Impact of Diabetes Care by Pharmacists as Part of Health Care Team in Ambulatory Settings: A Systematic Review and Meta-analysis

The Ambulatory Diabetes Outreach Program (ADOP): Rigorous Evaluation of a Pharmacist and Nurse-Led Care Model

BACKGROUND

Although several systematic reviews found that ambulatory diabetes mellitus (DM) interventions involving pharmacists generally yielded better outcomes than the ones that did not, existing studies have limitations in rigor and study design.

OBJECTIVE

To examine the intention-to-treat effects of the Ambulatory Diabetes Outreach Program (ADOP) on participants' A1c values and healthcare utilization over a 52-month follow-up period.

DESIGN

Difference-in-differences with staggered adoption. Specifically, we employed the Callaway and Sant'Anna's "group-time average treatment effect" estimator using not-yet treated as controls adjusting for patient's age, BMI, sex, race, comorbidity, payor, and socio-economic status.

PARTICIPANTS

All patients with at least one ADOP treatment encounter from July 2017 to October 2021, regardless of program completion or length of exposure to the program.

INTERVENTION

ADOP, a collaborative population health program led by pharmacists and nurse specialists to provide individualized type 2 DM management and education within a large and diverse health system.

MAIN MEASURES

Patients' A1c values and healthcare utilization, including inpatient admission, inpatient days, and numbers of visits to the emergency department, urgent care, and primary care in recent 6 months.

KEY RESULTS

ADOP participation was associated with an overall average reduction of 1.04 percentage points (95%CI - 1.12, - 0.95) in A1c level. Similar A1c reductions were also observed in the subgroups by sex and race/ethnicity. An average of 2 months were required to reach the overall average effect, which persisted over 4 years. Compared to the respective utilization levels pre-intervention, participants also had average reductions in inpatient admissions by 32.4%, inpatient days by 81.6%, visits to the emergency department by 21.6%, and primary care by 17.9%.

CONCLUSIONS

The results suggest that a collaborative model of pharmacist and nurse-led type 2 DM intervention was effective in improving A1c outcomes and reducing healthcare utilization in the long term.

Reprint of: Evaluation of a community-based pharmacy resident-led continuous glucose monitoring program within a family medicine clinic

BACKGROUND

Pharmacist-driven continuous glucose monitoring (CGM) is associated with reduced hemoglobin A1c (HbA1c) and achievement of daily glycemic goals. Community-based pharmacists are well-positioned to improve CGM uptake among patients with diabetes due to their accessibility and expertise. However, little data exist evaluating the outcomes of CGM services led by a community-based pharmacist.

OBJECTIVE

To evaluate the impact of a community-based pharmacy resident-driven CGM service on HbA1c, revenue, and patient satisfaction.

PRACTICE DESCRIPTION

Independent community pharmacy sharing a clinical services agreement with a primary care clinic for Postgraduate Year One (PGY1) Community-based Pharmacy Residents to provide patient care under general supervision of the physician.

PRACTICE INNOVATION

Patients were offered CGM services if they were 18+ years with an HbA1c > 7.0% and had insurance coverage for CGM. Enrolled patients engaged in three months of pharmacist-led appointments for CGM application, data interpretation, diabetes education, and lifestyle management. Current Procedural Terminology (CPT) codes 99211, 95250, or 95251 were billed based on each encounter. HbA1c values were collected at program enrollment and conclusion. Patients completed a satisfaction survey at program conclusion.

EVALUATION METHODS

Demographics and billed CPT codes were collected from the electronic health record. Descriptive statistics were used to analyze data.

RESULTS

Eighteen patients were included. A mean reduction of 1.2% occurred in HbA1c (n = 12; 9.7%-8.5%). Forty CPT codes were billed, generating $3671.40 of revenue. Satisfaction surveys were collected for 50% of participants (n = 9). Most were satisfied with the CGM service and its individual components (n = 8, 89%). Most were willing to continue using CGM devices and receive diabetes education from a pharmacist (n = 8, 89%).

CONCLUSION

A community-based pharmacist-led CGM service demonstrated a reduction in HbA1c and generated revenue for the clinic. Patients reported satisfaction and willingness to continue the service.

Evaluation of a community-based pharmacy resident-led continuous glucose monitoring program within a family medicine clinic

BACKGROUND

Pharmacist-driven continuous glucose monitoring (CGM) is associated with reduced hemoglobin A1c (HbA1c) and achievement of daily glycemic goals. Community-based pharmacists are well-positioned to improve CGM uptake among patients with diabetes due to their accessibility and expertise. However, little data exists evaluating the outcomes of CGM services led by a community-based pharmacist.

OBJECTIVE

To evaluate the impact of a community-based pharmacy resident-driven CGM service on HbA1c, revenue, and patient satisfaction.

PRACTICE DESCRIPTION

Independent community pharmacy sharing a clinical services agreement with a primary care clinic for Postgraduate Year One (PGY1) Community-based Pharmacy Residents to provide patient care under general supervision of the physician.

PRACTICE INNOVATION

Patients were offered CGM services if they were 18+ years with an HbA1c > 7.0% and had insurance coverage for CGM. Enrolled patients engaged in three months of pharmacist-led appointments for CGM application, data interpretation, diabetes education, and lifestyle management. Current Procedural Terminology (CPT) codes 99211, 95250, or 95251 were billed based on each encounter. HbA1c values were collected at program enrollment and conclusion. Patients completed a satisfaction survey at program conclusion.

EVALUATION METHODS

Demographics and billed CPT codes were collected from the electronic health record. Descriptive statistics were used to analyze data.

RESULTS

Eighteen patients were included. A mean reduction of 1.2% occurred in HbA1c (n = 12; 9.7%-8.5%). Forty CPT codes were billed, generating $3671.40 of revenue. Satisfaction surveys were collected for 50% of participants (n = 9). Most were satisfied with the CGM service and its individual components (n = 8, 89%). Most were willing to continue using CGM devices and receive diabetes education from a pharmacist (n = 8, 89%).

CONCLUSION

A community-based pharmacist-led CGM service demonstrated a reduction in HbA1c and generated revenue for the clinic. Patients reported satisfaction and willingness to continue the service.

Pharmacist impact on evidence-based prescribing of diabetes medications in patients with clinical atherosclerotic cardiovascular disease

BACKGROUND

Including pharmacists on care teams of patients with type 2 diabetes (T2D) has been shown to promote guideline-based prescribing and improve glycemic control, lowering risks of adverse cardiovascular outcomes. Evidence is lacking regarding whether including pharmacists on the care team is associated with the prescribing of GLP-1 receptor agonists (GLP-1 RA) and SGLT-2 inhibitors (SGLT-2i) recommended for use in patients with T2D and atherosclerotic cardiovascular disease (ASCVD).

OBJECTIVE

To assess the association between having a pharmacist on the primary care team of patients with T2D and ASCVD and being prescribed a guideline-recommended GLP-1 RA or SGLT-2i.

METHODS

A cross-sectional analysis of patients with T2D and ASCVD seen by primary care providers at an academic medical center between June 2019 and May 2020 was completed. Patients with prescriptions for GLP-1 RA or SGLT-2i with evidence of cardiovascular benefit were identified and compared between those with pharmacist care vs usual care using multivariable log-binominal regression analyses.

RESULTS

Of 1,497 included patients, 1,283 (85.7%) were in the usual care group (mean age 68.9 years, hemoglobin A1c 7.6%) and 214 (14.3%) in the pharmacist care group (mean age 64.5 years, A1c 9.0%). Of the pharmacist care group, 50.5% were prescribed a GLP-1 RA or SGLT-2i with cardiovascular benefit vs 17.9% in the usual care group (P < 0.001). In multivariable analyses controlling for A1c and other potential confounders, those in the pharmacist care group were 2.15 times as likely to have been prescribed a GLP-1 RA or SGLT-2i than those in the usual care group (adjusted risk ratio 2.15, 95% CI = 1.83-2.52; P < 0.001).

CONCLUSIONS

These data provide preliminary evidence that integrating pharmacists into patient care teams is associated with increased prescribing of guideline-recommended treatment with GLP-1 RA and SGLT-2i in patients with T2D and ASCVD, yet there is room for improvement in prescribing these agents to patients with T2D and ASCVD.

Georgia community pharmacies and clinics: An evaluation of health outcomes and care access

BACKGROUND

Care access remains a major social determinant of health. Safety net clinics may not be numerically sufficient to meet the health care demand for vulnerable populations. Community pharmacists remain a trusted health care provider and serve as first-line care access points. To date, Georgia care access points by safety net clinics and community pharmacies have not been compared.

OBJECTIVES

This study sought to evaluate care access across Georgia. County health outcomes and health factor rankings were compared with mortality prevalence of respiratory disease, diabetes mellitus, kidney disease, and a composite of ambulatory care sensitive conditions emergency department (ER) utilization and hospital discharge. In addition, this study sought to determine whether care access points improve if community pharmacies were to provide primary care services.

DESIGN AND OUTCOME MEASURES

Geographic information systems mapping was used to locate safety net clinics and community pharmacies. Care access difference was analyzed using a 2-sample t test and health outcomes and rankings were evaluated using ordinary least square regression analysis.

RESULTS

A significant difference in care access points was found between safety net clinics and community pharmacies across the state of Georgia (P < 0.05). Mortality prevalence for respiratory disease (P < 0.01), diabetes mellitus (P < 0.1), kidney disease (P < 0.05), ER utilization (P < 0.01), and hospital discharge (P < 0.01) was lower in counties in the top 50% than the bottom 50% health outcome ranking and health factor ranking. Approximately 95% of counties (n = 151) would experience more than a 50% increase in primary care access points by way of community pharmacies.

CONCLUSION

Community pharmacies are well positioned to address primary care disease states, reduce health care resource strain, and decrease preventable health care resource utilization. Leveraging pharmacists to provide primary care services can address care access issues and may improve care quality and reduce preventable hospitalizations and ER utilization in Georgia.

Diabetes care components effectively implemented in the ASEAN health systems: an umbrella review of systematic reviews

OBJECTIVES

Association of Southeast Asian Nations (ASEAN) is among the hardest hit low-income and middle-income countries by diabetes. Innovative Care for Chronic Conditions (ICCC) framework has been adopted by the WHO for health system transformation towards better care for chronic conditions including diabetes. We conducted an umbrella review of systematic reviews on diabetes care components effectively implemented in the ASEAN health systems and map those effective care components into the ICCC framework.

DESIGN

An umbrella review of systematic reviews and/or meta-analyses following JBI (Joanna Briggs Institute) guidelines.

DATA SOURCES

Health System Evidence, Health Evidence, PubMed and Ovid MEDLINE.

ELIGIBILITY CRITERIA

We included systematic reviews and/or meta-analyses which focused on management of type 2 diabetes, reported improvements in measured outcomes and had at least one ASEAN member state in the study setting.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data and mapped the included studies into the ICCC framework. A narrative synthesis method was used to summarise the findings. The included studies were assessed for methodological quality based on the JBI critical appraisal checklist for systematic reviews and research syntheses.

RESULTS

479 records were found of which 36 studies were included for the analysis. A multidisciplinary healthcare team including pharmacists and nurses has been reported to effectively support patients in self-management of their conditions. This can be supported by effective use of digital health interventions. Community health workers either peers or lay people with necessary software (knowledge and skills) and hardware (medical equipment and supplies) can provide complementary care to that of the healthcare staff.

CONCLUSION

To meet challenges of the increased burden of chronic conditions including diabetes, health policy-makers in the ASEAN member states can consider a paradigm shift in human resources for health towards the multidisciplinary, inclusive, collaborative and complementary team.

Mobile Health Intervention in Patients With Type 2 Diabetes: A Randomized Clinical Trial

Importance

Clinical pharmacists and health coaches using mobile health (mHealth) tools, such as telehealth and text messaging, may improve blood glucose levels in African American and Latinx populations with type 2 diabetes.

Objective

To determine whether clinical pharmacists and health coaches using mHealth tools can improve hemoglobin A1c (HbA1c) levels.

Design, Setting, and Participants

This randomized clinical trial included 221 African American or Latinx patients with type 2 diabetes and elevated HbA1c (≥8%) from an academic medical center in Chicago. Adult patients aged 21 to 75 years were enrolled and randomized from March 23, 2017, through January 8, 2020. Patients randomized to the intervention group received mHealth diabetes support for 1 year followed by monitored usual diabetes care during a second year (follow-up duration, 24 months). Those randomized to the waiting list control group received usual diabetes care for 1 year followed by the mHealth diabetes intervention during a second year.

Interventions

The mHealth diabetes intervention included remote support (eg, review of glucose levels and medication intensification) from clinical pharmacists via a video telehealth platform. Health coach activities (eg, addressing barriers to medication use and assisting pharmacists in medication reconciliation and telehealth) occurred in person at participant homes and via phone calls and text messaging. Usual diabetes care comprised routine health care from patients' primary care physicians, including medication reconciliation and adjustment.

Main Outcomes and Measures

Outcomes included HbA1c (primary outcome), blood pressure, cholesterol, body mass index, health-related quality of life, diabetes distress, diabetes self-efficacy, depressive symptoms, social support, medication-taking behavior, and diabetes self-care measured every 6 months.

Results

Among the 221 participants (mean [SD] age, 55.2 [9.5] years; 154 women [69.7%], 148 African American adults [67.0%], and 73 Latinx adults [33.0%]), the baseline mean (SD) HbA1c level was 9.23% (1.53%). Over the initial 12 months, HbA1c improved by a mean of -0.79 percentage points in the intervention group compared with -0.24 percentage points in the waiting list control group (treatment effect, -0.62; 95% CI, -1.04 to -0.19; P = .005). Over the subsequent 12 months, a significant change in HbA1c was observed in the waiting list control group after they received the same intervention (mean change, -0.57 percentage points; P = .002), while the intervention group maintained benefit (mean change, 0.17 percentage points; P = .35). No between-group differences were found in adjusted models for secondary outcomes.

Conclusions and Relevance

In this randomized clinical trial, HbA1c levels improved among African American and Latinx adults with type 2 diabetes. These findings suggest that a clinical pharmacist and health coach-delivered mobile health intervention can improve blood glucose levels in African American and Latinx populations and may help reduce racial and ethnic disparities.

Trial Registration

ClinicalTrials.gov Identifier: NCT02990299.

Patient-centered medical home pharmacists' impact on composite quality care measures for patients with uncontrolled type 2 diabetes

BACKGROUND

Patients with uncontrolled diabetes are at risk for developing complications. Many health care systems have implemented multidisciplinary care models including pharmacists to help achieve quality care measures to reduce complications.

OBJECTIVE

This study aimed to evaluate whether patients with uncontrolled type 2 diabetes mellitus (T2D) seen at patient-centered medical home (PCMH) clinics affiliated with an academic medical center are more likely to meet a composite of diabetes quality care measures with a pharmacist on their care team than usual care patients without a pharmacist on their care team.

METHODS

This is a cross-sectional study. The setting included PCMH primary care clinics affiliated with an academic medical center from January 2017 to December 2020. Included were adults aged 18 to 75 years with a diagnosis of T2D, hemoglobin A1C (A1C) more than 9%, and established with a PCMH provider. The intervention is inclusion of PCMH pharmacist on the patient's care team for management of T2D per a collaborative practice agreement. The main outcome measures included A1C ≤9% per last recorded value during observation period, a composite A1C ≤9% and completion of yearly laboratory tests, and a composite A1C ≤9%, completion of yearly laboratory tests, and statin prescription for adults aged 40-75 years.

RESULTS

Identified were 1807 patients in the usual care cohort with mean baseline A1C of 10.7% and 207 patients in the pharmacist cohort with mean baseline A1C of 11.1%. The pharmacist cohort was more likely to have an A1C of ≤9% at the end of the observation period (70.1% vs. 45.4%; P < 0.001), a composite of measures met (28.5% vs. 16.8%; P < 0.001), and a composite of measures met for patients aged 40-75 years (27.2% vs. 13.7%; P < 0.001).

CONCLUSION

Pharmacist involvement in the multidisciplinary management of uncontrolled T2D is associated with a higher attainment of a composite of quality care measures at the population health level.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Community pharmacist-led interventions for patients with type 2 diabetes in low-income and middle-income countries: A scoping review

BACKGROUND

Studies assessing community pharmacist-led interventions conducted in high-income countries indicate that community pharmacists are successful in taking opportunities to support diabetes management. It is not yet clear as to what extent this is also true for low-income and middle-income countries.

OBJECTIVES

To provide an overview of the types of interventions performed by community pharmacists and available evidence about their effects on patients with type 2 diabetes mellitus in low-income and middle-income countries.

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for (non) randomized controlled, before-and-after, and interrupted time series design studies. There was no restriction on publication language. Interventions to be included had to be delivered by community pharmacists in a primary care or community setting. Study quality was assessed using the National Institute of Health tools, with results analyzed qualitatively, and the review itself was conducted in accordance with guidelines for scoping reviews.

RESULTS

Twenty-eight studies were included, representing 4,434 patients (mean age from 47.4 to 59.5 years, 55.4% female) from community pharmacies (16 studies), primary care centers (8 studies) or community setting (4 studies). Four studies were single-component and the remaining represented multi-component interventions. Face-to-face counseling of patients was the most common intervention, often combined with the provision of printed materials, remote consultations, or conducting medication reviews. Generally, studies showed improved outcomes in the intervention group, including clinical, patient-reported and medication safety outcomes. In most studies, at least one domain was judged to be of poor quality, with heterogeneity among studies.

CONCLUSIONS

Community pharmacist-led interventions on type 2 diabetes mellitus patients showed various positive effects but the quality of the evidence was poor. Face-to-face counseling of varying intensity, often combined with other strategies and representing a multi-component intervention, was the most common type. Although these findings support the expansion of the community pharmacist's role in diabetes care in low-income and middle-income countries, better quality studies are needed to evaluate the impact of specific interventions.

Potentially inappropriate medication among older patients with diabetic kidney disease

Objective: Potentially inappropriate medications (PIM) contribute to poor outcomes in older patients, making it a widespread health problem. The study explored the occurrence and risk factors of PIM in older diabetic kidney disease (DKD) patients during hospitalization and investigated whether polypharmacy was associated with it. Methods: Retrospective analysis of the patients ≥ 65 years old diagnosed with DKD from July to December 2020; the PIM was evaluated according to the American Beers Criteria (2019). Factors with statistical significance in univariate analysis were included in Logistic multivariate analysis to explore the potential risk factors related to PIM. Results: Included 186 patients, 65.6% of patients had PIM, and 300 items were confirmed. The highest incidence of PIM was 41.7% for drugs that should be carefully used by the older, followed by 35.3% that should be avoided during hospitalization. The incidence of PIM related to diseases or symptoms, drug interactions to avoid, and drugs to avoid or reduce dose for renal insufficiency patients were 6.3%, 4.0% and 12.7%, respectively. The medications with a high incidence of PIM were diuretics (35.0%), benzodiazepines (10.7%) and peripheral ɑ1 blockers (8.7%). Compared with hospitalization, there were 26% of patients had increased PIM at discharge. Multivariate Logistic regression analysis showed that polypharmacy during hospitalization was an independent risk factor for PIM, OR = 4.471 (95% CI: 2.378, 8.406). Conclusion: The incidence of PIM in hospitalized older DKD patients is high; we should pay more attention to the problem of polypharmacy in these patients. Pharmacists identifying the subtypes and risk factors for PIM may facilitate risk reduction for older DKD patients.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Revitalizing Primary Care, Part 2: Hopes for the Future

Part 1 of this essay argued that the root causes of primary care's problems lie in (1) the low percent of national health expenditures dedicated to primary care and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access. Part 2 explores policies and practice changes that could solve or mitigate these primary care problems.Initiatives attempting to improve primary care are discussed. Diffuse multi-component initiatives-patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and Comprehensive Primary Care Plus (CPC+)-have had limited success in addressing primary care's core problems. More focused initiatives-care management, open access, and telehealth-offer more promise.To truly revitalize primary care, 2 fundamental changes are needed: (1) a substantially greater percent of health expenditures dedicated to primary care, and (2) the building of powerful teams that add capacity to care for large panels while reducing burnout.Part 2 of the essay reviews 3 approaches to increasing primary care spending: state-level legislation, eliminating Medicare's disparity between primary care and procedural specialty reimbursement, and efforts by health systems. The final section of Part 2 addresses the building of powerful core and interprofessional teams.

Less Timely Initiation of Glucose-Lowering Medication Among Younger and Male Patients With Diabetes and Similar Initiation of Blood Pressure-Lowering Medication Across Age and Sex: Trends Between 2015 and 2020

Aims: We aimed to assess trends in glycosylated hemoglobin A1c (HbA1c) and systolic blood pressure (SBP) thresholds at initiation of glucose- and blood pressure-lowering medication among patients with type 2 diabetes and assess the influence of age and sex on these trends. Materials and Methods: We used the Groningen Initiative to ANalyze Type 2 diabetes Treatment (GIANTT) primary care database. Patients initiating a first non-insulin glucose-lowering or any blood pressure-lowering medication between 2015 and 2020 with an HbA1c or SBP measurement in the 120 days before initiation were included. We used multilevel regression analyses adjusted for potential confounders to assess the influence of calendar year, age or sex, and the interaction between calendar year and age or sex on trends in HbA1c and SBP thresholds at initiation of medication. Results: We included 2,671 and 2,128 patients in the analyses of HbA1c and SBP thresholds, respectively. The overall mean HbA1c threshold at initiation of glucose-lowering medication significantly increased from 7.4% in 2015 to 8.0% in 2020 (p < 0.001), and particularly in the younger age groups. Compared to patients ≥80 years, patients aged 60-69 years initiated medication at lower levels mainly in the early years. Patients <60 years and between 70-79 years initiated medication at similar levels as patients ≥80 years. Females initiated medication at lower levels than males throughout the study period (p < 0.001). The mean SBP threshold at initiation of blood pressure-lowering medication varied from 145 to 149 mmHg without a clear trend (p = 0.676). There were no differences in SBP thresholds between patients of different ages or sex. Conclusion: The rising trend in the HbA1c threshold for initiating glucose-lowering medication in the lower age groups was unexpected and requires further investigation. Males appear to receive less timely initiation of glucose-lowering medication than females. The lack of higher thresholds for the oldest age group or lower thresholds for the youngest age group in recent years is not in line with the age-related recommendations for personalized diabetes care and calls for health systems interventions.

Clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus treated judicially

BACKGROUND

There is a lack of studies that assess the effectiveness of pharmacotherapeutic follow-up in the context of the judicialization of insulin analogues.

AIMS

To evaluate the clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus who receive insulin analogues by judicial decision in a Brazilian municipality.

METHODS

A quasi-experimental study of the before-and-after type was carried out through pharmacotherapeutic follow-up. Patients who accepted to participate in the study underwent laboratory tests of glycemic and lipid profile before and after the intervention, and underwent five pharmaceutical consultations. In addition, quality of life and health, knowledge, and skills related to insulin application techniques were analyzed.

RESULTS

28 patients participated in all stages. Of these, most were female (53.6%), with a mean age of 32.8 ± 11.6 years. After the intervention, there was a reduction in blood glucose levels, blood pressure, and increased body mass index. In addition, there was greater knowledge and skills regarding insulin application techniques, improved quality of life, health, greater number of medications used, reduction of pharmacotherapeutic problems, and improvement in eating habits.

CONCLUSION

The pharmacotherapeutic follow-up promoted clinical and humanistic benefits, with improvement in quality of life and health.

Impact of Pharmacists-Led Interventions in Primary Care for Adults with Type 2 Diabetes on HbA1c Levels: A Systematic Review and Meta-Analysis

Type 2 diabetes mellitus (T2D) is responsible for an important premature mortality. Pharmacists involved in community-based pharmaceutical care services could help patients with diabetes through education and management as they participate in their regular and long-term care. This meta-analysis aimed to evaluate the association between interventions led by pharmacists in the primary care setting and mean change in HbA1c levels. Randomized controlled trials and quasi-experimental studies with a control group were included. Standardized mean differences (SMD) and their 95% confidence intervals (95% CI) were calculated to compare the mean change in HbA1c values between baseline and end of the intervention in each group. Subgroup analyses were performed to explore heterogeneity. Twelve articles were included. The results showed that pharmacist’s interventions significantly reduced HbA1c compared to usual care with an overall SMD of −0.67 (95% CI = [−0.87; −0.48], p < 0.0001). Even if no significant difference between subgroups were found, the reduction of HbA1c seemed more important when baseline HbA1c was ≥8.5%, the intervention occurred monthly, in a primary care center and in countries with a lower human development index. Our results suggest that pharmacists-led interventions in the primary care setting can improve glycemic control for adults with T2D.

Effectiveness of telepharmacy diabetes services: A systematic review and meta-analysis

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these 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.

PURPOSE

Although pharmacist-provided diabetes services have been shown to be effective, the effectiveness of telepharmacy (TP) in diabetes management has not been clearly established. This systematic review and meta-analysis aims to evaluate the effectiveness of diabetes TP services.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched (from inception through September 2021) to identify published studies that evaluated the effect of TP services in patients with diabetes mellitus and reported either glycosylated hemoglobin (HbA1c) or fasting blood glucose (FBG) outcomes. Mean difference (MD), weighted mean difference (WMD), relative risk (RR), and 95% confidence intervals were calculated using the DerSimonian and Laird random-effects model.

RESULTS

36 studies involving 13,773 patients were included in the systematic review, and 23 studies were included in the meta-analysis. TP was associated with a statistically significant decrease in HbA1c (MD, -1.26%; 95% CI, -1.69 to -0.84) from baseline. FBG was not significantly affected (MD, -25.32 mg/dL; 95% CI, -57.62 to 6.98). Compared to non-TP service, TP was associated with a lower risk of hypoglycemia (RR, 0.48; 95% CI, 0.30-0.76). In a subset of studies that compared TP to face-to-face (FTF) pharmacy services, no significant difference in HbA1c lowering was seen between the 2 groups (WMD, -0.09%; 95% CI, -1.07 to 0.90).

CONCLUSION

Use of TP was associated with reduction of HbA1c and the risk of hypoglycemia in patients with diabetes mellitus. High-quality randomized controlled trials are needed to validate the effectiveness of diabetes TP services relative to FTF services.

Design and development of a continuous glucose monitoring educational module for students and practicing pharmacists

INTRODUCTION

This study aimed to investigate a 2-week, hands-on continuous glucose monitoring (CGM) module on third-year pharmacy students' and practicing pharmacists' knowledge and confidence.

METHODS

This was a prospective, single-center study. Week 1 included a CGM lecture and sensor placement. Participants then wore a CGM device for 1 week. Week 2 included reviewing CGM reports and patient cases, examining participants' reports, and discussing experiences. Pre-, immediate post-, and long-term post-surveys were administered to assess CGM-related knowledge, confidence, and clinical use. Immediate and long-term change in knowledge and confidence were assessed using repeated measures analysis of variance.

RESULTS

Pre- and immediate post-surveys were completed by 36 students and five pharmacists. Student CGM knowledge improved significantly. Students reported improved confidence for all CGM-specific tasks. Results from the pharmacist participants showed similar trends. Student confidence was maintained long-term, while knowledge trended downward. All participants stated they would recommend the activity.

CONCLUSIONS

Students and pharmacists demonstrated improved knowledge and confidence following this 2-week, hands-on CGM module. A hands-on CGM pedagogy is effective at increasing knowledge and confidence regarding this technology.

Pharmacist-Managed Diabetes Programs: Improving Treatment Adherence and Patient Outcomes

The health and economic burden of diabetes mellitus across the United States and the world is such that effective care is crucial to improving outcomes, including macro and microvascular complications, and lowering health care costs. Pharmacists are well placed within communities to provide the critical care necessary for patients with diabetes and have a unique skillset that has demonstrated clear benefits in clinical and non-clinical outcomes. Here, we will provide a narrative review of the literature including the role of the pharmacist in different care models, outcomes associated with pharmacist care, and future directions and opportunities for pharmacist-managed diabetes.

Rationale and Design of a Pharmacist-led Intervention for the Risk-Based Prevention of Heart Failure: The FIT-HF Pilot Study

Background: Given rising morbidity, mortality, and costs due to heart failure (HF), new approaches for prevention are needed. A quantitative risk-based strategy, in line with established guidelines for atherosclerotic cardiovascular disease prevention, may efficiently select patients most likely to benefit from intensification of preventive care, but a risk-based strategy has not yet been applied to HF prevention. Methods and Results: The Feasibility of the Implementation of Tools for Heart Failure Risk Prediction (FIT-HF) pilot study will enroll 100 participants free of cardiovascular disease who receive primary care at a single integrated health system and have a 10-year predicted risk of HF of ≥5% based on the previously validated Pooled Cohort equations to Prevent Heart Failure. All participants will complete a health and lifestyle questionnaire and undergo cardiac biomarker (B-type natriuretic peptide [BNP] and high-sensitivity cardiac troponin I [hs-cTn]) and echocardiography screening at baseline and 1-year follow-up. Participants will be randomized 1:1 to either a pharmacist-led intervention or usual care for 1 year. Participants in the intervention arm will undergo consultation with a pharmacist operating under a collaborative practice agreement with a supervising cardiologist. The pharmacist will perform lifestyle counseling and recommend initiation or intensification of therapies to optimize risk factor (hypertension, diabetes, and cholesterol) management according to the most recent clinical practice guidelines. The primary outcome is change in BNP at 1-year, and secondary and exploratory outcomes include changes in hs-cTn, risk factor levels, and cardiac mechanics at follow-up. Feasibility will be examined by monitoring retention rates. Conclusions: The FIT-HF pilot study will offer insight into the feasibility of a strategy of quantitative risk-based enrollment into a pharmacist-led prevention program to reduce heart failure risk. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04684264.

Optimization of Medication Regimens in Patients with Type 2 Diabetes and Clinical Atherosclerotic Cardiovascular Disease

The American Diabetes Association recommends that patients with type II diabetes and atherosclerotic cardiovascular disease be prescribed an SGLT-2 inhibitor or GLP-1 agonist for cardioprotective benefit. This project assessed the use of these medications in this patient population in a rural clinic by measuring prescribing rates of SGLT-2/GLP-1 therapy before and after pharmacist interventions. Of the 60 patients identified at baseline, 39.39% (13/33) managed by a pharmacist were prescribed SGLT-2/GLP-1 therapy compared to the 14.81% (4/27) who had not seen a pharmacist (p = 0.025). Of the 43 patients that were not on SGLT-2/GLP-1 therapy at baseline, 13 were lost to follow-up and 13 had contraindications. For the 17 remaining patients, pharmacists recommended initiating SGLT-2/GLP-1 therapy and were able to successfully initiate therapy for 9 patients (52.94%). Pharmacist interventions improved the prescription rates from a baseline of 36.17% (17/47) to 55.3% (26/47) (p = 0.002), with SGLT-2/GLP-1 therapy contraindicated in 27.66% (13/47) of patients. This suggests that patients managed by a pharmacist have medication regimens that were optimized at a greater rate and pharmacists can have a positive impact on the appropriate medication usage in this population.

Impact of pharmacist-involved collaborative care on diabetes management in a primary healthcare setting using real-world data

Background Diabetes mellitus is a complex multi-system disorder, requiring multi-disciplinary care. The conventional care model, where physicians are the sole caregivers may not be optimal. Addition of other healthcare team members improves healthcare outcomes for patients with diabetes. Aim To evaluate the impact of pharmacist-involved collaborative care on diabetes-related outcomes among patients with diabetes attending a primary healthcare setting  in Qatar using real-world data. Method A retrospective cohort study was conducted among patients with diabetes attending Qatar Petroleum Diabetes Clinic. Patients were categorized as either receiving pharmacist-involved collaborative care (intervention group) or usual care (control group). Data were analyzed using SPSS^®. Glycemic control (glycated hemoglobin A₁c, HbA₁c), blood pressure, lipid profile, and body mass index were evaluated at baseline and up to 17 months of follow-up. Results After 17 months of follow-up, pharmacist-involved collaborative care compared to usual care resulted in a significant decrease in HbA₁c (6.8 ± 1.2% vs. 7.1 ± 1.3%, p < 0.01). Moreover, compared to baseline, pharmacist-involved collaborative care significantly improved (p < 0.05) the levels of HbA_1c (7.5% vs. 6.8%), low-density lipoprotein cholesterol (3.7 mmol/L vs. 2.8 mmol/L), total cholesterol (5.43 mmol/L vs. 4.34 mmol/L), and body mass index (30.42 kg/m² vs. 30.17 kg/m²) after 17 months within the intervention group. However, no significant changes for these parameters occurred within the control group. Conclusion The implementation of pharmacist-involved collaborative care in a primary healthcare setting improved several diabetes-related outcomes over 17 months. Future studies should determine the long-term impact of this care model.

Delivery of Pharmacogenetic Testing with or without Medication Therapy Management in a Community Pharmacy Setting

Objective

The delivery of pharmacogenetic (PGx) testing has primarily been through clinical and hospital settings. We conducted a study to explore the feasibility of delivering PGx testing through community pharmacies, a less-studied setting.

Methods

We conducted a cluster randomized trial of community pharmacies in North Carolina through two approaches: the provision of PGx testing alone or PGx testing with medication therapy management (MTM).

Results

A total of 150 patient participants were enrolled at 17 pharmacies and reported high satisfaction with their testing experience. Participants in the PGx plus MTM arm were more likely to recall a higher number of results (p=0.04) and more likely to clearly understand their choices for prevention or early detection of side effects (p=0.01). A medication or dose change based on the PGx results was made for 8.7% of participants.

Conclusion

Limited differences were observed in the provision of PGx testing as a standalone test or combined with MTM. A limited number of treatment changes were made based on PGx test results. Patient acceptance of PGx testing offered through the community pharmacy was very high, but the addition of MTM did not impact patient-reported perceptions about PGx testing or medication adherence.

Impact of clinical pharmacy interventions on health and economic outcomes in type 2 diabetes: A systematic review and meta-analysis

AIM

To examine the effectiveness of clinical pharmacy interventions on health and economic outcomes of people with type 2 diabetes in hospital settings.

METHODS

We searched MEDLINE, EMBASE, PsycInfo, CINAHL, COCHRANE Library and citations and reference lists of key articles. We included randomized and non-randomized controlled trials, cohort and controlled before-after studies. Primary outcomes were glycosylated haemoglobin (HbA_1c ), all-cause mortality, major cardiovascular events, adverse events (AEs), health-related quality of life and economic outcomes.

RESULTS

We retrieved 11,853 studies, of which 44 studies were included in the review (n = 8623). We included 29 randomized controlled studies in the meta-analyses (n = 4055). Clinical pharmacy interventions significantly reduced HbA_1c levels compared to usual care (standardized mean difference: -0.52, p < 0.001). The interventions significantly reduced AEs compared to usual care. No studies were reported on the effectiveness of clinical pharmacy interventions on major cardiovascular events. In one study that examined the impact of clinical pharmacy interventions on all-cause mortality, a non-significant reduction was observed compared with usual care. There was significant improvement in quality of life and significant reduction in costs of type 2 diabetes care compared to usual care.

CONCLUSIONS

Clinical pharmacy interventions were effective in improving glycaemic control, quality of life and reducing the rate of AEs and costs of type 2 diabetes care.

Fucoidan reduces lipid accumulation by promoting foam cell autophagy via TFEB

Atherosclerotic cardiovascular disease became one of the major causes of morbidity and mortality worldwide. As a sulfated polysaccharide with anti-inflammatory and hypolipidemic activities, fucoidan can induce autophagy. We show here that fucoidan reduces lipid accumulation in foam cells, which is one of the causes of atherosclerosis. Further studies show that fucoidan promotes autophagy showed by the expression of p62/SQSTM1 and microtubule-associated protein light chain 3 (LC3) II, which can be blocked by autophagy inhibitors 3-MA and bafilomycin A1. In addition, the expression of transcription factor EB (TFEB), master regulator of autophagy and lysosome function, is upregulated after the treatment with fucoidan. Moreover, the knockout of TFEB with small interfering RNA suppressed the effect of fucoidan. Together, fucoidan reduces lipid accumulation in foam cells by enhancing autophagy through the upregulation of TFEB. In view of the role of foam cells in atherosclerosis, fucoidan can be valuable for the treatment of atherosclerosis.

Assessment of clinical inertia in people with diabetes within primary care

RATIONALE, AIMS AND OBJECTIVES

Clinical inertia, defined as a delay in treatment intensification, is prevalent in people with diabetes. Treatment intensification rates are as low as 37.1% in people with haemoglobin A1c (HbA1c) values >7%. Intensification by addition of medication therapy may take 1.6 to more than 7 years. Clinical inertia increases the risk of cardiovascular events. The primary objective was to evaluate rates of clinical inertia in people whose diabetes is managed by both pharmacists and primary care providers (PCPs). Secondary objectives included characterizing types of treatment intensification, HbA1c reduction, and time between treatment intensifications.

METHOD

Retrospective chart review of persons with diabetes managed by pharmacists at an academic, safety-net institution. Eligible subjects were referred to a pharmacist-managed cardiovascular risk reduction clinic while continuing to see their PCP between October 1, 2016 and June 30, 2018. All progress notes were evaluated for treatment intensification, HbA1c value, and type of medication intensification.

RESULTS

Three hundred sixty-three eligible patients were identified; baseline HbA1c 9.6% (7.9, 11.6) (median interquartile range [IQR]). One thousand one hundred ninety-two pharmacist and 1739 PCP visits were included in data analysis. Therapy was intensified at 60.5% (n = 721) pharmacist visits and 39.3% (n = 684) PCP visits (P < .001). The median (IQR) time between interventions was 49 (28, 92) days for pharmacists and 105 (38, 182) days for PCPs (P < .001). Pharmacists more frequently intensified treatment with glucagon-like peptide-1 agonists and sodium glucose cotransporter-2 inhibitors.

CONCLUSION

Pharmacist involvement in diabetes management may reduce the clinical inertia patients may otherwise experience in the primary care setting.

Professional continuous glucose monitoring and endocrinology eConsult for adults with type 2 diabetes in primary care: Results of a clinical pilot program

Background

Limitations in access to specialty diabetes care exist. Endocrinology eConsult that integrates professional continuous glucose monitoring (CGM-enhanced eConsult) may improve healthcare delivery, but has yet to be evaluated. We implemented a pilot program for patients with type 2 diabetes (T2DM) managed by primary care clinical pharmacists using CGM-enhanced eConsult and evaluated the acceptability and clinical outcomes in comparison to routine in-person endocrinology consultation.

Methods

Seventy-four adult patients with established T2DM (age 18-65) were included. Twenty-nine were seen in-person by endocrinology and 45 were seen by pharmacists in primary care. Thirteen patients were referred for CGM-enhanced eConsult. Acceptability was assessed with pre/post clinician acceptability questionnaires and patient assessment of perceived burden. Clinical outcomes included time to first specialty appointment, baseline and 3-month follow-up HbA1c, and antihyperglycemic medication use.

Results

There were no differences in patient acceptability of the CGM-enhanced eConsult as compared to endocrinology referral or pharmacy care. At baseline, all patients referred for eConsult were prescribed insulin. Three-month glycemic outcomes were comparable, with HbA1c reduction 1% + 2% in endocrinology, 1.5% + 1.1% with CGM-enhanced eConsult, and 1.6% + 1.8% in clinical pharmacy (p = 0.19). Time to an initial diabetes visit with a pharmacist was significantly shorter than with endocrinology, 20 days (IQR 26) for pharmacy vs. 45 days (IQR 54) for endocrinology, (p = 0.0001).

Conclusions

CGM-enhanced eConsult resulted in more timely access to endocrinology expertise, was acceptable to patients, and resulted in similar short-term glycemic outcomes compared to in-person consultation. Effectiveness of CGM-enhanced eConsults should be further explored.

A Pharmacist and Health Coach-Delivered Mobile Health Intervention for Type 2 Diabetes: Protocol for a Randomized Controlled Crossover Study

BACKGROUND

Aggressive management of blood glucose, blood pressure, and cholesterol through medication and lifestyle adherence is necessary to minimize the adverse health outcomes of type 2 diabetes. However, numerous psychosocial and environmental barriers to adherence prevent low-income, urban, and ethnic minority populations from achieving their management goals, resulting in diabetes complications. Health coaches working with clinical pharmacists represent a promising strategy for addressing common diabetes management barriers. Mobile health (mHealth) tools may further enhance their ability to support vulnerable minority populations in diabetes management.

OBJECTIVE

The aim of this study is to evaluate the impact of an mHealth clinical pharmacist and health coach-delivered intervention on hemoglobin A1c (HbA1c, primary outcome), blood pressure, and low-density lipoprotein (secondary outcomes) in African-Americans and Latinos with poorly controlled type 2 diabetes.

METHODS

A 2-year, randomized controlled crossover study will evaluate the effectiveness of an mHealth diabetes intervention delivered by a health coach and clinical pharmacist team compared with usual care. All patients will receive 1 year of team intervention, including lifestyle and medication support delivered in the home with videoconferencing and text messages. All patients will also receive 1 year of usual care without team intervention and no home visits. The order of the conditions received will be randomized. Our recruitment goal is 220 urban African-American or Latino adults with uncontrolled type 2 diabetes (HbA1c ≥8%) receiving care from a largely minority-serving, urban academic medical center. The intervention includes the following: health coaches supporting patients through home visits, phone calls, and text messaging and clinical pharmacists supporting patients through videoconferences facilitated by health coaches. Data collection includes physiologic (HbA1c, blood pressure, weight, and lipid profile) and survey measures (medication adherence, diabetes-related behaviors, and quality of life). Data collection during the second year of study will determine the maintenance of any physiological improvement among participants receiving the intervention during the first year.

RESULTS

Participant enrollment began in March 2017. We have recruited 221 patients. Intervention delivery and data collection will continue until November 2021. The results are expected to be published by May 2022.

CONCLUSIONS

This is among the first trials to incorporate health coaches, clinical pharmacists, and mHealth technologies to increase access to diabetes support among urban African-Americans and Latinos to achieve therapeutic goals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17170.

Evaluation of Patient Factors Associated With Achieving Goal Hemoglobin A1c in Collaborative Drug Therapy Management Ambulatory Care Clinics by Clinical Pharmacists: A Retrospective Chart Review

Background: Literature has shown the positive impact pharmacists have on diabetic outcome measures through collaborative drug therapy management (CDTM). There is minimal literature evaluating characteristics and clinical factors of patients who benefit from CDTM diabetes clinics by pharmacists. Objective: Identify patient characteristics and clinical factors that may be associated with patients who reach goal hemoglobin A1c (HbA1c) of <7% at discharge by pharmacists practicing under CDTM agreements. Methods: This retrospective chart review included patients referred to pharmacist CDTM clinics for type 2 diabetes with an HbA1c goal of <7%. Data were extracted from the electronic medical record at enrollment and discharge. Results: Of the 228 patients included, 84 achieved a goal HbA1c of <7%. Factors predictive of patient success were Asian ethnicity (odds ratio [OR] = 19.32), baseline HbA1c of 7% to 7.9% (OR = 2.34), enrolled in clinic for 5 to 6 months (OR = 2.06), in-person visit every 4 to <8 weeks (OR = 3.06), not on insulin initially or at discharge (OR = 1.79, OR = 2.02), or discharged on a glucagon-like peptide-1 receptor agonist (OR = 1.83). Factors predictive of not reaching goal were Black or African American ethnicity (OR = 0.42), <5 encounters of any type (OR = 0.44), an encounter of any type every 8 weeks or more (OR = 0.08), or discharged on a sodium-glucose cotransporter-2 inhibitor (OR = 0.27). Conclusion: Several clinical and demographic factors were identified that influenced a patient's ability to reach a goal HbA1c of <7%. The results of this study may be applied to further advance pharmacist-run clinics in optimizing diabetes care for patients.

Assessment of Interprofessional Collaborative Practices and Outcomes in Adults With Diabetes and Hypertension in Primary Care: A Systematic Review and Meta-analysis

Importance

Interprofessional collaborative practice (ICP), the collaboration of health workers from different professional backgrounds with patients, families, caregivers, and communities, is central to optimal primary care. However, limited evidence exists regarding its association with patient outcomes.

Objective

To examine the association of ICP with hemoglobin A1C (HbA1c), systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels among adults receiving primary care.

Data Sources

A literature search of English language journals (January 2013-2018; updated through March 2020) was conducted using MEDLINE; Embase; Ovid IPA; Cochrane Central Register of Controlled Trials: Issue 2 of 12, February 2018; NHS Economic Evaluation Database: Issue 2 of 4, April 2015; Clarivate Analytics WOS Science Citation Index Expanded (1990-2018); EBSCOhost CINAHL Plus With Full Text (1937-2018); Elsevier Scopus; FirstSearch OAIster; AHRQ PCMH Citations Collection; ClinicalTrials.gov; and HSRProj.

Study Selection

Studies needed to evaluate the association of ICP (≥3 professions) with HbA1c, SBP, or DBP levels in adults with diabetes and/or hypertension receiving primary care. A dual review was performed for screening and selection.

Data Extraction and Synthesis

This systematic review and meta-analysis followed the PRISMA guideline for data abstractions and Cochrane Collaboration recommendations for bias assessment. Two dual review teams conducted independent data extraction with consensus. Data were pooled using a random-effects model for meta-analyses and forest plots constructed to report standardized mean differences (SMDs). For high heterogeneity (I2), data were stratified by baseline level and by study design.

Main Outcomes and Measures

The primary outcomes included HbA1c, SBP, and DBP levels as determined before data collection.

Results

A total of 3543 titles or abstracts were screened; 170 abstracts or full texts were reviewed. Of 50 articles in the systematic review, 39 (15 randomized clinical trials [RCTs], 24 non-RCTs) were included in the meta-analyses of HbA1c (n = 34), SBP (n = 25), and DBP (n = 24). The sample size ranged from 40 to 20 524, and mean age ranged from 51 to 70 years, with 0% to 100% participants being male. Varied ICP features were reported. The SMD varied by baseline HbA1c, although all SMDs significantly favored ICP (HbA1c <8, SMD = -0.13; P < .001; HbA1c ≥8  to < 9, SMD = -0.24; P = .007; and HbA1c ≥9, SMD = -0.60; P < .001). The SMD for SBP and DBP were -0.31 (95% CI, -0.46 to -0.17); P < .001 and -0.28 (95% CI, -0.42 to -0.14); P < .001, respectively, with effect sizes not associated with baseline levels. Overall I2 was greater than 80% for all outcomes.

Conclusions and Relevance

This systematic review and meta-analysis found that ICP was associated with reductions in HbA1c regardless of baseline levels as well as with reduced SBP and DBP. However, the greatest reductions were found with HbA1c levels of 9 or higher. The implementation of ICP in primary care may be associated with improvements in patient outcomes in diabetes and hypertension.

A Systematic Review on Pharmaceutical Diabetic Care Services in the United Arab Emirates (UAE)

OBJECTIVE

the aim of this systematic review study is to evaluate the current services and pharmaceutical care practices for diabetic patients in the UAE.

METHODS

systematic review coverage conforms to the guidelines of the PRISMA; the search was limited to primary research articles, which describe the term "pharmaceutical diabetes care services in UAE". The search strategy was developed in collaboration with a health database librarian, and a predetermined protocol was developed in conjunction with the authors for search methods.

RESULTS

The findings showed the effect of a prescription treatment system on disease prevention and health-related quality of life in patients with type 2 diabetes in the United Arab Emirates. A retrospective interventional health evaluation was implemented to evaluate existing health procedures and the impact of conventional treatment on type 2 diabetes treatment (T2DM). The findings of this interventional evaluation were largely favorable, and the viability of changing the existing clinical procedure was stressed. The individualized strategy has helped clinicians finding a great result in terms of glycemic and BP, as well as patient satisfaction. The need for more work to clarify the long-term effect of organized strategy in enhancing the consistency of T2DM treatment in the UAE. The findings also showed increase community pharmacy services might further change the opinions of patients on the level of care provided by such pharmacies. The patients' quality of life would improve by drug treatment efficacy and pharmacist services to mitigate diabetes complications. The findings showed a prescription treatment system on disease prevention and health-related quality of life in patients with type 2 diabetes in the United Arab Emirates. A retrospective interventional health evaluation was implemented to evaluate existing health procedures and the impact of conventional treatment on type 2 diabetes treatment (T2DM). The findings of this interventional evaluation were largely favorable, and the viability of changing the existing clinical procedure was stressed. The individualized strategy has helped clinicians reach a great result in terms of glycemic and BP, as well as patient satisfaction. The need for more work to clarify the long-term effect of organized strategy in enhancing the consistency of T2DM treatment in the UAE. The findings also showed increase community pharmacy services mightfurther change the opinions of patients on the level of care provided by such pharmacies. The patients' quality of life would improve by drug treatment efficacy and pharmacist services to mitigate diabetes complications.

CONCLUSION

This systematic review reported beneficial pharmacist-led diabetic management services in the UAE. Several care strategies were also highlighted to improve service for type 2 diabetes mellitus patients.

Prevalence of people at risk of developing type 2 diabetes mellitus and the involvement of community pharmacies in a national screening campaign: a pioneer action in Brazil

BACKGROUND

Brazil is one of top 10 countries with the highest number of people with diabetes mellitus (DM), affecting 16.8 million peoples. It is estimated that 7.7 million people (20-79 years) in the country have not yet been diagnosed, representing an under-diagnosis rate of 46.0%. Herein we aimed to screen people for high blood glucose or risk for developing type 2 DM (T2DM) through community pharmacies in Brazil.

METHODS

A cross-sectional study was carried out in November 2018, involving 977 pharmacists from 345 municipalities in Brazil. The study evaluated people between 20 and 79 years old without a previous diagnosis of DM. Glycemia was considered high when its value was ≥ 100 mg/dL fasting and ≥ 140 mg/dL in a casual feeding state. The FINDRISC (Finnish Diabetes Risk Score) was used to estimate the risk for developing T2DM. The prevalence of high blood glucose was estimated and the associated factors were obtained using Poisson's multivariate analysis with robust variance.

RESULTS

During the national screening campaign, 17,580 people were tested with the majority of the consultations (78.2%) being carried out in private pharmacies. The population was composed mainly of women (59.5%) and people aged between 20 and 45 years (47.9%). The frequency of participants with high blood glucose was 18.4% (95% CI 17.9-19.0). Considering the FINDRISC, 22.7% of people had a high or very high risk for T2DM. The risk factors associated with high blood glucose were: Body Mass Index > 25 kg/m2, abdominal circumference > 94 cm for men and > 80 cm for women; education level below 15 years of study, no daily intake of vegetables and fruits; previous diagnosis of arterial hypertension; history of high blood glucose and family history of DM.

CONCLUSIONS

This is the largest screening study that evaluated the frequency of high blood glucose and its associated factors in a population without a previous diagnosis ever performed in community pharmacies in Brazil. These results may help to improve public health policies and reinforce the role of pharmacists in screening and education actions aimed at this undiagnosed population in a continent-size country such as Brazil.

The impact of pharmacist care on diabetes outcomes in primary care settings: An umbrella review of published systematic reviews

OBJECTIVE

To systematically review published systematic reviews (SRs) examining the impact of pharmacist interventions in multidisciplinary diabetes care teams on diabetes-related clinical, humanistic, and economic outcomes in primary care settings.

METHODS

PubMed, EMBASE, Scopus, Database of Abstracts of Reviews of Effects, Cochrane Library, Joanna Briggs Institute (JBI) Database, Google Scholar, and PROSPERO were searched from inception to 2018. Studies published in English evaluating the effect of pharmacist interventions on diabetes outcomes were included. Two independent reviewers were involved in screening of titles and abstracts, selection of studies, and methodological quality assessment.

RESULTS

Seven SRs were included in the study. Three of them included only randomized controlled trials, while the rest involved other study designs. Educational interventions by clinical pharmacists within the healthcare team were the most common types of interventions reported across all SRs. Pharmacist's interventions compared to usual care resulted in favorable significant improvements in hemoglobin A_1c (HbA_1c), fasting blood glucose, blood pressure, body mass index, total cholesterol, low density lipoprotein, high density lipoprotein and triglycerides in more than 50% of the SRs. Improvement in HbA_1c was the mostly reported clinical outcome of pharmacist intervention in the literature (reported in six SRs). Pharmacist's interventions led to significant cost-saving ($8-$85,000 per person per year), cost-utility, and cost-benefit (benefit-to-cost ratio range from 1:1 to 8.5:1) versus usual care. Pharmacist's interventions improved patients' quality of life (QoL) in three SRs; however, no conclusion can be drawn due to the use of diverse QoL assessment tools.

CONCLUSIONS

Most SRs support the benefit of pharmacist care on diabetes-related clinical, humanistic, and economic outcomes in primary care settings. Improvements in diabetes outcomes can significantly reduce the burden of diabetes on healthcare system. Hence, the incorporation of pharmacists into multidisciplinary diabetes care teams is beneficial and should be strongly considered by clinicians and health policymakers.

Clinical pharmacists´ interventions in the management of type 2 diabetes mellitus: a systematic review

Background

Type 2 diabetes mellitus is a chronic disease that is reaching epidemic proportions worldwide. It is imperative to adopt an integrated strategy, which involves a close collaboration between the patient and a multidisciplinary team of which pharmacists should be integral elements.

Objective

This work aims to identify and summarize the main effects of interventions carried out by clinical pharmacists in the management of patients with type 2 diabetes, considering clinical, humanistic and economic outcomes.

Methods

PubMed and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials assessing the effectiveness of such interventions compared with usual care that took place in hospitals or outpatient facilities.

Results

This review included 39 studies, involving a total of 5,474 participants. Beneficial effects were observed on various clinical outcomes such as glycemia, blood pressure, lipid profile, body mass index and coronary heart disease risk. For the following parameters, the range for the difference in change from baseline to final follow-up between the intervention and control groups was: HbA1c, -0.05% to -2.1%; systolic blood pressure, +3.45 mmHg to -10.6 mmHg; total cholesterol, +10.06 mg/dL to -32.48 mg/dL; body mass index, +0.6 kg/m² to -1.94 kg/m²; and coronary heart disease risk, -3.0% and -12.0% (among the studies that used Framinghan prediction method). The effect on medication adherence and health-related quality of life was also positive. In the studies that performed an economic evaluation, the interventions proved to be economically viable.

Conclusions

These findings support and encourage the integration of clinical pharmacists into multidisciplinary teams, underlining their role in improving the management of type 2 diabetes.

Breakdown in the expedited partner therapy treatment cascade: from reproductive healthcare provider to the pharmacist

BACKGROUND

The rising incidence rates of sexually transmitted infections in the United States highlight the need for concurrent treatment of patients and their sexual partners. Expedited partner therapy allows healthcare providers to offer antibiotic prescriptions or medications to an index patient for distribution to their sexual partner(s) without evaluating the partner. We hypothesized that there was a gap between expedited partner therapy policy at the state level and its downstream implementation by community pharmacists.

OBJECTIVE

The objectives of our study were to evaluate pharmacists' expedited partner therapy knowledge and practices in 41 expedited partner therapy-permissible US states, to determine whether there were differences in practice based on the length of time expedited partner therapy was permissible in the state and chlamydia incidence rates, and to measure the cost of expedited partner therapy treatment.

STUDY DESIGN

A randomized cohort of pharmacists (n=335) was invited to complete a telephone interview from November 2017 through January 2018. Descriptive statistics were calculated and stratified by early, mid, and late expedited partner therapy-adopter status based on the year of the state's expedited partner therapy enactment and the state's chlamydia incidence rate. Fisher's exact test and 1-way analyses of variance were used to compare measures across strata.

RESULTS

We had 143 pharmacists (42.7%) agree to complete the survey. Among our respondents, 40.6% (n=58/143) indicated that they were aware of expedited partner therapy; 14.7% (n=21/143) reported that they had ever received an expedited partner therapy prescription, and 97% (n=139/143) reported that they would dispense an expedited partner therapy prescription if they received 1 in the future. These findings were stable across the 6 strata defined by early, mid, or late expedited partner therapy-adopter and high or low incidence rates of chlamydia status. Mean cost of azithromycin 1000 mg and cefixime 400 mg for treatment of chlamydia and gonorrhea was $22.17 (95% confidence interval, 20.29-24.05) and $30.46 (95% confidence interval, 28.65-32.26), respectively.

CONCLUSION

Fewer than one-half of the pharmacists were aware of expedited partner therapy. A small minority of pharmacists reported ever having received an expedited partner therapy prescription, regardless of the length of time expedited partner therapy had been legal in their states and the incidence of chlamydia. However, almost all pharmacists reported that they would dispense an expedited partner therapy prescription if they received 1. Additionally, costs were high for expedited partner therapy for self-pay patients. These data suggest that there are opportunities to increase expedited partner therapy utilization by healthcare providers, patients, and pharmacists.

From Pilot to Scale, the 5 Year Growth of a Primary Care Pharmacist Model

This case report details the five year journey of implementing, growing and optimizing a primary care pharmacist model in the ambulatory clinic setting within a health system. There is published evidence supporting the numerous benefits of including pharmacists in the primary care medical team model. This case report provides information regarding evolution of practice, the pharmacists’ roles, justification and financial models for the pharmacist services, as well as lessons learned and determined conclusions.

Pharmacist-Led Chronic Care Management for Medically Underserved Rural Populations in Florida During the COVID-19 Pandemic

Medically underserved patients in rural areas are more vulnerable to poor health outcomes, including the risks associated with coronavirus disease 2019 (COVID-19). Pharmacists, student pharmacists, and other health care professionals are working together to implement new, innovative ways to deliver the same standard of care during the COVID-19 pandemic to these vulnerable patients. These services include telehealth with virtual and telephone medication therapy management sessions led by ambulatory care pharmacists and student pharmacists. Pharmacists, student pharmacists, and other health care professionals should continue to adapt to these new technologies to improve health outcomes for their patients during the pandemic.

Integrating pharmacists into care teams: a qualitative systematic review protocol

OBJECTIVE

This review will systematically examine the qualitative literature reporting on strategies that have been used (or could be developed) by health care services to integrate pharmacists into a multidisciplinary health care team.

INTRODUCTION

Delivery models of pharmaceutical care have been developed, trialed and refined since this concept was first defined more than 30 years ago. Delivery models that integrate pharmacists within a multidisciplinary team allow pharmacists to play a pivotal role in improving health outcomes for patients and contributing to patient self-management. Systematic reviews clearly demonstrate the effectiveness of these models; however, the attitudes, beliefs, expectations, understandings, perceptions and experiences of these multidisciplinary teams is less clear.

INCLUSION CRITERIA

The populations of interest in this review are health care providers, including hospital specialists, general practitioners, nurses, health workers, pharmacists, allied health workers, aged care workers, Indigenous health workers and health promotion workers. The phenomena of interest are attitudes, beliefs, expectations, understandings, perceptions and experiences of the populations of interest arising from experiencing, developing or implementing strategies that have or could support the integration of pharmacists into multidisciplinary health care teams.

METHODS

The databases to be searched include PubMed, Cochrane, EBSCO (CINAHL), Embase, MedNar, Trove and Australian Indigenous Health Infonet. Studies published from 2011 onwards and in English will be considered for inclusion. Selected studies will be assessed for methodological quality by two independent reviewers, using standardized critical appraisal instruments. Where possible, qualitative research findings will be pooled. Where textual pooling is not possible, the findings will be presented in narrative form.

Effect of Pharmacist-Driven Professional Continuous Glucose Monitoring in Adults with Uncontrolled Diabetes

BACKGROUND

Diabetes requires close monitoring to achieve optimal outcomes and avoid adverse effects. Continuous glucose monitoring (CGM) is one approach to measuring glycemia and has become more widespread with recent advances in technology; however, ideal implementation of CGM into clinical practice is unknown. CGM can be categorized as personal CGM, which can be for at-home use to replace self-monitoring of blood glucose, or professional CGM (proCGM), which is used intermittently under the direction of a health care professional. The expanding role of the clinical pharmacist allows pharmacists to be at the forefront of implementing proCGM technology, but literature on the effect of pharmacist-driven proCGM is lacking. Pharmacists and physicians within 1 physician-owned clinic used proCGM technology differently. Pharmacists conducted 1 or 2 office visits to interpret data and make interventions, while physicians interpreted data 1 time and relayed interventions via phone.

OBJECTIVES

To (a) compare the change in hemoglobin A1c from baseline to 6 months between the different methods of proCGM implementation, and (b) describe and compare the clinical interventions made as a result of the different methods of proCGM implementation.

METHODS

In this retrospective cohort study, adults identified in the electronic medical record via Current Procedural Terminology code 95250 or 95251 undergoing proCGM with CGM data interpreted and baseline A1c ≥ 7% were included. Patients with additional CGM use within the 6-month follow-up period were excluded. Data collection included demographics, A1c at baseline and during the 6-month follow-up period, and CGM-associated interventions. Patients were categorized as undergoing 1 pharmacist-driven encounter (RPh1), 2 pharmacist-driven encounters (RPh2), or 1 physician-driven encounter (MD1) for proCGM implementation. Combined RPh1 and RPh2 (cRPh) data were also used for analysis. The primary outcome was change in A1c from baseline to 6 months, which was evaluated by analysis of covariance.

RESULTS

Of 378 patient charts reviewed, 315 instances of proCGM implementation met inclusion criteria (58 RPh1, 35 RPh2, 222 MD1), and 253 had post-implementation A1c data for analysis of the primary outcome (52 RPh1, 30 RPh2, 171 MD1). Baseline A1c was 8.4%, 8.8%, and 9.1% with mean reduction from baseline to 6 months of 1.0%, 1.3%, and 0.6%, respectively. cRPh patients experienced a greater mean reduction in A1c compared with MD1 (P = 0.002). RPh2 patients had a statistically significant reduction compared with MD1 (P = 0.005), but RPh1 patients did not (P = 0.054). The number of CGM-associated pharmacological interventions was 1.33 for RPh1 patients, 1.63 for RPh2 at the first encounter and 1.34 at the second, and 1.17 for MD1.

CONCLUSIONS

Pharmacist-driven implementation of proCGM was associated with greater A1c reductions and more pharmacological interventions versus physician-driven implementation. This study demonstrated improved clinical outcomes with pharmacists providing direct patient care through implementation of new diabetes technology.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose. Preliminary results of this work were presented at the American College of Clinical Pharmacy Virtual Poster Symposium, May 28-29, 2019. The abstract was not peer-reviewed because of enrollment in the Mentored Research Investigator Training (MeRIT) program. Final peer-reviewed results were presented at the American College of Clinical Pharmacy Annual Meeting; October 26-29, 2019; New York, NY.

The role of community pharmacists and their position in the delivery of diabetes care: an update for medical professionals

Pharmacists are the third largest group of healthcare professionals worldwide, but are underused in the delivery of diabetes care. The aim of this narrative was to describe how integration of community pharmacy services into existing healthcare models may improve diabetes care. Relevant literature exploring pharmacy-led interventions for diabetes were identified from a search of Medline, Embase and Cinahl online databases. This review highlights that community pharmacists are accessible, experts in medicine management, trusted by the public and able to achieve financial savings. They are poorly integrated into existing healthcare models, and commissioning arrangements can be poorly perceived by the public and those working in primary care. Community pharmacy interventions in type 2 diabetes have similar, if not greater effects compared to those delivered by other healthcare professionals. It was concluded that community pharmacy interventions in diabetes are feasible, acceptable and deliver improved health outcomes. Future work should build public recognition of pharmacists and improve communication between them and other healthcare professionals.

Continuity of care and outpatient management for patients with and at high risk for cardiovascular disease during the COVID-19 pandemic: A scientific statement from the American Society for Preventive Cardiology

The coronavirus disease 2019 (COVID-19) pandemic has consumed our healthcare system, with immediate resource focus on the management of high numbers of critically ill patients. Those that fare poorly with COVID-19 infection more commonly have cardiovascular disease (CVD), hypertension and diabetes. There are also several other conditions that raise concern for the welfare of patients with and at high risk for CVD during this pandemic. Traditional ambulatory care is disrupted and many patients are delaying or deferring necessary care, including preventive care. New impediments to medication access and adherence have arisen. Social distancing measures can increase social isolation and alter physical activity and nutrition patterns. Virtually all facility based cardiac rehabilitation programs have temporarily closed. If not promptly addressed, these changes may result in delayed waves of vulnerable patients presenting for urgent and preventable CVD events. Here, we provide several recommendations to mitigate the adverse effects of these disruptions in outpatient care. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be continued in patients already taking these medications. Where possible, it is strongly preferred to continue visits via telehealth, and patients should be counselled about promptly reporting new symptoms. Barriers to medication access should be reviewed with patients at every contact, with implementation of strategies to ensure ongoing provision of medications. Team-based care should be leveraged to enhance the continuity of care and adherence to lifestyle recommendations. Patient encounters should include discussion of safe physical activity options and access to healthy food choices. Implementation of adaptive strategies for cardiac rehabilitation is recommended, including home based cardiac rehab, to ensure continuity of this essential service. While the practical implementation of these strategies will vary by local situation, there are a broad range of strategies available to ensure ongoing continuity of care and health preservation for those at higher risk of CVD during the COVID-19 pandemic.

Diabetes, Therapeutic Inertia, and Patients' Medication Experience

Factors contributing to therapeutic inertia related to patients' medication experiences include concerns about side effects and out-of-pocket costs, stigmatization for having diabetes, confusion about frequent changes in evidence-based guidelines, low health literacy, and social determinants of health. A variety of solutions to this multifactorial problem may be necessary, including integrating pharmacists into interprofessional care teams, using medication refill synchronization programs, maximizing time with patients to discuss fears and concerns, being cognizant of language used to discuss diabetes-related topics, and avoiding stigmatizing patients. Managing diabetes successfully is a team effort, and the full commitment of all team members (including patients) is required to achieve desired outcomes through an individualized approach.

Primary Care Providers' Acceptance of Pharmacists' Recommendations to Support Optimal Medication Management for Patients with Diabetic Kidney Disease

BACKGROUND

Patients with diabetic kidney disease (DKD) often struggle with blood pressure control. In team-based models of care, pharmacists and primary care providers (PCPs) play important roles in supporting patients' blood pressure management.

OBJECTIVE

To describe whether PCPs' acceptance of pharmacists' recommendations impacts systolic blood pressure (SBP) at 36 months.

DESIGN

An observational analysis of a subset of participants randomized to the intervention arm of the Simultaneous risk factor control using Telehealth to slOw Progression of Diabetic Kidney Disease (STOP-DKD) study.

PARTICIPANTS

STOP-DKD participants for whom (1) the pharmacist made at least one recommendation to the PCP; (2) there were available data regarding the PCP's corresponding action; and (3) there were SBP measurements at baseline and 36 months.

INTERVENTION

Participants received monthly telephone calls with a pharmacist addressing health behaviors and medication management. Pharmacists made medication-related recommendations to PCPs.

MAIN MEASURES

We fit an unadjusted generalized linear mixed model to assess the association between the number of pharmacists' recommendations for DKD and blood pressure management and PCPs' acceptance of such recommendations. We used a linear regression model to evaluate the association between PCP acceptance and SBP at 36 months, adjusted for baseline SBP.

KEY RESULTS

Pharmacists made 176 treatment recommendations (among 59 participants), of which 107 (61%) were accepted by PCPs. SBP significantly declined by an average of 10.5 mmHg (p < 0.01) among 47 of 59 participants who had valid measurements at baseline and 36 months. There was a significant association between the number of pharmacist recommendations and the odds of PCP acceptance (OR 1.19; 95%CI 1.00, 1.42; p < 0.05), but no association between the number of accepted recommendations and SBP.

CONCLUSIONS

Pharmacists provided actionable medication-related recommendations. We identified a significant decline in SBP at 36 months, but this reduction was not associated with recommendation acceptance.

TRIAL REGISTRATION

NCT01829256.

Pharmacy: Addressing substance use in the 21st century

Across all care environments, pharmacists play an essential role in the care of people who use and misuse psychoactive substances, including those diagnosed with substance use disorders. To optimize, sustain, and expand these independent and collaborative roles, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) has developed core competencies for pharmacists to address substance use in the 21st century. Key concepts, skills, and attitudes are outlined, with links to entrustable professional activities to assist with integration into a variety of ideally interdisciplinary curricular activities.

Educational Targets to Reduce Medication Errors by General Surgery Residents

OBJECTIVE

Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers.

DESIGN

This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018.

SETTING

A single large academic medical center located in the Midwest, United States.

PARTICIPANTS

General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders.

RESULTS

Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (n = 24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (n = 8703, 36.1%) or errors in renal dosing (n = 7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (n = 5280) and 13.5% (n = 3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (OR = 1.21, 95%CI = 1.14-1.29) and in August versus other months (OR = 1.09, 95%CI = 1.01-1.17), but were independent of other resident and order characteristics.

CONCLUSIONS

This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.