Student Pharmacists Provide Similar Quality Clinical Reasoning Feedback as Resident Teaching Assistants.

OBJECTIVE: Pharmacists utilize clinical reasoning (CR) to improve patient outcomes via medication optimization. It is critical to develop these skills in student pharmacists, yet optimal pedagogies to teach and assess CR are unknown. Peer feedback may be used to develop CR in student pharmacists, but a certain feedback quality must be reached to be effective. This study sought to evaluate if student pharmacists could provide similar quality peer feedback compared to pharmacy resident teaching assistant (TA) feedback. METHODS: This was a retrospective, mixed-methods pedagogical analysis comparing the quality of first-year student pharmacist peer feedback to resident TA CR feedback. The CR comments were defined using the intellectual standards of CR. Quality was assessed for task specification, gap identification, actionability, and process orientation by 2 independent investigators. Student performance and perceptions were also assessed. Mann-Whitney U, t tests, and descriptive statistics were used to analyze data where appropriate. RESULTS: Clinical reasoning feedback from peers (N = 805) and TAs (N = 206) were analyzed. Interrater reliability for feedback quality was moderate to substantial. Overall, peer CR feedback was of higher quality regarding task specification and process orientation while TA CR feedback was of higher quality regarding gap identification and actionability. Students receiving peer feedback performed better on a final patient case than those receiving TA feedback (95.2% vs 92.3%). Overall, the peer feedback process was well received by students. CONCLUSION: Student pharmacists can provide similar quality feedback as resident TAs. Peer feedback offers an alternative to resident TA feedback and has the potential to contribute to improved CR skills.

Enhanced renal clearance impacts levetiracetam concentrations in patients with traumatic brain injury with and without augmented renal clearance.

BACKGROUND: The purpose of this study was to examine the impact of ARC on levetiracetam concentrations during the first week following acute TBI. The hypothesis was levetiracetam concentrations are significantly lower in TBI patients with augmented renal clearance (ARC) compared to those with normal renal clearance. METHODS: This is a prospective cohort pharmacokinetic study of adults with moderate to severe TBI treated with levetiracetam during the first week after injury. Serial blood collections were performed daily for analysis of levetiracetam, cystatin C, and 12-hr creatinine clearance (CrCl) determinations. Patients were divided into two cohorts: with (CrCl ≥130 ml/min/1.73 m2) and without ARC. RESULTS: Twenty-two patients with moderate to severe TBI were included. The population consisted primarily of young male patients with severe TBI (mean age 40 years old, 68% male, median admission GCS 4). Each received levetiracetam 1000 mg IV every 12 h for the study period. ARC was present in 77.3% of patients, with significantly lower levetiracetam concentrations in ARC patients and below the conservative therapeutic range (< 6mcg/mL) for all study days. In patients without ARC, the serum concentrations were also below the expected range on all but two study days (Days 4 and 5). Four of the 22 (18.2%) patients exhibited seizure activity during the study period (two of these patients exhibited ARC). Cystatin C concentrations were significantly lower in patients with ARC, though the mean for all patients was within the typical normal range. CONCLUSIONS: ARC has a high prevalence in patients with moderate to severe TBI. Levetiracetam concentrations after standard dosing were low in all TBI patients, but significantly lower in patients with ARC. This study highlights the need to consider personalized drug dosing in TBI patients irrespective of the presence of ARC. CLINICAL TRIAL REGISTRATION: This study was registered at cliicaltrials.gov (NCT02437838) Registered on 08/05/2015, https://clinicaltrials.gov/ct2/show/NCT02437838 .

Key considerations for developing an equitable faculty teaching workload.

PURPOSE: Faculty teaching workload has become a focus for many academic institutions given the increasing amount of faculty burnout and need for equitable distribution of effort. Many gaps exist in faculty workload guidance which contribute to decreased faculty productivity, lack of appropriate recognition, faculty burnout, and subsequently, retention of faculty. A task force was created to develop teaching workload guidance and to outline minimum teaching expectations at our school of pharmacy. DESCRIPTION: This manuscript highlights the need for clarity around the definition of roles of the contemporary educator and considerations when developing guidance around teaching workload expectations using the "What? So What? Now What?" reflection framework. ANALYSIS/INTERPRETATION: Teaching workload guidance first starts with establishing a definition of the contemporary roles of the educator. Challenges, considerations, and eight next steps are outlined that are critical to address before equitable teaching workload guidance is established. CONCLUSIONS: Teaching workload guidance should include transparency, clarity, credit, norms, context, and accountability. Additionally, solutions created to address the gaps in workload policies should be data driven. IMPLICATIONS: The current traditional system of evaluating faculty workload has many gaps due to forces driving change in pharmacy education. Roles of the pharmacy educator should be valued and recognized across all mission centric learning programs.

Defining contemporary roles of the pharmacy educator: The essential first step in developing equitable faculty teaching workload.

INTRODUCTION: Faculty workload policy has gained increased attention recently given the growing amount of faculty burnout leading to decreased productivity, worsened faculty morale, and impaired retention. Faculty are one of the most valuable resources of an academic institution; thus, it is essential that a clear picture of the "jobs to be done" are defined and valued. PERSPECTIVE: The approach of a task force charged with developing a teaching workload policy is described. Through this work, it was recognized that essential roles of the contemporary pharmacy educator have not been defined, resulting in workload policies that might only value and recognize "traditional" educator roles. This led the task force to evaluate the forces driving change in education and to identify the roles of faculty as educators. The stepwise approach used to define nine essential roles of contemporary pharmacy educators is described. IMPLICATIONS: Roles of the educator have become more complex, and traditional definitions of these roles do not recognize and value the multifaceted nature of the job to be done. Consideration of contemporary definitions of educator roles is a critical first step for developing workload policies. The new definition of educator roles will allow the academic institution to have more clarity around total teaching effort and recognize the value faculty provide the institution. We believe this is the essential first step for the Academy when developing teaching workload policies that are fair and equitable, while also understanding the overall faculty needs for executing their educational enterprise.

Competency-based pharmacy education definition: What components need to be defined to implement it?

OBJECTIVES: This study aimed to define the essential elements in the proposed competency-based pharmacy education (CBPE) definition, provide the key defining components of each essential element on the basis of educational theory and evidence, and define how the essential elements meet the identified needs for CBPE. METHODS: best-practice integrative review was conducted as part of the work of the American Association of Colleges of Pharmacy CBPE Task Force to define the essential elements in the CBPE definition and how these elements fit with the need for CBPE. The definition was compared with other published competency-based education definitions across K-12, higher education, medical education, and veterinary education. Task Force members then met to develop a consensus on the core components of the 5 essential elements in the definition. Next, the Task Force evaluated the fit of CBPE by matching the identified needs, discussed in detail elsewhere, across each of the stakeholder perspectives with the core components of the 5 essential elements in the derived definition of CBPE. FINDINGS: Upon review of the proposed CBPE definition, the Task Force identified 5 essential elements. These elements include the following: meeting health care and societal needs, outcomes-based curricular model, de-emphasized time, learner-centered culture, and authentic teaching and learning strategies aligned to assessments. SUMMARY: This article helps to establish a common language for CBPE by defining the essential elements of the core components of the definition, and provides a starting point for further exploration of CBPE.

Examining Competency-Based Education Through the Lens of Implementation Science: A Scoping Review.

OBJECTIVES: This study aimed to identify evidence for the implementation and assessment of competency-based education (CBE) in health professions curricula using an implementation science framework. FINDINGS: Using the PRISMA framework, a systematic review of the literature applying a prespecified and piloted search strategy from 2017 to the present in PubMed and CINAHL was performed. References identified from the search strategy were imported into Covidence for title and abstract screening and full-text review by 2 researchers. A third researcher resolved discrepancies. Data were extracted and synthesized to identify key elements from the article related to implementation science, with a quality appraisal. A total of 25 studies out of 304 initially identified records were included. The studies covered a broad range of health professions and countries. Key findings were limited use of implementation science elements, including variability in CBE implementation, limited fidelity assessment, and partial examination of the process continuum. Programs with a more robust implementation approach have a team-based strategy to lead, implement, and support CBE. Motivation and training of faculty are also key components of successful CBE implementation. SUMMARY: Competency-based education is implemented differently across institutions, with variation among programs in their choice of elements of implementation science used. Further research is needed to examine CBE from an implementation science perspective and address remaining questions.

AACP's Strategic Commitment to Improving Pharmacy Education: Past, Present, and Future.

Since its founding in 1900, the American Association of Colleges of Pharmacy (AACP) has been focused on quality pharmacy education. As the Association and its institutional and individual members now consider contemporary issues in education, such as competency-based education, it is important to continue their collective work in the context of AACP's enduring mission: to advance pharmacy education, research, scholarship, practice, and service, in partnership with members and stakeholders, to improve health for all. While language, labels, and strategies evolve over time and across significant changes in social, economic, political, and health care environments, AACP's commitment to quality in education has been and must continue to be unwavering. Constraints and challenges perceived in the short term should not deter deliberate and strategic quality improvement efforts over time and in the longer term. AACP's 2021-2024 Strategic Plan, entitled Preparing Pharmacists and the Academy to Thrive in Challenging Times, acknowledges the need to prepare pharmacists for seemingly constant change in the health care environment.

Competency-Based Education: The Need to Debunk Misconceptions and Develop a Common Language.

Competency-based education (CBE) dates back to the early 1900s. A renewed interest in CBE in health professions education has been sparked by the recommendations that emerged from the 2017 Josiah Macy Jr Foundation conference on CBE. These recommendations urge changes in structure and pedagogy to address gaps between societal needs, health care practice, and health professions education. Despite widespread interest, there is significant variability in what constitutes CBE. This variability has challenged the development of an evidence base in the literature and has led to widespread misconceptions regarding CBE. Implementation science principles outline the need to develop a common language to inform effective and sustained implementation of an innovation. By misusing or overusing similar words and using different concepts interchangeably without first developing a common, widely understood language around CBE, we cannot expect that CBE will be among the tools successful in closing gaps between health care practice and education.

Assessing the Use of Microlearning for Preceptor Development.

The objective of this study was to evaluate microlearning as a preceptor development method compared to a traditional method of learning. Twenty-five preceptor participants volunteered to engage in a learning intervention about two preceptor development topics. Participants were randomized 1:1 to either a thirty-minute traditional learning experience or a fifteen-minute microlearning experience; participants then crossed over to the other intervention for comparison. Primary outcomes were satisfaction, changes in knowledge, self-efficacy, and perception of behavior, confidence scale, and self-reported frequency of behavior, respectively. One-way repeated measures ANOVA and Wilcoxon paired t-tests were used to analyze knowledge and self-efficacy, and Wilcoxon paired t-tests were utilized to assess satisfaction and perception of behavior. Most participants preferred microlearning over the traditional method (72% vs. 20%, p = 0.007). Free text satisfaction responses were analyzed using inductive coding and thematic analysis. Participants reported that microlearning was more engaging and efficient. There were no significant differences in knowledge, self-efficacy, or perception of behavior between microlearning and the traditional method. Knowledge and self-efficacy scores for each modality increased compared to the baseline. Microlearning shows promise for educating pharmacy preceptors. Further study is needed to confirm the findings and determine optimal delivery approaches.

Recommendations and Next Steps For Competency-Based Pharmacy Education.

In July 2021, the chairs of the American Association of Colleges of Pharmacy Council of Deans, Council of Faculties, and Council of Sections developed a task force to discuss potential ways to improve pharmacy education. The Competency-Based Education (CBE) Joint Task Force was created to explore the pros and cons of advancing a competency-based approach to pharmacy education (CBPE) and to determine ways to create more flexibility within pharmacy curricula to enable CBE. To achieve these goals, the Task Force systematically reviewed available resources and outlined the pros and cons of CBPE, best practices for implementation, strategies to minimize barriers, and recommendations on whether CBE should be implemented in pharmacy education. This commentary summarizes the Task Force's findings regarding whether CBPE is a suitable approach for pharmacy education and the next steps if implemented.

Is it Time for Competency-Based Education to Move Forward in Pharmacy Education?

Competency-based education is rapidly emerging as a paradigmatic shift in health professions education, as we grapple with the realities of ever-changing and increasing demands of society and health systems. While pharmacy educators are becoming more familiar with this paradigm, colleagues in medical education have been exploring models and methods of competency-based education for many years, and their experiences can be illuminating for us. The persistent question that drives continuous quality improvement in pharmacy education and the development of initiatives within American Association of Colleges of Pharmacy might be stated as "Is there a better (more effective, more efficient) way to prepare pharmacists (future and current) to meet the medication-related needs of the public?"

Personalized antiseizure medication therapy in critically ill adult patients.

Precision medicine has the potential to have a significant impact on both drug development and patient care. It is crucial to not only provide prompt effective antiseizure treatment for critically ill patients after seizures start but also have a proactive mindset and concentrate on epileptogenesis and the underlying cause of the seizures or seizure disorders. Critical illness presents different treatment issues compared with the ambulatory population, which makes it challenging to choose the best antiseizure medications and to administer them at the right time and at the right dose. Since there is a paucity of information available on antiseizure medication dosing in critically ill patients, therapeutic drug monitoring is a useful tool for defining each patient's personal therapeutic range and assisting clinicians in decision-making. Use of pharmacogenomic information relating to pharmacokinetics, hepatic metabolism, and seizure etiology may improve safety and efficacy by individualizing therapy. Studies evaluating the clinical implementation of pharmacogenomic information at the point-of-care and identification of biomarkers are also needed. These studies may make it possible to avoid adverse drug reactions, maximize drug efficacy, reduce drug-drug interactions, and optimize medications for each individual patient. This review will discuss the available literature and provide future insights on precision medicine use with antiseizure therapy in critically ill adult patients.

Augmented Renal Clearance in the Hematology and Oncology Populations: A Scoping Review for Pharmacists.

INTRODUCTION: Until recently, interest in renal function has focused on impairment to limit drug toxicity and increase medication safety. Augmented renal clearance (ARC) has been increasingly studied in multiple patient populations, including oncology, and could lead to decreased drug efficacy from faster elimination resulting in subtherapeutic concentrations. This scoping review sought to summarize ARC literature in cancer and identify areas of research to better inform pharmacy practitioners. DATA SOURCES: Electronic databases were searched for English articles related to augmented/enhanced renal function/clearance following a framework for scoping reviews. DATA SYNTHESIS: Fourteen articles were analyzed, divided according to article objective: descriptive studies or ARC's impact on pharmacokinetics/pharmacodynamics. ARC was most defined as creatinine clearance >130 mL/min/1.73 m2, reported in 10%-100% of patients. Febrile neutropenia in adult and pediatric patients, and age <50-65 years, hematologic malignancy, and lower serum creatinine in adult patients were notable risk factors for ARC. The impact of ARC has only been evaluated with antimicrobial agents consistently resulting in lower than anticipated trough levels. Identified gaps include: elucidation of ARC's mechanism and associated biomarkers, an inclusive ARC definition for relative renal enhancement, and study of additional drug classes to ascertain the breadth of ARC impact on drug therapy. CONCLUSIONS: ARC is proving to be a frequent phenomenon in patients with cancer which pharmacists could play a vital role. Further research is needed to better understand the impact of ARC in patient care and a potential need to stage ARC based on degree of renal enhancement to establish specific drug dosing recommendations.

Scoping review of rational polytherapy in patients with drug-resistant epilepsy.

There is a paucity of literature regarding the optimal selection of combination antiseizure medications (ASMs) for drug-resistant epilepsy (DRE). The aim of this scoping review is to evaluate current evidence related to "rational polytherapy" among adults with DRE. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-SCr) guidelines, PubMed, ProQuest, CINAHL, and Cochrane databases were searched using DRE- and polytherapy-related keywords. The exclusion criteria applied included: non-English; non-human studies; non-research studies; participants less than 18 years; status epilepticus; ASM monotherapy; and certain ASMs. In Covidence, two researchers independently reviewed articles for inclusion at each phase, with a third resolving conflicts. Data were extracted, with quality appraisal using the Mixed Methods Appraisal Tool (MMAT). Of the 6477 studies imported for screening, 33 studies were included. Clinical, humanistic, and economic outcomes were reported by 26, 12, and one study, respectively. Common efficacy-related clinical outcomes included ≥50% reduction in seizure frequency (n = 14), seizure freedom (n = 14), and percent reduction in seizure frequency (n = 8). Common humanistic outcomes included quality of life (n = 4), medication adherence (n = 2), sleep-related outcomes (n = 2), and physician and patient global assessments (n = 2). The economic study reported quality-adjusted life years. The median MMAT score was 80 (range: 60-100). Two studies referenced the standard definition of DRE, whereas five studies did not specifically define DRE. Gaps in the literature include limited generalizability, minimal reports in pregnancy, and lack of optimal ASM combinations, among others. Strengths of the evidence include addressing a variety of outcomes. Inconsistent definitions of DRE, small sample sizes, and heterogeneity among studies limit the ability to draw meaningful conclusions. Optimal combinations of ASMs for rational polytherapy for DRE is unclear.

Analysis of Expert Feedback to Determine Intellectual Standards for Student Pharmacist Clinical Reasoning Development.

Objectives. Clinical reasoning (CR) is one of the most important skills for pharmacy learners. Feedback has been proposed as a pedagogy to improve CR skills; however, essential components of CR have yet to be determined within pharmacy education. This study sought to streamline feedback to align with the Pharmacists' Patient Care Process (PPCP).Methods. The investigators used deidentified clinical reasoning "Keep," "Start," or "Stop" (KSS) feedback comments from student-written CR "think-aloud" sessions with pharmacy students in their third professional year. Sections were mapped to the PPCP and were coded by 2 independent investigators according to proposed essential components of CR, using an adapted grounded-theory approach. Investigators could inductively add codes after conferring with the other. Coded feedback was analyzed using a summative content approach. Intercoder reliability was calculated via Holsti index.Results. Five essential components of CR were identified after analysis of 635 KSS comments. The 5 essential components of CR were coded 1178 times. "Accurate," "Concise," "Specific," and "Thorough" were identified a priori, while "Connected" was discovered during feedback comment review. Literature analysis added supporting data to these results through the Paul-Elder Critical Thinking Framework. To maintain consistency in language, these essential components will be referred to as "intellectual standards" moving forward.Conclusion. This novel study successfully identified 5 key intellectual standards of CR. These intellectual standards provide a framework for pharmacy educators to focus feedback to improve student CR. Future research of other intellectual standards pertinent to experiential education is imperative.

Epidemiology and injectable antiseizure medication treatment patterns of seizure patients treated in United States hospitals.

Objective: This study aimed to examine the epidemiology of seizures, clinical outcomes, and antiseizure medication treatment patterns among seizure patients treated in United States hospitals. Design: A retrospective cross-sectional study was conducted using data from a large geographically diverse hospital discharge database. Setting: 860 acute care hospitals in the United States. Participants: Patients aged ≥18 years with an outpatient emergency department or inpatient visit between 1 July 2016-31 December 2019 were included. Intervention: None. Main outcomes and measures: Key outcomes included prevalence of seizure, seizure type, admission point of origin, intensive care unit admission, discharge status, and injectable antiseizure medication utilization. Seizures were identified by the International Classification of Disease, Tenth Revision, Clinical Modification diagnosis codes. Results: Among 36,598,627 unique emergency department outpatients (72,372,464 outpatient visits) and 16,543,592 unique inpatients (24,923,489 inpatient admissions) analyzed, seizure was present in 2.1% of outpatients (1.87% of outpatient visits) and 4.9% of inpatients (4.8% of inpatient admissions). In overall seizure patients, 49.1% were unclassified, 4.4% had generalized onset, 2.9% had focal onset, and 42.8% were categorized as other (including 38.5% with convulsion). Among seizure-associated inpatient admissions, <1% were transferred directly from skilled nursing facility or other long-term care facilities but 22.7% were discharged to such facilities. Nearly a third (31%) of all inpatients were admitted to ICU. About 88.3% of patients with injectable ASM use had monotherapy, 4.6% had polytherapy with 1 day or multiple non-consecutive days of overlap, and 7.0% had polytherapy with ≥2 consecutive days of overlap. The percentage of patients with no step down to any oral ASM ranged between 34.0-57.0%. Conclusions: Seizures affect a substantial number of hospital-based emergency department outpatient and inpatient encounters and are associated with poor clinical outcomes and significant healthcare burden. Concomitant use of injectable ASMs is uncommon and a high percentage of IV ASM users with a diagnosis of seizure had no step down to oral therapy. Relevance: The study findings may inform clinicians and hospital decision makers about current clinical practice and burden of seizures and identify areas to improve overall outcomes for patients with seizures.

Intravenous Brivaracetam in the Management of Acute Seizures in the Hospital Setting: A Scoping Review.

BACKGROUND: Clinical considerations for drug treatment of acute seizures involve variables such as safety, tolerability, drug-drug interactions, dosage, route of administration, and alterations in pharmacokinetics because of critical illness. Therapy options that are easily and quickly administered without dilution, well tolerated, and effective are needed for the treatment of acute seizures. The objective of this review is to focus on the clinical considerations relating to the use of intravenous brivaracetam (IV BRV) for the treatment of acute seizures in the hospital, focusing on critically ill patients. METHODS: This was a scoping literature review of PubMed from inception to April 13, 2021, and search of the American Academy of Neurology (AAN) 2021 Annual Meeting website for English language publications/conference abstracts reporting the results of IV BRV use in hospitalized patients, particularly in the critical care setting. Outcomes of interest relating to the clinical pharmacology, safety, tolerability, efficacy, and effectiveness of IV BRV were reviewed and are discussed. RESULTS: Twelve studies were included for analysis. One study showed that plasma concentrations of IV BRV 15 min after the first dose were similar between patients receiving IV BRV as bolus or infusion. IV BRV was generally well tolerated in patients with acute seizures in the hospital setting, with a low incidence of individual TEAEs classified as behavioral disorders. IV BRV demonstrated efficacy and effectiveness and had a rapid onset, with clinical and electrophysiological improvement in seizures observed within minutes. Although outside of the approved label, findings from several studies suggest that IV BRV reduces seizures and is generally well tolerated in patients with status epilepticus. CONCLUSIONS: IV BRV shows effectiveness, and is generally well tolerated in the management of acute seizures in hospitalized patients where rapid administration is needed, representing a clinically relevant antiseizure medication for potential use in the critical care setting.

Augmented Renal Clearance: An Under-Recognized Phenomenon Associated With COVID-19.

Augmented renal clearance (ARC) is a phenomenon that has been described mainly in critically ill patients and is characterized by increased creatinine clearance and elimination of renally cleared medications that could place patients at risk of therapeutic failure. The COVID-19 pandemic has led to an overwhelming number of ICU admissions with many reports of the impact of COVID-19 on the kidney. This report aims to increase clinician awareness of, and risk factors for ARC in patients with COVID-19, especially in comparison to other critical illnesses.

A Scoping Review of the Pharmacy Curriculum Outcomes Assessment Literature.

Objective. To identify themes, gaps, and sources of evidence from the literature regarding the Pharmacy Curriculum Outcomes Assessment (PCOA) to inform practice and additional areas for research in pharmacy education.Findings. Nineteen articles describing the administration and use of PCOA were identified. Since PCOA was made a curricular requirement by the Accreditation Council of Pharmacy Education in 2016, the focus of literature related to the PCOA has shifted from administration practices (four articles published before 2016 vs two articles published since) to determining models that may predict student performance on the assessment (two vs five articles) or how the examination might be used to predict future performance (one vs seven articles), especially on the North American Pharmacist Licensing Examination. While there is a growing body of literature focused on the PCOA's utility for measuring performance, few variables have been consistently used.Summary. This review found no studies with objectives that aligned with the initial intended use of the PCOA as defined by the National Association of Boards of Pharmacy, which included tracking individual student performance throughout the curriculum, benchmarking programs against other programs, and evaluating whether a program was meeting their desired outcomes. Additionally, no consensus across the Academy was found as to the proper use of the PCOA, and a paucity of literature exists regarding how the PCOA informs schools and colleges about the effectiveness of their curriculum. There is a need for the Academy to establish a uniform application for the PCOA in pharmacy schools, assess the resources that programs need to administer this required assessment, and determine the utility of the PCOA to measure curricular effectiveness and/or student performance.