Application of the replicating effective programs framework to design a COPD training program.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally and a common cause of hospital readmissions in the United States. While best practices exist in COPD management, incorporation of such approaches into routine clinical care remains a challenge. OBJECTIVES: This evaluation applied principles from the field of dissemination and implementation (D&I) science to design a training package integrating best practice for COPD management. The D&I field promotes evidence-based implementation strategies, frameworks, and assessment approaches that can be considered by clinicians to promote adoption of best practices. METHODS: This prospective mixed-methods evaluation applied a D&I science model to develop, implement, and evaluate an interprofessional training program for COPD management originally piloted in 2016. The authors provide a contextual example of how a guiding D&I framework, replicating effective programs, was applied to design and implement a Web-based training program for clinicians preparing to implement the COPD service. A questionnaire and profession-specific focus group sessions were conducted to evaluate trainee confidence and enactment of critical service components. RESULTS: A total of 41 of the 50 interprofessional trainees responded to the pre- and postquestionnaire including primary care clinical pharmacists (n = 15), primary care registered nurses (n = 9), triage registered nurses (n = 12), and respiratory therapists (n = 5). Statistically significant improvements in trainee confidence and enactment were observed in 31 of the 40 total survey items (77%). Pooled focus group data provided attestation that the training enhanced practitioners' confidence in their role within the service. Opportunities for further improvement were also identified, such as incorporating a video modeling clinic example and accompanying written materials. CONCLUSION: This evaluation provides a case-study example of how D&I science can be used to design, implement, and evaluate a training package for trainees to spread a promising best practice. Clinicians can consider similar applications of D&I science to enhance training and spread novel services across health systems.

Implementation of a pharmacist and student pharmacist-led primary care service to identify and treat rural veterans at risk for osteoporotic fracture.

OBJECTIVE: To develop and implement a pharmacist and student pharmacist-led osteoporosis service to increase dual-energy x-ray absorptiometry (DXA) screening rates among rural veterans and treat those at high risk of osteoporotic fractures. PRACTICE DESCRIPTION: Pharmacists are uniquely positioned to provide direct patient care in the Department of Veterans Affairs ambulatory care setting owing to their broad scope of practice. Clinical Pharmacy Specialists (CPSs) have the authority to order laboratory tests and imaging, prescribe medications, refer patients to specialty services, and monitor patients along with the primary care team. PRACTICE INNOVATION: The implementation of a pharmacist-led osteoporosis primary prevention service using student pharmacists to identify and treat patients has not been previously described in the literature to the authors' knowledge. EVALUATION METHODS: Student pharmacists in their third year contacted veterans who met the inclusion criteria for osteoporosis screening. The veterans were offered DXA scans and provided education on the risk factors for osteoporosis. After the DXA scans were completed, the students and the CPS reviewed the results to determine treatment strategies. The primary objective was evaluated by comparing the pre- and post-implementation rates of DXA screening. The other process markers that were evaluated included (1) completed DXA scans, (2) new diagnoses of osteoporosis or osteopenia, (3) patients eligible for treatment on the basis of the DXA screening results, and (4) patients who started oral bisphosphonate therapy. RESULTS: Of the 232 rural veterans evaluated, 36 had completed DXA scans before this service was implemented. After the service was implemented, 115 veterans completed DXA scans. A total of 57 patients received a new diagnosis, 33 were eligible for therapy, and 12 started oral bisphosphonate therapy after intervention by the CPS. CONCLUSION: The implementation of a pharmacist-driven osteoporosis screening and treatment service demonstrated an increase in the rate of DXA screening among rural veterans.

Helping women veterans quit smoking: a qualitative analysis of successful and unsuccessful attempts.

BACKGROUND: Tobacco use is the number one cause of death and disability of women in the United States, and our women Veteran population is disproportionately affected. Despite revisions to the Veterans Affairs' approach to smoking cessation, women continue to smoke at equal or higher rates than men, are prescribed cessation medications less frequently, and are less likely to quit. In this qualitative pilot study, individual interviews with women Veterans revealed their experiences with smoking cessation attempts. METHODS: The lead author conducted semi-structured interviews with 14 women Veterans who were either current or former smokers. Participants gave a narrative account of recent quit smoking attempts. Inductive thematic analysis explored the underlying themes. RESULTS: Four main themes emerged as important: health and well-being, smoking as an addiction, optimism, and resilience. Health and well-being encompassed physical health, mental health, and financial stability. Women often felt that stability in these key areas made a successful attempt possible. Women with successful quit attempts were more likely to consider tobacco use as an addiction, as well as expressed optimism about their quit attempts. Women with successful quit attempts also demonstrated more resilience to lapses and relapses. CONCLUSIONS: Women Veterans' quit smoking attempts demonstrate four main themes: baseline health and wellbeing, acknowledging smoking as an addiction, the participant's optimism towards quitting, and resilience. Patterns were observed within themes with respect to whether the woman was currently quit or had experienced a prolonged quit attempt in the past. Further research is needed to help women Veterans quit smoking.

Monoclonal antibodies neutralize Bacillus cereus Nhe enterotoxin by inhibiting ordered binding of its three exoprotein components.

The Nhe enterotoxin from Bacillus cereus is known to induce cytotoxicity on Vero and CaCo-2 cells by ordered binding of its single components NheA, NheB, and NheC. This study aimed to elucidate functional sites on NheB by identifying the epitopes of the neutralizing monoclonal antibodies 1E11 and 2B11. The binding regions of both antibodies were determined by using recombinant NheB fragments and synthetic peptides. The antigenic site of antibody 1E11 was located within the amino acids 321 to 341 of NheB, whereas reactivity of antibody 2B11 was dependent on the presence of amino acids 122 to 150 and on conformation. Both antibodies were able to bind simultaneously to NheB and did not interfere with target cell binding as shown by immunofluorescence microscopy. A set of neutralization assays revealed that antibody 2B11 most likely interfered with the interaction between NheB and NheC both on the epithelium cell surface and in solution. In contrast, antibody 1E11 inhibited association between NheA and cell-bound NheB in a competitive manner, and effectively neutralized Nhe cytotoxicity on a variety of human cell lines. This distinct mechanism further supports that NheA is the key component during the Nhe mode of action and the C-terminal epitope recognized by antibody 1E11 points to an important functional region of NheB.

Incorporation of Student Pharmacists into a Proton Pump Inhibitor Deprescribing Telehealth Program for Rural Veterans.

Background: Proton pump inhibitors (PPIs) are among the most widely prescribed class of medications in the United States. Although effective in the treatment of acid related disease, inappropriate PPI use is prevalent, and long-term PPI use has been associated with adverse effects. Objectives: This evaluation explores the novelty of a student-pharmacist directed PPI deprescribing telehealth program with the goals of (1) determining whether PPIs are appropriately prescribed in Veterans via remote student-led chart reviews, (2) identifying if a gap exists between urban and rural Veterans prescribed a PPI, and (3) assessing the feasibility of integrating student pharmacists into the PPI deprescribing process utilizing telehealth visits through a pilot study. Methods: Student pharmacists evaluated PPI appropriateness in Veterans at the William S. Middleton Veterans Hospital. Students collected data via remote chart reviews, compared appropriateness of PPI therapy in rural versus urban Veterans, and conducted a deprescribing pilot call study in rural Veterans with inappropriate PPI indications. Clinical decision-making was agreed upon in collaboration with pharmacist preceptors, however all means of communication with Veterans was performed by student pharmacists. Results: 51% of Veterans were found to have an inappropriate indication for their PPI, though comparison of inappropriate PPI use in rural versus urban Veterans was not statistically significant (n=170, p-value 0.34). 83% of Veterans agreed to proceed with PPI deprescribing and 71% of Veterans ended the pilot study with at least some degree of PPI dose reduction (n=33). Conclusion: Inappropriate PPI use among rural and urban Veterans is prevalent, however a significant difference was not observed between the two cohorts. Student pharmacists are capable of successful telehealth deprescribing interventions in collaboration with pharmacists.

Primary Care Shared Medical Appointment for Pain Management: A Pilot Program.

Effective strategies that are evidence-based and non-addictive are needed to manage chronic pain and combat the opioid crisis. One potential strategy is to utilize a shared medical appointment (SMA), which is a model of providing clinical care in a group setting with multiple healthcare team members for comprehensive pain management. The purpose of this retrospective chart review is to evaluate the impact of a pain management SMA at the William S. Middleton Veterans Affairs (VA) West Clinic on opioid use and behaviors. Quantitative and qualitative data was obtained from the electronic medical record of 16 Veterans who participated in the pain SMA and analyzed using descriptive statistics. In addition to a reduction in opioid doses six months post SMA, participants gained non-pharmacological referrals, addition of non-opioid pain medications, and a mix of didactic and experiential education on pharmacologic and non-pharmacologic treatment modalities to help manage their chronic pain. This SMA allowed for greater access to healthcare professionals with a sole focus on pain management and provided Veterans with a holistic approach to their pain management.

Impact of a novel project management course sequence on innovative thinking in pharmacy students.

BACKGROUND: As healthcare continues to become more complex, pharmacist innovators have worked to advance the profession and expand the role of the pharmacist on the healthcare team. Accreditation standards for schools of pharmacy recognize the importance of developing future pharmacist innovators capable of making positive change in the profession, but there are limited resources available on how to best instill innovative thinking in student pharmacists. EDUCATIONAL ACTIVITY: A two-semester elective course sequence was created for third-year doctor of pharmacy students requiring completion of a longitudinal quality improvement project at a partnering health system. Students collaborated with key stakeholders to design a project plan and charter, identify deliverables, and deliver project results. Innovative thinking was assessed using a mixed methods approach including questionnaires with forced choice and open response items, focus group data, and semi-structured interviews. Each questionnaire item mapped specifically to an element of a validated model for employee innovation. From the beginning to the end of the course sequence, there were significant improvements in student-perceived project management self-efficacy and innovative thinking. CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY: Student learning outcomes and the course structure mapped closely with a validated model of innovative behavior, demonstrating the effectiveness of utilizing project management to instill innovative thinking in student pharmacists. These findings support the concept that innovative thinking can be taught in pharmacy didactic curricula by situating students in the environment of real-world pharmacy practice.

Implementation of a Pilot Pharmacist Testosterone Therapy Management Service.

BACKGROUND: Recent literature findings suggest that opportunities exist to optimize testosterone replacement therapy management. OBJECTIVE: To evaluate the impact of a pilot clinical pharmacist testosterone therapy management service in a Veterans Affairs primary care setting. METHODS: A 6-month, single-clinic, prospective cohort quality improvement project included male patients with an active prescription for testosterone. Patients were excluded if they switched primary care providers or were managed by a specialty clinic. After diagnosis, primary care providers had the option of referring patients for clinical pharmacist testosterone replacement therapy management. The project investigated the impact of pharmacist management on adherence to guideline-defined baseline and therapeutic monitoring, prior authorization workload, time saved by primary care providers, and clinical pharmacist interventions. RESULTS: Sixty patients split between pharmacist management (N = 35) and nonpharmacist management (N = 25) cohorts. Monitoring of baseline parameters was significantly improved with clinical pharmacist management (54% vs 20%, P = 0.0006). Improved baseline monitoring decreased prior authorization team workload as requests were approved on the first submission at a higher rate (100% vs 75.4%, P = 0.06). Pharmacist management increased therapeutic monitoring for assessing symptom improvement (96% vs 26%, P < 0.001), monitoring of testosterone levels (96% vs 61%, P = 0.003), and safety monitoring with complete blood counts (100% vs 83%, P = 0.04). A total of 42 pharmacist-patient encounters saved over 600 minutes of primary care provider time. CONCLUSION: Clinical pharmacist involvement enhances therapeutic monitoring for male hypogonadism leaving room for expansion of clinical pharmacy services within testosterone replacement therapy management.