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.

Clinical Pharmacist Intervention to Engage Older Adults in Reducing Use of Alprazolam.

OBJECTIVE: To assess whether a letter explaining the risks of alprazolam can engage older adults to call a clinical pharmacist (CP) to initiate reduction in alprazolam use. DESIGN: Randomized, controlled study. SETTING: Integrated health care delivery system. PATIENTS: Patients 65 years of age and older who resided at home, had a current supply of alprazolam as of December 15, 2016, and had four outpatient dispensings of alprazolam during the previous 12 months. INTERVENTION: Patients were randomized to receive an educational outreach regarding alprazolam use reduction via a mailed letter (intervention group) or receive usual care (control group). Intervention patients/caregivers were requested to call the CP to discuss reduction of alprazolam use. For intervention patients who called and consented to participate, alternative treatment options were discussed on a case-by-case basis. MAIN OUTCOME MEASURES: Composite rate of 1) no alprazolam dispensing, 2) an alprazolam dose reduction, or 3) interchange to an alternative medication during the six-month follow-up. RESULTS: 153 and 173 patients were and were not, respectively, sent a letter. The mean age was 73 years and patients primarily were female. Thirty (19.6%) intervention patients called the CP. The composite rate was equivalent between the intervention (34.0%) and control (35.3%) groups (P = 0.822). In subanalyses, the composite rate was higher among intervention patients who did vs. those who did not call the CP (77.8% vs. 27.6%; P < 0.001). CONCLUSION: A low-cost patient educational outreach coupled with CP care efficiently engaged older adults in benzodiazepine use reduction process; however, alprazolam continues to be a challenging medication for patients to discontinue.

Effectiveness of Best Practice Alerts for Potentially Inappropriate Medication Orders in Older Adults in the Ambulatory Setting.

INTRODUCTION: Information is limited about the effectiveness of best practice alerts (BPAs) for potentially inappropriate medications (PIMs) in improving clinical outcomes in older adults. OBJECTIVE: To assess clinical outcomes of 11 BPAs for PIMs in older adults in the ambulatory setting. METHODS: A retrospective cohort study was conducted at an integrated health care delivery system with computerized provider order entry. Patients aged 65 years and older were included if they had a BPA triggered when a prescriber attempted to order a sedating PIM in the ambulatory setting. Patients were categorized into dispensed and nondispensed groups if they did and did not, respectively, have the study PIM for which the BPA was triggered dispensed within 30 days of the alert. Rates of fall, fracture, or other injury and cognitive impairment were measured during 180-day follow-up. RESULTS: A total of 2704 patients were included: 1373 (50.8%) and 1331 (49.2%) in the dispensed and nondispensed groups, respectively. The dispensed group had a lower unadjusted rate of fall/fracture/injury (3.4% vs 5.3%, p = 0.019), but this difference was attenuated with multivariable adjustment (adjusted odds ratio = 0.77, 95% confidence interval = 0.51-1.13). There was no difference in the rate of cognitive impairment between groups (4.6% vs 4.4%, adjusted odds ratio = 1.40, 95% confidence interval = 0.95-2.05). CONCLUSION: No association was identified between PIM dispensing after a prescriber was alerted with a BPA and reduced rates of falls/fractures/injuries and cognitive impairment.

Perceived value of leadership experiences in a postgraduate year 2 ambulatory care pharmacy residency.

PURPOSE: Leadership experiences taught within the Kaiser Permanente Colorado (KPCO) postgraduate year 2 (PGY2) ambulatory care pharmacy residency program were evaluated. METHODS: KPCO leadership training incorporated 6 mandatory leadership sessions and offered a 6-week elective rotation. In this qualitative study, an 18-item semistructured interview guide was developed, tested, and administered telephonically to former KPCO PGY2 residents who had been in clinical practice for a minimum of 1 year. The primary outcome was the perceived value of the leadership experiences, and perceived gaps was the secondary outcome. Qualitative analysis was performed for open-ended questions. Responses were coded and key phrases were highlighted to illustrate major concepts and themes. RESULTS: Of 34 former residents, 29 (85%) completed the interview. Ninety-seven percent of participants reported that the leadership experiences provided value in their professional career; 89% reported value in their personal development. The 3 most common themes of perceived value that emerged from the interviews were exposure to leadership, managing and leading self and others, and clinical service development. Identified gaps included further exposure to senior leadership within the organization and a better understanding of the national pharmacy landscape. CONCLUSION: Leadership experiences during the PGY2 ambulatory care pharmacy residency at KPCO were perceived positively by former residents on a professional and a personal level.

Opioid Use for Pain Management After Implementation of a Medicaid Short-Acting Opioid Quantity Limit.

BACKGROUND: The United States is currently experiencing an opioid abuse epidemic. Many policies and programs have been implemented at local, state, and national levels in an attempt to decrease prescription opioid addiction and overdose. On August 1, 2014, Colorado Medicaid implemented a policy change that limited the quantity of short-acting opioids (SAOs) that could be filled through the Medicaid benefit to no more than 4 tablets per day, or 120 tablets in 30 days. OBJECTIVE: To compare mean total daily dose (TDD) of opioids purchased by Kaiser Permanente Colorado (KPCO) Medicaid patients before and after implementation of the Medicaid SAO quantity limit. METHODS: This investigation used a pre/post study design to compare opioid use in Medicaid-eligible patients during the 90 days before implementation of the Medicaid quantity limit on August 1, 2014, and 90 days after full implementation of the change on December 31, 2014. The study was conducted at KPCO, an integrated care delivery system providing medical care for approximately 615,000 patients, of which over 54,000 are Medicaid members. Electronic medical and pharmacy records were used to identify patients and assess medication use. RESULTS: There was a small difference in opioid use in the population of Medicaid opioid users as evidenced by the median TDD of oral morphine equivalents (OME) purchased decreasing from 6.8 mg (IQR = 2.2-25.8) in the pre-implementation period to 6.6 mg (IQR = 1.7-24.0) in the postimplementation period (P = 0.027). The proportion of patients purchasing more than 120 mg OME per day and the proportion of patients purchasing long-acting opioids (LAOs) did not change significantly from the pre- to postimplementation period (OME > 120 of 4.2% vs. 3.6%, respectively, P = 0.290; LAO use of 12.9% vs. 13.6%, respectively, P = 0.465). CONCLUSIONS: This study found a statistically significant 3% decrease of 0.2 mg OME per day in the primary study population. A 24% reduction of 10 mg OME per day before and after implementation of the Medicaid SAO quantity limit was found in those patients identified as exceeding the Medicaid SAO quantity limit at baseline. These patients tended to be purchasing low to moderate total daily doses of opioids at baseline. DISCLOSURES: Internal funding was provided by the Department of Pharmacy at Kaiser Permanente Colorado. There are no external funding sources to disclose. Riggs, Milchak, Patel, and Heilmann are employed by Kaiser Permanente Colorado. The authors report no other potential conflicts of interest. Study concept and design were contributed by Riggs, Heilmann, and Billups, along with the other authors. Billups collected the data, and data interpretation was performed by Riggs, Milchak, and Flores, with assistance from the other authors. The manuscript was written primarily by Riggs, along with Flores, and revised by Billups, Milchak, Patel, and Heilmann.

Challenges to publishing pharmacy resident research projects from the perspectives of residency program directors and residents.

OBJECTIVE: To identify barriers to completing and publishing pharmacy residency research projects from the perspective of program directors and former residents. METHODS: This was a cross-sectional survey of pharmacy residency program directors and former post-graduate year one and two residents. Directors of pharmacy residency programs whose residents present their projects at the Western States Conference (n=216) were invited to complete an online survey and asked to forward the survey to former residents of their program in 2009, 2010, or 2011. The survey focused on four broad areas: 1) demographic characteristics of the residency programs, directors, and residents; 2) perceived value of the research project; 3) perceived barriers with various stages of research; and 4) self-identified barriers to successful research project completion and publication. RESULTS: A total of 32 program directors and 98 residents completed the survey. The minority of programs offered formal residency research training. Both groups reported value in the research project as part of residency training. Significantly more directors reported obtaining institutional review board approval and working through the publication process as barriers to the research project (46.7% vs. 22.6% and 73.3% vs. 43.0%, respectively p<0.05) while residents were more likely to report collecting and analyzing the data as barriers (34.4% vs. 13.3% and 39.8% vs. 20.0%, respectively, p<0.05). Both groups self-identified time constraints and limitations in study design or quality of the study as barriers. However, while program directors also indicated lack of resident motivation (65.5%), residents reported lack of mentorship or program structural issues (43.3%). CONCLUSIONS: Overall, while both groups found value in the residency research projects, there were barriers identified by both groups. The results of this study may provide areas of opportunity for improving the quality and publication rates of resident research projects.

Publication rates of abstracts presented by pharmacy residents at the Western States Conference.

PURPOSE: Investigators report the results of a study to determine the proportion of residency projects presented as abstracts at a regional residency conference that were subsequently published as full-length articles. SUMMARY: Using every third item listed in the abstract booklets from the Western States Conference for the years 1995, 2000, and 2005, a search of MEDLINE and EMBASE for journal citations indicating publication of the corresponding residency projects was conducted; the searches covered a period including and extending five years beyond the year of abstract presentation at the conference. Of the total of 270 abstracts evaluated, 17 were expanded to full-length articles and published within the search time frame. The average time to publication (mean ± S.D.) was 24 ± 10 months. The publication rates associated with abstracts presented at the 1995, 2000, and 2005 conferences were 4.2%, 5.2%, and 8.2%, respectively. All published articles appeared in peer-reviewed journals, with more than half (54.2%) in pharmacy journals. The majority of residency projects published were retrospective and prospective cohort studies. In most cases (58.8%), the resident was listed as the first author of the published journal article. CONCLUSION: The overall publication rate of abstracts presented at a regional residency conference in 1995, 2000, and 2005 was 6.3%, with an increase in the rate over those years.

Challenges to publishing pharmacy resident research projects from the perspectives of residency program directors and residents / El reto de publicar proyectos de investigación de los residentes en farmacia desde la perspectiva de loa directores y residentes de programas de residencia

Objective: To identify barriers to completing and publishing pharmacy residency research projects from the perspective of program directors and former residents. Methods: This was a cross-sectional survey of pharmacy residency program directors and former post-graduate year one and two residents. Directors of pharmacy residency programs whose residents present their projects at the Western States Conference (n=216) were invited to complete an online survey and asked to forward the survey to former residents of their program in 2009, 2010, or 2011. The survey focused on four broad areas: 1) demographic characteristics of the residency programs, directors, and residents; 2) perceived value of the research project; 3) perceived barriers with various stages of research; and 4) selfidentified barriers to successful research project completion and publication. Results: A total of 32 program directors and 98 residents completed the survey. The minority of programs offered formal residency research training. Both groups reported value in the research project as part of residency training. Significantly more directors reported obtaining institutional review board approval and working through the publication process as barriers to the research project (46.7% vs. 22.6% and 73.3% vs. 43.0%, respectively p<0.05) while residents were more likely to report collecting and analyzing the data as barriers (34.4% vs. 13.3% and 39.8% vs. 20.0%, respectively, p<0.05). Both groups self-identified time constraints and limitations in study design or quality of the study as barriers. However, while program directors also indicated lack of resident motivation (65.5%), residents reported lack of mentorship or program structural issues (43.3%). Conclusion: Overall, while both groups found value in the residency research projects, there were barriers identified by both groups. The results of this study may provide areas of opportunity for improving the quality and publication rates of resident research projects (AU)

Objetivo: Identificar las barreras para completar y publicar los proyectos de investigación de la residencia en farmacia desde la perspectiva de los directores de programas y de los antiguos residentes. Métodos: Este fue un estudio transversal de directores de programa de residencia y antiguos residentes post-graduados de año 1 y 2. Se invitó a completar un cuestionario online a los directores de programas de residencia cuyos residentes presentaron proyectos en la Western States Conference (n = 216) y se les pidió que pasasen el cuestionario a los antiguos residentes de sus programas de los años 2009, 2010 o 2011. El cuestionario se centraba en cuatro grandes áreas: 1) características demográficas de los programas de residencia, los directores y los residentes; 2) valor percibido del proyecto de investigación; 3) barreras percibidas en los diferentes pasos de la investigación; y 4) barreras auto-identificadas para la conclusión exitosa y publicación del proyecto de investigación. Resultados: Un total de 32 directores de programas y 98 residentes completaron el cuestionario. Una minoría de programas ofrecía formación formal en investigación. Ambos grupos encontraron valor al proyecto de investigación, como parte de la formación de la residencia. Significativamente más directores comunicó que obtener la aprobación de la comisión de investigación de la institución y el trabajo de la publicación eran barreras para el proyecto de investigación (46.7% vs. 22.6% y 73.3% vs. 43.0%, respectivamente p<0.05), mientras que los residentes reportaban con más probabilidad como barreras la recogida de datos y el análisis como barreras (34.4% vs. 13.3% y 39.8% vs. 20.0%, respectivamente, p<0.05). Ambos grupos auto-identifico la falta de tiempo y las limitaciones en la calidad del diseño del estudio o su calidad como barreras. Sin embargo, mientras que los directores también indicaban la falta de motivación de los residentes (65,5%), los residentes reportaron la falta de tutela o problemas estructurales del programa (43,3%). Conclusión: En general, mientras que los dos grupos encontraron valor en los proyectos de investigación en la residencia, había barreras identificadas por los dos grupos. Los resultados de este estudio pueden proporcionar áreas de posible mejora de la calidad y las tasas de publicación de los proyectos de investigación delos residentes (AU)

A descriptive evaluation of routine complete blood count monitoring in patients receiving anticoagulation therapy.

CONTEXT: The most prevalent side effect associated with warfarin therapy is bleeding. Routine monitoring of laboratory tests, such as complete blood counts (CBC), may provide theoretical benefit in this patient population as a means of detecting occult bleeding through hemoglobin values that decrease compared to baseline. OBJECTIVE: To describe the clinical outcomes associated with routine CBC monitoring in a large, diverse sample of anticoagulated patients. DESIGN: Forty-seven month retrospective, observational study. SETTING: Large non-profit, group-model health maintenance organization with a centralized clinical pharmacy anticoagulation service that routinely orders baseline CBCs on all patients enrolled in the service with follow up CBCs repeated at 3 months and yearly thereafter. PATIENTS: Patients continuously enrolled in the anticoagulation service for warfarin therapy monitoring for at least one year between January 1, 2000 and December 5, 2003. MAIN OUTCOME MEASURES: Medical records were reviewed to determine clinical outcomes associated with hemoglobin decreases of > or =2.0 gm/dL. Clinical outcomes included both overt and occult bleeding events and a determination of major or minor bleeding in these events. RESULTS: Of the 4033 patients included in the analysis, 578 (14.3%) experienced at least one decrease in hemoglobin > or =2.0 gm/dL. Occult bleeding was confirmed in 121 patients (3.0% of all patients monitored) with a decrease of hemoglobin > or =2.0 gm/dL but only 13 of these patients (0.3% of all patients monitored) experienced major bleeding. The annual detection rate of occult bleeding through routine CBC monitoring was 0.8%. CONCLUSIONS: Although routine CBC monitoring provides some utility in detecting occult bleeding, the yield of clinically important decreases in hemoglobin detected was low. For most anticoagulated patients, routine CBC monitoring appears to be clinically unnecessary.