Implementing a Systematic Approach to Deprescribing Proton Pump Inhibitor Therapy in Older Adults.

OBJECTIVE: To investigate the efficacy of a population health management initiative aimed at reducing the unnecessary use of proton pump inhibitors (PPIs) in elderly patients via a tapering process by measuring 1) the percentage of patients that initiate the PPI taper, 2) the number of patients 65 years of age and older with undocumented or unknown indication on PPI therapy for longer than eight weeks, and 3) the percentage of pharmacists' discontinuation recommendations accepted by the provider. DESIGN: Prospective, interventional pilot study. SETTING: Tier 3 patient-centered medical home within a major academic medical center with multiple sites. PARTICIPANTS: Five hundred fifteen elderly patients were identified with an active PPI prescription for longer than eight weeks. INTERVENTIONS: A report was generated using the electronic health record to identify patients 65 years of age and older on PPI therapy. Patients were contacted via secure portal or telephone and provided with the risks and benefits by use of an educational online tool from RxFiles. Patients who were agreeable to begin a taper were provided an individualized plan. PPI use was monitored at a predesignated interval. MAIN OUTCOME MEASURES: Patients initiating PPI taper, documented indication for PPI, and percent pharmacist recommendations accepted. RESULTS: Two hundred thirty-eight (46%) were eligible for intervention; 53 of 238 didn't have a documented indication. The provider approval rate of the pharmacist-recommended intervention was 86%, and 103 patients initiated the taper. Of these, 84 (81.6%) were successfully weaned off their PPI. CONCLUSION: A systematic approach to deprescribing PPI therapy was successfully implemented for an elderly patient population.

Patient-Level Medication Regimen Complexity in an Adolescent and Adult Population with Autism Spectrum Disorders.

BACKGROUND: Adults with autism spectrum disorder (ASD) frequently experience polypharmacy. However, there is limited understanding of how to quantify medication complexity in this vulnerable population. OBJECTIVES: This study examined medication administration difficulty using the Medication Regimen Complexity Index (MRCI) tool in adolescents and adults with ASD. The outcomes compared the mean total MRCI score with the medication count, described MRCI contributions for over-the-counter medication (OTC), and compared MRCI scores by patient characteristics. METHODS: This was a retrospective chart review of patients aged 7-45 years (mean = 20.1) enrolled in a primary care ASD transitions program. Each patient's listed medications were counted and then scored using the validated MRCI tool. RESULTS: For the 142 patients studied, mean total MRCI was 14.6 ± 14.6 (range 0-89) and mean medication count was 6.3 ± 5.4 (range 0-38). For patients on 0-4 medications (66 of 142; 46.5%), the mean MRCI was 5.5 ± 4.2, 5-9 medications (50 of 142; 35.2%) the mean MRCI was 15.2 ± 6.8, and 10-38 medications (26 of 142; 18.3%) the mean MRCI was 36.5 ± 18.9 (p<0.001). Sixty percent (85 of 142) reported OTC use, which contributed 26.6% to the mean total MRCI. Reported benzodiazepine (mean MRCI 25.8 ± 17.2), antiepileptic (mean MRCI 23.7 ± 16.9), antipsychotic (mean MRCI 19.7 ± 15.9), or antidepressant (mean MRCI 17.0 ± 14.8) use received higher MRCI scores compared to nonuse (p<0.001 for all except antidepressants [p=0.004]). Total MRCI did not differ significantly by age group, sex, or attention-deficit-hyperactivity disorder (ADHD) medication use (stimulant or nonstimulant). CONCLUSIONS: Medication regimen complexity in adolescents and adults with ASD was increased significantly for individuals taking ≥ 5 medications. Central nervous system agent use, other than ADHD therapy, identified patients with higher regimen complexity. The related clinical effects of these findings warrant further investigation.

Addressing medical needs of adolescents and adults with autism spectrum disorders in a primary care setting.

Little has been reported about how to improve health care access and delivery for adolescents and adults with autism spectrum disorder. To understand the contributions to the health disparities in the autism spectrum disorder population, we conducted two independent research approaches to learn about current medical needs. A retrospective chart review was performed to evaluate medical comorbidities and medication use. A focus group was also created to address barriers faced in providing medical care. Of 126 charts reviewed, 49% (n = 62) had intellectual disability, 49% (n = 62) had attention-deficit hyperactivity disorder, 52% (n = 65) had anxiety, 41% (n = 52) had obesity, 31% (n = 39) with a history of aggressive behavior, 31% (n = 31) had depression, 22% (n = 28) had seizures, and 9% (n = 11) had hypertension. A Medical Regimen Complexity Index score was determined to examine medication use trends in the autism spectrum disorder population. Medical Regimen Complexity Index scores were significantly higher for patients with intellectual disability, patients with seizures, and patients with a history of aggressive behavior. Both the focus group and our pre-visit assessment identified the waiting room and waiting time as barriers to care. Understanding the comorbidities, polypharmacy, and medical barriers should provide a better understanding of the current health care access and delivery needs of adolescents and adults with autism spectrum disorder.

Pharmacogenomic testing: aiding in the management of psychotropic therapy for adolescents with autism spectrum disorders.

Adolescents with autism have higher rates of anxiety than the general adolescent population. They often struggle to express psychological symptoms verbally where their symptoms may manifest as withdrawal and agitation. Adolescent patients with autism have higher rates of polypharmacy and high-risk psychiatric medication use (eg, atypical antipsychotics) than other patients with psychiatric illness. Primary care pediatricians are at the front lines of psychiatric management for patients with autism. Yet, they have inadequate access to pediatric psychiatry for complex medication management. Pharmacogenomic testing can provide personalized drug metabolism profiles for a majority of psychotropic medications. Primary care based pharmacogenomic testing for adolescents with autism on one or more psychiatric medications may help individualize and optimize complex medication regimens, while promoting drug safety.

Short-term outcomes of an employer-sponsored diabetes management program at an ambulatory care pharmacy clinic.

PURPOSE: The impact of a collaborative, employer-sponsored diabetes management program on glycemic control and other clinical endpoints over 6-12 months is reported. METHODS: In a retrospective, chart-based evaluation, glycosylated hemoglobin (HbA(1c)) and related health status indicators were assessed among first-year enrollees in the Healthy Outcome Partnership for Employees (HOPE) with Diabetes Program, an ongoing program sponsored by the Wake Forest Baptist Health (WFBH) system. Diabetes management services were provided by pharmacists in collaboration with providers inside and outside the WFBH system. The primary endpoint was the mean change in HbA(1c) during follow-up averaging 8.2 months; secondary endpoints included changes in blood pressure, cholesterol, and triglyceride levels. RESULTS: Among the 98 patients included in the data analysis (75.5% women, 72.4% Caucasian), the mean HbA(1c) value decreased significantly during the study period (from 7.8% to 7.1%, p < 0.01); the proportion of patients at the recommended goal of an HbA(1c) of ≤7.0% rose from 40.8% to 56.1% (p < 0.01). HOPE Program enrollees also experienced significant improvements in mean triglyceride, total cholesterol, and blood pressure values (p < 0.05 for all). A subgroup of patients with initially poor glycemic control (HbA(1c) of ≥8.0%) had a mean HbA(1c) reduction of 1.7 percentage points during the study (p < 0.01), suggesting that the greatest benefits occurred in the highest-risk patients. CONCLUSION: Among patients seen for at least six months at an employer-sponsored ambulatory care diabetes clinic managed by pharmacists, significant improvements from baseline in clinical end-points including HbA(1c) and blood pressure were demonstrated.

Evaluation of a pharmacist-managed lipid clinic that uses point-of-care lipid testing.

BACKGROUND: Hyperlipidemia is a significant, modifiable risk factor for developing coronary heart disease. Low-density lipoprotein cholesterol (LDL-C) goal achievement has improved overall, but many high-risk patients remain above the desired LDL-C goals. Published data have demonstrated the ability of pharmacist-managed lipid clinics to improve lipid management in a variety of clinical settings. OBJECTIVE: This observational analysis aimed to report the impact of a newly developed hospital-based, outpatient lipid clinic by the use of point-of-care testing on LDL-C goal attainment. METHODS: A retrospective, observational analysis was conducted from February 2007 to December 2008. The primary outcome measure was the change in the proportion of patients who achieved their LDL-C goal at the end of the observation period compared with baseline. RESULTS: A total of 81 patients met study inclusion criteria. Mean duration of follow-up was 9.0 ± 4.9 (SD) months. At the end of the observation period, 82.9% of patients achieved their LDL-C goal compared with 55.3% at baseline (P < .0001). The mean LDL-C decreased from 103 ± 45 mg/dL at baseline to 82 ± 28 mg/dL at the end of the observation period (P < .0001). CONCLUSION: An outpatient hospital-based, pharmacist-managed lipid clinic improved LDL-C goal attainment. Our results are unique in that pharmacists used point-of-care testing to obtain lipid results for making therapy adjustments during the face-to-face visit.