Implementation of a pharmacist-developed, indication-based order panel for outpatient prescribing of direct-acting oral anticoagulants.

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.

Pharmacist impact on evidence-based prescribing of diabetes medications in patients with clinical atherosclerotic cardiovascular disease.

BACKGROUND: Including pharmacists on care teams of patients with type 2 diabetes (T2D) has been shown to promote guideline-based prescribing and improve glycemic control, lowering risks of adverse cardiovascular outcomes. Evidence is lacking regarding whether including pharmacists on the care team is associated with the prescribing of GLP-1 receptor agonists (GLP-1 RA) and SGLT-2 inhibitors (SGLT-2i) recommended for use in patients with T2D and atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE: To assess the association between having a pharmacist on the primary care team of patients with T2D and ASCVD and being prescribed a guideline-recommended GLP-1 RA or SGLT-2i. METHODS: A cross-sectional analysis of patients with T2D and ASCVD seen by primary care providers at an academic medical center between June 2019 and May 2020 was completed. Patients with prescriptions for GLP-1 RA or SGLT-2i with evidence of cardiovascular benefit were identified and compared between those with pharmacist care vs usual care using multivariable log-binominal regression analyses. RESULTS: Of 1,497 included patients, 1,283 (85.7%) were in the usual care group (mean age 68.9 years, hemoglobin A1c 7.6%) and 214 (14.3%) in the pharmacist care group (mean age 64.5 years, A1c 9.0%). Of the pharmacist care group, 50.5% were prescribed a GLP-1 RA or SGLT-2i with cardiovascular benefit vs 17.9% in the usual care group (P < 0.001). In multivariable analyses controlling for A1c and other potential confounders, those in the pharmacist care group were 2.15 times as likely to have been prescribed a GLP-1 RA or SGLT-2i than those in the usual care group (adjusted risk ratio 2.15, 95% CI = 1.83-2.52; P < 0.001). CONCLUSIONS: These data provide preliminary evidence that integrating pharmacists into patient care teams is associated with increased prescribing of guideline-recommended treatment with GLP-1 RA and SGLT-2i in patients with T2D and ASCVD, yet there is room for improvement in prescribing these agents to patients with T2D and ASCVD.

Patient-centered medical home pharmacists' impact on composite quality care measures for patients with uncontrolled type 2 diabetes.

BACKGROUND: Patients with uncontrolled diabetes are at risk for developing complications. Many health care systems have implemented multidisciplinary care models including pharmacists to help achieve quality care measures to reduce complications. OBJECTIVE: This study aimed to evaluate whether patients with uncontrolled type 2 diabetes mellitus (T2D) seen at patient-centered medical home (PCMH) clinics affiliated with an academic medical center are more likely to meet a composite of diabetes quality care measures with a pharmacist on their care team than usual care patients without a pharmacist on their care team. METHODS: This is a cross-sectional study. The setting included PCMH primary care clinics affiliated with an academic medical center from January 2017 to December 2020. Included were adults aged 18 to 75 years with a diagnosis of T2D, hemoglobin A1C (A1C) more than 9%, and established with a PCMH provider. The intervention is inclusion of PCMH pharmacist on the patient's care team for management of T2D per a collaborative practice agreement. The main outcome measures included A1C ≤9% per last recorded value during observation period, a composite A1C ≤9% and completion of yearly laboratory tests, and a composite A1C ≤9%, completion of yearly laboratory tests, and statin prescription for adults aged 40-75 years. RESULTS: Identified were 1807 patients in the usual care cohort with mean baseline A1C of 10.7% and 207 patients in the pharmacist cohort with mean baseline A1C of 11.1%. The pharmacist cohort was more likely to have an A1C of ≤9% at the end of the observation period (70.1% vs. 45.4%; P < 0.001), a composite of measures met (28.5% vs. 16.8%; P < 0.001), and a composite of measures met for patients aged 40-75 years (27.2% vs. 13.7%; P < 0.001). CONCLUSION: Pharmacist involvement in the multidisciplinary management of uncontrolled T2D is associated with a higher attainment of a composite of quality care measures at the population health level.

Assessment of medication adherence after enrollment in a health system funded medication assistance program for patients with diabetes.

BACKGROUND: High costs for patients' medications decrease medication access and adherence which contributes to poor clinical outcomes. Numerous medication assistance programs exist, but many patients needing assistance, particularly insured patients, do not receive assistance due to eligibility criteria. OBJECTIVE: To determine if there is an association between medication adherence to antihyperglycemic therapy and patient access to Nebraska Medicine Charity Care (NMCC). PRACTICE DESCRIPTION: NMCC covers up to 100% of medication out-of-pocket costs for patients in financial need who do not qualify for other programs. PRACTICE INNOVATION: There is no published information about a long-term health system-led financial medication assistance program being utilized to improve patient medication adherence and clinical outcomes. EVALUATION METHODS: A retrospective cohort analysis was conducted to assess adherence in patients who initiated NMCC between July 1, 2018 and June 30, 2020, with a focus on diabetes for feasibility. Adherence was assessed using a modified medication possession ratio (mMPR) for 6 months after initiating NMCC based on health system dispensing data. Overall population adherence analyses were conducted in all available data, while pre-post analyses were conducted in those with antihyperglycemic medication fills during the prior 6 months. RESULTS: Of 2758 unique patients receiving NMCC support, 656 patients with diabetes medication use were included. Of these, 71% had prescription insurance and 28% had prescription fills in the baseline period. Mean (SD) adherence to noninsulin antihyperglycemic medications in the follow-up period was 0.80 (0.25) with 63% adherent per mMPR ≥0.80. In the prepost analysis, mMPR was significantly higher during the follow-up period at 0.83 (0.23) than during the preindex period at 0.34 (0.17), as was the proportion who were adherent (66% vs. 2%) (P < 0.001). CONCLUSION: This practice innovation observed an improvement in adherence and A1C outcomes in patients with diabetes who received medication financial assistance through a health system.

In-Person and Telehealth Provider Access and Glycemic Control for People With Diabetes During the COVID-19 Pandemic.

BACKGROUND: Ambulatory care underwent rapid changes at the onset of the COVID-19 pandemic. Care for people with diabetes shifted from an almost exclusively in-person model to a hybrid model consisting of in-person visits, telehealth visits, phone calls, and asynchronous messaging. METHODS: We analyzed data for all patients with diabetes and established with a provider at a large academic medical center to identify in-person and telehealth ambulatory provider visits over two periods of time (a "pre-COVID" and "COVID" period). RESULTS: While the number of people with diabetes and any ambulatory provider visit decreased during the COVID period, telehealth saw massive growth. Per Hemoglobin A1c, glycemic control remained stable from the pre-COVID to COVID time periods. CONCLUSIONS: Findings support continued use of telehealth, and we anticipate hybrid models of care will be utilized for people with diabetes beyond the pandemic.

Telemedicine and health access inequalities during the COVID-19 pandemic.

Background: During the COVID-19 pandemic, health systems rapidly introduced in-home telehealth to maintain access to care. Evidence is evolving regarding telehealth's impact on health disparities. Our objective was to evaluate associations between socioeconomic factors and rurality with access to ambulatory care and telehealth use during the COVID-19 pandemic. Methods: We conducted a retrospective study at an academic medical centre in midwestern United States. We included established and new patients who received care during a one-year COVID-19 period vs pre-COVID-19 baseline cohorts. The primary outcome was the occurrence of in-person or telehealth visits during the pandemic. Multivariable analyses identified factors associated with having a health care provider visit during the COVID-19 vs pre-COVID-19 period, as well as having at least one telehealth visit during the COVID-19 period. Results: All patient visit types were lower during the COVID-19 vs the pre-COVID-19 period. During the COVID-19 period, 125 855 of 255 742 established patients and 53 973 new patients had at least one health care provider visit, with 41.1% of established and 23.5% of new patients having at least one telehealth visit. Controlling for demographic and clinical characteristics, established patients had 30% lower odds of having any health care provider visit during COVID-19 vs pre-COVID-19 (adjusted odds ratio (aOR) = 0.71, 95% confidence interval (CI) = 0.698-0.71) period. Factors associated with lower odds of having a telehealth visit during COVID-19 period for established patients included older age, self-pay or other insurance vs commercial insurance, Black or Asian vs White race and non-English preferred languages. Female patients, patients with Medicare or Medicaid coverage, and those living in lower income zip codes were more likely to have a telehealth visit. Living in a zip code with higher average internet access was associated with telehealth use but living in a rural zip code was not. Factors affecting telehealth visit during the COVID-19 period for new patients were similar, although new patients living in more rural areas had a higher odds of telehealth use. Conclusion: Healthcare inequities existed during the COVID-19 pandemic, despite the availability of in-home telehealth. Patient-level solutions targeted at improving digital literacy, interpretive services, as well as increasing access to stable high-speed internet are needed to promote equitable health care access.

Pharmacist-led drug therapy management for hepatitis C at a federally qualified health care center.

BACKGROUND: Chronic hepatitis C (HCV) infection is challenging to address in patients with barriers to accessing care, including those from underserved populations. Linking at-risk patients through the HCV cascade of care can address such disparities by leveraging existing patient-provider relationships to identify and treat HCV. Pharmacists are ideal clinical team members to provide direct-acting antiviral (DAA) management, given their expertise in pharmacotherapy and medication access. However, literature describing pharmacist-led DAA management at federally qualified health centers (FQHCs) is limited. OBJECTIVE(S): To describe HCV screening, DAA prescribing and treatment initiation, post-treatment sustained virologic response (SVR) assessment, and treatment outcomes in an FQHC with pharmacist-led DAA management. METHODS: This study describes HCV screening rates in adults with select HCV risk factors receiving primary care at a Midwest FQHC over a 4-year period. In patients with a detectible HCV viral load, DAA prescription orders for patients referred to pharmacist-led DAA management was evaluated in comparison with usual care. Treatment completion and SVR results were assessed in patients referred to pharmacists. RESULTS: HCV screening in patients with identifiable risk factors increased from 8.0% to 67.5% over 4 years, driven by a clinical reminder for HCV screening in the birth year cohort. Of patients with positive HCV viral load results, 9.9% in the usual care group received an order for DAA therapy versus 57.1% (P < 0.001) in the pharmacist-led DAA management group. Of 162 patients referred to pharmacist-led DAA management, 61 (37.7%) initiated therapy. Of patients who initiated treatment, 57 (94.7%) had post-treatment viral load testing, with 46 (80.7% of treated patients) having SVR results and 45 (97.8% of SVR tested patients) testing negative. No usual care patients had subsequent negative HCV viral load results. CONCLUSION: Pharmacist-led DAA management is an effective intervention to improve the treatment of patients with HCV in the FQHC setting.