Digital Innovation to Grow Quality Care Through an Interprofessional Care Team (DIG IT) Among Underserved Patients With Hypertension.

PURPOSE: The impact of digital health on medically underserved patients is unclear. This study aimed to determine the early impact of a digital innovation to grow quality care through an interprofessional care team (DIG IT) on the blood pressure (BP) and 10-year atherosclerotic cardiovascular disease (ASCVD) risk score of medically underserved patients. METHODS: This was a 3-month, prospective intervention study that included patients aged 40 years or more with BP of 140/90 mmHg or higher who received care from DIG IT from August through December 2021. Sociodemographic and clinical outcomes of DIG IT were compared with historical controls (controls) whose data were randomly extracted by the University of California Data Warehouse and matched 1:1 based on age, ethnicity, and baseline BP of the DIG IT arm. Multiple linear regression was performed to adjust for potential confounding factors. RESULTS: A total of 140 patients (70 DIG IT, 70 controls) were included. Both arms were similar with an average age (SD) of 62.8 (9.7) years. The population was dominated by Latinx (79.3%) persons, with baseline mean BP of 163/81 mmHg, and mean ASCVD risk score of 23.9%. The mean (SD) reduction in systolic BP at 3 months in the DIG IT arm was twice that of the controls (30.8 [17.3] mmHg vs 15.2 [21.2] mmHg; P <.001). The mean (SD) ASCVD risk score reduction in the DIG IT arm was also twice that of the controls (6.4% [7.4%] vs 3.1% [5.1%]; P = .003). CONCLUSIONS: The DIG IT was more effective than controls (receiving usual care). Twofold improvement in the BP readings and ASCVD scores in medically underserved patients were achieved with DIG IT.

Effect of Metformin Use on Vitamin B12 Deficiency Over Time (EMBER): A Real-World Evidence Database Study.

OBJECTIVE: To examine the extent to which metformin increases the risk of vitamin B12 deficiency and borderline deficiency over time in participants with type 2 diabetes mellitus (T2DM). METHODS: Using the All of Us database, adults aged ≥18 years with T2DM and a documented history of metformin use were included for the evaluation of B12 deficiency. Those with B12 deficiency before metformin use were excluded. Adjusted logistic regression models were used to evaluate the association between metformin use and long-term metformin use (≥4 years) and the risk of B12 deficiency. We conducted a subgroup analysis comparing differences in borderline B12 deficiency in metformin and non-metformin users. RESULTS: Of 36 740 participants with T2DM, 6221 (16.9%) had documented metformin use. The mean age of metformin users was 65.3 years. B12 deficiency was confirmed in 464 (7.5%) metformin users, and 1919 of 30 519 participants (6.3%) did not use metformin. Metformin users had a 4.7% increased risk of developing B12 deficiency compared with nonmetformin users (P = .44). Each additional year of metformin use was associated with 5% increased likelihood of deficiency (P < .05). Metformin use for ≥4 years resulted in a 41.0% increased odds of B12 deficiency, compared with those who used <4 years of metformin (P < .05). Metformin use increased the odds of borderline B12 deficiency by 27.0% (P < .05). CONCLUSION: Long-term metformin use was associated with an increased risk of B12 deficiency in patients with T2DM, with compounding risk over time.

Using machine learning to develop a clinical prediction model for SSRI-associated bleeding: a feasibility study.

INTRODUCTION: Adverse drug events (ADEs) are associated with poor outcomes and increased costs but may be prevented with prediction tools. With the National Institute of Health All of Us (AoU) database, we employed machine learning (ML) to predict selective serotonin reuptake inhibitor (SSRI)-associated bleeding. METHODS: The AoU program, beginning in 05/2018, continues to recruit ≥ 18 years old individuals across the United States. Participants completed surveys and consented to contribute electronic health record (EHR) for research. Using the EHR, we determined participants who were exposed to SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vortioxetine). Features (n = 88) were selected with clinicians' input and comprised sociodemographic, lifestyle, comorbidities, and medication use information. We identified bleeding events with validated EHR algorithms and applied logistic regression, decision tree, random forest, and extreme gradient boost to predict bleeding during SSRI exposure. We assessed model performance with area under the receiver operating characteristic curve statistic (AUC) and defined clinically significant features as resulting in > 0.01 decline in AUC after removal from the model, in three of four ML models. RESULTS: There were 10,362 participants exposed to SSRIs, with 9.6% experiencing a bleeding event during SSRI exposure. For each SSRI, performance across all four ML models was relatively consistent. AUCs from the best models ranged 0.632-0.698. Clinically significant features included health literacy for escitalopram, and bleeding history and socioeconomic status for all SSRIs. CONCLUSIONS: We demonstrated feasibility of predicting ADEs using ML. Incorporating genomic features and drug interactions with deep learning models may improve ADE prediction.

Sociodemographic characteristics differ across routine adult vaccine cohorts: An All of Us descriptive study.

BACKGROUND: The National Institutes of Health All of Us (AoU) Research Program is currently building a database of 1million+ adult subjects. With it, we describe the characteristics of those with documented vaccinations. OBJECTIVES: To describe the sociodemographic, health status, and lifestyle factors associated with vaccinations. METHODS: This is a retrospective study involving data from the AoU program (R2020Q4R2, N = 315,297). Five vaccine cohorts [influenza, hepatitis B (HBV), pneumococcal <65 years old, pneumococcal ≥65 years old, and human papillomavirus (HPV)] were generated based on vaccination history. The influenza cohort comprised participants with documented influenza vaccinations in electronic health records (EHRs) from September 2017 to May 2018. Other vaccine cohorts comprised participants with ≥1 lifetime record(s) of vaccination documented in the EHR by December 2018. The vaccine cohorts were compared to the overall AoU cohort. Descriptive statistics were generated using EHR- and survey-based sociodemographic, health, and lifestyle information. The SAMBA (0.9.0) R package was utilized to adjust for EHR selection and outcome misclassification biases to infer sources of disparity for pneumococcal vaccinations in older adults. RESULTS: Cohort counts were as follows: influenza (n = 15,346), HBV (n = 6323), pneumococcal <65 (n = 15,217), pneumococcal ≥65 (n = 15,100), and HPV (n = 2125). All vaccine cohorts had higher proportions of White and non-Hispanic/Latino participants compared to the overall AoU cohort. The largest differences were found in pneumococcal age ≥65, with 80.2% White participants compared to 52.9% in the overall study population. Multivariable analysis revealed that race/ethnic disparities in pneumococcal vaccination among older adults were explained by biological sex, income, health insurance, and education-related variables. CONCLUSION: Racial, ethnic, education, and income characteristics differ across the vaccine cohorts among AoU participants. These findings inform future utilization of large health databases in vaccine epidemiology research and emphasize the need for more targeted interventions that address differences in vaccine uptake.

Guide for Drug Selection During Pregnancy and Lactation: What Pharmacists Need to Know for Current Practice.

OBJECTIVE: To provide guidance for clinicians on risk assessment of medication use during pregnancy and lactation. DATA SOURCES: Authors completed PubMed searches to identify articles focused on the use of medications in pregnancy, including fetal development, drug transfer across the placenta, trimester exposure, chronic conditions in pregnancy, medications in lactation, and lactation and chronic disease. STUDY SELECTION AND DATA EXTRACTION: Articles were reviewed to provide overall guidance to medication selection during pregnancy. The following information was reviewed: medication use in pregnancy, including fetal development, drug transfer across the placenta, trimester exposure, chronic conditions in pregnancy, medications in lactation, and lactation and chronic disease. DATA SYNTHESIS: This article will provide an overview of medication safety considerations during pregnancy and lactation. Information was interpreted to help clinicians predict the potential risk and benefit in each patient to make an evidence-based decision. The article concludes with guidance on risk assessment and how pharmacists may support fellow health care providers and their patients when considering medication use. CONCLUSIONS: Information about the effects of medication use during reproductive periods is limited. With the removal of the Food and Drug Administration pregnancy categories, clinicians will be relying on pharmacists to aid in the appropriate selection of therapies for patients. It is critical that pharmacists keep abreast of resources available and be able to assess data to help prescribers and their patients.

Pharmacotherapy of Chronic Neuropsychiatric Conditions During Pregnancy.

Many pregnant persons will experience neuropsychiatric conditions during pregnancy, including migraine, attention deficit disorder, depression, and anxiety. Treatment of each of these conditions requires shared decision-making among the individual, family, and health care team. Although medications may include risk, the benefits often outweigh the potential fetal risks. In this article, we review pharmacologic treatment options for each of these conditions and appropriate use in pregnancy to maintain the stability of conditions and to optimize maternal and fetal outcomes.

Psoriasis.

Psoriasis is a chronic inflammatory skin condition that is often associated with systemic manifestations. It affects about 2 percent of U.S. adults, and can significantly impact quality of life. The etiology includes genetic and environmental factors. Diagnosis is based on the typical erythematous, scaly skin lesions, often with additional manifestations in the nails and joints. Plaque psoriasis is the most common form. Atypical forms include guttate, pustular, erythrodermic, and inverse psoriasis. Psoriasis is associated with several comorbidities, including cardiovascular disease, lymphoma, and depression. Topical therapies such as corticosteroids, vitamin D analogs, and tazarotene are useful for treating mild to moderate psoriasis. More severe psoriasis may be treated with phototherapy, or may require systemic therapy. Biologic therapies, including tumor necrosis factor inhibitors, can be effective for severe psoriasis and psoriatic arthritis, but have significant adverse effect profiles and require regular monitoring. Management of psoriasis must be individualized and may involve combinations of different medications and phototherapy.

Musings of Two Administrators for Those Considering a Career Change.

There is a learning curve when stepping into an administrative position, whether you have been planning the change for years or find yourself asked to replace someone who has left unexpectedly. Two associate deans offer perspectives on things we wish we had known prior to taking on our current position. Some are practical skills that can also be helpful in any faculty position, while others relate to the different perspectives an administrator needs. We also point out some experiences we feel helped set us up for success, which should be available to anyone considering a similar change of career. Our experiences may offer some benefit for individuals considering administrative positions by helping them reflect on what questions to ask themselves while choosing their next career step.

An overview of Instructional approaches and decision-making strategies to curtail curricular overload.

OBJECTIVES: Curriculum overload often occurs when content is kept in the curriculum that may no longer be necessary to prepare students for professional practice. The overload becomes compounded by the addition of new content from the ever-changing professional practice needs and updates to accreditation standards. Challenges may occur when programs must first determine the "level" of proficiency a new graduate should attain and then determine the appropriate breadth and depth of educational outcomes in relation to proficiency, while examining what content should be retained from past curricula. Thus, the purpose of this manuscript is to summarize institutional approaches for making content delivery more effective and efficient with the goal of curtailing curriculum expansion. FINDINGS: Four key elements were consistently identified in the literature as important considerations to address curriculum overload - 1) communication and coordination among faculty, 2) incorporation of active learning strategies, 3) effective utilization of technology, and 4) minimizing faculty and student workload and cognitive burden. SUMMARY: Each pharmacy program will need to take an individualized approach in addressing curriculum overload; however, consideration of the aforementioned key elements can assist in making these decisions. With increased student engagement in the classroom, intentional design to reduce content and student workload, enhanced communication among faculty, and appropriate technology utilization, curriculum overload can be addressed at every level of pharmacy education.

Pharmacist-Managed Refill Service Impacts on Clinician Workload and Medication Interventions in a Federally Qualified Health Center.

INTRODUCTION: Increasing administrative workload is linked with lower quality of patient care and physician burnout. Conversely, models involving pharmacists can positively impact patient care and physician well-being. Research has consistently demonstrated that pharmacist-physician collaboration can improve outcomes for chronic diagnoses. Pharmacist-managed refill services may improve provider workload measures and clinical outcomes. METHODS: This was an evaluation of a pharmacist-managed refill service at a Federally Qualified Health Center (FQHC). Under collaborative practice agreement, pharmacists addressed refill requests and recommended interventions. Data analysis evaluated effectiveness of the model, including clinical interventions, and involved descriptive statistics and qualitative approaches. RESULTS: Average patient age was 55.5 years old and 53.1% were female. Turnaround time was within 48 h for 87.8% of refill encounters. During an average of 3.2 h per week, pharmacists addressed 9.2% (n = 1683 individual requests in 1255 indirect patient encounters) of the total clinic refill requests during the 1-year study period. In 453 of these encounters (36.1%), pharmacists recommended a total of 642 interventions. 64.8% of these were need for appointment (n = 211) or labs (n = 205). Drug therapy problems and medication list discrepancies were identified in 12.6% (n = 81) and 11.9% (n = 76) of encounters, respectively. DISCUSSION AND CONCLUSIONS: The results of this study are consistent with previous literature demonstrating the value of interprofessional collaboration. Pharmacists addressed refills in an efficient, clinically effective manner in an FQHC setting. This may positively impact primary care provider workload, patients' medication persistence, and clinical care.

The impact of failure on faculty development.

INTRODUCTION: Failure is an inevitable outcome in life. Even though this is a commonly accepted fact, the environment in academic pharmacy has stigmatized failure. This stigmatization potentially stunts faculty development if inappropriate coping strategies evolve and skills such as creativity and problem solving do not flourish. COMMENTARY: There is an opportunity for pharmacy academia, especially faculty, to assume a new lens when examining failure. The authors will examine the impact of failure on active learning and scholarship. IMPLICATION: Despite the many challenges and apprehensions that surround the concept of failure, it is important that academia reframes failure. This new perspective can positively view failure as a progressive mechanism by creating novel solutions to challenges in academia and demonstrating to pharmacy students that failure is something to embrace as a learning tool.

Peripartum Pharmacotherapy: A Pharmacist's Guide.

Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.

Azathioprine-induced fever in sarcoidosis.

OBJECTIVE: To report a case of drug-induced fever associated with azathioprine treatment in a patient with sarcoidosis. CASE SUMMARY: A 52-year-old man with pulmonary sarcoidosis presented to the emergency department with a 1-day history of fever (temperature 39.9 °C), chills, nausea, and vomiting. One week earlier, azathioprine 50 mg/day had been started for worsening dyspnea. The patient was admitted and evaluated for acute infectious processes. All of his home medications (hydroxychloroquine, prednisone, fluticasone/salmeterol, lovastatin, pantoprazole, zolpidem, ibandronate, albuterol), except prednisone, were held. Results of chest X-ray, viral cultures, and urine and blood cultures revealed no source of infection. The patient's temperature returned to normal within 30 hours after discontinuation of azathioprine; rechallenge was not performed. DISCUSSION: Fever as an adverse drug reaction is often unrecognized, particularly in medically complex patients. Azathioprine has been reported to cause drug fever in patients with inflammatory bowel disease and in those with rheumatoid arthritis; to our knowledge, there have been no previous reports documenting azathioprine-induced fever in patients with sarcoidosis. The chronological course of febrile response and defervescence is highly suggestive of drug-induced fever. CONCLUSIONS: The rapid resolution of fever after discontinuation of azathioprine suggests that it was the likely source of fever in this patient. If azathioprine is increasingly prescribed in patients with sarcoidosis, fever as an adverse reaction may become more common.

Differences in learning styles, critical thinking skills, and peer evaluations between students with and without leadership engagement.

INTRODUCTION: Leadership has long been suggested as an attribute essential to the pharmacy profession. Academic pharmacy has identified and addressed the need for leadership development among student pharmacists. The objective of this study is to assess differences in learning styles, critical thinking skills, and peer-perceived leadership skill evaluations between those with vs. without student leadership engagement (SLE). METHODS: Four cohorts of pharmacy students were included in the analysis. Each student completed the Kolb Learning Style Inventory and Health Science Reasoning Test (HSRT) during pharmacy school orientation. Student-peer evaluation scores were derived from three courses and assessed important leadership skills such as communication, critical thinking, teamwork, and professionalism. Descriptive analysis was performed; group difference was tested using independent group t-tests on continuous variables and Fisher exact tests on categorical variables. RESULTS: This study included 205 pharmacy students from the Classes of 2018 to 2021; 63 students (31%) displayed SLE. No significant differences were found in the peer evaluation scores between students with and without SLE. Students with SLE showed significantly higher scores in domains of the HSRT and the overall HSRT score. CONCLUSIONS: The study results showed that HSRT assessment of critical thinking skills was significantly higher in students engaging in leadership, suggesting that HSRT should be explored as a possible predictor for SLE in future studies.

Faculty assessment of scholarship of teaching and learning among United States pharmacy programs.

INTRODUCTION: Pharmacy faculty understanding of the scholarship of teaching and learning (SoTL) and its recognition remain unclear. This study aimed to determine faculty SoTL perceptions and whether it should be recognized in promotion and tenure decisions. METHODS: A survey instrument was developed and distributed to 6454 faculty in 139 United States pharmacy programs. The survey provided a list of scholarly activities and respondents were asked to select activities they perceived as SoTL and solicited faculty attitudes toward SoTL, its recognition and value in promotion and tenure, and SoTL engagement. Results were stratified based on SoTL participation, disciplines, and years of experience. RESULTS: Six hundred forty-three pharmacy faculty responded to the survey. Diverse scholarly works from teaching and learning practices to curriculum development, which lead to peer-reviewed public dissemination, were perceived as SoTL by most (78-98%) of the respondents. Participation in SoTL was reported by 74%. Pharmaceutical/biomedical science faculty were significantly less likely to accept the SoTL definition than pharmacy practice or social and administrative sciences faculty. Over 90% of participants indicated that college/school and departmental policies should encourage participation in SoTL activities. More than 70% of respondents strongly agreed that SoTL should be incorporated into criteria for promotion and tenure. Competing time commitments, lack of funding, interest, and institutional SoTL recognition were identified as challenges. CONCLUSION: Findings demonstrate that pharmacy faculty perceive SoTL as a broad spectrum of scholarly activities, including classroom practices and beyond, that culminate into peer-reviewed public dissemination. Pharmacy faculty support the incorporation of SoTL into promotion and tenure criteria.

The Report of the 2018-2019 Professional Affairs Standing Committee: The Role of Educators in Pharmacy Practice Transformation.

The 2018-2019 Professional Affairs Committee examined the potential roles and needs of clinical educators (faculty and preceptors) in leading transformation in pharmacy practice. The committee was charged to (1) discuss the potential roles and responsibilities of faculty and preceptors leading transformation and enhanced patient care services in pharmacy practice; (2) describe factors, including clinician well-being and resilience, which may influence faculty and preceptor involvement in practice transformation and the enhancement of patient care services; and (3) recommend how the efforts and successes of faculty and preceptors involved in pharmacy practice transformation can be replicated and recognized as well as identify the types of continuing professional development (CPD) that should be available to enable the influence and implementation of patient care services. This report provides a framework for addressing the committee charges by examining the roles of advocacy, collaboration, continuing professional development, and clinician resilience and well-being. The committee provides a revision to a current AACP policy regarding continuing professional development as well as several recommendations to AACP and suggestions to colleges and schools of pharmacy pertaining to the committee charges.

Easing vasomotor symptoms: Besides HRT, what works?

Prescription HRT is the most effective therapy for vasomotor symptoms, but some patients may find the risks unacceptable. Treatment with lower doses or alternative dosage forms for short periods may reduce risk. Soy isoflavones and black cohosh have a proven ability to reduce hot flashes, but they should not be used when estrogen is contraindicated. Bioidentical HRT may offer no benefits over conventional HRT. Neuroendocrine agents may reduce hot flashes effectively and can be used when estrogen is contraindicated, but these agents may cause significant CNS side effects. Lifestyle modifications are the foundation of vasomotor symptom therapy and are safe to recommend for all women. Clinicians and patients should carefully discuss the expectations for therapy, and the clinician should be prepared to customize the treatment regimen.

Do Electronic Cigarettes Have a Role in Tobacco Cessation?

Tobacco use continues to be a major cause of morbidity and mortality. Even with behavioral and pharmacologic treatment, long-term tobacco cessation rates are low. Electronic nicotine delivery systems, commonly referred to as electronic cigarettes or e-cigarettes, are increasingly used for tobacco cessation. Because e-cigarettes are widely used in this setting, health care professionals need to know if they are safe and effective. The purpose of this article is to review literature regarding use of e-cigarettes as a tool for tobacco cessation in patients who are ready to quit, as well as those who are not ready to quit, along with some selected patient populations. The safety and clinical implications of e-cigarette use are also reviewed. Small, short-term studies assessing smokers' use of e-cigarettes suggest that e-cigarettes may be well tolerated and modestly effective in achieving abstinence. High-quality studies are lacking to support e-cigarettes use for cessation in patients with mental health issues. One small prospective cohort study concluded that patients with mental health issues reduced cigarette use with e-cigarette use. Although one study found that patients with cancer reported using e-cigarettes as a tobacco-cessation strategy, e-cigarettes were not effective in supporting abstinence 6 and 12 months later. Additional research is needed to evaluate the use of e-cigarettes for smoking cessation in patients with pulmonary diseases. No data exist to describe the efficacy of e-cigarettes for smoking cessation in pregnant women. Although study subjects report minimal adverse effects with e-cigarettes and the incidence of adverse effects decreases over time, long-term safety data are lacking. Health care providers should assess e-cigarette use in their patients as part of the tobacco cessation process.

Student pharmacists' perceptions of immunizations.

PURPOSE: The primary aim of this study was to explore changes in knowledge level, perceived importance and apprehension of immunizations by first year pharmacy students pre- vs. post-immunization education and training. EDUCATIONAL ACTIVITY: First year pharmacy students at the University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences (UC San Diego SSPPS) completed a pre- and post-immunization training course questionnaire. Knowledge base and perceived importance level of immunizations including hepatitis B, influenza, measles, mumps, rubella (MMR), varicella, tetanus, diphtheria, pertussis (Tdap), meningococcal and human papilloma virus (HPV) were assessed. In addition, apprehension of needle administration and fears regarding safety and efficacy were evaluated. FINDINGS: Of 120 students, 85 (71%) completed pre- and post-course questionnaires for this study. Mean knowledge test scores increased from 56% pre-course to 83% post-course. Pre-course, 73% of participants considered immunizations as very important in preventing future disease outbreaks. Post-course, this percentage climbed to 94%. Prior to taking the course, 52% of students were apprehensive about administering injections; however, after completing the course this percentage declined to 33%. The majority of students who had been fearful prior to the course retained their fears of receiving needle injections. The proportion of students believing immunizations should be a personal choice, not mandatory, did not significantly change from pre-course (49%) to post-course (44%). SUMMARY: The UC San Diego SSPPS immunization course increased student knowledge of immunization facts and the perceived importance of immunizations. However, a substantial portion of students retained apprehension about administering and receiving needle injections and the proportion believing immunizations should be a personal choice, almost half, did not change appreciably.

The Report of the 2016-2017 Advocacy Standing Committee.

Based on the growing importance of community engagement and the recognition of its importance by the American Association of Colleges of Pharmacy (AACP), the committee offers several examples of community engagement activities for consideration and replication by our academy and beyond. These activities, including those of winning institutions of the Lawrence J. Weaver Transformational Community Engagement Award, can be mapped to the core components of community engagement presented in Table 1. The committee, using an implementation readiness framework, provides the reader with insight into the challenges that may impact successful community engagement and encourages our academy to continue its work to support faculty capacity in this area. Toward that end, the committee offers a policy statement that encourages schools and colleges of pharmacy to have an office or designate a faculty member whose focus is specifically on community engagement. The committee also offers a recommendation that the core components be included in the criteria for the Weaver Award.