understand glucose patterns in those with persistently uncontrolled type 2 diabetes.

Clinical and Financial Outcomes of a Pilot Pharmacist-Led Continuous Glucose Monitoring Clinic

Purpose: What are the clinical and financial outcomes of patients using a continuous glucose monitor (CGM) as part of a pilot pharmacist-led service in a Federally Qualified Health Center (FQHC)? Methods: This single-center, prospective cohort conducted in a FQHC from October 2022 to September 2023 was submitted to IRB for review [EXMT-P-22-F-17]. Patients were seen by a pharmacist in collaboration with an attending physician during diabetes specific visits. A total of 15 patients were seen in the pharmacist-led clinic (5 males and 10 females). While follow-up visits were scheduled in-person every 3 months to obtain a hemoglobin A1c (HbA1c), patients could also be seen in the clinic for additional visits. Reimbursement rates were analyzed to determine financial outcomes of the pharmacy service. Results: Pharmacists saw 15 patients for their initial CGM visits, with 8 patients returning for follow-up. The average HbA1c at the first visit was 10% ± 2.49 and decreased at the last follow-up to 8.05% ± 0.29. Time in range (TIR) was obtained for 8 patients through the CGM device or online data monitoring. The average TIR 2 weeks after the first pharmacist visit was 39.625% ± 23.19 and increased to 48.75% ± 11.41 at the completion of the project. A total of 39 visits were conducted, with a total reimbursement rate of $5,978.54. Conclusion: This pharmacist-led pilot CGM clinic showed improvements in clinical outcomes and provided financial reimbursement for diabetes management in addition to typical office visit revenue. Further research should focus on clinical impact of pharmacist-led continuous glucose monitor clinics in larger patient populations, as well as financial sustainability of the service in both physician clinics and FQHC's.

Pharmacists' Attitudes Towards Long-Term Use of Nasal Decongestants: A Cross-Sectional Study

Background

Rhinitis medicamentosa is a nonallergic inflammation of the nasal mucosa caused by topical decongestants overuse. It mainly affects young and middle-aged adults. Therefore, the aim of this study was to investigate the attitudes of pharmacists regarding the utilization of over-the-counter intranasal decongestants.

Methods

An online cross-sectional study was conducted from November 2021 to January 2022. The target population of the study included pharmacists who work in community pharmacies in Saudi Arabia. Binary logistic regression analysis was used to identify predictors of having positive attitude towards controlling the use of decongestant.

Results

A total of 220 participants were included in this study. Around 15.0% of them reported that ND come with a physician prescription. The majority of the participants (87.3%) reported that the less than 5 days is the maximum safe duration for the use of NDs. Overall, the study participants demonstrated moderately positive attitude towards controlling the use of decongestant with a mean attitude score of 2.5 (standard deviation: 1.2) out of 5; which represents 50.0% of the maximum score. Binary logistic regression analysis identified that pharmacists aged 31-40 years were two-folds more likely to have positive attitude towards controlling the use of decongestant compared to others (p<0.05). Around 45.9% of them reported that they recommend other over-the-counter treatments like nasal irrigation, nasal steroids, or antihistamine if they see a patient with RM asking for ND with or without prescription.

Conclusion

The majority of pharmacists in Saudi Arabia demonstrated sufficient awareness and understanding on the adverse effects associated with the excessive use of NDs. Rhinitis medicamentosa can be avoided by appropriate measures, highlighting the importance of raising awareness about the excessive use of decongestants among healthcare professionals and patients alike.

Mastering the art of managing up

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Advanced-scope pharmacist roles in medical outpatient clinics: a cost-consequence analysis

BACKGROUND

There is a growing body of evidence that supports the clinical effectiveness of pharmacist roles in outpatient settings. However, limited studies have investigated the economic efficiency of advanced-scope outpatient pharmacist roles, particularly in the Australian setting. Assessing the overall costs and benefits of these outpatient pharmacist roles is needed to ensure service sustainability.

AIMS

To use a cost-consequence approach to evaluate the advanced-scope outpatient pharmacist roles across multiple clinic disciplines from the hospital perspective.

METHODS

A cost-consequence analysis was undertaken using data from a previous clinical-effectiveness study. All outpatient pharmacist consults conducted from 1 June 2019 to 31 May 2020 across 18 clinic disciplines were evaluated. Consequences from the pharmacist services included number of consults conducted, number of medication-related activities and number of resolved recommendations.

RESULTS

The overall cost to the hospital for the outpatient pharmacist service across all clinics was AU$1 991 122, with a potential remuneration of AU$3 895 247. There were 10 059 pharmacist consults undertaken for the 12-month period. Medication-related activities performed by pharmacists primarily included 6438 counselling and education activities and 4307 medication list activities. When the specialist pharmacist roles were added to the outpatient clinics, several health service benefits were also realised.

CONCLUSIONS

The addition of pharmacist roles to outpatient clinics can increase the cost of services; however, they also can increase medication optimisation activities. Future research should examine a societal perspective that includes broader cost and effectiveness outcomes. This study could justify the implementation of advanced-scope outpatient pharmacist roles in other Australian hospitals.

Pharmacist Reported Protocols for QTc Monitoring of Psychiatric Medications

Background Psychiatric medications, such as antipsychotics and antidepressants, are associated with QTc interval prolongation. There is currently no consensus best practice on how to mitigate this risk. This study aimed to collect and analyze information about methods used for QTc monitoring in patients taking psychiatric medications to better understand current practice. Methods An anonymous electronic survey was distributed on September 22, 2022, using a national psychiatric pharmacist organization email list. The survey closed on December 15, 2022. Descriptive statistics were used to analyze the multiple-choice questions. Qualitative analysis applying grounded theory for thematic analysis was performed for free response questions. Results A total of 48 initiated the survey. Of the respondents, 11.4% (5/44) reported that their institution had a formal protocol for monitoring QTc intervals in patients receiving psychiatric medications, while 32.4% (12/37) reported that their institution had an informal process. Out of those with a protocol or process, approximately half reported that it was drug-specific. Among the respondents, 88.6% (31/35) reported that there was a psychiatric clinical pharmacy specialist at their institution and 34.3% (12/35) reported that pharmacists could order an electrocardiogram (ECG). Major themes that emerged from the qualitative analysis included pharmacist-driven QTc monitoring, referring the patient to another provider for monitoring, and encountering significant barriers to monitoring. Conclusion A variety of methods are currently being employed to monitor QTc prolongation risk in patients taking psychiatric medications. Pharmacist authorization to order ECGs may be an opportunity to advance practice and improve care for this population. Further research is needed to more clearly understand best practices for QTc prolongation risk mitigation in patients receiving psychiatric medications.

Implementation of a Pharmacist-Led, Long-Acting, Injectable Cabotegravir/Rilpivirine Program for HIV-1 at Health System-Based Clinics in the New York Metropolitan Area

Long-acting cabotegravir/rilpivirine (LA-CAB/RPV) is the first complete injectable antiretroviral for patients living with HIV. To facilitate patient access to long-acting injectable treatment, a system-wide, pharmacist-led, LA-CAB/RPV transition program was developed at four health system-based New York clinics. Provider referrals were received across four clinics between January 22nd, 2021, and December 31st, 2022. All referrals were evaluated by a pharmacist for clinical eligibility and medication access. The primary outcome was the treatment retention rate defined as the percentage of patients who remained on LA-CAB/RPV at 3 months post-transition. A total of 171 referrals were received, with 73 patients (43%) initiating LA-CAB/RPV. Baseline demographics included a median age of 38 years, 81% patients were male, 41% were African American, and 49% had commercial insurance coverage. The treatment retention rate was 90% at 3 months post-transition. By the end of the study period, 84% of patients who transitioned remained on LA-CAB/RPV. Treatment was discontinued due to reasons such as viral breakthrough (4%), emergence of mutations (4%), and intolerable side effects (4%). Injection site reactions were commonly reported (51%), but only resulting in treatment discontinuation for one patient. A pharmacist-led program can transition a diverse population of patients living with HIV to LA-CAB/RPV. Results from this study further add to clinical experiences with LA-CAB/RPV, demonstrating real-world treatment retention despite more frequent clinic visits for patients.

Utility of a pharmacist-managed Anticoagulation Program in patients with congenital heart disease

BACKGROUND

Warfarin remains the preferred anticoagulant for many patients with CHD. The complexity of management led our centre to shift from a nurse-physician-managed model with many providers to a pharmacist-managed model with a centralized anticoagulation team. We aim to describe the patient cohort managed by our Anticoagulation Program and evaluate the impact of implementation of this consistent, pharmacist-managed model on time in therapeutic range, an evidence-based marker for clinical outcomes.

METHODS

A single-centre retrospective cohort study was conducted to evaluate the impact of the transition to a pharmacist-managed model to improve anticoagulation management at a tertiary pediatric heart centre. The percent time in therapeutic range for a cohort managed by both models was compared using a paired t-test. Patient characteristics and time in therapeutic range of the program were also described.

RESULTS

After implementing the pharmacist-managed model, the time in therapeutic range for a cohort of 58 patients increased from 65.7 to 80.2% (p < .001), and our Anticoagulation Program consistently maintained this improvement from 2013 to 2022. The cohort of patients managed by the Anticoagulation Program in 2022 included 119 patients with a median age of 24 years (range 19 months-69 years) with the most common indication for warfarin being mechanical valve replacement (n = 81, 68%).

CONCLUSIONS

Through a practice change incorporating a collaborative, centralized, pharmacist-managed model, this cohort of CHD patients on warfarin had a fifteen percent increase in time in therapeutic range, which was sustained for nine years.

A decade of change: The evolution of pharmacy services at U.S. cystic fibrosis centers

INTRODUCTION

People with cystic fibrosis (pwCF) require a multidisciplinary care team due to disease complexity. The Cystic Fibrosis Foundation (CFF) notes that pharmacists are recommended, while other organizations consider pharmacists required. In 2016, the CFF initiated a grant program for CFF-accredited care centers and affiliate programs (CFF-ACCAP) to implement outpatient pharmacy services. The primary objective of this study was to compare surveys regarding pharmacy involvement in CFF-ACCAP pre- and post-grant implementation.

METHODS

This was an IRB-approved, survey-based study. The surveys were distributed via the CF pharmacist-pharmacy technician and center director e-mail exchanges.

RESULTS

There are currently 244 CFF-ACCAP and 158 pharmacists. Forty-two pharmacists completed the 2013 survey and 77 completed the 2023 survey. Practice site shifted from primarily the inpatient (58.5%) to outpatient settings (67.5%; p < .001). Most positions were created in the past 7 years (81%) with 50% currently or previously funded by the CFF grant program. CFF center director response decreased from 2013 to 2023 (106 vs. 48) but centers with a dedicated CF pharmacist increased from 2013 to 2023 (66%-86%; p = .014). In the 2023 survey, we received responses from 17 pharmacy technicians, who were newly included. Most of these technicians (64%) reported working in outpatient clinics.

CONCLUSIONS

Since 2013, pharmacy presence has grown at CFF-ACCAP, partly due to the CFF grant program. Despite pharmacists not being required members of the multidisciplinary care team, their presence is notable in 65% of CFF-ACCAP centers, where they contribute significantly to improving the care provided for pwCF.

Peter WL, Shubrook JH. Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes

Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.