Integration and compensation of pharmacists into primary care medical groups.

OBJECTIVE: To demonstrate the expansion of an outpatient pharmacy program within a health system via annual wellness visits (AWVs) and disease state management patient encounters at outpatient medical groups. SETTING: A referral-based pharmacist-managed ambulatory care center, a department of a hospital, and 4 primary care medical groups of a community practice hospital health system in Savannah and Pooler, Georgia, and Bluffton, South Carolina. PRACTICE DESCRIPTION: St. Joseph's/Candler is a 714 bed, 2 hospital community practice heath care system located in Savannah, Georgia. The St. Joseph's/Candler Center for Medication Management (CMM) is a pharmacist-managed ambulatory care clinic that provides referral-based ambulatory care services in anticoagulation, diabetes, heart failure, tobacco cessation, transitional care, vaccinations, and wellness contracts for self-insured organizations, and has 147 referring physicians. Nurse Practitioners and Pharmacists evaluate and manage patients under their scope of practice and supervising medical director for the CMM. Pharmacists and Nurse Practitioners educate patients and collaborate with referring physicians for disease state management but do not carry prescriptive authority at CMM. CMM bills for services as a provider-based department of the hospital. CMM is recognized as an Anticoagulation Center of Excellence by the Anticoagulation Forum and is interventional with ambulatory care quality initiatives of the health system. Pharmacists in CMM are board-certified in ambulatory care provided by Board of Pharmacy Specialties and have completed a minimum of a 1-year post-graduate training program accredited by the American Society of Health-System Pharmacists. CMM has 4 off-campus satellite locations providing ambulatory care referral-based services. Since 2007, the CMM has primarily provided anticoagulation services via laboratory monitoring and management of warfarin. PRACTICE INNOVATION: Pharmacists transitioned from provider-based departments of a hospital to outpatient primary care medical groups. This transition changed their job description and the model for reimbursement of the pharmacists' salaries. Four pharmacists were present 60 hours per week from January 2018 to August 2018, and 80 hours per week (2 full-time clinical pharmacist positions) from September 2018 to December 2018, to conduct AWVs and disease state management patient encounters. These pharmacists divided their time between a department of a hospital and a traditional medical group of the same health system. EVALUATION: For calendar year 2018, 1770 AWVs and 468 disease state management patient care visits were provided exclusively by pharmacists to patients of the 4 primary care medical groups of this community practice health system. Patient visits for disease state management included diabetes, hypertension, hyperlipidemia, anticoagulation, and tobacco cessation. RESULTS: For the calendar year 2018, 1770 AWVs and 468 disease state management patient visits were provided exclusively by pharmacists, under the direct supervision of physician, to patients of primary care medical groups. CONCLUSION: This is an example of expanding direct patient care pharmacy services, within a health system, to primary care medical groups, without direct grant or university funding.

Sitagliptin/Metformin (janumet) as combination therapy in the treatment of type-2 diabetes mellitus.

Used together, sitagliptin (Januvia) and metformin (Glucophage) help to improve glycemic levels in diabetic patients, suggesting a synergy between the agents. However, the cost of sitagliptin and the need for more data may restrict its use. More studies are needed to assess the effects of long-term sitagliptin and to determine its role in combination therapy.

Cost savings from dose rounding of biologic anticancer agents in adults.

PURPOSE: The purpose of this project was to determine the cost savings related to a dose-rounding process for adult biologic anticancer agents. METHODS: Biologic anticancer agents prepared by the inpatient pharmacy were identified retrospectively through completed chemotherapy preparation checklists and medication orders on file in the pharmacy or by the clinical pharmacist for adult oncology from the medical records of patients in her practice. The specific products screened for evaluation were aldesleukin, bevacizumab, cetuximab, denileukin diftitox, gemtuzumab, rituximab, and trastuzumab. Data collected included drug name, ordered dose, rounded dose, and product vials not wasted. Specific drug costs were provided by the department's purchasing office. The project was reviewed and approved by the institutional review board to allow retrospective data collection from patient records. Cost savings were evaluated retrospectively for the time period of January 1, 2005 through March 31, 2005. RESULTS: One hundred and twenty-six orders for biologic anticancer agents were processed by the pharmacy department during the 3-month time period of data collection. Dose rounding could reduce drug wastage for 42% of these orders. Potential cost savings from dose rounding was $24,434 for the 3-month interval evaluated. However, nonadherence to dose rounding for 29 rituximab orders decreased the actual cost savings to $15,922. Individual staff education was reinforced to address nonadherence. CONCLUSION: Routine dose rounding of biologic anticancer agents to an amount within 10% of the ordered dose achieved cost savings through reduction of drug wastage at our institution.

Antimuscarinic syndrome after propofol administration in the emergency department.

Antimuscarinic syndrome (AS), a rare but serious adverse event associated with propofol should be included in the differential diagnosis of patients who develop agitation after its administration. We report a case of antimuscarinic syndrome that developed in an emergency department patient immediately after receiving propofol for the reduction of an elbow dislocation. The patient had received therapeutic doses of meperidine and promethazie several hours before the administration of propofol, and had an estimated serum ethanol level of 64 mg/dL about 1 h before sedation. The patient was successfully treated with physostigmine. Administration of propofol in conjunction with other substances known to have antimuscarinic effects may increase the risk of developing AS.

The Role of Glucagon-like Peptide-1 Receptor Agonists in the Treatment of Type 2 Diabetes.

The role of GLP-1 agonists in the treatment of type 2 diabetes have been shown to be viable options for add-on therapy in diabetic patients, as well as potential monotherapy options. With six available GLP-1 agents, and new combination products in the pipeline, they are a promising drug class for type 2 diabetic patients, especially due to their extended dosing interval and potential weight loss benefits.

Assessment of reimbursement in a community hospital-based pharmacist-managed outpatient transition clinic.

PURPOSE: The assessment of reimbursement for and time spent on patient visits in a newly implemented, outpatient pharmacist-managed transition clinic (TC) was studied. METHODS: A retrospective chart review was conducted on clinic visits that occurred during January 1 to December 31, 2015. Patients who had at least one TC visit during the study period were included. Any visit with no response from insurance by March 31, 2016, was excluded. Services provided by the TC were billed using a facility fee billing model. The following data were collected: number of visits, time length of individual visits, billed amount, level of service, type of insurance, and amount reimbursed (from primary insurance, secondary insurance, and total amount). Data were analyzed using descriptive statistics. RESULTS: One hundred eight patients were eligible for inclusion in the study, with a total of 306 eligible visits. Each patient had a mean of 2.82 visits. The mean ± S.D. time spent per visit was 55 minutes. Visits were billed at level 2 (2%), level 3 (36%), and level 4 (62%). Two hundred seventy-two visits (89%) were partially or completely reimbursed by insurance, whereas 34 visits (11%) provided no reimbursement. The mean ± S.D. reimbursement was $99 ± $51.88 per visit. CONCLUSION: A pharmacist-managed TC service based in a community hospital achieved a positive return on investment through insurer reimbursement over a 12-month period.

Cesarean or Vaginal Birth Does Not Impact the Longitudinal Development of the Gut Microbiome in a Cohort of Exclusively Preterm Infants.

The short and long-term impact of birth mode on the developing gut microbiome in neonates has potential implications for the health of infants. In term infants, the microbiome immediately following birth across multiple body sites corresponds to birth mode, with increased Bacteroides in vaginally delivered infants. We aimed to determine the impact of birth mode of the preterm gut microbiome over the first 100 days of life and following neonatal intensive care unit (NICU) discharge. In total, 867 stool samples from 46 preterm infants (21 cesarean and 25 vaginal), median gestational age 27 weeks, were sequenced (V4 region 16S rRNA gene, Illumina MiSeq). Of these, 776 samples passed quality filtering and were included in the analysis. The overall longitudinal alpha-diversity and within infant beta-diversity was comparable between cesarean and vaginally delivered infants. Vaginally delivered infants kept significantly more OTUs from 2 months of life and following NICU discharge, but OTUs lost, gained, and regained were not different based on birth mode. Furthermore, the temporal progression of dominant genera was comparable between birth modes and no significant difference was found for any genera following adjustment for covariates. Lastly, preterm gut community types (PGCTs) showed some moderate differences in very early life, but progressed toward a comparable pattern by week 5. No PGCT was significantly associated with cesarean or vaginal birth. Unlike term infants, birth mode was not significantly associated with changes in microbial diversity, composition, specific taxa, or overall microbial development in preterm infants. This may result from the dominating effects of NICU exposures including the universal use of antibiotics immediately following birth and/or the lack of Bacteroides colonizing preterm infants.

Challenges in predicting the need for coronary artery bypass grafting at presentation in patients with non-ST-segment elevation acute coronary syndromes.

In the case of non-ST-segment elevation acute coronary syndromes (NSTE-ACSs), the acute use of certain antiplatelet agents is complicated by concerns about perioperative bleeding risks in patients requiring coronary artery bypass grafting (CABG) during the index hospitalization. As a result, clinicians often withhold potentially useful agents, such as clopidogrel, before determining patients' coronary anatomy. An accurate predictive model could allow for a better balance of this safety concern with the demonstrated benefits of agents such as clopidogrel. To create an accurate decision-making tool that would assess, at hospital presentation, the need for CABG in patients with NSTE-ACSs, we studied 61,974 high-risk patients with NSTE-ACS admitted to 311 CABG-capable hospitals participating in Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) from 2001 to 2003. A total of 8,395 patients (14%) underwent CABG during their initial hospital stay. A multivariate model was developed and identified 13 presenting clinical characteristics significantly associated with the likelihood of CABG (previous CABG, male gender, previous heart failure, diabetes, hyperlipidemia, renal insufficiency, ST depression and transient ST elevation, age > or = 75 years, previous percutaneous coronary intervention, family history of coronary artery disease, hypertension, trends in CABG rates, and previous stroke). This model had only modest predictive accuracy and calibration (c-index = 0.67). In conclusion, although certain presenting clinical features are associated with an increased likelihood of CABG in patients with NSTE-ACSs during the index hospitalization, it remains difficult to reliably identify, before diagnostic angiography, those who will subsequently undergo surgical revascularization.

The state of U.S. emergency care: a call to action for hospital pharmacists.

The recent publication of the Institute of Medicine/Board on Health Care Services reports on the future of emergency care in the US health system has identified the main limitations of the care provided by emergency departments (EDs). Increased development of ED pharmacy services and increased involvement of pharmacists in the ED can contribute to improvements in shortcomings identified in the report. Pharmacy training programs must take the initiative to incorporate emergency care into their curricula to meet the predicted increase in demand for ED pharmacists. Pharmacy associations, administrators, and ED practitioners must direct research on the impact of the pharmacist in the ED.

Randomized evaluation of adverse events and length-of-stay with routine emergency department use of phenytoin or fosphenytoin.

Intravenous phenytoin has come under increased scrutiny with the introduction of the prodrug, fosphenytoin. We evaluated adverse events and length-of-stay using parenteral the two drugs in routine emergency department use. Open-label randomization of phenytoin or fosphenytoin in 256 Emergency Department patients prescribed 279 parenteral doses of a phenytoin-equivalent. All phenytoin was administered intravenously, and fosphenytoin was given intravenously or intramuscularly (physician preference). Adverse events and Emergency Department length-of-stay were recorded; re-presentation to the Emergency Department within three months was reviewed for evidence of the purple glove syndrome. Nonparametric statistics were used to analyze the data. Seventy-seven patients received phenytoin and 202 fosphenytoin; 28 (10.0%) received intramuscular fosphenytoin. The mean phenytoin-equivalent dose was similar between the groups. Eighteen patients required reduction in infusion rates because of an adverse event (phenytoin = 6.5%, fosphenytoin = 6.4%; OR 0.9, 95% CI 0.4 2.6; p = 1.0). Adverse events occurred with similar frequency (phenytoin 9.1%, fosphenytoin 15.8%; OR 0.7, 95% CI 0.3 1.4; p = 0.3). The most common events were: pruritus, pain on infusion, and paresthesias. One patient developed hypotension (fosphenytoin); there were no other serious adverse events, including phlebitis. Median Emergency Department length-of-stay was 6.7 h for phenytoin and 5.7 h for fosphenytoin (p = 0.6). In routine Emergency Department use, our data do not support formulary conversion from phenytoin to fosphenytoin, based on the incidence of adverse events or Emergency Department length-of-stay.

Mortality benefit of immediate revascularization of acute ST-segment elevation myocardial infarction in patients with contraindications to thrombolytic therapy: a propensity analysis.

CONTEXT: There are no definitive recommendations for the management of acute myocardial infarction (AMI) in patients with ST-segment elevation who have contraindications to thrombolytic therapy. It is not clear whether, and the extent to which, immediate mechanical reperfusion (IMR) reduces in-hospital mortality in this population. OBJECTIVE: To determine whether IMR (defined as percutaneous coronary intervention or coronary artery bypass graft surgery) is associated with a mortality benefit in patients with acute ST-segment elevation AMI who are eligible for IMR but have contraindications to thrombolytic therapy. DESIGN, SETTING, AND PATIENTS: From June 1994 to January 2003, the National Registry of Myocardial Infarction 2, 3, and 4 enrolled 1 799 704 patients with AMI. A total of 19 917 patients with acute ST-segment elevation were eligible for IMR but had thrombolytic contraindications after excluding patients who were transferred in from or out to other facilities, patients who received intracoronary thrombolytics, and those who received no medications within 24 hours of arrival. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: Of the 19 917 patients, 4705 patients (23.6%) received IMR and 5173 patients (25.9%) died. In-hospital mortality rates in the IMR and non-IMR treated groups in the unadjusted analysis were 11.1%, representing 521 of 4705 patients, and 30.6%, representing 4652 of 15 212 patients, respectively, for a risk reduction of 63.7% (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.26-0.31). In a further analysis using a propensity matching score to reduce the effects of bias, 3905 patients who received IMR remained at lower risk for in-hospital mortality than 3905 matched patients (10.9% vs 20.1%, respectively, for a risk reduction of 45.8%; OR, 0.48; 95% CI, 0.43-0.55). Following a second logistic model applied to the matched groups to adjust for residual differences, a significant treatment effect persisted (OR, 0.64; 95% CI, 0.56-0.75). CONCLUSIONS: In this population, IMR was associated with a reduced risk of in-hospital mortality after appropriate adjustments. Of those we studied who were eligible for IMR, 15 212 patients (76.4%) did not receive it. These results suggest that using IMR in patients with acute ST-segment elevation AMI and contraindications to thrombolytics should be strongly considered.

Anticholinergic medications for managing noisy respirations in adult hospice patients.

PURPOSE: Anticholinergic medications for reducing noisy respirations in adult hospice patients are evaluated. SUMMARY: Anticholinergic medications used to reduce noisy respirations from retained secretions in terminal patients include atropine, glycopyrrolate, scopolamine, and scopolamine derivatives. Pharmaceutical anticholinergic treatment of retained secretions in hospice patients was evaluated in six studies, three of which compared the efficacy of glycopyrrolate to scopolamine in actively dying patients. Subcutaneous glycopyrrolate, scopolamine hydrobromide, and scopolamine butylbromide were similar in their ability to reduce noisy respirations overall and lower and the level of distress exhibited by family members and visitors. Two of the six studies compared the efficacy of medication therapy after institutional formulary changes from scopolamine to glycopyrrolate. The same dosages of subcutaneous glycopyrrolate and scopolamine, which delivered an initial bolus followed by continuous infusion, were reported in each study. Both studies concluded that there was equivalent efficacy between the two products. One study reported a more rapid response in patients treated with glycopyrrolate. In comparison, the last study reported more rapid responses in patients who received scopolamine compared with patients who received glycopyrrolate. Retrospective reports described symptom improvement with parenteral scopolamine in most patients. CONCLUSION: Parenteral and transdermal anticholinergic medications are useful for the reduction of noisy respirations in hospitalized hospice patients. Difficult administration makes oral and sublingual products less desirable for use in this population.