Implementing a Quality Intervention to Improve Confidence in Outpatient Venous Thromboembolism Management.

INTRODUCTION: Guidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED). METHODS: A pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records. RESULTS: Twenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect. CONCLUSION: Although the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.

When patients develop blood clots in their veins or have blood clots travel to their lungs, they may seek treatment at the hospital emergency department. As a best practice, most people can treat blood clots with medicines at home; however, many patients are treated at the hospital. This study looked at how an education program for doctors in the hospital could help more patients be treated at home. The education program improved doctors' knowledge and confidence when evaluating patients with blood clots who could be treated at home. However, this study found that the number of patients treated at home was the same before and after the doctors participated in the education program. Two major problems that prevented patients from being treated at home were not having follow-up appointments readily available and patients taking their medicine as needed. More and different types of programs may help doctors understand the best ways to treat patients with blood clots in the emergency department.

An interrupted time series study of electronic health record clinical decision support for providers caring for patients with atrial fibrillation at increased stroke risk.

PURPOSE: To measure the effect of clinical decision support (CDS) on anticoagulation rates in patients with atrial fibrillation (AFib) or atrial flutter (AFlut) at high stroke risk and receiving care in outpatient settings, and to assess provider response to CDS. METHODS: This observational, quasi-experimental, interrupted time series study utilized electronic health record data at a large integrated delivery network in Texas from April to November 2020. CDS consisted of an electronic Best Practice Advisory (BPA)/alert (Epic Systems Corporation, Verona, WI) with links to 2 AFib order sets displayed to providers in outpatient settings caring for non-anticoagulated patients with AFib and elevated CHA2DS2VASc scores. Weekly outpatient anticoagulation rates were assessed in patients with high stroke risk before and after implementation of CDS. Alert actions and acknowledgment reasons were evaluated descriptively. RESULTS: Mean (SD) weekly counts of eligible patients were 8,917 (566) before and 8,881 (811) after implementation. Weekly anticoagulation rates increased during the pre-BPA study period (ß1 = 0.07%; SE, 0.02%; P = 0.0062); however, there were no significant changes in the level (ß2 = 0.60%; SE, 0.42%; P = 0.1651) or trend (ß3 = -0.01%; SE, 0.05%; P = 0.8256) of anticoagulation rates associated with CDS implementation. In encounters with the BPA/alert displayed (n = 17,654), acknowledgment reasons were provided in 4,473 (25.3%) of the encounters, with prescribers most commonly citing bleeding risk (n = 1,327, 7.5%) and fall risk (n = 855, 4.8%). CONCLUSION: There was a significant trend of increasing anticoagulation rates during the pre-BPA period, with no significant change in trend during the post-BPA period relative to the pre-BPA period.

Cardiovascular Outcomes Among Patients with Type 2 Diabetes Newly Initiated on Sodium-Glucose Cotransporter-2 Inhibitors, Glucagon-Like Peptide-1 Receptor Agonists, and Other Antidiabetic Medications.

BACKGROUND: Cardiovascular disease (CVD) remains the most prevalent cause of morbidity and mortality in patients with type 2 diabetes (T2D) and is a primary driver for health care costs associated with diabetes management. Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have demonstrated significant reductions in cardiovascular endpoints in clinical trials compared with placebo. However, it is uncertain whether these findings can be applied to the broader T2D population because these trials specifically included high-risk patients with established CVD. OBJECTIVE: To evaluate and compare cardiovascular outcomes among adults with T2D newly initiated on SGLT-2is, GLP-1 RAs, and other antidiabetic medications (oADMs) in a real-world setting. METHODS: This retrospective new-user cohort study used administrative claims and electronic health record data from an integrated delivery network in Texas. Patients aged ≥18 years with T2D and ≥1 prescription claim for an SGLT-2i, a GLP-1 RA, or an oADM filled between April 2013 and December 2018 were included. Patients were divided into three 1:1 propensity-matched groups according to index medication identified. Primary outcomes were heart failure hospitalization and a composite end-point of myocardial infarction, stroke, unstable angina, or coronary revascularization. Cox proportional hazards regression was used to compare cumulative incidence of all outcome variables. RESULTS: Among 9,477 patients, 1,134 were initiated on SGLT-2is, 1,072 on GLP-1 RAs, and 7,271 on oADMs. Patients initiating SGLT-2is versus oADMs had significantly lower risk of the composite endpoint (HR = 0.64, 95% CI = 0.46-0.90), heart failure hospitalization (HR = 0.56, 95% CI = 0.39-0.81), and unstable angina requiring hospitalization (HR = 0.56, 95% CI = 0.39-0.81). Patients initiating GLP-1 RAs compared with oADMs had significantly lower risk of the composite endpoint (HR = 0.71, 95% CI = 0.52-0.98) and unstable angina requiring hospitalization (HR = 0.60, 95% CI = 0.41-0.86). No differences in cardiovascular outcomes were found between SGLT-2is and GLP-1 RAs. CONCLUSIONS: Both SGLT-2is and GLP-1 RAs showed significant reductions in the composite outcome and unstable angina requiring hospitalization versus oADMs. However, only SGLT-2is were associated with a lower risk for heart failure hospitalizations. Nevertheless, cardiovascular outcomes were similar between SGLT-2is and GLP-1 RAs. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to report.

Guidelines impact cholesterol management.

BACKGROUND: Previous research demonstrates increased utilization of high-intensity statins, but unchanged low-density lipoprotein cholesterol (LDL-C) levels, immediately after the 2013 American College of Cardiology (ACC) and the American Heart Association (AHA) guideline release. OBJECTIVE: The objective of this study was to determine achievement of statin therapy goals in patients with atherosclerotic cardiovascular disease (ASCVD) before and up to 4 years after the 2013 ACC/AHA guideline release compared with LDL-C goals of <70 mg/dL and <100 mg/dL previously recommended by other professional societies. METHODS: The single-system cohort study used medical records, laboratory results, and claims data (November 2012-October 2017) of adults with ≥1 claim for a statin, ≥1 ASCVD diagnosis in propensity score-matched analyses. RESULTS: Among 1938 patients (mean age 70 ± 11, 48% female) with ASCVD, the percentage on high-intensity statin therapy significantly increased over time: 24% in 2013, 34% 2014, 42% 2015, and 49% 2016 (P < .0001). The increase in high-intensity statin use was 13 to 22% higher among patients managed by subspecialists (cardiologist and endocrinologists) compared with those managed by primary care providers. Mean LDL-C level was slightly, but not significantly, lower in 2013 (80 mg/dL) than in other years: 85 mg/dL in 2014, 83 mg/dL in 2015, and 82 mg/dL in 2016. The proportion of patients reaching LDL-C goals ranged from 51% to 56% for the <70 mg/dL target and 77% to 85% for the <100 mg/dL target over time. CONCLUSION: High-intensity statin use among secondary prevention patients increased significantly immediately after the 2013 ACC/AHA guidelines release, primarily in those managed by subspecialists. However, the mean LDL-C and the proportion of patients reaching LDL-C < 70 mg/dL and < 100 mg/dL remain unchanged across comparison cohorts.

Predictors of Appropriate Pharmacotherapy Management of COPD Exacerbations and Impact on 6-Month Readmission.

BACKGROUND: Suboptimal treatment of exacerbations is a major concern in management of chronic obstructive pulmonary disease (COPD). The Pharmacotherapy Management of COPD Exacerbation (PCE) Healthcare Effectiveness Data and Information Set (HEDIS) measure is a quality measure included by the National Committee for Quality Assurance that focuses on appropriate use of steroids and bronchodilators during an acute COPD exacerbation. There is limited evidence evaluating predictors of this quality measure, as well as its association with hospital readmission and cost outcomes. OBJECTIVES: To (a) describe characteristics of patients hospitalized for COPD, (b) evaluate factors associated with appropriate receipt of pharmacotherapy upon discharge, and (c) evaluate factors associated with the rate of readmission. METHODS: In this retrospective, observational, event-based study of COPD-related hospital and ED visits, events were identified between 2007 and 2013 from a Central Texas health plan using administrative claims data. The index date was defined as the date of admission. Subjects were included if they were aged ≥ 40 years and had a medical claim with a primary diagnosis for COPD or a pharmacy claim for a COPD maintenance medication during the 1-year pre-index period. Study groups were identified based on the receipt of PCE within the time frame specified by HEDIS: (a) a systemic corticosteroid within 14 days of discharge (PCE-C) or (b) a bronchodilator within 30 days of discharge (PCE-D). Bivariate analyses of potential factors associated with the receipt of PCE were performed using t-tests for continuous data and chi-square tests for categorical data. Generalized estimating equations, including significant predictors from the bivariate analyses, were used to determine factors associated with receipt of PCE-C and/or PCE-D, as well association with COPD-related and all-cause readmission within 6 months of discharge. RESULTS: Of 375 identified index admissions, 254 (68%) patients received PCE-C; 299 (80%) received PCE-D; and 229 (61%) received both. Patients were more likely to receive PCE with an index inpatient visit as compared with an ED visit (PCE-C: RR = 2.25, 95% CI = 1.21-4.17, P = 0.010; PCE-D: RR = 1.90, 95% CI = 1.01-3.58, P = 0.048). Those with previous use of rescue medication were also more likely to receive PCE (PCE-C: RR = 1.88, 95% CI = 1.12-3.17, P = 0.018; PCE-D: RR = 2.11, 95% CI = 1.16-3.83, P = 0.014). Patients with greater adherence (proportion of days covered [PDC] ≥ 75%) to COPD maintenance medication before admission (RR = 8.67, 95% CI = 1.60-46.78, P = 0.012) were also more likely to receive PCE-D. Older patients were more likely to have a COPD-related readmission (RR = 1.07, 95% CI = 1.01-1.13, P = 0.028), while use of maintenance medication before admission was associated with lower risk of an all-cause readmission (RR = 0.49, 95% CI = 0.30-0.79, P = 0.004). In addition, patients with higher medical and pharmacy costs before the index event were more likely to have all-cause readmission (RR = 1.01, 95% CI = 1.00-1.02, P = 0.013). Receipt of PCE was not shown to be a significant predictor of all-cause or COPD-related readmission. CONCLUSIONS: The use of bronchodilators and systemic corticosteroids after a COPD-related inpatient or ED visit may be related to the severity of the index COPD exacerbation or patients' previous pattern of bronchodilator use. However, the use of maintenance medication before the index event was associated with a significant reduction in all-cause readmission, so proper treatment of the underlying disease may be an effective strategy in reducing readmission. DISCLOSURES: Funding for this study was provided by GlaxoSmithKline (HO-14-15081). Tran was a Fellow at Scott & White Health Plan (SWHP) during year 1 of this study and a Fellow at Novartis during year 2 of this study. Novartis did not have any input in this study nor did it contribute any funding or support for this research. Tran, Xiang, Godley, and Stock were employed by SWHP at the time of this study. Rascati is employed by the University of Texas at Austin and also by the Journal of Managed Care & Specialty Pharmacy and has received consulting fees from GlaxoSmithKline. Coleman, Bogart, and Stanford are GlaxoSmithKline employees and shareholders. Study design was created by Rascati, Tran, and Godley, with assistance from Stock, Coleman, Bogart, and Stanford. Tran and Xiang collected the data, with data analysis and interpretation performed by Stock and Rascati. The manuscript was written by Tran, Rascati, and Xiang and revised by Godley, Stock, Coleman, Bogart, and Stanford.

Analysis of Glycemic Control of a Pharmacist-Led Medication Management Program in Patients with Type 2 Diabetes.

BACKGROUND: An integrated health care system with its own regional health plan located in Texas implemented a pharmacist-led diabetes medication management program (MMP) to treat type 2 diabetic patients (baseline A1c > 7.5%). The MMP formed collaborative practice agreements with the system's physicians to allow ambulatory care pharmacists to modify and adjust diabetic drug regimens when appropriate. Enrolled MMP patients received personalized visits with ambulatory care pharmacists and a copay waiver on diabetes medications. OBJECTIVE: To study the outcomes of an outpatient, pharmacist-led MMP, along with a copay waiver on diabetes drugs, in treating adults with type 2 diabetes mellitus over a 2-year period compared with standard care practice. METHODS: This retrospective study employed a quasi-experimental design and used medical claims, pharmacy claims, eligibility data, and electronic medical records. Patients aged 18 to 62 years, who were diagnosed with type 2 diabetes mellitus, and had at least 1 diabetes-related pharmacy claim in the year before the MMP, as well as continuous enrollment in the health plan, were included. Patients enrolled in the pharmacist-led MMP for at least 2 years (n =75) were matched to standard care patients (n =75) on age, gender, baseline A1c, insulin use, and physical comorbidity. The primary outcome was the 2-year change in A1c. Secondary outcomes included inpatient costs, outpatient costs, and pharmacy costs from the baseline period (year before enrollment) compared with the follow-up period (second year of enrollment). RESULTS: After matching MMP patients (n = 75) to control patients (n = 75), the baseline A1c (9.30 and 9.26), the mean age (53.0 and 53.3, respectively), the Selim Physical Score (3.32 and 3.26, respectively), and the use of insulin (56.0% and 56.0%, respectively) were similar in both groups. MMP patients had a greater mean reduction in A1c compared with standard care patients (-1.24 vs. -0.59, P = 0.009) from baseline to after 2 years. After 2 years, the A1c for MMP patients was significantly lower compared with control patients (8.06 vs.8.67, respectively, P = 0.014). There was also a difference in A1c after 1 year for MMP patients versus control patients (8.18 and 8.69, respectively, P = 0.012). CONCLUSIONS: A pharmacist-led diabetes MMP, combined with a diabetes drug copay waiver, was effective in significantly reducing A1c over a 2-year period for type 2 diabetic patients in this regional health plan.

Development and implementation of a telephone medication therapy management program for Medicare beneficiaries.

PURPOSE: A pharmacist-provided telephone medication therapy management (MTM) program for Medicare beneficiaries is discussed. SUMMARY: The Medicare Modernization Act of 2003 requires the provision of MTM to eligible beneficiaries. Using an MTM framework as a guide, Scott & White Health Plan (SWHP), a regional Medicare Part D plan, developed and implemented a pharmacist-provided telephone MTM service for Medicare beneficiaries. A clinical pharmacist, practicing pharmacists, and physicians at SWHP were responsible for developing the MTM program. The MTM coordinator, who was also a pharmacist, worked with an information systems programmer to develop a custom-built database to support the documentation needs. Patients who were identified by SWHP as eligible to receive MTM services were mailed an MTM program information brochure each quarter. The brochure, which was sent out in two-week increments to manage the call volume, described the program and invited patients to participate. Interested patients were instructed to call SWHP to enroll in the MTM program. The medication therapy review, a core component of MTM, consisted of two steps: preassessment and assessment. Problems identified during the preassessment were confirmed or disproved, and during the assessment, medication-related problems were assessed. After the consultation, patients were mailed a portable personal medication record to use to fill out their medication lists. They also received a medication action plan that was tailored to each individual patient. The pharmacist provided consulting services and intervened to address medication- and health-related problems and to refer the patient to other health care providers if needed. CONCLUSION: A regional health plan successfully developed and implemented a telephone MTM service for Medicare beneficiaries provided and managed by pharmacists.

The need for improved medical management of patients with concomitant hypertension and type 2 diabetes mellitus.

OBJECTIVES: To determine level of blood pressure (BP) control and to evaluate hypertension management strategies in patients with hypertension and type 2 diabetes mellitus. STUDY DESIGN: Retrospective review of 2 consecutive years of pharmacy and medical insurance claims data and medical charts from patients participating in 10 health plans in 9 states. PATIENTS AND METHODS: Patients 18 years and older with a medical or pharmacy claim related to hypertension were identified and assessed for inclusion in the database. A random sample of medical charts was reviewed to confirm the diagnoses of hypertension and diabetes mellitus and degree of BP control and to assess the prevalence of other cardiovascular disease risk factors and current antihypertensive treatment. RESULTS: Type 2 diabetes mellitus was documented in 977 patients. The mean age was 64.3 years, and 55.1% were women. A BP goal of less than 130/85 mm Hg was achieved in 192 patients (19.7%), and a BP goal of less than 130/80 mm Hg was achieved in 135 patients (13.8%). Fifty-two percent of patients had dyslipidemia, and 87.6% were overweight, obese, or morbidly obese; tobacco use was documented in 19.5%. CONCLUSIONS: Hypertensive diabetic patients are frequently not treated to their goal BP, which requires the use of 2 or more agents in most patients. Quality improvement programs should emphasize the importance of treating hypertensive diabetic patients to their goal BP, as well as controlling other major cardiovascular disease risk factors, such as smoking, dyslipidemia, and overweight or obesity, that are prevalent among these high-risk patients.