An Evaluation of Managing and Educating Patients on the Risk of Glucocorticoid-Induced Osteoporosis

AbstractObjectiveTo assess the impact of risk management activities on patient risk of glucocorticoid-induced osteoporosis.MethodsNinety-six adult patients taking chronic glucocorticoid therapy in 15 community pharmacies. Patients in the control group received usual and customary care. Patients in the treatment pharmacies received education and an educational pamphlet about the risks of glucocorticoid-induced osteoporosis. In addition, the treatment group pharmacists monitored the patients' drug therapy, to identify and address drug-related problems. Data including the glucocorticoid taken by the patient, medications, and osteoporosis risk factors were collected at baseline and after 9 months of monitoring, via Web-based survey completed in the pharmacy. Using an intent to treat approach, the pre–post frequency changes were compared with contrasts for presence of bisphosphonate therapy, presence of estrogen therapy, presence of calcium supplement, discussion of glucocorticoid-induced osteoporosis risk, discussion of bone density test, presence of bone mineral density test, reported inactivity, and reported low calcium diet.ResultsThe contrast was significant in favor of the treatment pharmacies for the frequency of patients taking a calcium supplement (Control [−6.9%] vs. Treatment [17.1%], P < 0.05). No other contrast was significant.ConclusionsCommunity pharmacists are capable of increasing calcium supplementation among patients at risk for glucocorticoid-induced osteoporosis. Pharmacists who educate at-risk patients can impact the self-care of these patients

Description of the methods for describing and assessing the appropriateness of antibiotic prescribing and adherence to published treatment guidelines in an academic medical clinic

Overuse and inappropriate use of antibiotics have been associated with increased rates of antimicrobial resistance and increased healthcare expenditures. Tracking inpatient antimicrobial use has helped quantify the value of stewardship programs aimed at improving the rational use of antibiotics among hospitalized patients. Unfortunately, similar methods for tracking and assessing antibiotic use in the outpatient setting have not been well described. We developed a novel method to capture trends and assess appropriateness of antibiotic usage. This strategy is based on identification of antimicrobial prescriptions in an electronic medical record system, linking prescribing to patient data, and capturing information regarding dosing and indications for use. Using information on dose, frequency, and duration of the antibiotic prescribed, a parameter to quantify antibiotic exposure (Prescribed Therapeutic Regimen, PTR) is calculated. This parameter is compared to a database of information on agents recommended in published guidelines (Recommended Therapeutic Regimen, RTR). By linking an ICD-9 code and the prescribed antibiotic we determine the appropriateness of the PTR by comparing it to the RTR for a given indication. Data are used to establish a baseline pattern of antibiotic use in the clinic to gauge the impact of future stewardship activities. Additionally, individual clinics and prescribers are given a snapshot of their antibiotic use compared to other clinics and prescribers. This is a novel means of describing antibiotic use in the outpatient setting that could serve as a standardized model for various adult and pediatric outpatient practices. &nbsp; Type:&nbsp;Original Researc

Acceptability and Feasibility of a Pharmacist-Led HIV Pre-Exposure Prophylaxis (PrEP) Program in the Midwestern United States

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) substantially reduces the risk of HIV acquisition, yet significant barriers exist to its prescription and use. Incorporating pharmacists in the PrEP care process may help increase access to PrEP services. METHODS: Our pharmacist-led PrEP program (P-PrEP) included pharmacists from a university-based HIV clinic, a community pharmacy, and two community-based clinics. Through a collaborative practice agreement, pharmacists conducted PrEP visits with potential candidates for PrEP, according to the recommended CDC guidelines, and authorized emtricitabine-tenofovir disoproxil fumarate prescriptions. Demographics and retention in care over 12 months were summarized and participant satisfaction and pharmacist acceptability with the P-PrEP program were assessed by Likert-scale questionnaires. RESULTS: Sixty patients enrolled in the P-PrEP program between January and June 2017 completing 139 visits. The mean age was 34 years (range 20-61 years) and 88% identified as men who have sex with men, 91.7% were men, 83.3% were white, 80% were commercially insured, and 89.8% had completed some college education or higher. Participant retention at 3, 6, 9, and 12 months was 73%, 58%, 43%, and 28%, respectively. To date, no participant has seroconverted. One hundred percent of the participants who completed the patient satisfaction questionnaire would recommend the P-PrEP program. Pharmacists reported feeling comfortable performing point-of-care testing and rarely reported feeling uncomfortable during PrEP visits (3 occasions - 2.2%) or experiencing workflow disruption (1 occasion - 0.7%). CONCLUSIONS: Implementation of a pharmacist-led PrEP program is feasible and associated with high rates of patient satisfaction and pharmacist acceptability

Health Information Exchange to Support a Prescription Drug Monitoring Program

Objective: To describe barriers to the utilization of a query based Health Information Exchange (HIE) that supports a statewide Prescription Drug Monitoring Program (PDMP). Methods: Emergency room (ER) prescribers were surveyed bi-weekly and at the end of a four-month study to estimate HIE/PDMP utilization and identify barriers to utilization. Results: Self-reported utilization from seventeen providers in three emergency rooms was very low. Providers estimated that prescription history was rarely available when queried. Problem lists and laboratory reports were estimated to be available 60% of the time. Discussion: Barriers to HIE utilization for PDMP purposes included prescribers not finding the information they queried and lack of integration into clinical workflow. Low perceived need for PDMP and prescriber preparedness to manage abusers may also have reduced utilization. Recommendation: Financial and human resources must be available for training and integration of a HIE based PDMP into the ER's clinical workflow. Minimizing information gaps is also necessary to increase utilization. &nbsp; Type:&nbsp;Case Stud

Midwest Pharmacists\u27 Familiarity, Experience, and Willingness to Provide Pre-Exposure Prophylaxis (PrEP) for HIV

INTRODUCTION: Pharmacist provision of pre-exposure prophylaxis (PrEP) through collaborative practice agreements with physicians could expand access to people at risk for HIV. We characterized pharmacists\u27 familiarity with and willingness to provide PrEP services in Nebraska and Iowa. METHODS: An invitation to complete an 18-question survey was emailed to 1,140 pharmacists in Nebraska and Iowa in June and July of 2016. Descriptive analyses and Pearson chi-square tests were used to determine to what extent demographics, familiarity and experience were associated with respondent willingness to provide PrEP. Wilcoxon rank-sum tests compared ages and years of experience between groups of respondents. RESULTS: One hundred forty pharmacists (12.3%) responded. Less than half were familiar with the use of PrEP (42%) or the CDC guidelines for its use (25%). Respondents who were older (p = .015) and in practice longer (p = .005) were less likely to be familiar with PrEP. Overall, 54% indicated they were fairly or very likely to provide PrEP services as part of a collaborative practice agreement and after additional training. While familiarity with PrEP use or guidelines did not affect respondents\u27 willingness to provide PrEP, respondents were more likely to provide PrEP with prior experience counseling HIV-infected patients on antiretroviral therapy (OR 2.43; p = 0.023) or PrEP (OR 4.67; p = 0.013), and with prior HIV-related continuing education (OR 2.77; p = 0.032). CONCLUSIONS: Pharmacist respondents in Nebraska and Iowa had limited familiarity and experience with PrEP, but most indicated willingness to provide PrEP through collaborative practice agreements after additional training. Provision of PrEP-focused continuing education may lead to increased willingness to participate in PrEP programs

Implementing community pharmacy-based influenza point-of-care test-and-treat under collaborative practice agreement

Abstract Background Early and accessible testing for influenza with point-of-care testing (POCT) can be a critical factor for deciding to begin antiviral treatment. More than 10,000 pharmacies across the USA offer Clinical Laboratory Improvement Amendments-waived POCT for infectious diseases, such as influenza A/B. Knowledge of barriers and facilitators to large-scale POCT implementation may be useful in scaling POCT for influenza test-and-treat services (Flu POCT). The objective of this study was to explore the experiences of pharmacists who were early adopters of Flu POCT and treatment under collaborative practice agreement in community pharmacy settings. Methods Qualitative research design with in-depth, semi-structured virtual video interviews of licensed US community pharmacists. Interview questions were derived from the Consolidated Framework for Implementation Research (CFIR). Interviewees were selected via a purposeful sampling of pharmacists who were enrolled in a nationwide clinical trial involving pharmacy-based influenza test-and-treat under a collaborative agreement. Interviews were recorded and transcribed. A deductive analytic approach was used via constructs from the CFIR. Results Six pharmacists were interviewed. Interviews ranged from 28 to 70 min, with an average length of 46 min. Four broad themes emerged from the data, and each had corresponding subthemes and supporting quotes: influence of the Flu POCT service characteristics on pharmacy implementation, influence of factors outside of the pharmacy setting in Flu POCT implementation, factors within the pharmacy setting influencing implementation, and process of implementing Flu POCT. A novel pharmacy-based Flu POCT implementation framework is presented. Conclusions Implementation of community pharmacy-based Flu POCT services is feasible; but, a thorough understanding of both barriers and facilitators to their implementation is needed to increase the spread and scale of these programs. Specifically, pharmacy stakeholders should focus efforts on increasing patient and provider awareness, pharmacist acceptance, leadership support, and support of health providers external to the pharmacy to improve implementation success

Health Information Exchange to Support a Prescription Drug Monitoring Program

Objective: To describe barriers to the utilization of a query based Health Information Exchange (HIE) that supports a statewide Prescription Drug Monitoring Program (PDMP). Methods: Emergency room (ER) prescribers were surveyed bi-weekly and at the end of a four-month study to estimate HIE/PDMP utilization and identify barriers to utilization. Results: Self-reported utilization from seventeen providers in three emergency rooms was very low. Providers estimated that prescription history was rarely available when queried. Problem lists and laboratory reports were estimated to be available 60% of the time. Discussion: Barriers to HIE utilization for PDMP purposes included prescribers not finding the information they queried and lack of integration into clinical workflow. Low perceived need for PDMP and prescriber preparedness to manage abusers may also have reduced utilization. Recommendation: Financial and human resources must be available for training and integration of a HIE based PDMP into the ER's clinical workflow. Minimizing information gaps is also necessary to increase utilization.   Type: Case Stud

Retail Pharmacy Market Structure and Performance

Substantial variation has been observed in the use of prescription drugs from retail pharmacies, the level of services provided by retail pharmacies, and the prices paid for prescriptions from retail pharmacies. It is not clear whether local area retail pharmacy market structures affect these pharmacy outcomes. The goal of this paper is to discuss the potential research avenues to address these issues. The discussion provides: 1) background on the retail pharmacy and its place within the pharmaceutical supply chain; 2) a discussion of the data that are available to address these issues and the measures that can be developed from these data; and 3) a review of existing research findings and gaps in knowledge

Predictors of vaccination rates in people living with HIV followed at a specialty care clinic

People Living with HIV (PLWH) remain disproportionately susceptible to vaccine-preventable illnesses due to increased morbidity and mortality from common pathogens, increased transmission related to epidemiologic factors, and decreased vaccination rates. We aimed to describe patient-specific predictive factors that may impact adherence to the CDC’s recommended vaccination schedules in PLWH. We retrospectively evaluated adult PLWH in care at the University of Nebraska Medical Center’s HIV clinic and collected information related to demographics, clinic visits, vaccination status, and measures of HIV disease control. Patients were categorized as “Adherent” if they had received all vaccinations for which they were eligible and were categorized as “Non-Adherent” if they were deficient or delayed in receiving one or more vaccinations. Participant characteristics were compared between groups by multivariable logistic regression to identify predictors associated with vaccine schedule non-adherence. We evaluated 502 PLWH who met our inclusion criteria; 206 of these (41%) had received all eligible vaccinations, while 296 (59%) were missing one or more vaccinations. The mean age of participants was 48 years old, 76% were male, and 53% were white. Our participants had a median of 2.83 clinic visits per year and missed 8.3% of scheduled clinic visits. Factors associated with non-adherence to vaccination schedules included a high frequency of missed clinic appointments (>10%), men who have sex with men, and a CD4 count <200 cells/mm3. Knowledge of variables associated with vaccination rates may be beneficial in identifying patients at-risk for under-vaccination and designing targeted education programs for providers and patients

Treatment of Asymptomatic Bacteriuria after Implementation of an Inpatient Urine Culture Algorithm in the Electronic Medical Record

Ordering urine cultures in patients without pyuria is associated with the inappropriate treatment of asymptomatic bacteriuria (ASB). In 2015, our institution implemented recommendations based on practice guidelines for the management of ASB and revised the urine culture ordering process to limit cultures in immunocompetent patients without pyuria. The purpose of this study was to determine how the treatment of ASB has changed over time since altering the urine culture ordering process to reduce unnecessary cultures at an academic medical center. A quasi-experimental study was conducted for inpatients with urine cultures from January to March of 2014, 2015, 2016 and 2020. The primary outcome was the antibiotic treatment of asymptomatic bacteriuria for over 24 h. The secondary outcomes were the total days of antibiotic therapy, type of antibiotic prescribed and overall urine culture rates at the hospital. A total of 200 inpatients with ASB were included, 50 at random from each year. In both 2014 and 2015, 70% of the patients with ASB received antibiotic treatment. Antibiotics were prescribed to 68% and 54% of patients with ASB in 2016 and 2020, respectively. The average duration of therapy decreased from 5.12 days in 2014 to 3.46 days in 2020. Although the urine cultures were reduced, there was no immediate impact in the prescribing rates for patients with ASB after implementing this institutional guidance and an altered urine culture ordering process. Over time, there was an observed improvement in prescribing and the total days of antibiotic therapy. This could be attributed to increased familiarity with the guidelines, culture ordering practices or improved documentation. Based on these findings, additional provider education is needed to reinforce the guideline recommendations on the management of ASB