Clinical pharmacy cardiac risk service for managing patients with coronary artery disease in a health maintenance organization

Reducing Emergency Department Visits Among Patients With Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams

BACKGROUND

Pharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency department (ED) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care.

OBJECTIVE

The objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ED and hospital use for patients with diabetes.

DESIGN

This was a quasi-experimental study with a comparator group.

SUBJECTS

The analytic sample included patients with diabetes with uncontrolled cardiovascular risk factors (A1C >9%, blood pressure >140/90 mm Hg, low-density lipoprotein-cholesterol >130 mg/dL) who had 1 or more visits in either a UCMyRx (648 patients, 14 practices) or usual care practice (1944 patients, 14 practices).

MEASURES

Our outcomes were ED and hospitalization rates as measured before and after the consultations between UCMyRx and usual care. Our predictor variable was the pharmacist consultation. Poisson generalized estimating equations model was used to estimate the adjusted predicted change in utilization before and after the pharmacist consultation. The Average Treatment Effect on the Treated was estimated.

RESULTS

In models adjusted, the adjusted mean predicted number of emergency department visits/month during the year before the consultation was 0.09 among UCMyRx patients. During the year after initiating the care with the pharmacists, this rate decreased to an adjusted mean monthly rate of 0.07, with an Average Treatment Effect on the Treated=0.021 (P=0.035), a predicted reduction of 21% in emergency department visits associated with the clinical pharmacist consults. There was a nonsignificant predicted 3.2% reduction in hospitalizations over time for patients in the UCMyRx program.

CONCLUSION

Clinical pharmacists are an important addition to clinical care teams in primary care practices and significantly decreased utilization of the ED among patients with poorly controlled diabetes.

Development of a centralized, remote clinical pharmacy service to enhance primary care

More than 50% of Americans possess at least one chronic condition and another 25% suffer from two or more, leaving primary care teams tasked to care for the chronic, acute, and preventive care needs of their large patient panels. Pharmacists can reduce the burden on busy providers by effectively managing chronic diseases as members of health care teams. Many private physician practices lack the resources to include pharmacists on their teams. A centralized, remote clinical pharmacy services model allows pharmacists to remotely manage chronic disease in patients in collaboration with primary care providers. The purpose of this report is to describe how a centralized, remote clinical pharmacy team was developed, trained, and effectively integrated into multiple, diverse primary care settings across the U.S.

Long-term stroke risk with carotid endarterectomy in patients with severe carotid stenosis

OBJECTIVE

Informed debate regarding the optimal use of carotid endarterectomy (CEA) for stroke risk reduction requires contemporary assessment of both long-term risk and periprocedural risk. In this study, we report long-term stroke and death risk after CEA in a large integrated health care system.

METHODS

All patients with documented severe (70%-99%) stenosis from 2008 to 2012 who underwent CEA were identified and stratified by asymptomatic or symptomatic indication. Those with prior ipsilateral interventions were excluded. Patients were followed up through 2017 for the primary outcomes of any stroke/death within 30 days of intervention and long-term ipsilateral ischemic stroke; secondary outcomes were any stroke and overall survival.

RESULTS

Overall, 1949 patients (63.2% male; mean age, 71.3 ± 8.9 years) underwent 2078 primary CEAs, 1196 (58%) for asymptomatic stenosis and 882 (42%) for symptomatic stenosis. Mean follow-up was 5.5 ± 2.7 years. Median time to surgery was 72.0 (interquartile range, 38.5-198.0) days for asymptomatic patients and 21.0 (interquartile range, 5.0-55.0) days for symptomatic patients (P < .001). Most of the patients' demographics and characteristics were similar in both groups. Controlled blood pressure rates were similar at the time of CEA. Baseline statin use was seen in 60.5% of the asymptomatic group compared with 39.9% in the symptomatic group (P < .001), and statin adherence by 80% medication possession ratio was 19.3% asymptomatic vs 12.4% symptomatic (P < .001). The crude overall 30-day any stroke/death rates were 0.9% and 1.5% for the asymptomatic group and the symptomatic group, respectively. The 5-year risk of ipsilateral stroke and a combined end point of any stroke/death by Kaplan-Meier survival analysis were 2.5% and 28.7% for the asymptomatic group and 4.0% and 31.4% for the symptomatic group, respectively. Unadjusted cumulative all-cause survival was 74.2% for the asymptomatic group and 71.8% for the symptomatic group at 5 years.

CONCLUSIONS

In a contemporary review of CEA, outcomes for either operative indication show low adverse events perioperatively and low long-term stroke risk up to 5 years. These results are well within consensus guidelines and published trial outcomes and should help inform the discussion around optimal CEA use for severe carotid stenosis.

Trends in high intensity statin use among secondary prevention patients 76 years and older

Background:

High intensity statin therapy (HIST) is the gold standard therapy for decreasing the risk of recurrent atherosclerotic cardiovascular disease (ASCVD); however, little is known about the use of HIST in older adults with ASCVD.

Objectives:

The aim of this cross-sequential study was to determine trends in statin intensity in older adults over a 10-year timeframe.

Methods:

The study was conducted in an integrated healthcare delivery system. Patients were 76 years or older with validated coronary ASCVD. Data were collected from administrative databases. Statin intensity level was assessed in eligible patients on January 1st and July 1st from January 1, 2007 to December 31, 2016.

Results:

Overall, a total of 5,453 patients were included with 2,119 (38.9%) and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively. Included patients had a mean age of 79.8 years and were primarily male and white and had a cardiac intervention. The rate of HIST use increased from 14.5% to 41.3% over the study period (p<0.001 for trend). Conversely, the rates of moderate and low intensity statin use decreased from 61.8% and 9.8% to 41.2% and 4.8%, respectively (both p<0.001 for trend). Similar trends were identified for females and males.

Conclusions:

The percentage of patients with ASCVD 76 years and older who received HIST substantially increased from 2007 to 2016. This trend was identified in both females and males. Future comparative effectiveness research should be conducted in this patient population to examine cardiac-related outcomes with HIST and Non-HIST use.

Value of Pharmacy Students Performing Population Management Activity Interventions as an Advanced Pharmacy Practice Experience

Objective. To assess the value of an advanced pharmacy practice experience in which students engaged in population health management (PHM) activities for a managed care setting. Methods. Students were provided with a list of patients, trained on the requirements for each PHM activity and completed them independently. The students reviewed the electronic record for each patient on their list to identify those who were non-adherent to dual antiplatelet therapy (DAPT) within one year of coronary stent placement, non-adherent to beta blockers (BB) within six months post-acute myocardial infarction, or with renal dysfunction and requiring dose adjustment of lipid-lowering therapy. Students coded each intervention based on predefined categories such as patient education, medication discontinuation, or medication reconciliation, and then if necessary were reviewed with the pharmacy preceptor. The primary investigator determined the intervention to be either actionable or non-actionable. The primary outcome was the proportion and type of interventions made by each student. The secondary outcome was clinical pharmacist time offset. A retrospective, data-only pilot study was conducted to determine the outcomes from the program over four years. Results. Forty-six students made 3,774 interventions over the study period, 37% of which were categorized as actionable. The most common actionable interventions were providing patient education (52%), verifying prescription adherence (23%), and medication therapy adjustment (10.5%). Over the study period, an estimated 765.6 hours of clinical pharmacist time was offset, or approximately 191.4 hours per academic year. Conclusion. This study demonstrated that a population health management approach can be used successfully within an APPE. This approach can result in offset pharmacist time for precepting organizations, while offering meaningful clinical interventions for patients and learning opportunities for students.

Trends in high-intensity statin use and low-density lipoprotein cholesterol control among patients enrolled in a clinical pharmacy cardiac risk service

BACKGROUND

Although high-intensity statin therapy (HIST) is recommended for most patients between 21 and 75 years of age with atherosclerotic cardiovascular disease (ASCVD), several recent analyses examining contemporary statin use trends have identified a clinical care gap in the utilization of HIST.

OBJECTIVE

The objective of this study was to assess secular trends in lipid management for patients with ASCVD enrolled in a clinical pharmacy program within an integrated health care delivery system.

METHODS

We performed serial cross-sectional studies over time, comprising 18,006 adults with both acute and chronic ASCVD, to assess trends in statin use and low-density lipoprotein cholesterol (LDL-C) levels from 2007 to 2016.

RESULTS

Although the use of statin therapy (any intensity) remained relatively consistent throughout the 10-year study period (89% in 2007, 87% in 2016), the proportion of patients receiving HIST increased over time (44% in 2007, 67% in 2016; P < .001 for trend). Population mean LDL-C levels ranged from 73 to 83 mg/dL with a downward trend over the 10-year study period (P < .001 for trend). By 2016, the proportion of patients attaining an LDL-C <100 mg/dL and <70 mg/dL was 85% and 54%, respectively. Nonstatin lipid-lowering therapy use decreased over the study period, which was primarily driven by decreased use of ezetimibe (24% in 2007, 2% in 2016; P < .001 for trend).

CONCLUSIONS

Among adults with ASCVD enrolled in a clinical pharmacy cardiac risk reduction service, guideline-directed use of HIST significantly increased over the past 10 years and coincided with decreased population LDL-C levels.

Pharmacist prescribing practices in a clinical pharmacy cardiac risk service

PURPOSE

Prescribing practices within a clinical pharmacy cardiac risk service (CPCRS) and their impact on treatment outcomes in patients with atherosclerotic cardiovascular disease (ASCVD) are described.

SUMMARY

National healthcare reforms have increased the population of insured patients and placed increased demands on physicians and other providers. Pharmacists are well trained and positioned to aid in patient care by providing expertise in medication management and patient safety that can result in pharmacotherapy optimization and cost savings. Kaiser Permanente Colorado (KPCO), a group-model health maintenance organization with about 675,000 members served by 30 medical offices throughout Colorado, has adopted a collaborative drug therapy management (CDTM) model that enables pharmacist prescribing to improve patient access, patient care, and healthcare cost-effectiveness. Within the CPCRS established by KPCO, qualified pharmacists are permitted to prescribe initial therapy, modify drug regimens, order laboratory tests, and perform follow-up activities within their professional scope of practice. The CPCRS focuses on the long-term management of patients with ASCVD. The primary goals of the CPCRS are to optimize secondary-prevention pharmacotherapy, monitor and ensure medication adherence, assist in the management of risk factors for ASCVD, provide patient education and counseling, and serve as a resource for physicians and other healthcare providers. Working under a CDTM agreement, pharmacists are authorized to prescribe therapies to minimize the risk of future ASCVD events.

CONCLUSION

The CPCRS at KPCO has demonstrated successful maintenance of a clinical pharmacy service including pharmacist prescribing under a CDTM model to manage patients with ASCVD.

The role of the clinical pharmacist in the care of patients with cardiovascular disease

Team-based cardiovascular care, including the use of clinical pharmacists, can efficiently deliver high-quality care. This Joint Council Perspectives paper from the Cardiovascular Team and Prevention Councils of the American College of Cardiology provides background information on the clinical pharmacist's role, training, certification, and potential utilization in a variety of practice models. Selected systematic reviews and meta-analyses, highlighting the benefit of clinical pharmacy services, are summarized. Clinical pharmacists have a substantial effect in a wide variety of roles in inpatient and ambulatory settings, largely through optimization of drug use, avoidance of adverse drug events, and transitional care activities focusing on medication reconciliation and patient education. Expansion of clinical pharmacy services is often impeded by policy, legislation, and compensation barriers. Multidisciplinary organizations, including the American College of Cardiology, should support efforts to overcome these barriers, allowing pharmacists to deliver high-quality patient care to the full extent of their education and training.

Current Controversies With Recent Cholesterol Treatment Guidelines

Several guidelines and expert recommendations have been published recently regarding the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD) risk. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend a drastic paradigm change in the treatment of cholesterol where treatment, based on level of cardiovascular risk, is based around using a fixed statin intensity therapy. This approach is endorsed by the American Diabetes Association. However, recommendations by the National Lipid Association (NLA) consist of the traditional approach of titrating therapy to achieve patient-specific lipoprotein targets. Despite the differences in overall approaches, the use of statin therapy as the cornerstone of treatment to reduce risk of cardiovascular events in at risk patients is a strong common theme. Clinicians should be aware of these differences, as they represent controversies with the overall treatment of ASCVD risk. Additional controversies related to the treatment of patients with ASCVD risk pertain to the role of nonstatin drugs and approaches to managing side effects. These topics are reviewed within this article and discuss implications for patient care.

Self-Rated Health Among Patients with Coronary Artery Disease Enrolled in a Cardiovascular Risk Reduction Service

Little is known about the use of the single self-rated health (SRH) status item measuring health-related quality of life among people with coronary artery disease (CAD). The objective of this study was to assess relationships between SRH and recurrent coronary events, mortality, health care utilization, and intermediate clinical outcomes and to assess predictors of fair/poor SRH. A total of 5573 patients enrolled in a comprehensive cardiac risk reduction service managed by clinical pharmacy specialists were evaluated over a 2-year period. Regression modeling explored relationships among variables, modeling SRH separately as an independent and a dependent variable. The 1374 (24.7%) respondents reporting fair/poor SRH differed statistically from 4199 (75.3%) respondents reporting good/very good/excellent SRH in terms of age, sex, ethnicity, number of comorbid conditions, DxCG scores, lifestyle behaviors, blood pressure control, and inpatient and emergency department (ED) utilization. Respondents reporting fair/poor health were more likely to have recurrent major coronary events (MCE), including death. Fair/poor SRH was consistently statistically significant when it was included as a predictor in regression modeling for poor blood pressure control, health care utilization, MCE, and all-cause mortality. Variables associated with fair/poor SRH in regression modeling included females, Hispanic ethnicity, ≥1 baseline ED visit, and DxCG score. Exercising <30 minutes per week was strongly associated with fair/poor SRH. Single-item SRH status may help identify patients with CAD at higher risk of poor blood pressure control, recurrent MCE, and death and those who may benefit from interventions to increase physical activity.

Cluster-Randomized Trial of Clinical Pharmacist Tobacco Cessation Counseling Among Patients with Cardiovascular Disease

Optimal management of patients with cardiovascular disease (CVD) includes evaluation of risk factors using a team-based approach. Tobacco use often receives less attention than other CVD risk factors; therefore, utilization of nonphysician health care providers may be valuable in addressing tobacco use. The purpose of this trial was to assess the impact of brief, structured, telephone tobacco cessation counseling (BST) delivered by clinical pharmacists on tobacco cessation attempts compared to usual care. The BST consisted of 1 to 5 minutes discussing 3 key counseling points, including a recommendation to quit and education about cessation aids. This was a cluster-randomized trial of tobacco-using patients with CVD who were enrolled in a clinical pharmacist-managed, physician-directed, CVD disease state management service. Clinical pharmacists were randomized to provide usual care (control) or BST (intervention) to their tobacco-using patients during a 4-month period. Patients were surveyed 3 months later to assess their tobacco cessation attempts, use of tobacco cessation aids, and self-reported cessation. One hundred twenty patients were enrolled. Subjects were predominately white males, aged ≥65 years, with a history of myocardial infarction. One hundred and four subjects completed the follow-up survey. No differences were detected between the 36.2% and 38.6% of control and intervention subjects, respectively, reporting a tobacco cessation attempt (P=0.804) or in the other outcomes (all P>0.05). A BST delivered by clinical pharmacists may not adequately affect patient motivation enough to increase tobacco cessation attempts in tobacco-dependent patients with CVD. Future research is needed to evaluate other team-based strategies that can decrease tobacco use in patients with CVD.

Ambulatory treatment gaps in patients with ischemic stroke or transient ischemic attack

BACKGROUND

This study evaluated goal attainment for patients with a history of non-cardioembolic ischemic stroke (NCIS) or transient ischemic attack (TIA).

METHODS

A cross-sectional study was conducted in patients aged 18 to 85 years with a history of validated NCIS or TIA. Data collected were demographics, comorbidities, blood pressure (BP), low-density lipoprotein cholesterol (LDL-C) values, and medications within 365 days and most proximal to December 31, 2010. Goal LDL-C and BP were defined as < 100 mg/dL and < 140/90 mm Hg, respectively. Differences in sex and age (< 65 vs ≥ 65 years) were evaluated.

RESULTS

There were 1731 patients evaluated (mean age: 73.6 years; 58% women). Stroke type was NCIS in 51.9% and TIA in 48.1%. The LDL-C and BP were measured in 75.4% and 50.3% of patients, respectively. No difference in LDL-C screening rates existed for sex or age. Men and patients younger than age 65 years were significantly more likely to have BP measured. Overall, LDL-C and BP goals were attained by 48.9% and 43.3% of patients, respectively. Men and patients age 65 years or older were likelier than women and patients younger than age 65 years to attain LDL-C goals (p < 0.01). Men were also likelier than women to attain BP < 140/90 mm Hg (p < 0.01), but more patients younger than age 65 years vs older than age 65 years attained this goal (p < 0.01). Statins and antihypertensives were received by 51.9% and 46.9% of the patients, respectively.

CONCLUSION

Although attaining guideline-recommended goals for LDL-C and BP may present challenges, future research should focus on innovative methods to help patients attain optimal treatment goals.

A medication therapy management program's impact on low-density lipoprotein cholesterol goal attainment in Medicare Part D patients with diabetes

OBJECTIVES

To determine a medication therapy management (MTM) service's impact on (1) Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and (2) use and cost expenditures.

DESIGN

Nonequivalent group, quasiexperimental study.

SETTING

Florida, January 1, 2006, through September 30, 2007.

PARTICIPANTS

2,114 Florida Health Care Plans Medicare Part D enrollees with diabetes.

INTERVENTION

Intervention group participated in the MTM program during the HEDIS measurement year.

MAIN OUTCOME MEASURES

Presence of low-density lipoprotein cholesterol (LDL-C) screening, LDL-C values, and LDL-C control (<100 mg/dL). The use measure was the total number of 30-day medication equivalents. Cost measures were (1) total Medicare Part D drug cost, (2) enrollees' out-of-pocket Part D medication costs, and (3) total medication copayments. Statistical analyses included chi-square, independent and paired t tests, and analysis of variance with post hoc comparisons.

RESULTS

Of 2, 114 enrollees eligible for comprehensive diabetes care (CDC) according to HEDIS guidelines, 255 participated in the MTM intervention group and 56 patients were MTM eligible but opted out of the program or could not be reached for medication review during 2008 (MTM nonparticipants). A higher proportion of patients in the MTM participant group had LDL-C levels less than 100 mg/dL (69.0%) compared with those in the MTM nonparticipant (50.0%) and CDC only (54.1%) groups (chi2 = 20.9(3), P < 0.001). The two control groups' average LDL-C (90.8 and 93.6 mg/dL) was significantly higher than the intervention group (83.4 mg/dL, P < 0.001). Overall, per member per month use and drug costs differed from 2007 to 2008 and enrollees in the MTM participant group had greater percentage cost reductions.

CONCLUSION

Enrollees who were eligible for MTM services but did not receive them had poorer clinical, use, and cost outcomes compared with the MTM intervention group. Pharmacists collaborating with physicians through a MTM program can improve quality of metrics for chronic diseases and reduce medication costs.

Taking the lead: community pharmacists' perception of their role potential within the primary care team

BACKGROUND

Patient-focused care provided by an interprofessional team has long been presented as the preferred method of primary care delivery. Community pharmacists should and can provide leadership for many clinical and managerial activities within the primary care team.

OBJECTIVE

To determine the extent to which community pharmacists are prepared to be members of the health care team, and to assess their support for general expansion of clinical responsibilities.

METHODS

A mail questionnaire (in either English or French) was sent to 1500 community pharmacists between February and April 2004. Respondents were asked to indicate the necessity of pharmacy leadership for a range of clinical and managerial services associated with a primary care team. Respondents were also asked to indicate the extent to which they should be more involved in drug therapy selection and monitoring, as well as assuming greater responsibility for treating both minor and chronic illnesses.

RESULTS

The response rate was 35.2% (470/1337) with the highest response rate in the Prairie provinces (40.6%) and the lowest in Quebec (24.4%). Most pharmacists in the study did not advocate a strong leadership role for non-discipline-specific clinical and managerial activities. Most of them indicated that community pharmacists should be more involved in selecting (69.9%) and monitoring (81.0%) drug therapy, and be more responsible for treating minor illnesses (72.0%). Support for more responsibility declined to 50% for chronic illnesses.

CONCLUSIONS

The findings of the study suggest substantial variability among pharmacists in their perception of the need for pharmacy leadership across 16 clinical and managerial activities.

Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease

BACKGROUND

Little is known about the effect of nonadherence among patients with coronary artery disease (CAD) on a broad spectrum of outcomes including cardiovascular mortality, cardiovascular hospitalizations, and revascularization procedures.

METHODS

This was a retrospective cohort study of 15,767 patients with CAD. Medication adherence was calculated as proportion of days covered for filled prescriptions of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statin medications. Multivariable Cox regression assessed the association between medication nonadherence as a time-varying covariate and a broad range of outcomes, adjusting for demographics and clinical characteristics. Median follow-up was 4.1 years.

RESULTS

Rates of medication nonadherence were 28.8% for beta-blockers, 21.6% for ACE inhibitors, and 26.0% for statins. In unadjusted analysis, nonadherence to each class of medication was associated with higher all-cause and cardiovascular mortality. In multivariable analysis, nonadherence remained significantly associated with increased all-cause mortality risk for beta-blockers (hazard ratio [HR] 1.50, 95% CI 1.33-1.71), ACE inhibitors (HR 1.74, 95% CI 1.52-1.98), and statins (HR 1.85, 95% CI 1.63-2.09). In addition, nonadherence remained significantly associated with higher risk of cardiovascular mortality for beta-blockers (HR 1.53, 95% CI 1.16-2.01), ACE inhibitors (HR 1.66, 95% CI 1.26-2.20), and statins (HR 1.62, 95% CI 1.124-2.13). The findings of increased risk associated with nonadherence were consistent for cardiovascular hospitalization and revascularization procedures.

CONCLUSIONS

Nonadherence to cardioprotective medications is common in clinical practice and associated with a broad range of adverse outcomes. These findings suggest that medication nonadherence should be a target for quality improvement interventions to maximize the outcomes of patients with CAD.

Investigation of barriers to clinical practice guideline-recommended pharmacotherapy in the treatment of COPD

BACKGROUND

The adoption of clinical practice guideline recommendations for COPD is suboptimal. Determining the barriers to the implementation of these practice guidelines may help improve patient care.

OBJECTIVE

To determine whether barriers to the use of pharmacotherapy according to practice guidelines are related primarily to patient or prescriber factors.

METHODS

Retrospective cohort study. Members of a health maintenance organization identified as having spirometry-defined COPD ranging from stage II to IV. Electronic medical records were reviewed for documentation of the following: 1) patient affordability issues, 2) history of an adverse drug reaction, 3) history of inefficacy to therapy, and 4) prescription history.

RESULTS

A total of 111 medical records were reviewed. There were 51% of patients who had not filled medications that had been prescribed in accordance with guidelines and 43% did not have the guideline recommended medications prescribed in the previous year. Only 4% and 2% of patients had documented inefficacy and affordability issues, respectively. There were no reported cases of adverse drug reactions.

CONCLUSIONS

This study provides insight to the acceptance of COPD treatment recommendations by patients and providers. Further research is needed to design interventions to reduce barriers and optimize COPD treatment.