Hypertension care during the COVID-19 pandemic in an integrated health care system.

Retention in hypertension care, medication adherence, and blood pressure (BP) may have been affected by the COVID-19 pandemic. In a retrospective cohort study of 64 766 individuals with treated hypertension from an integrated health care system, we compared hypertension care during the year pre-COVID-19 (March 2019-February 2020) and the first year of COVID-19 (March 2020-February 2021). Retention in hypertension care was defined as receiving clinical BP measurements during COVID-19. Medication adherence was measured using prescription refills. Clinical care was assessed by in-person and virtual visits and changes in systolic and diastolic BP. The cohort had a mean age of 67.8 (12.2) years, 51.2% were women, and 73.5% were White. In 60 757 individuals with BP measurements pre-COVID-19, 16618 (27.4%) had no BP measurements during COVID-19. Medication adherence declined from 86.0% to 80.8% (p < .001). In-person primary care visits decreased from 2.7 (2.7) to 1.4 (1.9) per year, while virtual contacts increased from 9.5 (12.2) to 11.2 (14.2) per year (both p < .001). Among individuals with BP measurements, mean (SD) systolic BP was 126.5 mm Hg (11.8) pre-COVID-19 and 127.3 mm Hg (12.6) during COVID-19 (p = .14). Mean diastolic BP was 73.5 mm Hg (8.5) pre-COVID-19 and 73.5 mm Hg (8.7) during COVID-19 (p = .77). Even in this integrated health care system, many individuals did not receive clinical BP monitoring during COVID-19. Most individuals who remained in care maintained pre-COVID BP. Targeted outreach may be necessary to restore care continuity and hypertension control at the population level.

Transthyretin Amyloid Cardiomyopathy Risk Evaluation in a Cohort of Patients With Heart Failure.

Introduction Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, infiltrative form of heart failure (HF). Nevertheless, ATTR-CM is a largely underrecognized and misdiagnosed condition. This study's objective was to develop an efficient model to assess the chance of ATTR-CM in patients with HF. Methods This was an observational study of patients with HF who had a confirmed diagnosis of ATTR-CM and those with HF but without known ATTR-CM between January 1, 2019, and July 1, 2021. Patient characteristics were extracted from administrative and claims electronic databases and compared between the groups. A propensity score for having ATTR-CM was modeled. Samples of 50 control patients with the highest and lowest propensity scores were adjudicated to assess whether further workup to evaluate for ATTR-CM was warranted for each patient. The sensitivity and specificity of the model were calculated. Results Thirty-one patients with confirmed ATTR-CM and 7620 patients without known ATTR-CM were included in the study. Patients with ATTR-CM were more likely to be Black and to have atrial flutter/fibrillation, cardiomegaly, HF with preserved ejection fraction, pericardial effusion, carpal tunnel syndrome, joint disorders, and lumbar spinal stenosis and to use a diuretic (all p < 0.05). A propensity model with 16 inputs was developed (c-statistic = 0.875). The model's sensitivity and specificity were 71.9% and 95.2%, respectively. Conclusion The propensity model developed in this study provided an efficient means for identifying patients with HF who are more likely to have ATTR-CM and may warrant further workup.

Using pharmacy technicians and electronic health record capabilities to improve outcomes for patients with cardiovascular disease.

OBJECTIVE: This study aimed to compare lipid and blood pressure (BP) control before and after implementing a certified pharmacy technician (CPhT) protocol that optimized electronic health record (EHR) capabilities and shifted work from clinical pharmacy specialists (CPSs) to CPhT. SETTING: Kaiser Permanente Colorado's pharmacist-managed cardiac risk reduction service (which manages dyslipidemia, hypertension, and diabetes for all patients with atherosclerotic cardiovascular disease). PRACTICE DESCRIPTION: In 2019, a protocol that optimized EHR capabilities and allowed work to be offloaded from CPS to CPhT was implemented. Filtered views within the EHR were created that bucketed patients with specific lipid results criteria. The CPhT protocol provided guidance to CPhT on determining whether patients were at low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein (non-HDL) goals, on appropriate statin intensity, adherent to medications, and whether the most recent BP was controlled. The CPhT notified CPS of uncontrolled patients who would assess and manage these patients, as necessary. The CPhT notified controlled patients of their results. PRACTICE INNOVATION: Data on the outcomes of incorporating pharmacy technicians to support CPS clinical activities in ambulatory clinical pharmacy are limited. EVALUATION DETHODS: This retrospective study compared a "Pharmacist-Driven" (index date: January 1, 2016) with a "Tech-Enhanced" (index date: January 1, 2019) group. The primary outcome was the proportion of patients at all goals defined as LDL-C < 70 mg/dL, non-HDL < 100 mg/dL, and BP < 140/90 mm Hg at 1 year after the index dates. RESULTS: There were 6813 patients included (mean age: 70.2 ± 11.1 years, 71.4% male): 3130 and 3683 in the "Pharmacist-Driven" and "Tech-Enhanced" groups, respectively. The proportion of patients who attained LDL-C, non-HDL, and BP goals was higher in the "Tech-Enhanced" group (51.1% vs. 39.7%, P < 0.001) than the "Pharmacist-Driven" group. CONCLUSION: A protocol integrating EHR decision support and CPhTs enabled work to shift to from CPS to CPhT and improved clinical outcomes.

Switching from Biologic to Biosimilar Products: Insight from an Integrated Health Care System.

Biologics are indicated for the treatment of a wide range of conditions and have transformed care in several therapeutic areas; however, they are expensive for both health care systems and patients. The use of biosimilars, which are approved by the US Food and Drug Administration as being "highly similar" to the originator biologic, has the potential to change the health care landscape in the biologic space through considerable cost savings for both payors and patients. With the introduction of biosimilars, organizations are increasingly evaluating how to switch patients from originator biologics to biosimilars. While published studies have evaluated the outcomes of patients switched from originator biologics to biosimilars, there are few publications describing the process health care systems have used to adopt and switch patients to biosimilars. Since 2016, Kaiser Permanente Colorado (KPCO) has undertaken several biosimilar switches starting with the first biosimilar introduced to the market, filgrastim, and has been able to successfully switch 91.8% of patients receiving infliximab, 99.8% receiving rituximab, and 100% receiving filgrastim, trastuzumab, and bevacizumab originator biologics to their respective biosimilars. In an effort to support other health care systems and provide a framework for implementing biosimilar switches, the purpose of this paper is to describe the biosimilar switch model and share learnings from the KPCO experience.

Clinical outcomes of dabigatran use in patients with non-valvular atrial fibrillation and weight >120 kg.

BACKGROUND: Patients with obesity were underrepresented in studies evaluating the safety and effectiveness of direct oral anticoagulants (DOAC) in patients with non-valvular atrial fibrillation (NVAF). This study compared clinical outcomes in patients with NVAF and weighing >120 kg and ≤120 kg who were receiving dabigatran. MATERIALS AND METHODS: This retrospective, matched, longitudinal cohort study included patients from three integrated healthcare delivery systems. Patients ≥18 years of age with NVAF were included if between September 1, 2016 and June 30, 2019 they received dabigatran. Patients >120 kg and ≤120 kg were matched up to 1:6 on age, sex, and CHA2DS2-VASc score. Data were extracted from administrative databases. The primary outcome was a composite of ischemic stroke, clinically-relevant bleeding, systemic embolism, and all-cause mortality. Multivariable regression analyses were performed. RESULTS: 777 and 3522 patients >120 kg and ≤120 kg, respectively, were matched. The >120 kg group tended to be younger with a higher burden of chronic disease. There was no difference between groups in the composite outcome (adjusted hazard ratio [AHR] 1.10, 95% confidence interval 0.89-1.37) or individual components of the composite. A subanalysis of clinically-relevant bleeding identified that patients >120 kg were at a greater risk of gastrointestinal bleeding (AHR 1.44, 95% CI 1.01-2.05). CONCLUSIONS: In patients with NVAF and >120 kg, dabigatran use was associated with a small increased risk of gastrointestinal bleeding but no differences in stroke, mortality or clinically-relevant bleeding. These findings suggest that dabigatran use is reasonable in patients with NVAF and weight >120 kg.

Fixed-Dose Combination Medications for Treating Hypertension: A Review of Effectiveness, Safety, and Challenges.

PURPOSE OF REVIEW: To summarize the recent evidence on the effectiveness and safety of antihypertensive fixed-dose combination (FDC) medications, and to describe the facilitators and barriers to implementing FDCs in US clinical practice. RECENT FINDINGS: Recent clinical practice guidelines include FDC use for treating high BP. Clinical trials in recent years support the use of antihypertensive FDCs including low-dose triple- and quadruple-therapy FDCs. Initiating a low-to-standard dose dual-therapy FDCs showed better BP control than initiating treatment with a standard-dose monotherapy, and triple-therapy FDCs produced better BP control rates than dual-therapy FDCs. Retrospective cohort studies showed that FDCs are associated with increased medication adherence, reduced clinical inertia, decreased time to BP control, and improved cardiovascular outcomes. We further discussed barriers and facilitators of wider implementation of antihypertensive FDCs in clinical practice. FDC treatment for hypertension is not commonly used despite historical and recent data which support the effectiveness, safety, and benefits of FDCs. Simplified and protocolized treatment algorithms, team-based care, shared decision-making principles are crucial to successful utilization and implementation of FDC in clinical practice.

Perceptions of the Value of Clinical Pharmacy Medication Review for Women During Early Pregnancy.

BACKGROUND: The benefit of continuing medications to prevent or treat illness is often overlooked, since pregnant women tend to overestimate the teratogenic risk of medications. Pharmacists can serve as a resource to prescribers and pregnant women with their knowledge of the appropriate use and management of medications during pregnancy. Little information exists on the value women place on pharmacists' medication management during pregnancy. OBJECTIVE: To assess pregnant women's perceptions of an ambulatory care clinical pharmacist (CP) medication review service during early pregnancy that provided education regarding the risks and benefits of medication use during pregnancy. METHODS: This was a qualitative study of pregnant women using semistructured telephone interviews performed between December 12, 2018, and January 18, 2019, and conducted in an integrated health care delivery system. Potential participants were identified from CP encounter records. Consented English-speaking women aged ≥ 18 years participated in an up to 30-minute interview within 1 week of the CP encounter. Interviews were professionally transcribed and coded line by line using the constant comparison method with grounded theory used to gain insight into participants' perspectives. RESULTS: 62 women were invited to participate in semistructured telephone interviews of whom 24 (39%) completed the interview. Three main themes emerged from the qualitative analysis: satisfaction with the service, comfort with medication use during pregnancy, and connectedness to the health care team. Overall, the CP medication review and education service was perceived positively by the participants. Participants reported satisfaction in the quality, timeliness, and convenience of the service and found it beneficial to have their medications reviewed early during pregnancy to assist in medication use decisions before their first obstetric visit. CONCLUSIONS: CP medication review provided a comforting, valuable service for women during early pregnancy when medication-taking decisions can feel exigent. DISCLOSURES: This study was funded by Kaiser Permanente. The authors have nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors, May 2019, in Salt Lake City, UT.

Trends in high intensity statin use among secondary prevention patients 76 years and older.

BACKGROUND: High intensity statin therapy (HIST) is the gold standard therapy for decreasing the risk of recurrent atherosclerotic cardiovascular disease (ASCVD); however, little is known about the use of HIST in older adults with ASCVD. OBJECTIVES: The aim of this cross-sequential study was to determine trends in statin intensity in older adults over a 10-year timeframe. METHODS: The study was conducted in an integrated healthcare delivery system. Patients were 76 years or older with validated coronary ASCVD. Data were collected from administrative databases. Statin intensity level was assessed in eligible patients on January 1st and July 1st from January 1, 2007 to December 31, 2016. RESULTS: Overall, a total of 5,453 patients were included with 2,119 (38.9%) and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively. Included patients had a mean age of 79.8 years and were primarily male and white and had a cardiac intervention. The rate of HIST use increased from 14.5% to 41.3% over the study period (p<0.001 for trend). Conversely, the rates of moderate and low intensity statin use decreased from 61.8% and 9.8% to 41.2% and 4.8%, respectively (both p<0.001 for trend). Similar trends were identified for females and males. CONCLUSIONS: The percentage of patients with ASCVD 76 years and older who received HIST substantially increased from 2007 to 2016. This trend was identified in both females and males. Future comparative effectiveness research should be conducted in this patient population to examine cardiac-related outcomes with HIST and Non-HIST use.

Value of Pharmacy Students Performing Population Management Activity Interventions as an Advanced Pharmacy Practice Experience.

Objective. To assess the value of an advanced pharmacy practice experience in which students engaged in population health management (PHM) activities for a managed care setting. Methods. Students were provided with a list of patients, trained on the requirements for each PHM activity and completed them independently. The students reviewed the electronic record for each patient on their list to identify those who were non-adherent to dual antiplatelet therapy (DAPT) within one year of coronary stent placement, non-adherent to beta blockers (BB) within six months post-acute myocardial infarction, or with renal dysfunction and requiring dose adjustment of lipid-lowering therapy. Students coded each intervention based on predefined categories such as patient education, medication discontinuation, or medication reconciliation, and then if necessary were reviewed with the pharmacy preceptor. The primary investigator determined the intervention to be either actionable or non-actionable. The primary outcome was the proportion and type of interventions made by each student. The secondary outcome was clinical pharmacist time offset. A retrospective, data-only pilot study was conducted to determine the outcomes from the program over four years. Results. Forty-six students made 3,774 interventions over the study period, 37% of which were categorized as actionable. The most common actionable interventions were providing patient education (52%), verifying prescription adherence (23%), and medication therapy adjustment (10.5%). Over the study period, an estimated 765.6 hours of clinical pharmacist time was offset, or approximately 191.4 hours per academic year. Conclusion. This study demonstrated that a population health management approach can be used successfully within an APPE. This approach can result in offset pharmacist time for precepting organizations, while offering meaningful clinical interventions for patients and learning opportunities for students.

Trends in high intensity statin use among secondary prevention patients 76 years and older

Background: High intensity statin therapy (HIST) is the gold standard therapy for decreasing the risk of recurrent atherosclerotic cardiovascular disease (ASCVD); however, little is known about the use of HIST in older adults with ASCVD. Objectives: The aim of this cross-sequential study was to determine trends in statin intensity in older adults over a 10-year timeframe. Methods: The study was conducted in an integrated healthcare delivery system. Patients were 76 years or older with validated coronary ASCVD. Data were collected from administrative databases. Statin intensity level was assessed in eligible patients on January 1st and July 1st from January 1, 2007 to December 31, 2016. Results: Overall, a total of 5,453 patients were included with 2,119 (38.9%) and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively. Included patients had a mean age of 79.8 years and were primarily male and white and had a cardiac intervention. The rate of HIST use increased from 14.5% to 41.3% over the study period (p<0.001 for trend). Conversely, the rates of moderate and low intensity statin use decreased from 61.8% and 9.8% to 41.2% and 4.8%, respectively (both p<0.001 for trend). Similar trends were identified for females and males. Conclusions: The percentage of patients with ASCVD 76 years and older who received HIST substantially increased from 2007 to 2016. This trend was identified in both females and males. Future comparative effectiveness research should be conducted in this patient population to examine cardiac-related outcomes with HIST and Non-HIST use

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Trends in high-intensity statin use and low-density lipoprotein cholesterol control among patients enrolled in a clinical pharmacy cardiac risk service.

BACKGROUND: Although high-intensity statin therapy (HIST) is recommended for most patients between 21 and 75 years of age with atherosclerotic cardiovascular disease (ASCVD), several recent analyses examining contemporary statin use trends have identified a clinical care gap in the utilization of HIST. OBJECTIVE: The objective of this study was to assess secular trends in lipid management for patients with ASCVD enrolled in a clinical pharmacy program within an integrated health care delivery system. METHODS: We performed serial cross-sectional studies over time, comprising 18,006 adults with both acute and chronic ASCVD, to assess trends in statin use and low-density lipoprotein cholesterol (LDL-C) levels from 2007 to 2016. RESULTS: Although the use of statin therapy (any intensity) remained relatively consistent throughout the 10-year study period (89% in 2007, 87% in 2016), the proportion of patients receiving HIST increased over time (44% in 2007, 67% in 2016; P < .001 for trend). Population mean LDL-C levels ranged from 73 to 83 mg/dL with a downward trend over the 10-year study period (P < .001 for trend). By 2016, the proportion of patients attaining an LDL-C <100 mg/dL and <70 mg/dL was 85% and 54%, respectively. Nonstatin lipid-lowering therapy use decreased over the study period, which was primarily driven by decreased use of ezetimibe (24% in 2007, 2% in 2016; P < .001 for trend). CONCLUSIONS: Among adults with ASCVD enrolled in a clinical pharmacy cardiac risk reduction service, guideline-directed use of HIST significantly increased over the past 10 years and coincided with decreased population LDL-C levels.

Evaluation of the Effect of A Structured Program to Guide Residents' Experience in Research (ASPIRE) on Pharmacy Residents' Knowledge, Confidence, and Attitude toward Research.

STUDY OBJECTIVE: To evaluate the effect of A Structured Program to guide Resident Experience in Research (ASPIRE) on pharmacy residents' knowledge, confidence, and attitude toward research. DESIGN: Nonrandomized controlled study using data from a validated questionnaire administered through an online survey. PARTICIPANTS: Of 60 pharmacy residents (residency year 2013-2014) who completed the baseline assessment, the 41 residents who also completed the follow-up assessment were included in the final analysis; of those, 26 Colorado pharmacy postgraduate year 1 (PGY1) and year 2 (PGY2) residents were enrolled in ASPIRE between July 2013 and June 2014 (intervention group) and 16 PGY1 and PGY2 pharmacy residents outside of Colorado did not participate in ASPIRE (control group). MEASUREMENTS AND MAIN RESULTS: Both the intervention and control groups completed a pre- and post-assessment at the beginning (July 2013 [baseline]) and end (May/June 2014 [follow-up]), respectively, of their residency year that measured knowledge (with a tool measuring biostatistics and research methodology knowledge), confidence, and attitude toward research. Research knowledge scores improved similarly from baseline to follow-up in the intervention and control groups: 11.8% and 11.3%, respectively (adjusted p=0.8). Research confidence improved significantly more in the intervention group, with a 48% increase in confidence score from before to after residency completion, compared with a 15% increase in the control group (adjusted p=0.002). Residents in both the intervention and control groups expressed positive attitudes toward pharmacist-conducted research, with 100% and 87% of intervention and control residents, respectively (adjusted p=0.970), agreeing that pharmacist-conducted research is essential to driving pharmacy practice and expanding the roles of pharmacists. CONCLUSION: ASPIRE was not associated with greater research methodology knowledge but did significantly increase confidence in performing research.

Self-Rated Health Among Patients with Coronary Artery Disease Enrolled in a Cardiovascular Risk Reduction Service.

Little is known about the use of the single self-rated health (SRH) status item measuring health-related quality of life among people with coronary artery disease (CAD). The objective of this study was to assess relationships between SRH and recurrent coronary events, mortality, health care utilization, and intermediate clinical outcomes and to assess predictors of fair/poor SRH. A total of 5573 patients enrolled in a comprehensive cardiac risk reduction service managed by clinical pharmacy specialists were evaluated over a 2-year period. Regression modeling explored relationships among variables, modeling SRH separately as an independent and a dependent variable. The 1374 (24.7%) respondents reporting fair/poor SRH differed statistically from 4199 (75.3%) respondents reporting good/very good/excellent SRH in terms of age, sex, ethnicity, number of comorbid conditions, DxCG scores, lifestyle behaviors, blood pressure control, and inpatient and emergency department (ED) utilization. Respondents reporting fair/poor health were more likely to have recurrent major coronary events (MCE), including death. Fair/poor SRH was consistently statistically significant when it was included as a predictor in regression modeling for poor blood pressure control, health care utilization, MCE, and all-cause mortality. Variables associated with fair/poor SRH in regression modeling included females, Hispanic ethnicity, ≥1 baseline ED visit, and DxCG score. Exercising <30 minutes per week was strongly associated with fair/poor SRH. Single-item SRH status may help identify patients with CAD at higher risk of poor blood pressure control, recurrent MCE, and death and those who may benefit from interventions to increase physical activity.

Cluster-Randomized Trial of Clinical Pharmacist Tobacco Cessation Counseling Among Patients with Cardiovascular Disease.

Optimal management of patients with cardiovascular disease (CVD) includes evaluation of risk factors using a team-based approach. Tobacco use often receives less attention than other CVD risk factors; therefore, utilization of nonphysician health care providers may be valuable in addressing tobacco use. The purpose of this trial was to assess the impact of brief, structured, telephone tobacco cessation counseling (BST) delivered by clinical pharmacists on tobacco cessation attempts compared to usual care. The BST consisted of 1 to 5 minutes discussing 3 key counseling points, including a recommendation to quit and education about cessation aids. This was a cluster-randomized trial of tobacco-using patients with CVD who were enrolled in a clinical pharmacist-managed, physician-directed, CVD disease state management service. Clinical pharmacists were randomized to provide usual care (control) or BST (intervention) to their tobacco-using patients during a 4-month period. Patients were surveyed 3 months later to assess their tobacco cessation attempts, use of tobacco cessation aids, and self-reported cessation. One hundred twenty patients were enrolled. Subjects were predominately white males, aged ≥65 years, with a history of myocardial infarction. One hundred and four subjects completed the follow-up survey. No differences were detected between the 36.2% and 38.6% of control and intervention subjects, respectively, reporting a tobacco cessation attempt (P=0.804) or in the other outcomes (all P>0.05). A BST delivered by clinical pharmacists may not adequately affect patient motivation enough to increase tobacco cessation attempts in tobacco-dependent patients with CVD. Future research is needed to evaluate other team-based strategies that can decrease tobacco use in patients with CVD.

Impact of a clinical pharmacy research team on pharmacy resident research.

PURPOSE: A successful initiative by Kaiser Permanente Colorado (KPCO) to support pharmacy resident research projects and the publication of project results in peer-reviewed journals is described. METHODS: An observational study was conducted to evaluate the publication rates for resident research projects before and after the KPCO pharmacy department established a Clinical Pharmacy Research Team (CPRT) to encourage and enable resident research. All projects presented by KPCO residents at the annual Western States Conference (WSC) for Pharmacy Residents, Fellows, and Preceptors in the 10 years before the CPRT was established (1994-2004, the pre-CPRT group) and the 7 years after CPRT implementation (2005-11, the CPRT group) were included in the analysis. The proportions of presented projects in the two groups that were subsequently published in peer-reviewed journals were compared, with further analysis of project characteristics and publication outcomes. RESULTS: A total of 66 resident research projects were presented at the WSC during the study period: 30 (45.5%) and 36 (54.5%) in the pre-CPRT and CPRT groups, respectively. Overall, 45 projects (68.2%) were published in peer-reviewed journals. Projects in the CPRT group were significantly more likely than those in the pre-CPRT group to result in peer-reviewed publications (publication rate, 86.1% versus 46.7%; p = 0.001). The median times from residency completion to publication in the pre-CPRT and CPRT groups were 30 and 23 months, respectively (p = 0.08). CONCLUSION: An increase in the proportion of pharmacy resident research projects published in peer-reviewed journals was observed after the CPRT was established.

Cost-effectiveness evaluation of a home blood pressure monitoring program.

OBJECTIVES: To evaluate the health system cost of a home blood pressure monitoring (HBPM) program versus usual care in an integrated healthcare system. STUDY DESIGN: This cost-effectiveness analysis was based upon a previously completed randomized controlled trial of 348 hypertensive patients, in which mean systolic blood pressure (BP) was lowered 21 versus 8 mm Hg in the HBPM and usual care groups, respectively, and BP control was achieved in 54% versus 35% of patients (P < .001). METHODS: This analysis compared direct costs from the health plan perspective, including clinic visits, e-mail and telephone encounters, laboratory tests, medications, hospitalizations, and emergency department visits between the 2 groups. Primary outcomes were the incremental hypertension care-related cost of HBPM per mm Hg lowering of systolic BP per patient, per additional BP controlled, and per life-year gained. RESULTS: Median hypertension-related cost per patient over 6 months was $455 in the HBPM group and $179 for usual care (P < .001). This increase was attributable to additional e-mail and telephone encounters, greater antihypertensive medication use, additional laboratory monitoring, and the BP monitor. Median total cost per patient was $1530 and $1283 for the HBPM and usual care groups, respectively (P = .034). The HBPM program increased hypertension-related expenditures by $20.50 per mm Hg lowering of systolic BP, $1331 per additional patient achieving BP control at 6 months, and $3330 per life-year gained. CONCLUSIONS: The HBPM program requires investment in outpatient encounters, medications, and laboratory monitoring, but produces significantly improved BP control.

Use of a pharmacy technician to facilitate postfracture care provided by clinical pharmacy specialists.

PURPOSE: The ability of a pharmacy technician to support the patient screening and documentation-related functions of a pharmacist-driven osteoporosis management service was evaluated. METHODS: A two-phase prospective study was conducted within a large integrated health system to assess a pharmacy technician's performance in supporting a multisite team of clinical pharmacy specialists providing postfracture care. In phase I of the study, a specially trained pharmacy technician provided support to pharmacists at five participating medical offices, helping to identify patients requiring pharmacist intervention and, when applicable, collecting patient-specific clinical information from the electronic health record. In phase II of the study, the amount of pharmacist time saved through the use of technician support versus usual care was evaluated. RESULTS: The records of 127 patient cases were reviewed by the pharmacy technician during phase I of the study, and a pharmacist agreed with the technician's determination of the need for intervention in the majority of instances (92.9%). An additional 91 patient cases were reviewed by the technician in phase II of the research. With technician support, pharmacists spent less time reviewing cases subsequently determined as not requiring intervention (mean ± S.D., 5.0 ± 3.8 minutes per case compared with 5.2 ± 4.5 minutes under the usual care model; p = 0.78). In cases requiring intervention, technician support was associated with a reduction in the average pharmacist time spent on care plan development (13.5 ± 7.1 minutes versus 18.2 ± 16.6 minutes with usual care, p = 0.34). CONCLUSION: The study results suggest that a pharmacy technician can accurately determine if a patient is a candidate for pharmacist intervention and collect clinical information to facilitate care plan development.

Positive predictive values of ICD-9 codes to identify patients with stroke or TIA.

OBJECTIVES: To determine the positive predictive values of inpatient and outpatient ICD-9 codes and status code V12.54 for identifying confirmed history of stroke or transient ischemic attack (cerebral event) among patients within a managed care organization. STUDY DESIGN: Retrospective, cohort study. METHODS: Inpatient hospital claims and outpatient visit records were used to identify patients with ICD-9 codes (430.XX to 438.XX) or status code V12.54 in the primary or secondary position recorded between January 1, 2001, and December 31, 2009. A standardized chart abstraction tool was used by trained chart abstractors blinded to the coding to confirm the cerebral event and classify stroke type. Positive predictive values (PPVs) were calculated for each code based on care setting. RESULTS: A total of 4689 patients with 10,376 unique stroke codes recorded in the administrative data were reviewed. Of these, 2785 (59.4%) patients had a confirmed cerebral event. The codes with PPV less than 90% were 434.XX, 433 .X1, and V12.54 where codes were recorded in both the inpatient and outpatient settings. Overall, inpatient-only codes produced higher PPVs; however, relatively fewer events were captured in this setting. CONCLUSIONS: Administrative ICD-9 codes 434.XX, 433.X1, and V12.54 had consistently high PPVs in identifying patients with a confirmed cerebral event. These codes could be used as part of a probabilistic approach to focus care activities on patients with the highest likelihood of a cerebral event.

Interventions aimed at improving performance on medication adherence metrics.

BACKGROUND: medication adherence is one determining factor of treatment success. Poor medication adherence mitigates optimum clinical benefits and increases total health care costs. Current evidence suggests that for population-based adherence interventions to be effective, a multidisciplinary, multifactorial approach that can be tailored for each individual should be adopted. In the United States, national organizations such as the National Committee for Quality Assurance and the Centers for Medicare and Medicaid Services include medication adherence as a metric of health care system performance Aim of the COMMENTARY: This article provides an overview of efforts at Kaiser Permanente Colorado to impact medication adherence-related metrics. Described interventions are supported by electronic data gathering processes with an emphasis on the role of pharmacists.

Ambulatory treatment gaps in patients with ischemic stroke or transient ischemic attack.

BACKGROUND: This study evaluated goal attainment for patients with a history of non-cardioembolic ischemic stroke (NCIS) or transient ischemic attack (TIA). METHODS: A cross-sectional study was conducted in patients aged 18 to 85 years with a history of validated NCIS or TIA. Data collected were demographics, comorbidities, blood pressure (BP), low-density lipoprotein cholesterol (LDL-C) values, and medications within 365 days and most proximal to December 31, 2010. Goal LDL-C and BP were defined as < 100 mg/dL and < 140/90 mm Hg, respectively. Differences in sex and age (< 65 vs ≥ 65 years) were evaluated. RESULTS: There were 1731 patients evaluated (mean age: 73.6 years; 58% women). Stroke type was NCIS in 51.9% and TIA in 48.1%. The LDL-C and BP were measured in 75.4% and 50.3% of patients, respectively. No difference in LDL-C screening rates existed for sex or age. Men and patients younger than age 65 years were significantly more likely to have BP measured. Overall, LDL-C and BP goals were attained by 48.9% and 43.3% of patients, respectively. Men and patients age 65 years or older were likelier than women and patients younger than age 65 years to attain LDL-C goals (p < 0.01). Men were also likelier than women to attain BP < 140/90 mm Hg (p < 0.01), but more patients younger than age 65 years vs older than age 65 years attained this goal (p < 0.01). Statins and antihypertensives were received by 51.9% and 46.9% of the patients, respectively. CONCLUSION: Although attaining guideline-recommended goals for LDL-C and BP may present challenges, future research should focus on innovative methods to help patients attain optimal treatment goals.