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This article discusses the challenges and importance of developing precision-based pharmacotherapy management plans for critically ill patients. It emphasizes the need to consider various factors such as drug interactions, comorbid conditions, and socioeconomic backgrounds when creating these plans. Effective communication and collaboration among healthcare professionals are also highlighted. The text emphasizes the importance of taking a comprehensive approach and making adjustments based on trends and potential risks. It acknowledges the limitations of existing guidelines and emphasizes the need for precision-based management in complex cases. The document provides guidance on obtaining accurate information, modifying management plans as needed, and optimizing drug-related management plans for individual patients in the intensive care unit. [Extracted from the article]

Study Objective Physician-pharmacist collaborative models have been shown to improve the care of patients with numerous chronic medical conditions. Team-based health care using integrated clinical pharmacists provides one opportunity to improve quality in health care systems that use population-based financing. In November 2015, the Centers for Medicare and Medicaid Services ( CMS) requested that the relative value of pharmacists' work in team-based care needs to be established. Thus the objective of this study was to describe the components of pharmacists' work in the management of hypertension with a physician-pharmacist collaborative model. Design Descriptive analysis of the components of pharmacists' work in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now ( CAPTION) study, a prospective, cluster randomized trial. Measurements and Main Results This analysis was intended to provide policymakers with data and information, using the CAPTION study model, on the time and intensity of pharmacists' work to understand pharmacists' relative value contributions in the context of CMS financing and population management aims. The CAPTION trial was conducted in 32 community-based medical offices in 15 U.S. states and included 390 patients with multiple cardiovascular risk factors. Blood pressure was measured by trained study coordinators in each office, and patients were included in the study if they had uncontrolled blood pressure. Included patients were randomized to a 9-month intervention, a 24-month intervention, or usual care. The goal of the pharmacist intervention was to improve blood pressure control and resolve drug therapy problems impeding progress toward blood pressure goals. This intervention included medical record review, a structured assessment with the patient, collaboration to achieve goals of therapy, and patient follow-up. The two intervention arms (9 and 24 mo) were identical the first 9 months, and that time frame is the focus of this workload evaluation. Pharmacists completed study encounter forms for every patient encounter and estimated time spent in pre-visit, face-to-face care, and post-visit activities. Among the 390 patients, there were 2811 encounters with pharmacists that involved 3.44 hours/patient for face-to-face care visits plus 1.55 hours/patient for pre-visit and post-visit work. Intensity of work was reflected in interventions to resolve drug therapy problems with patients (43% of encounters) and with physicians (1169 recommendations, of which physicians accepted 1153 [98.6%]), resulting in improvement of patients' blood pressure goals achieved (from 0% at baseline to 43% at 9 months based on the primary study end point). Conclusion Pharmacists provided extensive interventions to patients with hypertension. This analysis provides a framework for health systems, provider groups, and payers to measure pharmacists' work in value-based financing and population management. [ABSTRACT FROM AUTHOR]

The Collaboration Among Pharmacists and Physicians To Improve Outcomes Now (CAPTION) trial recently found that a pharmacist intervention for hypertension could be implemented in diverse medical offices. In this issue of Pharmacotherapy, the article by Brian Isetts and colleagues discusses the complexity of the patient population, the specific functions the pharmacists performed, and the time estimates from billing records used to quantify time spent during face-to-face patient encounters. This invited commentary will discuss findings from the CAPTION trial and provide recommendations for strategies to implement similar interventions for patients with other chronic medical conditions seen in primary care practices. [ABSTRACT FROM AUTHOR]

Study Objective To evaluate the effect of pharmacist care on patients with dyslipidemia. Design Systematic review of 21 randomized controlled trials. Patients A total of 5416 patients who received enhanced pharmacist care or standard care as part of a research study. Measurements and Main Results Nineteen databases and four trial registries were systematically searched from inception through February 21, 2010, with an update in September 2011. In addition, Web sites of relevant professional associations, scientific meetings, and research groups were reviewed, and manual searches of select journals were performed. A total of 8771 articles were identified, and 21 studies included. Data from the studies were analyzed using a random-effects model. The primary outcome measure assessed was the difference between the groups (pharmacist intervention vs standard care) in low-density lipoprotein cholesterol ( LDL) level at the end of follow-up. Secondary outcome measures included the difference between the groups at the end of follow-up in total cholesterol, high-density lipoprotein cholesterol, and triglyceride levels; and the proportion of patients who achieved target lipid parameters, underwent lipid panel measurements, adhered to therapy, and/or were instructed to change their lipid-lowering therapy. At the end of follow-up, the mean LDL level was 10.7 mg/dl lower in the enhanced pharmacy care groups compared with the standard care groups (95% confidence interval [ CI] -16.9 to -4.6 mg/dl), with moderate heterogeneity. The mean total cholesterol level was significantly lower in the enhanced pharmacy care groups compared with the standard care groups; however, these results were highly heterogeneous. Patients who received enhanced pharmacist care were also more likely than those receiving standard care to achieve target lipid parameters (odds ratio [ OR] 2.46, 95% CI 1.43-4.25) and to have a lipid panel ordered or recommended by a pharmacist during the study ( OR 2.05, 95% CI 1.30-3.24). Patients in the pharmacist intervention groups were almost twice as likely as patients in the standard care groups to have a change in lipid-lowering therapy ( OR 1.82, 95% CI 1.09-3.06). Adherence data could not be analyzed. Conclusion This systematic review showed that enhanced pharmacist care improves lipid parameters, notably LDL levels, in patients with dyslipidemia. These results point to the benefit that pharmacist care can provide across the spectrum of dyslipidemia management, from screening patients to treating them to assisting them in the attainment of clinical targets. [ABSTRACT FROM AUTHOR]

Study Objective. To determine the relationship between poor adherence and self-efficacy or social support after a pharmacist intervention. Design. Post-hoc analysis of data from two randomized controlled trials of physician-pharmacist collaborative interventions (6 and 9 too, respectively) to improve blood pressure control. Setting. Eleven university-affiliated primary care clinics. Patients. Five hundred eighty-four patients (aged 21-85 yrs) with uncontrolled primary hypertension; 296 were in the intervention group and 288 were in the control group. Intervention. Pharmacists provided intensified hypertension management and drug adherence counseling to patients in the intervention group. Measurements and Main Results. Social support and self-efficacy questionnaires were administered at baseline and end-of-study visits. Patient adherence was monitored by using the Morisky self-reported adherence questionnaire. Self-reported adherence scores improved significantly in the control group (p=0.0053) but not in the intervention group; however, adherence at baseline in both groups was high. There were small, but significant, improvements in self-efficacy (p<0.04) and social support (p<0.05) scores in the intervention group but not the control group at the end of the study. Social support and, to a lesser extent, self-efficacy improved as a function of duration of study participation (9-mo vs 6-mo intervention), regardless of whether the patient received the intervention. Blood pressure control in both groups improved significantly at the end of the study; however, mean blood pressure was significantly lower in the intervention group (129.7/76.6 mm Hg) compared with the control group (140.8/78.9 mm Hg; p<0.0001 for systolic, p=0.032 for diastolic). Conclusion. Social support and self-efficacy improved significantly in the intervention group at the end of the pharmacist intervention. Drug adherence was correlated with self-efficacy even though drug adherence did not improve significantly in the intervention group. The fact that social support and self efficacy improved as a function of duration of study participation suggests that participation in a research study may have had a positive influence on these measures. Even though the changes in social support, self-efficacy, and drug adherence were modest, there was significantly better blood pressure control in the intervention group compared with the control group. These findings indicate that changes in drug adherence, self-efficacy, or social support probably played a minor role in the blood pressure outcomes in these studies. [ABSTRACT FROM AUTHOR]

A framework for evaluating pharmacists' impact on cost avoidance in the intensive care unit (ICU) and emergency department (ED) has not been established. This scoping review was registered (CRD42018091217) and conducted to identify, aggregate, and qualitatively describe the highest quality evidence for cost avoidance generated by clinical pharmacists on interventions performed in an ICU or ED. Searches were conducted in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until April 2018. The level of evidence (LOE) for each specific category of intervention was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation evidence‐to‐decision framework. The risks of bias for articles were evaluated using Newcastle Ottawa and Cochrane Collaboration tools. The values from all interventions were inflated to 2018 U.S. dollars using the consumer price index for medical care. Of the 464 articles initially identified, 371 were excluded and 93 were included. After reviewing references from the articles included, an additional 71 articles were also reviewed. The 38 cost intervention categories were supported by varying LOEs: IA (0 categories), IB (1 category), IIA (4 categories), IIB (0 categories), III (27 categories), and IV (6 categories), and articles mostly displayed low to moderate risks of bias. Pharmacists generate cost avoidance through a variety of interventions in critically and emergently ill patients. The quality of evidence supporting specific cost avoidance values is generally low. Quantification of and factors associated with the cost avoidance generated from pharmacists caring for these patients are of paramount importance. [ABSTRACT FROM AUTHOR]

The goal of this white paper is to provide direction for clinical pharmacists providing telehealth. Telehealth care is rapidly emerging to improve patient access to health care and optimize patient health outcomes. With the increasing ability to access electronic health record portals, as many as 75 million telehealth encounters are expected in North America annually. Although electronic “point of access” undoubtedly increases the use of medical and pharmacy services, the real value of telehealth lies in improved access to patients in remote areas lacking adequate medical and pharmacy services and to high‐risk patients requiring frequent monitoring. This document is intended to serve as a guide for those interested in or already using telehealth to provide direct patient care. Specifically, it focuses on general concepts of telehealth and demonstrates how the delivery of comprehensive medication management (CMM) by telehealth aligns with the Standards of Practice for Clinical Pharmacists set forth by the American College of Clinical Pharmacy. Although clinical pharmacists must be appropriately credentialed and privileged to provide CMM, their process of care must also be adapted to suit the remote patient. Patient assessment, evaluation of medication therapy, development and implementation of a plan of care, follow‐up, monitoring, and documentation of all processes of care are influenced by the technology available, the collaborations established, and the applicable regulations and requirements for telehealth practice. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the effectiveness of clinical pharmacists and community health workers (CHWs) in improving glycemic control within a low‐income ethnic minority population. Methods: In a two‐arm 2‐year crossover trial, 179 African‐American and 65 Hispanic adult patients with uncontrolled diabetes mellitus (hemoglobin A1c [Hb A1C] of 8% or higher) were randomized to CHW support either during the first or second year of the study. All participants received clinical pharmacist support for both years of the study. The primary outcome was change in HbA1C over 1 and 2 years. Results: Similar HbA1C declines were noted after receiving the 1 year of CHW support: −0.45% (95% confidence interval [CI] −0.96 to 0.05) with CHW versus −0.42% (95% CI −0.93 to 0.08) without CHW support. In addition, no differences were noted in change on secondary outcome measures including body mass index, systolic blood pressure, high‐density lipoprotein and low‐density lipoprotein cholesterol, quality of life, and perceived social support. A difference in diastolic blood pressure change was noted: 0.80 mm Hg (95% CI −1.92 to 3.53) with CHW versus −1.85 mm Hg (95% CI −4.74 to 1.03) without CHW support (p=0.0078). Patients receiving CHW support had more lipid‐lowering medication intensifications (0.39 [95% CI 0.27–0.52]) compared with those without CHW support (0.26 [95% CI 0.14–0.38], p<0.0001). However, no significant differences in intensification of antihyperglycemic and antihypertensive medications were observed between patients receiving CHW support and those without CHW support. Patients with low health literacy completed significantly more encounters with the pharmacist and CHW than those with high health literacy, although outcomes were comparable. Conclusions: No significant differences were noted between a clinical pharmacist–CHW team and clinical pharmacist alone in improving glycemic control within a low‐income ethnic minority population. [ABSTRACT FROM AUTHOR]

Background Numerous studies have demonstrated the value of including pharmacists in team-based care to improve adherence to cardiovascular ( CV) guidelines, medication adherence, and risk factor control. However, there is limited information on whether these models can be successfully implemented more widely in diverse settings and populations. The purpose of this study is to evaluate whether a centralized, web-based cardiovascular risk service ( CVRS) managed by clinical pharmacists will improve guideline adherence in multiple primary care medical offices with diverse geographic and patient characteristics. Methods This study is a prospective trial in 20 primary care offices stratified by the percent of under-represented minorities and then randomized to either the CVRS intervention or usual care. The intervention will last for 12 months and all subjects will have research visits at baseline and 12 months. The primary outcome is the difference in guideline adherence between groups. Data will also be abstracted from the medical record at 24 months to determine if the intervention effect is sustained after it is discontinued. Conclusions Patient enrollment will continue through 2016, with results expected in 2019. This study will provide information on whether a distant, centralized CVRS can be implemented in large numbers of medical offices, if it is effective in diverse populations, and if there is a long-term sustained effect. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to determine if institutions with inpatient cardiovascular credentialed pharmacists exhibit improved quality measures for acute myocardial infarction ( AMI) and heart failure ( HF) care compared with institutions without inpatient cardiovascular credentialed pharmacists. Methods We conducted a multicenter, retrospective, cross-sectional, matched case-control study. Hospitals with at least one Added Qualification in Cardiology ( AQCV) inpatient pharmacist were included in the case group. Each case group hospital was matched to hospitals without an AQCV pharmacist by region, number of cardiovascular discharges, and teaching hospital designation in a 1:3 ratio (case:control). The 34 AQCV hospitals were matched to 102 non- AQCV hospitals. The proportions of discharges meeting HF and AMI process of care measures and 30-day outcomes (readmission and mortality) for each hospital were determined from public data and compared between the case and control groups. Results Hospitals with AQCV pharmacists performed better on process of care measures than hospitals without AQCV pharmacists ( odds ratio 1.41, 95% confidence interval 1.25-1.58, p<0.0001, p<0.001 for heterogeneity), which was mainly driven by the aspirin on discharge for AMI and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker on discharge for HF measures. No differences were observed between the groups for either readmission or mortality at 30 days. Conclusions Hospitals that used inpatient AQCV pharmacists performed better on process of care measures than hospitals that do not use inpatient AQCV pharmacists. However, improvements in process of care performance measures observed in AQCV hospitals did not translate into improved 30-day clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effectiveness of a care management program provided by clinical pharmacists for veterans with dyslipidemia. Design Retrospective cohort design. Setting Two primary care clinics at a Veterans Affairs Medical Center. Patients An intervention ( IT) cohort of 213 patients referred for management of dyslipidemia by clinical pharmacists and a control cohort of 219 patients with dyslipidemia receiving usual care ( UC). Methods Data were obtained from electronic medical records regarding drug therapy, lipid levels, and patient characteristics. Using multivariable regression models to adjust for baseline characteristics, the primary analyses compared mean final measured values of low-density lipoprotein (LDL) cholesterol, total cholesterol ( TC), high-density lipoprotein ( HDL) cholesterol, and triglycerides ( TGs) among the IT and UC cohorts at the final follow-up visits. Secondary analyses compared the proportion of patients achieving National Cholesterol Education Program/Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults ( NCEP/ ATPIII) concordant LDL goals and the time to achieve LDL goals between the two groups. Results Compared with the UC cohort, the adjusted difference in the mean final measured LDL for the IT cohort was −10.4 mg/dl (95% confidence interval [ CI] −16.1 to −4.6, p < 0.001) and TC was −12.7 (95% CI −21.3 to −4.1, p=0.004). There were no significant differences in the adjusted mean final measured HDL or TGs between the two groups. The NCEP/ ATPIII goal LDL was met in 80.3% of patients in the IT cohort and 65.3% of patients in the UC cohort (odds ratio [ OR], 2.6; 95% CI 1.6-4.3, p<0.001). Time to achieve goal LDL was significantly shorter for the IT cohort compared with the UC cohort (risk ratio, 1.8; 95% CI 1.2-2.8, log-rank p=0.002). Conclusion Veterans referred to a clinical pharmacist for treatment of dyslipidemia achieved significant reductions in TC and LDL. A greater proportion of patients achieved NCEP/ ATPIII goal LDL, and the time to attainment of LDL goals was shorter in the pharmacist-managed cohort, supporting a continued role for pharmacy care management in the treatment of patients with dyslipidemia. [ABSTRACT FROM AUTHOR]

Current prescribing practices for venous thromboembolism ( VTE) prophylaxis and treatment are suboptimal, particularly regarding the use of appropriate prophylaxis in accordance with evidence-based guidelines. Failure to prevent avoidable VTE is associated with a substantial clinical and economic burden, due not only to the initial event, but also to VTE recurrence and long-term sequelae. Quality improvement initiatives such as the Surgical Care Improvement Project, the Centers for Medicare and Medicaid Services, the National Quality Forum, and The Joint Commission have developed performance measures to address the shortfall and improve adherence with best-practice recommendations. Several studies have highlighted the benefits of pharmacist-led anticoagulation services for reducing the occurrence of VTE and bleeding complications while reducing excess hospitalization and health care costs. By assuming responsibility for anticoagulation management, pharmacists can ensure that at-risk patients receive the correct drug at the correct dose for the correct duration, from initial presentation to outpatient follow-up. Increasing continuity of care in this manner will ultimately improve patient outcomes and reduce costs. Pharmacists can also play a key role in helping hospitals achieve performance measures by aiding in the development and implementation of local VTE guidelines, policies, and other quality improvement initiatives; by helping to establish critical pathways with protocols; and by providing valuable education for other health care professionals and patients alike. Pharmacists are in an ideal position to facilitate achievement of VTE-related performance measures and can thus substantially contribute to the much-needed improvement in current VTE prevention and care. [ABSTRACT FROM AUTHOR]

The article presents abstracts on pharmacotherapy topics which include "Observed incidence of linezolid-associated serotonin syndrome during concomitant serotonergic therapy," by Melanie R. Woytowish and Lena Maynor, "Characterization of Dabigatran discontinuation in the community setting," by Amanda Kerr et al, and "Dabigatran and warfarin: comparative analysis of safety and cost," by Niyati H. Vakil et al.

Study Objectives To determine whether the impact of anticoagulant control achieved in an Anticoagulation Management Service (AMS) is sustained after transfer of anticoagulation management to the primary care physician (PCP), and to assess patient satisfaction with their anticoagulation management by both the AMS and PCP. Design Prospective, randomized trial. Setting Pharmacist-directed ambulatory AMS located in a tertiary medical care facility and PCP practices in Canada. Patients Sixty-two adults who had received at least 6 months of warfarin therapy managed by the AMS. Intervention Patients were randomly assigned to remain with AMS care (32 patients) or to transfer their anticoagulation management care to their PCP (30 patients). After 4.5 months of care, patients in both groups completed a validated survey instrument assessing their satisfaction with the management of their warfarin therapy. Measurements and Main Results Of 295 patients screened, most were excluded from the study for denying consent or for having previous bleeding or clotting complications while taking warfarin. Patients in the AMS and PCP groups who completed the study were similar in age (median 70 and 76 yrs, respectively), and most had atrial fibrillation as an indication for warfarin (75% and 83%, respectively). The primary outcome measure-mean percentage of time within the desired international normalized ratio (INR) range after 6 months-was compared between the two groups, using both the actual range (INR 2.5 ± 0.5) and an expanded range (INR 2.5 ± 0.7). No significant difference was noted in this outcome between the groups (73.5 ± 19.1% vs 76.9 ± 24.5% for the AMS vs PCP groups, p=0.54). Other outcome measures were rates of thrombotic and hemorrhagic events resulting in emergency department visits or hospitalizations, patients' overall satisfaction with warfarin therapy, and patients' preferred anticoagulation management strategy. Two hemorrhagic events and one thrombotic event occurred in each group. Patients were more satisfied with their anticoagulant management by the AMS relative to PCP care (p=0.01), and given the choice, patients preferred AMS care (p=0.001). Conclusion During this 6-month trial, anticoagulation control did not significantly differ between patients who continued to receive anticoagulation management by the AMS and those who transferred to their PCP for anticoagulation management, indicating that the effects of AMS care were sustained. Although patients were more satisfied and preferred to stay with AMS care, this study shows that select patients could have their anticoagulation care transferred to their PCP without compromising anticoagulation control. [ABSTRACT FROM AUTHOR]

Study Objective. To assess blood pressure control after discontinuation of a physician-pharmacist collaborative intervention. Design. Comparative analysis of data of the patients who received the intervention versus a control group from a prospective, cluster-randomized, 9-month efficacy trial and the same patients' data 18 and 27 months after completion of the trial, abstracted from their medical records. Setting. Five primary care medical offices operated by a university health system. Patients. One hundred four patients with hypertension; 65 were in the intervention group, and 39 were in the control group. Measurements and Main Results. In the prospective study, patients were randomized to receive a physician-pharmacist collaborative intervention to improve blood pressure control or to the control group. Systolic and diastolic blood pressures were measured by a research nurse at baseline and at the end of the study (9 mo later). In the current study, data were abstracted for blood pressure and blood pressure control at 18 and 27 months (9 and 18 mo, respectively, after discontinuation of the study). At baseline, mean ± SD systolic blood pressure was 152.5 ± 9.5 and 150.1 ± 9.6 mm Hg in the intervention and control groups, respectively (p=0.22). At 9 months, systolic blood pressure decreased to 124.5 ± 10.7 and 132.0 ± 15.1 mm Hg (p=0.0038 between groups), and blood pressure was controlled in 78.5% and 48.7% (p=0.0017) of patients in the intervention and control groups, respectively By 18 months, systolic blood pressure had deteriorated to 131.0 ± 12.2 and 143.3 ± 17.5 mm Hg (p<0.001), and blood pressure control rates decreased to 53.9% and 30.8% (p=0.02). By 27 months, systolic blood pressure was 131.3 ± 13.0 and 141.2 ± 15.8 mm Hg (p=0.0008), and blood pressure control was 55.4% and 35.9% (p=0.05). Conclusion. A sustained positive effect on blood pressure control was noted up to 18 months after discontinuation of a physician-pharmacist collaborative intervention, when compared with a control group. Blood pressure control did deteriorate at a similar rate in both the intervention and control groups, but the percentage of patients with controlled blood pressure remained significantly higher in the intervention group. These results suggest that continued interventions by pharmacists may be necessary to maintain high rates of blood pressure control, especially in those patients whose blood pressure begins to increase. [ABSTRACT FROM AUTHOR]