Development of a value-based care and population health internship for student pharmacists.

INTRODUCTION: Pharmacists assist in achieving desired outcomes and reducing costs of care within newer value-based payment models. The purpose of this article is to describe a summer internship for first- and second-year student pharmacists to gain exposure to value-based care. METHODS: University Health Network is a clinically integrated health network and accountable care organization in East Tennessee. Two student interns completed consecutive seven-week programs alongside clinical pharmacist specialists in the primary care settings of the network. Program requirements included direct patient care for chronic disease state management, topic discussions, formal writing assignments and presentations, and a quality improvement project. Student perception of internship activities was measured using a Likert type survey and free response questionnaire. RESULTS: Student interns responded positively to program requirements with feelings of enhanced preparedness for advanced pharmacy practice experiences and post-graduate residency positions. Additionally, interns perceived themselves as more competitive for post-graduate positions having completed the internship. CONCLUSIONS: As the US continues to move toward value-based payment models, student pharmacists must be well prepared to contribute to quality and population health initiatives. Student pharmacists benefit from an internship in a clinically integrated health network by gaining an improved understanding of the future of United States healthcare, an expanded clinical skillset, experience in demonstrating a pharmacist's value to the healthcare team, and the ability to overcome barriers to pharmacy services. A pharmacy internship within a clinically integrated health network may help prepare students to successfully contribute to value-based models of healthcare.

Calcineurin Inhibitor-Based Maintenance Immunosuppression in Lung Transplant Recipients: Optimal Serum Levels for Managing Acute Rejection and Renal Function.

BACKGROUND: Although effective for curtailing alloimmune responses, calcineurin inhibitors (CNIs) have an adverse-effect profile that includes nephrotoxicity. In lung transplant (LTx) recipients, the optimal serum levels of the CNI tacrolimus necessary to control alloimmune responses and minimize nephrotoxicity are unknown. METHODS: This retrospective, single-center study reviewed tacrolimus whole blood trough levels (BTLs), grades of acute cellular rejection (ACR), acute rejection scores, and creatinine clearance (CrCl) obtained in LTx recipients within the first year after their transplant procedure. Comparisons were made between the first 90 days post LTx (when tacrolimus BTLs were maintained >10 µg/L) and the remainder of the post-LTX year (when BTLs were <10 µg/L). RESULTS: Despite tacrolimus mean BTLs being higher during the first 90 days post LTx compared with the remainder of the first post-LTx year (10.4 ± 0.3 µg/L vs 9.5 ± 0.3 µg/L, P < .0001) there was no association with lower grades of ACR (P = .24). The intensity of ACR (as determined by acute rejection scores) did not correlate with tacrolimus mean BTLs at any time during the first posttransplant year (P = .79). During the first 90 days post LTx there was a significant decline in CrCl and a correlation between increasing tacrolimus mean BTLs and declining CrCl (r = -0.26, P = .03); a correlation that was not observed during the remainder of the year (r = -0.09, P = .52). CONCLUSIONS: In LTx recipients, maintaining BTLs of the CNI tacrolimus >10µg/L did not result in superior control of acute rejection responses but was associated with declining renal function.

Efficacy of alvimopan following bowel resection: a comparison of two dosing strategies.

BACKGROUND: Alvimopan is indicated to accelerate the time to gastrointestinal recovery following partial bowel resection with primary anastomosis. The approved dosing regimen includes an initial dose prior to surgery and 12 mg twice daily after surgery for up to 7 days; however, there are no human studies evaluating the need for the preoperative dose. We report our experience with gastrointestinal recovery when the preoperative dose is omitted. OBJECTIVE: To evaluate the efficacy of alvimopan therapy when the preoperative dose is not administered. METHODS: This retrospective study included elective surgery patients who underwent bowel resection with primary anastomosis without colostomy or ileostomy. The study compared (a) patients who received alvimopan and received a dose preoperatively, (b) patients who received alvimopan but did not receive a dose preoperatively, and (c) matched control patients who did not receive alvimopan. Length of stay following bowel resection, direct hospital costs, time to first bowel movement, and time to oral diet were evaluated. RESULTS: Of 50 patients who received alvimopan, 27 received the preoperative dose and 23 did not. These 50 patients were matched to similar control patients who received no alvimopan during their admission for resection. Compared with controls, time to discharge was significantly shorter in patients who received alvimopan, regardless of whether the preoperative dose was administered (P < .001) or omitted (P = .03). Patients who did not receive the preoperative dose still experienced faster time to first bowel movement (71 vs 97 hours; P = .006) and faster time to first diet (17 vs 54 hours; P < .001) than non-alvimopan users. CONCLUSION: Patients receiving the approved alvimopan dosing regimen experienced the most rapid recovery of gastrointestinal function. However, administering alvimopan only postoperatively (if the preoperative dose is omitted) may still reduce the severity of postoperative ileus.