Pharmacotherapy of Chronic Neuropsychiatric Conditions During Pregnancy.

Many pregnant persons will experience neuropsychiatric conditions during pregnancy, including migraine, attention deficit disorder, depression, and anxiety. Treatment of each of these conditions requires shared decision-making among the individual, family, and health care team. Although medications may include risk, the benefits often outweigh the potential fetal risks. In this article, we review pharmacologic treatment options for each of these conditions and appropriate use in pregnancy to maintain the stability of conditions and to optimize maternal and fetal outcomes.

Reconsidering the residency training pathway for ambulatory care pharmacists.

Ambulatory care, commonly found in primary care settings, is a growing area of pharmacy practice supported by an expanding number of residency training opportunities in this setting. As this practice expands, the profession has chosen to adopt structures that define it as a specialty practice area, a departure from the medical profession. A key example of this definition is the profession's alignment of residency training for this setting within postgraduate year 2 standards. In this commentary, we explore the implications of this approach and share experience from more than 20 years of statewide ambulatory care residency training in Minnesota. We question whether current training expectations are rooted in an objective evaluation of the knowledge and skills required for ambulatory care pharmacy practice. Ultimately, we call on practice leaders to take account of the impact on current training expectations for learners and pharmacy workforce development and seek a rationalization of the training pathway for ambulatory care practice.

Building health plan-pharmacist provider partnerships to optimize medication outcomes.

Over the years, the practice of medication management has taken on various terms and definitions. As a result, health plans have developed different approaches to identifying beneficiaries for medication therapy management (MTM), engaging pharmacists to provide MTM, and adopting standards for documentation and quality assurance. This variation leads to inconsistent delivery of MTM and potential quality concerns. Therefore, an environment needs to be created that allows for health plans to discuss and share approaches, challenges, and best practices. To achieve this, the University of Minnesota College of Pharmacy has served as an organizer and facilitator of an ongoing series of Minnesota Health Plan Summits to drive sustainable and mutually beneficial MTM programs and payment models across the state. In less than 2 years, the University of Minnesota College of Pharmacy has hosted and organized 4 Health Plan Summits with the objective of sharing ideas and identifying mutual goals (short- and long-term) across health plans and pharmacy providers of MTM services to optimize medication outcomes for the citizens of Minnesota and beyond. These meetings have led to several productive discussions and takeaways, including: (1) having a convener is essential for these types of connections and discussions, (2) health plans and pharmacists find value in these summits, (3) there is a range of experience in MTM program development across health plans, and (4) there are important opportunities to enhance understanding between health plans and pharmacist providers. In addition, 3 workgroups have been established in the following areas: (1) improve consistency in the design of MTM benefits across health plans for service and delivery, including provider credentialing, (2) increase transparency and education between plans and providers on the "fixed points" (such as CMS requirements) vs modifiable portions of plan design, and (3) create agreement on a single quality metric to target, collect data, and demonstrate value of MTM. For change to occur, it often must start locally, suggesting that the formal, facilitated convening of local health plan leaders and pharmacist providers to discuss building consistent and high-quality MTM programs is an essential strategy for MTM program adoption and growth. Including both groups of stakeholders should not only focus on payment, but also the mechanisms necessary to support implementation and create a win-win for both groups. In sharing our experience in Minnesota, we aim to inspire others to form regional initiatives that create structured, facilitated conversations that can produce new partnerships. Strategies that have supported our success are described and can be adopted once a regional entity, such as a school of pharmacy or other trusted entity, chooses to convene a group of invested stakeholders.

Qualitative Assessment of a Human Trafficking Module Intervention in Pharmacy Education.

Description of the Problem: Human trafficking is a critical public health threat in the United States, yet education on human trafficking for pharmacy students has not been evaluated despite pharmacists being the most accessible health care professionals. Description of the Innovation: To evaluate the most valuable aspects of an introductory module on human trafficking, pharmacy students participated in a human trafficking module, and their perception of human trafficking was evaluated after the module. Content on human trafficking was delivered through an asynchronous online presentation followed by a synchronous Zoom class discussion. Fifty-three third-year pharmacy students from the Women's Health elective in the fall semester of 2020 at the University of Minnesota - College of Pharmacy were included. Consensual Qualitative Research methodology was used for qualitative data analysis. Critical Analysis: Students' perceptions of the value of this learning module was evaluated through consensual qualitative research. The findings suggest the module held significant value for students to better understand human trafficking and the role of pharmacists. Implications: A hybrid model on human trafficking involving discussions, case examples, and questions posed by students was found to have a positive impact on their knowledge on human trafficking. The results of this study will provide direction for future modules, classes, or adaptations to the curriculum on human trafficking for pharmacy students and may prove beneficial for other health care professionals.

PrEP-aring the General Gynecologist to Offer HIV Pre-exposure Prophylaxis.

It is estimated that 450,000 American women are at increased risk of infection with human immunodeficiency virus (HIV), and yet only 7% have a prescription for pre-exposure prophylaxis (PrEP). PrEP is a safe and effective method of HIV infection prevention via a daily use of an oral combination antiretroviral pill or longer-acting intramuscular injections. Gynecologists are experts in women's sexual health, and provide over half of annual preventative health visits, but are not yet routinely providing PrEP to patients, citing lack of knowledge as a major barrier. The authors aim to provide the general gynecologist with the skills to expertly provide PrEP to their patients to reduce HIV infection.

Maternal ADHD and Perinatal Prescription Stimulant Use.

OBJECTIVE: To describe patterns and predictors of perinatal prescription stimulant use. METHODS: We used MarketScan® commercial claims data (2013-2018) and a repeated cross-sectional study design to assess perinatal use of prescription stimulants. Clinical/demographic characteristics were compared across cohorts of women who continued versus discontinued stimulant treatment at various stages of pregnancy. Associations were tested for significance using chi-square tests (categorical variables) and independent t-tests (continuous variables). RESULTS: Out of 612,001 pregnancies, 15,413 involved pre-pregnancy stimulant use. Of these, stimulant treatment was discontinued prior to conception in 6,416 (42%), discontinued during trimester 1 in 5,977 (39%), and continued into later trimesters in 3,020 (19%). Compared with pregnancies involving stimulant discontinuation prior to conception, those that continued into pregnancy occurred in women who were older (29.9 vs. 28.9 years) and had more severe ADHD (3.1 vs. 1.8 ADHD-related billing claims). CONCLUSIONS: There is considerable heterogeneity in the management of ADHD during pregnancy.

Mobile Health Intervention to Close the Guidelines-To-Practice Gap in Hypertension Treatment: Protocol for the mGlide Randomized Controlled Trial.

BACKGROUND: Suboptimal treatment of hypertension remains a widespread problem, particularly among minorities and socioeconomically disadvantaged groups. We present a health system-based intervention with diverse patient populations using readily available smartphone technology. This intervention is designed to empower patients and create partnerships between patients and their provider team to promote hypertension control. OBJECTIVE: The mGlide randomized controlled trial is a National Institutes of Health-funded study, evaluating whether a mobile health (mHealth)-based intervention that is an active partnership between interprofessional health care teams and patients results in better hypertension control rates than a state-of-clinical care comparison. METHODS: We are recruiting 450 participants including stroke survivors and primary care patients with elevated cardiovascular disease risk from diverse health systems. These systems include an acute stroke service (n=100), an academic medical center (n=150), and community medical centers including Federally Qualified Health Centers serving low-income and minority (Latino, Hmong, African American, Somali) patients (n=200). The primary aim tests the clinical effectiveness of the 6-month mHealth intervention versus standard of care. Secondary aims evaluate sustained hypertension control rates at 12 months; describe provider experiences of system usability and satisfaction; examine patient experiences, including medication adherence and medication use self-efficacy, self-rated health and quality of life, and adverse event rates; and complete a cost-effectiveness analysis. RESULTS: To date, we have randomized 107 participants (54 intervention, 53 control). CONCLUSIONS: This study will provide evidence for whether a readily available mHealth care model is better than state-of-clinical care for bridging the guideline-to-practice gap in hypertension treatment in health systems serving diverse patient populations. TRIAL REGISTRATION: Clinicaltrials.gov NCT03612271; https://clinicaltrials.gov/ct2/show/NCT03612271. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/25424.

Management of hypertension in pregnancy: a descriptive report of two clinic practices.

Objective: To describe the current clinical practice in the treatment of hypertension in pregnancy.Methods: Retrospective chart review described hypertension treatment of pregnant women in two urban clinics in Minnesota USA, over 27 months. Data elements collected: blood pressure (BP) readings with gestational age, goal BP documented, and pharmacological treatments utilized.Results: Sixty patients had multiple elevated BP readings in prenatal care encounters. Of 60 included patients, 18 were treated with antihypertensives and 11 had documented BP goals. Documented goal BPs varied in numeric goal and some only listed systolic or diastolic goal.Conclusion: Inconsistencies exist in current treatment and documentation of hypertension in pregnancy.

Educational Prescriptions to Document Evidence-Based Medicine Questions in Ambulatory Care Advanced Pharmacy Practice Experiences.

Objective. To design, implement, and assess the use of "educational prescriptions" or Education Rx assignments in advanced pharmacy practice experiences (APPEs) in ambulatory care, and to assess the impact of the assignments on Doctor of Pharmacy (PharmD) students' self-efficacy to practice evidence-based medicine (EBM). Methods. Students enrolled in select ambulatory care APPEs completed up to four Education Rx assignments. The assignments required students to report the context of the question, source of information, results, appraisal of validity, and relevance of the evidence, and to answer the clinical question. A rubric was used that contained three subparts: a patient/population, intervention, comparison, outcome (PICO) conformity score (8 points), presence of answer to the PICO (1 point), and quality of answer to the PICO (6 points). Demographic information was collected and students were surveyed at the end of the APPE to rate their self-efficacy executing seven evidence-based medicine (EBM) skills. Results. Thirty students completed 110 Education Rxs. The average score (SD) was 13.6 (2.2) with a PICO conformity subsection score of 7.3 (1.3), and quality of answer subsection score of 5.3 (1.2). Only one Education Rx did not have an answer. Students consulted point-of-care references for a majority of the answers (65%). Sixteen (53%) students completed the self-assessment survey, and all strongly agreed or agreed that the Education Rx activity improved their ability to formulate a well-constructed clinical question and evaluate and apply the evidence. Conclusion. Through Education Rxs, PharmD students' self-confidence and their skills in finding answers to clinical questions increased.

Professional responsibilities reported by pharmacists completing residencies in community-based settings.

OBJECTIVES: To evaluate the professional responsibilities of pharmacists who completed residencies in a community-based setting and to determine if there is a difference in responsibilities for pharmacists completing different types of PGY-1 residency and PGY-2 residency training. METHODS: A survey was designed by adapting questions from the 2014 Pharmacist Workforce Survey and creating other questions designed for this project. Surveys were distributed electronically to residency program directors of PGY-1 community-based pharmacy residencies, PGY-1 pharmacy residencies in ambulatory care environments, and PGY-2 ambulatory care residencies; program directors were asked to distribute the survey to all residency alumni of their program. RESULTS: A total of 450 programs were identified; 349 responses were received, with respondents having completed residency training from 1989 to 2016. Respondents represented at least 73 different residency programs across the country. More than 97% of respondents agreed or strongly agreed that their residency training prepared them to be successful in their career. Nondispensing patient care, ranging from 39.0% to 52.5%, represented the largest percentage of job responsibilities. Current job responsibilities contained a higher percentage of business or organization management compared with first job (17.7% vs. 5.8%; P < 0.001). CONCLUSION: Pharmacists completing residency training have a large percentage of their first jobs associated with patient care responsibilities, regardless of the type of training received or the type of setting.

Benefits of Levonorgestrel Intrauterine Device Use vs. Oral or Transdermal Progesterone for Postmenopausal Women Using Estrogen Containing Hormone Therapy.

BACKGROUND: Endometrial hyperplasia is a major concern for women that start estrogen replacement therapy (ERT) to control symptoms experienced during perimenopause and postmenopause. Progesterone provides protection against endometrial hyperplasia, and there are multiple dosage forms of progesterone available. Intrauterine progesterone may offer an appealing option with additional benefits beyond endometrial protection for patients. OBJECTIVE: The overarching objective of this systematic review is to characterize the relationship between levonorgestrel containing intrauterine devices (LNG-IUD) and the prevention of endometrial hyperplasia in peri- and postmenopausal women. Specifically, this systematic review addresses whether LNG-IUD has equivalent efficacy of protecting against endometrial hyperplasia, but an improved safety profile when compared to oral progesterone in women using ERT. METHODS: OVID Medline, Scopus, and Cochrane were used to find available studies that have investigated the relationship between endometrial hyperplasia prevention and varying dosage forms of progesterone. Randomized control studies comparing LNG-IUD with no treatment, placebo, or other hormonal therapy in adult females were included. In addition, due to a lack of randomized control studies, four non-comparative studies were included. RESULTS: There were eleven total studies included that investigated LNG-IUD use in women on ERT. According to the studies, the LNG-IUD was equally effective as other routes (oral, vaginal) of progesterone administration in protecting against endometrial hyperplasia. CONCLUSIONS: The LNG-IUD prevents endometrial proliferation at least as effective as oral or vaginal forms of progesterone. LNG-IUD is a safe option for women starting estrogen replacement therapy and has added benefits due to decreased adverse effects.

Drug Therapy Problem Severity Following Hospitalization and Association With 30-Day Clinical Outcomes.

BACKGROUND: Improved understanding of how drug therapy problems (DTPs) contribute to rehospitalization is needed. OBJECTIVE: The primary objectives were to assess the association of DTP likelihood of harm (LoH) severity score, as measured by comprehensive medication management (CMM) pharmacist after hospital discharge, with 30-day risk of hospital readmission, observation visit, or emergency department visit, and to determine whether resolution of DTPs reduces 30-day risk. Secondary objectives were to determine if any eventswere associated with DTPs and preventability of events. METHODS: Data were collected for 365 patients who received CMM following hospitalization and had at least 1 DTP identified. Retrospective chart reviews were completed for 80 patients with subsequent events to assess associationg with a DTP and its preventability. RESULTS: For each 1-point increment in maximum LoH score, there was 10% higher risk of the composite end point (hazard ratio [HR]=1.10; 95% CI:0.97-1.26; P=0.13). When DTPs were resolved by the CMM pharmacist, the association was attenuated, with a HR of 1.15 (95% CI:0.96-1.38; P=0.12) when the DTP was unresolved and HR of 1.09 (95% CI:0.96-1.25; P=0.52) when resolved; for hospital readmission alone, the corresponding HRs were 1.23 (95% CI:1.00-1.53; P=0.05) and 1.05 (95% CI:0.87-1.27; P=0.60). Of 80 subsequent events, 44 were associated with a medication; 22 were considered preventable. Conclusion and Relevance: The LoH severity score was associated with risk of 30-day events. The strength of association was attenuated when DTPs were resolved by the CMM pharmacist. However, because of statistical uncertainty, larger studies are needed to confirm these patterns.

Complementary and alternative medicine in US adults with diabetes: Reasons for use and perceived benefits.

BACKGROUND: Although complementary and alternative medicine (CAM) is increasingly used, little is known about the reasons for CAM use (treatment, wellness, or both), or the self-reported perceived benefits among US adults with diabetes. In this study we estimated prevalence rates of overall and specific types of CAM, as well as the perceived benefits of CAM, by reason for use among US diabetic adults. METHODS: Cross-sectional data from the 2012 National Health Interview Survey, which represents non-institutionalized adults with diabetes (n = 3386 unweighted), were used to estimate prevalence rates of CAM use by reason. Multivariate logistic regression analyses were used to investigate the odds of perceived benefits of CAM by reason for use after controlling for covariates. RESULTS: Of US diabetic adults, 26.2% reported using some form of CAM in the past year. Of these, 56.7% used CAM for both treatment and wellness, 28.3% used CAM for wellness only, and 15.0% used CAM for treatment only. Regardless of reasons for use, most commonly used CAM were herbal therapies (56.9%), followed by chiropractic (25.3%) and massage (20.2%). Those using CAM for a combination of both treatment and wellness had a higher likelihood of self-reporting a "better sense of control over their health" (P = 0.011) and "improved overall health and feeling better" (P = 0.014) than those using CAM for treatment only. CONCLUSION: Although CAM may be a promising approach to improving health-related quality of life, future research should address efficacy and patient safety.

Residency pathways to ambulatory care practice: Essential insights for students, residents, and educators.

OBJECTIVE: To provide a guiding document describing residency training opportunities in ambulatory care for students, postgraduate year 1 (PGY1) residents, practicing pharmacists, and pharmacy educators. SUMMARY: Student pharmacists, residents, practitioners, and educators can benefit from a guiding document describing the various pathways to develop as an ambulatory care practitioner through residency training. The benefits and differences of PGY1 and postgraduate year 2 (PGY2) ambulatory care residency programs are included. CONCLUSION: There are many possible training options for pharmacists interested in pursuing a career in ambulatory care pharmacy practice. In addition to the required ambulatory and community experience required for all Doctorate of Pharmacy students, postgraduate training in an ambulatory environment can allow for specialization. Candidates for residency training can complete a PGY1 pharmacy residency or a PGY1 community-based pharmacy residency, possibly followed by a PGY2 ambulatory care residency. Career paths for ambulatory care pharmacists vary regionally across the country according to competition for positions, local availability of training programs, and the experience of regional leaders. A comprehensive description of these available training pathways and advantages of each are beneficial for students, residents, practicing pharmacists, and educators.

Expanding Ambulatory Care Pharmacy Residency Education Through a Multisite University-Affiliated Model.

INTRODUCTION: As the health-care system evolves and shifts to value-based payment systems, there is a recognized need to increase the number of ambulatory care trained pharmacists. OBJECTIVE: The objective of this article is to describe the administrative structure of the University of Minnesota Postgraduate Year 1 (PGY1) Pharmacy Residency program and to encourage adoption of similar models nationally in order to expand ambulatory care residency training opportunities and meet the demand for pharmacist practitioners. Program Structure: The University of Minnesota PGY1 Pharmacy Residency program is a multisite program centered on the practice of pharmaceutical care and provision of comprehensive medication management (CMM) services in ambulatory care settings. The centralized administration of a multisite academic-affiliated training model creates efficiency in the administration process, while allowing sites to focus on clinical training. This model also offers many innovative and unique opportunities to residents. CONCLUSION: A multisite university-affiliated ambulatory care residency training model provides efficiency in program administration, while successfully accelerating the growth of quality ambulatory care residency training and supporting innovative delivery of shared core learning experiences. Consequently, practice sites grow in their service delivery capacity and quality of care.

Impact of a Vitamin D Protocol in Pregnancy at an Urban Women's Health Clinic.

BACKGROUND: Adequate vitamin D levels are important during pregnancy for maternal and fetal health. The prevalence of vitamin D deficiency and appropriate treatment during pregnancy are not well documented. OBJECTIVES: This study aims to identify the prevalence of vitamin D deficiency in pregnant women and analyze the impact of a vitamin D protocol on achieving sufficient vitamin D levels. METHODS: A retrospective chart review was conducted among 200 women who received prenatal care between April 1, 2011, and December 1, 2012 (preprotocol) and July 1, 2013, and June 30, 2014 (postprotocol). In each sample period, 100 women were included. Women were included if they had 2 vitamin D levels drawn during pregnancy. Maternal age, ethnicity, vitamin D levels, gestational age at each level, and the status of vitamin D supplement were controlled for. RESULTS: Women in the preprotocol group achieving sufficiency (25[OH]D ≥ 30 ng/mL) increased from 43% to 60%. In the postprotocol group, sufficiency increased from 19% to 69%. Adherence to the protocol dose was highest in women who were initially deficient (25[OH]D ≤ 20 ng/mL), and correlation between adherence to the protocol dose and achievement of sufficiency was also highest in the group of women who were initially deficient. CONCLUSIONS: Vitamin D deficiency was prevalent (25% total) in this population. Implementation of a clinic-wide protocol for vitamin D supplementation during pregnancy resulted in a nonsignificant increase in the percentage of women achieving vitamin D sufficiency.

Use of Strontium Chloride for the Treatment of Osteoporosis: A Case Report.

Context • Strontium ranelate is an approved prescription medication for the treatment of osteoporosis in Europe. In the United States, the only available forms of strontium are those that are nonprescription, dietary supplements. Some patients with osteoporosis use those products because they prefer an alternate treatment to conventional therapy. Currently, no controlled trials have been conducted on the effectiveness of the supplements for treating osteoporosis. Objective • The study intended to examine how one woman responded to the use of strontium chloride. Design • This was a retrospective case study. Setting • The woman in the case study was a patient in an academic urban women's health clinic in Minneapolis, MN, USA. Participant • The participant was a postmenopausal woman with a history of vertebral fracture. Intervention • The participant took 680 mg daily of strontium chloride for 2.5 y. Outcome Measures • The patient had begun receiving dual-energy X-ray absorptiometry (DXA) scans in 2004 and continued to receive follow-up scans every 2 y. After beginning strontium therapy in December 2011, she received DXA scans in March 2012 and May 2014. Results • During the study, the analysis of the patient's DXA scans showed a positive increase in the bone mineral density (BMD) of her vertebrae and her right hip and maintenance of her BMD in her left hip. Conclusions • Although the current case report does not provide enough evidence to conclude that US dietary supplements of strontium are effective in preventing fractures, it demonstrates a positive experience for one patient.

Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences.

OBJECTIVE: To determine if the amount of exposure to patient encounters and clinical skills correlates to student clinical competency on ambulatory care advanced pharmacy practice experiences (APPEs). DESIGN: Students in ambulatory care APPEs tracked the number of patients encountered by medical condition and the number of patient care skills performed. At the end of the APPE, preceptors evaluated students' competency for each medical condition and skill, referencing the Dreyfus model for skill acquisition. ASSESSMENT: Data was collected from September 2012 through August 2014. Forty-six responses from a student tracking tool were matched to preceptor ratings. Students rated as competent saw more patients and performed more skills overall. Preceptors noted minimal impact on workload. CONCLUSIONS: Increased exposure to patient encounters and skills performed had a positive association with higher Dreyfus stage, which may represent a starting point in the conversation for more thoughtful design of ambulatory care APPEs.

Evaluation of the impact of comprehensive medication management services delivered posthospitalization on readmissions and emergency department visits.

BACKGROUND: The impact of providing cognitive pharmacy services following hospital discharge has been studied with various results. This study is specifically focused on comprehensive medication management services delivered postdischarge in an interprofessional team environment to patients aged >65 years. OBJECTIVE: To determine if delivery of comprehensive medication management services postdischarge will prevent hospital readmissions or emergency department visits within 6 months following discharge in patients aged >65 years. Secondary endpoints included 30-day and 60-day postdischarge events. METHODS: This was a prospective group matched-controlled study of patients aged >65 years with selected diagnoses identified as high risk for readmission. The intervention group received comprehensive medication management that was provided face-to-face in the patient's primary care clinic within 2 weeks of discharge. RESULTS: No statistically significant difference was found between intervention and control groups in hospital readmissions or emergency department visits at 30 days, 60 days, or 6 months after discharge. No statistically significant difference was seen in mortality between groups. CONCLUSIONS: Provision of comprehensive medication management services did not reduce emergency department visits or readmissions in this study. This study was limited by multiple other changes occurring in the health system during the time of this study that potentially confounded results. In addition, the study may have been too small to detect a difference.