Community Pharmacists' Role in Reducing the Incidence of Cardiometabolic Adverse Drug Events in Schizophrenia: Insights from Mental Health Professionals

Background and Objectives: Schizophrenia, a debilitating mental illness, is often associated with significant physical health risks. Many second-generation antipsychotics increase the risk of metabolic syndrome and cardiovascular disease. Community pharmacists are highly accessible and could play a role in monitoring cardiometabolic adverse drug events in people with schizophrenia. However, it remains uncertain whether mental health professionals perceive this as valuable. This study aimed to explore the opinions of mental healthcare professionals regarding the role of community pharmacists in reducing the incidence of cardiometabolic adverse events in people with schizophrenia and their integration into a multidisciplinary mental health team. Materials and Methods: Qualitative semi-structured interviews were conducted with Australian psychiatrists, mental health nurses and mental health pharmacists. Transcription of the interviews underwent thematic analysis using an inductive approach. Results: Eleven mental healthcare professionals from metropolitan and regional areas across Australia were interviewed, leading to the identification of five overarching themes. These themes encompassed the following aspects: the benefits of community pharmacists' involvement in managing cardiometabolic adverse drug events in people with schizophrenia, improving communication pathways with community pharmacists, defining roles and responsibilities for monitoring cardiometabolic parameters and managing adverse cardiometabolic drug events, fostering collaboration between community pharmacists and mental health care professionals, and recognising the acceptance of community pharmacists' integration within a multidisciplinary team. Mental health professionals believed that community pharmacists could play a role in reducing the incidence of cardiometabolic adverse events in schizophrenia. However, they underscored the need for enhanced communication and collaboration pathways with other healthcare professionals, emphasised the importance of more comprehensive mental health first aid training, and identified potential barriers for community pharmacists such as remuneration, workload, and staff resources. Conclusions: Mental health professionals acknowledged the benefits of incorporating community pharmacists into multidisciplinary teams as a strategy to reduce the incidence of adverse events among individuals with schizophrenia. They recognise the competence of community pharmacists in monitoring cardiometabolic adverse events. However, these professionals have also highlighted specific perceived barriers to the complete integration of community pharmacists within these teams. Notably, there are concerns related to remuneration, staff resources, time constraints, acceptance by other healthcare professionals and patients, and the need for improved communication pathways. Addressing these barriers and providing targeted training could facilitate the valuable inclusion of community pharmacists in the comprehensive care of people with schizophrenia.

Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers

OBJECTIVE

Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States.

METHODS

The authors conducted a secondary analysis of the 2020-2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing.

RESULTS

Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming.

CONCLUSIONS

Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.

Pharmacist Administration of Long-Acting Injectable Antipsychotics to Community-Dwelling Patients: A Scoping Review

Long-acting injectable antipsychotics (LAIAs) have demonstrated positive outcomes for people with serious mental illnesses. They are underused, and access to LAIAs can be challenging. Pharmacies could serve as suitable environments for LAIA injection by pharmacists. To map and characterize the literature regarding the administration of LAIAs by pharmacists, a scoping review was conducted. Electronic-database searches (e.g., PsycINFO, Ovid Medline, Scopus, and Embase) and others including ProQuest Dissertations & Theses Global and Google, were conducted. Citation lists and cited-reference searches were completed. Zotero was used as the reference-management database. Covidence was used for overall review management. Two authors independently screened articles and performed full-text abstractions. From all sources, 292 studies were imported, and 124 duplicates were removed. After screening, 13 studies were included for abstraction. Most articles were published in the US since 2010. Seven studies used database and survey methods, with adherence and patient satisfaction as the main patient-outcomes assessed. Reporting of pharmacists' and patients' perspectives surrounding LAIA administration was minimal and largely anecdotal. Financial analyses for services were also limited. The published literature surrounding pharmacist administration of LAIAs is limited, providing little-to-no guidance for the development and implementation of this service by others.

Pharmacist-led interventions for people living with severe and persistent mental illness: A systematic review

OBJECTIVE

People living with severe and persistent mental illness experience poorer physical health, often due to medication and preventable lifestyle factors, and exacerbated by barriers to accessing healthcare services. Pharmacists are well-positioned to improve the physical and mental health of this population. However, little is known about pharmacists' current practices when providing services to this population nor the impact of pharmacist-led interventions on consumer health outcomes. We undertook a systematic review to identify, describe and assess the effectiveness of pharmacist-led interventions for supporting people living with severe and persistent mental illness and the impact on consumer outcomes.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Scopus, Cochrane Library, International Pharmaceutical Abstracts and ProQuest Dissertations and Theses were searched between January 1990 and April 2020. Full-text studies exploring pharmacist-led interventions in any setting for people living with severe and persistent mental illness were included. A risk of bias assessment was conducted.

RESULTS

A total of 37 studies were included. More than half of the pharmacist interventions were multifaceted. The most common components of pharmacist-led interventions included education and/or patient counselling, providing recommendations to healthcare professionals and conducting medication reviews. Multifaceted interventions demonstrated improvements in clinical outcomes, whereas single interventions focused mostly on consumer-reported outcomes. The methodological quality of included studies was moderate-to-high risk of bias and there was considerable heterogeneity in the study design, interventions described, and outcomes reported.

CONCLUSION

There is evidence that pharmacist-led interventions improve consumer-reported and clinical outcomes for people living with severe and persistent mental illness. Pharmacists are capable and have a role in supporting people living with severe and persistent mental illness, either individually or as interprofessional collaborators with other healthcare professionals. Future research should attempt to better understand which particular intervention components have the greatest impact and also evaluate the implementation and long-term sustainability of such interventions.

Systematic review of community pharmacist administration of long-acting injectable antipsychotic medications

BACKGROUND

Long-acting injectable antipsychotic (LAIA) medications offer an effective treatment option for patients with serious mental illness. Despite demonstrated clinical safety and efficacy as well as increased adherence and less frequent administration compared with daily oral regimens, LAIAs remain underutilized in clinical practice. With legislation allowing pharmacists to administer injectable medications in 48 U.S. states, community pharmacies are uniquely positioned to serve as an access point for patients with serious mental illnesses to receive LAIA injections.

OBJECTIVE

This study aimed to conduct a systematic review of the health and economic benefits and costs of community pharmacist administration of LAIA medications.

METHODS

A systematic search of the literature published from January 1996 to April 2022 was conducted across 3 databases (Embase, PubMed, and Scopus Plus). Publications describing pharmacist administration of LAIA medications in outpatient settings were included. Publications that examined the use of LAIAs but did not involve a pharmacist administering the medication were excluded.

RESULTS

Of 2261 publications reviewed, we identified 8 publications (4 articles and 4 abstracts) that met our inclusion criteria, of which only 7 included results. Four studies reported high medication adherence achieved by patients receiving pharmacist-administered LAIAs. Two publications surveyed patient satisfaction with pharmacist administration of LAIAs in community pharmacy settings. One study found pharmacists' mixed attitudes regarding LAIA administration and time and safety barriers to offering the service.

CONCLUSION

We found very little evidence on the impact of pharmacist administration of LAIAs on patient outcomes. This review highlights the need to generate greater evidence on the health and economic benefits as well as financial models for pharmacists to administer LAIA medications in outpatient and community pharmacy settings. Such evidence could support more community pharmacists to offer LAIA medications and contribute to the shift toward value-based care.

Impact of integrated behavioral health services on adherence to long-acting injectable antipsychotics

Purpose

Integrated health care occurs when specialty and general care providers work together to address both the physical and mental health needs of their patients. The Substance Abuse and Mental Health Services Administration model of integration is broken into six levels of coordinated, co-located and integrated care. Our institution offers both co-located and integrated care among eight clinic sites. The care team is typically composed of the primary care provider, nurse and medical assistant, but other professionals may be introduced based on the patient’s medical and psychiatric conditions. The purpose of this prospective, quality improvement study was to compare the rates of adherence to long-acting injectable antipsychotics (LAIAs) between both types of integrated primary care settings at our institution. The comparison of the two settings sought to determine which environment provides improved outcomes for patients with serious psychiatric illnesses. Additionally, we aimed to assess the quality of medication-related monitoring and care team composition between care settings, and the ability of pharmacists to deliver interprofessional care team training and education on LAI use in clinical practice.

Design/methodology/approach

Subjects were identified and included in the study if they had received primary care services from our institution within the previous 12 months. Patient demographic and laboratory variables were collected at baseline and when clinically indicated. The rates of adherence between care settings were assessed at intervals that align with the medication’s administration schedule (e.g. every four weeks). Medication-related monitoring parameters were collected at baseline and when clinically indicated. The interprofessional care team completed Likert scale surveys to evaluate the pharmacist’s LAIA education and training.

Findings

There was not a statistically significant difference detected between integrated primary care settings on the rates of adherence to LAIAs. Additionally, there was not a statistically significant difference between rates of adherence to medication-related monitoring parameters or the effect of the patient treatment team composition. There was a statistically significant difference between pre- and post-session survey scores following interprofessional education and training provided by a pharmacist.

Originality/value

Because overall rates of adherence were low, both primary care settings were found to be equivalent. Our study may have been underpowered to detect a difference in the primary endpoint because of the small sample size. However, our study demonstrates that interprofessional education and training may lend itself to changes in practice, which is evident by the clinically significant relative increase in adherence. The Henry J. Austin Health Center network will be implementing a standard operating procedure regarding LAIA management within the primary care setting. Further studies are needed to assess a larger number of patients between both types of primary care settings, as well as the impact of the clinical psychiatric pharmacist as a member of the treatment team.

The current paradigm for biologic initiation: a mixed-methods exploration of practices, unmet needs, and innovation opportunities in self-injection training

BACKGROUND

Self-injection, particularly of biologics, has become a mainstay of chronic disease management. Despite labeling requirement for healthcare provider (HCP) training, current injection initiation experiences have been shown to be suboptimal. This study characterizes gaps in training and support during initiation and identifies rationales to inform solutions.

METHODS

We enrolled HCPs (n = 18) performing routine biologic initiation and patients (n = 24) currently self-injecting biologics. Participants completed activities through an online, remote ethnography tool. We conducted two focus groups with biologic-naïve patients (n = 5). Data was analyzed using thematic frameworks, Q methodology, and quantitative assessments.

RESULTS

Our results suggest considerable gaps exist. Analysis revealed five common themes that could explain these gaps: 1) minimal biologic-specific professional instruction is provided to HCPs; 2) nuanced injection use-steps are not universally understood; 3) no one stakeholder currently 'owns' training; 4) support offered by HCPs and manufacturers is perceived as biased; and 5) emotional burden is not accounted for.

CONCLUSIONS

Our study suggests optimizing several elements to facilitate successful initiations, including structured sessions, improved HCP injection device knowledge, demo-device practice, and focus on both emotional and mechanical aspects. Aligning these factors has potential to increase patient confidence, reduce burden on HCPs, and improve probability of success on therapy.

Medicaid reimbursement for pharmacist services: A strategy for the pharmacy profession

PURPOSE

Reimbursement for pharmacist services is complex due to a different set of rules for each payer. State legislatures, regulators, and professional licensing bodies have expanded the scope of practice for pharmacists in many states, representing a significant opportunity for third-party payers, including the Centers for Medicare and Medicaid Services, to enable and expand patient access to, and receipt of, care from pharmacists. This paper will introduce the term "other licensed practitioner" and describe how a state Medicaid program may include covered services provided by a pharmacist practitioner using the Medicaid state plan amendment process.

SUMMARY

In recent years, states have made great strides in training and educating high-quality pharmacist practitioners, expanding the scope of practice in all states, incorporating a credentialing and privileging process, and expanding the use of collaborative practice agreements with physicians and nurse practitioners. Pharmacists are well-positioned, essential members of the healthcare team, providing a spectrum of clinical and prevention services that increase access to care and improve health outcomes.

CONCLUSION

A broad coalition of stakeholders including states, the federal government, pharmacy organizations, and other parts of the health ecosystem, working together, can better address the health needs of a state and its Medicaid beneficiaries. Pharmacist practitioners across different settings of care can augment public health efforts, as well as primary and specialty care practices. State efforts should include enrollment and reimbursement of pharmacist practitioners as Medicaid providers for pertinent Medicaid-covered services.

Pharmacist-administered long-acting injectable PCSK9 service: A solution to improve patient access and adherence

In 2015, 2 proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, were approved by Food and Drug Administration (FDA). Both therapies reduce low-density lipoprotein cholesterol (LDL-C) by approximately 60% and reduce atherosclerotic cardiovascular disease (ASCVD) risk in patients with established ASCVD when added to background statin therapy. The initial cost of these medications was approximately $15,000 per year, which made them largely cost-prohibitive for many patients and the overall health care system. In recent years, the cost of both agents has been reduced by 60%, and they are no longer only available through specialty pharmacies. In addition, a third PCSK9-modulating therapy, inclisiran, is nearing FDA approval. Ongoing inclisiran therapy only requires biannual subcutaneous administration and achieves LDL-C reductions of approximately 50%. As the use of PCSK9-modulating therapies increases, models that improve adherence and persistence over time will be critical to ensure patient access and maximize their value. Community pharmacists can play an important role helping patients not only obtain access to these therapies by navigating previous authorization requests but also adhere to therapy by offering administration. Community pharmacists can also provide therapeutic monitoring using point-of-care lipid testing to ensure efficacy over time. Such a service could potentially be sustained through reimbursement for administration and point-of-care lipid testing. Given the cost of these therapies, innovative models involving community pharmacists will be necessary to ensure patient access to these preventive therapies and minimize overall costs to the health care system.