Primary Care Pharmacists Research Articles

A tool for incorporating interprofessional perspectives into dental students decision-making: A 2-year follow-up on this learning outcome.

ObjectivesTo analyze student performance when using a sustainable teaching tool developed to guide learning toward interprofessional perspectives.MethodsThis study compiled data about D4 students’ performance when using an interprofessional education (IPE) teaching tool reported previously in this journal, during their 5‐week Geriatric and Special Needs Program rotation in the academic years 2018–2019 and 2019–2020. Ninety‐two students were introduced to IPE concepts and teaching tools during their orientation. Students were then asked a question regarding the perspective of each healthcare team member and whether they would contact these healthcare team members for collaboration during the provision of oral care with regard to various patient cases. Students were scored on whether they answered the question about the perspective of each health care team member. The same two independent evaluators also noted whether the student thought each member of the health care team should be contacted.ResultsA majority (90.2%–95.7%) of dental students applied their knowledge to questions regarding each health care team member's perspectives. The profession that dental students most often indicated they wished to contact for collaboration was primary care providers (n = 70; 76.1%), followed by family caregivers (n = 54; 58.7%), and pharmacists (n = 46; 50.0%). The results of the interrater agreement between the two‐faculty scoring students were between 86.7% and 100%.ConclusionsThe teaching tool is sustainable and succinct. Students considered the perspectives of each health care team member at a rate above 90%, and the interrater agreement was high among the faculty evaluators. Students considered contacting primary care providers, family caregivers, and pharmacists more often than the other health care team members. We see this model as one approach to begin the articulation of learning outcomes for IPP.

Impact of pharmacist and physician collaborations in primary care on reducing readmission to hospital: A systematic review and meta-analysis.

Readmissions to hospital due to medication-related problems are common and may be preventable. Pharmacists act to optimise use of medicines during care transitions from hospital to community. To assess the impact of pharmacist-led interventions, which include communication with a primary care physician (PCP) on reducing hospital readmissions. PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science were searched for articles published from inception to March 2021 that described interventions involving a pharmacist interacting with a PCP in regards to medication management of patients recently discharged from hospital. The primary outcome was effect on all-cause readmission expressed as Mantel-Haenszel risk ratio (RR) derived from applying a random effects model to pooled data. Sensitivity analysis was also conducted to investigate differences between randomised controlled trials (RCTs) and non-RCTs. The GRADE system was applied in rating the quality of evidence and certainty in the estimates of effect. In total, 37 studies were included (16 RCTs and 29 non-RCTs). Compared to control patients, the proportion of intervention patients readmitted at least once was significantly reduced by 13% (RR=0.87, CI:0.79-0.97, p=0.01; low to very low certainty of evidence) over follow-up periods of variable duration in all studies combined, and by 22% (RR=0.78, CI:0.67-0.92; low certainty of evidence) at 30 day follow-up across studies reporting this time point. Analysis of data from RCTs only showed no significant reduction in readmissions (RR=0.92, CI:0.80-1.06; low certainty of evidence). The totality of evidence suggests pharmacist-led interventions with PCP communication are effective in reducing readmissions, especially at 30 days follow-up. Future studies need to adopt more rigorous study designs and apply well-defined patient eligibility criteria.

Beyond dispensing: Better integration of pharmacists within the Australian primary healthcare system

A well-integrated primary health care system helps address the health needs of an ageing population with complex multiple health conditions. In Australia pharmacists provide services to maximise health gains from medication use, although they are not well integrated into primary care. Using the case of Australia, this study investigates why integrating pharmacists in primary care has not been addressed at the national level and also identifies strategies that could promote policy change. Using a unique dataset generated via 33 semi-structured interviews with healthcare leaders and policymakers across relevant disciplines, we undertake a systematic and comprehensive analysis of the policy with the Multiple Stream Framework. This framework examines the policy process with five elements: problem, policy, and political streams; policy entrepreneur; and policy window. The problem stream shows that the primary healthcare system struggles to cope with the increasing healthcare demand and the prevalence of medication-related problems. The policy stream suggests that the consumers would benefit from an integration of pharmacists into primary care to solve these problems; however, policy proposals cannot survive under current circumstances. The political stream reveals the political barriers come from conflicts among interest groups within the profession and the healthcare sector. To advocate their pet policy, policy entrepreneurs should have stronger roles in shaping the “policy idea” to gain its acceptance among the policy community, and to reduce political barriers. Strategies to overcome the barriers include evidence accumulation, role development in light of population needs, and interorganisational collaboration across members of the healthcare network.

The Effect of Interventions Led by Community Pharmacists in Primary Care for Adults with Type 2 Diabetes Mellitus on Therapeutic Adherence and HbA1c Levels: A Systematic Review

Type 2 diabetes mellitus has been assessed as a widespread disease globally. Unfortunately, this illness can occasionally go undetected and without symptoms until it reaches the emergency condition, and this can be notably true in patients who do not receive routine medical care. Pharmacists are the foremost accessible health care providers. They can help patients select the most appropriate hypoglycemic management strategy through their experiences. This review aimed to provide an overview of the literature published on community pharmacists’ interventions that are currently used and their usefulness in improving patient adherence and glycosylated hemoglobin (HbA1c) levels. Relevant studies were retrieved through a comprehensive search of three databases, PubMed/Medline, Web of Science, and CINAHL (2010 to 2020). In total, 8362 publications were identified. The final protocol was based on the “Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA)”. After applying inclusion and exclusion measures, 21 articles were deemed relevant. In pharmacists’ interventions in diabetes care, patient education and counseling were the most common intervention methods. Essentially, this systematic review provides evidence and identifies the key features that may predict success in enhancing clinical outcomes and patient adherence to treatment. Based on our findings, we suggest further investigations of the root causes of non-adherence problems.

Elective surgery in ankle and foot disorders-best practices for management of pain: a guideline for clinicians.

Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines. A local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the "current state" of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and "current state" survey respondents to create a consensus document using a Delphi process conducted from September to December 2020. One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively. Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.

Systematic literature review of pharmacists in general practice in supporting the implementation of shared care agreements in primary care

BackgroundRising demand for healthcare continues to impact all sectors of the health service. As a result of the growing ageing population and the burden of chronic disease, healthcare has become more complex, and the need for more efficient management of specialist medication across the healthcare interface is of paramount importance. With the rising number of pharmacists working in primary care in clinical roles, is this a role that pharmacists could support to ensure the successful execution of shared care agreement (SCA) in primary care for these patients?Aim of the reviewSystematic review to identify activities and assess the interventions provided by pharmacists in primary care on SCA provision and how it affects health-related quality of life (HRQoL) for patients.MethodPrimary studies in English which tested the intervention or obtained views of stakeholders related to pharmacist input to shared care agreement within primary care were included. The following electronic databases were systematically searched from the date of inception to November 2021: AMED®, CINAHL®, Cochrane Database of Systematic Reviews (CDSR), EMBASE®, EMCARE®, Google Scholar, HMIC®, MEDLINE®, PsycINFO®, Scopus and Web of Science®. Grey literature sources were also searched. The search was adapted according to the respective database-specific search tools. It was searched using a combination of Medical Subject Heading terms (MeSH), free-text search terms and Boolean operators.ResultsA total of 5244 titles/abstracts were screened after duplicates were removed, and 64 full articles were assessed for eligibility. On examination of full text, no studies met the inclusion criteria for this review.ConclusionThis review highlights the need for further research to evaluate how pharmacists in general practice can support the safe and effective integration of specialist medication in primary care with the use of SCA.Systematic review registrationNIHR PROSPERO No: 2020 CRD42020165363.

The frequency and nature of prescribing problems by GPs-in-training (REVISiT): a retrospective review.

Prescribing errors can cause significant morbidity and occur in about 5% of prescriptions in English general practices. To describe the frequency and nature of prescribing problems in a cohort of GPs-in-training to determine whether they need additional prescribing support. A primary care pharmacist undertook a retrospective review of prescriptions issued between 9 October 2014 and 11 March 2015 by 10 GPs in their final year of training from 10 practices in England. Pre-existing standards and expert panel discussion were used to classify the appropriateness of prescribing. Data were imported into Stata (version 13) to perform descriptive analysis. An individualised report highlighting prescribing errors, suboptimal prescribing, and areas of good practice identified during the review was shared with the GPs-in-training and their trainers. This report was used to guide discussions during the GP-in-training's feedback session. A total of 1028 prescription items were reviewed from 643 consultations performed by 10 GPs-in-training. There were 92 prescribing errors (8.9%) and 360 episodes of suboptimal prescribing (35.0%). The most common types of error concerned medication dosages (n = 30, 32.6% of errors). Personalised review of prescribing revealed an error rate higher than recorded in a previous similar study mainly comprising GPs who had completed postgraduate training, and a substantially higher rate of suboptimal prescribing. A larger intervention study is now required to evaluate the effectiveness of receiving a personalised review of prescribing, and to assess its impact on patient safety.

Initiating Primary Care Services when the World Is Paused: Lessons for Pharmacists in the Post-COVID-19 Era.

The COVID-19 pandemic impacted primary care and required pharmacists to adapt when implementing primary care services. Many lessons learned through this process are applicable in the post-pandemic era. First, primary care pharmacists must prepare for an ever-changing role and communicate with stakeholders to align with shifting institutional priorities. Additionally, designing a workflow given limited staffing and in-person communication require flexibility for scheduling and referral processes. Proactive outreach and communication via virtual platforms may be used to build trust in place of in-office interactions with providers. Lastly, fostering relationships with patients is essential to the success of the service and often requires creation of patient-centered goals to account for personal barriers. Many pandemic obstacles are transient; however, telehealth, virtual communication, and the subsequent lessons learned in adaptability, creativity, and flexibility when building a clinic practice are everlasting.

The role of primary care pharmacist in the management of chronic illnesses in young people: a qualitative study

Abstract Introduction Recent evidence has shown that the incidence of long-term illnesses in young people is increasing (1). Pharmacists, as medicine experts, are in a unique position to promote young people’s health by improving their knowledge regarding effective use of medication through the provision of pharmaceutical services. To date, there are few studies that have explored the potential roles of primary care pharmacists in providing health care for young people with long term illnesses (2). This study attempts to show the potential role of primary care pharmacists in caring of young people with chronic illnesses. Aim To explore the role of primary care pharmacists in the management of chronic illnesses in young people aged 18-24 years. Methods A qualitative study was undertaken. From June to November 2019, semi-structured interviews were conducted with 23 primary care pharmacists in the UK. A purposive sampling strategy was followed to form a population for this study. The targeted participants were UK primary care pharmacists i.e. General Practice (GP) and community based pharmacists. Through professional networks, the participants were identified, approached and recruited by email or in person. Interviews on average lasted 35 minutes, and were audio recorded, transcribed verbatim and analysed inductively using thematic analysis. Emergent themes were reviewed by all authors and any discrepancies were resolved through discussion. Results Four themes emerged from the data: pharmacists’ roles, prescribing issues, pharmaceutical services and young people medication-related experiences. Participants identified several roles for primary care pharmacists in caring of young people with chronic illness. These roles included encouraging young people to visit the pharmacy to collect their medicines and ensuring that they have enough medicines supply, counselling and educating young people about their medicines and answering their queries, building trusted relationships directly with them, provision of specialist services, following up with young people and checking on medication compliance, and signposting them for further support. The most discussed chronic illnesses in young people by participants were respiratory diseases such as asthma and mental health illnesses. However, many pharmacists perceive a fundamental communication barrier that hinders the provision of this support, i.e., lack of access to the patient. Participants identified a lack of support from other health care providers as one of the associated challenges for pharmacists in supporting young people with chronic illness. Conclusion Primary care pharmacists felt that they have an important role in supporting young people with chronic illness. This study identified many ways in which pharmacists provide services and support to young people. This study makes a major contribution to the limited literature on primary care pharmacists’ experience of dealing with young people with chronic illness by exploring the pharmaceutical care currently available and identifying other issues which may influence pharmaceutical care. Although the research was limited by a relatively small number of participants, the findings of this research could inform future research to provide more evidence of the benefit of primary care pharmacists in supporting young people with chronic illness in the optimal use of their medication. References (1) Shah R, Hagell A, Cheung R. International comparisons of health and wellbeing in adolescence and early adulthood. London (UK): Nuffield Trust; 2019. (2) Gray N, Shaw K, Smith F, et al. The Role of Pharmacists in Caring for Young People With Chronic Illness. Journal of Adolescent Health, 2017; 60 (2): 219–225.

Pharmacists in primary care in Scotland: a mixed-methods exploration of pharmacists’ perceptions of a national educational resource package

Abstract Introduction There is growing pressure on primary care, which has resulted in an increased number of clinical pharmacists working within the setting. To help support this growing workforce in their role and with their development, several countries have created educational resources. Within Scotland, an educational resource package was created for pharmacists working in General Practice, containing a Competency and Capability Framework, an online platform and educational and clinical supervision. The implementation of these resources in Scotland has not been evaluated thus far, therefore it is unclear to what extent they may support and facilitate pharmacists in their professional role. Aim The aim of this project was to assess pharmacists’ perceptions of the educational resource package available to General Practice pharmacists in Scotland. Methods A mixed-methods study comprising an online questionnaire and semi-structured telephone interviews was undertaken between July and October 2019. The questionnaire sought to provide a more representative overview, with the interviews designed to gain an in-depth understanding, to support the development of recommendations to improve the educational resource package. A previously validated, online questionnaire (1) was used to explore pharmacists’ view on the adoption, acceptability, appropriateness, and feasibility of the educational resources based on Proctor’s model of implementation outcomes (2); similarly, the semi-structured telephone interviews explored pharmacists’ experiences with the resources, in addition to inquiring about its adoption, acceptability, appropriateness, and feasibility. The questionnaire included a Likert scale and free-text questions; quantitative responses were summarised, whereas the qualitative answers underwent a content analysis directed by Proctor’s implementation outcomes. The interview results were structured using the framework approach, with the data undergoing a thematic or summative content analysis. Results Overall, 52 pharmacists completed the questionnaire and 12 participated in the interviews. The results indicated widespread adoption and acceptance of the educational resource package. The level of acceptance was influenced by the perceived purpose of completing the resources, such as if they believed it provided development opportunities. Its appropriateness depended on the pharmacist’s individual situation since previous experiences and current job role differed. Additionally, several barriers complicated the feasibility of the resources, such as insufficient support and guidance. Conclusion The adoption and acceptance of the educational resource package for General Practice pharmacists in Scotland indicated its suitability for supporting their role; however, further facilitation would enhance their engagement with the resources, and potentially improve their perception of its appropriateness and feasibility. Despite the limited sample size, the study provided an in-depth understanding of general practice pharmacists perceptions of the educational recourse package, based on an established model. References (1) Proctor E, Silmere H, Raghavan R, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65-76. (2) Weiner BJ, Lewis CC, Stanick C, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017; 12(1): 108.

Pharmacists in primary care in Scotland: an exploration of competencies required for the provision of pharmacy services within general practice

Abstract Introduction Efforts are increasingly being made to implement pharmacists working in General Practice to support General Practitioners and alleviate pressure, mainly by providing pharmacotherapy services such as medication reviews and authorising prescribing requests (1). While there is wide interest in the contributions pharmacists can make within primary care, there is limited research exploring the competencies pharmacists need to safely and effectively provide care in this area. Aim The aim of this project was to identify competencies required for pharmacists providing pharmacotherapy services in General Practice. Methods Modified eDelphi study (2), comprising a series of online questionnaires conducted between July 2019 and January 2020. Participants were pharmacists working in General Practice in Scotland. The first questionnaire consisted of open-ended questions aimed at generating a list of competencies; competency categories and individual competency items relating to pharmacotherapy service tasks were identified based on the free text responses using content analysis. Subsequently, the second questionnaire aimed to establish consensus regarding the importance of the collected competencies, using a rating scale from 1 (“not important”) to 10 (“very important”); participants’ scores were aggregated using modes and medians, and the level of agreement among participants with regards to the importance of competencies was evaluated by calculating the percentage of scores between 8 and 10. Due to the novelty of this work and the resultant uncertainty surrounding participants’ responses, no cut-off point for agreement was pre-specified. Results Overall, 10 pharmacists completed the first questionnaire, and 11 completed the second. Building on the findings from the first questionnaire, a framework of competencies necessary to provide pharmacotherapy services in General Practice was developed, comprising eight competency categories, with a total of 31 individual competency items: General Skills (e.g. ability to record patient information); IT Skills (e.g. ability to use GP computer system to update documentation); Legal & Professional Frameworks (e.g. understanding of clinical guidelines); Procedural Skills (e.g. ability to arrange follow-up); Multidisciplinary Team Communication Skills (e.g. ability to communicate with others within the GP practice); Consultation Skills (e.g. ability to take a complete history); Clinical Knowledge (e.g. knowledge related to conditions being treated); and Clinical Skills (e.g. ability to interpret clinical information). All eight competency categories were considered important across the pharmacotherapy service, with high agreement (between 71 and 85%) among participants. Conclusion Using a bottom-up, exploratory approach, this study confirmed that practicing within the General Practice setting requires a wide set of competencies, including – but not limited to – advanced clinical and consultation skills. Nevertheless, findings should be interpreted cautiously due to the limited sample size; although results have tentatively been validated using a paper-based version of the second online questionnaire during an in-person event with General Practice pharmacists, results might not be reflective of all pharmacists working in this setting. References (1) Scottish Government. (2017). The 2018 General Medical Services Contract in Scotland. Retrieved from https://www.glasgowlmc.co.uk/download/contract%20and%20contractural%20Issues/The-2018-General-Medical-Services-Contract-in-Scotland.pdf (2) Hsu, C. C., & Sandford, B. A. (2007). The Delphi technique: Making sense of consensus. Practical Assessment, Research & Evaluation, 12, Article10. https://doi.org/10.7275/pdz9-th90

Implementation of a Targeted Inhaled Corticosteroid De-Escalation Process in Patients with Chronic Obstructive Pulmonary Disease in the Primary Care Setting.

Purpose: To evaluate the feasibility and success of a pharmacist-led, targeted inhaled corticosteroid (ICS) de-escalation process in patients with chronic obstructive pulmonary disease (COPD) where the risks of ICS therapy outweigh the potential benefits. Methods: A population health data management tool was leveraged to identify patients who may qualify for ICS de-escalation. Primary care pharmacists clinically reviewed and subsequently contacted patients who were determined to be appropriate candidates. After discussion on the risks and benefits of ICS therapy, a stepwise algorithm was utilized to assist with ICS de-escalation and optimization of bronchodilator therapy. Outcomes analyzed include the proportion of patients for whom ICS was de-escalated, patient acceptability of the intervention, time taken to complete the intervention, barriers to implementation, and the number of additional interventions made by pharmacists. Results: Of the 126 patients originally identified as potential candidates, 58 (46.0%) were deemed appropriate to proceed with ICS de-escalation and successfully contacted by a pharmacist. Of these patients, 49 (84.5%) were agreeable and ultimately 42 were successfully de-escalated with 37 patients maintained off ICS. The average time required for an encounter was 15.8 minutes. Conclusion: There is utility in a pharmacist-driven, targeted ICS de-escalation process to facilitate meeting guideline-directed medication therapy goals in patients with COPD, granted the availability of efficient tools to assist in identifying patients that qualify. Such a targeted approach increases pharmacist involvement in medication management of COPD and can expand the primary care pharmacy practice.

Person-centred care provided by a multidisciplinary primary care team to improve therapeutic adequacy in polymedicated elderly patients (PCMR): randomised controlled trial protocol

IntroductionThe increase in elderly population has led to an associated increase in multiple pathologies, frailty, polypharmacy, healthcare costs, decreased quality of life and mortality. We designed an intervention based on...

Patients' attitudes toward deprescribing and their experiences communicating with clinicians and pharmacists.

Purpose:Developing effective deprescribing interventions relies on understanding attitudes, beliefs, and communication challenges of those involved in the deprescribing decision-making process, including the patient, the primary care clinician, and the pharmacist. The objective of this study was to assess patients’ beliefs and attitudes and identify facilitators of and barriers to deprescribing.Methods:As part of a larger study, we recruited patients ⩾18 years of age taking ⩾3 chronic medications. Participants were recruited from retail pharmacies associated with the University of Kentucky HealthCare system. They completed an electronic survey that included demographic information, questions about communication with their primary care clinician and pharmacists, and the revised Patients’ Attitudes Toward Deprescribing (rPATD) questionnaire.Results:Our analyses included 103 participants (n = 65 identified as female and n = 74 as White/Caucasian) with a mean age of 50.4 years [standard deviation (SD) = 15.5]. Participants reported taking an average of 8.4 daily medications (SD = 6.1). Most participants reported effective communication with clinicians and pharmacists (66.9%) and expressed willingness to stop one of their medications if their clinician said it was possible (83.5%). Predictors of willingness to accept deprescribing were older age [odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.45–6.2], college/graduate degree (OR = 55.25, 95% CI = 5.74–531.4), perceiving medications as less appropriate (OR = 8.99, 95% CI = 1.1–73.62), and perceived effectiveness of communication with the clinician or pharmacist (OR = 4.56, 95% CI = 0.85–24.35).Conclusion:Adults taking ⩾3 chronic medications expressed high willingness to accept deprescribing of medications when their doctor said it was possible. Targeted strategies to facilitate communication within the patient–primary care clinician–pharmacist triad that consider patient characteristics such as age and education level may be necessary ingredients for developing successful deprescribing interventions.Plain Language Summary Are patients willing to accept stopping medications? Sometimes, medicines that a patient takes regularly become inappropriate. In other words, the risks of adverse effects might be greater than a medicine’s potential benefits. The decision to stop such medicines should involve the patient and consider their preferences. We surveyed a group of patients taking multiple medicines to see how they felt about having those medicines stopped. We also asked patients whether and how much they talk to their primary care clinician and pharmacists about their medicines. To qualify for this study, patients had to be at least 18 years old and to take three or more medicines daily; they also needed to speak English. Participants provided demographic information and answered questions about their medicines, their communication with primary care clinicians and pharmacists, and their feelings about having one or more of their medicines stopped. We recruited 107 people and were able to use responses from 103 of them. Their average age was 50 years; 65 of them identified as female, and 75 identified as White/Caucasian. Most of our participants mentioned having conversations with primary care clinicians and pharmacists and said they would be willing to stop a medication if their clinician said it was possible. Older participants, those with more years of education, those who thought their medications might lead to side effects, and those who communicated with their clinician or pharmacists were more willing to have one of their medicines stopped.Our results indicate that patient characteristics and communication with clinicians and pharmacists are factors to consider when designing interventions to reduce the use of inappropriate medicines.

Some patients switched to edoxaban without being properly informed, pharmacists say

Prescribers in England are switching patients to edoxaban without properly informing them, primary care pharmacists have told The Pharmaceutical Journal. This includes one pharmacist working in a primary care network (PCN) in London, who said a patient was taking two anticoagulants at once because they thought that edoxaban was a new addition to their prescription, […]

Epilepsy: symptoms and diagnosis

Epilepsy is the most common serious neurological condition in the UK, affecting around 600,000 people​[1]​. Pharmacy teams in primary and secondary care are therefore likely to encounter people with epilepsy on a regular basis. Owing to the strong focus on pharmacological management in epilepsy, pharmacists in primary and secondary care can actively support this patient […]

The role of managed care pharmacy in coprescribing naloxone for patients with specific risk: recommendations from the AMCP Addiction Advisory Group.

Prescription opioid misuse remains a significant cause of morbidity and mortality associated with drug overdose. Researchers, government agencies, public health interests, and professional organizations support the benefits of naloxone coprescribing for patients on chronic opioid therapy to prevent deaths from opioid overdose. However, gaps remain in the provision of naloxone to patients at risk. Currently, less than 1% of patients who should be prescribed naloxone with their opioid medications obtain a prescription for naloxone, illustrating an opportunity for health care providers to conduct thorough risk assessments for patients taking opioids and coprescribing naloxone to those at risk. There are documented barriers to the provision of naloxone for primary care providers, pharmacists, and patients. Managed care organizations have also created barriers. To better understand and evaluate trends in treatment, coverage, policies, and needs associated with providing health services to patients with substance use disorders, the Academy of Managed Care Pharmacy (AMCP) Addiction Advisory Group conducted a survey in 2019. Eighty percent of the managed behavioral health organizations and 47% of AMCP payer members who responded to the survey encouraged naloxone coprescribing in patients at high risk of overdose; however, no organizations require coprescribing. Health plans, managed care organizations, prescribers, pharmacists, patients, and others have important roles in decreasing the morbidity and mortality associated with opioid overdose. In particular, managed care organizations can take specific and meaningful actions to implement payment policies that improve naloxone coprescribing for patients at risk. In this article, opportunities have been outlined for managed care leadership that actively support public health policies for naloxone coprescribing, and 7 recommendations are presented. DISCLOSURES: The AMCP Addiction Advisory Group and the development of this article were supported by Alkermes and Precision Toxicology. Sponsors participated in the advisory group, which provided guidance in the development of the manuscript. Dharbhamalla is employed by AMCP. Skelton is a paid consultant working with AMCP.

Harnessing the Potential of Primary Care Pharmacists to Improve Heart Failure Management.

Improved utilization of guideline-directed medical therapy (GDMT) in the management of heart failure with reduced ejection fraction (HFrEF) can reduce mortality, reduce heart failure hospitalizations, and improve quality of life. Despite well-established clinical guidelines, these therapies remain significantly underprescribed. The goal of this intervention was to increase prescribing of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), and beta-blockers at ≥50% target doses. The study team identified key drivers to adequate dosing of GDMT: (1) frequent and reliable follow-up visits for titration opportunities, (2) identification of actionable patients for therapy initiation and titration, and (3) reduction in prescribing practice variability. The interventions were implemented at an outpatient clinical site and consisted of three main components: (1) establishing a pharmacist-led heart failure medication titration clinic, (2) creation of a standardized titration protocol, and (3) utilization of a patient dashboard to identify eligible patients. For patients seen in the titration clinic, in 14 months, the mean dose per patient increased from 31.3% to 70.5% of target dose for ACEI/ARB/ARNI, and from 45.8% to 85.4% for beta-blockers. At this clinical site, the percentage of HFrEF patients receiving >50% of targeted dose increased from 39.7% to 46.7% for ACEI/ARB/ARNI, and from 39.5% to 42.9% for beta-blockers. For ACEI/ARB/ARNI, use of target doses was 5.9% higher (95% confidence interval [CI] = 3.6%-8.3%, p < 0.0001) for the intervention site, 0.2% higher (95% CI = -2.2%-2.5%, p = 0.89) during the intervention period, and 10.4% higher (95% CI = 6.9%-13.9%, p <0.0001) for the interaction (intervention site during the intervention time period). For beta-blockers, use of target doses was 1.0% higher (95% CI = -0.6%-2.6%, p = 0.20) for the intervention site, 0.8% lower (95% CI = -2.4%-0.8%, p = 0.29) for the intervention period, and 5.8% higher (95% CI = 3.5%-8.1%, p < 0.0001) for the interaction (intervention site during the intervention time period). Through this project's interventions, the prescribing of ACEI/ARB/ARNI and beta-blocker therapy at ≥50% target doses for patients with HFrEF was increased. This study demonstrates the value of a multifaceted, team-based approach that integrates population-level interventions such as clinical dashboard management with a pharmacist-led heart failure medication titration clinic.

Opportunities and Barriers to Medication Safety in Community-Dwelling Older Adults

Community-dwelling multi-morbid older adults are a vulnerable population for medication safety-related threats. We interviewed a sample of these older adults recruited from local retirement communities and from primary care practices to learn their perceptions of barriers and enablers for their medication safety. The present study is part of the Partnership in Resilience for Medication Safety (PROMIS) study. One of the aims of this project is to identify barriers and opportunities to improve older adults' medication safety. These interviews were conducted during COVID-19 pandemic conditions. Results from this qualitative study suggest that trust between these older adults and their healthcare providers is an essential component of medication safety. Overarching themes include disruptions in medication management, caregivers caring for each other, patient safety practices or habits, and medication management literacy. Participants also shared strain due to lack of skills to navigate telemedicine visits, trust in Primary Care Providers (PCPs) and pharmacists to prescribe and dispense safely for them, reliance on PCPs and pharmacists to give essential information about medications without having to be asked. Our interviews illustrated large variations in older adults’ perceived role in medication safety, with some developing expertise in understanding how medications work for them and how long-term medications should be periodically reviewed. The types of information needs and supports from PCPs were likely different. Understanding these barriers and enablers for safe medication management can help us develop medication safety improvements for this vulnerable population.

\u201cA little bit more looking\u2026listening and feeling\u201d A qualitative interview study exploring advanced clinical practice in primary care and community pharmacy

Background Growing demands on healthcare globally, combined with workforce shortages, have led to greater skill mix in healthcare settings. Pharmacists are increasingly moving into complex areas of practice, a move supported by policy and education/training changes. Aim To understand the nature of extended roles for pharmacists practising at an advanced level in primary care and community pharmacy settings, to explore how clinical and physical examination was incorporated into practice and to understand the impact of providing such examination on practice and on patient relationships. Method Telephone interviews (N = 15) were conducted with a purposive sample of pharmacists using clinical and physical examination in their practice in Great Britain. The sample included primary care pharmacists (N = 5), community pharmacists (N = 4), pharmacists working across settings (N = 5) and one working in another primary care setting. Participants were recruited through professional networks, social media and snowballing. Results Primary care pharmacists and community pharmacists were utilising clinical and physical examination skills in their practice. Some community pharmacists were operating locally-commissioned services for low acuity conditions. Incorporating such examinations into practice enabled pharmacists to look at the patient holistically and enhanced pharmacist/patient relationships. Barriers to practise included lack of timely sharing of patient data and perceived reluctance on the part of some pharmacists for advanced practice. Conclusion With growing opportunities to provide patient-focussed care, it remains to be seen whether pharmacists, both in Great Britain and elsewhere, are able to overcome some of the organisational, structural and cultural barriers to advanced practice that currently exist in community pharmacy.