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.

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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PCSK9 inhibitors and managing cost in the managed care setting.

In patients with hypercholesterolemia who have atherosclerotic cardiovascular disease and/or familial hypercholesterolemia, a new class of drugs may be helpful in reducing serum levels of low-density lipoprotein cholesterol (LDL-C) beyond maximally tolerated statin therapy. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors lower LDL-C through a different mechanism of action than standard cholesterol-lowering therapies. Currently approved PCSK9 inhibitors are the monoclonal antibodies alirocumab and evolocumab. Although the drugs produce substantial reductions in LDL-C, cost issues and efficacy in preventing cardiovascular events should be evaluated when considering the adoption of PCSK9 inhibitors in the managed care setting.

Clinical Pharmacist Patient-Safety Initiative to Reduce Against-Label Prescribing of Statins With Cyclosporine.

BACKGROUND: Against-label prescribing of statins with interacting drugs, such as cyclosporine, represents an important patient safety concern. OBJECTIVE: To implement and evaluate the effectiveness of a clinical pharmacist patient-safety initiative to minimize against-label prescribing of statins with cyclosporine. METHODS: Kaiser Permanente Colorado clinical pharmacists identified patients receiving both cyclosporine and against-label statin through prescription claims data. Academic detailing on this interaction was provided to health care providers. Clinical pharmacists collaborated with physicians to facilitate conversion to on-label statin. Conversion rates along with changes in low-density lipoprotein cholesterol (LDL-C) were assessed. RESULTS: Of the 157 patients identified as taking cyclosporine, 48 were receiving concurrent statin therapy. Of these 48 patients, 33 (69%) were on an against-label statin regimen; 25 (76%) of these patients were converted to on-label statin. Overall, patients converted to on-label statin had a mean LDL-C prior to conversion of 82.9 (±26.4) mg/dL and mean LDL-C after conversion of 90.7 (±31.2) mg/dL ( P = 0.21). In all, 17 patients (68%) were switched to pravastatin 20 mg daily and 8 patients (32%) to rosuvastatin 5 mg daily. In patients converted to pravastatin 20 mg daily, the mean LDL-C was 13.5 mg/dL higher than prior to conversion ( P = 0.066). In patients converted to rosuvastatin 5 mg daily, the mean LDL-C was 3.8 mg/dL lower than prior to conversion ( P = 0.73). CONCLUSION: Utilizing a patient-safety-centered approach, clinical pharmacists were able to reduce the number of patients on against-label statin with cyclosporine while maintaining a comparable level of LDL-C control.

Pharmacist prescribing practices in a clinical pharmacy cardiac risk service.

PURPOSE: Prescribing practices within a clinical pharmacy cardiac risk service (CPCRS) and their impact on treatment outcomes in patients with atherosclerotic cardiovascular disease (ASCVD) are described. SUMMARY: National healthcare reforms have increased the population of insured patients and placed increased demands on physicians and other providers. Pharmacists are well trained and positioned to aid in patient care by providing expertise in medication management and patient safety that can result in pharmacotherapy optimization and cost savings. Kaiser Permanente Colorado (KPCO), a group-model health maintenance organization with about 675,000 members served by 30 medical offices throughout Colorado, has adopted a collaborative drug therapy management (CDTM) model that enables pharmacist prescribing to improve patient access, patient care, and healthcare cost-effectiveness. Within the CPCRS established by KPCO, qualified pharmacists are permitted to prescribe initial therapy, modify drug regimens, order laboratory tests, and perform follow-up activities within their professional scope of practice. The CPCRS focuses on the long-term management of patients with ASCVD. The primary goals of the CPCRS are to optimize secondary-prevention pharmacotherapy, monitor and ensure medication adherence, assist in the management of risk factors for ASCVD, provide patient education and counseling, and serve as a resource for physicians and other healthcare providers. Working under a CDTM agreement, pharmacists are authorized to prescribe therapies to minimize the risk of future ASCVD events. CONCLUSION: The CPCRS at KPCO has demonstrated successful maintenance of a clinical pharmacy service including pharmacist prescribing under a CDTM model to manage patients with ASCVD.

An assessment of cholesterol goal attainment in patients with chronic kidney disease.

BACKGROUND: Patients with chronic kidney disease (CKD) are at significant risk for cardiovascular disease (CVD). The National Kidney Foundation developed clinical practice guidelines (Kidney Disease Outcomes Quality Initiative) for targeting low-density lipoprotein cholesterol (LDL-C) goals. OBJECTIVE: This study evaluated the extent to which these guidelines were adhered to among patients with CKD and to examine factors associated with the attainment of LDL-C goals. METHODS: In this cross-sectional study we evaluated patients with a glomerular filtration rate of 15 to 59 mL/min per 1.73 m². Patients with previous CVD, who were receiving dialysis, or were post kidney transplant were excluded. Administrative databases were used to determine the percentage of patients with a fasting lipid profile performed within the previous year, the percentage who attained a LDL-C goal less than 100 mg/dL, and to determine lipid-lowering medications prescribed. Logistic regression analysis was used to identify factors associated with LDL-C goal attainment. RESULTS: Of the 4541 patients evaluated, 3157 (69.5%) had a fasting lipid profile performed within the previous year. Overall, 60.8% attained a LDL-C less than 100 mg/dL. Among patients at goal, 72.2% were taking lipid-lowering therapy compared with 37.9% of those not at goal (P < .01). Characteristics independently associated with LDL-C goal attainment were increasing age, male gender, increasing chronic disease score, history of diabetes, and statin use. CONCLUSION: Although most patients were screened and attained LDL-C goal, there was room for improvement. Statin use was independently associated with LDL-C goal attainment. Future prospective studies should focus on evaluating clinical outcomes of lipid-lowering interventions within the CKD population.