Assessment of Longitudinal Advanced Pharmacy Practice Experience Programs in Preparing Pharmacy Students for Residency Training.

OBJECTIVE: This study aimed to determine whether postgraduate year 1 (PGY-1) pharmacy residents felt more prepared for residency training after having completed a Longitudinal Advanced Pharmacy Practice Experience (LAPPE) program during pharmacy school. METHODS: This was a multicenter, two-arm, cross-sectional study among PGY-1 pharmacy residents. The primary outcome was self-reported residency preparedness. Secondary outcomes included self-reported competency in key indicators for success during early residency and matching with a preferred residency program. A survey was developed to obtain these data and was sent via email to all residency program directors of qualifying programs, who then redistributed it to PGY-1 residents in their respective programs. RESULTS: A total of 960 PGY-1 residents were included in the study. Of these, 180 (19%) reported prior participation in a LAPPE program. Longitudinal Advanced Pharmacy Practice Experience participants reported increased preparedness for residency training as compared to nonparticipants (mean 6.18 vs 5.72 on a 7-point Likert scale; difference 0.46, 95% CI 0.309-0.618). Longitudinal Advanced Pharmacy Practice Experience participation was also associated with greater self-reported clinical knowledge and skills (mean 5.18 vs 4.95, difference 0.23, 95% CI 0.093-0.372). Self-reported matching with a preferred residency program was common and similar between cohorts. CONCLUSION: Postgraduate year 1 residents who had completed a LAPPE felt better prepared for residency than those who had not completed a LAPPE. Prior LAPPE participation was also associated with greater self-reported clinical knowledge and skills at the start of residency training.

Factors Influencing Provider and Patient Choice of P2Y12 Inhibitor Therapy.

BACKGROUND: Clopidogrel is the most commonly prescribed P2Y12 inhibitor for acute coronary syndrome (ACS) or stent placement, though ticagrelor or prasugrel may be preferred. Medication-related factors may influence selection of therapy. OBJECTIVES: To determine which factors most greatly influence cardiology-provider and patient selection of P2Y12 inhibitor to guide shared-decision making (SDM). METHODS: Single-center study assessed survey responses from 32 cardiology-providers who prescribed and 105 patients who received clopidogrel, prasugrel, or ticagrelor for ACS or stent placement. Respondents ranked factors influencing P2Y12 inhibitor selection and reported preference of therapy. Patients reported experience with shared decision-making process. RESULTS: Cardiology-providers ranked risk of bleeding, comfort/experience, and cost as most influential. Patients ranked risk of drug interaction, adverse effects, and reduction in myocardial infarction as most influential. Significant differences between cardiology-providers and patients were found for 5 of 8 factors. Cardiology-providers ranked once daily administration (p = 0.01), risk of bleeding (p = 0.002), and cost (p < 0.001) as more important than patients. Patients ranked risk of adverse effects (p = 0.007) and drug interactions (p = 0.005) as more important than cardiology-providers. Cardiology-providers prescribed ticagrelor 42.3% of the time following ACS, though 78.1% ranked it as their preferred agent. Patients were prescribed ticagrelor 9.3% of the time, though 55.7% ranked it as their preferred agent. Use of SDM was reported by 21.6% of patients and 88.5% were unaware that multiple P2Y12 inhibitors existed. CONCLUSION: Significant differences exist between cardiology-providers and patients regarding factors influencing P2Y12 inhibitor selection, specifically safety-related factors, once daily administration, and cost. Most patients were not involved in SDM.

A clinical focus on the use of extended-duration thromboprophylaxis in medically ill patients.

PURPOSE: This review describes and analyzes literature to provide recommendations for use of extended-duration thromboprophylaxis (EDT) in medically ill patients. SUMMARY: Guidelines recommend pharmacologic thromboprophylaxis for patients at increased thrombosis risk during hospitalization and recommend against extending thromboprophylaxis beyond hospitalization. Despite these recommendations, observational data demonstrate that venous thromboembolism (VTE) risk persists following hospital discharge. A MEDLINE literature search was performed to identify original research evaluating the safety and efficacy of EDT. Eight meta-analyses and 5 randomized controlled trials-each varying in the agents studied (enoxaparin, rivaroxaban, apixaban, and betrixaban)-were selected for inclusion. Collectively, the evaluated data demonstrates that EDT reduces the incidence of VTE at the expense of increasing the risk of major bleeding and without providing mortality reduction. Variations in enrollment criteria, differences in EDT strategies, and uncertainty regarding proper patient selection limit the applicability of EDT in practice. Rivaroxaban and betrixaban gained Food and Drug Administration (FDA) approval on the basis of results of the APEX and MARINER trials and a post hoc analysis of the MAGELLEN trial results. Although a number of agents are FDA approved for use in EDT, clinicians must carefully weigh the risks vs benefits of EDT with these agents until studies demonstrate a more favorable risk-benefit profile. CONCLUSION: Evidence to support EDT in medically ill patients is inconclusive and has highlighted the need for an individualized approach. The reviewed evidence supports guideline recommendations from both the American College of Chest Physicians and the American Society of Hematology that recommend against routine use of EDT in the majority of medically ill patients. Future studies are needed to optimize the risk-benefit profile of EDT and to ensure proper patient selection.

Comparison of sustained rate control in atrial fibrillation with rapid ventricular rate: Metoprolol vs. Diltiazem.

OBJECTIVE: The objective of this study was to compare sustained rate control with intravenous (IV) diltiazem vs. IV metoprolol in acute treatment of atrial fibrillation (AF) with rapid ventricular rate (RVR) in the emergency department (ED). METHODS: This retrospective chart review at a large, academic medical center identified patients with AF with RVR diagnosis who received IV diltiazem or IV metoprolol in the ED. The primary outcome was sustained rate control defined as heart rate (HR) < 100 beats per minute without need for rescue IV medication for 3 h following initial rate control attainment. Secondary outcomes included time to initial rate control, HR at initial control and 3 h, time to oral dose, admission rates, and safety outcomes. RESULTS: Between January 1, 2016 and November 1, 2018, 51 patients met inclusion criteria (diltiazem n = 32, metoprolol n = 19). No difference in sustained rate control was found (diltiazem 87.5% vs. metoprolol 78.9%, p = 0.45). Time to rate control was significantly shorter with diltiazem compared to metoprolol (15 min vs. 30 min, respectively, p = 0.04). Neither hypotension nor bradycardia were significantly different between groups. CONCLUSIONS: Choice of rate control agent for acute management of AF with RVR did not significantly influence sustained rate control success. Safety outcomes did not differ between treatment groups.

Effect of Therapeutic Interchange on Medication Changes Between Admission and Discharge.

Background: Therapeutic interchange (TI) is the dispensing of an alternative medication within the same class as the original medication. TI often occurs in hospitals; however, failure to return patients to their original medications may increase the risk of adverse effects following hospital discharge. Objective: The purpose of this study was to evaluate the relationship between TI and discharge medication changes, hospital readmission rates, and emergency department visit rates following hospital discharge. Methods: Patient demographic and medication data were collected retrospectively for patients admitted to a nonprofit, acute care hospital. The primary outcome was the relationship between TI and the rate of discharge medication changes. Secondary outcomes included types of discharge medication changes and the relationship between TI and both hospital readmissions and emergency department visits following hospital discharge. Results: A total of 497 patients accounting for 1072 medications were included; 21.2% of home medications were interchanged following admission, and 21.8% of home medications were changed at discharge. TI increased the incidence of discharge medication changes by 70% (odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.22-2.37, P = .0021). Cardiovascular agents were most likely to be changed at discharge (26%), and gastrointestinal agents were most likely to be interchanged (65%). Psychotropic agents were least likely to be changed at discharge (12%) or interchanged (7%). Neither TI nor discharge medication changes were predictive of 30-, 60-, or 90-day hospital readmission or emergency department visits following discharge. Conclusion and Relevance: This study was the first to examine the effects of TI on post-discharge outcomes. Despite being associated with an increased rate of discharge medication changes, the presence of TI did not correlate with hospital readmission or emergency department visit rates. This study supports the safety of TI.

Effect of Nonselective ß-Blockers on Mortality in Patients With End-Stage Cirrhosis.

Background: Data regarding safety of nonselective ß-blockers (NSBBs) in patients with end-stage cirrhosis are conflicting, making it difficult for practitioners to justify if benefits outweigh the risks. Objective: Evaluate the effect of NSBB use on mortality in patients with end-stage cirrhosis. Methods: We performed a dual-center retrospective study of patients who received octreotide for a variceal bleed. Patients were stratified into 2 groups based on whether or not a NSBB was prescribed at hospital discharge. The primary outcome was 24-month mortality. Multivariable logistic regression, with 24-month mortality as the dependent variable, was performed to identify independent risk factors for the primary outcome. Results: 255 patients met inclusion criteria; 24-month mortality was 32.8%. The NSBB and no-NSBB groups had similar mortality rates at 24 months (32.0% vs 38.5%, P = 0.51). Mortality at 3 months (11.6% vs 23.3%, P = 0.08) and 12 months (22.2% vs 30.0%, P = 0.36) were similar, and there were no differences in rate of variceal bleeding (22.7% vs 13.3%, P = 0.34) or cirrhosis-related cause of death (20.4% vs 23.3%, P = 0.81). In the multivariable model, age, model for end-stage liver disease with sodium and hepatocellular carcinoma were independent risk factors for 24-month mortality. NSBB therapy had no effect on 24-month mortality (adjusted odds ratio = 1.05; 95% CI = 0.32 to 3.40). Conclusion and Relevance: In patients with end-stage cirrhosis, use of NSBBs did not affect 24-month mortality. More research is needed to determine when, and if, NSBBs should be discontinued in end-stage cirrhosis.

The Role of Cefepime in the Treatment of Extended-Spectrum Beta-Lactamase Infections.

OBJECTIVE: To review the efficacy of cefepime for use in infections caused by extended-spectrum beta-lactamase (ESBL)-producing organisms. DATA SOURCES: A PubMed literature search (May 2000 to June 2017) was performed using the keyword cefepime and the MeSH terms beta-lactamases, cephalosporinases, and Enterobacteriaceae infections. STUDY SELECTION AND DATA EXTRACTION: All human, English language studies evaluating cefepime use for the treatment of ESBL-producing Escherichia coli and Klebsiella pneumoniae infections were included. DATA SYNTHESIS: Studies assessing the use of cefepime for ESBL infections are few, and clinical studies are limited by design and sample size. The largest pharmacokinetic/pharmacodynamic study, a Monte Carlo simulation using data from the U.S. SENTRY antimicrobial surveillance program, evaluating cefepime use for infections due to ESBL-producing organisms found a 95% to 100% probability of target attainment with traditional cefepime dosing regimens. Most clinical studies found that patients treated with cefepime empirically and definitively had higher rates of mortality than those treated with carbapenems. However, in concordance with other studies reporting minimum inhibitory concentration (MIC) data, lower MICs were associated with lower mortality. CONCLUSIONS: Cefepime should be avoided for empiric treatment of suspected ESBL infections and should only be considered for definitive treatment if the MIC ≤1 µg/mL. However, the site and severity of infection, local resistance patterns, and patient-specific risk factors should also help guide antimicrobial selection.

The effect of repeated testing of pharmacy calculations and drug knowledge to improve knowledge retention in pharmacy students.

BACKGROUND AND PURPOSE: Repeated testing has been shown to improve knowledge retention in students. However, there is limited literature on the effect of repeated testing in pharmacy students. Our objective was to determine if repeated testing improved retention of pharmacy calculations and drug knowledge. EDUCATIONAL ACTIVITY AND SETTING: Second, third, and fourth year pharmacy students were invited to participate in this voluntary study. Participants were divided into GPA categories and randomly assigned to a control or study group. Seven quizzes were given to the study group over one academic year. No quizzes were given to the control group. Both groups had access to the question bank from which the quizzes were constructed. A final exam and survey were given to both groups at the end of the study. FINDINGS: We did not find an effect of repeated testing on knowledge retention for the study group compared to the control group in the study. However, when fourth year students were excluded from the analysis, we observed a benefit of repeated testing for lower-performing students. Over 90% of survey respondents agreed that repeated testing promoted long term knowledge and that students should test themselves repeatedly. However, approximately 60% of students admitted to not testing themselves repeatedly. Nearly 85% of survey respondents agreed that the school should implement a repeated testing program. SUMMARY: Overall, students believe repeated testing is beneficial, but few do it on their own. Repeated testing showed a benefit in at-risk students. Implementing a program of repeated testing can help low-performing students succeed academically.

Management of Direct-Acting Oral Anticoagulants Surrounding Dental Procedures With Low-to-Moderate Risk of Bleeding.

The purpose of this article is to review the available evidence regarding how to safely manage direct-acting oral anticoagulant (DOAC) therapy in patients requiring dental procedures with low-to-moderate risk of bleeding. A literature search was performed using MEDLINE and PubMed. Each author performed an independent search to ensure all pertinent articles were identified. The reference sections of each article were also reviewed. Pertinent articles were evaluated by each author for inclusion. Articles were eligible for inclusion if the participants were taking DOAC therapy surrounding a dental procedure known to have low-to-moderate risk of bleeding. Studies could be prospective or retrospective and included case reports, case series, and clinical trials. Articles were excluded if they assessed dental procedures known to carry a high risk of bleeding or were review articles. Twenty-five articles were identified, 5 of which met inclusion criteria including 2 case series, 1 retrospective study, and 2 prospective trials. Variation in the management of DOAC therapy surrounding these procedures was found. Among patients undergoing low-to-moderate risk dental procedures while receiving DOAC therapy, bleeding rates were low regardless of whether the DOAC was held or continued surrounding the procedure. Documented bleeding was mild and easily controlled by local hemostatic measures. Patients can safely continue DOAC therapy surrounding these dental procedures.

Aspirin Use for the Primary Prevention of Cardiovascular Disease in the Elderly.

OBJECTIVE: This article aims to use the available evidence assessing aspirin for primary prevention of cardiovascular (CV) events in the elderly to determine its appropriate use. DATA SOURCES: A literature search of clinical trials and meta-analyses was conducted using MEDLINE and PubMed with the search terms aspirin, bleeding, CV events, elderly, geriatrics, hemorrhage, myocardial infarction (MI), primary prevention, and stroke. STUDY SELECTION/DATA EXTRACTION: Twelve hundred fourteen (1,214) articles were initially found, and 55 were reviewed. These articles assessed the use of aspirin for primary prevention of CV events. Only trials comparing aspirin with placebo, a non-antiplatelet, or a non-anticoagulant were included in this review. Of the articles reviewed, 10 met the stated criteria. DATA SYNTHESIS: It is well documented that the risk of CV events increases as patients age. Primary prevention of these events with aspirin may be beneficial in some patients. Currently, a specific recommendation for the use of aspirin for primary prevention in the geriatric population is not available. This paper reviews the available evidence for primary prevention of CV disease. This population is under-represented in the literature, making it challenging to apply the study findings. CONCLUSION: Aspirin may be considered for the primary prevention of CV events in the elderly population. Because of the lack of data in patients 80 years of age and older, it is difficult to make a decision on the initiation of aspirin therapy in this population. Additional research is necessary to better balance the risk versus benefit of this treatment option.