Impact of a guideline-based best practice alert on pneumococcal vaccination rates in adults in a primary care setting.

BACKGROUND: Despite the high burden of pneumococcal disease, pneumococcal vaccine coverage continues to fall short of Healthy People 2020 goals. A quasi-experimental design was used to investigate the impact of pneumococcal-specific best-practice alerts (BPAs) with and without workflow redesign compared to health maintenance notifications only, on pneumococcal vaccination rates in at-risk and high-risk adults, and on series completion in immunocompetent adults aged 65+ years. METHODS: This retrospective study used electronic health record and administrative data to identify pneumococcal vaccinations using cross sectional and historical cohorts of adults age 19+ years from 2013 to 2017 who attended clinics associated with the University of Utah Health. Difference-in-differences (DD) analyses was used to assess the impact of interventions across three observation periods (Baseline, Interim, and Follow Up). Adherence to the 2-dose vaccination schedule in older adults was measured through a longitudinal analysis. RESULTS: In DD analyses, implementing both workflow redesign and the BPA raised the vaccination rate by 8 percentage points (pp) (P < 0.001) and implementing the BPA only raised the rate by 7 pp. (P < 0.001) among at-risk adults age 19-64 years, relative to implementing health maintenance notifications (i.e., usual care) only in comparison clinics. In high-risk adults age 19-64 years, the BPA with or without workflow redesign did not significantly affect vaccination rates from baseline to follow up relative to health maintenance notifications. Per DD analyses, the effect of the BPA was mixed in immunocompetent and immunocompromised adults age 65+ years. However, immunocompetent older adults attending a clinic that implemented the BPA plus health maintenance notifications and workflow redesign (all 3 interventions) had 1.94 times higher odds (Odds ratio (OR) 1.94; P = 0.0003, 95% CI 1.24, 3.01) to receive the second pneumococcal dose than patients attending a usual practice clinic (i.e., no intervention). CONCLUSIONS: A pneumococcal BPA tool that reflects current guidelines implemented with and without workflow redesign improved vaccination rates for at-risk adults age 19-64 years and increased the likelihood of adults aged 65+ to complete the recommended 2-dose series. However, in other adult patient groups, the BPA was not consistently associated with improvements in pneumococcal vaccination rates.

Lice and Scabies: Treatment Update.

Pediculosis and scabies are caused by ectoparasites. Pruritus is the most common presenting symptom. Head and pubic lice infestations are diagnosed with visualization of live lice. Nits (lice eggs or egg casings) alone are not sufficient to diagnose a current infestation. A "no-nit" policy for return to school is not recommended because nits can remain even after successful treatment. First-line pharmacologic treatment for pediculosis is permethrin 1% lotion or shampoo. Newer treatments are available but costly, and resistance patterns are generally unknown. Noninsecticidal agents, including dimethicone and isopropyl myristate, show promise in the treatment of pediculosis. Extensive environmental decontamination is not necessary after pediculosis is diagnosed. In adults, the presence of pubic lice should prompt an evaluation for sexually transmitted infections. Body lice infestation should be suspected in patients with pruritus who live in crowded conditions or have poor hygiene. Scabies in adults presents as a pruritic, papular rash in a typical distribution pattern. In infants, the rash can also be vesicular, pustular, or nodular. First-line treatment for scabies is permethrin 5% cream. Clothing and bedding of persons with scabies should be washed in hot water and dried in a hot dryer. Counseling regarding appropriate diagnosis and correct use of effective therapies is key to reducing the burden of lice and scabies.

Pharmacist-prescribed hormonal contraception: A review of the current landscape.

OBJECTIVE: The objective of this article is to review the current supply-side, demand-side, and regulatory landscape of pharmacist-prescribed hormonal contraception (HC) in the United States. SUMMARY: Pharmacists appear to be supportive of pharmacist-prescribed HC. However, support does not necessarily indicate likelihood to implement the practice, even when reimbursement mechanisms exist. The likelihood of implementation can be increased with education and training of HC prescribing. Previous investigations suggest that women broadly support accessing contraception within a pharmacy. Expanded access, where available, can improve rates of use and adherence. Women at higher risk for unintended pregnancy, such as younger women and women without health insurance, are likely to use the pharmacy to procure HC. Despite a willingness to pay for HC consultations with pharmacists, costs can remain a significant barrier for many women. CONCLUSIONS: Expanding access to HC through pharmacist-prescriptive authority could help curb the rates of unintended pregnancy in the United States. Pharmacists are well positioned for such a role; however, significant barriers for pharmacists and patients remain. Examination of current implementation methods will assist policy makers in overcoming these barriers.

Cost-Sharing Requirements for the Herpes Zoster Vaccine in Adults Aged 60.

Background: Rates of zoster vaccination in US adults aged 60+ were approximately 30.6% in 2015. Out-of-pocket cost-sharing has been identified as a major barrier to vaccination for patients. To date, herpes zoster vaccine cost-sharing requirements for adults aged 60 to 64 has not been described. Objective: Compare the cost-sharing requirements for zoster vaccination in adults aged 60 to 64 and adults aged 65+. Methods: A retrospective cohort design examined pharmacy claims for zoster vaccination from the Utah All Payer Claims Database for adults aged 60+. Descriptive statistics and a 2-part cost model compared cost-sharing requirements for adults aged 60 to 64 and adults 65+. Results: Of the 30 293 zoster vaccine claims, 13 398 (45.8%) had no cost-sharing, 1716 (5.9%) had low cost-sharing (defined as $1 to less than $30), and 14 133 (48.3%) had high cost-sharing (defined as $30 or more). In the cost models, adults aged 65+ had higher odds of any cost-sharing (odds ratio = 39.86) and 29% higher cost-sharing as compared with adults aged 60 to 64. Conclusions: Adults aged 60 to 64 encounter lower cost-sharing requirements than adults aged 65+. Providers should be cognizant of this dynamic and encourage zoster vaccination prior to the age of 65.

Residency pathways to ambulatory care practice: Essential insights for students, residents, and educators.

OBJECTIVE: To provide a guiding document describing residency training opportunities in ambulatory care for students, postgraduate year 1 (PGY1) residents, practicing pharmacists, and pharmacy educators. SUMMARY: Student pharmacists, residents, practitioners, and educators can benefit from a guiding document describing the various pathways to develop as an ambulatory care practitioner through residency training. The benefits and differences of PGY1 and postgraduate year 2 (PGY2) ambulatory care residency programs are included. CONCLUSION: There are many possible training options for pharmacists interested in pursuing a career in ambulatory care pharmacy practice. In addition to the required ambulatory and community experience required for all Doctorate of Pharmacy students, postgraduate training in an ambulatory environment can allow for specialization. Candidates for residency training can complete a PGY1 pharmacy residency or a PGY1 community-based pharmacy residency, possibly followed by a PGY2 ambulatory care residency. Career paths for ambulatory care pharmacists vary regionally across the country according to competition for positions, local availability of training programs, and the experience of regional leaders. A comprehensive description of these available training pathways and advantages of each are beneficial for students, residents, practicing pharmacists, and educators.

Achievement of Adequate Glycemic Control in Patients With Type 2 Diabetes and Comorbid Mental Health Conditions Treated in a Primary Care Setting.

OBJECTIVE: This study investigated the association between the presence of a mental health condition (MHC) diagnosis and glycemic control in patients with type 2 diabetes in a primary care clinic network. METHODS: This retrospective cross-sectional study compared adequate glycemic control (A1C <8.0%) in patients with type 2 diabetes with and without any MHC, as well as by MHC subtypes of depression or anxiety, bipolar or schizophrenia disorders, and substance use disorder. RESULTS: Of 3,025 patients with type 2 diabetes, 721 (24%) had a diagnosis for one or more MHC. The majority (54.9%) were <65 years of age, female (54.9%), and Caucasian (74.5%). Mean A1C was statistically lower in the MHC cohort at 7.14 ± 1.66% compared to 7.38 ± 1.73% in the group without any MHC (P = 0.001). Furthermore, those with an MHC were more likely to attain adequate glycemic control than those without an MHC (odds ratio 1.27, 95% CI 1.01-1.59). Among patients with MHCs, similar rates of adequate glycemic control were seen between those with depression or anxiety and those with other MHCs. However, fewer patients with substance use disorder had adequate glycemic control compared to those without this condition (66.7 vs. 80.10%, P = 0.004). CONCLUSION: Patients with diabetes and MHCs had slightly better glycemic control than those without any MHC. However, the presence of substance use disorder may present more barriers to adequate glycemic control. Additional research is needed to identify barriers unique to each MHC to optimize diabetes management in this population.

Team-based approach to addressing simvastatin safety concerns.

OBJECTIVE: To describe acceptance of systematic and organized pharmacist interventions to address simvastatin safety concerns. SETTING: University of Utah Redwood Health Center and Pharmacy, June 2011 to February 2012. PRACTICE DESCRIPTION: Redwood Health Center is an outpatient multispecialty clinic associated with University of Utah Health Care with approximately 85,000 annual visits between primary care and specialty practices. In addition to filling approximately 175,000 prescriptions per year, pharmacists provide disease management and education under collaborative practice agreements. PRACTICE INNOVATION: All patients identified as being treated outside the revised simvastatin labeling were included (n = 158). After pharmacist review, recommendations were made to providers via the electronic medical record to promote adherence with the June 2011 Food and Drug Administration (FDA) safety guidelines. In addition to recommendations regarding the FDA guidelines (n = 76), additional recommendations were made to optimize treatment based on low-density lipoprotein cholesterol goal or laboratory evaluation (n = 25). MAIN OUTCOME MEASURES: Acceptance rate of recommendations and resources needed to provide pharmacist interventions. RESULTS: Recommendations were accepted 92% of the time without modification and 7% of the time with modification. Total pharmacist time to conduct the interventions was 21.5 hours, and 3.9 hours of technician time were spent contacting patients. CONCLUSION: Targeted pharmacist interventions were effective in promoting adherence with this complex medication safety alert. A standardized, comprehensive approach to patient assessment, including use of evidence to support pharmacist recommendations, resulted in a high level of acceptance by prescribers.

Improving Patient Access to Primary Care Providers Using a Pharmacist-Physician Co-Visit Model.

Background: Implementation of a clinical pharmacist in the primary care setting can offset provider time spent managing chronic diseases using Collaborative Practice Agreements (CPAs). The pharmacist-physician co-visit model presents an opportunity for pharmacists to increase patient access to their primary care provider (PCP). Studies of the co-visit model show that co-visits increase clinic efficiency by allowing the PCP to see additional patients and achieve more health care goals compared with independent visits1-4. Objectives: The aim of this study was to increase patient access to their PCP by utilizing a pharmacist-physician co-visit model at the Madsen Health Center Family Medicine (MHC FM) Clinic. The primary outcome was to identify the number of co-visits completed compared to the number of possible co-visits, and the number of appointment slots made available. The secondary outcomes were to track the time spent with patients and to obtain provider feedback via a survey. Methods: The co-visit model was implemented as a 4-month pilot study at the MHC FM Clinic. Complex care appointments lasting 40 minutes were selected based on inclusion and exclusion criteria. Potential co-visit appointments were identified one week prior then provider consent was obtained to change the appointment into two separate 20-minute visits. Schedules were reviewed to determine if the appointment slot opened by the co-visit was filled by another patient. Upon completion of the study, a survey was distributed to providers to collect feedback. Results: A total of five co-visits were completed out of a possible 19 (26%). All the appointments made available were filled by another patient. On average, the provider and pharmacist spent 15 and 14 minutes with the patient, respectively. Conclusion: Implementation of the physician-pharmacist co-visit model increased the availability of the PCP to see more patients without disrupting clinic workflow and provider schedules.

Pediculosis and scabies: treatment update.

Pediculosis and scabies are caused by ectoparasites. Pruritus is the most common presenting symptom. Head and pubic lice infestations are diagnosed by visualization of live lice. Finding nits (louse egg shells) alone indicates a historical infestation. A "no nit" policy for schools and day care centers no longer is recommended because nits can persist after successful treatment with no risk of transmission. First-line pharmacologic treatment of pediculosis is permethrin 1% lotion or shampoo. Multiple novel treatments have shown limited evidence of effectiveness superior to permethrin. Wet combing is an effective nonpharmacologic treatment option. Finding pubic lice should prompt an evaluation for other sexually transmitted infections. Body lice infestation should be suspected when a patient with poor hygiene presents with pruritus. Washing affected clothing and bedding is essential if lice infestation is found, but no other environmental decontamination is necessary. Scabies in adults is recognized as a pruritic, papular rash with excoriations in a typical distribution pattern. In infants, children, and immunocompromised adults, the rash also can be vesicular, pustular, or nodular. First-line treatment of scabies is topical permethrin 5% cream. Clothing and bedding of persons with scabies should be washed in hot water and dried in a hot dryer.

The Report of the 2021-2022 Professional Affairs Standing Committee: Resource Guide for the Integration of Clinical Pharmacy Faculty in Professional Practice Settings.

The 2021-22 Professional Affairs Committee was charged to (1) Develop a resource guide for member institutions and faculty regarding payment for the practice-related activities of pharmacy faculty; (2) Nominate at least one person for an elected AACP or Council Office; and (3) Consider ways that AACP can improve its financial health. This report describes the methodology and content utilized for the development of an online resource guide for member institutions, faculty, and practice sites regarding the integration of clinical faculties' patient care services into patient care settings, including models for payment and value-based payment structures that can be utilized to support the practice-related activities of faculty. The committee offers a revision to a current association policy statement, a proposed policy statement as well as recommendations to AACP and suggestions to colleges and schools of pharmacy pertaining to the committee charges.

Covid Media Misguidance: A Case Report Highlighting the Influence of Media on Patient Medication Decision Making.

PURPOSE: This case report details the influence of media on patients and the responsibility of health care providers to educate their patients on proper use of medications, and to be aware of potential misadventures based on messages in popular media. SUMMARY: The sudden rise of the COVID19 pandemic has led to media outlets reporting science without necessary peer review and has resulted in preliminary data presented as factual evidence. It is difficult for patients without an extensive medical background in science to fully understand the uncertainty of information shared in popular media. This was demonstrated when preliminary data showed potential promise of hydroxychloroquine for the treatment/prevention of COVID19. This led to patients requesting hydroxychloroquine prescriptions from their providers, as well as stockpiling medication, which led to a shortage. In addition, patients began taking chloroquine containing substances not intended for human consumption. Popular media created a belief in the general public that all antimalarial drugs may work to prevent COVID19. This case report presents an elderly patient that presented to clinic with shortness of breath and lightheadedness. Upon interviewing the patient, it was discovered that he had been taking an old supply of atovaquone and proguanil hydrochloride. Physical exam, and laboratory examination were evaluated to rule out any other etiology with all tests and exams being unremarkable. Two weeks after stopping atovaquone and proguanil hydrochloride, the patient's symptoms completely resolved. CONCLUSION: The media provides a significant portion of the information that patients receive regarding rapidly changing treatment information in a pandemic. It is crucial for health care providers to know what information patients are exposed to, and to educate patients with evidence-based information. Pharmacists are the most accessible health care providers and have a key role in medication review and management. Educating patients on evidence-based use of medications may help avoid harm caused by misinformation from unreliable media sources.

Oral Semaglutide: Balancing Promising Therapeutics with Adverse Effects and Access Barriers.

DISCLOSURES: No funding was received for this commentary. The author has nothing to disclose.

Agreement between pharmacists for problem identification: an initial quality measurement of cognitive services.

BACKGROUND: Recent changes in national reimbursement policies expand the ability of pharmacists to seek reimbursement for cognitive services. The quality of pharmacist-provided cognitive services has, until now, remained unassessed. Pharmacists should demonstrate the quality and value of their work to ensure the continued and expanded acceptance of reimbursement for their services. A preliminary step in assessing quality is to compare agreement between pharmacists for basic problem identification. OBJECTIVE: To quantify agreement between pharmacist reviewers for problem identification among Utah Medicaid recipients. METHODS: Five pharmacists retrospectively reviewed drug regimens, patient characteristics, diagnosis codes, and procedures for 80 Medicaid patients in September 2008 and identified drug-related problems (DRPs) in 15 predetermined categories. Data for each patient were reviewed twice, and each combination of 2 pharmacists reviewed the same 8 patients' information. We calculated a reliability coefficient to compare the number of DRPs identified and used prevalence and bias adjusted kappa (PABAK) to determine interrater reliability for the presence of a specific DRP. RESULTS: Of the 15 DRPs categorized by pharmacist reviewers, 1 (untreated indications) had a PABAK coefficient of 0.20, indicating a relatively low level of agreement between reviewers. All other DRP categories had good to excellent agreement, with PABAK coefficients ranging between 0.43 and 0.98. CONCLUSIONS: Pharmacist reviewers exhibited less variability in DRP identification or categorization than had been expected for most categories. This work supports the conclusion that pharmacists in our center provide a basic and necessary level of quality for problem assessment. Future work is needed to document the impact of this quality on patient outcomes.

Vaccination Rates in Patients With Medical Indications for the Pneumococcal Polysaccharide Vaccine in a Family Medicine Clinic.

BACKGROUND: Pneumococcal vaccination rates among high-risk patients (eg, diabetes, asthma, smoking) seen in 2 family medicine clinics are unknown. OBJECTIVES: To assess differences in pneumococcal polysaccharide vaccination rates and reasons for nonvaccination among patients with diabetes and asthma and patients who smoke. METHODS: A chart review at 2 family medicine residency training clinics showed 425 patients with a medical indication for PPSV23 were seen between April 1, 2015, and April 30, 2015. One reviewer searched the electronic health records to assess reasons for nonvaccination. RESULTS: Rates of nonvaccination were 29.8% in patients with diabetes, 58.7% in patients with asthma, and 62.5% in patients who smoke cigarettes. Patients were classified into 3 groups based on the reasons for nonvaccination: documented patient refusal, not being addressed by a provider, and being documented as low risk despite the presence of a medical indication. CONCLUSION: The 3 reasons for nonvaccination were vaccination not being addressed, misclassification of high-risk patients as low-risk patients for infection, and documented patient refusal. Providers overlooked vaccination more often in patients with asthma and cigarette use than in patients with diabetes. Patients seeing pharmacists were most likely to be vaccinated, whereas patients seeing physician assistants were least likely to be vaccinated. Pharmacists see patients to provide medication management and preventive care, whereas other providers treat more urgent conditions. Because indications are often overlooked and not addressed, pharmacists can play a larger role in identifying and vaccinating high-risk patients.

The effect of a prescription order requirement for pharmacist-administered vaccination on herpes zoster vaccination rates.

OBJECTIVE: To determine the effect of a prescription order requirement for pharmacist-administered zoster vaccination on zoster vaccination in adults aged 60+. METHODS: A 50-state law review of statutes and regulations regarding pharmacists' ability to administer the zoster vaccine with/without a prescription order was performed. States were classified as prescription order required or not required as of January 1, 2014. Data on adults aged 60+ were obtained from the 2014 Behavioral Risk Factor Surveillance System (BRFSS). Chi-square tests and multilevel logistic regression models with and without propensity scores methods were used. RESULTS: Of the 50 states, 39 and the District of Columbia did not require a prescription order. After propensity score matching, zoster vaccination rates for adults ages 60 and older were significantly higher in states that did not require a prescription order (23.0% vs 21.1%, p = 0.0022). The propensity score-matched multilevel logistic regression model for adults aged 60+ found modestly higher odds of HZ vaccination for states that removed the prescription order requirement (OR 1.17, 95% CI 1.01-1.35). Similar estimates were found across other methodologies employed and age strata, although statistical significance varied. CONCLUSIONS: Prescription order requirements are associated with HZ vaccination rates. By removing a prescription order requirement, states may be able to promote increases in HZ vaccination in adults aged 60+.

Research in women and special populations.

The American College of Clinical Pharmacy charged a Task Force on Research in Special Populations to review, update, and broaden its 1993 White Paper on Women as Research Subjects. Participants of the task force included pharmacy clinicians and investigators in the field. This resulting White Paper, Research in Women and Special Populations, discusses the current concepts regarding the conduct of research in women, as well as in special populations such as children, elderly, minorities, cognitively impaired, and other vulnerable populations (e.g., prisoners and refugees). For each specific population, the barriers to research participation, current guidelines and regulations, and available recommendations to address these barriers are discussed. The participation in research by these populations requires addressing special social and ethical challenges. Clinical pharmacy researchers should be cognizant of these guidelines and be an advocate for the inclusion and the rights of women and special populations in research participation.

Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety.

INTRODUCTION: Primary care providers (PCPs) account for half of opioid prescriptions, often feel chronic pain patients are challenging to manage, and there is wide variability in practice patterns. The purpose of this pilot study was to evaluate the impact of a previsit pharmacist review of high-risk patients treated with opioids for chronic pain on compliance to guideline recommendations at a family medicine residency clinic. METHODS: All adult patients with an appointment for chronic pain who were prescribed >50 morphine milligram equivalents (MMEs)/day had charts reviewed by a pharmacist before each appointment; recommendations were sent electronically to the provider before the appointment. After 4 months of implementation, each patient's chart was manually reviewed to gather outcome variables. The primary outcomes were the mean MMEs/day and pain scores. RESULTS: Pharmacist previsit recommendations were provided for 45 patients. When comparing outcomes before and after intervention, the mean MMEs/day decreased by 14% (P < .001), with no change in pain scores (P = .783). Statistically significant improvements were noted in multiple other secondary opioid safety outcomes. CONCLUSION: Clinical pharmacists providing previsit recommendations was associated with decreased opioid utilization with no corresponding increase in pain scores and increased compliance to guideline recommendations.