Chronic Disease State Management Research Articles

Implementation of pharmacist-led services for sexual and gender minorities: A multisite descriptive report.

This paper compares and contrasts the implementation of pharmacist-led services for 3 different sexual and gender minority populations across California, Mississippi, and Florida. Implementation of pharmacist-led services tailored to sexual and gender minorities may be a potential mechanism to address health disparities in these populations. Clinical pharmacists have the potential to provide care with cultural humility and improve health outcomes by optimizing medication regimens, reducing adverse drug events, enhancing medication acquisition, and improving medication adherence. The services provided by clinical pharmacists varied across sites and included management of gender-affirming hormone therapy, HIV antiretroviral medication adherence programming, primary care and chronic disease state management, and involvement in care related to mental health, psychiatry, and substance use as well as sexual health. Various legislative and regulatory barriers and differences in scope of practice for pharmacists were also identified. This paper advocates for the expansion of pharmacy-led services and the adoption of a culturally humble approach to patient care.

Implementation and outcomes of an ambulatory care pharmacist service: Application of an implementation science framework.

As teams work to optimize the pharmacist's role on care teams, it is important to be proactive and strategic during the service creation process. Implementation science frameworks can help guide pharmacists as they work to translate evidence-based interventions into practice. When a care gap in respiratory chronic disease state management in the primary care setting was identified, a team was created to investigate whether an ambulatory care pharmacist service would be a valuable way to address the care gap. This paper outlines the steps taken to scope and implement a new pharmacist service. An implementation science framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, was used to guide the service implementation process. Postimplementation data were collected to assess the impact of the service. A total of 56 patients were managed by the pharmacist in the first year following implementation. Data suggested that the pharmacist service has clinical value based on an improvement in chronic obstructive pulmonary disease (COPD) symptom control, rescue inhaler use, adherence, and inhaler technique. The data also informed postimplementation changes for continuous quality improvement. The use of an implementation science framework to implement a new pharmacist service proved valuable. Although this project focused on addressing a care gap in COPD, implementation science frameworks can and should be used to guide the implementation of a variety of new clinical services to enhance impact and sustainability.

Development of a value-based care and population health internship for student pharmacists

IntroductionPharmacists assist in achieving desired outcomes and reducing costs of care within newer value-based payment models. The purpose of this article is to describe a summer internship for first- and second-year student pharmacists to gain exposure to value-based care. MethodsUniversity Health Network is a clinically integrated health network and accountable care organization in East Tennessee. Two student interns completed consecutive seven-week programs alongside clinical pharmacist specialists in the primary care settings of the network. Program requirements included direct patient care for chronic disease state management, topic discussions, formal writing assignments and presentations, and a quality improvement project. Student perception of internship activities was measured using a Likert type survey and free response questionnaire. ResultsStudent interns responded positively to program requirements with feelings of enhanced preparedness for advanced pharmacy practice experiences and post-graduate residency positions. Additionally, interns perceived themselves as more competitive for post-graduate positions having completed the internship. ConclusionsAs the US continues to move toward value-based payment models, student pharmacists must be well prepared to contribute to quality and population health initiatives. Student pharmacists benefit from an internship in a clinically integrated health network by gaining an improved understanding of the future of United States healthcare, an expanded clinical skillset, experience in demonstrating a pharmacist's value to the healthcare team, and the ability to overcome barriers to pharmacy services. A pharmacy internship within a clinically integrated health network may help prepare students to successfully contribute to value-based models of healthcare.

Promising practices and pockets of excellence: Community pharmacists supporting wellness for reproductive-age women.

Promising practices and pockets of excellence: Community pharmacists supporting wellness for reproductive-age women.

Vaccination approval literacy and its effects on intention to receive future COVID-19 immunization

BackgroundBefore the coronavirus disease 2019 (COVID-19) vaccine release, polls showed only 50% of Americans had intention to receive the COVID-19 vaccine. The vaccine hesitancy may result from a lack of confidence in vaccine safety and efficacy. More research is needed to identify whether knowledge of vaccine approval processes relates to vaccination intentions. ObjectivesThe objectives of this study were to (1) evaluate participants’ knowledge regarding COVID-19 and vaccine approval processes, (2) evaluate participants’ intentions to receive the COVID-19 vaccine, and (3) compare participants’ knowledge assessment results with COVID-19 vaccine intentions. MethodsA prospective, cross-sectional questionnaire was administered to patients participating in a pharmacist-led chronic disease state management program. The 22-item questionnaire assessed demographic information and evaluated the participant’s knowledge and vaccine intentions. Data were analyzed with an a priori alpha value of 0.05. ResultsNearly all participants answered correctly on questions pertaining to COVID-19 infection (n = 92, 93%), COVID-19 symptoms (n = 96, 96%), and the Food and Drug Administration’s roles in vaccine approval processes (n = 92, 92%). Participants scored lower on questions involving the differing requirements between clinical trial phases (n = 20, 21%) and vaccine safety in the United States (n = 51, 53%). Most participants (n = 54, 55.1%) did not believe the trials were taking too long to produce a vaccine, but 40.4% of the participants (n = 40) believed the vaccine was approved too quickly. More than half of the participants (n = 55, 56.1%) desired more information on how vaccines get approved in the United States. Participants who scored higher on the knowledge assessment were more likely to have a plan to receive the vaccine (P = 0.008). ConclusionsThe results of this study demonstrate the influence knowledge has on intentions to receive vaccines and may aid health care providers in their attempts to promote vaccinations.

Impact of a Pharmacist-Led Chronic Disease State Management Clinic on Patient Assessment of Chronic Illness Care.

Background: The Patient Assessment of Chronic Illness Care (PACIC) tool measures patient satisfaction with chronic disease care. Objective: A modified PACIC tool (PACIC-RxFM) was used to assess patient satisfaction in a pharmacist-led chronic disease state management clinic. The secondary outcome compared satisfaction with pharmacist-led and physician-led visits. Methods: This cross-sectional study surveyed individuals with ≥ 1 chronic disease who saw a pharmacist (pharmacotherapy) or primary care provider (usual care) in the Texas Tech Physicians Family Medicine Clinic. The PACIC-RxFM survey included 15 items rated on a five-point Likert scale (5 = “always satisfied”). Results: A total of 107 patients with no significant differences in demographics or complexity between groups were surveyed. All mean domain scores indicated a high level of satisfaction in the pharmacotherapy group with statements regarding perceptions of care organization and encouragement to go to group classes yielding statistically significantly higher scores than the usual care group. Conclusion: Patients are satisfied with both providers’ and pharmacists’ involvement in chronic illness care. This involvement leads to significant improvement in patient perception of care organization.

Clinical impact of a pharmacist + health coach chronic disease management program in a rural free clinic

ObjectivesRecent data have demonstrated benefits of pharmacist-led protocols for chronic disease state management in the primary care setting. Health coaching has also been shown to improve patient outcomes and reduce health care costs. A program was initiated in August 2017 at a rural, free clinic to provide team-based, patient-centered care management through the use of pharmacist-provider collaborative practice and health coaching for patients with chronic diseases such as diabetes, hypertension, and hyperlipidemia. MethodsAfter an initial patient examination, physicians could refer patients for management by the pharmacist + health coach team. Patients continued to see their primary care provider at least yearly and as needed. The pharmacist + health coach team provided a protocol-based approach to chronic disease management, as well as health education pertaining to diet and lifestyle recommendations. In-depth medication and disease state education were provided at each visit. Motivational interviewing was also conducted at each visit. Clinical metrics were collected at baseline and analyzed routinely after program initiation, including glycosylated hemoglobin (A1c), blood pressure, and lipids. Primary objectives were to evaluate the program’s impact on A1c, blood pressure, and cholesterol outcomes. ResultsA total of 95 patients were included in the analysis (A1c n = 37; systolic and diastolic blood pressure n = 47; total cholesterol n = 40; low-density lipoprotein [LDL] cholesterol n = 38; high-density lipoprotein cholesterol n = 40; and triglycerides n = 40). From baseline to 1 year, statistically significant improvements were observed for A1c (mean ± standard deviation, 8.55 ± 2.58 to 7.04 ± 1.12, P < 0.001), systolic blood pressure (136.79 ± 20.04 to 123.15 ± 16.81, P < 0.001), diastolic blood pressure (87.94 ± 12.28 to 78.64 ± 10.98, P < 0.001), total cholesterol (198.25 ± 52.47 to 183.55 ± 47.22, P = 0.014), and LDL cholesterol (115.74 ± 43.56 to 105.92 ± 39.27, P = 0.040). ConclusionA protocol-driven collaborative practice approach to chronic disease management by a clinical pharmacist in conjunction with health coaching by a registered nurse in a low-income, rural, primary care setting improved A1c, blood pressure, total cholesterol, and LDL cholesterol.

The Pharmacist as Part of the Primary Care Team During the COVID-19 Pandemic.

Pharmacists' roles and training have evolved to prepare pharmacists to provide clinical patient care services as part of interdisciplinary teams in primary care settings. Especially now, amidst a global health crisis such as COVID-19, patients may become more aware of their health status and be exposed to increased medical information in the media. Additionally, some patients may have delayed routine care, which may result in exacerbations of chronic disease states. Pharmacists can help alleviate the burden on primary care providers by serving as a drug information resource for patients and staff while providing patient education on management of chronic disease states.

Effect of Visit Frequency of Pharmacist-Led Diabetes Medication Management Program

Background: Pharmacists have a positive effect on clinical outcomes in chronic disease state management, however, few studies have evaluated the effect that frequency of visits may have on diabetes biomarkers such as hemoglobin A1c and blood pressure readings. Methods: Under the medication management program (MMP), patients with diabetes were seen monthly by pharmacists until early 2015, when time between visits was increased to every 3 months. A retrospective chart review was conducted to evaluate the primary outcome of the percent change in hemoglobin A1c and blood pressure after the change in visit frequency. Results: In the 303 patients enrolled, no statistical difference existed between the pre and post average A1c (p-value = 0.10). The intermediate average A1c was statistically lower from the preintervention mean A1c (p-value = 0.001) but not from the postintervention mean A1c (p-value = 0.30). No statistical differences were seen between systolic blood pressure and diastolic blood pressure. Conclusion: Patients who have been seen by a clinical pharmacist more frequently (every month or every other month) for several years may be able to maintain their reduction in A1c with less-frequent visits (every 3 to 6 months).

Implementation of a protocol-driven pharmacy technician refill process at a large physician network

ObjectivesTo describe the implementation of a centrally located certified pharmacy technician (CPhT) team to streamline the process of approving medication refills for chronic disease state management within a multisite physician network. SettingPrimary care (PC) offices within a large physician network. Practice descriptionIncoming medication refill requests from patients and community pharmacies were typically received at each PC office and processed by medical assistants, nurses, or providers. Practice InnovationsA centralized team of CPhTs managed medication refill requests for 9 PC offices. Standardized protocols for 14 drug classes were built into the electronic medical record (EMR) system. Incoming medication refills were shifted from PC offices to the centrally located CPhT team. EvaluationThe implementation process was assessed through pharmacists’ random audits and feedback from providers, office staff, and patients. Refill reports from January 2020 through March 2020 were obtained. Refill requests’ characteristics were summarized and evaluated to determine the volume of refill requests, approved or denied requests, and requests requiring further PC staff analysis. ResultsChanges to the protocol process and EMR documentation included modifying or removing laboratory test value parameters, adjusting “grace period” refill quantity on the basis of the scheduled office visit date, and expanding the CPhT role to include communicating with patients and pharmacies regarding denied refills. Data showed that the CPhT team processed 81.7% of all refill requests. This averaged 215 requests per CPhT per day. Of the refill requests approved, 22.5% passed the protocol for the maximum quantity and refills permitted, and 17.3% were granted grace supplies until office visit protocol criteria were met. ConclusionA CPhT team processed 81% of the medication refill requests for 9 PC offices with institution-approved EMR protocols and ambulatory pharmacist supervision. There were many barriers identified and addressed, but through continuous evaluation the workflow and protocol continue to improve.

Evaluation of a Pharmacy Service to Lower BMI Prior to Total Joint Arthroplasty

Background: Total joint arthroplasty (TJA) postsurgical complications are increased in patients with a body mass index (BMI) greater than 30 kg/m2. Reducing BMI prior to surgery can be complicated and it is important to find effective methods to achieve weight loss goals prior to surgery. Pharmacy services have proven to be effective models for weight loss in prior studies and may be an avenue for achieving BMI reduction prior to TJA surgeries. Objective: The purpose of this study was to examine the benefit of pharmacist-driven interventions in an ambulatory care setting to achieve weight loss goals prior to TJA orthopedic surgeries. Methods: A retrospective chart review was conducted on patients referred from an orthopedic surgeon’s office to a clinical pharmacist service providing chronic disease state management. Patients were referred based on need to decrease BMI prior to TJA orthopedic surgeries. Visits included evaluations of medications, education on weight loss management techniques, including therapeutic lifestyle changes, and recommendations for weight loss medications. Results: There was a statistically significant difference in post-BMI when compared with pre-BMI (P = .007). Of 16 subjects who had complete pre- and post-BMI measurements, 4 (25%) subjects met their BMI goal. There was a statistically significant relationship between the number of appointments and difference in BMI (ρ = −0.71, P = .002). Conclusion: Pharmacists may be utilized in a collaborative health care model in the ambulatory care setting to assist patients with lifestyle or medication management to achieve weight loss prior to orthopedic surgeries.

Economic evaluations of clinical pharmacy services in China: a systematic review

ObjectiveThis article reviewed research conducted on economic evaluations of clinical pharmacy services (CPS) in China. We aimed to identify the types of CPS and the possible economic effects of these...

Impact on an integrated psychiatric pharmacy service in a primary care clinic.

IntroductionTraditionally, clinical pharmacists have been employed in the primary care setting to help manage chronic disease states, such as diabetes and hypertension. Although the benefits of pharmacists managing chronic conditions have been extensively published, published data for clinical pharmacist mental health services in primary care is limited to Veterans Affairs populations. This article describes a practice model in which pharmacists are providing psychiatric medication management and consultation in a federally qualified health center.MethodsA period of 1 year from the psychiatric pharmacy service was analyzed from April 1, 2017, to March 31, 2018. Reports were generated that included information about psychiatric pharmacy consults, 1-on-1 psychiatric pharmacy visits, and psychotropic medication prescribing/dispensing trends. Each consult was further reviewed for additional details, including patient characteristics, medications prescribed, psychiatric diagnoses involved, and actions taken.ResultsA review of this pharmacy service showed significant pharmacist involvement in psychiatric medication consults and 1-on-1 visits. Common disease states consulted on were depressive disorders, anxiety disorders, and neurologic disorders, which reflects psychiatric disease states commonly seen in primary care practice. Provider satisfaction survey results showed that the service was valued and that providers felt their comfort in prescribing psychotropic medications improved due to the service.DiscussionThe service described here exemplifies the potential for pharmacists in the ambulatory care setting to expand beyond the traditional chronic disease state management. It also speaks to a potential role for psychiatric pharmacists in the primary care setting.

Clinical pharmacy specialists’ impact in patient aligned care teams for type 2 diabetes management

ObjectivesClinical pharmacy specialists (CPSs) are a core member of the primary care team, and they have been shown to improve outcomes, decrease overall cost, and increase the availability of primary care providers (PCPs) by assisting with the management of chronic disease states. CPSs have the opportunity to increase access to care if they are used at their full scope of practice. The objective of this study was to compare the reduction in HbA1c between CPSs and PCPs. MethodsThis retrospective, chart review study assessed the impact of CPSs on patients with uncontrolled type 2 diabetes who saw a CPS in addition to a PCP compared to those who saw a PCP alone from January 1, 2011, to October 1, 2016. The CPS held prescriptive authority and ordered, interpreted, and monitored laboratory results. Secondary outcomes included the reduction of blood pressure, appropriate statin intensity, weight loss, initiation of insulin, and access to care. ResultsSeventy-five patients were included in both the CPS and PCP groups. There was a statistically significant decrease in HbA1c in the CPS group (3.02% vs. 0.93%; P < 0.0001), with most patients reaching their HbA1c goal in 6 months or less with an average of 7 clinic visits in that timeframe. In addition, significantly more patients were taking the appropriate intensity statin in the CPS group (90.7% vs. 73.3%; P = 0.006). ConclusionThe use of CPSs in the management of type 2 diabetes led to similar achievements in HbA1c goal, but over a shorter duration. CPSs provided effective patient care while increasing access to health care.

Ohio Community Pharmacist Interest and Participation in Community-Clinical Linkages.

Community-clinical linkages have been promoted as a means to improve population health. The community pharmacy is an ideal location for these partnerships to occur due to the expertise of the community pharmacist. While the need for these partnerships exists, there are limited data regarding community pharmacists' current participation in such programs. The purpose of this analysis was to assess Ohio community pharmacists' involvement and interest in community-clinical linkages. An electronic survey tool containing 26 questions was developed to assess Ohio community pharmacists' participation in community-clinical linkages and interest to develop such partnerships. The tool was sent via email to a random sample of 500 pharmacists registered in Ohio and practicing in a community setting. Chi-square or Fisher exact nonparametric statistical tests were used as appropriate to identify whether there were any significant differences in current partnership or interest to partner with a prescriber who refers patients to their community pharmacy based on education (Bachelor of Science or Doctor of Pharmacy degree) or pharmacy location (urban, suburban, or rural). Nine emails were undeliverable, leaving a sample of 491 pharmacists. Ninety-three (19%) responded to the survey. Sixteen respondents (17%) indicated that they currently partner with a prescriber who refers patients to their pharmacy for assistance with medications or chronic disease state management; this practice was more often reported in urban settings (p=0.022). Of those not currently participating in such a partnership, 53 (57%) were interested in developing one. Thirty-two respondents (34%) reported providing referrals for at least 1 type of screening or counseling service. For some types of services, pharmacists reported that they provide the service in the pharmacy and/or were interested to develop the service in the pharmacy rather than provide a referral. However, for any given service there were a number of pharmacists who expressed interest in providing referrals although they were not currently doing so. This sample of Ohio community pharmacists reported limited participation in community-clinical linkages but interest to develop them. Further studies should explore the pharmacists' role and impact in such programs.

Implementation of a medication therapy management program in a primary care clinic

ObjectiveThis study examined the use of a medication therapy management (MTM) program by clinic-embedded pharmacists within a primary care clinic primarily by evaluating the impact on patient identification for pharmacy services. Secondary outcomes included characterizing intervention type, targeted drugs and disease states, and barriers to successful interventions, SettingPrimary care clinic. Practice descriptionCoxHealth Center Steeplechase is a primary care clinic of 13 providers with a clinic-embedded pharmacist, pharmacy residents, and student pharmacists providing chronic disease state management under collaborative practice agreements. Practice innovationCommunity pharmacists have an established history of providing services through MTM programs. Clinic-embedded pharmacists have the potential to participate in these programs as well, and many barriers to providing patient care services reported by community pharmacists can be overcome by clinic-embedded pharmacists, potentially allowing for greater success of MTM interventions. EvaluationA 4-week pilot, in which clinic-embedded pharmacists dedicated 4 hours per week of effort to MTM services, examined the effectiveness of the program at identifying patients not otherwise receiving clinical pharmacy services, types of identified interventions, intervention success rates, barriers to intervention success, and revenue generation. ResultsThe clinical pharmacy team attempted 46 interventions in 34 unique patients in this 4-week pilot. Of the identified patients, 67.7% (n = 23) had no contact with the clinical pharmacy team in the previous year. Targeted interventions were more frequently attempted (targeted interventions n = 42; comprehensive reviews n = 4) and more successful than comprehensive medication reviews (88% vs. 25% success rate). Barriers to success included patient refusal of services, inability to contact the patient, and inapplicability of targeted interventions. ConclusionImplementation of an MTM program in one clinic required coordinated interdepartmental efforts to implement, but it effectively expanded pharmacy services by identifying patients not otherwise referred to the clinical pharmacy team for chronic disease management.

Impact of Chronic Disease State Management by Clinical Pharmacists on Diabetes Outcomes: Interim Results of a Prospective Pilot Study

Impact of Chronic Disease State Management by Clinical Pharmacists on Diabetes Outcomes: Interim Results of a Prospective Pilot Study

The role of the pharmacist in hypertension management.

Hypertension remains a vital, modifiable risk factor in the prevention of cardiovascular disease. However, many patients do not achieve their therapeutic goals for numerous reasons which can include poor disease insight and nonadherence. Pharmacists can be key players in controlling hypertension, given their medication knowledge and patient counseling skills, yet they remain an underutilized resource in the management of chronic disease states. Various models exist that allow pharmacists to provide direct patient-centered care but practices differ from state to state since pharmacists are not recognized nationally as healthcare providers. This article aims to provide an update on the proven methods in which pharmacists contribute to the management of hypertensive patients. Several recently published studies demonstrate the positive impact of pharmacist intervention and care on patient outcomes in ambulatory and community settings. These practice models include medication therapy management, collaborative drug therapy management, telehealth and team-based care. The role of the pharmacist in hypertension encompasses medication management, disease state education and patient counseling and is most successful when integrated into the patient's care team. Further validation through larger, prospective trials and evaluation of long-term outcomes, such as mortality, remain viable research opportunities.

HIV update: Impact on chronic diseases

Abstract Objective To update pharmacists on select chronic disease state management for persons living with HIV. Data sources Clinical guidelines from the U.S. Department of Health and Human Services, American Association for the Study of Liver Diseases, American Diabetes Association, American College of Cardiology/American Heart Association Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, U.S. prescribing information, drug information databases, PubMed articles. Study selection At the author's discretion based on relevance of the information presented. Summary Widespread use of combination antiretroviral therapy in the last 2 decades has given rise to an aging HIV population. Management has shifted from acute opportunistic infection treatment to chronic comorbid disease state management. Common HIV comorbid conditions include hyperlipidemia, diabetes, cardiovascular disease, kidney dysfunction, psychiatric illness, and viral hepatitis B and C coinfection. While treatment guidelines do not drastically differ in recommendations, there are unique aspects of care to consider for persons living with HIV infection. Conclusion Historically, the pharmacist's role in HIV care has been to provide antiretroviral adherence counseling and drug information. As the HIV population continues to age, chronic disease state management has become a primary focus. As pharmacotherapy specialists, pharmacists have the clinical skills and knowledge to help optimize treatment outcomes for many comorbid conditions.

Comparing Clinical Outcomes of a Pharmacist-Managed Diabetes Clinic to Usual Physician-Based Care

Background: This study analyzed the impact of a pharmacist-managed diabetes clinic on clinical outcomes compared to usual care received from primary care providers (PCPs). This comparison may more definitively demonstrate the value of pharmacist management of chronic disease states. Methods: Retrospective observational cohort study conducted in patients referred to a pharmacist-managed pharmacotherapy (PT) clinic from July 2009 to October 2014. Results: For the primary outcome, the absolute change in A1c during the usual care phase was +1.53% (95% confidence interval [CI]: 1.10-1.96, P < .0001) versus an absolute change of −1.63% (95% CI: −1.28 to −1.97, P < .0001) in the intervention phase. For secondary outcomes, diabetes-related hospitalizations (10 vs 6, P = .104) and emergency room (ER) visits (27 vs 8, P = .049) decreased in the intervention phase compared to the usual care phase. The rate of diabetes-related interventions made per patient per year in the usual care phase was 2.7 versus 11.1 in the intervention phase (P < .0001). Conclusion: Patients referred to the PT clinic had worsening blood glucose control prior to referral, and their control improved after referral to the clinic. Furthermore, there was an improvement in all diabetes-related outcomes in the intervention phase compared to the usual care phase.