Identifying barriers to utilization of a medication access program among referred patients surveyed after discharge from an acute care hospital.

BACKGROUND: For uninsured residents of select counties in North Carolina, the Cumberland County Medication Access Program (CCMAP) provides prescriptions at no cost. Uninsured patients hospitalized at Cape Fear Valley Medical Center are referred to CCMAP at discharge by Cape Fear Valley Health System employees, primarily coordination of care personnel and outpatient pharmacy personnel. The purpose of this study was to describe the most frequently reported utilization barriers among surveyed patients referred to CCMAP after discharge from Cape Fear Valley Medical Center. METHODS: This was a single-center, survey-based, descriptive research study. Referring Cape Fear Valley Health System employees collected the medical record number of patients referred to CCMAP at discharge between October 22, 2020 and December 31, 2020. These patients were contacted via a research team member by telephone at least 30 days after discharge to voluntarily participate in a survey regarding their ability to receive prescriptions from CCMAP after discharge. Patient-reported utilization barriers and demographics were recorded. A similar survey was voluntarily completed by referring health system employees. Employee-reported utilization barriers were collected to identify discrepancies in perceived utilization barriers among discharged patients and referring health system employees. RESULTS: There were 69 patients referred to CCMAP at discharge by outpatient pharmacy personnel. A total of 17 patients met inclusion criteria and completed the survey. Of these, 35.29% of the patients reported their greatest utilization barrier to be uncertainty about how to apply for CCMAP. In addition, 25 surveys were completed by referring outpatient pharmacy personnel. Of these, 56% of the participants reported they believe the greatest utilization barrier to be patient uncertainty about how to apply for CCMAP. CONCLUSIONS: Uninsured patients discharged from Cape Fear Valley Medical Center could benefit from increased assistance with completing CCMAP applications and enrollment with the program before discharge to improve continuity of care.

The Role of Consumerism in Pharmacy Education.

The notion of consumerism and that students are customers of pharmacy colleges was explored by proponents and opponents of the idea. First, a working definition of a "customer" in pharmacy education is pondered with respect to the roles and responsibilities of students and schools/colleges of pharmacy. Second, the pros and cons of "student-centered" education are considered in the light of students and their families being consumers of the educational experience. Third, the duality of student-centered education is discussed including student engagement/disengagement in their learning, professional/unprofessional behaviors, and shared/individual responsibilities. Lastly, learning and teaching environment dynamics are discerned when higher education becomes more student-centric and how that may affect the overall outcome of the student and the goals of pharmacy educational programs.

Impact of Initial Therapy on Readmissions in Minority Versus White Populations With Heart Failure.

Background: Minority populations are often underrepresented in landmark trials for the management of heart failure with reduced ejection fraction (HFrEF). Major trials shaping the guidelines sometimes include as few as 5% black patients. Objective: The purpose of this pilot study was to evaluate the initiation of guideline-directed medical therapy (GDMT) for HFrEF on hospital discharge for minority vs white populations and its impact on all-cause 30-day readmission rates to identify areas for larger future research studies and opportunities for pharmacist intervention. Methods: A retrospective analysis was conducted on patients with HFrEF patients discharged over a 3-month period. The primary objective was to compare all-cause 30-day readmissions in minority vs white patients with HFrEF who were discharged on initial GDMT. Results: 300 patients were included in this study, with 188 patients in the minority group and 112 patients in the white group. The minority group was predominantly African American (92%). The primary endpoint demonstrated significantly higher 30-day all-cause readmissions in minority patients compared to white patients who received initial GDMT (20.5 vs 7.7%, P = .0144), despite similar rates of GDMT therapy between groups. Conclusion: Initial GDMT in minority patients may not reduce readmissions to the same extent seen in white patients. Special emphasis should be placed on evaluating minority patients with HFrEF for additional therapeutic interventions.

Pharmacotherapy Considerations in Heart Failure with Mildly-Reduced Ejection Fraction.

Heart failure with mildly reduced ejection fraction (HFmrEF) has been classified using various definitions since its first mention in the literature in 2014. This group was most recently defined in the Universal Definition and Classification of Heart Failure (HF) as HF with a left ventricular ejection fraction of 41% to 49%. An increasing emphasis has been placed on HFmrEF over the past several years, with many recent publications suggesting that common therapies used in HF with reduced ejection fraction provide benefit in this population as well. Patients with HFmrEF comprise approximately one-quarter of all patients with HF. The lack of authoritative guidance concerning pharmacotherapeutic approaches in these patients leaves a significant portion of HF patients without an evidence-based approach. Although it remains unclear if HFmrEF is simply a transitional state from preserved to reduced ejection fraction, or a distinct phenotype requiring medical optimization, there are clear cardiovascular benefits to managing this subset appropriately. This publication was created to help serve as a resource for clinicians on this evolving subset of HF and aid in preventing the progression of this disease state through improved therapy optimization. The objective of this article is to briefly discuss the epidemiology and pathophysiology of HFmrEF and review the pharmacology and clinical application of therapies for the management of HFmrEF.

Traditional Lecture versus Case-Based Learning in a Therapeutic Drug Monitoring Course within an Integrated Pharmacy Curriculum.

Background: Case-based learning has been shown to increase student perception and performance in multiple topics in pharmacy education. However, no studies have evaluated the impact of virtual patients and case-based learning on student knowledge and knowledge retention of therapeutic drug monitoring and dosing. Innovation: Due to a curriculum overhaul promoting integration and application-based learning, the traditional third-year (P3) therapeutic drug monitoring course was reduced from four (4) credit hours to two (2), in order to add time to pharmacotherapy and skills labs. In order to adapt to this change, the course was shifted to a case-based learning format utilizing virtual patients within a simulated electronic health record (EHR) where the course grade distribution shifted in favor of patient cases versus exam questions. An analysis of student knowledge and knowledge retention of antibiotic dosing and monitoring was conducted comparing students who completed the traditional course versus those who completed the case-based course. Findings: Despite the decrease in credit hours, there was no significant difference shown in the initial knowledge assessment between the traditional and case-based courses (87.0 vs 85.5%). Knowledge retention actually improved in the students who completed the case-based course (78.1% vs 82.5%). Conclusion: Utilizing case-based instruction to teach antibiotic dosing and monitoring was successful in preparing students for these skills during their experiential rotations. Even though students had half the instruction time, they were able to perform calculations and retain knowledge as well as students in the traditional curriculum.

Comparison of Student Pharmacists' Knowledge Retention Utilizing Electronic Health Records Versus Simultaneously Completing Simulated Experiences.

Objective. The purpose of this study was to determine whether the addition of standardized patients or the addition of interprofessional student teams with standardized patients to the use of a simulated electronic health record improved student knowledge retention and perceptions.Methods. This was a prospective cohort study assessing three cohorts of first-year student pharmacists in pharmacy skills laboratory activities that occurred in 2018, 2019, and 2021. The primary objective of the study was to compare knowledge retention of the case material between groups at one month. Each year, an element of simulated experience was added onto the previous year's case. In 2018, students completed the case using only the electronic health record web application. In 2019, the previous year's experience was combined with an objective structured clinical examination (OSCE) with standardized patients. In 2021, the 2019 experience was supplemented with student physician assistants. Case scores and student perceptions were also compared between groups.Results. Of the 260 potential participants, 238 students were included in the primary analysis. Results showed that with the addition of interprofessional team-based care and standardized patients, significant improvement was demonstrated in knowledge retention assessments at one month. Mean knowledge retention assessment scores for the 2018, 2019, and 2021 groups were 63.8%, 71.7%, and 76.1%, respectively. Significant improvement was also found in student perceptions.Conclusion. Adding standardized patients and interprofessional team-based care to a pharmacy skills laboratory that uses a simulated electronic health record significantly improved student knowledge retention and perceptions.

Reduced-Dose Apixaban in the Treatment of Left Ventricular Thrombus: A Report of 2 Cases.

According to the American College of Cardiology and the American Heart Association, warfarin has historically been the standard of care anticoagulant for the treatment of left ventricular thrombus. The use of direct oral anticoagulants (DOACs) has become more prevalent, as they require less frequent laboratory monitoring, offer fixed-dose regimens, are associated with fewer drug-drug and drug-food interactions, and provide more favorable safety profiles when compared to warfarin. However, DOACs are not currently FDA-indicated in the treatment of left ventricular (LV) thrombus. Numerous recent studies have reported and evaluated the use of DOACs for treatment of LV thrombus. Recently, a prospective, open-label, multicenter study evaluated warfarin compared to DOACs for LV thrombus treatment. The AHA recently published a scientific statement regarding the management of patients at risk for and with left ventricular thrombus, which included DOACs as a reasonable alternative to warfarin. This report describes two patients treated with DOACs following LV thrombus diagnosis. The first case is a 71-year-old male admitted for cerebrovascular accident and non-ST-elevation myocardial infarction complicated by a LV thrombus. The second case is an 83-year-old female admitted for acute myocardial infarction complicated with an LV thrombus. Both patients were prescribed apixaban 2.5 mg twice daily. Neither patient has experienced LV thrombus or DOAC treatment related complications. This case series serves as evidence for reduced-dose DOACs as an alternative to warfarin in the treatment of LV thrombus.

Benefits of Utilizing Pharmacy Learners in an Inpatient Anticoagulation Education Service.

Objective. The 2019 Hospital National Patient Safety Goal 03.05.01 indicates education regarding anticoagulant therapy should be provided to patients and families. Previous studies assessing pharmacist and pharmacy student involvement in oral anticoagulation (OAC) education services have focused on patient-related outcomes, with limited emphasis on the additional benefit to the student. The purpose of this study was to assess the benefit of pharmacy student involvement in anticoagulation education services both clinically and through their perceptions of participating in the service. Methods. This study assessed students' knowledge and perceptions of providing OAC education before and after a 1-month learning experience, where students provided counseling 2-3 days per week. The primary endpoint was comparing each student's pre- and post-rotation OAC education knowledge assessments. Secondary endpoints included percentage change in knowledge between the prospective cohort and a historical comparator group, perceived benefit of student participation in the service, percentage of patients able to recall counseling, and number of interventions made related to OAC therapy. Results. A total of 35 pharmacy students were included in this prospective study with 277 patients receiving counseling from June 2020 through March 2021. A total of 32 pharmacy students had assessment data available for retrospective comparison. The mean pharmacy student score within the prospective cohort improved significantly (21.5%) between the pre-assessment and post-assessment. Change in pre- and post-rotation knowledge assessment was also significantly higher in the prospective cohort compared to the retrospective group. Additionally, students gained confidence in their counseling abilities and OAC knowledge through participation. Conclusion. Pharmacy student participation within anticoagulation education services significantly improved student knowledge and confidence in their counseling abilities. It also allowed for over 70% of patients to successfully recall pertinent information about their anticoagulants over a week later and improved patient care through dosing interventions.

Implementation and justification of a curriculum-wide electronic health record platform.

BACKGROUND AND PURPOSE: In order to develop practice-ready pharmacists as mandated by the Accreditation Council for Pharmacy Education Accreditation Standards, exposing students to health information technologies used in clinical practice, like electronic health records (EHRs), is imperative. While the benefits of using EHRs have been described in the literature, limited information or guidance exists on how these tools can incorporate various activities and topics to be implemented throughout an entire curriculum. The purpose of this report is to describe the curriculum-wide implementation of a simulated EHR software, including the novel learning experiences and costs incurred by the college. EDUCATIONAL ACTIVITY AND SETTING: The EHR was implemented in various courses across the pharmacy school curriculum in the first, second, and third professional years. FINDINGS: During the final year of implementation, the EHR platform was utilized in each of the three didactic years of the pharmacy program. Twenty-two faculty members created cases using the EHR platform. These cases were used across 16 courses and were accessed by students 7191 times during the implementation process. The cost per use of the EHR platform was approximately half that of the most frequently used electronic learning database used in the program. SUMMARY: In the three years since its inception, the EHR has been highly utilized as evidenced by the overall number of experiences for students, the variety of experiences, and the number of faculty who used the EHR in their course.

Utilization of a Dextrose-Only Purge Solution for an LVAD in Patients With Suspected HIT: A Case Series.

The Impella devices are percutaneous intravascular ventricular assist devices indicated for use in patients with cardiogenic shock that occurs following acute myocardial infarction (MI) or open heart surgery. These devices must be used with a purge solution that contains heparin per manufacturer recommendation, which will prevent blood from reaching the motor causing pump thrombosis and mechanical failure. We describe the utilization of a dextrose-only purge solution plus systemic argatroban in 2 patients with suspected heparin-induced thrombocytopenia (HIT). Each case describes a patient with suspected HIT following Impella placement for cardiogenic shock post-MI that had an increased bleeding risk. In each case, pharmacy monitored and adjusted the patients' argatroban, resulting in therapeutic anticoagulation without major bleeding or thrombotic events. These case reports demonstrate that use of a dextrose-only purge solution in the Impella device may be a safe and effective option when combined with systemic argatroban in patients with suspected or confirmed HIT who exhibit increased bleeding risk. Further research is needed to determine the optimal concentrations and duration of anticoagulation-free purge solution in these patients.

Low Serum Albumin Predicts Severe Outcomes in COVID-19 Infection: A Single-Center Retrospective Case-Control Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) can cause serious complications such as multiorgan failure and death which are difficult to predict. We conducted this retrospective case-control observational study with the hypothesis that low serum albumin at presentation can predict serious outcomes in COVID-19 infection. METHODS: We included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed, hospitalized patients from March to July 2020 in a tertiary care hospital in the USA. Patients were followed for 21 days for the development of the primary endpoint defined as the composite outcome which included acute encephalopathy, acute kidney injury, the requirement of new renal replacement therapy, acute hypercoagulability, acute circulatory failure, new-onset heart failure, acute cardiac injury, acute arrhythmia, acute respiratory distress syndrome (ARDS), high flow oxygen support, intensive care unit (ICU) stay, mechanical ventilation or death; and the secondary endpoint of death only. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes. RESULTS: The mean age was 56.76 years vs. 55.67 years (P = 0.68) in the normal albumin vs. the low albumin group. We noticed an inverse relationship between serum albumin at presentation and serious outcomes. The low albumin group had a higher composite outcome (93.88% vs. 6.12%, P < 0.05) and higher mortality (13.87% vs. 2.38%, P < 0.05) in comparison to the normal albumin group. The multivariate logistic regression analysis revealed higher odds of having composite outcomes with lower albumin group (odds ratio (OR) 10.88, 95% confidence interval (CI) 4.74 - 24.97, P < 0.05). In the subgroup analysis, the multivariate logistic regression analysis revealed higher odds of having composite outcomes with the very low albumin group (OR 7.94, 95% CI 1.70 - 37.14, P < 0.05). CONCLUSIONS: Low serum albumin on presentation in COVID-19 infection is associated with serious outcomes not limited to mortality. The therapeutic option of albumin infusion should be investigated.

Evaluation of traditional initial vancomycin dosing versus utilizing an electronic AUC/MIC dosing program.

BACKGROUND: Area under the curve to minimum inhibitory concentration (AUC/MIC) has been recommended by the 2020 updated vancomycin guidelines for dosing vancomycin for both efficacy and safety. Previously, AUC/MIC has been cumbersome to calculate so surrogate trough concentrations of 15-20 mg/dL were utilized. However, trough-based dosing is not a sufficient surrogate as AUC/MIC targets of 400-600 can usually be reached without achieving troughs of 15-20 mg/dL. Targeting higher trough levels may also lead to adverse events including acute kidney injury (AKI) and nephrotoxicity. OBJECTIVE: To compare the mean total first day vancomycin dose in traditional trough-based dosing versus dosing recommended by an AUC/MIC dosing program. METHODS: Adult inpatients who received at least 24 hours of IV vancomycin treatment were included in this single-center, retrospective cohort study. The primary endpoint was difference in mean total first day vancomycin dose in milligrams (mg) received between patients' traditional trough-based dosing and recommended dose via AUC/MIC electronic dosing calculator. Patients served as their own control by analyzing both actual dose received and dose recommended by the electronic AUC/MIC program. Rates of vancomycin induced adverse events, including acute kidney injury, elevated steady-state trough concentrations, and Red Man's syndrome were also compared between patients who received doses consistent with the AUC/MIC dosing recommendation versus those who did not. RESULTS: 264 patients were included in this study. Initial 24-hour vancomycin exposure was significantly lower with the recommended AUC/MIC dose versus the dose received (2380.7; SD 966.6 mg vs 2649.6; SD 831.8 mg, [95% CI 114.7:423.1] p=0.0007). CONCLUSIONS: Utilizing an electronic AUC/MIC vancomycin dosing calculator would result in lower total first day vancomycin doses.

Mirtazapine-Induced Pancreatitis-A Case Report.

Acute pancreatitis has numerous etiologies, with the most common including gallstones, alcohol abuse, and medications such as angiotensin-converting enzyme (ACE) inhibitors, statins, and diuretics. Mirtazapine has been associated with increased serum cholesterol and serum triglyceride levels. However, few studies have reported dangerously elevated triglyceride levels resulting in acute pancreatitis. This report discusses a case of mirtazapine-induced pancreatitis in a 46-year-old African American female. The patient presented to the emergency department with pancreatitis, presumably alcohol-induced as with a prior admission, but she denied any recent alcohol use. Mirtazapine then became the suspected cause of her hypertriglyceridemia-induced pancreatitis and was discontinued. After discontinuing mirtazapine, and utilizing an insulin infusion, her triglyceride levels normalized and symptoms of pancreatitis resolved. Using the Naranjo Adverse Drug Reaction Probability Scale, a total score of 5 was calculated indicating a probable adverse drug reaction of acute pancreatitis from mirtazapine.

The Impact of Interprofessional Monitoring and Education on the Usage of Systemic Glucocorticoids in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Retrospective, Medication Use Review.

Background Systemic corticosteroid therapy for chronic obstructive pulmonary disease (COPD) exacerbations is routine in clinical practice, however, dosing is variable. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) panel recommends a short course of systemic corticosteroids for acute COPD exacerbation treatment. Despite these recommendations, institutions continue to use higher doses and longer durations of systemic corticosteroid therapies. Methods This single-center, retrospective, cohort study evaluated systemic corticosteroid use in inpatient treatment of COPD exacerbations. Data were collected on patients with a diagnosis of COPD exacerbation from October 2017 to February 2018 in both the control and education groups. An interprofessional, learner-centric, quality improvement, educational seminar was performed. Providers were given accompanying pocket reference material for improved adherence to GOLD guidelines for the management of acute COPD exacerbations. Results Of the 137 charts reviewed in the control group, 130 of 137 patients (94.9%) received systemic corticosteroid doses exceeding GOLD guideline recommendations. These patients received an average daily dose of 147.5 mg of prednisone equivalents. These patients also experienced more adverse drug reactions as compared to their post-intervention counterparts. The 105 charts examined post-educational intervention revealed 47 of 105 patients (44.8%) received GOLD guideline-directed doses of systemic corticosteroids. This was an improvement from 2.9% (4 of 137) in the control group (p-value < 0.001). The average daily dose decreased to 58 mg daily (p-value < 0.001), and the number of doses over the recommended 40 mg of prednisone equivalents (54 of 105) was a 43.5% reduction (p-value < 0.001). Length of stay also decreased in the education group from 6.1 +/- 4.1 to 4.7 +/- 2.8 days (p-value 0.009). The 30-day readmission rate, however, was not statistically different between the two groups, 31.4% pre- and 21.0% post-educational intervention (p-value 0.098). Conclusions The interprofessional education seminar and pocket reference sheet realigned clinical practice with guideline-based therapy in this tertiary care, community hospital. These data validate that learner-centric innovation will benefit patient outcomes and improve the educational potential of the interdisciplinary rounding team.

Evaluation of a vancomycin dosing nomogram in obese patients weighing at least 100 kilograms.

BACKGROUND: There remains variability in both practice and evidence related to optimal initial empiric dosing strategies for vancomycin. OBJECTIVE: Our primary objective was to describe the percentage of obese patients receiving vancomycin doses consistent with nomogram recommendations achieving targeted initial steady-state serum vancomycin concentrations. Secondary objectives were to describe the primary endpoint in subgroups based on patient weight and estimated creatinine clearance, to describe the rate of supratherapeutic vancomycin accumulation following an initial therapeutic trough concentration, and to describe the rate of vancomycin-related adverse events. METHODS: This single-center, IRB-approved, retrospective cohort included adult patients ≥ 100 kilograms total body weight with a body mass index (BMI) >30 kilograms/m2 who received a stable nomogram-based vancomycin regimen and had at least one steady-state vancomycin trough concentration. Data collected included vancomycin regimens and concentrations, vancomycin indication, serum creatinine, and vancomycin-related adverse events. Patients were divided into two cohorts by goal trough concentration: 10-15 mcg/mL and 15-20 mcg/mL. RESULTS: Of 325 patients screened, 85 were included. Goal steady-state concentrations were reached in 42/85 (49.4%) of total patients. CONCLUSIONS: Achievement of initial steady-state vancomycin serum concentrations in the present study (approximately 50%) was consistent with the use of published vancomycin dosing nomograms.

Impact of Standardized Simulated Patients on First-Year Pharmacy Students' Knowledge Retention of Insulin Injection Technique and Counseling Skills.

Objective. To compare pre- and post-intervention test scores assessing insulin injection technique and counseling skills among P1 students with (intervention) or without (control) simulated patients, and to compare counseling checklist and knowledge retention test scores between groups. Methods. This study utilized cluster randomization. In addition to traditional instruction, the intervention group counseled a simulated patient on the use of insulin using the teach-back method. Test score changes from baseline were analyzed via two-sample t-test. Results. The intervention group exhibited a significantly greater increase in knowledge test scores from baseline compared to the control group. Similar changes were seen in post-instruction counseling checklist scores and knowledge retention test scores from baseline. Conclusion. Simulated patient interactions, when added to traditional coursework within a P1 skills lab, improve student counseling aptitude and knowledge retention scores.