Improving Patient Access to Primary Care Providers Using a Pharmacist-Physician Co-Visit Model.

Background: Implementation of a clinical pharmacist in the primary care setting can offset provider time spent managing chronic diseases using Collaborative Practice Agreements (CPAs). The pharmacist-physician co-visit model presents an opportunity for pharmacists to increase patient access to their primary care provider (PCP). Studies of the co-visit model show that co-visits increase clinic efficiency by allowing the PCP to see additional patients and achieve more health care goals compared with independent visits1-4. Objectives: The aim of this study was to increase patient access to their PCP by utilizing a pharmacist-physician co-visit model at the Madsen Health Center Family Medicine (MHC FM) Clinic. The primary outcome was to identify the number of co-visits completed compared to the number of possible co-visits, and the number of appointment slots made available. The secondary outcomes were to track the time spent with patients and to obtain provider feedback via a survey. Methods: The co-visit model was implemented as a 4-month pilot study at the MHC FM Clinic. Complex care appointments lasting 40 minutes were selected based on inclusion and exclusion criteria. Potential co-visit appointments were identified one week prior then provider consent was obtained to change the appointment into two separate 20-minute visits. Schedules were reviewed to determine if the appointment slot opened by the co-visit was filled by another patient. Upon completion of the study, a survey was distributed to providers to collect feedback. Results: A total of five co-visits were completed out of a possible 19 (26%). All the appointments made available were filled by another patient. On average, the provider and pharmacist spent 15 and 14 minutes with the patient, respectively. Conclusion: Implementation of the physician-pharmacist co-visit model increased the availability of the PCP to see more patients without disrupting clinic workflow and provider schedules.

Clinical and economic implications of increasing access to herpes zoster vaccination rate in community pharmacies.

BACKGROUND: A community pharmacist plays an important role in providing vaccination to the general public in the United States. No economic models have been used to assess the impact of these services on public health and economic benefits. OBJECTIVE: This study aimed to estimate the clinical and economic implications of community pharmacy-based herpes zoster (HZ) vaccination services with a hypothetical scenario of nonpharmacy-based vaccination in the State of Utah. METHODS: A hybrid model of decision tree and Markov models was used to estimate lifetime cost and health outcomes. This open-cohort model was populated based on Utah population statistics and included a population of 50 years and older who were eligible for HZ vaccination between the years 2010 and 2020. Data were derived from the U.S. Bureau of Labor Statistics, the Utah Immunization Coverage Report, the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System, the CDC National Health Interview Survey, and existing literature. The analysis was performed from a societal perspective. A lifetime time horizon was used. The primary outcomes were the number of vaccination cases increased and the number of shingles and postherpetic neuralgia (PHN) cases averted. Total costs and quality-adjusted life-years (QALYs) were also estimated. RESULTS: Based on a cohort of 853,550 people eligible for HZ vaccination in Utah, an additional 11,576 individuals were vaccinated in the community pharmacy-based scenario compared with the nonpharmacy-based vaccination, resulting in 706 averted cases of shingles and 143 averted cases of PHN. Community pharmacy-based HZ vaccination was less costly (-$131,894) and gained more QALYs (52.2) compared with the nonpharmacy-based vaccination. A series of sensitivity analyses showed that the findings were robust. CONCLUSIONS: Community pharmacy-based HZ vaccination was less costly and gained more QALYs and was associated with improved other clinical outcomes in the State of Utah. This study might be used as a model for future evaluations of other community pharmacy-based vaccination programs in the United States.

Comparison of a Self-Care Therapeutics Course Taught in the P1 vs the P2 Year.

Objective: The objective of this study was to compare student learning outcomes, behaviors, and attitudes in a non-prescription drug and self-care therapeutics course taught in the second professional (P2) year vs the first professional (P1) year at one pharmacy school. Methods: Mean performance of students by class year on case consultations and exam scores was compared. Focus groups with student volunteers and course teaching assistants (TAs) and one-on-one interviews with a subset of instructors were conducted by an outside educational evaluation specialist to capture perceptions of student learning behaviors and attitudes. Results: There was no difference in performance on graded case consultations (mean difference = 0.16, P = .74, 95% CI [-0.77 to 1.09]), mid-term examinations (mean difference = 0.53, P = .62, 95% CI [-1.59 to 2.65]), or final examinations (mean difference = 0.73, P = .57, 95% CI [-1.83 to 3.30]) between P1 and P2 students. P1 students reported being more consistent in completing pre-class readings and in feeling less distracted by other courses than did P2 students. Students, TAs, and instructors consistently spoke about advantages of the course in the P1 year (e.g., less stress and greater eagerness to learn and apply skills at work) and disadvantages in the P2 year (e.g., distraction from concurrent P2 integrated pharmacotherapeutics course and tension between real-world experience and constraints of grading rubric). Conclusion: P1 students, despite one year earlier in their curriculum, performed equally well as P2 students. All stakeholders agree that the advantages of teaching a self-care course on students' learning behaviors and attitudes in the P1 year outweigh disadvantages.

Assessment of pharmacy technician job satisfaction and duties in ambulatory care pharmacy settings: A mixed-methods analysis.

PURPOSE: Expansion of pharmacy services into ambulatory care has prompted the integration of pharmacy technicians into this setting. Many models exist for technician practice in ambulatory care, and job satisfaction in these settings needs evaluation. This study assessed the job satisfaction of ambulatory care pharmacy technicians, obtained a deeper understanding of their varied roles, and examined commitment to the pharmacy technician career and their employing organization. METHODS: This study used a mixed-methods sequential explanatory design of quantitative followed by qualitative data analysis. The phases included a validated questionnaire on job satisfaction and semistructured interviews using a modified guide and findings from the quantitative data. Descriptive statistics and constant comparative analysis were used to analyze quantitative and qualitative data, and data were integrated in the discussion. RESULTS: The questionnaire was sent to 125 potential participants at 11 organizations in 8 unique states. Seventy-four technicians participated in the quantitative phase. Seventeen of these were interviewed in the qualitative phase. Interviewees represented 7 different institutions in 6 states in the Southeast, Midwest, and Western regions of the US. Both phases indicated that respondents felt a strong commitment to their organization, with 60% of respondents indicating this on the questionnaire. Reasons for this commitment were further elucidated in the qualitative phase, which indicated high satisfaction with technician autonomy, work schedules, and ability to provide important services to patients. It was also found in both phases that technician duties varied greatly among organizations, although most technicians were involved in facilitating medication access. CONCLUSION: Ambulatory care pharmacy technicians are highly satisfied with their positions and careers. Although technician roles vary within ambulatory care settings, the majority involve facilitating medication access in various ways. As these positions become more prevalent in pharmacy practice, it will be important to continue to capitalize on satisfiers and mitigate dissatisfiers to advance the profession and ultimately provide optimal patient care.

Evaluation of a Pharmacist-Led Diabetes Collaborative Drug Therapy Management Service.

OBJECTIVE: To evaluate the pharmacist-led diabetes collaborative drug therapy management services in a family medicine and internal medicine clinic. DESIGN: Mixed methods of evaluation based on the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. RESULTS: Reach: 71.3% of patients who were independently consulted (n = 184/258) and 1.6% (n = 11/680) of patients who triggered a best practice advisory (BPA) were enrolled. Effectiveness: 27.7% of patients (n = 54/195) enrolled were lost to follow-up. Adoption: 55% of eligible providers (n = 77/140) have placed a consult. Implementation: Providers independently choose to refer patients and are also prompted to place consults by a BPA that triggers for patients with an HbA1c ≥ 9%. Common reasons providers did not place a consult include: alignment with workflow, patient refusal, and patients followed by other services. Regarding patient perceptions, patients valued the service. Patients reported increased accountability with disease state maintenance and increased self-efficacy. Regarding how to improve the service, patients wanted more information on expectations before engaging with the pharmacist. Patients suggested to replicate this service for pain, cancer, and blood pressure management. Maintenance: 96.7% of providers (n = 30/31) reported they were very likely/likely to place a consult in the future and 60% of providers (n = 18/30) reported they were very likely/likely to place a consult when prompted by the BPA. CONCLUSION: These results can be utilized to make improvements to the pharmacist-led diabetes collaborative drug therapy management service to ensure sustainability. This study also provides lessons learned and strategies for future adoption, implementation, and maintenance of similar services for other disease states.

Association of proton-pump inhibitor use with adverse health outcomes: A systematic umbrella review of meta-analyses of cohort studies and randomised controlled trials.

AIMS: The aim was to perform an umbrella review to summarise the existing evidence on proton-pump inhibitor (PPI) use and adverse outcomes and to grade the certainty of evidence. METHODS: Electronic databases were searched up to July 2021 for meta-analyses of cohort studies and/or randomised controlled trials (RCTs). Summary effect sizes from a random-effects model, between-study heterogeneity, 95% prediction interval, small-study effect, excess significance and credibility ceilings were devised to classify the credibility of evidence from meta-analyses of cohort studies, whereas the GRADE approach was used for meta-analyses of RCTs. RESULTS: In meta-analyses of cohort studies, 52 of the 91 examined associations were statistically significant (P ≤ .05). Convincing evidence emerged from main analysis for the association between PPI use and risk of all-site fracture and chronic kidney disease in the elderly population. However, none of these associations remained supported by convincing evidence after sensitivity analyses. The use of PPI is also associated with an increased risk of mortality due to COVID-19 infection and other related adverse outcomes, but the quality of evidence was weak. In meta-analyses of RCTs, 38 of the 63 examined associations were statistically significant. However, no associations were supported by high or moderate-quality evidence. CONCLUSION: This study's findings imply that most putative adverse outcomes associated with PPI use may not be supported by high-quality evidence and are likely to have been affected by underlying confounding factors. Future research is needed to confirm the causal association between PPI use and risk of fracture and chronic kidney disease.

From Precision Metapharmacology to Patient Empowerment: Delivery of Self-Care Practices for Epilepsy, Pain, Depression and Cancer Using Digital Health Technologies.

To improve long-term outcomes of therapies for chronic diseases, health promotion and lifestyle modifications are the most promising and sustainable strategies. In addition, advances in digital technologies provide new opportunities to address limitations of drug-based treatments, such as medication non-adherence, adverse effects, toxicity, drug resistance, drug shortages, affordability, and accessibility. Pharmaceutical drugs and biologics can be combined with digital health technologies, including mobile medical apps (digital therapeutics), which offer additional clinical benefits and cost-effectiveness. Promises of drug+digital combination therapies are recognized by pharmaceutical and digital health companies, opening opportunities for integrating pharmacotherapies with non-pharmacological interventions (metapharmacology). Herein we present unique features of digital health technologies which can deliver personalized self-care modalities such as breathing exercises, mindfulness meditation, yoga, physical activity, adequate sleep, listening to preferred music, forgiveness and gratitude. Clinical studies reveal how aforementioned complimentary practices may support treatments of epilepsy, chronic pain, depression, cancer, and other chronic diseases. This article also describes how digital therapies delivering "medicinal" self-care and other non-pharmacological interventions can also be personalized by accounting for: 1) genetic risks for comorbidities, 2) adverse childhood experiences, 3) increased risks for viral infections such as seasonal influenza, or COVID-19, and 4) just-in-time stressful and traumatic circumstances. Development and implementation of personalized pharmacological-behavioral combination therapies (precision metapharmacology) require aligning priorities of key stakeholders including patients, research communities, healthcare industry, regulatory and funding agencies. In conclusion, digital technologies enable integration of pharmacotherapies with self-care, lifestyle interventions and patient empowerment, while concurrently advancing patient-centered care, integrative medicine and digital health ecosystems.

Melatonin may slow disease progression in amyotrophic lateral sclerosis: Findings from the Pooled Resource Open-Access ALS Clinic Trials database.

INTRODUCTION: We utilized the Pooled Resource Open-Access Clinical Trials (PRO-ACT) database to investigate whether melatonin use among patients with amyotrophic lateral sclerosis (ALS) was associated with slower disease progression and prolonged survival. METHODS: This retrospective analysis of the PRO-ACT database addresses the impact of melatonin on progression and overall survival of ALS. A Cox proportional hazards ratio model was performed to investigate the effect that melatonin had on time to death. For secondary outcome measures, linear mixed effects regression models were used to ascertain the effect of melatonin on change in standardized ALS Functional Rating Scale (sALSFRS) and percentage predicted forced vital capacity (FVC) scores. RESULTS: Melatonin users had a significantly decreased annualized hazard death rate compared with the non-melatonin users (hazard ratio, 0.241; 95% confidence interval, 0.088-0.659; P = .0056). The melatonin users also had a slower rate of decline in sALSFRS score (t = 2.71; P = .0069) and change in percent predicted FVC score (t = 2.94; P = .0035) compared with the non-melatonin users. DISCUSSION: Our findings suggest that melatonin may be beneficial for patients with ALS. Due to the nature of this database, our results are solely intended to be hypothesis-generating and no strong associations can be made. Given the low cost and favorable safety profile of melatonin, the hypotheses generated warrant further investigation.

Antihypertensive Agents in the Dialysis Patient.

PURPOSE OF REVIEW: Hypertension and antihypertensive drug utilization are remarkably prevalent in ESRD patients. Management of blood pressure elevation in this population is complicated by many factors, including a multidimensional etiology, challenges in obtaining accurate and appropriately timed blood pressure measurements, highly specific drug dosing requirements, and a paucity of outcomes-based evidence to guide management decisions. The purpose of this review is to summarize and apply knowledge from existing clinical trials to enhance safe and effective use of antihypertensive agents in dialysis patients. RECENT FINDINGS: Two meta-analyses have established the benefit of antihypertensive therapy in ESRD. Data supporting the use of one antihypertensive class over another is less robust; however, beta-blockers have more clearly demonstrated improved cardiovascular outcomes in prospective randomized trials. Interdialytic home blood pressure monitoring has been demonstrated to be better associated with cardiovascular outcomes than clinic pre- or post-dialysis readings and should ideally be considered as a routine part of blood pressure management in this population. As data from small trials provides limited guidance for the management of hypertension in ESRD, more research is needed to guide medication selection and utilization. Specifically, large prospective randomized trails comparing cardiovascular outcomes of various medication classes and differing blood pressure targets are needed.