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Response to: The expanded role of the transplant pharmacist: A 10-year follow-up by Lichvar et al. Am J Transplant 2023; 23:2011-2012. [PMID: 37573017 DOI: 10.1016/j.ajt.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/29/2023] [Indexed: 08/14/2023]
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The real unmet need: A multifactorial approach for identifying sensitized kidney candidates with low access to transplant. Clin Transplant 2023; 37:e14946. [PMID: 36841966 DOI: 10.1111/ctr.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/30/2023] [Accepted: 02/08/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND At the start of 2020, the kidney waiting list consisted of 2526 candidates with a calculated panel reactive antibody (CPRA) of 99.9% or greater, a cohort demonstrated in published research to have meaningfully lower than average access to transplantation even under the revised kidney allocation system (KAS). METHODS This was a retrospective analysis of US kidney registrations using data from the OPTN [Reference (https://optn.transplant.hrsa.gov/data/about-data/)]. The period-prevalent study cohort consisted of US kidney-alone registrations who waited at least 1 day between April 1, 2016, when HLA DQ-Alpha and DP-Beta unacceptable antigen data became available in OPTN data collection, to December 31, 2019. Poisson rate regression was used to model deceased donor kidney transplant rates per active year waiting and using an offset term to account for differential at-risk periods. Median time to transplant was estimated for each IRR group using the Kaplan-Meier method. Sensitivity analyses were included to address geographic variation in supply-to-demand ratios and differences in dialysis time or waiting time. RESULTS In this study, we found 1597 additional sensitized (CPRA 50-<99.9%) candidates with meaningfully lower than average access to transplant when simultaneously taking into account CPRA and other factors. In combination with CPRA, candidate blood type, Estimated Post-Transplant Survival Score (EPTS), and presence of other antibody specificities beyond those in the current, 5-locus CPRA were found to influence the likelihood of transplant. CONCLUSION In total, this suggests approximately 4100 sensitized candidates are on the waiting list who represent a community of disadvantaged patients who may benefit from progressive therapies and interventions to facilitate incompatible transplantation. Though associated with higher risks, such interventions may nevertheless be more attractive than remaining on dialysis with the associated accumulation of mortality risk over time.
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Imlifidase for the treatment of anti-HLA antibody-mediated processes in kidney transplantation. Am J Transplant 2022; 22:691-697. [PMID: 34467625 PMCID: PMC9293130 DOI: 10.1111/ajt.16828] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/08/2021] [Accepted: 08/26/2021] [Indexed: 01/25/2023]
Abstract
The IgG-degrading enzyme derived from Streptococcus pyogenes (Imlifidase, Hansa Biopharma) is a novel agent that cleaves all four human subclasses of IgG and has therapeutic potential for HLA desensitization in kidney transplantation and antibody-mediated rejection. Data from clinical trials in kidney transplantation demonstrated rapid degradation of anti-HLA donor-specific antibodies facilitating HLA-incompatible transplantation, which led to conditional approval of imlifidase by the European Medicines Agency for desensitization in kidney transplant recipients of a deceased donor with a positive cross match. Important considerations arising from the early experiences with imilfidase on kinetics of donor-specific antibodies after administration, timing of complementary therapeutic monoclonal or polyclonal IgG antibodies, and interference with cross match assays should be recognized as imlifidase emerges as a therapeutic agent for clinical transplantation.
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Outcomes at 3 years posttransplant in imlifidase-desensitized kidney transplant patients. Am J Transplant 2021; 21:3907-3918. [PMID: 34236770 PMCID: PMC9290474 DOI: 10.1111/ajt.16754] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/11/2021] [Accepted: 07/04/2021] [Indexed: 01/25/2023]
Abstract
Imlifidase is a cysteine proteinase which specifically cleaves IgG, inhibiting Fc-mediated effector function within hours of administration. Imlifidase converts a positive crossmatch to a potential donor (T cell, B cell, or both), to negative, enabling transplantation to occur between previously HLA incompatible donor-recipient pairs. To date, 39 crossmatch positive patients received imlifidase prior to a kidney transplant in four single-arm, open-label, phase 2 studies. At 3 years, for patients who were AMR+ compared to AMR-, death-censored allograft survival was 93% vs 77%, patient survival was 85% vs 94%, and mean eGFR was 49 ml/min/1.73 m2 vs 61 ml/min/1.73 m2 , respectively. The incidence of AMR was 38% with most episodes occurring within the first month post-transplantation. Sub-analysis of patients deemed highly sensitized with cPRA ≥ 99.9%, and unlikely to be transplanted who received crossmatch-positive, deceased donor transplants had similar rates of patient survival, graft survival, and eGFR but a higher rate of AMR. These data demonstrate that outcomes and safety up to 3 years in recipients of imlifidase-enabled allografts is comparable to outcomes in other highly sensitized patients undergoing HLA-incompatible transplantation. Thus, imlifidase is a potent option to facilitate transplantation among patients who have a significant immunologic barrier to successful kidney transplantation. Clinical Trial: ClinicalTrials.gov (NCT02790437), EudraCT Number: 2016-002064-13.
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Augmenting the Transplant Team With Artificial Intelligence: Toward Meaningful AI Use in Solid Organ Transplant. Front Immunol 2021; 12:694222. [PMID: 34177958 PMCID: PMC8226178 DOI: 10.3389/fimmu.2021.694222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/27/2021] [Indexed: 11/19/2022] Open
Abstract
Advances in systems immunology, such as new biomarkers, offer the potential for highly personalized immunosuppression regimens that could improve patient outcomes. In the future, integrating all of this information with other patient history data will likely have to rely on artificial intelligence (AI). AI agents can help augment transplant decision making by discovering patterns and making predictions for specific patients that are not covered in the literature or in ways that are impossible for humans to anticipate by integrating vast amounts of data (e.g. trending across numerous biomarkers). Similar to other clinical decision support systems, AI may help overcome human biases or judgment errors. However, AI is not widely utilized in transplant to date. In this rapid review, we survey the methods employed in recent research in transplant-related AI applications and identify concerns related to implementing these tools. We identify three key challenges (bias/accuracy, clinical decision process/AI explainability, AI acceptability criteria) holding back AI in transplant. We also identify steps that can be taken in the near term to help advance meaningful use of AI in transplant (forming a Transplant AI Team at each center, establishing clinical and ethical acceptability criteria, and incorporating AI into the Shared Decision Making Model).
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Advances in personalized medicine and noninvasive diagnostics in solid organ transplantation. Pharmacotherapy 2021; 41:132-143. [PMID: 33156560 DOI: 10.1002/phar.2484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/29/2020] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Abstract
Personalized medicine has been a mainstay and in practice in transplant pharmacotherapy since the advent of the field. Decisions pertaining to the diagnosis, selection, and monitoring of transplant pharmacotherapy are aimed toward the individual, the allograft, and the overall immunologic needs of the patient. Recent advances in pharmacogenomics, noninvasive biomarkers, and artificial intelligence (AI) technologies have the promise of transforming the way we individualize treatment and monitor allograft function. Pharmacogenomic testing can provide clinicians with additional data that can minimize toxicity and maximize therapeutic dosing in high-risk patients, leading to more informed decisions that may decrease the risk of rejection and adverse outcomes related to immunosuppressive therapies. Development of noninvasive strategies to monitor allograft function may offer safer and more convenient methods to detect allograft injury. Cell free DNA and gene expression profiling offer the potential to serve as "liquid biopsies" minimizing the risk to patients and providing clinicians with useful molecular data that may help individualize immunosuppression and rejection treatment. Use of big data in transplant and novel AI platforms, such as the iBox, hold tremendous promise in providing clinicians a "glimpse into the future" thereby allowing for a more individualized approach to immunosuppressive therapy that may minimize future adverse outcomes. Advances in diagnostics, laboratory science, and AI have made the application of personalized medicine even more tailored for solid organ transplant recipients. In this perspective, we summarize the current and emerging tools available, literature supporting use, and the horizon for future personalization of transplantation.
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ASHP Guidelines on Pharmacy Services in Solid Organ Transplantation. Am J Health Syst Pharm 2019; 77:222-232. [DOI: 10.1093/ajhp/zxz291] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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PRN OPINION PAPER: Application of precision medicine across pharmacy specialty areas. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Meeting report: Consensus recommendations for a research agenda to address immunosuppressant nonadherence in organ transplantation. Clin Transplant 2018; 32:e13362. [DOI: 10.1111/ctr.13362] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/13/2018] [Accepted: 07/24/2018] [Indexed: 11/26/2022]
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Transplant recipients are vulnerable to coverage denial under Medicare Part D. Am J Transplant 2018; 18:1502-1509. [PMID: 29446874 DOI: 10.1111/ajt.14703] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 02/05/2018] [Accepted: 02/07/2018] [Indexed: 01/25/2023]
Abstract
Transplant immunosuppressants are often used off-label because of insufficient randomized prospective trial data to achieve organ-specific US Food and Drug Administration (FDA) approval. Transplant recipients who rely on Medicare Part D for immunosuppressant drug coverage are vulnerable to coverage denial for off-label prescriptions, unless use is supported by Centers for Medicare & Medicaid Services (CMS)-approved compendia. An integrated dataset including national transplant registry data and 3 years of dispensed pharmacy records was used to identify the prevalence of immunosuppression use that is both off-label and not supported by CMS-approved compendia. Numbers of potentially vulnerable transplant recipients were identified. Off-label and off-compendia immunosuppression regimens are frequently prescribed (3-year mean: lung 66.5%, intestine 34.2%, pancreas 33.4%, heart 21.8%, liver 16.5%, kidney 0%). The annual retail cost of these at-risk medications exceeds $30 million. This population-based study of transplant immunosuppressants vulnerable to claim denials under Medicare Part D coverage demonstrates a substantial gap between clinical practice, current FDA approval processes, and policy mandates for pharmaceutical coverage. This coverage barrier reduces access to life-saving medications for patients without alternative resources and may increase the risk of graft loss and death from medication nonadherence.
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Impact of CYP3A5 genomic variances on clinical outcomes among African American kidney transplant recipients. Clin Transplant 2017; 32. [PMID: 29161757 DOI: 10.1111/ctr.13162] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2017] [Indexed: 01/22/2023]
Abstract
Little is known about the impact of CYP3A5 polymorphisms on transplantation outcomes among African American (AA) kidney transplant recipients (KTRs). To assess this issue, clinical outcomes were compared between AA CYP3A5*1 expressers and nonexpressers. This retrospective cohort study analyzed AA KTRs. Biopsy-proven acute rejection (BPAR), delayed graft function (DGF), glomerular filtration rate (GFR), infections, and tacrolimus dosing requirements were examined in 106 immunologically high-risk AA kidney transplant patients over a 2-year follow-up period. In CYP3A5*1 expressers compared to nonexpressers, the incidence of BPAR was significantly higher in the first 6 months (13% vs 0%; P = .016) compared to 24 months (13% vs 7%; P = .521). Tacrolimus total daily dose at first therapeutic level was significantly higher in CYP3A5*1 expressers (12 mg/day) compared to nonexpressers (8 mg/day; P < .001). Compared to CYP3A5*1 nonexpressers, DGF incidence was significantly higher among CYP3A5*1 expressers (27.6% vs 6.7%; P = .006). By contrast, median GFR was significantly higher in CYP3A5*1 expressers compared to nonexpressers (54.5 mL/min vs 50.0 mL/min; P = .003) at 24 months. The findings from this retrospective study suggest that AAs with CYP3A5*1 expression require 50% more tacrolimus and have an increased incidence of DGF and acute rejection.
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Barriers to vaccination in renal transplant recipients. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 04/05/2017] [Accepted: 04/21/2017] [Indexed: 12/19/2022]
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Prevalence of CYP3A5
Genomic Variances and Their Impact on Tacrolimus Dosing Requirements among Kidney Transplant Recipients in Eastern North Carolina. Pharmacotherapy 2017; 37:1081-1088. [DOI: 10.1002/phar.1970] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Early Outcomes From de Novo Weight-Based Dosing Compared With Conservative Dosing of Tacrolimus in Kidney Transplant Recipients: A Multisite Perspective. Ann Pharmacother 2017; 51:518-519. [PMID: 28478720 DOI: 10.1177/1060028017695328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Racial differences in incident de novo
donor-specific anti-HLA antibody among primary renal allograft recipients: results from a single center cohort study. Transpl Int 2017; 30:566-578. [DOI: 10.1111/tri.12937] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 11/14/2016] [Accepted: 02/13/2017] [Indexed: 12/16/2022]
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Expanding transplant pharmacist presence in pretransplantation ambulatory care. Am J Health Syst Pharm 2017; 74:22-25. [PMID: 28069678 DOI: 10.2146/ajhp160142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Onset and progression of de novo donor-specific anti-human leukocyte antigen antibodies after BK polyomavirus and preemptive immunosuppression reduction. Transpl Infect Dis 2016; 17:848-58. [PMID: 26442607 DOI: 10.1111/tid.12467] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 09/21/2015] [Accepted: 09/25/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND BK polyomavirus (BKPyV) viremia/nephropathy and reduction in immunosuppression following viremia may increase the risk of alloimmune activation and allograft rejection. This study investigates the impact of BKPyV viremia on de novo donor anti-human leukocyte antigen (HLA)-specific antibodies (dnDSA). PATIENTS AND METHODS All primary renal transplants at East Carolina University from March 1999 to December 2010, with at least 1 post-transplant BKPyV viral load testing, were analyzed. Patients were negative for anti-HLA antibodies to donor antigens (tested via single antigen beads) at transplantation and at first BKPyV testing. RESULTS Nineteen of 174 patients (11%) tested positive for BKPyV viremia. Within 24 months of BKPyV viremia detection, 79% of BKPyV-viremic patients developed dnDSA. Only 20% of BKPyV viremia-persistent cases, compared to 86% of BKPyV viremia-resolved cases, developed dnDSA (P = 0.03). Poor allograft survival was evident in BKPyV viremia-persistent patients (60% failure by 2 years post BKPyV diagnosis) and in BKPyV viremia-resolved patients with dnDSA (5-year post BKPyV diagnosis allograft survival of 48%). CONCLUSIONS Post-transplant BKPyV viremia and preemptive immunosuppression reduction is associated with high rates of dnDSA. When preemptively treating BKPyV viremia, dnDSA should be monitored to prevent allograft consequences.
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Impact of the Pharmacy Practice Model Initiative on Clinical Pharmacy Specialist Practice: An Alternative Viewpoint. Pharmacotherapy 2016; 36:e195-e197. [PMID: 27714823 DOI: 10.1002/phar.1844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Nonadherence to therapy after adult solid organ transplantation: A focus on risks and mitigation strategies. Am J Health Syst Pharm 2016; 73:909-20. [PMID: 27189855 DOI: 10.2146/ajhp150650] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Assessing pharmacologic and nonpharmacologic risks in candidates for kidney transplantation. Am J Health Syst Pharm 2015; 72:781-93. [DOI: 10.2146/ajhp140476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Building a business plan to support a transplantation pharmacy practice model. Am J Health Syst Pharm 2014; 71:751-7. [PMID: 24733139 DOI: 10.2146/ajhp130555] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Efficacy of Valganciclovir Plus Cytomegalovirus Immune Globulin for Prevention of Cytomegalovirus Disease in High-Risk Renal Transplant Recipients. Ann Pharmacother 2014; 48:548-9. [DOI: 10.1177/1060028013513427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Physicians' attitude toward organ donation and transplantation in the USA. Clin Transplant 2013; 28:149-51. [DOI: 10.1111/ctr.12307] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2013] [Indexed: 11/27/2022]
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Changing transplant recipient education and inpatient transplant pharmacy practices: A single-center perspective. Am J Health Syst Pharm 2013; 70:900-4. [DOI: 10.2146/ajhp120254] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Impact of participation on a solid organ transplant team on student pharmacists' perceptions of interprofessional roles. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2013; 77:74. [PMID: 23716742 PMCID: PMC3663628 DOI: 10.5688/ajpe77474] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 11/29/2012] [Indexed: 05/22/2023]
Abstract
OBJECTIVE To examine student pharmacists' perceptions of interprofessional roles before and after completing an advanced pharmacy practice experience on solid organ transplantation. METHODS Student pharmacists across the United States participating in an APPE on a solid organ transplant team completed an online pre- and post-APPE survey instrument examining perceptions of interprofessional roles, communication, and teamwork. RESULTS Student pharmacists' scores on interprofessionalism increased significantly on 17 of 22 items. Positive changes were seen in the interprofessional education core competency areas of roles and responsibilities, interprofessional communication, and teams and teamwork. CONCLUSION Student pharmacist participation in interprofessional clinical APPEs can positively influence their professional development as they prepare to become members of multi-disciplinary teams in the healthcare workforce.
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Abstract
PURPOSE The economic impact of out-patient pharmacy services in a transplant program was evaluated. METHODS Full-time kidney transplant pharmacy services were implemented at Providence Sacred Heart Medical Center (PSHMC) in the fall of 2008, with two pharmacists combining hours to provide one full-time-equivalent position. At PSHMC, posttransplantation patients are seen three times per week. The number of patient visits with pharmacists for 2010 was compared with the total number of patient visits. The face-to-face time spent with the patient was translated to a level of billing that was associated with a set reimbursement schedule. For each patient encounter in which a pharmacist was involved, the incremental difference between the nursing and pharmacy levels of billing was examined, as were the levels most often billed by pharmacists. The difference in billing levels between pharmacists and nurses for the same patient encounter was also evaluated. RESULTS Overall, pharmacist visits accounted for 208 (22%) of the 994 out-patient kidney transplant visits in 2010, with pharmacists billing at a higher level of acuity compared with nursing for the same patient encounter 48% of the time. This translated to an approximate increase of $100 per patient visit. For the one-year study period, pharmacists utilizing facility- fee billing increased out-patient reimbursement by approximately $10,000. CONCLUSION By utilizing outpatient facility-fee billing for pharmacy services, the transplant program at PSHMC increased reimbursement in the outpatient setting.
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