Evaluation of Aspirin Prescribing and Gastrointestinal Bleeding in Adults 60 Years of Age and Older in a Large, Academic Health System.

Background National guidelines no longer recommend adults 60 years of age and older to begin treatment with low-dose daily aspirin for primary prevention of atherosclerotic cardiovascular disease (CVD) due to a lack of proven net benefit and a higher risk of bleeding. Objective The objective of this cross-sectional retrospective analysis was to evaluate the appropriateness of low-dose aspirin prescribing and subsequent gastrointestinal bleeding in older persons receiving primary care in a large academic health system. Setting Large, academic health system within Colorado. Patients Patients with an active order for daily low-dose aspirin as of July 1, 2021, were assessed for appropriateness based on indication (primary vs secondary prevention) and use of a concomitant proton-pump inhibitor (PPI). Incident gastrointestinal bleeds (GIBs) in the subsequent 12 months and GIB risk factors were also evaluated. Results A total of 19,525 patients were included in the analysis. Eighty-nine percent of patients identified as White and 54% identified as male. Of the total cohort, 44% had CVD and 19% were co-prescribed a PPI. GIB occurred in 247 patients (1.27%) within the subsequent year. Risk factors significantly associated with a GIB within 1 year included: history of GIB, history of peptic ulcer disease, other esophageal issue (esophagitis, Barrett's esophagus, Mallory Weiss tears, etc.), 75 years of age or older, and history of gastroesophageal reflux disease. Conclusion This evaluation found that many older persons at this institution may be inappropriately prescribed aspirin, providing opportunities for pharmacists to improve medication safety by deprescribing aspirin among primary prevention patients or potentially co-prescribing a PPI in secondary prevention patients.

Improving Maternal Health Care Quality and Outcomes: Evaluation of a Pregnancy Medical Home.

Current maternal care recommendations in the United States focus on monitoring fetal development, management of pregnancy complications, and screening for behavioral health concerns. Often missing from these recommendations is support for patients experiencing socioeconomic or behavioral health challenges during pregnancy. A Pregnancy Medical Home (PMH) is a multidisciplinary maternal health care team with nurse navigators serving as patient advocates to improve the quality of care a patient receives and health outcomes for both mother and infant. Using bivariate comparisons between PMH patients and reference groups, as well as interviews with project team members and PMH graduates, this evaluation assessed the impact of a PMH at an academic medical university on patient care and birth outcomes. This PMH increased depression screenings during pregnancy and increased referrals to behavioral health care. This evaluation did not find improvements in maternal or infant birth outcomes. Interviews found notable successes and areas for program enhancement.

Primary Care and Infectious Disease Provider Adherence to HIV Pre-exposure Prophylaxis (PrEP) Prescribing and Monitoring Recommendations.

This study aimed to compare primary care (PC) and infectious diseases (ID) provider adherence to HIV pre-exposure prophylaxis (PrEP) prescribing and monitoring parameters outlined in Centers for Disease Control/Department of Health and Human Services (CDC/DHHS) guidelines. This retrospective cohort analysis from 2017 to 2022 used prescription and laboratory order data to identify patients prescribed PrEP by PC or ID providers. Primary endpoints assessed were adherence to baseline and follow-up HIV monitoring recommendations in the 12 months following the initial PrEP prescription. Secondary endpoints included appropriate PrEP prescription order quantities (≤ 90-day supply), appropriate renal function monitoring, and identification of factors independently associated with follow-up HIV monitoring adherence. Of the 324 eligible patients identified, 112 received PrEP from an ID specialist and 212 from a PC provider. Patients prescribed PrEP from an ID specialist were more likely to have appropriately completed baseline HIV monitoring (OR = 2.56, 95% CI 1.20, 5.47), follow-up HIV monitoring (OR = 1.81, 95% CI 1.08, 3.05), and renal function monitoring (OR = 2.81, 95% CI 1.69, 4.68); The ID group was also more likely to have PrEP prescriptions appropriately authorized for a days' supply of ≤ 90 days (OR = 4.41, 95% CI 2.60, 7.48). Patients receiving PrEP care from ID specialists had better adherence to all assessed PrEP prescribing and monitoring recommendations compared to those receiving care from PC providers.

Patient Perception and Impact of Home Test Kits on Health Care Utilization for Urinary Tract Infection.

Urinary tract infection (UTI) is a common reason for emergency department (ED) utilization that could potentially be treated by a primary care provider (PCP). This study assessed patient perceived value of a home UTI test kit plus educational materials and its impact on ED utilization for a UTI symptom episode. Women aged 18-75 years with Medicaid insurance and a history of 1-3 uncomplicated UTIs in the past year were prospectively identified and randomized to the intervention, intervention plus (intervention plus a patient portal message before its delivery), or standard of care group. A telephone survey was conducted 3-5 months after the mailing. Site of care for each UTI symptom episode was measured 12 months before and 6 months after the intervention. Test kit packages were mailed to 266 intervention individuals, and 150 responded to the telephone survey. Utilization outcomes were compared between a combined intervention group and a control group. Approximately one-third of the intervention patients experienced UTI symptoms within 5 months, and 73% used the test kit. Of those who experienced UTI symptoms, 58% contacted their PCP to seek care and 96% reported that the test kit was helpful. ED utilization was not significantly different in the intervention groups before and after the intervention, nor between the intervention and control groups postintervention. A home UTI test kit plus educational materials mailed to patients with a history of uncomplicated UTI was deemed helpful but did not have a measurable impact on ED utilization.

Lessons Learned: Evaluation of Fracture Liaison Service Quality Improvement Efforts in a Large Academic Healthcare System.

BACKGROUND: The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist. OBJECTIVE: We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation, and describe circumstances surrounding continued care gaps. DESIGN: Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation. PATIENTS: Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 and 3/31/22. INTERVENTION: A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit. MAIN MEASURES: Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated. KEY RESULTS: Of 1204 new fractures between 7/1/16 and 3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1] (p<0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p<0.001 versus pre), and 163/187 (87%) POST2 (p< 0.001 versus PRE, p=0.59 versus POST1). Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61%, p=0.016). CONCLUSION: An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates.

Bad to the bones: prescribing of drugs for the prevention and treatment of osteoporosis in patients on chronic glucocorticoids.

Of patients prescribed systemic glucocorticoids, this study identifies the proportion prescribed osteoporosis pharmacologic treatment and associated characteristics. Overall, 13.2% of patients were prescribed osteoporosis pharmacologic treatment. Predictors included documented osteoporosis, past DXA or fracture, and provision of care within a department using embedded protocols, suggesting electronic medical record-based tools may be beneficial. PURPOSE: This study aimed to identify a cohort of patients at risk for glucocorticoid-induced osteoporosis based on their prescribed glucocorticoid regimens and to quantify the proportion who were also prescribed osteoporosis pharmacologic treatment. The secondary objective was to recognize patient characteristics associated with receiving such treatment. METHODS: A retrospective single-site cohort study used prescription order data to identify 7774 adults prescribed chronic glucocorticoids and measure the proportion also prescribed osteoporosis pharmacologic treatment. RESULTS: Of the total cohort, 1026/7774 (13.2%) had osteoporosis pharmacologic treatment prescribed. Of the subgroups prescribed a prednisone-equivalent of 5, 10, or 20 mg per day or more for at least 180 days, 584/4262 (13.7%), 153/1048 (14.6%), and 47/344 (13.7%) had treatment prescribed. Factors independently associated with osteoporosis pharmacologic treatment initiation included having osteoporosis or osteopenia on the problem list (OR = 4.45, 95% CI 3.70-5.34), history of dual-energy X-ray absorptiometry (DXA) screening (OR = 2.18, 95% CI 1.82-2.62), history of fracture (OR = 1.83, 95% CI 1.54-2.167), and longer duration of glucocorticoid use (OR = 1.33, 95% CI 1.10-1.59). The prescribing department was also a significant predictor of medication initiation, with cardiac transplant (OR = 6.04, 95% CI 3.97-9.17), oncology (OR = 4.11, OR 3.28-5.14), and lung transplant (OR = 1.51, 95% CI 1.08, 2.12) being positively correlated with this outcome, and nephrology (OR = 0.51, 95% CI 0.36-0.72) and kidney transplant (OR = 0.53, 95% CI 0.37, 0.75) being negatively correlated. CONCLUSION: Prescribing rate of osteoporosis pharmacologic treatment in patients using chronic glucocorticoids is low. Examining practices with higher prescribing rates may offer insight into improving protection against osteoporosis-induced fractures.

Centrally supported clinical pharmacist intervention to reduce clinical inertia in hypertension.

PURPOSE: To assess the impact of a one-time hypertension (HTN)-focused clinical pharmacist intervention on the occurrence of clinical inertia and change in blood pressure (BP). METHODS: This retrospective study included patients 18 to 89 years of age with a current diagnosis of HTN and average systolic BP of ≥150 mm Hg. Centralized outreach coordinators performed telephone outreach to patients to schedule an HTN-focused visit with their primary care provider (PCP) and forwarded outreach notes for half of these patients to clinical pharmacists embedded in an internal medicine clinic. The clinical pharmacists performed a one-time focused medication review and provided evidence-based recommendations to a patient's PCP prior to the scheduled appointment. The primary outcome was therapy intensification (medication adjustment or adherence discussion) as a measure of overcoming clinical inertia. Secondary outcomes were the mean changes in systolic and diastolic BP from preintervention values to 6-month follow-up in the intervention group versus the control group. RESULTS: A total of 91 patients were included, and 34 of 47 intervention patients (72%) had therapy intensification at the HTN-focused PCP appointment, compared to 20 of 44 control patients (46%) (P =0.017). The mean (SD) systolic BP reductions from baseline were 12.26 (29.04) mm Hg and 6.97 (27.05) mm Hg for the intervention and control groups, respectively (P =0.427), with diastolic BP reductions of 3.83 (13.14) mm Hg and 1.35 (10.60) mm Hg, respectively (P =0.380). CONCLUSION: A collaborative model involving centralized outreach coordinators and embedded clinical pharmacists led to a significant reduction in clinical inertia. This was a small-scale pilot study, and further research is needed to determine the effect of this intervention on BP reduction.

Evaluation of Loop Diuretic Dosing Following Sodium-Glucose Cotransporter 2 Inhibitor Initiation in Patients With Heart Failure.

Introduction: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have demonstrated cardiovascular benefits in patients with heart failure, many of which take loop diuretics. There are no evidence-based recommendations identifying which patients may require loop diuretic dose decreases or how to adjust loop diuretic doses when SGLT2is are initiated. Objectives: The main objective of this study was to investigate the frequency and degree of adjustments in loop diuretic doses after SGLT2i initiation in patients with heart failure. Methods: In this retrospective evaluation, patients seen in the UCHealth system with a diagnosis of heart failure who were prescribed a loop diuretic before initiation of SGLT2i were identified. We described loop diuretic dose changes at the time of SGLT2i initiation, at 6 months after initiation, and at 1 year after initiation. We also described de-escalation of maintenance medications that can contribute to hypotension at these time points. Data were evaluated using descriptive statistics. Results: A total of 100 patients were included. Loop diuretic dose was reduced empirically upon SGLT2i initiation in 2.0% of patients. Reduction of loop diuretic dose within the first 6 months of starting an SGLT2i occurred in 8.0% of patients. From baseline to 12 months after starting SGLT2i therapy, 14.0% of patients had loop diuretic dose reduction. Conclusions: Most of our patients with HF did not have change in loop diuretic dose after initiation of an SGLT2i. In patients who did have loop diuretic dose reduction, most occurred within 6 months after starting SGLT2i therapy rather than empirically at time of initiation.

Stop the denosumab delay! The effect of implementing an automatic reminder in the electronic medical record.

Delays in denosumab dosing for osteoporosis treatment may lead to rapid bone loss or increased fractures. We assessed the frequency of delayed denosumab dosing before and after the implementation of a structured ordering plan with automated reminders and found that the rate of delayed denosumab dosing was cut in half. PURPOSE: The purpose of our study was to assess the frequency of delayed denosumab dosing before and after the implementation of a structured ordering plan with automated reminders. METHODS: We conducted a retrospective chart review of 720 adults with osteoporosis who received at least two denosumab doses within the UCHealth system before and after the plan went into effect. RESULTS: There was a significant reduction in delayed dosing from 24.0% (PRE) to 12.6% (POST) (p < 0.001) after implementation of the automated reminder. The fraction of delayed denosumab doses due to scheduling issues decreased significantly between PRE and POST time periods (16.4% vs. 3.3%, p = 0.011), while patient-related issues increased from 31.2% to 46.7% (p = 0.041). The rate of provider, medical, and other/unknown issues did not differ between the two time periods. When normalized to patient-years of follow-up, the number of fractures was the same for both groups at 0.016 fractures per patient-year. Fractures in both the PRE and POST groups were related to dosing delays, but the study was not powered to detect the differences in fracture rates between the groups. CONCLUSION: Electronic records with automatic reminders can reduce delayed dosing of denosumab and may lead to reductions in fractures associated with delays.

An evaluation of clinical decision support tools for Patient Health Questionnaire-9 administration.

INTRODUCTION: Many health care institutions are working to improve depression screening and management with the use of the Patient Health Questionnaire 9 (PHQ-9). Clinical decision support (CDS) within the EHR is one strategy, but little is known about effective approaches to design or implement such CDS. The purpose of this study is to compare implementation outcomes of two versions of a CDS tool to improve PHQ-9 administration for patients with depression. METHODS: This was a retrospective, observational study comparing two versions of a CDS. Version 1 interrupted clinician workflow, and version 2 did not interrupt workflow. Outcomes of interest included reach, adoption, and effectiveness. PHQ-9 administration was determined by chart review. Chi-square tests were used to evaluate associations between PHQ-9 administration with versions 1 and 2. RESULTS: Version 1 resulted in PHQ-9 administration 77 times (15.3% of 504 unique encounters) compared with 49 times (9.8% of 502 unique encounters) with version 2 (P = .011). DISCUSSION: An interruptive CDS tool may be more effective at increasing PHQ-9 administration, but a noninterruptive CDS tool may be preferred to minimize alert fatigue despite a decrease in effectiveness.

Sodium-glucose cotransporter-2 inhibitors and risk for genitourinary infections in older adults with type 2 diabetes.

BACKGROUND AND AIMS: Although landmark clinical trials have demonstrated an increased risk for genitourinary infection (GUI) after initiation of sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy that led to an FDA label warning, real world findings have been inconsistent and evidence specifically in older adults is lacking. The objective of the study was to examine the incidence of GUI in patients aged 65 years or older initiated on SGLT2i compared with glucagon-like peptide-1 receptor agonist (GLP1-RA) therapy at a large academic health system. METHODS: A retrospective population-based cohort study was conducted using electronic health records of patients aged 65 years and older with a diagnosis of type 2 diabetes mellitus. Patients newly initiated on SGLT2i or GLP1-RA therapy with estimated glomerular filtration rate (eGFR) ⩾30 mL/min per 1.73 m² and active within the health system for at least 1 year prior to initiation were included. We compared the incidence of inpatient, emergency room, or outpatient diagnosis of GUI (bacterial and mycotic) within 6 months of SGLT2i or GLP1-RA initiation. A chi-square or Fisher's exact test were used to analyze between-group differences for categorical variables, while a t-test was used for continuous variables. A Cox proportional hazards model was used to estimate the impact of confounding variables on the primary outcome. RESULTS: One hundred and thirty-three patients were initiated on SGLT2i therapy and 341 patients newly initiated on GLP1-RA therapy. After adjusting for differences in age, A1c, body mass index, eGFR, race and sex, there was no statistically significant difference in GUI incidence within 6 months of SGLT2i versus GLP1-RA initiation (3.8% versus 6.5%, adjusted hazard ratio: 0.784, 95% confidence interval 0.260-2.367). CONCLUSION: We found no increased risk of composite GUI within 6 months of initiating SGLT2i compared with GLP1-RA therapy. These real-world data in older adults add to previous findings, which suggest no increased risk of urinary tract infection with SGLT2i initiation. PLAIN LANGUAGE SUMMARY: A class of antidiabetic medications and risk for genitourinary infections in older adults with type 2 diabetesOlder adults with type 2 diabetes often benefit from a class of antidiabetic medications known as sodium-glucose cotransporter-2 inhibitors (SGLT2is) which help to lower blood glucose, decrease risk for cardiovascular disease and prevent kidney disease progression. However, there is concern that these medications may increase risk for urinary tract infections and/or genital fungal infections in older adults based on clinical trial evidence. Our study evaluated the real-world occurrence of these safety events in patients aged 65 years or older who were newly started on these medications. We compared these patients with a group of patients newly started on an alternative class of antidiabetic agents which are not expected to increase risk for infections, known as glucagon-like peptide-1 receptor agonists (GLP1-RA). In our study, we included 133 patients who started an SGLT2i and 341 patients who started a GLP1-RA at a large teaching hospital. We evaluated the occurrence of infection up to 6 months after initiation of these mediations. We found no significant difference in infection rate between these two groups. We conclude in the study that the use of SGLT2i in older adults was not associated with increased risk for urinary tract infections or genital fungal infections when compared with GLP1-RA use.

Prescribing practices of migraine-specific pharmacotherapy associated with emergency department use for migraine.

OBJECTIVE: This study compared migraine medication prescribing between patients with a migraine diagnosis who used versus did not use the emergency department (ED) for migraine. BACKGROUND: Headache is the fifth most common chief complaint for ED visits nationwide and the third most common potentially avoidable ED diagnosis in the University of Colorado Health system. The reasons some patients use the ED for migraine management while others do not and whether some ED admissions might be preventable remain unclear. METHODS: This retrospective cohort study identified adults with migraine-related diagnoses within 1 year before the index date of July 1, 2018 and compared patient characteristics and migraine medication prescribing patterns between those who did or did not have a subsequent migraine-related ED encounter the following year. ED admission notes were manually reviewed to identify potentially preventable circumstances that led to the ED visit. The primary outcome was the proportion of patients with an active triptan prescription at the index date. RESULTS: Of the 3843 patients identified, 35 patients (0.9%) had a migraine-related ED encounter. Of these, 17/35 (49%) had an active triptan prescription compared to 1360/3808 (36%) of non-ED utilizers (p = 0.114), OR 1.22 (95% CI 0.61-2.45). More ED utilizers had an active prescription for opioids (11/35 [31%] vs. 663/3808 [17%], p = 0.030) and migraine preventive therapy (19/35 [54%] vs. 1149/3808 [30%], p = 0.002), and neurology referrals (20/35 [57%] vs. 654/3808 [17%], p < 0.001) compared to non-ED utilizers. The most common circumstance for migraine-related ED visits was nonresponse to migraine abortive medications administered at home. CONCLUSIONS: Triptan prescribing did not differ between ED utilizers and non-ED utilizers for migraine. Overall, less than half of the total patient population had a triptan prescribed. More ED utilizers had neurology referrals, prescriptions for opioids and preventive therapies, and a history of previous ED visit for any reason, which may be markers for higher disease severity or behavior patterns. Future research and interventions to reduce migraine-related ED use could target high-risk patients such as those with previous ED visits for any indication and neurology referrals.

Early impact of the 2018 AHA/ACC/multisociety cholesterol guideline on lipid monitoring after statin initiation.

BACKGROUND: The 2018 AHA/ACC/multisociety cholesterol guideline emphasizes the need for lipid monitoring more strongly than the previous 2013 guideline to ensure patients reach recommended percent low-density lipoprotein cholesterol reductions. Real-world compliance to monitoring recommendations is currently unknown. OBJECTIVES: This study examined the proportion of patients with a lipid panel measured within 3 months of statin initiation. METHODS: This retrospective cohort study evaluated University of Colorado Health primary care patients aged 18 to 89 years with a new statin prescription identified via the Epic Clarity database. Patients initiated on a statin during January 1, 2018 to June 30, 2018 and January 1, 2019 to June 30, 2019 were included in the pre-2018 guideline cohort and the post-2018 guideline cohort, respectively. Patients with active liver disease, pregnancy, or missing demographic data were excluded. RESULTS: A total of 13,726 patients were included, 7476 in the preguideline cohort and 6250 in the postguideline cohort. A total of 13.9% of patients in the preguideline cohort had a lipid panel completed within 3 months of statin initiation compared with 16.2% in the postguideline cohort (adjusted P < .001). In the postguideline cohort, 56% (n = 857) of patients with lipid monitoring warranted a therapeutic intensification as recommended by the 2018 guideline; however, only 5% had their lipid-lowering regimen changed. CONCLUSION: In a large integrated health system, lipid monitoring increased among patients newly started on statin therapy soon after release of the 2018 guideline but remains low. Clinical interventions are needed to improve lipid monitoring to optimize low-density lipoprotein cholesterol-lowering therapy and ensure that guideline-recommended goals are achieved.

Pharmacist-Led Transition of Care Pilot Targeting Older People After Emergency Department Discharge.

OBJECTIVE: To evaluate the impact of a pharmacist-led transitional care intervention targeting high-risk older people after an emergency department (ED) visit.
DESIGN: Retrospective cohort study of older people with ED visits prior to and during a pharmacist-led intervention.
SETTING: Patients receiving primary care from the University of Colorado Health Seniors Clinic.
PARTICIPANTS: The intervention cohort comprised 170 patients with an ED visit between August 18, 2018, and February 19, 2019, and the historical cohort included 166 patients with an ED visit between August 18, 2017, and February 19, 2018. All included patients either had a historical diagnosis of heart failure or chronic obstructive pulmonary disease, or they had an additional ED visit in the previous six months.
INTERVENTIONS: The pilot intervention involved postED discharge telephonic outreach and assessment by a clinical pharmacist, with triaging to other staff if necessary.
MAIN OUTCOME MEASURE: The primary outcome was the proportion of patients with at least one repeat ED visit, hospitalization, or death within 30 days of ED discharge. Outcome rates were also assessed at 90 days postdischarge.
RESULTS: The primary outcome occurred in 21% of the historical cohort and 25% of the intervention cohort (adjusted P-value = 0.48). The incidence of the composite outcome within 90 days of ED discharge was 43% in the historical group compared with 38% in the intervention group (adjusted P-value = 0.29).
CONCLUSION: A pharmacist-led telephonic intervention pilot targeting older people did not appear to have a significant effect on the composite of repeat ED visit, hospitalization, or death within 30 or 90 days of ED discharge. A limited sample size may hinder the ability to make definitive conclusions based on these findings.

A comparison of clinical pharmacist management of type 2 diabetes versus usual care in a federally qualified health center

BACKGROUND: Clinical pharmacists have demonstrated their ability to improve patient outcomes over usual care for patients with type 2 diabetes and glycemic levels above goal, though reasons for this are not well defined. Numerous medications exist for the management of patients with type 2 diabetes and different patterns of medication use by clinical pharmacists may explain these benefits. OBJECTIVE: The objective of this study was to compare pharmacotherapy approaches to managing patients with uncontrolled type 2 diabetes receiving basal insulin by a clinical pharmacist versus usual care by a physician or advanced practice provider in a federally qualified health center. METHODS: A retrospective cohort study of patients 18 to 85 years old with type 2 diabetes, A1C ≥9%, receiving basal insulin was conducted. Patients were grouped into two cohorts: (1) those who received clinical pharmacist care and (2) those who received usual care from a physician or advanced practice provider. The primary outcome evaluated the proportion of patients treated with the addition of a non-basal insulin medication. Type of medication changes or additions as well as change in A1C and change in weight were also analyzed. Outcomes were evaluated at six months post-index A1C. RESULTS: A total of 202 patients were identified (n=129 in the usual care group and n=73 in the clinical pharmacist group). A non-basal insulin medication was added in 29% of patients receiving usual care versus 41% of patients receiving clinical pharmacist care (adjusted p = 0.040). Usual care providers more frequently added metformin, sulfonylureas and thiazolidinediones, while clinical pharmacists more frequently added prandial insulin, DPP-4 inhibitors, GLP-1 agonists, and SGLT-2 inhibitors. A1C decreased 1.6% in the clinical pharmacist group versus 0.9% in the usual care group (adjusted p = 0.055). No significant change in weight was observed between the clinical pharmacist and usual care group (0.2 kg versus -1.0 kg, respectively; adjusted p = 0.175). CONCLUSIONS: Pharmacotherapy approaches to managing patients with uncontrolled type 2 diabetes varied between clinical pharmacists and other clinician providers. For patients already on basal insulin, clinical pharmacists were more likely to intensify therapy with the addition of non-basal insulin, including more frequent initiation of prandial insulin and by adding newer antihyperglycemic agents

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Social and Psychosocial Determinants of Health Associated With Uncontrolled Diabetes in a Federally Qualified Health Center Population.

PURPOSE: Many people with diabetes have difficulty achieving glycemic targets, and social and psychosocial determinants of health may influence their ability to obtain glycemic goals. The objective of this study was to identify characteristics independently associated with A1C >9% or untested A1C compared to those with A1C ≤9% at a federally qualified health center. METHODS: This retrospective cohort study included people with a diagnosis of diabetes, who were 18-89 years of age and had a medical evaluation from a primary care provider between 1 September 2016 and 31 August 2017. The primary outcome was to identify characteristics associated with an A1C >9% or untested A1C compared to those with an A1C ≤9%. RESULTS: Of 6,185 patients meeting inclusion criteria, 2,965 (48%) had uncontrolled A1C. In the uncontrolled A1C group, 1,549 patients (52%) were female, 1,296 (44%) preferred care in a language other than English (1,273 [43%] in Spanish), and 535 (18%) had a concurrent mental health diagnosis. Multivariable logistic regression of 4,774 patients with complete data revealed that poor appointment adherence (odds ratio [OR] 3.24, 95% CI 2.30-4.57) and/or a positive Patient Health Questionnaire-2 depression screen (OR 1.35, 95% CI 1.12-1.62) had an increased risk of being in the uncontrolled A1C group. Patients with a prescription for antidepressant medication were more likely to be in the controlled group. CONCLUSION: Poor adherence to appointments and presence of depressive symptoms were associated with high A1C values. Interventions can be developed targeting these determinants to improve blood glucose levels.

Evaluating the feasibility of a pharmacist-guided patient-driven intervention to improve blood pressure control in patients with CKD.

BACKGROUND: Self-titration of blood pressure (BP) medications and lifestyle modifications are effective and safe strategies to lower BP. We assessed the feasibility of implementing a pharmacist-guided, patient-driven self-titration protocol and standardized dietary counseling to improve BP in the chronic kidney disease (CKD) clinic. METHODS: Adult patients seen in the CKD clinic were identified via registry screening. Inclusion criteria were as follows: a diagnosis of hypertension, average of the last 3 office BP > 150/90 mmHg, and prescribed 3 or fewer BP medications. Patients with severe hypertension were excluded. BP goals were established and patients were referred to the clinical pharmacist who provided them a BP cuff, a BP medication titration plan (based on home BP monitoring), and dietary education. The following outcomes were evaluated: appeal of the program to patients identified by the registry, patient adherence to the protocol and 6-month office BP, and provider attitudes and acceptance of the protocol. RESULTS: Seventeen patients enrolled in the pilot, the majority recruited via clinic schedule screening. Eleven of the 17 patients completed a 6-month office follow-up visit. Three of the 11 patients met their pre-specified office BP goal. There was, however, significant improvement in 6-month office systolic and diastolic BP. Twelve of 17 patients were adherent to entering home BP in EMR. Provider satisfaction with the protocol was high. CONCLUSION: Our preliminary data suggest that patient-driven self-titration of BP medications is feasible and well received by providers. Future studies are needed to validate these findings and to evaluate the safety and efficacy of this approach.

A comparison of clinical pharmacist management of type 2 diabetes versus usual care in a federally qualified health center.

BACKGROUND: Clinical pharmacists have demonstrated their ability to improve patient outcomes over usual care for patients with type 2 diabetes and glycemic levels above goal, though reasons for this are not well defined. Numerous medications exist for the management of patients with type 2 diabetes and different patterns of medication use by clinical pharmacists may explain these benefits. OBJECTIVE: The objective of this study was to compare pharmacotherapy approaches to managing patients with uncontrolled type 2 diabetes receiving basal insulin by a clinical pharmacist versus usual care by a physician or advanced practice provider in a federally qualified health center. METHODS: A retrospective cohort study of patients 18 to 85 years old with type 2 diabetes, A1C ≥9%, receiving basal insulin was conducted. Patients were grouped into two cohorts (1) those who received clinical pharmacist care and (2) those who received usual care from a physician or advanced practice provider. The primary outcome evaluated the proportion of patients treated with the addition of a non-basal insulin medication. Type of medication changes or additions as well as change in A1C and change in weight were also analyzed. Outcomes were evaluated at six months post-index A1C. RESULTS: A total of 202 patients were identified (n=129 in the usual care group and n=73 in the clinical pharmacist group). A non-basal insulin medication was added in 29% of patients receiving usual care versus 41% of patients receiving clinical pharmacist care (adjusted p=0.040). Usual care providers more frequently added metformin, sulfonylureas and thiazolidinediones, while clinical pharmacists more frequently added prandial insulin, DPP-4 inhibitors, GLP-1 agonists, and SGLT-2 inhibitors. A1C decreased 1.6% in the clinical pharmacist group versus 0.9% in the usual care group (adjusted p=0.055). No significant change in weight was observed between the clinical pharmacist and usual care group (0.2 kg versus -1.0 kg, respectively; adjusted p=0.175). CONCLUSIONS: Pharmacotherapy approaches to managing patients with uncontrolled type 2 diabetes varied between clinical pharmacists and other clinician providers. For patients already on basal insulin, clinical pharmacists were more likely to intensify therapy with the addition of non-basal insulin, including more frequent initiation of prandial insulin and by adding newer antihyperglycemic agents.

Changes in pharmacy students' perceptions of underserved populations after a six-week clinical rotation in a federally qualified health center clinic.

BACKGROUND AND PURPOSE: The primary objective of this study was to assess changes in pharmacy students' attitudes and perceptions toward providing care to underserved populations after a six-week clinical experience within a Federally Qualified Health Center (FQHC) clinic. EDUCATIONAL ACTIVITY AND SETTING: A pre-post survey design was utilized to evaluate third- and fourth-year pharmacy students' attitudes and perceptions before and after a six-week clinical rotation providing direct patient care to underserved patients in FQHC clinics. Results were collected via self-administered online surveys that collected information on participants' (1) demographics, (2) past experiences interacting with underserved populations, (3) type of clinical activities completed during the rotation, and (4) personal opinions and perceptions of providing care to underserved populations. FINDINGS: Responses to seven of the 18 attitudinal questions showed a statistically significant positive change from baseline, with three questions being related to educational satisfaction. Changes in attitudes for questions related to domains of personal impact and perceptions/barriers were also significant. DISCUSSION/SUMMARY: Clinical rotations within an FQHC clinic can positively impact pharmacy students' attitudes towards underserved populations. If more students are exposed to direct patient care with underserved populations throughout their experiential training, the number of graduating student pharmacists that explore job opportunities within underserved areas may increase. Clinical rotations within an FQHC clinic can positively impact pharmacy students' attitudes towards underserved populations. If more students are exposed to direct patient care with underserved populations throughout their experiential training, the number of graduating student pharmacists that explore job opportunities within underserved areas may increase.