Understanding Factors Associated with Quality of Life in Patients with Venous Thromboembolism.

INTRODUCTION: Quality of life (QoL) deficits have been noted among patients with venous thromboembolism (VTE) but understanding of the drivers of that poorer QoL is limited. The objective of this study was to examine associations between a variety of factors and QoL in patients with VTE. METHODS: Adult patients who had experienced at least one VTE episode within the past 2 years completed an online survey between May and July 2016 with responses to a variety of questions designed to ascertain QoL scores, Optum Short Form-12, and potential factors associated with these scores. RESULTS: Most of the 907 patients were female (56.7%) and Caucasian (88.6%). Physical and mental QoL scores below the general population average were present in 76.0 and 56.7% of patients, respectively. Multiple regression modeling revealed several factors associated with below average physical QoL scores including unemployment (odds ratio [OR] 3.77, 95% confidence interval [CI] 1.76-8.05), gastrointestinal bleeding (OR 2.54, 95% CI 1.28-5.01), high depression scores (OR 4.02, 95% CI 1.88-8.58), or difficulty accessing VTE care (OR 4.24, 95% CI 1.77-10.17). Factors associated with below average mental QoL scores included experiencing VTE within the last month (OR 3.85, 95% CI 1.58-9.41), unemployment (OR 2.83, 95% CI 1.30-6.16), or high depression (OR 3.85, 95% CI 1.60-9.28) and/or anxiety (OR 9.17, 95% CI 4.81-17.47) scores. CONCLUSION: Most patients with recently diagnosed VTE reported below average QoL. Many of the factors associated with below average QoL are modifiable, indicating that patients with VTE could potentially benefit from interventions aimed at improving QoL.

Understanding patients' care barriers in the treatment of venous thromboembolism.

Venous thromboembolism (VTE) is a major health care problem. There are common barriers to quality healthcare but are these barriers the same for VTE patients? A national online survey was administered to adults who had experienced a recent VTE event. The survey assessed perceptions of VTE care barriers: (1) Difficulty to meet healthcare costs related to VTE care; (2) difficulty to meet costs for VTE prescription medications; (3) difficulty with transportation to get VTE care; and (4) the degree of support of others needed to get VTE care. Each question was correlated with patient demographics including income level, place of residence, current work status, and health insurance; care related patient harms experienced with the VTE episode; number of lifetime VTE events; beliefs concerning VTE outcomes, and oral anticoagulant therapy type. Logistic regression analysis was used to determine the effect of independent variables on barriers to VTE care. Approximately 30% of VTE patients reported at least one significant barrier to VTE care. Patients rated healthcare costs and VTE prescription medication costs mildly difficult. The odds of reporting barriers were positively associated with the number of DVTs experienced in the previous 2 years. VTE-related depression was also moderately associated with increased odds of reporting significant VTE care barriers. Nearly 1 in 3 VTE sufferers reported significant barriers to VTE care, with healthcare costs and VTE medication costs being the most common. Efforts to identify patients who may experience barriers should be sought early in care.

Leading Change in Academic Pharmacy: Report of the 2018-2019 AACP Academic Affairs Committee.

EXECUTIVE SUMMARYThe Committee was charged with the responsibility for examining the need for change in pharmacy education and the models of leadership that would enable that change to occur across the academy. They also examined the question of faculty wellbeing in a time of change and made several recommendations and suggestions regarding both charges. Building upon the work of the previous Academic Affairs Committee, the 2018-19 AAC encourages the academy to implement new curricular models supporting personalized learning that creates engaged and lifelong learners. This will require transformational leadership and substantial investments in faculty development and new assessment strategies and resources. Recognizing that the magnitude of the recommended change will produce new stress on faculty, the committee identified the need for much additional work on student, faculty and leaders' wellbeing, noting the limited amount of empirical evidence on pharmacy related to stress and resilience. That said, if faculty and administrators are not able to address personal and community wellbeing, their ability to support their students' wellbeing will be compromised.

Clinical and Economic Outcomes of Ranolazine Versus Conventional Antianginals Users Among Veterans With Chronic Stable Angina Pectoris.

Real-world outcomes in patients with chronic stable angina treated with ranolazine and other antianginal medications as second- or third-line therapy are limited. In a historical cohort study of veterans with chronic stable angina, we compared time with coronary revascularization procedures, hospitalizations, and 1-year healthcare costs between new-users of ranolazine versus conventional antianginals (i.e., calcium channel blockers, ß blockers, or long-acting nitrates) as second- or third-line. Weighted regression models calculated adjusted hazard ratios (HR) at up to 8-year follow-up, and adjusted incremental costs in the first year. Weighted groups comprised 4,699 ranolazine users and 31,815 conventional antianginal users. Percutaneous coronary intervention (PCI) occurred more often in ranolazine users compared with conventional antianginal users (HR 1.16; 95% confidence intervals [CI] 1.08 to 1.25, p <0.001), and coronary artery bypass grafting occurred less often (HR 0.82; 95% CI 0.68 to 1.00, p <0.046). All-cause and atrial fibrillation (AF) hospitalizations were less common with ranolazine users compared with conventional users (all-cause: HR 0.94; 95% CI 0.90 to 0.99, p <0.010; AF:HR 0.74; 95% CI 0.67 to 0.82, p <0.001), and acute coronary syndrome was more common (HR 1.13; 95% CI 1.00 to 1.27, p <0.042). Adjusted 1-year costs were $24,517 in ranolazine users and $24,798 in conventional users (difference, $-280; 95% CI $-1,742 to $1,181, p = 0.71). In conclusion, ranolazine users had lower rates of coronary artery bypass grafting and all-cause and AF hospitalizations, but higher rates of percutaneous coronary intervention and hospitalizations due to acute coronary syndrome compared with conventional antianginal users. Healthcare costs were similar between ranolazine and conventional antianginal users.

Pharmacist's Demand for Optimal Primary Care Service Delivery in a Community Pharmacy: The OPTiPharm Study.

BACKGROUND: The US population continues to expand providing the need for primary health care services. Community pharmacies integrated with medicine may provide greater access while providing high quality care. OBJECTIVE: To gauge pharmacists' demand for primary health care services delivered through community pharmacies. METHODS: An online survey was administered to determine community pharmacists' preferences for varying primary care services that could be offered in the community pharmacy setting. A Discrete Choice Experiment was employed to show pharmacists competing scenarios with varied primary care service offerings in the community pharmacy setting. Attributes evaluated were operation hours, service provider, medical records, service logistics, physical examinations, point-of-care diagnostic testing, preventative care, and drug prescribing. Respondents chose the scenario most likely to induce switching employment from base pharmacy to one providing advanced services. RESULTS: The optimal service delivery model from 291 community pharmacists comprised: inclusion of patient prescriptions and health information into the patient's medical record; provision of point of care testing and vital sign, including blood pressure, heart rate and breathing rate, and blood sugar and cholesterol measurement; and pharmacists prescribing (under physician oversight). Pharmacists were 4 times more likely to switch employment from their current pharmacy to their choice for advanced pharmacy services. Pharmacist demand was highest among those with a PharmD, less experience, working >40 hours per week, and in rural areas. CONCLUSIONS: This study provides empirical support for the model of pharmacists playing a greater role in the provision of primary care health services through community pharmacy settings.

Factors predicting self-reported medication low adherence in a large sample of adults in the US general population: a cross-sectional study.

OBJECTIVES: The study objective was to determine the level and correlates of self-reported medication low adherence in the US general population. SETTING: A 30 min cross-sectional online survey was conducted with a national sample of adults. PARTICIPANTS: 9202 adults (aged 18+) who had filled at least three or more prescriptions at a community pharmacy in the past 12 months. PRIMARY AND SECONDARY OUTCOME MEASURES: Self-reported medication adherence was measured with the 8-item Morisky Medication Adherence Scale. RESULTS: Low adherence was reported by 42.0%, 29.4% had medium adherence and 28.6% had high adherence. Low adherence was significantly associated with: lower age, being of Hispanic origin or African-American, having difficulty with healthcare, medication or transportation costs, needing the support of others to access primary care, health limiting activity, using multiple providers, infrequent visits to primary care providers and visiting an emergency department >3 times in last 12 months. CONCLUSIONS: A very high level of low medication adherence is seen in the general population, particularly for ethnic minorities, those who use multiple healthcare providers and those who experience barriers to access for regular primary care. As clinical, patient education and counselling, and healthcare policy initiatives are directed to tracking the problem of low medication adherence, these should be priority populations for research and interventions.

Qualitative interviews regarding pharmacist prescribing in the community setting.

PURPOSE: The perceived demand for and barriers to pharmacist prescribing in the community pharmacy setting were studied. METHODS: Qualitative interviews were conducted with 19 consumers, 20 community pharmacists, and 8 reimbursement decision-makers from payer organizations between April and June 2015. Respondents were invited to participate in a daylong interview process online. Interviews with consumers and pharmacists were conducted using online bulletin board technology. Telephone interviews were conducted with reimbursement decision-makers. As with all qualitative research, the sample sizes used were restrictive and sufficient to gauge the perceptions of those respondents only. Interview responses were not intended to be generalizable to the groups or populations from which the respondents came. RESULTS: There was a continuum of interest in pharmacist prescribing across the three constituencies. Consumers were predominantly resistant to the notion; however, one third were more positive about the idea. Community pharmacists were more open, particularly when prescribing was restricted to a limited set of conditions or medications. Reimbursement decision-makers were most receptive to the notion. Key barriers to pharmacist prescribing included low awareness of current pharmacist prescribing authority among consumers, concerns about the adequacy of pharmacist training, potential conflicts of interest when the prescriber was also a dispenser, and potential liability issues. CONCLUSION: Consumer respondents were generally resistant to the notion of pharmacist prescribing, with most viewing pharmacists as dispensers and not prescribers. Community pharmacists were more open to the idea, while reimbursement decision-makers were the most receptive to the notion of pharmacist prescribing.

National evaluation of prescriber drug dispensing.

OBJECTIVE: To describe the legal, professional, and consumer status of prescribers dispensing legend and over-the-counter drugs in the United States. METHODS: Legal and academic databases were searched to identify those states that permit prescribers to dispense medications to patients and any limitations on such practice. In addition, prescribers and patients-consumers were surveyed to learn about the prevalence and perceptions of such practice. The use of drug samples was explicitly excluded from the study. MAIN RESULTS: Surveys were obtained from 556 physicians, 64 NPs, and 999 patient-consumers of drugs dispensed by prescribers. Forty-four states authorize prescriber dispensing. Midlevel practitioners (i.e., NPs and physician assistants) are authorized to dispense in 43 states. Thirty-two states do not require dispensing prescribers to compete additional registration to dispense medications, and 30 states require some level of compliance with pharmacy practice requirements. Prescriber dispensing is common, independent of patient age or insurance coverage. Prescriber dispensing appears driven by physician and patient perceptions of convenience and cost reductions. Future dispensing is likely to increase due to consumers' satisfaction with the practice. Consumer self-reported adverse drug reactions (ADRs) were equivalent between pharmacist- and physician-dispensed drugs, but urgent and emergency clinic ADR consultations were slightly lower with physician dispensing. CONCLUSIONS: Prescriber dispensing is firmly entrenched in the U.S. health care system, is likely to increase, does not appear to increase ADRs, and may reduce urgent care and emergency department visits. The reduction in urgent care and emergency department visits requires further study to confirm these preliminary findings.

Assessment of orally dosed commercial silver nanoparticles on human ex vivo platelet aggregation.

Enhanced in vitro human and ex vivo rat platelet aggregation from direct exposure to silver nanoparticles is previously reported. Given the increasing human use of engineered silver nanoscale products, platelet aggregation prompted by silver nanoparticles may contribute to human cardiovascular events. To understand how direct washed platelet exposure to silver nanoparticles translates to ex vivo platelet aggregation, the authors conducted a placebo-controlled, single-blind, dose-monitored, cross-over study design in 18 healthy human volunteers. After 2 weeks of daily oral silver nanoparticle ingestion, platelet aggregation was evaluated by light transmission aggregometry in response to collagen and ADP agonists, both at baseline and after silver nanoparticle or placebo diluent oral dosing. Final percent aggregation (PA) and the changes in PA were determined using a paired design (i.e., active and placebo solutions). Enhanced ex vivo platelet activation was not detectable at peak serum silver concentrations <10 µg/L. Further studies of colloidal silver nanoparticles on human platelet activities are warranted.

Assessment of time to follow-up visits in newly-treated hypertensive patients using an electronic medical record database.

OBJECTIVE: Use of electronic medical record (EMR) data for evaluating healthcare processes and outcomes is relatively new. Using EMR data, this study evaluated the time from antihypertensive initiation to the first follow-up office visit controlling for adverse events (AEs) and other factors that could influence follow-up timing. Findings were compared to treatment guidelines which recommend monthly follow-up in treatment naive patients until blood pressure (BP) levels are controlled. RESEARCH DESIGN AND METHODS: Treatment-naïve hypertensive adult patients in the General Electric Centricity EMR database (1996-2006) with a new antihypertensive prescription were evaluated. Time from treatment initiation to first office visit was identified and stratified by occurrence of AEs and therapy change. BP was assessed at 120 +/- 30 days. RESULTS: The mean +/- SD time from first antihypertensive prescription (index date) to the first office visit was 96.2 +/- 160.6 days; 38% returned within a month of treatment initiation. Controlling for baseline demographic and clinical characteristics, the adjusted time until first office visit was shorter for those with an AE and therapy change than for those with neither event (61 vs. 158 days). Of the patients with follow-up BP data for analysis (n = 27,875), more of those seen within a month of treatment initiation achieved BP goal at 120 days (<140/90 mmHg) than those who were not seen within a month (64.3 vs. 61.7% respectively; p < 0.001). CONCLUSIONS: This study demonstrates that EMR data can be used to assess quality measures which in turn can inform efforts to improve treatment outcomes. Specifically, this study evaluated mean time to first office visit after antihypertensive therapy initiation controlling for clinical factors that could influence office visit intervals based on data available in a national EMR dataset. A key limitation of this study is that the EMR may not represent patient care delivered by other providers, thus, use of antihypertensives, changes in therapy, and office visits may be underreported.

Epidemiology and practice patterns of acute decompensated heart failure.

The epidemiology and clinical characteristics of acute decompensated heart failure (ADHF) and the management of patients with ADHF are discussed. ADHF has become a significant health care problem in the United States. In an effort to fully understand the current epidemiology, clinical characteristics, and management of patients hospitalized with ADHF, a national registry was started in 2002 as a joint collaboration between academic heart failure specialists and the bio-pharmaceutical industry. The largest compilation of ADHF data has been collected in the Acute Decompensated Heart Failure National Registry (ADHERE). This article describes ADHERE, which suggests that the health care industry needs to conduct root-cause analysis of outpatient and inpatient practices toward these patients and make adjustments in these treatment patterns if we are going to reduce the morbidity, mortality, and health care costs in these patients.