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.

Diabetes Mellitus: Screening and Diagnosis.

Diabetes mellitus is one of the most common diagnoses made by family physicians. Uncontrolled diabetes can lead to blindness, limb amputation, kidney failure, and vascular and heart disease. Screening patients before signs and symptoms develop leads to earlier diagnosis and treatment, but may not reduce rates of end-organ damage. Randomized trials show that screening for type 2 diabetes does not reduce mortality after 10 years, although some data suggest mortality benefits after 23 to 30 years. Lifestyle and pharmacologic interventions decrease progression to diabetes in patients with impaired fasting glucose or impaired glucose tolerance. Screening for type 1 diabetes is not recommended. The U.S. Preventive Services Task Force recommends screening for abnormal blood glucose and type 2 diabetes in adults 40 to 70 years of age who are overweight or obese, and repeating testing every three years if results are normal. Individuals at higher risk should be considered for earlier and more frequent screening. The American Diabetes Association recommends screening for type 2 diabetes annually in patients 45 years and older, or in patients younger than 45 years with major risk factors. The diagnosis can be made with a fasting plasma glucose level of 126 mg per dL or greater; an A1C level of 6.5% or greater; a random plasma glucose level of 200 mg per dL or greater; or a 75-g two-hour oral glucose tolerance test with a plasma glucose level of 200 mg per dL or greater. Results should be confirmed with repeat testing on a subsequent day; however, a single random plasma glucose level of 200 mg per dL or greater with typical signs and symptoms of hyperglycemia likely indicates diabetes. Additional testing to determine the etiology of diabetes is not routinely recommended.

Effects of 5 Dynamics on student perception of team performance.

INTRODUCTION AND LEADERSHIP FRAMEWORK: Leadership development has emerged as an essential component of pharmacy school curricula. Recognizing the need for curricular integration of leadership and teaming throughout each year, the University of Utah implemented a longitudinal leadership framework called Relational Leadership. 5 Dynamics was used as a tool to teach concepts of effective teamwork and leadership in different courses within this framework. EDUCATIONAL CONTEXT AND METHODS: 5 Dynamics was used within two courses in the curricula. 5 Dynamics is designed to enhance self-awareness and improve team skills by providing a detailed assessment of how each student prefers to work and collaborate and how their respective preferences or energies can be utilized in a team setting. Learning outcomes were assessed using the Team Performance Survey. FINDINGS AND DISCUSSION: Each student was provided with an individualized energy profile from 5 Dynamics and used their particular energies to complete various activities, assignments, and projects. The highest energy was Examine, with 61% of students being either "effortless" or "abundant". A total of 64% of students reported they strongly agreed with the statement that they understood how to apply their 5 Dynamics results to learning, work, and collaboration. Student survey scores from the Team Performance Survey administered at the end of each course indicated high-quality team interactions between students. IMPLICATIONS: 5 Dynamics is a tool that may help students in maximizing their leadership and teamwork skills. This tool may be utilized by other institutions in diverse courses to teach concepts of teaming, leadership, and self-awareness.

A Modeling Exercise to Identify Predictors of Student Readiness for Advanced Pharmacy Practice Experiences.

Objective. To model the relationship of common pharmacy education assessment data including student demographics, pre-pharmacy performance, core didactic performance, and external testing measures to identify predictors of student readiness for advanced pharmacy practice experiences (APPEs). Methods. The associations between 23 predictive covariates from 226 graduating students from 2015-2018 (5786 observations) and APPE readiness as measured by midpoint core APPE scores were modeled. Multiple linear and Poisson regression models with backward selection were used. A selection criterion of p >.10 was used for covariate elimination from the model. Three models were evaluated: average of all midpoint core APPE rotation scores; average of midpoint acute care pharmacy practice and ambulatory care APPE rotation scores; and number of midpoint core clerkship failing scores. Results. The average age of the population at admission was 25.4±4.5 years, 47% were female, and 75.2% had prior degrees. Across the three prediction models, knowledge-retention covariates were the strongest predictors. Total score on the Pharmacy Curriculum Outcomes Assessment was a modest yet consistent predictor across the models. All other significant predictors were unique to the various models. Conclusion. This four-year, population-based modeling study of the relationship of common pharmacy education assessment data to APPE midpoint scores shows a modest correlation with knowledge-based measures. There is a need for greater innovation in this area of research.

Impact of statin guidelines on statin utilization and costs in an employer-based primary care clinic.

OBJECTIVES: The purpose of this study was to describe statin utilization and costs in an employer-based patient cohort by comparing actual practice and assumed adoption of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) or 2016 US Preventive Services Task Force (USPSTF) statin recommendations versus the guidelines described in 2001 (and supplemented in 2004) in the Third Report of the National Cholesterol Education Program's Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (ATPIII). STUDY DESIGN: Descriptive cohort analysis included patients treated in an employer-based primary care clinic between January 2012 and April 2014. METHODS: ATPIII, ACC/AHA, and USPSTF recommendations were retrospectively applied at the patient level based on lipid levels and statin prescribing data collected from a health risk assessment and electronic health record. Actual statin prescribing was compared with prescribing predicted by guideline recommendations. Costs for each strategy were estimated using employer pharmacy claims data. RESULTS: The study included 555 patients, of whom 112 (20.2%) were treated with a statin at baseline. ATPIII and ACC/AHA recommended statin use in 284 (51.2%) and 279 (50.3%) patients, respectively. Within the subgroup of 479 primary prevention patients, ACC/AHA recommended statin use in 203 (42.4%) versus USPSTF, which recommended statin use in 91 (19.0%). The 90-day cost per patient was similar to baseline with implementation of ATPIII or ACC/AHA recommendations, excluding use of brand name-only high-intensity statins, and costs could be reduced slightly with implementation of USPSTF guidelines. CONCLUSIONS: Despite differences in ATPIII, ACC/AHA, and USPSTF guidelines, application of any of these statin recommendations would result in optimized statin utilization and fairly neutral effects on cost in this real-world employer-based population.

SGLT2 inhibitors or GLP-1 receptor agonists as second-line therapy in type 2 diabetes: patient selection and perspectives.

Controversy exists regarding the selection of second-line therapy for patients with type 2 diabetes mellitus (T2DM) who are unable to achieve glycemic control with metformin therapy alone. Newer pharmacologic treatments for T2DM include glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors. Both the classes of medication are efficacious, exhibit positive effects on weight, and are associated with minimal risk of hypoglycemia. The purpose of this review is to compare the clinical trial and real-world effectiveness data of glucagon-like peptide-1 receptor agonists versus sodium-glucose cotransporter 2 inhibitors related to A1c reduction, weight loss, cost-effectiveness, cardiovascular outcomes, and safety in patients with T2DM. This review summarizes comparative evidence for providers who are determining which of the two classes may be the most appropriate for a specific patient.

The 2016 ACCP Pharmacotherapy Didactic Curriculum Toolkit.

The 2016 American College of Clinical Pharmacy (ACCP) Educational Affairs Committee was charged with updating and contemporizing ACCP's 2009 Pharmacotherapy Didactic Curriculum Toolkit. The toolkit has been designed to guide schools and colleges of pharmacy in developing, maintaining, and modifying their curricula. The 2016 committee reviewed the recent medical literature and other documents to identify disease states that are responsive to drug therapy. Diseases and content topics were organized by organ system, when feasible, and grouped into tiers as defined by practice competency. Tier 1 topics should be taught in a manner that prepares all students to provide collaborative, patient-centered care upon graduation and licensure. Tier 2 topics are generally taught in the professional curriculum, but students may require additional knowledge or skills after graduation (e.g., residency training) to achieve competency in providing direct patient care. Tier 3 topics may not be taught in the professional curriculum; thus, graduates will be required to obtain the necessary knowledge and skills on their own to provide direct patient care, if required in their practice. The 2016 toolkit contains 276 diseases and content topics, of which 87 (32%) are categorized as tier 1, 133 (48%) as tier 2, and 56 (20%) as tier 3. The large number of tier 1 topics will require schools and colleges to use creative pedagogical strategies to achieve the necessary practice competencies. Almost half of the topics (48%) are tier 2, highlighting the importance of postgraduate residency training or equivalent practice experience to competently care for patients with these disorders. The Pharmacotherapy Didactic Curriculum Toolkit will continue to be updated to provide guidance to faculty at schools and colleges of pharmacy as these academic pharmacy institutions regularly evaluate and modify their curricula to keep abreast of scientific advances and associated practice changes. Access the current Pharmacotherapy Didactic Curriculum Toolkit at http://www.accp.com/docs/positions/misc/Toolkit_final.pdf.

Once-weekly exenatide as a treatment for Type 2 diabetes.

Type 2 diabetes mellitus is a progressive disease that requires pharmacologic treatment to prevent microvascular and macrovascular complications. As the disease progresses, most patients require combination therapy to achieve glucose control targets. Exenatide once weekly (EQW) is a glucagon-like peptide-1 receptor agonist approved in the United States in 2012 for use as a second-line agent to treat Type 2 diabetes mellitus. EQW has shown reductions in HbA1c and weight without causing an increased risk of hypoglycemia. This review will summarize the current clinical trial, observational study, and pharmacoeconomic analyses evaluating EQW and its impact on HbA1c and weight.

Impact of traveling to visit friends and relatives on chronic disease management.

BACKGROUND: Travelers visiting friends and relatives (VFR) are known to be at high risk of acquiring infectious diseases during travel. However, little is known about the impact of VFR travel on chronic diseases. METHODS: This was a nonrandomized, retrospective observational study. Patients were adult VFR travelers who received care from an internal medical clinic serving immigrants and refugees. The primary objective was to determine the impact of VFR travel on markers of chronic disease management including: blood pressure, glycosylated hemoglobin, body mass index, serum creatinine, and anticoagulation. RESULTS: Of the 110 VFR travelers in our study, N = 48 traveled to Africa and N = 62 traveled to Asia for a mean duration of 59 (range 21-303) days. Of the 433 counseling points discussed at pre-travel visits, 71% were infectious disease prevention, 16% chronic disease related, and 13% travel safety. A total of 63 patients (57%) reported one or more health problems while traveling. Of these, 35 patients (32%) experienced a problem related to a chronic condition. In comparison, 24 (22%) patients experienced an acute infection. Sixty percent of patients were nonadherent to medications during travel. An average increase in diastolic blood pressure of 3.6 mmHg among patients with hypertension was the only statistically significant change in a chronic disease marker when values before and after travel were compared. Subgroup analysis revealed that travel to Africa and nonadherence to medications were also associated with worsening blood pressure control, and patients traveling to Africa experienced a decrease in body mass index. CONCLUSIONS: This study identified a high proportion of problems related to chronic conditions experienced during VFR travel, while pre-travel appointments tended to focus on infectious disease prevention. A greater emphasis on medication adherence and chronic disease management during VFR travel is also needed during pre-travel preparations.

Antifungal use in hospitalized adults in U.S. academic health centers.

PURPOSE: Use of antifungal agents and predictors of total antifungal use among adult inpatients at U.S. academic health centers was characterized. METHODS: Claims data obtained from a geographically representative sample of U.S. nonprofit academic health centers were analyzed to characterize use of systemic antifungals during the period 2004-08. Aggregate data were analyzed to identify trends in use of three antifungal classes (azoles, polyenes, echinocandins), as well as individual antifungal agents. Multivariate regression analysis was employed to investigate predictors of total antifungal use and interhospital variability in antifungal use. RESULTS: Aggregate antifungal use at health centers included in the data analysis increased from (mean ± S.D.) 82 ± 36 days of therapy (DOT) per 1000 patient-days in 2004 to 88 ± 39 DOT per 1000 patient-days in 2007 and then declined to 77 ± 36 DOT per 1000 patient-days in 2008. Use of voriconazole increased significantly during the study period (p < 0.0001), while use of caspofungin decreased significantly (p < 0.0001). Higher use of third- or fourth- generation cephalosporins was a significant predictor of higher total antifungal use (p = 0.0005); performance of more stem cell or bone marrow transplants was also significantly associated with greater antifungal use. CONCLUSION: Total antifungal use at a sample of U.S. academic health centers increased from 2004 to 2007 but decreased to below baseline in 2008. Azoles were the most commonly used agents. In 2008, total antifungal use at the centers ranged from 29 to 334 DOT per 1000 patient-days.

Trends in antibacterial use in hospitalized pediatric patients in United States academic health centers.

Trends in pediatric antibacterial use were examined in 20 academic health centers during the period 2002-2007. There was a significant increase in the use of linezolid (P < .001) and of macrolides (P = .001) and a significant decrease in the use of aminoglycosides (P < .001) and of first-generation cephalosporins (P < .001).