Impact of pharmacist outreach on glucagon prescribing.

BACKGROUND: Hypoglycemia is a major limiting factor in the glycemic management of diabetes. As a method of treating hypoglycemia, the American Diabetes Association recommends glucagon to be prescribed for all individuals at increased risk of clinically impactful hypoglycemia. Glucagon Emergency Kits have been shown to reduce emergency department visits and overall health care costs. Despite these known benefits, glucagon continues to be underprescribed. Previous pharmacist-led interventions embedded in a single clinic have been shown to positively affect the rate of glucagon prescribing in patients with diabetes. OBJECTIVE: This study aimed to compare the rate of glucagon prescribing between quality improvement remote pharmacist outreach to multiple primary care and endocrinology specialty clinics and the control group in 1 month following a pharmacist-led provider outreach. METHODS: This was a single-center, 2-arm study with a simple randomization design. RESULTS: On pharmacist outreach, 61 of 109 patients (56.0%) in the outreach group were prescribed a glucagon product within 1 month of their primary care provider (PCP) or endocrinology appointment compared with 1 of 113 (0.9%) of patients in the control group (P < 0.001). Glucagon prescribing occurred in 25 of 35 Black patients (71.4%) compared with 36 of 73 white patients (49.3%) in the outreach group. Glucagon prescribing was associated with race (P = 0.03; chi-square test). CONCLUSIONS: The pharmacist-led provider outreach before a PCP or endocrinology appointment has a positive and statistically significant impact on glucagon prescribing rates. The pharmacist outreach had a higher impact on Black patients than white patients, possibly because of a lower rate of glucagon prescribing in Black patients before the outreach.

Impact of a clinical pharmacist on provider prescribing patterns in a primary care clinic.

BACKGROUND: Sodium-glucose transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists have demonstrated beneficial outcomes in patients with type 2 diabetes at high cardiovascular risk. Unfortunately, these agents are still underutilized in primary care practice. A clinical pharmacist was embedded at a primary care clinic to provide diabetes and hypertension management under a collaborative practice agreement with a supervising physician. OBJECTIVES: This study will evaluate whether the presence of an embedded pharmacist in a primary care clinic affects prescribing patterns of novel, evidence-based diabetes therapies. METHODS: We abstracted information on SGLT2 inhibitor and GLP-1 agonist prescribing patterns from 3 primary care clinics across 2 time periods as a single-center, retrospective cohort study. We used a difference-in-difference analysis to compare prescription rates and assess the impact of embedding the pharmacist into clinical practice. Prescriptions written by the pharmacist were excluded. RESULTS: Across all 3 clinics, 1309 and 1489 patients were included in the pre-intervention and postintervention periods, respectively. The percentage of patients prescribed either an SGLT2 inhibitor or GLP-1 agonist, similar between both groups at baseline, rose to 11.6% in the nonintervention clinics and 15.0% in the intervention clinic. There was a statistically significant increase in SGLT2 inhibitor and GLP-1 agonist prescribing in the intervention clinic compared with nonintervention clinics (P = 0.034). This change in prescribing patterns appeared even greater when excluding prescribers who were not present during both pre-intervention and postintervention periods (P = 0.009). CONCLUSION: The presence of a pharmacist is associated with increased SGLT2 inhibitor and GLP-1 agonist prescribing within a clinic, even in patients not seen directly by the pharmacist. These results suggest that an on-site clinical pharmacist providing care for patients with diabetes may indirectly influence the prescribing behavior of co-located primary care providers, increasing the adoption of novel noninsulin diabetic medications.

Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting.

OBJECTIVE: This study aimed to reduce high-risk medication (HRM) prescribing by direct electronic medical record messaging to providers. SETTING: Lincoln Community Health Center is a federally qualified health center in the southeast United States. PRACTICE DESCRIPTION: This was a single-center, observational study performed with quality improvement methodology including define, measure, analyze, improve, and control phases. A total of 89 patients, aged 65 years or older, received 115 HRM prescriptions from August 2016 to August 2018. Project follow-up period included September 2018 to April 2019, with 19 additional patients receiving 23 HRM prescriptions. PRACTICE INNOVATION: Shared electronic medical records allowed pharmacists to electronically communicate indication of HRM, possible alternatives to HRM, and pharmacy of choice to providers to reduce HRM prescribing. Pharmacists' recommendations were timed to appear in providers' inboxes 3 to 5 days before the patient's clinic visit. Patients not returning to the clinic in a timely manner were telephoned by pharmacists with medical provider approved HRM alternative recommendations. EVALUATION: Discontinuation of HRMs were verified by chart review and insurance claims. The Cochran-Armitage trend test was used to examine significance of change related to national benchmark prescribing rates. Two-sided z test was used to analyze significance of change from implementation to follow-up period. RESULTS: Fifty-two provider communications sent by clinical pharmacists resulted in a therapy modification rate of 71.2%. National benchmark data that reflected a peak HRM prescribing rate of 10.7% was reduced to 1.9% within 18 months (P = 0.014). The national benchmark goal of less than 3% HRM prescribing was achieved and sustained from February 2019 to May 2019. CONCLUSION: Using interdisciplinary access to electronic medical records resulted in significant rates of HRM discontinuation. Timing messages before patient clinic visits promotes shared decision making.

The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia.

OBJECTIVE: Assess clinical and economic outcomes of a community-based, long-term medication therapy management (MTM) program for hypertension (HTN)/dyslipidemia. DESIGN: Quasi-experimental, longitudinal, pre-post study. SETTING: 12 community and hospital pharmacy clinics in Asheville, N.C., over a 6-year period from 2000 through 2005. PARTICIPANTS: Patients covered by two self-insured health plans; educators at Mission Hospitals; 18 certificate-trained pharmacists. INTERVENTIONS: Cardiovascular or cerebrovascular (collectively abbreviated as CV) risk reduction education; regular, long-term follow-up by pharmacists (reimbursed by health plans) using scheduled consultations, monitoring, and recommendations to physicians. MAIN OUTCOME MEASURES: Clinical and economic parameters. RESULTS: Sufficient data were available for 620 patients in the financial cohort and 565 patients in clinical cohort. Several indicators of cardiovascular health improved over the course of the study: mean systolic blood pressure, from 137.3 to 126.3 mm Hg; mean diastolic blood pressure, from 82.6 to 77.8 mm Hg; percentage of patients at blood pressure goal, from 40.2% to 67.4%; mean low-density lipoprotein (LDL) cholesterol, from 127.2 to 108.3 mg/dL; percentage of patients at LDL cholesterol goal, from 49.9% to 74.6%; mean total cholesterol, from 211.4 to 184.3 mg/dL; and mean serum triglycerides, from 192.8 to 154.4 mg/dL. Mean high-density lipoprotein (HDL) cholesterol decreased from 48 to 46.6 mg/dL. The CV event rate during the historical period, 77 per 1,000 person-years, declined by almost one-half (38 per 1,000 person-years) during the study period. Mean cost per CV event in the study period was $9,931, compared with $14,343 during the historical period. During the study period, CV medication use increased nearly threefold, but CV-related medical costs decreased by 46.5%. CV-related medical costs decreased from 30.6% of total health care costs to 19%. A 53% decrease in risk of a CV event and greater than 50% decrease in risk of a CV-related emergency department (ED)/hospital visit were also observed. CONCLUSION: Patients with HTN and/or dyslipidemia receiving education and long-term MTM services achieved significant clinical improvements that were sustained for as long as 6 years, a significant increase in the use of CV medications, and a decrease in CV events and related medical costs.

Antiretrovirals, part 1: overview, history, and focus on protease inhibitors.

This column is the first in a series on HIV/AIDS antiretroviral drugs. This first review summarizes the history of HIV/AIDS and the development of highly active antiretroviral therapy (HAART) and highlights why it is important for non-HIV specialists to know about these drugs. There are four broad classes of HIV medications used in varying combinations in HAART: the protease inhibitors, nucleoside analogue reverse transcriptase inhibitors, the non-nucleoside reverse transcriptase inhibitors, and cell membrane fusion inhibitors. This paper reviews the mechanism of action, side effects, toxicities, and drug interactions of the protease inhibitors.