Comparison of Clinical Interventions between Student Pharmacists on Advanced Pharmacy Practice Experiences in Indianapolis, Indiana versus Eldoret, Kenya.

Student pharmacists can have a positive impact on patient care. The objective of this research was to compare clinical interventions made by Purdue University College of Pharmacy (PUCOP) student pharmacists completing internal medicine Advanced Pharmacy Practice Experiences (APPE) in Kenya and the US. A retrospective analysis of interventions made by PUCOP student pharmacists participating in either the 8-week global health APPE at Moi Teaching and Referral Hospital (MTRH-Kenya) or the 4-week adult medicine APPE at the Sydney & Lois Eskenazi Hospital (SLEH-US) was completed. Twenty-nine students (94%) documented interventions from the MTRH-Kenya cohort and 23 (82%) from the SLEH-US cohort. The median number of patients cared for per day was similar between the MTRH-Kenya (6.98 patients per day, interquartile range [IQR] = 5.75 to 8.15) and SLEH-US students (6.47 patients per day, IQR = 5.58 to 7.83). MTRH-Kenya students made a median number of 25.44 interventions per day (IQR = 20.80 to 28.95), while SLEH-US students made 14.77 (IQR = 9.80 to 17.72). The most common interventions were medication reconciliation/t-sheet rewrite and patient chart reviews for MTRH-Kenya and the SLEH-US, respectively. This research highlights how student pharmacists, supported in a well-designed, location-appropriate learning environment, can positively impact patient care.

Analysis of Pharmacy Cardiac Optimization Clinic for Patients with New Onset Atrial Fibrillation Detected via Cardiac Implantable Electronic Device Clinic.

For patients with cardiac implantable electronic devices (CIEDs), arrythmias such as atrial fibrillation (AF) can be detected and actions taken to rapidly assess and initiate treatment where appropriate. Actions include timely initiation of anticoagulation, review of blood pressure, and optimization of cholesterol/lipids to prevent unfavorable outcomes, such as stroke and other cardiovascular complications. Delays to initiating anticoagulation can have devastating consequences. We sought to implement a virtual clinic, where a pharmacist reviews patient referrals from a CIED clinic after detecting AF from the CIED. Anticoagulation choice is determined by patient-specific factors, and a shared patient-provider decision to start oral anticoagulation is made. In addition, blood pressure readings and medications are assessed with lipid-lowering therapies for optimization. A total of 315 patients have been admitted through this clinic and anticoagulated over a two-year span; in addition, 322 successful interventions were made for optimization of cardiac therapy. Rapid initiation of anticoagulation within five days of referral was likely to have reduced unfavorable outcomes, such as stroke and other cardiovascular optimizations, leading to improved patient outcomes.

Critical moments in student learning on international advanced pharmacy practice experiences.

INTRODUCTION: The purpose of this study was to evaluate self-perceived critical moments that were transformative to learning in students who participated in an international advanced pharmacy practice experience (APPE). METHODS: Twenty-two pharmacy students from Purdue University College of Pharmacy, the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and the University of North Carolina Eshelman School of Pharmacy who went on an international APPE participated in a one-hour focus group evaluating self-perceived critical moments that impacted their learning. Focus groups were coded using a conventional content analysis approach and went through a two-cycle open coding process to identify major themes according to country income classification. RESULTS: Twenty-two students participated in the focus groups with 18% going to a high-income country (HIC) and 82% going to a low-to-middle income country (LMIC) location. Major themes identified within HIC locations included witnessing an innovative patient care technique and experiencing interprofessional healthcare team dynamics. Major themes identified within LMIC locations included engaging in a sensitive patient interaction, experiencing healthcare system barriers, going out of their comfort zone, and making a difference. CONCLUSIONS: International APPEs in both HIC and LMICs provided students with disorienting experiences that facilitated transformative learning and led to changes in their perspectives on patient care and pharmacy practice. While critical moments were different across country income locations, both provided valuable experiences that could be translated into local context.

Integration of Intercultural Learning into an International Advanced Pharmacy Practice Experience in London, England.

As the number of international advanced pharmacy practice experiences (APPEs) continues to grow, this is an opportunity to incorporate intercultural learning (ICL) to further advance student pharmacist training. Purdue University student pharmacists participated in a clinical research focused APPE in London, England. To prepare for this APPE, students completed a one-credit course focused on intercultural learning and travel preparation. The purpose of this report is to describe the implementation and assessment of ICL during this course and international APPE. The course includes interactive ICL activities, reflective assignments, and personalized assessments. During the eight-week APPE, student pharmacists worked on an individualized Intercultural Development Plan®, which includes ICL activities, focused reflection, and check-ins. ICL was assessed using the Intercultural Development Inventory® (IDI®) at the beginning of the course and at least four weeks after APPE completion. Student APPE feedback was also reviewed for evidence of ICL. Twenty-seven students completed the course and APPE from 2018 to 2020. The average IDI developmental orientation (DO) before the course was 91.7, placing students in minimization. The average perceived orientation was 120.9, placing students in acceptance. There were 18 students who completed the post-APPE IDI: 12 students demonstrated growth in the DO (range: 1.5-23.72), and six students experienced a decrease in their DO. Intercultural learning can be implemented and assessed as part of an international APPE.

Development of a Global Health Learning Progression (GHELP) Model.

There has been a steady increase in global health experiential opportunities offered within healthcare professional training programs and with this, a need to describe the process for learning. This article describes a model to contextualize global health learning for students who complete international advanced pharmacy practice experiences (APPEs). Students from University of North Carolina at Chapel Hill, Purdue University, and the University of Colorado completed a post-APPE survey which included open-ended questions about knowledge, skills, and attitudes one week after completing an international APPE. Students were also invited to participate in a focus group. All 81 students who participated in an international APPE completed the open-ended survey questions and 22 students participated in a focus group discussion. Qualitative data from both the survey and focus groups were coded in a two-cycle open coding process. Code mapping and analytic memo writing were analyzed to derive to a conceptual learning model. The Global Health Experience Learning Progression (GHELP) model was derived to describe the process of student learning while on global health experiences. This progression model has three constructs and incorporates learning from external and internal influences. The model describes how students can advance from cultural awareness to cultural sensitivity and describes how student pharmacists who participate in international experiential education develop global health knowledge, skills, and attitudes.

Framework and case study for establishing impactful global health programs through academia - biopharmaceutical industry partnerships.

BACKGROUND: The field of global health has grown with multiple different public and private stakeholders engaging in the effort to improve health outcomes for underserved populations around the world. There is, however, only limited published guidance on how to promote successful partnerships between academia and the biopharmaceutical industry. OBJECTIVE: This analysis will provide a framework for developing successful partnerships around five central principles. This framework will then be applied to two representative pharmacy collaboration case studies focused on training and donations. FRAMEWORK DESCRIPTION AND CASE STUDY FINDINGS: Within the Academic Model Providing Access to Healthcare (AMPATH), successful collaborations between the biopharmaceutical industry philanthropic entities and academic partners have consistently prioritized 1) contextualization, 2) collaboration, 3) local priorities, 4) institutional commitment, and 5) integration. In the first case study, the application of this framework to clinical pharmacy training activities sponsored by Celgene and implemented by the Purdue Kenya Partnership has helped the program transition from an entirely donor dependent training program to a revenue generating, locally administered program which is now recognized and accredited by the Kenyan government. In the second case study, medication donations from Eli Lilly and Company have been converted from a traditional donation program in one Kenyan health facility to a replicable and sustainable supply chain model which has been expanded to more than 70 public sector facilities across western Kenya. CONCLUSION: Adherence to the five core principles of the proposed framework can help guide partnerships between academic institutions and the biopharmaceutical industry to advance healthcare services for underserved populations around the world. As large-scale government-based development agencies continue to primarily focus on specific disease states, biopharmaceutical industry-based collaborations can help initiate activities in underfunded therapeutic areas such as non-communicable diseases.

Global Health Learning Outcomes by Country Location and Duration for International Experiences.

Objective. To determine the impact of country income classification and experience duration on learning outcomes for student pharmacists participating in international advanced pharmacy practice experiences (APPEs). Methods. A mixed-methods, longitudinal study evaluated 81 fourth-year student pharmacists participating in an international APPE through one of three US universities. A pre-post survey was administered to evaluate students' self-perceived growth across 13 competencies established by the Consortium of Universities for Global Health (CUGH). The survey included four additional open-ended questions. Student pharmacists were also invited to participate in a focus group. Paired and independent t tests and multiple linear regression were conducted. Qualitative survey and focus group data underwent a two-cycle, open-coding process using conventional content analysis. Results. Students who completed their APPE in a low- to middle-income country had greater growth in all CUGH competency statements compared to those who completed their APPE in a high-income country. Completing the APPE in a low- to middle-income country and prior travel for non-vacation purposes were significant predictors of student growth. Students who went to a low- to middle-income country demonstrated increased cultural sensitivity, more patient-centered care, and skill development, while students who went to a high-income country displayed increased knowledge regarding differences in health care system components, pharmacy practice, pharmacy education, and an appreciation for alternative patient care approaches. Conclusion. Learning outcomes differed between students who completed an APPE in a high-income rather than a low- to middle-income country, with both types of locations providing valuable educational opportunities and professional and personal development.

Creating global health leaders in pharmacy by evolving postgraduate training.

There has been a push for increasing global health education and training opportunities within the pharmacy profession. Global health postgraduate learning opportunities are necessary to define pharmacy career paths in global health and develop global health leaders. There are many challenges to starting a global health postgraduate training program including economic burden, logistics of extramural rotations, local and international resources, and program sustainability. In the face of barriers inhibiting formal program establishment, different strategies can be used to incorporate global health topics into existing postgraduate training opportunities. Possible solutions include relating local health to global health to develop a global mindset, expanding upon existing partnerships to provide international global health experiences, use of technology and simulation for virtual global health interaction, and emphasis of implementation science principles to connect and translate local health interventions to a global scale.

An Ethics-based approach to Global Health Research Part 3: Emphasis on Partnership Funding.

Acquiring funding for global health research within pharmacy can be challenging, particularly for new investigators who may have a strong interest in resolving global dilemmas related to health. Moreover, there can be inherent imbalances and ethical issues when navigating the funding process for global partnerships. There exists a lack of literature providing ethical guidance for mitigating dilemmas that may arise. This commentary discusses current funding streams for investigators interested in global pharmacy research, as well as specific recommendations for the funding process. These recommendations include managing award funds, ethical considerations for funding research partnerships, and balancing power between low to middle income countries and high-income countries. Lastly, case examples of funding partnerships involving pharmacy are highlighted, emphasizing important lessons learned. This commentary addresses the critical need for providing global health researchers with both important considerations and experience-based recommendations for navigating global funding partnerships using an ethical approach.

Global Health Learning Outcomes in Pharmacy Students Completing International Advanced Pharmacy Practice Experiences.

Objective. To examine the global health learning outcomes of Doctor of Pharmacy (PharmD) students from three US schools who participated in international advanced pharmacy practice experiences (APPEs). Methods. A mixed-methods, prospective study was used to assess fourth-year PharmD students at three US pharmacy schools who participated in an international APPE during the 2017-2018 academic year and a matched cohort (control group) of PharmD students who did not participate in an international APPE. To evaluate students' self-perceived growth in the Consortium of Universities for Global Health (CUGH) competencies, all students completed a 13-item retrospective pre-post instrument using a five-point Likert scale. The students who had completed an international APPE were invited to participate in a focus group (N=22). Paired and independent t tests and multiple linear regression were used to analyze data. Qualitative open-ended questions and focus group data were mapped to knowledge, skills, and attitudes themes. Results. The students who completed an international APPE (N=81) showed significantly more growth in CUGH competencies than students who did not (mean improvement in total score of 10.3 [7.0] vs 2.4 [6.0]). International APPE participation was the only significant predictor of growth in CUGH competencies. The international APPE students reported improvements in cultural awareness and appreciation, communication skills, problem-solving skills, adaptability, self-awareness, personal and professional outlook, and global health perspective. Conclusion. Pharmacy students' participation in international APPEs led to significant improvement in all CUGH competencies. The CUGH competency framework appears to be a suitable instrument to assess pharmacy students' global health learning outcomes.

Criteria for evaluating global health partnerships in colleges of pharmacy and health sciences.

BACKGROUND AND PURPOSE: The demand for international experiences as part of education and training for healthcare providers continues to increase. As schools/colleges of pharmacy increase training opportunities in global health, there is a demand for a strategic way to evaluate opportunities. Evaluation tools can be utilized to facilitate this type of assessment. EDUCATIONAL ACTIVITY AND SETTING: The purpose of this article is to highlight two different international experiential education site evaluation tools, discuss lessons learned when applying these tools in the field, and outline steps for a college of pharmacy to create their own tool to meet institution specific needs. FINDINGS: The involvement of key stakeholders is important to developing an evaluation tool. Identification and prioritization of key criteria for assessing partnerships is essential. There are many criteria and each institution may consider a unique set of criteria, the most appropriate way to evaluate these, and who should be completing this evaluation. DISCUSSION AND SUMMARY: An evaluation tool may serve as a framework of discussion for new and existing international partnerships. The use of a global partnership evaluation tool allows for a more consistent discussion when deciding if the partnership is appropriate for both parties, helps the involved faculty know what criteria are required to be evaluated and outlines what resources should be considered.

Meeting the Needs of Underserved Patients in Western Kenya by Creating the Next Generation of Global Health Pharmacists.

Objective. To describe a novel training model used to create a sustainable public health-focused pharmacy residency based in Kenya and to describe the outcomes of this training program on underserved populations. Design. The postgraduate year 2 residency was designed to expose trainees to the unique public health facets of inpatient, outpatient, and community-based care delivery in low and middle-income countries. Public health areas of focus included supply chain management, reproductive health, pediatrics, HIV, chronic disease management, and teaching. Assessment. The outcomes of the residency were assessed based on the number of new clinical programs developed by residents, articles and abstracts written by residents, and resident participation in grant writing. To date, six residents from the United States and eight Kenyan residents have completed the residency. Eleven sustainable patient care services have been implemented as a result of the residency program. Conclusion. This pharmacy residency training model developed accomplished pharmacists in public health pharmacy, with each residency class expanding funding and clinical programming, contributing to curriculum development, and creating jobs.

An elective pharmaceutical care course to prepare students for an advanced pharmacy practice experience in Kenya.

OBJECTIVE. To develop a prerequisite elective course to prepare students for an advanced pharmacy practice experience (APPE) in Kenya. DESIGN. The course addressed Kenyan culture, travel preparation, patient care, and disease-state management. Instructional formats used were small-group discussions and lectures, including some Web-based presentations by Kenyan pharmacists on disease states commonly treated in Kenya. Cultural activities include instruction in conversational and medical Kiswahili and reading of a novel related to global health programs. ASSESSMENT. Student performance was assessed using written care plans, quizzes, reflection papers, a formulary management exercise, and pre- and post-course assessments. Student feedback on course evaluations indicated that the course was well received and students felt prepared for the APPE. CONCLUSION. This course offered a unique opportunity for students to learn about pharmacy practice in global health and to apply previously acquired skills in a resource-constrained international setting. It prepares students to actively participate in clinical care activities during an international APPE.

The oncology pharmacy in cancer care delivery in a resource-constrained setting in western Kenya.

The movement to deliver cancer care in resource-limited settings is gaining momentum, with particular emphasis on the creation of cost-effective, rational algorithms utilizing affordable chemotherapeutics to treat curable disease. The delivery of cancer care in resource-replete settings is a concerted effort by a team of multidisciplinary care providers. The oncology pharmacy, which is now considered integral to cancer care in resourced medical practice, developed over the last several decades in an effort to limit healthcare provider exposure to workplace hazards and to limit risk to patients. In developing cancer care services in resource-constrained settings, creation of oncology pharmacies can help to both mitigate the risks to practitioners and patients, and also limit the costs of cancer care and the environmental impact of chemotherapeutics. This article describes the experience and lessons learned in establishing a chemotherapy pharmacy in western Kenya.

Clinical pharmacy consultations provided by American and Kenyan pharmacy students during an acute care advanced pharmacy practice experience.

OBJECTIVE: To compare the clinical consultations provided by American and Kenyan pharmacy students in an acute care setting in a developing country. METHODS: The documented pharmacy consultation recommendations made by American and Kenyan pharmacy students during patient care rounds on an advanced pharmacy practice experience at a referral hospital in Kenya were reviewed and classified according to type of intervention and therapeutic area. RESULTS: The Kenyan students documented more interventions than American students (16.7 vs. 12.0 interventions/day) and provided significantly more consultations regarding human immunodeficiency virus (HIV) and antibiotics. The top area of consultations provided by American students was cardiovascular diseases. CONCLUSIONS: American and Kenyan pharmacy students successfully providing clinical pharmacy consultations in a resource-constrained, acute-care practice setting suggests an important role for pharmacy students in the reconciliation of prescriber orders with medication administration records and in providing drug information.

Needs assessment analysis for vitamin K antagonist anticoagulation in the resource-constrained setting of Eldoret, Kenya.

OBJECTIVES: To assess the frequency of indications for vitamin K antagonist (VKA) therapy in the inpatient and outpatient setting in Eldoret, Kenya, and to describe the strategies used for managing these conditions. METHODS: All inpatient admissions during a 1.5-month period were prospectively assessed for any indications for VKA therapy by clinical pharmacy staff. For the outpatient assessment, the files of all patients receiving care in the outpatient adult cardiology clinic within the previous 6 months were identified and evaluated for indications for VKA therapy. For patients identified with an indication for VKA therapy, additional information was collected, including the VKA indication, pharmacologic management, and any other risk-modifying conditions. RESULTS: In the primary analysis, 20 of the 554 patients admitted to the public adult wards (3.61% [95% CI 2.14-5.08]) were candidates for VKA therapy. Of the 168 outpatient cardiology clinic charts reviewed, 72 patients (42.8% [37.96-47.76]) had indications for VKA therapy. In the secondary analysis, 70% of the inpatient population and 93% of the outpatient population received suboptimal VKA therapy. Of these patients in need of VKA therapy, 53.3% were on aspirin therapy only and 33.7% were not receiving any pharmacologic therapy. CONCLUSION: As developing countries begin to address the growing burden of chronic diseases, a commensurate focus on providing infrastructure for comprehensive cardiovascular care, including an organized VKA monitoring service, needs to occur.

Retrospective analysis of the efficacy of gemcitabine for previously treated AIDS-associated Kaposi's sarcoma in western Kenya.

OBJECTIVES: Evaluation of outcomes in the use of single-agent gemcitabine for the treatment of AIDS-associated Kaposi's sarcoma (KS) in a western Kenyan cancer treatment program. METHODS: Retrospective chart review of all patients with KS treated with single agent gemcitabine following failure of first-line Adriamycin, bleomycin, and vincristine (ABV). Baseline demographics were collected, and clinicians' assessments of response were utilized to fill out objective criteria for both response as well as symptom benefit assessment. RESULTS: Twenty-three patients with KS who had previously failed first-line therapy with ABV were evaluated. Following treatment, 22 of the 23 patients responded positively to treatment with stable disease or better. Of the 18 patients who had completed therapy, with a median follow-up of 5 months, 12 patients had no documented progression. CONCLUSIONS: Treatment options in the resource-constrained setting are limited, both by financial constraints as well as the need to avoid myelotoxicity, which is associated with high morbidity in this treatment setting. This work shows that gemcitabine has promising activity in KS, with both objective responses and clinical benefit observed in this care setting. Gemcitabine as a single agent merits further investigation for AIDS-associated KS.

Collaborative partnership for clinical pharmacy services in Kenya.

PURPOSE: A collaborative partnership for clinical pharmacy services in Kenya is described. SUMMARY: Purdue University School of Pharmacy and Pharmaceutical Sciences (PUSOPPS) agreed to collaborate with the United States Agency for International Development-Academic Model for Providing Access to Healthcare (USAID-AMPATH) partnership to provide pharmacy services necessary for patients infected with human immunodeficiency virus (HIV) in Kenya. In addition to assisting Kenyan collaborators, the full-time, onsite faculty member from PUSOPPS serves as a preceptor to pharmacy clerkship students from PUSOPPS and the University of Nairobi in the delivery of clinical pharmacy services in inpatient and outpatient settings. Through PUSOPPS's unique collaboration, Kenyan pharmacy technologist students and University of Nairobi pharmacy students partner with clerkship students from PUSOPPS to participate in eight-week rotations. In addition to inpatient activities, students spend one day each week at one of the rural HIV clinics or observing one of the burgeoning specialized care clinics. Students also participate in public health activities, such as providing adherence counseling for HIV-infected patients, participating in door-to-door HIV counseling and testing, and preparing educational and recreational activities for pediatric patients. PUSOPPS's sustainable involvement with this program has addressed many of the immediate pharmacy needs of providing antiretroviral therapy and medications for opportunistic infections throughout western Kenya. CONCLUSION: The collaboration between PUSOPPS and USAID-AMPATH in Eldoret, Kenya, has provided a bilateral educational exchange for Kenyan and American pharmacy students and has allowed for year-round clinical pharmacy services in both inpatient and outpatient settings.

Effect of time to titration to maximum dose of statins on cardiovascular outcomes: a retrospective analysis in high-risk patients.

BACKGROUND: Recent trials have shown that high-dose HMG-CoA reductase inhibitor (statin) therapy reduces cardiovascular events in high-risk subjects within weeks of initiating therapy. We investigated the effect of time to titration to maximum dose of statin therapy on cardiovascular events. METHODS: From a list of all patients actively taking simvastatin 80 mg/day as of April 2003 at our hospital, two clinical pharmacists reviewed 213 electronic medical records including pharmacy records from November 1992 to April 2003. Data on cardiovascular risk factors, laboratory results, titration schedules, and outcomes were extracted from the electronic database. RESULTS: Titration period time frames were compared between patient groups using a Student t-test and multiple-variable logistic regression to account for other risk factors. Titration schedules and time frames to attain a regimen of simvastatin 80 mg/day were available for 154 (73%) subjects. Titrations ranged from 1 to 8 and averaged 2.3 +/- 1.3 titrations per patient (median titrations = 2) over 1 month to 8.4 years. On follow-up, 47 patients experienced 80 cardiovascular-related outcomes. The average time to titration to maximum dose of statin therapy was longer for patients who experienced a cardiac event than for those who did not (3.5 +/- 2.2 vs 2.1 +/- 1.8 years; p = 0.0004). After accounting for other risk factors, the titration period was still significantly related to the presence of a cardiac event (p = 0.0060, odds ratio per month increase in the titration period 1.3, 95% CI 1.08, 1.58). CONCLUSIONS: Despite potential limitations, the results of our study show that an excessive delay in titrating statin therapy to the optimal dose may lead to an increased risk of atherosclerosis-related events in high-risk patients.

Effect of 80 mg/day simvastatin therapy on cardiovascular outcomes in adults with versus without metabolic syndrome.

It is not known whether high-dose statins can reduce the excess burden (and consequent adverse cardiovascular outcomes) of coronary artery disease in patients with metabolic syndrome compared with those without metabolic syndrome. The results of our study suggest that high-dose simvastatin may be required to reduce excess events in very high-risk cohorts with metabolic syndrome.