Training Future Pharmacists to Optimize the Healthcare Workforce.

Many efforts are taking place to improve the quality of healthcare and reduce healthcare cost. Pharmacists play a key role in optimizing the healthcare workforce, and colleges of pharmacy are adapting to this need by emphasizing skills needed to improve quality health measures, interprofessional collaboration and communication, and supplying quality drug information. The University of Hawai'i at Hilo Daniel K. Inouye College of Pharmacy has incorporated additional pharmacy practice experience electives to teach pharmacy students to analyze and optimize workflow, identify high-risk patients in need of intervention, and work collaboratively with providers to decrease patient burden. The pharmacy curriculum has also increased the number of interprofessional educational events for enhancing interprofessional collaboration and communication, including in a telehealth setting. Furthermore, the college of pharmacy has increased the number of drug information assignments and practical exams to increase competency and the speed of providing quality, evidence-based drug information to providers. This article presents on overview of the health care workforce needs and examples of the increased efforts to train future pharmacists in Hawai'i to improve healthcare access and quality of patient care, as well as decrease healthcare costs.

The Daniel K. Inouye College of Pharmacy Scripts: The Effects of Vancomycin Use and De-escalation in Patients Hospitalized with Pneumonia.

Methicillin-resistant Staphylococcus aureus (MRSA) causes about 80,000 severe infections each year. Compared to Methicillin-susceptible Staphylococcus aureus (MSSA), MRSA is associated with higher mortality and increased hospital length of stay (LOS). Vancomycin hydrochloride, an antibiotic with activity against MRSA is often used as empiric therapy for pneumonia. However, current pneumonia treatment guidelines recommend against the routine use of MRSA coverage since MRSA prevalence rates are low. In this retrospective, observational study, 38.3% of the population received vancomycin while only 2.6% had evidence of a MRSA infection. Data was gathered manually from electronic medical records from four hospitals over a six-month period. To identify a well-balanced comparison and account for potential confounders, matching on the propensity scores was conducted. Prior to matching, those who received vancomycin had a significantly higher rate of mortality (14.3% vs 4.9%, P < .001) and higher LOS (9.6 days vs 7.2 days, P < .001). Those who were de-escalated from vancomycin had a significantly lower LOS (8.3 days vs 11.6 days, P = .001) with no difference in mortality. After performing a survival analysis on matching data, those who received vancomycin had a significantly higher LOS (9.2 days vs 7.5 days, P = .002) with no difference in mortality (P = .1737). Those who were de-escalated had a significantly lower LOS (8.3 days vs 11.3 days, P=.005) with no difference in mortality (P = .8624). This study demonstrates a low prevalence of MRSA with the potential overuse of vancomycin. This along with no difference in mortality and a lower LOS supports the recommendation to limit vancomycin use as clinically appropriate. If vancomycin is used, assessment for rapid de-escalation is needed.

Potentially preventable medication-related hospitalizations: A clinical pharmacist approach to assessment, categorization, and quality improvement.

OBJECTIVES: The primary objective of this report is to describe a quality improvement practice designed to identify and categorize potentially preventable medication-related hospital admissions. The secondary objective is to present data collected from this practice and describe how it was used to improve a pharmacist intervention focused on reducing medication-related readmissions. SETTING: This practice was developed as part of the quality improvement system supporting a pharmacist-led care transition model that was implemented across rural and urban counties in Hawaii. PRACTICE DESCRIPTION: Pharmacists systematically assessed readmissions of the high-risk patients who were enrolled in the care transition model to determine the reasons for the admission and whether each was potentially preventable and medication related. This information was then used to improve the care transition model. PRACTICE INNOVATION: This admission categorization system is the first based on best practice in pharmaceutical care and identifies indication, effectiveness, safety, and adherence problems, as well as subcategories within each of those domains. EVALUATION: This quality improvement practice was applied to 401 readmissions. A chi-square test was used to determine if there were differences between urban and more rural areas regarding percentage of readmissions that were potentially preventable and medication related. RESULTS: Twenty-six percent of the readmissions were determined to be potentially preventable and medication related. The most common categories were nonadherence due to patient choice (23.8%), untreated condition for which medication is indicated (13.3%), dose too high (10.5%), and dose too low (10.5%). The percentage of readmissions that were potentially preventable and medication related was significantly higher in more rural areas (30%) compared with urban areas (17%). There were no significant rural-urban differences by major category of potentially preventable medication-related admissions. CONCLUSION: This systematic and actionable approach to reviewing and categorizing potentially preventable medication-related admissions can facilitate improvement in care and document the value of pharmacists serving in patient care roles.

The Daniel K. Inouye College of Pharmacy Scripts: The Development of Antimicrobial Stewardship Programs in Hawai'i.

In recent years the misuse of antimicrobials has contributed to the growing problem of antimicrobial resistance. Antimicrobial Stewardship Programs (ASP) decrease the misuse of antimicrobials by supporting a rational, systematic approach. ASP strategies vary from broad-ranging policies and other decision support tools to prospective audit review of patients on antimicrobials. Many healthcare facilities, however, have been slow to adopt stewardship attributable to the fact that early ASP models required individuals with specialized training, and a significant amount of time and infrastructural investment from facilities. In response to the increasing need for ASPs in Hawai'i, the Hawai'i Department of Health (HDOH) partnered with the Daniel K. Inouye College of Pharmacy (DKICP) to develop the Hawai'i Antimicrobial Stewardship Collaborative (HASC), a voluntary collaboration whose main objective is to assist hospital institutions in the implementation of a simplified model of the Centers for Disease Control and Prevention's Core Elements of Hospital Antimicrobial Stewardship Programs. The work of HASC places Hawai'i's health care institutions in an advantageous position to be able to comply with impending accreditation standards relating to antibiotics and infections.

The Daniel K. Inouye College of Pharmacy Scripts: pharmacy school graduates continue training in postgraduate residency programs.

Residency training is designed to provide recent pharmacy school graduates who have the profession's terminal Doctor of Pharmacy (PharmD) degree with accelerated growth beyond entry-level professional competence. Placement into residency programs is highly competitive through an application and match process. These programs provide additional training in patient-centered care with advancement of skills in clinical judgment, pharmacy operations, clinical research, project management, and leadership. Approximately 20% of a pharmacy graduating class will apply for a residency. With increasing numbers of pharmacy schools across the country, the availability of residency programs is falling behind applicants. The establishment of the Daniel K. Inouye College of Pharmacy (DKICP) has addressed the shortage of pharmacists within the state. In recent years, resident positions in Hawai'i have doubled to a total of ten first year residency (PGY1) and two second year (PGY2) specialty residencies. Given the limited availability of positions in Hawai'i, graduates continue to return to the continental US to seek positions, thus increasing the likelihood of them not returning to practice in Hawai'i. Establishing residency programs is essential to elevate the level of pharmacy practice toward innovation and adherence to best practices, academia/teaching and scholarly research. This descriptive paper will detail the general components and types of pharmacy practice residency, the unique components of the Hawai'i programs, the career placement of Hawai'i's programs graduates and future challenges.

Disparities in medication therapy in patients with heart failure across the State of Hawai'i.

The purpose of this study is to evaluate if heart failure patients in Hawai'i are receiving recommended standard therapy of a select beta-blocker in combination with an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB), and to determine if a gap in quality of care exists between the different regions within the state. A retrospective claims-based analysis of all adult patients (age > 18 years of age) with CHF who were enrolled in a large health plan in Hawai'i was performed (n = 24,149). Data collected included the presence of pharmaceutical claims for ACEI, ARBs and select ß-blockers, region of residence, gender, and age. Multivariable logistic regression was used to examine whether there were regional differences in Hawai'i related to medication usage, after adjustment for age and gender. Results showed that only 28.4 % of patients were placed on the recommended therapy of an ACEI or ARB and a select ß-blocker with significant differences being found between different regions. Further research is needed to better understand factors affecting regional differences in prescribing patterns.

Significance of HbA1c and its measurement in the diagnosis of diabetes mellitus: US experience.

The 2014 American Diabetes Association guidelines denote four means of diagnosing diabetes. The first of these is a glycosylated hemoglobin (HbA1c) >6.5%. This literature review summarizes studies (n=47) in the USA examining the significance, strengths, and limitations of using HbA1c as a diagnostic tool for diabetes, relative to other available means. Due to the relatively recent adoption of HbA1c as a diabetes mellitus diagnostic tool, a hybrid systematic, truncated review of the literature was implemented. Based on these studies, we conclude that HbA1c screening for diabetes has been found to be convenient and effective in diagnosing diabetes. HbA1c screening is particularly helpful in community-based and acute care settings where tests requiring fasting are not practical. Using HbA1c to diagnose diabetes also has some limitations. For instance, HbA1c testing may underestimate the prevalence of diabetes, particularly among whites. Because this bias differs by racial group, prevalence and resulting estimates of health disparities based on HbA1c screening differ from those based on other methods of diagnosis. In addition, existing evidence suggests that HbA1c screening may not be valid in certain subgroups, such as children, women with gestational diabetes, patients with human immunodeficiency virus, and those with prediabetes. Further guidelines are needed to clarify the appropriate use of HbA1c screening in these populations.

Factors associated with poor glycemic control or wide glycemic variability among diabetes patients in Hawaii, 2006-2009.

INTRODUCTION: Although glycemic control is known to reduce complications associated with diabetes, it is an elusive goal for many patients with diabetes. The objective of this study was to identify factors associated with sustained poor glycemic control, some glycemic variability, and wide glycemic variability among diabetes patients over 3 years. METHODS: This retrospective study was conducted among 2,970 diabetes patients with poor glycemic control (hemoglobin A1c [HbA1c] >9%) who were enrolled in a health plan in Hawaii in 2006. We conducted multivariable logistic regressions to examine factors related to sustained poor control, some glycemic variability, and wide glycemic variability during the next 3 years. Independent variables evaluated as possible predictors were age, sex, type of insurance coverage, morbidity, diabetes duration, history of cardiovascular disease, and number of medications. RESULTS: Longer duration of diabetes, being under age 35, and taking 15 or more medications were significantly associated with sustained poor glycemic control. Preferred provider organization and Medicare (vs health maintenance organization) enrollees and patients with high morbidity were less likely to have sustained poor glycemic control. Wide glycemic variability was significantly related to being younger than age 50, longer duration of diabetes, having coronary artery disease, and taking 5 to 9 medications per year. CONCLUSION: Results indicate that duration of diabetes, age, number of medications, morbidity, and type of insurance coverage are risk factors for sustained poor glycemic control. Patients with these characteristics may need additional therapies and targeted interventions to improve glycemic control. Patients younger than age 50 and those with a history of coronary heart disease should be warned of the health risks of wide glycemic variability.