Professional responsibilities reported by pharmacists completing residencies in community-based settings.

OBJECTIVES: To evaluate the professional responsibilities of pharmacists who completed residencies in a community-based setting and to determine if there is a difference in responsibilities for pharmacists completing different types of PGY-1 residency and PGY-2 residency training. METHODS: A survey was designed by adapting questions from the 2014 Pharmacist Workforce Survey and creating other questions designed for this project. Surveys were distributed electronically to residency program directors of PGY-1 community-based pharmacy residencies, PGY-1 pharmacy residencies in ambulatory care environments, and PGY-2 ambulatory care residencies; program directors were asked to distribute the survey to all residency alumni of their program. RESULTS: A total of 450 programs were identified; 349 responses were received, with respondents having completed residency training from 1989 to 2016. Respondents represented at least 73 different residency programs across the country. More than 97% of respondents agreed or strongly agreed that their residency training prepared them to be successful in their career. Nondispensing patient care, ranging from 39.0% to 52.5%, represented the largest percentage of job responsibilities. Current job responsibilities contained a higher percentage of business or organization management compared with first job (17.7% vs. 5.8%; P < 0.001). CONCLUSION: Pharmacists completing residency training have a large percentage of their first jobs associated with patient care responsibilities, regardless of the type of training received or the type of setting.

A naloxone and harm reduction educational program across four years of a doctor of pharmacy program.

BACKGROUND AND PURPOSE: Naloxone distribution is an increasing service provided by pharmacists as more states enact laws enabling pharmacists to dispense naloxone without a prescription or per protocol to individuals in the wake of an opioid overdose epidemic. Education and training programs are necessary to ensure students and practicing pharmacists are able to effectively provide the service. EDUCATIONAL ACTIVITY AND SETTING: All first, second, and third year students in the doctor of pharmacy (PharmD) program at The Ohio State University College of Pharmacy (OSUCOP) participated in a pilot naloxone and harm reduction educational program. The program consisted of a three-part recorded lecture and a hands-on interactive workshop. Fourth-year students had the opportunity to participate. Students completed a ten-question assessment based on the content of the recorded lecture. Following the workshop, self-reflection and feedback were solicited. FINDINGS: Qualitative data indicated students felt the naloxone educational program was beneficial. Inclusion of harm reduction strategies, a mock counseling session, hands-on practice with naloxone delivery devices, and patient case discussions were valued. DISCUSSION AND SUMMARY: OSUCOP was able to develop and deliver a naloxone and harm reduction educational program across all four years of the PharmD curriculum within one year of passage of laws increasing pharmacist dispensing of naloxone.

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.

Identification and Characterization of Adverse Drug Events in Primary Care.

The purpose of this study was to identify and characterize adverse drug events (ADEs) in a primary care setting using an electronic health record (EHR). This prospective, observational study enrolled patients with any medication change who were seen at an outpatient internal medicine clinic. Patients were evaluated for ADEs by EHR review and telephone interview. ADEs were independently assessed for causality, severity, preventability, and ameliorability by a physician and a pharmacist using a grading instrument. There were 1368 unique medication changes for 701 individuals who completed the study (1.95 changes per person). Of the 226 suspected ADEs, 68 (58%) were deemed to be "definite" or "probable" following causality assessment; 21% were preventable and 40% ameliorable. Only 2 ADEs were serious or life-threatening. Compared with prior reports, ADEs in primary care have decreased in frequency and severity, yet the occurrence of preventable and ameliorable ADEs has increased.

Comparison of 2 Population Health Management Approaches to Increase Vitamin B12 Monitoring in Patients Taking Metformin.

BACKGROUND: Population health management uses proactive, targeted interventions to improve health outcomes. OBJECTIVES: To compare the effectiveness of and time required for 2 pharmacist-driven population health management interventions to improve vitamin B12 monitoring in patients taking metformin. METHODS: Physicians were randomized to 1 of 2 population health management interventions. For all patients of physicians assigned to the patient portal intervention, a pharmacist communicated need for vitamin B12 monitoring directly to the patient using an electronic patient portal. For all patients of physicians assigned to the office visit intervention, a pharmacist communicated monitoring recommendations to the physician prior to a scheduled office visit through the electronic health record. The proportion of patients in each group who received vitamin B12 monitoring 30 days after the intervention was quantified. RESULTS: A total of 489 patients of 26 physicians within 5 general internal medicine clinics who had taken metformin for at least 1 year and had not received vitamin B12 monitoring within the past year were identified. The intervention delivered as part of an office visit resulted in increased serum vitamin B12 monitoring compared with the intervention using electronic communication through a patient portal (odds ratio = 4.05; 95% CI = 1.22, 13.46; P = 0.03). The office visit intervention and the patient portal intervention took an average of 8.2 and 0.9 minutes per patient, respectively. CONCLUSIONS: Population health management completed during the course of office visits was more effective at increasing vitamin B12 monitoring and required more time than an intervention delivered through an electronic patient portal.

Measuring preadvanced practice experience outcomes as part of a PharmD capstone experience.

OBJECTIVE: To describe a capstone experience to: 1) assess student preparedness for Advanced Pharmacy Practice Experiences (APPE) and 2) provide program-level assessment data. DESIGN: A capstone course was added immediately prior to APPEs. All capstone activities emphasized application and integration and were mapped to ACPE Appendix D, which details performance abilities expected of students prior to APPEs. Eleven learning activities comprising 20 assessments were created. Each assessment was pass/fail; students had to pass 15 of 20 assessments to pass the capstone course. Evaluation rubrics emphasized formative feedback for students. ASSESSMENT: The capstone experience was delivered 4 times over 4 consecutive years. One student did not pass; 55-68% of the students passed all activities. Program-level assessment data provided details on individual student preparedness prior to APPE, important information for accreditation, and basis for curriculum revisions. CONCLUSION: A capstone experience can be a valuable addition to a PharmD curriculum. Capstone activities incorporating authentic assessments provide important program-level assessment data for colleges/schools of pharmacy.

Pharmacist-driven renal medication dosing intervention in a primary care patient-centered medical home.

PURPOSE: The purposes of this population management intervention were to identify patients with stage 3, 4, or 5 chronic kidney disease (CKD) and to improve care in a patient-centered medical home (PCMH). Objectives of the intervention were to (i) increase the identification of CKD, (ii) increase the use of aspirin and angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin II receptor blockers (ARBs) in patients with CKD, and (iii) ensure that all medications prescribed to patients with CKD were dosed appropriately based on renal function. SETTING: This intervention was completed at a National Committee for Quality Assurance tier 3 PCMH associated with a major, academic health system. PATIENTS: A list of 328 patients with an estimated glomerular filtration rate of < 60 mL/min per 1.73 m(2) was generated using the electronic medical record; 146 patients underwent the intervention. MEASUREMENTS AND OBSERVATIONS: A pharmacist review of the electronic medical record was completed to confirm stage 3, 4, or 5 CKD based on estimated glomerular filtration rate, to ensure that ACE-Is/ARBs and aspirin were prescribed, and to ensure that all medications were dosed appropriately based on renal dosing adjustment recommendations. Recommendations were made to improve medication use and safety in patients with CKD. Before intervention, 73% of patients were prescribed an ACE-I/ARB and 72% of patients were prescribed aspirin. After the intervention, use of these medications increased to 77% and 82% of patients, respectively. Pharmacist recommendations to adjust medication dosing based on Cockcroft-Gault calculated creatinine clearance were made for 138 medications (0.95 medication per patient); 90 (65.2%) recommendations were accepted by the patients' physicians. CONCLUSION: These results demonstrate the impact of a pharmacist-driven renal medication dosing intervention within a PCMH on medication use and safety for patients with CKD.

Improving herpes zoster vaccination rates through use of a clinical pharmacist and a personal health record.

BACKGROUND: Preventative health services, including herpes zoster vaccination rates, remain low despite known benefits. A new care model to improve preventative health services is warranted. The objective of this study is to investigate whether the functions of an electronic medical record, in combination with a pharmacist as part of the care team, can improve the herpes zoster vaccination rate. METHODS: This study was a 6-month, randomized controlled trial at a General Internal Medicine clinic at The Ohio State University. The 2589 patients aged 60 years and older without documented herpes zoster vaccination in the electronic medical record were stratified on the basis of activated personal health record status, an online tool used to share health information between patient and provider. Of the 674 personal health record users, 250 were randomized to receive information regarding the herpes zoster vaccination via an electronic message and 424 were randomized to standard of care. Likewise, of the 1915 nonpersonal health record users, 250 were randomized to receive the same information via the US Postal Service and 1665 were randomized to standard of care. After pharmacist chart review, eligible patients were mailed a herpes zoster vaccine prescription. Herpes zoster vaccination rates were compared by chi-square tests. RESULTS: Intervention recipients had significantly higher vaccination rates than controls in both personal health record (relative risk, 2.7; P = .0007) and nonpersonal health record (relative risk, 2.9; P = .0001) patient populations. CONCLUSIONS: Communication outside of face-to-face office visits, by both personal health record electronic message and information by mail, can improve preventative health intervention rates compared with standard care.

Administration technique and storage of disposable insulin pens reported by patients with diabetes.

PURPOSE: The purpose of the study was to evaluate insulin injection technique and storage of insulin pens as reported by patients with diabetes and to compare correct pen use to initial education on injection technique, hemoglobin A1C, duration of insulin therapy, and duration of insulin pen. METHODS: Cross-sectional questionnaire orally administered to patients at a university-affiliated primary care practice. Subjects were patients with diabetes who were 18 years or older and prescribed a disposable insulin pen for at least 4 weeks. A correct usage score was calculated for each patient based on manufacturer recommendations for disposable insulin pen use. Associations were made between the correct usage score and certainty in technique, initial education, years of insulin therapy, duration of pen use, and hemoglobin A1C. RESULTS: Sixty-seven patients completed the questionnaire, reporting total use of 94 insulin pens. The 3 components most often neglected by patients were priming pen needle, holding for specific count time before withdrawal of pen needle from skin, and storing an in-use pen. For three-fourths of the insulin pens being used, users did not follow the manufacturer's instructions for proper administration and storage of insulin pens. Correct usage scores were significantly higher if initial education on insulin pens was performed by a pharmacist or nurse. CONCLUSIONS: The majority of patients may be ignoring or unaware of key components for consistent insulin dosing using disposable insulin pens; therefore, initial education and reeducation on correct use of disposable insulin pens by health care professionals are needed.

Current trends in outpatient pharmacy services and billing.

OBJECTIVES: To provide a summary of community and ambulatory pharmacy practices and billing patterns for medication therapy management (MTM) services and to identify reasons pharmacists report not billing for direct patient care services. DESIGN: Cross-sectional study. SETTING: United States, February 2011. PARTICIPANTS: Members of the American College of Clinical Pharmacy Ambulatory Care Practice and Research Network, American Society of Health-System Pharmacists Ambulatory and Chronic Care Practitioners, and American Pharmacists Association MTM e-community. INTERVENTION: Online survey. MAIN OUTCOME MEASURES: Practice setting, pharmacy services performed, billing technique, and payer, as well as reasons for not billing. RESULTS: MTM services were provided by 287 pharmacists. The most common practice settings included physician office (23.6%), health-system outpatient facility (21.7%), and community pharmacy (20.2%). A total of 149 of 276 pharmacists (54.0%) reported billing for MTM services; 16 of 276 (5.8%) did not know if they were currently billing. Community pharmacists were more likely to bill than all other sites combined (80.5% vs. 53.1%, P < 0.001), and pharmacists with >75% of visits face-to-face were more likely to bill (66.2% vs. 46.6%, P < 0.002). CONCLUSION: A variety of MTM services are provided in outpatient settings with inconsistent billing techniques and reimbursement. Pharmacists should continue to work toward consistent, sustainable reimbursement to expand MTM services.

Team-based learning in therapeutics workshop sessions.

OBJECTIVES: To implement team-based learning in the workshop portion of a pathophysiology and therapeutics sequence of courses to promote integration of concepts across the pharmacy curriculum, provide a consistent problem-solving approach to patient care, and determine the impact on student perceptions of professionalism and teamwork. DESIGN: Team-based learning was incorporated into the workshop portion of 3 of 6 pathophysiology and therapeutics courses. Assignments that promoted team-building and application of key concepts were created. ASSESSMENT: Readiness assurance tests were used to assess individual and team understanding of course materials. Students consistently scored 20% higher on team assessments compared with individual assessments. Mean professionalism and teamwork scores were significantly higher after implementation of team-based learning; however, this improvement was not considered educationally significant. Approximately 91% of students felt team-based learning improved understanding of course materials and 93% of students felt teamwork should continue in workshops. CONCLUSION: Team-based learning is an effective teaching method to ensure a consistent approach to problem-solving and curriculum integration in workshop sessions for a pathophysiology and therapeutics course sequence.

A progress assessment to evaluate pharmacy students' knowledge prior to beginning advanced pharmacy practice experiences.

OBJECTIVE: To develop an assessment that would (1) help doctor of pharmacy (PharmD) students review therapeutic decision making and build confidence in their skills, (2) provide pharmacy practice residents with the opportunity to lead small group discussions, and (3) provide the assessment committee with program-level assessment data. DESIGN: A case-based interactive assessment was developed and delivered to PharmD students immediately prior to advanced pharmacy practice experiences (APPEs). The assessment used an audience response system to allow immediate feedback followed by small group discussions led by pharmacy-practice residents. Students self-assessed their knowledge and confidence levels and developed personalized learning objectives for APPEs. ASSESSMENT: Eighty-nine percent of students found the assessment useful, and pharmacy practice residents reported that it was helpful in developing precepting skills. The college assessment committee was able to use the data to supplement the ongoing College curricular mapping process. CONCLUSIONS: An interactive assessment process can help students build confidence for experiential training, provide a learning opportunity for pharmacy residents, and produce program-level data for college assessment purposes. Planned modifications of the assessment include expanding the content areas covered and adding ability-based assessments such as communication skills.

Practice-based research network as a research training model for community/ambulatory pharmacy residents.

OBJECTIVE: To describe our experience with a practice-based research training network (PBRTN) in a 1-year residency program. SETTING: Ohio State University in Columbus from 1997 to 2007. PRACTICE DESCRIPTION: The program includes two accredited postgraduate year 1 residencies and one postgraduate year 2 residency. Seven residents, 11 preceptors, and three faculty members participated during the time frame discussed in this article. Practice settings included three community sites and three ambulatory sites. PRACTICE INNOVATION: The PBRTN includes a residency director, a research director, preceptor and resident members, and research faculty. The group works collaboratively to meet training goals. The PBRTN maintains a project timeline, foundational training, and structured research development, implementation, and presentation phases. Each resident submits five required research products: abstract, grant, poster, podium presentation, and research manuscript. MAIN OUTCOME MEASURES: Quantitative measures included the number of abstracts, grants, and peer-reviewed publications over two time periods, one before and one after a deliberate attempt to increase the research focus of the residencies. The ratio of research products to number of residents was used as a measure of productivity. Postresidency career choice and postresidency publications are reported. RESULTS: Over a decade, the program has produced 37 graduates, 50 abstracts, 15 grants, and 12 peer-reviewed publications. The publication-to-resident ratio increased from 0.25 in the pre-emphasis period of 1997-2001 to 0.56 in 2002-2007, after the research focus was intensified. Of graduates, 38% are in faculty positions, with 48 postresidency publications. CONCLUSION: Use of a PBRTN has successfully provided research training and improved research outcomes for the program. This model could be implemented in other residencies.

Community and ambulatory pharmacy: evaluation of patient care services and billing patterns before implementation of Medicare part D.

OBJECTIVE: To provide a summary of community and ambulatory pharmacy practice and billing patterns for medication therapy management services before implementation of Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). DESIGN: Cross-sectional survey. SETTING: Ambulatory care and community pharmacy practice settings in the United States in January 2004. PARTICIPANTS: Members of the American College of Clinical Pharmacy Ambulatory Practice and Research Network, preceptors of the American Pharmacists Association (APhA) Community Pharmacy Residency Programs, and participants in the APhA Immunizing Pharmacist listserv. INTERVENTIONS: E-mail invitations to participate in a Web-based survey. MAIN OUTCOME MEASURES: Practice setting; pharmacy services performed; whether pharmacists were billing for pharmacy services; if billing, the billing technique used; if not billing, the reason for not billing. RESULTS: Of 349 respondents, 127 (36.4%) were practicing within a physician office, while 121 (34.7%) were practicing in community pharmacies. Diabetes, anticoagulation, dyslipidemia, hypertension, and smoking cessation management services were performed significantly more often in physician offices. Immunization delivery and diabetes, dyslipidemia, and osteoporosis screenings were performed significantly more often in community settings. A total of 190 (54.5%) pharmacists stated that they were billing for pharmacy services. More community pharmacists were billing for services compared with other combined practice settings (69.2% versus 46.7%, P < .001). Top reasons identified for not billing for services were salaried position, indigent population, and discomfort with the billing process. CONCLUSION: Valuable baseline data are provided regarding pharmacy services that have been successfully implemented in ambulatory and community practice settings and which billing techniques were used to receive reimbursement before the implementation of MMA.

Decreased warfarin effect after initiation of high-protein, low-carbohydrate diets.

OBJECTIVE: To report 2 cases of decreased international normalized ratio (INR) after initiation of a high-protein, low-carbohydrate diet. CASE SUMMARIES: Case 1. A 67-year-old white woman had been receiving warfarin for 3 years for venous thromboembolism. After initiation of a high-protein, low-carbohydrate diet, the patient required a 22.2% increase (from 45 to 57.5 mg/wk) in warfarin dose. Her INR remained in the therapeutic range on this dose for 8 weeks. When the patient stopped the high-protein, low-carbohydrate diet, a decrease back to the original warfarin dose was required to return to a therapeutic INR. Case 2. A 58-year-old white man had been receiving warfarin for 8 years for a cerebrovascular accident. Initiation of a high-protein, low-carbohydrate diet resulted in a 30% increase (from 26.25 to 37.5 mg/wk) in warfarin dose. His warfarin dose was reduced to the original dose after he stopped the high-protein, low-carbohydrate diet. DISCUSSION: The Naranjo probability scale indicated a possible adverse effect between warfarin and high-protein diets. High-protein diets have been shown to increase serum albumin levels. This may result in more warfarin binding to serum albumin, thereby decreasing the anticoagulant effect of warfarin. The increase of albumin occurs rapidly after initiation of a high-protein diet and appears to promptly affect anticoagulation therapy with warfarin. CONCLUSIONS: These cases indicate a significant interaction between high-protein, low-carbohydrate diets and warfarin therapy. Patients receiving warfarin therapy should be educated on and monitored for the potential interaction that occurs with warfarin therapy and high-protein, low-carbohydrate diets.