Proportion of work appropriate for pharmacy technicians in anticoagulation clinics

A two-part study helped to determine how much of a pharmacists work in an anticoagulation clinic (AC) could be shifted to CPTs. A group of eight clinical pharmacists and four pharmacy technicians from VA Anticoagulation clinics used a categorization technique called the Delphi process to categorize AC tasks as either appropriate or inappropriate for a CPT.

Methods included interviewing CPTs about their current roles and duties within the AC, and asking clinical pharmacists to categorize tasks currently performed at the AC as appropriate or inappropriate for an AC to perform. The framework for a standard job description for a CPT within an anticoagulation clinic was compiled. Then, an investigator observed one pharmacist at a single AC completing all of the tasks three different times.

It was found that most of the CPTS from the AC locations investigated performed administrative duties, took phone calls regarding refilling prescriptions, and clarifying dosing. CPTS also contacted no show patients and rescheduled their appointments. Two of four CPTs at one AC clinic had roles that were extended to include the clinical, task based role of calling patients with in-range INRs, which inherently includes interviewing, documenting, and scheduling. Clinical pharmacists reported that it was appropriate for CPT’s to perform administrative tasks and even some clinical tasks. There were mixed opinions of clinical pharmacists on whether point of care finger-stick INR rests, answering questions about interactions, and renewing warfarin prescriptions were appropriate or not.

This study shows that further training CPT’s to take on some of the more clinical based work within the scope of appropriateness can alleviate some time for pharmacists. I think that in the setting of an anticoagulation clinic, more specialized technicians can really be a valuable asset.

 

Am J Health-Syst Pharm. 2016;73(5):322-327. Link to Article

Impact of Clinical Pharmacists on Initiation of Postintubation Analgesia in the Emergency Department

Clinical pharmacists trained in emergency medicine can intervene to help optimize drug therapies and efficiency in emergency rooms. In this cohort study, pain and anxiety associated with the ventilation of patients in the emergency department was specifically studied and the rate of initiation of postintubation analgesia in the ED by clinical pharmacists was measured. The primary endpoint was overall frequency of initiating analgesia after intubation. The secondary outcomes were frequency of sedative or anti-anxiety drug use without analgesia, time to initiation of posintubation analgesia, and adverse drug events caused by discontinuing analgesics.

Forty-one patients from a mixed adult and pediatric ED were selected for use from a pool of 180 pre-screened patients. ED pharmacy specialists arranged to have premixed fentanyl infusions stocked in automated dispensing cabinets. Electronic medial records of the patients were reviewed, and definitions for intubation, indications, ADES, time of intubation and medication administration were established before data collection. After statistical analysis, initiation of posintubation analgesia was seen to be increased after clinical pharmacist intervention, from 20% to 49%. In a preintervention group, more patients received solely sedation and no analgesics. The time of initiation of analgesia following intubation decreased from 98 minutes to 45 minutes.

Pharmacists in the emergency room can help to focus patient care and make sure intubated patients’ pain is being managed. Do you think that pharmacists should be required to assess if patients would benefit from analgesics after intubation, and possibly manage these analgesic drugs for all patients? Based off this study, what other important areas in emergency medicine do you think pharmacists can be utilized in?

 

J Emerg Med. 2016;50(2):308-314. Link To Article

Evaluation of a pharmacist-run antiarrhythmic clinic in an ambulatory practice

A private practice in Findlay, OH has five staff pharmacists and 15 staff physicians. An evaluation was conducted of one of the pharmacist run clinics where the pharmacists coordinate and monitor results as well as interact with patients. The clinic focused on giving antiarrhythmic treatment and this study evaluated the adherence of patients to amiodarone and sotalol. These antiarrhythmic drugs play a huge role in treating cardiac arrhythmias like atrial fibrillation and atrial flutter, and need to be closely monitored.

A chart review was conducted to compare adherence to the monitoring protocols for the patients referred to the pharmacist run clinic. Patients included on the review were on amiodarone or sotalol and had been taking the drug for 6 months. The medications must have been managed by a clinical pharmacist to be included. Statistical analyses were performed using the Pearson’s chi-square test or Fisher exact test. Out of the total 130 patient charts reviewed, pharmacists identified 59 adverse effects caused by amiodarone. These included increased hepatic enzymes, increased thyroid function, decreased thyroid function, QT prolongation, and decreased pulmonary function. Three adverse effects caused by sotalol were identified. A total of 39 pharmacist interventions were identified: 25 patients required increased monitoring, 4 patients required dosage decreases, and 8 patients were started on levothyroxine therapy.

This study highlights the importance of pharmacists in an interdisciplinary team when managing a specific disease state with complicated drugs. Increasing pharmacist-provided care for patients using antiarrhythmic drugs resulted in better drug therapy outcomes as well as changes in drug therapy that might not have otherwise been initiated. I found it interesting that in this study, patient referrals to the pharmacist clinic are based completely on the prescriber’s decision. Here, the physicians and pharmacists seem to have an effective and collaborative relationship and I think that many other healthcare settings could be positively influenced by this same type of model.

J Am Pharm Assoc. 2015; 55(5):546-552. Link to Article

Antenatal Betamethasone for Women at Risk for Late Preterm Delivery

The effects of betamethasone in increasing survival rate and respiratory distress of infants born at 34-36 weeks of gestation (late preterm) were investigated. A total of 17 university-based clinical centers were selected and women with a singleton pregnancy at 34 weeks + 0 days to 36 weeks +5 days of gestation with a high probability of late preterm delivery were selected. Women were not eligible for the study if they had received antenatal glucocorticoids at all during her pregnancy or if the patient was expected to go into labor in less than 12 hours.

The treatment of patients followed a strict protocol, and placebos were randomly assigned. Women either received a course of two intramuscular injections of 12 mg betamethasone or a matching placebo, 24 hours apart. The participants and the investigators were both unaware of the treatment and study group assignments. If delivery did not occur, patients were discharged if they were assessed to be stable, and for women who were suspected to go into preterm delivery at that time, labor inductions and C-sections were scheduled accordingly. Outcomes analyzed for this study were the need for respiratory infant support 72 hours after birth and the use of a continuous positive airway pressure cannula to assist with breathing.

It was found that administration of betamethasone decreased the risk for substantial respiratory assistance in infants born late preterm. The rate of the primary outcome, respiratory support, was lower in the betamethasone group than in the placebo group by about 4%. Serious maternal adverse events occurred in 10 women.

In a study such as this one, administering a drug to pregnant women who have high chance of an early delivery or complications can be dangerous. I found it shocking that there were no pharmacists listed as an author or contributor to this study. As I read this article, I was consistently drawn back to how these medical professionals handled patient care, since having a high risk pregnancy is extremely scary for some women. While pregnant, taking a drug whose effects are still being studied is probably even more unsettling.

 

NEJM. 2016;1-10. Link to Article

Development of an algorithm to assess appropriateness of overriding alerts for nonformulary medications in a computerized prescriber-order-entry system

Hospital use formularies, or lists of medications and products agreed on by an institutions’ healthcare providers, to routinely guide which medications are ordered, stocked, and dispensed for patients. The use of non-formulary medications (NFMs) is inevitable, however, because often patients are already taking a different medication before admission and cannot switch. Non-formulary medications are associated with an average labor cost ranging from $15.94 to $23.34 per order, and most prescribers are likely to have therapy delays when using NFMs very formulary alternatives.

A random sample study done at the Brigham and Women’s hospital investigated an algorithm for assessing how appropriate physicians non-formulary medication alert override were. Reasons selected by physicians for why they override alerts when attempting to use a non-formulary medications were categorized. Among the random sample of 5000 NFM alert overrides, there were 1157 unique reasons given by doctors to justify formulary deviation. Nine override response categories were made. They included: no reason, home or preadmission medication, disease or condition listens, marginal value for NF decision, specialist recommendation, therapeutic failures of other medication, pharmacologic reasons, end-of-life care/comfort measure, and drug shortage. Providers most commonly provided no reason for overriding the NFM alert and about one third of reasons fell into the “home or preadmission” category. The article discussed the long standing issue discussed in literature about preadmission medications and non-formulary medications. The author mention that there is currently insufficient data to guide hospitals on how to effectively handle this issue of the frequency of use of NFM’s and the wide range of reasons for deviation.

This study concluded that they were unsure how this developed algorithm and range of results compared to other NFM override reasons, simply due to a lack of research. While this study and this algorithm is only just a baseline evaluation of the complex reasons and decisions between using formulary and non-formulary medications, I find it interesting to consider the practical reasonings of using both non-formulary and formulary medications in a hospital. As a physician, I am sure it can become irritating to always have to provide reasons for selecting a medication in which you believe is the best for your patient. On the other hand, though, pharmacies cannot possibly carry all medications – they must try and direct medication orders to be formulary for both cost and practical reasons.

 

Am J Health-Syst Pharm. 2016; 73:e34-45 Link to Article

Endocrine Effects of Inhaled Corticosteroids in Children

The effectiveness of inhaled corticosteroids (ICSs) in treating various chronic respiratory illnesses, such as allergic rhinitis, asthma, and cystic fibrosis, has increased over the years. Newer devices and formulations of the inhaled drug have reduced local adverse effects, but the improved delivery of the drug to the lungs increases systemic absorption and consequently can present a new set of adverse effects. This review article reviews the range and severity of these effects in children and sites various recommendations for prescribers and health care professionals when giving such inhalants.

The most serious potential adverse effect that can result from inhaled corticosteroids is adrenal insufficiency. Long term use of ICSs in children can lead to bone mineralization, DM1 and DM2, obesity, and this insufficiency, or suppression of the hypothalamic-pituitary-adrenal. The authors reviewed a case study on a 7-year-old female that presented with a new onset seizure due to adrenal insufficiency after using an inhalant regimen to treat her asthma. They concluded that clinical effectiveness of inhalants and systemic absorption have a strong positive correlation that can only be partially explained by the device and formulation modifications of the drug. Conclusions and research were also done on the drugs’ effects on bone mineral density, which were found to be mild, and suppression of linear growth, which were found to be slightly correlated. The article presents that generally, inhaled corticosteroids are safe and effective drugs, but life-threatening endocrine effects can occur even with normal doses. It is suggested that reducing systemic adverse effects could require increasing drug protein binding and rapid clearance time, as well as decreased lipophilicity.

This article brings to light something that most parents of children using inhaled corticosteroids are unaware about. I think that using education in this case is probably the best way to avoid this problem, seeing as inhaled corticosteroids are the most effective treatment in reducing respiratory distress. Pharmacists caring for children that routinely use ICSs could really play a major part in watching for adverse endocrine effects by providing correct dosing schedules and learning about how often patients use their inhalers.

JAMA Pediatr. 2016;170(2):163-170. Link to Article

 

Antidepressants’ Black Box Warning: 10 Years Later

Almost ten years after the antidepressant black-box warning was first issued by the FDA, the impact of this labeling is now being weighed against the growing number of untreated cases of depression in the United States. This review article considers how drastically the FDA’s decision to warn the public of this risk has influenced prescribing patterns and rates of depression with the epidemiological data now available.

This article first discusses the increased risk of suicidal thinking, feeling, and behavior in young people taking antidepressants and the basis for issuing the black box warning. The initial 372 clinical trials showed that 4% of patients receiving the antidepressant displayed suicidal thinking compared with 2% of placebo, and age analyses did show that this increased risk was higher in children under the age of 18.

Now, a cohort study revealed that there has been a reduction in antidepressant use within two years after the FDA advisory was issued. Reductions of 31%, 24.3%, and 14.5% in adolescents, young adults, and adults were seen, respectively. It was also found that the number of adults with depression who did not receive an antidepressant medication increased from 20% to 30% from 2003 to 2004. Other trends that have seem to emerged since the FDA advisory include an increase in psychotropic-drug poisoning, although trends are not directly proven to be related to intentional suicide attempts. This review really calls for an increased knowledge and education, most importantly for primary care providers, to know the risk posed by untreated depression – and how to balance this risk with the small risk associated with antidepressant treatment to best help their patients.

This article really brought to light something I had never thought about before in regards to antidepressant pharmacotherapy. Black-box warnings are obviously important in helping the public understand the risks associated with their medications. I personally had never thought that such a warning on antidepressants may really reverse the goal of using SSRIS. A question I have is how pharmacists may be able to bridge this gap between the benefits of using antidepressants and the reluctance of patients to want to start medication therapy because of this black box warning?

New England Journal of Medicine. 2014;371:18. Link to Article

Pilot study of patient perception of pharmacists as care providers based on student pharmacist health screening

The role of pharmacists as reliable health care practitioners is a perception that is still evolving today. A pilot study done at the University of of Minnesota evaluated patient perceptions on the care pharmacists can provide to patients, mainly through student pharmacist-led interactions with patients. By allowing student pharmacists to use the AIDET communication technique learned in pharmacy courses, perceptions on both student pharmacists and registered pharmacists were discussed. The AIDET communication technique stands for acknowledge, introduce, duration, explanation, and thank you. The acronym allows student pharmacists and providers to create a patient focused interaction eloquently and to allow students to develop a culture of service. The University of Minnesota College of Pharmacy incorporates this framework early in their curriculum with the hope to make future patients of pharmacists feel comfortable with their health care interactions.

This study used an IRB-approved survey that assessed current perceptions of pharmacists and patient awareness of pharmacist involvement in point of care (POC) services. It also gauged how patients felt about pharmacy students performing health screenings. All survey participants provided information on their normal pharmacy experiences, education and income level, demographics. At the health fair, patients blood glucose, blood pressure, and bone density were screened. Responses were recorded before and after student assessments using AIDET communication. Results from this pilot study indicated that only 94.8% of patients surveyed prior to AIDET implantation said they would consider seeing a pharmacist to provide the selected health screenings, and 100% of patients responded that they would after AIDET implantation. Overall, a majority of those respondents 65 and older said they knew before the health fair that pharmacist was able to provide POC screening. 50% of participants indicated that they were trusting of the student pharmacists performing their screenings before the interaction, and 70% indicated that they were trusting post-AIDET implementation.

I think that it’s extremely relevant for pharmacy students to try and understand the perceptions their patients have of pharmacists in general – because this will almost always influence their interactions with us as student pharmacists. It can be scary as a student to interact with patients and provide accurate health information. It often crosses your mind if your patient even think that their community pharmacist is a trusted and reliable professional. The AIDET mnemonic sited in this study seems to be a good way to introduce the basics of patient communication to students, however, I think that students should be careful in getting stuck using a rigid framework in their practice. This may make it more difficult in the future to adapt to some of the harder or difficult patient interactions they are sure to experience as a practicing pharmacist and professional.

 

J Am Pharm Assoc. 2015;55:626–633. Link to Article: http://www.japha.org/article/S1544-3191(16)30007-3/pdf