Clinical pharmacy specialists providing consistent comprehensive medication management with increased efficiency through telemedicine during the COVID19 pandemic.

INTRODUCTION: The Veterans Affairs (VA) has been at the forefront of harnessing the skills of clinical pharmacy specialists (CPS) in patient-aligned care teams (PACT) to improve patient care outcomes and create access for veterans. With the unfortunate arrival of Coronavirus disease 2019 (COVID19), PACT CPS were duty-bound to expand telehealth services at an accelerated rate. The purpose of this quality improvement analysis is to compare CPS efficiency as well as some objective patient metrics to assess for a change in the quality of care. This is the first study to compare the efficiency and quality of care by CPS in the VA pre-COVID19 and during the COVID19 pandemic. METHODS: This is a retrospective review of PACT CPS comprehensive medication management from 3/10/19 to 11/30/19 and 3/10/20 to 11/30/20. Data points focused on clinic encounters, patient accountability to appointments, disease state expansion, and markers of disease-state management. Given diabetes and hypertension are the main disease states managed by most PACT CPS', the study evaluated changes in hemoglobin A1c (HbA1c) and blood pressure (BP) between the two cohorts as well. Data were analyzed using GraphPad Software or Microsoft Excel. A student T-test was used for continuous data and Chi-squared or Fishers Exact for nominal data. RESULTS: The total number of PACT CPS encounters increased 32% in 2020, and the number of unique patients increased by 12%. There were a statistically significant increase in telephone and direct-to-consumer (DCT) video visits. The rates of no shows and cancellations significantly decreased between 2019 and 2020. There was no difference in the average change in HbA1c or average blood pressure between the two study groups. CONCLUSIONS: When PACT CPS services transitioned from primarily face-to-face visits to all virtual care, the consistency of care improved, and the quality of care was not compromised.

Implementation and Effect of a Pharmacist-to-Pharmacist Transitions of Care Initiative on Ambulatory Care Sensitive Conditions.

BACKGROUND: One of the most vulnerable times in a patient's encounter with a health care system is during transitions of care (TOC), defined by the Joint Commission as the movement of a patient from one health care provider or setting to another. The use of a clinical pharmacist as a member of the care transitions team has received focused attention and shown improved benefit. OBJECTIVE: To determine the effect of a large-scale pharmacist-to-pharmacist TOC model where inpatient clinical pharmacists identify patients during a hospital stay, provide evidence-based care and education, and then coordinate follow-up with an outpatient clinical pharmacist who provided comprehensive medication management (CMM) under a scope of practice. METHODS: This was a multisite, single health care system, quasi-experimental, matched interrupted time series design study conducted at an integrated Veterans Affairs (VA) health care system. Patients admitted with a primary or secondary diagnosis of diabetes, hypertension, chronic obstructive pulmonary disease (COPD) and heart failure (HF) were included for enrollment. Clinical pharmacists rounding on inpatient medical teams provided evidence-based recommendations to optimize medications while coordinating follow-up by an outpatient clinical pharmacy specialist within 10 days of discharge for CMM. The primary endpoint of this study was to determine the effect on the composite all-cause 30-day acute care utilization rate (emergency department [ED] visit or hospital readmission) for patients discharged with a primary or secondary diagnosis of diabetes, hypertension, COPD, and HF compared with a comparator group of patients with similar discharge diagnosis before implementation of the TOC program. RESULTS: 484 patients (242 in each group, with 366 heart failure, 66 COPD, 10 hypertension, and 42 diabetes) were included for analysis. For the primary outcome of composite 30-day, all-cause acute care utilization rates, no statistically significant difference was identified, with 26.9% of patients in the intervention group and 28.9% in the historical group readmitted or seen in the ED within 30 days of discharge (P = 0.6852). Outcomes for the HF index acute care utilization rate (i.e., admission for the same disease state discharged with), including 30-day index readmissions (P = 0.0014), 30-day index ED visits (P = 0.0047), and 90-day index readmissions for HF (P < 0.0001) were significantly reduced. CONCLUSIONS: Our study is one of the first to identify at-risk patients using rounding clinical pharmacists in the acute care arena and coordination of care systematically with a clinical pharmacy specialist practicing under a scope of practice targeted for CMM. Although the overall primary endpoint was not met, a reduction in acute care utilization rates for HF at 30 and 90 days can be achieved. DISCLOSURES: No outside funding supported this research. The authors report no conflicts of interest.

Utilizing clinical video telehealth to improve access and optimize pharmacists' role in diabetes management.

OBJECTIVES: To evaluate whether clinical pharmacy specialist (CPS) services delivered using clinical video telehealth (CVT) is consistent with CPS services via face-to-face (FTF) visits in a cohort of patients with poorly controlled type 2 diabetes mellitus. In addition, the study aimed to evaluate the potential benefits for the patient with implementation of CVT services. METHODS: Single-center retrospective cohort study. FTF services provided at a single community-based outpatient clinic (CBOC). CVT services provided at a main campus targeting the same CBOC. Patients with type 2 diabetes mellitus (A1c > 7%) consulted for management by a CPS between April 2013 and October 2014 were included. The primary outcome was mean A1c reduction at 3 and 6 months. Secondary outcomes included time from consult placement to visit, average travel distance averted, and average travel time averted. RESULTS: Mean A1c reduction at 3 months was 1.096 ± 1.8 for FTF services before CVT (P ≤ 0.0001), 1.839 ± 1.7 for FTF services after CVT (P ≤ 0.0001), and 2.262 ± 2.8 (P = 0.0004) for CVT services. At 6 months, the mean A1c reduction was 1.202 ± 1.9 (P ≤ 0.0001), 1.965 ± 2 (P ≤ 0.0001), and 2.610 ± 3.8 (P = 0.0004). At 6 months there was no statistical difference between groups. The average time in days from consult placement to initial visit decreased from 106.3 ± 24.5 to 46 ± 35.3 (P ≤ 0.0001). The average travel distance in miles averted per patient was 99.5 ± 20.3, and the average travel time in hours averted was 1.6 ± 0.3. CONCLUSIONS: Diabetes care provided by a CPS via CVT was as effective for the management of type 2 diabetes compared to FTF management by a CPS. Implementation of telehealth services increased access to providers as shown by the reduction in time from consult placement until initial visit.

Implementation of a pharmacotherapy clinic into the patient centered medical home model by a second year pharmacy resident.

OBJECTIVE: Evaluate the impact a post graduate year 2 (PGY-2) pharmacy resident run clinic incorporated into the patient centered medical home (PCMH) model may have on achieving reduction in glycosylated hemoglobin (A1c), low density lipoprotein (LDL), and systolic and diastolic blood pressures (SBP and DBP) over six months in type 2 diabetics within the Veterans Health Administration (VHA). METHODS: This was a prospective, quasi-experimental study enrolling type 2 diabetics referred to the pharmacist-run clinic not meeting American Diabetes Association (ADA) treatment goals for A1c less than 7%, and/or LDL less than 100 mg/dL, and/or blood pressure (BP) less than 130/80 mmHg. Once signed informed consent was obtained, veterans were followed according to usual standards of care for six months with visits and lab follow-up at baseline, three, and six months (±45 days). The primary endpoint was the change in HbA1c, LDL, and BP from baseline to six months. Secondary endpoints included the change from baseline to three months in A1c, LDL, and BP and the percentage of patients who achieved ADA treatment goals for A1c, LDL, and BP at six months. RESULTS: Among the 24 patients included in the data analysis (100% male, 92% Caucasian), A1c decreased significantly from 7.56% to 7.19% (p = 0.0122) as well as LDL from 92.9 to 68.5 mg/dL (p = 0.0023), SBP from 131 to 124 mmHg (p = 0.0302), and DBP from 71.5 to 64.8 mmHg (p = 0.0012). The proportion of patients at recommended goal A1c <7% rose from 17% to 38%, as did the percentage of patients meeting ADA goals for LDL (75% to 96%), SBP (46% to 71%), and DBP (79% to 92%). CONCLUSION: Patients followed in a resident run pharmacotherapy clinic in the PCMH model with interventions over six months showed significant improvements in clinical endpoints including A1c, LDL, SBP, and DBP.

Designing a resident research program.

PURPOSE: The development of a resident research program and the role of the residency research advisory board (RRAB) in the program are described. SUMMARY: Over the past decade, there have been numerous barriers to successfully implementing a residency research program. An RRAB was subsequently developed to assist with research mentoring to help prepare residents to incorporate research into future positions. Within this board, one clinical pharmacy practitioner or preceptor serves as the research coordinator and acts as chair and liaison to the institutional review board (IRB) and research and development (R&D) committee. All members of the RRAB function as research experts in various aspects of the research process. The RRAB comprises three members to navigate IRB and R&D paperwork, generate and develop research ideas, create relationships with institutional research committees, educate pharmacy residents in a consistent manner on research methods in a longitudinal fashion, provide mentorship to preceptors, and facilitate service-related communication on our research timelines, plans, local and distant presentations, and other related efforts. The development of the resident research program and the RRAB have resulted in an improvement in the level of research conducted by our residents and preceptors. Due to the support of the RRAB, residents are submitting and presenting posters at local, state, and national meetings as well as submitting manuscripts to and publishing manuscripts in health care journals. CONCLUSION: Development of an RRAB increased residents' manuscript publication and poster presentation rates and facilitated the research process.

INR goal attainment and oral anticoagulation knowledge of patients enrolled in an anticoagulation clinic in a Veterans Affairs medical center.

BACKGROUND: In January 2009, the Joint Commission implemented a National Patient Safety Goal (NPSG) for ambulatory care, NPSG 3E, intended to reduce harm associated with the use of anticoagulation therapy. The 2011 NPSG 3E encompasses 8 elements of performance, including requirements that each organization (a) provide education regarding anticoagulation therapy to staff, patients, and families and (b) evaluate its safety practices and take appropriate action to improve its practices. The Alvin C. York (ACY) outpatient anticoagulation clinic provides education to new patients and their families at the initial clinic visit, with follow-up reinforcement of education as needed throughout their care. OBJECTIVES: To (a) assess the knowledge level of patients receiving warfarin therapy in an anticoagulation clinic using the validated Anticoagulation Knowledge Assessment (AKA) questionnaire and (b) examine the relationship between patient anticoagulation knowledge and anticoagulation control as measured by the international normalized ratio (INR). METHODS: All ACY Veterans Affairs (VA) anticoagulation clinic patients seen during their routine visit within an 8-week recruitment period from February 2010 to April 2010 were asked to complete the AKA questionnaire. Upon voluntary consent, the questionnaire was completed by the patient either during the clinic visit or returned later by mail. Demographic and clinical data were manually extracted from the computerized patient record system and included age, gender, indication for and duration of anticoagulation therapy, goal INR range, and the 10 INR values preceding the date of consent. A passing score was defined as at least 21 correct responses on the 29-item AKA questionnaire (72.4% correct). Statistical analyses included comparisons of demographic and clinical characteristics for patients with passing versus failing scores, assessed with Pearson chi-square and Fisher's exact test, and bivariate analyses of INR control with anticoagulation knowledge, assessed with Spearman's rho correlation. INR control was defined by 3 outcome measures: number of INRs within therapeutic range, time in therapeutic range (TTR) calculated using the Rosendaal method, and standard deviation (SD) of INR values. Anticoagulation knowledge was assessed with 2 measures: total AKA score and count of correct answers to a subset of 15 AKA items deemed by the investigators to be relevant to INR control. RESULTS: Of 447 patients enrolled in the anticoagulation clinic, 260 consented to participate in the survey, of whom 185 patients completed the AKA instrument (n=171 [92.4%] by mail) and were successfully matched to patient record system data. 178 (96.2%) respondents were male with a mean (SD) age of 68 (10.1) years. The majority of patients were undergoing anticoagulation treatment for atrial fibrillation (n=113, 61.1%) or deep venous/pulmonary thromboembolism (n=48, 25.9%). The majority of patients had been treated with warfarin for at least 1 year (n=162, 87.6%). Most patients had goal INR ranges of 2.0 to 3.0 (n=166, 89.7%). Of the 185 patients who completed the questionnaire, 137 (74.1%) achieved a passing score. The mean (SD) AKA questionnaire score was 78.1% (12.1%). There were 8 questions that were answered correctly by less than 70% of patients and identified as potential deficiencies in patient education. For the 167 patients who had been on warfarin therapy for at least 6 months and had 10 previous INR values, there was no significant Spearman's rho correlation between total number of correct questionnaire responses and INR control, defined as the count of the 10 previous INR values within goal range (rho =-0.022, P=0.776), TTR (rho=0.015, P=0.848), and SD (rho=0.047, P=0.550). There was also no significant relationship between number of correct INR-relevant responses and INR control by any of the 3 outcome measures (count in range rho=0.033, P=0.676; TTR rho=0.067, P=0.388; and SD rho=-0.029, P=0.708). CONCLUSIONS: Although 74.1% of patients on long-term warfarin therapy achieved a passing score of at least 21 correct answers on the 29-question AKA instrument, there was no significant relationship between patient warfarin knowledge and INR control. Areas for improvement in patient education have been identified and procedures for educational modification are currently in development.