Impact of an online pharmacy precepting-focused continuing professional development program.

INTRODUCTION: This study aimed to determine the preceptor-reported impact of an online continuing professional development (CPD) program on pharmacy preceptors' abilities and techniques for teaching students in clinical settings. METHODS: In 2017, an online program to educate and support pharmacy preceptors' use of CPD to create individualized clinical teaching development plans was launched. After allowing time for preceptors to implement their CPD plan, a follow-up program was launched in 2019 where preceptors completed a seven-question survey to assess their impact on clinical teaching from the initial program. Two questions described completion of the CPD plan with response options including "Yes," "No," or "Partially". Five open-ended questions allowed for descriptions of changes implemented and overall teaching impact. Impact of implemented changes were categorized as positive, negative, or no change. Changes implemented by preceptors were categorized as goal setting, feedback, communication/education skills, student-teacher connection, or educational resources development. RESULTS: Of the 119 preceptors who responded to at least one question, 52% fully implemented and 39% partially implemented their pre-identified CPD plan. A total of 75 preceptors provided responses regarding impact of implemented activities; 69 (92%) were coded as a positive impact on their clinical teaching. Preceptor skill development was most commonly in communication/educational skills (45%), student/teacher connection (33%), and educational resources development (33%). CONCLUSIONS: This online precepting CPD program had a positive preceptor-reported impact on clinical teaching delivered by preceptors to students. Further investigation is warranted to disseminate this program.

Real-world, long-term evaluation of the tolerability and therapy retention of Epidiolex® (cannabidiol) in patients with refractory epilepsy.

OBJECTIVE: Epidiolex® (CBD) is FDA-approved for seizures associated with Lennox-Gastaut syndrome (LGS), Dravet syndrome (DS), and tuberous sclerosis complex (TSC). Phase III studies suggest that certain adverse effects (AEs), possibly linked to pharmacokinetic/pharmacodynamic (PK/PD) interactions may be therapy-limiting. We sought to identify these factors that contribute to treatment success and retention of therapy. METHODS: A single-center, retrospective review of patients with refractory epilepsy taking Epidiolex® was performed. Kaplan-Meier analysis was performed to describe Epidiolex® retention, as a measure of overall effectiveness. RESULTS: One hundred and twelve patients were screened; 4 were excluded due to loss to follow-up or never starting Epidiolex®. Of 108 patients, mean age was 20.3 years (13.1, range 2 to 63), and 52.8% were female. Mean initial and maintenance doses were 5.3 mg/kg/day (1.3) and 15.3 mg/kg/day (5.8), respectively. At the final evaluation, 75% of patients remained on Epidiolex®. The 25th percentile for discontinuation was 19 months. 46.3% of patients experienced at least one treatment-emergent adverse effect (TEAE) with 14.5% d/c Epidiolex® due to treatment emerging adverse effects (TEAE). The most common reasons for discontinuation were lack of efficacy (37%), increased seizure activity (22%), worsened behavior (22%), and sedation (22%). One out of 27 discontinuations was due to liver function test (LFT) elevations (3.7%). At initiation, 47.2% were concurrently taking clobazam, and 39.2% of those patients had an initial clobazam dose decrease. 53% of patients were able to either discontinue or lower the dose of at least one other antiseizure medication. SIGNIFICANCE: Epidiolex® is generally well-tolerated and the majority continued long-term treatment. Patterns of adverse effects were similar to clinical trials, however gastrointestinal complaints, and significant LFT elevations were less common. Our data suggest most patients discontinue within the first several months of treatment and suggest that further studies designed to evaluate early identification and potential mitigation of adverse effects and including drug interactions are warranted.

Associating Student Performance in Pharmacy Practice Didactic and Skills-Based Courses With Advanced Pharmacy Practice Experiences.

Objective. To determine the association between pharmacy practice didactic course examinations and performance-based assessments with students' performance during their advanced pharmacy practice experiences (APPEs).Methods. This retrospective analysis included data from the graduating classes of 2018 to 2020. Students were coded as APPE poor performers (final course grade <83%) or acceptable performers. Assessments in pharmacy practice didactic and skills-based courses in students' second and third years were included in the analysis, with thresholds correlating to grade cutoffs. The association between poor performance mean examination scores and performance-based assessments with APPE performance was calculated.Results. Of the 403 graduates, analysis sample sizes ranged from 254 to 403. There were 49 students (12%) who met the criteria for poor performance in the APPE year. When comparing pharmacy practice didactic course performance to APPE poor performance, the proportion of mean examination scores that were <83% for six of the seven pharmacy practice didactic courses was significant; five of the seven mean examination scores were significant at the <78% threshold. Performance-based assessments that were significantly associated with APPE poor performance often required critical thinking.Conclusion. A gap in identification of students with APPE poor performance who did not fail a didactic course was demonstrated. Specifically, this finding suggests that pre-APPE curriculum should focus on assessments that include critical thinking. These methods could be used by other pharmacy programs to find components of their curricula that help identify students who need additional support prior to the APPE year.

Evaluation of a statewide pharmacy student writing club program: Opportunities to enhance professional writing skills.

INTRODUCTION: Skills gained by writing a scholarly manuscript coincide with graduation expectations prior to matriculation into practice. A partnership between The Journal of the Pharmacy Society of Wisconsin and four affiliated pharmacy schools developed student writing clubs (SWC) to fill this need. The objectives of this project were to explore the structure of SWCs and evaluate the experiences of participants. METHODS: Two investigator-designed, voluntary, anonymous surveys were distributed to each school. A survey for pharmacy students assessed motivations for participating within a SWC, impact on skills, and suggestions for improvement. The second survey to the SWC faculty advisors explored programmatic structure. RESULTS: Of forty student respondents, most SWC participants felt comfortable with each step of the writing process. Participants were motivated by manuscript publication opportunity (88%), improvement of writing skills (80%), and the addition to their curriculum vitae (60%). Students suggested process improvements including better communication on deadlines, more connections to writing resources, and developing writing workshops for guidance on professional writing. Barriers to participation included unclear expectations (60%) and not feeling prepared or skilled enough (53%). Most importantly, both students and faculty perceived the SWC at each program as a skill-building extracurricular activity that brings value to student pharmacist development. CONCLUSIONS: Manuscript preparation and publication within a structured environment, such as a SWC, is a valuable skill-building opportunity. Creation of a centralized writing workshop will provide guidance for participants throughout the manuscript process.

Feasibility of a centralized specialty biologic medication management clinic at a VA hospital.

BACKGROUND: Given the cost and complexity of home subcutaneous biologic use, a centralized specialty medication management (CSMM) service was developed utilizing clinical pharmacist practitioners (CPPs). OBJECTIVE: To determine the implementation feasibility of the CSMM service. PRACTICE DESCRIPTION: The CSMM service was implemented in a Veterans Health Administration (VHA) hospital. The VHA does not use dedicated specialty pharmacies. PRACTICE INNOVATION: The CSMM service was developed utilizing CPPs who operated as an advance practice provider under a national VHA scope of practice. The CPP staffing the CSMM service performed patient education, screened for medication appropriateness, and monitored for safety and efficacy via videoconference or telephone. All patients newly starting a home subcutaneous biologic were offered the service from allergy, cardiology, dermatology, gastroenterology, and rheumatology clinics, as appropriate. EVALUATION METHODS: A retrospective chart review was completed through the first year the service was offered, which included the recruitment and retention of patients, number of follow-up appointments, and interventions made. RESULTS: Of the 68 patients offered clinic enrollment, 54 were enrolled in the service (79.4%). Of the 44 who had completed an initial appointment with the CPP, 42 had either received an initial follow-up or were scheduled for a follow-up (95.5%). A total of 161 clinical outcomes have been performed by the CSMM CPP including administrative assistance (33.5%), initial patient education (17.4%), technique correction (7.5%), and medication changes or discontinuations (6.8%). CONCLUSION: Given the high rate of enrollment and retention, the implementation of the CSMM service at a VA hospital was feasible. The service contributed to safe and effective medication use for enrolled patients and continues to grow in both patient enrollment and services offered.

Implementation of the Individual Teamwork Observation and Feedback Tool to Evaluate Pharmacy Student Performance.

Objective. To determine the appropriateness and feasibility of implementing the Individual Teamwork Observation and Feedback Tool (iTOFT) in advanced pharmacy practice experiences (APPEs) to allow direct observation and rating of students' interprofessional teamwork skills.Methods. In the academic year 2018-2019, preceptors administered iTOFT at least once during required acute care and ambulatory care APPEs. After administration, which involved direct observation of students' behavior on an interprofessional team, preceptors evaluated iTOFT results and offered feedback to students. To determine implementation success of the iTOFT activity, an implementation satisfaction survey was administered to preceptors and students, which included questions on appropriateness and feasibility.Results. The iTOFT activity was completed 149 times each during required acute care and ambulatory care APPEs. Results demonstrated positive teamwork behaviors, eg, no students received an "inappropriate" rating on any iTOFT item. The implementation survey response rate was 33% (34/102) for preceptors and 40% (50/125) for students. Both groups reported that the iTOFT activity was feasible. Respondents also reported that completing the iTOFT activity did not interfere with workflow and that it was not difficult to find opportunities to complete it. Per preceptor report, mean time to complete the iTOFT activity was 37.7 minutes, but there were concerns identified regarding fidelity with all iTOFT steps.Conclusion. Incorporation of the iTOFT activity into the required acute and ambulatory care APPEs at a school of pharmacy was feasible. Future directions include determining ways to increase iTOFT fidelity.

Extending the reach of science - Talk in plain language.

There has been increasing interest by the general public to read and share mainstream medical and scientific literature. Consequently, more and more medical journals are adopting strategies to make complex literature more accessible to the lay public. One such strategy is the creation of so called "lay summaries". The benefits of lay summaries can include wider dissemination of knowledge, and is increasingly being recognized as a unique expertise by authors. While on the surface, it may seem to be an easy task to translate scientific literature into a lay summary. However, occasionally authors who are experienced in communicating complex information to a peer group, may struggle with translating their work to an audience with limited medical or scientific background. The objective of this review is to discuss strategies that scientific writers may consider to better facilitate translating scientific literature into lay summaries.

Application of the replicating effective programs framework to design a COPD training program.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally and a common cause of hospital readmissions in the United States. While best practices exist in COPD management, incorporation of such approaches into routine clinical care remains a challenge. OBJECTIVES: This evaluation applied principles from the field of dissemination and implementation (D&I) science to design a training package integrating best practice for COPD management. The D&I field promotes evidence-based implementation strategies, frameworks, and assessment approaches that can be considered by clinicians to promote adoption of best practices. METHODS: This prospective mixed-methods evaluation applied a D&I science model to develop, implement, and evaluate an interprofessional training program for COPD management originally piloted in 2016. The authors provide a contextual example of how a guiding D&I framework, replicating effective programs, was applied to design and implement a Web-based training program for clinicians preparing to implement the COPD service. A questionnaire and profession-specific focus group sessions were conducted to evaluate trainee confidence and enactment of critical service components. RESULTS: A total of 41 of the 50 interprofessional trainees responded to the pre- and postquestionnaire including primary care clinical pharmacists (n = 15), primary care registered nurses (n = 9), triage registered nurses (n = 12), and respiratory therapists (n = 5). Statistically significant improvements in trainee confidence and enactment were observed in 31 of the 40 total survey items (77%). Pooled focus group data provided attestation that the training enhanced practitioners' confidence in their role within the service. Opportunities for further improvement were also identified, such as incorporating a video modeling clinic example and accompanying written materials. CONCLUSION: This evaluation provides a case-study example of how D&I science can be used to design, implement, and evaluate a training package for trainees to spread a promising best practice. Clinicians can consider similar applications of D&I science to enhance training and spread novel services across health systems.

Longitudinal Assessment of Pharmacy Students' Confidence and Skill in Providing Evidence-based Answers to Clinical Questions.

Objective. To assess Doctor of Pharmacy (PharmD) students' skills and confidence in using an evidence-based medicine (EBM) approach to answer practice-based, clinical questions. Methods. Pharmacy students' ability to provide evidence-based answers for real-world clinical questions was assessed at two time points in the PharmD curriculum using a standard tool and trained evaluators. Pharmacy students' confidence regarding their EBM skills was self-assessed at four points in the program, with the first survey administered before the EBM sequence and the final survey administered prior to graduation. The survey included five self-assessed skill questions and nine self-confidence questions. Results. Two hundred twenty-four students from two graduating classes were included in the analysis. Over 97% of students received passing scores on their clinical inquiries (mean score=90.4%), confirming their competency in EBM skills. Students' survey responses on all self-assessed skill and confidence questions improved significantly from baseline to graduation. Conclusion. Longitudinal teaching of EBM concepts and opportunities for skills practice developed PharmD students' ability to successfully provide evidence-based answers to authentic clinical questions. This was consistent with students' confidence level and self-assessed skill levels reported on surveys. Future directions include confirming students' use and understanding of EBM concepts after graduation.

Use of a novel videotaped presentation to improve pharmacy student confidence in presenting evidence-based medicine.

INTRODUCTION: We assessed the use of a novel videotaped presentation on pharmacy student confidence in presenting an evidence-based recommendation to theoretical healthcare professionals from various disciplines. METHODS: Students in a required drug literature evaluation course prepared a three-min videotaped presentation critiquing an assigned journal article with the goal of providing a patient care recommendation to a fictional physician. To determine change in confidence, students completed a pre-/post-survey on a 5-point scale. Survey questions explored confidence in presenting and discussing article evidence with both peers and licensed healthcare providers as well as making verbal recommendations for medication use. The survey also included open-ended questions to assess perceptions of the assignment and suggestions for assignment improvement. RESULTS: Over two years, 208 students completed both surveys (75.9%). Student confidence significantly increased for all items from the pre- to the post-survey. Items with the largest increase in confidence were presenting medical literature to peers, pharmacists, and other healthcare professionals (range 0.72 to 0.89 mean increase for these items). Students reported increased preparedness in presenting, improved conciseness in presenting, and increased self-awareness as a result of the assignment. The majority of students had no suggestions for assignment improvements. CONCLUSIONS: Use of a videotaped assignment is a novel, low-resource option for assessing student skills. This video presentation activity allowed students to gain additional communication practice without additional administrative resources. The activity resulted in increased pharmacy student confidence in discussing medical literature and making evidence-based recommendations for medication use.

Characteristics of Individuals Who Chose to Participate in a Preceptor Continuing Professional Development Program.

An online program for pharmacy preceptors to improve their clinical teaching using continuing professional development (CPD) was launched in 2017. While 491 preceptors participated in the CPD program, only 35% of potential participants completed this voluntary program. A secondary data analysis was undertaken to determine the characteristics of preceptors who completed the program and identify ways to target program advertising for those who did not complete it. Residency-trained preceptors were more likely to complete the CPD program compared with those without residency training (45% and 37%, respectively; p = 0.011). This may be due to the inclusion of CPD in residency accreditation standards. To improve completion of the CPD program by preceptors without residencies, a brief introduction to CPD, a statement of benefits, and use of a personalized plan should be included in advertisements. Preceptors teaching more experiential students were more likely to complete the CPD program (p < 0.001 for introductory and advanced experiences). To encourage preceptors with less students to participate, the CPD program should be advertised year-round to allow preceptors to complete the training when it is most relevant to their precepting schedule. Future directions include the monitoring of changes in CPD program participation rates following changes in advertisements and exploring other motivations for program completion such as collaborations with employers.

Longitudinal evaluation of pharmacy students' metacognition in interpretation of evidence-based medicine.

BACKGROUND AND PURPOSE: Metacognition is one's ability to "think about thinking" and to understand what knowledge and skills one has. Pharmacy professionals are required to have high metacognitive skills to ensure they are aware of what information they know and when to utilize resources. This longitudinal evaluation of pharmacy students' metacognitive ability was conducted via analysis of students' knowledge and confidence in evidence-based medicine (EBM) skills. EDUCATIONAL ACTIVITY AND SETTING: A survey was administered to the graduating classes of 2017 and 2018 four times, from the beginning of the second-year drug literature evaluation course (baseline) through graduation. The surveys included seven self-confidence questions for which a corresponding knowledge question was asked. Students' metacognition was evaluated on the basis of whether the level of confidence was a "match" or a "mismatch" to their corresponding level of knowledge of each question. The proportion of matches over time was determined. FINDINGS: Fifty-eight students (22%) completed all four surveys. The mean proportion of matches at baseline was 40% and increased over time until graduation when the proportion of matches was 74%. The proportion of matches at baseline for all seven questions were ranged from 33% to 57%. An improvement in meta-cognition was seen in 5 out 7 questions. SUMMARY: This evaluation provides evidence that as students learned material and revisited concepts, their confidence, knowledge, and potentially metacognition regarding EBM concepts increased. However, as 26% of items measured were not a match at graduation, interventions need to be designed and tested to improve student metacognition.

Effects of enzyme-inducing antiseizure medication on vitamin D dosing in adult veterans with epilepsy.

BACKGROUND: The association of antiseizure medication (ASM) and bone density abnormalities has long been recognized; however, there remains a lack of consensus on efficacy and optimal vitamin D dosing in patients receiving enzyme inducing and non-inducing ASMs. The objective was to explore the relationship between ASMs and vitamin D supplementation requirements in a population of adult patients with epilepsy. METHODS: Patients with a diagnosis of epilepsy receiving supplemental vitamin D were included in this retrospective chart review. All instances of 25-hydroxyvitamin D3 (25-OHD) measured among those patients were compared between patients taking an enzyme inducing antiseizure medication (EIASM) to patients receiving ASM regimens only containing non-enzyme inducing antiseizure medications (NIASM). ASM use, prescription and over the counter (OTC) vitamin D use, 25-OHD plasma concentration, presence of chronic kidney disease (CKD), age, gender, and ethnicity were collected. Multiple linear regression was used to adjust for potentially confounding variables; the model included a cluster by participant term to account for repeated patients in the dataset. RESULTS: There were 542 vitamin D levels evaluated from 172 unique patients. There was an 11.5 % higher absolute percent increase in patients who achieved a 25-OHD level over 30 ng/mL in the NIASM (p = 0.012). Patients on EIASMs were supplemented with an additional 508 units of vitamin D daily (95 %CI 136-878, p = 0.007). When adjusted for CKD, OTC vitamin D use, OTC multivitamin use, age, gender, and ethnicity, patients on EIASMs were supplemented with an additional 445 units of vitamin D (95 %CI -69 to 960, p = 0.089) compared to NIASM use. CONCLUSIONS: Patients taking EIASMs had an increase in vitamin D deficiency and vitamin D supplementation suggesting that EIASMs impact vitamin D metabolism. Closer monitoring of vitamin D status in patients with epilepsy, especially those on EIASMs, is warranted. This evaluation suggests that for patients taking ASM, use of a lower dose OTC requires closer monitoring of vitamin D status in patients with epilepsy, especially those on EIASMs, is warranted. vitamin D agent may not be adequate.

Patient Satisfaction With Extended International Normalized Ratio Follow-up Intervals in a Veteran Population.

Background: For highly stable warfarin patients, limited data exists regarding patient satisfaction on extended international normalized ratio (INR) follow-up intervals and how this population compares with patients on a direct oral anticoagulant (DOAC). Objective: To assess the impact on patient satisfaction of extending INR follow-up intervals. Methods: Veterans on stable warfarin doses had extended INR follow-up intervals up to 12 weeks in a single-arm prospective cohort study for 2 years. This analysis included participants who completed at least 2 Duke Anticoagulation Satisfaction Scales (DASS). The primary outcome was the change in the DASS. A focus group described participant experiences. Participant satisfaction was compared to patients on a DOAC. Results: Of the 51 participants, 48 were included in the warfarin extended INR follow-up group. Compared with baseline, the mean DASS score (42.9 ± 12.08) was worse at 24 months (46.82 ± 15.2, P = 0.0266), with a small effect size (Cohen's d = 0.29). The 8 participants in the focus group were satisfied with the extended INR follow-up interval but would be uncomfortable extending follow-up past 2 to 3 months. The extended INR follow-up interval study had similar DASS scores as the 33 participants included on DOAC therapy (46.8 ± 15.1, P = 0.9970) but may be limited by differing populations using DOACs. Conclusion and Relevance: For patients currently stable on warfarin therapy, extending the INR follow-up interval up to 12 weeks or changing to a DOAC does not appear to improve patient satisfaction.

Making the switch: From case studies to N-of-1 trials.

Case studies can generate hypothesis based on unique clinical patient encounters and provide guidance among populations with limited numbers of patients. However, case studies are not blinded and are susceptible to a variety of factors that can influence study outcomes. One potential solution to minimize this bias is to use an N-of-1 trial. N-of-1 trials are a double-blinded randomized crossover trial within a limited number of patients, often as small as a single patient. These trials borrow many concepts from randomized controlled trials (RCTs), which in turn increases the validity of findings compared with a case report. Situations best suited for an N-of-1 trial include chronic disease states and therapies with quick onset and offset, such as in patients with seizures. There are many opportunities to use N-of-1 trials among patients with epilepsy, and providers are encouraged to explore and employ these methods. The purpose of this article was to describe N-of-1 trials along with considerations for conducting, publishing, and evaluating N-of-1 trials.

Impact of an extended International Normalized Ratio follow-up interval on healthcare use among veteran patients on stable warfarin doses.

PURPOSE: To analyze the impact of a 12-week extended International Normalized Ratio (INR) follow-up interval on healthcare use. METHODS: A prospective cohort study of the use of an extended INR follow-up interval of up to 12 weeks was conducted over 2 years in a pharmacist-managed anticoagulation clinic. A detailed protocol was used to extend the INR follow-up interval to 5-6 weeks and then 7-8 weeks and 11-12 weeks. The number of planned and unplanned anticoagulation encounters, procedures requiring warfarin interruption, telephone triage phone calls, emergency department visits, and hospitalizations were collected. A post hoc subanalysis was also completed on participants who were scheduled for 4 consecutive 12-week intervals. RESULTS: Compared to baseline, at 12 months there was a mean decrease in planned anticoagulation encounters of 2.24 visits (p < 0.001) among 44 participants. From 12 to 24 months compared to baseline, there was a mean decrease in planned anticoagulation encounters of 3.13 visits (p < 0.001) and an increase of 0.54 unplanned anticoagulation encounters (p = 0.04) among 39 participants. The remainder of healthcare use variables were not statistically significantly different from baseline at any time point. Of the 15 participants scheduled for 4 consecutive 12-week intervals, there was a decrease from baseline of approximately 5 visits over the course of a year (p < 0.001). CONCLUSION: An extended INR follow-up interval appears to decrease anticoagulation healthcare use without an increase in acute healthcare use. While this intervention could be cost-effective, institutions need to consider safety, efficacy, and feasibility prior to implementation.

Pharmacist-reported practice change as a result of a statewide community pharmacy accreditation program.

OBJECTIVES: To assess pharmacist-reported practice change as a result of participation in a community pharmacy accreditation program. SETTING: Community pharmacy practice in Wisconsin. PRACTICE INNOVATION: The Wisconsin Pharmacy Quality Collaborative (WPQC) is a network of pharmacies and pharmacists who provide standardized pharmacy services. WPQC is based on a unique set of quality-based best practices designed to improve patient safety in the medication use process. WPQC is supported by the statewide pharmacy organization, the Pharmacy Society of Wisconsin (PSW), which provides resources focused on implementation and engagement to support the success of WPQC-accredited pharmacies. PROGRAM EVALUATION: PSW used a 24-question online survey to evaluate the degree of pharmacist-reported practice change as a result of the WPQC quality-based best practices. RESULTS: Pharmacist-reported frequency and consistency of all quality-based best practices and services increased after WPQC accreditation (P < 0.05), with the exception of robotic dispensing systems, holding regular staff meetings for team communication, and providing incentives for recording quality-related events. In addition, quality-based best practices and WPQC services had a positive impact on pharmacist perceptions of their quality of patient care, patient safety, patient satisfaction, and patient relationships in WPQC-accredited pharmacies. The majority of pharmacies valued WPQC accreditation and shared positive comments about their experiences. CONCLUSION: A community pharmacy accreditation program using standardized quality-based best practices can create and reinforce behavior change in the community pharmacy setting to positively affect patient care and medication safety. Research is needed to determine if there are actual behavior changes as a result of WPQC accreditation compared with pharmacies that have elected not to participate.

Preceptor Fidelity to the Creation of Precepting-Focused Continuing Professional Development Learning Plans.

OBJECTIVES: To determine preceptor fidelity to the creation of continuing professional development (CPD) learning plans for improvements in clinical teaching. To determine topics of interest for preceptor development programming with a focus on clinical teaching skills. METHODS: An online CPD program focusing on the reflect and plan stages was launched. The online program introduced preceptors to CPD, encouraged preceptors to review student feedback, and required completion of a CPD precepting plan. Preceptors were provided four guided questions to develop their plans. Preceptor fidelity to the creation of a CPD plan to improve precepting skills was rated as: 1) having a plan for improving a precepting skill, 2) having a plan for improving precepting, but not skill-based, or 3) having a plan lacking a precepting focus. Topics of precepting improvement were identified. RESULTS: Of the 491 preceptors who completed CPD plans, 46.2% of the plans were skill-based. Of those, 59.5% of the CPD plans included specific learning items. Only 3.9% of preceptors submitted nonprecepting focused CPD plans and the remaining 49.9% of CPD plans were non skill-based, but precepting focused. Giving feedback was the most frequently listed topic with 45.8% of preceptors including it in their CPD plans. CONCLUSIONS: This online precepting CPD program successfully guided preceptors in developing CPD plans that have the potential to improve student learning experiences. Future precepting CPD programs will need to provide direction on the use of skill-based objectives. Further investigation is needed to determine the effectiveness of the program in changing precepting behavior.

Feasibility and safety of a 12-week INR follow-up protocol over 2 years in an anticoagulation clinic: a single-arm prospective cohort study.

The 2012 American College of Chest Physicians' guidelines recommended a 12-week INR follow-up interval may be appropriate for patients on stable warfarin doses. Limited evidence supports this recommendation. A single-arm, prospective cohort study over 24 months was completed in a Veterans Affairs anticoagulation clinic to determine the long-term feasibility and safety of implementing an extended INR follow-up interval in Veterans on stable doses of warfarin. Participants were required to have a stable warfarin dose for 6 months prior to enrollment. A prespecified protocol was used to titrate, extend, and manage the INR interval up to 12 weeks. Scheduling of extended INR intervals was a primary outcome. Safety outcomes included major and serious bleeding and thromboembolic events. A post-hoc comparison of baseline characteristics between individuals who were scheduled for at least 4 consecutive 12-week INR follow-up intervals and those who were not was completed. Of the 50 participants, 36 (72%) were scheduled for at least one 12-week interval and 15 (30%) were scheduled for 4 consecutive intervals. There were 2 thromboembolic events that occurred in 1 participant. There were 28 major and serious bleeding events in 19 participants; 8 occurred while on the extended INR interval. In the post-hoc analysis, no participants scheduled for 4 consecutive 12-week intervals had heart failure. Based on 2 years of monitoring, a 12-week INR follow-up interval using a detailed protocol with titration of INR interval extension appears feasible for a subset of patients. Patients with heart failure may not be suitable for this intervention.

Reducing COPD Readmission Rates: Using a COPD Care Service During Care Transitions.

A chronic obstructive pulmonary disease care service improves timely access to follow-up care and patient education at the time of transition from hospital to home.