Adverse childhood experiences among doctor of pharmacy students.

OBJECTIVE: Adverse Childhood Experiences (ACEs) have demonstrated negative impact on physical, emotional, and cognitive health outcomes. This study aimed to assess prevalence of ACEs among Doctor of Pharmacy (PharmD) students, and their associations with mental health, substance use, academic performance, and sleep patterns. METHODS: A cross-sectional survey was conducted on PharmD students at a private University. ACE scores, mental health history, substance use, academic performance, and sleep habits were self-reported. Descriptive statistics and chi-square tests were used for analysis. RESULTS: From 54 participants across all cohorts of students in the curriculum (response rate: 19%), 48% reported ≥4 ACEs. A majority of students reported having been diagnosed with or sought treatment for depression (56%) or anxiety (67%), while 42.9% reported a history of contemplating suicide. Participants with ACE scores of ≥4 were more likely to have sought treatment for depression, any mental health condition, contemplated suicide, or used alcohol for mental health purposes. No differences in academic performance based on ACE scores were found. CONCLUSION: High numbers of ACEs were common and linked to mental illness, suicidality, and use of alcohol for mental health purposes. While no direct academic impact was found in this small sample size, adopting a trauma-informed approach is crucial to supporting student well-being. Further research in this area is needed to optimize interventions to support academic and professional success among students with ≥4 ACEs.

Pharmacy Students' Perceived Ability to Implement the Pharmacist's Patient Care Process before and after a Redesigned Case Study Series in the United States.

Since the incorporation of the Pharmacist's Patient Care Process (PPCP) into the American Association of Colleges of Pharmacy standards, the process has been integrated in a variety of ways across curriculums. A two-semester case-based course was redesigned as a four-semester case-based course formally integrating the PPCP. Pharmacy students completing the original, two-semester course series and those completing the first two semesters of the redesigned course were given a voluntary survey to assess their perceived ability to integrate the PPCP into practice after the completion of each course. A total of 107 pharmacy students, 61 students completing the original series and 46 students completing two semesters of the redesigned series, completed the survey. The pharmacy students completing the redesigned, four-semester course series had a significantly higher perception of their ability to integrate the PPCP into patient care compared to the students completing the original series. This included the perceived ability to ask appropriate questions, identify medication-related problems (MRPs), document MRPs, and develop a plan for addressing MRPs. A significant difference was found in the students' perceived ability to ask pertinent questions in an appropriate manner, identifying and documenting MRPs, managing and solving MRPs, and documenting patient interactions. No significant difference was identified regarding the students' perceived ability to document the interaction or ensure that treatment-related plans were implemented. The students' perception regarding the importance of asking pertinent questions, identifying MRPs, and documentation in patient care did not differ between the cohorts. The case-based course series redesigned from two to four semesters with formal integration of the PPCP resulted in an increase in the students' perceptions of their ability to integrate the PPCP into patient care.

Impact of pharmacist-provided Medicare annual wellness visits and chronic care management on reimbursement and quality measures in a privately owned family medicine clinic.

PURPOSE: Improvement in patient outcomes from collaboration between pharmacists and physicians in ambulatory clinics has been well documented. Barriers to payment have made widespread growth of these collaborations slow. Medicare annual wellness visits (AWVs) and chronic care management (CCM) provide an opportunity for pharmacist-physician collaborations that are directly revenue generating. The objective of this study was to evaluate the impact of pharmacist-led AWVs and CCM on reimbursement and quality measures in a private family medicine clinic. METHODS: This was a retrospective observational study in which the rate of reimbursement for AWVs and CCM was compared before and after implementation of pharmacist-provided services. Claims data were reviewed for Current Procedural Terminology codes and reimbursement applicable to AWVs and CCM. Secondary outcomes included the total number of AWV and CCM appointments, Healthcare Effectiveness Data and Information Set (HEDIS) measure completion rates, and average change in quality ratings. Outcomes were analyzed utilizing descriptive statistics. RESULTS: Reimbursement from AWVs increased by $25,807.21 in 2018 and $26,410.01 in 2019 compared to 2017. Reimbursement from CCM increased by $16,664.29 in 2018 and $5,698.85 in 2019. In 2017, 228 AWVs and 5 CCM encounters were completed. After implementation of pharmacist services, the number of CCM encounters increased to 362 in 2018 and 152 in 2019 and the number of AWVs totaled 236 and 267, respectively. Completed HEDIS measures and star ratings increased during the study. CONCLUSION: Pharmacist provision of AWVs and CCM addressed a gap in care by increasing the number of patients who received these services while also increasing reimbursement in a privately owned family medicine clinic.

Reflections on work-life integration post-pandemic: A perspective from pharmacy practice faculty.

INTRODUCTION: The effects of COVID-19 will have a lasting impact on how work is conducted moving forward. Prior to the pandemic, work-life integration and well-being were priorities for many organizations, including pharmacy. The disruption associated with the COVID-19 pandemic pushed businesses and organizations worldwide into an era of agility and flexibility previously unknown to the majority of workplaces. PERSPECTIVE: Increased remote work has presented both increased challenges (e.g., engagement) and opportunities (e.g., productivity). After a year of experience, this shift in the nature of how work is done has provided an opportunity to reimagine how and where work will be conducted in the future. IMPLICATIONS: Schools and colleges of pharmacy have an opportunity to re-evaluate how academic and practice responsibilities are accomplished in regards to work life-integration and management of concurrent work and family responsibilities. Administration and faculty should foster a culture of transparency on this topic to collaboratively incorporate methods that better facilitate work-life integration moving forward.

Effect of pharmacogenomic testing on pharmacotherapy decision making in patients with symptoms of depression in an interprofessional primary care clinic.

BACKGROUND: Variability in individual drug response may delay time to relief of symptoms for various disease states. As pharmacogenomic (PGx) testing becomes more widespread, providers are tasked with determining when and in who PGx testing is most appropriate. The use of PGx testing in patients with depressive symptoms has shown some utility, but how this translates to a general population within a primary care setting has yet to be determined. OBJECTIVE: The objective of this pilot study was to determine the effect of PGx testing on treatment decisions in patients with depressive symptoms in an interprofessional primary care setting. METHODS: This was a retrospective observational study in which patients who underwent PGx testing for psychotropic medications between April 2019 and March 2021 at a private interprofessional primary care clinic were identified. Charts were reviewed to determine whether a resultant change was made to the prescribed psychotropic medication regimen based on PGx testing results. The number of antidepressants trialed before and after testing was also reviewed. Data were analyzed using descriptive statistics and t test where appropriate. RESULTS: A total of 78 patients were included in the study. A total of 42 patients (53.8%) experienced a change to their antidepressant regimen after PGx testing. The most frequent change identified was the addition of another antidepressant (50%). This was followed by switching the antidepressant and then by an increase in dose of the prescribed antidepressant. No difference between the number of antidepressants trialed before and after testing was identified. CONCLUSION: PGx testing in an interprofessional primary care setting leads to a medication change in most patients in this study. Based on the changes identified, testing may be most useful in those beginning treatment with an antidepressant or in those who experience an inadequate response to their prescribed regimen.

Pharmacy student perceptions of their preparedness to address vaccine hesitancy and refusal.

INTRODUCTION: Vaccine hesitancy/refusal is a growing issue worldwide. Pharmacists are well suited to address vaccine hesitancy; however, the extent to which they feel trained to do so may vary. The objective of this study was to determine pharmacy student confidence in addressing vaccine hesitancy/refusal. METHODS: Students in their penultimate didactic and experiential years at United States schools of pharmacy were invited to participate in a 30-item electronic survey concerning perceptions of preparedness to address vaccine hesitancy/refusal. The primary outcome was pharmacy students' perception of their ability to address vaccine hesitancy/refusal. Secondary outcomes included student confidence in their knowledge of and ability to speak to vaccine controversies and support for pharmacist/patient vaccine responsibilities. Outcomes were addressed using five-point Likert-type items. Median values and interquartile ranges were reported, with chi-square analysis accounting for possible heterogeneity between groups. RESULTS: A total of 1433 students (estimated response rate = 20%) completed the survey. Respondents indicated confidence in their preparedness to address patient immunization concerns, hesitancy, and refusal with a median score of 4 (scale of 5, with 1 = the least confident and 5 = the most confident). Secondary outcome analysis revealed varying degrees of confidence regarding specific vaccine hesitancy controversies. CONCLUSIONS: Pharmacy students were confident in their ability to address vaccine hesitancy/refusal. Students held beliefs of responsibility for limiting non-vaccination, but felt less confident in addressing concerns regarding specific vaccine components and immune system overload.

Addressing Sexual and Gender Harassment in Pharmacy Education to Improve Provider Wellness and Patient Care.

Research indicates widespread sexual harassment has not significantly decreased in health care over the last several decades. Attention focused on sexual harassment in the last few years has prompted a renewed conversation in health care about these complex issues and the unique challenges they present. Given the significant implications for individuals, organizations, and patient care, addressing harassment should be a priority. Pharmacy schools and supporting pharmacy organizations should proactively address sexual and gender harassment and provide education about this issue.

Implementation of a modified multiple mini-interview method to assess non-cognitive qualities during resident candidate interviews.

BACKGROUND AND PURPOSE: Conventional onsite interview methods often make comparing applicants difficult. Literature has noted conventional interviews leave room for bias and high interrater variability, making non-cognitive attributes difficult to ascertain. In 2016, the residency committee of a small, multi-site, academic-based postgraduate year one residency program implemented a modified multiple mini-interview (MMI) approach as a component of the residency interview process to better qualify candidate attributes. EDUCATIONAL ACTIVITY AND SETTING: A modified MMI was developed to address the non-cognitive attributes, ethical reasoning, communication, and professionalism. Scenarios, scripts, questions, and rubrics were developed by residency committee members. The author of the case was assigned to role play that scenario with candidates while other committee members silently observed. Candidates and residency committee members were surveyed to explore their perception of the MMI as a component of the residency interview process. FINDINGS: Thirty-one candidates have been interviewed since the incorporation of the modified MMI. Of those, 20 completed the post-interview survey. The majority of resident candidates (55%) completing the survey felt they were able to portray strengths and abilities more effectively vs. a conventional interview. Of the five residency committee members, all (100%) completed the survey and all (100%) perceived implementation of the modified MMI provided increased confidence in determining candidate ranking. SUMMARY: Implementation of a modified MMI approach to an onsite residency interview process assisted residency committee members in assessing non-cognitive attributes and contributed to greater confidence in determining resident candidate ranking.

Evaluation of pharmacy resident perceived impact of natural disaster on stress during pharmacy residency training.

INTRODUCTION: Natural disasters present unique challenges for healthcare training programs. Limited literature has been published regarding the impact of natural disasters on pharmacy residency training. The objective of this study was to determine the degree of perceived impact natural disasters have on pharmacy resident stress and which factors contribute to any perceived change in stress. METHODS: A cross-sectional study was conducted via a survey distributed to pharmacy residents whose program was located in an area potentially affected by natural disaster in the first six months of the 2017-2018 resident year. A modified Likert scale utilizing a 10-point scale was used to assess resident stress. Potential sources of stress were assessed via multiple-choice questions. The primary outcome was the degree of change in resident perceived stress compared to baseline during and after the natural disaster. RESULTS: One hundred twenty-nine pharmacy residents completed the survey. Stress increased from baseline during the natural disaster and remained elevated after compared to baseline. Main sources of stress were increased residency workload, natural disaster preparation and recovery, and concerns regarding friends and family. Half of residents reported their residency program did not have an established natural disaster policy in place. CONCLUSIONS: Improved planning and communication regarding workload expectations may minimize stress among residents balancing increased personal responsibilities during times of natural disaster.

Emerging therapies for the management of chronic hyperkalemia in the ambulatory care setting.

PURPOSE: Emerging treatment options for the management of chronic hyperkalemia in the outpatient setting are reviewed. SUMMARY: Current treatment options for the management of hyperkalemia are limited and often accompanied by serious adverse effects. Two investigational drugs for the treatment of hyperkalemia are being evaluated in Phase III trials: sodium zirconium cyclosilicate and patiromer. Both of these drugs are administered orally and act by enhancing potassium's removal, predominantly through the gastrointestinal tract. The safety and efficacy of sodium zirconium cyclosilicate and patiromer were evaluated in Phase II and III trials. Both agents were studied in patients with chronic mild-to-severe hyperkalemia, chronic kidney disease (CKD), or heart failure as well as those taking a renin-angiotensin system (RAS) inhibitor, an aldosterone antagonist, or both therapies. These clinical trials found that sodium zirconium cyclosilicate and patiromer normalized serum potassium levels quickly and maintained normalized serum potassium levels over several weeks. Both medications caused a rapid decrease in serum potassium, with two studies examining efficacy endpoints for 12 weeks or longer. The overall frequency of adverse effects in these clinical trials was low, with gastrointestinal adverse events being the most commonly observed. CONCLUSION: Options for the management of hyperkalemia, particularly chronic hyperkalemia in the outpatient setting, are limited. Both sodium zirconium cyclosilicate and patiromer are emerging therapies that may provide long-term management of hyperkalemia, particularly in patients with underlying heart failure or CKD as well as those taking an RAS inhibitor, an aldosterone antagonist, or both.

Evidence-based strategies to reduce intravenous immunoglobulin-induced headaches.

OBJECTIVE: To review the literature evaluating pharmacotherapeutic and nonpharmacotherapeutic options available to reduce migraines or headaches associated with intravenous immunoglobulin (IVIG) treatment. DATA SOURCES: A search of MEDLINE (1946 to February 2015) and other secondary resources was performed using the terms immunoglobulin, immune globulin, intravenous immunoglobulins, migraine, and headache. Other relevant articles referenced from the MEDLINE search were also utilized. STUDY SELECTION AND DATA EXTRACTION: Data sources were limited to English language clinical trials and case studies. In all, 6 clinical studies and 2 case reports met the criteria. DATA SYNTHESIS: Headaches or migraines are common adverse effects associated with the administration of IVIG. We evaluated 6 clinical studies and 2 case reports discussing this adverse event in patients treated with IVIG. Strategies used were hydration, switching to an alternate IVIG product, decreased infusion rates, or treating with oral analgesics, opioids, propranolol, sumatriptan, or dihydroergotamines before, during, or after the IVIG infusion. Overall, the majority of patients experienced improvement in headache symptoms, suggesting benefit, after using the various strategies discussed. However, the evidence is limited to case reports and clinical studies with small sample sizes that do not directly measure cause and effect of headache resolution and therapy given in those treated with IVIG. CONCLUSIONS: An individualized treatment plan consisting of a pharmacotherapy or nonpharmacotherapy strategy used in the literature should be recommended after careful consideration of the patient's condition, specific IVIG product used, history of migraine, and previously failed and successful therapies.

Risk of hypotension with concomitant use of calcium-channel blockers and macrolide antibiotics.

PURPOSE: The literature describing the risk of hypotension in patients receiving concomitant therapy with a calcium-channel blocker (CCB) and a macrolide antibiotic is reviewed. SUMMARY: A literature search was conducted to identify studies and reports describing significant drug interactions between CCBs and macrolide antibiotics resulting in hypotension. One retrospective clinical trial, one pharmacokinetics study, and five case reports were found using MEDLINE. While both dihydropyridine and nondihydropyridine CCBs are cytochrome P-450 isoenzyme 3A4 (CYP3A4) substrates, verapamil was the CCB implicated in three of the five case reports. Based on currently available literature, it is unknown whether the risk of clinically significant hypotension is higher for patients receiving nondihydropyridine CCBs; however, due to the drugs' effects on the coronary arteries, there is the potential for more-serious cardiac complications with these agents. Both erythromycin and clarithromycin have been shown to prolong the Q-T interval, an effect that appears to increase when these drugs are given with CYP3A4 inhibitors. The potential for Q-T interval prolongation by both erythromycin and clarithromycin may increase the risk of clinically relevant hypotension and even shock in patients taking CCBs, in particular nondihydropyridines. CONCLUSION: Potentially significant hypotension and shock may occur when macrolide antibiotics, particularly erythromycin and clarithromycin, are administered concomitantly with CCBs. The frequency of hypotension as a result of concomitant CCB and macrolide administration appears to be small, but the risk of adverse effects and the severity of the effects appear to be greater for those patients who are older and in those with multiple comorbidities.

Antibiotic prophylaxis for prevention of spontaneous bacterial peritonitis in patients without gastrointestinal bleeding.

OBJECTIVE: To review relevant studies for both primary and secondary antibiotic prophylaxis of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis without gastrointestinal bleeding. DATA SOURCES: A search of PubMed (1980-July 2010) was conducted using the terms prophylaxis, SBP, and antibiotics. A manual review of bibliographies was conducted for inclusion of relevant articles. STUDY SELECTION AND DATA EXTRACTION: Prospective studies and meta-analyses published in English were included. DATA SYNTHESIS: Ten trials and 3 meta-analyses were included. Of the 10 trials, 2 examined the use of secondary prophylaxis for prevention of subsequent episodes of SBP, 4 examined the use of primary prophylaxis to prevent an initial SBP episode, and 4 examined the use of antibiotic prophylaxis in a mixed population. Seven trials evaluated the use of an antibiotic compared to placebo or no treatment. Only 1 trial evaluated norfloxacin versus trimethoprim/sulfamethoxazole. Trial duration varied from 24 days to 12 months. In general, trials examining norfloxacin as secondary prophylaxis found significantly decreased occurrence of SBP but no significant difference in mortality rates. Primary prophylaxis studies found no significant difference in the incidence of infections, including SBP, with norfloxacin or ciprofloxacin treatment but significantly lower incidence of gram-negative infections. Mixed population studies found a significantly decreased incidence of SBP but no significant difference in mortality. In the 3 meta-analyses, a significant decrease in mortality and an overall decrease in SBP incidence in the treatment groups were noted. CONCLUSIONS: Based on currently available data, the use of prophylactic antibiotic therapy is warranted for the prevention of recurrent SBP in patients with cirrhosis and ascites. In patients with low ascetic fluid protein and at least 1 more risk factor, primary prophylaxis may be considered. Further studies with improved methodology are needed to determine whether prophylactic antibiotic therapy has an impact on mortality.