Community Pharmacists Identification of Gaps in Care - Statin Utilization for Primary Prevention.

Background: Statins are a highly effective lipid-lowering therapy associated with significant reductions in atherosclerotic cardiovascular disease (ASCVD) events and death. Despite these benefits, statins are underutilized. Pharmacist-led interventions to increase statin prescribing are effective. To our knowledge, no prior studies implemented a comprehensive cardiovascular risk assessment utilizing point-of-care (POC) testing in community pharmacies. Objectives: The primary objective was to determine if community pharmacists can be utilized to identify gaps in care regarding appropriate use of statin therapy for prevention of ASCVD events in HPSAs. Secondary objectives were to assess public interest in ASCVD risk assessment and statin prescribing by the pharmacist, and to identify factors associated with statin gaps in care. Methods: A cross-sectional study was conducted at three independent community pharmacies. Participants were identified based on age and medication history and were scheduled at their pharmacy to receive a comprehensive ASCVD risk screening consisting of POC measurement of a complete lipid panel, blood glucose or A1C, and blood pressure. Participants were informed of their statin candidacy at the screening. Participants completed a survey regarding perceptions of the services provided and opinions of statin prescribing by pharmacists. Results: Of the 57 participants, 43 (75.4%) were possible statin candidates. Most indicated trusting their pharmacist to prescribe a cholesterol-lowering medication and felt insurance should pay for these screenings. Conclusion: ASCVD risk assessment conducted within the community pharmacy setting for can be utilized to identify treatment gaps in status use. Participants indicated trusting pharmacists to provide this service and found the service valuable.

Considerations of gender-affirming care for transgender and gender-diverse youth.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Contraceptive use in patients with gender dysphoria who were assigned female at birth receiving care at a specialty gender-affirming clinic.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recommend that all patients, regardless of gender identity or sexual orientation, should be offered family planning and contraceptive options without assumptions of sexual behaviors and pregnancy risk. Current research on family planning services for lesbian, gay, bisexual, transgender, and queer or questioning patients is limited, but patients who are sexual or gender minorities are at increased risk for unintended pregnancy. OBJECTIVES: The objective of this study was to describe contraceptive use in patients assigned female at birth with gender dysphoria at a gender-affirming primary care clinic. METHODS: A retrospective descriptive study was conducted. Patients were included if they were 18 to 44 years old, received care at University of New Mexico Truman Health Services in 2019, were diagnosed with gender dysphoria, and were assigned female at birth. Patients were excluded if they had never developed female reproductive organs. Data were collected from the electronic medical records. Potential differences in contraceptive use based on demographic characteristics, having a family planning discussion, and having a contraceptive use discussion were analyzed using chi-square analyses. Potential predictors of contraceptive use were identified using exploratory forward conditional logistic regression and univariate logistic regression analyses. RESULTS: A total of 163 patients were included; average age was 26.6 years; 71% identified as male, 5% identified as masculine, and 25% identified as nonbinary. Most patients (92%) were prescribed masculinizing therapy (testosterone). Forty-five (28%) patients had documented contraception use; the most common form was permanent contraception (76%). Most patients (68%) did not have any documented contraindications to contraception based on CDC US Medical Eligibility Criteria for contraceptive use. Of 113 patients with a documented sexual orientation, 45 patients (40%) reported having sex with persons who have a penis; only 13 (29%) of those patients had a documented form of contraception. Family planning discussions were documented for 82% of patients. Family planning discussions that specifically addressed contraception were documented in only 49% of patients. However, the odds of a patient having a documented use of contraception was 9.26 times higher when family planning discussions specifically addressed contraception. CONCLUSION: Documented contraception use was low in people assigned female at birth of childbearing age receiving care at a gender-affirming clinic. Due to increased risks of unintended pregnancy in this population and the teratogenic nature of testosterone, family planning discussion should also include discussions related to contraception, as this was associated with increased contraception use. Additional research is needed to address potential barriers to contraception use in this population.

Patient perspectives and needs regarding contraception in female patients with HIV: A qualitative study.

BACKGROUND: Women with human immunodeficiency virus (HIV) are at risk of unintended pregnancy and may experience barriers to accessing contraception such as social stigma, concern for drug-drug interactions with HIV regimens, cost, and access to care. As pharmacist prescriptive authority for contraception becomes more prevalent, pharmacists may play a role in expanding access to contraception for women with HIV. Little is known about perspectives in this population regarding pharmacists prescribing contraception. OBJECTIVES: The objective of our study was to explore participants' experiences with contraception and childbearing, identify barriers to receiving contraception and unmet needs for contraceptive services, and explore perspectives on pharmacists prescribing contraception among women with HIV receiving care at a specialty HIV clinic. METHODS: This qualitative study used semistructured phone interviews with female patients receiving care at the University of New Mexico Truman Health Services in Albuquerque, New Mexico (NM). Interviews were transcribed verbatim and analyzed by 2 independent coders using Dedoose software. RESULTS: Contraception use was high in our population, with 75% of participants reporting a current contraceptive method. Among our population, participants were supportive of pharmacists prescribing contraception. Participants appreciated that pharmacies were accessible and convenient and that pharmacists are well trained and able to manage drug-drug interactions. Participants expressed a preference for pharmacists to explain all available contraceptive options and to have a thorough understanding of their medical history and medications. Participants expressed concern about privacy and disclosure of their HIV status when receiving contraception from a pharmacist. CONCLUSION: Among our population of women with HIV receiving care at a specialty clinic in NM, participants were supportive of pharmacists prescribing contraception. Pharmacists should consider the preferences of this population when prescribing contraception. Further research is warranted in additional populations of women with HIV to further explore unique perspectives among non-English speaking patients and those who do not receive care at specialty clinics.

A Resource Compendium for Embedding LGBTQIA+ Patient Care in the Professional Identity of Community Pharmacists.

OBJECTIVES: Cultural, clinical, social, and legally competent patient care for lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) patients is currently scarcely incorporated in pharmacy curricula. Furthermore, clinical, legal, and socio-cultural training that prepares pharmacists on the job to provide LGBTQIA+ competent patient care is scant. Here, our objectives were to (1) systematically review the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify trends in community pharmacists' professional identity development related to the provision of competent LGBTQIA+ patient care, and (2) create a reference guide for community pharmacists for self-directed learning. The literature search focused on 4 professional identity domains common to most pharmacists: academic and clinical competence, cultural sensitivity, knowledge of state and federal laws, and continuing professional development. FINDINGS: A total of 207 articles were identified, with 93 retrieved, of which 26 articles were included in the final analysis based on title and abstract and other inclusion criteria. SUMMARY: Overall, our search identified that the LGBTQIA+ health professions literature focused on the following themes: guidance for appropriate drug selection and therapy, creation of cultural sensitivity training curricula, community pharmacists' perceptions of their ability to provide LGBTQIA+ care, health system interventions, and Allyship education for advancing LGBTQIA+ care, the need for enhanced training of pharmacists for understanding the federal and state laws and requirements while providing care, and the need for a resource compendium to help community pharmacists access self-directed learning information, for which we have created a self-help resource guide for pharmacists in these 4 professional pharmacist identity domains.

Risk Assessment and Coronary Artery Calcium Scoring in Transgender and Gender-Diverse Individuals Receiving Gender-Affirming Hormone Therapy.

OBJECTIVE: To evaluate cardiovascular risk factors and prevalent coronary artery disease (CAD) using Coronary Artery Calcium (CAC) scoring in transgender and gender-diverse (TGD) individuals receiving gender-affirming hormone therapy (GAHT) and compare the CAC scores of TGD individuals with those of the general population. METHODS: TGD individuals aged ≥30 years, without known risk factors for cardiovascular disease (CVD), other than tobacco use and family history of CVD, on GAHT were recruited, and baseline information, including metabolic parameters, was collected. CAC scores were obtained and compared with those of a cisgender age-matched population. RESULTS: Of 25 transwomen recruited, 24 underwent CAC scans. Of them, 2 (8.3%) had a CAC score of >0 to 99 and 1 (4.1%) had a CAC score of ≥100. Of 22 transmen recruited, 16 underwent CAC scans. Of them, 26 (12.5%) had a CAC score of >0 to 99 and none had a CAC score of ≥100. Framingham Risk Scores were not correlated with the presence of CAC. CONCLUSION: The presence of CAC in this small cohort of TGD individuals on GAHT was similar to that in the cisgender age-matched population. CAC scoring is a means to assess the prevalence of CAD in TGD individuals and identify those in whom aggressive risk reduction is indicated.

Contraceptive Use and Missed Opportunities for Family Planning Discussions in Women Living with Human Immunodeficiency Virus at an HIV Clinic.

The objective of this study was to examine contraception use and family planning discussions (FPD) in female people living with HIV (PLWH). A retrospective cohort study was conducted. Female PLWH were included if they were 18-44 years and received care in 2019 at an HIV clinic. 74 patients met inclusion; mean age was 35 years, 53% were white. All patients were prescribed antiretroviral therapy. 48.6% of patients had documented FPD. 64.9% of patients were using contraception; sterilization was most common (41.7%). Only five patients had a contraindication to hormonal contraception. No differences in contraception use were observed based on age, race, HIV viral load, number of visits, or past pregnancies. However, patients with documented FPD were more likely to use contraception (OR 4.55; 95% CI 1.35-15.29). Routine FPD and contraception use in female PLWH were low. Rates of sterilization were high in female PLWH. Providing quality family planning services is critical to increase contraception use and selection of the most appropriate contraception form.

Underprescribing of statin therapy in people with HIV at risk for atherosclerotic cardiovascular disease.

PURPOSE: People with HIV (PWH) are at increased risk for developing atherosclerotic cardiovascular disease (ASCVD). The primary objective of this study was to evaluate adherence to guideline recommendations on statin use in PWH for both primary and secondary ASCVD prevention in a single healthcare institution. METHODS: A retrospective chart review was performed to evaluate statin use for cardiovascular risk reduction in PWH 40 to 75 years of age at an HIV clinic over a 1-year evaluation period. The study included patients who met one of the 4 criteria for statin therapy defined in the "ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults." Patient demographics were collected and a 10-year ASCVD risk score was calculated. RESULTS: A total of 432 PWH were evaluated for statin therapy; 205 patients (47.5%) met criteria for statin therapy. The majority of patients were male, the average age was 58 years, and the average time since HIV diagnosis was 19 years. The mean ASCVD risk score was 14.2%. Only 79 patients (38.5%) who met criteria were prescribed statin therapy, and only 45 (56.9%) were prescribed statin therapy of appropriate intensity. Use of ART pharmacokinetic enhancer was low and did not affect statin prescribing. Multivariable analysis found that age, diabetes, clinical ASCVD, and an appointment with a pharmacist clinician prescriber predicted statin utilization. A high ASCVD risk score (>20%) did not predict statin treatment. CONCLUSION: Statin prescribing is low in PWH, who are at increased risk for ASCVD. Future research in PWH should focus on improving ASCVD risk assessment and exploring causes for statin underprescribing.

Improving Pharmacy Students' Clinical Knowledge on Providing Care for Patients Belonging to the LGBTQ+ Community.

A 12-question survey instrument was developed, pilot-tested, and administered to 191 pharmacy students in their first professional year after engaging in a learning activity focusing on topics across five categories with clinical relevance to providing care to the LGBTQ+ community. A paired student t-test was performed on survey tool pre-test and post-test survey responses, with p < 0.05 considered significant. A total of 183 usable pre-test and post-test survey responses were received. Statistically significant differences between the pre-test and post-test correct responses were observed for scenarios involving proper pronoun use, hormone therapy (HT) counseling, immunization best practices, and communication hesitancy. The greatest knowledge change was reported in the categories of immunization best practices (48.9%), HT counseling (33.6%), and pronoun use (22.8%). Active learning assignments are effective teaching strategies to promote clinical knowledge in providing inclusive and culturally competent care to LGBTQ+ patients. Clinical topic areas including proper pronoun use, HT counseling, immunization best practices, privacy, risk awareness, and communication hesitancy are effective curricula additions for pharmacy colleges to advance inclusive curricula concerning providing care to the LGBTQ+ community.

Long-Acting Basal Insulins: A Review of the More Recently Approved Agents.

Long-acting basal insulins are used for the management of both type 1 and type 2 diabetes mellitus. Long-acting basal insulins were developed utilizing recombinant DNA technology and have been available since 2000 with the approval of insulin glargine U-100 followed by insulin detemir in 2005. In recent years, diabetes management has become more complex with the approval of insulin glargine U-300 and insulin degludec U-100 and U-200. Both insulin glargine U-300 and insulin degludec have been compared with insulin glargine U-100 and have demonstrated longer durations of action, as well as lower rates of hypoglycemia. This review discusses the Food and Drug Administration-approved long-acting insulins with a focus on recently approved agents and their efficacy and safety compared with the first long-acting basal insulins.

Examining community-based pharmacist perceptions on the care of transgender patients.

OBJECTIVE: The objective of this study was to determine whether community-based pharmacists in North Carolina have the personal confidence, comfort level, and resources needed to care appropriately for and interact with transgender patients. METHODS: Using the North Carolina Board of Pharmacy database, a link to a 25-item questionnaire was e-mailed to all actively licensed community pharmacists in North Carolina. Survey items included pharmacist demographics, prior or current education on transgender health care, comfort regarding care provision for transgender patients, and the ability to care for transgender patients at the practice site. Questionnaire items were developed in collaboration with a pharmacist who actively participates in the care of transgender patients. The questionnaire was pilot-tested among a convenience sample of student pharmacists and pharmacists for feedback on validity and question structure. The survey was open for 30 days with a reminder sent on day 15. Upon survey completion, participants had the option to be entered into a drawing to receive a gift card incentive. RESULTS: In total, 342 surveys were completed of 4784 surveys distributed, yielding a 7.1% response rate. Three percent of survey respondents reported receiving education on treating transgender patients during their respective pharmacy school curricula, and 12% of respondents sought other forms of transgender education (i.e., continuing education). Seventy-one percent of respondents viewed the role of the pharmacist as important in the care of transgender patients. Sixty-six percent of respondents were comfortable welcoming transgender patients into their practice sites, and 36% were comfortable asking for pronouns. CONCLUSION: Survey participants reported a lack of formal or postgraduate education, which describes a need for accessible education on transgender care. North Carolina community-based pharmacists believe that it is within their role as pharmacists to provide gender-affirming care, but they may need additional training to feel comfortable in providing this care.