Evaluating the Clinical Effect of Personal Continuous Glucose Monitoring in a Diverse Population With Type 2 Diabetes.

Objective: To determine the clinical effect of personal continuous glucose monitoring (CGM) in a diverse population with type 2 diabetes (T2D). Research Design and Methods: A report was created from the electronic health record identifying adults prescribed CGM at an urban family medicine clinic between January 1, 2019, and February 23, 2022. An "index date" was identified as the start of CGM. The closest hemoglobin A1c (A1c) 6 months or more after the index date was identified as the "follow-up date." The primary outcome of this study was to compare the percentage of individuals meeting the MN Community Measure (MNCM) D5 HbA1c goal of <8% at the follow-up date versus the index date. Results: Seventy-two patients were identified after the exclusion criteria were applied. Approximately one-third of patients required utilization of an interpreter and 76% of patients were of a racial or ethnic minority. The mean HbA1c prior to CGM use was 9.8%, with 16.7% of the population meeting the MNCM D5 A1c goal of <8%. At the follow-up date, the mean A1c was 8.4% (mean difference -1.4%; p < 0.001), with 41.7% of the population meeting goal (mean difference +25%; p < 0.001). Subgroup analyses affirm that the results of the primary outcome were sustained despite insulin use status. Conclusion: A diverse population with T2D had a significant reduction in A1c and was more likely to meet the MNCM D5 A1c goal of <8% after an average of 6 months using personal CGM.

Using 15-Minute Serial Blood Pressures as an Alternative to Measuring a Single Blood Pressure.

Thirty-minute office blood pressure (OBP-30) is an alternative to ambulatory blood pressure (BP) measurement, yet is impractical to implement. This study aimed to determine whether unattended BP readings over 15 minutes would result in a similar probability of obtaining a BP of <140/90. Sixty-seven adults self-described as having high BP were analyzed. BP was measured at baseline and every 5 minutes for 15 minutes with the initial reading compared to the average of the last three readings (OBP-15). Compared to baseline, there was a decline in both average systolic (4.2 points) and diastolic (2.8 points) BP. The probability of BP control predicted by multivariate model was 71.6% at baseline and 78.0% using OBP-15 (p=0.011). The increase in BP control from initial to OBP-15 measurement was significant for indigenous or persons of color compared to whites, and men compared to women. OBP-15 is convenient and results in lower BP readings and higher probability of BP control compared to the initial reading.

How Does Cognitive Bias Affect Conversations With Patients About Dietary Supplements?

Many patients use dietary supplements but do not inform their clinicians. Some allopathic clinicians' conscious and unconscious cognitive and emotional biases against complementary and alternative medicine can affect whether patients disclose details about dietary supplement use, the quality of communication during clinical encounters, and the information clinicians draw upon to make decisions and recommendations. This article describes 6 cognitive biases that can influence patient-clinician communication and shared decision making about dietary supplements and suggests 6 ways to mitigate biases' negative effects on patient-clinician relationships.

Evaluation of 30-Minute Office Blood Pressure in a Diverse Urban Population.

BACKGROUND: Previous studies have shown benefits of 30-minute office blood pressure (OBP-30) but did not report on race and gender. The purpose of this study was to determine if similar effects are seen in a diverse urban population. METHODS: Patients with diabetes and/or cardiovascular disease (age 18-89) were invited to participate. Blood pressure was measured using standard procedure (SOBP). Patients were left alone in an exam room connected to an automated office blood pressure monitor which obtained BP readings every 5 minutes for 30 minutes. The last 5 measurements were averaged for the OBP-30 measurement. Primary outcomes were BPs measured using SOBP and OBP-30. Multivariate logit methods were used to estimate the average probability of having a BP measured <140/90 mm Hg (BPM <140/90) for the 2 measurement methods. Differences were computed across methods, in total and by sex and race, all other factors held constant. RESULTS: The adjusted probability of having a BPM <140/90 was 47.1% using SOBP and 66.7% using OBP-30 (P < 0.01). Using SOBP, females had a 26.2 PP lower probability of having a BPM <140/90 (P < 0.001) than males. Relative to white patients, Black patients had a 43.9 PP lower (P < 0.001) and other races a 38.5 PP lower (P < 0.001) probability of having a BPM <140/90 using SOBP. Using OBP-30, these differences narrowed and became statistically insignificant. CONCLUSIONS: OBP-30 may increase the probability of BPM meeting goals, especially in females and patients who are Black, indigenous, or persons of color.

Successful deprescribing of unnecessary proton pump inhibitors in a primary care clinic.

OBJECTIVE: The objective of this study was to determine the rate of successful deprescribing of unnecessary proton pump inhibitors (PPIs) after implementation of a clinical pharmacist- managed program that included detailed tapering instructions, patient education, and follow-up. SETTING: The setting was a family medicine clinic in St. Paul, MN, in an underserved community. PRACTICE DESCRIPTION: Eligible patients were taking a long-term PPI for gastroesophageal reflux disease without esophagitis, or without a clear indication. Each morning, the clinical pharmacist generated a report in the electronic medical record that identified patients with appointments who were currently prescribed a PPI. After chart review, the pharmacist determined if patients were candidates for PPI deprescribing. If so, a focused visit with these patients was conducted. PRACTICE INNOVATION: A unique pharmacist-managed PPI tapering schedule was developed and implemented to deprescribe unnecessary PPI therapy in a family medicine clinic. EVALUATION: Eligible patients were seen by the pharmacist and initiated on a PPI taper. After 8 weeks, the patients who were initiated on a PPI taper were evaluated to determine if they successfully discontinued the PPI completely, decreased the dose or frequency, or were unsuccessful at tapering the PPI. RESULTS: Of the patients assessed (N = 126), 60% were excluded, 19% were unable to be seen, and 21% were willing to attempt the taper and discontinue their PPI. Of the 22 patients who initiated PPI deprescribing, 19 (86%) successfully discontinued their PPI completely, 2 (9%) decreased the dose or frequency, and 1 (5%) was unable to decrease or discontinue their PPI. This success rate of PPI discontinuation was higher than that in previous studies in primary care settings (31%-66%). CONCLUSION: Deprescribing long-term PPI therapy can be successful in a family medicine clinic when implementing a clinical pharmacist-managed program that includes detailed tapering instructions, patient education, and follow-up.

Reasons for and perceived benefits of utilizing complementary and alternative medicine in U.S. adults with migraines/severe headaches.

We estimated prevalence rates of complementary and alternative medicine (CAM) use by reason for use (treatment, wellness, or both), and examined perceived benefits of using CAM among U.S. adults with migraines/severe headaches. The 2012 National Health Interview Survey, which represents non-institutionalized adults with migraines/severe headaches (n = 4447 unweighted), were used. Of the study sample, 41.3% used some form of CAM in the past year. Nearly a third of them (29.6%) used CAM for wellness only and 59% used CAM for both wellness and treatment. In given six self-reported perceived benefits, those who used CAM for wellness only and for a combination of both treatment and wellness had higher likelihoods of reporting benefits for all categories (p < 0.05), except for better sleep, when compared to those who used CAM for treatment only. CAM use was associated with an improvement in several health-related quality of life outcomes in U.S. adults with migraines/severe headaches.

Complementary and alternative medicine in US adults with diabetes: Reasons for use and perceived benefits.

BACKGROUND: Although complementary and alternative medicine (CAM) is increasingly used, little is known about the reasons for CAM use (treatment, wellness, or both), or the self-reported perceived benefits among US adults with diabetes. In this study we estimated prevalence rates of overall and specific types of CAM, as well as the perceived benefits of CAM, by reason for use among US diabetic adults. METHODS: Cross-sectional data from the 2012 National Health Interview Survey, which represents non-institutionalized adults with diabetes (n = 3386 unweighted), were used to estimate prevalence rates of CAM use by reason. Multivariate logistic regression analyses were used to investigate the odds of perceived benefits of CAM by reason for use after controlling for covariates. RESULTS: Of US diabetic adults, 26.2% reported using some form of CAM in the past year. Of these, 56.7% used CAM for both treatment and wellness, 28.3% used CAM for wellness only, and 15.0% used CAM for treatment only. Regardless of reasons for use, most commonly used CAM were herbal therapies (56.9%), followed by chiropractic (25.3%) and massage (20.2%). Those using CAM for a combination of both treatment and wellness had a higher likelihood of self-reporting a "better sense of control over their health" (P = 0.011) and "improved overall health and feeling better" (P = 0.014) than those using CAM for treatment only. CONCLUSION: Although CAM may be a promising approach to improving health-related quality of life, future research should address efficacy and patient safety.

Gender Differences in the Use of Complementary and Alternative Medicine and Their Association With Moderate Mental Distress in U.S. Adults With Migraines/Severe Headaches.

OBJECTIVE: We examined whether the prevalence of complementary and alternative medicine (CAM) use varies by gender, and assessed the interaction of gender and CAM use on moderate mental distress (MMD) in U.S. adults with migraines/severe headaches. METHODS: We used data from the 2012 National Health Interview Survey, which represents non-institutionalized U.S. adults with migraines/severe headaches (n = 4645 unweighted). Using a cross-sectional design with survey sampling techniques, we conducted descriptive analyses for prevalence of CAM use by gender. Multivariate logistic regression analyses were run to investigate potential roles of migraines/severe headaches and CAM use on MMD by gender. RESULTS: The overall prevalence of past year CAM use was 44.4%. Women consistently used CAM more frequently than men (P = .004). The most commonly used CAM types included herbal supplements (22.2%), massage (14.2%), and chiropractic/osteopathic (13.9%). After controlling for covariates, the odds of MDD were increased by the presence of migraines/severe headaches (P < .001) and the use of any CAM (P < .001). The interaction effect of migraines/severe headaches and CAM use decreased the odds of MMD by 27% in women (P < .05), but not in men. CONCLUSION: Women used CAM more frequently than men among adults with migraines/severe headaches in the United States. In addition, the interaction of gender and CAM use exists; the CAM use was associated with decreased odds of MMD among women only, suggesting that women with migraines/severe headaches may have benefited from CAM for their mental distress. Future research is needed to explore why such patterns vary by gender.

Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences.

OBJECTIVE: To determine if the amount of exposure to patient encounters and clinical skills correlates to student clinical competency on ambulatory care advanced pharmacy practice experiences (APPEs). DESIGN: Students in ambulatory care APPEs tracked the number of patients encountered by medical condition and the number of patient care skills performed. At the end of the APPE, preceptors evaluated students' competency for each medical condition and skill, referencing the Dreyfus model for skill acquisition. ASSESSMENT: Data was collected from September 2012 through August 2014. Forty-six responses from a student tracking tool were matched to preceptor ratings. Students rated as competent saw more patients and performed more skills overall. Preceptors noted minimal impact on workload. CONCLUSIONS: Increased exposure to patient encounters and skills performed had a positive association with higher Dreyfus stage, which may represent a starting point in the conversation for more thoughtful design of ambulatory care APPEs.

Medication discrepancies associated with subsequent pharmacist-performed medication reconciliations in an ambulatory clinic.

OBJECTIVE: To describe the number of medication discrepancies associated with subsequent medication reconciliations by a clinical pharmacist in an ambulatory family medicine clinic and the proportion of subsequent medication reconciliation visits that were associated with hospital discharge, long-term anticoagulation management, or both. METHODS: Data on medication reconciliations were collected over a 2-year time period in an ambulatory family medicine clinic for patients taking 10 or more medications. RESULTS: Medication reconciliation was performed 752 times for 500 patients. A total of 5,046 discrepancies were identified, with more than one-half deemed clinically important. A mean (± SD) of 6.7 ± 4.6 discrepancies per visit (3.5 ± 3.2 clinically important) were identified. The findings showed that the distribution of total discrepancies identified by pharmacist-performed medication reconciliation was significantly different over the course of subsequent medication reconciliations. However, the distribution of clinically important discrepancies was not significantly different; important discrepancies were as likely to be found in later reconciliations as in earlier ones. As subsequent medication reconciliation visits were performed, an increasing proportion consisted of post-hospital discharge visits, long-term anticoagulation managed by a clinical pharmacist, or both. CONCLUSION: Patients with a recent hospital discharge, on long-term anticoagulation management, or both, were more likely to have multiple sessions with a clinical pharmacist for medication reconciliation. These findings can help identify patients for whom medication reconciliation is warranted.

Clinical pharmacy should adopt a consistent process of direct patient care.

Although the application of a consistent process of care serves as a foundational principle for most health care professions, this is not true for the discipline of clinical pharmacy. Without an explicit, reproducible process of care, it is not possible to demonstrate to patients, caregivers, or health professionals the ways in which the clinical pharmacist can reliably contribute to improved medication-related outcomes. A consistent patient care process should describe the key steps that all clinical pharmacists will follow when they encounter a patient, regardless of the type of practice, the clinical setting, or the medical conditions or medications involved. Four essential elements serve as the cornerstones of the clinical pharmacist's patient care process: assess the patient and his or her medication therapy, develop a plan of care, implement the plan, and evaluate the outcomes of the plan. Despite the fact that several processes of care have been advocated for clinical pharmacists, none has been adopted by the clinical pharmacy discipline. In addition, numerous publications evaluate outcomes related to clinical pharmacy services, but it is difficult to determine what process of patient care was used in most of these studies. In our view, a consistent process of direct patient care that includes the four essential elements should be adopted by the clinical pharmacy discipline. This process should be clear, straightforward and intuitive, readily documentable, and applicable to all practice settings. Once adopted, the process should be implemented across practice settings, taught in professional degree programs, integrated into students' clinical rotations, refined during residency training, and used as a foundation for future large-scale studies to rigorously study the effects of the clinical pharmacist on patients' medication-related outcomes.

Medication reconciliation by clinical pharmacists in an outpatient family medicine clinic.

OBJECTIVES To evaluate the incidence of medication discrepancies in electronic health record (EHR) medication lists in an outpatient family medicine clinic where clinical pharmacists perform medication reconciliation, to classify and resolve the discrepancies, to identify the most common medication classes involved, and to assess the clinical importance of the discrepancies. METHODS This research was conducted at Bethesda Family Medicine Clinic in St. Paul, MN, with data collected from February 2009 to February 2010. To be included, patients had to be 18 years or older and have at least 10 medications listed in the EHR. The clinical pharmacist saw each patient before the physician, reviewed the medication list with the patient, and made corrections to the EHR medication list. When possible, comprehensive medication management (CMM) also was conducted. RESULTS During 1 year, 327 patients were seen for medication reconciliation. A total of 2,167 discrepancies were identified and resolved, with a mean (±SD) of 6.6 ± 4.5 total discrepancies and 3.4 ± 3.2 clinically important discrepancies per patient. The range of total discrepancies per patient was 0 to 26. The most common discrepancy category was "patient not taking medication on list" (54.1%). Overall, the source of the discrepancy usually was the patient, but it varied according to discrepancy category. The most common medication classes involved were pain medications, gastrointestinal medications, and topical medications. Of the 2,167 discrepancies, 51.1% were determined to be clinically important by the pharmacist. The pharmacist conducted CMM in 48% of patients. CONCLUSION Outpatient medication reconciliation by a pharmacist identified and resolved a large number of medication discrepancies and improved the accuracy of EHR medication lists. Because more than 50% of the discrepancies were thought to be clinically important, improving the accuracy of medication lists could affect patient care.

Outcomes of medication therapy review in a family medicine clinic.

OBJECTIVE: To evaluate the effects of pharmacist-conducted medication therapy review (MTR) and intervention on the quality of care of patients in a family medicine clinic. DESIGN: Prospective, observational, cohort study. SETTING: Family medicine clinic in Minnesota during 2000-2001. PATIENTS: Patients were enrolled in a statewide nonprofit managed care organization; selected patients were seen by a clinical pharmacist. INTERVENTION: Following MTR, medication-related problems (MRPs) were identified and resolved. MAIN OUTCOME MEASURES: MRPs identified and resolved, improvement in clinical status, achievement of therapeutic goals, important medication use, and reduction in number of medications. RESULTS: 92 patients were included in the study, with a total of 203 patient encounters. MRPs were identified in 90% of patients, with a total of 250 identified. Overall status of medical conditions improved in 45% of patients, 46% stayed the same, and 9% declined (P < 0.001). Significant improvement in status was found for hypertension (P = 0.007), dyslipidemia (P = 0.002), and asthma (P = 0.011). Significant improvement was seen for aspirin use for myocardial infarction prevention (50% vs. 93%, P = 0.031) and inhaled steroids for asthma (36% vs. 64%, P = 0.031). The number of medications was reduced from an average of 3.92 to 3.04 (P < 0.001) per patient. CONCLUSION: MTR and intervention by a pharmacist positively affected quality of care in this family medicine clinic.

Developing a business-practice model for pharmacy services in ambulatory settings.

A business-practice model is a guide, or toolkit, to assist managers and clinical pharmacy practitioners in the exploration, proposal, development and implementation of new clinical pharmacy services and/or the enhancement of existing services. This document was developed by the American College of Clinical Pharmacy Task Force on Ambulatory Practice to assist clinical pharmacy practitioners and administrators in the development of business-practice models for new and existing clinical pharmacy services in ambulatory settings. This document provides detailed instructions, examples, and resources on conducting a market assessment and a needs assessment, types of clinical services, operations, legal and regulatory issues, marketing and promotion, service development and exit plan, evaluation of service outcomes, and financial considerations in the development of a clinical pharmacy service in the ambulatory environment. Available literature is summarized, and an appendix provides valuable citations and resources. As ambulatory care practices continue to evolve, there will be increased knowledge of how to initiate and expand the services. This document is intended to serve as an essential resource to assist in the growth and development of clinical pharmacy services in the ambulatory environment.

Attitudes towards complementary and alternative medicine among pharmacy faculty and students.

OBJECTIVES: To determine pharmacy faculty members' and students' attitudes and perceptions regarding the use of complementary and alternative medicine (CAM). METHODS: A survey was used to obtain data on the following information concerning CAM: general attitudes, perceived barriers to use, training received and desired, personal use, and information sources used. RESULTS: In general, attitudes of pharmacy faculty members and students towards CAM were positive. Lack of evidence for CAM practices was considered the greatest barrier to the use of CAM by faculty members and students. Many CAM therapies were perceived to be effective. A high percentage of students desire more training in the areas of herbal medicine and nutritional supplements. Faculty members and students believe that CAM should be included in the curriculum. CONCLUSIONS: General attitudes towards CAM are positive among pharmacy faculty members and students, and most believe that CAM should be taught in the pharmacy curriculum. More resources and training of faculty members may be necessary.