Association between pharmacist-led telehealth services and improvements in cardiovascular outcomes among patients with cardiovascular risk factors: A scoping review.

Background: Cardiovascular disease is the leading cause of death globally. Despite the effectiveness of lifestyle changes and recommended therapeutics, access to primary care and treatments to improve cardiovascular risk-factors (CRFs) remains challenging. Pharmacists and telehealth services have been proposed as potential solutions to overcome these barriers. Methods: PubMed, OVID, and CINAHL databases were searched from January 2006 to March 2023. The primary outcomes were changes from baseline in systolic/diastolic blood pressure, glycated hemoglobin (A1c), cholesterol levels, and adherence to any patient counseling. Only studies conducted in the United States and Canada were included in the review. Results: Of 110 screened bibliographic records, 14 studies were included in the review. The pharmacist-led telehealth interventions included medication therapy management, medication reviews, and counseling on lifestyle changes. Nine studies reported significant improvements with intervention, 7 studies on CRFs and 2 studies on medication adherence at the 12-month follow-up, when pharmacist-led telehealth services were compared to usual care or historical data (p < 0.05). Conclusion: This scoping review provides evidence for continued support to the development and implementation of pharmacist-led telehealth services in primary cardiovascular care. The findings suggest that pharmacist-led telehealth interventions can improve cardiovascular outcomes and adherence to drug and non-drug therapy among patients with CRFs. However, because of lack of published randomized clinical studies on patients with CRFs residing in underserved communities, future directions in research should focus on exploring the implementation of pharmacist-led telehealth services in rural or underserved communities, utilizing various payment models to enhance accessibility and feasibility.

Development and validation of a tool to predict high-need, high-cost patients hospitalised with ischaemic heart disease.

OBJECTIVE: To develop and validate a tool to predict patients with ischaemic heart disease (IHD) at risk of excessive healthcare resource utilisation. DESIGN: A retrospective cohort study. SETTING: We identified patients through the State of Florida Agency for Health Care Administration (N=586 518) inpatient dataset. PARTICIPANTS: Adult patients (at least 40 years of age) admitted to the hospital with a diagnosis of IHD between 1 January 2007 and 31 December 2016. PRIMARY OUTCOME MEASURES: We identified patients whose healthcare utilisation is higher than presumed (analysis of residuals) and used logistic regression (binary and multinomial) in estimating the predictive models to classify individual as high-need, high-care (HNHC) patients relative to inpatient visits (frequency of hospitalisation), cost and hospital length of stay. Discrimination power, prediction accuracy and model improvement for the binary logistic model were assessed using receiver operating characteristic statistic, the Brier score and the log-likelihood (LL)-based pseudo-R2, respectively. LL-based pseudo-R2 and Brier score were used for multinomial logistic models. RESULTS: The binary logistic model had good discrimination power (c-statistic=0.6496), an accuracy of probabilistic predictions (Brier score) of 0.0621 and an LL-based pseudo-R2 of 0.0338 in the development cohort. The model performed similarly in the validation cohort (c-statistic=0.6480), an accuracy of probabilistic predictions (Brier score) of 0.0620 and an LL-based pseudo-R2 of 0.0380. A user-friendly Excel-based HNHC risk predictive tool was developed and readily available for clinicians and policy decision-makers. CONCLUSIONS: The Excel-based HNHC risk predictive tool can accurately identify at-risk patients for HNHC based on three measures of healthcare expenditures.

A quantitative analysis of the effect of continuity of care on 30-day readmission and in-hospital mortality among patients with acute ischemic stroke.

BACKGROUND: Continuity of care is a core element of high-quality patient care in a primary care setting and one of a national priority. OBJECTIVE: To assess and quantify the impact of continuity of care on 30-day readmissions, 30-day inpatient mortality, and hospital length of stay (LOS), among hospitalized patients with acute ischemic stroke disease. DESIGN AND SUBJECTS: Observational retrospective cohort (n = 356,134) using a 2.75% random sample (n=1,036,753) from the State of Florida Agency for Health Care Administration (AHCA) database from 2006 to 2016. MEASURES: We assessed continuity of care using an integrated continuity of care CoC score, calculated by merging three standard indices of continuity of care - Bice-Boxerman Continuity of Care Index (COCI), Herfindahl Index (HI), and Usual Provider of Care (UPC) Index via a Principal Component Analysis (PCA). We measured 30-day hospital readmissions, 30-day inpatient mortality, and LOS. RESULTS: Our analysis revealed that hospital LOS was significantly affected by CoC. The statistically significant average treatment effect (ATEs), expressed in risk difference (RD), ranged between 0.27 [95%CI: (0.07, 0.48)] and 1.0 day [95%CI: (0.57, 1.43)]. A similar trend was observed for 30-day readmission (ATEs ranging from 0.0067 [95%CI: (0.0002, 0.0132) to 0.0071 [95%CI: (0.0005, 0.0136)]), and inpatient mortality (ATEs ranging from 0.0006 [95% confidence interval (CI): (0.0001, 0.0012)] to 0.0007 [95%CI: (0.0001, 0.0012)]). CONCLUSIONS: Our findings suggest a strong association between continuity of care and clinical outcomes. Continuity of care leads to a reduction in mortality, rehospitalization, and hospital length of stay.

Policy Reform with Marijuana Use: Weighing Risks and Benefits.

With the current legalization of medical marijuana and the possibility of recreational use being permitted in some states, the health care benefits associated with the use of marijuana is questionable. States that are on the path of legalizing marijuana, should recognize that as there are perceived positive benefits, there are also many evidence-based negative health consequences which may result in negative economic and societal consequences. As more data on health outcomes regarding the use of marijuana continue to emerge, policies directed toward legalizing marijuana, whether medical or recreational, should consider protecting the society from both harm and societal cost.

Effects of Statins on Hospital Length of Stay and All-Cause Readmissions Among Hospitalized Patients With a Primary Diagnosis of Sepsis.

BACKGROUND: There is little information on the impact of statins on hospital length of stay (LOS) or readmission among patients with sepsis. OBJECTIVE: The objective of this study is to evaluate the association between statin use and LOS and all-cause readmissions among sepsis patients hospitalized in the medical unit. METHODS: The design was a retrospective propensity score-matched study of adult patients with a primary diagnosis of sepsis from 2007 to 2013. Information was extracted from the electronic health record. Sepsis patients were identified using ICD-9CM codes. Propensity scores estimated the probability that a patient would be on statins, and patients who were on statins were then matched with those who were not, within ±0.05. Additional greedy matching criteria were organ dysfunction (yes/no) and all patient refined diagnosis-related group (APR-DRG) medical/surgical. The primary outcome was LOS, and the secondary outcomes were all-cause readmission at 30, 60, and 90 days, adjusted for age, sex, modified Deyo-Charlson comorbidity index, APR-DRG severity of illness (SOI), and APR-DRG medical/surgical, as appropriate. RESULTS: Patients taking statins had a shorter LOS than patients not taking statins, 8.7 ± 3.7 and 10.3 ± 2.7 days, respectively (P value = 0.018). There was no significant difference (P> 0.05) in all cause readmissions between statin and nonstatin patients. Presence of comorbidities and SOI were significant factors for 60- and 90-day readmissions. CONCLUSIONS: The use of statins among patients admitted with primary sepsis in the medical unit was associated with shorter length of hospital stay. However, it did not affect frequency of readmissions.

Dapagliflozin for the Treatment of Type 2 Diabetes Mellitus.

OBJECTIVE: To review the pharmacology, pharmacokinetics, clinical trials, and adverse effects of dapagliflozin, a sodium glucose co-transporter 2 (SGLT-2) inhibitor. DATA SOURCES: Data were gathered from articles indexed in PubMed, International Pharmaceutical from (2006 to April 2014) was performed using the following terms "dapagliflozin," "SGLT-2 inhibitor," and "Farxiga." Abstracts and manufacturer's package insert were also used as an additional reference. STUDY SELECTION AND DATA EXTRACTION: All English language prospective randomized, double-blinded trials evaluating the efficacy of dapagliflozin for the treatment of type 2 diabetes were identified. DATA SYNTHESIS: We evaluated 9 clinical trials with dapagliflozin as monotherapy or add-on therapy. Results from these studies demonstrated that dapagliflozin to be noninferior to metformin in treatment naïve patients for reduction in A1C. Additionally, dapagliflozin was noninferior to glimepiride when added on to metformin. As an add-on therapy to insulin, insulin sensitizers or sitagliptin, dapagliflozin was found to be clinically effective compared to placebo. Finally, in all of the clinical trials increased risk of urinary infection was common in dapagliflozin group. CONCLUSION: As the second SGLT-2 inhibitor approved in the United States, dapagliflozin is safe and effective for treatment of type 2 diabetes mellitus. It appears to have no increased cardiovascular risk and provides a moderate benefit for patients with high blood pressure or those who are overweight. However, dapagliflozin was found to be associated with nasopharyngitis, mycotic infections, and genital or urinary tract infections. This medication may be best used as adjunctive therapy for patients not well-controlled on other antidiabetic agents. However, caution should be taken when used in patients at risk of urinary tract infections and dehydration.