Survey of Anticoagulation Practices with the Impella Percutaneous Ventricular Assist Device at High-Volume Centers.

OBJECTIVES: To characterize anticoagulation practices with the Impella percutaneous ventricular assist device (pVAD). BACKGROUND: Managing anticoagulation in patients being supported by the Impella pVAD is made challenging by several unique features of the device. These include the release of a dextrose-based purge solution containing unfractionated heparin (UFH), the need to concurrently administer systemic anticoagulation with intravenous UFH, and the lack of an alternative strategy in patients with contraindications to UFH. METHODS: To characterize anticoagulation practices with the Impella pVAD, we conducted a survey of centers in the United States performing a high volume of Impella cases, which we defined as > 1 per month. Centers were contacted via email or phone and individuals who agreed to participate were provided with a link to complete the survey online. The primary measures of interest were variations in practice across centers and variations from the manufacturer's recommendations. RESULTS: Practices varied considerably among respondents (65 of 182 centers, or 35.7%) and often diverged from manufacturer recommendations. Approximately half of centers (52.4%) reported using a UFH concentration of 50 units/mL in the purge solution, whereas most of the remaining centers (41.3%) reported using lower concentrations. Strategies for the initiation and adjustment of systemic therapy also varied, as did practices for routinely monitoring for hemolysis. Nearly one-fifth of centers (16.7%) had not developed an alternative strategy for the purge solution in patients with contraindications to UFH. Most centers (58.4%) reported using argatroban or bivalirudin in this scenario, a strategy that diverges from the manufacturer's recommendations. CONCLUSIONS: Given these findings, studies to determine a systematic approach to anticoagulation with the Impella device are warranted.

Observation of Patients Transitioned to an Oral Loop Diuretic Before Discharge and Risk of Readmission for Acute Decompensated Heart Failure.

BACKGROUND: Heart failure (HF) is associated with high 30-day readmission rates and places significant financial burden on the health care system. The aim of this study was to determine if the duration of observation on an oral loop diuretic before discharge is associated with a reduction in 30-day HF readmission in patients with acute decompensated HF (ADHF). METHODS AND RESULTS: This was a retrospective study of adult patients admitted for ADHF at a large academic medical center. A total of 123 patients were included. Baseline characteristics were similar between groups. The primary outcome of 30-day HF readmission occurred in 11 of 61 patients (18%) observed on an oral loop diuretic for <24 hours and in 2 of 62 patients (3.2%) observed on an oral loop diuretic for ≥24 hours (P = .023). Readmissions for 60- and 90-day HF were also significantly lower in patients observed for ≥24 hours (P = .014 and P = .049, respectively). Associations became stronger after multivariate analysis (P < .001). Observation for <24 hours and previous admission within 30 days were independent predictors of 30-day HF readmission (P = .03). CONCLUSIONS: Observation of patients on an oral loop diuretic for <24 hours was associated with significantly higher 30-day HF readmission. Therefore, observation on an oral loop diuretic for ≥24 hours before discharge in patients presenting with ADHF should be strongly considered.

No filter: A characterization of #pharmacist posts on Instagram.

OBJECTIVES: The primary objective was to characterize the underlying intent of Instagram posts using the hashtag metadata term "#pharmacist" over a 1-year period. The secondary objective was to determine whether statistically significant relationships existed between the categories and the 2 dichotomous variables tested, self-portrayed images, and relation to health care. DESIGN: Retrospective, cross-sectional, mixed methods, exploratory, descriptive study. SETTING: A review of available Instagram posts using the hashtag metadata "#pharmacist" from November 4, 2014, to November 3, 2015. Data were collected using software provided by NEXT Analytics. A sample of 14 random days was selected. PARTICIPANTS: Six hundred sixty-one Instagram posts containing "#pharmacist" in the caption. OUTCOME MEASURES: Categorization of post (including both picture and primary caption), self-portrayed images (i.e., "selfie"), and health care-related images. RESULTS: One thousand three hundred thirty-eight posts were collected from the 14-day sample. Of the posts, 661 (49.4%) were analyzed; the remainder were excluded for being written in a non-English language or containing "#pharmacist" in the comments of the post, rather than the primary caption; 19.7% of all posts fell into the Celebration category, followed by Work Experience and Advertisement with 18.6% and 12.6%, respectively. The remainder of the categories contained 10% or fewer posts. Less than 25% of posts were self-portrayed images, and 88% of posts were deemed health care-related. CONCLUSIONS: Instagram is an emerging social media platform that can be used to expand patient education, professional advocacy, and public health outreach. In this study, the majority of #pharmacist posts were celebratory in nature, and the majority were determined to be related to health care. Posts containing #pharmacist may provide the opportunity to educate the public regarding the knowledge and capabilities of pharmacists.

Diuretic Resistance in Acute Decompensated Heart Failure: A Challenging Clinical Conundrum.

Most patients with acute decompensated heart failure (ADHF) present with signs and symptoms of volume overload, and those with a significant history of diuretic exposure may demonstrate varying degrees of diuretic resistance. Although this phenomenon is commonly reported, no consensus definition exists and recommendations regarding an optimal therapeutic approach remain limited. Optimizing the use of intravenous (IV) loop diuretic therapy is the most common initial approach, and therapy may be augmented by the addition of a thiazide-type diuretic or an IV vasodilator. Patients whose resistance to diuretic therapy is due to low cardiac output may require inotropic therapy, and other options (eg, ultrafiltration and vasopressin antagonists) may be considered in select populations. The purpose of this review is to describe diuretic resistance and its underlying mechanisms in ADHF, as well as the most commonly employed strategies for overcoming it. A stepwise approach to managing volume overload in patients with ADHF and diuretic resistance is also provided.

The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action.

Shortages of cardiovascular drugs have become increasingly common, representing an ongoing public health crisis. Given few therapeutic alternatives to many of the drugs in short supply, these shortages also pose a major challenge for cardiovascular care professionals. Although changes in the regulatory environment have led to some improvements in recent years, problems involving manufacturing processes remain the most common underlying cause. Because of the complex nature of drug shortages, sustainable solutions to prevent and mitigate them will require collaboration between regulatory agencies, drug manufacturers, and other key stakeholder groups. In this report, we describe the scope of the cardiovascular drug shortage crisis in the United States, including its underlying causes and the efforts currently being made to address it. Furthermore, we provide specific recommendations for how cardiovascular care professionals can be involved in efforts to limit the impact of drug shortages on patient care as well as policy changes aimed at preventing and mitigating them.

Beliefs and behaviors of professionally engaged pharmacists.

OBJECTIVES: To define professional engagement and establish a list of beliefs and behaviors characteristic of professionally engaged pharmacists. DESIGN: A 4-round online Delphi consensus technique. Round 1: Panelists were asked to identify the beliefs and behaviors characteristic of professionally engaged pharmacists. Investigators then crafted representative statements. Round 2: Panelists agreed with statements as written, agreed with changes, or disagreed. Round 3: Panelists distributed 100 points among the modified belief and behavior statements, reflecting the relative weight and importance of each. Round 4: Panelists rated overall agreement with statements and the definition of professional engagement with the use of a 4-point Likert scale. SETTING: Not applicable. PARTICIPANTS: Fifteen pharmacists with a deep interest in and knowledge of professional engagement. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Consensus statements regarding the beliefs and behaviors characteristic of a professionally engaged pharmacist and a consensus definition of professional engagement. RESULTS: From 128 submissions regarding beliefs provided by panelists in round 1, 18 statements were crafted and 12 statements achieved consensus. From 72 submissions regarding behaviors provided by panelists in round 1, 15 statements were crafted and 9 statements achieved consensus. Panelists' agreement with each of the final statements achieved a mean score greater than 3.9 on a 4-point Likert scale. Consensus was achieved regarding the definition of professional engagement. The professionally engaged pharmacist "thinks and behaves in ways that positively affect patients' health and advance the profession's values and societal mission." CONCLUSION: Professional engagement in pharmacists is composed of cognitive, behavioral, and affective components. This work provides a framework to describe professional engagement and lays the foundation for future scholarly work. The ability to measure professional engagement will allow us to correlate professional engagement with outcomes and design interventions to catalyze increased engagement in the profession.

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.

Impact of video technology on efficiency of pharmacist-provided anticoagulation counseling and patient comprehension.

BACKGROUND: Discharge anticoagulation counseling is important for ensuring patient comprehension and optimizing clinical outcomes. As pharmacy resources become increasingly limited, the impact of informational videos on the counseling process becomes more relevant. OBJECTIVE: To evaluate differences in pharmacist time spent counseling and patient comprehension (measured by the Oral Anticoagulation Knowledge [OAK] test) between informational videos and traditional face-to-face (oral) counseling. METHODS: This prospective, open, parallel-group study at an academic medical center randomized 40 individuals-17 warfarin-naïve ("New Start") and 23 with prior warfarin use ("Restart")-to receive warfarin discharge education by video or face-to-face counseling. "Teach-back" questions were used in both groups. RESULTS: Although overall pharmacist time was reduced in the video counseling group (P < 0.001), an interaction between prior warfarin use and counseling method (P = 0.012) suggests the difference between counseling methods was smaller in New Start participants. Following adjustment, mean total time was reduced 8.71 (95% CI = 5.15-12.26) minutes (adjusted P < 0.001) in Restart participants and 2.31 (-2.19 to 6.81) minutes (adjusted P = 0.472) in New Start participants receiving video counseling. Postcounseling OAK test scores did not differ. Age, gender, socioeconomic status, and years of education were not predictive of total time or OAK test score. CONCLUSION: Use of informational videos coupled with teach-back questions significantly reduced pharmacist time spent on anticoagulation counseling without compromising short-term patient comprehension, primarily in patients with prior warfarin use. Study results demonstrate that video technology provides an efficient method of anticoagulation counseling while achieving similar comprehension.

Time and technology will tell: the pathophysiologic basis of neurohormonal modulation in heart failure.

The central roles of neurohormonal abnormalities in the pathobiology of heart failure have been defined in recent decades. Experiments have revealed both systemic involvement and intricate subcellular regulation by circulating effectors of the sympathetic nervous system, the renin-angiotensin-aldosterone system, and others. Randomized clinical trials substantiated these findings, establishing neurohormonal antagonists as cornerstones of heart failure pharmacotherapy, and occasionally offering further insight on mode of benefit. This review discusses the use of ß-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists in the treatment of heart failure, with particular attention to the pathophysiologic basis and mechanisms of action.

Polypharmacy in heart failure: drugs to use and avoid.

Polypharmacy, the use of 4 or more medications, is universal in patients with heart failure (HF). Evidence-based combination therapy is prescribed in patients with HF with reduced ejection fraction (HFrEF). Additionally, treatment of the high prevalence of comorbidities presents many therapeutic dilemmas. The use of nonprescription medications is common, adding further complexity to the medication therapy regimens of patients with HF. An approach for combining evidence-based therapies in patients with HFrEF is presented. Strategies for optimizing the management of common comorbidities in patients with HF are reviewed. Both prescription and nonprescription medications to avoid or use with caution are highlighted.

From symptoms to solutions: A structured approach to alleviating burnout among critical care pharmacists.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

An Exploratory Qualitative Study of Student Pharmacist Perspectives on Leadership.

OBJECTIVES: The objectives of this study were to (1) explore student pharmacists' knowledge and perceptions of leadership characteristics and behaviors, and (2) identify where students have opportunities to observe and exhibit leadership. METHODS: Data were collected from 32 students participating in a pharmacy leadership elective. Students submitted reflections about leadership definitions, characteristics, observations of leadership, and times when they felt like a leader. An inductive constant comparative analysis was used to code and categorize text segments from the reflections using NVivo 1.7.1 (Lumivero; Denver, CO). Holistic consideration of the reflections was used to identify an overarching theme. RESULTS: Three categories were specified to organize the data from the qualitative analysis: (1) Leader Characteristics, (2) Leading Behaviors, and (3) Leadership Contexts. One overarching theme was proposed encompassing the categories and sub-categories: Leadership Contradictions. The theme is based on the finding that students seemed able to identify leadership characteristics but emphasized descriptions like holding titles and completing managerial or task-focused duties, suggesting contradictions between conceptual understanding of leadership and leadership behaviors. CONCLUSION: The contradictions between students' conceptual understanding of leadership and what they offered as examples of how and where leadership was observed or applied to practice suggest additional activities and experiences may be warranted to help students appreciate that leadership extends beyond formal roles and demonstrates the ability to influence and support the achievement of shared goals of a team. Additionally, a multi-modal approach may enhance leadership assessment.

Exploring the Utility and Fairness of a Multi-institutional Situational Judgment Test.

OBJECTIVE: To pilot a situational judgment test (SJT) developed to assess empathy, integrity, and teamwork and explore differences in performance between first-year (P1) and fourth-year (P4) student pharmacists based on gender, race or ethnicity, and geographical region. METHODS: An SJT was developed to assess empathy, integrity, and teamwork, using best practices. The SJT was piloted tested with P1 and P4 student pharmacists at 5 institutions. Scores were adjusted for elevation and scatter to minimize the subgroup differences in response styles. RESULTS: The unadjusted mean SJT scores for P1 and P4 student pharmacists were 79.7 % and 80.7 %, respectively. The adjusted scores for P1 and P4 student pharmacists were 86.3 % and 87.2 %, respectively. Small differences were observed across institutions which can likely explained by multiple factors. The mean scores were higher among students who were older, female, identified as White, and spoke English as their first language. The subgroup differences persisted even after adjusting scores for elevation and scatter. CONCLUSION: Performance on an SJT designed to assess empathy, integrity, and teamwork was similar to others in the literature; however, differences in performance were observed across subgroups. Additional research is needed to determine whether these differences reflect test bias or other possible factors.

How Resilience and Wellness Behaviors Affected Burnout and Academic Performance of First-Year Pharmacy Students During COVID-19.

Objective. To determine whether students' levels of resilience and self-reported wellness behaviors predicted burnout and grade point average at the end of the first fall semester of the COVID-19 pandemic.Methods. We measured first-year students' resilience, burnout (exhaustion and disengagement), and self-reported wellness behaviors (sleep, nutrition, social time, and self-care activities) at the beginning and end of the fall 2020 semester of pharmacy school. We also collected students' demographic information and end-of-semester grade point average from their academic records. Using multivariable regression, we assessed whether students' resilience and wellness behaviors predicted burnout and grade point average at the end of the semester. We also assessed for changes in burnout and wellness behaviors over time.Results. Resilience was positively associated with older age and was lower among students of color. Exhaustion and disengagement were high at baseline and continued to worsen over time. Students' self-reported wellness behaviors also decreased over time, except for ratings of sleep adequacy. Resilience predicted lower levels of disengagement at the end of the semester, but its relationship with exhaustion was inconsistent. The only wellness behaviors associated with lower burnout were nutrition and sleep adequacy. Students' end-of-semester grade point average was also related to nutrition and sleep adequacy but not resilience or burnout.Conclusion. Resilience offered some protection from burnout, but its relationship to immutable factors suggests that individual-focused interventions to improve student well-being (eg, wellness behaviors such as mindfulness meditation) should be complemented by organizational support, especially for younger students and students of color.

Improving and Expanding Research on Burnout and Stress in the Academy.

Objective. To conduct an integrative review of existing literature evaluating burnout and stress to identify reliable, valid, psychometrically sound survey instruments that are frequently used in published studies and to provide best practices in conducting burnout and stress research within academic pharmacy.Findings. We reviewed 491 articles and found 11 validated reliable surveys to be most frequently cited in the literature that can be used in future burnout and stress research. We also noted frequent misunderstandings and misuse of burnout and stress terminology along with inappropriate measurement. Additionally, we identified a variety of useful websites during the review. Lastly, we identified a relative dearth of published research evaluating organizational solutions to burnout and stress beyond personal factors, ie, resilience.Summary. Burnout and stress among student pharmacists, faculty, and staff is an important research area that necessitates more robust, rigorous evaluation using validated reliable surveys with appropriate contextualization within psychological frameworks and theory. Future research evaluating organizational-level attempts to remedy sources of burnout and stress is also needed.

Opening the Black Box: Agreement and Reliability of a Situational Judgment Test Across Multiple Institutions.

OBJECTIVE: The primary objective of this study was to examine the levels of agreement and reliability of a situational judgment test (SJT) using a diverse pool of pharmacy practice faculty as subject matter experts. Secondary aims included analyses to build support for test validity and fairness. METHODS: An SJT containing 18 scenarios and 118 responses assessing empathy, integrity, and teamwork was developed and delivered to pharmacy practice faculty at 5 schools of pharmacy across the United States. Reliability was assessed by examining internal consistency, inter-rater reliability, and split-half reliability. Only responses which attained an inter-rater agreement>0.7 were included in the final version of the SJT. All responses were scored using a near-miss system, allowing higher scores for answers more closely aligned with the key, which was determined by the faculty who completed the SJT. Test fairness was reported using descriptive statistics. RESULTS: Thirty-nine faculty across the 5 participating institutions completed the SJT. The final version of the SJT included 105 responses, achieving an inter-rater agreement of>0.7 (inter-rater reliability of 0.98). Split-half reliability was 0.72. The average score was 85.7%, and no differences in performance were observed based on demographic characteristics. CONCLUSION: An SJT designed to assess empathy, integrity, and teamwork achieved reasonable levels of reliability among pharmacy practice faculty across the United States, and the results provided initial support for test validity and fairness. These results support a pilot to assess this SJT among students representing multiple institutions.

Association of lower urinary tract symptoms and diuretic adherence.

OBJECTIVE: To assess whether more severe urinary symptoms and poorer quality of life among patients on diuretic therapy are associated with decreased adherence to the diuretic regimen. METHODS: Participants were recruited via ResearchMatch.org and sent a REDCap survey. The Overactive Bladder Questionnaire-Short Form (OAB-q SF) was used to assess urinary symptom bother and health-related quality of life (HRQL). Participants were asked if they skip diuretic doses due to urinary symptoms with a bivariate (yes or no) outcome. Subgroup analyses of loop vs non-loop diuretic and those taking the diuretic for a cardiovascular indication (hypertension or heart failure) were performed. RESULTS: A total of 4029 surveys were sent, 285 were returned (7.1% response rate), and 279 were included in the study. Fifty-three participants admitted to skipping diuretic doses due to urinary symptoms. Lower HRQL scores were significantly associated with poorer adherence scores among all participants (P < .001), among participants taking a loop diuretic (P < .001), and among participants with hypertension and heart failure (P < .039). Association between symptoms and adherence remained significant after adjustment in the multivariate model for the whole cohort and loop diuretic subgroup but lost significance in the hypertension and heart failure subgroup. CONCLUSIONS: Worsening quality of life due to urinary symptoms may be associated with poorer adherence to diuretics, particularly loop diuretics.