The addition of women's health initiatives to an established remote population health introductory pharmacy practice experience.

BACKGROUND: In 2018, a Department of Veterans Affairs (VA) primary care service and a school of pharmacy collaborated to offer introductory pharmacy practice experiences (IPPEs) in population health. Working remotely from the VA facility, students spent 2 hours per week using information from VA clinical dashboards and electronic health records (EHRs) to perform population health activities. Beginning August 2020, women's health initiatives were incorporated. OBJECTIVE: The objective was to evaluate student learning and productivity in an established remote population health IPPE that included women's health initiatives during a coronavirus disease (COVID-19)-related university closure. PRACTICE DESCRIPTION: During 2 IPPE semesters, activities of second-year student pharmacists were tracked. The course is typically conducted remotely at the university; however, owing to COVID-19 restrictions, students completed the course from their homes. Students were granted remote access privileges to VA's EHR and precepted by VA clinical pharmacists using Microsoft Teams. Students performed prescription drug monitoring program activities; reviewed outside medical records for breast and cervical cancer screening results, laboratory test results for diabetes, and medication safety monitoring; and documented progress notes. PRACTICE INNOVATION: Population health IPPEs can be tailored each semester to include a variety of initiatives. Activities are conducted remotely, eliminating the need for space and computers at the VA facility. The remote design enabled students to continue the IPPE during COVID-19 restrictions. EVALUATION: Students completed a survey about their confidence performing population health activities at baseline and at the completion of the IPPE. Student workload data were collected over 2 semesters. RESULTS: A total of 70 students reviewed 8865 health records and documented 5322 progress notes. Statistically significant improvements in student's reported abilities were reported from baseline to course completion such as explaining breast and cervical cancer screening recommendations. CONCLUSION: Incorporating women's health initiatives into a remote population health IPPE assisted the VA facility with population health activities and increased students' perceived skill.

Remote introductory pharmacy practice experiences focused on veterans prescribed chronic opioid therapy.

PURPOSE: The Department of Veterans Affairs (VA) Northern California Health Care System (NCHCS) uses a dashboard to identify monitoring needs for veterans prescribed chronic opioid therapy (COT). Schools of pharmacy require introductory pharmacy practice experiences (IPPEs); however, resources for providing IPPEs at medical facilities are limited. This article describes collaboration by a primary care service and a school of pharmacy to provide services for patients prescribed COT through remote access to the VA electronic health record (EHR) system. SUMMARY: Pharmacy students in a required population health IPPE provided clinical services for veterans remotely. Students were supervised by VA clinical pharmacists and granted remote EHR access privileges. Using personally owned laptops and VA cell phones, students performed prescription drug monitoring program (PDMP) activities, reviewed urine drug screening (UDS) results, called patients to assess pain, and documented progress notes. Students completed an assessment on the first and final days of the experience; a retrospective analysis was conducted to examine differences in student knowledge of and confidence in providing COT-focused services. The dashboard scorecard and student workload were tracked over a 1-year period. In that year, 143 students wrote 7,001 PDMP notes, reviewed 6,130 UDS results, and documented 202 pain assessments. Statistically significant improvements were reported in students' level of confidence in performing population health activities for patients prescribed COT, including interpreting PDMP and UDS results and talking with patients. CONCLUSION: The ongoing collaboration provides real-world population management experiences for future pharmacists and supports monitoring requirements for veterans prescribed COT. The program has helped NCHCS accomplish its teaching mission without dedicating clinic workspace or computers and gain an additional team to address quality measures and support population health activities.

A Module in Medication Safety Involving Remote Access and Review of Veterans' Health Records.

Objective. To describe and assess the effectiveness of an ambulatory care introductory pharmacy practice experience (IPPE) module in medication safety monitoring that was conducted remotely for first- and second-year pharmacy students in collaboration with a Department of Veterans Affairs (VA) health care system.Methods. A module in medication safety was developed and piloted as part of a required, one-unit IPPE in ambulatory care. The module encompassed three sessions of the 15-week course. Working remotely at the school under the direct supervision of VA clinical pharmacists, students accessed the electronic health records (EHRs) of veterans for whom methotrexate, sulfasalazine, or mineralocorticoid receptor antagonists had been prescribed as such patients require ongoing laboratory monitoring to screen for adverse drug effects. After reviewing the record, students ordered laboratory tests under the prescriber's name, documented notes in the patient's EHR, and sent laboratory reminder letters to patients. Students completed a brief survey at the beginning and end of the course. Differences in survey responses were compared using the Wilcoxon signed rank test.Results. Fifty-eight students reviewed 148 patient records, including non-VA electronic records, and ordered laboratory tests for 79 patients. On the follow-up survey at course completion, students reported significant changes in their ability to monitor laboratory tests, use an actual (non-simulated) EHR to perform patient care, and explain the role of a clinical dashboard to conduct population health activities.Conclusion. Remotely conducting an ambulatory care IPPE course in which pharmacy students used an actual EHR to participate in medication safety monitoring for ambulatory patients expanded the pharmacy school's ability to provide crucial practice experience. Other pharmacy schools struggling with logistical challenges and limited resources should explore this approach to fulfilling the experiential education requirements for pharmacy students.

Assessing student knowledge, confidence, accuracy, and proficiency in providing Medicare Part D assistance.

PURPOSE: To assess the impact of coordinated didactic, simulation-based, and experiential learning on pharmacy students' knowledge and confidence with Medicare Part D and their accuracy and proficiency with the Medicare Plan Finder Tool. EDUCATIONAL ACTIVITY: Forty-two pharmacy students participated in a two-semester Medicare Part D elective course in which didactic, simulation-based and experiential learning methods were employed. Students' knowledge, confidence, accuracy, and proficiency were assessed at three course time points: first day of class, last day of in-class education, and after completion of outreach. FINDINGS: Student confidence with Part D and efficiency using the Plan Finder Tool significantly improved at each successive time point (p<0.01). Student knowledge was significantly improved both on the last day of class and after outreach completion as compared to the first day of class (p<0.01). SUMMARY: Basic Part D knowledge improved with the didactic and simulation-based portion of the course. The experiential component improved student confidence and efficiency in helping Medicare beneficiaries.

Detecting and Managing Adverse Effects of Antipsychotic Medications: Current State of Play.

Antipsychotics are some of the most frequently prescribed medications not only for psychotic disorders and symptoms but also for a wide range of on-label and off-label indications. Because second-generation antipsychotics have largely replaced first-generation antipsychotics as first-line options due to their substantially decreased risk of extrapyramidal side effects, attention has shifted to other clinically concerning adverse events associated with antipsychotic therapy. The focus of this article is to update the nonextrapyramidal side effects associated with second-generation antipsychotics. Issues surrounding diagnosis and monitoring as well as clinical management are addressed.

An overview and study of beneficiaries' knowledge, attitudes, and perceptions of the medicare part d benefit.

PURPOSE: Medicare beneficiaries' knowledge, attitudes, and perceptions (KAP) of the Medicare Part D prescription drug benefit have been under evaluation since the 2006 inception of the Part D benefit. OBJECTIVE: This study sought to examine beneficiaries' satisfaction with their Medicare Part D prescription drug plan, knowledge of the coverage gap, attitudes about the relative importance of certain insurance parameters, and overall perceptions of the Part D benefit. DESIGN: Cross-sectional, descriptive study design. SETTING: Thirteen outreach events targeting Medicare beneficiaries in northern California during the 2012 open-enrollment period. PARTICIPANTS: A total of 576 Medicare beneficiaries. INTERVENTIONS: Beneficiaries were asked questions related to their KAP of the Part D benefit as part of a plan to evaluate their need for assistance. Sociodemographic data were collected via a standardized survey. MAIN OUTCOME MEASURES: Identify variances in KAP related to beneficiary sociodemographic and clinical characteristics. RESULTS: Forty-seven percent of beneficiaries claimed to be "very" or "extremely" satisfied with Part D, yet only 40.3% of those with a prescription drug plan (PDP) rated their plan as "very good" or "excellent." Those automatically enrolled into their plan by Medicare were significantly less satisfied with their plan (P = 0.048). Almost three in four recipients not receiving Medicare subsidies have heard of the gap in prescription drug coverage, i.e., the "donut hole." Additionally, there were significant racial disparities in knowledge of the gap. Only 62.7% of beneficiaries indicated that "total out-of-pocket cost during the year" was the most important plan characteristic for them. CONCLUSIONS: An understanding of beneficiaries' attitudes may help explain suboptimal Part D plan selection. Moreover, evaluating beneficiaries' knowledge of the Part D benefit can assist advocacy groups in creating educational materials to better assist this vulnerable population in choosing an appropriate plan.

Minimizing out-of-pocket prescription drug costs for Medicare beneficiaries: not just 'a drop in the bucket'.

OBJECTIVE: To identify the frequency of uptake and financial impact of four cost-minimization strategies used to assist Medicare beneficiaries in lowering their out-of-pocket (OOP) costs. DESIGN: Cost-savings analysis. SETTING: Twelve outreach events were conducted in six different cities throughout Northern and Central California during the 2013 Medicare open enrollment period. PARTICIPANTS: Noninstitutionalized Medicare beneficiaries from various socioeconomic backgrounds, including those receiving Medicaid. MAIN OUTCOME MEASURES: Potential OOP cost savings for the upcoming year. RESULTS: In total, 621 beneficiaries were assisted. Part D plan optimization was performed for 535 beneficiaries; the findings indicated that 435 (81%) could save money (average: $1,334) by switching plans in the upcoming year. The results also demonstrated that 28 beneficiaries could save money (mean: $1,274) through a patient assistance program. In total, 16 beneficiaries had self-reported income and/or assets that were low enough to qualify for additional governmental assistance through the low-income subsidy. Finally, less costly therapeutic alternatives were identified for 7 beneficiaries and prescribers accepted recommendations for change in 6 (85%) such cases. In total, beneficiaries could realize more than $770,000 in potential OOP savings from the performed interventions. CONCLUSION: Targeted assistance to beneficiaries through a variety of cost-lowering strategies can help significantly reduce OOP costs and thus may also result in lower cost-related medication nonadherence and improved beneficiary outcomes.

Medication adherence behaviors of Medicare beneficiaries.

BACKGROUND: Medication adherence is crucial for positive outcomes in the management of chronic conditions. Comprehensive medication consultation can improve medication adherence by addressing intentional and unintentional nonadherence. The Medicare Part D prescription drug benefit has eliminated some cost barriers. We sought to examine variables that impact self-reported medication adherence behaviors in an ambulatory Medicare-beneficiary population and to identify the factors that influence what information is provided during a pharmacist consultation. METHODS: Medicare beneficiaries who attended health fairs in northern California were offered medication therapy management (MTM) services during which demographic, social, and health information, and responses to survey questions regarding adherence were collected. Beneficiaries were also asked which critical elements of a consultation were typically provided by their community pharmacist. Survey responses were examined as a function of demographic, socioeconomic, and health-related factors. RESULTS: Of the 586 beneficiaries who were provided MTM services, 575 (98%) completed the adherence questions. Of responders, 406 (70%) reported taking medications "all of the time". Of the remaining 169 (30%), the following reasons for nonadherence were provided: 123 (73%) forgetfulness; 18 (11%) side effects; and 17 (10%) the medication was not needed. Lower adherence rates were associated with difficulty paying for medication, presence of a medication-related problem, and certain symptomatic chronic conditions. Of the 532 who completed survey questions regarding the content of a typical pharmacist consultation, the topics included: 378 (71%) medication name and indication; 361 (68%) administration instructions; 307 (58%) side effects; 257 (48%) missed-dose instructions; and 245 (46%) interactions. Subsidy recipients and non-English speakers were significantly less likely to be counseled on drug name, indication, and side effects. The presence of certain health conditions was also associated with missing consultation elements. CONCLUSION: While Medicare beneficiaries are generally adherent to medication therapy, adherence barriers must be identified and addressed during comprehensive medication consultation.

A collaborative approach to combining service, teaching, and research.

OBJECTIVE: To describe a faculty-student collaborative model and its outcomes on teaching, service, and scholarship. DESIGN: A Medicare Part D elective course was offered that consisted of classroom and experiential learning where pharmacy students participated in community outreach events to assist Medicare beneficiaries with Part D plan selection. The course training was expanded to include medication therapy management (MTM) and the administration of immunizations. At the completion of the course, students collaborated with faculty members on research endeavors. EVALUATION: During the first 6 years of this course, the class size more than doubled from 20 to 42 students, and all students participating in the course met the IPPE requirements for community outreach. Over that same period, the number of beneficiaries receiving assistance with their Part D plan grew from 72 to 610; and with the help of students starting in 2011, faculty members had 28 poster presentations at national conferences, 7 invited podium presentations at national/international meetings, and published 8 manuscripts in peer-reviewed journals. CONCLUSION: Through collaborative efforts, this model took an elective course and provided classroom and experiential learning for students, needed health services for the community, and opportunities to pursue wide ranging research projects for faculty members and students.

Cost variability of suggested generic treatment alternatives under the Medicare Part D benefit.

BACKGROUND: The substitution of generic treatment alternatives for brand-name drugs is a strategy that can help lower Medicare beneficiary out-of-pocket costs. Beginning in 2011, Medicare beneficiaries reaching the coverage gap received a 50% discount on the full drug cost of brand-name medications and a 7% discount on generic medications filled during the gap. This discount will increase until 2020, when beneficiaries will be responsible for 25% of total drug costs during the coverage gap. OBJECTIVE: To examine the cost variability of brand and generic drugs within 4 therapeutic classes before and during the coverage gap for each 2011 California stand-alone prescription drug plan (PDP) and prospective coverage gap costs in 2020 to determine the effects on beneficiary out-of-pocket drug costs. METHODS: Equivalent doses of brand and generic drugs in the following 4 pharmacological classes were examined: angiotensin II receptor blockers (ARBs), bisphosphonates, HMG-CoA reductase inhibitors (statins), and proton pump inhibitors (PPIs). The full drug cost and patient copay/coinsurance amounts during initial coverage and the coverage gap of each drug was recorded based on information retrieved from the Medicare website. These drug cost data were recorded for 28 California PDPs. RESULTS: The highest cost difference between a brand medication and a Centers for Medicare Medicaid Services (CMS)-suggested generic treatment alternative varied between $110.53 and $195.49 at full cost and between $51.37 and $82.35 in the coverage gap. The lowest cost difference varied between $38.45 and $76.93 at full cost and between -$4.11 and $18.52 during the gap. CONCLUSION: Medicare beneficiaries can realize significant out-of-pocket cost savings for their drugs by taking CMS-suggested generic treatment alternatives. However, due to larger discounts on brand medications made available through recent changes reducing the coverage gap, the potential dollar savings by taking suggested generic treatment alternatives during the gap is less compelling and will decrease as subsidies increase.

Assessing Medicare beneficiaries' willingness-to-pay for medication therapy management services.

OBJECTIVES: To assess Medicare beneficiaries' willingness-to-pay (WTP) for medication therapy management (MTM) services and determine sociodemographic and clinical characteristics influencing this payment amount. DESIGN: A cross-sectional, descriptive study design was adopted to elicit Medicare beneficiaries' WTP for MTM. SETTING: Nine outreach events in cities across Central/Northern California during Medicare's 2011 open-enrollment period. PARTICIPANTS: A total of 277 Medicare beneficiaries participated in the study. INTERVENTIONS: Comprehensive MTM was offered to each beneficiary. Pharmacy students conducted the MTM session under the supervision of licensed pharmacists. At the end of each MTM session, beneficiaries were asked to indicate their WTP for the service. Medication, self-reported chronic conditions, and beneficiary demographic data were collected and recorded via a survey during the session. RESULTS: The mean WTP for MTM was $33.15 for the 277 beneficiaries receiving the service and answering the WTP question. WTP by low-income subsidy recipients (mean ± standard deviation; $12.80 ± $24.10) was significantly lower than for nonsubsidy recipients ($41.13 ± $88.79). WTP was significantly (positively) correlated with number of medications regularly taken and annual out-of-pocket drug costs. CONCLUSION: The mean WTP for MTM was $33.15. WTP for MTM significantly varied by race, subsidy status, and number of prescription medications taken. WTP was significantly higher for nonsubsidy recipients than subsidy recipients, and significantly positively correlated with the number of medications regularly taken and the beneficiary rating of the delivered services.

The Utility of Concept Maps to Facilitate Higher-Level Learning in a Large Classroom Setting.

OBJECTIVE: To describe the utility of concept mapping in a cardiovascular therapeutics course within a large classroom setting. DESIGN: Students enrolled in a cardiovascular care therapeutics course completed concept maps for each major chronic cardiovascular condition. A grading rubric was used to facilitate peer-assessment of the concept map. ASSESSMENT: Students were administered a survey at the end of the course assessing their perceptions on the usefulness of the concept maps during the course and also during APPEs to assess utility beyond the course. Question item analyses were conducted on cumulative final examinations comparing student performance on concept-mapped topics compared to nonconcept-mapped topics. CONCLUSION: Concept maps help to facilitate meaningful learning within the course and the majority of students utilized them beyond the course.

Assessing quality of life in an ambulatory medicare population.

OBJECTIVE: Medicare beneficiaries have unique health-related challenges causing significant impact on quality of life. This study examined the overall health-related quality of life (HRQOL) and differences in HRQOL between subgroups of an ambulatory Medicare beneficiary population. METHODS: Nine outreach events were held during the 2011 Medicare Part D prescription drug open-enrollment period, in which 397 beneficiaries were assisted with Part D plan evaluation and comprehensive medication therapy review. Demographic data were collected, and the SF-36v2 was administered to measure beneficiaries' self-reported HRQOL. Correlations were assessed between the mental component summary (MCS) or physical component summary (PCS) scores of the SF-36v2, prescription utilization, number of chronic conditions, and whether beneficiaries were government subsidy recipients. RESULTS: Mean Å standard deviation of PCS and MCS scores were 43.3 Å 11.4 and 52.2 Å 11.7, respectively. Both PCS and MCS scores were negatively correlated with the number of prescription medications and number of self-reported chronic conditions. Both PCS and MCS scores related to sociodemographics were significantly lower (P < 0.05) in subsidy and least-educated recipients. CONCLUSIONS: HRQOL can vary widely as a result of sociodemographic, drug, or disease differences in an ambulatory Medicare beneficiary population.

Impact of an elective course on pharmacy students' attitudes, beliefs, and competency regarding Medicare Part D.

OBJECTIVE: To determine the impact of an elective course on pharmacy students' perceptions, knowledge, and confidence regarding Medicare Part D, medication therapy management (MTM), and immunizations. DESIGN: Thirty-three pharmacy students were enrolled in a Medicare Part D elective course that included both classroom instruction and experiential training. ASSESSMENT: Students' self-reported confidence in and knowledge of Part D significantly improved upon course completion. End-of-course student perceptions about the relative importance of various aspects of MTM interventions and their confidence in performing MTM services significantly improved from those at the beginning of the course. Students' confidence in performing immunizations also increased significantly from the start of the course. CONCLUSION: A classroom course covering Medicare Part D with an experiential requirement serving beneficiaries can improve students' attitudes and knowledge about Medicare Part D and their confidence in providing related services to beneficiaries in the community.

Effects of switching pravastatin to cerivastatin on C-reactive protein, butyrylcholinesterase, and lipids.

OBJECTIVE: C-reactive protein (CRP) concentrations, butyrylcholinesterase (BChE) activity, total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides (TG) were evaluated in patients switched from pravastatin to cerivastatin. The purpose of this study was to determine whether a more potent statin (cerivastatin) would further affect CRP, whether a relation ship between CRP and BChE existed, and if there were any relationships between CRP or BChE and lipids. In view of the withdrawal of cerivastatin from the market, studies considering the effects of conversion of patients from one statin to another are warranted. RESEARCH DESIGN AND METHODS: Thirty-seven patients actively taking pravastatin (10 mg-40 mg) were switched to cerivastatin (0.2 mg-0.8 mg) at the initial visit in the Lipid Clinic at David Grant Medical Center, Travis Air Force Base. Samples were collected before the conversion (pravastatin phase) and at 6 weeks and 12 weeks post-conversion. Patients were excluded from the study if they were taking gemfibrozil concomitantly. Patients were counseled on the adverse effects of cerivastatin, including rhabdomyolsis. RESULTS: Median CRP levels at the pravastatin phase, 6 weeks of cerivastatin, and 12 weeks of cerivastatin, were 0.380 mg/dL, 0.403 mg/dL, and 0.364 mg/dL (p = 0.772), respectively. Median BChE activity at the pravastatin phase, 6 weeks of cerivastatin, and 12 weeks of cerivastatin were 0.338 micromol/mL/min, 0.332 micromol/mL/min, 0.33 micromol/mL/min (p = 0.746), respectively. A negative correlation was observed between CRP and BChE at baseline only (r = -0.353, p = 0.032). There was a significant decline in mean TC (p < 0.001) and median LDL (p < 0.001) and a significant increase in mean HDL (p = 0.017) over the three time points. Numerically TG declined, but it was not statistically significant (p = 0.649). No correlations were observed between CRP or BChE and any of the lipids. Gender, aspirin use, and the presence of CHD or diabetes did not affect CRP levels or BChE activity. CONCLUSION: Median CRP remained stable with pravastatin and cerivastatin use, although TC and LDL decreased. The further decline observed with LDL, but not CRP suggests differing effects of statins on LDL and CRP. Limitations include no serum levels prior to statin use and small sample size; thus, future studies are needed to address the relationship between cholesterol and CRP and the mechanism of action of statins on CRP.

Levofloxacin-induced autoimmune hemolytic anemia.

OBJECTIVE: To report a case of autoimmune hemolytic anemia (AIHA) secondary to levofloxacin. CASE SUMMARY: An 82-year-old white man was treated with levofloxacin 500 mg/d for cellulitis. Three days following completion of levofloxacin therapy, the patient presented to the emergency department with severe jaundice, dizziness, and loss of vision. He received packed red blood cells (PRBCs) and was discharged home. Two days later at the follow-up visit, he was diagnosed with AIHA secondary to levofloxacin. The patient was hospitalized and treated with a tapering dose of prednisone and additional PRBC infusion. He was discharged from the hospital in stable condition after 3 days. Repeated hematologic laboratory studies following discharge demonstrated that the hemolytic anemia had resolved. DISCUSSION: Hemolytic anemia due to levofloxacin is an extremely rare, but potentially fatal, adverse drug event. An objective causality assessment revealed that the adverse reaction was probable. To our knowledge, this is the first published case of levofloxacin-induced AIHA. However, there are published case reports of hemolytic anemia with other fluoroquinolones including ciprofloxacin (n = 12) and temafloxacin (n = 95). Temafloxacin was withdrawn from the market in 1992 due to this adverse effect. The mechanism by which levofloxacin triggers hemolytic anemia is unknown. We believe that an immune-mediated reaction is most likely. CONCLUSIONS: Levofloxacin-induced AIHA is a rare but serious complication of therapy. Immediate discontinuation of the offending medication and treatment of the hemolytic anemia are essential. Until more information is available, levofloxacin should not be prescribed for patients with previous reactions to any fluoroquinolone.