Impact of Simulation Manikins to Train Pharmacy Students in Nasal, Throat, and Oral Fluid Swab Collection.

Introduction: A point-of-care testing (POCT) certificate was implemented in a required pharmacy skills-based course. The purpose of this study was to evaluate the impact of manikins on student confidence in performing POCT swabs for infectious diseases. Innovation: Manikins were used to train second-year pharmacy students on nasal swabs, throat swabs, and oral fluid swabs. Student skills were assessed on manikins first, then on a peer. Proficiency was defined as a score of 90% or higher. Students completed a pre- and post-training survey regarding their confidence performing swabs. Student confidence was based on Likert style responses (i.e., 'Strongly Disagree' [score: 1], to 'Strongly Agree' [score: 5]) performing the swabs. Median change in confidence was calculated using quantile regression. Findings: All students (n=63) demonstrated proficiency in performing swabs. Median confidence for nasal, throat, and oral fluid swabs changed by 2.0 (95% CI: 1.5, 2.5), 2.0 (95% CI: 1.5, 2.5), and 2.0 (95%CI: 1.3, 2.7), respectively. The majority of students reported time spent practicing was adequate for the nasal (n=51, 81%), throat (n=51, 81%), and oral fluid swab (n=59, 94%). All participating students reported manikins to be moderately (n=17, 27%) or extremely (n=46, 73%) valuable, and all students rated their overall experience with manikins as positive (n=63, 100%). Student comments revealed manikins helped to visualize anatomy, practice skills without peer discomfort, and minimize risk during the COVID-19 pandemic. Conclusion: This study demonstrated that inclusion of practice on manikins increased student confidence in performing POCT for infectious diseases. In addition, the majority of students indicated that the use of manikins was valuable to their learning and reported feeling prepared to perform POCT in practice after using the manikins.

Use of a script concordance test to evaluate the impact of a targeted educational strategy on clinical reasoning in advanced pharmacy practice experiential students.

BACKGROUND AND PURPOSE: It is unclear how clinical reasoning is impacted by a single advanced pharmacy practice experience (APPE) and how preceptors can further develop these skills. EDUCATIONAL ACTIVITY AND SETTING: Students completing an APPE within four sites were invited to participate. To assess clinical reasoning skills, students completed a 30 item script concordance test (SCT) during week 1 and week 5 of a rotation. Students were divided into control and intervention groups. The intervention group participated in a clinical reasoning discussion, during which students presented a case and led a discussion on how to reason through treatment options. FINDINGS: Change in mean SCT scores between week 1 and week 5 were 0.84 (2.8%) and 1.23 (4.1%) in the control (n = 15) and intervention groups (n = 28), respectively. There was no significant change in scores in the control group (P = .07, CI -0.34, 2.01). The change in scores was statistically significant in the intervention group (P = .02, CI 0.23, 2.23). An independent samples t-test comparing the SCT score change for the control and intervention group showed no significant difference (P = .62, CI -1.18, 1.96). SUMMARY: This study demonstrated the feasibility of implementing a SCT in experiential education. SCT scores did not significantly improve beyond the standard APPE in response to the focused educational intervention, but investigators found that the discussion facilitated rich conversations about patient cases and was valuable for assessing a student's thinking pattern.

Faculty preceptors' strategies for teaching clinical reasoning skills in the advanced pharmacy practice experience setting.

INTRODUCTION: Clinical reasoning is essential to providing quality patient care. However, advanced pharmacy practice experience (APPE) students may struggle with the real-life aspects of patient care, and it may be difficult to quickly identify these students in order to make meaningful interventions. The purpose of this study was to explore pharmacy faculty preceptors' strategies for identifying gaps and teaching clinical reasoning in the APPE setting. METHODS: A qualitative study utilizing 30-min, one-on-one phone interviews was conducted with faculty members from two schools of pharmacy. Faculty participants were invited based on their APPE preceptor role and expertise in adult general medicine. Interview questions collected faculty demographics and reflections on evaluation and instruction of clinical reasoning skills. Demographics were analyzed using descriptive statistics. Thematic analysis was completed to identify themes from qualitative interview data. RESULTS: Fifteen faculty preceptors participated. The cohort had an average of 17.1 pharmacy practice years and an average of 11.9 faculty member years. Interviews yielded a 7735-word document for data analysis, which resulted in 11 themes. CONCLUSIONS: This study explored pharmacy faculty preceptors' strategies for identifying gaps in clinical reasoning and their instructional methods to improve those skills, which resulted in 11 themes. Future directions include implementation of a standardized clinical reasoning assessment tool in the APPE setting and exploration of targeted educational interventions.

Real-World Evaluation of Dosing in Patients Converted From Insulin Glargine (Lantus) to Insulin Glargine (Basaglar).

Background: Basaglar, insulin glargine (BGlar; Eli Lilly, Indianapolis, IN), a follow-on biologic, was developed after the patent for Lantus, insulin glargine (LGlar; Sanofi-Aventis, Paris, France) expired. Objective: To compare the dosing and hemoglobin A1C (A1C)-lowering effects of BGlar compared with LGlar in a real-world setting. Methods: Adult patients, at 5 clinics, with type 1 (T1DM) or type 2 diabetes mellitus (T2DM) who were converted from LGlar to BGlar were included in this retrospective observational study. The primary outcome compared mean basal insulin dose (U/d) from the date of conversion to 6 months. Basal insulin and total daily insulin doses were also compared from baseline to 3- and 12-months postconversion, as also change in A1C, body weight, and estimated monthly acquisition costs of basal insulin. Results: Of the 225 patients included, 56% were male, and 81% had T2DM. The mean conversion dose (U/d) of LGlar was 46.3 ± 32.7. There was no significant difference in the mean BGlar dose (U/d) at 6 months (45.9 ± 33.5; P = 0.52), nor was there a statistical difference at 3 or 12 months. There were no significant differences in change in A1C at any time point. The estimated monthly acquisition cost of BGlar was significantly less than that for LGlar at conversion ($286 vs $341, P < 0.001) and 6 months ($290 vs $351, P < 0.001) respectively. Conclusion/Relevance: The results of this retrospective study suggest that BGlar resulted in similar glycemic outcomes compared with LGlar in a real-world setting and may be a preferable option in a value-based health care environment.

Communication networks of medication management in an ambulatory care setting.

BACKGROUND: Systems approaches in healthcare address complexities of care related to medication safety. Adverse drug events can be prevented by communication between providers. Thus, methods that depict the structures and processes of communications are foundational for prevention efforts. Social network analysis is a methodology applied in healthcare settings to describe and quantify communication patterns. Knowledge of the structures and processes surrounding medication management communications will be useful to explain and intervene on related quality or safety outcomes. OBJECTIVES: The aim of this study was to use social network analysis as a tool to describe the communication structures and processes of medication management for patients on warfarin therapy in an ambulatory care setting. METHOD: A longitudinal, roster-based assessment was used for the social network analysis. Data were collected from electronic medical records and coded using a fixed-list format. Information was collected regarding who was involved as well as frequency and type of communications. The analysis followed 16 subjects at one internal medicine clinic over six months. RESULTS: Structurally, communications were unidirectional and most often connected actors from different groups. Most communications were directed from nursing staff to patients. Central actors were a pharmacist, several nursing staff and one prescriber. Difference in processes were identified by characterizing communications according to level of impact on patient safety. Moderate impact communications corresponded to focused connections between providers. Further, the pharmacist was measured as the most prominent gatekeeper in moderate impact communications compared to an advanced registered nurse practitioner for low impact communications. CONCLUSIONS: Medication management reflected a unidirectional and interdisciplinary communication structure that maintained process variation according to the potential impact on patient safety. The level of influence of the pharmacist as a connector in the network rose in conjunction with the level of potential impact the communication had on patient safety.

A prospective, multi-center cohort study: investigating the ability of warfarin-treated patients to predict their INR.

BACKGROUND: In practice, warfarin-treated patients may share insight regarding their international normalized ratio (INR) value before it is measured. The accuracy and potential utility of these predictions have not been evaluated. OBJECTIVE: To (1) test how accurately patients can predict their INR; (2) identify demographic factors associated with their ability to predict their INR accurately; and (3) identify demographic factors associated with the patient's INR being in the therapeutic range. METHODS: A prospective, multi-center cohort study enrolled patients from eight anticoagulation clinics in Iowa. Inclusion criteria were: age ≥ 18 years, warfarin use ≥ 60 days, INR goal of 2.0-3.0, and expected warfarin use > 6 months. Subjects completed a data collection form during enrollment and before each INR measurement. Data included demographics, a set of medication taking beliefs and practices, self-reported adherence, past INR values, INR prediction and reason(s) for the prediction. RESULTS: There were 87 subjects enrolled with 372 INR measurements. The mean (SD) number of INRs per subject was 4.3 (1.8). Thirty percent of subjects reported they could tell when their INR is out of goal range. Patients predicted that 90.5% of their INRs would be within goal range, although only 65.5% of INRs were therapeutic. Patients correctly predicted a low INR as low or high INR as high in only 9.4% of out of range instances. A set of demographic characteristics and medication beliefs were not associated with prediction accuracy or percentage of INR measurements in range (PINRR). Most patients did not give a reason for their predicted result. For those that did, the most common factor was perceived stability at current dose. CONCLUSION: While some patients believed they could predict when their INR was out of range, only few were able to do so. Most patients assumed a therapeutic INR and missed when their INR was high or low. Patients should be advised against modifying their warfarin dose without consulting the provider that manages their therapy. TRIAL REGISTRATION: ClinicalTrials.gov number, NCT 02764112.

Comparison of faculty and student self-assessment scores of aseptic technique skills and the impact of video review on self-awareness for second-year pharmacy students.

BACKGROUND AND PURPOSE: Educating students about aseptic technique presents many challenges. Students at Drake University have limited exposure to this skill outside of the classroom setting, and students have previously shown a lack of awareness related to their own aseptic technique skills. One approach to developing self-awareness in this area may be the incorporation of activities involving video viewing and self-reflection. EDUCATIONAL ACTIVITY AND SETTING: Second-year pharmacy students in the Intermediate Pharmacy Skills and Applications 2 course completed four total aseptic technique activities, each of which was assessed by faculty using a standardized assessment tool. Each student was video-recorded during one of these aseptic technique activities. Students were asked to self-reflect on their performance immediately after the activity and again after viewing the video recording of their performance (using the same criteria included in a standardized faculty assessment tool). Student self-reflection scores before and after video viewing were then compared to faculty scores. FINDINGS: One-hundred six students participated in the video recording and self-reflection activity. Compared to faculty assessment scores, there was no significant difference between the self-reflections before or after video viewing (p = 0.571). DISCUSSION: Video self-reflection had no significant impact on the ability to accurately self-assess aseptic technique skills, but this study did reveal several other opportunities for future teaching and research. SUMMARY: Future efforts to impact student self-awareness should include additional self-reflection instruction, repeated self-reflection activities conducted over the course of a semester, and improved video recording technology.

Impact of debates on student perceptions and competency scores in the advanced pharmacy practice setting.

BACKGROUND AND PURPOSE: Advanced pharmacy practice experience (APPE) students are faced with the difficult reality that there is rarely one correct answer to a patient care question. Faculty preceptors developed a clinical debate activity to provide students with an opportunity to explore pharmacy topics with competing viewpoints. EDUCATIONAL ACTIVITY AND SETTING: The clinical debate activity was implemented in the APPE setting as a collaboration between three faculty preceptors from Drake University and University of Iowa. Student pre-debate and post-debate survey data was collected to assess the perceived impact of clinical debates on student confidence in skills related to the debate. Students were also asked to provide which skills were developed through the debate, whether participation in the debate changed their opinion on the issue, and if debates should be used as a teaching tool. Faculty preceptor scores on midpoint and final evaluations for applicable APPE competencies were also evaluated. FINDINGS: Forty-two students participated in a clinical debate over a 12-month period. Students demonstrated improved confidence in almost all areas assessed, and 90.5% of students felt debates should be used as a teaching tool. Assessment of faculty midpoint (pre-debate) and final (post-debate) evaluation scores revealed statistically significant improvements in competencies related to literature evaluation and communication skills. DISCUSSION AND CONCLUSIONS: Clinical debates have had a positive impact on both subjective and objective results in this APPE setting. Preceptors are encouraged to consider implementing a similar activity. Debates are a useful teaching tool in developing confidence and skills.

Comparison of electronic versus paper rubrics to assess patient counseling experiences in a skills-based lab course.

BACKGROUND AND PURPOSE: To evaluate an electronic counseling rubric to facilitate timely student feedback and explore differences in student performance, student anxiety, and self-perceived preparedness in a high stakes practical exam when using a paper rubric versus an electronic rubric. EDUCATIONAL ACTIVITY AND SETTING: Two cohorts of students in the third professional year were evaluated using the same rubric criteria: cohort 1 (n = 97) used traditional paper rubrics and cohort 2 (n = 104) used electronic rubrics. Cohorts were surveyed to measure anxiety and perceived preparedness in patient counseling skills one week prior to a practical exam, and cohort responses were compared. Student practical exam performance was also compared between the two cohorts. FINDINGS: Results showed no significant relationship between electronic rubric use and student anxiety (p = 0.07) or student exam performance [average score 53.42 points (SD 3.65) and 53.93 points (SD 3.78) in Cohort 1 and Cohort 2, respectively]. Perceived exam preparedness was higher among students using electronic rubrics, with timing of feedback being the mediating process in increasing preparedness (p < 0.01). DISCUSSION AND SUMMARY: Electronic rubrics resulted in more timely feedback on patient counseling skills, and students felt more prepared for their practical exam. This did not result in a significant difference in practical exam performance between the two cohorts. Additional methods to incorporate electronic rubrics into the course will be explored.

Retrospective Evaluation of ASCVD Risk and Statin Therapy Need in Nondiabetic Patients Based on the 2013 ACC/AHA Cholesterol Guidelines.

PURPOSE: Study goal was to assess the impact of the 2013 American College of Cardiology and the American Heart Association (ACC/AHA) Cholesterol Guidelines on patients in the fourth statin benefit group which included patients aged 40 to 75 years, without diabetes or clinical atherosclerotic cardiovascular disease (ASCVD), and have an ASCVD score ≥7.5%. These patients could benefit from treatment interventions by a pharmacist. METHODS: Patients were identified from electronic health records. A sample of 3503 patients was ascertained from having a lipid panel performed within the 12 months before November 1, 2013. Patients were excluded if we were unable to calculate 10-year ASCVD risk. RESULTS: A total of 3203 patients were included, with 2008 not on statin therapy. Of those, 1507 (75%) had a 10-year ASCVD risk score <7.5% and 501 (25%) had a score > 7.5%. Patient characteristics leading to an increase in risk included advanced age, smoker, male, and hypertension treatment. Of 2008 nonstatin patients, there were 466 (23.2%) who fit criteria for initiation of moderate- or high-intensity statin. CONCLUSION: Widespread adoption of the 2013 ACC/AHA Cholesterol Guidelines will expand prescribing rates of statins. Implementing screening strategies may help identify patients who require treatment in this fourth statin benefit group. A pharmacist can be vital in screening patients, educating patients regarding the need for medication therapy, and monitoring for adherence in these new regimens.

A Retrospective Evaluation of Response to Vitamin D Supplementation in Obese Versus Nonobese Patients.

OBJECTIVE: To evaluate the impact of body mass index (BMI) on vitamin D status following ergocalciferol therapy. METHODS: A retrospective evaluation of patients aged 18 years and older with a baseline serum 25(OH)D < 30 ng/mL who received prescription ergocalciferol 50 000 IU at any dose between July 2009 and November 2011 was conducted. Patients were included if pre- and posttreatment 25(OH)D levels were available within 3 months of therapy. RESULTS: Two hundred and thirteen patients were included in the study with 52% having a BMI ≥30 kg/m(2). Thirty-eight different ergocalciferol regimens were prescribed, and the majority of patients (66.2%) received a regimen consisting of 50 000 IU once weekly for variable durations. Mean 25(OH)D levels increased from 18.8 ± 6.6 ng/mL at baseline to 35.0 ± 13.8 ng/mL with 61.0% (n = 130) of patients having attained vitamin D sufficiency, 25(OH)D ≥ 30 ng/mL, with their prescribed ergocalciferol regimen. Obese patients with a BMI ≥30 were less likely to attain vitamin D sufficiency following replacement than patients with a BMI <30 kg/m(2) (52% vs 71%; P = .0161). CONCLUSION: Our study demonstrated an overall moderate response rate to replacement therapy with ergocalciferol and considerable variability in vitamin D replacement strategies initiated by primary care providers. Based on our findings, elevated BMI ≥30 kg/m(2) may impact the likelihood of attaining vitamin D sufficiency with ergocalciferol.

Irritable bowel syndrome: a concise review of current treatment concepts.

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders causing patients to seek medical treatment. It is relatively resource intensive and the source of significant morbidity. Recent insights into the pathophysiology and treatment of IBS has given clinicians more options than ever to contend with this disorder. The purpose of our paper is to review older, "classic" treatments for IBS as well as newer agents and "alternative" therapies. We discuss the evidence base of these drugs and provide context to help develop appropriate treatment plans for IBS patients.

Assessing pharmacy students' ability to accurately measure blood pressure using a blood pressure simulator arm.

OBJECTIVE: To compare student accuracy in measuring normal and high blood pressures using a simulator arm. METHODS: In this prospective, single-blind, study involving third-year pharmacy students, simulator arms were programmed with prespecified normal and high blood pressures. Students measured preset normal and high diastolic and systolic blood pressure using a crossover design. RESULTS: One hundred sixteen students completed both blood pressure measurements. There was a significant difference between the accuracy of high systolic blood pressure (HSBP) measurement and normal systolic blood pressure (NSBP) measurement (mean HSBP difference 8.4 ± 10.9 mmHg vs NSBP 3.6 ± 6.4 mmHg; p<0.001). However, there was no difference between the accuracy of high diastolic blood pressure (HDBP) measurement and normal diastolic blood pressure (NDBP) measurement (mean HDBP difference 6.8 ± 9.6 mmHg vs. mean NDBP difference 4.6 ± 4.5 mmHg; p=0.089). CONCLUSIONS: Pharmacy students may need additional instruction and experience with taking high blood pressure measurements to ensure they are able to accurately assess this important vital sign.

Evaluation of dosing and clinical outcomes in patients undergoing conversion of insulin glargine to insulin detemir.

STUDY OBJECTIVES: To evaluate the dose and frequency of insulin detemir for patients with diabetes mellitus undergoing conversion from insulin glargine to insulin detemir, and to assess glycemic control, weight gain, and risk of hypoglycemia after converting to insulin detemir. DESIGN: Retrospective medical record review. SETTING: Large academic medical center. PATIENTS: Thirty-one patients with type 1 (10 patients) or type 2 (21 patients) diabetes who were converted from insulin glargine to insulin detemir by usual practice between January 1, 2006, and March 3, 2007, after an Iowa Medicaid formulary switch. MEASUREMENT AND MAIN RESULTS: Data were collected for 12 months after conversion from insulin glargine to insulin detemir. No significant change in mean basal insulin dose was noted in patients with type 1 diabetes at the end of 12 months (insulin detemir 31.1 units/day vs baseline insulin glargine 32.0 units/day, p=0.89; insulin detemir 0.41 unit/kg/day vs baseline insulin glargine 0.42 unit/kg/day, p=0.91). In patients with type 2 diabetes, however, the mean basal insulin dose was significantly higher with insulin detemir compared with baseline insulin glargine (74.2 vs 55.8 units/day, p=0.002; 0.68 vs 0.48 unit/kg/day, p=0.001) at the end of 12 months. Twice-daily administration was required in a higher proportion of patients receiving insulin detemir (15 patients [48%]) at 12 months compared with insulin glargine (4 patients [13%]) at baseline (p=0.043). A significant change in hemoglobin A(1c) was not observed in patients with type 1 diabetes (9.7% with insulin detemir vs 9.3% with insulin glargine, p=0.41) or type 2 diabetes (9.4% with insulin detemir vs 9.7% with insulin glargine at baseline, p=0.57) despite the use of higher insulin detemir doses in patients with type 2 diabetes. No significant differences in weight or frequency of hypoglycemia were noted. CONCLUSION: Treatment with insulin detemir appears to require more frequent administration and higher insulin doses compared with insulin glargine in patients with type 2 diabetes, with 33% higher doses, on average, observed in this study. These findings suggest that a unit-for-unit conversion from insulin glargine to insulin detemir, as suggested by the manufacturer of insulin detemir, may not be adequate in patients with type 2 diabetes.