A Geriatric Pharmacy Resident's Clinical and Educational Activities During Weekly interprofessional Team Meetings.

OBJECTIVES: To describe and gather further details about the clinical and educational activities that were documented by the geriatric pharmacist resident during both weekly interprofessional Acute Care for the Elderly (ACE) rounds as well as bedside patient counseling. DESIGN: Retrospective chart review (quality improvement project). SETTING: Inpatient geriatric service at University of Pittsburgh Medical Center (UPMC). PATIENTS: Medical learners selected one complex patient from the geriatric service for ACE rounds each week. ACTIVITIES: The geriatric pharmacist resident provided clinical information and medication education to the interprofessional team and to the patient and/or family at their bedside. Activities were documented in a newly developed template. MAIN OUTCOME MEASURES: Patient demographics, medication categories, discrepancies and dosing changes, time-in-rounds, and team members. RESULTS: De-identified data from 18 patients (72.2% female, average age 82.5 ± 9.18 years) over a 6-month period were collected and analyzed. The geriatric pharmacist resident provided most education to the team on antibiotics, antidepressants, over-thecounters (OTCs), and prescription pain medications during ACE rounds. They provided most education to the patient/family on prescription pain medications, antidepressants, OTCs, and anticoagulants. The pharmacist resident identified 38 medication discrepancies (72.2% of patients had ≥ 1 discrepancy, range 0-7) and clinically significant drug-drug interactions in 15 patients. The pharmacist resident recommended dosing changes in 12 patients and therapeutic alternatives in 11 patients. The ACE rounds lasted on average 26.6 [± 6.42] minutes and included medicine, pharmacy, social work, nurse case management, nursing, and nutrition and rehabilitative services when necessary. CONCLUSION: The results provide insight into both the clinical and educational activities of the geriatric pharmacist resident in support of interprofessional rounds.

Evaluation of Direct Oral Anticoagulant Dosing and Monitoring in Two Geriatric Outpatient Clinics.

OBJECTIVE: This study was conducted to evaluate direct oral anticoagulants (DOACs) prescribed to elderly patients in an outpatient setting, specifically evaluating if Food and Drug Administration (FDA) -approved dosing recommendations are followed.
DESIGN: This study was a retrospective quality improvement project.
SETTING: This study was conducted at geriatric hospital-based primary care clinics at the University of Pittsburgh Medical Center (UPMC), UPMC Senior Care Institute and UPMC Benedum Geriatric Center.
PATIENTS: Subjects included were 65 years of age or older; had an office visit at UPMC Senior Care Institute or UPMC Benedum Geriatric Center from September 1, 2015, to August 31, 2017; and had a DOAC on their home medications.
INTERVENTIONS: Data were obtained through retrospective chart review.
MAIN OUTCOME MEASURE: The primary objective of the study was to evaluate the appropriateness of dosing of DOACs based on FDA-labeled recommendations.
RESULTS: Of 232 patients included in analysis, 42.7% were found to have dosing inconsistent with FDAlabeled recommendations (47.3% apixaban, 35.8% rivaroxaban, and 31.6% dabigatran). No patients were prescribed edoxaban. The majority (72.7%) were dosed lower than FDA-recommended doses. Of all patients, the most frequent parameter (54.5%) for inappropriate dosing was patients meeting only 1 of 3 dose-reduction criteria when prescribed reduced-dose apixaban. Geriatrician and nongeriatrician prescribers had similar rates of prescribing DOACs with doses inconsistent with FDA-labeled recommendations (44.0% vs. 40.8%; P = 0.62).
CONCLUSION: Results suggest that DOACs used in outpatient geriatric patients are frequently dosed inconsistent with FDA-approved dosing recommendations. Further research is needed regarding clinical outcomes in older patients receiving DOACs and in those with dose adjustments inconsistent with FDA-labeled recommendations.
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Perceptions of care among high-risk geriatric patients, families, and caregivers in a patient-centered medical home.

OBJECTIVE: A survey was conducted by the pharmacy team to identify improvement areas in the delivery of care in high-risk patients at a patient-centered medical home (PCMH) at the University of Pittsburgh Medical Center (UPMC). DESIGN: This survey was a quality improvement project. SETTING: The survey was conducted at UPMC Senior Care, a level-three accredited PCMH. PATIENTS: The survey was conducted in a sample of preidentified high-risk patients. INTERVENTIONS: Pharmacy performed a survey, analyzed responses for common themes, and conducted follow-up phone calls to determine the degree of goal-achievement and efficacy of educational materials provided during the initial survey. MAIN OUTCOME MEASURE: The primary goal for conducting the survey was to identify needed areas for improvement in three specific domains, namely, medication decisions, communication with providers, and goals of care. RESULTS: Medication reviews were provided for 23 of 24 surveyed, leading to medication discrepancy resolution in 58%. Almost 80% of the respondents were satisfied with the team's communication. More than 85% of respondents verbalized the goals they wanted to achieve in three months. The follow-up phone calls were conducted in 20 of those initially surveyed. Only 5 patients did not meet their goals. The following improvement areas were identified: need to provide medication lists and correct medication inaccuracies, need for medication review, patient goals documentation, and patient education and the appropriate medium of education. CONCLUSION: Future appointments for high-risk patients at the PCMH should include the pharmacist. The team should focus education on families/caregivers and utilize alternate patient education methods.