Practical Approaches to Antipsychotic-Associated Corrected QT Interval Prolongation in Patients With Serious Mental Illness: A Review of Cases.

Background: There is no consensus for assessment and management of patients with serious mental illness (SMI) who are at risk for cardiac morbidity and mortality due to antipsychotic-associated QTc prolongation. Objective: The objective of this review was to assess methods for risk scoring, QT correction calculation, and clinical management in SMI patients with antipsychotic-associated QTc prolongation. Methods: A search was performed in PubMed for case reports that described QTc prolongation in adult patients with schizophrenia or bipolar disorder prescribed an antipsychotic. Reports published in North America between 2000 and 2020 were eligible. The Mayo, Tisdale, and RISQ-PATH scoring tools were applied to cases to categorize risk level. Results: Seventeen cases were included. Most patients were prescribed a second-generation antipsychotic for schizophrenia, with baseline and maximum QTc values of 429 milliseconds and 545 milliseconds, respectively. The Mayo scoring tool identified 17 (100%) cases as "high risk," Tisdale identified 9 (53%) cases as "moderate risk" and 7 (41%) cases as "low risk," while RISQ-PATH identified 9 (53%) cases as "not low risk" and 8 (47%) cases as "low risk." Three cases reported the QT correction formula utilized (18%). The most common intervention to address antipsychotic-associated QTc prolongation was switching to a different antipsychotic (35%). Approximately one third of patients experienced Torsades de Pointes. Conclusion: There is a lack of standardization for antipsychotic-associated QTc prolongation risk assessment and management in patients with SMI. This review provides real-world data representing actual clinical practice.

Implementing medicare education for medication access: A review of the literature using the RE-AIM framework.

BACKGROUND: The rising cost of medications has a disproportionate effect on community-dwelling older adults despite policy changes designed to improve medication access. Medicare insurance counseling provided by pharmacists, including individualized plan comparison and enrollment assistance, improves medication adherence and health care utilization, yet only 15% of community dwelling older adults report using a pharmacy or pharmacist for Medicare information. To determine what information is available to inform expanding implementation of pharmacy as a resource for Medicare insurance counseling, a systematic review of published studies using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was conducted. METHODS: Articles meeting inclusion criteria were identified through a literature search using PubMed and GoogleScholar; 27 pharmacy Medicare insurance counseling studies were identified representing 13 unique programs in clinical, community outreach, and community pharmacy settings. Each article was coded by two researchers using the RE-AIM Coding Sheet for Publications and the extent of RE-AIM dimension reporting was determined using descriptive statistics at the program level. Discussions were used to arrive at coding consensus and concordance was measured with Krippendorff's alpha. RESULTS: Across all studies (15 quasi experimental, 10 analytical case reports, and 2 case reports) more than half of the programs reported framework component dimensions for Reach (69%), Adoption (58%), Implementation (54%), and Maintenance (54%), and fewer than half reported comprehensively on Effectiveness (44%). Ten studies in 7 of 13 programs reported estimated out-of-pocket cost savings. Two studies measured patient-centered outcomes: medication adherence by proportion of days covered (PDC) and health care utilization by hospital admissions and emergency department visits. Gaps in the external validity of pharmacy Medicare education programs were identified including staff participation rates, methods to identify participating settings and program costs. CONCLUSIONS: Based on this review, current research on pharmacy Medicare education is insufficient to guide broad implementation. Additional studies are needed to determine how Medicare education integrating pharmacists and pharmacies can be implemented to address cost-related non-adherence for community dwelling older adults.

Mindset and team communication in pharmacists: Examination of pharmacist's self-views.

OBJECTIVES: Pharmacists provide care in a complex adaptive system, which requires action and teamwork to address unexpected outcomes. We assessed practicing pharmacists' self-views of growth mindset and team communication across multiple practice settings. DESIGN: The validated Growth Mindset and Team Communication (GMTC) tool, a multicomponent quantitative and qualitative survey instrument was used to conduct a descriptive study of pharmacist self views. SETTING AND PARTICIPANTS: Survey instrument was distributed electronically to all licensed North Carolina pharmacists. OUTCOME MEASURES: The survey consisted of 4 sections: (1) growth mindset self-evaluation (14 questions), (2) team communication self-evaluation (13 questions), (3) description of previous teamwork experience (1 question), and (4) demographics (8 questions). Data were analyzed using descriptive statistics, and responses to the open-ended question were assessed using qualitative content analysis. RESULTS: A total of 507 pharmacists participated in the survey. Participants reported primary practice settings, 42.1% in community, 38.9% in health system, and 17.3% in other settings, and 52.1% reported more than 20 years' total pharmacy experience. The total GMTC scale average score was 81.9 ± 7.9 out of 108 possible points. The growth mindset subscale indicated an overall average score of 43.5 ± 4.4 out of 56 possible points The team communication subscale indicated an overall average score of 38.3 ± 5.2 out of 52 possible points. The self-view of a growth mindset was not affected by years of pharmacy experience or primary practice site, but additional teamwork credentials were positively correlated with the overall GMTC score driven by the team communication subscale. CONCLUSIONS: A growth mindset is prevalent among experienced pharmacists from multiple practice settings. Pharmacists recognize teamwork as an essential work element and rate their team communication skills highly.

A Teamwork Workshop to Improve Pharmacy Students' Growth Mindset and Communication Skills.

Objective. To determine the impact of a workshop on the growth mindset and team communication of first year Doctor of Pharmacy (PharmD) students.Methods. A multi-week workshop was developed for first year pharmacy students. The workshop included completion of the StrengthsFinder 2.0, a session on identifying individual and team member strengths, a session on situational communication and conflict resolution models, and a work-up of two pharmacy scenarios requiring conflict resolution. The workshop was delivered to two intervention groups (fall 2019 and fall 2018) and compared to a control group (fall 2017). A pre-post survey was administered to measure change in students' growth mindset and team communication using the validated Growth Mindset and Team Communication (GMTC) tool. Data were analyzed using descriptive statistics, independent sample t tests, and chi-square tests to compare difference and association. Focus groups were conducted in fall 2017 and fall 2018 to assess students' views regarding teamwork.Results. Team communication subscale scores increased significantly among students in the intervention group while there was no significant change in these scores among students in the control group. The focus groups reflected that students had overall positive views about team communication and collaboration, which were also supported by discussions of advantages and challenges during teamwork.Conclusion. A teamwork workshop affected pharmacy students' communication skills. Future work should focus on longitudinal measurement of students' self-views to determine the long-term impact of teamwork training interventions.

Communicating definitive uncertainty: Teaching pharmacy students to say "I don't know".

BACKGROUND AND PURPOSE: Communicating uncertainty is an art requiring practice. The purpose of this study was to compare pedagogies for the instruction of pharmacy students in communicating definitive uncertainty. EDUCATIONAL ACTIVITY AND SETTING: A case scenario featuring a busy physician asking a question without a definitive answer was directed to the pharmacy student using two pedagogies: (1) in-person standardized client and (2) virtual written case. Students provided self-assessments of their confidence in communicating uncertainty after completing the case utilizing a survey containing both rating scale questions and open-ended questions. Self-confidence within-group differences were compared using Wilcoxon signed-rank tests and between-group differences were compared using Mann-Whitney U tests. Responses to open-ended questions were descriptively analyzed for themes using qualitative assessment methods. FINDINGS: Both the in-person standardized client (70 to 81, P ≤ .001) and the virtual written case (74 to 85, P ≤ .001) significantly increased students' self-rated confidence to verbalize "I don't know" to a healthcare provider. No significant differences were observed between the pedagogies. However, students who participated in the virtual written case mentioned a desire for "additional practice opportunities" more frequently than students who participated in the in-person standardized client. SUMMARY: In-person standardized client and virtual written case are effective methods for increasing pharmacy student comfort with communicating definitive uncertainty. Further research is needed to instruct pharmacists in uncertainty communication.

Psychometric validation of a growth Mindset and Team Communication Tool to measure self-views of growth mindset and team communication skills.

OBJECTIVE: The objective of this study was to develop and conduct psychometric validation of a tool to assess self-views of a growth mindset and team communication skills among pharmacists. DESIGN: The Mindset and Team Communication Tool was developed to assess self-views of growth mindset and team communication. The survey consisted of 2 parts: (1) 14 items on growth mindset and (2) 13 items on team communication; a 4-point Likert scale of agreement was used as an option to answer all items. SETTING AND PARTICIPANTS: The survey was administered to first-year student pharmacists from 2017 to 2019. The participants completed a presurvey at the beginning of the semester and a postsurvey at the end of the semester (3-month follow-up period). OUTCOME MEASURES: Psychometric validation was performed by assessing the following properties: face and content validity, internal consistency reliability, construct validity, test-retest reliability, responsiveness validity, and convergent validity. RESULTS: A total of 174 participants completed both the pre- and postsurvey (response rate = 92.7%). Internal consistency reliability demonstrated a Cronbach alpha coefficient of 0.827. Construct validity showed that all measures, except for 6 items, loaded highly onto 2 components. Test-retest reliability revealed a statistically significantly positive relationship between the pre- and postsurvey scores. Responsiveness validity demonstrated a statistically significant improvement in the score when an intervention was provided. Convergent validity showed no correlation between the tool score and course grades. CONCLUSION: The Mindset and Team Communication Tool demonstrated validity and reliability across a robust set of psychometric values and provides a foundation to describe pharmacists' self-views and explore associations of these views with behavior in teamwork-based environments.

Rates and Types of Medication-Related Problems in Patients Rehospitalized Within 30 Days of Discharge From a Community Hospital.

Background: Impact of medication-related problems (MRPs) on persistently high hospital readmission rates are not well described. Objective: The purpose of this study was to determine the rate and type of MRPs attributed to rehospitalization within 30 days of discharge from a general internal medicine hospitalists' service at a nonacademic medical center. Methods: A retrospective cohort study was conducted evaluating consecutive patients readmitted within 30-days after discharge to home from an internal medicine hospitalist service. Readmissions attributed to MRPs in physician documentation were systematically classified as indication, effectiveness, adverse drug reaction, or nonadherence problems and evaluated for possible preventability. Descriptive statistics were used to describe the rate and type of MRP. Results: Evaluation of consecutive 30-day readmissions (n = 203) to a nonteaching community hospital identified 50.2% of admissions attributed to MRPs. MRPs (n = 102) were categorized as problems of indication (34.3%), efficacy (19.6%), adverse drug events (18.6%), and nonadherence (27.5%). One third of 30-day readmissions in this cohort were attributed to potentially preventable MRPs. Conclusion: MRPs are frequently implicated in 30-day hospital readmissions in a nonteaching community hospital representing an opportunity for context-specific improvements.

Design of hospital errors and omissions activities that include patient-specific medication related problems.

BACKGROUND AND PURPOSE: Medication-related problems persist in hospital settings. New types of errors have emerged with changing technology. There is a need for updated, realistic, and patient-specific activities to train student pharmacists to identify medication-related problems. EDUCATIONAL ACTIVITY AND SETTING: We describe efforts to redesign hospital errors and omissions activities in a clinical skills lab course. A hospital errors and omissions template is described with multiple-choice answer options redesigned to reinforce that each instance of dispensing in a hospital is an opportunity for patient-centered care. FINDINGS: In the redesigned hospital errors and omissions activities, students identified the correct errors and omissions 77% of the time with an average point biserial of 0.491. Qualitative evaluation of student course evaluations and student self-selected learning goals suggest that students perceived the revised activity to be valuable. SUMMARY: It is possible to create and deliver hospital errors and omissions activities that include patient-specific medication related problems.

Evaluation of an Evidence-Based Medicine Curriculum in a PGY1 Pharmacy Residency Program Using the Fresno Test.

Objective. To assess the effectiveness of a longitudinal evidence-based medicine (EBM) curriculum to improve pharmacy resident knowledge and skills in evidence-based practice as measured by the Fresno Test. Methods. Residency program director and clinical pharmacist preceptors in a community teaching hospital developed a longitudinal EBM curriculum for a postgraduate year one (PGY1) pharmacy practice residency. The program was offered as a yearlong series of 1-hour meetings to train residents in evidence-based practice. A pre/post study design was used to evaluate the program. The full 12-item Fresno Test was used to measure specific EBP skills: Ask, Acquire, Appraise, Apply and Assess. Pre/post composite and item mean scores were compared using Student's paired t-test. Results. Forty-three residents completed pre- and post-Fresno Test evaluations between 2008 and 2014 with a mean increase in pre- and post-training scores from 125.9 (SD 32.9) to 138.5 (SD 33.6), p=.02. Conclusion. A longitudinal training program in EBM in a pharmacy residency demonstrated improvement in core evidence-based practice abilities as measured by the Fresno Test.

Experience with a pharmacy technician medication history program.

PURPOSE: The implementation and outcomes of a pharmacy technician medication history program are described. SUMMARY: An interprofessional medication reconciliation team, led by a clinical pharmacist and a clinical nurse specialist, was charged with implementing a new electronic medication reconciliation system to improve compliance with medication reconciliation at discharge and capture compliance-linked reimbursement. The team recommended that the pharmacy department be allocated new pharmacy technician full-time-equivalent positions to assume ownership of the medication history process. Concurrent with the implementation of this program, a medication history standard was developed to define rules for documentation of what a patient reports he or she is actually taking. The standard requires a structured interview with the patient or caregiver and validation with outside sources as indicated to determine which medications to document in the medication history. The standard is based on four medication administration category rules: scheduled, as-needed, short-term, and discontinued medications. The medication history standard forms the core of the medication history technician training and accountability program. Pharmacy technicians are supervised by pharmacists, using a defined accountability plan based on a set of medical staff approved rules for what medications comprise a best possible medication history. Medication history accuracy and completeness rates have been consistently over 90% and rates of provider compliance with medication reconciliation rose from under 20% to 100% since program implementation. CONCLUSION: A defined medication history based on a medication history standard served as an effective foundation for a pharmacy technician medication history program, which helped improve provider compliance with discharge medication reconciliation.

High-Risk Non-ST Elevation Acute Coronary Syndrome Outcomes in Patients Treated with Unfractionated Heparin Monitored Using Anti-Xa Concentrations Versus Activated Partial Thromboplastin Time.

BACKGROUND: While the activated partial thromboplastin time (aPTT) is the most widely used assay to monitor unfractionated heparin (UFH), providing a general measure of the extent of anticoagulation, it does not reliably correlate with the blood concentration of heparin or its antithrombotic effect. While cost and availability have limited the widespread use of UFH in hospitals, monitoring UFH with heparin levels has been shown to reduce both the number of monitoring tests and the time to a therapeutic range. OBJECTIVES: To compare outcomes in patients with non-ST elevation acute coronary syndrome (ACS) treated with weight-based UFH monitored with anti-Xa concentrations versus aPTT. METHODS: A retrospective chart review was completed in patients admitted with high-risk ACS and compared to the UFH arm of the SYNERGY trial. The primary outcome included the clinical endpoint of all-cause death or non-fatal myocardial infarction until time of hospital discharge. Safety endpoints evaluated included incidence of stroke and major bleeding. RESULTS: The primary endpoint occurred in 6.3% of patients in the study cohort compared to 6.5% of patients in the heparin arm of the SYNERGY trial at 48 hours (P = .006). Bleeding was reduced in the study cohort with a significant decrease in GUSTO severe bleeding (P = .007). Additionally the study cohort had significantly fewer patients with an absolute drop in hemoglobin or hematocrit. Thrombolysis in Myocardial Infarction (TIMI) major and minor bleeding, rate of transfusion, and platelet counts were similar between groups. CONCLUSIONS: Outcomes for high-risk ACS patients receiving heparin monitored by anti-Xa concentrations are noninferior to heparin monitored by aPTT.