Providence Pharmacy PGY2 Program at Providence Medical Group 2020

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  Clinical Pharmacist-Led Intervention to Improve Statin Metric for Secondary Prevention at Providence Medical Group – Southern Oregon Region

  Chloe Nguyen, Judy Wong, and Karen White

  Clinical Pharmacist-Led Intervention to Improve Statin Metric for Secondary Prevention at Providence Medical Group – Southern Oregon Region

  Chloe Nguyen, PharmD, Judy Wong, PharmD, BCACP, and Karen White, PharmD, BCACP

  Background: Currently, there is a gap in meeting the statin metric at Providence Medical Group in Southern Oregon Region. The purpose of this project is to identify intervention strategies to improve statin metric for secondary prevention among patients with clinical atherosclerotic cardiovascular disease (ASCVD).

  Methods: This quality improvement project was approved by the system’s Institutional Review Board. Patients at least 18 years of age with diagnosis of clinical ASCVD not prescribed statin therapy or prescribed sub-optimal statin therapy were included. Different strategies were implemented at Central Point Family Medicine Clinic. A presentation was delivered to the providers in late December to address barriers with statin prescribing. Pre- and post-surveys were collected to assess the effectiveness of the presentation and knowledge of providers regarding statin prescribing in patients with clinical ASCVD. Chart reviews were performed in January on identified patients to provide recommendation to providers. The primary outcomes were to assess impact of academic detailing intervention on perceived barriers on statin initiation or optimization via pre- and post-surveys and to calculate the percentage of approved recommendation from providers. The secondary outcome was the percentage of statins prescribed per each intervention strategy: refer to clinical pharmacist for management, discuss statin therapy during the next appointment with provider, or update problem list and medication list.

  Results: Prior to the intervention, a majority of providers believed that statins caused myopathy, liver injury, and rhabdomyolysis which can influence their decision when prescribing statin therapies and discussing statin treatment with patients. Post-survey results showed a slight decrease in belief that statins cause myopathy, liver injury, incidental diabetes, cognitive impairment and rhabdomyolysis. In addition, providers were more likely to retry a different statin or at a lower dose if patient had a documented intolerance to previous statin therapy following education.

  In a sample of 35 chart reviews, 5 patients were receiving sub-optimal statin therapies, 7 had documented reason for statin intolerance, and 3 were not candidates to receive high intensity statin. A majority of recommendations were approved by providers. The most common intervention chosen by providers (51.4%) was to discuss statin options with patient in next office visit. However, no changes were observed from this intervention. Out of the 10 patients who were referred to clinical pharmacy services for management, 5 declined statin and 4 were unable to reach. Only one patient was successfully started on high intensity statin.

  Conclusions: Beliefs and approaches to statin discussions are varied among PCPs and can be contributing factors for statin initiation or optimization. These results highlight the complexity of finding interventions that would be most successful for improving statin metric for secondary prevention among patients with clinical ASCVD. Nonetheless, we can be vigilant about working with providers to provide recommendations for the remaining patients with clinical ASCVD and create appropriate follow-up plans for those who were unable to be reached and those who do not have upcoming appointment with providers.

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  Effect of a pharmacist-led antimicrobial stewardship (AMS) program on outpatient fluoroquinolone prescribing in the elderly

  Katie LaRue, Chelsea Mannebach, and Bonnie Jiron

  Title: Effect of a pharmacist-led antimicrobial stewardship (AMS) program on outpatient fluoroquinolone prescribing in the elderly

  Authors: LaRue, Katie PharmD; Mannebach, Chelsea PharmD, BCPS, BCACP; Jiron, Bonnie, PharmD, BCACP

  Introduction: The Center for Disease Control and Prevention, the Society of Infectious Diseases Pharmacists, and American Pharmacists Association recognize the need for outpatient AMS programs and the important role pharmacists play in appropriate prescribing. Fluoroquinolones (FQ) pose many risks, highlighted by U.S Food and Drug Administration safety warnings, including aortic dissection, hypoglycemia, mental health side effects, and tendonitis, along with the risk of Clostridium difficile infections, particularly in the elderly.

  Outcomes: The primary outcome is to determine the change in the number of FQ prescriptions written for patients ≥65 years of age in the primary care setting between March 2018 and 2019, and March 2019 and 2020. Secondary objectives include determining the appropriateness of fluoroquinolone prescriptions before and after education intervention, and provider attitudes towards outpatient AMS.

  Methods: Education on fluoroquinolone antibiotic risks, safety warnings, and guideline-directed uses was provided to prescribers in February 2020. During education, prescribers were given a report of the number of fluoroquinolones prescribed to patients ≥65 years of age during March 2018 and March 2019 with comparison to other prescribers. Data was collected for March 2020 and a similar report was given to prescribers. Approximately 15% of fluoroquinolone prescriptions were reviewed for secondary outcomes. Changes in fluoroquinolone prescriptions will be analyzed by Bayesian inference and secondary outcomes will be reported with descriptive statistics.

  Results: There was a decrease in the total number of fluoroquinolone prescriptions in March 2020 (n=134) compared to March 2019 (n=200) and March 2018 (n=272). After secondary review of 15% of these prescriptions, there was an increase in appropriately prescribed fluoroquinolones from 2.4% in March 2018 (n=41) to 27.8% in March 2020 (n=18). Of 118 providers surveyed before and after the educational presentation, 6.8% correctly identified all risks associated with fluoroquinolone therapy prior to the education and 84.1% correctly identified all risks associated with fluoroquinolone therapy after receiving education. After the education, an increase in providers reported being very comfortable discussing the risks and benefits of FQ therapy with their patients, from 23% prior to the education to 65% after the education.

  Conclusions: Provider education on risks associated with fluoroquinolone use in the elderly and individualized provider reports was associated with a decrease in total fluoroquinolones prescribed to patients ≥65 years of age in the included primary care clinics. Additionally, a higher percentage of fluoroquinolones were prescribed appropriately based on evidence-based guidelines. Ongoing AMS efforts are needed to continually improve patient safety and reduce unnecessary antimicrobial exposure.

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  Impact of academic detailing on clinical pharmacy specialist involvement in medication assisted

  Lindsey M. Bartos, Kristin A. Tallman, and Dara L. Johnson

  Title: Impact of academic detailing on clinical pharmacy specialist involvement in medication assisted treatment for opioid use disorder in a primary care setting

  Lindsey Bartos, PharmD; Kristin Tallman, PharmD, BCPS, BCACP; Dara Johnson, PharmD, BCPP, BCACP

  Introduction: Opioid prescribing and opioid overdose deaths have increased steadily since the 1990s, reaching a 6-fold increase between 1999 and 2017. The opioid crisis, as it became known, was declared a public health emergency in 2017. In 2018 alone, an estimated two million people had a diagnosed opioid use disorder (OUD). The use of medication-assisted treatment (MAT) for OUD reduces the use and cravings of opiates, and risk of all-cause and opioid-related mortality. The inclusion of clinical pharmacy specialists (CPSs) on multidisciplinary healthcare teams has been shown to improve health outcomes, increase cost-effectiveness, and improve the quality of healthcare. Nevertheless, CPS involvement in MAT for OUD in a primary care setting remains limited. This study will provide information regarding barriers to CPS involvement in MAT, and the effectiveness of academic detailing provided to CPSs in increasing CPS involvement.

  Objectives: The objectives of this project are to identify and describe the most common barriers to CPS involvement in MAT for OUD, then assess the impact of academic detailing on CPS comfort level with being involved in the care of patients undergoing MAT for OUD in the primary care setting. Additionally, this project will assess the hypothesis that academic detailing will increase the number of patients with a CPS involved in the treatment of OUD.

  Methods: Study participants are CPSs recruited from a large medical group in Oregon and SW Washington who completed a survey before and after participating in academic detailing. The pre-survey was used to assess demographics, current involvement with MAT, perceived barriers to involvement in MAT, and asked participants to anonymously assess their comfort level, knowledge, and beliefs regarding MAT for OUD using a 0-5 point scale. Academic detailing was developed based on reported barriers, and consisted of handouts, two 45 minute interactive presentations, and small group work with case-based application. Participants then filled out a post-survey to re-assess their comfort level, knowledge, and beliefs regarding MAT for OUD following academic detailing. Survey results were compared and summarized by using either % of respondents in each category or mean (standard deviation) for each question across all respondents, then compared using a Wilcoxon-rank-sum test. CPS involvement in MAT will be reassessed using a survey or electronic intervention tracking in June.

  Results: 19 CPSs responded to the pre-survey and 20 CPSs responded to the post-survey. 4 respondents (21.05%) were currently active in MAT, and of these respondents, 3 indicated they are involved with MAT for 1-5 patients annually, and 1 indicated they are involved with MAT for 20+ patients annually. The most common barriers to involvement in MAT were lack of time (23.08%), lack of X-waivered providers (23.08%), and lack of knowledge regarding MAT (21.15%). There was no change in the number of CPSs involved in MAT between the pre-survey and the post-survey. Median responses to 6 of the 8 survey questions differed significantly between the pre and post surveys (p

  Conclusions: Most CPSs within PMG are not involved in the use of buprenorphine in MAT for OUD, likely due to a combination of time constraints, a lack of providers with the ability to prescribe buprenorphine, and unfamiliarity with buprenorphine in MAT. Following academic detailing to address these barriers, CPS comfort with buprenorphine in MAT had significantly improved in most areas. CPS involvement in MAT for OUT will be reassessed in June, 3 months following the academic detailing intervention.

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  Impact of pharmacist-led appointments for hypertension management in a primary care setting: a retrospective analysis

  Anne Marie Thibodeaux, Christine Doran, and Ben Rosati

  Impact of pharmacist-led appointments for hypertension management in a primary care setting: a retrospective analysis

  Introduction: High blood pressure is a major risk factor for heart disease and stroke, two of the leading causes of death for Americans.1 Evidence supports the idea that pharmacist-led hypertension management can result in overall blood pressure reduction; however, it remains unclear whether pharmacist-led initiatives can also improve performance metrics.2-5

  Research question: Can pharmacist-led appointments for blood pressure management positively impact hypertension metrics?

  Study design: Retrospective chart review

  Methods: Primary outcome data was measured via metric inventory, defined as percentage of patients who had reached their blood pressure goal. Two time points were compared at two primary care clinics (1 month before the pharmacist-led HTN appointments were established compared to 4 months after) to determine a potential change in percentage of patients achieving BP goal. Secondary outcome data was obtained via chart review for patients whose hypertension was managed by the pharmacist (n=50) and matched patients managed by their primary care physician (n=50).

  Results: Overall, the metric for Clinic A decreased from 74.7% to 73.5%, and Clinic B decreased from 72.2% to 65.5%, illustrating less patients had achieved their blood pressure goal. However, a change in the metric definition occurred in the middle of the study period, which may explain the percentage decrease. Examining pharmacist visits, only 38% of patients were at their goal blood pressure initially, but 80% of patients were at their BP goal during their final visit. Pharmacists had an average of 2.2 medication interventions per patient per visit.

  Conclusions: The overall change in the metric does not suggest pharmacist-led appointments for hypertension management can positively impact the metric; however, changes in the metric definition interfered with proper assessment. Overall, pharmacists were able to optimize medication regimens, and almost half of the patients who were not at goal initially were able to achieve it within 4 months.