Collaborative Practice Agreement Research Articles

Abstract 4137531: A Pharmacist Medication Titration Program for Patients with Cardiac Sarcoidosis and Systolic Heart Failure

Introduction: Cardiac sarcoidosis (CS) often results in systolic heart failure (HF) and responds favorably to guideline directed medical therapy (GDMT). A multidisciplinary team approach to HF care is recommended but few published examples exist in CS patients. Methods: We queried an institutional registry of 599 CS patients (2000-2023) for patients with index LVEF < 50% (within 90 d of index CS evaluation) and follow-up TTE within 11-36 months. In our CS medication therapy management (MTM) program (started 1/8/2019), pharmacists conduct independent visits with CS patients (in person or remote), discuss GDMT tolerance and symptoms, review monitoring laboratory studies, and adjust GDMT (ACEi/ARB/ARNi, beta-blocker, MRA, and/or SGLT2i) via collaborative practice agreement with the CS cardiologists. Patients were classified as MTM (≥1 MTM encounter) or NMTM patients (0 encounters). We compared (1) GDMT, (2) cardiac remodeling, and (3) clinical outcomes (event free survival to first heart failure hospitalization, LVAD, heart transplant, or death). Results: Nineteen percent (113/599) CS patients met inclusion criteria (34% female, 92% white, median age 57 y, 19% definite CS, 58% probable CS, 31% presumed CS), with 44 MTM (median 11.5 encounters, IQR 11) and 69 NMTM patients. Both MTM and NMTM patients were on a median 2 GDMT agents at index evaluation (p=0.21). At follow-up (median 19 mo MTM, 15 mo NMTM, p=0.05), MTM patients were on more GDMT agents than NMTM (median 3.0 vs 2.0, p<0.001), with higher % target dose of ACEi/ARB/ARNi (98% vs 71%, p=0.009), beta-blocker (87% vs 57%, p=0.004), and SGLT2i use (30% vs 9%, p=0.004), but similar MRA use (48% vs 32%, p=0.09). Immunosuppressive therapy was used in 88% patients (89% MTM vs 87% NMTM, p=0.79). Index LVEF was similar (MTM 36%, NMTM 32%, p=0.07). Mean change in LVEF (excluding LVAD/transplant patients) demonstrated a non-significant trend towards improved remodeling in MTM (+8.6%) vs NMTM patients (+5.5%; p=0.39). MTM patients exhibited lower risk of the clinical outcome (1/44 MTM vs 16/69 MTM patients; univariable HR 0.08 [95%CI 0.01 - 0.63], log-rank p=0.016). Conclusions: A pharmacist MTM program for CS patients with HF is associated with improved GDMT uptitration and clinical outcomes, emphasizing the value of collaborative multidisciplinary CS care.

Implementation of a Collaborative Practice Agreement for Depression and Anxiety in the Primary Care Setting

BackgroundThere is a lack of appropriate access to mental health care in the United States, particularly in the underserved community. Data shows that individuals living below the poverty level are 2.5 times more likely to develop depression and similar trends have been reported for anxiety. However, socioeconomic status and these conditions are not mutually exclusive and occur throughout the general population. To expand patient access, a collaborative practice agreement for major depressive disorder (MDD) and generalized anxiety disorder (GAD) was developed and implemented within a network of primary care clinics. ObjectivesThis study aimed to (1) describe the development of a pharmacist-led collaborative practice agreement for MDD and GAD within an outpatient primary care clinic and (2) describe the growth of the depression and anxiety CPA service after implementation. Practice DescriptionThis intervention was completed at a network of 7 primary care clinics associated with a large academic medical center in Columbus, Ohio. Practice InnovationA collaborative practice agreement for MDD and GAD was created and implemented in November 2021. Evaluation MethodsAn electronic health record-generated report was used to identify patients for which a referral to pharmacy for MDD or GAD was placed between November 1, 2021 and March 1, 2023. Retrospective chart review was utilized to collect information to describe the growth of the service. Data were analyzed using descriptive statistics. ResultsA total of 308 patients were appropriately referred to the pharmacist-led service for MDD and GAD between November 1, 2021 and March 1, 2023. Of the patients that established care with the pharmacist, 35% (54/155) experienced improvement in symptoms and 29% (45/155) achieved remission. ConclusionThe implementation of a pharmacist-led CPA for MDD and GAD in a primary care setting improved patient access to pharmacotherapy management for depression and anxiety.

A Review of Studies on HIV Pre-Exposure Prophylaxis in Community Pharmacies in States with Restrictive Pharmacist Prescription Authority in the United States.

A systemic literature review was conducted to identify the primary literature that involved community pharmacy service and PrEP conducted in states that do not have expanded pharmacist prescriptive authority between 2000 to 2024. Ten publications were identified, describing nine studies, including four interview and survey studies, three intervention reports, and two ongoing clinical trials. None of these studies have a control group. Most pharmacists provide PrEP services in the community through a collaborative practice agreement with a primary care provider. Future clinical studies with randomized controlled designs are required to test novel strategies in the education and implementation of pharmacy-led PrEP services in a community pharmacy setting to increase PrEP access.

Unique model for pharmacist cross‐coverage in the ambulatory care setting

AbstractClinical cross‐coverage in ambulatory care pharmacy practice is currently lacking and can lead to gaps in patient care, lost revenue generation, and pharmacist burnout due to a lack of time and support for indirect patient care and non‐clinical activities. To address this need, a cross‐coverage model for a team of ambulatory care pharmacists practicing in diverse clinical settings was developed and is primarily supported by a single broadly‐trained pharmacist known as an ambulatory care generalist. Cross‐coverage from the ambulatory care generalist includes in‐person and virtual patient care as well as in‐basket management and is available to all clinic‐based pharmacists on the specialty and primary care team with a few select clinics involving a designated collaborative practice agreement. The cross‐covering pharmacist has been shown to positively impact productivity measures and components of pharmacist burnout. Widespread implementation of this cross‐coverage model has the potential to greatly impact pharmacy practice and patient care in the ambulatory care setting and increase sources of revenue.

Impact of a diabetic retinal exam screening program on quality measure gaps at a family medicine practice

BackgroundDiabetic retinopathy is a common complication in people with diabetes, and annual screening is recommended by the American Diabetes Association. This annual exam is also a Health Effectiveness Data and Information Set quality measure. Barriers such as lack of access to healthcare or cost of specialist visits may impact the number of patients who receive these exams. ObjectiveThe objective of this study is to describe the impact of a diabetic retinal exam screening program at a rural family medicine center on the number of quality measure gaps resolved. Practice descriptionThis study occurred at a rural family medicine center in southwestern Pennsylvania with a medically underserved patient population. A pharmacist at the site holds board certifications in Advanced Diabetes Management and as a Diabetes Care and Education Specialist and manages diabetes through a collaborative practice agreement. Practice innovationA regional Medicaid plan provided a list of patients with a quality measure gap for an annual diabetic retinal exam and loaned a RetinaVue 700 Imager to take retinal photos. After screening eligible patients via phone, retinal exams were administered by student pharmacists and medical assistants to consenting patients over the course of 9 days. Images were then sent to an ophthalmologist to be interpreted. Evaluation methodsThe rate of quality measure gaps closed and satisfaction survey results are reported using descriptive statistics. ResultsA total of 61 patients were included in the analysis. This program closed quality measure gaps for 11 (18.0%) patients who were able to receive an in-office eye exam. ConclusionThis pilot project shows that offering in-office diabetic retinal exams may be an effective strategy to close quality measure gaps and provide access to screening among a medically underserved population.

Assessment of PrEP and PEP furnishing in San Francisco Bay Area pharmacies: An observational cross-sectional study

BackgroundOver 1 million people in the United States are infected with human immunodeficiency virus (HIV). As of 2021, pharmacists in California can prescribe PrEP and PEP without establishing a collaborative practice agreement in an effort to reduce HIV transmission. However, in 2021 less than 3% of independent pharmacies in the San Francisco Bay Area did so. To our knowledge, there has been no follow-up research assessing potential changes in pre-exposure prophylaxis/postexposure prophylaxis (PrEP/PEP) furnishing rates in the region. ObjectiveAssess the extent of PrEP/PEP furnishing in San Francisco Bay Area pharmacies 3 years after policy implementation. MethodsWe conducted an observational, cross-sectional study to identify independent community and mail-order pharmacies furnishing PrEP/PEP in the nine-county San Francisco Bay Area in 2024. Furnishing pharmacies were identified via phone calls and the findings were validated with in-person visits. We also identified the number of retail chain pharmacies furnishing PrEP/PEP in San Francisco County. ResultsWe contacted 202 independent community and mail order pharmacies in the nine-county San Francisco Bay Area by telephone; of these, 16 reported furnishing PEP/PrEP and all confirmed their ability to furnish when visited in person. We contacted 67 retail chain pharmacies in San Francisco County; of these, 11 pharmacies reported furnishing PrEP/PEP (10 Safeway; 1 Walgreens). ConclusionsMore pharmacies furnished PrEP/PEP in the 9-county San Francisco Bay Area in 2024 (8%) than in 2021 (3%); in addition, one retail chain pharmacy had instituted a furnishing protocol. However, furnishing rates remained low. Past research suggests that advertising and the development of furnishing protocols may help increase furnishing and increase medication access.

Implementation of an interprofessional model for the management of postpartum hypertension.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Postpartum hypertension (PPHTN) poses increased risks, including of stroke. Timely assessment and management by clinicians is imperative but challenging. Team-based care involving pharmacists has shown promise in improving blood pressure control, yet its application in PPHTN management remains unexplored. The objective of this study was to determine the impact and feasibility of an interprofessional model for PPHTN management. This initiative implemented a novel interprofessional model at a safety-net hospital to address previous workflow limitations. Ambulatory care pharmacists collaborated with an obstetric nurse (OBRN) and a maternal fetal medicine specialist to manage high-risk patients with PPHTN utilizing electronic consults (e-consults). Data collection and symptom assessment were completed by an OBRN via telemedicine appointments. Pharmacists employed a collaborative practice agreement based on a preestablished algorithm to initiate medications. Data on patient demographics, consult volume, prescriptions, and pharmacist comfort were collected during the first quarter of full integration. Pharmacists completed 55 e-consults and generated 54 prescriptions. The average time spent per chart review was 12.5 minutes, and the average time to completion of e-consults was 54 minutes. Forty-five unique patients received care, who were primarily non-English-speaking and non-Hispanic Black patients. Pharmacists reported moderate to high comfort levels in managing PPHTN based on the algorithm and provided feedback leading to workflow adjustments. Integration of pharmacists into PPHTN care enables prompt medication initiation and titration. This innovative model, involving remote blood pressure monitoring, telemedicine visits with an OBRN, and e-consults completed by pharmacists, ensures delivery of timely and equitable care and improved access across a diverse population.

Implementation of a Pharmacist-Driven Contraception Service at a Safety-Net Health-System.

Background: Access to safe, effective, and appropriate contraception significantly reduces the rates of unintended pregnancies; however, this preventative care is not always easily accessible. There is a high patient demand for contraception visits that is often delayed or unmet due to lack of access to traditional providers. Pharmacists are highly accessible and can help manage this high demand, yet clinical pharmacists as providers of contraception services remains a gap in published literature. Objective: Develop and implement a pharmacist-led contraception service at a safety-net health-system. Methods: A comprehensive pharmacist-led clinical contraception service was created to improve patient access. To support this project, a collaborative practice agreement (CPA) was developed and enhancements were built into an electronic medical record. The CPA allowed the pharmacist to complete contraception-related interventions such as ordering urine pregnancy tests, prescribing hormonal and emergency contraceptives, and manage adverse effects. The piloting pharmacist was available at the Narcotics Treatment Program (NTP) clinic one half-day each week for scheduled and same-day visits. Results: Within the initial five half-day clinic sessions at NTP, the pharmacist had written seven prescriptions, including three for emergency contraceptives. Of all patients seen for this service at NTP, only one had been using a method of contraception consistently prior to their visit. Conclusion: The interventions that were able to be made by the pharmacist highlighted the need for improved access to contraceptives. Pharmacist-managed services in sexual and reproductive health can help fill this gap. Patients also self-reported ease of access as a benefit to this service.

An umbrella review of pharmacist prescribing: stakeholders’ views and impact on patient outcomes

Abstract Introduction There is great geographical diversity in the degree of prescribing rights pharmacists have. In some countries such as the United Kingdom (UK), pharmacists have unrestricted prescribing rights following appropriate training; in other countries, pharmacists cannot legally prescribe. The impact of pharmacist prescribing (PP) has been studied in various qualitative and quantitative research studies, but this evidence has not been synthesised to support the development of PP internationally. Aim The aim of this umbrella review was to describe the international PP models, establish the impact of PP on patient outcomes and describe key stakeholders’ views of PP, by synthesising all the available systematic reviews (SRs). Methods Six databases (Embase, CINAHL, MEDLINE, Web of Science, Cochrane Library and PsycINFO) were searched, from January 2003 to June 2023, for key terms such as ‘pharmacist’, ‘prescribing’, ‘prescription’ and ‘systematic review’, ‘meta-analysis’, ‘meta-synthesis’. Systematic reviews that examined PP for any clinical condition, for patients of any age and in any healthcare setting were eligible for inclusion. SRs examining pharmacists’ interventions other than PP were excluded as were articles not published in English. Two researchers independently screened titles, abstracts and full texts for eligibility; discrepancies were resolved by discussion with a third reviewer. A data extraction tool was developed, piloted and refined prior to data extraction based on guidance from PRIOR[1] and the Joanna Briggs Institute (JBI).[2] Extracted information included: SR characteristics; inclusion and exclusion criteria; description of prescribing models, setting, clinical conditions, clinical and health service utilisation outcomes and key stakeholders’ views of PP. Data have been synthesised narratively due to the heterogeneity of included studies. Results A total of 6439 titles were retrieved from searches, with 917 duplicates removed. Following abstracts and full text screening (5522 and 129 respectively), 39 systematic reviews (8 qualitative; 19 quantitative and 12 mixed-methods) were included. The description of PP models varied within and between the SRs and demonstrated implementation of different PP models globally. Collaborative practice agreement with a physician, dependant prescribing by protocol and/or formularies were common in Canada and the United States, while supplementary prescribing and independent prescribing models were described in the UK. Prescribing activity was evident in all care settings and for a wide range of clinical conditions. SRs reporting on targeted clinical conditions, noted that patients of pharmacist prescribers had similar blood pressure control and depressive symptoms, better cholesterol and blood glucose control and reduced pain intensity when compared with patients of medical prescribers. SRs also suggests that pharmacist prescribers make fewer errors than non-pharmacists. Key stakeholders noted largely positive views towards PP, with a reduction in physician workload, an improvement in pharmacist job satisfaction, better utilisation of pharmacist knowledge and skills noted. Concerns over pharmacists’ diagnostic abilities, legal accountability for errors and appropriate implementation of PP models were noted. Conclusion A variety of PP models exist internationally. Careful examination of each model should be undertaken prior to adoption and implementation in countries where PP is currently not permitted.

Medication Management Through Collaborative Practice for Children With Medical Complexity: A Prospective Case Series

OBJECTIVE Care coordination for children and youth with special health care needs and medical complexity (CYSHCN-CMC), especially medication management, is difficult for providers, parents/caregivers, and ­patients. This report describes the creation of a clinical pharmacotherapy practice in a pediatric long-term care facility (pLTCF), application of standard operating procedures to guide comprehensive medication management (CMM), and establishment of a collaborative practice agreement (CPA) to guide drug therapy. METHODS In a prospective case series, 102 patients characterized as CYSHCN-CMC were included in this pLTCF quality improvement project during a 9-month period. RESULTS Pharmacists identified, prevented, or resolved 1355 drug therapy problems (DTP) with an average of 13 interventions per patient. The patients averaged 9.5 complex chronic medical conditions with a ­median length of stay of 2815 days (7.7 years). The most common medications discontinued due to pharmacist assessment and recommendation included diphenhydramine, albuterol, sodium phosphate enema, ipratropium, and metoclopramide. The average number of medications per patient was reduced from 23 to 20. A pharmacoeconomic analysis of 244 of the interventions revealed a monthly direct cost savings of $44,304 ($434 per patient per month) and monthly cost avoidance of $48,835 ($479 per patient per month). Twenty-eight ED visits/admissions and 61 clinic and urgent care visits were avoided. Hospital ­readmissions were reduced by 44%. Pharmacist recommendations had a 98% acceptance rate. CONCLUSIONS Use of a CPA to conduct CMM in CYSHCN-CMC decreased medication burden, resolved, and prevented adverse events, reduced health care-related costs, reduced hospital readmissions and was well-accepted and implemented collaboratively with pLTCF providers.

Establishment of a Clinical Pharmacist-Led Multiple Myeloma Clinic with Collaborative Prescribing Model at the National Center for Cancer Care and Research in Qatar

Introduction Multiple Myeloma (MM) is a chronic and incurable hematologic malignancy affecting the plasma cells, and is more prevalent among the elderly. Interprofessional patient care showed superiority over physician-only care in multiple settings, including MM. (Sweiss K et al.2019)In Qatar, real-world data analysis of MM patients treated in the ambulatory setting at the National Center for Cancer Care and Research (NCCCR) showed that clinical pharmacists (CPs) had an evident role in therapy optimization and ensuring adherence to treatment protocol schedule and supportive medications.(Elazzazy S et al.,2023) We aimed to provide a more structured and accessible link to MM patients considering the complexity of their treatment protocols and supportive care through the establishment of a clinical pharmacist-led clinic (CPLC). The most common challenges to optimum care of MM patients in the NCCCR before CPLC were identified and categorized (Figure 1) and then used to design the collaborative model for the MM CPLC (Figure 2). Methods The collaborative MM CPLC was initiated at NCCCR in February 2022. A collaborative practice agreement was established for this clinic, to allow clinical pharmacists -managing MM patients- to issue refills for supportive medications, and order any necessary laboratory tests. To investigate the quality of care provided by the clinic, data was retrospectively collected and analyzed for all MM patients managed in the clinic between February 2022 and February 2023. All patients who were newly diagnosed with MM were eligible for referral by the attending physician. Dedicated advanced hematology CPs provided consultation twice weekly for referred patients without additional fees. The provided services (in-person or virtual) included thorough medication profile review (prescribed antineoplastic and refills of supportive medications), and ordering follow-up laboratory tests. Services also included assessment and optimization of medication adherence, including immunomodulators and supportive medications (i.e., Venous Thromboembolism (VTE) prophylaxis, antimicrobial prophylaxis, bone modifying agents and vaccinations), providing comprehensive patient education, and communicating the recommended adjustments with physicians. Results During the 12-month period, there was a total of 22 patients referred to the clinic. The average age for patients was 51 years (range 36-72). Patient characteristics are summarized in Table 1. The total number of documented encounters with the pharmacists was 73 visits, corresponding to a median of 4 visits per patient (range 1-11). The total amount of time spent with each patient over the course of their referral was 15 minutes. A total of 343 CPs interventions (average of 5 interventions per visit) were performed with an acceptance rate of 100%. The most common intervention was medication reconciliation (n=124), followed by monitoring for medication outcomes (n=72, safety and efficacy), addition of required medication (n=40), patient education (n=27), issuing refills (n=24), drug interactions review and management (n=19), suggesting referrals to relevant subspecialities (n=16), identification of adverse drug reactions (n=7), and required dose adjustments (n=12). Twenty-two medication refills for supportive medications and eight pre-chemotherapy laboratory investigations were issued and ordered by CPs, respectively. All newly diagnosed patients were started on the appropriate bisphosphonate therapy without the previously observed delay, with the median from diagnosis to initiation being 14 days [range from 1 to 117 days]. All clinic patients were maintained on the appropriate VTE prophylaxis (aspirin [n=14], rivaroxaban [n=7], warfarin [n=1]). All patients were adherent to antiviral and Pneumocystis jirovecii Pneumonia prophylaxis. Conclusion CPLC for MM patients treated in the ambulatory setting provided a robust and timely link to patients in alignment with the published literature. The newly implemented collaborative prescribing model in MM clinic encouraged the expansion of pharmacy services in other ambulatory clinics. Our collaborative model could be potentially applied to different cancer settings to optimize a safe and effective patient care. Further analysis is planned to compare the adherence to international MM care guidelines pre- and post-launch of our CPLC.

Pharmacy-based expansion of buprenorphine access

IntroductionAccess to evidence-based medication treatment is a challenge for most Americans with opioid use disorder. New models of collaborative care that actively incorporate pharmacists are being trialed. MethodsWe author a commentary based on our experiences providing clinical care as part of a randomized controlled trial of pharmacy-based addiction care. ResultsThis commentary describes some of the experiences of working with a Collaborative Practice Agreement between pharmacists and physicians to provide pharmacy-based, low-threshold buprenorphine access. ConclusionGiven that 87 % of Americans with opioid use disorder are not getting access to buprenorphine or methadone, establishing a pharmacy-based buprenorphine treatment program is a promising strategy to address that gap and should be explored promptly.

Integration of clinical pharmacists to assist with medication surveillance for patients receiving gender-affirming hormone therapy in a community ambulatory setting within the United States

BackgroundGender-affirming care (GAC) for gender diverse individuals (includes transgender and nonbinary persons) requires a comprehensive approach to medication surveillance, including monitoring and follow-up. Limited access to these health services can present a barrier to follow-up for routine care. Integration of a pharmacist into therapeutic management has shown positive clinical outcomes; however, their involvement with gender-affirming hormone therapy (GAHT), including routine laboratory monitoring, is not well established. ObjectiveThis study aimed to describe the development and implementation of a protocol involving the integration of clinical pharmacists into GAC for gender diverse patients in a community ambulatory setting. Practice descriptionCleveland Clinic’s Center for LGBTQ+ Care is embedded in a primary care practice and has an established protocol for GAHT management. The health system also has an established model that uses pharmacists for the management of patients, within the primary care and specialty clinic settings, under a collaborative practice agreement (CPA). Practice innovationThe medical director of the Cleveland Clinic’s Center for LGBTQ+ Care and the institution’s primary care pharmacists collaborated to propose an update to the CPA to include GAHT monitoring to improve access to routine GAHT follow-up. Evaluation methodsGAHT management was approved to be added to the pharmacist CPA in May of 2022 and the pharmacists started seeing patients in February of 2023. The team opted to start with those patients already established on GAHT for at least 6 months, at least 1 year after transition, and with a primary care provider managing their GAHT. ConclusionAccess to follow-up for individuals receiving GAHT may be improved through the utilization of pharmacist services. The incorporation of a CPA with pharmacists for GAHT management can allow for a multidisciplinary approach once a patient is on a stable regimen, thereby increasing provider access to new patients.

Implementing pharmacist-led diabetic digital retina scan services at a federally qualified health center

BackgroundDue to low national and local rates for annual eye exams in patients with diabetes, a pharmacist-led chronic care clinic creates a unique opportunity for pharmacists to provide digital retina scans in the primary care setting. ObjectivesThe primary objective is to assess the impact of a pharmacist-led digital retina scan service on rates of annual eye exams among patients with diabetes. Practice DescriptionKC CARE Health Center, a federally qualified health center in Kansas City, Missouri, offers healthcare services to any member of the community regardless of insurance status. Pharmacists work in this setting to assist with management of chronic disease under a collaborative practice agreement. Practice InnovationA pharmacist developed a workflow process to provide digital retina scans in the primary care setting for patients with diabetes who had not had an eye exam in the past 12 months. Images of each eye are captured using a RetinaVue 700 Imager and these images are submitted to an ophthalmologist for review. Evaluation MethodsRates of annual eye exams among patients with diabetes seen in the primary care clinic before and after retina scan service implementation were analyzed using a chi-squared test with an a-priori alpha of 0.05. Survey data of patient-reported barriers to follow-up were reported using descriptive statistics. ResultsThere was a 5% increase in the annual eye exam rate of patients with diabetes seen at the clinic during the study period. The increase in rate of annual eye exam from before the intervention to after was statistically significant (P < 0.001). ConclusionImplementing a pharmacist-led retina scan program in the primary care setting improved the rate of annual diabetic eye exams and demonstrated the benefit that pharmacists can have in enhancing accessibility to preventative care services.

Patient-centered medical home pharmacists’ impact on composite quality care measures for patients with uncontrolled type 2 diabetes

BackgroundPatients with uncontrolled diabetes are at risk for developing complications. Many health care systems have implemented multidisciplinary care models including pharmacists to help achieve quality care measures to reduce complications. ObjectiveThis study aimed to evaluate whether patients with uncontrolled type 2 diabetes mellitus (T2D) seen at patient-centered medical home (PCMH) clinics affiliated with an academic medical center are more likely to meet a composite of diabetes quality care measures with a pharmacist on their care team than usual care patients without a pharmacist on their care team. MethodsThis is a cross-sectional study. The setting included PCMH primary care clinics affiliated with an academic medical center from January 2017 to December 2020. Included were adults aged 18 to 75 years with a diagnosis of T2D, hemoglobin A1C (A1C) more than 9%, and established with a PCMH provider. The intervention is inclusion of PCMH pharmacist on the patient’s care team for management of T2D per a collaborative practice agreement. The main outcome measures included A1C ≤9% per last recorded value during observation period, a composite A1C ≤9% and completion of yearly laboratory tests, and a composite A1C ≤9%, completion of yearly laboratory tests, and statin prescription for adults aged 40-75 years. ResultsIdentified were 1807 patients in the usual care cohort with mean baseline A1C of 10.7% and 207 patients in the pharmacist cohort with mean baseline A1C of 11.1%. The pharmacist cohort was more likely to have an A1C of ≤9% at the end of the observation period (70.1% vs. 45.4%; P < 0.001), a composite of measures met (28.5% vs. 16.8%; P < 0.001), and a composite of measures met for patients aged 40-75 years (27.2% vs. 13.7%; P < 0.001). ConclusionPharmacist involvement in the multidisciplinary management of uncontrolled T2D is associated with a higher attainment of a composite of quality care measures at the population health level.

Blessings and barriers: Achieving autonomous practice in Florida.

Florida advanced practice registered nurses have worked tirelessly for many years to practice to the fullest extent of their training and education, yet medical associations halted any progress they have tried to make. In the 2020 legislative session, House Bill 607, the Direct Care Workers bill was finally passed, allowing nurse practitioners who practice in specific primary care areas to practice autonomously. This still requires many Advanced Practice Registered Nurses in the state to have a collaborative practice agreement. Therefore, there is more work to be done to remove those practice barriers.

292 Augmented Renal Clearance in Burn Patients: Incidence and Discordance with Standard Creatinine Clearance Estimation

Abstract Introduction Augmented renal clearance (ARC) is a phenomenon that occurs in some critically ill populations. ARC is associated with drug failure, commonly antimicrobials, due to subtherapeutic drug exposure. Patient specific factors for ARC have not been well described in the burn population. The aim of this study is to describe the incidence and patient characteristics associated with ARC in those admitted to a burn service for a mixed severity of illness. Methods Consecutive adult patients admitted to an ABA verified burn center were screened under an institutional collaborative practice agreement for identification of ARC via a 12-hour urine collection (UC-12). Data was collected retrospectively under an IRB approved protocol. Creatinine clearance (CrCl) was calculated directly from UC-12 whereas Cockcroft-Gault (C-G) was calculated using a standard equation with adjusted body weight when applicable. A UC-12 CrCl greater than 130 mL/min was considered ARC and all values were compared to C-G estimations. Descriptive and inferential analyses were non-parametric using a two-sided alpha value of &amp;lt; 0.05 as significant. Results A total of 53 patients over 8 months completed a UC-12 with a median 2 (range 1-9) collected during hospitalization. The population was largely male (81%), without trauma (91%), median age 43 (interquartile range [IQR] 35.5-58.5), total body surface area (TBSA) 20% (IQR 7.25-23.55), with thermal injuries (91%). Of the 53 patients, ARC was identified during hospitalization in 68%. There were no significant differences in median age, TBSA, proportion of trauma, or thermal burn between patients with ARC and those without (41 vs 48 years, 20.25 vs 13%, 11 vs 6%, and 94 vs 82%, respectively; p &amp;gt;0.1 for all). Of the 117 UC-12 measurements, ARC was identified in 61.5%, occurring a median 9 days (range 0-72) post injury. Overall median UC-12 CrCl was 148 mL/min (IQR 105-199) and C-G estimation was 139 mL/min (IQR 106-162) with a median discordance of 16 mL/min (IQR -14-58). Discordance of 30mL/min or more (positively or negatively) was frequent comparing actual CrCl to estimates using C-G (58%). Conclusions ARC, as directly measured by UC-12, is common in a mixed burn population. Additional research is required to identify patients at increased risk for ARC and subsequent drug dosing strategies to maintain efficacy without undue risk of toxicity. Applicability of Research to Practice Widely accepted estimations of CrCl may result in incorrect drug dosing and commonly underestimates actual CrCl which has implications for drug clearance, and therefore, dosing. Patients with ARC likely require dosing that exceeds FDA recommendations when titration to a dynamic effect or real-time pharmacokinetics are unavailable. Timed urine collection for CrCl calculation should be considered in the burn population.

A Versatile Prison Psychiatric Pharmacy Program

BackgroundBefore the coronavirus disease 2019 (COVID-19) pandemic, 20% of the adult population in the United States experienced mental illness annually. Since the COVID-19 pandemic, 93% of countries have reported disruptions to mental health services. The demand for services is high whereas infrastructure and qualified professionals are appallingly low. Health care in the correctional setting is unique, where mental illness prevalence is double than that in the community. The intersection of policies and procedures and the beneficence plus nonmaleficence responsibility of health care professionals is exceptionally complex. Studies have shown the potential benefits of pharmacists following patients in chronic care psychiatry visits. ObjectivesAn inpatient psychiatric pharmacy clinic was launched to fill gaps to provide safe and up-to-date patient-centric services for more than 240 extremely psychiatrically ill inmate patients at the Federal Correctional Center Butner (FCC Butner), a Federal Bureau of Prisons medical center. MethodsThe inpatient psychiatric pharmacist practiced independently under a collaborative practice agreement and completed mental health clinical visits for a revolving portion of 240 inpatient mental health inmate patients at FCC Butner. The pharmacist provided ancillary services including completing movement disorder testing, monitoring narrow therapeutic index medication laboratory test results, and executing an antipsychotic psychoeducation meeting with other health care departments and inmate patients. ResultsNotably, 74% of patients monitored in the specialty program experienced stable or improved symptoms of depression, schizophrenia, and bipolar disorder. Adverse effects, particularly psychiatric-related movement disorders, were also more closely managed. Finally, 43% of the total inmate patient population who previously declined psychiatric medication treatment consented to begin treatment after participation in a pilot antipsychotic psychoeducation meeting. ConclusionThe inpatient psychiatric pharmacy program at FCC Butner is a dynamic program that has bolstered the facility’s health care mission. The services detailed in this article can be applied to other correctional environments that have a medical outpatient or inpatient presence.

Feasibility evaluation to expand a collaborative practice agreement and discontinue antibiotics after an emergency department or urgent care visit.

The impact of pharmacist-led culture follow-up programs for positive cultures is well established. The benefits and feasibility of evaluating negative cultures and deprescribing unnecessary antibiotics after emergency department (ED) and urgent care (UC) visits are unknown; therefore, this evaluation characterized the burden of negative urine cultures and chlamydia tests and estimated how many potential antibiotic days could be saved with deprescribing. This retrospective, descriptive study evaluated patients discharged from an ED or UC location with a pharmacist-led culture follow-up program. The primary objective was to characterize the proportion of patients with a negative urine culture or chlamydia test where an opportunity would exist to deprescribe antibiotics at follow-up. Secondary endpoints included estimating the number of potential antibiotic days that could be saved, postvisit healthcare utilization, and documented adverse drug reactions (ADRs). For a 1-month period, pharmacists reviewed 398 cultures, of which 208 (52%) were urine cultures or chlamydia tests with negative results. Fifty patients (24%) with negative results had been prescribed empiric antibiotics. The median duration of antibiotic treatment was 7 days (interquartile range [IQR], 5-7 days), while the median time to culture finalization was 2 days (IQR, 1-2 days). There was an opportunity to save a median of 5 antibiotic days per patient. Thirty-two patients (15.3%) followed up with their primary care physician within 7 days; of these patients, 1 (0.05%) had their antibiotic prescription discontinued by the primary care physician. There were no documented ADRs. Expansion of pharmacist-led culture follow-up programs to deprescribe antibiotics for patients with negative cultures has the potential to save significant antibiotic exposure.

Community pharmacist intervention to optimize statin adherence in diabetes care: The GuIDE-S study

BackgroundStatin use in people with type 2 diabetes (T2D) reduces cardiovascular events, yet adherence remains suboptimal. ObjectiveThis study evaluated the impact of a community pharmacist intervention on statin adherence in new users with T2D. MethodsAs part of a quasi-experimental study, community pharmacy staff proactively identified adult patients with T2D who were not prescribed a statin. When appropriate, the pharmacist prescribed a statin via a collaborative practice agreement or facilitated acquisition of a prescription from another prescriber. Patients received individualized education and follow-up and monitoring for 1 year. Adherence was defined as the proportion of days covered (PDC) by a statin over 12 months. Linear and logistic regression were used to compare the effect of the intervention on continuous and a binary adherence threshold, defined as PDC ≥ 80%, respectively. ResultsOverall, 185 patients started statin therapy and were matched to 370 control patients for analysis. Adjusted average PDC was 3.1% higher in the intervention group (95% CI −0.037 to 0.098). Patients in the intervention group were 21.2% more likely to have PDC ≥ 80% (95% CI 0.828–1.774). ConclusionThe intervention resulted in higher statin adherence than usual care; however, the differences were not statistically significant.