Medication Safety Events After Acute Myocardial Infarction Among Veterans Treated at VA Versus Non-VA Hospitals.

INTRODUCTION: Fragmentation of health care across systems can contribute to mistakes in prescribing and filling medications among patients treated for myocardial infarction (MI). We sought to compare omissions, duplications, and delays in outpatient medications used for secondary prevention among veterans treated for MI at Veterans Affairs (VA) versus non-VA hospitals. METHODS: We utilized national VA and Centers for Medicare and Medicaid Services data (2012-2018) to identify veterans 65 years or older hospitalized for MI and measured the use of outpatient medications for secondary prevention in the 30 days after MI among those treated at VA versus non-VA hospitals. RESULTS: A total of 118,456 veterans experiencing MI were included; of which 102,209 were hospitalized at non-VA hospitals. An omission in any medication class occurred more frequently among veterans treated at non-VA versus VA hospitals (82.8% vs 67.8%, P < 0.001). In multivariable modeling, the odds of omissions in any medication class were higher among those treated at non-VA versus VA hospitals (odds ratio: 3.04; 95% CI: 2.88-3.20). Duplications occurred more frequently in veterans treated at non-VA versus VA hospitals: 1.9% versus 1.6% had 1 or more for non-VA versus VA hospitals ( P < 0.001). Veterans treated at non-VA hospitals were more likely to have delays of 3 days or more in prescription fills after hospital discharge (88.4% vs 70.6% across all classes, P < 0.001). CONCLUSIONS: Omissions, duplications, and delays in outpatient prescribing of secondary prevention medications were more common among 118,456 veterans treated at non-VA versus VA hospitals for MI. Interventions aimed at improving care transitions and optimizing medication use among veterans treated at non-VA hospitals should be implemented.

Medication adherence to sodium-glucose cotransporter-2 inhibitors versus glucagon-like peptide-1 receptor agonists: A meta-analysis.

AIM: To perform a meta-analysis comparing real-world medication adherence to sodium-glucose cotransporter-2 inhibitors (SGLT2is) versus glucagon-like peptide-1 receptor agonists (GLP-1RAs). MATERIALS AND METHODS: A systematic search of Medline and Embase was conducted through October 2023. To meet inclusion criteria, articles had to be published in full text form and directly compare medication adherence to SGLT2is versus GLP-1RAs in adults. Only studies evaluating real-world data and utilizing the proportion of days covered (PDC) to measure adherence were included. Non-adherence, defined as the proportion of patients with a PDC <80%, was the primary outcome. A subgroup analysis evaluating results among studies conducted in the United States was performed. RESULTS: We identified eight studies evaluating 205 103 patients for inclusion. The most common country from which the data was derived was the United States (n = 5 studies). Upon meta-analysis, we observed no difference in non-adherence (i.e. PDC <80%) to SGLT2is versus GLP-1RAs (relative risk = 0.86; 95% confidence interval = 0.72-1.02). In the analysis, including only US studies, SGLT2i use was associated with a 23% lower risk of non-adherence compared with GLP-1RA use (relative risk = 0.77; 95% confidence interval = 0.72-0.82). CONCLUSIONS: In this meta-analysis of eight studies that included approximately 200 000 patients, there was no difference in adherence to SGLT2is versus GLP-1RAs. However, SGLT2i use was associated with higher adherence when the analysis was limited to US studies.

Evaluation of postoperative delirium in geriatric patients given acetaminophen with and without melatonin: A retrospective cohort study.

OBJECTIVE: Postoperative delirium has many consequences and should be prevented when possible. Non-opioid pain treatments have known delirium prevention benefits, while melatonin has promising prevention data in non-surgical populations. The incidence of postoperative delirium was retrospectively compared in patients prescribed acetaminophen with and without melatonin following orthopedic surgery. METHODS: Retrospective data was analyzed in adults ≥65-years-old who were hospitalized within one health system following an orthopedic procedure. Patients receiving at least acetaminophen 1000 mg/day with and without melatonin 1 mg/day for at least 48 hours perioperatively were included. Patients were excluded if they had prior delirium, an intensive care unit placement >24 hours, or other risk factors for developing delirium to reduce confounders. The primary outcome was delirium incidence or positive CAM-ICU score. Key secondary endpoints included hospital length of stay and 30-day hospital readmission. RESULTS: Two hundred patients were assessed, and 134 patients were included in the analysis (ie, 66 acetaminophen plus melatonin, 68 acetaminophen alone). There was a lower rate of delirium when comparing the combination vs acetaminophen alone (5% vs 25%; P = 0.001). There were no differences in 30-day readmission. Patients taking the combination had a longer length of stay than acetaminophen alone (5 vs 4 days; P = 0.04). CONCLUSION: Geriatric patients taking acetaminophen plus melatonin after orthopedic surgery had a significantly lower risk of delirium than patients receiving acetaminophen alone. Using combination melatonin and acetaminophen before orthopedic surgery is a promising delirium prevention strategy and should be considered in future prospective trials.

Geographic distribution of United States clinical trial sites utilized for guideline changing studies of cholesterol management.

BACKGROUND: This study aimed to evaluate the geographic distribution of United States (US) clinical trial sites utilizedfor guideline changing studies of cholesterol management. METHODS: Randomized trials evaluating pharmacologic interventions for cholesterol treatment and reporting location data (ie, zip code of trial sites) were identified. Location data was abstracted from ClinicalTrials.gov. RESULTS: Half of US counties were over 30 miles from a study site and, social determinants of health were more favorable in counties with versus without clinical trial sites. CONCLUSIONS: Stakeholders such as regulatory bodies andtrial sponsors should incentivize and support infrastructure that would enable a larger number of US counties to be utilized for clinical trial sites. TRIAL REGISTRATION: Not applicable.

Effectiveness and Safety of Twice- Versus Thrice-Daily Subcutaneous Heparin for Venous Thromboembolism Prophylaxis at a Large Academic Medical Center.

BACKGROUND: Dosing variation of subcutaneous unfractionated heparin (UFH) exist for venous thromboembolism prophylaxis (VTEP). OBJECTIVE: The purpose of this study was to compare the safety and effectiveness of thrice-daily (TID) versus twice-daily (BID) administration of UFH during a heparin shortage for VTEP. METHODS: A single-center retrospective analysis was conducted in patients with orders for BID subcutaneous UFH during a heparin shortage from September 1, 2019, to February 4, 2020. These patients were matched to patients with TID subcutaneous UFH orders from January 1, 2019, to May 31, 2019. The primary outcome was the incidence of deep-vein thrombosis or pulmonary embolism confirmed by imaging during hospitalization. The secondary outcome was the incidence of major or clinically relevant nonmajor bleeding events as defined by International Society on Thrombosis and Haemostasis (ISTH) definitions. RESULTS: A total of 277 patients with orders for BID UFH and meeting inclusion criteria were evaluated and matched to patients who received TID UFH. After the exclusion criteria were implemented, 510 patients remained in the TID group. The primary outcome occurred in 4% of patients in the BID group and 3% in the TID group (P = 0.645). Major bleeding or clinically relevant nonmajor bleeding events occurred in 10% of patients in the BID group and 8% in the TID group (P = 0.310). CONCLUSION AND RELEVANCE: There was no difference in effectiveness or safety of TID versus BID subcutaneous UFH for VTEP. During a heparin shortage, transitioning patients to BID UFH for VTEP to conserve supply may be considered.

Risk Factors for Antibiotic Resistant Urinary Pathogens in Patients Discharged From the Emergency Department.

Purpose: Urinary tract infections (UTIs) are one of the most common indications for antimicrobial use in the emergency department (ED). Appropriate empiric selection is crucial to ensure optimal care while limiting broad-spectrum antibiotic use. The primary objective of this study was to evaluate the relationship between patient-specific risk factors and drug resistant urinary pathogens in patients discharged from the ED and followed by Emergency Medicine Pharmacists (EMPs). Methods: This was a single-center, retrospective chart review of adult (≥18 years old) patients with positive urine cultures discharged from the ED. The association between risk factors and pathogen resistance to ≥1 classes of antibiotics was evaluated using multivariate logistic regression. Risk factors included the following: hospitalization within the previous 30 days, intravenous antibiotic use within 90 days, diabetes, clinical atherosclerotic cardiovascular disease, psychiatric disorder, dementia, current antibiotic use for any indication, previous lifetime history of UTIs, indwelling or intermittent catheterization, hemodialysis, previous lifetime history of a urologic procedure, urinary tract abnormality, immunosuppressive disease or medications, current residence in a nursing or rehabilitation facility, and history of a multidrug resistant organism (MDRO). Results: A total of 1018 patients were included. There was an increase in the odds of antibiotic resistance in patients with cystitis and ≥2 risk factors (Odds Ratio [OR] = 1.70, 95% CI = 1.24-2.32). In those with pyelonephritis, there was a non-significant increase in the odds of resistance for those with ≥2 risk factors (OR = 1.83, 95% CI = 0.98-3.42). Patients with pyelonephritis discharged on inappropriate antibiotics were more likely to return to the ED within 30 days (P = .03). Conclusions: For patients with cystitis discharged from the ED, those with ≥2 patient-specific risk factors had significantly increased odds of antibiotic resistance. Patients with pyelonephritis, but not cystitis, who were discharged on inappropriate antibiotics were more likely to return to the ED within 30 days. In conjunction with an EMP culture follow-up program, the identification of risk factors for antimicrobial resistance can be used to design more patient-specific empiric antibiotic selections.

Intravenous insulin for the management of non-emergent hyperglycemia in the emergency department.

PURPOSE: There is currently no consensus regarding the necessity of emergency department (ED) glucose reduction to manage hyperglycemia in patients presenting without a hyperglycemic emergency. Known consequences of intravenous (IV) insulin administration include hypoglycemia, hypokalemia, and increased ED length of stay. The primary objective of this study was to assess the impact of IV regular insulin on glucose reduction and ED length of stay in patients presenting to the ED with non-emergent hyperglycemia. Secondary objectives included the characterization of potential adverse events. METHODS: This was a retrospective, observational study of patients ≥18 years who received IV regular insulin and were discharged from the ED at a large academic Trauma Center. Univariate and multivariable regression analyses were utilized to determine if an association existed between IV insulin administration and blood glucose as well as ED length of stay. RESULTS: A total of 405 patients were included in the analysis. An insulin dose >5 units was associated with a greater reduction in blood glucose (difference = 37.4 mg/dL; p < .001) but no difference in ED length of stay relative to ≤5 units. Furthermore, 7.9% of patients developed hypokalemia and 0.4% developed hypoglycemia. CONCLUSION: The use of >5 units of IV regular insulin for the management of isolated hyperglycemia in the ED was associated with a modest reduction in blood glucose and no difference in ED length of stay compared with those that received ≤5 units. However, use of IV insulin for this purpose resulted in a 7.9% occurrence of hypokalemia.

Medication adherence to injectable glucagon-like peptide-1 (GLP-1) receptor agonists dosed once weekly vs once daily in patients with type 2 diabetes: A meta-analysis.

BACKGROUND: Suboptimal medication adherence has been associated with increased resource utilisation and mortality among patients with type 2 diabetes (T2D). Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are becoming increasingly important in the treatment of T2D. However, medications in this class differ considerably in their dosing frequency, which may impact adherence. We sought to perform a meta-analysis to compare adherence to injectable GLP-1RAs dosed once weekly vs once daily in patients with T2D. METHODS: Medline and Scopus were searched from 1/2005 to 7/2020 using keywords and MeSH terms pertaining to adherence and GLP-1RAs. Studies of adults with T2D were included if they compared adherence (as measured by proportion of days covered [PDC]) to injectable GLP-1RAs dosed once weekly vs once daily. A meta-analysis of non-overlapping studies was performed to evaluate the primary outcome of non-adherence, defined as the proportion of patients with a PDC < 80. RESULTS: A total of 7 studies evaluating 75 159 patients (range: 2886-30 097) with T2D were included. The follow-up periods of included studies ranged from 6 to 12 months. Injectable GLP-1RAs dosed once weekly were either dulaglutide, albiglutide or exenatide extended release; while liraglutide was the injectable once daily agent evaluated in all included studies. Upon meta-analysis, once weekly GLP-1RA dosing was associated with an 11% lower risk of non-adherence compared to once daily dosing (risk ratio = 0.89; 95% confidence interval = 0.83-0.95; I2  = 89%). CONCLUSION: Once weekly dosing of injectable GLP-1RAs was associated with better adherence vs once daily dosing among patients with T2D. These findings coupled with the known detrimental consequences of non-adherence suggest that dosing frequency is an important factor to consider when selecting a GLP-1RA.

Development of a Pharmacy Residency Research Certificate Program.

Background: Similar to teaching certificate programs, which have been incorporated in many pharmacy residencies to improve teaching skills, resident research certificate programs could provide residents with more exposure to biostatistics and research design. However, few research certificate programs have been described. Objective: To assess the impact of a research certificate program on residents' attitude toward, confidence in, and knowledge of research. Methods: A resident research certificate program was created for the 2018-2019 residency class at our institution, which included 33 pharmacy residents (15 postgraduate year-1 [PGY1] and 18 PGY2 residents). The program consisted of 7 sessions aimed at providing residents with research training. To earn a certificate, participants were required to attend 6 or more sessions and achieve a score greater than or equal to 70% on a postassessment. An optional questionnaire assessing attitude, confidence, and knowledge was also administered at baseline and following the certificate program. Results: Of the 33 residents participating in the research certificate program, 21 (9 PGY1 and 12 PGY2) residents completed both the baseline and follow-up questionnaire and were included in the analysis. All items assessing attitude and 3 of 6 items assessing confidence improved significantly following the certificate program when compared to baseline (P < .05 for all). Median knowledge scores were no different on the baseline versus follow-up questionnaire (P = .54). Conclusions: After completing a research certificate program, resident knowledge scores did not differ from baseline, but attitudes toward research and confidence appeared to improve. Research certificate programs could be an avenue for providing pharmacy residents with increased exposure to and comfort with biostatistics and research design.

Costs and factors associated with heart failure following kidney transplantation - a single-center retrospective cohort study.

The number of adults with heart failure (HF) will increase by ~50% between 2012 and 2030. Among kidney transplant recipients, HF accounts for 16% of all post-transplant admissions. We describe the burden of HF and predictors of healthcare utilization following kidney transplantation. We retrospectively identified adults who underwent kidney transplantation at our institution (01/2007-12/2017). Data were acquired from electronic health records, with healthcare utilization obtained from a statewide database. The HF incidence rate and prevalence were estimated for each year, total charges for HF and non-HF patients were compared, and logistic regression was employed for a 3-year predictive model of healthcare utilization associated with HF. Among 1731 kidney transplant recipients, the post-transplant HF incidence rate ranged from 1.91 (year 3) to 6.80 (year 10) per 100 person-years, while the prevalence increased from 31.7% (year 1) to 48.1% (year 10). Median charges were $75 837 (HF) compared to $42 940 (non-HF) per person-year (P < 0.001). Pretransplant HF [odds ratio (OR) = 3.12] and an eGFR < 45 (OR = 4.73) were the strongest predictors of HF encounters (P < 0.05 for both). We observed a high and increasing prevalence of HF, which was associated with twice the costs. Kidney transplant recipients would benefit from interventions aimed at mitigating HF risk factors.