Medication Regimen Complexity Index in the Elderly in an Outpatient Setting: A Literature Review.

Objective To review current literature reporting outcomes associated with utilization of the Medication Regimen Complexity Index (MRCI) with older adults in an outpatient setting. Data sources The National Library of Medicine via PubMed, International Pharmaceutical Abstracts, and the Cochrane Database were used to identify clinical trials evaluating outcomes associated with utilization of the MRCI. The medical subject heading terms "geriatrics" and "medication adherence" were used in combination with key terms "medication regimen complexity index" and "medication complexity." Study selection/data extraction Seventy-five articles met the search criteria and were reviewed. Studies were included if they had MRCI-related outcomes and were performed in patients 60 years of age and older in an outpatient setting. Eleven articles met the stated criteria. Data synthesis Higher MRCI scores may be associated with increased mortality rates, medication nonadherence, and unplanned hospitalizations; however, when compared with medication number, MRCI did not better predict increased medication nonadherence and unplanned hospitalizations. Conclusion The MRCI is a useful tool to determine medication complexity; however, current literature is limited by its observational design. Also, MRCI does not take into account potential factors such as high-risk medications and comorbid conditions, which may affect MRCI scores; therefore, additional trials are warranted before suggesting pharmacists implement this tool in their everyday practice.

Impact of an Antibiotic-specific Sepsis Bundle on Appropriate and Timely Antibiotic Administration for Severe Sepsis in the Emergency Department.

BACKGROUND: Guidelines recommend initiation of appropriate antimicrobial therapy within 1 h of severe sepsis diagnosis. Few sepsis bundles exist in the literature emphasizing initiation of specific antibiotic therapy. OBJECTIVE: To determine the impact of an antibiotic-specific sepsis bundle on the timely initiation of appropriate antibiotics. METHODS: For this before-and-after interventional study, the sepsis bundle at this 803-bed academic tertiary-care facility was redesigned to include specific antibiotic selection and dosing, based on suspected source of infection and susceptibility patterns. Protocol education and advertising was completed and bundle-specific antibiotics were put in the automated medication cabinet. RESULTS: Stepwise analysis of timely initiation of appropriate antibiotics included: 1) Was the initial antibiotic appropriate? 2) If so, was it initiated within 1 h of diagnosis? 3) If so, were all necessary appropriate antibiotics started? and 4) If so, were they started within 3 h of diagnosis? In comparing the 3-month-before group and 3-month-after group (n = 124), the appropriate initial antibiotic was started in 33.9% vs. 54.8% of patients (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.19-0.93, p = 0.03) and within 1 h in 22.6% vs. 14.5% of patients (OR 1.71, 95% CI 0.62-4.92, p = 0.36), respectively. All necessary appropriate antibiotics were initiated in 16.1% vs. 12.9% of patients (OR 1.30, 95% CI 0.42-4.10, p = 0.80), and within 3 h in 14.5% vs. 9.7% of patients, respectively (OR 1.58, 95% CI 0.46-5.78, p = 0.58). CONCLUSIONS: An updated antibiotic-specific sepsis bundle, with antibiotics put in an automated medication cabinet, can result in improvements in the initiation of appropriate initial antibiotic therapy for severe sepsis in the emergency department.

From Pilot to Practice: A Trainee-Integrated Pharmacy Practice Model in Cardiology.

OBJECTIVES: Problems related to medication use portend poor outcomes, but resources for expanding clinical pharmacy services are limited. We conducted a pilot study in the area of cardiology to determine the impact and feasibility of a trainee-integrated pharmacy practice (TIPP) model comprised of pharmacy residents and a clinical pharmacist. METHODS: Coverage of 2 acute care and 1 intensive care team was distributed among 1 clinical pharmacist and 3 pharmacy residents. Patient care services included interdisciplinary rounds, order verification, medication reconciliation, counseling, clinical monitoring, and documentation. A pharmacy technician collected medication histories for newly admitted patients. Data related to medication reconciliation, clinical interventions, and time requirements were collected. Clinical services were compared to historical controls where data were available. RESULTS: Over the 18-day pilot study, the mean daily census consisted of 33.4 ± 5.3 patients. Admission medication reconciliation was performed on 8.1 patients per day, resulting in the discovery of 3.5 discrepancies per patient. Of 18 patients receiving anticoagulant therapy, 9 were counseled prior to discharge. Compared to historical controls, the number of patients receiving medication reconciliation and discharge counseling improved by 81% and 70%, respectively (both P < .05). A total of 763 clinical interventions were recommended (42.4 per day), with many recognized in peer-reviewed literature as conferring improvements in clinical outcomes. Members of the model were active for a mean of 10-12 hours each day, with 6.3-7.2 hours corresponding to direct patient care. LIMITATIONS: This was a single-arm, observational pilot study. CONCLUSION: Implementation of a TIPP model significantly expanded clinical pharmacy services on an acute care cardiology service, but it required significant time commitments.

LOGAN-CV: A Prospective Study of a Multifaceted Intervention Targeting United States Clinicians to Improve Guideline-Based Management of Lipid-Lowering Therapy.

INTRODUCTION: The 2018 American Heart Association (AHA)/American College of Cardiology (ACC)/Multisociety blood cholesterol guidelines recommend clinicians consider adding non-statin therapy for patients with very high-risk (VHR) atherosclerotic cardiovascular disease (ASCVD) and low-density lipoprotein cholesterol (LDL-C) ≥ 70 mg/dl while receiving maximally tolerated statins. However, according to a recent study, only 17.1% of patients with established ASCVD received appropriate lipid-lowering therapy (LLT) intensification. Here, we describe the design of a prospective, 12-month study (LOGAN-CV) evaluating a multifaceted site-level intervention to enhance clinicians' adherence to guidelines to improve LDL-C levels for patients with VHR ASCVD. METHODS: Clinicians from up to ten research sites are eligible if they care for adult patients with ASCVD. Interventions include educational modules, a cloud-based performance platform providing clinicians a tailored summary of their LDL-C management performance, newsletters, periodic peer-to-peer calls, and pre- and post-intervention surveys evaluating knowledge, attitudes, and beliefs around LDL-C management, with additional interventions for clinicians demonstrating a lower readiness to make treatment decisions based on guideline recommendations. Patients with VHR ASCVD, defined as having recent myocardial infarction and LDL-C ≥ 70 mg/dl despite statin treatment, will be included in the study. Patient data will be collected from electronic medical records from baseline (clinician enrollment) through the 12-month intervention. The study started in October 2022, with anticipated completion in March 2024. PLANNED OUTCOMES: The change in proportion of patients with LDL-C < 70 mg/dl achieved at any time during the 12-month intervention (primary); LLT intensification, changes in guideline-aligned LDL-C testing and LLT titration over 12 months, and change in overall clinicians' knowledge, attitudes, and beliefs are key outcomes of interest. The LOGAN-CV study addresses a critical unmet need in LDL-C control in patients with VHR ASCVD and evaluates the effect of a multifaceted intervention targeting clinicians to improve their adherence to guidelines and consequently improve clinical outcomes for patients.

Low-Density Lipoprotein Cholesterol Testing Following Myocardial Infarction Hospitalization Among Medicare Beneficiaries.

Background: Low-density lipoprotein cholesterol (LDL-C) is used to guide lipid-lowering therapy after a myocardial infarction (MI). Lack of LDL-C testing represents a missed opportunity for optimizing therapy and reducing cardiovascular risk. Objectives: The purpose of this study was to estimate the proportion of Medicare beneficiaries who had their LDL-C measured within 90 days following MI hospital discharge. Methods: We conducted a retrospective cohort study of Medicare beneficiaries ≥66 years of age with an MI hospitalization between 2016 and 2020. The primary analysis used data from all beneficiaries with fee-for-service coverage and pharmacy benefits (532,767 MI hospitalizations). In secondary analyses, we used data from a 5% random sample of beneficiaries with fee-for-service coverage without pharmacy benefits (10,394 MI hospitalizations), and from beneficiaries with Medicare Advantage (176,268 MI hospitalizations). The proportion of beneficiaries who had their LDL-C measured following MI hospital discharge was estimated accounting for the competing risk of death. Results: In the primary analysis (mean age 76.9 years, 84.4% non-Hispanic White), 29.9% of beneficiaries had their LDL-C measured within 90 days following MI hospital discharge. Among Hispanic, Asian, non-Hispanic White, and non-Hispanic Black beneficiaries, the 90-day postdischarge LDL-C testing was 33.8%, 32.5%, 30.0%, and 26.0%, respectively. Postdischarge LDL-C testing within 90 days was highest in the Middle Atlantic (36.4%) and lowest in the West North Central (23.4%) U.S. regions. In secondary analyses, the 90-day postdischarge LDL-C testing was 26.9% among beneficiaries with fee-for-service coverage without pharmacy benefits, and 28.6% among beneficiaries with Medicare Advantage coverage. Conclusions: LDL-C testing following MI hospital discharge among Medicare beneficiaries was low.

Lipid-Lowering Therapy Utilization and Dosage Among Patients with Acute Coronary Syndrome Events: A Retrospective Cohort from 12 Community Hospitals.

Introduction: Clinical practice guidelines recommend initiating a high-intensity LLT and continued monitoring of low-density lipoprotein cholesterol (LDL-C) following acute coronary syndrome (ACS). We used real-world data to describe LLT utilization after discharge and 1-year adherence. The reduction in LDL-C was also evaluated. Methods: Data were extracted from electronic health records (EHRs) from 12 hospitals in a large community healthcare system in midwestern United States between 2013 and 2019. Data on eligible patients recently discharged with an ACS event were linked to pharmacy claims data to describe LLT fill rates and 1-year post-discharge adherence. Adherence was reported as the proportion of days covered ≥80%. Results: Of the 10,589 eligible patients, 49% filled a high-intensity statin at discharge and only 36% were adherent at 1 year. The mean (SD) age was 66.1±13.3, 39.3% were females, 58.8% were Caucasian, and 53.0% had Medicare. There was a clear trend for greater fill rates at discharge among patients with higher LDL-C values than those with lower values (p<0.01). Key predictors of high-intensity (versus medium-intensity) LLT use within 21 days after an ACS event included ACS type (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.52-0.67 for NSTEMI versus STEMI), age group (OR: 0.59; 95% CI: 0.48-0.72 for >75 years versus <65 years), and statin use before index ACS event (OR: 1.56; 95% CI: 1.23-1.88). Conclusion: This real-world study found that despite recommendations in clinical practice guidelines, high-intensity LLT fill rates at discharge and 1-year adherence to LLT remain suboptimal. Clinical characteristics, including ACS type and LDL-C values, were strong predictors of filling and adherence to guideline-recommended therapy. Age, sex, and race/ethnicity disparities were observed in discharge fill rates and 1-year adherence. These results highlight the need for continued efforts at the patient and provider levels to improve LLT adherence among ACS patients.

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.

Correlation between medication regimen complexity and quality of life in patients with heart failure.

PURPOSE: To determine if a correlation exists between the medication regimen complexity index (MRCI) and quality of life (QoL) in patients with heart failure (HF) assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). METHODS: Retrospective chart review from July 2012 through June 2018 identified patients for inclusion who completed an MLHFQ. Baseline and, if available, follow-up MLHFQ scores were collected. The medication list documented on the date of the MLHFQ was used to calculate the MRCI. RESULTS: Patients with a documented MLHFQ score were included (n = 72) in the primary analysis. No correlation existed between baseline MRCI and MLHFQ (r = 0.07; p = 0.55). A secondary analysis of correlation between change in MRCI and MLHFQ was conducted for patients (n = 30) with a follow-up MLHFQ score. A moderate, negative correlation (r = -0.47; p = 0.009) existed between change in MRCI and MLHFQ from baseline to follow-up. CONCLUSION: No significant correlation between MRCI and MLHFQ scores were found at baseline. Patients with follow-up MLHFQ scores demonstrated improvements in QoL, despite increasingly complex medication regimens. Medication regimen complexity alone is likely an insufficient marker for predicting QoL in patients with HF.

Evaluation of Bexar County community pharmacist attitudes toward harm reduction.

INTRODUCTION: Harm reduction is a term for strategies that minimize the negative outcomes of drug use. Given the progressing opioid epidemic, identifying barriers to harm reduction dispensing in community pharmacies is essential. METHODS: This online, survey-based study assessed community pharmacist attitudes toward harm reduction and perceived dispense rates of both naloxone and needles/syringes to patients without verifiable injectable prescriptions. The online survey was distributed to members of the Bexar County Pharmacist Association and university alumni. The survey collected demographics, perceived dispense rates of naloxone, needles and syringes, availability of pharmacy protocols for dispensing these products, and Likert-scaled attitudinal questions. Responses were collected for 6 weeks. RESULTS: Thirty-two survey responses were analyzed. Participants were generally white (n = 14) or Hispanic/Latino (n = 14), had a median age of 37 years (interquartile range, 32-49 years), and had a median graduation year of 2011 (interquartile range, 1988-2016). Most pharmacists agreed or strongly agreed they should be involved in harm reduction (n = 26) and that pharmacies are an appropriate place to access these resources (n = 26). However, most reported never or rarely dispensing both naloxone (n = 19) and needles and syringes (n = 22). Naloxone or needle and syringe protocol use was reported by 66% (n = 21) and 47% (n = 15) of pharmacists, respectively. Pharmacy protocols significantly enhanced the likelihood of naloxone dispensing (P = .007) but not needle and syringe dispensing (P = .24). CONCLUSION: Community pharmacists exhibited positive attitudes toward harm reduction but reported low rates of dispensing both naloxone and needles and syringes. Pharmacy protocols could be enhanced to better support community pharmacists in this area.

Medication Management of Patients Undergoing Transcatheter Aortic Valve Replacement.

Aortic stenosis (AS) is the most common form of valvular heart disease. A detailed diagnostic workup is necessary to promptly stage and classify disease severity to determine optimal management. Medical therapy and valvuloplasty are options that fail to delay or reverse disease progression. Surgical aortic valve replacement (SAVR) is curative but has significant limitations for some patient populations. A newer option, transcatheter aortic valve replacement (TAVR), has become more widely available to patients with intermediate- or high-operative risk. Periprocedural medication management is imperative for successful valve implantation and to minimize adverse events. Stroke remains one of the most common complications of TAVR and is associated with increased mortality. Thus, intra- and postprocedural antithrombotic therapy is required, although the regimen that best minimizes thromboembolic events and bleeding complications has yet to be defined. Patients undergoing TAVR with comorbid conditions requiring oral anticoagulation or individuals who develop subvalvular thromboses pose unique challenges. Antiplatelet and anticoagulant therapy should be carefully balanced. This article summarizes key literature supporting the pharmacologic management of patients receiving TAVR.