Implementation of a Pharmacist-Driven Aspirin Deprescribing Protocol Among Older Veterans in a Primary Care Setting.

Background Recent cardiovascular guideline updates recommend against the use of aspirin for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in older people. However, aspirin use remains common in this population. Objective To implement and evaluate the benefit of a pharmacist-driven aspirin deprescribing protocol compared with primary care provider (PCP) education-only in a primary care setting. Methods This prospective, cohort project targeted deprescribing for patients prescribed aspirin for primary prevention of ASCVD. Patients were included if they received primary care services at the Milwaukee Veterans Health Administration Medical Center (VHA) and were 70 years of age or older. Criteria for exclusion were aspirin obtained outside the VHA system, aspirin prescribed for a non-ASCVD-related condition, and/or a history of ASCVD. Active deprescribing by pharmacists and PCP education took place in the intervention group with PCP education only in the standard-of-care group. The primary outcome was the proportion of patients who had aspirin deprescribed in each group. Secondary outcomes included patient acceptability of the intervention and barriers to implementation. Results A total of 520 patients were prescribed aspirin in the intervention group versus 417 in the education-only group. Sixty-five patients met intervention criteria and were contacted for aspirin deprescribing. The pharmacist-led active deprescribing group led to a higher rate of aspirin deprescriptions versus the education-only group (54% vs 18%; P = 0.0001) for patients who met criteria. Conclusion A pharmacist-led aspirin deprescribing protocol within a primary care setting significantly decreased the number of aspirin prescriptions compared with PCP education only.

Development and Validation of Quality Measures for Testosterone Prescribing.

Context: Accurate measures to assess appropriateness of testosterone prescribing are needed to improve prescribing practices. Objective: This work aimed to develop and validate quality measures around the initiation and monitoring of testosterone prescribing. Methods: This retrospective cohort study comprised a national cohort of male patients receiving care in the Veterans Health Administration who initiated testosterone during January or February 2020. Using laboratory data and diagnostic codes, we developed 9 initiation and 7 monitoring measures. These were based on the current Endocrine Society guidelines supplemented by expert opinion and prior work. We chose measures that could be operationalized using national VA electronic health record (EHR) data. We assessed criterion validity for these 16 measures by manual review of 142 charts. Main outcome measures included positive and negative predictive values (PPVs, NPVs), overall accuracy (OA), and Matthews Correlation Coefficients (MCCs). Results: We found high PPVs (>78%), NPVs (>98%), OA (≥94%), and MCCs (>0.85) for the 10 measures based on laboratory data (5 initiation and 5 monitoring). For the 6 measures relying on diagnostic codes, we similarly found high NPVs (100%) and OAs (≥98%). However, PPVs for measures of acute conditions occurring before testosterone initiation (ie, acute myocardial infarction or stroke) or new conditions occurring after initiation (ie, prostate or breast cancer) PPVs were much lower (0% to 50%) due to few or no cases. Conclusion: We developed several valid EHR-based quality measures for assessing testosterone-prescribing practices. Deployment of these measures in health care systems can facilitate identification of quality gaps in testosterone-prescribing and improve care of men with hypogonadism.

Narrative Literature Review Guided Approach of Inhaled Corticosteroid de-escalation in Chronic Obstructive Pulmonary Disease.

Objective: To review the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report recommendations and create an algorithm to assist clinicians in determining which chronic obstructive pulmonary disease (COPD) patients qualify for inhaled corticosteroid (ICS) de-escalation. Data Sources: A literature search of MEDLINE/PubMed from 2002 to August 2021 was conducted using the search terms inhaled corticosteroids, chronic obstructive pulmonary disease, and de-escalation and review of the reference lists of identified articles for pertinent citations. Study Selection and Data Extraction: Relevant studies and articles were included if they focused on the utilization of ICS in COPD. Data Synthesis: The 2020 GOLD report only recommends triple therapy with ICS, long acting beta agonists, and long acting muscarinic antagonists for patients with frequent exacerbations, frequent hospitalizations, or elevated blood eosinophil counts. Despite this clear framework, patients are prescribed ICS without these characteristics. Available evidence suggests that these patients can be de-escalated from ICS therapy without concern for worsening lung function or exacerbations. Relevance to Patient Care and Clinical Practice: Patients with COPD may be experiencing more risk than benefit on ICS therapy. Clinicians should be knowledgeable on how to evaluate patient therapy for appropriateness and know how to safely deprescribe ICS given their limited efficacy in many COPD patients. Conclusion: There remains no specific guidance on how to de-escalate patients off an ICS when the therapy is not indicated. Use of clinical evidence with stepwise algorithms can be models to approach de-escalation of ICS in patients with COPD.

Implementation of a Targeted Inhaled Corticosteroid De-Escalation Process in Patients with Chronic Obstructive Pulmonary Disease in the Primary Care Setting.

Purpose: To evaluate the feasibility and success of a pharmacist-led, targeted inhaled corticosteroid (ICS) de-escalation process in patients with chronic obstructive pulmonary disease (COPD) where the risks of ICS therapy outweigh the potential benefits. Methods: A population health data management tool was leveraged to identify patients who may qualify for ICS de-escalation. Primary care pharmacists clinically reviewed and subsequently contacted patients who were determined to be appropriate candidates. After discussion on the risks and benefits of ICS therapy, a stepwise algorithm was utilized to assist with ICS de-escalation and optimization of bronchodilator therapy. Outcomes analyzed include the proportion of patients for whom ICS was de-escalated, patient acceptability of the intervention, time taken to complete the intervention, barriers to implementation, and the number of additional interventions made by pharmacists. Results: Of the 126 patients originally identified as potential candidates, 58 (46.0%) were deemed appropriate to proceed with ICS de-escalation and successfully contacted by a pharmacist. Of these patients, 49 (84.5%) were agreeable and ultimately 42 were successfully de-escalated with 37 patients maintained off ICS. The average time required for an encounter was 15.8 minutes. Conclusion: There is utility in a pharmacist-driven, targeted ICS de-escalation process to facilitate meeting guideline-directed medication therapy goals in patients with COPD, granted the availability of efficient tools to assist in identifying patients that qualify. Such a targeted approach increases pharmacist involvement in medication management of COPD and can expand the primary care pharmacy practice.

Evaluation of a statewide pharmacy student writing club program: Opportunities to enhance professional writing skills.

INTRODUCTION: Skills gained by writing a scholarly manuscript coincide with graduation expectations prior to matriculation into practice. A partnership between The Journal of the Pharmacy Society of Wisconsin and four affiliated pharmacy schools developed student writing clubs (SWC) to fill this need. The objectives of this project were to explore the structure of SWCs and evaluate the experiences of participants. METHODS: Two investigator-designed, voluntary, anonymous surveys were distributed to each school. A survey for pharmacy students assessed motivations for participating within a SWC, impact on skills, and suggestions for improvement. The second survey to the SWC faculty advisors explored programmatic structure. RESULTS: Of forty student respondents, most SWC participants felt comfortable with each step of the writing process. Participants were motivated by manuscript publication opportunity (88%), improvement of writing skills (80%), and the addition to their curriculum vitae (60%). Students suggested process improvements including better communication on deadlines, more connections to writing resources, and developing writing workshops for guidance on professional writing. Barriers to participation included unclear expectations (60%) and not feeling prepared or skilled enough (53%). Most importantly, both students and faculty perceived the SWC at each program as a skill-building extracurricular activity that brings value to student pharmacist development. CONCLUSIONS: Manuscript preparation and publication within a structured environment, such as a SWC, is a valuable skill-building opportunity. Creation of a centralized writing workshop will provide guidance for participants throughout the manuscript process.

Implementation of a Pilot Pharmacist Testosterone Therapy Management Service.

BACKGROUND: Recent literature findings suggest that opportunities exist to optimize testosterone replacement therapy management. OBJECTIVE: To evaluate the impact of a pilot clinical pharmacist testosterone therapy management service in a Veterans Affairs primary care setting. METHODS: A 6-month, single-clinic, prospective cohort quality improvement project included male patients with an active prescription for testosterone. Patients were excluded if they switched primary care providers or were managed by a specialty clinic. After diagnosis, primary care providers had the option of referring patients for clinical pharmacist testosterone replacement therapy management. The project investigated the impact of pharmacist management on adherence to guideline-defined baseline and therapeutic monitoring, prior authorization workload, time saved by primary care providers, and clinical pharmacist interventions. RESULTS: Sixty patients split between pharmacist management (N = 35) and nonpharmacist management (N = 25) cohorts. Monitoring of baseline parameters was significantly improved with clinical pharmacist management (54% vs 20%, P = 0.0006). Improved baseline monitoring decreased prior authorization team workload as requests were approved on the first submission at a higher rate (100% vs 75.4%, P = 0.06). Pharmacist management increased therapeutic monitoring for assessing symptom improvement (96% vs 26%, P < 0.001), monitoring of testosterone levels (96% vs 61%, P = 0.003), and safety monitoring with complete blood counts (100% vs 83%, P = 0.04). A total of 42 pharmacist-patient encounters saved over 600 minutes of primary care provider time. CONCLUSION: Clinical pharmacist involvement enhances therapeutic monitoring for male hypogonadism leaving room for expansion of clinical pharmacy services within testosterone replacement therapy management.

Patient Satisfaction With Extended International Normalized Ratio Follow-up Intervals in a Veteran Population.

Background: For highly stable warfarin patients, limited data exists regarding patient satisfaction on extended international normalized ratio (INR) follow-up intervals and how this population compares with patients on a direct oral anticoagulant (DOAC). Objective: To assess the impact on patient satisfaction of extending INR follow-up intervals. Methods: Veterans on stable warfarin doses had extended INR follow-up intervals up to 12 weeks in a single-arm prospective cohort study for 2 years. This analysis included participants who completed at least 2 Duke Anticoagulation Satisfaction Scales (DASS). The primary outcome was the change in the DASS. A focus group described participant experiences. Participant satisfaction was compared to patients on a DOAC. Results: Of the 51 participants, 48 were included in the warfarin extended INR follow-up group. Compared with baseline, the mean DASS score (42.9 ± 12.08) was worse at 24 months (46.82 ± 15.2, P = 0.0266), with a small effect size (Cohen's d = 0.29). The 8 participants in the focus group were satisfied with the extended INR follow-up interval but would be uncomfortable extending follow-up past 2 to 3 months. The extended INR follow-up interval study had similar DASS scores as the 33 participants included on DOAC therapy (46.8 ± 15.1, P = 0.9970) but may be limited by differing populations using DOACs. Conclusion and Relevance: For patients currently stable on warfarin therapy, extending the INR follow-up interval up to 12 weeks or changing to a DOAC does not appear to improve patient satisfaction.

Population Health Management during Student Pharmacist Introductory Experiential Education to Expand Clinical Pharmacist Impact.

OBJECTIVE: To evaluate the impact of incorporating pre-advanced pharmacy practice experience (pre-APPE) student pharmacists into three different population health management (PHM) projects. METHODS: The prospective quality improvement projects incorporated three third-year student pharmacists who developed and conducted individual PHM projects over the course of three to seven months. The projects included hypoglycemia screening, hepatitis C virus and human immunodeficiency virus screening, and statin use evaluations for atherosclerotic cardiovascular disease risk reduction. Under the guidance of a clinical pharmacist, students developed project materials, conducted patient chart reviews, and contacted patients to make interventions such as recommendations for therapy, ambulatory patient monitoring, patient education, and arranging provider follow-up. Student impact was evaluated through the number of patients screened, the number of eligible patients contacted, and the total number of interventions or recommendations made. Student time spent was tracked throughout the projects. RESULTS: Out of 244 patients screened, 198 patients met inclusion criteria and 162 patients were contacted or assessed by a student pharmacist. Students made a total of 319 interventions, including patient education (132), patient monitoring (132), pharmacotherapy recommendations (28), and arranging follow-up (27). On average students screened 33 patients per month, and, per patient, required 8.6 minutes for eligibility assessment and approximately 6 minutes for telephone interviews. CONCLUSION: This report demonstrates that pre-APPE student pharmacists are well-equipped to design and implement PHM projects. Utilization of student pharmacists in similar PHM programs can expand the pharmacist's impact on patient care in the ambulatory care setting.

Feasibility and safety of a 12-week INR follow-up protocol over 2 years in an anticoagulation clinic: a single-arm prospective cohort study.

The 2012 American College of Chest Physicians' guidelines recommended a 12-week INR follow-up interval may be appropriate for patients on stable warfarin doses. Limited evidence supports this recommendation. A single-arm, prospective cohort study over 24 months was completed in a Veterans Affairs anticoagulation clinic to determine the long-term feasibility and safety of implementing an extended INR follow-up interval in Veterans on stable doses of warfarin. Participants were required to have a stable warfarin dose for 6 months prior to enrollment. A prespecified protocol was used to titrate, extend, and manage the INR interval up to 12 weeks. Scheduling of extended INR intervals was a primary outcome. Safety outcomes included major and serious bleeding and thromboembolic events. A post-hoc comparison of baseline characteristics between individuals who were scheduled for at least 4 consecutive 12-week INR follow-up intervals and those who were not was completed. Of the 50 participants, 36 (72%) were scheduled for at least one 12-week interval and 15 (30%) were scheduled for 4 consecutive intervals. There were 2 thromboembolic events that occurred in 1 participant. There were 28 major and serious bleeding events in 19 participants; 8 occurred while on the extended INR interval. In the post-hoc analysis, no participants scheduled for 4 consecutive 12-week intervals had heart failure. Based on 2 years of monitoring, a 12-week INR follow-up interval using a detailed protocol with titration of INR interval extension appears feasible for a subset of patients. Patients with heart failure may not be suitable for this intervention.

Integration and assessment of the situation-background-assessment-recommendation framework into a pharmacotherapy skills laboratory for interprofessional communication and documentation.

BACKGROUND AND PURPOSE: The situation-background-assessment-recommendation (SBAR) framework is a commonly used method to structure verbal communication in the nursing and medicine disciplines and increases the effectiveness of interprofessional communication. The purpose of this manuscript is to describe how the SBAR framework is integrated into a pharmacotherapy skills laboratory for interprofessional communication and to report on student agreement of perceived realism, preparedness, and fairness of assessment relating to simulated SBAR activities. EDUCATIONAL ACTIVITY AND SETTING: Simulated, authentic interactions with healthcare providers were incorporated into a pharmacotherapy skills laboratory using the SBAR framework. Activities culminated with a performance-based assessment (PBA) exam which included verbal and written SBAR stations. Students completed a PBA exit survey reporting level of agreement with perceived realism, preparedness, and fairness of assessment related to the exam and answered open-ended questions reporting what they most and least liked. FINDINGS: After completion of the PBA exam, students reported they agreed or strongly agreed (78%) the PBA was realistic to practice. Students reported increased agreement they were prepared to verbally communicate recommendations compared to document recommendations in the written SBAR framework (64% and 52% agreed or strongly agreed, respectively). Thematic content analysis revealed students preferred to document in the SBAR format and felt it was more realistic than the subjective-objective-assessment-plan (SOAP) note format. DISCUSSION AND SUMMARY: The SBAR framework is relevant for pharmacist verbal communication and written documentation. Incorporation of the SBAR framework into a skills laboratory appears to prepare students for a PBA that was perceived as both realistic and fair.

Thermoreversible partitioning of poly(ethylene oxide)s between water and a hydrophobic ionic liquid.

We describe a poly(ethylene oxide) (PEO) homopolymer "shuttle" between water and a hydrophobic ionic liquid, 1-ethyl-3-methylimidazolium bis(trifluoromethylsulfonyl)imide ([EMIM][TFSI]). PEO homopolymers with varying molecular weight transferred reversibly and quantitatively between water at room temperature and [EMIM][TFSI] at an elevated temperature. The temperature of the transfer from water to [EMIM][TFSI] shows a linear dependence on PEO molecular weight and a dependence on polymer concentration consistent with expectation based on Flory-Huggins theory. These results are also consistent with the previously observed lower critical solution temperature (LCST) behavior of PEO in water. Dynamic light scattering study of the concentration and temperature dependence of the swelling degree of PEO corona of polybutadiene (PB)-PEO block copolymer micelles indicates that the solvent quality of [EMIM][TFSI] for PEO remains essentially the same as a good solvent over the temperature range of the PEO shuttle. Fundamental understanding of the PEO shuttle is of significance in development of systems for phase transfer of reagents and reaction products between ionic liquids and water.

A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted Lipoplasty and suction-assisted Lipoplasty.

BACKGROUND: No scientific comparative study has demonstrated any statistically significant clinical improvement attributable to a new lipoplasty technology relative to traditional suction-assisted lipoplasty. This prospective study used a contralateral study design to evaluate postoperative differences between vibration amplification of sound energy at resonance (VASER)-assisted lipoplasty and suction-assisted lipoplasty. METHODS: Twenty female patients between the ages of 20 and 48 years received contralateral treatment with suction-assisted lipoplasty and VASER-assisted lipoplasty in one or more anatomical regions for a total of 33 regions. Patients received suction-assisted lipoplasty on one side of the body and VASER-assisted lipoplasty on the contralateral side. Patients were blinded to technology application. Aspirate was analyzed for blood content, and skin retraction was analyzed by measuring changes in ultraviolet light tattoos. RESULTS: Regarding skin retraction, the VASER-assisted lipoplasty-treated side resulted in a statistically significant improvement in skin retraction of 53 percent relative to suction-assisted lipoplasty (17 percent per liter versus 11 percent per liter, p = 0.003) with 33 paired sites using a two-tailed t test. Regarding blood loss, VASER-assisted lipoplasty treatment resulted in a statistically significant reduction in blood loss of 26 percent (11.2 versus 14.0 cc blood/100 cc) relative to the suction-assisted lipoplasty side (p = 0.019 with n = 20 using a two-tailed t test). Subjective measures (i.e., pain, swelling, appearance, and patient and physician preference) showed no statistical difference between the two methods at the 6-month evaluation. CONCLUSIONS: The VASER-assisted lipoplasty method demonstrated improved skin retraction and reduction in blood loss compared with suction-assisted lipoplasty. This is the first study to demonstrate statistically significant and clinically relevant improvements in a new lipoplasty technology relative to suction-assisted lipoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.