Health Literacy of Patients using Continuous Glucose Monitoring.

BACKGROUND: Low health literacy and numeracy are associated with poor health outcomes and lower self-efficacy. Continuous glucose monitors (CGMs) can improve diabetes management, but their benefits may be limited by health literacy levels. OBJECTIVES: Our objective was to characterize health literacy levels of ambulatory care patients using CGMs to manage their diabetes in one urban health system. Secondary aims were to identify specific knowledge deficits related to CGM education and determine predictors of self-rated comfort with and understanding of CGM use. METHODS: Participants with type 1 or type 2 diabetes using CGMs were identified using electronic medical records. Participants completed a telephone survey, including the Health Literacy/Subjective Numeracy Scale (HLS/SNS) and an investigator-developed survey assessing CGM comfort and understanding. Descriptive statistics were reported for demographic information. The associations between patient characteristics and survey responses were evaluated using the chi-square test, Fisher's exact test, or Wilcoxon rank-sum test. RESULTS: Eighty-two participants completed the surveys. The median HLS/SNS score for study participants was 80 (IQR 71-89). Associations were found between HLS/SNS scores and education level, reported income, and private insurance coverage. Participants with higher HLS/SNS scores reported higher levels of CGM understanding and comfort. Fifty-one percent of participants (n=42) reported no or inadequate training prior to CGM initiation. Better A1C results (<8%) were associated with higher self-rated responses in the investigator-developed survey. CONCLUSION: CGMs should not be withheld from individuals with low health literacy. Incorporating baseline health literacy assessment and offering literacy sensitive training will help optimize the benefits derived from this technology.

Statin gap in patients living with HIV: assessing dose appropriateness.

OBJECTIVES: Patients living with HIV (PLWH) are predisposed to atherosclerotic cardiovascular disease (ASCVD), resulting in concomitant antiretroviral and statin use. A statin prescribing gap for PLWH has been reported, but appropriateness of statin selection and dosing (ASD) has not been described. METHODS: This is a comparative, retrospective study reviewing ASD in PLWH vs. uninfected patients at two outpatient clinics within an academic medical centre. Adults > 21 years old indicated for statin therapy were included. The primary outcome was percentage of PLWH prescribed an appropriately dosed statin, accounting for clinical- and patient-related variables, compared with uninfected patients. The secondary outcome was to identify patient characteristics associated with inappropriately dosed statins. RESULTS: After propensity score matching, 879 PLWH and 879 uninfected patients were included for analysis. Fewer PLWH (27.8%, n = 244) were prescribed an ASD compared with uninfected patients (40.5%, n = 356, P < 0.001). Similar rates of statin omission were seen in both populations (P = 0.11). More PLWH received too low a dose compared with the uninfected population (P < 0.0064). There were lower ASD rates in PLWH for subgroups of patients with clinical ASCVD (P = 0.00013) and 10-year ASCVD risk ≥7.5% (P = 0.00055), but not in patients with low-density lipoprotein cholesterol ≥190 mg/dL or diabetes. CONCLUSIONS: Although a statin gap exists in both PLWH and uninfected patients, the clinical significance may be greater for PLWH given the increased risk of ASCVD. This study confirms a larger statin gap in PLWH, particularly when underdosing of statin medications is considered. Additional analysis is warranted to investigate reasons for the ASD gap and beneficial clinical interventions.

A Multicenter Focus Group Analysis of Medicare Beneficiaries Perception of Annual Wellness Visits.

ABSTRACT: National utilization of Medicare's Annual Wellness Visits (AWVs) benefit is low. Few studies have evaluated how beneficiaries perceive this service. This study aimed to characterize beneficiaries' opinion on the value of AWVs, preventive care services offered by Medicare, and barriers and facilitators to receiving those services. This qualitative study used semistructured focus group interviews of Medicare beneficiaries aged 65 years or older with a standardized facilitator guide. Four focus groups were conducted with 30 Medicare beneficiaries in an assisted-living facility, senior housing apartments, and a primary care office. Qualitative thematic analysis of focus group responses revealed that preventive healthcare was valued, but access to quality preventive care remains an issue for patients. Most participants did not know about AWVs and reported confusion over the terminology "wellness visit" compared with checkup or physical. Medicare beneficiaries are not commonly aware of AWVs. Increased promotion of AWV services by healthcare professionals may increase the number of beneficiaries participating in these preventive visits.

Best practices for safe use of SGLT-2 inhibitors developed from an expert panel Delphi consensus process.

PURPOSE: Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have demonstrated glycemic efficacy and cardiovascular and renal benefits in people with type 2 diabetes mellitus (T2DM). However, they are also associated with serious adverse events (AEs), but little consensus exists for clinicians regarding AE management. This study aimed to develop a list of best practices for the safe use and monitoring of SGLT-2 inhibitors in people with T2DM. METHODS: A 15-member interprofessional panel was surveyed in a four-round Delphi process. Panelists were asked to comment on and rank statements regarding initial prescribing considerations and actions for minimizing and managing eight specific AEs and a broad category for other AEs. In the final round, panelists selected if the statements should be considered a best practice specific to SGLT-2 inhibitors, a best practice for general safe medication use in T2DM, or if the statement should not be considered as a best practice for safe medication use. RESULTS: Consensus was achieved for 36 best practice statements specific to SGLT-2 inhibitors and 24 statements as general best practices for safe medication use. Fifty-six percent of the best practice statements for SGLT-2 inhibitors related to managing and/or preventing hypotension, urinary tract infections, and genital infections. The general best practices for safe medication use primarily focused on medication histories, past medical history considerations, physical exam components, and patient education. CONCLUSION: A list of best practice statements was developed using the Delphi method, which can be utilized by clinicians to guide the safe use and monitoring of SGLT-2 inhibitors in people with T2DM.

Addressing preceptor shortages with a novel structure of blended ambulatory care rotations.

INTRODUCTION: Schools of pharmacy are challenged to ensure sufficient full-time ambulatory care advance pharmacy practice experiences (APPEs). University of Maryland designed an innovative solution to create additional rotations utilizing faculty with part-time ambulatory care practices, by combining two rotation blocks into a 10-week "blended" ambulatory care/community pharmacy experience. The objective of this study is to characterize perceptions and impact of this format on student and preceptor skills, performance, and overall satisfaction, compared with the traditional five-week ambulatory care rotation. METHODS: Ambulatory care preceptors were surveyed regarding student skills in interviewing, documentation, patient assessment, building pharmacist-patient relationships, and mentorship opportunities. Students were surveyed regarding the number of preceptors and patient interactions/week, rotation hours, clinical abilities developed, patient relationships, patient population diversity, preceptor mentorship, clinical track participation, rotation expectations, professional benefit, career development, overall satisfaction, and likelihood to recommend the rotation. Chi-square test was used to evaluate statistically significant differences in cohort responses. RESULTS: Survey responses from 74 students (49%) and 21 preceptors (46%) were included. Student perceptions were generally positive and comparable between groups. Statistically significant differences were observed between groups in students' perception of "patient diversity" and preceptors' perception of "patient-pharmacist relationship". CONCLUSION: The 10-week blended format provides a unique and viable option that offers a solution to shortages of preceptor availability for ambulatory care APPEs by providing a rotation format that is more conducive to clinical practice faculty part-time ambulatory clinic schedules.

The Current Landscape of Transitions of Care Practice Models: A Scoping Review.

Transitions of care (TOC) are a set of actions to ensure patient coordination and continuity of care as patients transfer between different locations or levels. During transitions associated with chronic or acute illness, vulnerable patients may be placed at risk with fragmented systems compromising their health and safety. In addition, poor care transitions also have an enormous impact on health care spending. The primary objective of this scoping review is to summarize the current landscape of practice models that deliver TOC services in the United States. The secondary objective is to use the information to characterize the current state of best practice models. A search of the PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, International Pharmaceutical Abstracts, National Center for Biotechnology Information at the U.S. National Library of Medicine, and Cochrane Library databases (January 1, 2000-April 13, 2015) for articles pertaining to TOC models, limited to U.S. studies published in the English language with human subjects, gleaned 1362 articles. An additional 26 articles were added from the gray literature. Articles meeting inclusion criteria underwent a second review and were categorized into four groups: background information, original TOC research articles not evaluating practice model interventions, original TOC research articles describing practice models, and systematic or Cochrane reviews. The reviewers met weekly to discuss the challenges and resolve disagreements regarding literature reviews with consensus before progressing. A total of 188 articles describing TOC practice models met the inclusion criteria. Despite the strengths of several quality TOC models, none satisfied all the components recommended by leading experts. Multimodal interventions by multidisciplinary teams appear to represent a best practice model for TOC to improve patient outcomes and reduce readmissions, but one size does not fit all. Best model TOC services must include services along the TOC continuum: pretransition and posttransition, as well as at home and in outpatient health care settings. Studies clearly show that single-modal interventions are rarely successful in reducing readmissions and that successful TOC services must be multimodal and multidisciplinary, and continue throughout the care transition. Utilizing best practice TOC models described in this article as a starting point, practitioners interested in developing their own TOC program should test these tools in new practice environments and add to the body of literature by publishing their findings.

Behavioral influences on prescription inhaler acquisition for persistent asthma in a patient-centered medical home.

BACKGROUND: Medication adherence can be said to begin with the patient acquiring, or picking up their prescribed medications. There has been considerable study of asthma patients' adherence beliefs once they have possessed medication; however, little is known about attitudes that facilitate or impede their acquisition of such medication. OBJECTIVES: The purpose of this study was to examine the behavioral influences, motivation, and self-efficacy that may guide a patient's decision to pick up asthma controller medications from the pharmacy for the treatment of persistent asthma. METHODS: A chart review of patients with an asthma diagnosis treated at an academic family medicine practice identified 582 English-speaking adults prescribed an asthma medication. Participants were contacted in a randomized order via telephone and asked to complete an investigator-developed survey based upon the Theory of Planned Behavior. Descriptive statistics, chi square and t-tests were used for data analysis. RESULTS: 240 individuals were contacted, and 27 individuals consented and completed a survey. Eighteen individuals (67%) were prescribed a controller inhaler in the past year, fourteen of whom picked up their prescription from the pharmacy. Individuals who did not pick up their prescription reported more strongly than those who did that using their inhaler is important (P = 0.01). No other statistically significant differences were identified. CONCLUSION: Use of an inhaler is important to the patient based upon survey results; however, this belief did not correlate with adherence. Future studies that investigate patient-specific motivators would allow practitioners to better target clinical interventions to improve medication adherence in patients with asthma.

Review of the Target-Specific Oral Anticoagulants in Development for the Treatment and Prevention of Venous Thromboembolism.

Anticoagulation therapy is often indicated for the treatment and prevention of venous thromboembolism (VTE). Despite advances in anticoagulant management with parenteral anticoagulants and vitamin K antagonists, limitations to their use still exists, leading to investigation of alternative anticoagulants such as factor Xa inhibitors and direct thrombin inhibitors. To date, 3 target-specific oral anticoagulants (TSOACs) are Food and Drug Administration approved; several other agents are currently in development to optimize VTE management and minimize bleeding risks. The objective of this systematic review article is to provide clinicians an overview of the clinical evidence on the investigational TSOACs for the treatment and prevention of VTE. Of the agents in development, edoxaban holds the most promise due to robust data supporting its clinical benefit with a similar bleeding risk to currently approved agents. Clinicians should understand the TSOACs under investigation, since differences in pharmacokinetics and pharmacodynamics may influence clinical decision making and agent selection for management of VTE. Currently, no direct comparisons between TSOACs have been conducted. Agents under investigation have yet to overcome the major limitations of the currently existing TSOACs. Further studies are necessary to clarify which TSOAC agent is best for management of VTE in clinical practice.

A framework for pharmacist-assisted medication adherence in hard-to-reach patients.

BACKGROUND: Medication adherence rates are notably lower in hard-to-reach populations than in the general population. Pharmacists are uniquely qualified to address barriers to improve adherence. A number of pharmacist-led interventions have lacked theoretical underpinnings and thus have limited generalizability across disease states and care settings. OBJECTIVE: This study aims to create a model for use in patient-centered, pharmacist-led interactions to improve medication adherence. METHODS: The Health Action Process Approach (HAPA), a behavioral change framework, was adapted to known barriers of medication adherence. Semi-structured interviews were conducted with patients from the target population. Thematic analysis was performed after two weeks. Each subsequent interview was analyzed for additional themes. MAIN FINDINGS: Themes from the interviews fit into the following domains: outcomes expectancies, risk awareness, goals and motivations, planning, and follow through. The framework was then adapted to include thematic data. CONCLUSIONS: The newly developed framework provides a patient centered approach to facilitate and improve pharmacist-patient conversations regarding medication adherence. Its basis in a theoretical model allows for potential application across multiple care settings and multiple medications, regardless of disease state.

Prophylaxis of thromboembolic events in patients with nephrotic syndrome.

OBJECTIVE: To review published literature regarding use of strategies to prevent thrombotic events in patients with nephrotic syndrome (NS). DATA SOURCES: The MEDLINE/PubMed, EMBASE, and Cochrane databases were queried from 1980 to December 2012 for articles in English using the search terms nephrotic syndrome, thrombosis, thromboembolism, anticoagulation, warfarin, heparin, low-molecular-weight heparin, enoxaparin, dalteparin, tinzaparin, statin, atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin, aspirin, direct thrombin inhibitor, rivaroxaban, argatroban, lepirudin, bivalirudin, dabigatran, factor Xa inhibitor, fondaparinux, rivaroxaban, clopidogrel, ticlopidine, and prasugrel. STUDY SELECTION AND DATA EXTRACTION: All relevant original studies, meta-analyses, systematic reviews, guidelines, and review articles were assessed for inclusion. References from pertinent articles were examined for additional content not found during the initial search. DATA SYNTHESIS: NS leads to multiple complications, including hypercoagulability. A small prospective cohort study used enoxaparin for primary prophylaxis and demonstrated successful prevention of thrombotic events with minimal adverse events. Additional information has come in the form of decision analyses, which show potential decreased morbidity and mortality when primary prophylaxis for thrombotic events is used; however, all data have numerous limitations. Other strategies for thrombus prevention, including statins and antiplatelet agents, also have been investigated. CONCLUSIONS: When patients with NS are admitted to the hospital, develop an acute medical illness, or acquire an additional thrombotic events risk factor such as surgery, active malignancy, or pregnancy, consideration for primary pharmacologic prophylaxis with appropriately dosed low-molecular-weight heparin or other indicated anticoagulant should include the potential for increased thrombotic events risk in this patient population. Consideration may also be given to the use of primary pharmacologic prophylaxis with low-molecular-weight heparin or oral vitamin K antagonist in patients with membranous nephropathy once the albumin level drops below 2.0-2.5 g/dL. Short-term use of pharmacologic prophylaxis during the first 6 months following diagnosis warrants further investigation.

Risk of venous thromboembolism in patients with chronic liver disease and the utility of venous thromboembolism prophylaxis.

OBJECTIVE: To review the current literature on the risk of venous thromboembolism (VTE) in patients with chronic liver disease (CLD). DATA SOURCES: Literature was accessed through MEDLINE/PubMed (1996-December 2011) using the search terms liver disease, cirrhosis, venous thromboembolism, deep vein thrombosis, and pulmonary embolism. STUDY SELECTION AND DATA EXTRACTION: Relevant observational and population-based studies were included to present background information. Bibliographies of all relevant articles were reviewed for additional citations. DATA SYNTHESIS: Liver disease affects the synthesis of procoagulants and anticoagulants, resulting in hemostatic alterations and abnormal laboratory values. Retrospective studies characterized the VTE incidence to be 0.5-6.3%. Population-based studies reported VTE relative risks of 1.74-2.10 in patients with CLD compared with population controls and VTE odds ratios of 0.9-1.39 for hospitalized patients with CLD compared with controls without liver disease. There is a paucity of data on the use of pharmacologic prophylaxis in patients with CLD. CONCLUSIONS: Patients with CLD should be assessed for VTE risk and given VTE prophylaxis when the benefits outweigh the risks. Diagnoses of CLD or elevated international normalized ratio do not confer protection against development of VTE and do not justify withholding pharmacologic prophylaxis based on this diagnosis.