RESUMO
STUDY OBJECTIVE: Data from randomized controlled trials support a mortality benefit with ticagrelor versus clopidogrel among patients with acute myocardial infarction (AMI). Many healthcare providers preferentially treat patients with AMI with ticagrelor. The goal of this study was to determine the association between out-of-pocket drug costs and ticagrelor continuation compared with switching to clopidogrel among patients hospitalized for AMI, following a pharmacist-led discussion on outpatient co-payment costs for ticagrelor. DESIGN: Retrospective cohort study. SETTING: A tertiary care academic medical center. PATIENTS: Patients hospitalized with AMI between February 15, 2015 and January 23, 2017, who were loaded with ticagrelor on presentation. MAIN RESULTS: Of 143 patients with AMI loaded with ticagrelor, 70 (49%) switched to clopidogrel after cost discussion. The median monthly ticagrelor co-payment was $268.29 (interquartile range [IQR] $45-$350) for switchers, versus $18 (IQR $6-$24) for non-switchers (p<0.001). Patients with co-payments of $100/month or more were 3.4 times more likely to switch to clopidogrel (relative risk 3.41, 95% confidence interval 2.12 to 5.47), compared with patients with co-payments of less than $100/month. CONCLUSIONS: Following a discussion of outpatient costs, half of patients with AMI switched from ticagrelor to clopidogrel when given the choice.
RESUMO
BACKGROUND: Critical care pharmacists are established and valuable members of the critical care team, however there is rarely written evidence of their daily involvement in the patient's electronic medical record (EMR). Documentation in the EMR has the advantage of ensuring a seamless pass-off and provides an opportunity to capture the pharmacist's cognitive and clinical impact in a way that traditional systems of tracking "interventions" fail to do. We investigated implementation of pharmacist progress notes in a surgical intensive care unit (ICU) and their utility in measuring pharmacist activity. METHODS: Daily pharmacist progress notes written in a surgical ICU over a period of 2 months were reviewed. Each pharmacist action identified through progress note review was quantified and scored by an independent reviewer using a newly developed scoring system, the clinical impact score (CIS). This was developed as a way to quantify pharmacist actions and to classify those actions by clinical impact. RESULTS: Four hundred sixty-two daily pharmacist progress notes were reviewed over a 2-month period. There were 1,055 actions identified that resulted in a therapy change. Four of these actions resulted in the potential avoidance of a sentinel event. Of patients with at least 5 progress notes (n = 44), the majority of pharmacist actions occurred on ICU day 1. CONCLUSION: The results of this descriptive study demonstrate that the implementation of daily pharmacist progress notes is feasible in an advanced practice setting, and the pharmacist's contribution to patient care may be obtained through review of this documentation in the patient's medical record. The critical care pharmacist's daily involvement in patient care most commonly results in optimization of pharmacotherapy and avoidance of drug misadventure.
