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Purpose This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2021 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring, and monitoring/medication reconciliation. Articles evaluating at least one step of the MUP were assessed for their usefulness toward practice improvement. Summary A PubMed search was conducted in January 2022 for articles published in calendar year 2021 using targeted Medical Subject Headings (MeSH) keywords, and searches of the table of contents of selected pharmacy journals were conducted, providing a total of 7,178 articles. A thorough review identified 79 potentially practice-enhancing articles: 15 for prescribing/transcribing, 17 for dispensing, 4 for administration, 21 for monitoring, and 22 for monitoring/medication reconciliation. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of their importance within health-system pharmacy. The other articles are listed for further review and evaluation. Conclusion It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful publications. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level. [ABSTRACT FROM AUTHOR]

Purpose We describe the implementation and ongoing maintenance of CYP2C19 and CYP2D6 focused pharmacogenetic (PGx) testing to guide antidepressant and antianxiety medication prescriptions in a large rural, nonprofit health system. Summary Depression and anxiety are common psychiatric conditions. Sanford Health implemented PGx testing for metabolism of cytochrome P450 (CYP) isozymes 2C19 and 2D6 in 2014 to inform prescribing for multiple medications, including antidepressant and antianxiety therapies. As guidelines, genotype to phenotype translation, panel offerings, and other resources are updated, we adapt our approach. We make educational and informational materials available to providers and patients. Pharmacogenomic clinical pharmacists review PGx results with discrete values and provide guidance documentation in the electronic medical record. A robust clinical decision support system is in place to provide interruptive alerts, noninterruptive alerts, and genomic indicators. A referral-based interdisciplinary clinic is also available to provide in-depth education to patients regarding PGx results and implications. Additionally, partnering with our health plan has expanded access to PGx testing for patients with anxiety or depression. Conclusion The implementation and maintenance of Sanford Health's PGx program to guide antidepressant and antianxiety medication use continues to evolve and requires a multipronged approach relying on both human and informatics-based resources. [ABSTRACT FROM AUTHOR]

Purpose To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2024 in the United States, with a focus on the nonfederal hospital and clinic sectors. Methods Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2024 were reviewed—including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, endocrine drugs, generics, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2024 were based on a combination of quantitative analyses and expert opinion. Results In 2023, overall pharmaceutical expenditures in the US grew 13.6% compared to 2022, for a total of $722.5 billion. Utilization (a 6.5% increase), new drugs (a 4.2% increase) and price (a 2.9% increase) drove this increase. Semaglutide was the top drug in 2023, followed by adalimumab and apixaban. Drug expenditures were $37.1 billion (a 1.1% decrease) and $135.7 billion (a 15.0% increase) in nonfederal hospitals and clinics, respectively. In clinics, increased utilization drove growth, with a small impact from price and new products. In nonfederal hospitals, a drop in utilization led the decrease in expenditures, with price and new drugs modestly contributing to growth in spending. Several new drugs that will influence spending are expected to be approved in 2024. Specialty, endocrine, and cancer drugs will continue to drive expenditures. Conclusion For 2024, we expect overall prescription drug spending to rise by 10.0% to 12.0%, whereas in clinics and hospitals we anticipate an 11.0% to 13.0% increase and a 0% to 2.0% increase, respectively, compared to 2023. These national estimates of future pharmaceutical expenditure growth may not be representative of any health system because of the myriad of local factors that influence actual spending. [ABSTRACT FROM AUTHOR]

The article discusses the American Society of Health-System Pharmacists (ASHP) and Society of Infectious Diseases Pharmacists (SIDP) joint statement on the pharmacist's role in antimicrobial stewardship (AMS) in 2023. Topics covered includes establishing AMS programs as a priority with dedicated resources, promoting optimal use of antimicrobial agents, and education and training for pharmacists involved in AMS. Also noted is the need for all pharmacists to promote AMS efforts.

Purpose To describe the implementation of clinical decision support tools for alerting prescribers of actionable drug-gene interactions in the Veterans Health Administration (VHA). Summary Drug-gene interactions have been the focus of clinicians for years. Interactions between SCLO1B1 genotype and statin medications are of particular interest as these can inform risk for statin-associated muscle symptoms (SAMS). VHA identified approximately 500,000 new users of statin medications prescribed in VHA in fiscal year 2021, some of whom could benefit from pharmacogenomic testing for the SCLO1B1 gene. In 2019, VHA implemented the Pharmacogenomic Testing for Veterans (PHASER) program to offer panel-based, preemptive pharmacogenomic testing and interpretation. The PHASER panel includes SLCO1B1 , and VHA utilized Clinical Pharmacogenomics Implementation Consortium statin guidelines to build its clinical decision support tools. The program's overarching goal is to reduce the risk of adverse drug reactions such as SAMS and improve medication efficacy by alerting practitioners of actionable drug-gene interactions. We describe the development and implementation of decision support for the SLCO1B1 gene as an example of the approach being used for the nearly 40 drug-gene interactions screened for by the panel. Conclusion The VHA PHASER program identifies and addresses drug-gene interactions as an application of precision medicine to reduce veterans' risks for adverse events. The PHASER program's implementation of statin pharmacogenomics utilizes a patient's SCLO1B1 phenotype to alert providers of the risk for SAMS with the statin being prescribed and how to lower that risk through a lower dose or alternative statin selection. The PHASER program may help reduce the number of veterans who experience SAMS and may improve their adherence to statin medications. [ABSTRACT FROM AUTHOR]

Purpose To compare rates of prescriber acceptance of interruptive and noninterruptive clinical decision support (CDS) alerts regarding potential diminished therapeutic effectiveness and safety risks associated with proton pump inhibitor (PPI) use in carriers of gene variants affecting cytochrome P450 (CYP) isozyme 2C19 metabolism. Methods A retrospective study was conducted at a large rural health system to examine different approaches to improving CDS alert acceptance while minimizing alert fatigue. Manual reviews were conducted to identify alerts regarding CYP2C19 metabolizer status displayed at the time of PPI ordering over 30-day periods before and after the transition from interruptive to noninterruptive CDS alert functionality. A chi-square test was conducted to analyze prescriber acceptance of CDS recommendations by alert modality and type of treatment modification. Results Overall, interruptive alerts had an acceptance rate of 18.6% (64/344), compared to 8.4% acceptance (30/357 alerts) for noninterruptive alerts (P ≤ 0.0001). Analysis of acceptance criteria -revealed the noninterruptive alert cohort had higher acceptance, as determined by documented medication dose adjustments, than the interruptive alert cohort (53.3% [16/30] and 4.7% [3/64], respectively). The difference in acceptance rates by CDS modality and treatment modification was statistically significant (P ≤ 0.00001). The predominant indication for PPI use was gastroesophageal reflux disease (GERD) in both cohorts. Conclusion Interruptive alerts that actively influenced workflow had higher acceptance rates than noninterruptive alerts that served an informational purpose without a direct disruption of workflow. The study results suggest the utilization of noninterruptive alerts may be a beneficial tool for prompting clinicians to alter dosing regimens rather than transition to an alternative agent. [ABSTRACT FROM AUTHOR]

Purpose Results of the 2022 ASHP National Survey of Pharmacy Practice in Hospital Settings are presented. Methods Pharmacy directors at 1,498 general and children's medical/surgical hospitals in the United States were surveyed using a mixed-mode method of contact by email and mail. Survey completion was online. IQVIA supplied data on hospital characteristics; the survey sample was drawn from IQVIA's hospital database. Results The response rate was 23.7%. Inpatient pharmacists independently prescribe in 27.1% of hospitals. Advanced analytics are used in 8.7% of hospitals. Pharmacists work in ambulatory or primary care clinics in 51.6% of hospitals operating outpatient clinics. Some level of pharmacy service integration is reported in 53.6% of hospitals. More advanced pharmacy technician roles are emerging. For health systems offering hospital at home services, 65.9% of pharmacy departments are involved. Shortages of pharmacists and technicians were reported but are more acute for pharmacy technicians. Aspects of burnout are being measured in 34.0% of hospitals, and 83.7% are attempting to prevent and mitigate burnout. The average number of full-time equivalents per 100 occupied beds is 16.9 for pharmacists and 16.1 for pharmacy technicians. Conclusion Health-system pharmacies are experiencing workforce shortages; however, these shortages have had limited impact on budgeted positions. Workforce challenges are influencing the work of pharmacists and pharmacy technicians. Adoption of practice advancement initiatives has continued the positive trend from past years despite workforce issues. [ABSTRACT FROM AUTHOR]

Purpose To identify current challenges in detection of medication-related symptoms, and review technology-based opportunities to increase the patient-centeredness of postmarketing pharmacosurveillance to promote more accountable, safer, patient-friendly, and equitable medication prescribing. Summary Pharmacists have an important role to play in detection and evaluation of adverse drug reactions (ADRs). The pharmacist's role in medication management should extend beyond simply dispensing drugs, and this article delineates the rationale and proactive approaches for pharmacist detection and assessment of ADRs. We describe a stepwise approach for assessment, best practices, and lessons learned from a pharmacist-led randomized trial, the CEDAR (Calling for Detection of Adverse Drug Reactions) project. Conclusion Health systems need to be redesigned to more fully utilize health information technologies and pharmacists in detecting and responding to ADRs. [ABSTRACT FROM AUTHOR]

Purpose To describe the Norton Healthcare electronic antimicrobial stewardship program (E-ASP), a novel prospective audit and feedback approach that leverages the electronic medical record to overcome efficiency barriers. Additionally, to describe an accompanying opt-out antimicrobial stewardship approach that addresses provider nonresponsiveness. Summary Prospective audit and feedback is recommended by antimicrobial stewardship guidelines; however, execution can be difficult due to labor requirements, delays in communication, and provider nonparticipation. The Norton E-ASP was developed to address these issues by reliably identifying target patients, documenting assessments, streamlining recommendation delivery, promoting handoff, and providing automated tracking of recommendation responses. Opt-out stewardship allows recommendations to be implemented if not rejected after 24 hours. Conclusion A 25% reduction in target antimicrobial use has been achieved and sustained with the program. Use of the Norton E-ASP, including opt-out antimicrobial stewardship, broadened the reach and furthered the impact of infectious diseases pharmacists. Successes of this program justified addition of 3 full-time infectious diseases pharmacist positions at a large community health system. This strategy may serve as a model for tele-antimicrobial stewardship or other pharmacy recommendations. [ABSTRACT FROM AUTHOR]

The article argues for the independence of pharmacists to practice, prescribe and provide collaborative care and not to be dependent on collaborative practice agreements (SPA) with other health care practitioners. It points out the value of CPAs for the advancement of pharmacist services and the need for pharmacists to find a practitioner willing to delegate permission to provide agreed-upon services. It contends that team-based care should be the foundation for all healthcare.

Purpose To characterize ambulatory care adverse drug events reported to the Collaborative Healthcare Patient Safety Organization (CHPSO), a network of 400 hospitals across the United States, and identify addressable contributing factors. Methods We abstracted deidentified ambulatory care CHPSO reports compiled from May 2012 to October 2018 that included medication-related adverse events to identify implicated medications and contributing factors. We dual-coded 20% of the sample. We quantitatively calculated co-occurring frequent item sets of contributing factors and then applied a qualitative thematic analysis of co-occurring sets of contributing factors for each drug class using an inductive analytic approach to develop formal themes. Results Of 1,244 events in the sample, 208 were medication related. The most commonly implicated medication classes were anticoagulants (n = 97, or 46% of events), antibiotics (n = 24, 11%), hypoglycemics (n = 19, 9%), and opioids (n = 17, 8%). For anticoagulants, timely follow-up on supratherapeutic international normalized ratio (INR) values occurred before the development of symptoms. Incident reports citing antibiotics often described prescribing errors and failure to review clinical contraindications. Reports citing hypoglycemic drugs described low blood sugar events due to a lack of patient education or communication. Reports citing opioids described drug-drug interactions, commonly involving benzodiazepines. Conclusion Ambulatory care prescribing clinicians and community pharmacists have the potential to mitigate harm related to anticoagulants, antibiotics, hypoglycemics, and opioids. Recommendations include increased follow-up for subtherapeutic INRs, improved medical record integration and chart review for antibiotic prescriptions, enhanced patient education regarding hypoglycemics, and alerts to dissuade coprescription of opioids and benzodiazepines. [ABSTRACT FROM AUTHOR]

Purpose Culture response programs are an important antimicrobial stewardship strategy in the emergency department. Pharmacists often have a key role in culture response but are most often dependent on other providers to optimize a patient's antimicrobial therapy. This study assessed the impact of advanced practice pharmacists, with independent prescribing authority, on an emergency department culture response program. Methods This was a quasi-experimental preimplementation vs postimplementation evaluation performed at an academic medical center, with a 91-bed adult and pediatric emergency department, during the transition from a nurse-driven to an advanced practice pharmacist–driven program. The primary endpoint was time elapsed between initial culture review and intervention. Results Data on 200 interventions were collected from both the pre- and postimplementation phases. Median time from culture review to intervention was 5.27 hours (interquartile range [IQR], 2.8-24.2 hours) before implementation, compared to 2.95 hours (IQR, 1.4-6.1) after implementation (P < 0.001). The nurse-driven program intervened on 27% of positive cultures, while pharmacists intervened on 42% of positive cultures. The types of interventions performed and antibiotic prescribing patterns differed between the 2 study phases, but all choices were deemed appropriate by the criteria set for the purposes of this study. Conclusion The roles of advanced practice pharmacists allowed for the establishment of a streamlined culture response workflow. Culture responses occurred at a faster rate than with the previous nurse-driven program while maintaining high-quality clinical decision-making. [ABSTRACT FROM AUTHOR]

Purpose People with HIV (PWH) are at increased risk for developing atherosclerotic cardiovascular disease (ASCVD). The primary objective of this study was to evaluate adherence to guideline recommendations on statin use in PWH for both primary and secondary ASCVD prevention in a single healthcare institution. Methods A retrospective chart review was performed to evaluate statin use for cardiovascular risk reduction in PWH 40 to 75 years of age at an HIV clinic over a 1-year evaluation period. The study included patients who met one of the 4 criteria for statin therapy defined in the "ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults." Patient demographics were collected and a 10-year ASCVD risk score was calculated. Results A total of 432 PWH were evaluated for statin therapy; 205 patients (47.5%) met criteria for statin therapy. The majority of patients were male, the average age was 58 years, and the average time since HIV diagnosis was 19 years. The mean ASCVD risk score was 14.2%. Only 79 patients (38.5%) who met criteria were prescribed statin therapy, and only 45 (56.9%) were prescribed statin therapy of appropriate intensity. Use of ART pharmacokinetic enhancer was low and did not affect statin prescribing. Multivariable analysis found that age, diabetes, clinical ASCVD, and an appointment with a pharmacist clinician prescriber predicted statin utilization. A high ASCVD risk score (>20%) did not predict statin treatment. Conclusion Statin prescribing is low in PWH, who are at increased risk for ASCVD. Future research in PWH should focus on improving ASCVD risk assessment and exploring causes for statin underprescribing. [ABSTRACT FROM AUTHOR]

Purpose This article identifies, prioritizes, and summarizes published literature on the ambulatory care medication-use process (ACMUP) from calendar year 2020 that can impact ambulatory pharmacy practice. Summary The medication-use process is the foundational system that provides the framework for safe medication utilization within the healthcare environment and was reimagined to focus on new innovations and advancements in ambulatory pharmacy practice. The ACMUP is defined in this article as having the following components: transitions of care, prescribing and collaborative practice, accessing care, adherence, and monitoring and quality. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement. A PubMed search covering calendar year 2020 was conducted in January 2021 using targeted Medical Subject Headings (MeSH) keywords and the table of contents of selected pharmacy journals, providing a total of 9,433 articles. A thorough review identified 65 potentially practice-enhancing articles: 14 for transitions of care, 19 for prescribing and collaborative practice, 10 for adherence, 6 for accessing care, and 16 for monitoring and quality. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important. The other articles are listed for further review and evaluation. Conclusion It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article is the first to define and evaluate the currently published literature pertinent to the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate. [ABSTRACT FROM AUTHOR]

Purpose Gabapentin is a widely prescribed analgesic with increased popularity over recent years. Previous studies have characterized use of gabapentin in the outpatient setting, but minimal data exist for its initiation in the inpatient setting. The objective of this study was to characterize the prescribing patterns of gabapentin when it was initiated in the inpatient setting. Methods This was a retrospective cohort study of a random sample of adult patients who received new-start gabapentin during hospital admission. Patients for whom gabapentin was prescribed as a home medication, with one-time, on-call, or as-needed orders, or who died during hospital admission were excluded. The primary outcome was characterization of the gabapentin indication; secondary outcomes included the starting and discharge doses, the number of dose titrations, the rate of concomitant opioid prescribing, and pain clinic follow-up. Patients were stratified by surgical vs nonsurgical status. Results A total of 464 patients were included, 283 (61.0%) of whom were surgical and 181 (39.0%) of whom were nonsurgical. The cohort was 60% male with a mean (SD) age of 56 (18) years; surgical patients were younger and included more women. The most common indications for surgical patients were multimodal analgesia (161; 56.9%), postoperative pain (53; 18.7%), and neuropathic pain (26; 9.2%), while those for nonsurgical patients were neuropathic pain (72; 39.8%) and multimodal analgesia (53; 29.3%). The mean starting dose was similar between the subgroups (613 mg for surgical patients vs 560 mg for nonsurgical patients; P = 0.196). A total of 51.6% vs 81.8% of patients received gabapentin at discharge (P < 0.0001), while referral/follow-up to a pain clinic was minimal and similar between the subgroups (1.1% vs 3.9%; P = 0.210). Conclusion Inpatients were commonly initiated on gabapentin for generalized indications, with approximately half discharged on gabapentin. Further studies are needed to assess the impact of this prescribing on chronic utilization. [ABSTRACT FROM AUTHOR]

Purpose Discharge prescriptions represent an important aspect of care for patients seen in the emergency department (ED) setting and are used by providers to continue therapy for acute illness once patients leave the ED or to prevent future exacerbations of chronic conditions. The success of an ED discharge and the medications prescribed rely on patient compliance. Compliance depends on patients' ability to obtain prescriptions, which can be hindered by limited access to pharmacies and cost. Summary In order to address issues traditionally associated with medication noncompliance, a discharge pharmacy was implemented within a busy urban ED. The pharmacy began processing prescriptions on December 18, 2019, using a formulary aimed towards providing commonly prescribed and high-risk medications. The pharmacy accepts insurance plans in addition to utilizing 340B Drug Pricing Program pricing to offer affordable medications to patients. During the first year of operation 10,230 prescriptions were filled for 5,703 patients, representing 13% of all patients discharged during that time. Of the prescriptions filled, 35.4% were for products considered high-risk medications, including epinephrine auto-injectors, insulin, and antibiotics. Over 50% of these high-risk medications were provided to patients through reduced cash pricing. Pharmacist interventions were made on 4.3% of prescriptions to address incorrect dosing, avoid use of inappropriate antibiotics, and recommend alternative therapies. Conclusion The implementation of a discharge pharmacy within the ED allowed over 5,700 patients to be discharged with medications and represents a potential solution to issues surrounding medication noncompliance. Similar initiatives have the opportunity to improve medication access for a larger ED population. [ABSTRACT FROM AUTHOR]

Purpose Despite high type 2 diabetes mellitus (T2DM) prevalence in Medicare enrollees, newer therapeutic options, and revised treatment guidelines, little is known about US antihyperglycemic prescribing trends after 2015. This research describes recent monthly antihyperglycemic prescribing trends in a large, diverse population of Medicare enrollees from the US Mid-Atlantic region. Methods Encounter data (July 2018-July 2020) for Medicare enrollees 65 years of age or older with T2DM were extracted from electronic health records of a large integrated health system. Descriptive time-series regression models were estimated to describe monthly prescribing rates (ie, prescription orders per 100 eligible plan members with T2DM) overall and by medication subgroups for all-eligible and continuously-eligible samples. Trends in monthly prescription orders per 100 eligible plan members with T2DM were reported. Results The monthly all-eligible member sample (n > 22,000) exhibited an overall positive baseline monthly prescribing rate of 23.88 T2DM medication orders per 100 members with T2DM and a significant positive monthly prescribing rate trend (ie, change) of 0.12 T2DM medication orders per 100 members with T2DM (P < 0.05). Subgroup T2DM medication order rates per 100 members with T2DM at baseline were 16.28 for first-generation medications, 3.87 for human insulins, 3.04 for insulin analogs, 0.58 for second-generation medications, and 0.11 for combination medications. Human insulins, insulin analogs, and second-generation medications had positive monthly trends (P < 0.05). Among second-generation medications, sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) agonists had positive monthly trends (P < 0.05). Continuously eligible members with T2DM (n = 19,185) had no significant overall monthly prescribing trend; however, human insulins, insulin analogs, and second-generation medications and the SGLT-2 inhibitor class had positive monthly prescribing trends (P < 0.05). Conclusion In a diverse Medicare sample, this study observed increasing monthly trends for second-generation medications, human insulins, and insulin analogs consistent with emerging evidence. Among second-generation medications, SGLT-2 inhibitors became the most commonly prescribed over time. [ABSTRACT FROM AUTHOR]

Purpose Current literature surrounding management of patients with reported β-lactam allergies focuses on allergy delabeling. Standard clinical decision support tools have not been optimized to be compatible with the currently accepted cross-reaction rate of 1% to 2%. This potentially promotes use of non–β-lactam antibiotics, which are often not first-line therapy and may carry increased risks. The impact of electronic medical record (EMR) clinical decision support tool optimization on utilization of β-lactam antibiotics in β-lactam–allergic patients was evaluated. Methods A retrospective pre-post β-lactam cross-allergy EMR alert suppression quality improvement intervention cohort study of β-lactam–allergic adult inpatients prescribed antibiotics was conducted. Preintervention baseline data were collected for an initial cohort admitted during September 2018. The intervention, in which clinical decision support rules were updated to display β-lactam cross-sensitivity allergy alerts only for β-lactam–allergic patients with documentation of organization-defined high-severity reactions of anaphylaxis, hives, and shortness of breath, was implemented August 20, 2019. The postintervention cohort included patients admitted during September 2019. Results A 91% increase in the percentage of β-lactam–allergic patients who received a β-lactam agent at any time during their admission was noted after the intervention (26.6% vs 51%, P < 0.001). Statistically significant decreases in prescribing of alternative antibiotic classes were seen for fluoroquinolones (decrease from 45.3% to 26%, P < 0.001), aminoglycosides (decrease from 9.4% to 2.9%, P = 0.002), and aztreonam (decrease from 30% to 16.7%, P < 0.001). Conclusion EMR β-lactam cross-allergy alert optimization consistent with current literature significantly improved the utilization of alternative β-lactam subclasses, mostly through β-lactam prescribing as initial therapy in β-lactam–allergic patients. [ABSTRACT FROM AUTHOR]

Purpose This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2020 that can impact health-system pharmacy daily practice. Summary The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles evaluating at least one step of the MUP were assessed for their usefulness in practice improvement. A PubMed search for articles published in calendar year 2020 was conducted in January 2021 using targeted Medical Subject Headings (MeSH) keywords, and the table of contents of selected pharmacy journals was searched, providing a total of 9,433 articles. A thorough review identified 49 potentially practice-enhancing articles: 15 for prescribing/transcribing, 10 for dispensing, 6 for administration, and 18 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why they are important within health-system pharmacy. The other articles are listed for further review and evaluation. Conclusion It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful recently published literature. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the moist significant published studies can assist in changing practice at the institutional level. [ABSTRACT FROM AUTHOR]

Purpose To describe the development of a multidisciplinary anticoagulant safety taskforce (ASTF) to address anticoagulation-related issues across the medication-use system. Summary Oral and parenteral anticoagulants have been classified as high-alert medications because of their potential for harm. Errors at the point of prescribing, monitoring, and administering therapy have been noted in safety literature. Our hospital system, which includes 1 academic medical center, 6 community hospitals, and 1 long-term care facility, designed a multidisciplinary ASTF to address anticoagulation-related issues. The ASTF used the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Antithrombotic Therapy as the primary tool for reviewing current practices, performing gap analyses, and identifying our greatest areas of opportunity. The top 8 best practice elements related to anticoagulant use were identified for initial efforts of ASTF activity. Meetings were led by a medication safety pharmacist who reviewed process opportunities and actions to address gaps. The hospital chief quality and patient safety officer and the vice president of quality were the executive sponsors of the ASTF. Key stakeholders such as the medication safety committee chair and the president of the medical staff were instrumental in leading the initiative. Recommendations from the ASTF were reviewed and approved by the system medication safety committee and the system pharmacy and therapeutics committee to support system-wide implementation. The ASTF accomplished more than initially planned within its first year. Error mitigation occurred through policy revisions, order set development and modification, and implementation of practice changes to comply with each best practice. The ISMP antithrombotic self-assessment score improved from 67% to 87%, surpassing the initially targeted score of 75%. To overcome implementation barriers with the electronic health record, we enlisted support from our informatics leadership to leverage information technology. Overall, the success of the taskforce was attributed to the teamwork and leadership of key individuals within the organization. Conclusion Leveraging interest from key stakeholders across multiple disciplines with an established assessment tool was key in developing a productive and successful ASTF. The group came together to evaluate anticoagulant-related issues and implement sustainable changes to decrease anticoagulation error potential. [ABSTRACT FROM AUTHOR]

The article addresses belief of the American Society of Health-System Pharmacists (ASHP) that statins are an ideal candidate for dispensing under pharmacist prescribing models. Topics discussed include information on the ASHP Practice Advancement Initiative (PAI) 2030, background on the use of statins to lower cholesterol and reduce morbidity and mortality in patients at risk of cardiovascular events, and pharmacogenomics of statin therapy.

Purpose Gabapentin has increasingly been identified as a drug of abuse, especially when used concurrently with opioids. Rescheduling gabapentin as a Schedule V controlled substance may strengthen monitoring and prescribing restrictions. The purpose of this study was to characterize the impact of rescheduling gabapentin from a nonscheduled to a Schedule V substance in Virginia on discharge prescribing patterns in a health system. Methods This was a retrospective, pre-post, multicenter chart review conducted at 4 sites. Data from 3 months before gabapentin rescheduling (prerescheduling group) and 3 months after gabapentin rescheduling (postrescheduling group) were evaluated. The primary outcome was the percentage of newly prescribed gabapentin prescriptions upon discharge, which was compared between the pre- and postrescheduling groups. Results A similar percentage of gabapentin prescriptions were newly prescribed in the prerescheduling group as compared to the postrescheduling group (55.0% vs 50.0%, P = 0.479). Gabapentin prescribing characteristics did not differ between the groups for new gabapentin prescriptions (n = 55 in the prerescheduling group, n = 50 in the postrescheduling group). Concomitant discharge prescribing of benzodiazepines (5.5% vs 2.0%, P = 0.619) and opioids (45.5% vs 60.0%, P = 0.136) did not differ significantly between the postrescheduling group and prerescheduling group for new gabapentin prescriptions. However, fewer opioid prescriptions exceeded 90 daily morphine milligram equivalents (MME) in the postrescheduling group as compared to the prerescheduling group for new gabapentin prescriptions (36.0% vs 20.0%, P = 0.020). Conclusion Gabapentin prescribing practices did not differ before and after rescheduling of gabapentin as a controlled substance. There was a trend toward dosages with reduced daily MME for concomitant opioid prescriptions after rescheduling. However, additional investigation with larger studies over longer periods of time is needed to discover whether gabapentin rescheduling significantly changes prescribing practices. [ABSTRACT FROM AUTHOR]

Purpose The objective of this study was to implement a standardized process across health systems to determine the prevalence and clinical relevance of prescribing errors intercepted by pharmacists. Methods This prospective, multicenter, observational study was conducted across 11 hospitals. Pharmacist-intercepted prescribing errors were collected during inpatient order verification over 6 consecutive weeks utilizing a standardized documentation process. The potential harm of each error was evaluated using a modified National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) index with physician validation, and errors were stratified into those with potentially low, serious, or life-threatening harm. Endpoints included the median error rate per 1,000 patient days, error type, and potential harm with correlating cost avoidance. Results Pharmacists intervened on 7,187 errors, resulting in a mean error rate of 39 errors per 1,000 patient days. Among the errors, 46.6% (n = 3,349) were determined to have potentially serious consequences and 2.4% (n = 175) could have been life-threatening if not intercepted. This equates to $874,000 in avoided cost. The top 3 error types occurring with the highest frequency were "wrong dose/rate/frequency" (n = 2,298, 32.0%), "duplicate therapy" (n = 1,431, 19.9%), and "wrong timing" (n = 960, 13.4%). "Wrong dose/rate/frequency" (n = 49, 28%), "duplicate therapy" (n = 26, 14.9%), and "drug-disease interaction" (n = 24, 13.7%) errors occurred with the highest frequency among errors with potential for life-threatening harm. "Wrong dose/rate/frequency" (n = 1,028, 30.7%), "wrong timing" (n = 573, 17.1%), and "duplicate therapy" (n = 482, 14.4%) errors occurred with the highest frequency among errors with potentially serious harm. Conclusion Documentation of pharmacist intervention on prescribing errors via a standardized process creates a platform for multicenter analysis of prescribing error trends and an opportunity for development of system-wide solutions to reduce potential harm from prescribing errors. [ABSTRACT FROM AUTHOR]

Purpose Preliminary reports suggest that critically ill patients with coronavirus disease 2019 (COVID-19) infection requiring mechanical ventilation may have markedly increased sedation needs compared with critically ill, mechanically ventilated patients without COVID-19. We conducted a study to examine sedative use for this patient population within multiple intensive care units (ICUs) of a large academic medical center. Methods A retrospective, single-center cohort study of sedation practices for critically ill patients with COVID-19 during the first 10 days of mechanical ventilation was conducted in 8 ICUs at Massachusetts General Hospital, Boston, MA. The study population was a sequential cohort of 86 critically ill, mechanically ventilated patients with COVID-19. Data characterizing the sedative medications, doses, drug combinations, and duration of administration were collected daily and compared to published recommendations for sedation of critically ill patients without COVID-19. The associations between drug doses, number of drugs administered, baseline patient characteristics, and inflammatory markers were investigated. Results Among the study cohort, propofol and hydromorphone were the most common initial drug combination, with these medications being used on a given day in up to 100% and 88% of patients, respectively. The doses of sedative and analgesic infusions increased for patients over the first 10 days, reaching or exceeding the upper limits of published dosage guidelines for propofol (48% of patients), dexmedetomidine (29%), midazolam (7.7%), ketamine (32%), and hydromorphone (38%). The number of sedative and analgesic agents simultaneously administered increased over time for each patient, with more than 50% of patients requiring 3 or more agents by day 2. Compared with patients requiring 3 or fewer agents, patients requiring more than 3 agents were of younger age, had an increased body mass index, had increased serum ferritin and lactate dehydrogenase concentrations, had a lower Pao2:Fio2 (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen), and were more likely to receive neuromuscular blockade. Conclusion Our study confirmed the clinical impression of elevated sedative use in critically ill, mechanically ventilated patients with COVID-19 relative to guideline-recommended sedation practices in other critically ill populations. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this project was to identify current emergency medicine pharmacist (EMP) practices at each site and create a plan to integrate, align, and optimize pharmacy services across the health system with established American Society of Health-System Pharmacists (ASHP) best practices for EMPs. Summary Initially, a review was performed of the literature and guidelines from professional organizations relating to EMPs. A survey was distributed across the health system to assess EMP services at each site, and survey results were used to conduct a gap analysis, comparing current practices to established ASHP best practices. The survey identified unique components of each site, including the patient population served and EMP coverage and responsibilities. To prioritize, design, and execute the gap closure plan, a systemwide EMP workgroup was created. The workgroup formulated a toolkit to provide pharmacy leaders, pharmacy informatics, and EMPs resources to facilitate alignment on the prioritized areas. Conclusion This project successfully identified gaps in EMP services and alignment with best practices across the health system. Through prioritization of essential EMP responsibilities, workflow standardization, and EHR optimization, a gap closure plan was formulated to align with ASHP best practices. [ABSTRACT FROM AUTHOR]

Purpose Results of the 2020 ASHP national survey of pharmacy practice in hospital settings pertaining to pharmacy operational changes implemented in response to the coronavirus disease 2019 (COVID-19) pandemic are presented. Methods Pharmacy directors at 1,437 general and children's medical/surgical hospitals in the United States were surveyed using a mixed-mode method of contact by email and mail. Survey completion was online. Results The response rate was 18.7%. Seventy-three percent of hospitals implemented changes to hospital units, including 46% that increased intensive care unit bed capacity; 94% made changes to pharmacy supply chain acquisition, changes to products, and/or increased inventory. Staffing changes were implemented by 69% of hospitals, with the most common being staffing reductions (55%) and salary reductions (16%). Medication-use changes were implemented by 86% of hospitals, with treatment guidelines for COVID-19 treatment (79%) and opening compassionate use or investigational drug studies (55%) being the most common. Changes in sterile compounding processes were implemented by 84% of hospitals. Personal protective equipment (PPE) shortages led to 71% of hospitals modifying PPE use standards in sterile compounding. Eighty-seven percent of hospitals changed operational activities, such as changing medication return practices (56%), medication reconciliation processes (46%), intravenous medication recycling (38%), and discharge counseling (37%). Hospitals experienced shortages of many medications, including albuterol inhalers (60%), sedatives and anesthetic agents (58%), neuromuscular blockers (43%), corticosteroids (34%), cardiovascular agents (24%), investigational agents (24%), and dialysis solutions (6%). Conclusion The pharmacy profession responded to myriad threats to operations and patient care during the COVID-19 pandemic in 2020. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study was to evaluate the effect of an antimicrobial stewardship bundle on the management of asymptomatic bacteriuria (ASB). Methods In this quasi-experimental study, patients were selected by retrospective, consecutive sampling of patients with a positive urine culture report in 3 separate groups: preintervention, postdiagnostic intervention, and posteducation. Patients met the prespecified criteria for non–catheter-associated ASB. The diagnostic intervention involved a new urinalysis/urine culture ordering process in place of urinalysis with reflex to urine culture. Additionally, an educational intervention involved pharmacist-led sessions to educate providers with patient cases and guideline-based recommendations. The primary outcome of this study was the difference in the rate of inappropriate management of ASB, defined as the use of antimicrobial agents intended to treat ASB. Secondary outcomes included length of antimicrobial therapy, length of stay, and change in urine culture orders per 1,000 patient-days. Results A total of 120 patients were included. There was a significant reduction in the inappropriate management of ASB between the preintervention and postdiagnostic intervention groups (P = 0.0349). This was not seen when comparing the postdiagnostic intervention and posteducation groups (P = 0.93). Additionally, there was a significant difference in urinalysis/urine culture ordering between the preintervention and postdiagnostic intervention groups (370 vs 224 urinalysis orders per 1,000 days present, P < 0.0001; 131 vs 54 urine culture orders per 1,000 days present, P < 0.0001). Conclusion An antimicrobial stewardship bundle involving a diagnostic stewardship intervention and pharmacist-led education reduced treatment of ASB in patients without urinary catheters. [ABSTRACT FROM AUTHOR]

Purpose To provide an overview of the impact of pharmacist interventions on antibiotic prescribing and the resultant clinical outcomes in an outpatient antibiotic stewardship program (ASP) in the United States. Methods Reports on studies of pharmacist-led ASP interventions implemented in US outpatient settings published from January 2000 to November 2020 and indexed in PubMed or Google Scholar were included. Additionally, studies documented at the ClinicalTrials.gov website were evaluated. Study selection was based on predetermined inclusion criteria; only randomized controlled trials, observational studies, nonrandomized controlled trials, and case-control studies conducted in outpatient settings in the United States were included. The primary outcome was the observed differences in antibiotic prescribing or clinical benefits between pharmacist-led ASP interventions and usual care. Results Of the 196 studies retrieved for full-text review, a cumulative total of 15 studies were included for final evaluation. Upon analysis, we observed that there was no consistent methodology in the implementation of ASPs and, in most cases, the outcome of interest varied. Nonetheless, there was a trend toward improvement in antibiotic prescribing with pharmacist interventions in ASPs compared with that under usual care (P < 0.05). However, the results of these studies are not easily generalizable. Conclusion Our findings suggest a need for a consistent approach for the practical application of outpatient pharmacist-led ASPs. Managed care organizations could play a significant role in ensuring the successful implementation of pharmacist-led ASPs in outpatient settings. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the impact of a urinary tract infection (UTI) pocket card on preferred antibiotic prescribing for patients discharged from the emergency department (ED) with a diagnosis of cystitis. Methods A multicenter, retrospective, pre-post study was conducted to compare outcomes following the introduction of a UTI pocket card. The primary outcome was prescribing rates for institutional first-line preferred antibiotics (cephalexin and nitrofurantoin) versus other antimicrobials for cystitis. Secondary outcomes included prescriber adherence to recommended therapy in regards to discharge dose, frequency, duration, and healthcare utilization rates. Results The study included 915 patients in total, 407 in the preintervention group and 508 in the postintervention group. The frequency of preferred antibiotic prescribing was significantly increased after the introduction of a UTI pocket card compared to prior to its introduction (81.7% vs 72.0%, P = 0.001). Significant increases in prescribing of an appropriate antibiotic dose (78.0% vs 66.8%, P < 0.0001) and frequency (64.2% vs 47.4%, P < 0.0001) were also found post intervention. No significant differences were seen between the pre- and postintervention groups with regards to healthcare utilization rates. Conclusion A UTI pocket card increased preferred antibiotic prescribing for cystitis in the ED. This study provides data on a successful antimicrobial stewardship intervention in the ED setting. [ABSTRACT FROM AUTHOR]

Purpose The use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to treat hypertension (HTN) during pregnancy presents well-established risks to a developing fetus. A cross-sectional study was conducted to evaluate the current state of antihypertensive prescribing and contraceptive use in females of childbearing age within a large safety-net health system. Methods The retrospective cross-sectional study focused on females aged 18-49 years with a documented diagnosis of HTN. The proportion of patients prescribed an ACE inhibitor or ARB and using a documented form of contraception was calculated. Documented forms of contraception included oral contraceptives, intrauterine devices, injections, implants, and surgical intervention. Results A total of 4,187 patients were identified from the HTN registry; after application of exclusion criteria 3,045 patients were included in the study population. The mean age was 39 years (range, 18-49 years). The most frequently prescribed classes of antihypertensive medications were ACE inhibitors and ARBs (one or the other was used by 1,146 patients [37.6%]), followed by thiazide diuretics (n = 710, 23.3%) and calcium channel blockers (n = 599, 19.7%). Of the 1,146 patients prescribed an ACE inhibitor or ARB, 553 (48%) were using a documented form of contraception. Conclusion Rates of ACE inhibitor or ARB prescribing to females of childbearing age were high despite the teratogenic risks, and fewer than half of patients had documented protection from pregnancy. Provider and patient education and potential creation of best practice alerts in the electronic medical record regarding the risks of using ACE inhibitors and ARBs in females of childbearing age are warranted. [ABSTRACT FROM AUTHOR]

Purpose An estimated 30% of all outpatient antibiotic prescriptions in the United States are unnecessary. The Joint Commission, in 2016, implemented core elements of performance requiring antimicrobial stewardship programs (ASPs) to expand to outpatient practice settings. A study was conducted to determine whether pharmacist-led audit and feedback would improve antibiotic prescribing for urinary tract infections (UTIs) and skin and soft tissue infection (SSTIs) at 2 primary care practices. Methods A retrospective, quasi-experimental study was conducted to evaluate antibiotic prescribing for patients treated for a UTI or SSTI at 2 primary care offices (a family medicine office and an internal medicine office). The primary objective was to compare the rate of appropriate antibiotic prescribing to patients treated before implementation of a pharmacist-led audit-and-feedback process for reviewing antibiotics prescribed for UTIs and SSTIs (the pre-ASP group) and patients treated after process implementation (the post-ASP group). Total regimen appropriateness was defined by appropriate antibiotic selection, dose, duration, and therapy indication in accordance with institutional outpatient empiric therapy guidelines. Secondary objectives included comparing rates of infection-related revisits and Clostridioides difficile infection between groups. Results A total of 400 patients were included in the study (pre-ASP group, n = 200; post-ASP group, n = 200). The rate of total antibiotic prescribing appropriateness improved significantly, from 27.5% to 50.5% (P < 0.0001), after implementation of the audit-and-feedback process. There were also significant improvements in the post-ASP group vs the pre-ASP period in the individual components of regimen appropriateness: appropriate drug (70% vs 53%, P < 0.001), appropriate duration (83.5% vs 57.5%, P < 0.001), and appropriate therapy indication (98% vs 94%, P = 0.041). There were no significant between-group differences in other outcomes such as rates of adverse events, treatment failure, C. difficile infection, and infection-related revisits or hospitalizations within 30 days. Conclusion A pharmacist-led audit-and-feedback outpatient stewardship strategy was demonstrated to achieve significant improvement in outpatient antibiotic prescribing for UTI and SSTI. [ABSTRACT FROM AUTHOR]

A correction to the article "DEA-Registered Clinical Pharmacist Practitioners: Progressing Practice to Increase Patient Care Access," by Shekinah G. Baum and colleagues that was previously published in the August 2023 issue of the periodical "American Journal of Health-System Pharmacy" is presented.

Purpose The results of a study to determine the difference in HIV management with clinical pharmacist input in an adult psychiatric hospitalized patient population are reported. Methods Single-center, retrospective study of patients admitted to a psychiatric hospital on antiretroviral (ARV) medication(s) from October 2016 to March 2017 (phase I: no pharmacist involvement), October 2017 to March 2018 (phase II: partial pharmacist involvement), and November 2018 to January 2019 (phase III: consistent pharmacist involvement). Patients were excluded if less than 18 years of age, pregnant, incarcerated, or taking ARV medication(s) for non-HIV indications. The primary outcome was difference in appropriateness of ARV therapy prior to and during pharmacist involvement. Secondary outcomes were appropriateness of opportunistic infection (OI) prophylaxis, laboratory testing, and comprehensive HIV management. Results Thirty-seven patients were included per phase. An increased number of appropriate ARV regimens were initiated in phase II compared to phase I (62% vs 32%; P = 0.01) and in phase III compared to phase II (84% vs 62%; P = 0.036). Increased laboratory monitoring was seen with partial and consistent pharmacist involvement. Among the patients requiring OI prophylaxis, appropriate prophylaxis was initiated in more patients in phase III (57%) than in phase II (50%) or phase I (11%). More patients had comprehensive HIV management in phase II compared to phase I (38% vs 5%; P < 0.001) and in phase III compared to phase II (46% vs 38%; P = 0.48). Conclusion Pharmacist involvement in HIV management in a psychiatric patient population increased appropriateness of ARV therapy, laboratory testing, and OI prophylaxis. [ABSTRACT FROM AUTHOR]

Purpose To describe the implementation of a comprehensive program to address the opioid epidemic in a large health system and to assess the effect of the program on opioid prescribing. Summary Mercy Health is a nonprofit, Catholic health system that employs over 1,400 providers and operates 23 hospitals in Ohio and Kentucky, 2 states that have experienced large numbers of overdoses. As a good community partner, the health system developed a comprehensive plan to address the opioid crisis. A system-wide Opioid Steering Committee was established to implement and manage the program. The committee was chaired by a senior pharmacy executive and supported by 4 subcommittees: the data analytics, education development, outreach and assessment, and electronic health record (EHR) subcommittees. The 4 subcommittees developed and implemented several initiatives, including forming a database with prescribing data by specialty and geographical location, implementing a standardized screening approach in the emergency department, challenging hospitals to create partnerships with local schools, and creating EHR enhancements to change opioid prescribing habits. When normalized for patient volume, the prescribed opioid burden was reduced from 65.3 to 35.2 morphine milligram equivalents per unique patient from 2016 to 2019 (a 46% absolute reduction). During this same time the number of acute prescription orders with a morphine equivalent dose greater than 30 was reduced by 52% (from 37,793 to 17,822 prescriptions per year). Conclusion Mercy Health's comprehensive approach to the opioid epidemic has successfully impacted opioid prescribing habits, screening practices, and community outreach. [ABSTRACT FROM AUTHOR]

Purpose The Department of Veterans Affairs (VA) Northern California Health Care System (NCHCS) uses a dashboard to identify monitoring needs for veterans prescribed chronic opioid therapy (COT). Schools of pharmacy require introductory pharmacy practice experiences (IPPEs); however, resources for providing IPPEs at medical facilities are limited. This article describes collaboration by a primary care service and a school of pharmacy to provide services for patients prescribed COT through remote access to the VA electronic health record (EHR) system. Summary Pharmacy students in a required population health IPPE provided clinical services for veterans remotely. Students were supervised by VA clinical pharmacists and granted remote EHR access privileges. Using personally owned laptops and VA cell phones, students performed prescription drug monitoring program (PDMP) activities, reviewed urine drug screening (UDS) results, called patients to assess pain, and documented progress notes. Students completed an assessment on the first and final days of the experience; a retrospective analysis was conducted to examine differences in student knowledge of and confidence in providing COT-focused services. The dashboard scorecard and student workload were tracked over a 1-year period. In that year, 143 students wrote 7,001 PDMP notes, reviewed 6,130 UDS results, and documented 202 pain assessments. Statistically significant improvements were reported in students' level of confidence in performing population health activities for patients prescribed COT, including interpreting PDMP and UDS results and talking with patients. Conclusion The ongoing collaboration provides real-world population management experiences for future pharmacists and supports monitoring requirements for veterans prescribed COT. The program has helped NCHCS accomplish its teaching mission without dedicating clinic workspace or computers and gain an additional team to address quality measures and support population health activities. [ABSTRACT FROM AUTHOR]

Purpose This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change. Summary A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation. Conclusion It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level. [ABSTRACT FROM AUTHOR]

Purpose The coronavirus disease 2019 (COVID-19) pandemic has caused health systems across the country to plan for field hospitals to care for patients outside of traditional healthcare settings in the event of a second surge. Here we describe key considerations for the implementation of pharmacy operations and a field hospital formulary at an offsite location within a 2-week time frame. Summary Development of an offsite field hospital formulary is first dependent on the location and patient population defined for the field hospital. Creation of a limited formulary for a planned field hospital in Michigan involved reviewing physical space limitations and drug distribution workflows, assessing current prescribing trends, creating drug categories, and creating formulary guidelines to limit formulary options in each therapeutic category. Ultimately, our institution developed a 140-medication field hospital formulary, a process to enable appropriate use of nonformulary drugs, and a mixed operations model including automated dispensing cabinets and a manual cart-fill process. Although the institution did not have to open the field hospital, the process used for developing the formulary and determining distribution models will allow for an immediate implementation if a second surge occurs. Conclusion A methodical approach to developing limited formularies and pharmacy operations in a field hospital setting will allow health systems to establish efficient and effective medication distribution services in the event of a second surge of COVID-19 cases. [ABSTRACT FROM AUTHOR]

Purpose The design and implementation of alternatives to opioids (ALTO) order sets for the treatment of acute pain in a community health system's emergency departments are described. Summary Healthcare institutions nationwide have incorporated policies and procedures to assist prescribers in the safe and effective management of pain. These adopted approaches may be targeted at mitigating opioid prescribing as well as promoting the optimization of nonopioid analgesics. Institutions that enact innovations and track outcomes may be eligible for reimbursement through the Centers for Medicare and Medicaid Services' Merit-based Incentive Payment System. Emergency departments may monitor implementation progress and outcomes through participation in the American College of Emergency Physician's Emergency Quality Network. Clinical pharmacists were tasked with assisting an institution's emergency departments to create and implement two order sets containing ALTO analgesics and supportive medications for atraumatic headache and general acute pain management. Key steps of order set implementation included collaborative development with emergency department providers, implementation with information services, and the development of provider-focused education by project pharmacists. The implementation of ALTO order sets has set the foundation for expansion of pain control protocols and algorithms within our institution. Furthermore, the approach detailed in this article can be adapted and implemented by other healthcare systems to help reduce opioid prescribing. Conclusion The implementation of ALTO order sets within an electronic health record can encourage decreased prescribing of opioids for the treatment of acute pain, promote and optimize dosing of nonopioid analgesics, and may augment reimbursement for services in the emergency department. [ABSTRACT FROM AUTHOR]

The article presents a report of the American Society of Health-System Pharmacists (ASHP) Opioid Task Force that was tasked with identifying actionable recommendations, solutions and resources to help address the national opioid epidemic with the help of pharmacists. Topics covered include the core Domains and number of recommendations, and the roles pharmacists in ensuring the success of collaborative pain management and opioid stewardship strategies that were recommended.

Purpose Results of the 2019 ASHP national survey of pharmacy practice in hospital settings are presented. Methods Pharmacy directors at 4,863 general and children's medical/surgical hospitals in the United States were surveyed using a mixed-mode method of contact by email and mail. Survey completion was online, using an online survey application. IQVIA supplied data on hospital characteristics; the survey sample was drawn from the IMS Health hospital database. Results The response rate was 10.8%. Pharmacists are increasingly managing medication use in the areas of vancomycin therapy, antibiotic selection and dosing, and anticoagulation. Electronic health record (EHR) decision support is guiding prescribing, and nearly 50% of hospitals are customizing drug warnings. Adoption of compounding technology continues, with 43.6% of hospitals using technology in their sterile compounding processes. Nearly half of hospitals have active opioid stewardship programs, and pharmacists are leading these efforts. Specialty pharmacy operations are growing in health systems. Human resource commitments to support new services are increasing; however, vacancy rates for technicians are challenging. Staff credentialing continues to expand for pharmacist and technicians. Conclusion Pharmacists continue to assume greater responsibility for writing medication orders, dosing, ordering laboratory tests, and monitoring outcomes. Health-system pharmacists are taking a leading role in addressing the opioid crisis, advancing safety in compounded sterile preparations through adoption of intravenous workflow technologies, and optimizing EHR applications to leverage clinical decision support tools to improve the safe prescribing and use of medications. [ABSTRACT FROM AUTHOR]

Purpose To describe the development of and implementation of a patient-centric clinical indications library (CIL) into the prescribing process and determine the operational and humanistic outcomes (from prescriber, pharmacist, and patient perspectives) of including indications on outpatient prescription labels. Methods A descriptive retrospective data analysis was conducted. Multiple stakeholder groups were engaged to develop and integrate the CIL into the prescription package. After CIL integration, prescribers, pharmacists, and patients were surveyed. A focus group discussion consisting of Veterans and caregivers was held. Results Following implementation of the CIL, the proportion of prescriptions associated with an indication increased from 88% to 96%. Surveyed clinicians responded that indications helped them better understand a patient's profile (61.1% of prescribers and 100% of pharmacists). Among surveyed pharmacists, 61.5% and 53.8%, respectively, believed that indications helped them catch instances of wrong medications and wrong doses ordered. Veterans surveyed found that indications on their prescription labels helped them know what their medications were for (91.0% of respondents) and why it is important to take their medications (70.7%). In focus group discussions, Veterans and family members and/or caregivers expressed a preference to see indications that describe how a medication works (eg, "to lower blood sugar" vs "for diabetes") because they felt that type of phrasing is measurable, action oriented (which was appealing due to Veterans' military background), provides surreptitious education, and tells the users what to expect. Conclusion Engaging multidisciplinary stakeholder groups, optimizing the electronic health record system, and authorizing pharmacists to add known indications to prescriptions increased the number of prescriptions with indications, decreased the perceived time spent on order entry and verification, and enabled better understanding of each medication's purpose by providers and patients. [ABSTRACT FROM AUTHOR]

Purpose The opioid epidemic continues to result in significant morbidity and mortality even within hospitals where opioids are the second most common cause of adverse events. Opioid stewardship represents one model for hospitals to promote safe and rational prescribing of opioids to mitigate preventable adverse events in alliance with new Joint Commission standards. The purpose of this study was to identify the prevalence of current hospital practices to improve opioid use. Methods A cross-sectional survey of hospital best practices for opioid use was electronically distributed via electronic listservs in March 2018 to examine the presence of an opioid stewardship program and related practices, including formulary restrictions, specialist involvement for high-risk patients, types of risk factors screened, and educational activities. Results Among 133 included hospitals, 23% reported a stewardship program and 14% reported a prospective screening process to identify patients at high risk of opioid-related adverse events (ORAEs). Among those with a prospective screening process, there was variability in ORAE risk factor screening. Formulary restrictions were dependent on specific opioids and formulations. Patient-controlled analgesia was restricted at 45% of hospitals. Most hospitals reported having a pain management service (90%) and a palliative care service providing pain management (67%). Conclusion The absence of opioid stewardship and prospectively screening ORAEs represents a gap in current practice at surveyed hospitals. Hospitals have an opportunity to implement and refine best practices such as access to pain management specialists, use of formulary restrictions, and retrospective and prospective monitoring of adverse events to improve opioid use. [ABSTRACT FROM AUTHOR]

Purpose To assess the accuracy of antibiotic indication documentation provided during order entry and prescriber perceptions of the requirement to specify indications. Methods Patients who received 1 of 6 selected antibiotics from May 1 through June 30, 2017, were identified. Records of 30 randomly selected patients who received each study antibiotic were retrospectively reviewed. The primary endpoint was indication accuracy, defined as agreement of the indication entered during order entry with that documented in progress notes at the time of order entry. Secondary endpoints included correlation of entered indication and final diagnosis for empiric antibiotics. A brief survey was emailed to prescribers to assess the burden and perceptions of requiring an indication during order entry. Results Four thousand five hundred twenty-four patients received 1 or more doses of a study antibiotic. For the 180 patients selected for evaluation, 89.4% of indications were accurate. Indications for antibiotics ordered for prophylaxis were more likely to be inaccurate than those for empiric or definitive antibiotics (accuracy rates of 46%, 94%, and 92%, respectively, p < 0.05). For empiric antibiotics, 78.5% of indications documented at order entry matched the final diagnosis. Two hundred fifty-four of 863 prescribers (29%) responded to the survey request. Most respondents felt that documenting the indication took no more than 20 seconds, was a "minor nuisance" or "occasionally burdensome," and had no impact on their consideration of antibiotic appropriateness. Conclusion With the exception of prophylaxis, the indications documented during order entry were sufficiently accurate to assist antimicrobial stewardship efforts. Although indication documentation was perceived as a minor burden, surveyed prescribers indicated it had only a minimal beneficial effect on antibiotic prescribing. [ABSTRACT FROM AUTHOR]

Purpose A Universal Medication Schedule (UMS) that uses explicit language to describe when to take medicine has been proposed as a patient-centered prescribing and dispensing standard. Despite widespread support, evidence of its actual use and efficacy is limited. We investigated the prevalence of UMS instructions and whether their use was associated with higher rates of medication adherence. Methods National pharmacy records were analyzed for a cohort of type 2 diabetic adults ≥18 years old (N = 676,739) new to ≥1 oral diabetes medications between January and June 2014. Prescription instructions (N = 796,909) dispensed with medications were classified as UMS or non-UMS. Instructions coded as UMS were further categorized as either providing precise UMS language (tier 1: "take 1 pill at morning, noon, evening, or bedtime") or offering some explicit guidance (tier 2: "take 1 tablet by mouth before breakfast"; tier 3: "take 1 tablet twice daily with a meal"). Adherence over 12 months was measured by proportion of days covered. Results One-third of instructions (32.4%, n = 258,508) were classified as UMS (tier 1: 12.6%, n = 100,589; tier 2: 6.0%, n = 47,914; tier 3: 13.8%, n = 110,005). In multivariable analyses, UMS instructions (all tiers) exhibited better adherence compared to non-UMS instructions (relative risk [RR], 1.01; 95% confidence interval [CI], 1.00-1.02; P = 0.01). Patients older than 65 years who were less educated and taking medication more than once daily received greater benefit from tier 1 UMS instructions (RR, 1.14; 95% CI, 1.07-1.21; P < 0.001). Conclusion While infrequently used, the UMS could help older, less-educated patients adhere to more complex regimens with minimal investment. [ABSTRACT FROM AUTHOR]

The authors discuss the expansion of pharmacists' prescribing authority in Oregon through a precautionary methodology. Topics mentioned include the two primary categories of pharmacist prescriptive authority in the U.S., the statute on pharmacist-administered immunization revised by U.S. Senate Bill (SB) 520, and prescription of self-administered hormonal contraceptives.

Purpose Results of a study to determine the effect of a pharmacist-led opioid task force on emergency department (ED) opioid use and discharge prescriptions are presented. Methods An observational evaluation was conducted at a large tertiary care center (ED volume of 115,000 visits per year) to evaluate selected opioid use outcomes before and after implementation of an ED opioid reduction program by interdisciplinary task force of pharmacists, physicians, and nurses. Volumes of ED opioid orders and discharge prescriptions were evaluated over the entire 25-month study period and during designated 1-month preimplementation and postimplementation periods (January 2017 and January 2018). Opioid order trends were evaluated using linear regression analysis and further investigated with an interrupted time series analysis to determine the immediate and sustained effects of the program. Results From January 2017 to January 2018, ED opioid orders were reduced by 63.5% and discharge prescriptions by 55.8% from preimplementation levels: from 246.8 to 90.1 orders and from 85.3 to 37.7 prescriptions per 1,000 patient visits, respectively. Over the entire study period, there were significant decreases in both opioid orders (β, –78.4; 95% confidence interval [CI], –88.0 to –68.9; R 2 , 0.93; p < 0.0001) and ED discharge prescriptions (β, –24.4; 95% CI, –27.9 to –20.9; R 2 , 0.90; p < 0.001). The efforts of the task force had an immediate effect on opioid prescribing practices; results for effect sustainability were mixed. Conclusion A clinical pharmacist–led opioid reduction program in the ED was demonstrated to have positive results, with a more than 50% reduction in both ED opioid orders and discharge prescriptions. [ABSTRACT FROM AUTHOR]

Purpose To assess antibiotic selection, administration, and prescribing practices in emergency departments across a large hospital system using evidence-based practices and susceptibility patterns. Methods This retrospective data review was conducted using health system–level electronic data compiled from 145 emergency departments (EDs) across the United States. Data were examined for national generalizability, most common diagnoses of infectious origin seen in nonadmitted patients in the ED, most commonly administered antibiotics in the ED, and geographically defined areas' unique patterns of antibiotic resistance and susceptibility. Results More than 627,000 unique patient encounters and 780,000 antibiotic administrations were assessed for trends in patient demographics, antibiotics administered for a diagnosis of infectious origin, and corresponding susceptibility patterns. Results indicated that practices in the EDs of this health system aligned with evidence-based practices for streptococcal pharyngitis, otitis media, cellulitis, and uncomplicated urinary tract infections. Conclusion These results provide a representative sample of the current state of practices within many EDs across the United States for nonadmitted patients. A similar data reconstruction can be completed by other health systems to assess their prescribing practices in the ED to improve and elevate care for patients visiting the emergency room and treated as outpatients. [ABSTRACT FROM AUTHOR]

Purpose Results of a study to elucidate perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless are reported. Methods A qualitative descriptive study involving semistructured interviews was conducted to gather information and characterize hospitalized homeless patients' views and attitudes regarding medication use, with a focus on medication nonadherence. Medication nonadherence has been shown to be a factor contributing to higher rates of emergency department visits, increased hospital lengths of stay, and increased healthcare costs in homeless populations. Interviews were conducted during patients' admissions to the internal medicine service of a tertiary care, inner-city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes. Results Twelve interviews were conducted (median patient age, 48.5 years). Eight patients (66.7%) were living in a shelter, and 11 (91.7%) had a mental illness. Patients were prescribed a median of 4 medications at the time of hospital admission. Four themes were identified: (1) a new appreciation of medications was acquired during hospitalization, (2) medications were perceived as necessary for maintaining health, (3) there was an interest in receiving medication education, and (4) concerns were expressed regarding medication adverse effects. Conclusion In interviews conducted during hospital admission, homeless patients expressed positive perceptions about the necessity of their medications but also concerns about medication adverse effects. Interventions to improve adherence may be successful if directed toward addressing treatment-related concerns. [ABSTRACT FROM AUTHOR]

Purpose Results of a literature review to identify indicators of inappropriate opioid prescribing are presented. Summary While prescription opioids can be effective for the treatment of acute pain, inappropriate prescribing practices can increase the risk of opioid-related harms, including overdose and mortality. To date, little research has been conducted to determine how best to define inappropriate opioid prescribing. Five electronic databases were searched to identify studies (published from database inception to January 2017) that defined inappropriate opioid prescribing practices. Search terms varied slightly across databases but included opioid, analgesics, inappropriate prescribing, practice patterns, and prescription drug misuse. Gray literature and references of published literature reviews were manually searched to identify additional relevant articles. From among the 4,665 identified articles, 41 studies were selected for data extraction and analysis. Fourteen studies identified high-daily-dose opioid prescriptions, 14 studies identified coadministration of benzodiazepines and opioids, 10 studies identified inappropriate opioid prescribing in geriatric populations, 8 studies identified other patient-specific factors, 4 studies identified opioid prescribing for the wrong indication, and 4 studies identified factors such as initiation of long-acting opioids in opioid-naive patients as indicators of inappropriate opioid prescribing. Conclusion A literature review identified various indicators of inappropriate opioid prescribing, including the prescribing of high daily doses of opioids, concurrent benzodiazepine administration, and geriatric-related indicators. Given the significant contribution of inappropriate opioid prescribing to opioid-related harms, identification of these criteria is important to inform and improve opioid prescribing practices among healthcare providers. [ABSTRACT FROM AUTHOR]

The article discusses artificial intelligence (AI) in the context of its use in health-system pharmacy practice. Topics discussed include capacity of AI to compress data into recognizable patterns, possibility for machines to process natural human language with few errors, and the use of machine learning to improve medication use safety.