Implementation of Antimicrobial Stewardship Interventions in Primary Care: Acute Bacterial Rhinosinusitis Treatment Strategies.

BACKGROUND: The highest prescribing rates for antibiotics occur in primary care, therefore, ambulatory care pharmacist interventions could play a major role in preventing overuse and misuse of antibiotics. Delegated pharmacists in the SJC primary care setting guided 3 activities with a goal of positively impacting prescribing patterns: monthly webinars provided by Agency for Healthcare Research and Quality (AHRQ), quarterly reporting to physicians of antibiotic prescribing patterns, and development of a clinical decision-making support tool for antibiotic prescribing. METHODS: Retrospective, observational data was collected to evaluate antibiotic prescribing patterns in patients diagnosed with acute sinusitis both before initiatives were implemented (July 1, 2019 through June 30, 2020) and after the initiatives were implemented (April 1, 2022 through June 30, 2022). RESULTS: A total of 675 patients were diagnosed with acute bacterial sinusitis during the specified time frame. Of these, 138 patients were excluded. A total of 279 antibiotics were prescribed in the preintervention group out of 298 patient encounters (93.6%) and 225 antibiotics were prescribed in the post-intervention group out of 244 patient encounters (92.9%) (p = .26). Although the primary outcome was not statistically significant, a significant reduction in patients treated with fluoroquinolones was noted, with 59/298 (20%) of those being prescribed in the pre-intervention group and 20/244 (8%) in the post intervention group (P = .02). CONCLUSIONS: While pharmacist-led antimicrobial stewardship interventions in primary care did not result in a decrease in the overall prescription of antibiotics for acute sinusitis, our study did reveal a notable reduction in the use of fluoroquinolones. This finding highlights a promising avenue for expanding the role of ambulatory care pharmacists.

Expansion of a postgraduate year 2 ambulatory care pharmacy residency program utilizing Medicare annual wellness visits within primary care.

BACKGROUND: Funding for pharmacy residency programs is traditionally allocated by the Centers for Medicare and Medicaid Services. In 2003, funding for postgraduate year 2 (PGY-2) was retracted. PGY-2 sites must develop additional funding methods to facilitate program expansion. OBJECTIVE: To describe the impact of expanding a PGY-2 ambulatory care pharmacy residency through an innovative funding model. PRACTICE DESCRIPTION: St. Joseph's/Candler Health System (SJC) employs pharmacists, including ambulatory care pharmacists, supported by revenue from Medicare annual wellness visits (AWVs) and pharmacy residents. PRACTICE INNOVATION: The PGY-2 ambulatory care program at SJC historically offered 1 position supported by SJC. The program expanded in 2020 to further patient outreach with disease state management by increasing the number of pharmacists providing comprehensive patient care. The additional position was primarily supported using funding from AWVs completed by pharmacy residents. To ensure adherence with the American Society of Health-System Pharmacists, residents were evaluated quarterly by preceptor based on feedback provided by clinicians at the practice site. EVALUATION METHODS: In addition to conducting AWVs, residents worked with physicians within the state-defined scope of practice to optimize medications, support office visits, promote medication adherence and antimicrobial stewardship improvement activities, and implement a blood pressure monitoring program. RESULTS: From July 15, 2020 to March 31, 2021, 407 AWVs were completed by SJC PGY-2 ambulatory care residents, and average AWVs per day increased from 4.5 to 6.9. As compared with the previous year, total AWVs at the primary clinic doubled after pharmacy resident addition, increasing from 251 to 550 (P < 0.001). CONCLUSION: Through an additional position fiscally supported by reimbursement from AWVs, SJC Ambulatory Care PGY-2 residents increased patient outreach to preventative services as compared with the previous year, expanded pharmacy practice to a new practice site, and generated revenue. This funding method is a viable option to expand postgraduate pharmacy training and ensure optimal patient care in the outpatient setting.

Diabetes outcomes before and during telehealth advancements surrounding COVID-19.

BACKGROUND: Pharmacists can optimize outcomes related to type-2 diabetes (T2D) by taking advantage of telehealth opportunities despite the coronavirus 2019 (COVID-19) Public Health Emergency (PHE). OBJECTIVE: Identify and compare changes in T2D outcomes before (August 2019 through February 2020) and during (March 2020 through October 2020) the COVID-19 PHE. Secondary objectives were to identify and compare pay-for-performance metrics and additional fee-for-service submitted in these patients. METHODS: This study examined changes in T2D outcomes at one primary care office within a community health system. Pharmacists started regularly using Remote Patient Monitoring (RPM) services during the COVID-19 PHE to reduce in-person visits. Patients with an initial glycosylated hemoglobin (A1C) greater than or equal to 8% were included. Data collected included comorbidities, change in A1C, and diabetes and statin medication therapy adherence. Percentage of Healthcare Effectiveness Data and Information Set (HEDIS) and Merit-Based Incentive Payment System (MIPS) measures were met, and billing code frequencies were also assessed. RESULTS: In the pre-COVID-19 PHE group (N = 30), the average 3- and 6-month A1C reductions were 1.3% and 1.2%, respectively, and the reductions were 2.0% and 2.2% in the during-COVID-19 PHE group (N = 61). The percentage of patients appropriately initiated or maintained on statins was 96.2% in the pre-COVID-19 PHE group versus 82.6% in the during-COVID-19 PHE group. Related to HEDIS, statin adherence was 95.2% in the pre-COVID-19 PHE group and 84.2% in the during-COVID-19 PHE group, and A1C control was 41.7% versus 54%, respectively. A1C control related to MIPS was 60% before COVID-19 PHE versus 73.8% during the COVID-19 PHE. Diabetes medication adherence related to HEDIS and medication reconciliation related to MIPS was 100% for both groups. CONCLUSION: Data demonstrate the opportunity for pharmacists to maintain and improve clinical outcomes related to T2D despite the ongoing COVID-19 PHE through implementation of telephonic monitoring.

Integration and compensation of pharmacists into primary care medical groups.

OBJECTIVE: To demonstrate the expansion of an outpatient pharmacy program within a health system via annual wellness visits (AWVs) and disease state management patient encounters at outpatient medical groups. SETTING: A referral-based pharmacist-managed ambulatory care center, a department of a hospital, and 4 primary care medical groups of a community practice hospital health system in Savannah and Pooler, Georgia, and Bluffton, South Carolina. PRACTICE DESCRIPTION: St. Joseph's/Candler is a 714 bed, 2 hospital community practice heath care system located in Savannah, Georgia. The St. Joseph's/Candler Center for Medication Management (CMM) is a pharmacist-managed ambulatory care clinic that provides referral-based ambulatory care services in anticoagulation, diabetes, heart failure, tobacco cessation, transitional care, vaccinations, and wellness contracts for self-insured organizations, and has 147 referring physicians. Nurse Practitioners and Pharmacists evaluate and manage patients under their scope of practice and supervising medical director for the CMM. Pharmacists and Nurse Practitioners educate patients and collaborate with referring physicians for disease state management but do not carry prescriptive authority at CMM. CMM bills for services as a provider-based department of the hospital. CMM is recognized as an Anticoagulation Center of Excellence by the Anticoagulation Forum and is interventional with ambulatory care quality initiatives of the health system. Pharmacists in CMM are board-certified in ambulatory care provided by Board of Pharmacy Specialties and have completed a minimum of a 1-year post-graduate training program accredited by the American Society of Health-System Pharmacists. CMM has 4 off-campus satellite locations providing ambulatory care referral-based services. Since 2007, the CMM has primarily provided anticoagulation services via laboratory monitoring and management of warfarin. PRACTICE INNOVATION: Pharmacists transitioned from provider-based departments of a hospital to outpatient primary care medical groups. This transition changed their job description and the model for reimbursement of the pharmacists' salaries. Four pharmacists were present 60 hours per week from January 2018 to August 2018, and 80 hours per week (2 full-time clinical pharmacist positions) from September 2018 to December 2018, to conduct AWVs and disease state management patient encounters. These pharmacists divided their time between a department of a hospital and a traditional medical group of the same health system. EVALUATION: For calendar year 2018, 1770 AWVs and 468 disease state management patient care visits were provided exclusively by pharmacists to patients of the 4 primary care medical groups of this community practice health system. Patient visits for disease state management included diabetes, hypertension, hyperlipidemia, anticoagulation, and tobacco cessation. RESULTS: For the calendar year 2018, 1770 AWVs and 468 disease state management patient visits were provided exclusively by pharmacists, under the direct supervision of physician, to patients of primary care medical groups. CONCLUSION: This is an example of expanding direct patient care pharmacy services, within a health system, to primary care medical groups, without direct grant or university funding.