Part Two: Diabetes Part 2: A Review of Insulin Therapy in Older Patients

Diabetes mellitus is a common disease state among older people, with type 2 diabetes making up most cases. As the disease progresses, many patients will need to transition to insulin therapy. Pharmacists can play a pivotal role in the care of older people with diabetes by providing recommendations related to insulin therapy. Senior care pharmacists need to be knowledgeable about the pharmacokinetics, dosing, adverse effects, and cost concerns related to insulin therapy.

Use of Learning Management System Data to Predict Student Success in a Pharmacy Capstone Course

Objective. Learning management system (LMS) data from online classes may provide opportunities to identify students at risk of failure. Previous LMS studies have not addressed the possibility of change in student engagement over time. The purpose of this study was to apply a novel statistical technique, group-based trajectory modeling (GBTM) to LMS data in an online course to identify predictors of successful course completion.Methods. Exploratory GBTM was used to assess the association of LMS activity (total activity time, dates of activity, and pages viewed) and attendance at virtual synchronous learning sessions with examination performance in a capstone disease-management course delivered in the final didactic quarter of a three-year Doctor of Pharmacy program. Groups were assigned based on trajectories of weekly page view counts using structural-equation modeling.Results. Group-based trajectory modeling identified three page view engagement groups (median total page views, n): group 1, high (1,818, n=24): group 2, moderate (1,029, n=74), and group 3, low (441 views, n=35). Group assignment alone was somewhat associated with final grade. Stratification based on consistent virtual synchronous learning session attendance improved predictive accuracy; for example, a top (A or A-) grade was earned by 49.0% and 24.0%, respectively, of group 2 students with and without consistent synchronous engagement.Conclusion. Application of GBTM to LMS data, including information about synchronous engagement, could provide data that allow educators to identify early warning signs that a student may fail a course and target interventions to those at-risk students. The technique should be further tested with alternative LMS data and obtained early in the didactic curriculum, before patterns of engagement are established.

The Medication-Related, Information-Seeking Experiences and Barriers for Family Caregivers of Older People

Objective To characterize family caregivers of older people' experiences related to medication information-seeking, including the ability to find medication information and barriers faced in the medication information-seeking process. Design A prospective cross-sectional survey of family caregivers of older people. Setting An online panel of self-identified family caregivers. Participants Family caregivers of older people 60 years of age or older. Results A total 555 family caregivers of older people responded to the survey. Caregiver respondents' mean age was 43.6 (± 14.0) years; they were primarily female (82.5%) and White (74.4%). About three-quarters of respondents assisted with managing medications for care-recipients. Caregivers whose care-recipients were taking medications (n = 537) performed a variety of medication-related activities with 67.8% looking up information online in the last month. While 70.6% of caregivers have asked pharmacists about medication information, only 21.0% considered pharmacists their primary source of such information. Barriers to looking for medication-related information included lack of time to speak to medical providers (51.0%) and pharmacists (45.3%), being unsure about the best source for information (45.9%), and time needed to care for others (43.0%). Conclusion Family caregivers of older people are involved in managing medications, including looking up medication-related information. Several barriers impact caregivers' ability to find medication-related information. Pharmacists can be more proactive in assessing and supporting caregivers' medication-related information needs.

Development of a tool to assess and advance the effectiveness of preceptors: The Habits of Preceptors Rubric

PURPOSE

Present the research performed to identify and describe habits of effective pharmacy preceptors and provide a framework for targeted preceptor assessment and development.

METHODS

A 5-round Delphi consensus-building process was used to refine the initial Habits of Preceptors Rubric (HOP-R) developed by the research team. Twenty experts in pharmacy experiential education participated. During the Delphi process, feedback and agreement on all parts of the HOP-R were sought, including the premise, introductory content, framework, preceptor domains, habits, habit level descriptions, and continuous professional development (CPD) plan. After each Delphi round, the research team grouped responses into themes and modified the draft rubric accordingly. These themes were used to frame the response document sent to the expert panel for the following Delphi round; this document explained modifications made to the HOP-R. Consensus was defined as a mean score of ≥3.25 on a 4-point scale (4 = strongly agree, 1 = strongly disagree) for posed statements or ≥70% agreement for ranked items.

RESULTS

In the final Delphi round (response rate, 95%), consensus was achieved for all HOP-R individual structural and content elements except the habit level descriptors, for which a secondary rank order analysis was performed. The final HOP-R has 3 domains encompassing 11 preceptor habits that can be displayed across 4 habit levels progressing from developing to master.

CONCLUSION

The HOP-R was developed to assess, quantify, and demonstrate growth across a wide variety of pharmacy preceptor habits. Potential utility includes use as a framework to articulate the knowledge, skills, and behaviors of effective preceptors, facilitate the creation of individualized CPD plans, and assess the impact of participation in teaching and learning curricula.

Evaluation of a peer- and self-grading process for clinical writing assignments

OBJECTIVES

As class sizes in pharmacy education increase, faculty must develop new assessment strategies for essay writing assignments. This study evaluated accuracy and student perceptions of an innovative grading process that utilizes both peer- and self-assessment.

METHODS

Four SOAP note sessions were evaluated. Each session included four activities: a writing workshop, assessment workshop, and reflection session. For each assessment workshop students scored their note and a blinded peer's note using a grading form, facilitated by a faculty-led discussion. In a subsequent reflection session, students reviewed their peer- and self-assigned grades and could petition for faculty review if desired. The average self-, peer-, and final-grades were compared for each of the four SOAP note sessions using ANOVA. After the fourth session, students completed an anonymous 10-question Likert-scale survey regarding their perceptions of the process and three open-response questions. Survey results were analyzed with descriptive statistics.

RESULTS

Approximately 140 students participated. No difference was found between the average self-, peer-, and final-grades for all four sessions (p > 0.05). The survey response rate was 65% (91/140). Survey questions were grouped into three themes. The majority of students either strongly agreed or agreed that sessions were well organized and effective (≥84%), assessment workshops enhanced learning (≥68%), and the scoring method was fair (≥72%). The lowest score (mean 2.53 on a 4-point scale) reflected satisfaction with peer-provided feedback. When asked what they liked most, respondents most commonly cited that faculty-led review and discussion enhanced clinical knowledge.

IMPLICATIONS

The combination of a peer- and self-assessment process was accurate, well-received, and can be used to decrease faculty workload.

Evaluating Prescribing Practices of Apixaban in the Elderly

OBJECTIVE: The aim of this study was to evaluate prescribing practices for elderly patients started on apixaban in multiple practice settings.<br/> DESIGN: Retrospective, chart review.<br/> SETTING: One outpatient and three inpatient settings in Arizona and Massachusetts.<br/> PATIENT, PARTICIPANTS: Patients who received a new order for apixaban between July 1, 2015, and December 31, 2016. Inclusion criteria included adults 65 years of age and older who were receiving apixaban for atrial fibrillation or venous thromboembolism (VTE) at a current treatment dose.<br/> There were 1,045 patients included, the average age was 78 years, 52% were male, and 90% had atrial fibrillation.<br/> MAIN OUTCOME MEASURE: Appropriate prescribing of apixaban based on Food and Drug Administration (FDA)-labeling (age, weight, serum creatinine).<br/> RESULTS: Six patients who were on hemodialysis were excluded from the analysis, leaving 1,039 patients to be analyzed. 16.2% (168/1,039) of patients had an incorrect dose of apixaban prescribed based on their indication. Of those, 75% (126/168) were taking the medication for atrial fibrillation and 25% (42/168) for VTE. For those with atrial fibrillation (n = 126), the majority of inappropriate orders resulted from doses that were lower than indicated (113/126).<br/> CONCLUSION: This research suggests that elderly patients may receive inappropriately lower doses of apixaban than indicated, which may decrease the effectiveness of the medication. This research supports the fact that pharmacists can play a vital role in anticoagulation stewardship by verifying apixaban doses for accuracy.

Evaluating Prescribing Practices of Apixaban in the Elderly

OBJECTIVE: The aim of this study was to evaluate prescribing practices for elderly patients started on apixaban in multiple practice settings.<br/> DESIGN: Retrospective, chart review.<br/> SETTING: One outpatient and three inpatient settings in Arizona and Massachusetts.<br/> PATIENT, PARTICIPANTS: Patients who received a new order for apixaban between July 1, 2015, and December 31, 2016. Inclusion criteria included adults 65 years of age and older who were receiving apixaban for atrial fibrillation or venous thromboembolism (VTE) at a current treatment dose.<br/> There were 1,045 patients included, the average age was 78 years, 52% were male, and 90% had atrial fibrillation.<br/> MAIN OUTCOME MEASURE: Appropriate prescribing of apixaban based on Food and Drug Administration (FDA)-labeling (age, weight, serum creatinine).<br/> RESULTS: Six patients who were on hemodialysis were excluded from the analysis, leaving 1,039 patients to be analyzed. 16.2% (168/1,039) of patients had an incorrect dose of apixaban prescribed based on their indication. Of those, 75% (126/168) were taking the medication for atrial fibrillation and 25% (42/168) for VTE. For those with atrial fibrillation (n = 126), the majority of inappropriate orders resulted from doses that were lower than indicated (113/126).<br/> CONCLUSION: This research suggests that elderly patients may receive inappropriately lower doses of apixaban than indicated, which may decrease the effectiveness of the medication. This research supports the fact that pharmacists can play a vital role in anticoagulation stewardship by verifying apixaban doses for accuracy.

Evaluation of a Pharmacist and Nurse Practitioner Smoking Cessation Program

Purpose:

To evaluate the efficacy of a smoking cessation program led by a pharmacist and a nurse practitioner.

Methods:

During a 6-month period, patients attended 7 one-on-one face-to-face smoking cessation counseling sessions with a pharmacist and 1 to 2 one-on-one face-to-face smoking cessation counseling sessions with a nurse practitioner. The primary outcome was smoking cessation point prevalence rates at months 1, 3, and 5 post-quit date. Secondary outcomes included medication adherence rates at months 1, 3, and 5 post-quit date, nicotine dependence at baseline versus program end, and patient satisfaction.

Results:

Nine (47%) of 19 total participants completed the program. Seven of the 9 patients who completed the program were smoke-free upon study completion. Point prevalence rates at months 1, 3, and 5 post-quit date were 66%, 77%, and 77%, respectively, based on patients who completed the program. Medication adherence rates were 88.6%, 54.6%, and 75% at months 1, 3, and 5 post-quit date, respectively. Based on the Fagerstrom test, nicotine dependence decreased from baseline to the end of the study, 4.89 to 0.33 ( P < .001). Overall, participants rated the program highly.

Conclusion:

A joint pharmacist and nurse practitioner smoking cessation program can assist patients in becoming smoke-free.

A Pilot Study to Evaluate Effectiveness of INR Self-Testing in Elderly Patients

OBJECTIVE

To determine if international normalized ratio (INR) patient self-testing (PST) resulted in an increased time in therapeutic range (TTR) in an elderly population when compared with clinic testing over a six-month period.

DESIGN

A pilot study and retrospective chart review from August 2010 to August 2014.

SETTING

Ambulatory, anticoagulation clinic with two locations in Sun City West and Peoria, Arizona.

PARTICIPANTS

Of 91 patients, the data of 20 patients who were 65 years of age or older and had at least six months of pre- and post-PST INR data were extracted and analyzed.

OUTCOMES

The primary outcome evaluated improvement of TTR during post-PST in elderly patients compared with clinic management over a six-month period. Secondary outcomes assessed patients' satisfaction with PST and identified barriers to PST.

RESULTS

The post-PST mean TTR significantly increased to 73% from 63.6% for the first six months of PST (P = 0.04). Participants were satisfied with PST, with an average score ranging from 4.6 to 5 on a Likert scale of 1 to 5 on 10 satisfaction survey questions. Cost was identified as the most common barrier to PST, with 43% of patients not participating in PST because of financial burden.

CONCLUSION

With appropriate screening and training, PST is associated with improved TTRs and higher patient satisfaction in elderly patients when compared with clinic testing. Barriers identified to PST include cost, the complex process, and noncompliance.

Evaluation of a pharmacist-led, 6-month weight loss program in obese patients

OBJECTIVE

To evaluate a pharmacist-led weight loss program based on the general requirements set forth by the Centers for Medicare & Medicaid Services' (CMS) Decision Memo for Intensive Behavioral Therapy for Obesity.

SETTING

Onsite Walgreens pharmacy located inside the main administration building of Maricopa County in downtown Phoenix, AZ.

PRACTICE DESCRIPTION

A prevention and wellness behavioral therapy weight loss program was developed for patients of the Maricopa County on-site Walgreens.

PRACTICE INNOVATION

Current pharmacy patients were recruited to attend 14 one-on-one, pharmacist-led, face-to-face behavioral therapy sessions during a 6-month period that addressed diet, exercise, and nutrition. Interactive PowerPoint presentations were used throughout the sessions.

MAIN OUTCOME MEASURES

The primary outcome was mean weight loss from baseline to the end of the study. Secondary outcomes included changes in body composition, changes in nutritional intake, and participant satisfaction.

RESULTS

Of 12 enrolled participants, 11 (92%) completed the program. The mean weight loss from baseline to the end of the program was 5 kg (P <0.001), representing an average 4.5% weight loss. There was a statistically significant decrease in body mass index (BMI), waist circumference, and percent visceral fat from baseline to the end of the study; however, the increase in percent muscle mass, decrease in percent body fat, and change in nutrition intake was not statistically significant. Overall, the participants rated the program highly.

CONCLUSION

Pharmacists are accessible health care providers who can effectively provide intensive behavioral therapy for obesity in a manner consistent with the CMS guidelines.

A team-based learning course on nutrition and lifestyle modification

OBJECTIVE

To create, implement, and evaluate an elective team-based learning (TBL) course on nutrition and lifestyle modification for pharmacy students.

DESIGN

An elective course with 15 contact hours was developed for second-year pharmacy students based on the principles of TBL. Student knowledge gained and satisfaction with the course were measured.

ASSESSMENT

Sixty-two students completed the course. Knowledge about nutrition and lifestyle modification was significantly improved by completing the course (59% and 91%, respectively, p=<0.001). The satisfaction survey instrument had a response rate of 97%, and the majority of students (>85%) responded favorably to the TBL components.

CONCLUSION

An elective course using TBL effectively delivered course content while teaching students communication and teamwork skills. The course was well received by students.

Vitamin D and Alzheimer's disease: is there a link?

OBJECTIVE

To review the research on a possible link between Alzheimer's disease (AD) and vitamin D deficiency.

DATA SOURCE

MEDLINE/PUBMED (January 1950-January 2010) and ISI Web of Science searches (January 1900-January 2010) were conducted using the key words vitamin D, Alzheimer disease, and dementia to identify pertinent studies. The Cochrane Library was searched to identify review articles along with clinicaltrials.gov to identify unpublished research.

STUDY SELECTION AND DATA EXTRACTION

Vitamin D and (Alzheimer* disease or dementia) was entered into each database. Manual review of the search results identified trials that discussed an association between AD or dementia and vitamin D. Manual bibliography searches were performed to identify other pertinent articles.

DATA SYNTHESIS

Vitamin D deficiency is a widespread problem among the elderly and has been associated with multiple disease states. Vitamin D deficiency has recently been linked to dementia, particularly AD, through several mechanisms. Current clinical trials discuss a possible link between low vitamin D levels and low cognitive test scores in AD patients.

CONCLUSION

The current observational studies seem to identify a link between vitamin D and dementia, particularly AD. Before this evidence can be used to make a recommendation for routine supplementation in elderly patients to prevent AD, more prospective trials with a longer follow-up period are needed to show a causality relationship.