Choosing Wisely: Pharmacy’s role in effective use of medications

A new initiative directed by the American Board of Internal Medicine, known as Choosing Wisely, presents a compilation of 415 evidence-based recommendations to ensure the safest and most effective treatments for patients.  The primary target of this list was for the practitioners who diagnose and prescribe to target identified problems of underuse, overuse, and misuse of therapies and diagnostic testing. Once the recommendations were reviewed, it was found that 110 were related to the use of medications and drug classes. The most popular classes addressed were antimicrobials, pain management, neurologic, anticoagulants, and oncology medications.

After reviewing the recommendations, pharmacists supported the proposed list, but also looked to determine their own set of recommendations that could be of value to the patients they serve. One proposed pharmacy recommendation suggests not prescribing medication to patients older than 65 already, who are already on 5 or more medications without a comprehensive medication review of existing medications.  Another states, “Do not initiate medications to treat symptoms, adverse events, or side effects without determining if an existing therapy is the cause and whether a dosage reduction.” The goal of defining a set of recommendations for pharmacists is to ensure that patients are on therapies that are indicated, effective, and safe in treating their health conditions.

The program, Choosing Wisely, is important for pharmacists to be aware of in order to have active participation with the entire healthcare team. By knowing the recommendations that other providers are using, we can understand their reasoning behind diagnosis and treatment decisions. Pharmacists can also serve as a check-point to determine if the correct recommendation has been followed before dispensing the prescribed medication. Further, the idea of pharmacists defining their own set of practice recommendations is very interesting. From reading the proposed ideas, it is easy to see the need and the benefit that these implementations can have on patient health. However, having two separate recommendations lists could get confusing for pharmacists to reference. If pharmacists were able to merge their own recommendations with with already existing Choosing Wisely list, I think it would optimize healthcare decisions and allow for a more streamlined process for communication within the interprofessional team.

Reference:

Am J Health-Syst Pharm. 2015;72: 1529-1530.

http://www.ajhp.org/content/72/18/1529.full.pdf+html

Self-Reported Medication Adherence Barriers Among Ambulatory Older Adults with Mild Cognitive Impairment

Medication nonadherence in elderly patients is a huge problem affecting more than half of patients visiting community pharmacies and is expected to lead to greater than $100 billion costs to patients and healthcare systems. Furthermore, nearly 20% of this elderly patient population, aged 65 and over, has a diagnosis of mild cognitive impairment (MCI). MCI is an early stage impairment which increases a person’s risk of developing dementia. Because a majority of the elderly population suffers from multiple medical comorbidities and requires many different medications, it is important to address their cognitive ability and how it can impact their capability to be adherent to their medications.

Many interventions have been implemented to assist older adults in being adherent to their medications, but only one intervention focused on helping patients diagnosed with an MCI has been identified and involved reminder phone calls at each dosing time throughout the day. This article focuses on a study that compared barriers to adherence faced by older adults with MCI and those without at outpatient or home-care programs. The identification of barriers was used to create new interventions that would aid in adherence among this population. Patients were surveyed using a 17-item questionnaire to determine barriers to adherence related to knowledge, cost, behavior, and physical ability. Of the 200 participants surveyed, 82.5% reported to having at least one barrier to medication adherence. There was found to not be a significant different to the average number of barriers per patient between the MCI and non-MCI group. 49% of the barriers were categorized as difficulty remembering the time or number to take for the medication.

Many self-reported barriers to medication adherence were identified, regardless of whether or not the patient had been diagnosed with a cognitive disability. Overall, the need for multi-component intervention for older adults is important to recognize and these intervention program must make targeting a barrier caused by memory their priority. These interventions must be tailored to each patient’s need and work to minimize and adherence barriers.

The information presented in this article is important to recognize as a pharmacist. As an accessible healthcare provider present at the time of dispensing, we can play a very influential role in promoting adherence to our patients. By learning to recognize common barriers or challenges that certain populations are facing, we can address these concerns or identify resources available that can improve the overall health of our patients. I think this article also presents a very interesting point in that the prevalence of barriers to adherence in older patients. Regardless of an MCI diagnosis or not, patients still reported to facing roughly the same number and type of challenges, highlighting the fact that regardless off health conditions, most patients are still plagued by challenges leading to nonadherence. Once we learn to recognize these problems and identify the cause, we can develop strategies to help these patients.

Reference:

Pharmacotherapy. 2016;36:196-202.

http://onlinelibrary.wiley.com/doi/10.1002/phar.1702/epdf

TransitionRx: Impact of community pharmacy postdischarge medication therapy management on hospital readmission rate

It has been found that nearly 20% of Medicare patients are readmitted to the hospital within 30 days of discharge. This high incidence of readmission can lead to increased costs for Medicare and its beneficiaries.  Because of this, the Centers for Medicare and Medicaid Services have begun penalizing hospitals with readmission rates higher than the national average for a particular disease state by decreasing reimbursement back to the hospital. The leading cause for readmission of these patients was attributed to a medication-related problem. A study conducted in Ohio looked to determine the impact that pharmacist intervention can have when implemented during transition of care.

Kroger pharmacies partnered with two small community hospitals in the Cincinnati area for patient referral as part of the TransitionRx program. At the time of hospital discharge, nurses counseled the patients on their medications with no input from pharmacists. Patients included in the study were aged 18 or older and diagnosed with either CHF, COPD, or pneumonia. Seven clinical pharmacists received training to provide MTM services with a special focus on counseling post-discharge patients. At the time of discharge, the hospitals faxed patient information, including discharge instruction and medications to the pharmacists at the designated Kroger locations. Pharmacists then made phone calls to these patients to schedule an in-person MTM session ideally within 3 days of discharge. During these appointments, the pharmacists provided a discussion of any changes in medication, a comprehensive medication review, and disease-state education, with a special focus on “red flags”. “Red flags” were defined as specific symptoms that patients could monitor for that could indicate their disease is deteriorating. Patients were provided with a personal medication record, health action plan, an appointment list, a self-monitoring log, if applicable, and a summary of the visit was sent to the patient’s physician. A follow-up was conducted via telephone.

90 patients participated in the study and 30 received the pharmacist intervention. Of the 60 patients that did not receive discharge counseling from a pharmacist, 20% were readmitted to the hospital within 30 days, while only 7% of patients in the intervention group were readmitted. Over 200 unique interventions were made by the pharmacists to the 30 patients that they saw, with 7 interventions per patient on average.

I enjoyed reading this article because the MTM sessions carried out by the pharmacists are extremely similar to what we have been learning to do in POP with standardized patients and with SilverScripts. It is encouraging to know that even as P1’s we are already preparing for our future careers and learning skills that will be essential to patient care in the future. Understanding Medicare STAR ratings and hospital reimbursements as the future of healthcare and realizing that patient health is the priority will help to develop a patient-centered approach as pharmacists. This article also highlights the need for pharmacists working with the interprofessional healthcare team and the benefits that can be provided. With just 7 participating pharmacists being able to identify over 200 drug therapy problems in 30 patients, the need for intervention is clear to see.

Reference:

J Am Pharm Assoc. 2015;55:246-254.

http://www.japha.org/article/S1544-3191(15)30055-8/pdf

Adverse event potentially due to an interaction between ibrutinib and verapamil: a case report

Ibrutinib was recently approved as an oral anti-cancer agent in 2014 to treat B-cell malignancies. It is effective in irreversibly inhibiting a tyrosine kinase to prevent cell proliferation. The drug is mostly seen clinically in the ambulatory care setting. Ibrutinib is given to patients orally, completely absorbed, and undergoes extensive first-pass metabolism by CYP3A4 in the liver resulting in an oral bioavailability of only 4 %. Therefore, it is clear to see that the dosing, effectiveness, and exposure of Iburtinib in the body is highly dependent on the activity of CYP3A4.

In this article, a 68 yo male presented to the emergency department after falling and losing consciousness for several minutes. He also had been experiencing severe diarrhea in the past few weeks leading up the fall. He had a history of colorectal cancer, hepatitis B, hypertension left ventricular hypertrophy, dyslipidemia, and relapsed mantle cell lymphoma which was currently be treated with 560 mg of ibrutinib daily. The patient was treated and stabilized, but still suffered from diarrhea. A clinical pharmacist in the ED reviewed his medication list which included the ibrutinib, entecavir, fenofibrate, olmesartan, loratadine, and a verapamil/trandolapril combination. The pharmacist was able to determine a significant drug interaction between ibrutinib and verapamil, a moderate CYP3A4 inhibitor.

Because the enzyme that normally highly metabolized ibrutinib was inhibited, a large amount of this drug was reaching system exposure in the patient. The most common side effects of ibrutinib are described as diarrhea, nausea, and dizziness, with the possibility of falls, all of which the patient had been experiencing. The pharmacist switched this patient to an alternative anti-hypertensive medication that did not interact with CYP3A4. Three months later, the patient’s blood pressure remained controlled and he was still able to take the ibrutinib for cancer treatment without the unwanted side effects.

I found this article to be very interesting in showing the crucial role that pharmacists, as the medication experts, can have in optimizing a patient’s therapy. By understanding the patient’s reason for admission and side effects, a pharmacist was able to analyze his current medication list, find drug therapy problems, and determine the cause of these events, much like we have learned to do with standardized patient cases in POP. Furthermore, the article states that the community pharmacist who dispensed the patient’s verapamil, was completely unware that this patient was also taking the oral ibrutinib, as it is only available from a hospital pharmacy. This is important to note how crucial communication between providers and patients is in order to catch potential drug interactions. Had the two pharmacies caring for this patient communicated or had either pharmacist asked this patient what other medications he was taking, these side effects and costly hospitalization could have been avoided.

Reference:

J Clin Pharm Ther. 2016;41:104-105.

http://onlinelibrary.wiley.com/doi/10.1111/jcpt.12355/epdf

Pharmacists can improve COPD care

Chronic obstructive pulmonary disease is a progressive disease disturbing a patient’s ability to breath and affects 6.3% of adults nationally. It is described by the CDC as a group of diseases causing air flow blockage and can include emphysema, chronic bronchitis, and asthma.

In this article, a pharmacy resident noticed that COPD was a growing issue in the patient population he cared for and began a program to establish a pharmacist managed COPD clinic, much like other programs for anticoagulation therapy or infectious disease. He stabled a program to use his ability and knowledge of pharmacist to optimize COPD therapy and monitor patient inhaler techniques in collaboration with other healthcare providers. This clinic also made it possible for patient’s prescribed an inhaler during their hospital stay to keep the device after discharge. Previously these inhalers were going to waste and being thrown out, while patients were going without their medication. Through discharge counseling and education at the clinic, patient health improved, showing a decrease from 21% to 9% patients readmitted within 30 days after discharge. Even after his residency has ended, patients are still referred to this COPD clinic highlighting its success.

This article represents the benefit that pharmacist intervention and management of patients’ disease states and therapy can have. Furthermore, as future pharmacists we must serve as advocates for our patients and recognize when their needs are not being met. The pharmacist in this article was able to identify a problem and create a solution to provide the best possible care to his patients. As we have learned last semester, it is essential to recognize situations where a pharmacist can optimize patient care in an area that we are passionate about to create our own jobs and learning opportunities, much like this pharmacy resident has done.

Reference:

Am J Health-Syst Pharm. 2015;72:2004-2006.

http://www.ajhp.org/content/72/23/2004.full.pdf+html

Evaluation of a pharmacist-performed tuberculosis testing initiative in New Mexico

Tuberculosis (TB) is a bacterial disease that remains a leading cause of death throughout the world. However, contraction of TB has steadily declined in the US due to early detection and treatment to prevent progression and transmission of the disease. To aid in identifying and controlling TB infection, pharmacists in New Mexico were provided with training and certification before being granted the ability to prescribe, administer, and read TB skin tests.

Many healthcare clinics in New Mexico offered TB skin tests and treatment, but only to infected or high-risk patients. Wanting to provide these services to others in the area needing TB tests for different reasons, pharmacists in the area received board approval and underwent a 1-hour online training, followed by a 4-hour practicum of hands-on training and demonstrations outlined by the CDC. These pharmacists were then able to provide a total of 606 TB skin tests to their patients at their community pharmacies, with the most common reason being for school or employment eligibility.

This article is important because it illustrates how pharmacists are able to expand their scope of practice and provide essential services to their patients and provide a public health benefit. Following this study, the demand for pharmacists certified to preform TB skin tests is expected to increase as patients become aware that this service is available at their local pharmacy. I think it is a good idea to expand this practice and the number of pharmacists certified to provide tests in the community setting as it is easily accessible, generally has extended hours, and would not require patients to schedule an appointment.

Many of us as student pharmacists were required to get a TB skin test before school and before going to some of our service learning sites. Would you have preferred just being able to go to your local pharmacy to receive this test? Do you think giving more pharmacists the ability to preform this service would make it more accessible and easier to complete? Would you feel comfortable having your pharmacist or, even as a future pharmacist, initiating a TB test or treatment?

Reference:

J Am. Pharm. Assoc. 2015;55:307-312.

http://www.japha.org/article/S1544-3191(15)30065-0/pdf

Access to patients’ health records for drug therapy problem determination by pharmacists

Patients receiving care at both a community pharmacy and primary care clinic were selected and were evaluated by pharmacy residents to identify drug therapy problems, create a care plan, and a follow-up visit. The pharmacists first completed the assessment in the pharmacy without access to their patient’s health record and recorded their level of confidence in their identified drug therapy problem and any additional data they needed. The pharmacist then completed the same process with access to their patients’ health records from their primary care provider.

Following the study, it was determined that a change in the pharmacist’s initial assessment without access to the patients’ health records was made in all cases studied. 72% of the initially found drug therapy problems were confirmed, while 31 problems were found to be false and 9 new were identified after access the health records.

Overall, this study proves that pharmacist access to primary care health records of the patients they treat is extremely beneficial in accurately determining drug therapy problems and creating their care plans. The chance of either identifying an incorrect problem or failing to identify is largely increased when pharmacists only have access to the patient’s medication record in the pharmacy. Providing pharmacists access to health records can help to reduce the amount of time and limit the possibility of error when conducting medication therapy management to provide optimal patient care. With the advancement of electronic health records, the ability of pharmacists in any setting to access information about their patient can become possible.

I found this study to be significant in highlighting the importance of the collaboration of an interprofessional healthcare team in caring for patients. When the pharmacists were able to access another provider’s documentation and care plans, they could accurately identify problems and were able to provide more effective care plans themselves. I believe that this further emphasizes what we have learned in POP1/2 in interacting with patients. We have always communicated with the patient’s provider so that the healthcare team is well informed of the actions taken with each patient and so that nothing is overlooked. It is reassuring to know that we are developing as student pharmacists and will be prepared to begin our careers knowing newly developing and effective methods of practice.

Reference:

J Am Pharm Assoc. 2015;55:278-281.

http://www.japha.org/article/S1544-3191(15)30060-1/pdf

Keeping kidneys safe: The pharmacist’s role in NSAID avoidance in high-risk patients

The use of NSAIDs, both prescription and OTC, continues to grow each year. Furthermore, NSAIDs are one of the most common drug classes inappropriately prescribed to older patient populations. This is an alarming issues as NSAIDs can lead to long-term complications putting at-risk patients at a higher chance of developing an acute kidney injury (AKI), which can lead to the development or progression of chronic kidney disease (CKD). It was found that 5% of patients with documented kidney disease use OTC NSAIDs on a regularly basis with 66.1% of those patients using NSAIDS for over a year.

Over 70 million prescriptions are filled each year for NSAIDs, while an additional 30 billion are purchased over the counter. NSAIDs put patients at risk for an acute kidney injury because they can lead to a disruption of blood flow to the kidneys. Reduced blood flow and kidney function results in symptoms that can be recognized as elevated blood urea nitrogen and serum creatinine levels, decreased urine output, and weight gain. Additionally, NSAIDs inhibit prostaglandin-mediated renin release, which can lead to hyperkalemia as the kidney’s ability to excrete potassium is reduced.

Chronic kidney disease is a public health epidemic, with 26 million Americans living with CKD and another 20 million at risk for developing it.  The major causes of CKD are diabetes and hypertension, making it a highly preventable disease if high-risk patients are recognized and their drug therapies optimized. Therefore, the majority of NSAID-induced AKI leading to CKD can be avoided.

Community pharmacy NSAID-counseling at the time of dispensing or purchase of OTCs allows for frequent patient interaction and continuous education. Similar targeted counseling in community pharmacies has proven to be effecting, providing hope that pharmacists can successfully educate patients on the risks of NSAIDs and development of kidney complications. Even without significant lab data, pharmacists can review patient medication profiles and screen for certain risk factors that may predispose a patient to developing an AKI. Risk factors include antihypertensive medications, especially ACEs, ARBs, and diuretics, anti-diabetics, digoxin, or any other medications used to treat chronic liver disease. After high-risk patients have been identified, pharmacists can initiate counseling on the dangers of using NSAIDs by marking their prescriptions with brightly colored stickers or tags as a reminder. In a busy pharmacy with limited time, patients can be provided with brochures and handouts out on the safe use of NSAIDS. If patients are resistant to stopping the use of NSAIDs, pharmacists can counsel them on the taking the lowest possible dose for no more than 10 days.

I found this article to be very interesting and also extremely relevant to what we are currently leaning in anatomy about kidney function. Furthermore, this article explores another way in which pharmacists can provide care and improve the health of our patients. Even as student pharmacists, we can be aware of the prominent use of NSAIDs and must recognize when they can be detrimental to a patient’s well-being. By being informed that older population and those with diabetes or hypertension are at a greater risk for developing an acute kidney injury when using an NSAID, we can better recognize high-risk patients and possibly prevent complications from occurring. This may be especially relevant as we begin going to our Silver Scripts sites and caring for older adults who especially susceptive to CKD. We must remember to ask about over-the-counter medications that our patient may be taking, including NSAIDs, and be prepared to counsel them on dangers and safe use to prevent injury or costly hospitalization.

 

Reference:

J Am Pharm Assoc. 2015;55:15-25.

http://www.japha.org/article/S1544-3191(15)30021-2/pdf