The Potential Effects of Implementing an Antibiotic Stewardship Program by Integrating It with Medication Therapy Service in a Low-Income Serving Clinic - A Single-Center Experience.

Background: Bacterial antimicrobial resistance (AMR) is a leading cause of mortality worldwide. Although AMR is common in low-income communities, there is limited evidence of the effect of antibiotic stewardship programs in low-income communities in the United States. Objectives: Our goal is to assess the effects of implementing pharmacist-led ASP by integrating it with medication therapy management service (MTM) in a low-income serving clinic. We evaluated the following 1) antibiotic prescriptions per 1000 patients, 2) the frequency of clinic (office) visits 30-day post-index clinic visits for recurring infections. Methods: To achieve our goal, we conducted a pre-post, quasi-experimental intervention study using an interrupted time-series analysis to assess the following: 1) antibiotic prescriptions per 1000 patients and the 2) frequency of office visits (including telehealth) within 30-day post-index clinic visits associated with recurrent infection. Results: Our findings revealed that the long-term effect of our antibiotic stewardship program intervention was associated with 63.69% reduction in antibiotic prescriptions per 1000 patients (change in slope = -0.173, [95% CI: (-0.30, -0.05)], P < 0.007) and a reduction in the frequency of office visits within 30-day post-index clinic visits by 67.27% (change in slope = -2.043, [95% CI: (-3.84, -0.24)], P < 0.028). Conclusion: Implementing antibiotic stewardship programs is feasible for clinics serving low-income populations. It was associated with a reduction in antibiotic prescriptions and preventable clinic (office) visits within 30 days due to infection recurrence.

Clinical impact of pharmacist-led antibiotic stewardship programs in outpatient settings in the United States: A scoping review.

PURPOSE: To provide an overview of the impact of pharmacist interventions on antibiotic prescribing and the resultant clinical outcomes in an outpatient antibiotic stewardship program (ASP) in the United States. METHODS: Reports on studies of pharmacist-led ASP interventions implemented in US outpatient settings published from January 2000 to November 2020 and indexed in PubMed or Google Scholar were included. Additionally, studies documented at the ClinicalTrials.gov website were evaluated. Study selection was based on predetermined inclusion criteria; only randomized controlled trials, observational studies, nonrandomized controlled trials, and case-control studies conducted in outpatient settings in the United States were included. The primary outcome was the observed differences in antibiotic prescribing or clinical benefits between pharmacist-led ASP interventions and usual care. RESULTS: Of the 196 studies retrieved for full-text review, a cumulative total of 15 studies were included for final evaluation. Upon analysis, we observed that there was no consistent methodology in the implementation of ASPs and, in most cases, the outcome of interest varied. Nonetheless, there was a trend toward improvement in antibiotic prescribing with pharmacist interventions in ASPs compared with that under usual care (P < 0.05). However, the results of these studies are not easily generalizable. CONCLUSION: Our findings suggest a need for a consistent approach for the practical application of outpatient pharmacist-led ASPs. Managed care organizations could play a significant role in ensuring the successful implementation of pharmacist-led ASPs in outpatient settings.

Mixed methods study of the potential therapeutic benefits from medical cannabis for patients in Florida.

OBJECTIVES: To evaluate medical marijuana patients' perceptions of therapeutic benefits for self-reported medical conditions. DESIGN: The study was a concurrent mixed methods study with adult medical marijuana patients. Survey data were collected using a web-based survey, and interviews were conducted in person or over the phone. SETTING: The study recruited 196 medical marijuana patients to complete surveys and 13 patients to participate in qualitative interviews in Florida. MEASURES: A validated patient survey was distributed via Florida medical marijuana social media groups to examine the therapeutic benefits of the cannabis plant for medical conditions and overall well-being. Concurrently, qualitative interviews were conducted to understand barriers and facilitators to accessing medical cannabis and explore preferences for different forms and strains, as well as any unexpected side effects. RESULTS: Patients used medical cannabis for relief of chronic pain or depression, followed by arthritis and nausea. Survey results indicated 89 % of patients reported "great relief" for their medical condition. Over 76 % of patients reported a score of 8 or higher on a 10-point scale that their medical condition had improved, and over 68 % reported a score of 8 or higher that medical cannabis had reduced their pain. Interviews indicated medical cannabis was effective for pain relief and reducing the use of prescription medicines, but the drug was perceived as too expensive. CONCLUSIONS: Medical marijuana patients were positive about the health benefits they received and the fact they were able to reduce or eliminate many prescription medications; however, there were concerns about the costs.

Identification of risk factors of 30-day readmission and 180-day in-hospital mortality, and its corresponding relative importance in patients with Ischemic heart disease: a machine learning approach.

Background: The primary objective of this study is to identify non-laboratory predictors for 30-day hospital readmission and 180-day in-hospital mortality rates among patients hospitalized with ischemic heart disease (IHD).Research design and methods: This is a retrospective cohort study of hospitalized patients (≥ 40 years) with a primary diagnosis of IHD. Data were extracted from the Florida Agency for Health Care Administration dataset from 2006 to 2016. A machine learning approach was used to identify predictors of 30-day hospital readmission and 180-day in-hospital mortality.Results: 346,390 patient records for incident IHD cases were identified. The top two predictors of 30-day readmission were the length of stay and the Elixhauser comorbidity index for readmission [ECI] (Area Under the Curve [AUC]=88%) using decision tree algorithms. For in-hospital mortality, the top two predictors were LOS and ECI (AUC=92%) using gradient boosting regressors. The cumulative 30-day readmission and the 180-day probability of mortality rates were 9.82% and 4.6% respectively.Conclusions: Risk factors of 30-day readmission and 180-day mortality in hospitalized IHD patients identified by machine learning and their relative importance (value) will help pharmacists and other health care providers to prioritize their disease management strategies as they improve the care provided to IHD patients.

An Evaluation of the Cost-effectiveness of Comprehensive MTM Integrated with Point-of-Care Phenotypic and Genetic Testing for U.S. Elderly Patients After Percutaneous Coronary Intervention.

BACKGROUND: Poor health outcomes after percutaneous coronary intervention (PCI) in elderly patients is an area of concern among policymakers and administrators. In an effort to determine the best strategy to improve outcomes among elderly patients who underwent PCI, several studies have evaluated the cost-effectiveness of genotype-guided antiplatelet therapy compared with universal use of any one of the antiplatelet drugs indicated for patients with acute coronary syndrome (ACS) who underwent PCI. The results have either been in favor of genotype-guided antiplatelet therapy or universal use of ticagrelor. However, no study has yet evaluated the cost-effectiveness of pharmacist-provided face-to-face medication therapy management (MTM) combined with point-of-care genotype-guided antiplatelet therapy (POCP) when compared with universal use of ticagrelor or clopidogrel for the elderly after PCI. OBJECTIVE: To evaluate the cost-effectiveness of a pharmacist integration of MTM with POCP (MTM-POCP) when compared with universal use of ticagrelor or clopidogrel combined with MTM (MTM-ticagrelor or MTM-clopidogrel). METHODS: We conducted a cost-effectiveness analysis from the perspective of the U.S. health care system. A hybrid model, consisting of a 1-year decision tree and a 20-year Markov model, was used to simulate a cohort of elderly patients (aged at least 65 years) with ACS who underwent PCI. Treatment strategies available to patients were POCP, POCP-MTM, MTM-clopidogrel, or MTM-ticagrelor. Data used to populate the model were obtained from the PLATO trial and other published studies. Outcome measures were costs, quality-adjusted life-years (QALYs) and incremental cost per QALY gained. A deterministic and probabilistic sensitivity analysis was conducted to account for the joint uncertainty around the key parameters of the model. Finally, a benchmark willingness to pay of $50,000-200,000 was considered. RESULTS: The use of PCOP (with dual antiplatelet therapy) resulted in 5.29 QALYs, at a cost of $50,207. MTM-clopidogrel resulted in 5.34 QALYs, at a cost of $50,011. The use of POCP-MTM resulted in 5.36 QALYs, at a cost of $50,270. Finally, MTM-ticagrelor resulted in 5.42 QALYs, at a cost of $53,346. MTM-ticagrelor was found to be cost-effective compared with MTM-clopidogrel or MTM-POCP, irrespective of the willingness to pay. The deterministic and probabilistic sensitivity analyses confirmed the robustness of the base-case analysis. CONCLUSIONS: The combination of MTM-ticagrelor was cost-effective when compared with MTM-POCP or MTM-clopidogrel. The transitional probabilities, however, were mostly based on published studies. Analysis based on a prospective randomized clinical study, comparing all the treatment strategies included in this study, is warranted to confirm our findings. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Okere and Diaby. Ezendu took the lead in data collection, along with Okere. Data interpretation was performed by all the authors. The manuscript was written by Okere, Diaby, and Berthe and revised by Okere and Diaby.

Implementation and Development of Emergency Department Pharmacist-Driven Patient-Care Transitional Model: A Discussion of Our Experiences and Processes.

Frequent preventable emergency department (ED) visits is an area of great concern among healthcare administrators. Although pharmacist interventions have been shown to reduce re-hospitalizations, studies demonstrating reduction in ED utilizations among the elderly are limited. Additionally, factors influencing readmissions in the ED are multifactorial. Hence, some healthcare systems struggle to reduce readmissions using pharmacy services. This has been a major issue facing care provided to the elderly in the ED. As healthcare care systems develops and implement a collaborative pharmacist and physician/mid-level provider comprehensive transitional model of care in the ED, the quality of care provided to the elderly will be enhanced which will ultimately translate to reduced inappropriate ED visit and re-hospitalization with corresponding reduction in financial burden placed on both the patient, caregiver and the society. Therefore, the objective of this article is to discuss our process with implementing pharmacist-providers transitional model in the ED. The intent is to elucidate some pharmacist-intervention principles and a pharmacist-driven, patient-care transitional model that would provide direction for other healthcare systems to improve ED visits within their locality.

An Evaluation of the Clinical Therapeutic Effect of Lixisenatide in Type 2 Diabetes Patients: A Systematic Literature Review.

BACKGROUND: With cardiovascular disease accounting for approximately 50% of deaths in patients diagnosed with type 2 diabetes, it is pertinent to initiate anti-diabetic medications with cardiovascular benefits. This systematic clinical review critically examines the clinical therapeutic effect of lixisenatide. METHODS: Data were gathered from articles indexed in PubMed, Google Scholar and Medline from 2010 - 2017, with the following search terms, "lixisenatide" and "GLP-1 receptor agonist". Studies written in the English language were included. RESULTS: Thirteen clinical studies which evaluated the efficacy of lixisenatide were analyzed. Results from these studies showed that lixisenatide is an effective monotherapy in the reduction of glycated hemoglobin (A1C), Postprandial Glucose (PPG) and Fasting Blood Glucose (FPG). As an add-on therapy to metformin or sulfonylureas and insulin, it was found to be clinically effective compared to placebo. In all reviewed trials, there were higher proportions of patients who achieved A1C < 7% or < 6.5% compared to placebo without a corresponding increase in weight. Finally, the use of lixisenatide was not associated with an increased risk of cardiovascular events. The most common adverse events in all lixisenatide groups were nausea, vomiting, and diarrhea. CONCLUSION: Lixisenatide appears to be safe and effective therapy for the management of type 2 diabetes mellitus. It is not associated with either the risk of cardiovascular events or symptomatic hypoglycemia. Finally, lixisenatide may be best used as an adjunct therapy for patients who are inadequately controlled with other diabetic medications, or select group of patients at risk of insulin induced obesity, hypertension or heart failure.

Predictors of Hospital Length of Stay and Readmissions in Ischemic Stroke Patients and the Impact of Inpatient Medication Management.

OBJECTIVE: This study was designed to evaluate predictors of hospital length of stay (LOS) and readmissions among nonsurgical ischemic stroke patient, and the impact of inpatient medication management. METHODS: This retrospective cohort study includes adult patients (≥18 years) hospitalized with a diagnosis of nonsurgical ischemic stroke from November 2007 to March 2013. In November 2011, an inpatient medication management model was implemented in the stroke unit. At the end of the study period, patients were matched before and after implementation of the inpatient medication management model (non-PHC [pharmacist-hospitalist collaborative] and PHC, respectively) to evaluate change in outcomes. The primary outcome of the study is an evaluation of predictive factors affecting LOS and readmissions. Additionally, changes in LOS and all-cause readmission at 30, 60, and 90 days when compared between PHC and non-PHC were evaluated. FINDINGS: A total of 151 PHC patients were matched to 248 non-PHC patients. There was no difference in LOS between the PHC and non-PHC patients (mean adjusted difference -.14; P = .66). Similar finding was observed for readmissions (P > .05). Insurance type was a significant predictor of LOS, with Medicare patients having an extended LOS compared to patients with private insurance (mean difference -1.00; P = .005). Patients taking statins and patients aged less than 80 years had a lower 30-day readmission rate compared to nonstatin users and patients aged 80 years or older, respectively (P < .05). CONCLUSIONS: Insurance type and severity of illness are important predictors of LOS, whereas readmissions are mostly influenced by age and statin use.

Comparison of a pharmacist-hospitalist collaborative model of inpatient care with multidisciplinary rounds in achieving quality measures.

PURPOSE: Results of a study of hospitalization outcomes with the use of a pharmacist-hospitalist collaborative (PHC) model of care as an alternative to multidisciplinary rounds (MDR) are reported. METHODS: In a retrospective matched-cohort study, data on more than 2000 adults discharged from two medical units of a community teaching hospital were analyzed to compare selected outcomes before and after the units augmented traditional hospitalist care (usual care) with either MDR or a PHC care model emphasizing pharmacist involvement in case review and medication management. The study cohorts were matched for primary diagnosis, severity of illness, and other variables. The outcomes were mean length of stay (LOS) and rates of all-cause readmission during designated preintervention and intervention periods. RESULTS: Among patients admitted to the unit that implemented the PHC care model, those admitted during the preintervention period had a longer mean LOS than matched intervention-phase patients: 5.5 days (95% confidence interval [CI], 5.0-6.0 days) versus 4.7 days (95% CI, 4.2-5.3 days); p = 0.002. Patients admitted to the MDR unit during the preintervention period also had a significantly longer mean LOS than those in the matched intervention-phase cohort. There were no significant between-group differences in all-cause readmissions. CONCLUSION: Systematic implementation of either the PHC or the MDR model of care was associated with a decreased mean hospital LOS relative to LOS values with usual care only. No significant differences in readmissions at 30, 60, and 90 days were attributable to implementation of the PHC or the MDR model.

Evaluation of the Potential Role of Alirocumab in the Management of Hypercholesterolemia in Patients with High-Risk Cardiovascular Disease.

A high level of low-density lipoprotein cholesterol (LDL-C) has proved to have a positive correlation with mortality from cardiovascular disease, and it is the key modifiable risk factor for cardiovascular disease. Lowering levels of LDL-C with statins reduces both vascular morbidity and mortality; however, myalgias occur in 10% to 15% of patients, and many patients managed with statins achieve suboptimal levels of LDL-C. The injectable drug alirocumab-the first of a new class of drugs called proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors-is a monoclonal antibody to the PCSK9 gene, which regulates LDL receptor expression and circulating levels of LDL-C. In this review, we evaluated the efficacy and safety of alirocumab and its potential role in the management of patients with high-risk cardiovascular disease. Data were gathered from articles indexed in the PubMed database (2006-April 2015). All English-language, prospective, randomized, double-blinded trials evaluating the efficacy of alirocumab, as a monotherapy or in combination with statins, for treatment of hypercholesterolemia were identified. Five clinical trials were evaluated, and the results from these studies revealed that the use of alirocumab, both as monotherapy or in combination with statins, significantly reduced LDL-C levels. Patients treated with alirocumab, with or without statins, were more likely to achieve LDL-C goals of less than 100 or 70 mg/dl compared with placebo. Despite its ability to lower LDL-C level, one study did not show any antiinflammatory activity (i.e., reduced C-reactive protein level) among patients who received alirocumab; however, more clinical trials will be needed to further assess this effect. Alirocumab also appears to cause regression of plaque. The most commonly reported adverse effect was mild injection-site reaction. With increased odds of statin discontinuation among patients taking high-intensity statins, alirocumab will contribute to atherosclerotic cardiovascular disease risk reduction. However, morbidity and mortality data, as well as long-term safety data, are pending. Therefore, we propose that alirocumab will better serve as an adjuvant therapy for the management of hypercholesterolemia in patients at high risk for cardiovascular events. As with all new promising injectable drugs, cost will also be a key consideration.

Evaluation of the influence of a pharmacist-led patient-centered medication therapy management and reconciliation service in collaboration with emergency department physicians.

BACKGROUND: The implementation of the Patient Protection and Affordable Care Act is anticipated to increase the frequency of emergency department (ED) visits. Therefore, there is a critical need to improve the quality of care transitions among ED patients from ED to outpatient services.  OBJECTIVE: To evaluate the effect of systematic implementation of a pharmacist-led patient-centered approach to medication therapy management and reconciliation service (MRS) in the ED on patient utilization of available health care services. METHODS: A single institution prospective randomized cohort study with 90-day postvisit observation randomized patients into 2 groups: (1) medication therapy management reconciliation service following a patient-centered approach (MRS) or (2) usual care provided by the institution (non-MRS). To align patient enrollment with availability of other primary care services, subjects were enrolled during weekday daytime hours. Data for the 90 days before and after the index ED visit were matched in all analyses. Generalized estimating equations evaluated any primary care (PC), urgent care (UC), and ED visits during the 90 days post-index ED visit, adjusted by age and sex and weighted by survival time. Generalized linear models evaluated the average number of ED visits during that period, adjusted by age and sex and weighted by survival time. Data were analyzed for all adult patients (ADLTS), aged ≥ 18 years, and the subpopulation taking 1 or more prescribed daily medication at the time of the index ED visit (ADLTS1+)-the patients expected to receive greatest benefit from an MRS program. RESULTS: ADLTS MRS patients were 1.9 more likely than non-MRS patients to visit their PC providers (mean difference 0.15, P less than 0.001). Similarly, ADLTS1+ MRS patients were 1.5 times more likely to visit their PC providers (mean difference 0.10, P = 0.026). Although ADLT MRS patients were less likely to visit the UC, this was not significant. However, ADLTS1+ MRS patients were significantly less likely than non-MRS patients (OR = 0.5, 95% CI = 0.3-0.9) to visit the UC. No significant difference was seen in ED visits. CONCLUSIONS: The implementation of a patient-centered approach to medication therapy management and reconciliation improved the odds of patients visiting their PC providers, a positive first step in transitioning patients toward an appropriate use of PC services.

Development and validation of a survey to assess patient-perceived medication knowledge and confidence in medication use.

BACKGROUND AND PURPOSE: The primary objective of this study is to establish the validity and reliability of a perceived medication knowledge and confidence survey instrument (Okere-Renier Survey). METHODS: Two-stage psychometric analyses were conducted to assess reliability (Cronbach's alpha > .70) of the associated knowledge scale. To evaluate the construct validity, exploratory and confirmatory factor analyses were performed. RESULTS: Exploratory factor analysis (EFA) revealed three subscale measures and confirmatory factor analysis (CFA) indicated an acceptable fit to the data (goodness-of-fit index [GFI = 0.962], adjusted goodness-of-fit index [AGFI = 0.919], root mean square residual [RMR = 0.065], root mean square error of approximation [RMSEA] = 0.073). A high internal consistency with Cronbach's a of .833 and .744 were observed in study Stages 1 and 2, respectively. CONCLUSIONS: The Okere-Renier Survey is a reliable instrument for predicting patient-perceived level of medication knowledge and confidence.