Orlando Veterans Affairs Stratification Tool for Opioid Risk Mitigation (STORM) Very High Risk Interdisciplinary Team Review: A Brief Report.

BACKGROUND: Compared to the general population, Veterans Health Administration (VHA) patients have higher rates of mental illness, chronic pain, and substance use disorders (SUD), conditions that increase risk for opioid-related adverse events. VHA developed the Stratification Tool for Opioid Risk Mitigation (STORM) and mandated case reviews by an interdisciplinary team (IDT) for patients identified as very high risk, a process implemented and led by clinical pharmacist practitioners at the Orlando Veterans Affairs Healthcare System (OVAHCS) in 2018. OBJECTIVE: To evaluate and describe the implementation and process for IDT reviews of patients identified as very high risk by the STORM clinical decision support tool at OVAHCS. METHODS: A single center, retrospective, observational chart review was conducted. Veterans reviewed by the STORM IDT between January to September 2018 were reviewed for change in Morphine Equivalent Daily Dose (MEDD), naloxone, non-opioid analgesics, medications for SUD, benzodiazepines, engagement with clinical services (e.g., mental health, SUD, pain clinic), and overdose or suicide attempts in the year prior versus the year after IDT review. The frequency of follow-up IDT reviews was evaluated. RESULTS: Seventeen patients were identified. Four were excluded due to non-opioid related death within 12 months after review. The average baseline MEDD was 82.2mg (range 10 - 496mg) and average 12 months after review was 7.5mg (range 0 - 67.5mg), a decrease of 74.7mg, or 90.9% reduction. An increase in medications for SUD (3 patients; 23%), SUD engagement (3 to 6 patients), and urine drug tests was observed (79% increase). Benzodiazepine use decreased by 50%. CONCLUSION: This report provides insight on the IDT case review process at OVAHCS, a process that may vary widely across facilities. A reduction in MEDD, increase in SUD treatment, and improved risk mitigation was observed. The central role of clinical pharmacy and expanded process for continued follow-up warrants further study.

Association of diurnal blood pressure pattern with risk of hospitalization or death in men with heart failure.

BACKGROUND: An altered diurnal blood pressure (BP) pattern has been linked to the risk of developing heart failure (HF). We tested whether an altered diurnal BP pattern is associated with adverse outcomes (death or hospitalization for HF exacerbation) in patients with HF. METHODS AND RESULTS: A total of 118 patients with HF were enrolled from a tertiary care HF clinic and followed for death or HF hospitalization for up to 4 years; 24-hour ambulatory BP was monitored. Forty patients (34%) had a normal BP dipping pattern (night-day ambulatory BP ratio < 0.9), 44 patients (37%) had a nondipping pattern (0.9 < or = night-day ambulatory BP ratio < 1.0), and 34 patients (29%) had a reverse dipping BP pattern (night-day ambulatory BP ratio > or = 1.0). A total of 39 patients had an adverse outcome. Adverse outcome rates were the lowest in dippers and the highest in reverse dippers (log rank P = .052). Predictors of adverse outcomes, selected on the basis of log likelihood contrast, were as follows: New York Heart Association functional class (hazard ratio [HR] 1.96, 95% confidence interval [CI] 1.11-3.44), anemia (HR 2.50, 95% CI 1.23-5.08), and dipping status (HR 1.65, 95% CI 1.08-2.50). CONCLUSION: In addition to other traditional predictors, BP dipping status may be an important prognostic factor in HF.

Predictors for glucose change in hypertensive participants following short-term treatment with atenolol or hydrochlorothiazide.

STUDY OBJECTIVE: To develop and validate a predictive model for glucose change and risk for new-onset impaired fasting glucose in hypertensive participants following treatment with atenolol or hydrochlorothiazide (HCTZ). DESIGN: Randomized multicenter clinical trial. PATIENTS: A total of 735 white or African-American men and women with uncomplicated hypertension. MEASUREMENTS AND MAIN RESULTS: Pharmacogenomic Evaluation of Antihypertensive Responses (PEAR) is a randomized clinical trial to assess the genetic and nongenetic predictors of blood pressure response and adverse metabolic effects following treatment with atenolol or HCTZ. To develop and validate predictive models for glucose change, PEAR participants were randomly divided into a derivation cohort of 367 and a validation cohort of 368. Linear and logistic regression modeling were used to build models of drug-associated glucose change and impaired fasting glucose (IFG), respectively, in the derivation cohorts. These models were then evaluated in the validation cohorts. For glucose change after atenolol or HCTZ treatment, baseline glucose was a significant (p<0.0001) predictor, explaining 13% of the variability in glucose change after atenolol and 12% of the variability in glucose change after HCTZ. Baseline glucose was also the strongest and most consistent predictor (p<0.0001) for development of IFG after atenolol or HCTZ monotherapy. The area under the receiver operating curve was 0.77 for IFG after atenolol and 0.71 after HCTZ treatment, respectively. CONCLUSION: Baseline glucose is the primary predictor of atenolol or HCTZ-associated glucose increase and development of IFG after treatment with either drug.

A summer research training program to foster PharmD students' interest in research.

OBJECTIVES: To establish and assess the effectiveness of a 10-week summer research program on increasing doctor of pharmacy (PharmD) students' interest in research, particularly as it related to future career choices. DESIGN: Survey instruments were sent to 25 participants who had completed the research program in the summer of 2004, 2005, or 2006 to assess their satisfaction with the program and its influence on their career choices after graduation. ASSESSMENT: Respondents reported a high degree of satisfaction with the program, indicating that the program allowed them to determine their suitability for a career in research, and 55% reported their intention to pursue additional research training. CONCLUSION: A brief introduction to the clinical research environment helped pharmacy students understand the clinical sciences and careers in research. The introduction increased the likelihood of students pursuing a research career path after obtaining their PharmD degree.