Evaluating Pharmacist-Written Recommendations to Providers in a Medicare Advantage Plan: Factors Associated with Provider Acceptance

BC Clinical impact of medication reviews with follow-up in cardiovascular older patients in primary care: A cluster-randomized controlled trial

AIMS

Cardiovascular diseases (CVD) are the primary cause of death in Chile. Pharmacist-led medication review with follow-up (MRF) has improved CVD risk factors control in Europe and North America. However, their healthcare systems differ from Chile's, precluding generalizability. This trial aimed to determine the effect of MRF on CVD risk factor control among older patients with polypharmacy attending public primary care centres in Chile.

METHODS

A cluster-randomized controlled trial was conducted in 24 centres. Patients older than 65 years with moderate-to-high CVD risk, five or more medications, hypertension, type 2 diabetes or dyslipidaemia, received MRF in addition to usual care or usual care alone for 12 months. Primary outcome measures were clinical goal achievement for hypertension, type 2 diabetes and dyslipidaemia, as well as medication adherence, medication number and CVD risk score. Adjusted generalized estimating equations were used, with odds ratios (ORs) for binary measures and mean differences for continuous measures.

RESULTS

In total, 324 patients from 12 centres (174 MRF group, 150 usual care group, six centres each) received four pharmacist visits. Significant improvements were found for goal achievement in hypertension (OR 4.37, 95% confidence interval [CI] 2.54 to 7.51, P = .001), LDL cholesterol (OR 3.67, 95% CI 2.13 to 6.33, P = .001), type 2 diabetes (OR 6.97, 95% CI 3.69 to 13.2, P = .001), medication adherence (OR 6.60, 95% CI 1.36 to 31.9, P = .022), medications number (-0.86, 95% CI -1.14 to -0.58, P < .001) and CVD risk score (-2.27, 95% CI -2.84 to -1.69, P < .001).

CONCLUSION

Pharmacist-led medication review with follow-up improved cardiovascular disease risk factor control and medication adherence. This study supports pharmacists' inclusion in primary care teams.

Implementation and Evaluation of Clinical Pharmacy Services on Improving Quality of Prescribing in Geriatric Inpatients in Vietnam: An Example in a Low-Resources Setting

Purpose

Geriatric inpatients generally have a high risk of drug-related problems (DRP) in prescribing following hospital admission, which are likely to cause negative clinical consequences. This is particularly evident in developing countries such as Vietnam. Therefore, clinical pharmacy service (CPS) aims to identify and resolve these DRPs to improve the quality use of medicines in the older population following hospital admission.

Patients and Methods

The study was conducted as a prospective, single-center study implemented at a general public hospital in Hanoi. Patients aged ≥60 years with at least three chronic diseases admitted to the Internal Medicine Department between August 2020 and December 2020 were eligible to be enrolled. A well-trained clinical pharmacist provided a structured CPS to identify any DRP in prescribing for each patient in the study. Clinical pharmacist interventions were then proposed to the attending physicians and documented in the DRP reporting system.

Results

A total of 255 DRP were identified in 185 patients during the study period. The most frequent types of DRP were underuse (21.2%), dose too high (12.2%), and contraindication (11.8%). There was a very high rate of approval and uptake by the physicians regarding the interventions proposed by the clinical pharmacist (82.4% fully accepted and 12.5% partially accepted). Of the interventions, 73.4% were clinically relevant (pADE score ≥0.1). In general, 9 out of 10 physicians agreed that CPS has significant benefits for both patients and physicians.

Conclusion

Improving clinical pharmacy services can potentially have a positive impact on the quality of prescribing in elderly inpatients. These services should officially be implemented to optimize the quality use of medicines in this population group in Vietnam.

Understanding the factors influencing prescriber uptake of pharmacist recommendations in secondary care

BACKGROUND

Pharmacists are increasingly recognized as medication experts who can bring much to clinical teams and decision making. The inclusion of a pharmacist into a multidisciplinary team, including ward rounds, can be sporadic in some settings, meaning pharmacists are not always present at the point of decision making. In this way, subsequent recommendations may not always be adopted. Understanding the perceptions of prescribers to pharmacist input and preferences for receiving pharmacist input, may result in more effective and efficient patient care.

OBJECTIVE

The purpose of this study is to understand how prescribers view pharmacist contributions and the factors that facilitate or hinder acceptance of pharmacist recommendations within a hospital setting.

METHOD

This mixed methods study consisted of two stages, initially focus groups and an online survey. Thematic analysis of the focus group discussions was conducted, and these formed the basis of the survey. A total of 17 prescribers participated in the focus groups and 99 of 335 prescribers participated in the survey. The questions centred on 4 key aspects, 1) the perceived role of a pharmacist, 2) communication strategies 3) the value added by pharmacists and 4) barriers and enablers to adopting pharmacist recommendations.

RESULTS

Prescribers strongly valued dosing advice and information on medication interactions. Some prescribers did not believe that a pharmacist should attend ward rounds, with more senior clinicians seeing value of recommendations being given at the time of medication initiation. Within a busy clinical setting several barriers were identified, including communication method, differing priorities, presence of pharmacist at the time of decision making, and consultant led hierarchy.

CONCLUSION

Several factors influence acceptance of pharmacists' recommendations. Working on communication methods may overcome some, but others such as pharmacist presence on rounds and consultant led decision-making hierarchy may be harder to change.

Maximizing acceptance of clinical pharmacy recommendations to reduce length of hospital stay in a private hospital from Amman, Jordan

Background

Clinical pharmacy interventions (CPI) usually require prior medical authorization. Physicians approve 80% of CPI and reject 20%. If pharmacists show that physicians should authorize all 100% CPI, the profession will step closer to a fully independent prescriber status. This study used an artificial neural network (ANN) model to determine whether clinical pharmacy (CP) may improve outcomes associated with rejected CPI.

Method

This is a non-interventional, retrospective analysis of documented CPI in a 100-bed, acute-care private hospital in Amman, Jordan. Study consisted of 542 patients, 574 admissions, and 1694 CPI. Team collected demographic and clinical data using a standardized tool. Input consisted of 54 variables with some taking merely repetitive values for each CPI in each patient whereas others varying with every CPI. Therefore, CPI was consolidated to one rejected and/or one accepted per patient per admission. Groups of accepted and rejected CPI were compared in terms of matched and unmatched variables. ANN were, subsequently, trained and internally as well as cross validated for outcomes of interest. Outcomes were length of hospital and intensive care stay after the index CPI (LOSTA & LOSICUA, respectively), readmissions, mortality, and cost of hospitalization. Best models were finally used to compare the two scenarios of approving 80% versus 100% of CPI. Variable impacts (VI) automatically generated by the ANN were compared to evaluate the effect of rejecting CPI. Main outcome measure was Lengths of hospital stay after the index CPI (LOSTA).

Results

ANN configurations converged within 18 s and 300 trials. All models showed a significant reduction in LOSTA with 100% versus 80% accepted CPI of about 0.4 days (2.6 ± 3.4, median (range) of 2 (0–28) versus 3.0 ± 3.8, 2 (0–30), P-value = 0.022). Average savings with acceptance of those rejected CPI was 55 JD (~ 78 US dollars) and could help hire about 1.3 extra clinical pharmacist full-time equivalents.

Conclusions

Maximizing acceptance of CPI reduced the length of hospital stay in this model. Practicing Clinical Pharmacists may qualify for further privileges including promotion to a fully independent prescriber status.

Evaluation of Pharmacist Medication Review Service in an Outpatient Heart Failure Clinic

Purpose:

The purpose of this study was to evaluate the impact of pharmacist medication reviews on drug-related problems (DRPs) in a population with ambulatory heart failure (HF).

Methods:

The HF pharmacist medication review service incorporated a comprehensive medication review note provided to the cardiologist in a HF clinic. A retrospective chart review was performed on 64 control patients with no previous pharmacist review and 64 intervention patients who had a pharmacist medication review. The primary end point was the number of DRPs identified per patient in the intervention group 2 weeks after pharmacist medication review compared to the number of DRPs identified per patient in the control group.

Results:

The average DRPs per patient was reduced from 2.80 to 1.95 in intervention group after pharmacist intervention. There was a statistically significant difference between the average DRPs per patient in the control and intervention groups, 2.55 DRPs versus 1.95 DRPs per patient, respectively ( P = .016). Medication adherence (78%), renal dosing (67%), hypertension (58%), and HF DRPs (55%) had the highest acceptance rate. The majority of DRP recommendations in the intervention (87%) and control groups (87%) were high-impact recommendations.

Conclusions:

Pharmacist medication reviews in an ambulatory HF clinic lead to significantly fewer DRPs.

Assessment of Clinical Pharmacy Interventions to Reduce Outpatient Use of High-Risk Medications in the Elderly

BACKGROUND

Use of high-risk medications in the elderly (HRME) and drug-disease (Rx-DIS) interactions in the elderly, as defined by the Healthcare Effectiveness Data and Information Set (HEDIS) Measures, are significantly associated with mortality, hospital admission, and need for emergency care. No published studies to date evaluate interventions to reduce the use of HEDIS-defined HRME, although many studies have postulated a beneficial effect of such interventions.

OBJECTIVE

To evaluate the effect of pharmacist interventions on use of HRME and Rx-DIS interactions in the outpatient elderly population.

METHODS

This retrospective cohort study was conducted in a resident-based family medicine clinic. Patients aged ≥ 65 years were prospectively screened for the use of HRME and Rx-DIS interactions before their visits with their primary care providers. If HRME or Rx-DIS interactions were noted, the clinical pharmacist sent messages to the physicians through the electronic medical record, alerting them of the findings with suggestions of safer alternative agents, if applicable. The recommendation acceptance rate was assessed and then compared with a historical control from a similar time frame. The primary outcome was assessed with a chi square analysis. Secondary outcomes were assessed with descriptive statistics, chi square test, and Fisher's exact test.

RESULTS

HRME and/or Rx-DIS interactions were changed 25.9% of the time in the pharmacist intervention group compared with only 2.0% of the time in the historical control group (P = 0.001). The most frequently changed medication classes included skeletal muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs. Over 85% of the medication changes were preserved at the end of the study period. There was no difference between groups in the number of patients with HRME or Rx-DIS interactions.

CONCLUSIONS

Clinical pharmacy interventions result in significant reductions in use of HRME and Rx-DIS interactions in the outpatient elderly population. Using electronic communication allows pharmacists to provide meaningful interventions for numerous patients receiving care in a high-volume family medicine clinic setting.

DISCLOSURES

There was no funding or sponsorship for this study. Rowe reports personal fees from The Medicines Company, outside the submitted work. The other authors have nothing to disclose. Study concept and design were contributed by Jeter, Chamberlin, and Weddle, with assistance from Rowe and Franks. Weddle and Renwick collected the data, and data interpretation was performed by Weddle and Rowe, with assistance from Franks. The manuscript was written by Weddle and Rowe and revised by Weddle and Franks, assisted by Chamberlin. The abstract for the completed study was presented at the American College of Clinical Pharmacy Global Conference, San Francisco, California, October 2015, and the Southeastern Residency Conference, Athens, Georgia, April 2015 (platform presentation). The research-in-progress abstract was presented at the Tennessee Society of Health System Pharmacists, Nashville, Tennessee, February 2015; the American Society of Health System Pharmacists Midyear Clinical Meeting, Anaheim, California, December 2014; and the University HealthSystem Consortium Pharmacy Council, Anaheim, California, December 2014.

Clinic-Level Population Health Intervention by PGY2 Ambulatory Care Pharmacy Residents to Optimize Medication Management in a Self-Insured Employer Health Plan Population

BACKGROUND

Postgraduate year 2 ambulatory care pharmacy residents (PGY2 residents) may be able to improve healthcare quality by providing clinical pharmacy services provided to self-insured employer health plan patients. The objectives of this study are to describe this care delivery in a family medicine clinic, and to identify patients most likely to benefit from the service.

METHODS

From October 1, 2014 till June 30, 2015, comprehensive medication review was completed by PGY2 residents for patients insured by CU Anthem at the University of Colorado Westminster Family Medicine. For patients with medication-related problems (MRPs), a note was sent to the provider before the patient visit. Patient characteristics were compared in those who received a clinical pharmacy note with those who did not.

RESULTS

Sixty-eight MRPs were identified in 39 notes; 40 (58.8%) recommendations were implemented. The following Clinical Pharmacy Priority (CP2) score criteria were identified more frequently in patients with MRPs: age ≥65 years, diagnosis of diabetes, hypertension, chronic obstructive pulmonary disease, cardiovascular disease, blood pressure ≥140/90, hemoglobin A_1c >7.9%, and ≥6 items on the medication list.

CONCLUSION

PGY2 residents identified and resolved numerous clinically relevant MRPs. Patient-specific criteria can be utilized to target self-insured employer health plan patients who are likely to have clinically relevant MRPs.

Primary care providers' use of pharmacist support for delivery of pharmacogenetic testing

AIM

To investigate provider utilization of pharmacist support in the delivery of pharmacogenetic testing in a primary care setting.

METHODS

Two primary care clinics within Duke University Health System participated in the study between December 2012 and July 2013. One clinic was provided with an in-house pharmacist and the second clinic had an on-call pharmacist.

RESULTS

Providers in the in-house pharmacist arm consulted with the pharmacist for 13 of 15 cases, or about one of every four patients tested compared with one of every 7.5 patients in the on-call pharmacist arm. A total of 63 tests were ordered, 48 by providers in the pharmacist-in-house arm.

CONCLUSION

These findings suggest that the availability of an in-house pharmacist increases the likelihood of pharmacogenetic test utilization.