Clinical learnings from a virtual primary care program monitoring mild to moderate COVID-19 patients at home.

BACKGROUND: Virtual consults have replaced in-person visits for many home-isolated patients with COVID-19 disease. OBJECTIVES: To describe the natural history, clinical management and outcomes of community-dwelling patients with COVID-19, who received support from a family medicine-led, virtual CovidCare@Home program in Toronto, Ontario, Canada. METHODS: Observational, descriptive study conducted by retrospective chart review of 98 patients enrolled during the first 5 weeks of program implementation (8 April-11 May 2020); 73 patients with laboratory-confirmed COVID-19, with symptom onset ≤ 14 days before initial consult were included for analysis. Patients were classified as mild, moderate or severe based on WHO Criteria. RESULTS: All patients in the program experienced mild (88%) or moderate (12.3%) disease. No patients were hospitalized or died. Patients were mainly female (70%); with mean age of 43.3 years. Most patients (82.2%) worked in higher risk, healthcare settings. Almost 40% had no medical co-morbidities. Common symptoms were cough (65.8%), fatigue (60.3%), headache (42.5%) and myalgia (39.7%), followed by fever (32.9%), sore throat (21.9%), nasal congestion (21.9%) and rhinorrhea (20.5%). Headache (51%) and anosmia (45.1%) were common among females; fever and breathlessness among males (40.9%). Nine patients (12.3%) experienced worsening of symptoms (mainly respiratory) or exacerbation of co-morbidities, which required care outside the virtual service. CONCLUSION: Patients with mild to moderate COVID-19 disease can be managed safely and effectively in a family medicine-led virtual program. Some sex differences in symptoms were observed. Future work should focus on long-term follow up in view of the existence of so-called 'long-haulers'.

A developmental evaluation of an intraprofessional Pharmacy Communication Partnership (PROMPT) to improve transitions in care from hospital to community: A mixed-methods study.

BACKGROUND: People transitioning from hospital- to community-based care are at increased risk of experiencing medication problems that can lead to adverse drug events and poor health outcomes. Community pharmacists provide medication expertise and support during care transitions yet are not routinely included in communications between hospitals and other primary health care providers. The PhaRmacy COMmunication ParTnership (PROMPT) intervention facilitates medication management by optimizing information sharing between pharmacists across care settings. This developmental evaluation sought to assess the feasibility and acceptability of implementing the PROMPT intervention, and to explore how contextual factors influenced its implementation. METHODS: PROMPT was implemented for 14 weeks (January-April, 2018) in the general internal medicine units at two teaching hospitals in Toronto, Canada. PROMPT featured two contact points between hospital and community pharmacists around patient discharge: (1) faxing an enhanced discharge prescription and discharge summary to a patient's community pharmacy and (2) a follow-up phone call from the hospital pharmacist to the community pharmacist. Our mixed-method evaluation involved electronic patient records, process measures using tracking forms, telephone surveys and semi-structured interviews with participating community and hospital pharmacists. RESULTS: The intervention involved 45 patients with communication between 12 hospital and 45 community pharmacists. Overall, the intervention had challenges with feasibility. Issues with fidelity included challenges with the medical discharge summary being available at the time of faxing and hospital pharmacists' difficulties with incorporating novel elements of the program into their existing practices. However, both community and hospital pharmacists recognized the potential benefits to patient care that PROMPT offered, and both groups proposed recommendations for further improvements. Suggestions included enhancing hospital staffing and resources. CONCLUSION: Improving intraprofessional collaboration, through interventions such as PROMPT, positions pharmacists as leaders of medication management services across care settings and has the potential to improve patient care; however, more co-design work is needed to enhance the intervention and its fidelity.

Enhanced communication between inpatient and community pharmacists to optimize medication management during transitions of care.

OBJECTIVES: To describe the Pharmacy Communication Partnership (PROMPT) program's approach to improving medication management for patients during transitions from hospital to the community. SETTING: Two general internal medicine units within a multisite academic hospital in Canada. PRACTICE INNOVATION: Designed by an interprofessional working group, PROMPT uses evidence-informed approaches to facilitate communication between pharmacists in different settings: faxing of the discharge prescription and medical discharge summary to a patient's community pharmacy, followed by a telephone call to the community pharmacist. EVALUATION: A multimethod cross-sectional study used telephone surveys and retrospective chart reviews to describe: 1) the characteristics of patients that hospital pharmacists thought would benefit from PROMPT and the community pharmacies that served them; 2) the number and nature of communication attempts made by community and hospital pharmacists; and 3) community pharmacists' views about PROMPT's potential impact on continuity of care and potential program enhancements. RESULTS: A convenience sample of 100 patients (median age 77 years, interquartile range 66 to 83) who received care from 86 pharmacies were used to evaluate the program. The majority of community pharmacists participating in the surveys considered the intervention to be helpful. Of the 53.7% (n = 44/82) community pharmacists who received discharge summaries, 93.2% (n = 41/44) found the summaries to be useful. Themes arising from community pharmacists' comments were categorized into 3 topics: 1) the benefits of PROMPT; 2) topics of discussion and clarification during telephone calls with hospital pharmacists; and 3) future program improvements. CONCLUSION: Community pharmacists described PROMPT as a time-efficient and helpful bridge linking community pharmacy to hospital inpatient care. Opportunities for future research include determining the characteristics of patients who may benefit most from PROMPT, determining the optimal components of discharge information needed by community pharmacists to enhance medication management, and evaluating whether follow-up telephone calls from the hospital to community pharmacists are necessary for all patients.

Pharmacists as Personalized Medicine Experts (PRIME): Experiences Implementing Pharmacist-Led Pharmacogenomic Testing in Primary Care Practices.

Research exploring the integration of pharmacogenomics (PGx) testing by pharmacists into their primary care practices (including community pharmacies) has focused on the "external" factors that impact practice implementation. In this study, additional "internal" factors, related to the capabilities, opportunities, and motivations of pharmacists that influence their ability to implement PGx testing, were analyzed. Semi-structured interview data from the Pharmacists as Personalized Medicine Experts (PRIME) study, which examined the barriers and facilitators to implementing PGx testing by pharmacists into primary care practice, were analyzed. Through thematic analysis, using the theoretical domains framework (TDF) domains as deductive codes, the authors identified the most relevant TDF domains and applied the behavioural change wheel (BCW) to generate intervention types to aid in the implementation of PGx testing. Pharmacists described how their professional identities, practice environments, self-confidence, and beliefs in the benefits of PGx impacted their ability to provide a PGx-testing service. Potential interventions to improve the implementation of the PGx service included preparing pharmacists for managing an increased patient load, helping pharmacists navigate the software and technology requirements associated with the PGx service, and streamlining workflows and documentation requirements. As interest in the wide-scale implementation of PGx testing through community pharmacies grows, additional strategies need to address the "internal" factors that influence the ability of pharmacists to integrate testing into their practices.

Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain.

BACKGROUND/OBJECTIVES: Gabapentinoids are commonly prescribed to relieve pain. The development of edema, an established adverse effect of gabapentinoids, may lead to a potentially harmful prescribing cascade whereby individuals are subsequently prescribed diuretics and exposed to diuretic-induced adverse events. The frequency of this prescribing cascade is unknown. Our objective was to measure the association between new dispensing of a gabapentinoid and the subsequent dispensing of a diuretic in older adults with new low back pain. DESIGN: Population-based cohort study. SETTING: Ontario, Canada. PARTICIPANTS: A total of 260,344 community-dwelling adults aged 66 years or older, newly diagnosed with low back pain between April 1, 2011, and March 31, 2019. MEASUREMENTS: Exposure status was assigned using dispensed medications in the 1 week after low back pain diagnosis. Older adults newly dispensed a gabapentinoid (N = 7867) were compared with older adults who were not newly dispensed a gabapentinoid (N = 252,477). Hazard ratios (HRs) with 95% confidence intervals (CIs) for dispensing of a diuretic within 90 days of follow-up among older adults prescribed gabapentin relative to those who were not. RESULTS: Older adults newly dispensed a gabapentinoid had a higher risk of being subsequently dispensed a diuretic within 90 days compared with older adults who were not prescribed a gabapentinoid (2.0% vs. 1.3%). After covariate adjustment, new gabapentinoid users had a higher rate of being dispensed a diuretic compared with those not prescribed a gabapentinoid (HR: 1.44, 95% CI: 1.23, 1.70). The rate of diuretic prescription among new gabapentinoid users increased with increasing gabapentinoid dosages. CONCLUSIONS: We have demonstrated the presence of a potentially inappropriate and harmful prescribing cascade. Given the widespread use of gabapentinoids, the population-based scale of this problem may be substantial. Increased awareness of this prescribing cascade is required to reduce the unnecessary use of diuretics and the exposure of patients to additional adverse drug events.

A Continuing Professional Development Program for Pharmacists Implementing Pharmacogenomics into Practice.

A continuing professional development (CPD) program for pharmacists practicing in community and team-based primary care settings was developed and evaluated using Moore's framework for the assessment of continuing medical education. The program had three components: online lectures, a two-day training workshop, and patient case studies. Knowledge (pre-post multiple choice test); attitudes, readiness, and comfort with applying pharmacogenomics in their practices (pre-post surveys); and experiences of implementing pharmacogenomics in practice (semi-structured interviews) were assessed. Twenty-one of 26 enrolled pharmacists successfully completed the program, and were satisfied with their experience. Almost all achieved a score of 80% or higher on the post-training multiple choice test, with significantly improved scores compared to the pre-training test. Pre- and post-training surveys demonstrated that participants felt that their knowledge and competence increased upon completion of the training. In the follow-up, 15 pharmacists incorporated pharmacogenomics testing into care for 117 patients. Ten pharmacists participated in semi-structured interviews, reporting strong performance in the program, but some difficulty implementing new knowledge in their practices. This multi-component CPD program successfully increased pharmacists' knowledge, readiness, and comfort in applying pharmacogenomics to patient care in the short-term, yet some pharmacists struggled to integrate this new service into their practices.

Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension.

Importance: Calcium channel blockers (CCBs) are commonly prescribed agents for hypertension that can cause peripheral edema. A prescribing cascade occurs when the edema is misinterpreted as a new medical condition and a diuretic is subsequently prescribed to treat the edema. The extent to which this prescribing cascade occurs at a population level is not well understood. Objective: To measure the association between being newly dispensed a CCB and subsequent dispensing of a loop diuretic in older adults with hypertension. Design, Setting, and Participants: A population-based cohort study was performed using linked health administrative databases of community-dwelling adults 66 years or older with hypertension and new prescription drug claims from September 30, 2011, to September 30, 2016, in Ontario, Canada. The dates of analysis were September 1, 2018, to May 30, 2019. Exposures: Individuals who were newly dispensed a CCB were compared with the following 2 groups: (1) individuals who were newly dispensed an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker and (2) individuals who were newly dispensed an unrelated medication. Main Outcomes and Measures: Hazard ratios (HRs) with 95% CIs were estimated for individuals who were dispensed a loop diuretic within 90 days of follow-up using Cox proportional hazards regression models. Results: The cohort included 41 086 older adults (≥66 years) with hypertension who were newly dispensed a CCB, 66 494 individuals who were newly dispensed another antihypertensive medication, and 231 439 individuals who were newly dispensed an unrelated medication. At index (ie, the dispensing date), the mean (SD) age was 74.5 (6.9) years, and 191 685 (56.5%) were women. Individuals who were newly dispensed a CCB had a higher cumulative incidence at 90 days of being dispensed a loop diuretic than individuals in both control groups (1.4% vs 0.7% and 0.5%, P < .001). After adjustment, individuals who were newly dispensed a CCB had increased relative rates of being dispensed a loop diuretic compared with individuals who were newly dispensed an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (HR, 1.68; 95% CI, 1.38-2.05 in the first 30 days after index [days 1-30]; 2.26; 95% CI, 1.76-2.92 in the subsequent 30 days [days 31-60]; and 2.40; 95% CI, 1.84-3.13 in the third month of follow-up [days 61-90]) and individuals who were newly dispensed unrelated medications (HR, 2.51; 95% CI, 2.13-2.96 for 1-30 days after index; 2.99; 95% CI, 2.43-3.69 for 31-60 days after index; and 3.89; 95% CI, 3.11-4.87 for 61-90 days after index). This association persisted, although slightly attenuated, from 90 days to up to 1 year of follow-up and when restricted to a subgroup of individuals who were newly dispensed amlodipine. Conclusions and Relevance: Many older adults with hypertension who are newly dispensed a CCB subsequently receive a loop diuretic. Given how widely CCBs are prescribed, interventions are needed to raise clinicians' awareness of this common prescribing cascade to reduce the prescribing of potentially unnecessary medications that may cause harm.