Race and ethnicity and pharmacy dispensing of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes.

Background: Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) and Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA) improve cardiorenal outcomes in patients with type 2 diabetes. Equitable use of SGLT2i and GLP-1 RA has the potential to reduce racial and ethnic health disparities. We evaluated trends in pharmacy dispensing of SGLT2i and GLP-1 RA by race and ethnicity. Methods: Retrospective cohort study of patients (≥18 years) with type 2 diabetes using 2014-2022 electronic health record data from six US care delivery systems. Entry was at earliest pharmacy dispensing of any type 2 diabetes medication. We used multivariable logistic regression to evaluate the association between pharmacy dispensing of SGLT2i and GLP1-RA and race and ethnicity. Findings: Our cohort included 687,165 patients (median 6 years of dispensing data; median 60 years; 0.3% American Indian/Alaska Native (AI/AN), 16.6% Asian, 10.5% Black, 1.4% Hawaiian or Pacific Islander (HPI), 31.1% Hispanic, 3.8% Other, and 36.3% White). SGLT2i was lower for AI/AN (OR 0.80, 95% confidence interval 0.68-0.94), Black (0.89, 0.86-0.92) and Hispanic (0.87, 0.85-0.89) compared to White patients. GLP-1 RA was lower for AI/AN (0.78, 0.63-0.97), Asian (0.50, 0.48-0.53), Black (0.86, 0.83-0.90), HPI (0.52, 0.46-0.57), Hispanic (0.69, 0.66-0.71), and Other (0.78, 0.73-0.83) compared to White patients. Interpretation: Dispensing of SGLT2is, and GLP-1 RAs was lower in minority group patients. There is a need to evaluate approaches to increase use of these cardiorenal protective drugs in patients from racial and ethnic minority groups with type 2 diabetes to reduce adverse cardiorenal outcomes and improve health equity. Funding: Patient-Centered Outcomes Research Institute and National Institutes of Health.

Impact of interdisciplinary case management and pharmacist transitions of care interventions on 30-day readmissions.

BACKGROUND: Pharmacists and case managers positively impact patient health outcomes during the transition of care from the hospital to the home. However, the combination of both specialties completing post-discharge telephone calls has not been clearly studied. OBJECTIVES: The primary outcome of this research was to identify the combined impact of post-discharge telephone calls from both pharmacists and case managers on all cause 30-day hospital readmissions when compared to a call from either group alone. Secondary outcomes included 30-day emergency department visits and types of medication therapy problems identified by pharmacists during the call. METHODS: This retrospective study included high risk patients eligible for a post-discharge telephone call from both pharmacy and case management from January 1, 2021 to September 1, 2021. Patients were excluded if they did not complete a telephone call from either group or were deceased within 30 days of discharge. Results were analyzed using descriptive and chi square analyses. RESULTS: Eighty-five hospital discharges were included in the study, with 24 patients receiving post-discharge telephone calls from both case management and pharmacy, and 61 patients receiving a call from either group alone. Thirty-day all cause readmissions occurred in 13% of the combined group versus 26% in either group alone (p = 0.171). Thirty-day all cause emergency department visits were 8% in the combined group versus 11% in either group alone (p = 0.617). Of the 38 post-discharge encounters completed by pharmacists, 120 medication therapy problems were identified, averaging over 3 medication issues per patient. CONCLUSIONS: Collaboration amongst pharmacists and case managers has the potential to positively impact patient outcomes upon discharge from the hospital. Health systems should work to integrate transitions of care services performed across disciplines.

Key factors for sustainable integration of pharmacists in team-based primary care physician practices.

OBJECTIVES: To (1) identify strategies for financial justification of pharmacists integrated into team-based primary care, (2) describe the payment models currently used for integration of pharmacists into team-based primary care, and (3) elicit key factors facilitating sustainable pharmacist-provided patient care services in the primary care setting. DESIGN: Qualitative analysis using semistructured interviews. SETTING: Nonacademic outpatient primary care physician practices throughout the United States from January to April 2014. PARTICIPANTS: Pharmacists responsible for leadership of clinical pharmacists in primary care practices whose positions are supported through nondispensing patient care services. MAIN OUTCOME MEASURES: Current payment model, infrastructure, documentation strategies, and methods of quality assessment. RESULTS: Twelve interviews were conducted. Practices included a combination of single- and mixed-payer models in integrated and nonintegrated health systems. Various billing strategies were used, particularly in nonintegrated models, to sustain pharmacists in primary care practices utilizing both fee-for-service (FFS) and value-based incentives payments. Five main themes were elicited: (1) Pharmacists are integrated and valuable members of health care teams; (2) pharmacists are documenting in an accessible electronic health record; (3) data tracking is a facilitator for justifying and adapting practice; (4) systematized processes for pharmacist integration exist in each practice; and (5) pharmacists' responsibilities on the team have grown and evolved over time. CONCLUSION: Pharmacists' contributions to improving patients' medication-related care are the same regardless of payment model. Financially sustainable integration of pharmacists on the team involves using a combination of FFS and value-based incentive payments, consistent documentation, meaningful collection of pharmacists' contributions to improve the quality of care, and a firm understanding of the practice's needs and financial structure. These themes can be used as a guide for pharmacists as they establish themselves in an FFS environment and adapt to a future in value-based care.

Pharmacist-Delivered Comprehensive Medication Management Within Family Medicine Practices An Evaluation of the SCRIPT Project.

BACKGROUND AND OBJECTIVES: Pharmacist inclusion in patient-centered medical home (PCMH) teams has been shown to benefit both patients and practices. However, pharmacists' inclusion on these teams is not widespread, partly because the work they do is not well known. The Successful Collaborative Relationships to Improve PatienT care (SCRIPT) project was started in August 2009 to understand the clinical and economic impact of pharmacists providing direct patient care. The objective of this study was to describe the work of pharmacists practicing as integrated members of the patient care team within PCMHs through retrospective analysis of their patient care documentation over a 4-year time frame. Two pharmacists were placed into four suburban medical home practices in Pittsburgh, Pennsylvania to perform comprehensive medication management (CMM). These pharmacists documented their CMM encounters in an electronic health record and a database for reporting purposes. METHODS: This study is a retrospective, descriptive analysis of pharmacist-documented CMM encounters from February 2010 through February 2014. Pharmacists' work-including patient demographics, disease states, and medication therapy problems-was recorded in a Microsoft Access database and tabulated. RESULTS: The pharmacists conducted 11,206 CMM encounters with 3,777 unique patients during the study period. The pharmacists identified 9,375 medication therapy problems (MTPs) and performed 14,092 interventions. Pharmacists most commonly worked with patients with diabetes, hypertension, pain, and hyperlipidemia. Physician and patient acceptance of the pharmacists' work was high. CONCLUSIONS: Pharmacists working in family medicine offices contribute to patient care through identification and resolution of MTPs and also by collaborating with PCMH teams.

Thermodynamics of ligand binding to a heterogeneous RNA population in the malachite green aptamer.

The malachite green aptamer binds two closely related ligands, malachite green (MG) and tetramethylrosamine (TMR), with nearly equal affinity. The MG ligand consists of three phenyl rings emanating from a central carbon, while TMR has two of the three rings connected by an ether linkage. The binding pockets for MG and TMR in the aptamer, known from high-resolution structures, differ only in the conformation of a few nucleotides. Herein, we applied isothermal titration calorimetry (ITC) to compare the thermodynamics of binding of MG and TMR to the aptamer. Binding heat capacities were obtained from ITC titrations over the temperature range of 15-60 °C. Two temperature regimes were found for MG binding: one from 15 to 45 °C where MG bound with a large negative heat capacity and an apparent stoichiometry (n) of ~0.4 and another from 50 to 60 °C where MG bound with a positive heat capacity and an n of ~1.1. The binding of TMR, on the other hand, revealed only one temperature regime for binding, with a more modest negative heat capacity and an n of ~1.2. The large difference in heat capacity between the two ligands suggests that significantly more conformational rearrangement occurs upon the binding of MG than that of TMR, which is consistent with differences in solvent accessible surface area calculated for available ligand-bound structures. Lastly, we note that the binding stoichiometry of MG was improved not only by an increase in the temperature but also by a decrease in the concentration of Mg(2+) or an increase in the time between ITC injections. These studies suggest that binding of a dynamical ligand to a functional RNA requires the RNA itself to have significant dynamics.

Prevalence of syn nucleobases in the active sites of functional RNAs.

Biological RNAs, like their DNA counterparts, contain helical stretches, which have standard Watson-Crick base pairs in the anti conformation. Most functional RNAs also adopt geometries with far greater complexity such as bulges, loops, and multihelical junctions. Occasionally, nucleobases in these regions populate the syn conformation wherein the base resides close to or over the ribose sugar, which leads to a more compact state. The importance of the syn conformation to RNA function is largely unknown. In this study, we analyze 51 RNAs with tertiary structure, including aptamers, riboswitches, ribozymes, and ribosomal RNAs, for number, location, and properties of syn nucleobases. These RNAs represent the set of nonoverlapping, moderate- to high-resolution structures available at present. We find that syn nucleobases are much more common among purines than pyrimidines, and that they favor C2'-endo-like conformations especially among those nucleobases in the intermediate syn conformation. Strikingly, most syn nucleobases participate in tertiary stacking and base-pairing interactions: Inspection of RNA structures revealed that the majority of the syn nucleobases are in regions assigned to function, with many syn nucleobases interacting directly with a ligand or ribozyme active site. These observations suggest that judicious placement of conformationally restricted nucleotides biased into the syn conformation could enhance RNA folding and catalysis. Such changes could also be useful for locking RNAs into functionally competent folds for use in X-ray crystallography and NMR.