Bending the Cardiovascular Event Curve by Evaluating the Potential Impact of Achieving Low-Density Lipoprotein Cholesterol Goal Across a Large Health System Among Secondary Prevention Patients

Guidelines recommend aggressive low-density lipoprotein cholesterol (LDL-C) lowering in patients with atherosclerotic cardiovascular disease (ASCVD). However, the recommended threshold of LDL-C ≤70 mg/dL is often not achieved. We used data from the Duke University Health System electronic health record to characterize patterns of lipid levels and lipid management in patients with ASCVD to estimate the number of clinical events that could be prevented by achieving LDL-C ≤70 mg/dL . A multivariable logistic regression model was developed to predict the 1-year composite of all-cause mortality, myocardial infarction, stroke, or coronary revascularization and was validated through bootstrapping. The number needed to treat to prevent an event was then determined. Among 56,230 patients with ASCVD, the median (quartile 1, quartile 3) age was 68.6 years (59.9, 76.2), 47% were women, and 27% were non-Hispanic Black. LDL-C was >70 mg/dL in 39,566 of patients (70%); these patients were more frequently female (51% vs 36%), non-Hispanic Black (28% vs 23%), and less frequently on statin therapy (67% vs 91%) than those with LDL-C ≤70 mg/dL . A predictive model with reasonable discrimination (c-index 0.77, 95% confidence interval 0.760 to 0.77) and calibration (slope 0.99) determined that if the overall population achieved an LDL-C ≤70 mg/dL, 734 clinical events (455 myocardial infarctions, 186 strokes, and 93 coronary revascularizations) could be prevented in a year. Achieving LDL-C ≤70 mg/dL in patients with ASCVD across a health system could prevent significant clinical events within a single year. In conclusion, this study quantifies the potential benefit of a system-wide effort to achieve guideline-based LDL-C goals.

Major Ocular Abnormalities Among Hemodialysis Patients in Indonesia

BACKGROUND

This study aimed to identify the major ocular abnormality findings (i.e., cataract and conjunctival and corneal calcification (CCC)) among hemodialysis (HD) patients and their risk factors.

METHODS

A single institute-based cross-sectional study in Indonesia. Demographic data, medical histories, and complete ocular examinations were collected. For two major ocular abnormalities found, a generalized estimating equation was incorporated in a logistic regression model to assess the relationship with their risk factors.

RESULTS

We analyzed 318 eyes (159 individuals), of which 54.7% male and 45.3% female. The mean age was 51.6±11.3 years. The mean HD period was 3.5±3.2 years. Hypertension and diabetes mellitus (DM) was found in 81.1% and 34.6%, respectively. The major ocular abnormalities found were cataract (206 eyes; 64.78% (95% CI 59.53-70.03)), followed by CCC (135 eyes; 42.45% (95 % CI 37.02-47.88)). In a multivariate model, higher education (odds ratio (OR) 0.17; 95% CI 0.04-0.74), hypertension (OR 0.15; 95% CI 0.03-0.79), DM (OR 10.49; 95% CI 1.57-70.06), Systolic Blood Pressure (SBP) 120-129 mmHg (OR 0.05; 95% CI 0.003-0.69), SBP >140 mmHg (OR 0.05; 95% CI 0.004-0.67), Diastolic Blood Pressure (DBP) 80-89 mmHg (OR 7.44; 95% CI 1.13-48.73), and DBP >90 mmHg (OR 48.47; 95% CI 3.4-692.03) showed significant association with cataract. Meanwhile, there was no significant association between CCC and any predictor.

CONCLUSION

Cataract and CCC were found to be the major ocular abnormalities among HD patients in this study, with DM and higher DBP as the risk factors for cataract. This finding supports recommendations for integrated regular eye screening in HD patients.

Survey of Health-System Pharmacy Leadership Pathways: A 10-Year Revisit

OBJECTIVE

To compare health-system pharmacy leadership pathways and opinions in the last decade.

METHODS

A 33 question survey was recreated from the 2009 survey of health-system pharmacy leadership pathways and reviewed and modified by the original creators. In November 2019, investigators sent two invites to complete a Qualtrics^XM survey to individuals listed on the ASHP Connect Pharmacy Practice Leaders listserver. The survey closed on December 15, 2019.

RESULTS

Two-hundred-thirteen pharmacy leaders responded to the survey. Survey respondents identified completing a pharmacy practice (PGY1) residency as the most common health-system pharmacy leadership pathway. Respondents stated on-the-job experience contributed most to their leadership development. Interpersonal skills (20%), human resource management (19%), and finance and budget management (13%) were classified as the most valuable skill-sets to a health-systems leader. Thirty-nine percent of eligible respondents stated they were interested in seeking a health-system pharmacy director position and 23% stated they may be interested. The majority of directors stated that they preferred to hire those with previous on-the job experience into leadership positions.

CONCLUSION

Regardless of leadership pathway, those interested in pursuing health-system pharmacy leadership positions should pursue as much on-the-job experience as possible, build relationships through networking, and find a strong, helpful mentor.

Hospital- and System-Wide Interventions for Health Care-Associated Infections: A Systematic Review

Hospitals face increasing pressure to reduce health care-associated infections (HAI) due to their costs and evidence of preventability. However, there is limited synthesis of evidence regarding interventions that can be successfully implemented hospital- or system-wide. Using Donabedian's structure-process-outcome model, we conducted a systematic literature review from 2008 to early 2019, identifying 96 studies with 214 outcomes examining the relationship between hospital- or system-wide interventions and HAIs. This literature's methodologic and reporting quality was generally poor. The most common HAIs studied were methicillin-resistant Staphylococcus aureus (22%) and Clostridium difficile (21%). 97 outcomes showed a desirable change, 72 showed no significant effect, 17 showed conflicting effects, and 3 found undesirable effects; 25 outcomes were from studies without a statistical analysis. Our findings highlight structural and process approaches meriting additional research and policy exploration, and identify recommendations for future investigation and reporting of hospital and system-wide HAI interventions to address gaps in existing literature.

Creating a Pharmacy Internship: A Toolbox for Success

Objective:

To describe available compensated student internships and provide guidance for new program development.

Methods:

A search was conducted using PubMed, MEDLINE, and Google with the following search terms: pharmacy, intern, internship, and student. All English language publications were considered for inclusion. Articles describing IPPE or APPE student utilization were excluded.

Key findings:

Pharmacy student internship programs are common in practice, though there are few with published outcome data. Most often, interns serve as pharmacist extenders and participate in activities that center around extension of pharmacy services within the institution. Development of new programs should include partnering with nearby pharmacy programs and state boards of pharmacy to develop a well matched curriculum and allow for interns to practice at the top of their license. Lastly, outcomes should be measured and disseminated for the benefit of the academy. Additional considerations for developing a student internship program and guidance are provided.

Conclusions:

Although in existence for decades, minimal published reports showcase institutional outcomes associated with student internships. No data is available to show the downstream effect an internship can have on direct patient care activities.