Evaluation of Patient Adherence to Vaccine and Screening Recommendations during Community Pharmacist-led Medicare Annual Wellness Visits in a Family Medicine Clinic.

Background: The Centers for Medicare and Medicaid Services initiated annual wellness visits (AWV) to reduce healthcare costs and improve preventive healthcare for beneficiaries. Provider time constraints and varying preferences to perform AWVs have limited its clinical implementation in some areas, affording pharmacists an opportunity to expand their role. Objective: To evaluate patient adherence to pharmacist recommendations for vaccinations and preventive screenings in an annual wellness visit service at a family medicine clinic in northeast Mississippi. Methods: This study included patients receiving at least one vaccination or screening recommendation during an AWV. Investigators provided vaccination (influenza, pneumococcal and herpes zoster) and screening (mammograms, DEXA, and colorectal cancer) recommendations based on current guidelines. For services not provided in-clinic, investigators contacted outside facilities 45 days post-visit to confirm adherence to recommendations. Primary endpoints included the composite adherence rate of all recommendations and percentage of patients achieving the 60% goal composite adherence rate. Secondary endpoints included individual vaccination and screening adherence rates. Results: Investigators recommended 715 interventions to a total of 254 patients, of which 239 were completed within 45 days for a 33.4 percent composite adherence rate. 20.1 percent of all participants achieved the goal composite adherence rate (60%). Overall, participants were 30.5 and 41 percent adherent to all vaccinations and preventive screening recommendations, respectively. Conclusion: Pharmacists providing AWVs increased patient access to preventive health recommendations. Although, adherence to recommendations remains a challenge and warrants further study. The findings and limitations observed in this study have identified opportunities for future research to evaluate pharmacist-led AWV services.

Development and Evaluation of a Pharmacist-Driven Vitamin D Protocol for a Cystic Fibrosis Clinic.

OBJECTIVE: Vitamin D deficiency is commonly found in patients with cystic fibrosis (CF) and can have a negative effect on patients who are not at target goal according to Cystic Fibrosis Foundation's Vitamin D Deficiency Clinical Care Guidelines. The objective of this study is to determine the effectiveness of a pharmacist-driven vitamin D protocol (PDVDP) in improving, achieving, and maintaining 25-hydroxyvitamin D levels of patients in a pediatric CF clinic. METHODS: A retrospective chart review was conducted for pediatric patients with CF from August 2018 to March 2020 to determine the percent of patients with improvement in 25-hydroxyvitamin D levels to target goal (≥ 30 ng/mL). Patients' 25-hydroxyvitamin D levels at 6, 12, and 18 months after automatic enrollment into the PDVDP were compared to determine if improvement occurred, and to calculate relative percent increase of 25-hydroxyvitamin D levels for these patients. RESULTS: The mean 25-hydroxyvitamin D levels of the patients at baseline before the protocol and 6, 12, and 18 months after enrollment in the protocol were 23.2, 33.3, 32.7, and 34.6 ng/mL, respectively. These results demonstrate mean 25-hydroxyvitamin D levels at all follow-up time points were significantly greater than baseline (p < 0.001). At 6 months, 50% (n = 20) of pediatric patients reached the target 25-hydroxyvitamin D levels. CONCLUSIONS: The PDVDP was effective in increasing the number of patients able to reach target 25-hydroxyvitamin D levels. Our PDVDP process may also be used at other CF clinics to improve vitamin D outcomes collaboratively with the interprofessional CF team.

Evaluation of a novel process for selecting advanced pharmacy practice experiences.

INTRODUCTION: Matching an increasing number of pharmacy students with a limited number of advanced pharmacy practice experience (APPE) sites has become challenging for pharmacy schools. Selective tiered optimization (STO), a process for matching students with competitive APPE electives, was implemented by The University of Mississippi School of Pharmacy (UMSOP) in 2015 to address these concerns. This pilot study sought to evaluate student and preceptor satisfaction with the process. METHODS: Electronic surveys were sent to students enrolled in APPEs and individuals who precepted APPE students at the UMSOP from 2016 to 2019. The surveys were designed to gauge satisfaction with STO's process, goals, utility, and fairness. RESULTS: There were 63 responses from 149 preceptors (42% response rate) and 70 respondents from 314 students (22% response rate). Overall, both students and preceptors expressed satisfaction and found value in participating in STO. Both groups indicated that the benefit they received from participating in STO outweighed the extra effort required. Preceptors indicated that students who participated in STO were of higher quality and more focused, hardworking, and interested than those who did not participate. CONCLUSIONS: Respondents were satisfied with the STO process and experience. The process was perceived by preceptors to be fair for all students and worthwhile for its participants. Our results also demonstrated that this process is effective for easing the competitive APPE selection process. Schools and colleges of pharmacy should consider utilizing this process to alleviate applicable challenges with APPE selection.

Determining student-level characteristics predictive of successful matching in PGY1 community-based residency programs: A curriculum vitae analysis.

INTRODUCTION: The purpose of this analysis was to determine which characteristics increase a candidate's likelihood of matching with a post-graduate year 1 (PGY1) community-based residency program (CBRP). METHODS: Current and former CBRP residents' curriculum vitae (CVs) were collected and reviewed utilizing a survey and standardized rubric. Eligible participants were current PGY1 CBRP residents or had completed a PGY1 program no earlier than 2015. Primary endpoints included number of participants with extensive leadership experience, relevant experiential rotations, presentation history, and involvement in pharmacy organizations. Descriptive statistics were performed to identify the most common characteristics and their relative quantities. RESULTS: A total of 50 eligible CVs were submitted and reviewed. The majority of participants had extensive (defined as four or more) presentation experiences, at least three mid- to high-level leadership experiences, multiple ambulatory/outpatient pharmacy experiential rotations, and involvement in pharmacy organizations. Few participants (26%) had previous teaching experience. CONCLUSIONS: Residency candidates who matched with CBRPs tended to have extensive mid- to high-level leadership experiences and presentation experience. Based on these findings, additional studies are warranted to compare existing and/or redesigned postgraduate training preparation curricula and their impact on residency match rates.

Infectious complications of newer agents in the fight against diabetes.

Infectious complications have been reported with antidiabetic medications. Glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors have been associated with upper respiratory tract infections and urinary tract infections. Sodium-glucose cotransporter 2 inhibitors have been associated with lower limb amputations, urinary tract infections, genital mycotic infections, and Fournier gangrene.

The Mississippi Delta Health Collaborative Medication Therapy Management Model: Public Health and Pharmacy Working Together to Improve Population Health in the Mississippi Delta.

INTRODUCTION: The Mississippi Delta has high rates of chronic disease and is known for its poor health outcomes and health disparities. The University of Mississippi School of Pharmacy (UMSOP) and the Mississippi State Department of Health partnered in 2009 through the Mississippi Delta Health Collaborative to reduce health disparities and improve clinical outcomes by expanding the UMSOP's evidence-based medication therapy management (MTM) initiative, focused in Mississippi's 18-county Delta region, to federally qualified health centers (FQHCs) in 4 of those counties. METHODS: Between January 2009 and August 2018, the MTM initiative targeted FQHC patients aged 18 years or older with a diagnosis of diabetes, hypertension, and/or dyslipidemia. Pharmacists initially met face-to-face with patients to review all medications, provide education about chronic diseases, identify and resolve drug therapy problems, and take appropriate actions to help improve the effectiveness of medication therapies. Clinical parameters evaluated were systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, and hemoglobin A1c (HbA1c). RESULTS: The analysis included 335 patients with hypertension (n = 287), dyslipidemia (n = 131), and/or diabetes (n = 331). Significant mean reductions occurred in the following metrics: SBP (7.1 mm Hg), DBP (6.3 mm Hg), LDL cholesterol (24.9 mg/dL), triglycerides (45.5 mg/dL), total cholesterol (37.7 mg/dL), and HbA1c (1.6% [baseline ≥6%] and 1.9% [baseline ≥9%]). CONCLUSION: Despite the cultural and environmental disadvantages present in the Mississippi Delta, the integrated MTM treatment program demonstrated significant health improvements across 3 chronic diseases: hypertension, dyslipidemia, and diabetes. This model demonstrates that a partnership between public health and pharmacy is a successful and innovative approach to care.

Pharmacist linkage in care transitions: From academic medical center to community.

OBJECTIVES: To improve the care of patients discharged from the University of Mississippi Medical Center (UMMC) after treatment for acute myocardial infarction, heart failure, pneumonia, and chronic obstructive pulmonary disease; reduce preventable hospital readmissions; and inform future care transition collaborations between hospital teams and community pharmacies. SETTING: Study was conducted at UMMC, UMMC outpatient pharmacies, and targeted community pharmacies. PRACTICE DESCRIPTION: UMMC is the state's only academic health science center, providing all levels of care. Participants were at UMMC's 722-bed hospital in Jackson, MS. Participating pharmacies included 2 UMMC outpatient pharmacies and community pharmacy research partner sites within 60 miles of UMMC. PRACTICE INNOVATION: A pharmacist transitions coordinator (PTC) worked with inpatient and community-based pharmacists to provide predischarge medication reconciliation and 30 days of medications on discharge. The PTC with access to inpatient and outpatient records facilitated communication among settings/providers. Community pharmacists provided telephonic and face-to-face medication therapy management (MTM). EVALUATION: The project was structured as a prospective, randomized controlled trial of pharmacist-led care coordination during transition from inpatient to community setting, with follow-up MTM by community pharmacists. In this intention-to-treat analysis, readmission rates were assessed with propensity adjustment. Drug therapy problems (DTPs) identified/resolved were assessed and reported through descriptive statistics. RESULTS: Ninety-six patients were enrolled. Positive outcomes in overall reduced readmission rates were observed in the intervention group at 30, 60, 90, and 180 days, although statistical significance was not achieved because of limited enrollment. Approximately 60% participated in MTM postdischarge, with 453 interventions and 169 DTPs identified and addressed (98% > 1 DTP; 20% > 5 DTPs). Implementation experience includes PTC successes, new partnerships, and connectivity among all providers, as well as enrollment challenges, follow-up, and service delivery timeframe. CONCLUSION: With access to patient records, pharmacists have the potential to positively affect patient outcomes through medication management during care transitions.

Public perceptions of naloxone use in the outpatient setting.

INTRODUCTION: Naloxone has become an important component of preventing deaths from opioid overdose. Although studies have confirmed its cost-effectiveness, naloxone is rarely prescribed proactively in case of accidental overdose. The perception still exists that a reversal agent may enable patients with opioid use disorder to continue abusing opioids without fear of death from overdose. This study was designed to determine the general public's knowledge of naloxone and their perceptions about receiving a naloxone prescription with opioid use. METHODS: Participants were recruited through Amazon Mechanical Turk (MTurk), where a link directed participants to an electronic survey. Participants were included if they were 18 years of age or greater and currently living in the United States. Participants were paid $0.10 USD via Amazon MTurk upon completing the survey. RESULTS: Four hundred five participants successfully completed the survey, and 61% were aware that there is a medication available to treat opioid overdose. The majority of participants responded positively to the idea of acquiring naloxone. Responses were evenly split for agreeing and disagreeing with the statement "naloxone is only necessary for people who abuse opioids." Although 51% of respondents believed that having naloxone available enables people who abuse opioids, 88% agreed that naloxone is beneficial for people who accidentally overdose on opioids. A majority believed that naloxone should be made available upon request to anyone concerned about opioid overdose. DISCUSSION: Participants were generally aware of the availability of an opioid reversal agent and responded positively to 3 different methods of acquiring naloxone through their prescriber or pharmacist.

Effect of fish oil supplement administration method on tolerability and adherence: a randomized pilot clinical trial.

OBJECTIVES: Anecdotally, several strategies have been suggested in order to improve tolerability of fish oil supplements, but there is little evidence supporting any of these strategies. The aim of this study was to determine if there is a difference among four methods of oral administration of fish oil supplementation in terms of tolerability and adherence. METHODS: A randomized, prospective, open-label, four-arm pilot study was conducted on 60 healthy adult subjects randomized to different fish oil supplement administration methods with (1) milk, (2) food, (3) an empty stomach, and (4) frozen capsules prior to ingestion. Each subject was instructed to take two capsules three times daily for 30 consecutive days. Adherence was assessed by pill counts. Adverse effects were assessed by survey and patient exit interview. RESULTS: No apparent differences were demonstrated among the four administration groups in terms of adherence, reasons for non-adherence, or self-reported adverse effects. CONCLUSIONS: Method of administration did not affect rates of adherence or incidence of adverse effects in a small cohort of healthy adults taking fish oil supplement capsules for 30 days. TRIAL REGISTRATION: ClinicalTrials.gov NCT01471366. Registered November 16, 2011.

Ultra-long-acting insulins: A review of efficacy, safety, and implications for practice.

BACKGROUND AND PURPOSE: In the past decade, there has been much advancement in oral antidiabetic agents, but few changes in insulin therapy. With the addition of the ultra-long-acting insulins, insulin glargine U300 (IGlar 300) and insulin degludec (IDeg 100 and IDeg 200), it is important to understand key aspects in the agents' clinical properties, efficacy, safety, dosing, packaging, and place in therapy. METHODS: A literature review was conducted using PubMed database and was limited to English, full-text articles published from January 2000 to January 2018. The following search terms were used: insulin glargine 300, insulin degludec, Toujeo, Tresiba, and ultra-long-acting insulin. CONCLUSIONS: These agents are longer acting with sustained insulin coverage as compared with other basal insulins while having a low potential for hypoglycemia. Efficacy and safety profiles are quite good, and potential for weight gain was similar to IGlar 100. IMPLICATIONS FOR PRACTICE: Depending on the patient's needs, these newer agents may offer some advantages. Insulin glargine U300 and IDeg 200 are concentrated, allowing for administration of large doses by less volume, thereby theoretically improving absorption. For patients needing flexible dosing, IDeg may be beneficial. The ultra-long-acting agents may also be useful if it is suspected that the basal insulin is not lasting the entire day.

The impact of participation in a Research/Writing Group on scholarly pursuits by non-tenure track clinical faculty.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the success of a faculty Research/Writing Group (RWG) by quantifying the amount of scholarly productivity from participants in the group compared with that of a matched cohort. EDUCATIONAL ACTIVITY AND SETTING: The RWG meets monthly to discuss current projects, providing an assessment of their scholarly activity. Participants offer ideas on improvement, resources and possible platforms for presentations and/or publications. FINDINGS: To evaluate the success of this model, scholarly production from the participants in the RWG was compared to a matched group of clinical non-tenure track faculty not participating in the group over a three year period. Faculty perception of RWG participation was evaluated by data collected through a survey using Qualtrics. SUMMARY: Participation in the RWG provided these junior faculty the support system to feel confident in their pursuit of scholarly activities; and therefore, they outpaced their counterparts in dissemination of their research.

Comparison of Pharmacist and Physician Managed Annual Medicare Wellness Services.

BACKGROUND: Medicare Annual Wellness Visits (AWV) are a benefit provided for Medicare beneficiaries to increase focus on wellness and preventive measures. Pharmacists can conduct AWVs, which offers a potential avenue for outpatient revenue generation. PROGRAM DESCRIPTION: To compare a composite of interventions and screenings and revenue generated by a pharmacist with those made by a physician during a subsequent AWV. A report generated through the electronic health record was used to determine AWVs conducted by a pharmacist or 3 participating physicians from December 2013 to March 2016, including revenue generated. Through electronic chart review, documentation was accessed to quantify and categorize the number and types of referrals, health advice, laboratory tests, procedures, vaccinations, and screenings that were recommended during each patient's AWV. OBSERVATIONS: The pharmacist performed 19 subsequent visits, and the 3 physicians performed 89 subsequent visits. Overall, the composite of interventions and screenings was significantly higher in the pharmacist group than the physician group (P = 0.03). More interventions were made in the areas of health advice (P = 0.020), vaccine recommendations (P = 0.009), and screenings in the pharmacist group (P < 0.001). The physicians ordered significantly more laboratory tests per visit (P < 0.001). The pharmacist was reimbursed on average $105 per visit versus $99 per visit for the physicians. IMPLICATIONS: Pharmacist-provided AWVs are at least comparable to those provided by physicians and offer an additional access point for valuable services for Medicare beneficiaries. DISCLOSURES: There was no financial contribution to this study. Riche reports participation in the Speaker's Bureau for Merck and the Speaker's Bureau and Advisory Board for Novo Nordisk. The authors have no other conflicts of interest to report pertinent to this research. This data has not been previously published in any other location. Richie, Sewell, Malinowski, Jackson, and Fleming were involved in study design and manuscript preparation/approval. Jackson was involved in data collection, and Richie and Sewell were involved in data collection and data analysis. Sewell and Richie had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

A multipreceptor approach to ambulatory care topic discussions.

OBJECTIVE: To assess the impact of a multipreceptor approach to facilitating topic discussions on students' knowledge and confidence in clinical decision-making during an ambulatory care advanced pharmacy practice experiences (APPEs). DESIGN: Faculty members with relevant expertise and experience facilitated discussions with fourth-year doctor of pharmacy (PharmD) students regarding 7 ambulatory care topics. A student self-assessment survey and knowledge-assessment instrument was administered before and after discussions. ASSESSMENT: Students' examination scores increased significantly from 59.1% ± 13.9% at baseline to 76.5% ± 12.6% at the end of the 5-week experience (p<0.001). The majority of participants were comfortable making therapeutic decisions regarding medication use as it related to all discussion topics except heart failure. CONCLUSIONS: Participation in topic discussions led by faculty members with expertise and experience for each ambulatory care topic was associated with a significant improvement in knowledge-assessment scores.

Resistant nonalcoholic fatty liver disease amelioration with rosuvastatin and pioglitazone combination therapy in a patient with metabolic syndrome.

OBJECTIVE: To report a case describing resolution of persistently elevated aminotransferases in a patient with severe, resistant nonalcoholic fatty liver disease (NAFLD) using combination therapy. CASE SUMMARY: A 47-year-old obese male patient presented with a history of elevated aminotransferases and numerous statin intolerances. In addition to worsening control of diabetes and dyslipidemia, severe NAFLD was confirmed. Rosuvastatin was started, which induced short-term elevations in aminotransferases resulting in patient discontinuation. Biochemical markers of NAFLD worsened over time. Therefore, both rosuvastatin 20 mg daily and pioglitazone 15 mg daily were started simultaneously to potentially blunt the early increase in transaminases seen with rosuvastatin. At 2 weeks, the patient's alanine aminotransferase (ALT) and aspartate aminotransferase (AST) had decreased 57% and 56% from baseline, respectively. By 9 months, the patient's ALT and AST serum concentrations had normalized. Repeat liver ultrasound demonstrated improvement in steatosis grading and reduction in liver size. These improvements occurred despite a 4.5-kg weight gain since starting rosuvastatin and pioglitazone. DISCUSSION: Pharmacotherapy in NAFLD is not well validated, particularly combination therapy. Medications that target obesity-related consequences are commonly used, although evidence regarding biochemical and histological improvement is inconclusive. Consideration should be given to the use of combination of thiazolidinediones and statins for rapid biochemical improvement and long-term histological impact. CONCLUSIONS: The improvement in this patient's biochemical and ultrasonographic markers of resistant, severe NAFLD was rapid and sustained with combination therapy. This case represents a potential solution for initiating or maintaining statin therapy in patients with NAFLD who are at high cardiovascular risk.

Pharmacologic therapy for nonalcoholic fatty liver disease in adults.

Nonalcoholic fatty liver disease (NAFLD) is characterized by the accumulation of triglycerides in hepatocytes in the absence of excessive alcohol intake, ranging in severity from simple steatosis to nonalcoholic steatohepatitis (NASH). Nonalcoholic steatohepatitis can ultimately progress to cirrhosis and hepatocellular carcinoma. NAFLD is associated with cardiometabolic risk factors and is the most common chronic liver disease among adults in the Western Hemisphere. Although simple steatosis is generally considered a self-limiting disease, evidence suggests an increased risk of cardiovascular disease, and, less conclusively, mortality, among individuals with NAFLD and/or NASH. The current standard of care for the treatment of patients with NAFLD focuses on lifestyle interventions, particularly diet and exercise. There is a lack of consensus regarding the most effective and appropriate pharmacologic therapy. A PubMed search was conducted using the medical subject heading terms "fatty liver" and "steatohepatitis." This review focuses on the current pharmacologic options available for treating adults with NAFLD and/or NASH. Continued investigation of drugs or combinations that improve NAFLD progression is crucial. Clinicians, particularly pharmacists, must take an active role in identification and appropriate selection of pharmacotherapy for NAFLD.

Nutritional and metabolic complications of bariatric surgery.

Bariatric surgery is an effective treatment for patients with clinically severe obesity. In addition to significant weight loss, it is also associated with improvements in comorbidities. Unfortunately, bariatric surgery also has the potential to cause a variety of nutritional and metabolic complications. These complications are mostly due to the extensive surgically induced anatomical changes incurred by the patient's gastrointestinal tract, particularly with roux-en-Y gastric bypass and biliopancreatic diversion. Complications associated with vertical banded gastroplasty are mostly due to decreased intake amounts of specific nutrients. Macronutrient deficiencies can include severe protein-calorie malnutrition and fat malabsorption. The most common micronutrient deficiencies are of vitamin B12, iron, calcium, and vitamin D. Other micronutrient deficiencies that can lead to serious complications include thiamine, folate, and the fat-soluble vitamins. Counseling, monitoring, and nutrient and mineral supplementation are essential for the treatment and prevention of nutritional and metabolic complications after bariatric surgery.