Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations: A Report from the Accountable Care Organization Research Network, Services, and Education.

BACKGROUND: The accountable care organization (ACO) is an innovative health care delivery model centered on value-based care. ACOs consisting of primary care providers are increasingly becoming commonplace in practice; however, medication management remains suboptimal. PROGRAM DESCRIPTION: As experts in medication management, pharmacists perform direct patient care and assist in the transition from one provider to another, which places them in an ideal position to manage multiple aspects of patient care. Pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits. Although pharmacists have become key team members of interdisciplinary teams within traditional care settings, their role has often been overlooked in the primary care-based ACO. In 2015, Nova Southeastern University College of Pharmacy founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED), a team of pharmacy practice faculty dedicated to using innovative approaches to patient care, while providing unique learning experiences for pharmacy students by partnering with ACOs in the South Florida region. Five opportunities are presented for pharmacists to improve medication use specifically in primary care-based ACOs: medication therapy management, annual wellness visits, chronic disease state management, chronic care management, and transitions of care. OBSERVATIONS: Several challenges and barriers that prevent the full integration of pharmacists into primary care-based ACOs include lack of awareness of pharmacist roles in primary care; complex laws and regulations surrounding clinical protocols, such as collaborative practice agreements; provider status that allows compensation for pharmacist services; and limited access to medical records. By understanding and maximizing the role of pharmacists, several opportunities exist to better manage the medication-use process in value-based care settings. IMPLICATIONS/RECOMMENDATIONS: As more organizations realize benefits and overcome barriers to the integration of pharmacists into patient care, programs involve pharmacists will become an increasingly common approach to improve outcomes and reduce the total cost of care and will improve the financial viability of primary care-based ACOs. DISCLOSURES: No outside funding supported this research. The authors report no conflicts of interest related to this manuscript. Study concept and design were contributed by Joseph, Hale, and Eltaki, with assistance from the other authors. Prados and Jones took the lead in data collection and data interpretation and analysis, with assistance from the other authors. The manuscript was written primarily by Joseph and Hale, along with the other authors, and revised primarily by Seamon and Gernant, along with the other authors.

Role of Residency Interview Preparatory Activities as a Determinant on Pharmacy Residency Match Rates.

PURPOSE: Different strategies have been implemented to assist students in securing residency positions. The purpose of this study was to explore the impact of student participation in residency preparation activities on match rates. METHODS: A retrospective observational study was conducted to explore the effect of participation in residency preparation activities and grade point average (GPA) on residency match rate. Match rates for students participating in the Residency Interview Preparation Seminar (RIPS) or mock interviews (ie, intervention group) were compared with students who participated in neither activity (ie, control group). RESULTS: A total of 118 individuals were included in the comparison. Forty-eight students participated in RIPS (n = 29) or mock interviews (n = 19), while 70 students were in the control group. The intervention group had a statistically larger proportion of students securing residency than the control group (81% vs 57%; P = .009). Match rates between students enrolled in RIPS versus those in the mock interview group were not significant. No statistically significant differences were observed based on GPA. CONCLUSION: Students receiving additional preparation prior to interviews when seeking postdoctoral training were significantly more likely to obtain a residency position. In academic settings with limited resources, mock interviews may be preferred over comprehensive preparatory courses.

Medical marijuana and the developing role of the pharmacist.

PURPOSE: The pharmacology, therapeutic uses, safety, drug-drug interactions, and drug-disease interactions of medical marijuana are reviewed, and the legal issues related to its use and the implications of medical marijuana for the pharmacist are presented. SUMMARY: Marijuana contains more than 460 active chemicals and over 60 unique cannabinoids. The legal landscape surrounding marijuana is surprisingly complex and unsettled. In the United States, 11 states and several municipalities have legalized medical marijuana. Another state provides legislation that allows patients to claim a defense of medical necessity. Nevertheless, patients using medical marijuana may never interact with a pharmacist. Marijuana is a Schedule I controlled substance and its use is illegal under federal law. Marijuana has a number of purported therapeutic uses with a broad range of supporting evidence. There are five general indications for medical marijuana: (1) severe nausea and vomiting associated with cancer chemotherapy or other causes, (2) weight loss associated with debilitating illnesses, including HIV infection and cancer, (3) spasticity secondary to neurologic diseases, such as multiple sclerosis, (4) pain syndromes, and (5) other uses, such as for glaucoma. Marijuana is associated with adverse psychiatric, cardiovascular, respiratory, and immunologic events. Moreover, marijuana may interact with a number of prescription drugs and concomitant disease states. CONCLUSION: Several states have legalized the use of marijuana for chronic and debilitating medication conditions. Pharmacists need to understand the complex legal framework surrounding this issue so that they can protect themselves and better serve their patients.

Clinical decision support tools: analysis of online drug information databases.

BACKGROUND: Online drug information databases are used to assist in enhancing clinical decision support. However, the choice of which online database to consult, purchase or subscribe to is likely made based on subjective elements such as history of use, familiarity, or availability during professional training. The purpose of this study was to evaluate clinical decision support tools for drug information by systematically comparing the most commonly used online drug information databases. METHODS: Five commercially available and two freely available online drug information databases were evaluated according to scope (presence or absence of answer), completeness (the comprehensiveness of the answers), and ease of use. Additionally, a composite score integrating all three criteria was utilized. Fifteen weighted categories comprised of 158 questions were used to conduct the analysis. Descriptive statistics and Chi-square were used to summarize the evaluation components and make comparisons between databases. Scheffe's multiple comparison procedure was used to determine statistically different scope and completeness scores. The composite score was subjected to sensitivity analysis to investigate the effect of the choice of percentages for scope and completeness. RESULTS: The rankings for the databases from highest to lowest, based on composite scores were Clinical Pharmacology, Micromedex, Lexi-Comp Online, Facts & Comparisons 4.0, Epocrates Online Premium, RxList.com, and Epocrates Online Free. Differences in scope produced three statistical groupings with Group 1 (best) performers being: Clinical Pharmacology, Micromedex, Facts & Comparisons 4.0, Lexi-Comp Online, Group 2: Epocrates Premium and RxList.com and Group 3: Epocrates Free (p < 0.05). Completeness scores were similarly stratified. Collapsing the databases into two groups by access (subscription or free), showed the subscription databases performed better than the free databases in the measured criteria (p < 0.001). CONCLUSION: Online drug information databases, which belong to clinical decision support, vary in their ability to answer questions across a range of categories.

The legal status of medical marijuana.

OBJECTIVE: To review the legal status of medical marijuana in the US. DATA SOURCES: Relevant publications were located using LexisNexis (1982-October 2006), WestLaw (1996-October 2006), BNA Health Law Reporter (1996-October 2006), MEDLINE (1996-October 2006), EMBASE (1980-October 2006), International Pharmaceutical Abstracts (1970-October 2006), and an Internet search targeting government sites using the key words medical marijuana. STUDY SELECTION AND DATA EXTRACTION: Federal and state medical marijuana laws were examined. Relevant cannabinoid-based drug products were reviewed. Federal and State Supreme Court and Appeal level cases involving medical marijuana were evaluated. DATA SYNTHESIS: Marijuana is regulated as a Schedule I controlled substance and its use is prohibited under federal law. Dronabinol and nabilone are synthetic cannabinoids approved by the Food and Drug Administration and Sativex is a cannabis-based extract being evaluated in Phase III trials. The federal government sponsors a single patient compassionate use Investigational New Drug Application program providing medical marijuana for a small number of patients. Eleven states permit marijuana use for medical purposes and one state provides a defense of medical necessity. Employers do not have to provide workplace accommodations for employees using medical marijuana and can terminate them at will. Healthcare providers have First Amendment constitutional protections that allow them to discuss marijuana with patients. CONCLUSIONS: Until the Supreme Court rules directly on the constitutionality of state medical marijuana laws, a conflict remains. Marijuana use remains illegal under federal law and states assume their medical marijuana laws to be constitutional.

Statin withdrawal: clinical implications and molecular mechanisms.

Retrospective analyses of data from the Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM), the National Registry of Myocardial Infarction 4, and the Global Registry of Acute Coronary Events (GRACE) trials revealed that the benefits of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) on acute coronary outcomes are rapidly lost and outcomes worsened if statins are discontinued during a patient's hospitalization for an acute coronary syndrome. Withdrawal of statin therapy in the first 24 hours of hospitalization for non-ST-elevation myocardial infarction increased the hospital morbidity and mortality rate versus continued therapy (11.9% vs 5.7%, p<0.01). Data from the Treating New Targets (TNT) study, however, suggested that short-term discontinuation of statin therapy in patients with stable cardiac conditions may not substantially increase the risk of acute coronary syndromes. In patients with acute coronary syndromes who discontinue statins, the rapid increase in risk of an event may result not only from the lost benefits from the therapy, but also from rebound inhibition of vascular protective substances and activation of vascular deleterious substances. Statins inhibit cholesterol synthesis in vascular cells. By reducing levels of isoprenoid intermediates, statins increase the production of nitric oxide and downregulate angiotensin II AT(1) receptors, endothelin-1, vascular inflammatory adhesion molecules, and inflammatory cytokines. These benefits are rapidly lost and often transiently reversed when statins are acutely discontinued. Acute removal of pleiotropic effects and rebound vascular dysfunction may be more important in an acute coronary event, where inflammation promotes rupture of atherosclerotic plaques and inflammatory and prothrombosis markers are present in high concentration, than in stable chronic vascular disease. In the absence of data from randomized controlled trials, current information suggests that statin therapy should be continued, and possibly boosted, during hospitalization for an acute coronary syndrome. Because statins are discontinued during the early hospitalization of many patients, practitioners must ensure that statins are not omitted, unless contraindicated, from the treatment of patients with acute coronary syndromes.

Ephedra: yesterday, DSHEA, and tomorrow--a ten year perspective on the Dietary Supplement Health and Education Act of 1994.

The Dietary Supplement Heath and Education Act of 1994 (DSHEA) established the regulatory framework for dietary supplements in the United States, triggering the growth of a multi-billion dollar industry. Ephedra is a dietary supplement used for weight loss. However, due to its sympathomimetic activity, it has caused stroke, cardiac arrhythmia, and death. Accordingly, the Food and Drug Administration (FDA) has prohibited its sale in the United States since April 12, 2004. Consequently, numerous other dietary supplements are attempting to fill the marketing void. An evaluation of these products demonstrates a general lack of efficacy and safety data. Thus, in the ten years since the passage of DSHEA, the dietary supplement industry remains controversial and a concern for consumer safety.

Evaluation of drug information databases for personal digital assistants.

PURPOSE: Core and supplemental drug information databases available for use with personal digital assistants (PDAs) were evaluated. METHODS: Ten core (or standalone) databases, six drug interaction analyzers, and three dietary supplement databases used with the Palm and Pocket PC operating systems were selected for study. The databases were rated for scope (the absence or presence of an answer to a drug information question), completeness (the comprehensiveness of an answer), and ease of use (the number of hypertext links needed to reach the desired answer). A total of 14 weighted categories, consisting of 146 and 30 drug questions for the core and supplemental databases, respectively, were used to determine the overall scores. RESULTS: The best overall performers were, in order of total scores, Lexi-Drugs Platinum, Tarascon Pocket Pharmacopoeia, ePocrates Rx Pro, and Clinical Pharmacology OnHand. The databases with the lowest composite scores were Triple i Prescribing Guide and A2Z Drugs. CONCLUSION: Drug information databases for PDAs varied in scope, completeness, and ease of use. The results may help clinicians find the most appropriate product for their practice setting.