Multimodal Intervention Assessing the Appropriateness of Acid Suppression Therapy is Associated With Reduced Prescriptions at the Time of Discharge for Hospitalized Inpatients.

Background: Acid suppression therapy (AST), including proton pump inhibitors and histamine 2 receptor antagonists, are an overused class of medications. When used inappropriately, AST leads to polypharmacy, increased healthcare costs, and possible negative health consequences. Objective: To assess whether an intervention including prescriber education combined with a pharmacist-driven protocol was effective in reducing the percentage of patients who were discharged with inappropriate AST. Methods: This was a prospective pre-post study of adult patients who were prescribed AST before or during their admission to an internal medicine teaching service. All internal medicine resident physicians received education on appropriate AST prescribing. During the 4-week intervention period, dedicated pharmacists assessed the appropriateness of AST and made recommendations regarding deprescribing if no appropriate indication was identified. Results: During the study period, there were 14 166 admissions during which patients were prescribed AST. Out of the 1143 admissions during the intervention period, appropriateness of AST was assessed by a pharmacist for 163 patients. AST was determined to be inappropriate for 52.8% (n = 86) of patients and discontinuation or de-escalate of therapy occurred in 79.1% (n = 68) of these cases. The percentage of patients discharged on AST decreased from 42.5% before the intervention to 39.9% after the intervention (P = .007). Conclusion: This study suggests that a multimodal deprescribing intervention reduced prescriptions for AST without an appropriate indication at the time of discharge. To increase the efficiency of the pharmacist assessment several workflow improvements were identified. Further study is necessary to understand the long-term outcomes of this intervention.

Ensuring safe and optimal medication use in older community residents: Collaboration between a nurse and a pharmacist.

The purpose of this retrospective review is to describe 1) a nurse-pharmacist collaboration within a home based nurse-occupational therapist-handyman program called CAPABLE and 2) potential medication problems and 3) information communicated to participants and prescribers about those problems. A chart review was performed for each participant that one CAPABLE nurse referred to the pharmacists. We identified recommendations provided by pharmacists, synthesized common questions posed to the pharmacists' and developed exemplar cases of participant encounters. Fifty-nine participants were reviewed. The median number of total medications was 11 (IQR 9-14.5). Participants were most commonly taking antihypertensives (93%), statins (66%), and supplements/vitamins (61%). Pharmacists provided 83 unique recommendations for the 59 participants. The recommendations from the pharmacist were communicated for 49 of the 59 participants (83%), by the nurse. The nurse-pharmacist collaboration identified medication-related problems and solutions aimed at improving the quality of life for home-dwelling seniors with functional limitations.

Transforming Health Care from Volume to Value: Targeting Essential Therapies for Improved Health.

The healthcare landscape is evolving rapidly due to escalating costs from the traditional fee-for-service model. Value-based care has emerged as a viable solution, and initiatives focus on areas prone to overuse, waste, or high costs, such as advanced imaging and avoidable acute care resource utilization. Improving medication use is an important component of this work, and it requires organizational commitment, interdisciplinary collaboration, and targeted strategies for specific therapeutic areas. This review article discusses the value-based care approach to optimizing medications and blood product prescribing, spotlighting opportunities to reduce the overuse of opioid, antimicrobial, and proton pump inhibitor medications, alongside the underuse of guideline-based medical therapies in managing chronic diseases like coronary artery disease, heart failure, and chronic obstructive pulmonary disease.

Establishing the Content Validity of a Student Pharmacist Patient Counseling Competency Assessment in Oncology.

Objective. The goal of this project was to establish content validity and describe internal consistency of a patient counseling competency assessment instrument used to evaluate student pharmacists practicing in an oncology setting.Methods. The study involved a modified e-Delphi panel of oncology clinical pharmacy specialists, clinical pharmacy generalists, and oncology pharmacy residents. Iterative rounds of the e-Delphi process were conducted until consensus was reached on most instrument items. Consensus was defined as agreement by at least 75% of participants that an item was or was not important.Results. The modified e-Delphi process included three rounds of responses from 13 panelists and resulted in a 35-item instrument with consensus reached on 33/35 (94%) of the items. All participants indicated that the assessment result options allowed them to indicate the student's level of competency either extremely well or very well.Conclusion. A modified e-Delphi method was used to validate a reliable instrument for the assessment of student pharmacist counseling abilities in an oncology setting. Similar methodology should be considered during the development of student assessment tools, especially for high-impact student pharmacist activities such as chemotherapeutic medication counseling.

Indications for the Use of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Peptic Ulcer Bleeding in Hospitalized Patients.

Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.

Reducing Overuse of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Nonvariceal Gastrointestinal Bleeding in the Hospital: A Narrative Review and Implementation Guide.

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.

Expansion of inpatient clinical pharmacy services through reallocation of pharmacists.

PURPOSE: The redesign of an inpatient pharmacy practice model through reallocation of pharmacy resources in order to expand clinical services is described. METHODS: A pharmacy practice model change was implemented at a nonprofit academic medical center to meet the increasing demand for direct patient care services. In order to accomplish this change, the following steps were completed: reevaluation of daily tasks and responsibilities, reallocation of remaining tasks to the most appropriate pharmacy staff member, determination of the ideal number of positions needed to complete each task, and reorganization of the model into a collection of teams. Data were collected in both the preimplementation and postimplementation periods to assess the impact of the model change on operational workflow and clinical service expansion. RESULTS: The mean ± S.D. times to order verification were 17 ± 52 minutes during the preimplementation period and 21 ± 70 minutes in the postimplementation period (p < 0.001). During the 3 months before and after implementation of the model change, the mean number of medication reconciliations performed increased from 114 to 144. After implementation of the model change, total interventions increased 194%. Notably, there was a 736% increase in the number of interventions focused on facilitating safe discharge. CONCLUSION: A pharmacy practice model change was successfully implemented by reallocating existing pharmacist and technician roles and increasing incorporation of pharmacy residents and students. This change led to an expansion of direct patient care coordination services without negatively affecting the operational responsibilities of the pharmacy or the need to hire additional staff.

Implementation of an emergency department-based clinical pharmacist transitions-of-care program.

PURPOSE: The implementation of an emergency department (ED)-based clinical pharmacist transitions-of-care (TOC) program is described. SUMMARY: The intervention program consisted of collaboration between ED and ambulatory care pharmacists to provide patient-specific comprehensive medication review and education in the ED setting and to help ensure a coordinated transition to the ambulatory care setting by scheduling an ambulatory pharmacy clinic or home-based visit. Patients who sought care at an adult ED for an exacerbation of asthma, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF) were assessed for issues with medication adherence or administration technique, patient-specific concerns regarding medication use, access to medications at discharge, the need for modification of chronic therapy, contraindicated medications, and vaccination status, if applicable. The pharmacist then referred the patient to follow up in an ambulatory care pharmacy clinic or with the home-based medication management (HBMM) program. Of the 18 program participants who were referred to follow-up care, 5 successfully followed up with a pharmacist after ED discharge. The mean time from the ED visit to follow-up for these 5 patients was 16.6 ± 8.6 days. In addition, 5 patients followed up with their primary care provider within 30 days of the initial ED visit; 2 of these patients also followed up with a pharmacist. Within 30 days of the initial ED encounter, 4 patients had ED revisits. CONCLUSION: A TOC pharmacist-led program targeting patients who arrived at the ED with the chief complaint of asthma exacerbation, COPD, or CHF provided interventions from an ED or ambulatory care pharmacist as well as follow-up opportunities at outpatient clinics or an HBMM program.

Development and implementation of a postdischarge home-based medication management service.

PURPOSE: The development and implementation of a postdischarge home-based, pharmacist-provided medication management service are described. SUMMARY: A work group composed of pharmacy administrators, clinical specialists, physicians, and nursing leadership developed the structure and training requirements to implement the service. Eligible patients were identified during their hospital admission by acute care pharmacists and consented for study participation. Pharmacists and pharmacy residents visited the patient at home after discharge and conducted medication reconciliation, provided patient education, and completed a comprehensive medication review. Recommendations for medication optimization were communicated to the patient's primary care provider, and a reconciled medication list was faxed to the patient's community pharmacy. Demographic and medication-related data were collected to characterize patients receiving the home-based service. A total of 50 patients were seen by pharmacists in the home. Patient education provided by the home-based pharmacists included monitoring instructions, adherence reinforcement, therapeutic lifestyle changes, administration instructions, and medication disposal instructions. Pharmacists provided the following recommendations to providers to optimize medication regimens: adjust dosage, suggest laboratory tests, add medication, discontinue medication, need prescription for refills, and change product formulation. Pharmacists identified a median of two medication discrepancies per patient and made a median of two recommendations for medication optimization to patients' primary care providers. CONCLUSION: The implementation of a post-discharge, pharmacist-provided home-based medication management service enhanced the continuity of patient care during the transition from hospital to home. Pharmacists identified and resolved medication discrepancies, educated patients about their medications, and provided primary care providers and community pharmacies with a complete and reconciled medication list.