Acute Asthma Exacerbations: Management Strategies.

Asthma exacerbations, defined as a deterioration in baseline symptoms or lung function, cause significant morbidity and mortality. Asthma action plans help patients triage and manage symptoms at home. In patients 12 years and older, home management includes an inhaled corticosteroid/formoterol combination for those who are not using an inhaled corticosteroid/long-acting beta2 agonist inhaler for maintenance, or a short-acting beta2 agonist for those using an inhaled corticosteroid/long-acting beta2 agonist inhaler that does not include formoterol. In children four to 11 years of age, an inhaled corticosteroid/formoterol inhaler, up to eight puffs daily, can be used to reduce the risk of exacerbations and need for oral corticosteroids. In the office setting, it is important to assess exacerbation severity and begin a short-acting beta2 agonist and oxygen to maintain oxygen saturations, with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids. Patients with severe exacerbations should be transferred to an acute care facility and treated with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids. The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations. Patients needing admission to the hospital require continued monitoring and systemic therapy similar to treatments used in the emergency department. Improvement in symptoms and forced expiratory volume in one second or peak expiratory flow to 60% to 80% of predicted values helps determine appropriateness for discharge. The addition of inhaled corticosteroids, consideration of stepping up asthma maintenance therapy, close follow-up, and education on asthma action plans are important next steps to prevent future exacerbations.

Utilizing the Newest Vital Sign (NVS) to Assess Health Literacy at a Regional Academic Medical Center's Family Medicine Clinic.

Researchers examined the correlation between the physician's subjective assessment of health literacy rates and actual health literacy rates among patients as determined by the Newest Vital Sign (NVS). A sample of n = 150 patients, 18 years of age or older, were verbally interviewed using NVS tool before seeing their physician. After the physician met with the patient, the physician was asked to measure that patient's level of health literacy on a Likert-type scale and a "yes/no" scale. Frequency and percentage statistics were performed in SPSS to describe the distributions of patient and physician responses. Between-subjects statistics were used. Analysis of the patient surveys revealed one in 4 patients has a high likelihood of low health literacy. Analysis revealed there were significant positive correlations between physician response to perception of a patient's low health literacy risk and NVS survey responses. Despite the risk of limited literacy, 97.3% of physicians perceived the patient to understand what the physician was saying. Physicians should use teach-back and other health literacy principles with each patient, regardless of perceived risk.

Availability of the HPV Vaccine in Regional Pharmacies and Provider Perceptions Regarding HPV Vaccination in the Pharmacy Setting.

There is increasing support for HPV vaccination in the pharmacy setting, but the availability of the HPV vaccine is not well known. Additionally, little is known about perceptions of medical providers regarding referring patients to community pharmacies for HPV vaccination. The purpose of this study was to determine HPV vaccine availability in community pharmacies and to understand, among family medicine and obstetrics-gynecology providers, the willingness of and perceived barriers to referring patients for HPV vaccination in a pharmacy setting. HPV vaccine availability data were collected from pharmacies in a southern region of the United States. Family medicine and obstetrics-gynecology providers were surveyed regarding vaccine referral practices and perceived barriers to HPV vaccination in a community pharmacy. Results indicated the HPV vaccine was available in most pharmacies. Providers were willing to refer patients to a community pharmacy for HPV vaccination, despite this not being a common practice, likely due to numerous barriers reported. Pharmacist-administered HPV vaccination continues to be a commonly reported strategy for increasing HPV vaccination coverage. However, coordinated efforts to increase collaboration among vaccinators in different settings and to overcome systematic and legislative barriers to increasing HPV vaccination rates are still needed.

Evaluation of student-perceived growth in entrustable professional activities after involvement in a transitions-of-care process within an adult medicine advanced pharmacy practice experience.

BACKGROUND AND PURPOSE: Involvement of pharmacists and trainees in care transitions reduces medication-related problems. Participation in the transitions-of-care (TOC) process may impact self-perceived growth of autonomy within selected entrustable professional activities (EPAs). EDUCATIONAL ACTIVITY AND SETTING: A student-driven TOC documentation process was implemented within an inpatient family medicine advanced pharmacy practice experience. During the month-long rotation, students rounded with an interdisciplinary care team. Responsibilities included ensuring accurate medication reconciliation at care transitions throughout hospitalization and prior to discharge as well as medication optimization during hospitalization. Another responsibility was completing a medication-specific TOC note in the clinic-based electronic health record at discharge for patients receiving primary care from the associated clinic. The note was available to the outpatient interdisciplinary care team during the hospital follow-up appointment. Student-perceived growth in autonomy within selected EPAs was determined through an online anonymous survey. FINDINGS: Ninety percent (n = 18) of eligible students completed the survey. For specific EPA statements (collecting information, establishing patient-centered goals and establishing a care plan, implementing a care plan, collaborating as an interdisciplinary team member, and ensuring immunization), student-perceived autonomy increased after involvement in this student-driven TOC process. During the study period, 215 notes were generated by student pharmacists and included interventions/recommendations within the following themes: evidence-based changes in therapy, patient counseling, and medication access. SUMMARY: The importance of pharmacist and pharmacy trainee involvement in the TOC process has been well-documented. Involving students in student-driven TOC documentation processes serves to facilitate student-perceived growth in autonomy within selected EPAs.

Pharmacists' Perceived Barriers to Human Papillomavirus (HPV) Vaccination: A Systematic Literature Review.

About 45:000 cancers are linked to HPV each year in the United States alone. The HPV vaccine prevents cancer and is highly effective, yet vaccination coverage remains low. Pharmacies can play a meaningful role in increasing HPV vaccination access due to their availability and convenience. However, little is known about pharmacists' perceived barriers to HPV vaccination. The objective of this systematic review was to summarize existing literature on perceived barriers to administering HPV vaccination reported by pharmacists. Barriers identified from selected studies were synthesized and further grouped into patient, parental, (pharmacist's) personal, and system/organization barrier groups. Six studies were included in this review. The cost of the HPV vaccine, insurance coverage and reimbursement were commonly reported perceived barriers. Adolescent HPV vaccination barriers related to parental concerns, beliefs, and inadequate knowledge about the HPV vaccine. Perceived (pharmacist's) personal barriers were related to lack of information and knowledge about HPV vaccine and recommendations. At the system/organization level, barriers reported included lack of time/staff/space; difficulty in series completion; tracking and recall of patient; perceived competition with providers; and other responsibilities/vaccines taking precedence. Future strategies involving pharmacy settings in HPV-related cancer prevention efforts should consider research on multilevel pharmacy-driven interventions addressing barriers.

YouTube as a Guide for Respimat® Soft Mist™ Inhaler Technique.

BACKGROUND: Consumers are involved more than ever in their health care, with many utilizing the Internet for health information. YouTube is a convenient and vast source of health education videos. Pharmaceutical companies, health organizations, providers, and others post instructional videos for the use of the Respimat® Soft Mist™ Inhaler device on sites like YouTube. Therefore, review of content and quality is important to ensure consumers are directed to the best information available. OBJECTIVE: Assess content and quality of YouTube videos demonstrating Respimat Soft Mist inhaler technique. METHODS: YouTube was queried May 16, 2018 using the term "Respimat inhaler." The first 35 unique videos in English with instructions for use were assessed. Technical quality of each video was evaluated using a validated scale and content assessed using manufacturer/package insert. RESULTS: Of 35 videos reviewed, median duration was 2 minutes 50 seconds (interquartile range [IQR]: 1 minute 23 seconds-4 minutes 22 seconds). Target audience was laypeople for 97% (n = 34) of videos. The source was a professional organization for 70% (n = 24). Most (74%, n = 24) received the maximum quality score of 5. Commonly omitted steps included documentation of the discard date (74%), repetitive dose activation until spray is visible (49%), and pointing inhaler to the back of the throat (43%). CONCLUSIONS: Proper technique is crucial for patients to achieve optimal results from inhaled medications. While many videos are available through YouTube for demonstration of Respimat Soft Mist inhaler technique, some omitted key steps. Thorough and repetitive patient education should be provided, and augmented with reputable online sources.

Comparison of traditional anesthesia method and jet injector anesthesia method (MadaJet XL®) for Nexplanon® insertion and removal.

BACKGROUND: This study compared a needle-free anesthesia method with traditional local anesthesia for insertion and removal of Nexplanon® long-acting removable contraceptive device. In our clinic, patients often avoid this highly effective form of contraception due to fear of needles. We sought to determine if patients perceived a difference in pain with the injection, anxiety level or pain with the procedure when local anesthesia was given with a needle v/s a needle-free jet injector device. METHODS: Patients were randomly assigned to one of two groups: jet injector or needle lidocaine delivery. Outcomes were ease of use, patient anxiety level, painfulness, and efficacy of anesthesia method. RESULTS: Patient pain perception with administration of jet injector lidocaine was statistically lower than traditional needle with no difference in anxiety or ease of use, or efficacy of the anesthesia. CONCLUSION: The jet injector device is a reasonable alternative to needle injection delivery of anesthesia prior to insertion/removal of Nexplanon® device. Further studies may determine whether this needle-free alternative for administration of local anesthetic would result in more women choosing Nexplanon® as a contraceptive method.

Development and implementation of a clinical decision support tool for treatment of uncomplicated urinary tract infections in a family medicine resident clinic.

OBJECTIVES: Outpatient antimicrobial stewardship has become increasingly important. While clinical decision support (CDS) tools have been effective in improving guideline-directed antibiotic prescribing, most notably for upper respiratory tract infections, their use for uncomplicated urinary tract infections (UTIs) has been less extensively studied. The objective of this study was to develop and implement a CDS tool to optimize antimicrobial prescribing for uncomplicated UTIs. SETTING: University-affiliated family medicine resident clinic. PRACTICE DESCRIPTION: This outpatient clinic is the practice site for 24 medical residents, 12 full-time faculty physicians, 1 nurse practitioner, and 1 full-time clinical pharmacist. PRACTICE INNOVATION: An interdisciplinary team including physicians, pharmacists, quality coordinator, and a coding and billing specialist collaborated to develop and implement a CDS tool into the clinic electronic health record to guide diagnosis, documentation, and antibiotic prescribing for uncomplicated UTIs. Prescribing practices were characterized, and a clinic-specific antibiogram was developed to identify focus areas for the CDS tool. EVALUATION: A retrospective chart review was conducted to evaluate empiric antibiotic prescribing before and after implementation of the CDS tool and after implementation when the tool was used or not used. RESULTS: Utilization of the tool clinic-wide was 29%. Overall fluoroquinolone use decreased from 42% to 15% after tool implementation (odds ratio [OR] 0.25; 95% CI 0.13-0.5; P < 0.001). Specifically, when the CDS tool was used, no patients received empiric therapy with fluoroquinolones (P = 0.005). With use of the tool following implementation, trimethoprim/sulfamethoxazole use decreased by 20% (OR 0.21; 95% CI 0.45-0.955; P = 0.003), nitrofurantoin for cystitis increased by 31% (OR 3.83; 95% CI 1.32-11.1; P = 0.01), and guideline-directed duration of therapy increased 32% (OR 4.34; 95% CI 1.48-12.73; P = 0.005). CONCLUSION: In an attempt to optimize empiric antimicrobial treatment for uncomplicated UTIs, we developed and implemented a CDS tool into the electronic health record in a family medicine resident clinic. Despite a 29% usage rate, many benefits were seen after tool implementation.

Implementation and assessment of a pulmonary diseases elective course for third-year pharmacy students.

BACKGROUND: Given the significant public health burden of pulmonary diseases and the vital role pharmacists play in management across the continuum of care (and within transitions in care), an elective course for pharmacy students focused on pulmonary diseases was developed. EDUCATIONAL ACTIVITY: A month-long elective course for third-year pharmacy students consisting of 12 class sessions delivered in two-hour periods three times per week, was implemented. The course was delivered using the team-based learning (TBL) format in addition to hands-on skills and simulation sessions. Knowledge and skills assessments were administered before and after completion of the course. Student perceptions of self-confidence and ability regarding management of pulmonary diseases pre- and post-course and their perceptions of the course and TBL as a teaching strategy for this course were evaluated upon course completion. CRITICAL ANALYSIS: Nine students completed the course. Mean scores on knowledge and skills assessment significantly improved after completion of the course (54.5% pre-course vs. 79.3% post-course; p < 0.05% and 60.3% pre-course vs. 93.2% post-course; p < 0.05, respectively). Student perceptions of their ability to care for patients with pulmonary diseases significantly increased, compared to pre-assessments, in all areas taught in the course (p< 0.05). Additionally, students' confidence in managing specific disease states significantly improved in all areas (p < 0.05) except for spirometry (p = 0.06). Students' knowledge, skills, and confidence regarding management of common pulmonary disease states improved following this month-long elective course delivered using a combination of TBL activities and hands-on skills sessions.

Assessment of Clinical Pharmacy Interventions to Reduce Outpatient Use of High-Risk Medications in the Elderly.

BACKGROUND: Use of high-risk medications in the elderly (HRME) and drug-disease (Rx-DIS) interactions in the elderly, as defined by the Healthcare Effectiveness Data and Information Set (HEDIS) Measures, are significantly associated with mortality, hospital admission, and need for emergency care. No published studies to date evaluate interventions to reduce the use of HEDIS-defined HRME, although many studies have postulated a beneficial effect of such interventions. OBJECTIVE: To evaluate the effect of pharmacist interventions on use of HRME and Rx-DIS interactions in the outpatient elderly population. METHODS: This retrospective cohort study was conducted in a resident-based family medicine clinic. Patients aged ≥ 65 years were prospectively screened for the use of HRME and Rx-DIS interactions before their visits with their primary care providers. If HRME or Rx-DIS interactions were noted, the clinical pharmacist sent messages to the physicians through the electronic medical record, alerting them of the findings with suggestions of safer alternative agents, if applicable. The recommendation acceptance rate was assessed and then compared with a historical control from a similar time frame. The primary outcome was assessed with a chi square analysis. Secondary outcomes were assessed with descriptive statistics, chi square test, and Fisher's exact test. RESULTS: HRME and/or Rx-DIS interactions were changed 25.9% of the time in the pharmacist intervention group compared with only 2.0% of the time in the historical control group (P = 0.001). The most frequently changed medication classes included skeletal muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs. Over 85% of the medication changes were preserved at the end of the study period. There was no difference between groups in the number of patients with HRME or Rx-DIS interactions. CONCLUSIONS: Clinical pharmacy interventions result in significant reductions in use of HRME and Rx-DIS interactions in the outpatient elderly population. Using electronic communication allows pharmacists to provide meaningful interventions for numerous patients receiving care in a high-volume family medicine clinic setting. DISCLOSURES: There was no funding or sponsorship for this study. Rowe reports personal fees from The Medicines Company, outside the submitted work. The other authors have nothing to disclose. Study concept and design were contributed by Jeter, Chamberlin, and Weddle, with assistance from Rowe and Franks. Weddle and Renwick collected the data, and data interpretation was performed by Weddle and Rowe, with assistance from Franks. The manuscript was written by Weddle and Rowe and revised by Weddle and Franks, assisted by Chamberlin. The abstract for the completed study was presented at the American College of Clinical Pharmacy Global Conference, San Francisco, California, October 2015, and the Southeastern Residency Conference, Athens, Georgia, April 2015 (platform presentation). The research-in-progress abstract was presented at the Tennessee Society of Health System Pharmacists, Nashville, Tennessee, February 2015; the American Society of Health System Pharmacists Midyear Clinical Meeting, Anaheim, California, December 2014; and the University HealthSystem Consortium Pharmacy Council, Anaheim, California, December 2014.