Pharmacists providing care in statewide physician organizations: findings from the Michigan Pharmacists Transforming Care and Quality Collaborative.

BACKGROUND: Clinical services provided by pharmacists embedded in practices can improve patient outcomes within the primary care setting. Little is known about whether physician organizations (POs) will retain the services of clinical pharmacists after outside funding for a statewide implementation program is ended. OBJECTIVE: To evaluate a statewide program, Michigan Pharmacists Transforming Care and Quality (MPTCQ), that incorporated pharmacists within 17 POs. METHODS: A descriptive study was conducted using data collected from June 2016 to September 2018 from primary care clinical pharmacist encounters in POs participating in MPTCQ. Process outcomes included the number of participating POs, patient encounters, and average visits per patient. Analyses at the encounter level were stratified by 2 encounter types: disease state management (DSM) or comprehensive medication review (CMR). Separately by encounter type, pharmacist effect was described by the number, type, and reasons for medication changes, as well as medication adherence and cost barriers found and addressed. Clinical outcomes included hemoglobin A1c and blood pressure change. Sustainability and patient satisfaction of pharmacists providing clinical services are reported. RESULTS: Across 17 POs, 27 pharmacists participated in the MPTCQ program. Pharmacists completed 24,523 patient encounters for DSM with 5,942 patients, with an average of 5 visits per patient with diabetes and 2 visits for hypertension. Pharmacists made 15,153 therapeutic medication changes during visits for diabetes and hypertension, with approximately 70% related to efficacy. Pharmacists completed 4,203 CMR visits for 3,092 patients. During CMR visits, 1,296 therapeutic medication changes were recommended. Problems with medication cost were identified in 13% of CMR visits. Blood pressure and A1c levels decreased in patients managed by pharmacists. In 157 patients surveyed, 87% rated their pharmacists' care as excellent. Sixteen POs retained their pharmacists at the end of funding. CONCLUSIONS: A statewide provider-payer partnership successfully integrated and retained primary care pharmacists within POs. Pharmacists in the MPTCQ program contributed to improvements in disease control by changing medications to improve patient clinical outcomes. DISCLOSURES: Support for MPTCQ was provided by Blue Cross and Blue Shield of Michigan (BCBSM) as part of the BCBSM Value Partnerships program. Coe was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR002241. Although BCBSM and MPTCQ work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have no conflicts of interest to report.

Approaches to Medication Management in Patients with Kidney Failure Opting for Conservative Management.

After consideration of risks and benefits, some patients with kidney failure choose conservative management. Conservative management of kidney failure (CM-KF) does not include dialysis or transplant and utilizes primarily pharmacologic strategies for symptom management, which can be challenging due to the number and complexity of symptoms. Additionally, there are safety concerns regarding altered pharmacokinetics and the adverse effects induced by some of the therapies that may be selected to treat symptoms. This review describes common kidney failure symptoms and provides recommendations for pharmacologic management in CM-KF. Selection of medication should be individualized to the patient and comorbidities, drug interactions, cost, and adverse effects should be carefully considered. Additional studies specifically focused on CM-KF are needed.

Implementation and barriers to uptake of interactive voice response technology aimed to improve blood pressure control at a large academic medical center.

OBJECTIVES: Blood pressure control among patients with hypertension is a widely recognized quality metric, but many large health systems fail to reach targets set by the Healthcare Effectiveness Data and Information Set. We developed an interactive voice response (IVR) system called the "Mobile You Blood Pressure Program" at a large academic medical center and linked it to the health system's electronic health record (EHR). The goal of the program was to capture home blood pressure readings in the EHR and to alert ambulatory care clinical pharmacists automatically of readings below or above clinical thresholds through direct messaging in the EHR. The goal of this report is to describe implementation of IVR, initial patient participation rates, and pharmacist-identified barriers to patient enrollment. SETTING: Ambulatory care clinical pharmacist specialists' practice in 14 clinics in family medicine and internal medicine at Michigan Medicine, an academic health system serving more than 24,000 patients with a diagnosis of hypertension. PRACTICE DESCRIPTION: This study describes implementation and initial patient enrollment in IVR linked to the EHR for home blood pressure monitoring. EVALUATION: We tracked the number of hypertensive patients enrolled and IVR call completion rates between September 2017 and February 2018. We also assessed pharmacist-identified barriers to patient enrollment during 2 separate 2-week intervals in January and February 2018. RESULTS: Between September 1, 2017, and February 28, 2018, a total of 71 patients were enrolled from 14 clinics. Patients were scheduled for 1-3 IVR calls per week focusing on medication adherence and blood pressure control. A total of 936 IVR phone calls were made, with 488 (52%) calls completed. Access to a validated home blood pressure monitor was the largest pharmacist-identified barrier to patient enrollment. CONCLUSIONS: The IVR Mobile You Blood Pressure Program represents a new application of digital technology within our health system. Pharmacist-identified barriers to patient participation included access to a validated home blood pressure monitor.

Evaluation of a pharmacist-led outpatient direct oral anticoagulant service.

PURPOSE: The impact of a pharmacist-led direct oral anticoagulant (DOAC) service on prescription appropriateness and patient adherence was simultaneously evaluated. METHODS: In this retrospective analysis, patients age 18 years or older for whom a DOAC was prescribed from September 20, 2013, through December 31, 2014, were identified through electronic medical record review of all DOAC prescriptions within the University of Michigan Health System. Patients had their DOAC therapy managed by a pharmacist-led DOAC service or by their physician (usual care). Primary endpoints included the percentage of patients who had appropriate DOAC therapy prescribed at baseline and at follow-up appointments at 3-6 months. Secondary endpoints included mean medication possession ratios (MPRs). RESULTS: A total of 258 patients were included in the study, with 129 in each group. Patients in the pharmacist-led DOAC service were significantly more likely to have an appropriate combination of DOAC and dosage prescribed for their indication at baseline compared with the usual care group (p = 0.009), a finding that persisted at follow up (p = 0.016). There was no significant difference between groups in the number of patients determined to have an appropriate DOAC prescribed for an approved indication (independent of dose) in the pharmacist-led service (95.3%) versus usual care (93.0%) at baseline. Patients in the pharmacist-led service had a greater mean adjusted MPR compared with the usual care group (p = 0.0014) over a median follow-up period of 248 days. CONCLUSION: A pharmacist-led DOAC service increased appropriate dosing of DOACs at baseline and follow up as well as patient adherence to therapy.

The Importance of Research and Scholarly Activity in Pharmacy Training.

Regardless of practice setting, it is imperative that pharmacists be able to either participate in generating new knowledge or use the ever-expanding body of literature to guide patient care. However, competing priorities in Pharm.D. curricula and residency training programs have resulted in limited emphasis on acquiring research and scholarly skills. Factors likely contributing to this reduced focus include the lack of curricular and postgraduate training standards emphasizing the development of research skills, time to commit to scholarly activity, and accessibility to experienced mentors. Strategies for increasing scholarly activity for pharmacy students and residents should therefore continue to be a focus of professional degree and residency training programs. Several resources are available for academic planners, program directors, and institutions to augment scholarly experience for pharmacy trainees and clinicians. This commentary highlights the importance of providing research opportunities for students and residents, describes the potential barriers to these activities, and provides recommendations on how to increase the instruction and mentoring of trainees to generate and use research.

A Self-Assessment Guide for Resident Teaching Experiences.

The 2015 American College of Clinical Pharmacy (ACCP) Educational Affairs Committee was charged with developing a self-assessment guide for residency programs to quantitatively and qualitatively evaluate the outcomes of resident teaching curricula. After extensively reviewing the literature, the committee developed assessment rubrics modeled after the 2013 ACCP white paper titled "Guidelines for Resident Teaching Experiences" and the revised American Society of Health-System Pharmacists (ASHP) 2014 accreditation standards for PGY1 residencies, which place greater emphasis on the teaching and learning curriculum (TLC) than the previous accreditation standards. The self-assessment guide developed by the present committee can serve as an assessment tool for both basic and expanded TLCs. It provides the criteria for program goals, mentoring, directed readings with topic discussions, teaching experiences, and assessment methodology. For an expanded TLC, the committee has provided additional guidance on developing a teaching philosophy, becoming involved in interactive seminars, expanding teaching experiences, developing courses, and serving on academic committees. All the guidelines listed in the present paper use the measures "not present," "developing," and "well developed" so that residency program directors can self-assess along the continuum and identify areas of excellence and areas for improvement. Residency program directors should consider using this new assessment tool to measure program quality and outcomes of residency teaching experiences. Results of the assessment will help residency programs focus on areas within the TLC that will potentially benefit from additional attention and possible modification.

Evaluation of outpatient medication reconciliation involving student pharmacists at a comprehensive cancer center.

OBJECTIVE: To determine the number of discrepancies and medication-related problems found as a result of pharmacy-led medication reconciliation involving introductory pharmacy practice experience (IPPE) students at a comprehensive cancer center. SETTING: Outpatient infusion center of a National Cancer Institute (NCI)-designated and National Comprehensive Cancer Network (NCCN) cancer center. PRACTICE DESCRIPTION AND INNOVATION: Third-year IPPE students contacted and completed medication reconciliation for 510 hematology/oncology patients scheduled for infusion center appointments without a coupled provider visit. IPPE students discussed the findings of the medication reconciliations with their pharmacist preceptors, who updated the medication histories in the electronic medical record (EMR) and communicated with prescribers directly about identified medication-related problems. All medication reconciliation was documented using a standardized note template in the EMR. MAIN OUTCOME MEASURES: Number of medication discrepancies found, including medication additions, medication deletions, dose changes, and herbal product additions; medication-related problems-including drug-drug interactions, untreated indications (e.g., nausea, vomiting, pain, need for prophylactic medications), failure of patients to receive prescribed medications, and adverse drug reactions-were also documented. RESULTS: Medication reconciliation was completed for 510 patients through the student pharmacist/pharmacist preceptor-led intervention during a 1-year period between January 1, 2013, and December 31, 2013. A total of 88% of patients had at least one discrepancy identified in their medication history and corrected in the EMR. In addition, 11.4% of patients had a medication-related problem identified. CONCLUSIONS: Pharmacy-led medication reconciliation identified a large number of discrepancies among our hematology/oncology patients. This intervention allowed for correction of discrepancies in the EMR leading to improved accuracy of patient medication lists. In addition, it provided a valuable learning experience for student pharmacists.