Perceptions of the Value of Clinical Pharmacy Medication Review for Women During Early Pregnancy.

BACKGROUND: The benefit of continuing medications to prevent or treat illness is often overlooked, since pregnant women tend to overestimate the teratogenic risk of medications. Pharmacists can serve as a resource to prescribers and pregnant women with their knowledge of the appropriate use and management of medications during pregnancy. Little information exists on the value women place on pharmacists' medication management during pregnancy. OBJECTIVE: To assess pregnant women's perceptions of an ambulatory care clinical pharmacist (CP) medication review service during early pregnancy that provided education regarding the risks and benefits of medication use during pregnancy. METHODS: This was a qualitative study of pregnant women using semistructured telephone interviews performed between December 12, 2018, and January 18, 2019, and conducted in an integrated health care delivery system. Potential participants were identified from CP encounter records. Consented English-speaking women aged ≥ 18 years participated in an up to 30-minute interview within 1 week of the CP encounter. Interviews were professionally transcribed and coded line by line using the constant comparison method with grounded theory used to gain insight into participants' perspectives. RESULTS: 62 women were invited to participate in semistructured telephone interviews of whom 24 (39%) completed the interview. Three main themes emerged from the qualitative analysis: satisfaction with the service, comfort with medication use during pregnancy, and connectedness to the health care team. Overall, the CP medication review and education service was perceived positively by the participants. Participants reported satisfaction in the quality, timeliness, and convenience of the service and found it beneficial to have their medications reviewed early during pregnancy to assist in medication use decisions before their first obstetric visit. CONCLUSIONS: CP medication review provided a comforting, valuable service for women during early pregnancy when medication-taking decisions can feel exigent. DISCLOSURES: This study was funded by Kaiser Permanente. The authors have nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors, May 2019, in Salt Lake City, UT.

Outcomes of a pharmacist-managed medication refill program.

OBJECTIVE: To compare the completeness of medication and blood pressure monitoring among patients requesting medication refills through the pharmacist-managed medication refill and laboratory monitoring program (MRLMP) versus usual care. DESIGN: Quasiexperimental study. SETTING: Kaiser Permanente Colorado between November 2011 and June 2012. PATIENTS: Patients requesting chronic medication prescription refills. INTERVENTION: Community pharmacists managed the refill authorization request (RAR) process at the intervention site. For each RAR, the pharmacist reviewed patient medication monitoring needs and ordered laboratory test(s) or a clinic visit, as needed, before approval. MAIN OUTCOME MEASURES: For medications due for laboratory or blood pressure monitoring at the time of the RAR, the 1-month rate of attaining complete monitoring was compared between groups. Pharmacist, primary care physician (PCP), and patient satisfaction and PCP time saved also were compared. RESULTS: 3,797 RARs for MRLMP-eligible medications were approved in the month following MRLMP implementation in the intervention and control clinics. The intervention and control groups converted 49% and 29% of medications due for laboratory monitoring ( P < 0.001) and 56% and 33% of those due for blood pressure monitoring, respectively ( P = 0.020). The intervention group PCPs were more likely than control group PCPs to report being "very satisfied" with the RAR process (80% vs. 27%, P = 0.015) and spent fewer minutes per day on refill requests (mean 17 vs. 23, P = 0.049). The intervention group pharmacists reported higher job satisfaction (mean index score 22 vs. 18, P = 0.024), and intervention group patients reported higher satisfaction with the "readiness" of their prescription when they came to pick it up (91% vs. 80%, P = 0.004). CONCLUSION: A pharmacist-managed MRLMP resulted in improved process-related outcomes. Future studies should assess clinical outcomes.

Assessment of compliance with lipid guidelines in an academic medical center.

BACKGROUND: The importance of achieving a low-density lipoprotein cholesterol (LDL-C) level less than 100 mg/dL in patients with coronary artery disease (CAD) or cerebrovascular disease (CVD) is well established. Emerging evidence supports the recognition and management of secondary lipid goals, high-density lipoprotein cholesterol (HDL-C) level greater than 40 mg/dL, and triglyceride level less than 150 mg/dL. OBJECTIVE: To evaluate whether inpatient services within an academic setting were achieving/addressing primary and secondary lipid goals in patients with established CAD or CVD. METHODS: Patients with a discharge diagnosis of acute myocardial infarction, myocardial revascularization procedures, and/or ischemic stroke were identified. A retrospective chart review was done to assess adherence to the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for lipid management. RESULTS: On average, 63% of patients with CAD or CVD had a lipid panel assessed during their hospitalization. Of the patients who had a fasting lipid panel checked, only 40% (72/178) had an LDL-C level less than 100 mg/dL. Of those patients, only 31% (22) also had an HDL-C level greater than 40 mg/dL. Even fewer patients (24%; 17) met both primary and secondary goals. Of the 287 patients included in the study, 69% (199) were prescribed a statin, 3% (9) a fibrate, and 3% (8) niacin on discharge. CONCLUSIONS: Few patients with CAD or CVD met the AHA/ACC goals for lipid management, yet a significant number were not prescribed appropriate lipid-lowering therapy at discharge. This finding strongly suggests that more awareness in this area is needed.

Use of a modified dosing weight for heparin therapy in a morbidly obese patient.

OBJECTIVE: To report a case of successful anticoagulation using a modified dosing weight (DW) for unfractionated heparin (UFH) therapy in a morbidly obese female. CASE SUMMARY: A 54-year-old morbidly obese (182.4 kg, 155 cm) white female presented to the emergency department with tachycardia, shortness of breath, and chest pain, and was diagnosed with a pulmonary embolism. Anticoagulation with UFH was initiated. A modified DW of 120 kg was obtained from the average of the actual body weight (ABW) and ideal body weight ( approximately 50 kg). We selected this modified DW to account for heparin's altered volume of distribution in an obese patient and avoid potentially supratherapeutic activated partial thromboplastin times (aPTTs) using ABW and subtherapeutic aPTTs using DW. Therapy was initiated with a bolus dose of 9600 units (80 units/kg x 120 kg) and continuous infusion rate of 2160 units/h (18 units/kg/h x 120 kg). This infusion rate was maintained throughout the course of heparin therapy and was successful in maintaining therapeutic aPTTs. DISCUSSION: Proper diagnosis and rapid initiation of therapy prevent mortality in patients with PE. Although weight-based heparin nomograms provide standardization through initial bolus and continuous infusion recommendations, many do not address dosing in morbidly obese patients. Several retrospective studies have evaluated actual, dosing, and ideal body weights for heparin therapy in obese patients; however, none has evaluated modified DW. In our patient, successful anticoagulation was objectively confirmed. CONCLUSIONS: Further investigation is necessary to determine the optimal DW for UFH in morbidly obese patients presenting with acute thrombosis.