Blood Pressure, Readmission, and Mortality Among Patients Hospitalized With Acute Kidney Injury.

Importance: Acute kidney injury (AKI) complicates 20% to 25% of hospital admissions and is associated with long-term mortality, especially from cardiovascular disease. Lower systolic blood pressure (SBP) following AKI may be associated with lower mortality, but potentially at the cost of higher short-term complications. Objective: To determine associations of SBP with mortality and hospital readmissions following AKI, and to determine whether time from discharge affects these associations. Design, Setting, and Participants: This retrospective cohort study of adults with AKI during a hospitalization in Veteran Healthcare Association (VHA) hospitals was conducted between January 2013 and December 2018. Patients with 1 year or less of data within the VA system prior to admission, severe or end-stage liver disease, stage 4 or 5 chronic kidney disease, end-stage kidney disease, metastatic cancer, and no blood pressure values within 30 days of discharge were excluded. Data analysis was conducted from May 2022 to February 2024. Exposure: SBP was treated as time-dependent (categorized as <120 mm Hg, 120-129 mm Hg, 130-139 mm Hg, 140-149 mm Hg, 150-159 mm Hg, and ≥160 mm Hg [comparator]). Time spent in each SBP category was accumulated over time and represented in 30-day increments. Main Outcomes and Measures: Primary outcomes were time to mortality and time to all-cause hospital readmission. Cox proportional hazards regression was adjusted for demographics, comorbidities, and laboratory values. To evaluate associations over time, hazard ratios (HRs) were calculated at 60 days, 90 days, 120 days, 180 days, 270 days, and 365 days from discharge. Results: Of 237 409 admissions with AKI, 80 960 (57 242 aged 65 years or older [70.7%]; 77 965 male [96.3%] and 2995 female [3.7%]) were included. The cohort had high rates of diabetes (16 060 patients [20.0%]), congestive heart failure (22 516 patients [28.1%]), and chronic lung disease (27 682 patients [34.2%]), and 1-year mortality was 15.9% (12 876 patients). Overall, patients with SBP between 130 and 139 mm Hg had the most favorable risk level for mortality and readmission. There were clear, time-dependent mediations on associations in all groups. Compared with patients with SBP of 160 mm Hg or greater, the risk of mortality for patients with SBP between 130 and 139 mm Hg decreased between 60 days (adjusted HR, 1.20; 99% CI, 1.00-1.44) and 365 days (adjusted HR, 0.58; 99% CI, 0.45-0.76). SBP less than 120 mm Hg was associated with increased risk of mortality at all time points. Conclusions and Relevance: In this retrospective cohort study of post-AKI patients, there were important time-dependent mediations of the association of blood pressure with mortality and readmission. These findings may inform timing of post-AKI blood pressure treatment.

A Nationwide Emergency Department Data Analysis to Predict Beers List Medications Use Among Older Adults.

BACKGROUND: The use of potentially inappropriate medications (PIMs) is considered an important quality indicator for older adults seen in the ambulatory care setting. STUDY OBJECTIVES: To evaluate the pattern of potentially inappropriate medication (PIMs) use as specified in the Beers Criteria, for older adults during emergency department (ED) visits in the United States. METHODS: Using data from the National Hospital Ambulatory Care Survey (NHAMCS) we identified older adults (age 65 or older) discharged home from an ED visit in 2019. We defined PIMs as those with an 'avoid' recommendation under the American Geriatrics Society (AGS) 2019 Beers Criteria in older adults. Logistic regression models were used to assess demographic, clinical, and hospital factors associated with the use of any PIMs upon ED discharge. RESULTS: Overall, 5.9% of visits by older adults discharged from the ED included administration or prescriptions for PIMs. Among those who received any PIMs, 25.5% received benzodiazepines, 42.5 % received anticholinergics, 1.4% received nonbenzodiazepine hypnotics, and 0.5% received barbiturates. A multivariable model showed statistically significant associations for age 65 to 74 (OR 1.91, 95% CI 1.39-2.62 vs. age >=75), dementia (OR 0.45, 95% CI 0.21-0.95), lower immediacy (OR 2.45, 95% CI 1.56-3.84 vs. higher immediacy), and Northeastern rural region (OR 0.34, 95% CI 0.21-0.55 vs. Midwestern rural). CONCLUSION: We found that younger age and lower immediacy were associated with increased prescriptions of PIMs for older adults seen, while dementia and Northeastern rural region was associated with reduced use of PIMs seen and discharged from EDs in United States.

Pharmacist, nurse, and physician perspectives on the implementation of the pharmacist discharge care (pharm-dc) intervention: A qualitative study.

BACKGROUND: The PHARMacist Discharge Care (PHARM-DC) intervention is a pharmacist-led Transitions of Care (TOC) program intended to reduce 30-day hospital readmissions and emergency department visits which has been implemented at two hospitals in the United States. The objectives of this study were to: 1) explore perspectives surrounding the PHARM-DC program from healthcare providers, leaders, and administrators at both institutions, and 2) identify factors which may contribute to intervention success and sustainability. METHODS: Focus groups and interviews were conducted with pharmacists, physicians, nurses, hospital leaders, and pharmacy administrators at two institutions in the Northeastern and Western United States. Interviews were audio recorded and transcribed, with transcriptions imported into NVivo for qualitative analysis. Thematic analysis was performed using an iterative process, with two study authors independently coding transcripts to identify themes. RESULTS: Overall, 37 individuals participated in ten focus groups and seven interviews. The themes identified included: 1) Organizational, Pharmacist, and Patient Factors Contributing to Transitions of Care, 2) Medication Challenges in Transitions of Care at Admission and Discharge, 3) Transitions of Care Communication and Discharge Follow-up, and 4) Opportunities for Improvement and Sustainability. The four themes were mapped to the constructs of the CFIR and RE-AIM frameworks. Some factors facilitating intervention success and sustainability were accurate medication histories collected on admission, addressing medication barriers before discharge, coordinating discharge using electronic health record discharge features, and having a structured process for intervention training and delivery. Barriers to intervention implementation and sustainability included gaps in communication with other care team members, and variable pharmacist skills for delivering the intervention. This study identified that using educational resources to standardize the TOC process addressed the issue of variations in pharmacists' skills for delivering TOC interventions. CONCLUSIONS: Nurses, physicians, pharmacists, pharmacist leaders, and hospital administrators were in agreement regarding the usefulness of the PHARM-DC intervention, while acknowledging challenges in its implementation and opportunities for improvement. Future research should focus on developing training materials to standardize and scale the intervention, eliminating barriers to medication access pre-discharge, coordinating discharge across care team members, and communicating medication changes to primary care providers post-discharge.

Evaluation of a Telehealth-Based Pharmacist Led Chronic Care Management Program.

Background: Clinical pharmacy services improve several patient chronic disease outcomes. This review evaluates a pharmacist-led chronic care management (CCM) program partnered with a health system for patient outcomes and sustainability. Methods: A mixed methods evaluation based on the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework was completed. Patient A1c and blood pressure readings were retrospectively collected from the electronic health record from August 2018-April 2022. Patients that completed >4 CCM visits with a diagnosis of diabetes and/or hypertension were included. Results: 557 patients enrolled, 53 had uncontrolled systolic blood pressure (SBP), SBP >130 mmHg. Average SBP at baseline was 141.0 mmHg and average SBP at 6 months was 130.2 mmHg, (P < .001). 76 patients had uncontrolled diabetes, A1c > 7%. Average A1c at baseline = 9.1% and average A1c at 6 months = 8.3%, (P < .001). 4464 CCM visits with 247 disease-state targeted patients were completed over 44-month with a 100% adoption rate across clinic locations. Implementation facilitators included patient medication cost concerns, disease burden, provider revenue generation, CCM dedicated software, streamlined call process, and remote EMR access. Implementation barriers included provider discomfort "selling the program," potential patient costs, unclear need from patient, pharmacists not considered providers, pharmacist cost, multi-platform software, reprioritized stakeholder support, and lack of partner site diversification. Program maintenance showed revenue generation was $5925.31-$8879.89 from August 2021-May 2022 and profitability was $3385.61-$1614.23. Conclusion: This study provides lessons learned, strategies for implementation, and ideas for process efficiencies leading to maintenance of a telehealth pharmacist-led CCM service.

Naloxone analogy and opioid overdose terminology preferences among rural caregivers: Differences by race.

BACKGROUND: Despite national and state policies aimed at increasing naloxone access via pharmacies, opioid overdose death rates rose during the COVID-19 pandemic, particularly among Blacks and American Indians (AIs) in rural areas. Caregivers, or third parties who can administer naloxone during an overdose event, are important individuals in the naloxone administration cascade, yet no studies have explored rural caregivers' opioid overdose terminology and naloxone analogy preferences or whether these preferences differ by race. OBJECTIVES: To identify rural caregivers' overdose terminology and naloxone analogy preferences and determine whether preferences differ by race. METHODS: A sample of 40 caregivers who lived with someone at high risk of overdose and used pharmacies in 4 largely rural states was recruited. Each caregiver completed a demographic survey and a 20- to 45-minute audio-recorded semi-structured interview that was transcribed, de-identified, and imported into a qualitative software package for thematic analysis by 2 independent coders using a codebook. Overdose terminology and naloxone analogy preferences were analyzed for differences by race. RESULTS: The sample was 57.5% white, 35% Black, and 7.5% AIs. Many participants (43%) preferred that pharmacists use the term "bad reaction" to refer to overdose events over the terms "accidental overdose" (37%) and "overdose" (20%). The majority of white and Black participants preferred "bad reaction" while AI participants preferred "accidental overdose." For naloxone analogies, "EpiPen" was most preferred (64%), regardless of race. "Fire extinguisher" (17%), "lifesaver" (9.5%), and other analogies (9.5%) were preferred by some white and Black participants but not AI participants. CONCLUSION: Our findings suggest that pharmacists should use the "bad reaction" term and "EpiPen" analogy when counseling rural caregivers about overdose and naloxone, respectively. Caregivers' preferences varied by race, suggesting that pharmacists may want to tailor the terminology and analogy they use when discussing naloxone with caregivers.

Identifying barriers and facilitators to deprescribing benzodiazepines and sedative hypnotics in the hospital setting using the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behaviour (COM-B) Model: a qualitative study.

OBJECTIVES: Geriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers. DESIGN: We used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group. SETTING: Interviews took place in a tertiary, 886-bed hospital located in Los Angeles, California. PARTICIPANTS: Interview participants included physicians, pharmacists, pharmacist technicians, and nurses. RESULTS: We interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge. CONCLUSIONS: While we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.

Patient preferences and willingness-to-pay for community pharmacy-led Medicare Part D consultation services: A discrete choice experiment.

INTRODUCTION: Community pharmacies currently offer Medicare Part D consultation services, often at no-cost. Despite facilitating plan-switching behavior, identifying potential cost-savings, and increasing medication adherence, patient uptake of these services remains low. OBJECTIVES: To investigate patient preferences for specific service-offering attributes and marginal willingness-to-pay (mWTP) for an enhanced community pharmacy Medicare Part D consultation service. METHODS: A discrete choice experiment (DCE) guided by the SERVQUAL framework was developed and administered using a national online survey panel. Study participants were English-speaking adults (≥65 years) residing in the United States enrolled in a Medicare Part D or Medicare Advantage plan and had filled a prescription at a community pharmacy within the last 12 months. An orthogonal design resulted in 120 paired-choice tasks distributed equally across 10 survey blocks. Data were analyzed using mixed logit and latent class models. RESULTS: In total, 540 responses were collected, with the average age of respondents being 71 years. The majority of respondents were females (60%) and reported taking four or more prescription medication (51%). Service attribute levels with the highest utility were: 15-min intervention duration (0.392), discussion of services + a follow-up phone call (0.069), in-person at the pharmacy (0.328), provided by a pharmacist the patient knew (0.578), and no-cost (3.382). The attribute with the largest mWTP value was a service provided by a pharmacist the participant knew ($8.42). Latent class analysis revealed that patient preferences for service attributes significantly differed by gender and difficulty affording prescription medications. CONCLUSIONS: Quantifying patient preference using discrete choice methodology provides pharmacies with information needed to design service offerings that balance patient preference and sustainability. Pharmacies may consider providing interventions at no-cost to subsets of patients placing high importance on a service cost attribute. Further, patient preference for 15-min interventions may inform Medicare Part D service delivery and facilitate service sustainability.

Incorporation of an Efficient Pharmacist Workflow During the Transition From In-Person to Telemedicine Geriatric Clinics in Response to the COVID-19 Pandemic.

The COVID-19 pandemic created care continuity challenges for older adults in the ambulatory care setting. Similarly, maintaining the multidisciplinary team concept of geriatric care among healthcare practitioners working from home presented several logistical difficulties. It became apparent there was a need to address these problems to avoid care gaps in this vulnerable population. Realizing that in-person clinics could put vulnerable older adults at increased risk of contracting COVID-19, a workflow was proactively developed to convert a traditional in-person multidisciplinary geriatric clinic to a telemedicine-based model. A video patient encounter option within our electronic health record along with a secure on-line meeting platform was used to maintain a team-based approach to care. This resulted not only in a high level of efficiency in care delivery, but also ensured the safety of older adult patients served by the clinic. This model provides a template for the continued use of telemedicine as a strategy for the care of vulnerable older adults who experience challenges with attending in-person clinics.

Pharmacist discharge summary: Impact of inpatient to community pharmacist handoff at hospital discharge.

BACKGROUND: Community pharmacists are often the initial health professionals whom patients encounter after hospital discharge but are rarely provided relevant discharge information. OBJECTIVES: Implement a pharmacist-to-pharmacist discharge summary (P2PDS) to improve the safety of pharmacist care provision to patients transitioning home from the hospital. PRACTICE DESCRIPTION: Inpatient pharmacists at an academic medical center conduct discharge medication reconciliation and release discharge electronic prescriptions to dispensing pharmacies. PRACTICE INNOVATION: A multidisciplinary intersystem quality improvement project was conducted to demonstrate the impact of clinical information sharing via the P2PDS to community pharmacists. EVALUATION METHODS: With input from community pharmacists, the P2PDS was created and implemented on inpatient units throughout the health system. Outcomes assessed included identification of medication discrepancies, enrollment into reimbursable medication management services, and pharmacist confidence when filling discharge prescriptions. RESULTS: During the study period, community pharmacists identified a total of 388 medication discrepancies in 161 patients; 16% of discrepancies were considered "unintentional." Twenty-five discharging patients were identified for enrollment in medication management services, with 20 of these patients enrolling in all 3 services (medication delivery, synchronization, and medication packaging). The P2PDS increased community pharmacist confidence in discharge medication filling (40% vs. 95%, P < 0.001) and increased the percent of patients receiving community pharmacist medication reconciliation (14%-76%, P < 0.001). CONCLUSION: Enhancing pharmacist communication across practice settings with a P2PDS decreases care fragmentation through identification of medication discrepancies and improves pharmacist confidence in patient care provision.

Addressing the opioid epidemic through community pharmacy engagement: Study protocol for a randomized controlled trial.

BACKGROUND: Despite the authority to dispense naloxone, pharmacists have been reluctant to offer and dispense it, often due to discomfort communicating about the sensitive topic of opioid overdose. Because existing online naloxone trainings do not sufficiently address how to communicate effectively with patients about naloxone, Nalox-Comm, a training module designed to improve pharmacists' self-efficacy to engage in naloxone discussions, was developed. OBJECTIVE: To describe the study protocol to evaluate the effectiveness of the Nalox-Comm training module on naloxone dispensing rates. METHODS: A randomized controlled trial, which began in July 2021, is used to evaluate the pre-post Nalox-Comm training intervention. Sixty pharmacists are being recruited from 62 pharmacies part of a single grocery store chain in rural counties of the southeastern United States. After completing a baseline survey, pharmacists are observed by simulated patients (SPs) who rate the quality of their pre-training naloxone communication. Pharmacists are then invited to complete either a basic online naloxone training module (control group) or a newly developed Nalox-Comm training (experimental group), after which they complete a post-training survey and are observed a second time by SPs. Three months post-training, study participants complete a final follow-up survey. Naloxone dispensing records are obtained from each participating pharmacy to assess change in naloxone dispensing rates. CONCLUSION: Informed by rural pharmacist stakeholders, the Nalox-Comm training module addresses communication barriers specific to rural communities. Compared to those in the control group, we hypothesize that pharmacies in the experimental group will dispense more naloxone in the three months post-training intervention.

Determining the Factors that Impede or Facilitate the Utilization of Telemedicine (Video Visits) for Geriatric Patients.

Objective: The objective of the study was to evaluate the barriers and facilitators of telemedicine utilization experienced by geriatric patients at the University of Iowa Family Medicine Clinic and selected Senior Living Communities in Iowa City, to inform recommendations for improving the telemedicine delivery process for older adults. Methods: The study population was elderly patients (65-85 years old) living independently, and in long-term care facilities, who received health care using telemedicine during the period of the study from March to July 2020. A Mixed Methods study design was utilized with qualitative data collected through semistructured telephone and Zoom interviews and quantitative data through surveys. Results: A total of 33 study participants (n = 33) were interviewed or surveyed, including 3 patients (n = 3), 4 caregivers (n = 4), 19 physicians (n = 19), 5 medical assistants (n = 5), and 2 schedulers (n = 2). The results showed that geriatric patients and their caregivers, as well as health and nonhealth care personnel experience barriers, including difficulty navigating technology, privacy concerns, and lack of technical support; and facilitators, such as customer service support and having protocols to guide patients on telemedicine use. Conclusion: Geriatric patients face certain barriers and facilitators (self-identified or identified by their caregivers, physicians, and other health and nonhealth care personnel) that can make it either more or less difficult for them to maximize the benefits of telemedicine. As a result, health systems should consider older adults' needs and preferences when implementing telemedicine systems in outpatient settings.

A qualitative dual-site analysis of the pharmacist discharge care (PHARM-DC) intervention using the CFIR framework.

INTRODUCTION: Older adults face several challenges when transitioning from acute hospitals to community-based care. The PHARMacist Discharge Care (PHARM-DC) intervention is a pharmacist-led Transitions of Care (TOC) program intended to reduce 30-day hospital readmissions and emergency department visits at two large hospitals. This study used the Consolidated Framework for Implementation Research (CFIR) framework to evaluate pharmacist perceptions of the PHARM-DC intervention. METHODS: Intervention pharmacists and pharmacy administrators were purposively recruited by study team members located within each participating institution. Study team members located within each institution coordinated with two study authors unaffiliated with the institutions implementing the intervention to conduct interviews and focus groups remotely via telecommunication software. Interviews were recorded and transcribed, with transcriptions imported into NVivo for qualitative analysis. Qualitative analysis was performed using an iterative process to identify "a priori" constructs based on CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation) and to create overarching themes as identified during coding. RESULTS: In total, ten semi-structured interviews and one focus group were completed across both hospitals. At Site A, six interviews were conducted with intervention pharmacists and pharmacists in administrative roles. Also at Site A, one focus group comprised of five intervention pharmacists was conducted. At Site B, interviews were conducted with four intervention pharmacists and pharmacists in administrative roles. Three overarching themes were identified: PHARM-DC and Institutional Context, Importance of PHARM-DC Adaptability, and Recommendations for PHARM-DC Improvement and Sustainability. Increasing pharmacist support for technical tasks and navigating pharmacist-patient language barriers were important to intervention implementation and delivery. Identifying cost-savings and quantifying outcomes as a result of the intervention were particularly important when considering how to sustain and expand the PHARM-DC intervention. CONCLUSION: The PHARM-DC intervention can successfully be implemented at two institutions with considerable variations in TOC initiatives, resources, and staffing. Future implementation of PHARM-DC interventions should consider the themes identified, including an examination of institution-specific contextual factors such as the roles that pharmacy technicians may play in TOC interventions, the importance of intervention adaptability to account for patient needs and institutional resources, and pharmacist recommendations for intervention improvement and sustainability. TRIAL REGISTRATION: NCT04071951 .

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.

Medication Management and Deprescribing in Assisted Living Facilities.

Medication management for seniors is a foundation for keeping them healthy and independent. A vital aspect of medication management is the selective discontinuation of medications, or deprescribing. While this is a common practice within nursing homes it seems to be less common among those who live in assisted living facilities. Shockingly little exiting literature was found when conducting a literature review concerning deprescribing in assisted living facilities. Therefore, it was determined to set forth this call to action to focus on deprescribing in assisted living facilities hoping that it would be given more attention to keep our seniors healthy and safe.

Lessons learned recruiting a diverse sample of rural study participants during the COVID-19 pandemic.

Residents of rural areas have been a hard-to-reach population for researchers. Geographical isolation and lower population density in rural areas can make it particularly challenging to identify eligible individuals and recruit them for research studies. If the study is about a stigmatizing topic, such as opioid overdose, recruitment can be even more difficult due to confidentiality concerns and distrust of outside researchers. This paper shares lessons learned, both successes and failures, for recruiting a diverse sample of rural participants for a multi-state research study about naloxone, an opioid overdose reversal agent. In addition, because our recruitment spanned the period before and after the COVID-19 pandemic in the U.S., we share lessons learned regarding the transition to all remote recruitment and data collection. We utilized various recruitment strategies including rural community pharmacy referrals, community outreach, participant referrals, mass emails, and social media with varying degrees of success. Among these modalities, pharmacist referrals and community outreach produced the highest number of participants. The trust and rapport that pharmacists have with rural community members eased their concerns about working with unknown researchers from outside their communities and facilitated study team members' ability to contact those individuals. Even with the limited in-person options during the pandemic, we reached our recruitment targets by employing multiple recruitment strategies with digital flyers and emails. We also report on the importance of establishing trust and maintaining honest communication with potential participants as well as how to account for regional characteristics to identify the most effective recruitment methods for a particular rural area. Our suggested strategies and recommendations may benefit researchers who plan to recruit underrepresented minority groups in rural communities and other historically hard-to-reach populations for future studies.

The Pharmacist Discharge Care (PHARM-DC) study: A multicenter RCT of pharmacist-directed transitional care to reduce post-hospitalization utilization.

BACKGROUND: Older adults commonly face challenges in understanding, obtaining, administering, and monitoring medication regimens after hospitalization. These difficulties can lead to avoidable morbidity, mortality, and hospital readmissions. Pharmacist-led peri-discharge interventions can reduce adverse drug events, but few large randomized trials have examined their effectiveness in reducing readmissions. Demonstrating reductions in 30-day readmissions can make a financial case for implementing pharmacist-led programs across hospitals. METHODS/DESIGN: The PHARMacist Discharge Care, or the PHARM-DC intervention, includes medication reconciliation at admission and discharge, medication review, increased communication with caregivers, providers, and retail pharmacies, and patient education and counseling during and after discharge. The intervention is being implemented in two large hospitals: Cedars-Sinai Medical Center and the Brigham and Women's Hospital. To evaluate the intervention, we are using a pragmatic, randomized clinical trial design with randomization at the patient level. The primary outcome is utilization within 30 days of hospital discharge, including unforeseen emergency department visits, observation stays, and readmissions. Randomizing 9776 patients will achieve 80% power to detect an absolute reduction of 2.5% from an estimated baseline rate of 27.5%. Qualitative analysis will use interviews with key stakeholders to study barriers to and facilitators of implementing PHARM-DC. A cost-effectiveness analysis using a time-and-motion study to estimate time spent on the intervention will highlight the potential cost savings per readmission. DISCUSSION: If this trial demonstrates a business case for the PHARM-DC intervention, with few barriers to implementation, hospitals may be much more likely to adopt pharmacist-led peri-discharge medication management programs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04071951.

Development of a centralized, remote clinical pharmacy service to enhance primary care.

More than 50% of Americans possess at least one chronic condition and another 25% suffer from two or more, leaving primary care teams tasked to care for the chronic, acute, and preventive care needs of their large patient panels. Pharmacists can reduce the burden on busy providers by effectively managing chronic diseases as members of health care teams. Many private physician practices lack the resources to include pharmacists on their teams. A centralized, remote clinical pharmacy services model allows pharmacists to remotely manage chronic disease in patients in collaboration with primary care providers. The purpose of this report is to describe how a centralized, remote clinical pharmacy team was developed, trained, and effectively integrated into multiple, diverse primary care settings across the U.S.

Development of a centralized, remote clinical pharmacy service to enhance primary care

More than 50% of Americans possess at least one chronic condition and another 25% suffer from two or more, leaving primary care teams tasked to care for the chronic, acute, and preventive care needs of their large patient panels. Pharmacists can reduce the burden on busy providers by effectively managing chronic diseases as members of health care teams. Many private physician practices lack the resources to include pharmacists on their teams. A centralized, remote clinical pharmacy services model allows pharmacists to remotely manage chronic disease in patients in collaboration with primary care providers. The purpose of this report is to describe how a centralized, remote clinical pharmacy team was developed, trained, and effectively integrated into multiple, diverse primary care settings across the U.S

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Dissemination of a telehealth cardiovascular risk service: The CVRS live protocol.

BACKGROUND: Medical clinics are increasingly hiring clinical pharmacists to improve management of cardiovascular disease (CVD). However, the limited number of clinical pharmacists employed in a clinic may not impact the large number of complex patients needing the services. We have developed a remote telehealth service provided by clinical pharmacists to complement CVD services provided by on-site clinical pharmacists and aid sites without a clinical pharmacist. This cardiovascular risk service (CVRS) has been studied in two NIH-funded trials, however, we identified barriers to optimal intervention implementation. The purpose of this study is to examine how to implement the CVRS into medical offices and see if the intervention will be sustained. METHODS: This is a 5-year, pragmatic, cluster-randomized clinical trial in 13 primary care clinics across the US. We randomized clinics to receive CVRS or usual care and will enroll 325 patient subjects and 288 key stakeholder subjects. We have obtained access to the electronic medical records (EMRs) of all study clinics to recruit subjects and provide the pharmacist intervention. The intervention is staggered so that after 12 months, the usual care sites will receive the intervention for 12 months. Follow-up will be accomplished though medical record abstraction at baseline, 12 months, 24 months, and 36 months. CONCLUSIONS: This study will enroll subjects through 2021 and results will be available in 2024. This study will provide unique information on how the CVRS provided by remote clinical pharmacists can be effectively implemented in medical offices, many of which already employ on-site clinical pharmacists. CLINICAL TRIAL REGISTRATION INFORMATION: NCT03660631: http://clinicaltrials.gov/ct2/show/NCT03660631.