Finding our Voice: Evaluation of Goal Setting Using the Habits of Preceptors Rubric in Terms of Focus, "SMARTness," and Impact.

INTRODUCTION: Effective leadership propels teams from effectiveness to greatness and is accomplished when everyone achieves and contributes their full potential, or "voice." The Clinician Educators Program Teaching and Learning Curriculum fosters preceptor development using the Habits of Preceptors Rubric (HOP-R) to guide participants in finding their precepting "voice." After the HOP-R self-assessment, participants select a habit of focus (HOF) and craft a SMART (specific/measurable/achievable/relevant/time-bound) goal. This report describes a pilot rubric, SMART-EP (emotional intelligence(EI)/professionalism), exploring goal "SMARTness" alongside change (impact) in participants' perceived precepting capabilities. METHODS: HOP-R self-ratings (2018-2020) and HOF/SMART goals (2019-2020) were retrospectively reviewed by two raters. Perceived preceptor capabilities were measured by analyzing the change in self-assessed habit level ratings between the first/fourth-quarter surveys. SMART goals were categorized by HOF and inclusion of SMART-EP components. Participants were guided in the inclusion of SMART, but not -EP, components. RESULTS: In aggregate, 120 participants completed HOP-R surveys (2018-2020). Within-subject changes across all 11 habits were significant (P < .001). For the SMART-EP rubric analysis (2019-2020), 71 participants had an average "SMARTness" score of 3.92 (of 5) with corresponding interrater reliability of 0.91. Goals included 2.77 (of 4) EI traits and 1.72 (of 3) professionalism components. DISCUSSION: The SMART-EP rubric provided insights into preceptor development opportunities among participants. Beyond SMART components, participants often included elements of EI and professionalism. Ratings confirm and support the consistency of the HOP-R as a tool to assess precepting habits.

Geriatric Pharmacotherapy Case Series: Heart Failure With Reduced Ejection Fraction Pharmacotherapy Optimization in Older People.

This case illustrates the pharmacist's role in the outpatient management of heart failure with reduced ejection fracture in a community-dwelling older person. In this case, the patient has a long-standing history of heart failure because of ischemic causes. Relatively active and working full-time, he presented to the pharmacist clinic for optimization of heart failure therapy. This case focuses on the role of mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors in heart failure with reduced ejection fraction management.

Are beta-blockers safe and effective after myocardial infarction in patients with COPD?

ABSTRACT: Clinicians may be hesitant to prescribe beta-blockers in patients with chronic obstructive pulmonary disease (COPD) who have a comorbid compelling cardiovascular indication for beta-blocker therapy. This article summarizes the available data on the safety and efficacy of beta-blockers in patients with COPD and recent myocardial infarction.

Geriatric Pharmacotherapy Case Series: Neurogenic Orthostatic Hypotension.

This case illustrates the pharmacist's role in the outpatient management of neurogenic orthostatic hypotension (nOH) in a community-dwelling older person. In this case, the patient has a long-standing history of asymptomatic hypotension with recent onset of falls with temporary loss of consciousness prompting initiation of pharmacologic therapy. This case reviews nonpharmacological and pharmacological treatment options for older people with symptomatic nOH.

Part Six: Antidiabetic Medication Benefits Beyond Glucose Lowering in Older People.

Older people with type 2 diabetes are at an increased risk for macrovascular (damage to arteries that can lead to myocardial infarction or stroke) and microvascular (damage to small blood vessels including retinopathy and nephropathy) disease. Since 2008, newly approved antidiabetic medications have been required to show cardiovascular safety as part of the US Food and Drug Administration approval process. Since this time, new data have emerged regarding the differences between agents in terms of reducing diabetes-related complications. Older people often are at risk for or currently have one or more diabetes-related complication. When managing antidiabetic medication in older people, it is imperative to consider the risk versus benefit of each medication and to use agents that have proven benefits.

Pharmacists' Impact on Older Adults Transitioning To and From Patient Care Centers: A Scoping Review.

Objective: Expand upon previous reviews conducted on transitions of care (TOC) services with a focus on pharmacist interventions for older adults specifically transitioning to and from long-term care, acute rehabilitation, residential care facilities, care homes, skilled nursing, or assisted living facilities, collectively termed patient care centers (PCC). Data Sources: A PubMed and Ovid MEDLINE search was conducted including citations between 1974 and July 14, 2022. Bibliographies were also reviewed for additional citations. Methods: Articles included described pharmacist interventions during TOC for patients transitioning to and from PCC, were written in English, and reported outcomes pertaining to TOC services. Of 873 citations reviewed, 22 articles met the inclusion criteria. Results: Most studies were prospective in design with small sample sizes, of limited duration, and with varying interventions and reported outcomes. Most explored the transition from hospital to PCC and included a pharmacist intervention involving the identification of medication errors and discrepancies during the TOC. Few studies reported cost savings or 30- and 60-day reductions in readmission rates or mortality. Conclusions: This scoping review revealed a lack of robust clinical trials to assess the effectiveness of specific interventions performed by pharmacists for patients transitioning to and from PCC. Of the available data, pharmacist involvement within an interprofessional team can be an effective intervention to resolve medication discrepancies, reduce readmissions, and medication-related adverse events. An opportunity exists for future studies to explore ways to improve outcomes during TOC within PCC.

Evaluating the impact of integrating SMART goal setting in preceptor development using the Habits of Preceptors Rubric.

PURPOSE: The impact of goal setting in pharmacy preceptor development was evaluated using the Habits of Preceptors Rubric (HOP-R), a criterion-referenced assessment developed to assess, quantify, and demonstrate growth across 11 preceptor habits. METHODS: This study retrospectively evaluated initial and follow-up survey responses from the 2019-2020 Clinician Educators Program cohort at Midwestern University College of Pharmacy, Glendale Campus. Enrollees in this teaching and learning curriculum (TLC) were invited to assess their precepting habits using the HOP-R after attending the first seminar and again toward the end of the longitudinal program. Using online surveys, participants rated their precepting capabilities as developing, proficient, accomplished, or master level for each habit. In the initial survey, each participant selected a habit of focus for deliberate development and established an individualized goal using the specific, measurable, achievable, relevant, and time-bound (SMART) framework. In the follow-up survey, participants indicated their satisfaction with and progress toward accomplishing their precepting goal. RESULTS: Initial survey results from 55 study participants identified developing as the most frequently self-reported habit level (53%; n = 605 ratings), while master was the least frequently reported (1%). In the follow-up assessment, accomplished (45%) was the most frequently self-reported habit level, while master (5%) remained the least reported. The cohort reported a median progress in SMART goal accomplishment of 69% (range, 12% to 100%; n = 54). CONCLUSION: Preceptor and resident pharmacists reported perceived advancement in precepting capabilities within the conceptual framework of the HOP-R encompassing both their self-selected habit of focus and adjacent habits while enrolled in a TLC. SMART goals facilitated qualitative and quantitative assessment of development.

Outcome Benefits Seen With 1 Year of Optimized Sacubitril/Valsartan for the Treatment of Systolic Heart Failure Managed by Pharmacists in a Cardiology Practice.

BACKGROUND: Pharmacists' care in heart failure (HF) management has been shown to better clinical outcomes, including use of guideline-directed medical therapy and hospital readmission, although the impact observed has varied among studies. OBJECTIVE: To investigate the rates of all-cause hospitalization and hospitalization from HF (hHF) and changes in surrogate markers (left-ventricular ejection fraction, New York Heart Association Functional Classification [NYHA FC], diuretic requirements) for patients with HF with reduced ejection fraction (HFrEF) on angiotensin receptor-neprilysin inhibitor (ARNi) therapy optimized within a pharmacist clinic. METHODS: Retrospective chart review of patients with HFrEF on sacubitril/valsartan from July 7, 2015, through January 1, 2018. RESULTS: For the primary outcome analysis, 70 patients with pre/post hospitalization data had a reduction in the rate of all-cause hospitalization from 45.7% in the 12 months prior to ARNi therapy initiation to 24.3% during the first year on optimized ARNi therapy (P = 0.004). The rate of hHF reduced from 24.3% to 8.6% (P = 0.003). For the secondary outcome analyses at the 6-month assessment point, which included 104 patients, ejection fraction improved from 26% to 34% (P < 0.001), NYHA FC improved or remained unchanged in 86.6% of patients, and weekly loop diuretic dosing requirements were significantly reduced. CONCLUSION AND RELEVANCE: Real-world use of sacubitril/valsartan optimized within a pharmacist clinic was associated with reduced prevalence of all-cause and hHF during the first year of ARNi therapy. This study corroborates pharmacist involvement in HF management, which could be used to support further research and expanded pharmacist services.

Understanding medication use behaviors and perspectives in an older cardiovascular patient population: Opportunities for patient-centered deprescribing.

Study objective: Describe self-reported medication use behaviors and perspectives to identify opportunities for collaborative deprescribing among older cardiovascular patients. Design: Patient survey using convenience sampling. Setting: Private cardiology practice in Maricopa County, Arizona, USA. Participants: Established patients aged ≥65 years with an active medication list indicating prescription polypharmacy (≥5 medications) and/or use of ≥1 high risk medication (anticoagulant, antiarrhythmic, anti-hypotensive, insulin). Intervention: Anonymous online survey. Main outcome measures: Current medication use (prescription and over-the-counter), self-reported medication use behaviors measured by the Adherence to Refills and Medications Scale (ARMS-12), and perspectives on deprescribing. Results: Overall, 138 participants were recruited, with a mean age of 76.7 years. All but two self-identified as Caucasian. Prescription polypharmacy was reported by 80 (58.0 %), with use of 5-9 medications by 66 (47.8 %) and use of ≥10 medications (excessive polypharmacy) by 14 (10.1 %). Approximately one-third (n = 45, 32.6 %) had ARMS = 12, indicating adherence to taking and refilling medications. More than 1 in 10 patients (11.6 %) used >1 high-risk medication. About 4 in 10 (40.6 %) used ≥5 OTC medications. Most highly prioritized reasons for continuing medications were to prolong life (40 %), feel better (17 %), and reduce stroke risk (15 %). Despite 66.7 % of patients indicating taking "just the right amount of medications," willingness to stop ≥1 medication was very high at 80.4 %. Conclusion: Among older cardiovascular patients, prescription polypharmacy is prevalent as are medication use behaviors associated with some degree of nonadherence. Patients are supportive of deprescribing. Prioritizing what matters most to patients and focusing efforts to deprescribe potentially inappropriate medications is recommended.

Evaluating the impact of a "grand rounds" elective course on students' perceived motivations, comfort, and confidence in providing constructive and reinforcing feedback to guest lecturers.

BACKGROUND AND PURPOSE: Providing feedback is an important skill for all healthcare professionals both within and outside of their discipline. Although student pharmacists frequently receive feedback during both didactic and experiential education, training on how to provide feedback to others is less common. EDUCATIONAL ACTIVITY AND SETTING: An elective was designed to expose second-year pharmacy students to "grand rounds" with practicing pharmacists as the presenters. Students provided feedback to presenters on presentation style and assessment questions. The primary objective of this research project was to determine if the elective improved students' motivations, comfort, and confidence in providing constructive written feedback. FINDINGS: Over two course offerings, 54% (19 of 35) of enrolled students completed both the pre- and post-surveys. At baseline, the majority of students self-identified as being motivated, comfortable, and confident with providing quality written feedback with the exception of two specific areas: motivation to provide quality written feedback and comfort with providing difficult or sensitive written feedback. At the end of the course, the majority of students self-identified as being motivated, comfortable, and confident across all areas queried. All students agreed or strongly agreed that the efficiency and quality of their written feedback improved during the course. SUMMARY: The course offered several benefits to students, including learning clinical topics from a variety of presenters and developing feedback skills. The implementation of the grand rounds elective provided students an opportunity to develop their motivation, comfort, and confidence with providing quality constructive written feedback.

Fostering Mindfulness in Continuing Pharmacy Education Using a Board Game: Initial Experiences and Perceptions.

INTRODUCTION: Expansion of pharmacists' scope of practice creates a need to optimize learning within continuing professional development (CPD) that can simultaneously promote mindfulness and enhance clinical decision-making. An educational board game embracing the principles of situated learning was developed with the purpose of promoting clinical reasoning skills and mindfulness. METHODS: Iter Vitae was used in a national pharmacy meeting CPD session. An evaluation was conducted by a voluntary survey to gather perceptions of game-based instruction. RESULTS: Ninety of 115 session-attendees completed the anonymous survey. Participants strongly agreed that Iter Vitae is an effective learning tool of appropriate complexity for CPD sessions. Participant perceptions suggest that playing Iter Vitae may enhance clinical knowledge, foster critical thinking, and influence provider empathy. Open-ended responses revealed appreciation of collaborative learning within authentic case scenarios. DISCUSSION: This game-based CPD session gave participants an opportunity to develop elements of mindful practice embedded within authentic case scenarios. Further research on game-based instruction is needed to determine its effects on knowledge and skill acquisition, retention, and impact on clinical practice.

A Retrospective Chart Review Evaluating Efficacy, Tolerability, and Cost of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors (PCSK9i) in Older Adults.

INTRODUCTION: Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) are proven to have profound lowering of low-density lipoprotein cholesterol (LDL-C) in patients with clinical atherosclerotic cardiovascular disease or familial hypercholesterolemia. AIM: The primary purpose of this study was to evaluate PCSK9i utilization in older adults, with a focus on efficacy outcomes within 6 months of initiation. Secondary outcomes included tolerability, out-of-pocket expenses (OPE), and barriers to initiation of therapy. METHODS: We conducted a retrospective chart review of patients ≥ 65 years prescribed PCSK9i therapy by a pharmacist-run lipid clinic within a cardiology practice. RESULTS: A total of 136 older adults were prescribed PCSK9i therapy for a Food and Drug Administration-approved indication between September 2015 and March 2019 with 98 patients included in the analyses. In terms of efficacy, 51 patients who took ≥ 3 doses of PCSK9i with baseline and follow-up lipid panels were assessed. On average, LDL-C reduced by 60% (169-67 mg/dL, p < 0.001). For tolerability, 15 patients reported treatment-emergent side effects, resulting in 10 therapy discontinuations. For the cost analysis, 72 patients reported anticipated OPE for 1 month of therapy. Ultimately 17 patients were approved for manufacturer patient assistance with $0 OPE and 31 patients utilized insurance coverage to obtain therapy reporting a median OPE of $9 United States Dollars ($0-$450). The main barrier to initiation was high OPE. CONCLUSIONS: PCSK9i are effective at lowering LDL-C in older adults. Tolerability was high among patients without a history of statin intolerance. PCSK9i remain high-cost medications to both insurance companies and patients in terms of cost-sharing responsibilities.

A Pilot Study on an Interprofessional Course Involving Pharmacy and Dental Students in a Dental Clinic.

Objective. To assess the effect of a dental clinical rotation program involving pharmacy students and dental students. Methods. An interprofessional education (IPE) course was offered as an elective to second-year pharmacy students and required for third-year dental students. The course included two in-class sessions, one online lecture, and five clinic sessions. Program evaluation analyses included a comparison of participating versus nonparticipating students on a knowledge survey of pharmacotherapy and IPE, and a descriptive analysis of IPE course evaluation results. Results. Among pharmacy students, mean scores were significantly higher for participants than nonparticipants on the 31-item pharmacy knowledge component of the survey. On the eight-item IPE component of the survey, scores were significantly higher for participants than for nonparticipants, both among pharmacy students and among dental students. Awareness and attitudes about IPE were generally high among course participants. Conclusion. An IPE course that integrates second-year pharmacy students with third-year dental students in the dental clinic to provide medication history, education, and identification of potential drug-related problems improved pharmacy students' knowledge of pharmacotherapy related to or associated with dental conditions and improved pharmacy and dental students' knowledge and attitudes about IPE.

Evaluating the Safety and Tolerability of Sacubitril/Valsartan for HFrEF Managed Within a Pharmacist Clinic.

OBJECTIVE: The objective of this research was to describe the use of pharmacist-managed sacubitril/valsartan therapy in a multi-center, outpatient cardiac group. BACKGROUND: Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNi), is a novel agent for the treatment of heart failure. An ARNi is recommended by national guidelines to be used in place of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) therapy for patients who remain symptomatic. METHODS: A retrospective chart review was performed to identify patients initiated and fully titrated on sacubitril/valsartan therapy from July 7, 2015 to March 7, 2017. RESULTS: Fifty-two of the 72 symptomatic heart failure with reduced ejection fraction (HFrEF) patients prescribed sacubitril/valsartan during the 21-month period were included in this analysis. The average ejection fraction was 26%. The average age was 69 years. At baseline, 26.9% of patients were not on ACEi/ARB therapy and 13.5% were on target-dose therapy. After completing the uptitration process, the maximally tolerated dose of sacubitril/valsartan was 5.8% low-dose, 7.7% mid-dose, and 86.5% target-dose. Loop and thiazide diuretic use decreased significantly. There was a significant mean reduction in systolic blood pressure of 6 mmHg with no significant changes in serum creatinine, blood urea nitrogen, or potassium levels. CONCLUSIONS: With close monitoring and follow-up, ARNi therapy was a safe alternative to ACEi/ARB therapy for chronic symptomatic HFrEF when initiated within a pharmacist clinic.

Provision of Lifestyle Counseling and the Prescribing of Pharmacotherapy for Hyperlipidemia Among US Ambulatory Patients: A National Assessment of Office-Based Physician Visits.

BACKGROUND: An estimated 27.8% of the United States (US) population aged ≥20 years has hyperlipidemia, defined as total serum cholesterol of ≥240 mg/dL. A previous study of US physician office visits for hyperlipidemia in 2005 found both suboptimal compliance and racial/ethnic disparities in screening and treatment. OBJECTIVE: The aim was to estimate current rates of laboratory testing, lifestyle education, and pharmacotherapy for hyperlipidemia. METHODS: Data were derived from the US National Ambulatory Medical Care Survey (NAMCS), a nationally representative study of office-based physician visits, for 2013-2014. Patients aged ≥20 years with a primary or secondary diagnosis of hyperlipidemia were sampled. Study outcomes included receipt or ordering of total cholesterol testing, diet/nutrition counseling, exercise counseling, and pharmacotherapy prescription including statins, ezetimibe, omega-3 fatty acids, niacin, or combination therapies. RESULTS: Compared with previously reported results for 2005, rates of pharmacotherapy have remained static (52.2 vs. 54.6% for 2005 and 2013-2014, respectively), while rates of lifestyle education have markedly declined for diet/nutrition (from 39.7 to 22.4%) and exercise (from 32.1 to 16.0%). Lifestyle education did not vary appreciably by race/ethnicity in 2013-2014. However, rates of lipid testing were much higher for whites (41.6%) than for blacks (29.9%) or Hispanics (34.2%). Tobacco education was ordered/provided in only 4.0% of office visits. CONCLUSION: Compliance with guidelines for the screening and treatment of hyperlipidemia remains suboptimal, and rates of lifestyle education have declined since 2005. There exists an urgent need for enhanced levels of provider intervention to reduce the morbidity and mortality associated with hyperlipidemia.

The Diuretic Potential of Sacubitril/Valsartan: A Tale of 2 Patients.

BACKGROUND: Heart failure prevalence continues to rise in the United States causing significant morbidity and mortality and costing billions in healthcare expenditures. Consensus guidelines updated in 2016 recommend an angiotensin receptor-neprilysin inhibitor (ARNi) as a therapeutic option in lieu of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for the management of stage C heart failure with reduced ejection fraction (HFrEF). For chronic HFrEF patients with New York Heart Association class II or III symptoms tolerating an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, a change in therapy to an ARNi is recommended to further reduce morbidity and mortality. PURPOSE: We present a brief case series of 2 patients initiated on ARNi therapy for treatment of HFrEF and evaluate their fluid status and diuretic needs before and after ARNi dose optimization. CONCLUSIONS: After titration to target-dose ARNi therapy, both patients demonstrated improved fluid and electrolyte balance, as well as a reduction in diuretic therapy requirements, suggesting a mechanism of diuresis attributable to ARNi therapy. CLINICAL IMPLICATIONS: Angiotensin receptor-neprilysin inhibitor therapy seems to promote a clinically relevant diuresis in heart failure patients because of increased levels of functioning natriuretic peptides. Awareness of this diuretic potential may allow for optimization of heart failure regimens with pharmacologic agents demonstrated to improve morbidity and mortality, while preventing adverse effects that may occur with overdiuresis.

Elevated international normalized ratio associated with use of dronedarone and warfarin.

OBJECTIVE: To describe a case of elevated international normalized ratio (INR) after addition of dronedarone to warfarin therapy. CASE SUMMARY: A 72-year-old white female with a history of tinnitus, gastroesophageal reflux disease, and permanent pacemaker implantation was taking warfarin (target INR 2-3) and sotalol for chronic atrial fibrillation; atorvastatin for hyperlipidemia; and risedronate for osteopenia. Her warfarin therapy had been managed by a nurse-run anticoagulation clinic for several years. During the prior year, her INR had been stable with a weekly dose of warfarin 25 mg. After persistent episodes of atrial fibrillation, the antiarrhythmic agent was changed from sotalol to dronedarone 400 mg twice daily. Approximately 10 days after starting dronedarone, the INR was 4.8; she stated that there was no bleeding. The warfarin dose was decreased to 20 mg/wk, and the INR remained stable with that dosage for the next 11 months. DISCUSSION: Postmarketing surveillance has revealed cases of increased INR values with or without bleeding in patients taking warfarin who were started on dronedarone. In this case, the Horn Drug Interaction Probability Scale suggested a probable causality for an interaction between dronedarone and warfarin. Based on current knowledge, this interaction may involve an indirect gastrointestinal mechanism and/or a direct pharmacokinetic mechanism. CONCLUSIONS: Clinicians should monitor patients who are taking warfarin and dronedarone for INR changes and bleeding episodes about 1 week after initiation of dronedarone. If a significant interaction is noted, the warfarin dosage should be decreased and the patient should be monitored within 2 weeks to assess the need for further adjustments.