Pharmacy Support Research Articles

Nutrition support pharmacy practices in hospitalized cancer patients admitted to bone marrow transplant units: A 3-year retrospective analysis of clinical nutrition support pharmacists’ interventions

Nutrition support pharmacy practices in hospitalized cancer patients admitted to bone marrow transplant units: A 3-year retrospective analysis of clinical nutrition support pharmacists’ interventions

A study comparing the cost-effectiveness of conventional and drug-eluting transarterial chemoembolisation (cTACE and DEB-TACE) for the treatment of hepatocellular carcinoma in an Australian public hospital.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality and transarterial chemoembolisation (TACE) is an established technique to treat patients with intermediate-stage HCC. The aim of this study was to generate accurate costing data on cTACE and DEB-TACE in an Australian setting and assess whether one of the procedures offers favourable cost-effectiveness. Costing study using data from all TACE procedures performed at a single centre between January 2018 and December 2022. Data were included from all direct and indirect costs including operative costs, wages, overheads, ward costs, transfusion, pathology, pharmacy and ward support. Cost-effectiveness was assessed by dividing local costs by existing high-quality data on quality-adjusted life years (QALYs). 64 TACE treatments were performed on 44 patients. Mean age was 66.5 years and 91% were male. Overall median total cost per patient for the entire TACE treatment regime was AUD$7380 (range AUD$3719-$20,258). However, 39% of patients received more than one treatment, and the median cost per individual treatment was AUD$5270 (range AUD$3533-$15,818). The difference in median cost between cTACE (AUD$4978) and DEB-TACE (AUD$9202) was significant, P < 0.001. In calculating cost-effectiveness, each cTACE treatment cost AUD$2489 per QALY gained, while each DEB-TACE cost AUD$3834 per QALY gained. The incremental cost-effectiveness ratio (ICER) for DEB-TACE over cTACE was AUD$10,560 per QALY gained. Both cTACE and DEB-TACE are low-cost treatments in Australia. However, DEB-TACE offers a solution with an ICER of AUD$10,560 per QALY gained which is below the Australian government willingness to pay threshold and thus is a more cost-effective treatment.

Operation CoVER Saint Louis (COVID-19 Vaccine in the Emergency Room): Impact of a Vaccination Program in the Emergency Department.

Coronavirus 2019 (COVID-19) inequitably impacted minority populations and regions with limited access to healthcare resources. The Barnes-Jewish Emergency Department in St. Louis, MO, serves such a population. The COVID-19 vaccine is an available defense to help achieve community immunity. The emergency department (ED) is a potential societal resource to provide access to a vaccination intervention. Our objective in this study was to describe and evaluate a novel ED COVID-19 vaccine program, including its impact on the local surrounding underserved community. This was a retrospective, post-protocol implementation review of an ED COVID-19 vaccination program. Over the initial six-month period, we compiled data on all vaccinated patients out of the ED to evaluate demographic data and the impact on underserved regional areas. We report a successful ED-based COVID-19 vaccine program (with over 1,000 vaccines administered). This program helped raise regional and state vaccination rates. Over 50% of the population that received the COVID-19 vaccine from the ED were from defined socially vulnerable patient populations. No adverse effects were documented. Operation CoVER (COVID-19 Vaccine in the Emergency Room) Saint Louis was able to successfully vaccinate a socially vulnerable patient population. This free, COVID-19 ED-based vaccine program with dedicated pharmacy support, was novel in emergency medicine practice. Similar ED-based vaccine programs could help with future vaccine distribution.

What Should Healthcare Systems Consider When Modernizing Call Centers? Early Considerations From the Veterans Health Administration.

Growing numbers of hospitals and payers are using call centers to answer patients' clinical and administrative questions, schedule appointments, address billing issues, and offer supplementary care during public health emergencies and national disasters. In 2020, the Veterans Health Administration (VA) implemented VA Health Connect, an enterprise-wide initiative to modernize call centers. VA Health Connect is designed to improve the care experience with the convenience, flexibility, and simplicity of a single toll-free number connected to a range of 24/7 virtual services. The services are organized into four areas: administrative guidance for scheduling and general inquiries; pharmacy support for medication matters; clinical triage for evaluation of symptoms and recommended care; and virtual visits with providers for urgent and episodic care. Through a qualitative evaluation of VA Health Connect, we sought to identify the factors that affected the development of this program and to compile considerations to support the implementation of other enterprise-wide initiatives. The evaluation team interviewed 29 clinical and administrative leads from across the VA. These leads were responsible for the modernization of their local service networks. PhD-level qualitative methodologists conducted the interviews, asking participants to reflect on barriers and facilitators to modernization and implementation. The team employed a rapid qualitative analytic approach commonly used in healthcare research to distill robust results. A review of the early implementation of VA Health Connect found: (1) deadlines proved challenging but provided momentum for the initiative; (2) a balance between standardized processes and local adaptations facilitated implementation; (3) attention to staffing, hiring, and training of call center staff before implementation expedited workflows; (4) establishing national and local leadership commitment to the innovation from the onset increased team cohesion and efficacy; and (5) anticipating information technology infrastructure needs prevented delays to modernization and implementation. Our findings suggest that healthcare systems would benefit from anticipating likely obstacles (e.g., delays in software implementations and negotiations with unions), thus providing ample time to secure leadership buy-in and identify local champions, communicating early and often, and supporting flexible implementation to meet local needs. VA leadership can use this evaluation to refine implementation, and it could also have important implications for regulators, federal health exchanges, insurers, and other healthcare systems when determining resource levels for call centers.

A mixed methods evaluation of the appropriateness of hospital on-call pharmacy service use

Abstract Introduction Most English hospitals provide out-of-hours pharmacy support via an ‘on-call pharmacist’.[1] There is scant published literature characterising these services. Prior research[2] suggests a significant number of calls may be inappropriate requests for non-urgent medication or information readily available elsewhere. Delaying while the on-call pharmacist is unnecessarily contacted may avoidably compromise patient care. Handling inappropriate calls may decrease pharmacist job satisfaction and compromise rest between shifts. Dissatisfaction with the on-call commitment is regularly raised at local departmental meetings and exit interviews. Servicing such calls is not sustainable. Aim To explore and quantify appropriateness of calls to the on-call pharmacy service at a single, large, acute English hospital, and to explore the influencing factors behind any inappropriate calls using a theoretically informed approach. Methods A retrospective review of existing on-call records quantified and characterised service use in 2021. Missed calls, callers who did not want the on-call pharmacist and internal pharmacy handovers were excluded. As per previous work, calls were considered inappropriate where an available resource would have provided a complete solution/answer at the caller’s level.[2] Service users were invited to semi-structured interviews via email to explore their capability, opportunity, and motivation to handle pharmaceutical issues. Interviews were conducted and recorded on Microsoft Teams before being transcribed and analysed using a framework based on the COM-B model of behaviour. Quantitative data were analysed in Excel and SPSS v27. Pearson’s chi-square test of independence was calculated for several pre-defined variables with p&amp;lt;0.05 considered significant Results There were 1139 calls in 2021, with 32 meeting exclusion criteria. Of the 1107 remaining, 410 (37%) were inappropriate and 697 (63%) appropriate. Eighty-one (20%) inappropriate calls occurred overnight (22:00-08:30). Almost 90 hours were spent on inappropriate calls, generating £3,144.96 in additional overtime payments to pharmacists. Appropriateness was found to be significantly higher on weekdays (66%) versus weekends (58%), p=0.008, from surgical wards (67%) versus medical wards (58%), p = 0.042 and from doctors (74%) versus nurses (54%), p&amp;lt;0.001. All respondents (five doctors) were interviewed. Analysis found limited training and familiarisation led to low awareness of available resources. Access was often restricted by a cumbersome Trust intranet rather than lack of time. Participants were highly motivated to resolve issues themselves, believing this to be best practice. Conclusion The high proportion, high volume and high cost of inappropriate calls warrants further investigation and intervention. Unfortunately, no nurses responded to interview invitations; this is a significant limitation as nurses were more likely to place inappropriate calls. Future work should consider how nurses can be recruited more effectively. However, analysis of calls combined with elucidation of doctors’ behavioural determinants makes it possible to propose informed interventions. Doctors would benefit from improved awareness of/ability to use resources and improved access to them. Therefore, a searchable electronic “signpost” highlighting resources relevant to common on-call queries is proposed. This would leverage the doctors’ high motivation and the rich data collected in a sustainable, evidence-based intervention designed around service user needs.

Barriers and Facilitators to Long-Acting Injectable HIV Pre-Exposure Prophylaxis Implementation in Primary Care Since Its Approval in the United States.

HIV pre-exposure prophylaxis (PrEP) is a highly effective method to mitigate the HIV epidemic, but uptake of PrEP has been slow and is associated with racial and gender disparities. Oral PrEP requires high levels of adherence to be effective, which may disadvantage certain high-risk groups. The first injectable HIV PrEP, a drug given every 2 months rather than as a daily pill, was approved by the US Food & Drug Administration in December 2021. A Family Medicine practice in a single health organization in the United States (November 2022 to February 2023). We conducted interviews with patients and key stakeholders to characterize factors affecting long-acting injectable (LAI) PrEP implementation. Data collection and analysis were guided by the Consolidated Framework for Implementation Research. Interviews were transcribed and analyzed using guided content analysis. Twenty-five patients (n = 13) and practice stakeholders (n = 12) were interviewed. Overall, stakeholders described a very low uptake of LAI PrEP. Barriers to LAI PrEP included a lack of awareness, insurance and access issues, a lack of streamlined workflow, and a trust in pills over injectables. Facilitators to LAI PrEP implementation included the absence of a pill burden, a culture of shared decision making, and pharmacy support. Although uptake has been slow, we have identified several promising strategies for improving rollout and implementation of LAI PrEP. Approaches that can bolster rollout of LAI PrEP include having an interdisciplinary care team that is supported by PrEP navigators and pharmacists and are informed by a patient-centered model of care to increase patient engagement and trust.

A service evaluation and stakeholder perspectives of the ‘Pharmacy Support and Development’ Service across a GP Federation

Abstract Introduction Since 2019 in England, introduction of the Additional Roles Reimbursement Scheme (ARRS), which includes pharmacists and pharmacy technicians1, has led to staggering growth in General Practice (GP) pharmacy workforce. According to workforce data, in 2017 there were 584 pharmacists and 0 pharmacy technicians in GP, and in 2021 numbers soared to 4684 and 989, respectively2. In 2022, The King’s Fund explored issues affecting implementation and integration of ARRS roles in GP and found that roles are inadequately supported and not implemented effectively3. They concluded that critical to the effective integration of ARRS roles within GP is support involving clinical supervision and peer support3. In South &amp; East Leeds (SEL) GP Group (a GP Federation), provision of the Pharmacy Support and Development service, consisting of a Head of Clinical Pharmacy and Advanced Education &amp; Training Pharmacist, has been in place since 2019. It aims to facilitate training and provide peer support and clinical supervision for pharmacy professionals employed across the seven Primary Care Networks (PCN), and member practices within SEL GP Group. Aim To evaluate the Pharmacy Support and Development service at SEL GP Group by assessing effectiveness of current provision through exploration of stakeholder perspectives and identifying levels of satisfaction. Methods Two digital surveys were created and sent via email to all SEL GP members (PCN managers and Clinical Directors, n=13) and all SEL GP pharmacy staff (PCN Pharmacy technicians and Pharmacists, n=37). Questions focussed on obtaining perspectives from stakeholders on current provision and seeking suggestions for improvement. Data was collected between January-February 2023. All surveys were anonymous, and participants aware of this before completing the survey. No ethical approval was required for this service evaluation involving only SEL GP employees, and this was agreed within the organisation. Results There were 8 responses (62%) from SEL GP members and 26 (70%) from SEL GP PCN pharmacy staff. For members: 88% felt the service supported retention of pharmacy ARRS staff, 63% felt the service positively influenced their decision to recruit pharmacy ARRS staff, and 88% ‘Agree’ or ‘Strongly Agree’ that offering this service is attractive to prospective employees. Overall, 88% described the service as ‘Outstanding’ or ‘Excellent’. For pharmacy staff: 96% felt the service helped them integrate as new starters, 100% agreed the service supported understanding of their role, 88% ‘Agree’ or ‘Strongly Agree’ that having this service aids recruitment of pharmacy ARRS roles, and 96% felt they receive appropriate support and supervision. Overall, 85% felt ‘Very Satisfied’ with the service. Discussion/Conclusion The findings suggest that the Pharmacy Support and Development service at SEL GP Group is favourably perceived by stakeholders and thus far, has had a positive impact on integration and continued recruitment of pharmacy ARRS staff. Questionnaires were not returned by 38% of SEL GP members and 30% of SEL GP PCN pharmacy staff, and this is a potential limitation. However, since the findings indicate that the Pharmacy Support and Development service has been instrumental to staff retention and integration into practice teams, our next steps are to consider adopting this model for non-pharmacy ARRS staff within SEL GP Group.

Pharmacy and Genomic Medicine: A UK-wide survey of pharmacy staff assessing their prior education, confidence and educational needs

Abstract Introduction Pharmacy teams are key in helping patients to get the most from genomic medicine.1,2 However, genomics has only recently been included in undergraduate curricula, and it has been suggested that all healthcare professionals could benefit from education in pharmacogenomics2. We surveyed pharmacy staff to gather information on previous education, current practice and future educational needs in genomics and pharmacogenomics. Aim This survey aimed to establish existing levels of education and confidence in genomics and pharmacogenomics in pharmacy staff working in any role, in any sector, across the UK, and to investigate respondents’ preferences in delivery of genomic education. Methods The survey was based on a 2021 survey of genomic knowledge among medical staff by Health Education England (HEE)3, and amended to reflect pharmacy roles and practice following discussion with pharmacy leads from the 7 NHS Genomic Medicine Service Alliances in England, and from Scotland, Wales and Northern Ireland. SmartSurvey software was used to host the survey, with data held securely. The survey was open between 1st March and 16th May 2022, and was publicised via pharmacy groups including the Royal Pharmaceutical Society, National Pharmacy Association, Local Pharmaceutical Committees, chief pharmacists networks in primary and secondary care, and social media. This work was assessed using the NHS Health Research Authority Research screening tool and judged as ‘not research’; therefore ethical approval was not required. Results 1,552 responses were received from pharmacists, pharmacy technicians, dispensers and other pharmacy staff across the UK; 68% of responses were from England, 13% from Scotland, 10% from Northern Ireland and 9% from Wales. The majority of responses (69%) were from Pharmacists, with 24% from Pharmacy Technicians and 4% from Pharmacy support workers. Only 13% of respondents had received any formal training in genomics. Most respondents felt unprepared to use genomic testing in their practice; just 8% of pharmacists (including trainees), and 1% of pharmacy technicians (including trainees) felt prepared. However, 65% of respondents thought that genomics would change their practice within the next 5 years, and over 70% of pharmacists, and 56% of pharmacy technicians, could envisage ordering, advising on, or counselling patients on genomic testing in the future after appropriate training. 29% of respondents (mainly pharmacy managers) did not currently see patients and therefore might not train personally in genomics. Discussion/Conclusion This work suggests that pharmacy teams are likely to require educational support to embrace the opportunities of genomic medicine. High survey engagement suggested that respondents were keen to make their voices heard. Pharmacists appeared more confident in their ability to advise patients on genomics than Technicians, however both groups seemed keen to receive training. One limitation is that respondents were likely interested in genomics; those with no interest may not have completed the survey. Additionally, pharmacy managers who do not see patients might not train personally in genomics, but may influence strategy for pharmacy genomics service development and delivery. National bodies should capitalise on enthusiasm across the sector to help drive pharmacy genomics services forward through education and training.

How does community pharmacy support patients living with asthma?

Abstract Introduction Asthma is a chronic respiratory condition that is currently an increasing issue worldwide. Particularly in the United Kingdom, 185 people are admitted to hospital because of an attack and 3 people die daily despite the National Healthcare Service (NHS) spending £1 billion on asthma care.1 Community pharmacies are taking on a more clinical role in the NHS but the extent of their role in primary care, specifically regarding helping patients living with asthma is unknown. Aim This study aimed to identify how community pharmacists reduced the general practitioners (GPs) workload by helping patients living with asthma. Methods The study used a 30-question survey to collect data from community pharmacists in North-East London boroughs (n=206 pharmacies). The survey consisted of both closed and open-ended questions, exploring the asthma interventions pharmacists conducted and the impact this had on patients, as well as the medication or devices that patients were struggling with the most and how confident pharmacists felt about all aspects of asthma. The paper-based survey was handed to each responsible pharmacist for completion. Data was input into SPSS for analysis. The study received ethical approval from Kingston University. Results Participants found the New Medicines Service to be the most helpful service (4.4/5) for patients living with asthma, followed by influenza vaccine (4/5), Community Pharmacy Consultation Service (CPCS) (3.8/5) and inhaler technique checks (3.8/5). The percentage of referrals to the GP that resulted from these services were 0-20% of patients in an average week. The most frequently referred medication was salbutamol (56.5%) due to its overuse or exacerbation of symptoms with Clenil® (15.2%) the second most referred medicine due to side-effects such as a sore throat. The most frequent inhaler device dispensed was the metered dose inhalers (94%), however the most troublesome inhalers were dry powder inhalers (50.8%) due to patient’s poor inhalation capacity, dexterity, inability to load the capsules and poor knowledge. Overall, pharmacists were confident in their ability to help asthma patients, however, younger pharmacists were less likely to check inhaler technique at every dispensing (p=0.016), more likely to check it only upon patient request (p=0.042) and were more likely to refer patients to the GP after consultations. Contrastingly, nearly all participants (93.2%) found their training for asthma and its services to be sufficient, with 62.5% using centre for pharmacy postgraduate education as their training provider. Discussion/Conclusion The results suggest that most of the time pharmacists were well trained, addressed patients concerns adequately and were able to support with adherence and usage of inhalers.2 It was clear that pharmacists do play an active role in the lives of asthma patients through the services they conduct. Their training allows pharmacists to be confident when carrying out these services so that majority of patient’s concerns are addressed within the pharmacy and only a few require GP referral. It may be beneficial to carry out technique checks more frequently, conduct asthma reviews within the pharmacy and provide additional resources to newly qualified pharmacists to aid their confidence in helping asthma patients.

Supporting Fracture Liaison Services in England and Wales: A role for pharmacists?

Abstract Introduction Fracture Liaison Service (FLS) deliver secondary fracture prevention to adults aged 50 years and over. Performance is measured against ten benchmarks [B1-10]: cases identified [B1], spine fractures [B2], assessment within 90 days [B3], dual x-ray absorptiometry (DXA) within 90 days [B4], falls risk assessment [B5], bone treatment recommended [B6], strength and balance by 16 weeks [B7], 16-week follow-up [B8], treatment by first follow-up [B9] and 1-year drug adherence check [B10]. Each indicator has standards for meeting &amp;gt;80% of target (green), 50-79% (amber) and &amp;lt;50% (red). For Spine fractures [B2], &amp;gt;20% identified denotes green, amber for 11-19% and red for &amp;lt;10%. For bone treatment recommended [B6], green denotes &amp;gt;50% and red &amp;lt;50%. Audit data is uploaded to the Fracture Liaison Service Database (FLS-DB).1 Aim To establish whether FLSs meet performance targets and identify how pharmacists could support the service. Methods This work was done as part of a PhD project at the University of Nottingham looking at how pharmacists could improve osteoporosis medication adherence. Therefore, an existing service which encounters people with osteoporosis (FLS) was investigated to see if it required support. Approval reference: 017-2021. National averages for benchmarks were analysed to see if targets were being met over a 5-year period (2016-2020).1 The Royal Osteoporosis Society (ROS) Clinical Standards for FLSs2 were reviewed to identify areas where pharmacists could support the service. Findings were reviewed by two authors of the Clinical Standards for FLSs. Results Less than half (49%) of FLSs’ in England and Wales submitted data consistently between 2016-2020. Of those who submitted, only recommendations to initiate bone treatment [B6] met the required target (&amp;gt;50% of patients) in 2018 (53%), 2019 (52.4%) and 2020 (52.9%). However, B9: Treatment by 1st follow-up targets were not met. Possibly due to the lack of data for pharmacy support, the ROS Clinical Standards for FLSs do not mention pharmacists. Staffing data shows no pharmacists employed at FLSs. However, the research team identified eleven areas where implementation of referral pathways between community pharmacy (CP) and FLSs could support patient management. These were related to identification of people aged over 50 years with a fragility fracture (1.1), investigations of fragility fracture risk within 12 weeks of a fracture diagnosis (2.1, 2.2), provision of information to patients and healthcare professionals (3.1, 3.2, 3.3, 3.4), interventions such as drug treatment initiation, reviews, referrals to falls prevention services (4.1, 4.2, 4.3) and integration of the wider healthcare system to ensure long term management of osteoporosis (5.1). Multi-disciplinary working and incorporating primary and secondary fracture prevention and medicines review outcomes,3 would help inform transfer of care on this pathway. Discussion/Conclusion FLSs’ needs support to ensure benchmark targets are met especially related to anti-osteoporosis medication initiation and adherence. Due to their expertise, pharmacists could support the FLS, particularly with treatment initiation and adherence related monitoring. Implementation of a two-way referral pathway between FLSs’ and community pharmacy could help improve patient outcomes. Limitation: There is missing data as not all FLSs upload to the FLS-DB.

The impact of implementing an allergic rhinitis clinical management pathway (AR-CMaP) in the community pharmacy

BackgroundThe Allergic Rhinitis Clinical Management Pathway (AR-CMaP) was developed to overcome the challenge of implementing current AR guidelines in the Australian community pharmacy practice and support pharmacists in optimally managing patients' AR. Objective(s)To evaluate the impact of AR-CMaP on patients' behaviour and pharmacists' needs in managing AR in the pharmacy. MethodsThis study used a cross-sectional, pre-post study design in which the primary outcome was the appropriateness of medications purchased from community pharmacies in Australia. Patient data were collected before and after the implementation of AR-CMaP. Pharmacist needs were recorded before and after AR-CMaP training. Data were analysed descriptively. ResultsSix pharmacies, 19 pharmacists and a total of 416 patients were included in the study; 206 pre-AR-CMaP implementation and 210 post-AR-CMaP implementation. Pre-AR-CMaP, 22.4% of patients purchased appropriate AR medication compared with 29.0% post-AR-CMaP implementation. Over half the patient cohort (52%) consulted a pharmacist pre-AR-CMaP and 37% consulted a pharmacist post-AR-CMaP implementation. Post-AR-CMaP, pharmacists reported increased awareness of barriers such as patients' lack of time, patients' perceptions about the pharmacist's role and patient choice to self-manage. Pharmacists also rated an increased desire to interact with other health care providers (HCPs) in caring for patients with AR. ConclusionsWhile there was a non-statistically significant increase in the proportion of patients purchasing optimal AR medication, AR-CMaP did empower patients to self-select their own medication without further detriment. Moreover, following the implementation of AR-CMaP, pharmacists developed a greater awareness of their role in AR management, exemplified by their increased desire to be actively involved in AR management and increased interaction with other HCPs. Future research needs to explore more effective tools to support pharmacists' clinical decision-making and target patients' self-selection of AR medications. This study highlights that there is an ingrained self-reliance of AR decision-making that has become a habit for people living with AR.

High sustained virologic response rates, regardless of race or socioeconomic class, in patients treated with chronic hepatitis C in community practice using a specialized pharmacy team.

Approved direct-acting antiviral (DAA) regimens against hepatitis C virus (HCV) can cure nearly all patients; however, socioeconomic disparities may impact access and outcome. This study assesses socioeconomic factors, differences in insurance coverage and the drug prior authorization process in HCV-infected patients managed in community practices partnered with a dedicated pharmacy team with expertise in liver disease. This Institutional Review Board-approved, ongoing study captures data on a cohort of 2480 patients from community practices. Patients had chronic hepatitis C and were treated with DAA regimens selected by their physician. The HCV Health Outcomes Centers Network provides comprehensive patient management including a dedicated pharmacy support team with expertise in the prior authorization process. In this cohort, 60.1% were male, 49% were Hispanic Whites (HW), 37% were Non-Hispanic Whites (NHW), and 14% were Black/African American (BAA). Eighty-seven percent of patients were treatment-naïve, 74% were infected with genotype 1 virus and 63% had advanced fibrosis/cirrhosis (F3/F4 = 68.2% HW, 65.6% BAA, 55.4% NHW). Forty percent of patients were on disability with the highest percentage in the BAA group and less than one-third were employed full time, regardless of race/ethnicity. Medicare covered 42% of BAA patients versus 32% of HW and NHW. The vast majority of HW (80%) and BAA (75%) had a median income below the median income of Texas residents. Additionally, 75% of HW and 71% of BAA had median income below the poverty level in Texas. Despite the above socioeconomic factors, 92% of all prior authorizations were approved upon first submission and patients received DAAs an average of 17 days from prescription. DAA therapy resulted in cure in 95.3% of patients (sustained virologic response = 94.8% HW, 94.0% BAA, 96.5% NHW). Despite having more advanced diseases and more negative socioeconomic factors, >94% of HW and BAA patients were cured. Continued patient education and communication with the healthcare team can lead to high adherence and > 94% HCV cure rates regardless of race/ethnicity or underlying socioeconomic factors in the community setting.

Implementation of an integrated ambulatory care pharmacist collaborative care workflow model in specialty clinics in a large academic health system.

Ambulatory care and specialty pharmacy practices are rapidly growing in tandem with the accelerated development of advanced therapies for complex disease states. A coordinated and standardized interprofessional team-based approach is critical to providing high-quality care to specialty patients on complex, expensive, and high-risk therapies. Yale New Haven Health System dedicated resources to the creation of a medication management clinic under a unique care model that integrates ambulatory care pharmacists within specialty clinics who coordinate with centralized specialty pharmacists. The new care model workflow encompasses ambulatory care pharmacists, specialty pharmacists, ambulatory care pharmacy technicians, specialty pharmacy liaisons, clinicians, and clinic support staff. The strategies employed to design, implement, and optimize this workflow to meet the increasing demand for pharmacy support in specialty care is discussed. The workflow incorporated key activities from highly diverse existing specialty pharmacy, ambulatory care pharmacy, and specialty clinic practices. Standard processes were developed for patient identification, referral placement, visit scheduling, encounter documentation, medication fulfillment, and clinical follow-up. Resources were created or optimized to support successful implementation, including an electronic pharmacy referral, specialty collaborative practice agreements to facilitate pharmacist-led comprehensive medication management, and a standardized note template. Communication strategies were developed to facilitate feedback and process updates. Enhancements focused on eliminating documentation redundancies and delegating nonclinical tasks to a dedicated ambulatory care pharmacy technician. The workflow was implemented in 5 ambulatory rheumatology, digestive health, and infectious diseases clinics. Pharmacists utilized this workflow to complete 1,237 patient visits, serving 550 individual patients over 11 months. This initiative created a standard workflow to support an interdisciplinary standard of specialty patient care that is robust to accommodate planned expansion. This workflow implementation approach can serve as a road map for other healthcare systems with integrated specialty and ambulatory pharmacy departments undertaking similar models for specialty patient management.

The Utilization of the Ketogenic Diet for Adults with Status Epilepticus (P8-7.003)

<h3>Objective:</h3> To characterize the utilization of ketogenic diet (KD) among healthcare providers caring for adult patients with status epilepticus (SE). <h3>Background:</h3> KD is a high fat, low carbohydrate diet that has been shown to effectively treat refractory seizures, both in the outpatient and inpatient settings. The successful implementation of KD involves a multifaceted, interdisciplinary approach with many potential barriers. <h3>Design/Methods:</h3> 27-question web-based survey (Qualtrics®) targeting healthcare providers who manage adult SE patients in both academic and community-based settings distributed by various neurology and critical care specialties societies. <h3>Results:</h3> Of 156 respondents, 80% of physicians and 18% of non-physicians reported using KD for SE. Achieving ketosis (36.3%), lack of expertise (24.2%), and lack of resources (20.9%) were identified as some of the most important barriers limiting the utilization of KD. Absence of nutrition support (37.1%) and of pharmacy support (25.7%) were the most important missing resources. Reasons for stopping KD were identified as ineffectiveness (29.1%), difficulty achieving ketosis (24.6%) and side-effects (17.3%). The discrepancies are evident when comparing providers in the academic versus non-academic settings. The former has significantly more experience with the use of KD and EEG monitoring availability, and fewer barriers to its implementation. The need for more randomized clinical trials supporting efficacy (36.5%) and increased practical guidelines for implementation and maintenance of KD (29.6%) were mostly cited as factors to increase the utilization of KD for SE. <h3>Conclusions:</h3> We identified multiple target areas to improve the utilization of KD through future research. These include better interdisciplinary collaboration, studies exploring factors affecting the achievement of ketosis and the management of side effects, and large-scale clinical trials examining the efficacy of this treatment. KD represents an underexplored treatment modality which may prove crucial in improving management of SE. <b>Disclosure:</b> Dr. Jacinto Pereira Teixeira has nothing to disclose. Ms. Shannon has nothing to disclose. Dr. Robinson has nothing to disclose. Bakhtawar Ahmad has nothing to disclose. Mr. Katz has nothing to disclose. Guanhong Miao has nothing to disclose. Ms. Seckar has nothing to disclose. Dr. Bruzzone has nothing to disclose. Dr. Busl has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Society of Critical Care Medicine. The institution of Dr. Busl has received research support from University of Florida Self Insurance Program. The institution of Dr. Busl has received research support from National Institutes of Health. Dr. Busl has a non-compensated relationship as a Board Member with Art in Medicine that is relevant to AAN interests or activities. Dr. Busl has a non-compensated relationship as a Associate Editor with Critical Care Explorations that is relevant to AAN interests or activities. Dr. Busl has a non-compensated relationship as a Editorial Board Member with Neurocritical Care that is relevant to AAN interests or activities. Dr. Cervenka has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Nutricia. Dr. Cervenka has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Nestle Health Science/Vitaflo. The institution of Dr. Cervenka has received research support from Nestle Health Science/Vitaflo. Dr. Cervenka has received publishing royalties from a publication relating to health care. Dr. Maciel has received research support from American Heart Association. Dr. Maciel has received research support from National Institute of Health.

P013 A three-year audit of dose tapering biologic medications in a rheumatology service

Abstract Background/Aims Dose tapering of biologic therapies is supported by both ACR and EULAR guidelines. Identification of appropriate patients may deliver cost savings whilst minimising the risk of disease flare. To audit dose tapering activity for patients treated with bDMARD for rheumatoid (RA), psoriatic arthritis (PsA) and ankylosing spondylosis (AS) meeting locally agreed criteria over three years. Methods All patients treated with a bDMARD for RA, PsA or AS fulfilling criteria for dose tapering between 1st October 2019 - 1st October 2021 were identified from electronic health records (EHR). Rituximab patients were excluded due to reactive treatment responding to flare. Patients were required to have been on their bDMARD for = &amp;gt; one year, not prescribed oral steroids / treated with parenteral steroids in the past six months, no swollen joints in the past six months, and not failed dose tapering in the previous year. RA patients were ineligible if DAS ≥3.2 in the previous year; PsA if their biologic was prescribed by dermatology /active psoriasis; AS patients if BASDAI score of &amp;gt; 4 in past year. Records were flagged to prompt a shared decision-making discussion between the treating clinician and patient during routine appointments; additional patients were identified through clinical assessment. Failing dose tapering was defined as a post tapering flare requiring dose increase within one year. Patients were tapered by increasing the interval of a bDMARD. Results The number of patients that dose tapered increased from 24 in 2019 to 51 in 2021, making a total estimated NHS list saving of up to £170,000 per annum. (Table 1). Tapering was unsuccessful for 7/116 (6%) due to post tapering flares. Patients flaring after tapering were reassessed urgently and had their bDMARD dose reviewed. More patients were eligible than identified from EHR search due to missing data in coding; 787 (61%) across all years. Conclusion Dose tapering was well tolerated in eligible patients making this a safe and acceptable initiative. Use of EHR data and behavioural prompts for clinicians supported this in practice. Cost savings were reinvested to increase pharmacy support for homecare prescription management. Disclosure H. Light: None. J. Firth: None. J. Bluett: Grants/research support; JB has received a research grant from Pfizer. Other; JB has received travel/conference fees from UCB, Pfizer and Eli Lilly. K. Kinsey: None.

A descriptive analysis of primary care providers' interest in clinical pharmacy services

BackgroundVarious clinical pharmacy services exist to improve the health outcomes of patients. However, there are numerous barriers to their implementation and execution, especially in outpatient settings. As pharmacists design and implement clinical pharmacy services in outpatient settings, they often do not consider the needs of providers until after service development. ObjectivesThe purpose of this study was to assess primary care providers' (PCPs') perceptions of clinical pharmacy services and their clinical pharmacy support needs. MethodsA web-based survey was distributed via email to PCPs across North Carolina (NC). Survey dissemination was completed in two phases. Data analysis consisted of mixed methods – quantitative and qualitative. Descriptive statistics were used to analyze demographic differences within each phase as well as the ranking of medication classes/disease states by providers. Qualitative data analysis through inductive coding was done to assess provider perceptions of clinical pharmacy services. ResultsThe response rate of the survey was 19.7%. Providers with previous experience with a clinical pharmacist rated overall services as positive. 62.9% of PCPs (N = 80) provided their perception of the positive attributes (pros) of clinical pharmacy services. 53.5% of PCPs (N = 68) provided their perception of the negative attributes (cons) of clinical pharmacy services. The top three medication classes/disease states that providers indicated they would value clinical pharmacy services for were: comprehensive medication management (CMM), diabetes medication management, and anticoagulation medication management. Of the remaining areas assessed, statin and steroid management ranked the lowest. ConclusionsThe results from this study demonstrated that clinical pharmacy services are valued by PCPs. They also highlighted how pharmacists can best contribute to collaborative care in outpatient settings. As pharmacists, we should aim to implement the clinical pharmacy services that PCPs would value most.

Building an antimicrobial stewardship program: A narrative of six years under the Donabedian perspective.

Introduction: Antimicrobial resistance (AMR) is increasing and represents one of the world's major challenges. AMR increase morbimortality, length of hospital stay and costs. Antimicrobial Stewardship Programs (ASP) are one of the key strategies to promote the rational use of antimicrobials since AMR is mostly driven by antimicrobial consumption. Objective: To describe the ASP implementation in a teaching hospital from the perspective of Donabedian quality assessment and the Brazilian regulatory requirements. Method: This was a descriptive study with secondary data collection, including document review of the ASP. The study setting was a general public 392-bed hospital. The ASP activities were performed by the hospital infection control committee (HICC), hospital pharmacy (HP) and diagnostic support laboratory (DSL). The description of the three services mainly involved in the ASP was based on a quality assessment model involving the dimensions of "structure", "process" and "result" proposed by Donabedian. The distribution among dimensions was guided by the checklist of essential elements of the ASP that compose the Brazilian regulatory requirements. The checklist was applied in July, 2022, and the ASP results described from 2016 to 2021. Results: ASP actions have been gradually implemented since 2008 with the implementation of HICC and improved over the years. Regarding structure, the investments in technology were mapped, quantifying 26 computers and three software programs employed to computerize the ASP processes performed in specific physical areas by HICC, HP and DSL. Institutional guidelines used by HICC, HP and DSL guided clinical practices to operationalize ASP. The evaluation metrics improved for 10 indicators and worsened for four indicators. From the 60 items composing the checklist, the hospital met the requirements in 73.3% of the items (n = 44). Conclusion: This study described the implementation of ASP in a teaching hospital, applying the Donabedian perspective. Although the hospital still does not have a classic ASP model, there were investments to improve structure, processes and results, aiming to comply with international guidelines. A high proportion of key elements of ASP in the hospital were followed according to the Brazilian regulatory requirements. Aspects related to antimicrobial consumption and the emergence of microbial resistance deserve further investigations.

Significant Published Articles in 2022 for Pharmacy Nutrition Support Practice.

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2022 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the article to be important. Guideline and consensus papers, important to practice but not ranked, were also included. Results: A total of 162 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 10 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

Global overview of pharmacy support personnel training programmes: a scoping review protocol

IntroductionA global variation in the pharmacy support personnel training programmes has been observed. The objective of this scoping review is to map out global evidence available on the pharmacy support...

Online education for safer opioid prescribing in hospitals-lessons learnt from the Opioid Use Change (OUCh) project.

Opioids are often required for acute inpatient pain relief but lack of knowledge about common and less common long-term side effects can lead to inappropriate discharge prescribing. There are few validated educational tools available for junior prescribers on hospital wards. Education around opioid prescribing and deprescribing remains limited in the undergraduate curriculum and yet almost all controlled drug prescribing in hospitals is done by junior doctors. A 5-minute video was developed with iterative feedback from medical students, junior prescribers, pain specialists, primary care educational leads, and a patient who had developed opioid addiction after hospital prescribing. It explained the need for clear stop dates on discharge summaries and the range of opioid side effects. It also highlighted the hospital admission as an opportunity to reduce inappropriate high-dose opioids. A short knowledge-based quiz before and after viewing the video was used to evaluate the impact on and change in knowledge and confidence around opioid prescribing. This tool was designed to be used entirely online to allow delivery within existing mandatory training. Feedback was positive and showed that knowledge of side effects significantly increased but also contacts with ward pharmacists and the acute pain team increased. Junior doctors highlighted that the undergraduate curriculum did little to prepare them for prescription addiction and that pharmacy and senior support was needed to support any changes in longer-term, high-dose opioids. This short educational video improved knowledge of safe opioid prescribing and could be incorporated within wider opioid education in UK healthcare.