Community-Based Pharmacist Anticoagulation Clinic Outcomes Compared with Physician Management.

Background: Warfarin has many indications; however, it is the only anticoagulant that is indicated for mechanical mitral value and antiphospholipid syndrome. Management may be conducted by pharmacists in medical clinic settings. Objectives: To evaluate the percentage difference in the international normalized ratio (INR) target range when managed by a community-based pharmacist with a collaborative practice agreement (CPA) versus a physician and to analyze patient satisfaction of an anticoagulation clinic when managed by a community-based pharmacist with a CPA versus a physician. Practice Description: Independent community-based pharmacy. Practice Innovation: Community-based pharmacist managed anticoagulation clinic. Pharmacist provides anticoagulation services under a collaborative practice agreement or conducts INR testing and reporting with physician management of anticoagulation. Methods: Quasi-experiment study design with retrospective and prospective evaluation of warfarin management and patient satisfaction. A retrospective chart review was conducted of patients enrolled in the anticoagulation clinic from January 1st, 2020 to June 30th, 2022. Patients, 18 years or older with an indication for warfarin and attendance of at least 3 anticoagulation appointments were included. The Time in Therapeutic Range (TTR) was determined using the traditional method. TTR differences across the two groups were reported using descriptive, bi-variate, and multivariate statistics. All statistical tests were conducted using SAS 9.0. Patient satisfaction was collected for 6 months using a survey created by the investigators. Survey consisted of 18 questions using a 3-point Likert scale. Survey was assessed using descriptive statistics. Results: Thirty-seven patients met the inclusion criteria, 26 were in the pharmacist management group with 609 appointments, and 11 patients were in the physician management group with 123 appointments. There was no statistical significance for the time in the therapeutic range between the pharmacist-managed group (60.7%) and the physician-managed group (59.4%); p-value of <0.829. Results of the satisfaction survey suggest that patients slightly prefer management by a pharmacist over a physician. Conclusion: Community-based pharmacist warfarin management of time in therapeutic range was equivalent to physician management and with similar patient satisfaction.

A retrospective review of the impact of immunization eCare plans in community-based pharmacy setting.

BACKGROUND: The Pharmacist Electronic Care (eCare) plan is an electronic documentation and billing platform that allows for exchanging and integrating pharmacy patient care information. eCare plans make it easier for pharmacists to track recommendations and referrals to both patients and providers and to bill for services. OBJECTIVES: To determine the impact on the type and number of vaccines administered after the completion of immunization eCare plans and to examine sociodemographic differences in patients who received immunizations were documented in an eCare plan in a community-based pharmacy setting. PRACTICE DESCRIPTION: Bremo Pharmacy is an independently owned pharmacy located in Richmond, Virginia. Bremo Pharmacy offers a medication synchronization program targeting patients for enrollment in compliance packaging and clinical services. PRACTICE INNOVATION: Bremo Pharmacists use eCare plans to track patient and provider interactions, goals, and medication-related information. Pharmacists used eCare plans to document vaccine recommendations and interactions with patients as a tool to increase vaccinations. EVALUATION METHODS: Reports were generated to extract data containing information from each eCare plan during the intervention period and the number and type of vaccines administered 1 and 2 years before the intervention. Percent change was used to calculate the change in vaccines administered between years. The sociodemographic data was analyzed using descriptive statistics and bivariate statistical analysis using SAS 9.0 (Cary, NC). RESULTS: There were a total of 1105 immunization eCare plans completed. An increase of 136.6% in vaccines administered occurred after the implementation of the eCare plans. While the number of vaccines administered increased, no significant differences were found in vaccine uptake by gender or age. CONCLUSION: Immunization eCare plans are a useful tool to help pharmacists increase the number of vaccines administered in an independent pharmacy.

Assessing Willingness of Patients with Diabetes to Attend Pharmacist-Led Structured and Patient Specific Diabetes Self-Management Education.

Background: The American Diabetes Association recommends that people with diabetes should participate in diabetes self-management education, however data shows that many patients do not attend educational classes. Objectives: To examine the views of patients with diabetes who utilize services at an independent pharmacy in Richmond, Virginia regarding their (1) interest in attending diabetes self-management education and support (DSMES) services, (2) perceptions of a pharmacist leading DSMES services, (3) willingness to pay for DSMES services, and (4) relationship between self-reported diabetes management status with their willingness to attend DSMES services. Methods: A qualitative survey was administered over five months to patients with diabetes at an independent community pharmacy in Richmond, VA. The survey included 35 questions in a mixed format of Likert scale, dichotomous, and fill in the blank. Survey data was analyzed using univariate, bivariate, and/or multivariate analysis using SAS 9.4. Results: Twenty seven surveys were completed, 15% response rate. Patients were female (56.7%) with an average age of 69 ± 10.8 years. Caucasian race accounted for 90% of patients, 6.7% reported Black or African American, the remainder responded "other". Patients agreed they were interested in attending individual virtual and in person DSMES sessions with a rate of 52% and 87%, respectively. When asked about the full service of 9 group sessions, 33% responded disagree and 30% reported agree. 52% of patients reported belief that pharmacists had the knowledge to lead sessions. When asked about willingness to pay, patients mostly selected the lowest cost option ($25 - $35). Conclusion: Patients with diabetes are willing to participate in DSMES services and believe pharmacists can lead the sessions. It is important to continue to advocate for DSMES services so patients can understand the full benefits of the program and receive the best possible care.

Effect of text message communication on patient presentation for an influenza vaccination in a community-based pharmacy setting.

BACKGROUND: Community pharmacies use text message communications for information regarding approaching refills and fill status. Patients can also be notified regarding annual influenza vaccine availability and schedule an appointment for the vaccine. OBJECTIVES: This study aimed to evaluate whether text message communications affected patient presentation and resulted in a percent increase of patients receiving an influenza vaccine compared with previous vaccine season and to determine whether additional vaccines are administered upon presentation. METHODS: Ambidirectional study retrospectively analyzed the impact, nationally, of a new text message communication on influenza vaccinations at a large community pharmacy chain and prospectively surveyed patients receiving an influenza vaccine at 2 geographically similar pharmacies of the chain in Southwest Virginia. Text message communications regarding vaccine and appointment availability were sent to patients at the age of 18 years and older who opted in to text message communications and received an influenza vaccine with the chain during the 2019-2020 influenza season. Vaccine data from consecutive seasons were compared. Eligible patients in Southwest Virginia were surveyed about how they were informed about availability, previous intent to receive an influenza vaccine, applicability to other vaccines, and effect of the coronavirus disease 2019 pandemic on vaccination. Results were analyzed using bivariate and multivariate analyses. RESULTS: Nationally, influenza vaccines administered increased by 17.45% in patients who permitted text message communication and overall by 13.22% after implementation. Decreases in co-administered pneumococcal vaccines and tetanus, diphtheria, and pertussis vaccines and an increase in co-administered zoster vaccines were observed. A total of 111 patients were surveyed; 4% presented owing to text message communication. A majority were intent on receiving the vaccine before being notified and reported that the pandemic did not affect presentation. Notably, 45.05% of patients were likely to receive routine vaccines if notified by text message. CONCLUSION: Text message communications are another viable way to increase vaccinations, but further studies should be conducted outside of a pandemic setting.

Effect of community pharmacist-provided patient education of partial fill availability for acute opioid prescriptions.

BACKGROUND: More than 191 million opioid prescriptions were filled in the United States during 2017, and studies have shown that patients often have leftover medication. OBJECTIVES: To (1) measure the percentage filled as partial quantities and the percentage subsequently filled to completion; (2) determine which medications are filled as partial, completion, and full fills; and (3) identify patient reasons and demographics for partial, completion, and full fills. PRACTICE DESCRIPTION: Two pharmacies of a national community pharmacy chain in Richmond, VA. PRACTICE INNOVATION: Virginia law allows prescriptions to be filled in partial quantities as long as the total quantity does not exceed the written quantity and the remaining portions are filled within 30 days of the written date. Pharmacists developed an intervention to educate patients about the option to fill opioid prescriptions as a partial quantity. EVALUATION METHODS: Retrospective analysis of drug utilization reports to identify the impact of the pharmacist intervention for acute, nonmaintenance opioid prescriptions filled as partial, completion, or full fill during a 5-month period. Patient demographics and reasons for choosing a partial or full fill were collected using surveys completed at prescription pickup. RESULTS: A total of 25.6% of included prescriptions were partially filled, and of these, only 31.9% were filled to completion. Hydrocodone-acetaminophen was the most common prescription, 35.8% full, 28.3% partial, and 36.4% completion fills. Patients' motivation was driven by the pharmacist's suggestion (48.5%) for partial fill and desire to have the medication if needed (36.6%) for full fill. CONCLUSION: Pharmacist offer of partial filling of acute opioid prescriptions may lead patients to partially fill prescriptions, and patients cited the pharmacist suggestion as a motivator.

Evaluation of patient satisfaction and perceptions of a long-acting injectable antipsychotic medication administration service in a community-based pharmacy during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic, restrictions, and social distancing requirements for medical offices reduced scheduling availability and increased virtual televisits by providers. COVID-19 restrictions created a barrier to health care access for patients who are being administered long-acting injectable antipsychotics (LAIs) in an already vulnerable population. OBJECTIVE: To describe an LAI medication administration service at a community-based pharmacy during the COVID-19 pandemic, to evaluate patient satisfaction with the administration of LAIs by a pharmacist service in a community-based pharmacy during the COVID-19 pandemic, and to compare the patient's perceptions of receiving LAIs in a community-based pharmacy with those in another setting previously used for medication administration. PRACTICE DESCRIPTION: Independent full-service community-based pharmacy. PRACTICE INNOVATION: Implementation of an LAI administration service after an increase in provider referrals of patients to the community-based pharmacy during the COVID-19 pandemic. EVALUATION METHODS: A 4-month prospective convenience sample study conducted to evaluate the LAI medication administration service. The survey containing 32 questions was adapted with permission from a previous survey administered in a large grocery store chain to a similar population. Survey results were reported using descriptive statistics. RESULTS: Eleven patients completed the survey. A total of 82% of patients strongly agreed that they felt comfortable with receiving this service at the community-based pharmacy and were satisfied with the privacy during the service. Seventy-one percent of patients who received this service elsewhere strongly agreed the LAI medication administration service was more convenient than a similar service received elsewhere, yet only 18% of patients strongly agreed that the community-based pharmacy was near their work or home. CONCLUSION: A medication administration service for LAIs was developed in a community-based pharmacy, and patients were satisfied with the service. Further research needs to be completed to evaluate health outcomes and financial implications of this service for the patient and health care system.

Intravenous Versus Oral Acetaminophen Use in Febrile Neurocritical Care Patients.

The use of intravenous (IV) acetaminophen (APAP) for fever has not been thoroughly studied in neurocritical care (NCC) patients, in whom a temperature of ≥38°C is associated with poor outcomes and treatment to normothermia is common practice. This retrospective study evaluated NCC patients admitted between May 1, 2012, and April 30, 2013, and received at least one dose of IV or oral (PO) APAP for a body temperature of ≥38°C. The primary aim of this study was to compare the reduction in body temperature (RIT) between IV and PO APAP, calculated as the change in temperature before and 0.5, 1, 2, 3, and 6 hours after administration. Descriptive statistics were used to assess use characteristics, and Kruskal-Wallis and Mann-Whitney U tests were used for between-group differences. There were 142 NCC patients who received a total of 405 IV APAP and 253 PO APAP doses. Seventy percent of all APAP doses resulted in a temperature of <38°C within 6 hours. The median oral body temperature before APAP was 38.8°C and 38.6°C for IV and PO APAP, respectively (p < 0.01). The median RIT at 0.5 (IV 0.25°C vs. PO 0.2°C), 1 (IV 0.4°C vs. PO 0.2°C), 2 (IV 0.7°C vs. PO 0.5°C), 3 (IV 0.9°C vs. PO 0.6°C), and 6 (IV 1°C vs. PO 0.8°C) hours was significantly greater for IV APAP than for PO APAP at all time points (p < 0.05). Patients with an acute ischemic stroke and patients with an intracerebral hemorrhage had a statistically significantly greater RIT with IV APAP therapy. IV APAP administered to febrile NCC patients was associated with a significantly greater RIT than PO, but 70% of all APAP doses resulted in a body temperature of <38°C within 6 hours. Further prospective studies are needed to determine if IV APAP improves clinical outcomes.

Over-the-counter medication use in residents of senior living communities: A survey study.

BACKGROUND: Self-medication with over-the-counter (OTC) products is common among older adults. Although OTC self-medication is a convenient way to manage some health issues, older persons may be at higher risk of experiencing medication-related problems. This study examines the prevalence, practices, and preferences associated with OTC medication use in older adult residents of senior living communities. OBJECTIVES: The study aimed to examine the characteristics of OTC medication users and to quantify the prevalence, attitudes, perceptions, preferences, and practices regarding OTC medication use and decision-making in 2 senior living communities in central Virginia. METHODS: The study used survey methodology. A 51-item semistructured questionnaire was designed by the research team of geriatrics specialists, and mixed-methods and evaluation researchers. The questionnaire was administered in-person to participants (N = 88). Descriptive analyses were conducted using SAS 9.4. Characteristics of those using OTC medications as directed by a health professional were compared with those of whom were self-medicating with OTC medications. RESULTS: Most of the sample were women (55%), black (61%) and had less than or equal to a high school education (55%). Analgesics were the most (76%) prevalent OTC therapeutic category used, and aspirin was the most (65%) prevalent OTC medication. A greater (82%) proportion of respondents reported self-recommended OTC medication use (self-medication with OTC medications) rather than physician recommended use (18%). A high (41%) prevalence of inappropriate use of OTC medications was observed in this sample of older adults. Most (80%) considered OTC medications safe and effective. The pharmacy was the most (93%) commonly reported purchase location to buy an OTC medication. Physicians were the most (90%) commonly reported information source for OTC medications. CONCLUSION: Considering the high percentage of self-reported self-medication, inappropriate use, and experiences of adverse effects, steps should be taken to develop consumer education and relationships with pharmacists to encourage the responsible use of OTC medications in this population.

Assessment of hemp oil-based cannabidiol use in a community-based pharmacy setting.

BACKGROUND: The Agricultural Improvement Act of 2018 legalized the commercial use of hemp-based products, including cannabidiol (CBD). However, the U.S. Food and Drug Administration (FDA) does not currently regulate the commercial sale of hemp oil-based CBD, and there is no FDA-approved indication for its nonprescription formulations despite the growing demand for, and use of, hemp oil-based CBD. OBJECTIVES: Characterize the use of hemp oil-based CBD, including brands, formulations, and reasons for use, in a community pharmacy setting and identify the perceived barriers related to the use of hemp oil-based CBD. METHODS: A pretested 17-question survey was distributed at the point of care at 2 community pharmacy locations and at hemp oil-based CBD education presentations over a 3-month period. The survey consisted of multiple-choice, open-ended, and select-all-that-apply questions, which were analyzed using univariate and bivariate analyses. RESULTS: A total of 101 participants completed the survey: 38 were CBD-naive, and 63 were CBD-exposed. Most of the participants were women (79%) and Caucasian (81.6%), with an average age of 59 years (SD 17.26). In the CBD-naive group, the most commonly stated barrier to using hemp oil-based CBD was not enough information about the product. Among the participants who had used or were using at least 1 CBD product, the most commonly used dosage form was sublingual, followed by topical: 46 (46/63 [73%]) and 34 (34/63 [54%]) participants, respectively. Thirty-eight participants used hemp oil-based CBD for pain, 24 participants for sleep, and 17 participants for anxiety. Of these, 62% of the participants informed a health care provider that they were using a hemp oil-based CBD product. CONCLUSION: The participants were using different brands and formulations of hemp oil-based CBD for multiple reasons. The greatest barrier to trying CBD was limited education, which may suggest a need for community education about hemp oil-based CBD products.

Evaluation of the impact of a community-based, pharmacist-led weight loss program focused on a high-protein diet on risk factors for cardiovascular disease.

BACKGROUND: Lifestyle choices such as poor diet, physical inactivity, and smoking contribute to modifiable cardiovascular (CV) risk factors. OBJECTIVES: To evaluate clinical outcomes (blood pressure, glycosylated hemoglobin [A1C] level, lipid profile, weight, and waist circumference) that affect CV disease and the American Heart Association (AHA) Life's Simple 7 score before and after completion of a weight loss program focusing on a high-protein, low-calorie, low-carbohydrate, and low-fat diet. PRACTICE DESCRIPTION: Independent pharmacy in Richmond, VA. PRACTICE INNOVATION: Pharmacist-led weight loss program focusing on a high-protein, low-calorie, low-carbohydrate, and low-fat diet. EVALUATION METHODS: A retrospective analysis of electronic patient records was conducted to evaluate a pharmacist-led weight loss program focusing on a high-protein, low-calorie, low-carbohydrate, and low-fat diet. Baseline information included age, gender, race, height, comorbid conditions, diet, physical activity, and smoking status. Clinical CV outcomes (blood pressure, A1C level, lipid profile, weight, and waist circumference) were compared from baseline and at completion. Participants beginning calculated AHA Life's Simple 7 score was compared with the calculated score at completion. The Wilcoxon signed-rank test was used to analyze data. RESULTS: Fourteen participants completed the program. Improvements in risk factors included systolic blood pressure (5.79 ± 5.56 mm Hg, P < 0.005), diastolic blood pressure (2.57 ± 3.37 mm Hg, P < 0.012), A1C level (0.6% ± 0.99%, P < 0.001), total cholesterol (22.21 ± 17.79 mg/dL, P < 0.001), low-density lipoprotein cholesterol (18 mg/dL, P < 0.041), weight (11.06 ± 5.65 kilograms, P < 0.001), and waist circumference (5.44 ± 4.24 centimeters, P < 0.001). The AHA Life's Simple 7 scores increased after the weight loss program (3.21 ± 0.89, P < 0.001). CONCLUSION: A community-based, pharmacist-led weight loss program focusing on a high-protein, low-calorie, low-carbohydrate, and low-fat diet improved participants' AHA Life's Simple 7 scores and modifiable risk factors for CV disease.

Impact of pharmacist counseling to enhance the accessibility of naloxone nasal spray to patients in a community pharmacy setting.

BACKGROUND: The Centers for Disease Control and Prevention guidelines recommend naloxone for every high-dose opioid prescription; in 2018, only 1 naloxone prescription was dispensed for every 69 high-dose opioid prescriptions. In Virginia, strategies for creating awareness and availability include the REVIVE! training and the standing protocol for pharmacists to dispense naloxone. OBJECTIVES: To evaluate if a proactive offer for counseling by pharmacists improves the percent change of patients who receive a prescription for naloxone nasal spray compared with the previous year's naloxone nasal spray fill history and to determine if the pharmacist's counseling affects a patient's confidence with opioid overdose and naloxone use. METHODS: Prospective 4-month, interventional study in southwest Virginia conducted at 5 geographically similar large community chain pharmacies. A National Drug Code activity report within each store was used to identify patients, aged 18-64 years, filling opioid medication without naloxone. A pharmacist recommended naloxone to patients at the point of care. Patients accepting the recommendation for naloxone received pharmacist counseling from a standardized counseling script and by using a naloxone nasal spray demo kit. All eligible patients were provided a postintervention survey assessing their confidence with naloxone, if naloxone had been recommended before, and if they were picking up naloxone on the basis of the pharmacist's recommendation. Results were analyzed using univariate and bivariate analyses. RESULTS: A total of 121 naloxone prescriptions were dispensed; an increase of 36% compared with the same period during the previous year. In total, 38 patients completed the postintervention survey. After receiving pharmacist counseling, patients indicated being very confident with administering naloxone correctly and for recognizing an opioid overdose, 73.9% and 65.2%, respectively. Of the patients who completed the survey, 60.5% received naloxone and accepted counseling from the pharmacist. CONCLUSION: After pharmacist counseling, naloxone dispensing increased, and patients were confident with both administration and recognition.

The Impact of a Digital Vaccine Consent Form in a Large Community Pharmacy Chain.

Background: A large community pharmacy chain implemented a new digital platform to eliminate the need for patients to fill out a traditional vaccine consent form in the pharmacy. The new digital vaccine consent form allowed patients to complete the form online, where it was transmitted directly to the pharmacy's network. Objectives: To identify the characteristics of patients who used an online digital vaccine consent form to receive vaccinations and to evaluate patient satisfaction and confidence in utilizing the digital vaccine consent form to receive pharmacy services. Methods: This three-month prospective study was conducted in the Mid-Atlantic division of a large community pharmacy chain. A 16-question survey was developed using information from the literature to collect demographic information and patient confidence and satisfaction with the digital vaccine consent form. An email was sent to pharmacy staff containing instructions on the procedure for posting a recruitment flyer, distributing the survey post-vaccination, and how to return completed surveys. Univariate and bi-variate analysis were conducted. Results: Thirty-six participants responded to the survey, majority of participants were female (56%). Two patients used the digital vaccine consent form; both used because it was more convenient and were likely to use the form again. For those who did not use the digital vaccine consent form, 32% feel somewhat unconfident in using digital technologies for pharmacy services. A majority of patients prefer to be notified about new online services by email (39%) or advertisements in the pharmacy (31%). When asked the likelihood of using the digital vaccine consent form in the future, majority stated unlikely (34%) or neutral (25%). Conclusions: Most participants did not utilize the new digital vaccine form. This provides an opportunity to further engage patients on the availability and use of the digital vaccine consent form in order to advance digital technologies for pharmacy services.

Economic burden of pediatric prescription opioid poisonings in the United States.

BACKGROUND: Among the different drugs involved in pediatric exposures and poisonings, opioids are the most important, given their rise in nonmedical use. Opioid poisonings in children can result in serious symptoms or complications, including respiratory disorders such as apnea, respiratory failure, and respiratory depression; psychiatric or nervous system disorders such as agitation, seizures, and coma; and cardiac disorders such as tachycardia, bradycardia, and cardiac arrest. Opioid poisonings in children can have delayed onset of symptoms as well as severe and prolonged toxic effects. Many studies have examined the economic burden of opioid poisoning in the general population, but very little is known about the pediatric population. OBJECTIVE: To estimate the economic burden associated with pediatric prescription opioid poisonings. METHODS: This study examined opioid poisonings in pediatric patients, defined as patients aged less than 18 years, for the 2012 base year. Costs were estimated using the 2012 Nationwide Emergency Department Sample (NEDS), Kids' Inpatient Database (KID), Multiple Cause-of-Death (MCOD) file, and other published sources, while applying a societal perspective. The Bottom Up approach was used to estimate the total cost of pediatric prescription opioid poisonings. Direct costs included costs associated with emergency department (ED) visits, hospitalizations, and ambulance transports. Indirect costs were estimated using the human capital method and included productivity costs due to caregivers' absenteeism and premature mortality among children. Descriptive statistics were employed in calculating costs. RESULTS: The total costs of pediatric prescription opioid poisonings and exposure in the United States were $230.8 million in 2012. Total direct costs were estimated to be over $21.1 million, the majority resulting from prescription opioid poisoning-related inpatient stays. Total indirect (productivity) costs were calculated at $209.7 million, and 98.6% of these costs were attributed to opioid poisoning-related mortality. Pediatric prescription opioid poisoning-related ED visits, inpatient stays, and deaths were most common in patients aged 13-17 years and those in mid to large urban areas. Most were unintentional. CONCLUSIONS: Pediatric prescription opioid poisonings resulted in direct and indirect costs of $230.8 million in 2012. While these costs are low in comparison with the costs of prescription opioid poisoning in the general population, the number of pediatric poisonings represents only a small fraction of total poisonings. Quantified costs associated with pediatric prescription opioid poisonings can help decision makers to understand the economic trade-offs in planning interventions. DISCLOSURES: This research had no external funding but was funded by an unrestricted research grant made to the Department of Pharmacotherapy & Outcomes Science by kaléo Pharma, maker of a naloxone product. The authors declare no conflicts of interest or financial interests. Portions of this study were presented as an abstract at the 22nd Annual ISPOR Meeting; May 22, 2017; Boston, MA.

Pharmacist impact on pneumococcal polysaccharide vaccination rates in patients with diabetes in a national grocery chain pharmacy.

OBJECTIVES: To evaluate the impact of pharmacist education and intervention on pneumococcal polysaccharide (PPSV23) vaccination rates in patients with diabetes in a national grocery chain pharmacy and assess patient awareness and barriers to receiving the PPSV23 vaccine. METHODS: Prospective interventional 4-month study in 3 grocery chain pharmacies targeted patients aged between 19 years and 64 years who filled a medication for diabetes 90 days before the study period. Immunization status was verified with pharmacy records and the Virginia Immunization Information System. A note was added to the profile of patients who did not have a record of PPSV23 immunization to alert the pharmacist to provide patient education about the vaccine the next time the patient presented to the pharmacy. Patients who received education either accepted or declined the recommendation for the vaccine and completed a voluntary survey assessing awareness and barriers to receiving the vaccine. Vaccination rates were calculated before and after pharmacist intervention. RESULTS: Pharmacists provided education to 126 out of the 321 patients potentially eligible to receive the vaccine. For patients receiving the intervention, 51 patients were excluded, 7 patients refused the survey, and 68 patients completed the survey. Twelve patients accepted the pharmacist's recommendation to receive the vaccine. Of patients who completed the survey, 83.6% had type 2 diabetes, 61.8% were men, 77.9% were Caucasian, and the mean age was 51.5 years. More than one-half of the patients (54%) were not aware of the recommendation to receive the PPSV23 vaccine, and 46% of patients wanted to discuss it with their primary care provider. The PPSV23 vaccination rate was 28.6% before pharmacist education and increased to 31.8% after intervention. CONCLUSION: Pharmacist education increased PPSV23 vaccination rates at the pharmacy, and the primary barrier identified for patients receiving the vaccine was that the patients wanted to discuss the recommendation with their provider.

Impact of Adherence Education and Monitoring on Community Pharmacy Performance Scores and Patient Satisfaction.

BACKGROUND: Adherence, specifically to noninsulin diabetes medications, statins, and renin-angiotensin system antagonists (i.e. angiotensin-converting-enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARBs), and aliskiren), is a measure tracked by the Centers for Medicare and Medicaid Services (CMS) to give Medicare Part D plans a star rating; pharmacies are impacted by these star ratings. The pharmacy is given a performance score based on the measure. Some pharmacies use a performance information management platform (PIMP) that allows pharmacies to better understand performance information to impact patient care. OBJECTIVES: (1) To evaluate if a monthly adherence monitoring and education service impacts the percentage of patientsadherent determined by pharmacy performance scores; (2) To determine patient satisfaction with the service in a large community pharmacy chain. METHODS: A six-month prospective interventional pilot study including patients with a proportion of days covered (PDC) of less than 80% for oral diabetes or renin-angiotensin system antagonists (RASA) medications was conducted in two pharmacies of a large community pharmacy chain in Southwest Virginia. Using pharmacy internal data analytics and PIMP data, the percentage of patients who are adherent to oral diabetes or RASA medications was determined including the baseline PDC for each patient. At the start of the study, the standard of care in this large community chain pharmacy was to address adherence, follow-up in one month and every three months thereafter. In this study, pharmacists provided monthly telephonic adherence monitoring and education for a six-month period. Each session was scripted for medication adherence history, education and data collection. The pharmacist provided guidance and counseling based on how the patient answered the questions. Pharmacists gathered information about adherence patterns and behaviors using a 14 item Likert-scale and multiple choice-based questionnaire during the first session. After completion of the final adherence monitoring and education session, pharmacists gathered patient satisfaction information using an eight item Likert-scale questionnaire. At the end of the six-month period, using PIMP data, the percentage of patients adherent to oral diabetes or RASA medications was determined based on pharmacy performance scores. The data was analyzed using uni-variate and bi-variate statistics to determine if there was a difference in pharmacy performance scores from the pre-study analysis. The adherence patterns and behaviors, as well as patient satisfaction with the program was evaluated to determine factors influencing nonadherence. RESULTS: A total of 55 patients were identified in two pharmacies, ten of which were excluded or declined involvement, leaving 45 enrolled in the adherence monitoring and education service. Of the 45 enrolled patients, ten completed the adherence patterns and behaviors questionnaire. About half of the patients were men (50.95%) with an average age of 71.17 years and taking an average of 6.55 prescription medications. All patients had Medicare Part D insurance and majority had a yearly income of less than $40,000. The average baseline PDC was 68.92. In pharmacy 1, the average performance score for oral diabetes medications trended down and the average performance score for hypertension medications trended up over the study period. In pharmacy 2, the average performance score for oral diabetes medications trended up and the average performance score in hypertension medications trended up over the study period. The adherence patterns and behaviors questionnaire revealed the majority of patients rarely forgot to take medications or run out of medications. Additionally, cost of medications did not seem to impact adherence and majority of patients knew the names and indications of their medications. Only one patient completed the patient satisfaction survey. CONCLUSIONS: An adherence monitoring and education service had mixed results in improving patient adherence and pharmacy performance scores. Only one patient completed the satisfaction survey, thus no conclusions can be made regarding patient satisfaction of the program. More research needs to be done regarding telephonic adherence programs.

Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting.

OBJECTIVE: To compare community-based pharmacy medication errors before and after a one-hour live interactive training session for both pharmacists and technicians. METHODS: A one group pre-post intervention design study was conducted in 20 community-based pharmacies in a district of a large national community pharmacy chain. A one-hour live, interactive session was developed based on incident reports and medication error trends including medication error definition, ways in which medication errors occur, strategies for mitigating errors, information about human error, and methods and habits to improve patient safety. At least 50% of full-time staff for each of the 20 pharmacies were required to attend a training session between December 1, 2017-January 15, 2018. Participants completed a demographics survey documenting gender, age, credentials, number of years of experience, and years of service with the company. Pharmacies were categorized as low, medium or high volume based on prescription count. Medication errors were compared six months pre- and post-live education session. Data were analyzed using SAS version 9.4. RESULTS: One hundred and thirty- five errors and 111 errors were reported pre-and post-live training (mean 6.85 and 5.55, p < 0.301), respectively. Nine pharmacies were low, eight medium, and three high volume with the mean number of medication errors reported pre- and post-live training; low 4.33 vs 4.11 p<0.478, medium 9.37 vs 6.87 p<0.443, and high 7.66 vs 6.33 p<0.593, respectively. Sixty pharmacy staff (34 pharmacists, 26 technicians) attended one of the live training sessions; 73% female; most frequently reported age range 35-50 years; 23 Doctor of Pharmacy, 11 Bachelor of Science in Pharmacy, and 26 Certified Technician; and average number of years' experience was 13.6 and average service with the company was 8.6 years. CONCLUSIONS: A live training session for both pharmacists and technicians did not significantly decrease medication errors, but could be incorporated as an element of a medication safety program. It should be considered for implementation in other districts of this large national pharmacy chain as a part of an improved patient safety effort.

Combination therapy with once-weekly glucagon like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes: a case series

BACKGROUND: National treatment guidelines recommend glucagon-like peptide receptor agonists (GLP-1 RAs) as add-on therapy to oral agents. However, GLP-1 RAs in combination with dipeptidyl peptidase-4 (DPP-4) inhibitors is not recommended due to a lack of evidence. OBJECTIVE: This case series aims to describe the efficacy and safety of once-weekly GLP-1 RAs administered concomitantly with DPP-4 inhibitors in patients with type 2 diabetes. METHODS: A retrospective chart review of electronic medical records at a free health clinic was conducted between July 2014 and September 2016. Patients 18 years and older with type 2 diabetes were included if they received concomitant DPP-4 inhibitor and once-weekly GLP-1 RA therapy with at least one glycated hemoglobin A1c (HbA1c) measurement within three to six months of starting the combination. The primary and secondary outcomes included change in HbA1c and weight, and patient reported adverse events. RESULTS: Out of forty-three patients that received combination DPP-4 inhibitor plus GLP-1 RA therapy, only eighteen received once-weekly GLP-1 RA. At 3 months, the median (IQR) HbA1c and weight change was -0.8% (-4.3 to 2%) and -0.4kg (-4.2 to 5.8 kg) respectively. No patients reached an HbA1c below 7% and only three patients (17%) reached a HbA1c less than 8%. Patient reported adverse effects included gastrointestinal disturbances (28%), hypoglycemic symptoms (17%), and injection site reactions (0.6%). CONCLUSIONS: Concomitant use of once-weekly GLP-1 RAs and DPP-4 inhibitors provides only modest improvement in glycemic control with minimal weight loss benefits, which is similar to monotherapy with either agent. The combination is unlikely to provide synergistic effects and is not cost effective. These data support the current recommendations against use of combined incretin therapy

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Medication therapy problems and vaccine needs identified during initial appointment-based medication synchronization visits.

OBJECTIVE: To characterize medication therapy problems (MTPs) and vaccines recommended and administered by pharmacists during initial appointment-based medication synchronization (ABMS) visits, in a community pharmacy setting. METHODS: A retrospective observational study evaluated comprehensive medication reviews documented by pharmacists during initial ABMS visits in 16 supermarket chain pharmacies in Central Virginia from September to December 2017. The documentation was examined to obtain patient demographics, MTPs, and recommended and administered vaccines. Other data collected included disease states, number of medications synchronized per patient, and average time spent per initial ABMS visit. Classifications of MTPs were adherence (overuse and underuse), adverse drug reaction, cost-efficacy management, drug interactions (drug-drug/drug-disease), excessive dose/duration, needs additional therapy (for chronic conditions), suboptimal drug selection, and unnecessary therapy. Data were analyzed using descriptive statistics, and Wilcoxon-Mann-Whitney test was used to compare group differences. RESULTS: One hundred eighty-four patients received an initial ABMS visit (118 female and 66 male patients). The mean age was 70 years for women and 65 years for men, range 18 to 19 years (P < 0.08). Disease states documented included asthma, benign prostatic hyperplasia, chronic pain, epilepsy, depression, diabetes mellitus, dementia, gastroesophageal reflux disease, history of myocardial infarction, human immunodeficiency virus, hyperlipidemia, and hypertension. Women had a significantly higher number of disease states than men did (P < 0.03). Thirty-seven MTPs were identified with no statistical difference between men and women (P < 0.98). Pharmacists reported spending an average of 17 minutes with patients during the initial visit for an average of 6 medications synchronized per patient. Six hundred thirty-three vaccines were recommended, and 51 were administered. CONCLUSION: Initial ABMS visit with a comprehensive medication review facilitated pharmacists in detecting medication therapy problems. Although vaccines administered were lower than recommended, community pharmacists play an important role in preventive health through vaccine screenings and recommendations. Future plans include evaluating the outcomes of MTPs identified and resolved in the ABMS service.

Patient satisfaction with pharmacist-administered Mantoux tuberculin skin test in a community-based pharmacy setting.

OBJECTIVES: The objective of this study was to determine patient satisfaction with pharmacist-administered Mantoux tuberculin skin test (TST) in a community-based pharmacy. METHODS: A prospective 6-month convenience sample study was conducted in an independent community pharmacy. Initial and follow-up surveys were developed with content and design informed by the literature. Surveys were peer reviewed and pretested with a sample group of 2 patients for clarity. The initial survey consisted of 26 questions including Likert-type scale, multiple choice, and free response. There were 7 demographic questions, 17 patient satisfaction questions divided into 2 domains (satisfaction with the pharmacy setting and the pharmacist), 1 question about "how you heard about us," and 1 free-response question. The follow-up survey consisted of 20 questions, also including Likert-type scale, multiple choice, and free response. There were 17 questions related to patient satisfaction identical to the initial survey. Patients who were 18 years of age and older completed the initial survey when the Mantoux TST was administered and the follow-up survey when the test was read by the pharmacist. Patients created a unique identifier code to match the follow-up survey to the initial survey. The data were evaluated with the use of univariate and bivariate analysis. RESULTS: Sixty-four matched surveys were completed and included in the data analysis, with a response rate of 51.6%. Ninety-two percent of the patients were female, and the most frequent age range was 25-34 years (20%). Satisfaction scores between the initial survey and follow-up survey were not statistically different regarding pharmacy setting or pharmacist services. All satisfaction scores were above 90% except for the initial satisfaction scores for convenience and timeliness, which were both 88% in the initial survey. CONCLUSION: Patient satisfaction is consistently high with pharmacist-provided Mantoux TST in a community-based pharmacy.

Pharmacy interns' perceptions of knowledge and skills required for delivery of patient care services.

OBJECTIVES: To explore how pharmacy interns' training experiences during internship influence understanding and confidence about preparation for providing patient care services in a large community pharmacy chain. METHODS: A descriptive survey design using a census sample of the 98 pharmacy interns, aged 18 years and older, employed in 52 pharmacies of one community pharmacy chain was conducted. Training experiences influencing understanding and confidence were evaluated with the use of a 38-question survey instrument developed with a focus group of pharmacy interns and distributed via Qualtrics over a period of 12 weeks. Responses were stored in Qualtrics and analyzed with the use of SAS version 9.4. RESULTS: Thirty-four surveys were returned, for a response rate of 35%, with a 20% response rate for all of the questions. Pharmacy interns who completed the American Pharmacist Association "Delivering Medication Therapy Management Services" certificate training program were more likely to agree with statements evaluating understanding (P < 0.02) and confidence (P < 0.09) in completing a comprehensive medication review and less likely to indicate a need for training (P < 0.02). Pharmacy interns have a greater understanding and confidence incorporating immunizations into workflow (both 85%). They also have a greater understanding and confidence in using Advisory Committee on Immunization Practices/Centers for Disease Control and Prevention guidelines for immunization recommendations (90% and 85%, respectively). Pharmacy interns reported that they did not have a strong understanding of and confidence level in providing other patient care services, including medication therapy management services, clinical queue, and point-of-care testing. Survey respondents reported a desire for additional training in these areas. CONCLUSION: Although pharmacy interns have a greater understanding of how to incorporate immunizations into pharmacy workload and use immunization guidelines, levels of understanding and confidence in providing other patient care services were not as strong. Future development of training for patient care services may help to increase pharmacy intern understanding and confidence.