Comparison of 3 risk factor-based screening tools for the identification of prediabetes.

OBJECTIVE: To compare risk factor-based screening tools for identifying prediabetes. METHODS: Participants in an employer-based wellness program were tested for glycosylated hemoglobin (A1C) at a regularly scheduled appointment, and prediabetes risk factor information was collected. The likelihood of having prediabetes and the need for laboratory testing were determined based on 3 risk factor-based screening tools: the Prediabetes Screening Test (PST), Prediabetes Risk Test (PRT), and 2016 American Diabetes Association guidelines (ADA2016). The results from the screening tools were compared with those of the A1C test. The predictive ability of the PST, PRT, and ADA2016 were compared using logistic regression. Results were validated with data from a secondary population. RESULTS: Of the 3 risk factor-based tools examined, the PRT demonstrated the best combination of sensitivity and specificity for identifying prediabetes. From July 2016 to March 2017, 740 beneficiaries of an employer-sponsored wellness program had their A1C tested and provided risk factor information. The population prevalence of prediabetes was 9.3%. Analysis of a second independent population with a prediabetes prevalence of more than 50% of confirmed PRT's superiority despite differences in the calculated sensitivity and specificity for each population. CONCLUSION: Because PRT predicts prediabetes better than PST or ADA2016, it should be used preferentially.

Description of a pharmacist-led diabetes prevention service within an employer-based wellness program.

OBJECTIVES: To describe a pharmacist-led diabetes prevention service piloted within an employer-based wellness program. PRACTICE DESCRIPTION: A pharmacist-led ambulatory care clinic within a school of pharmacy that provides wellness services to university employees. PRACTICE INNOVATION: Implementation of a diabetes prevention service using opportunistic A1C screening within a biometric screening program. Patients with a prediabetes-level A1C from July 2016 to March 2019 were invited to participate in the National Diabetes Prevention Program (NDPP). EVALUATION: Comparison of baseline characteristics of participants with normal and elevated A1C. Evaluation of participation in the NDPP and changes in clinical values at the subsequent biometric screening appointment for individuals with a prediabetes-level AlC. RESULTS: A1C testing of 740 individuals identified 69 participants (9.3%) with a prediabetes-level A1C and 7 (1.0%) with a diabetes-level A1C. Compared with those with a normal A1C (< 5.7%), participants with an elevated A1C were more likely to be older, nonwhite, obese, and physically inactive, to have a sibling with diabetes, higher random blood sugar (RBS), lower high-density lipoprotein (HDL), and more likely to have hypertension. Twelve patients participated in the NDPP, although most attended only 1 session. Attenders had a significantly lower baseline weight and body mass index (BMI). There were no significant differences in the changes in A1C, BMI, weight, RBS, or HDL between attenders and nonattenders approximately 1 year later. CONCLUSION: This pilot demonstrated that opportunistic A1C testing could be incorporated into an ambulatory care clinic within a pharmacist-led employer-based wellness program. Uptake and retention of the NDPP were poor. Barriers to NDPP participation need to be investigated and addressed to improve service impact.

Systematic Diabetes Screening Using Point-of-Care HbA1c Testing Facilitates Identification of Prediabetes.

This prospective longitudinal study compares diabetes screenings between standard practices vs systematically offered point-of-care (POC) hemoglobin A1c (HbA1c) tests in patients aged 45 years or older. Systematically screened participants (n = 164) identified 63% (n = 104) with unknown hyperglycemia and 53% (n = 88) in prediabetes. The standard practice (n = 324) screened 22% (n = 73), most commonly by blood glucose (96%); 8% (n = 6) and 33% (n = 24) were found to have diabetes and prediabetes, respectively. The association between screening outcome and screening method was statistically significant (P = 0.005) in favor of HbA1C HbA1c may be the most effective method to identify patients unknowingly living in hyperglycemia. Point-of-care tests further facilitate screening evaluation in a timely and feasible fashion.

Selecting an A1C Point-of-Care Instrument.

A1C point-of-care (POC) instruments benefit patients with diabetes by facilitating clinician decision making that results in significant glycemic improvements. Three National Glycohemoglobin Standardization Program (NGSP)-certified POC products are available in the United States: the handheld A1CNow (formerly manufactured by Bayer Diabetes Care but now made by Chek Diagnostics) and two bench-top models called the Axis-Shield Afinion Analyzer and the Siemens DCA Vantage. This article compares the three available NGSP-certified POC products in terms of accuracy, precision, ease of use, cost, and additional features. Its goal is to aid health care facilities in conveniently identifying the A1C POC product that best meets their needs. It additionally reviews evidence that supports the continued use of A1C POC instruments in the clinical arena.

An Online, Multi-institutional Debate on Diabetes Medications by Advanced Pharmacy Practice Experience Students.

Objective. The purpose of this study was to evaluate changes in advanced pharmacy practice experience (APPE) students' knowledge and to measure student perceptions of an online, multi-institutional debate curriculum as an alternative to a journal club to improve critical thinking skills related to diabetes medications.Methods. All APPE students assigned to four faculty (n=37) at three different colleges during the 2020-2021 academic year received instruction on diabetes medication classes and their cardiovascular outcome trials. Students debated via the Lincoln-Douglas format whether the preferred second-line therapies for patients with type 2 diabetes mellitus are either glucagon-like peptide-1 receptor agonists or sodium-glucose cotransporter-2 inhibitors. Matched pre- and post-APPE knowledge scores were measured using a seven-item assessment tool. A 22-item post-debate survey measured student perceptions of the activity.Results. Pre- and post-APPE knowledge scores were compared in 32 students, yielding an 86% response rate. Knowledge scores improved 32% (59% pre vs 87% post). Thirty-three students completed the perceptions survey, yielding an 89% response rate. Students reported that the debate activity was beneficial (100%) and rated it more effective than a journal club at improving critical thinking skills and knowledge retention.Conclusion. Preliminary results suggest that incorporating an online, multi-institutional debate as an alternative to journal clubs during APPE rotations was well received. Further research is warranted on the impact of the multi-institutional debate and how to best deliver it during the APPEs of a pharmacy curriculum.

National survey of educational impact on pharmacy learners by volunteering at camps for children with diabetes.

INTRODUCTION: Current literature on pharmacy students' and residents' experience attending camps for children with diabetes focuses on the experience at an individual campsite. The objective of this study was to examine the demographics and gains in understanding that pharmacy learners achieve when volunteering as medical staff at camps for children with type 1 diabetes (T1D). METHODS: National listservs were used to identify pharmacists who precept pharmacy students and residents at diabetes camps. These self-identified pharmacists shared pre- and post-camp electronic surveys with their respective pharmacy learners. Statistical analysis was completed using SPSS Version 25 (IBM, Corp.). RESULTS: Eighty-six pharmacy learners completed the pre-camp survey and 69 completed the post-camp survey. Most were Caucasian, in their fourth professional year, and participated in residential camps that lasted six and one-half days on average. Learners consistently engaged in patient care activities including: carbohydrate counting (87%), bolus insulin dose calculations (86%), treatment of hypo/hyperglycemic episodes (86%), blood glucose testing (83%), blood sugar trend evaluation (78%), basal insulin dosing calculations (74%), and insulin pump site changes (72%). Learners demonstrated statistically significant gains in every index measured with the exception of glucometer use. Eighty-seven percent indicated they learned how to appropriately manage T1D, 37% gained empathy for those living with T1D, and 13% learned how to work in a medical team. CONCLUSIONS: Pharmacy learners who volunteered at diabetes camps experienced large gains in their understanding of concepts and devices, comfort with performing patient care tasks, and compassion for children and their families living with T1D.

Telehealth delivery of motivational interviewing for diabetes management: A systematic review of randomized controlled trials.

OBJECTIVES: The objective of this systematic review was to explore and report the evidence and gaps in the literature for randomized controlled trials (RCTs) studying the effects of motivational interviewing (MI)-based telehealth interventions on outcomes among persons with diabetes (PWD) or prediabetes. METHODS: Following a modified Cochrane approach, we searched Pubmed, CENTRAL, CINAHL, PsycINFO, and Clinicaltrials.gov. Included studies were RCTs published in English before March 25, 2021 evaluating MI-based telehealth on outcomes for adults with diabetes or prediabetes. RESULTS: A total of 21 retained articles captured results for 6436 PWD. Among the most commonly investigated outcomes, 60% of articles documented A1C reductions (ranging from<1% to>3%), 56% documented systolic blood pressure reductions, 57% documented diabetes self-efficacy/empowerment improvements, and 40% documented physical activity improvements. Conversely, diastolic blood pressure, lipid panels, body mass index, depressive symptoms, and quality of life were frequently measured outcomes, where MI-based telehealth yielded minor effects (<30% of articles demonstrating improvements). CONCLUSIONS: MI-based telehealth seems most effective for improving A1C, systolic blood pressure, diabetes self-efficacy, and physical activity behaviors. Variability in outcome assessment and intervention heterogeneity were key challenges impeding comparisons across retained articles. PRACTICE IMPLICATIONS: MI-based telehealth interventions demonstrate promising results for improving outcomes in PWD.

Systematic literature review of insulin dose adjustments when initiating hemodialysis or peritoneal dialysis.

Chronically uncontrolled hyperglycemia is the leading cause of end stage kidney disease (ESKD) necessitating dialysis. During times of transition to hemodialysis (HD) or peritoneal dialysis (PD), considerations must be given to insulin dosing adjustments for persons with diabetes (PWD) in efforts to maintain glycemic control. However, the literature is sparse with few clear and direct practical clinical recommendations for therapeutic insulin dosing adjustments in PWD and ESKD. The objective of this systematic review was to identify and report the evidence and gaps in the literature for adjustments in therapeutic insulin recommendations when initiating HD or PD in patients with ESKD and diabetes mellitus. A literature search using PubMed, CENTRAL, MEDLINE, CINAHL, Google Scholar, and ClinicalTrials.gov revealed 242 results. After removing duplicates and articles not reaching pre-specified criteria, 29 relevant articles remained for further analysis. Following the exclusion of 18 articles after full-text review due to lack of relevance or inappropriate publication type, 11 articles remained and were included in the review. The most common recommendation regarding HD was to reduce the basal insulin dose up to 25% on HD days to prevent hypoglycemia, although a lack of consensus exists on the percent reduction. Little information was found relating to insulin management with continuous ambulatory PD or automated PD. During PD, insulin may be administered subcutaneously, IP, or with the dialysis fluid. Administration of insulin with dialysate may necessitate a dose increase of up to 30% due to a loss to tubing and dilution. Furthermore, the use of dextrose-based dialysate may require additional insulin to mitigate systemic impact of dextrose absorption on BG. Overall, a gap exists in the primary literature regarding recommendations for prophylactically adjusting insulin therapy when initiating HD or PD, or when switching between the two. More research is needed to clarify ideal alterations in insulin dosing, administration techniques, and product selections for PWD and ESKD undergoing dialysis.

Patients' Preferences for Sodium-Glucose Cotransporter 2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists.

Purpose: To determine patients' preferences for sodium-glucose cotransporter 2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs). Patients and Methods: A cross-sectional, web-based discrete choice experiment was conducted among US adults with type 2 diabetes mellitus (T2DM) in May 2021. Six attributes-the route and frequency of administration, the chance of reaching target HbA1c in six months, the percentage reduction in the risk of major adverse cardiovascular events (MACE), the chance of gastrointestinal side effects, the chance of genital infection, and out-of-pocket cost per month-were identified from literature review and consultation with patients and clinicians. A Bayesian efficient design was used to generate choice sets. Each choice set contained two hypothetical SGLT-2i and GLP-1 RA alternatives described by the attributes and an opt-out alternative. A total of 176 patients were asked to select the most preferred option from each choice set. Mixed logit (ML) and latent class (LC) models were developed. The conditional relative importance of each attribute was determined. Results: The ML model showed the out-of-pocket cost had the highest conditional relative importance, followed by the chance of reaching the target HbA1c. The best LC model revealed two patient classes. All attributes were significantly important to the patients in both classes, except the chance of genital infection in class 2. Compared to the patients in class 2, the patients in class 1 were older (approximately 65 vs 56 years) and had a higher number of comorbidities (approximately three vs two). Conclusion: T2DM patients placed different preference weights or importance across SGLT-2i and GLP-1 RA attributes. Preference heterogeneity was found among patients with different ages and numbers of comorbidities.

Survey of patient knowledge related to acetaminophen recognition, dosing, and toxicity.

OBJECTIVE: To assess patient knowledge regarding acetaminophen dosing, toxicity, and recognition of acetaminophen-containing products. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: Alabama, January 2007 to February 2008. PATIENTS: 284 patients at four outpatient medical facilities. INTERVENTION: 12-item investigator-administered questionnaire. MAIN OUTCOME MEASURES: Degree of patient knowledge regarding acetaminophen safety, dosing recommendations, toxicity, alternative names and abbreviations, and products. RESULTS: Two-thirds of the 284 patients completing the survey reported current or recent use of pain, cold, or allergy medication. Of these, 25% reported knowing the active ingredient. Of patients, 46% and 13% knew that "acetaminophen" and "APAP," respectively, were synonymous with "Tylenol." Several patients (12%) believed that ingesting a harmful amount of acetaminophen was difficult or impossible. One-third of patients correctly identified the maximum daily dose, 10% reported a dose greater than 4 g, 25% were unsure of the dose, and 7% were unsure whether a maximum dose existed. One-half recognized liver damage as the primary toxicity. Results were similar between acetaminophen users and nonusers. CONCLUSION: Deficiencies were found in patient knowledge regarding acetaminophen recognition, dosing, and potential for toxicity. The development of effective educational initiatives is warranted to ensure patient awareness and limit the potential for acetaminophen overdose.

Interdisciplinary speed dating augments diabetes self-management education and support to improve health outcomes.

OBJECTIVE: To determine if a novel interdisciplinary "speed-dating" clinic augments Diabetes Self-Management Education and Support (DSMES). METHODS: Adult patients with diabetes attended a DSMES class. Two weeks later patients attended an interdisciplinary clinic utilizing a "speed-dating" format during which they progressed through 5 stations hosted by different healthcare disciplines at 30-minute increments: physician, pharmacist, nurse/dietitian, case manager, and psychologist. Shared decision-making was utilized to identify mutually agreeable recommendations. Change in clinical outcomes were compared for DSMES-only attenders versus Dual-attendees; utilization of emergency department and hospital services were measured 12 months before and after attending the Speed Dating clinic. This analysis represents patients attending the program during 2016. RESULTS: Sixty-nine attended the DSMES class, 40 of whom followed-up in the "speed-dating" clinic (58% return rate). Attending the Speed Dating clinic improved A1C (p = 0.003) and LDL-C (p = 0.003) compared to the DSMES class alone. Comparatively, after attending the speed-dating clinic, patients had fewer emergency department (p = 0.366) and hospital admissions (p = 0.036), and shorter lengths of hospital stay (p = 0.030). CONCLUSIONS: The interdisciplinary "speed-dating" approach improved diabetes outcomes beyond DSMES alone and reduced utilization of hospital services. PRACTICE IMPLICATIONS: Patients should attend DSMES but also participate in an Interdisciplinary Speed Dating follow-up to further improve outcomes.

Student pharmacists' service-oriented learning at a camp for children with type 1 diabetes mellitus.

BACKGROUND AND PURPOSE: To describe advanced pharmacy practice experience (APPE) students' active learning engagement and changes in self-reported comfort with diabetes care activities by attending an overnight camp for children with type 1 diabetes mellitus (T1DM). EDUCATIONAL ACTIVITY AND SETTING: Fourth-year pharmacy students spend one or two weeks at an overnight camp for children ages six to 18 years with T1DM as part of their APPE and assist with diabetes care activities while participating in daily living activities. Students complete a survey one week before and one week after camp where they self-report their comfort level performing 16 different diabetes-related tasks. FINDINGS: Students (n = 21) participate in hands-on active learning while volunteering at a camp for children with diabetes. Before camp, 40-61% of students reported comfort with diabetes care activities related to pharmacotherapy, monitoring, and lifestyle management. After camp, the percent of students reporting comfort with these tasks increased to 78-96%. Specific items with greatest improvement were: when to monitor ketone levels (+79%), use of insulin pens and pumps (+64%), treatment of hypoglycemia (+50%), and carbohydrate counting (+50%). SUMMARY: By attending and participating at an overnight camp for children with T1DM, APPE students self-report gain in comfort in performing many diabetes care-related tasks.

Rationale of family medicine physicians in effectively identifying patients with chronic hyperglycemia through point-of-care hemoglobin A1C screenings.

PURPOSE: Many patients are unknowingly living with chronic hyperglycemia, possibly due to low screening rates. We aimed to correlate detection of unidentified chronic hyperglycemia to practitioner reported rationale for conducting diabetes screening. METHODS: Physicians screened patients via a point-of-care A1C tests and recorded corresponding rationales. Elevated outcomes (A1C ≥ 5.7%) were correlated to recorded rationales, frequency of repeat screenings, documented diagnoses, and therapeutic actions taken as a result of elevated A1C. RESULTS: Nearly one-half (45%) of selected patients were unknowingly living with chronic hyperglycemia, having an average A1C of 7.92% for outcomes ≥6.5%. Most commonly recorded rationales were overweight status (71%), high-risk ethnicity (58%), and age > 45 years (48%); previously recorded A1C result of ≥5.7% (χ2 16.02, p < 0.001) and hypertension diagnosis (χ2 10.37, p = 0.0013) showed statistically significant correlation with elevated A1C outcomes. A1C results ≥6.5% versus 5.7-6.5% more frequently prompted repeat screenings (77% vs 20%), ICD-10 code documentation (91% vs 28%), lifestyle modification recommendations (78% vs 35%), and drug therapy initiation (78% vs 9%). CONCLUSIONS: Reported rationales were largely impacted by visual inspections of age, race, and weight, and prediabetic A1C values garnered less attention compared to higher values. Utilization of POC A1C screening followed by conformational repeat testing is a practical approach to improve diagnostic rates and initiation of care for diabetes.

Development and Validation of a Rubric to Evaluate Diabetes SOAP Note Writing in APPE.

Objective. To develop and establish validity for a grading rubric to evaluate diabetes subjective, objective, assessment, plan (SOAP) note writing on primary care (PC) advanced pharmacy practice experiences (APPEs), and to assess reliability and student perceptions of the rubric. Methods. Ten PC APPE faculty members collaborated to develop a rubric to provide formative and summative feedback on three written SOAP notes per APPE student over a 10-month period. Correlation analyses were conducted between rubric scores and three criterion variables to assess criterion-related validity: APPE grades, Pharmaceutical Care Ability Profile Scores, and Global Impression Scores. Inter-rater and intra-rater reliability testing were completed using Cohen's kappa and Intraclass Correlation Coefficients (ICC). Student perceptions were assessed through an anonymous student survey. Results. Fifty-one students and 167 SOAP notes were evaluated using the final rubric. The mean score significantly increased from the first to second SOAP note and from the first to third SOAP note. Statistically significant positive correlations were found between final rubric scores and criterion variables. The ICC for inter-rater reliability was fair (.59) for final rubric scores and excellent for intra-rater reliability (.98 to1.00). Students responded that the rubric improved their ability (84.9%) and confidence (92.4%) to write SOAP notes. Conclusion. The rubric may be used to make valid decisions about students' SOAP note writing ability and may increase their confidence in this area. The use of the rubric allows for greater reliability among multiple graders, supporting grading consistency.

Interference with smoking-cessation effects of varenicline after administration of immediate-release amphetamine-dextroamphetamine.

An 18-year-old man with attention-deficit-hyperactivity disorder (ADHD) was prescribed varenicline for smoking cessation. He quit smoking after 1 week of therapy and remained smoke free for the next 17 days. During that time, he had also been taking amphetamine-dextroamphetamine (Adderall) on work days for his ADHD. Because his supply of amphetamine-dextroamphetamine was diminishing, he took only half (30 mg every morning) of his prescribed dosage from days 4-12 of varenicline therapy. He further reduced his dosage to 15 mg every morning on days 13 and 14 of varenicline therapy, and his supply of amphetamine-dextroamphetamine was depleted on day 15. On day 23 of varenicline therapy, he received and filled a new prescription for amphetamine-dextroamphetamine and resumed his prescribed dosage (30 mg twice/day). He began smoking again within 48 hours. Rechallenge with varenicline while the patient continued to receive amphetamine-dextroamphetamine yielded similar results. Data suggest that addition of amphetamine to varenicline may negate the partial agonism of varenicline, resulting in elimination of the smoking-cessation aid's benefits. Other potential mechanisms for the drug interaction may also exist. Thus, varenicline may not aid smoking cessation in patients undergoing treatment with amphetamine and amphetamine-like drugs.

5-year evaluation of electronic medical record flag alerts for patients warranting secondary prevention of coronary heart disease.

STUDY OBJECTIVES: To assess the effect of flag alerts that were placed in electronic medical records on patients' adherence with National Cholesterol Education Program (NCEP) guidelines for secondary prevention of coronary heart disease. A secondary objective was to identify the proportion of patients who were prescribed lipid-lowering agents and assess the barriers of patients who did not reach low-density lipoprotein cholesterol (LDL) goals 5.6 years after the intervention. DESIGN: Retrospective analysis of a prospective medical record intervention. SETTING: University-based primary care clinic. PATIENTS: Eighty-nine adult patients with atherosclerotic vascular disease. INTERVENTION: For each patient identified as needing secondary prevention for coronary heart disease according to NCEP guidelines, flags were inserted into the patient's electronic medical record. MEASUREMENTS AND MAIN RESULTS: Baseline patient data were collected. After 5.6 years, we performed a retrospective analysis. At that time, 72 patients were evaluated; 17 were lost to follow-up. Fifty-four percent of patients (39 of 72 patients) had reached their LDL goal compared with 25% (16 of 64 patients for whom complete lipid panels had been obtained) at baseline (p=0.001). The proportion of patients prescribed lipid-lowering agents rose from 16% at baseline to 75% at follow-up (p=0.0001). However, 33 patients (46%) were above their LDL goal levels at follow-up. Reasons for failure to reach LDL goal were as follows: drug dosage not titrated (10 patients [30%]), adverse drug reaction (four patients [12%]), planned to adjust therapy in the future (three patients [9%]), high drug cost (two patients [6%]), drug contraindicated (two patients [6%]), and non-compliance (one patient [3%]). In 11 patients (33%), the reason for failure was not addressed in the progress notes. Thus, inadequate drug dosage titration (dosage not titrated, planned to adjust therapy, and reason not addressed [assume no action]) occurred in more than 70% of these patients. CONCLUSIONS: These findings emphasize the need for regular evaluation of patients' lipid panels followed by appropriate therapy titration to reach LDL goals. Further study of factors influencing cholesterol management and methods to improve adherence is needed.

Practical Team-Based Learning from Planning to Implementation.

Team-based learning (TBL) helps instructors develop an active teaching approach for the classroom through group work. The TBL infrastructure engages students in the learning process through the Readiness Assessment Process, problem-solving through team discussions, and peer feedback to ensure accountability. This manuscript describes the benefits and barriers of TBL, and the tools necessary for developing, implementing, and critically evaluating the technique within coursework in a user-friendly method. Specifically, the manuscript describes the processes underpinning effective TBL development, preparation, implementation, assessment, and evaluation, as well as practical techniques and advice from authors' classroom experiences. The paper also highlights published articles in the area of TBL in education, with a focus on pharmacy education.