Integration of outpatient infectious diseases clinic pharmacy services and specialty pharmacy services for patients with HIV infection

Clinician Specialty and HIV PrEP Prescription Reversals and Abandonments

Importance

Clinicians are a key component of preexposure prophylaxis (PrEP) care. Yet, no prior studies have quantitatively investigated how PrEP adherence differs by clinician specialty.

Objective

To understand the association between prescribing clinician specialty and patients not picking up (reversal/abandonment) their initial PrEP prescription.

Design, Setting, and Participants

This cross-sectional study of patients who were 18 years or older used pharmacy claims data from 2015 to 2019 on new insurer-approved PrEP prescriptions that were matched with clinician data from the US National Plan and Provider Enumeration System. Data were analyzed from January to May 2022.

Main Outcomes and Measures

Clinician specialties included primary care practitioners (PCPs), infectious disease (ID), or other specialties. Reversal was defined as a patient not picking up their insurer-approved initial PrEP prescription. Abandonment was defined as a patient who reversed and still did not pick their prescription within 365 days.

Results

Of the 37 003 patients, 4439 (12%) were female and 32 564 (88%) were male, and 77% were aged 25 to 54 years. A total of 24 604 (67%) received prescriptions from PCPs, 3571 (10%) from ID specialists, and 8828 (24%) from other specialty clinicians. The prevalence of reversals for patients of PCPs, ID specialists, and other specialty clinicians was 18%, 18%, and 25%, respectively, and for abandonments was 12%, 12%, and 20%, respectively. After adjusting for confounding, logistic regression models showed that, compared with patients who were prescribed PrEP by a PCP, patients prescribed PrEP by ID specialists had 10% lower odds of reversals (odds ratio [OR], 0.90; 95% CI, 0.81-0.99) and 12% lower odds of abandonment (OR, 0.88; 95% CI, 0.78-0.98), while patients prescribed by other clinicians had 33% higher odds of reversals (OR, 1.33; 95% CI, 1.25-1.41) and 54% higher odds of abandonment (OR, 1.54; 95% CI, 1.44-1.65).

Conclusion

The results of this cross-sectional study suggest that PCPs do most of the new PrEP prescribing and are a critical entry point for patients. PrEP adherence differs by clinician specialties, likely due to the populations served by them. Future studies to test interventions that provide adherence support and education are needed.

Consensus methodology to investigate the crucial referral criteria to pharmacist-led counseling clinics in Makkah City

Aim

Identifying and prioritizing criteria for referring patients to a counseling clinic managed by hospital pharmacists in the tertiary care setting in Saudi Arabia (SA).

Method

A two-phase consensus Delphi methodological approach was adopted in this study. Data was collected from physicians and pharmacists from different specialties working in different hospitals in Makkah City. In Phase 1, semi-structured interviews were conducted with physicians and pharmacists to discuss and develop the initial list of potential referral criteria for post-discharge counseling. Phase 2 consisted of two rounds of online surveys where participants were asked to independently rank the referral criteria using a 5-point Likert Scale.

Results

In Phase 1, four participants undertook the interviews (two physicians and two pharmacists). Overall, no major comments were given on the suggested criteria. In Phase 2, most suggested referral criteria to the counseling clinic reached participants' consensus agreement of >70 % in both rounds for all three domains. Among all criteria that achieved consensus agreement, two demographic criteria were top-ranked by the participants; the elderly patients (100 %) and those who needed help with their devices (96 %). These were followed by five medication-related criteria, which are medication-related problems, polypharmacy, medication that needs monitoring, high-risk medication, and medication with special formulations. All had a consensus agreement of 96 %.

Conclusion

This study suggests that a counseling clinic led by pharmacists is particularly advisable for the elderly, individuals requiring assistance with their devices, and those encountering medication issues. It is essential to prioritize specific patient demographics when contemplating the extensive establishment and integration of such clinics across various hospitals in SA.

Assessment of pharmacy technician job satisfaction and duties in ambulatory care pharmacy settings: A mixed-methods analysis

PURPOSE

Expansion of pharmacy services into ambulatory care has prompted the integration of pharmacy technicians into this setting. Many models exist for technician practice in ambulatory care, and job satisfaction in these settings needs evaluation. This study assessed the job satisfaction of ambulatory care pharmacy technicians, obtained a deeper understanding of their varied roles, and examined commitment to the pharmacy technician career and their employing organization.

METHODS

This study used a mixed-methods sequential explanatory design of quantitative followed by qualitative data analysis. The phases included a validated questionnaire on job satisfaction and semistructured interviews using a modified guide and findings from the quantitative data. Descriptive statistics and constant comparative analysis were used to analyze quantitative and qualitative data, and data were integrated in the discussion.

RESULTS

The questionnaire was sent to 125 potential participants at 11 organizations in 8 unique states. Seventy-four technicians participated in the quantitative phase. Seventeen of these were interviewed in the qualitative phase. Interviewees represented 7 different institutions in 6 states in the Southeast, Midwest, and Western regions of the US. Both phases indicated that respondents felt a strong commitment to their organization, with 60% of respondents indicating this on the questionnaire. Reasons for this commitment were further elucidated in the qualitative phase, which indicated high satisfaction with technician autonomy, work schedules, and ability to provide important services to patients. It was also found in both phases that technician duties varied greatly among organizations, although most technicians were involved in facilitating medication access.

CONCLUSION

Ambulatory care pharmacy technicians are highly satisfied with their positions and careers. Although technician roles vary within ambulatory care settings, the majority involve facilitating medication access in various ways. As these positions become more prevalent in pharmacy practice, it will be important to continue to capitalize on satisfiers and mitigate dissatisfiers to advance the profession and ultimately provide optimal patient care.

Health-system specialty pharmacy role and outcomes: A review of current literature

DISCLAIMER

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

PURPOSE

Specialty medications can have life-altering outcomes for patients with complex diseases. However, their benefit relies on appropriate treatment selection, patients' ability to afford and initiate treatment, and ongoing treatment optimization based on patient response to therapy. Mounting research demonstrates the benefits of the health-system specialty pharmacy (HSSP) in improving specialty medication access, affordability, and outcomes. The purpose of this rapid review is to describe the currently reported role and function of HSSP pharmacists and outcomes reported with use of the HSSP model, and to identify gaps in the literature where more information is needed to better understand the HSSP model and outcomes.

SUMMARY

Current literature describes the role of HSSP pharmacists in facilitating patient access, affordability, and initiation and maintenance of specialty medications. Though it is clear HSSP pharmacists are involved in treatment monitoring, often through utilizing the electronic health record, more information is needed to elucidate the frequency, method, and extent of monitoring. Despite several valuable continuity of care services reported to be provided by HSSPs, the breadth and degree of standardization of these services remains unclear. There is minimal literature describing HSSP education and research involvement. HSSPs have reported significant benefits of this patient care model, as demonstrated by higher adherence and persistence; better clinical outcomes; financial benefits to patients, payers and the health system; better quality of care; higher patient and provider satisfaction with services, and highly efficient specialty pharmacy services. More literature comparing clinical and diagnosis-related outcomes in HSSP versus non-HSSP patients is needed.

CONCLUSION

HSSPs provide comprehensive, patient-centered specialty medication management that result in improved care across the continuum of the specialty patient journey and act as a valuable resource for specialty clinics and patients beyond medication management. Future research should build on the current description of HSSP services, how services affect patient outcomes, and the impact HSSP network restrictions.

Implementation of an integrated pharmacist collaborative care model in specialty disease state clinics

DISCLAIMER

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

PURPOSE

To expand health-system specialty pharmacy (HSSP) clinical continuity by implementing a specialty integrated model for clinical services in target sites.

SUMMARY

After evaluation of baseline clinical continuity and institutional goals, select clinics were identified as target sites to which to expand this integrated approach of a medication management clinic (MMC). In this MMC model, the key steps included engaging stakeholders, workflow training, optimization of the electronic health record, service evaluation, compliance with regulatory standards, and development of marketing strategies. The initial focus was development of innovative collaborative practice agreements (CPAs) to expand the scope of ambulatory care pharmacists' practice. Analysis of existing specialty and ambulatory workflows and technology was completed before development of the integrated workflow. Existing credentialing policies were updated to support expanded practices, and marketing collaterals were developed to support growth of pharmacy referrals. Meetings with stakeholders took place to ensure smooth transitions into integrated areas. Primary endpoints included clinical continuity, as determined by prescription orders placed within the health system sent to the HSSP, and number of signed referrals to MMC. Secondary endpoints included disease state-specific clinical outcomes as well as overall outcomes such as medication adherence, laboratory test adherence, immunization rates, and patient and clinician satisfaction. An MMC model was successfully implemented in 5 target specialty practices. Specialty clinic CPAs were developed for rheumatology and digestive health (including viral hepatitis). Since implementation, clinical continuity increased 23% and referrals exceeded the target at 165%. Data on secondary endpoints are currently being collected to evaluate quality of pharmacy services. Pharmacy services have enhanced patient care and received positive feedback from clinicians.

CONCLUSION

Expansion of integrated decentralized pharmacists into target practices has increased clinical continuity and the number of pharmacist referrals. Clinicians have regarded pharmacists as vital members of the team. Creation of additional specialty CPAs will be needed to support further growth in other clinics.

Pharmacist's role in HIV care in France. Implication for clinical improvement of people living with HIV worldwide

In France, antiretroviral (ARV) treatment can be dispensed by hospital and/or community pharmacies. Since January 2016, an online patient medication file can be used to optimize dispensing, but medication interviews have not yet been incorporated into this system. To understand both people living with HIV (PLHIV) and their pharmacists’ habits and expectations of patient medication file and interviews, two consecutive national surveys were organized. The first one, carried out in October 2016 in care centers, was an anonymous questionnaire for PLHIV. The second one was an online survey for community and hospital pharmacies conducted in February 2017. A total of 1137 PLHIV (68% men, of mean age 50.2 ± 11.5 years, CD4 count 671 ± 354, 90% with undetectable HIV viral load (VL) and 64.2% reporting comorbidities) and 246 pharmacies responded. While the existence of the online medication file is known by 58% of PLHIV, only 40% of pharmacists declare it to be systematically offered. It was offered to 120/694 (17%) PLHIV and 96 (80%) accepted it. Currently, 78 (7%) PLHIV feel well taken care of because they are offered medication interviews, 343/1078 (32%) would like to take advantage of this program, mainly those with a shorter ARV duration (OR ARV duration 0.97 [0.95‐0.99]), a VL less often undetectable (OR undetectable VL 0.55 [0.31‐0.98]), and those who feel anxious more often (OR anxious 2.38 [1.48‐3.84]). These results suggest that better implementation of medication files and interviews will strengthen current clinical pathways.

Evaluation of a pharmacy technician-based medication prior authorization program

BACKGROUND

The roles of pharmacy technicians in clinical practice are being explored. Medication prior authorizations (PAs) from insurers can lead to delays in pharmacotherapy.

OBJECTIVE

To assess the efficiency of our clinical pharmacy technicians in processing PAs for medications.

PRACTICE DESCRIPTION

Outpatient clinics in a comprehensive health care provider group.

PRACTICE INNOVATION

PA requests are routed to technicians for initial data collection. Clinical pharmacists can review their work before submission.

EVALUATION METHODS

Clinical pharmacy staff in 4 clinics recorded information about PA requests from January 21, 2020, to April 21, 2020. In 3 of the clinics, PA requests were primarily processed by clinical pharmacy technicians. In another clinic, requests were processed by a clinical pharmacist. Information collected included the date the request was received, outcomes (e.g., approval, therapy change, or nonapproval), and the date of final outcome. Descriptive statistics were prepared, including number of requests that were approved, number of business days between request and decision, and final outcome.

RESULTS

Overall, 720 PA requests were received. Of these, 88.6% were approved with first response, and 673 (93.5%) were eventually approved. Median time to first response was 0 business days, regardless of clinic. In 75% of cases, first response was within 1 business day. PA characteristics varied across clinics; however, PA approval percentages were comparable (91.2%-94.3%).

CONCLUSION

In an assessment of clinical pharmacy technicians' efficiency in responding to pharmacy plan PA requests, more than 90% were approved, often within one business day. Our results must be interpreted in light of local factors and a virus pandemic during the study. However, results of requests handled by technicians were similar to results when the requests were handled by a clinical pharmacist. Clinical pharmacy technicians can be efficient and cost-effective in this role.

Comparison of provider satisfaction with specialty pharmacy services in integrated health-system and external practice models: A multisite survey

Purpose

The purpose of this study is to obtain insight into providers’ satisfaction with services offered by health-system integrated specialty pharmacies and to determine whether providers’ perceptions of services offered under an integrated model differ from perceptions of external specialty pharmacy services.

Methods

A multi-site, cross-sectional, online survey of specialty clinic healthcare providers at 10 academic health systems with integrated specialty pharmacies was conducted. The questionnaire was developed by members of the Vizient Specialty Pharmacy Outcomes and Benchmarking Workgroup and was pretested at 3 pilot sites prior to dissemination. Prescribers of specialty medications within each institution were identified and sent an email invitation to participate in the study that included a link to the anonymous questionnaire. Respondents were asked to rate their agreement with 10 statements regarding quality of services of integrated and external specialty pharmacies on a 5-point scale (1 = strongly disagree, 5 = strongly agree). An analysis to determine differences in providers’ overall satisfaction with the integrated and external specialty pharmacy practice models, as well as differences in satisfaction scores for each of the 10 statements, was performed using paired-samples t tests.

Results

The mean (SD) score for overall satisfaction with integrated specialty pharmacies was significantly higher than the score for satisfaction with external specialty pharmacies: 4.72 (0.58) vs 2.97 (1.20); 95% confidence interval, 1.64-1.87; P < 0.001. Provider ratings of the integrated specialty pharmacy model were also higher for all 10 items evaluating the quality of services (P < 0.05 for all comparisons).

Conclusion

The study results confirm that the health-system integrated specialty pharmacy practice model promotes high rates of provider satisfaction with services and perceived benefits.

Embedding an Advanced Pharmacy Technician in an Adult Specialty Pulmonary Clinic to Complete Prior Authorizations Improves Efficiency and Provider Satisfaction

PURPOSE

The purpose of this study is to assess the impact of a clinic embedded Medication Assistance Program (MAP) specialist on the prescription benefit prior authorization (PA) process and provider satisfaction in an adult pulmonary clinic.

METHODS

In this mixed methods study, a retrospective cohort analysis was done to determine the turnaround time for the PA process from initial referral to approval or final denial in an adult pulmonary clinic. Additionally, a pre- and post-implementation survey to providers was conducted to assess provider satisfaction and perceptions around the prescription benefit PA process. The first study aim assessed PA efficiency by summarizing PA approval rate and PA turnaround time using descriptive statistics. Any prescriptions written by a clinic provider requiring a PA during the timeframe of June 2018 through August 2018 were included. The second study aim assessed change in provider satisfaction, analyzed via the Mann-Whitney U test.

RESULTS

The MAP specialist completed 110 PAs over 3 months for 110 unique patients. Median turnaround time was 3 hours, with 76% of PAs approved in less than 24 hours. Initial approval rate was 82.7%, and overall approval rate following the appeals process was 87.3%. A significant difference between the pre- and post-survey responses were identified in 2 of the 17 questions.

CONCLUSION

Implementation of a clinic embedded MAP specialist to complete PAs demonstrated an efficient process while also improving provider satisfaction.

The Effect of an Integrated Health System Specialty Pharmacy on HIV Antiretroviral Therapy Adherence, Viral Suppression, and CD4 Count in an Outpatient Infectious Disease Clinic

BACKGROUND

Adherence to antiretroviral (ARV) therapy is critical in order to achieve and maintain viral suppression and improve immune function. Clinical pharmacists and pharmacies focused on human immunodeficiency virus (HIV) have demonstrated the ability to increase ARV medication adherence and subsequently have a positive effect on these lab markers.

OBJECTIVES

To evaluate the effect of an integrated health system specialty pharmacy service with a clinic-embedded, HIV-trained pharmacist and pharmacy technician on ARV medication adherence rate, viral load, and CD4 count.

METHODS

This was a single-center, retrospective cohort study conducted from August 7, 2017, to June 30, 2018, at an indigent outpatient infectious disease clinic within Atrium Health (AH), a not-for-profit health system based in Charlotte, NC. The intervention group (opt-in group) received HIV patient care that involved the health system specialty pharmacy service. Once a patient was enrolled in the specialty pharmacy service, medication reconciliation was completed by the pharmacist, financial assistance and prior authorizations were completed if needed; prescriptions were delivered to the patient; and monthly refills calls were conducted to assess adherence, tolerability, and medication changes. The control group (opt-out group) received HIV patient care that did not incorporate the health system specialty pharmacy. The primary endpoints were medication adherence, viral suppression, and CD4 counts. Within-group comparisons from baseline to follow-up were made along with group-to-group comparisons. Adherence was calculated using medication possession ratio.

RESULTS

For those patients using Atrium Health Specialty Pharmacy Service (AH SPS; n = 46), the overall median adherence rate was higher at 100% versus only 94% for those patients (n = 50) that opted out of the service (P < 0.01). All but 3 patients (21.7% at baseline vs. 6.5% at follow-up, P = 0.03) using AH SPS reached viral suppression, and all but 1 had improved immune function with a CD4 count of 200 or greater by the end of the observation period (P = 0.03). The change in viral suppression and CD4 count of 200 or greater was not statistically improved between baseline and follow-up in those opting out of using AH SPS. When comparing the 2 groups at reaching these endpoints, there was no statistically significant difference in viral suppression and CD4 count.

CONCLUSIONS

AH SPS was able to demonstrate improved ARV adherence in those patients using an integrated specialty pharmacy with an embedded pharmacy team, coordinated monthly medication delivery, and refill reminder and adherence calls. This in turn led to improved viral suppression and immune markers by the end of the observation window for patients using AH SPS.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose.

Monitoring of Delay to Pharmacy Refill in Assessing Adherence to Antiretroviral Therapy

BACKGROUND

Adherence to antiretroviral (ARV) therapy remains a major challenge in HIV therapeutics.

OBJECTIVE

To assess the adherence to ARV therapy by measuring the delay in monthly refilling of ARV drugs using pharmacy records and to correlate this with HIV plasma RNA measurements and CD4⁺ cell count.

METHOD

Records of 170 HIV-positive patients were examined to identify HIV viral load (VL)/CD4⁺ results and the time interval to refill ARVs at the pharmacy. The correlation between the number of days missed to refill ARVs and plasma HIV-RNA detectability/CD4⁺ count was performed using the Spearman's correlation coefficient (r).

RESULTS

Fewer days missed to refill ARV was positively correlated with undetectable VL and increase in CD4⁺ count (r = 0.407 and 0.237, respectively). Increase in adherence was correlated with longer retention in the cohort (r = 0.208).

CONCLUSION

Monitoring the delay to pick up ARVs from the pharmacy can be an important and simple tool to identify patients requiring assessment of their adherence.

Advancing Patient Care Through Specialty Pharmacy Services in an Academic Health System

BACKGROUND

With the rapid growth of specialty pharmacies, including those within academic health systems, pharmacists have the opportunity to improve patient care through the management of specialty medications. Specialty pharmacists within academic health systems are uniquely positioned to overcome restrictions to medication access, financial constraints, and provider burdens that often lead to obstacles for patients to start and maintain necessary treatments. The Vanderbilt Specialty Pharmacy (VSP) model at Vanderbilt University Medical Center (VUMC) provides an example of a patient-centered, collaborative care prototype that places pharmacists directly into specialty clinics to assist with comprehensive management of patients on specialty medications.

PROGRAM DESCRIPTION

VSP integrates specialty pharmacy services within existing specialty clinics based on the needs of each individual clinic. Each clinic is staffed with at least 1 clinical pharmacist and 1 pharmacy technician. The pharmacist is integrally involved in medication selection, initiation, and monitoring. The specialty pharmacy team ensures appropriate medication access and cost, provides extensive medication education, ensures patients are adherent to treatment, and coordinates care between patients and providers using the electronic medical record.

OBSERVATIONS

Integration of pharmacists within specialty clinics at VUMC benefits providers, the health system, and patient care. This model has demonstrated decreased provider and clinic burden, decreased time to medication approval and initiation, excellent patient and provider satisfaction, substantial patient cost savings, optimal medication adherence, and overall improved continuity of care for patients on specialty medications. Since its inception in 2011, VSP has integrated 24 clinical pharmacists and 17 pharmacy technicians into 20 specialty clinics, with continued quarterly growth.

IMPLICATIONS

The VSP model advances the role of pharmacists in managing patients on specialty medications in collaboration with providers. The integrated collaborative approach as presented by VSP represents a best practices model for those establishing and advancing specialty pharmacy services within academic health systems.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose. Study concept and design were principally contributed by Bagwell and Newman, along with the other authors. Lee took the lead in data collection, along with Carver, Bagwell, Kelley, and Newman. Data interpretation was performed by Carver, Kelley, Lee, and Bagwell, with assistance from Newman. The manuscript was written by Bagwell, Carver, Kelley, and Lee and revised primarily by Bagwell, along with the other authors.

Advancing the role of the pharmacy technician: A systematic review

OBJECTIVES

To summarize the findings of a literature search on advancing the role of pharmacy technicians, including the types of training identified and the potential costs and benefits to both the technician and the pharmacy.

DATA SOURCES

A literature search of Scopus, Embase, and Medline was conducted on January 11, 2017.

STUDY SELECTION

Original research, research reports, case studies, or association reports were included for review. Articles were considered to be relevant based on identification of an advanced pharmacy technician role or addressing additional training/education for technician functions.

DATA EXTRACTION

A standard data extraction form was used to collect study authors, article title, year published, journal title, study design, brief description of methods, primary outcome measures, advanced technician roles identified, additional education or training addressed, and additional costs and benefits identified in each article.

RESULTS

A total of 33 articles were included for full review and data extraction. Study design varied, with 17 (52%) quantitative, 1 (3%) qualitative, 5 (15%) mixed-method, and 10 (30%) case study designs. Seventeen (52%) of the studies included were published after 2006. The mechanism of training was primarily through supervised on-the-job training, allowing technicians to assume administrative-based positions that facilitated a pharmacist-led clinical service, with either the pharmacist or the pharmacy receiving the greatest benefits.

CONCLUSION

Although the literature supports technicians performing advanced roles in the pharmacy, resulting in either improved patient outcomes or opportunities for pharmacists to engage in additional clinical services, the benefits to the technician were primarily indirect, such as an increase in job satisfaction or a more desirable work schedule. If a technician is to take on additional roles that require completion of a formalized training or educational program, benefits that are more tangible may help to inspire technicians to pursue these roles.