Aligning Formulary Restrictions Across a Health System and Improving Access to and Clarity of Medication Restrictions.

BACKGROUND: In 2013, formulary medications were aligned among the three hospitals within our health system. However, as formulary medication restrictions were not aligned, the three hospitals continued to have inconsistent medication restrictions. This led to confusion among prescribers and pharmacists about which medications were restricted, what the restrictions were, and where to access information about the restrictions. To alleviate this confusion, we set out to align formulary restrictions and to provide medication restriction details at the points of entering and verifying medication orders. OBJECTIVES: The primary objective was to align 100% of the formulary medication restrictions at our health system. The secondary objectives were to improve ease of access to restriction information and to improve the clarity of medication restrictions for pharmacists. METHODS: The process of alignment involved completing a gap analysis to identify differences between each site's medication restrictions and site-specific interventions. The gap analysis, proposed restrictions, and proposed interventions were reviewed by the system's pharmacy, nutrition, and therapeutics (PNT) planning committee. The committee reviewed each medication, the restrictions, and the proposed modifications. The consensus of formulary medication restrictions was presented to the PNT committee for approval. Restriction information was added to each drug monograph in the online medication information database and the interventions were built into the electronic medical record (EMR). Five intervention types were included: restriction removal, "outpatient use only" added to the medication name, order-specific questions, alternative alerts, and information put into order instructions seen by both ordering providers and verifying pharmacists. Pharmacists were educated about the restricted medication-alignment initiative. A survey was administered after education to assess the ease of access to restricted medication information and clarity of medication restrictions. Because of the scope of this project, education and survey administration was limited to pharmacists only. RESULTS: Aligned medication restrictions increased from 11% to 100%. Of the 110 medication restrictions that were not aligned, 17 restrictions were removed, 37 medications were restricted to outpatient use only, and 56 restricted medications were further aligned across the health system. Results from the survey showed that more pharmacists utilized the online medication information database to find information regarding restricted medications and that it was easier for more pharmacists to find this information.

The Missing Link: Evolving Accessibility To Formulary-Related Information.

BACKGROUND: Formulary management is a key component to ensuring the safe, effective, and fiscally responsible use of medications for health systems. One challenge in the formulary management process is making the most relevant formulary information easily accessible to practitioners involved in medication therapy decisions at the point of care. In September 2014, Froedtert and the Medical College of Wisconsin (F&MCW) implemented a commercial formulary management tool (CFMT) to improve accessibility to the recently aligned health-system formulary. The CFMT replaced an internally developed formulary management tool. OBJECTIVES: The primary objective was to determine pharmacist end-user satisfaction with accessibility to system formulary and formulary-related information through a new CMFT compared with the historical formulary management tool (HFMT). The secondary objective was to measure the use of formulary-related information in the CFMT and HFMT. METHODS: The primary objective was measured through pharmacist end-user satisfaction surveys before and after integration of formulary-related information into the CFMT. The secondary objective was measured by comparing monthly usage reports for the CFMT with monthly usage reports for the HFMT. RESULTS: Survey respondents reported being satisfied (52.5%) or very satisfied (18.8%) more frequently with the CFMT compared with the HFMT (31.7% satisfied and 2.5% very satisfied). Between October 2014 and January 2015 the frequency of access to formulary-related information increased from 92 to 104 requests per day through the CFMT and decreased from 47 to 33 requests per day through the HFMT. CONCLUSIONS: Initial data suggest incorporating system formulary-related information and related resources into a single platform increases pharmacist end-user satisfaction and overall use of formulary-related information.

An Interdisciplinary Approach to the Introduction of Point-of-Care Ultrasound in an Urban Academic Primary Care Center.

Introduction Limited guidance exists for primary and urgent care ultrasound applications. This study sought to identify the most useful applications for providers in these clinical settings, to create and implement a structured interdisciplinary point-of-care ultrasound (POCUS) curriculum, and to assess the effectiveness of the course.  Methods This prospective cohort study took place at an urban academic medical center. After a needs-based assessment of ultrasound applications in primary and urgent care, the Emergency Medicine ultrasound faculty and fellows were paired with a primary or urgent care provider (N = 6). The pairings met for scanning sessions in the emergency department to practice image acquisition, documentation, and incorporation of ultrasound into the workflow. Participants were given POCUS pre-work to review before each session. The final bedside session included a formal Objective Standard Clinical Examination (OSCE) to assess learner proficiency to be cleared for independent imaging. The program was assessed using pre- and post-training surveys.  Results The survey results demonstrated that renal, gallbladder, and soft tissue scans were the most interesting and useful to primary and urgent care providers after completion of the training course.  Conclusion The course was effective, and efficient, simple, high-yield POCUS applications should be included in future programs and organizational guidelines for primary and urgent care POCUS education.

Developing pharmacy services in a home hospital program: The Mayo Clinic experience.

PURPOSE: Home hospital programs are rapidly becoming a more common patient care model in the market. The impact on hospital pharmacy practices is not well defined. This article describes the development of pharmacy services in a home hospital program in an attempt to help other organizations create their own home hospital pharmacy programs. SUMMARY: Caring for acutely ill patients in their home was a novel idea when Mayo Clinic began considering this in January 2020. Since then, the coronavirus disease 2019 (COVID-19) pandemic has rapidly escalated interest in and pursuit of these programs. One question we asked ourselves, and many colleagues are asking us today, is "How does pharmacy fit in?" Through 2 years of active engagement, innovation, and persistence, our team has developed a robust pharmacy presence in the home hospital care team and a well-articulated approach to medication management for our patients. We have tightly aligned and blended our clinical efforts to mirror our typical inpatient and ambulatory care clinical activities. We have also developed and modified our dispensing functions to serve the unique needs of the care model. CONCLUSION: Home hospital medication management is both complex and ripe with opportunities for pharmacy engagement.

Evaluation of BCG Vaccination and Plasma Amyloid: A Prospective, Pilot Study with Implications for Alzheimer's Disease.

BCG vaccine has been used for 100 years to prevent tuberculosis. Not all countries, including the United States, adopted the initial World Health Organization recommendation to use BCG. Moreover, many Western countries that had routinely used BCG have discontinued its use. Recent population studies demonstrate lower prevalence of Alzheimer's disease (AD) in countries with high BCG coverage. Intravesicular instillation of BCG is also used to treat bladder cancer that has not invaded the bladder muscle wall and has been shown to reduce recurrence. Several retrospective studies of bladder cancer patients demonstrated that BCG treatment was associated with a significantly reduced risk of developing AD. Plasma amyloid ß assessment has become a fertile area of study for an AD biomarker that is predictive of a positive amyloid PET scan. Mass spectrometry-based plasma amyloid 42/40 ratio has proven to be accurate and robust, and when combined with age and ApoE, is shown to accurately predict current and future brain amyloid status. These parameters, amyloid 42/40 ratio, age and ApoE genotype are incorporated into an Amyloid Probability Score (APS)-a score that identifies low, intermediate or high risk of having a PET scan positive for cerebral amyloid. Community recruitment was used for this open-label pilot study. Forty-nine BCG-naïve, immunocompetent individuals completed our study: prior to BCG prime and boost, as determined by the APS, 34 had low risk (APS 0-35), 5 had intermediate risk (APS 36-57) and 10 had high risk (APS 58-100). The APS range for the participant group was 0 to 94. Follow-up plasma amyloid testing 9 months after vaccination revealed a reduction in the APS in all the risk groups: low risk group (p = 0. 37), intermediate risk group (p = 0.13) and the high-risk group (statistically significant, p = 0.016). Greater benefit was seen in younger participants and those with the highest risk. The small number of participants and the nascent status of plasma amyloid testing will rightfully temper embracement of these results. However, both the favorable direction of change after BCG as well as the utility of the APS-a valuable surrogate AD biomarker-may prompt a definitive large-scale multicenter investigation of BCG and AD risk as determined by plasma amyloid peptide ratios and APS.

Effect of a Statewide Controlled-Substance Monitoring Requirement on the Opioid Prescribing Practice for Treatment of Acute Pain.

BACKGROUND: The US government affirmed the opioid epidemic as a public health emergency in late 2017. Prior to that, as part of the Heroin, Opiate, Prevention, and Education (HOPE) Agenda, the state of Wisconsin enacted 2015 Wisconsin Act 266. This law, which went into effect April 1, 2017, requires prescribers to review data from the state's enhanced Prescription Drug Monitoring Program (ePDMP) before issuing an opioid prescription, in order to reduce inappropriate prescriptions and, ultimately, decrease opioid overuse. OBJECTIVE: To evaluate the effect of 2015 Wisconsin Act 266 on opioid prescriptions for acute pain in Mayo Clinic Health System sites in northwest Wisconsin. PATIENTS AND METHODS: This retrospective review included all eligible patients who were discharged from emergency or urgent care departments in the Mayo Clinic Health System at northwest Wisconsin sites during the study period. The quantity of opioids prescribed (measured in morphine milligram equivalents per patient encounter) and the total number of opioid prescriptions were compared for the periods May and June 2016 (prior to implementation of Act 266) versus May and June 2017 (post-implementation of Act 266). RESULTS: A 33% reduction occurred in the median opioid quantity prescribed per patient encounter in the post-implementation period vs the pre-implementation period (P <0.001). In addition, a 13% relative reduction occurred in the percentage of patient encounters that involved an opioid prescription (P <0.001). No difference was observed in opioid prescription agents between time periods, except for an increase in morphine prescriptions (P <0.001. CONCLUSION: The HOPE Agenda, specifically 2015 Wisconsin Act 266, appears to have had a positive effect on decreased opioid prescriptions for acute pain at Mayo Clinic Health System sites in northwest Wisconsin.