A Randomized Controlled Trial to Improve Unmet Social Needs and Clinical Outcomes Among Adults with Diabetes.

BACKGROUND: Adults with type 1 or type 2 diabetes often face financial challenges and other unmet social needs to effective diabetes self-management. OBJECTIVE: Whether a digital intervention focused on addressing socioeconomic determinants of health improves diabetes clinical outcomes more than usual care. DESIGN: Randomized trial from 2019 to 2023. PARTICIPANTS: A total of 600 adults with diabetes, HbA1c ≥ 7.5%, and self-reported unmet social needs or financial burden from a health system and randomized to the intervention or standard care. INTERVENTION: CareAvenue is an automated, e-health intervention with eight videos that address unmet social needs contributing to poor outcomes. MEASURES: Primary outcome was HbA1c, measured at baseline, and 6 and 12 months after randomization. Secondary outcomes included systolic blood pressure and reported met social needs, cost-related non-adherence (CRN), and financial burden. We examined main effects and variation in effects across predefined subgroups. RESULTS: Seventy-eight percent of CareAvenue participants completed one or more modules of the website. At 12-month follow-up, there were no significant differences in HbA1c changes between CareAvenue and control group (p = 0.24). There were also no significant between-group differences in systolic blood pressure (p = 0.29), met social needs (p = 0.25), CRN (p = 0.18), and perceived financial burden (p = 0.31). In subgroup analyses, participants with household incomes 100-400% FPL (1.93 (SE = 0.76), p < 0.01), 201-400% FPL (1.30 (SE = 0.62), p < 0.04), and > 400% FPL (1.27 (SE = 0.64), p < 0.05) had significantly less A1c decreases compared to the control group. CONCLUSIONS: On average, CareAvenue participants did not achieve better A1c lowering, met needs, CRN, or perceived financial burden compared to control participants. CareAvenue participants with higher incomes achieved significantly less A1c reductions than control. Further research is needed on social needs interventions that consider tailored approaches to population subgroups. CLINICAL TRIALS REGISTRY: ClinicalTrials.gov ID NCT03950973, May 2019.

Enhancing availability of services to control hypertension through a team-based care approach that includes pharmacists.

BACKGROUND: Primary care physician (PCP) shortages are expected to increase. The Michigan Medicine Hypertension Pharmacists' Program uses a team-based care (TBC) approach to redistribute some patient care responsibilities from PCPs to pharmacists for patients with diagnosed hypertension. OBJECTIVE: This evaluation analyzed whether the Michigan Medicine Hypertension Pharmacists' Program increased the availability of hypertension management services and described facilitators that addressed barriers to program sustainability and replicability. METHODS: We conducted a retrospective observational study that used a mixed methods approach. We examined the availability of hypertension management services using the number of pharmacists' referrals of patients to other services and the number of PCP appointments. We analyzed qualitative interviews with program staff and site-level quantitative data to examine the program's impact on the availability of services, the impact of TBC that engaged pharmacists, and program barriers and facilitators. RESULTS: Patients who visited a pharmacist had fewer PCP visits over 3- and 6-month periods compared to a matched comparison group that did not see a pharmacist and were 1.35 times more likely to receive a referral to a specialist within a 3-month period. Support from leaders and physicians, shared electronic health record access, and financial backing emerged as leading factors for program sustainability and replicability. CONCLUSION: Adding pharmacists to the care team reduced the number of PCP appointments per patient while increasing the availability of hypertension management services; this may in turn improve PCPs' availability. Similar models may be sustainable and replicable by relying on organizational buy-in, accessible infrastructure, and financing.

Comprehensive medication review service by embedded pharmacists in primary care: Innovations and impact.

BACKGROUND: Primary care may offer innovations in delivering comprehensive medication reviews (CMRs). OBJECTIVES: This study aimed to (1) describe innovations to improve delivery and impact of CMR, (2) quantify CMR completion rates and patient satisfaction, and (3) characterize medication changes and impact on medication costs. PRACTICE DESCRIPTION: Board-certified ambulatory care pharmacists with collaborative practice agreements embedded in primary care provided CMRs in 5 clinics for eligible university prescription plan retirees. PRACTICE INNOVATION: Innovations included (1) physician review of potential CMR recipient list, (2) use of trained student pharmacists to recruit and set up CMR visits, (3) use of clinical information in a standardized CMR 2-visit approach by embedded pharmacists, and (4) enrollment into disease management programs or referrals to other providers. EVALUATION METHODS: Data from a retrospective cohort were collected. The CMR completion rate and therapeutic interventions were documented. Prescription fill data were available for 6 months before and after the CMR. An anonymous survey assessed patient satisfaction. Frequencies and descriptive statistics characterized completion rate, interventions, and patient satisfaction. The median cost to the plan of deleted versus added medications and per member per month total drug costs before and after the CMR were compared. RESULTS: Among 729 beneficiaries screened, 489 were eligible and 223 (46%) received a CMR. There were 388 medication interventions: the most common intervention was to delete medications (41.0%). One in 4 was enrolled into the pharmacists' disease management programs. Individuals reported 4.68 (SD 0.67) of 5 for helpfulness of the CMR. The ratio of median costs for medication deletions versus additions was $1.46 vs. $1.00. CONCLUSION: Innovations to deliver CMRs capitalized on well-established physician-pharmacist relationships and nonpharmacist personnel to recruit and prepare the intake. Almost half of eligible beneficiaries received a CMR, and the CMRs were impactful for patients and payers. The most prevalent intervention was to discontinue medications for efficacy reasons.

Primary care provider perceptions of an integrated community pharmacy hypertension management program.

BACKGROUND: Trained community pharmacists provided hypertension (HTN) management services in collaboration with a patient-centered medical home (PCMH). OBJECTIVE: To explore primary care provider (PCP) perceptions of a HTN management program in which patients at the PCMH with elevated blood pressure could choose to receive follow-up care with a trained community pharmacist at a chain community pharmacy. METHODS: We conducted informal interviews with 8 PCPs with a range of level of involvement with the collaborative HTN management program to inform the development of a 13-question online survey that was distributed to PCPs at 10 participating Michigan Medicine PCMH clinics. The primary outcome was the percent of PCPs who reported that the program improved their patient's blood pressure. Secondary outcomes included awareness of the program, alternative follow-up strategies, PCP satisfaction, and barriers to using the program. RESULTS: A total of 39 PCPs (30.0%) responded to the survey. More than one-half (n = 21 of 39, 53.9%) of respondents reported that at least 1 of their patients had seen a trained community pharmacist for HTN management services. Almost all of these PCPs (n = 19 of 21, 90.5%) reported being satisfied with the program, and 80.9% (n = 17 of 21) agreed that it helped patients improve their blood pressure control. The most common barriers identified were patients preferring to follow up directly with their PCP (n = 18 of 39, 46.2%), PCPs being more comfortable with patients having a visit with an embedded ambulatory care pharmacist (n = 16 of 39, 41.0%), and a lack of written materials to share with patients about the program (n = 15 of 39, 38.5%). CONCLUSION: PCPs who used the integrated community pharmacy HTN management program were satisfied with the program and thought that it resulted in improved blood pressure control. PCPs may benefit from written information to share with their patients as well as education to increase their awareness of the program and its beneficial effect on patient blood pressure.

Understanding the Feasibility, Acceptability, and Efficacy of a Clinical Pharmacist-led Mobile Approach (BPTrack) to Hypertension Management: Mixed Methods Pilot Study.

BACKGROUND: Hypertension is a prevalent and costly burden in the United States. Clinical pharmacists within care teams provide effective management of hypertension, as does home blood pressure monitoring; however, concerns about data quality and latency are widespread. One approach to close the gap between clinical pharmacist intervention and home blood pressure monitoring is the use of mobile health (mHealth) technology. OBJECTIVE: We sought to investigate the feasibility, acceptability, and preliminary effectiveness of BPTrack, a clinical pharmacist-led intervention that incorporates patient- and clinician-facing apps to make electronically collected, patient-generated data available to providers in real time for hypertension management. The patient app also included customizable daily medication reminders and educational messages. Additionally, this study sought to understand barriers to adoption and areas for improvement identified by key stakeholders, so more widespread use of such interventions may be achieved. METHODS: We conducted a mixed methods pilot study of BPTrack, to improve blood pressure control in patients with uncontrolled hypertension through a 12-week pre-post intervention. All patients were recruited from a primary care setting where they worked with a clinical pharmacist for hypertension management. Participants completed a baseline visit, then spent 12 weeks utilizing BPTrack before returning to the clinic for follow-up. Collected data from patient participants included surveys pre- and postintervention, clinical measures (for establishing effectiveness, with the primary outcome being a change in blood pressure and the secondary outcome being a change in medication adherence), utilization of the BPTrack app, interviews at follow-up, and chart review. We also conducted interviews with key stakeholders. RESULTS: A total of 15 patient participants were included (13 remained through follow-up for an 86.7% retention rate) in a single group, pre-post assessment pilot study. Data supported the hypothesis that BPTrack was feasible and acceptable for use by patient and provider participants and was effective at reducing patient blood pressure. At the 12-week follow-up, patients exhibited significant reductions in both systolic blood pressure (baseline mean 137.3 mm Hg, SD 11.1 mm Hg; follow-up mean 131.0 mm Hg, SD 9.9 mm Hg; P=.02) and diastolic blood pressure (baseline mean 89.4 mm Hg, SD 7.7 mm Hg; follow-up mean 82.5 mm Hg, SD 8.2 mm Hg; P<.001). On average, patients uploaded at least one blood pressure measurement on 75% (SD 25%) of study days. No improvements in medication adherence were noted. Interview data revealed areas of improvement and refinement for the patient experience. Furthermore, stakeholders require integration into the electronic health record and a modified clinical workflow for BPTrack to be truly useful; however, both patients and stakeholders perceived benefits of BPTrack when used within the context of a clinical relationship. CONCLUSIONS: Results demonstrate that a pharmacist-led mHealth intervention promoting home blood pressure monitoring and clinical pharmacist management of hypertension can be effective at reducing blood pressure in primary care patients with uncontrolled hypertension. Our data also support the feasibility and acceptability of these types of interventions for patients and providers. TRIAL REGISTRATION: ClinicalTrials.gov NCT02898584; https://clinicaltrials.gov/ct2/show/NCT02898584. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.8059.

Comprehensive medication reviews: Optimal delivery setting and recommendations for quality assessment.

OBJECTIVES: To propose a metric evaluating the quality of comprehensive medication reviews (CMRs), and to discuss the optimal setting for CMR delivery. SUMMARY: First, we provide a current assessment of the quality of CMRs performed in community, payer, and health system/clinic settings, with recommended opportunities for improvement. Thereafter, a companion metric for CMR quality is discussed, because this is critical to ensuring that patients are not just receiving CMR services, but that CMRs reflect evidence-based recommendations supporting optimal patient outcomes. CONCLUSION: Based on the data currently available, accessibility to electronic medical records would enhance patient-specific recommendations to optimize CMR delivery and patient outcomes. Future studies may help to identify additional factors, such as pharmacist-physician collaboration in clinic and use of evidence-based recommendations, that can further enhance CMR quality.

Provider perceptions of pharmacists providing mental health medication support in patient-centered medical homes.

OBJECTIVES: To identify primary care providers' (PCPs') comfort level, potential barriers to management of patients with mental health disorders, and attitudes around clinical pharmacist-provided mental health medication-related support. METHODS: A 16-item cross-sectional survey was completed by PCPs in 14 patient-centered medical homes (PCMHs) at 1 academic medical center. Items assessed include PCPs' perceptions of the proportion of patients with a mental health condition, access to psychiatry services, confidence in mental health condition management, clinical pharmacist-provided mental health medication support, and demographics. Checklist, Likert-type-scale agreement statements, and an open-ended question to assess barriers to managing mental health medications were included. Descriptive statistics and qualitative content analysis were used. RESULTS: Respondents (n = 85) included attending physicians (67.1%), resident physicians (24.7%), and advanced practice providers (8.2%). The average number of years in practice was 11 (SD 8.6). The majority perceived that 26% to 50% of their patients had a psychiatric illness (57.7%), referred < 10% of their patients (67.1%) to psychiatry services, and disagreed that access to psychiatric services was acceptably timely (87.0%). Participants felt confident diagnosing a patient with depression (97.6%) and starting antidepressants (94.1%) compared with antipsychotics (11.7%) or mood stabilizers (7.1%). Participants agreed that having the clinical pharmacist in clinic to provide support regarding psychiatric medications would increase their comfort level; increase in comfort level by provider type was not different (P = 0.20). Emerging barriers were lack of knowledge or training, low comfort in diagnosing severe psychiatric conditions, and access to psychiatry services. CONCLUSION: Outside of the diagnosis and treatment of depression, PCPs indicate a lack of comfort in treating PCMH patients with mental health disorders. Pharmacists can play a key role by providing mental health medication management support to improve access and address PCMH patients' mental health needs.

Implementation and barriers to uptake of interactive voice response technology aimed to improve blood pressure control at a large academic medical center.

OBJECTIVES: Blood pressure control among patients with hypertension is a widely recognized quality metric, but many large health systems fail to reach targets set by the Healthcare Effectiveness Data and Information Set. We developed an interactive voice response (IVR) system called the "Mobile You Blood Pressure Program" at a large academic medical center and linked it to the health system's electronic health record (EHR). The goal of the program was to capture home blood pressure readings in the EHR and to alert ambulatory care clinical pharmacists automatically of readings below or above clinical thresholds through direct messaging in the EHR. The goal of this report is to describe implementation of IVR, initial patient participation rates, and pharmacist-identified barriers to patient enrollment. SETTING: Ambulatory care clinical pharmacist specialists' practice in 14 clinics in family medicine and internal medicine at Michigan Medicine, an academic health system serving more than 24,000 patients with a diagnosis of hypertension. PRACTICE DESCRIPTION: This study describes implementation and initial patient enrollment in IVR linked to the EHR for home blood pressure monitoring. EVALUATION: We tracked the number of hypertensive patients enrolled and IVR call completion rates between September 2017 and February 2018. We also assessed pharmacist-identified barriers to patient enrollment during 2 separate 2-week intervals in January and February 2018. RESULTS: Between September 1, 2017, and February 28, 2018, a total of 71 patients were enrolled from 14 clinics. Patients were scheduled for 1-3 IVR calls per week focusing on medication adherence and blood pressure control. A total of 936 IVR phone calls were made, with 488 (52%) calls completed. Access to a validated home blood pressure monitor was the largest pharmacist-identified barrier to patient enrollment. CONCLUSIONS: The IVR Mobile You Blood Pressure Program represents a new application of digital technology within our health system. Pharmacist-identified barriers to patient participation included access to a validated home blood pressure monitor.

Linking the patient-centered medical home to community pharmacy via an innovative pharmacist care model.

OBJECTIVES: To develop and pilot test a model that extends pharmacists' direct patient care from the patient-centered medical home (PCMH) to the community pharmacy. SETTING: Two Michigan Medicine PCMH clinics and 2 CVS Pharmacy sites in Ann Arbor, MI. PRACTICE DESCRIPTION: In the PCMH clinics, pharmacists have provided patient care using collaborative practice agreements for diabetes, hypertension, and hyperlipidemia for more than 5 years. PRACTICE INNOVATION: Legal agreements were developed for sharing data and for accessing the Michigan Medicine Electronic Medical Record (EMR) in the CVS pharmacies. An immersion training model was used to train 2 community pharmacists to provide direct patient care and change medications to improve disease control. Then these community pharmacists provided disease management and comprehensive medication reviews (CMRs) in either the PCMH clinic or in CVS pharmacies. MAIN OUTCOME MEASURES: Glycosylated hemoglobin (A1C ≤ 9% and < 7%) and blood pressure (BP < 140/90) were compared for patients seen by PCMH pharmacists, patients seen by community pharmacists, and a propensity score-generated control group. Surveys were used to assess patient satisfaction. RESULTS: Of 503 shared patients, 200 received disease management and 113 received a CMR from the community pharmacists. Lack of efficacy was the most common reason for medication changes in diabetes (n = 136) and hypertension (n = 188). For CMR, optimizing the dosage regimen was the most common intervention. For the community pharmacist group, the odds of patients having an A1C ≤ 9% increased by 8% in each time period, whereas the odds decreased by 16% for the control group (odds ratio 1.29; P = 0.0028). No statistically significant differences were seen in the outcomes for patients seen by PCMH versus community pharmacists. Most patients (90%) rated the care as excellent. CONCLUSION: Direct patient care provided by community pharmacists, either in PCMH clinics or CVS pharmacies, was consistent with care provided by PCMH pharmacists. Patients were highly satisfied with the services provided.

Description of pharmacist-led quality improvement huddles in the patient-centered medical home model.

OBJECTIVES: This case study describes the implementation of pharmacist-led quality improvement team huddles in the patient-centered medical home clinic model. The purpose of these huddles is to have an impact on clinic-based quality metrics. SETTING: Pharmacists embedded into primary care clinics at 2 separate health centers, within a large academic medical center, were funded by the clinics to lead their quality improvement (QI) team huddles. PRACTICE DESCRIPTION: Huddle team members vary depending on the practice sites and can include physicians, pharmacists, advanced practice providers, nurses, administrative managers, social workers, and medical assistants. These huddles are typically held every 1-2 weeks for 15-20 minutes. Small rapid plan-do-check-act cycles allow the process to be quickly assessed and altered if needed. The quality metric that the team focused on changed based on clinic goals. Two case studies showcase successful examples of quality improvement initiatives that had a significant impact on the individual clinic-based metrics. INNOVATION: The 2 case studies focus on pharmacist-led quality team huddles for controlled substance and asthma action plan metrics. The clinical pharmacists involved were pivotal to organizing and helping incorporate new processes within their clinics sites. RESULTS: The work of the team huddles brought the clinics from a nonreimbursable status to reimbursable for these metrics. DISCUSSION: Because pharmacists in the ambulatory care setting focus on chronic care disease management and QI, they are in an excellent position to lead team huddles focused on QI and registry management. By establishing interdisciplinary QI team huddles led by clinical pharmacists, these clinics were able to increase revenue for the clinic in the way of increasing pay-for-performance measures. CONCLUSION: Pharmacist-led quality improvement team huddles can have a positive impact on quality metrics, population health, and reimbursement.

Unintended Consequences of Adjusting Citalopram Prescriptions Following the 2011 FDA Warning.

OBJECTIVES: In 2011, the U.S. Food and Drug Administration (FDA) issued a safety announcement cautioning providers against prescribing citalopram above 40 mg per day given concerns for QT prolongation. We assessed the impact of a health system quality improvement initiative to identify patients taking higher than the recommended dose of citalopram. DESIGN: Retrospective cohort study. SETTING: Nine primary care clinics within the University of Michigan from March 2012 to February 2013. PARTICIPANTS: Adult patients taking a higher-than-recommended dose of citalopram following the FDA warning in 2011 (N = 199). MEASUREMENTS: Frequency of EKG monitoring, clinical factors associated with patients whose citalopram dose or use was adjusted, and potential impact of these changes on overall health care utilization was assessed. RESULTS: In patients prescribed higher-than-recommended doses of citalopram and who received a note from a pharmacist regarding the FDA warnings, only 8.5% received electrocardiogram (EKG) monitoring. Patients who were converted to an alternative antidepressant from citalopram were more likely to receive subsequent new prescriptions for benzodiazepines and sedative hypnotics (χ2 = 7.9, p = 0.048). Patients who had any adjustments to their antidepressant medication had greater overall health care utilization (OR: 25.0; 95% CI: 5.7-109.6; p < 0.001) than patients remaining on the same dose of citalopram. CONCLUSIONS: Despite a targeted quality intervention to address the FDA warning regarding citalopram, the warning was associated with low levels of EKG monitoring, increased anxiolytic and sedative medication use, and higher healthcare utilization. This finding may represent destabilization of patients on previously therapeutic doses of their antidepressant and an unintended consequence of the FDA warning.

Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study.

Purpose: The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy. Patients and Methods: The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert. Results: 332 patients were included. The BPA triggered 29 times. The following actions were taken among 16 patients for whom the BPA triggered: "override the alert" (n=13); "cancel the alert" (n=2); and 'remove the opioid order set' (n=1). 12/16 patients had discharge prescriptions: one patient received 20 tablets; two received 10 tablets; and nine received 15 tablets. Top reasons for over prescribing included concerns for pain control and lack of alternatives. Conclusion: Implementing a post-discharge opioid prescribing BPA aligned opioid prescribing following benign minimally invasive hysterectomy with guideline recommendations.

Identifying the prevalence of clinically actionable drug-gene interactions in a health system biorepository to guide pharmacogenetics implementation services.

Understanding patterns of drug-gene interactions (DGIs) is important for advancing the clinical implementation of pharmacogenetics (PGx) into routine practice. Prior studies have estimated the prevalence of DGIs, but few have confirmed DGIs in patients with known genotypes and prescriptions, nor have they evaluated clinician characteristics associated with DGI-prescribing. This retrospective chart review assessed prevalence of DGI, defined as a medication prescription in a patient with a PGx phenotype that has a clinical practice guideline recommendation to adjust therapy or monitor drug response, for patients enrolled in a research genetic biorepository linked to electronic health records (EHRs). The prevalence of prescriptions for medications with pharmacogenetic (PGx) guidelines, proportion of prescriptions with DGI, location of DGI prescription, and clinical service of the prescriber were evaluated descriptively. Seventy-five percent (57,058/75,337) of patients had a prescription for a medication with a PGx guideline. Up to 60% (n = 26,067/43,647) of patients had at least one DGI when considering recommendations to adjust or monitor therapy based on genotype. The majority (61%) of DGIs occurred in outpatient prescriptions. Proton pump inhibitors were the most common DGI medication for 11 of 12 clinical services. Almost 25% of patients (n = 10,706/43,647) had more than one unique DGI, and, among this group of patients, 61% had a DGI with more than one gene. These findings can inform future clinical implementation by identifying key stakeholders for initial DGI prescriptions, helping to inform workflows. The high prevalence of multigene interactions identified also support the use of panel PGx testing as an implementation strategy.

Employer-based patient-centered medication therapy management program: evidence and recommendations for future programs.

OBJECTIVE: To evaluate a patient-centered employer-based medication therapy management (MTM) program. DESIGN: Randomized controlled study. SETTING: Health promotion program at the University of Michigan from June 2009 to December 2011. PARTICIPANTS: Employees, retirees, and their dependents taking seven or more prescription medications. INTERVENTION: Focus on Medicines (FOM) was a two-visit, patient-centered service with a 4-month follow-up. A comprehensive medication review occurred during the first visit. Pharmacists provided recommendations and a medication action plan at the second visit. The MAP incorporated patient preferences for problem resolution. MAIN OUTCOME MEASURES: Patient uptake, medication cost, medication adherence, patient satisfaction with treatment, patient reasons for participation, patient satisfaction with the FOM program, drug-related problems, pharmacist recommendations, implementation of recommendations. RESULTS: The FOM program attracted 128 individuals wanting information about their medications and an individualized drug regimen assessment to ensure that their therapy was safe and effective and that all medications were necessary. On average, 3.3 medication therapy problems were identified per patient; most were safety related. Overall, 63% of pharmacist recommendations were implemented. When a prescriber was contacted, 83% of pharmacist recommendations were implemented. A reduction in drug cost for patients and the employer was shown. Patients reported improved convenience in taking medications and rated the program favorably. CONCLUSION: A personalized dialogue about medication use appears to meet a need among individuals taking large numbers of medications. Understanding why patients participate in MTM programs and what program features patients appreciate is useful in designing quality MTM programs.

Pharmacist engagement in a community pharmacy hypertension management program in collaboration with an academic medical center.

PURPOSE: To explore the perceptions of pharmacists and administrators who had an integral role in designing and operationalizing an integrated community pharmacist hypertension management program with collaboration between an academic medical center and a regional chain community pharmacy. SUMMARY: Community pharmacists (n = 3), ambulatory care pharmacists (n = 2), medical directors (n = 2), and health-system (n = 1) and pharmacy (n = 1) administrators reported positive experiences engaging with the hypertension management program. Strengths of the program included comprehensive training by the ambulatory care pharmacists, community pharmacist access to the electronic health record (EHR), and primary care providers who were receptive to referring patients and accepting recommendations from the community pharmacists. All participants felt that the program had a positive outlook and saw opportunity for expansion, such as extended hours of operation, new locations, and additional pharmacists. CONCLUSION: Pharmacists are well positioned to extend hypertension management programs from primary care clinics into local pharmacies if they have appropriate training, access to the EHR, and ongoing support from collaborating primary care offices. Additional research using implementation science methods is needed to further test the scalability and replicability of the program among different patient populations, community pharmacies, and health systems.

Measurement and Validation of the Comprehensive Score for Financial Toxicity (COST) in a Population With Diabetes.

OBJECTIVE: The Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) is a validated instrument measuring financial distress among people with cancer. The reliability and construct validity of the 11-item COST-FACIT were examined in adults with diabetes and high A1C. RESEARCH DESIGN AND METHODS: We examined the factor structure (exploratory factor analysis), internal consistency reliability (Cronbach α), floor/ceiling effects, known-groups validity, and predictive validity among a sample of 600 adults with diabetes and high A1C. RESULTS: COST-FACIT demonstrated a two-factor structure with high internal consistency: general financial situation (7-items, α = 0.86) and impact of illness on financial situation (4-items, α = 0.73). The measure demonstrated a ceiling effect for 2% of participants and floor effects for 7%. Worse financial toxicity scores were observed among adults who were women, were below the poverty line, had government-sponsored health insurance, were middle-aged, were not in the workforce, and had less educational attainment (P < 0.01). Worse financial toxicity was observed for those engaging in cost coping behaviors, such as taking less or skipping medicines, delaying care, borrowing money, "maxing out" the limit on credit cards, and not paying bills (P < 0.01). In regression models for the full measure and its two factors, worse financial toxicity was correlated with higher A1C (P < 0.01), higher levels of diabetes distress (P < 0.01), more chronic conditions (P < 0.01), and more depressive symptoms (P < 0.01). CONCLUSIONS: Findings support both the reliability and validity of the COST-FACIT tool among adults with diabetes and high A1C levels. More research is needed to support the use of the COST-FACIT tool as a clinically relevant patient-centered instrument for diabetes care.

Impacts of the COVID-19 pandemic on unmet social needs, self-care, and outcomes among people with diabetes and poor glycemic control.

AIMS: The purpose of this study was to examine whether pandemic exposure impacted unmet social and diabetes needs, self-care behaviors, and diabetes outcomes in a sample with diabetes and poor glycemic control. METHODS: This was a cross-sectional analysis of participants with diabetes and poor glycemic control in an ongoing trial (n = 353). We compared the prevalence of unmet needs, self-care behaviors, and diabetes outcomes in successive cohorts of enrollees surveyed pre-pandemic (prior to March 11, 2020, n = 182), in the early stages of the pandemic (May-September, 2020, n = 75), and later (September 2020-January 2021, n = 96) stratified by income and gender. Adjusted multivariable regression models were used to examine trends. RESULTS: More participants with low income reported food insecurity (70% vs. 83%, p < 0.05) and needs related to access to blood glucose supplies (19% vs. 67%, p < 0.05) during the pandemic compared to pre-pandemic levels. In adjusted models among people with low incomes, the odds of housing insecurity increased among participants during the early pandemic months compared with participants pre-pandemic (OR 20.2 [95% CI 2.8-145.2], p < 0.01). A1c levels were better among participants later in the pandemic than those pre-pandemic (ß = -1.1 [95% CI -1.8 to -0.4], p < 0.01), but systolic blood pressure control was substantially worse (ß = 11.5 [95% CI 4.2-18.8, p < 0.001). CONCLUSION: Adults with low-incomes and diabetes were most impacted by the pandemic. A1c may not fully capture challenges that people with diabetes are facing to manage their condition; systolic blood pressures may have worsened and problems with self-care may forebode longer-term challenges in diabetes control.

Evaluation of a Pharmacists' Patient Care Process Approach for Hypertension.

INTRODUCTION: An estimated 116 million American adults (47.3%) have hypertension. Most adults with hypertension do not have it controlled-3 in 4 (92.1 million) U.S. adults with hypertension have a blood pressure ≥130/80 mmHg. The Pharmacists' Patient Care Process is a standardized patient-centered approach to the provision of pharmacist care that is done in collaboration with other healthcare providers. Through the Michigan Medicine Hypertension Pharmacists' Program, pharmacists use the Pharmacists' Patient Care Process to provide hypertension management services in collaboration with physicians in primary care and community pharmacy settings. In 2019, the impact of Michigan Medicine Hypertension Pharmacists' Program patient participation on blood pressure control was evaluated. METHODS: Propensity scoring was used to match patients in the intervention group with patients in the comparison group and regression analyses were then conducted to compare the 2 groups on key patient outcomes. Negative binomial regression was used to examine the number of days with blood pressure under control. The findings presented in this brief are part of a larger multimethod evaluation. RESULTS: More patients in the intervention group than in the comparison group achieved blood pressure control at 3 months (66.3% vs 42.4%) and 6 months (69.1% vs 56.5%). The intervention group experienced more days with blood pressure under control within a 3-month (18.6 vs 9.5 days) and 6-month period (57.0 vs 37.4 days) than the comparison group did. CONCLUSIONS: Findings support the effectiveness of the Michigan Medicine Hypertension Pharmacists' Program approach to implementing the Pharmacists' Patient Care Process to improve blood pressure control.

Establishment of a Pharmacogenetics Service Focused on Optimizing Existing Pharmacogenetic Testing at a Large Academic Health Center.

Multiple groups have described strategies for clinical implementation of pharmacogenetics (PGx) that often include internal laboratory tests that are specifically developed for their implementation needs. However, many institutions are not able to follow this practice and instead must utilize external laboratories to obtain PGx testing results. As each external laboratory might have different ordering and reporting workflows, consistent reporting and storing of PGx results within the medical record can be a challenge. This might result in patient safety concerns as important PGx information might not be easily identifiable at the point of current or future prescribing. Herein, we describe initial PGx clinical implementation efforts at a large academic medical center, focusing on optimizing three different test ordering workflows and two distinct result reporting strategies. From this, we identified common issues such as variable reporting location and structure of PGx results, as well as duplicate PGx testing. We identified several opportunities to optimize our current processes, including-(1) PGx laboratory stewardship, (2) increasing visibility of PGx tests, and (3) clinician and patient education. Key to the success was the importance of engaging clinician, informatics, and pathology stakeholders, as we developed interventions to improve our PGX implementation processes.

Evaluation of Clinical Pharmacist Services in a Transitions of Care Program Provided to Patients at Highest Risk for Readmission.

BACKGROUND: An ambulatory transition of care program, including a pharmacist-provided comprehensive medication review (CMR), was implemented. OBJECTIVES: The objectives were to: (1) compare 30-day hospital readmission rates between those who received the pharmacist CMR versus eligible patients not scheduled, (2) describe identified problems and recommendations, and (3) quantify recommendation acceptance rates. METHODS: A retrospective cohort study was conducted between March and October 2016. Inclusion criteria were: LACE score of ≥13, established Michigan Medicine primary care, and discharged from specific inpatient services to home. The primary outcome was 30-day hospital readmission rates. Pharmacist-identified problems, recommendations, and recommendation acceptance rates were examined. χ2 analysis and descriptive statistics were used. RESULTS: 355 discharges met inclusion criteria and pharmacists provided CMRs for 159 patients. The average age was 60 years (standard deviation [SD]: 14.3), the majority were female (54%), and white/Caucasian (69%). There was no significant difference in 30-day readmission rates in patients who received a CMR (p = .96). A mean of 3.1 problems were identified per visit (SD: 1.8, range: 1-10). 509 recommendations were provided and approximately 50% were provider accepted. CONCLUSIONS: Reduced readmission rates were not observed; however, pharmacists identified many areas for intervention in highest risk patients during the transition from hospital to home.