Part Six: Antidiabetic Medication Benefits Beyond Glucose Lowering in Older People.

Older people with type 2 diabetes are at an increased risk for macrovascular (damage to arteries that can lead to myocardial infarction or stroke) and microvascular (damage to small blood vessels including retinopathy and nephropathy) disease. Since 2008, newly approved antidiabetic medications have been required to show cardiovascular safety as part of the US Food and Drug Administration approval process. Since this time, new data have emerged regarding the differences between agents in terms of reducing diabetes-related complications. Older people often are at risk for or currently have one or more diabetes-related complication. When managing antidiabetic medication in older people, it is imperative to consider the risk versus benefit of each medication and to use agents that have proven benefits.

Evaluating the impact of integrating SMART goal setting in preceptor development using the Habits of Preceptors Rubric.

PURPOSE: The impact of goal setting in pharmacy preceptor development was evaluated using the Habits of Preceptors Rubric (HOP-R), a criterion-referenced assessment developed to assess, quantify, and demonstrate growth across 11 preceptor habits. METHODS: This study retrospectively evaluated initial and follow-up survey responses from the 2019-2020 Clinician Educators Program cohort at Midwestern University College of Pharmacy, Glendale Campus. Enrollees in this teaching and learning curriculum (TLC) were invited to assess their precepting habits using the HOP-R after attending the first seminar and again toward the end of the longitudinal program. Using online surveys, participants rated their precepting capabilities as developing, proficient, accomplished, or master level for each habit. In the initial survey, each participant selected a habit of focus for deliberate development and established an individualized goal using the specific, measurable, achievable, relevant, and time-bound (SMART) framework. In the follow-up survey, participants indicated their satisfaction with and progress toward accomplishing their precepting goal. RESULTS: Initial survey results from 55 study participants identified developing as the most frequently self-reported habit level (53%; n = 605 ratings), while master was the least frequently reported (1%). In the follow-up assessment, accomplished (45%) was the most frequently self-reported habit level, while master (5%) remained the least reported. The cohort reported a median progress in SMART goal accomplishment of 69% (range, 12% to 100%; n = 54). CONCLUSION: Preceptor and resident pharmacists reported perceived advancement in precepting capabilities within the conceptual framework of the HOP-R encompassing both their self-selected habit of focus and adjacent habits while enrolled in a TLC. SMART goals facilitated qualitative and quantitative assessment of development.

Association of Cardiovascular Disease and Military Veteran Status With Impairments in Physical and Psychological Functioning: Retrospective Cross-Sectional Analysis of US National Survey Data.

INTRODUCTION: The Veterans Health Administration (VHA) provides multidisciplinary team-based care with peer-to-peer support for diabetes and obesity, but not for most heart diseases. OBJECTIVE: To inform disease-care models, assess physical and psychological functioning in veterans with, or at high risk of, heart disease. METHODS: Retrospective, cross-sectional cohort analysis of data from the National Survey on Drug Use and Health, 2015-2019, based on standard measures of functioning: self-rated health, serious psychological distress, and high-risk substance use. Cohorts were veterans with respondent-reported heart disease, or at high risk of cardiovascular disease based on age/comorbidity combinations (HD/risk); nonveterans with HD/risk; and veterans without HD/risk. Ordinal logistic regression models adjusted for demographics, social determinants of health, and chronic conditions. A priori alpha was set to 0.01 because of large sample size (N = 28,314). RESULTS: Among those with HD/risk, veterans (n = 3,483) and nonveterans (n = 16,438) had similar physical impairments, but distress trended higher among veterans (adjusted odds ratio = 1.36, 99% confidence interval [CI] = 0.99-1.86). Among those with comorbid HD/risk and behavioral health problems, regression-adjusted treatment rates were similar for veterans and nonveterans with psychological symptoms (55.9% vs. 55.2%, respectively, P = 0.531) or high-risk substance use (18.7% vs. 19.4%, P = .547); veterans were more likely to receive outpatient mental health treatment (36.1% [CI = 34.4%-37.8%] vs. 28.9% [CI = 28.2%-29.6%]). CONCLUSION: An upward trend in distress among veterans compared with nonveterans with HD/risk was not explained by differences in behavioral health treatment utilization. Further research should test multidisciplinary team-based care for veterans with HD/risk, similar to that used for other chronic diseases.

Evaluating the impact of a "grand rounds" elective course on students' perceived motivations, comfort, and confidence in providing constructive and reinforcing feedback to guest lecturers.

BACKGROUND AND PURPOSE: Providing feedback is an important skill for all healthcare professionals both within and outside of their discipline. Although student pharmacists frequently receive feedback during both didactic and experiential education, training on how to provide feedback to others is less common. EDUCATIONAL ACTIVITY AND SETTING: An elective was designed to expose second-year pharmacy students to "grand rounds" with practicing pharmacists as the presenters. Students provided feedback to presenters on presentation style and assessment questions. The primary objective of this research project was to determine if the elective improved students' motivations, comfort, and confidence in providing constructive written feedback. FINDINGS: Over two course offerings, 54% (19 of 35) of enrolled students completed both the pre- and post-surveys. At baseline, the majority of students self-identified as being motivated, comfortable, and confident with providing quality written feedback with the exception of two specific areas: motivation to provide quality written feedback and comfort with providing difficult or sensitive written feedback. At the end of the course, the majority of students self-identified as being motivated, comfortable, and confident across all areas queried. All students agreed or strongly agreed that the efficiency and quality of their written feedback improved during the course. SUMMARY: The course offered several benefits to students, including learning clinical topics from a variety of presenters and developing feedback skills. The implementation of the grand rounds elective provided students an opportunity to develop their motivation, comfort, and confidence with providing quality constructive written feedback.

Experiential Pharmacy Education During a Pandemic: Lessons Learned.

The COVID-19 pandemic has radically changed how the world operates and introduced a multitude of unprecedented challenges for all health professionals, especially for those responsible for training learners, including pharmacy residents and students. Due to density and social distancing restrictions, many pharmacy schools and residency programs had to transition to virtual experiential learning-with little to no existing literature, structure, or adequate time for planning. This article offers a variety of approaches to ensure that pharmacy learners meet accreditation requirements, engage in interprofessional education and collaboration, reflect on their learning, prioritize self-care, and are adequately prepared to enter geriatric pharmacy practice despite current challenges with the COVID-19 pandemic. Authors address both challenges, as well as opportunities to expand future experiential education for all pharmacy learners.

Rates and Predictors of Physician-Recommended and Self-Reported Aspirin Use in 2015.

OBJECTIVE: This study assesses the rate of providerrecommended aspirin use through the National Ambulatory Medical Care Survey (NAMCS) database versus self-reported aspirin use through the Behavioral Risk Factor Surveillance System (BRFSS) database and identifies factors that predict initiation of aspirin. This study provides insight into the rate of providerrecommended aspirin use versus self-reported aspirin use prior to the 2016 United States Preventive Service Task Force primary prevention recommendation update.
DESIGN: Retrospective, cross-sectional analysis of US population data obtained from medical records (NAMCS) and community-dwelling residents in four states (BRFSS) in 2015.
SETTING: Physician offices (NAMCS) and households or telephone (BRFSS).
PATIENTS, PARTICIPANTS: NAMCS: visits made by patients 40 years of age or older to physicians who permitted federal employees to abstract officevisit data. BRFSS: household or telephone interview respondents 40 years of age or older.
INTERVENTIONS: Comparisons of persons with (secondary prevention) versus without (primary prevention) cardiovascular disease.
MAIN OUTCOME MEASURED: Recommended (NAMCS) or self-reported (BRFSS) use of aspirin.
RESULTS: The sample included 19 170 patients (NAMCS), with 2 205 having a history of cardiovascular disease and 14 872 respondents (BRFSS) with 2 024 having a history of cardiovascular disease. For both primary and secondary prevention, respondents from BRFSS reported higher rates of aspirin use (27.7% primary, 65.6% secondary prevention) compared with prescribed rates from NAMCS (11.7% primary, 45.6% secondary prevention).
CONCLUSIONS: Study results highlight the value of obtaining a complete medication history, including aspirin use, from all patients.

Impact of COVID-19 on Residency Training.

The novel coronavirus disease 2019 (COVID-19) pandemic has impacted pharmacists in a variety of ways, including increased workloads, reduced hours, and ever-changing recommendations for managing this unique infection. Trainees, both students and residents, have also dealt with numerous challenges and changes during this pandemic.

Treatment Needs and Service Utilization in Older U.S. Adults Evidencing High-Risk Substance Use.

Objectives: Because substance misuse by older adults poses clinical risks and has not been recently assessed, we examined substance use patterns, treatment needs, and service utilization in those evidencing high-risk use. Methods: We identified National Survey on Drug Use and Health respondents (2015-2018) aged ≥50 years reporting multiple-occasion binge drinking, illicit drug use, prescription drug misuse, or substance dependence. Past-year psychological symptoms were assessed using validated scales. Results: The sample, representing 10.2% of community-dwelling older U.S. adults, evidenced clinically important risks: 65.2% past-month binge drinking, 27.3% mental illness, 14.3% psychological distress, 10.6% combined alcohol/drug use, and 6.5% suicidality. Treatment receipt was uncommon (27.7%), positively associated with distress, and negatively associated with binge drinking. Of those not receiving treatment, 3.8% perceived treatment need. Discussion: Findings highlight the value of substance misuse screening and brief interventions, suggesting potential treatment referral opportunities for those evidencing psychological distress.

Estimated Cardiovascular Risk and Guideline-Concordant Primary Prevention With Statins: Retrospective Cross-Sectional Analyses of US Ambulatory Visits Using Competing Algorithms.

INTRODUCTION: The 2013 pooled cohort equations (PCE) may misestimate cardiovascular event (CVE) risk, particularly for black patients. Alternatives to the original PCE (O-PCE) to assess potential statin benefit for primary prevention-a revised PCE (R-PCE) and US Preventive Services Task Force (USPSTF) algorithms-have not been compared in contemporary US patients in routine office-based practice. METHODS: We performed retrospective, cross-sectional analysis of a nationally representative, US sample of office visits made from 2011 to 2014. Sampling criteria matched those used for PCE development: aged 40 to 79 years, black or white race, no cardiovascular disease. Original PCE, R-PCE, and USPSTF algorithms were applied to biometric and demographic data. Outcomes included estimated 10-year CVE risk, percentage exceeding each algorithm's statin-treatment threshold (>7.5% risk for O-PCE and R-PCE, and >10% O-PCE plus >1 risk factor for USPSTF), and percentage prescribed statin therapy. RESULTS: In 12 556 visits (representing 285 330 123 nationwide), 10.8% of patients were black, 27.1% had diabetes, and 15.7% were current smokers. Replacing O-PCE with R-PCE decreased mean (95% confidence interval [CI]) estimated CVE risk from 12.4% (12.0%-12.7%) to 8.5% (8.2%-8.8%). Significant (P < 0.05) racial disparity in the rate of CVE risk >7.5% was identified using O-PCE (black and white patients [95% CI], respectively: 58.8% [54.6%-62.9%] vs 52.8% [51.1%-54.4%], P = .006) but not R-PCE (41.6% [37.6%-45.7%] vs 39.9% [38.3%-41.5%], P = .448). Revised PCE and USPSTF recommendations were concordant for 90% of patients. Significant racial disparity in guideline-concordant statin prescribing was found using O-PCE (black and white patients, respectively, 35.0% [30.5%-39.9%] vs 41.8% [39.9%-44.4%], P = .013), but not R-PCE (40.6% [35.0%-46.6%] vs 43.0% [40.0%-45.9%], P = .482) or USPSTF recommendations (39.0% [33.8%-44.5%] vs 44.4% [41.5%-47.5%], P = .073). CONCLUSIONS: Use of an alternative to O-PCE may reduce racial disparity in estimated CVE risk and may facilitate shared decision-making about primary prevention.

Joint effects of advancing age and number of potentially inappropriate medication classes on risk of falls in Medicare enrollees.

BACKGROUND: Injurious falls among older adults are both common and costly. The prevalence of falls is known to increase with age and with use of fall-risk drugs/potentially inappropriate medications (FRD/PIM). Little is known about the joint effects of these two risk factors. METHODS: Data for 2013-2015 were obtained from the Truven Health MarketScan® Medicare database comprising utilization and eligibility (enrollment) data for approximately 4 million enrollees annually. A case-control design was used to compare enrollees aged 65-99 years diagnosed with > 1 fall event (n = 110,625) with enrollees without falls (n = 1,567,412). An exploratory analysis of joint age-FRD/PIM effects on fall risks was based on number needed to harm (NNH) calculations for each FRD/PIM therapy class count (compared with 0 FRD/PIMs), stratified by age group. Logistic regression analyses adjusted for demographics, comorbidities, and fracture history, measured in the 1 year prior to the fall date (cases) or a randomly assigned date (controls). RESULTS: For each FRD/PIM class count, NNH values decreased with older age (e.g., for 1 FRD/PIM class: from NNH = 333 for ages 65-74 years to NNH = 83 for ages 90-99 years; for 2 FRD/PIM classes: from NNH = 91 for ages 65-74 years to NNH = 38 for ages 90-99 years). NNH decreased to < 15 patients at > 6 classes for age 65-74 years, > 5 classes for age 75-84 years, and > 4 classes for age 85-99 years. Adjusted odds of falling were increased for age-FRD/PIM combinations with smaller NNH values: adjusted odds ratio (AOR) = 1.127 (95% confidence interval [CI] = 1.098-1.156) for NNH = 83-91; AOR = 1.427 (95% CI = 1.398-1.456) for NNH = 17-48; AOR = 1.983 (1.9034-2.032) for NNH < 15. CONCLUSION: FRD/PIM use and age appear to have joint effects on fall risk. Older adults at high risk, indicated by small NNH, may be appropriate for fall prevention initiatives, and clinicians may wish to consider decreasing the number of FRD/PIMs utilized by these patients.

High-risk opioid prescribing trends in the outpatient setting prior to issuance of federal guidance.

Co-prescription of opioid and benzodiazepine products increases the risk of overdose-related mortality four-fold due to respiratory depression. Accordingly, prevention of high-risk opioid prescribing (HROP) has become a focus over the past two decades and was the subject of a black-box warning (BBW) issued by the U.S. Food and Drug Administration (FDA) on August 31, 2016. Because older patients are at increased risk for these outcomes, we compared rates of HROP for older (aged ≥65 years) and younger (aged 18-64 years) adults using a repeated cross-sectional cohort design. Data from the National Ambulatory Medical Care Survey of U.S. office-based physician visits were accessed for 2006-2016 August. From 2006 to 2016, the opioid-prescribing rate increased by 40% among those aged 18-64 years and by 54% among those aged ≥65 years. From 2012-2013 to 2014-2016, the HROP rate, expressed as a proportion of all opioid-prescribing visits, increased to 26.6% among those aged 18-64 years but declined to 21.0% among those aged ≥65 years, primarily because of changes for patients aged ≥75 years. Prior to the FDA-issued BBW, the HROP prescribing rate trended upward for all adults, except in 2014-2016 when it began to decline among older adults.

Provision of Lifestyle Counseling and the Prescribing of Pharmacotherapy for Hyperlipidemia Among US Ambulatory Patients: A National Assessment of Office-Based Physician Visits.

BACKGROUND: An estimated 27.8% of the United States (US) population aged ≥20 years has hyperlipidemia, defined as total serum cholesterol of ≥240 mg/dL. A previous study of US physician office visits for hyperlipidemia in 2005 found both suboptimal compliance and racial/ethnic disparities in screening and treatment. OBJECTIVE: The aim was to estimate current rates of laboratory testing, lifestyle education, and pharmacotherapy for hyperlipidemia. METHODS: Data were derived from the US National Ambulatory Medical Care Survey (NAMCS), a nationally representative study of office-based physician visits, for 2013-2014. Patients aged ≥20 years with a primary or secondary diagnosis of hyperlipidemia were sampled. Study outcomes included receipt or ordering of total cholesterol testing, diet/nutrition counseling, exercise counseling, and pharmacotherapy prescription including statins, ezetimibe, omega-3 fatty acids, niacin, or combination therapies. RESULTS: Compared with previously reported results for 2005, rates of pharmacotherapy have remained static (52.2 vs. 54.6% for 2005 and 2013-2014, respectively), while rates of lifestyle education have markedly declined for diet/nutrition (from 39.7 to 22.4%) and exercise (from 32.1 to 16.0%). Lifestyle education did not vary appreciably by race/ethnicity in 2013-2014. However, rates of lipid testing were much higher for whites (41.6%) than for blacks (29.9%) or Hispanics (34.2%). Tobacco education was ordered/provided in only 4.0% of office visits. CONCLUSION: Compliance with guidelines for the screening and treatment of hyperlipidemia remains suboptimal, and rates of lifestyle education have declined since 2005. There exists an urgent need for enhanced levels of provider intervention to reduce the morbidity and mortality associated with hyperlipidemia.

Accuracy of community-based blood pressure devices versus validated self-use devices.

OBJECTIVES: To examine the accuracy of a community-based blood pressure monitor (CBPM) versus a validated automatic blood pressure monitor (ABPM); to assess providers' recommendations regarding use of CBPMs; and to assess if potentially inaccurate blood pressure readings may result in treatment changes. METHODS: A convenience sample of 50 participants was recruited and met criteria for a randomized, controlled, crossover design trial in a community pharmacy in January and February 2013. Participants completed a screening survey and were educated about how a pharmacist can assist in achieving blood pressure control. Blood pressure measurements were performed using a CBPM and a validated ABPM. Participants were asked to identify their primary care provider (PCP); if identified, the PCP was faxed a survey to complete. The difference in blood pressure readings between the two monitors was examined and PCP survey responses were examined. RESULTS: There were significant differences between the means obtained from the two different monitors for systolic blood pressure (P = 0.006) and diastolic blood pressure (P = 0.012) measurements. Due to differences between readings, recommendations for change in treatment (or initiation of blood pressure medication) may have been different for 38% of participants. PCPs indicated that they often recommend CBPMs for self-monitoring. CONCLUSION: Patients, pharmacists, and providers should be aware of potential inaccuracies when using a CBPM for self-monitoring.

Managing acute coronary syndromes in the elderly.

OBJECTIVE: To provide an up-to-date review of the available evidence regarding treatment of acute coronary syndromes (ACS) in elderly patients. DATA SOURCE: A PubMed search of articles published through January 2015 was done using a combination of the following words: acute coronary syndrome, pharmacy, elderly, geriatric, myocardial infarction, beta-blocker, statin, antiplatelet, antithrombin, angiotensin-converting enzyme inhibitor, and aspirin. STUDY SELECTION/DATA EXTRACTION: Relevant original research, review articles, and guidelines were assessed for the management of elderly patients with ACS. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS: Because of the high prevalence of ACS in elderly patients, appropriate treatment is necessary to reduce morbidity and mortality; however, these patients are often under-represented in trials. This article provides a review of the current literature on treatment of ACS in the elderly and provides guidance to pharmacists regarding optimal pharmacotherapy for these patients. CONCLUSION: Appropriate treatment of ACS can help improve outcomes in elderly patients, and the pharmacist can provide guidance regarding evidence-based therapy.