A Pharmacist-Assisted Initiative to Improve Chronic Pain Management and Reduce Opioid Use in Primary Care.

Background- Since publication of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, there have been growing concerns that providers, including those in primary care, are tapering opioids too quickly and without concomitant use of non-opioid strategies for pain, leading to inadequate pain management. As a result, in November 2022 the CDC published Clinical Practice Guidelines for Prescribing Opioids for Pain, emphasizing the importance of creating comprehensive care plans for pain management and developing a consensual plan between provider and patient when tapering opioids. Objective-Determine the impact of a pharmacist-assisted approach aimed at helping primary care providers minimize opioid use while improving management of chronic, non-malignant pain (CNMP). Methods - This quality improvement project focused on one primary care provider partnering with a pharmacist to reassess the management of patients on long-term opioid therapy (LTOT) for CNMP. The intervention included a letter informing patients of the provider's intent, pharmacist outreach to intervention patients, and pharmacist development of a patient registry, updated regularly with clinical data, recommendations, and outcomes for the provider to reference throughout the project. The intervention group was compared to patients prescribed opioids for CNMP by the remaining providers at the clinic who did not engage in the quality initiative. Results - The intervention group had a mean effective daily morphine milligram equivalent (MME) reduction of 73.7% (17.2% control) after 18 months and 60% of patients discontinued opioids (14.3% control). In a subset of patients with functional assessment scores, 93.3% were either improved or unchanged, despite a 62.5% decrease in their mean effective daily MME. In both groups, one patient transferred care to a new provider. Conclusions - With targeted recommendations and assistance from a pharmacist, a primary care provider can make significant progress in improving management of CNMP while reducing opioid prescribing.

Using personal writings to detect dementia: A text mining approach.

A novel text mining pilot for dementia detection using Linguistic Inquiry and Word Count (LIWC) was tested on public figures' writings looking at word choice and affect compared to those with and without dementia. The differences found in this analysis mirror the expected patterns where writings of people with dementia reflect significantly more analytical thinking words, but significantly less authentic and emotional tone. In addition, the analysis found that people with dementia use significantly less functional words, such as grammar, and affections (happiness, sadness, anger, sadness), but tend to use significantly more pronouns in their writings. Written samples of those with dementia also use significantly less time-oriented words that indicate past, present, or future. The analysis of free form text suggests a potential avenue for detecting early changes that correlate with dementia, allowing for early preventative treatment before noticeable cognitive impairment occurs.

Coworker abuse in healthcare: voices of mistreated workers.

PURPOSE: The appalling abuse healthcare workers have endured from patients is long documented in the popular press and social media. Less explored in the healthcare management literature is workplace abuse that professional nurses experience from their coworkers. DESIGN/METHODOLOGY/APPROACH: The authors use text-based first-hand accounts from nurses posting on Reddit (N = 75) to better understand the types and context of abusive acts endured by their coworkers in the contemporary healthcare setting. Each account is content analyzed using two raters, and thematic analysis is utilized to summarize findings. FINDINGS: Findings indicate that nurse workplace abuse frequently targets new entrants to a work unit (e.g. recent grads), typically is ongoing, takes verbal and nonverbal forms, mainly stems from coworkers (i.e. lateral mistreatment), and frequently takes place in front of other coworkers, mainly in hospital settings. PRACTICAL IMPLICATIONS: By applying the lens of mindfulness, healthcare organizations can transform these harmful interactions within the nursing profession. The authors offer administrators and frontline workers practical implications for mitigating workplace abuse, including reshaping the culture, bystander interventions and explicit leadership support. ORIGINALITY/VALUE: First-hand accounts from nurses in the frontlines of healthcare provide a rich voice that reveals the reality of ongoing verbal and nonverbal peer abuse in hospitals and healthcare settings.

Randomized comparison of self-monitored blood glucose (BGM) versus continuous glucose monitoring (CGM) data to optimize glucose control in type 2 diabetes.

AIMS: Evaluate whether structured BGM testing (BGM) or real-time CGM (CGM) lead to improved glucose control (A1c). Determine which approach optimized glucose control more effectively. METHODS-MULTI-ARM PARALLEL: trial of three type 2 diabetes (T2D) therapies ± metformin: (1) sulfonylurea (SU), (2) incretin (DPP4 inhibitor or GLP-1 agonist), or (3) insulin. After a baseline CGM, 114 adult subjects were randomized to either BGM (4 times daily) or CGM (24/7) for 16 weeks with therapies adjusted every 4 weeks. RESULTS: A1c means decreased from 8.19 to 7.07 (1.12% difference) with CGM (n = 59) and 7.85 to 7.03 (0.82% difference) with BGM (n = 55) (p < 0.001). BGM and CGM groups showed significant improvements in time in range and glucose variability-with no significant difference between the two groups. Clinically important hypoglycemia (<50 mg/dL) was significantly reduced for the CGM group compared with BGM (p < 0.01), particularly in subjects taking insulin or therapies with higher hypoglycemic risk (SU). CONCLUSION: In T2D, structured, consistent use of glucose data regardless of device (structured BGM or CGM) leads to improvements in A1c control. CGM is more effective than BGM in minimizing hypoglycemia particularly for those using higher hypoglycemic risk therapies.

Comparing Patch vs Pen Bolus Insulin Delivery in Type 2 Diabetes Using Continuous Glucose Monitoring Metrics and Profiles.

OBJECTIVE: CeQur Simplicity™ (CeQur, Marlborough, MA) is a 3-day insulin delivery patch designed to meet mealtime insulin requirements. A recently reported 48-week, randomized, multicenter, interventional trial compared efficacy, safety and self-reported outcomes in 278 adults with type 2 diabetes (T2D) on basal insulin therapy who initiated and managed mealtime insulin therapy with a patch pump versus insulin pen. We assessed changes in key glycemic metrics among a subset of patients who wore a continuous glucose monitoring (CGM) device. METHODS: Study participants (patch, n = 49; pen, n = 48) wore a CGM device in masked setting during the baseline period and prior to week 24. Glycemic control was assessed using international consensus guidelines for percentage of Time In Range (%TIR: >70% at 70-180 mg/dL), Time Below Range (%TBR: <4% at <70 mg/dL; <1% at <54 mg/dL), and Time Above Range (%TAR: <25% at >180 mg/dL; <5% at >250 mg/dL). RESULTS: Both the patch and pen groups achieved recommended targets in %TIR (74.1% ± 18.7%, 75.2 ± 16.1%, respectively) and marked reductions in %TAR >180 mg/dL (21.1% ± 19.9%, 19.7% ± 17.5%, respectively) but with increased %TBR <70 mg/dL (4.7% ± 5.2%, 5.1 ± 5.8, respectively), all P < .0001. No significant between-group differences in glycemic improvements or adverse events were observed. CONCLUSIONS: CGM confirmed that the patch or pen can be used to safely initiate and optimize basal-bolus therapy using a simple insulin adjustment algorithm with SMBG. Preference data suggest that use of the patch vs pen may enhance treatment adherence.

Patient Perspectives: Valuable Food Insecurity Interventions.

INTRODUCTION: Food insecurity (FI), defined as "limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways," affects over 12% of US households. Embarrassment persists for patients with FI, and due to the potential consequences of FI, including increased utilization of the health care system, it is important to find causes and potential interventions for FI. The purpose of this project was to better understand FI from the patient perspective, including contributing factors, perceived health effects, and helpful interventions. METHODS: Interviews (N=21) were conducted with suburban community residency clinic patients who screened positive for FI in the last 12 months. Six open-ended questions and a ranking question examined contributors to FI, effects of FI, perceptions of clinic intervention helpfulness, and ideas for novel interventions. RESULTS: Patients identified lack of income (85.7%) as the primary issue they faced. Secondary identified issues were lack of transportation (38.1%), too much debt (33.3%), and food assistance programs not providing for all needs (33.3%). FI effects on patients' health included difficulty adhering to specialized diets and the need to modify eating patterns due to lack of food. Surprisingly, 28.6% perceived no FI related-health effects. Patients felt that the most valuable clinic intervention was provision of urgent need food boxes, followed by FI screening and referrals to community food resources. CONCLUSIONS: Frequent FI screening is in itself useful to patients. Screening paired with community food resource referrals and urgent-need food boxes are the most helpful interventions according to patients.

EVALUATION OF INSULIN GLARGINE AND EXENATIDE ALONE AND IN COMBINATION: A RANDOMIZED CLINICAL TRIAL WITH CONTINUOUS GLUCOSE MONITORING AND AMBULATORY GLUCOSE PROFILE ANALYSIS.

Objective: Characterize the effectiveness of insulin glargine alone, exenatide alone, or combined in subjects taking stable doses of metformin and evaluate their impact on hemoglobin A1C, hypoglycemia, weight, and glucose variability. Methods: Open-label, randomized, parallel-arm study of adults with type 2 diabetes naïve to both insulin and glucagon-like peptide 1 (GLP-1) agonist who were not at A1C goal despite treatment with metformin. This prospective interventional study employed blinded continuous glucose monitoring ambulatory glucose profile (AGP) reports over 32 weeks. Subjects were randomized to treatment with glargine (Iglar), exenatide (GLP-1), or combination of glargine and exenatide (Iglar + GLP-1). At midpoint, those not at A1C target had the second medication added; those on Iglar + GLP-1 continued therapy optimization. Results: Decreases in A1C were: 7.6 to 6.2% for Iglar + GLP-1, 7.5 to 6.6% for Iglar, and 7.5 to 6.4% for GLP-1. Iglar + GLP-1 achieved A1C targets faster (14 to 16 weeks) but had more hypoglycemia. Hypoglycemia rates increased slightly for all arms. Weight loss was achieved in all regimens including GLP-1. Glucose variability was not reduced to the same extent in the Iglar arm as the GLP-1 arm. Conclusion: Addition of Iglar and/or GLP-1 to metformin for patients not at treatment goal was safe and effective. The order of medication addition needs to consider individualized AGP patterns and goals. Iglar + GLP-1 resulted in rapid A1C lowering, whereas GLP-1 was noted to have less hypoglycemia. Weight loss was most pronounced in GLP-1 monotherapy, suggesting that GLP-1 may mitigate the weight gain of Iglar. Any treatment with GLP-1 showed significant decreases in glucose variability. Abbreviations: A1C = hemoglobin A1c; AGP = ambulatory glucose profile; CGM = continuous glucose monitoring; GLM = general linear model; GLP-1 = glucagon-like peptide 1 (exenatide); Iglar = insulin glargine; SGLT2 = sodium-glucose cotransporter 2; SMBG = self-monitoring blood glucose; SU = sulfonylurea; T2D = type 2 diabetes mellitus.

Time Savings Using a Standardized Glucose Reporting System and Ambulatory Glucose Profile.

BACKGROUND: Diabetes care is predominately done at home by the patient. When clinics do not have a reliable, easy process for obtaining this patient data, clinical decisions must be made with incomplete verbal recall reports. Unused or inaccessible glucose data represent a large information gap affecting clinical decision making. This study's purpose was to design an optimized glucose device download system with a standardized report and to evaluate its efficiency. METHODS: Observations and evaluations of glucose data retrieval occurred at two clinics; an additional clinic utilized the optimized process doing only post process timings. Patients/families and clinicians were surveyed about their experiences with the system and the standardized report (AGP). The study was approved by all the sites' IRBs. RESULTS: Optimized systems saved staff at least 3 min per patient. Standardized AGP reports and an optimized data system made the work flow of glucose data easier to complete. The AGP report was preferred by patients, families, and clinicians. CONCLUSIONS: An optimized system takes advantage of patient lobby downtime to download glucose devices and ensures that diabetes clinical decisions are made utilizing all available data. Staff and patients liked the software lobby system and found it a valuable time-saving tool.

The Fallacy of Average: How Using HbA1c Alone to Assess Glycemic Control Can Be Misleading.

HbA1c is a valuable metric for comparing treatment groups in a randomized trial, for assessing glycemic trends in a population over time, or for cross-sectional comparisons of glycemic control in different populations. However, what is not widely appreciated is that HbA1c may not be a good indicator of an individual patient's glycemic control because of the wide range of mean glucose concentrations and glucose profiles that can be associated with a given HbA1c level. To illustrate this point, we plotted mean glucose measured with continuous glucose monitoring (CGM) versus central laboratory-measured HbA1c in 387 participants in three randomized trials, showing that not infrequently HbA1c may underestimate or overestimate mean glucose, sometimes substantially. Thus, if HbA1c is to be used to assess glycemic control, it is imperative to know the patient's actual mean glucose to understand how well HbA1c is an indicator of the patient's glycemic control. With knowledge of the mean glucose, an estimated HbA1c (eA1C) can be calculated with the formula provided in this article to compare with the measured HbA1c. Estimating glycemic control from HbA1c alone is in essence applying a population average to an individual, which can be misleading. Thus, a patient's CGM glucose profile has considerable value for optimizing his or her diabetes management. In this era of personalized, precision medicine, there are few better examples with respect to the fallacy of applying a population average to a specific patient rather than using specific information about the patient to determine the optimal approach to treatment.

Clinical Use of Continuous Glucose Monitoring in Adults with Type 2 Diabetes.

BACKGROUND: Hemoglobin A1c is an excellent population health measure for the risk of vascular complications in diabetes, while continuous glucose monitoring (CGM) is a tool to help personalize a diabetes treatment plan. The value of CGM in individuals with type 1 diabetes (T1D) has been well demonstrated when compared with utilizing self-monitoring of blood glucose (SMBG) to guide treatment decisions. CGM is a tool for patients and clinicians to visualize the important role that diet, exercise, stress management, and the appropriate selection of diabetes medications can have in managing type 2 diabetes (T2D). Several diabetes organizations have recently reviewed the literature on the appropriate use of CGM in diabetes management and concluded CGM may be a useful educational and management tool particularly for patients on insulin therapy. The indications for using CGM either as a clinic-based loaner distribution model for intermittent use (professional CGM) or a CGM system owned by the patient and used at home with real-time glucose reading (personal CGM) are only beginning to be addressed in T2D. Most summaries of CGM studies conclude that having a standardized glucose pattern report, such as the ambulatory glucose profile (AGP) report, should help facilitate effective shared decision-making sessions. The future of CGM indications for the use of CGM is evolving rapidly. In some instances, CGM is now approved for making medication adjustments without SMBG confirmation and it appears that some forms of CGM will be approved for use in the Medicare population in the United States in the near future. Many individuals with T1D and T2D and their care teams will come to depend on CGM as a key tool for diabetes management.

Trends in E-Cigarette Awareness and Perceived Harmfulness in the U.S.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are gaining in popularity as an alternative to regular cigarettes, as they are viewed as potentially less harmful. However, it remains unclear how awareness about e-cigarettes is permeating through the general U.S. POPULATION: This study seeks to extend previous research and examine trends in e-cigarette awareness and perceived harmfulness, and their association with smoking-cessation efforts. METHODS: Data from three cycles (2012, 2013, and 2014) of the Health Information National Trends Survey were combined into a single data set. Controlling for survey year, multivariate logit models were used to determine the association between demographic characteristics and e-cigarette awareness, perceived harmfulness, quit attempts, and quit intentions. Data were analyzed in 2015. RESULTS: Awareness of e-cigarettes increased from 77.1% in 2012 to 94.3% in 2014. Controlling for demographic characteristics, e-cigarette awareness significantly increased in both 2013 and 2014, relative to 2012. Perception that e-cigarettes were less harmful than regular cigarettes declined from 50.7% in 2012 to 43.1% in 2014. Among smokers, no relationship was observed between e-cigarette awareness and past-year quit attempts or quit intentions, but those that viewed e-cigarettes as less harmful were less likely to have a past-year quit attempt. CONCLUSIONS: These analyses reveal a continued increase in overall public awareness of e-cigarettes and shifting harm perceptions relative to regular cigarettes. New regulatory oversight by the U.S. Food and Drug Administration may have major effects on both dimensions, which are worth continued monitoring.

HOSPITAL INSULIN PROTOCOL AIMS FOR GLUCOSE CONTROL IN GLUCOCORTICOID-INDUCED HYPERGLYCEMIA.

OBJECTIVE: To compare the effectiveness of 2 insulin protocols to treat glucocorticoid-induced hyperglycemia in the nonintensive care hospital setting. METHODS: A randomized, open-label, parallel-arm study was conducted comparing standard recommended care of complete insulin orders (CIO) (i.e., 3-part insulin regimen of long-acting basal [background], rapid-acting bolus [mealtime], and rapid-acting correction factor) to an experimental group following a regimen of Neutral Protamine Hagedorn (NPH) plus CIO (NPH-CIO). The primary outcome was mean blood glucose (BG), and the secondary outcome was percent of BG in target range of 70 to 180 mg/dL. Hypoglycemia was also evaluated. RESULTS: Sixty-one patients completed 2 to 5 consecutive inpatient days (31 CIO; 30 NPH-CIO). Baseline mean BG results were 237.2 ± 50.2 and 221.9 ± 35.8 mg/dL (P = .30) in the CIO and NPH-CIO groups, respectively. No significant difference in overall mean BG between the 2 groups was detected; however, a significant difference arose on day 3: mean BG 181.8 ± 32.6 mg/dL (CIO) versus 157.2 ± 6.1 mg/dL (NPH-CIO) (P = .03). Moreover, the total daily doses (TDDs) of insulin did not differ: 34.8 ± 43.0 units (CIO) versus 35.8 ± 25.0 units (NPH-CIO) (P = .13). Percent of BG in target was 54.6% (CIO) and 62% (NPH-CIO) (P = .24). Incidence of severe hypoglycemia (<50 mg/dL) was the same in both groups (0.1%). CONCLUSION: NPH added to 3-part insulin regimen (CIO) may be an effective way to a combat glucocorticoid-induced hyperglycemia, though further research is needed in a larger population.

Health-system-based interventions to improve care in pediatric and adolescent type 1 diabetes.

Despite significant advances in pharmacology and technology, glycemic targets are difficult to achieve for patients with type 1 diabetes (T1D) and management remains burdensome for patients and their families. Quality improvement (QI) science offers a methodology to identify an aim, evaluate complex contributors to the goal, and test potential interventions to achieve outcomes of interest. Day-to-day management of diabetes is often an iterative process but interventions exist at all care levels: individual patient and family, clinic, and larger population and health system. This article reviews current literature and proposes novel QI interventions for enhancing health outcomes, with attention to essential determinants or drivers of improved glycemic control and patient experience for pediatric T1D in the context of the Chronic Care Model. In-depth consideration of key drivers of successful T1D care, including self-management and integration of technology, are explored, and examples of larger health systems with improved outcomes, including Learning Health Systems are highlighted.

Adherence to optimal lifestyle behaviors is related to emotional health indicators among employees.

Simultaneous adherence to abstinence from smoking, adequate physical activity, eating 5 servings of fruits and vegetables each day, and consuming limited or no amount of alcohol has been associated with a variety of health outcomes, but not emotional health. The purpose of this investigation was to study the association between optimal lifestyle behaviors and self-reported emotional health indicators among employed adults. Emotional health indicators studied were feeling depressed, stress risk, and the impact of emotional health on daily life among employees (N = 34,603). Binary logistic regression models were used to predict likelihood of feeling depressed and risk of stress based on degree of adherence to optimal lifestyle. Multinomial logistic regression models were used to assess the association between adherence to optimal lifestyle and likelihood of emotional quality of life among employees. Analyses were adjusted for age, sex, socioeconomic status (using the area deprivation index), sleep, self-perceived health status, self-efficacy, and chronic conditions including depression. All data were self-reported except for the area deprivation index. Adherence to any 3 or 4 components of the optimal lifestyle was associated with all 3 emotional health issues studied: Lower odds of feeling depressed, reporting stress risk, and emotional health affecting daily life. Adherence to any 2 components of the optimal lifestyle metric was associated with lower odds of feeling depressed and emotional health affecting daily life. All 4 individual lifestyle behaviors had significant associations with at least 2 of the 3 emotional health outcomes studied. Adherence to optimal lifestyle is associated with significantly more positive emotional health states as measured by feeling depressed, risk for high stress, and impact of emotional health on daily life. While causality cannot be inferred, the strength of the associations warrants trials to determine the extent to which adopting positive lifestyles can result in improved mental health.

Longitudinal cost experience for gastric bypass patients.

BACKGROUND: To assess the effect of gastric bypass surgery on the total cost of medical care for morbidly obese members compared with obese members and a general population. METHODS: We used an observational pre-post test design to analyze the administrative claim records of 224 gastric bypass patients during 3 periods (preoperative, surgical, and postoperative years) for a total of 7.5 years. The estimated future care costs for gastric bypass patients were determined from their preoperative cost trends, adjusting for the annualized actuarial trends. The general membership population actuarial trends and overweight/obese member medical expenditure data were used as comparison groups. RESULTS: The inflation adjusted mean per member per year total paid decreased by $1895 in the fifth year after surgery. The mean costs for gastric bypass patients were lower within the first year after surgery than their preoperative costs. At 3.5 years after surgery, the surgical costs had been recouped for patients undergoing gastric bypass surgery, and by year 2, they had incurred fewer costs than the obese health plan population. CONCLUSION: Although gastric bypass is a costly surgical procedure, the longitudinal costs savings and overall health improvement for patients undergoing gastric bypass surgery are cost-effective within a closed, experienced network. Weight loss surgery decreased the annual costs per patient in the years after surgery. The costs were slightly elevated in the fifth year after surgery because of maternity cases and orthopedic surgeries.

Comparing specialists' performance to improve quality.

The health care community must address criticisms that the quality of health care in the United States is inadequate. This article describes one successful program in a large, not-for-profit health plan in which key aspects of physician specialty groups' performance are evaluated by both patients and the generalists who refer them. The results of the evaluations, which include comparisons among practices, are provided to the specialist groups, who use the information to improve their quality of care. The authors also discuss features that are essential to the success of such quality-improvement programs.

Novel lipoglycopeptides as inhibitors of bacterial signal peptidase I.

Signal peptidase (SPase) I is responsible for the cleavage of signal peptides of many secreted proteins in bacteria. Because of its unique physiological and biochemical properties, it serves as a potential target for development of novel antibacterial agents. In this study, we report the production, isolation, and structure determination of a family of structurally related novel lipoglycopeptides from a Streptomyces sp. as inhibitors of SPase I. Detailed spectroscopic analyses, including MS and NMR, revealed that these lipoglycopeptides share a common 14-membered cyclic peptide core, an acyclic tripeptide chain, and a deoxy-alpha-mannose sugar, but differ in the degree of oxidation of the N-methylphenylglycine residue and the length and branching of the fatty acyl chain. Biochemical analysis demonstrated that these peptides are potent and competitive inhibitors of SPase I with K(i) 50 to 158 nm. In addition, they showed modest antibacterial activity against a panel of pathogenic Gram-positive and Gram-negative bacteria with minimal inhibitory concentration of 8-64 microm against Streptococcus pneumonniae and 4-8 microm against Escherichia coli. Notably, they mechanistically blocked the protein secretion in whole cells as demonstrated by inhibiting beta-lactamase release from Staphylococcus aureus. Taken together, the present discovery of a family of novel lipoglycopeptides as potent inhibitors of bacterial SPase I may lead to the development of a novel class of broad-spectrum antibiotics.

Balanced scorecards for specialists: a tool for quality improvement.

This article describes a program that HealthPartners uses to assess and compare the performance of specialists that serve its members. HealthPartners' Balanced Scorecards program focuses on cardiologist and orthopedist practices in the Minneapolis/St. Paul metro area and St. Cloud, Minnesota. The scorecards assess the clinical and business processes of specialist practices, their use of resources, the degree to which patients and referring physicians are satisfied with their performance, and their patient outcomes. Unblinded comparative data is made available to referring physicians, employers, and consumers only after each individual specialist group has had the opportunity to review its own data against blinded results, discuss the methodology, and comment on the results.

Glycopeptide carboxamides active against vancomycin-resistant enterococci.

Glycopeptide antibiotics were synthesized via the PyBOP mediated condensation of aliphatic, heterocyclic and aromatic amines with the C-terminus of vancomycin, LY264826 (A82846B) and semi-synthetic derivatives of these natural products. Amides of LY264826 and vancomycin demonstrated excellent activity against staphylococci and streptococci as compared to the parent natural product. However, the amides of N-alkylated LY264826 and N-alkylated vancomycin were active against vancomycin-resistant enterococci as well as other gram-positive pathogens such as Staphylococcus aureus, S. haemolyticus, S. epidermidis and Streptococcus pneumoniae.