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1.
J Am Med Inform Assoc ; 29(11): 1859-1869, 2022 10 07.
Article in English | MEDLINE | ID: mdl-35927972

ABSTRACT

OBJECTIVE: To determine the extent of implementation, completeness, and accuracy of Structured and Codified SIG (S&C SIG) directions on electronic prescriptions (e-prescriptions). MATERIALS AND METHODS: A retrospective analysis of a random sample of 3.8 million e-prescriptions sent from electronic prescribing (e-prescribing) software to outpatient pharmacies in the United States between 2019 and 2021. Natural language processing was used to identify direction components, including action verb, dose, frequency, route, duration, and indication from free-text directions and were compared to the S&C SIG format. Inductive qualitative analysis of S&C direction identified error types and frequencies for each component. RESULTS: Implementation of the S&C SIG format in e-prescribing software resulted in 32.4% of e-prescriptions transmitted with these standardized directions. Directions using the S&C SIG format contained a greater percentage of each direction component compared to free-text directions, except for the indication component. Structured and codified directions contained quality issues in 10.3% of cases. DISCUSSION: Expanding adoption of more diverse direction terminology for the S&C SIG formats can improve the coverage of directions using the S&C SIG format. Building out e-prescribing software interfaces to include more direction components can improve patient medication use and safety. Quality improvement efforts, such as improving the design of e-prescribing software and auditing for discrepancies, are needed to identify and eliminate implementation-related issues with direction information from the S&C SIG format so that e-prescription directions are always accurately represented. CONCLUSION: Although directions using the S&C SIG format may result in more complete directions, greater adoption of the format and best practices for preventing its incorrect use are necessary.


Subject(s)
Electronic Prescribing , Pharmacies , Drug Prescriptions , Humans , Medication Errors/prevention & control , Natural Language Processing , Retrospective Studies , United States
2.
Curr Pharm Teach Learn ; 14(6): 729-736, 2022 06.
Article in English | MEDLINE | ID: mdl-35809902

ABSTRACT

INTRODUCTION: Mental illness is extremely prevalent, yet many pharmacy students get little exposure to mental health training. The majority of studies assessing mental health training and Mental Health First Aid (MHFA) are focused on undergraduate programs. This study critically evaluated the impact of MHFA on pharmacy students' knowledge, confidence, and perceptions as they pertain to mental health, as well as the appropriateness of MHFA as a training course for pharmacy students. METHODS: There were two parts to this study: (1) a pre-/post-survey that assessed the impact of MHFA on pharmacy students as well as the appropriateness of MHFA for students at this level of education and training and (2) a college-wide survey that assessed the impact of mental health training of any type on confidence in mental health-related skills and the perceived usefulness of mental health training for pharmacy students. RESULTS: Participants of the MHFA portion of the study demonstrated a statistically significant improvement in knowledge of mental health-related topics and confidence to interact with someone experiencing mental illness (P < .05) after completing the MHFA course. Perceptions of mental illness did not improve significantly following a single training. The college-wide survey (N = 275) revealed a significantly higher confidence level among students who had previously completed any mental health training program compared to those who had not (P < .05). CONCLUSIONS: MHFA training significantly increased students' knowledge and confidence in approaching and interacting with persons experiencing mental illness.


Subject(s)
Education, Pharmacy , Mental Disorders , Students, Pharmacy , Humans , Mental Disorders/psychology , Mental Health , Needs Assessment , Students, Pharmacy/psychology
3.
J Am Med Inform Assoc ; 29(9): 1471-1479, 2022 08 16.
Article in English | MEDLINE | ID: mdl-35773948

ABSTRACT

OBJECTIVE: To determine the variability of ingredient, strength, and dose form information from drug product descriptions in real-world electronic prescription (e-prescription) data. MATERIALS AND METHODS: A sample of 10 399 324 e-prescriptions from 2019 to 2021 were obtained. Drug product descriptions were analyzed with a named entity extraction model and National Drug Codes (NDCs) were used to get RxNorm Concept Unique Identifiers (RxCUI) via RxNorm. The number of drug product description variants for each RxCUI was determined. Variants identified were compared to RxNorm to determine the extent of matching terminology used. RESULTS: A total of 353 002 unique pairs of drug product descriptions and NDCs were analyzed. The median (1st-3rd quartile) number of variants extracted for each standardized expression in RxNorm, was 3 (2-7) for ingredients, 4 (2-8) for strength, and 41 (11-122) for dosage forms. Of the pairs, 42.35% of ingredients (n = 328 032), 51.23% of strengths (n = 321 706), and 10.60% of dose forms (n = 326 653) used matching terminology, while 16.31%, 24.85%, and 13.05% contained nonmatching terminology, respectively. DISCUSSION: A wide variety of drug product descriptions makes it difficult to determine whether 2 drug product descriptions describe the same drug product (eg, using abbreviations to describe an active ingredient or using different units to represent a concentration). This results in patient safety risks that lead to incorrect drug products being ordered, dispensed, and used by patients. Implementation and use of standardized terminology may reduce these risks. CONCLUSION: Drug product descriptions on real-world e-prescriptions exhibit large variation resulting in unnecessary ambiguity and potential patient safety risks.


Subject(s)
Electronic Prescribing , RxNorm , Drug Prescriptions , Humans , Vocabulary, Controlled
4.
J Pain Palliat Care Pharmacother ; 36(2): 95-102, 2022 Jun.
Article in English | MEDLINE | ID: mdl-35652581

ABSTRACT

To improve the management of cancer related pain, the National Comprehensive Cancer Network (NCCN) publishes the Adult Cancer Pain guideline on an annual basis. However, a large majority of oncology patients still report inadequate pain control. Single-center, retrospective cohort study of adult patients admitted for uncontrolled pain or pain crisis between 3/1/19 and 06/30/20 were assigned to cohorts of either adherent or non-adherent to NCCN guideline recommendations for management of pain crises based on their initial opioid orders. Patients must have reported a pain score >/= 4 and received at least one dose of opioids within 24 hours upon admission. The length of stay (LOS), pain scores, and naloxone administration were compared between both groups. Patients in the adherent group had a shorter median LOS (3.7 days [range: 1 to 18.93] vs 5.4 days [range: 1.45 to 19.64 days], p = 0.04). Patients that received lower doses than recommended had longer LOS compared to adherent group (6.1 vs. 3.7 days; p = 0.009). When adjusted for confounders, this significance did not remain. The lowest reported pain score within 24 hours of admission was lower in the adherent group (median 3 vs 4, p = 0.04). Predictors of LOS included opioid tolerance and a pain or palliative care consult. Adherence to NCCN guidelines for acute pain crisis management in adult patients with cancer remains poor. Patients who received guideline adherent initial opioid regimens demonstrated a trend toward a shorter LOS. Opioid-tolerant patient outcomes remain inadequate; appropriate pain management for these patients need to improve.


Subject(s)
Cancer Pain , Neoplasms , Adult , Analgesics, Opioid/therapeutic use , Cancer Pain/drug therapy , Drug Tolerance , Guideline Adherence , Humans , Length of Stay , Neoplasms/complications , Pain/drug therapy , Pain/etiology , Retrospective Studies
5.
J Am Pharm Assoc (2003) ; 62(3): 834-839.e1, 2022.
Article in English | MEDLINE | ID: mdl-34844885

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has drastically disrupted primary health care and pharmacy services, posing a challenge in people with chronic diseases who receive routine care. Currently, there exists limited literature on the indirect impact of the pandemic on chronic disease management, particularly related to accessibility to medications and health care resources. OBJECTIVES: To determine the prevalence of medical- and medication-related problems reported by people with chronic diseases during the pandemic. The secondary objective was to identify the barriers and contributing factors related to these medical- and medication-related problems. METHODS: The anonymous and voluntary, Web-based survey was filled out by interested adult respondents with chronic disease(s) across Michigan between September 1, 2020, and January 1, 2021. The primary outcome included self-reported medical- and medication-related problems during the pandemic. Secondary outcomes included potential risk factors for medical- and medication-related problems. Descriptive statistics was used to describe respondents' demographics, chronic disease characteristics, medication adherence, medical- and medication-related problems, and COVID-19-related factors. The multivariable Firth logistic regression was used to analyze correlations between potential risk factors associated with medical- and medication-related problems. RESULTS: A total of 1103 respondents completed the survey and were included in the analysis. Approximately, 51% of respondents reported a medication-related problem with 19.6% reported problems obtaining medication(s) and 31.7% reported forgetting or not taking their medication(s). The top reason for problems obtaining medication(s) was doctor's office being closed for in-person visit(s). In addition, of all responses, more than half reported worsening symptoms of their chronic disease(s) during the pandemic especially with psychiatric disorders (79.5%) and inflammatory bowel disease (60%). Respondents with a significantly higher risk of medication-related problems included those who were younger, were female, and had psychiatric disorder(s), diabetes, arthritis, or lupus, and respondents with a significantly higher risk of medical-related problems included those with multiple chronic diseases, psychiatric disorder(s), and heart failure. CONCLUSION: Understanding the consequences of the pandemic, such as medical- and medication-related problems, in this population is critical to improving health care accessibility and resources through potential outpatient pharmacy services during this and future pandemics.


Subject(s)
COVID-19 , Pandemics , Adult , Chronic Disease , Female , Humans , Male , Medication Adherence , Surveys and Questionnaires
6.
Am J Pharm Educ ; 86(7): 8752, 2022 10.
Article in English | MEDLINE | ID: mdl-34753713

ABSTRACT

Objective. To assess empathy longitudinally in student pharmacists and describe how it changes during their four years of pharmacy education.Methods. The Jefferson Scale of Empathy Health Professions Student version (JSE-HPS) was completed by a cohort of student pharmacists at the beginning and end of their first year of pharmacy school (P1), then at the end of their second, third, and fourth years of pharmacy school (P2, P3, P4). Demographic data and information about students' previous pharmacy work experience and experience interacting with patients were also collected.Results. Student pharmacists' empathy scores were relatively high at the beginning of P1, comparable to scores reported for medical and other health professions students. Empathy scores declined over the first two years of the pharmacy curriculum but increased during both P3 and P4, recovering to the level observed at the beginning of P1. Factor analysis identified three factors, namely "perspective taking," "compassionate care," and "walking in a patient's shoes" that accounted for 26%, 19%, and 7% of the variance, respectively, and supported the construct validity of the JSE-HPS.Conclusion. Student pharmacists' empathy decreased during the early, primarily didactic years of the pharmacy curriculum but increased during the latter years that emphasize clinical experiences.


Subject(s)
Education, Pharmacy , Students, Pharmacy , Education, Pharmacy/methods , Empathy , Factor Analysis, Statistical , Humans , Pharmacists
7.
J Am Pharm Assoc (2003) ; 62(2): 580-587.e1, 2022.
Article in English | MEDLINE | ID: mdl-34696978

ABSTRACT

BACKGROUND: Primary care may offer innovations in delivering comprehensive medication reviews (CMRs). OBJECTIVES: This study aimed to (1) describe innovations to improve delivery and impact of CMR, (2) quantify CMR completion rates and patient satisfaction, and (3) characterize medication changes and impact on medication costs. PRACTICE DESCRIPTION: Board-certified ambulatory care pharmacists with collaborative practice agreements embedded in primary care provided CMRs in 5 clinics for eligible university prescription plan retirees. PRACTICE INNOVATION: Innovations included (1) physician review of potential CMR recipient list, (2) use of trained student pharmacists to recruit and set up CMR visits, (3) use of clinical information in a standardized CMR 2-visit approach by embedded pharmacists, and (4) enrollment into disease management programs or referrals to other providers. EVALUATION METHODS: Data from a retrospective cohort were collected. The CMR completion rate and therapeutic interventions were documented. Prescription fill data were available for 6 months before and after the CMR. An anonymous survey assessed patient satisfaction. Frequencies and descriptive statistics characterized completion rate, interventions, and patient satisfaction. The median cost to the plan of deleted versus added medications and per member per month total drug costs before and after the CMR were compared. RESULTS: Among 729 beneficiaries screened, 489 were eligible and 223 (46%) received a CMR. There were 388 medication interventions: the most common intervention was to delete medications (41.0%). One in 4 was enrolled into the pharmacists' disease management programs. Individuals reported 4.68 (SD 0.67) of 5 for helpfulness of the CMR. The ratio of median costs for medication deletions versus additions was $1.46 vs. $1.00. CONCLUSION: Innovations to deliver CMRs capitalized on well-established physician-pharmacist relationships and nonpharmacist personnel to recruit and prepare the intake. Almost half of eligible beneficiaries received a CMR, and the CMRs were impactful for patients and payers. The most prevalent intervention was to discontinue medications for efficacy reasons.


Subject(s)
Medicare Part D , Pharmacists , Humans , Medication Review , Medication Therapy Management , Pharmaceutical Preparations , Primary Health Care , Retrospective Studies , United States
8.
Open Forum Infect Dis ; 8(7): ofab268, 2021 Jul.
Article in English | MEDLINE | ID: mdl-34291118

ABSTRACT

Monoclonal antibodies targeting the receptor binding domain (RBD) of severe acute respiratory syndrome coronavirus 2 spike protein are important outpatient treatment options in coronavirus disease 2019 to mitigate progression of disease and prevent hospitalization. The impact of different RBD mutations on the efficacy of the available monoclonal antibodies and processes for incorporating this impact into treatment algorithms are ill defined. Herein, we synthesize the data surrounding the impact of key RBD mutations on the efficacy of US Food and Drug Administration Emergency Use Authorized monoclonal antibodies and describe our approach at Michigan Medicine at monitoring mutation frequency in circulating virus and developing an algorithm that incorporates these data into outpatient treatment pathways.

9.
Innov Pharm ; 10(3)2019.
Article in English | MEDLINE | ID: mdl-34007564

ABSTRACT

OBJECTIVE: To evaluate the impact of a post-discharge pharmacist telephone call on 30- and 90- day readmission rates as part of a transitional care management (TCM) service in a geriatric patient-centered medical home (PCMH). METHODS: Adults 60 years of age and older who had established primary care at the PCMH for at least one year and were discharged from the hospital between 7/1/2013 and 2/21/2016 were included. Readmission rates for patients who received and did not receive a pharmacist TCM phone call were compared. Secondary data analysis was conducted between individuals who received all three components of the service compared with those who received on a nurse navigator plus primary care provider (PCP) visit. RESULTS: Among 513 discharges of unique patients (mean age, 80.4 years; women 63%), 269 (52.4%) received a pharmacist phone call. Readmission rates at 30 days were 8.9% for patients who received a pharmacist TCM phone call compared to 12.7% for those who did not receive this service (OR 0.67 [95% CI, 0.38-1.18; P=0.17]). When comparing only those individuals who received all three components of the service (pharmacist, nurse navigator, and PCP) (n=215) compared to those who received only a nurse navigator plus PCP visit (n=66), there was no difference in 30-day readmission rates (7.9% vs. 10.6%, p=0.49). However, there were significantly fewer readmissions within 90-days (16.3% vs. 31.8%, p=0.01). CONCLUSION: Pharmacist phone calls as part of an interdisciplinary TCM service did not result in a statistically significant difference regarding readmission rates at 30 days; however, patients who received all three components of the service had significantly fewer readmissions at 90 days, compared to patients who did not speak with a pharmacist but did complete a visit with a nurse navigator and physician. Future research is needed to determine which patients may benefit the most from this service and to identify strategies to increase patient participation.

10.
Pharmgenomics Pers Med ; 14: 319-326, 2021.
Article in English | MEDLINE | ID: mdl-33746516

ABSTRACT

PURPOSE: CYP3A5 genotype is a significant contributor to inter-individual tacrolimus exposure and may impact the time required to achieve therapeutic concentrations and number of tacrolimus dose adjustments in transplant patients. Increased modifications to tacrolimus therapy may indicate a higher burden on healthcare resources. The purpose of this study was to evaluate whether CYP3A5 genotype was predictive of healthcare resource utilization in pediatric renal and heart transplant recipients. PATIENTS AND METHODS: Patients <18 years of age with a renal or heart transplant between 6/1/2014-12/31/2018 and tacrolimus-based immunosuppression were included. Secondary use samples were obtained for CYP3A5 genotyping. Clinical data was retrospectively collected from the electronic medical record. Healthcare resource utilization measures included the number of dose changes, number of tacrolimus concentrations, length of stay, number of clinical encounters, and total charges within the first year post-transplant. Rejection and donor-specific antibody (DSA) formation within the first year were also collected. The impact of CYP3A5 genotype was evaluated via univariate analysis for the first year and multivariable analysis at 30, 90, 180, 270, and 365 days post-transplant. RESULTS: Eighty-five subjects were included, 48 renal transplant recipients and 37 heart transplant recipients. CYP3A5 genotype was not associated with any outcomes in renal transplant, however, a CYP3A5 expresser phenotype was a predictor of more dose changes, more tacrolimus concentrations, longer length of stay, and higher total charges in heart transplant recipients. CYP3A5 genotype was not associated with rejection or DSA formation. Age and induction therapy were associated with higher total charges. CONCLUSION: CYP3A5 genotype may predict healthcare resource utilization in the first year post-transplant, although this may be mitigated by differences in tacrolimus management. Future studies should evaluate the impact of genotype-guided dosing strategies for tacrolimus on healthcare utilization resources.

11.
Crit Care Explor ; 2(12): e0303, 2020 Dec.
Article in English | MEDLINE | ID: mdl-33354676

ABSTRACT

OBJECTIVES: To characterize the incidence and characteristics of propofol-associated hypertriglyceridemia in coronavirus disease 2019 versus noncoronavirus disease 2019 acute respiratory distress syndrome. DESIGN: Single-center prospective, observational cohort study. SETTING: Medical ICU and regional infectious containment unit. PATIENTS: Patients with acute respiratory distress syndrome admitted from April 7, 2020, to May 15, 2020, requiring continuous propofol administration. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 50 patients enrolled, 54% had coronavirus disease 2019 acute respiratory distress syndrome. Median Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were 35.5 (interquartile range, 30.2-41) and 8 (interquartile range, 6-9). Pao2/Fio2 ratio was 130.5 (interquartile range, 94.5-193.8). Patients with coronavirus disease 2019-associated acute respiratory distress syndrome experienced a higher rate of hypertriglyceridemia (triglyceride ≥ 500 mg/dL) than noncoronavirus disease 2019-associated acute respiratory distress syndrome (9 [33.3%] vs 1 [4.3%]; p = 0.014). Those with coronavirus disease 2019, compared with those without, received more propofol prior to becoming hypertriglyceridemic (median, 5,436.0 mg [interquartile range, 3,405.5-6,845.5 mg] vs 4,229.0 mg [interquartile range, 2,083.4-4,972.1 mg]; p = 0.027). After adjustment for propofol dose with logistic regression (odds ratio, 5.97; 95% CI, 1.16-59.57; p = 0.031) and propensity score matching (odds ratio, 8.64; 95% CI, 1.27-149.12; p = 0.025), there remained a significant difference in the development of hypertriglyceridemia between coronavirus disease 2019-associated acute respiratory distress syndrome and noncoronavirus disease 2019-associated acute respiratory distress syndrome. There was no difference between groups in time to hypertriglyceridemia (p = 0.063). Serum lipase was not different between those who did or did not develop hypertriglyceridemia (p = 0.545). No patients experienced signs or symptoms of pancreatitis. CONCLUSIONS: Patients with coronavirus disease 2019 acute respiratory distress syndrome experienced a higher rate of propofol-associated hypertriglyceridemia than noncoronavirus disease 2019 acute respiratory distress syndrome patients, even after accounting for differences in propofol administration.

12.
Curr Pharm Teach Learn ; 12(12): 1431-1436, 2020 12.
Article in English | MEDLINE | ID: mdl-33092773

ABSTRACT

INTRODUCTION: This paper assesses use of ExamSoft strength and opportunity (S&O) reports amongst doctor of pharmacy students, student perceptions of the reports, and the effect of instructing students on how best to use the reports. METHODS: Second-year pharmacy students enrolled in the medicinal chemistry and pharmacology course sequence completed a baseline survey regarding use of S&O reports in the fall semester. Educational interventions describing best practices on how to use the S&O report were provided to students. A follow-up survey was conducted in the winter semester. RESULTS: Eighty-four percent (69/82) of students returned a valid baseline survey, and 89% (71/80) returned a valid follow-up survey. At baseline, 55% (38/69) always/sometimes downloaded the report; this increased to 68% (48/71) after educational interventions (P = .06). Students who downloaded the report were asked to provide their perceived usefulness of the S&O report. At baseline, 76% (29/38) of students downloading the report rated it as either somewhat/very useful; this increased to 94% (45/48) following educational interventions (P = .002). Fewer students reported not being able to interpret the report post-intervention vs. baseline, although the decrease was not significant (9% vs. 21%, respectively; P = .07). CONCLUSIONS: Our findings indicate that providing students with a downloadable S&O report after exams is beneficial. There was a trend towards increased student use and a significant increase in perceived usefulness of the report following brief educational interventions. Our pilot data suggest that educational interventions on use of S&O reports should be included in student ExamSoft training.


Subject(s)
Education, Pharmacy , Students, Pharmacy , Humans , Pharmacists , Surveys and Questionnaires
13.
J Clin Pharm Ther ; 45(6): 1398-1404, 2020 Dec.
Article in English | MEDLINE | ID: mdl-32767599

ABSTRACT

WHAT IS KNOWN AND OBJECTIVE: Metabolic syndrome is a well-documented adverse effect of second-generation antipsychotics (SGAs). Patients with metabolic syndrome are at an increased risk of potentially fatal cardiovascular events, including myocardial infarction and stroke. This elevated risk prompted the creation of a national guideline on metabolic monitoring for patients on SGAs in 2004. However, monitoring practices remained low at our clinic. To address this concern, a clinical decision support system was developed to alert providers of monitoring requirements. The purpose of this study is to determine the effect of the best practice alert (BPA), and to assess the impact of provider and patient characteristics on metabolic laboratory (lab) order rates. METHODS: A retrospective chart review was conducted at a large outpatient psychiatric clinic. Data were collected from all adult patients who were prescribed an SGA and triggered the BPA (indicating lab monitoring is needed for the patient). Data collection included a variety of patient, provider and alert variables. The primary outcome was a composite of fasting blood glucose (FBG), haemoglobin A1c (HbA1c) and/or fasting lipid panel order rates. Secondary outcomes included the rate of valid response, which considered appropriate reasons for not ordering labs (ie monitoring already completed during recent primary care visit), as well as order rates of individual labs. RESULTS AND DISCUSSION: Data from 1112 patients were collected and analysed. Patients with a thought disorder diagnosis had significantly more labs ordered than those without. No other patient factors affected order rates. Resident psychiatrists and nurse practitioners ordered significantly more labs and had significantly more valid responses than attending psychiatrists. An active alert, which fired during medication order entry, was associated with a higher rate of lab ordering and valid response compared to a passive alert, which fired whenever a prescribing healthcare provider opened the chart. WHAT IS NEW AND CONCLUSION: Prescribers may associate metabolic syndrome with schizophrenia or with use of SGAs specifically in thought disorders, even though these medications pose a risk for all indications. Higher rates of monitoring by resident physicians may have been due to spending more time with patients during the encounter and in documentation. Lastly, the active BPA was an effective tool to increase metabolic monitoring in patients taking SGAs. Continued education on the importance of regular metabolic monitoring should be implemented for all providers.


Subject(s)
Antipsychotic Agents/administration & dosage , Drug Monitoring/methods , Mental Disorders/drug therapy , Metabolic Syndrome/chemically induced , Adult , Antipsychotic Agents/adverse effects , Blood Glucose/analysis , Decision Support Systems, Clinical , Female , Humans , Male , Medical Order Entry Systems , Mental Disorders/physiopathology , Middle Aged , Outpatients , Retrospective Studies
14.
Infect Control Hosp Epidemiol ; 41(10): 1136-1141, 2020 10.
Article in English | MEDLINE | ID: mdl-32489156

ABSTRACT

OBJECTIVE: To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea. DESIGN: Single center, quasi-experimental before-and-after study. SETTING: Tertiary-care, academic medical center in Ann Arbor, Michigan. PATIENTS: Adult and pediatric patients admitted between September 11, 2019 and December 10, 2019 were included if they had an order placed for 1 of the following: (1) C. difficile enzyme immunoassay (EIA) in patients hospitalized >72 hours and received laxatives, oral contrast, or initiated tube feeds within the prior 48 hours, (2) repeat molecular multiplex gastrointestinal pathogen panel (GIPAN) testing, or (3) GIPAN testing in patients hospitalized >72 hours. INTERVENTION: A best-practice alert prompting prior authorization by the antimicrobial stewardship program (ASP) for EIA or GIPAN testing was implemented. Approval required the provider to page the ASP pharmacist and discuss rationale for testing. The provider could not proceed with the order if ASP approval was not obtained. RESULTS: An average of 2.5 requests per day were received over the 3-month intervention period. The weekly rate of EIA and GIPAN orders per 1,000 patient days decreased significantly from 6.05 ± 0.94 to 4.87 ± 0.78 (IRR, 0.72; 95% CI, 0.56-0.93; P = .010) and from 1.72 ± 0.37 to 0.89 ± 0.29 (IRR, 0.53; 95% CI, 0.37-0.77; P = .001), respectively. CONCLUSIONS: We identified an efficient, effective C. difficile and GIPAN diagnostic stewardship approval model.


Subject(s)
Antimicrobial Stewardship , Clostridioides difficile , Adult , Child , Clostridioides , Humans , Pharmacists , Prior Authorization , Workflow
15.
Transpl Int ; 33(7): 740-751, 2020 07.
Article in English | MEDLINE | ID: mdl-32107804

ABSTRACT

Despite the increased use, comparative safety and efficacy of direct-acting oral anticoagulants (DOACs) against warfarin have not been well studied in kidney transplant recipients. In this single-center retrospective study, we evaluated 197 adult kidney transplant recipients on DOAC or warfarin between January 1, 2011, and June 30, 2018. The primary outcome was incidence of major bleeding defined as a hemoglobin decrease ≥2 g/dl, blood transfusion ≥2 units, or symptomatic bleeding in a critical area or organ. Patients were initiated on anticoagulation therapy at a median of 6.5 years post-transplant and followed for a median of 12.3 months. The rates of major bleeding were 7.2% per year with DOACs vs. 11.4% per year with warfarin (Mantel-Cox P = 0.15). No difference was found in composite bleeding, clinically relevant nonmajor bleeding, or thromboembolic events between the groups. There was a lower incidence of major bleeding with apixaban compared to all other anticoagulants (6.7% vs. 19.0%, P = 0.027). After controlling for potential confounders, DOAC use was not associated with an increased risk of major bleeding (HR 0.73, 95% CI 0.27-1.95). Further research is warranted to definitively determine whether DOACs are effective and safe alternatives to warfarin for anticoagulation in kidney transplant recipients.


Subject(s)
Kidney Transplantation , Warfarin , Administration, Oral , Adult , Anticoagulants/adverse effects , Cohort Studies , Factor Xa Inhibitors , Humans , Retrospective Studies , Warfarin/adverse effects
16.
J Am Med Inform Assoc ; 27(2): 284-293, 2020 02 01.
Article in English | MEDLINE | ID: mdl-31626294

ABSTRACT

OBJECTIVE: To assess if the amount of time a pharmacist spends verifying medication orders increases as medication orders become more complex. MATERIALS AND METHODS: The study was conducted by observing pharmacist verification of adult medication orders in an academic medical center. Drug order complexity was prospectively defined and validated using a classification system derived from 3 factors: the degree of order variability, ISMP high-alert classification, and a pharmacist perception survey. Screen capture software was used to measure pharmacist order review time for each classification. The annualized volume of low complexity drug orders was used to calculate the potential time savings if these were verified using an alternate system that did not require pharmacist review. RESULTS: The primary study hypothesis was not achieved. Regression results did not show statistical significance for moderate (n = 30, 23.7 seconds, sd = 23.3) or high complexity (n = 30, 18.6 seconds, sd = 23.1) drugs relative to the low complexity drugs (n = 30, 8.0 seconds, sd = 14.4) nor for moderate vs high complexity; (ßmoderate vs low = 15.6, P = .113), (ßhigh vs low = 10.3, P = .235), (ßmoderate vs high = 5.3, P = .737). The sensitivity analysis showed statistical significance in the high vs low comparison (ßhigh vs low = 13.8, P = .017). DISCUSSION: This study showed that verifying pharmacists spent less time than projected to verify medication orders of different complexities, but the time did not correlate with the classifications used in our complexity scale. Several mitigating factors, including operational aspects associated with timing antimicrobial orders, likely influenced order verification time. These factors should be evaluated in future studies which seek to define drug order complexity and optimize pharmacist time spent in medication order verification. CONCLUSION: The findings suggest that there may be other factors involved in pharmacist decision-making that should be considered when categorizing drugs by perceived complexity.


Subject(s)
Drug Prescriptions , Medication Systems, Hospital , Pharmacists/statistics & numerical data , Humans , Pharmaceutical Preparations , Pharmacy Service, Hospital , Time Factors
17.
Am J Cardiol ; 124(9): 1478-1483, 2019 11 01.
Article in English | MEDLINE | ID: mdl-31500818

ABSTRACT

Cardiac rehabilitation (CR) is associated with decreased mortality and rehospitalization rates for patients with a variety of cardiac conditions. Although CR referral rates for STEMI patients have improved, rates for heart failure have remained low. Many of these patients are admitted to the cardiac intensive care unit (CICU). However, it is unknown how often CICU survivors qualify for cardiac rehabilitation, how often they are referred, and why eligible patients are not referred. This is a retrospective single-center study of 417 consecutive patients admitted to CICU for >48 hours from March 30, 2016 to March 30, 2017. We excluded patients with in-hospital mortality or those discharged AMA, to hospice or transferred. Chart abstraction was used to determine CR indications based on known American College of Cardiology/American Heart Association guidelines. If CR was indicated, medical records through September 2017 were reviewed to determine both referral and participation rates. In the absence of a referral, medical records were reviewed for potential barriers. A total of 296 CICU survivors were identified upon discharge with 185 (63%) having guideline-directed indications for CR referral. The most common indications were heart failure with reduced ejection fraction (HFrEF, 38%), cardiothoracic surgery (26%), and STEMI (23%). Upon discharge, only 30% of patients were referred to CR. The referral rate increased by 33% to 63% by 18 months postdischarge. CR referrals were most frequently placed following STEMI (91%), NSTEMI (80%), and postpercutaneous coronary intervention (80%). Only 35% of HFrEF discharges were referred to CR. Of patients not referred to CR, no explanation for a lack of referral was documented 87% of the time. In conclusion, nearly 2 of 3 patients discharged from the CICU had CR indications, most commonly HFrEF. CR referrals are frequently not placed and reason for nonreferral is rarely documented. CICU admission may provide a defined event to prompt referral.


Subject(s)
Cardiac Rehabilitation/statistics & numerical data , Coronary Care Units/statistics & numerical data , Hospitalization/statistics & numerical data , Myocardial Ischemia/rehabilitation , Survivors/statistics & numerical data , Aged , Female , Follow-Up Studies , Hospital Mortality/trends , Humans , Incidence , Male , Michigan/epidemiology , Middle Aged , Myocardial Ischemia/epidemiology , Retrospective Studies , Survival Rate/trends
18.
Am J Manag Care ; 25(7): e219-e223, 2019 07 01.
Article in English | MEDLINE | ID: mdl-31318513

ABSTRACT

OBJECTIVES: To evaluate the effect of an interdisciplinary transitions of care (TOC) service on readmission rates in a geriatric population. STUDY DESIGN: Single-center retrospective cohort study of adults 60 years or older discharged from an academic medical center. METHODS: From July 1, 2013, to February 21, 2016, a total of 4626 patients discharged from 1 hospital, including inpatient, emergency department, observation, and short-stay units, were included. Cases were scheduled for a TOC service with the interdisciplinary team. Controls received usual care at other sites. All-cause 14-, 30-, and 90-day readmission rates between propensity score-matched study groups were evaluated by intention-to-treat (ITT), per-protocol (PP), and as-treated methods. RESULTS: During the study period, 513 patients were scheduled for at least 1 component of the TOC intervention (ITT group). Of those patients, 215 completed all scheduled visits (PP group). Readmission rate after 30 days demonstrated no difference in the ITT group compared with the control group (12.8% vs 10.7%; P = .215), although it was significantly lower in the PP group in comparison with the control group (12.8% vs 7.9%; P = .042). CONCLUSIONS: An interdisciplinary team based in a patient-centered medical home improved readmission rates for all patients who completed the intervention (PP group).


Subject(s)
Delivery of Health Care/organization & administration , Health Services for the Aged/organization & administration , Patient Care Team/organization & administration , Patient Discharge/statistics & numerical data , Patient Readmission/statistics & numerical data , Patient Transfer/organization & administration , Academic Medical Centers/statistics & numerical data , Aged , Aged, 80 and over , Cohort Studies , Delivery of Health Care/statistics & numerical data , Female , Health Services for the Aged/statistics & numerical data , Humans , Male , Middle Aged , Patient Care Team/statistics & numerical data , Patient Transfer/statistics & numerical data , Retrospective Studies , United States
19.
Open Forum Infect Dis ; 6(5): ofz176, 2019 May.
Article in English | MEDLINE | ID: mdl-31123689

ABSTRACT

BACKGROUND: Despite fungal prophylaxis, invasive mold infections (IMIs) are a significant cause of morbidity and mortality in patients with acute myeloid leukemia (AML) receiving remission induction chemotherapy. The choice of antifungal prophylaxis agent remains controversial, especially in the era of novel targeted therapies. We conducted a retrospective case-control study to determine the incidence of fungal infections and to identify risk factors associated with IMI. METHODS: Adult patients with AML receiving anti-Aspergillus prophylaxis were included to determine the incidence of IMI per 1000 prophylaxis-days. Patients without and with IMI were matched 2:1 based on the day of IMI diagnosis, and multivariable models using logistic regression were constructed to identify risk factors for IMI. RESULTS: Of the 162 included patients, 28 patients had a possible (n = 22), probable, or proven (n = 6) diagnosis of IMI. The incidence of proven or probable IMI per 1000 prophylaxis-days was not statistically different between anti-Aspergillus azoles and micafungin (1.6 vs 5.4, P = .11). The duration of prophylaxis with each agent did not predict IMI occurrence on regression analysis. Older age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.004-1.081; P = .03) and relapsed/refractory AML diagnosis (OR, 4.44; 95% CI, 1.56-12.64; P = .003) were associated with IMI on multivariable analysis. CONCLUSIONS: In cases that preclude use of anti-Aspergillus azoles for prophylaxis, micafungin 100 mg once daily may be considered; however, in older patients and those with relapsed/refractory disease, diligent monitoring for IMI is required, irrespective of the agent used for antifungal prophylaxis.

20.
J Am Pharm Assoc (2003) ; 59(1): 70-78.e3, 2019.
Article in English | MEDLINE | ID: mdl-30416067

ABSTRACT

OBJECTIVES: To develop and pilot test a model that extends pharmacists' direct patient care from the patient-centered medical home (PCMH) to the community pharmacy. SETTING: Two Michigan Medicine PCMH clinics and 2 CVS Pharmacy sites in Ann Arbor, MI. PRACTICE DESCRIPTION: In the PCMH clinics, pharmacists have provided patient care using collaborative practice agreements for diabetes, hypertension, and hyperlipidemia for more than 5 years. PRACTICE INNOVATION: Legal agreements were developed for sharing data and for accessing the Michigan Medicine Electronic Medical Record (EMR) in the CVS pharmacies. An immersion training model was used to train 2 community pharmacists to provide direct patient care and change medications to improve disease control. Then these community pharmacists provided disease management and comprehensive medication reviews (CMRs) in either the PCMH clinic or in CVS pharmacies. MAIN OUTCOME MEASURES: Glycosylated hemoglobin (A1C ≤ 9% and < 7%) and blood pressure (BP < 140/90) were compared for patients seen by PCMH pharmacists, patients seen by community pharmacists, and a propensity score-generated control group. Surveys were used to assess patient satisfaction. RESULTS: Of 503 shared patients, 200 received disease management and 113 received a CMR from the community pharmacists. Lack of efficacy was the most common reason for medication changes in diabetes (n = 136) and hypertension (n = 188). For CMR, optimizing the dosage regimen was the most common intervention. For the community pharmacist group, the odds of patients having an A1C ≤ 9% increased by 8% in each time period, whereas the odds decreased by 16% for the control group (odds ratio 1.29; P = 0.0028). No statistically significant differences were seen in the outcomes for patients seen by PCMH versus community pharmacists. Most patients (90%) rated the care as excellent. CONCLUSION: Direct patient care provided by community pharmacists, either in PCMH clinics or CVS pharmacies, was consistent with care provided by PCMH pharmacists. Patients were highly satisfied with the services provided.


Subject(s)
Community Pharmacy Services/organization & administration , Patient Care/methods , Patient-Centered Care/organization & administration , Pharmacists , Aged , Blood Pressure/physiology , Female , Humans , Male , Middle Aged , Patient Satisfaction , Pilot Projects , Professional Role , Program Development , Program Evaluation/statistics & numerical data
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