Ambulatory Care Pharmacists Research Articles

Implementing outpatient antimicrobial stewardship in a primary care office through ambulatory care pharmacist-led audit and feedback

ObjectivesThis study aimed to determine the impact of a pharmacist-led antimicrobial stewardship program (ASP) intervention on outpatient antibiotic prescribing for upper respiratory tract infections (URIs) and urinary tract infections (UTIs) in a primary care office. The primary outcome of this study was to characterize antibiotic prescribing over time. Secondary outcomes included describing ambulatory care pharmacist (ACP) workload and types of feedback given. MethodsA retrospective pilot study was conducted within a primary care office. The office included a 0.6 full-time equivalent ACP and is part of a health system supported by a pharmacist and a physician co-led ASP. Education and guidelines were provided by the ACP and ASP leads before the intervention period August 2017–February 2018. The ACP provided bi-weekly audit of all URI and UTI prescriptions and written feedback to prescribers. ResultsDuring the 7-month intervention period, 1107 prescriptions were audited by the ACP, 825 URI and 282 UTI. The most common reasons for feedback included inappropriate agent (26.3%) or prolonged duration of therapy (24.3%). Guideline-concordant agent prescribed for a UTI increased from 20% at baseline to a median of 69.2%, whereas duration increased from 55% to 70.4%. Guideline-concordant agent prescribed for a URI increased from 43.3% to 86.8%, whereas the median duration of therapy decreased from 10 to 7 days. ConclusionAn ACP-led ASP intervention within a primary care office incorporating audit and feedback improved antibiotic prescribing for URIs and UTIs, including prescribing antibiotics when indicated, guideline-concordant antibiotic selection, and duration of therapy. Pharmacists practicing in ambulatory care settings may serve a vital role in leading successful outpatient ASP interventions.

How a State Measures Up: Ambulatory Care Pharmacists' Perception of Practice Management Systems for Comprehensive Medication Management in Utah.

Comprehensive medication management (CMM) is a patient-centered standard of care that ensures a patient’s medications are optimized. The CMM Practice Management Assessment Tool (PMAT) is a tool to assess areas of CMM practice management. The purpose of this project was to assess the state of CMM practice management based on clinical pharmacist perception for two health systems in the state of Utah, and to identify areas of excellence and/or improvement utilizing a novel method for PMAT analysis. The PMAT was distributed to all primary care-focused ambulatory care pharmacists employed by University of Utah Health (U of U Health) and Intermountain Healthcare (Intermountain). Ordinal responses were assigned to three possible categories of CMM support (High, Indifferent, and Low). Ten surveys were completed from U of U Health, and nine were completed from Intermountain. Thirty-two of the 86 survey questions resulted in a high level of support, and 25 questions resulted in a low level of support from the majority of respondents. Statistically significant differences between the institutions were found for 18 questions. The utilization of the PMAT within two Utah health systems highlighted areas of excellence and improvement and demonstrates a unique method for analysis of PMAT results.

The Role of Pharmacists in the Fight Against COVID-19

COVID-19 is a respiratory infection caused by SARSCoV-2, a newly identified coronavirus. The disease has quickly spread throughout the world and was declared a pandemic. Older people and those with comorbid conditions carry the highest burden of morbidity and mortality associated with COVID-19. As the most accessible health care professionals, community and ambulatory care pharmacists are well positioned to respond to this public health crisis by testing eligible patients–recently allowed by federal regulation–counseling them on treatment options for symptomatic relief, reinforcing prevention measures, and managing drug shortages. Hospital pharmacists also play an important role by assisting prescribers in selecting the best treatment regimens for patients, evaluating and securing investigational agents, developing criteria for drug use, mitigating drug shortages, and preserving personal protective equipment. In addition, long-term care pharmacists are instrumental in optimizing medication management and developing policies to reduce the risk of COVID-19 transmission among vulnerable residents.

The Role of Pharmacists in the Fight Against COVID-19.

COVID-19 is a respiratory infection caused by SARSCoV-2, a newly identified coronavirus. The disease has quickly spread throughout the world and was declared a pandemic. Older people and those with comorbid conditions carry the highest burden of morbidity and mortality associated with COVID-19. As the most accessible health care professionals, community and ambulatory care pharmacists are well positioned to respond to this public health crisis by testing eligible patients–recently allowed by federal regulation–counseling them on treatment options for symptomatic relief, reinforcing prevention measures, and managing drug shortages. Hospital pharmacists also play an important role by assisting prescribers in selecting the best treatment regimens for patients, evaluating and securing investigational agents, developing criteria for drug use, mitigating drug shortages, and preserving personal protective equipment. In addition, long-term care pharmacists are instrumental in optimizing medication management and developing policies to reduce the risk of COVID-19 transmission among vulnerable residents.

Improving transitions of care for critically ill adult patients on pulmonary arterial hypertension medications.

The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications. Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge. Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers.

Frontline perspective on credentialing and privileging of ambulatory care pharmacists.

To present the current state of, and frontline advice on, the implementation of successful credentialing and privileging processes for practicing pharmacists in the United States. The American Society of Health-System Pharmacists (ASHP) Section Advisory Group on Compensation and Practice Sustainability surveyed ambulatory care pharmacists via ASHP Connect about the status, structure and oversight of their ambulatory care clinical practice sites with credentialed and privileged (C&P) pharmacists. Over 80% of survey respondents identified themselves as a C&P pharmacist, and over 90% indicated it is 'Important' or 'Very Important' for pharmacists to be C&P. Qualitative survey responses indicated the most important considerations for establishing or expanding a credentialing and privileging process for ambulatory care pharmacists were 'don't re-create the wheel', 'establish a physician champion and/or obtain leadership buy-in', 'be persistent and patient', 'develop a guidance document' and 'work within existing processes'. Starting a credentialing and privileging process is critical in preparation for, or response to, provider status recognition of pharmacists in the United States. When used with existing guidance documents on credentialing and privileging, 'front line' advice from practicing pharmacists can help promote expanded roles for pharmacists within healthcare systems.

Identifying vaccination rates of adult patients in ambulatory care clinics.

Background:While pharmacists have provided vaccinations to patients in the community pharmacy setting, pharmacist involvement within the medical office setting is not well documented in the literature. The American Society of Health-System Pharmacists reports that ambulatory care pharmacists are screening for and administering vaccinations at a declining rate, despite standards of practice. Vaccination rates for adults 19–64 years of age remain low, based on Healthy People 2020 goals, putting them at risk for vaccine-preventable diseases.Objectives:The aim of the study was to assess vaccination rates of ambulatory care pharmacy clinic patients aged 19–64 years and to compare the rates between three clinics and to Healthy People 2020 goals.Methods:This was a baseline retrospective analysis of vaccination rates for patients aged 19–64 years who attended at least one pharmacy clinic visit at one of the three medical office practices. Age, sex, medical conditions, cigarette or alcohol use, immunosuppressive medications, and vaccines recommended and received were recorded. Vaccination status was assessed according to the Advisory Committee for Immunization Practices recommendations. Data were collected from January 2016 to March 2017. The percentage of eligible patients who received each vaccine was determined overall and for each clinic.Results:There were 240 patients who met the inclusion criteria, with a mean age of 52.8 years. The percentage of patients with vaccination documented in the medical record was 25% for pneumococcal conjugate, 35.7% for pneumococcal polysaccharide, 26.9% for zoster vaccine live, 6.4% for hepatitis B, and 50.6% for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis. Vaccination rates for pneumococcal conjugate, pneumococcal polysaccharide, and zoster vaccine live were below established Healthy People 2020 goals.Conclusion:Vaccination rates remain low in adults 19–64 years of age. Ambulatory care pharmacists should consider assessing vaccination status during clinic visits as a component of comprehensive vaccination programs.

Polypharmacy as a Clinical Pharmacist Specialist Practice

The objective of this manuscript is to review an ambulatory care pharmacist service that evolved into a pharmacotherapy, polypharmacy service with multiple submodels. The practice is located in a multispecialty, tertiary care, destination medical clinic in Florida. Ambulatory care pharmacist services have evolved to demand expertise in multiple, specialized areas to address the more complex medical issues of the polypharmacy patient. Many of these patients are older than 65 years of age, with broad medical care needs. A number of changes have led to the need for these expanded services: the growth and diversification of pharmacists' ambulatory care services, the multitude of sophisticated medications, the continued direct-to-consumer commercialization, the growth of dietary supplements, and the implementation of pharmacogenomic testing, In addition, new advances in clinical and laboratory technologies make polypharmacy a viable pharmacist clinical specialty. With the broad knowledge base needed for these patients, a polypharmacy pharmacist may function as a pharmacology troubleshooter expert.

Pharmacist-led transitions-of-care services in primary care settings: Opportunities, experiences, and challenges

ObjectiveTo initiate a call to action for ambulatory care pharmacists to play a more active role in transitional care management within primary care settings by discussing relevant opportunities, experiences, and challenges. SummaryWith the shift to value-based health care, greater emphasis is being placed on improving patient care quality at the lowest cost. This represents an opportunity for pharmacist integration into primary care teams to address medication management challenges in the postdischarge period. Primary care pharmacists are uniquely positioned to close gaps in care not typically addressed by hospital-based programs. These pharmacists can provide complex transition interventions tailored toward individual patients, including comprehensive medication review, patient counseling, and direct collaboration with providers. For broad acceptance of these services, current challenges include identifying and prioritizing high-risk patients, establishing the cost-effectiveness of these strategies, and ultimately applying dissemination and implementation methodologies to increase the potential impact of these interventions. ConclusionOpportunities are expanding for primary care pharmacists to play a more substantial role in transitional care management in sustainable ways. For widespread implementation of these strategies, additional research is necessary to determine their clinical effectiveness as well as cost-effectiveness and to understand better the barriers and facilitators to adopting these interventions.

Pharmacist implementation of a transitions of care electronic referral process to provide hand-off between inpatient and outpatient settings

ObjectiveTo describe the implementation of an electronic transitions of care referral process within a large, academic medical center. Practice setting and descriptionTo improve communication between the inpatient and ambulatory care pharmacists, the pharmacy department created an electronic referral (e-referral) order, which becomes part of the patient’s electronic medical record. Data were collected to describe use of the electronic order and to discuss the role of the referrals in supporting a newly developed ambulatory care pharmacy service. Practice innovationThe e-referral was built to enhance the efficiency of direct patient care and prioritize patient care activities. This electronic order was built to collect specific details focused on medication-related concerns and provide hand-off to ambulatory care pharmacists for outpatient follow-up. EvaluationA retrospective, cohort analysis of patients was conducted from August 1, 2014, to July 31, 2015. Patients were included in the project if they were 18 years of age or older and received an e-referral order upon transition from the inpatient to the outpatient setting. Patients were excluded if the e-referral was sent from an outpatient setting or if they were younger than 18 years of age. Data were collected to describe the e-referral process and discuss how these referrals supported a new outpatient pulmonary clinic. ResultsA total of 268 inpatient referral orders were included for analysis. Common indications for the referrals included education (49%), follow-up from inpatient consult (46%), adherence (45%), and therapy optimization (42%). A total of 241 (90%) e-referrals were sent from an inpatient pharmacist to an ambulatory care pharmacist; the other 27 (10%) referrals were sent by a physician or mid-level provider. Of the 241 pharmacist referrals, 46 (19%) were placed by pharmacy residents. The majority of inpatient e-referrals (63.4%) were for chronic obstructive pulmonary disease and sent to the outpatient pulmonary clinical pharmacist for follow-up after discharge. The pulmonary clinic ambulatory care pharmacist completed 110 discharge calls (95.7%). ConclusionAn e-referral from inpatient to ambulatory care pharmacists provides pharmacist-to-pharmacist hand-off for medication-related needs after discharge.

Staying in touch with your patients to improve their care

Lately, I’ve been hearing a lot about pharmacy “touches.” An ambulatory care pharmacist colleague described a shift in recent years in the way she documents her impact on patient care in her multidisciplinary clinic practice. She said that she previously tracked only the number of scheduled visits for chronic disease management, but she has realized that she affects patients’ care in so many other ways. Whether in a hallway consult with a physician about a drug therapy change, in an impromptu patient education session, or through efforts to help a patient afford a new medication, she improves care through many avenues, and she now keeps track of all these big and small patient “touches.” This issue of Pharmacy Today highlights innovations in specialty pharmacy—where pharmacists work with often costly, “high-touch” medications (page 28). Some specialty pharmacies are increasingly taking an integrated approach to care, with pharmacists focusing on patient education as part of a multidisciplinary team. Pharmacists practicing in this model cite the benefits of having a pharmacist “closer to patients and their providers” to manage medication access and monitor drug therapy. You’ll also find the latest information on vaping and vaping-related illness (page 27), learn about an increasing trend of antibiotic use without a prescription (page 26), and get new guidelines on treating migraines in children (page 14) in this issue of Today. Stay up to date with the latest Beers Criteria on medication use in older adults with this month’s CPE article (page 42). Whether counseling patients in the pharmacy, interacting with providers in clinic, or helping patients to access and safely use their specialty medications, we are touching patients’ lives to improve their care. Investing in these small but essential daily interactions with our patients helps us to connect with them, stay in touch with their needs, and bring value to their care. Have a great Today!

Resident physicians' perceptions of ambulatory care pharmacy.

Background:Physicians’ acceptance of clinical pharmacy services is dependent on exposure to those services, with use increasing as resident physicians progress through their training. Resident physicians train within environments that have a multidisciplinary teaching and clinical care approach, working closely with other healthcare professionals. Ambulatory care pharmacists are increasingly working with resident physicians in clinic settings as part of the multidisciplinary team, and identification of resident physicians’ perceptions may influence future collaboration.Objective:The objective of this research is to evaluate the perception of ambulatory care clinical pharmacy services from the perspective of resident physicians.Methods:A statewide network of ambulatory care pharmacists was identified and received an electronic questionnaire. Pharmacists working within clinics that serve as training sites for resident physicians then completed and distributed questionnaires to the resident physicians within their clinical site. Items related to demographics and perception of involvement and interactions with clinical pharmacists.Results:Forty-five resident physicians responded from four unique clinical sites (response rate = 42%). They agreed or strongly agreed that pharmacists help patients obtain their therapeutic goals (97.8%), are able to educate patients effectively (95.6%), provide high quality care (97.8%), and do a good job helping co-manage patients (91.1%). Previous exposure to pharmacists was limited primarily to the drugstore (48.9%) and hospital (51.1%) settings. Resident physicians in the third year of training and those reporting a friend was a pharmacist, were more likely to have a positive perception of the pharmacist’s role as a resident educator (p=0.048 and p=0.044, respectively).Conclusions:Resident physicians with a longer duration of exposure and personal friendship with a pharmacist are more likely to express positive perceptions. Areas for further enhancements in this interprofessional relationship related to perceptions about pharmacist autonomy and patient relationships were identified.

Ambulatory Care Pharmacists’ Perception of Prediabetes

Introduction: Eighty-four million patients in the United States have prediabetes yet evidence-based interventions to prevent diabetes are infrequently used. The concept of prediabetes is contentious, although preventive interventions are guideline supported. Team-based care models incorporating pharmacists for prediabetes have been proposed; however, pharmacist perception regarding prediabetes has not been assessed. This study's objective was to assess ambulatory care pharmacists’ perception of recommendations for prediabetes. Methods: An anonymous survey was electronically distributed through the American College of Clinical Pharmacy Ambulatory Care Practice and Research Network. The primary outcome was the proportion of respondents who reported supporting 3 main recommendations related to prediabetes (ie, screening, evidence-based lifestyle-intervention, metformin). The study was approved by the University of South Florida Institutional Review Board. Data collection and analysis occurred in 2017. Results: The survey was distributed to approximately 2209 potential participants. One hundred thirty-three surveys were completed. The American Diabetes Association guideline was the most common primarily supported guideline related to prediabetes (89%). Of the respondents, 87% supported all 3 main recommendations regarding prediabetes. Qualitative feedback demonstrated the full range of opinions; programs for prediabetes, limited intervention for prediabetes, and against prediabetes as a concept. Conclusions: The majority of ambulatory care pharmacists responding supported all main recommendations related to prediabetes and therefore may be practicable for disseminating diabetes prevention interventions. However, barriers to implementation should be expected.

Students’ Perceptions on a Business Plan Assignment for an Ambulatory Care Pharmacy Elective

Objective. To evaluate a business-centered assignment implemented in a pharmacy elective course at two different institutions and analyze student perceptions of the delivery platforms used and the value and utility of the assignment. Methods. The ambulatory care electives at Butler University and Samford University introduce students to the expanding role of the ambulatory care pharmacist, emphasizing business plan development for new ambulatory care pharmacy services. As part of the elective, students are asked to work in groups to complete a business plan for a new ambulatory care service of their choosing. A survey was conducted to assess student perceptions on the assignment. Results. Of the 58 students who completed the business plan assignment, 49 completed the survey and were included in the data analysis. Overall, 100% of Samford students and 97% of Butler students either strongly agreed or agreed that the business plan was an innovative assignment unlike others completed in the curriculum. Samford students strongly agreed (100%) that if asked by a future employer to develop a new pharmacy service, concepts learned from this assignment would be useful, compared to 59% of Butler students who felt this way. While both the web and written delivery platforms had identical learning outcomes, the written business plan was the approach that the majority of students were more comfortable using. Conclusion. The business plan assignment was used as a method to familiarize students with the process of developing new ambulatory care pharmacy services. Based on survey results, the students perceived this to be an innovative assignment that allowed them to feel confident in developing and communicating ambulatory care business plans. As the practice of ambulatory care pharmacy expands, assignments such as this can be included in the pharmacy curriculum to meet the need for teaching effective business strategies to future pharmacists.

Physician-pharmacist collaboration on chronic non-cancer pain management during the opioid crisis: A qualitative interview study.

Management of chronic non-cancer pain is complex, requiring clinicians to balance pain management with the risk of opioid abuse. The role of ambulatory care pharmacists in chronic pain management is well-established, but little research has explored the feasibility of building collaboration on chronic pain and opioid management between physicians and community pharmacists. To explore physician and pharmacist perspectives on the opioid crisis and the possibility of physician and community pharmacist collaborations to manage chronic non-cancer pain in the context of the opioid crisis. Semi-structured interviews were performed with a snowball convenience sample 15 physicians and 25 pharmacists in North Carolina between November 2016 and April 2017. Transcribed data were analyzed using applied thematic analysis, and resulting codes were organized into themes and domains which emerged from analysis. Both physicians and pharmacists described current care deficiencies and steps needed to mitigate opioid abuse and diversion. Physicians discussed the need for additional supports and resources for chronic pain management and regarded positively the role of the community pharmacist in chronic pain management and mitigating opioid abuse. Pharmacists identified cost as the major barrier to implementing new services, and expressed willingness to participate in new chronic pain and opioid interventions. Within the study sample, strong interest exists for collaboration between physicians and community pharmacists. This highlights a potential opportunity to expand care for patients with chronic non-cancer pain.

Quantitative analysis of nonvisit care activities performed by ambulatory care pharmacists in the outpatient primary care clinic setting

IntroductionThe value of pharmacists as direct patient care providers in integrated ambulatory care teams has been demonstrated. As the reimbursement landscape changes, patient care outside of office visits is increasing through nonvisit care.ObjectiveWe aimed to quantify the time spent by ambulatory care pharmacists on nonvisit care activities in the outpatient primary care clinic setting.MethodsData were collected from four outpatient ambulatory care practices in our institution over 12 weeks. The primary objective was to quantify the time spent performing nonvisit care activities. Secondary objectives were to quantify the number of patients affected, the number of nonvisit care activities, the types of medication therapy problems (MTPs) encountered during nonvisit care activities, and the resulting medication therapy interventions.ResultsA total of 1311 patients were affected during the study, and pharmacists spent a daily average of 1.6 hours performing nonvisit patient care. Among 1548 nonvisit care activities, staff face‐to‐face curbside consult was the most frequent (41%). Among 1866 MTPs identified (1.4 MTP per patient), the most common problems identified were need for education (31%), adverse medication events (21%), need for an additional medication (20%), and nonadherence (12%). The most common interventions were health care team education (28%), recommendation to switch medication (18%), patient education (17%), and start a new medication (14%).ConclusionAmbulatory care pharmacists spent considerable time performing nonvisit care, with multiple MTPs identified during these encounters. Health care teams frequently used pharmacists for nonvisit patient care. Further research is needed to determine the best utilization of pharmacist resources allocated to nonvisit care in an integrated ambulatory care practice.

The New Era of Pharmacists in Ambulatory Patient Care.

Pharmacy is evolving from a product-oriented to a patient-oriented profession. This role modification is extremely healthy for the patient, the pharmacist, and other members of the health-care team. However, the evolution will present pharmacists with a number of new challenges. Now, more than in the past, pharmacists must make the acquisition of contemporary practice knowledge and skills a high priority, to render the level of service embodied in the concept of pharmaceutical care. Pharmacy educators' organizations and regulatory bodies must all work together to support pharmacists as they assume expanded health-care roles. Pharmacy and the healthcare industry must work to ensure that the pharmacist is compensated justly for all services. But before this can happen it will be necessary for pharmacy to demonstrate value-added to the cost of the prescription. Marketing of the purpose of pharmacy in the health-care morass and of the services provided by the pharmacist is needed to generate an appropriate perceived value among purchasers and users of health-care services. Pharmacists should view themselves as dispensers of therapy and drug effect interpretations as well as of drugs themselves. Service components of pharmacy should be identified clearly to third party payers and be visible to consumers, so that they know what is available at what cost and how it may be accessed. In the future, pharmacy services must be evaluated on patient outcome (i.e., pharmaceutical care) rather than the number of prescriptions dispensed, and pharmacy must evolve toward interpretation and patient consultation, related to the use of medication technologies.

1845. Implementing Outpatient Antimicrobial Stewardship in a Primary Care Office Through Pharmacist-led Audit and Feedback

BackgroundMore than 30% of antibiotics prescribed in the outpatient setting are unnecessary. This study aimed to determine the impact of pharmacist-led audit and feedback on outpatient antibiotic prescribing for upper respiratory tract infections (URIs) and urinary tract infections (UTIs).MethodsA retrospective, observational study was conducted at an outpatient primary care office to evaluate implementation of a pharmacist-led audit and feedback process. The office includes 0.6 FTE ambulatory care pharmacist (ACP) who completed antimicrobial stewardship training, and is part of a health system supported by a pharmacist and physician co-led antimicrobial stewardship program (ASP). Education, including pocket cards with URI and UTI guidelines was provided by the ASP leads in July 2017 prior to the study period (August 2017–March 2018). The ACP was responsible for weekly audit of all prescribed antibiotics for URI and UTI and provided feedback to prescribers. Appropriateness of therapy was determined via the guidelines presented by the ASP team. Feedback included recommendations regarding watch-and-wait, antimicrobial selection, dose, and duration of therapy. The primary outcome was to compare antibiotic use over time following the implementation of the audit and feedback program.ResultsOver the study period 1,107 prescriptions were audited by the ACP: 825 URI and 282 UTI. Feedback was provided for all cases, positive feedback for 580 (52.4%), negative feedback for 380, (34.3%) and mixed feedback for 147 (13.3%). The most common reasons for feedback were inappropriate agent (26.3%) and too long of duration of therapy (24.3%). Fluoroquinolone prescribing rates for UTIs decreased from 85% at baseline to 40% in Month 1 and to 11.7% of UTI prescriptions over the next 6 months. Nitrofurantoin prescribing increased from 0.4% in Month 1 to 38.6% of UTI prescriptions over the next 6 months to become the most commonly prescribed agent. Β-lactams were the most commonly prescribed antibiotics for URIs (66.7%). The median URI duration of therapy decreased from 10 days at baseline to 7 days across all 7 study months.ConclusionPharmacist-led audit and feedback significantly reduced fluoroquinolone prescribing for UTIs and shortened median duration of therapy for URIs in the outpatient setting.Disclosures All authors: No reported disclosures.

Impact of an ambulatory care pharmacist in an occupational health clinic

ObjectivesTo describe and evaluate a novel practice setting for a pharmacist within an occupational health clinic. SettingAmbulatory care facility. Practice DescriptionImplementation and evaluation of a new practice site embedding a clinical pharmacist into the workplace to provide ambulatory care services, such as comprehensive medication management, disease state management, and immunizations to a broad diversity of patients. Practice InnovationA clinical pharmacist provides pharmacy services as part of a collaborative occupational health clinic at a large, self-insured company. The pharmacy services are open to employees and family members with any chronic disease states, elevated biometric results, or medication questions, with the goal of improving patient care on a consistent basis. During visits, the pharmacist works to identify and resolve drug-related problems by educating the patient or reaching out to the patient’s health care provider and to develop strategies with the patient to achieve desired health care outcomes. The pharmacist assists with patient outreach events and immunizations during the flu clinic. EvaluationIdentification of drug-related problems, resolution status, patient satisfaction via survey results, immunizations provided. ResultsIn 4.3 years of operation, the pharmacist conducted 604 visits with 172 patients. During these visits, the pharmacist identified 611 drug-related problems, of which 49.4% have been confirmed as resolved. All patients who completed the patient satisfaction survey said that they would recommend the pharmacy services to others. For the past 3 years, the pharmacist and pharmacy students immunized approximately 1000 patients each year during the company flu clinic. ConclusionAn occupational health clinic is a unique and convenient location for a pharmacist to provide ambulatory care services to employees and family members, as long as methods to identify patients and appropriate sources of referral exist. The pharmacist was able to help patients resolve approximately 50% of identified drug-related problems, and patients were highly satisfied with services provided.

Essential factors demonstrating readiness of primary care practices for clinical pharmacy services

The characteristics of primary care practices that are necessary to establish and maintain ambulatory care clinical pharmacy services were identified. A focus group of 15 ambulatory care pharmacists in Western North Carolina developed a survey of 26 practice readiness statements pertaining to the development of clinical pharmacy services in primary care. National ambulatory care pharmacy experts were then surveyed using a modified Delphi model for consensus building to determine which items were essential. Four rounds of surveys were completed. After each round, statements were accepted as consensus, modified, or removed from the survey based on responses. Statements were deemed to have reached consensus when 80% of respondents were in agreement. A total of 6 statements reached agreement after 4 rounds of survey: (1) full integration into the team, (2) access to the electronic health record (EHR), (3) a physician or administrative champion, (4) appropriate equipment provided by the clinic, (5) a private room to see patients, and (6) a practice that is open to team-based care. An expert panel of ambulatory care pharmacists identified 6 factors that should be considered prior to establishing ambulatory care services in primary care practices. Of these, foundational elements included full integration into the care team, presence of a physician or administrative champion, and a practice that is ready for team-based care. Operational elements included access to the practice's EHR, equipment provided by the practice, and private space to see patients.