Provision of ambrisentan from a health-system specialty pharmacy affiliated with a pulmonary hypertension Center of Comprehensive Care.

PURPOSE: This descriptive report describes the process used to obtain access to providing ambrisentan from a health-system specialty pharmacy (HSSP) affiliated with a pulmonary hypertension Center of Comprehensive Care, develop a pulmonary arterial hypertension (PAH) care team at the HSSP, and characterize medication adherence and access metrics. SUMMARY: PAH is a rare disease treated with several specialty medications requiring intensive monitoring. Historically, specialty medications used to treat PAH have been provided by only select specialty pharmacies due to restricted drug distribution channels. It is recommended that patients with PAH receive their care at centers with expertise in the diagnosis and management of this disorder, but the HSSPs at these expert centers are unable to provide specialty PAH medications. The current care model for PAH leads to patients receiving their medical and pharmaceutical care from separate entities. This descriptive report describes a multidisciplinary team's approach to gaining access to providing ambrisentan and developing a disease state care team within an established HSSP. After implementing this service, specialty pharmacy metrics were assessed, including proportion of days covered (PDC), time to first fill, patient contact rate, Risk Evaluation and Mitigation Strategy (REMS) program compliance, time to prior authorization (PA) approval, rate of optimal adherence (PDC of >80%), and PA renewal rate, to demonstrate a proof-of-concept HSSP model for PAH. In this model, the HSSP was able to demonstrate high-quality specialty pharmacy metrics with regard to medication adherence, medication access, and REMS program compliance. CONCLUSION: The development of a PAH care team to provide ambrisentan at an existing HSSP was associated with high adherence rates, efficient and reliable medication access, and REMS program compliance.

Pharmacist hypertension management using an electronic health record-based approach.

OBJECTIVES: To evaluate the impact of the chronic medication optimization pharmacist (CMOP) program on blood pressure (BP) control and time to goal compared with usual care in the ambulatory care setting. STUDY DESIGN: This was a retrospective cohort study that included patients from June 2018 to June 2020 who were seen in an ambulatory care clinic for hypertension management. METHODS: Patients aged 18 to 80 years were divided into 2 cohorts based on hypertension management by usual care or the CMOP program. Patients were enrolled in the CMOP program either by referral or identification via a data analytics tool. The primary outcome assessed the proportion of patients within BP goal (< 140/90 mm Hg) at 3 months. Secondary outcomes assessed the proportion of patients within goal at 6 months, time and number of visits to goal, and adherence (CMOP cohort only). RESULTS: The primary end point demonstrated a greater proportion of patients within goal in the CMOP cohort compared with usual care (69.4% vs 42.3%; P < .001). The CMOP cohort also displayed a greater proportion of patients achieving goal within 6 months (75.7% vs 60.4%; P = .014) and faster time to goal (42.99 vs 63.12 days; P = .002), but more visits (1.67 vs 1.18; P = .001). Lastly, adherence improved from 50.4% to 72.1% in the patients with a documented adherence assessment in the pharmacist group (P = .03). CONCLUSIONS: The pharmacist intervention improved BP control in a primarily African American patient population compared with usual care. Future studies should assess the sustainability of this intervention.

Variations in pharmacy-based transition-of-care activities in the United States: a national survey.

PURPOSE: A national survey was conducted to assess pharmacist roles in transition-of-care (TOC) activities in the United States. METHODS: An online survey was sent to 1246 pharmacy directors who were members of the American Society of Health-System Pharmacists to assess their involvement in TOC activities including medication reconciliation, admission histories, medication counseling, and postdischarge follow-up; pharmacy student and pharmacy technician involvement in TOC activities; the use of technology to facilitate TOC activities; and barriers to performing such activities. RESULTS: A total of 393 respondents completed the survey (31.5% response rate). Twenty-seven percent of respondents indicated that pharmacists complete medication histories on admission, and 5% indicated that pharmacy technicians complete medication histories. Most respondents indicated that pharmacists do not routinely or consistently provide patients with tools to facilitate medication adherence before hospital discharge and that pharmacists do not routinely or consistently follow up with patients after discharge. Fifty-six percent of respondents indicated that pharmacists provide patient education for specific medications or for medications for specific diseases. Few respondents indicated that student pharmacists are involved with TOC activities. Most respondents either agreed or strongly agreed that it is important for pharmacists to be involved in TOC activities for hospitalized patients. CONCLUSION: Approximately one third of survey respondents indicated that pharmacists complete medication histories. Most respondents indicated that pharmacists do not routinely or consistently provide patients with tools to facilitate medication adherence before hospital discharge or follow up with patients after discharge. Lack of pharmacy staff resources and insufficient recognition of the value of pharmacists' provision of TOC by health care executives, medical staff, nursing staff, and other health care professionals were the most frequently cited barriers to pharmacists assuming more significant roles in the TOC at the respondent's institution.

The impact of pharmacist-directed patient education and anticoagulant care coordination on patient satisfaction.

BACKGROUND: Patient satisfaction data played a role in determining Medicare reimbursement as of October 2012. Clinical pharmacy services could improve satisfaction of hospital inpatients but it is unclear whether this relates to performance on standardized hospital surveys. OBJECTIVE: To describe the impact on patient satisfaction of patient education and follow-up care coordination provided by an inpatient pharmacist-directed anticoagulation service (PDAS). METHODS: This study was conducted at an urban, tertiary care hospital. PDAS is a clinical pharmacy service that has improved transition-of-care, safety, and efficacy involving anticoagulation at our institution. Patients receiving inpatient anticoagulation during February 2001-April 2007 (pre-PDAS) and December 2008-December 2010 (post-PDAS), who responded to a mail-in survey, were included. Survey items included satisfaction ("How satisfied were you with the medical care?"), amount of information ("Was the amount of information you received about your medicine...?"), clarity of information ("Was the clarity of the information about your medicine...?"), answer quality ("Were the answers to your questions about your medicine...?"), and spoke to a pharmacist ("Did a pharmacist speak with you during your stay?"). Response options for amount of information, clarity of information, answer quality, and satisfaction used a symmetric 5-point Likert-type scale, with options 1-5 indicating most to least positive, respectively. Options 1-2 were considered positive and options 3-5 were considered negative. Primary analysis compared patient satisfaction (defined as rate of positive responses) between pre-PDAS and post-PDAS respondents. χ² test was used for all comparisons. RESULTS: Surveys were distributed to 1694 patients after discharge, with 687 (40.6%) responding. Post-PDAS respondents had improved patient satisfaction for all positive response items, compared to pre-PDAS scores. Amount of information increased by 37.2%, clarity of information increased by 35.2%, answer quality increased by 29.5%, and satisfaction increased by 10.6% (p < 0.001 for all comparisons). CONCLUSIONS: Hospitals deploying focused programs with systematic approaches to patient-pharmacist communication may positively impact patient satisfaction.

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

BACKGROUND: Warfarin is implicated in approximately 30% of reported anticoagulant-related errors. In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist-Directed Anticoagulation Service (PDAS). OBJECTIVE: To evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation. DESIGN: Cluster randomized trial. SETTING: Large, urban teaching hospital and level 1 trauma center. PATIENTS: All patients receiving warfarin on two medical and two cardiology units. INTERVENTION: A PDAS provided dosing, monitoring, and coordination of transition from the inpatient-to-outpatient setting. MEASUREMENTS: Endpoints were assessed during hospitalization and 30 days after discharge. Transition of care was considered effective if compliance with all of the transition of care metrics occurred. The transition of care metrics included: appropriate enrollment in the anticoagulation clinic, documented inpatient-to-outpatient provider contact, documented inpatient provider-to-anticoagulation clinic communication and patient follow-up with the anticoagulation clinic within five days of discharge. Safety was measured by the composite endpoint of thromboembolism, major bleeding, or international normalized ratio (INR) ≥5. RESULTS: This study included 500 patients. Transition of care metric compliance occurred in 73% more patients in the PDAS group (P < 0.001). There was also a 32% reduction in the composite safety endpoint in the PDAS group (P = 0.103). This finding was driven by a reduction in rate of INR ≥5 (P = 0.076). CONCLUSIONS: Implementation of a PDAS provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting.

Impact of a Pharmacist-Directed Anticoagulation Service on the Quality and Safety of Heparin-Induced Thrombocytopenia Management.

BACKGROUND: The use of anticoagulant medications is complex and prone to error in the inpatient setting. Patients with heparin-induced thrombocytopenia (HIT) must receive treatment with alternative anticoagulant agents to ensure optimal patient outcomes. OBJECTIVE: To evaluate the impact of an inpatient pharmacist-directed anticoagulation service (PDAS) on the safety and efficiency of direct thrombin inhibitor use in patients with HIT. METHODS: This was a quasi-experimental pre/postintervention study comparing patients with HIT managed with usual care to patients managed with a focused inpatient anticoagulation service. The primary endpoints of the study were the percent of time that the activated partial thromboplastin time (aPTT) remained within the therapeutic range and time to achievement of a therapeutic aPTT. Bleeding and appropriateness of warfarin initiation were evaluated as secondary endpoints. RESULTS: A total of 193 patients were included in the study. Percent of time that aPTT was in the therapeutic range was 32% higher with the PDAS (p < 0.001) and time to therapeutic aPTT was shortened by approximately 12.5 hours in patients managed by the PDAS (p < 0.001). There was a trend for more bleeding events, regardless of severity, among control patients (p = 0.130). Rate of TIMI (Thrombolysis in Myocardial Infarction) major bleeding was lower in the PDAS group (p = 0.006), but there was no significant difference between groups in GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) moderate/severe bleeding (p = 0.679). Appropriateness of warfarin initiation was also similar between groups. CONCLUSIONS: Implementation of a focused inpatient PDAS was associated with improved efficiency of dosing, improved monitoring, and low bleeding risk.

Nontraditional pharmacy residency at a large teaching hospital.

PURPOSE: The structure and implementation of a nontraditional pharmacy residency program in a large teaching hospital are described. SUMMARY: A nontraditional track of the postgraduate year 1 (PGY1) residency program at a large teaching hospital in Detroit, Michigan, was developed for clinical staff pharmacists employed by the hospital. The program, accredited by the American Society of Health-System Pharmacists, allows pharmacists to complete 10 four-week rotations, in addition to three longitudinal rotations, over a three-year period. Required four-week rotations include 1 orientation rotation, 6 adult medicine rotations, 1 intensive care unit rotation, and 2 elective rotations. Because a pharmacist must first be employed by the hospital before applying to the nontraditional residency program, a staff pharmacist position is used to fund the nontraditional residency program. Since the inception of the nontraditional PGY1 residency program in 2005, two residents have graduated from the program. After completion of the residency, the first resident remained at the institution as a clinical staff pharmacist. The current and recently graduated nontraditional residents have demonstrated significant advancement of their clinical skills as a result of their participation in the program. Challenges faced during program implementation included scheduling and coordinating the resident's rotations and activities. CONCLUSION: A three-year nontraditional residency program was developed at a large teaching hospital to provide an alternative method for enhancing a pharmacist's clinical practice skills beyond those of an entry-level practitioner through completion of a systematic training program.