ABSTRACT
PURPOSE: Chronic disease state management utilizing pharmacists improves quality metrics, allows providers to focus on acute issues, and decreases physician burnout risk. Minimal data exist on pharmacist panel size and its impact. This study aimed to determine appropriate pharmacist panel size based on workload, quality metrics, and patient access. METHODS: This study was a retrospective, multiclinic cohort analysis of patients with diabetes managed by pharmacists at 7 outpatient clinics. The primary objective calculated panel size per full-time equivalent (FTE) utilizing the National Health Interview Survey. Secondary objectives calculated the ideal FTE based on provider to pharmacist ratio and determined the impact of pharmacist panel size on patient access and quality metrics. RESULTS: A total of 4,399 patients were analyzed from 2017 through 2019, with age (range, 57.4 to 62.6 years), sex (52.5% to 63.5% female), race (41.2% to 93.7% African American), insurance type (13.3% to 41% Medicaid), and mean number of medications (13.1 to 20.3) significantly different between sites. Primary outcome results showed that actual panel sizes were less than calculated. However, secondary outcomes indicated that each site was understaffed (actual 0.2 to 0.5 FTE vs calculated 2.52 to 7.34 FTEs) and overbooked (95% to 122% capacity, 17 to 54.2 days for time to third next available appointment). Patients met the composite quality metric 35.1% to 56.3% of the time across sites. CONCLUSION: This study supports the use of patient access data to determine appropriate pharmacist panel size. Utilizing provider panel size to pharmacist ratio and time to third next available appointment is preferable for determining appropriate pharmacist panel size. Further research is needed to evaluate return times to help determine an ideal pharmacist panel size.
Subject(s)
Benchmarking , Pharmacists , Humans , Female , Middle Aged , Male , Retrospective Studies , Ambulatory Care/methods , Primary Health CareABSTRACT
INTRODUCTION: Type 2 diabetes mellitus (T2DM) affected over 30 million individuals in the United States as of 2015. Due to the national diabetes guidelines recommending drug selection based on several patient specific factors and varying formulary restrictions, prescribers are often inundated when selecting treatment. Currently, limited evidence is available regarding the primary factors influencing prescribers' drug therapy selection. OBJECTIVES: The purpose of this study was to identify factors that influence providers during T2DM medication selection. METHODS: The study was conducted with providers at a large, academic, safety net health system. All prescribers were sent an electronic, optional and anonymous survey. Prescribers treating T2DM in non-pregnant adult patients were the only prescribers assessed. Factors evaluated were: cost, A1c, comorbidities, adherence, weight, tolerability, patient limitations, and use of guidelines. RESULTS: A total of 86 prescribers responded, yielding a response rate of 31%. The respondents included physicians (56.3%), nurse practitioners (21.8%), medical residents (18.4%), and fellows (3.4%); with the majority practicing in internal or family medicine (47.1%). The most frequently prescribed T2DM medications included: metformin (83.8%), insulin (78.1%), and sulfonylureas (64.8%). Cost and A1c elevation were two of the major factors influencing prescribing of metformin (94.1% and 81.2%), insulin (57.4% and 69.6%), and sulfonylureas (81.2% and 89.9%) respectively. Due to cost concerns, respondents reported rarely or never prescribing glucagon-like peptide-1 agonists (GLP-1RA) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) despite recognizing benefits on diabetes related comorbidities. CONCLUSION: Although current literature from the national guidelines encourages the use of GLP-1RA and SGLT2i as first-line options after metformin in T2DM, these classes of medications were not reported among the most commonly prescribed despite providers correctly identifying positive medication attributes such as cardio- and nephroprotection and weight loss. However, cost of these medications appears to outweigh the benefits when selecting medication therapy.
ABSTRACT
Nafcillin, a beta-lactam semisynthetic penicillin, is highly resistant to penicillinase and is similar to other penicillins except that it is primarily metabolized in the liver. It is believed that nafcillin causes CYP3A4 enzyme induction which decreases warfarin's half-life. The onset of CYP3A4 induction by nafcillin occurs within the first 7 days, but maximal effects may take up to 2 weeks. Once nafcillin is discontinued, the effects persist for several weeks. A 79-year-old male with a history of atrial fibrillation and a 53-year-old male with a history of recurrent venous thromboembolism required significantly higher weekly warfarin doses during courses of nafcillin therapy. Both patients required a 2.5-3.5-fold increase from their baseline weekly warfarin dose to achieve therapeutic international normalized ratios (INRs) while on nafcillin. Traditional protocol-driven warfarin management can result in suboptimal anticoagulation in patients on warfarin and nafcillin.
ABSTRACT
PURPOSE: Current literature supports pharmacists effectively lower hemoglobin A1c (HbA1c) in diabetic patients. Little data exists on pharmacists' effects on comorbidity management, patient satisfaction, or the financial viability of these positions. This study looked to assess the impact of pharmacists on diabetes management compared to usual care. METHODS: This multi-site, two-part study includes a retrospective chart review of patients referred to the pharmacist versus usual care within a large academic health system. The pharmacists collaborated under a consult agreement with primary care physicians. The second part of the study assessed patient satisfaction through an abbreviated CG-CAHPS survey. RESULTS: A total of 206 patients with diabetes for an average of 12 years were included. The average patient age was 62 years with 60% of patients identifying as female and 81% as African-American. Patients were enrolled in a 2:1 fashion with 138 patients in the pharmacist-management group. Average baseline HbA1c was 10.1% in the pharmacist-management group and 9.3% in the usual care group (p= 0.0125). At 6 months, the mean change in HbA1c was -2.17% and 0.48% for the intervention and control groups respectively (p < 0.001). CONCLUSION: Pharmacists are effective at lowering HbA1c in primary care clinics, and patients were highly satisfied with these services. While direct revenue from this service did not meet cost, the pharmacist did positively affect outcomes that contribute to reimbursement.
