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Purpose The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications. Summary Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge. Conclusion Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers.

Pulmonary arterial hypertension has evolved from a fatal disease with few treatment options to a chronic condition with improved survival. This improvement is possible through development of effective therapies as well as the expansion of risk stratification scores to assist clinical decision making. Despite improved disease control, quality of life, and overall prognosis, many challenges remain. The treatment itself is burdensome, with significant impact on quality of life. Many patients with pulmonary arterial hypertension still present with advanced, often end-stage disease. Increased use of mechanical circulatory support and catheter-based interventions have expanded use of extracorporeal life support and right ventricle assist devices. For these reasons as well as the long-term relationships pulmonary hypertension physicians have with patients and their families, navigating the course of the illness in a considered, proactive way is essential. Understanding individual goals and revisiting them as they change over time requires comfort with the conversation itself. There are many barriers and challenges to having effective, compassionate conversations in the clinical setting with time constraints being the most often cited. Compressed visits are necessarily focused on the clinical aspects, therapy and medication adherence and tolerance. Clinicians are sometimes wary of diminishing hope in the face of ongoing treatment. Having sufficient experience and comfort with these discussions can be empowering. In this paper, we discuss the challenges involved and propose a framework to assist in incorporating these discussions into clinical care.

Treprostinil diolamine is the first oral dosage preparation of a prostacyclin analogue for use in treatment naive pulmonary arterial hypertension (PAH). This case series and review of the available literature describes the experience of patients with PAH receiving treprostinil by intravenous (IV), subcutaneous (SQ), or inhalation route who were transitioned to treprostinil diolamine. At our institution, 3 patients were transitioned to treprostinil diolamine who received treprostinil administered by each of the alternative routes: IV, SQ, and inhalation. All patients tolerated the transition without significant worsening of disease end points. In the literature, 5 additional reports representing 48 patients were transitioned to treprostinil diolamine from an alternate route of administration. A majority (92%) of patients were hospitalized during the cross-titration phase and tolerated the transition without changes in disease markers or significant adverse effect. Six (13%) patients required reinitiation of parenteral therapy due to clinical decline. The most common dosing frequency utilized for treprostinil diolamine was 3 times per day. In patients with stable PAH receiving parenteral or inhaled treprostinil, a transition to treprostinil diolamine was a safe approach in a highly select population meeting clinical end points. Additional studies are required to further describe this clinical strategy before accepted in clinical practice.

The research published in the Journal of Applied Behavior Analysis (1968 to 1975) was surveyed for three basic elements: data-collection methods, reliability procedures, and reliability scores. Three-quarters of the studies reported observational data. Most of these studies' observational methods were variations of event recording, trial scoring, interval recording, or time-sample recording. Almost all studies reported assessment of observer reliability, usually total or point-by-point percentage agreement scores. About half the agreement scores were consistently above 90%. Less than one-quarter of the studies reported that reliability was assessed at least once per condition.

Three publication sources were reviewed to determine the recent conventions for collecting, and assessing the reliability of, academic permanent-product data (handwriting, examination papers, etc in applied behavior analysis. The primary source was the Journal of Applied Behavior Analysis (1968–1974). Secondary sources included conference proceedings titled, A new direction in education: behavior analysis (E. Ramp and B. L. Hopkins, Eds., Lawrence, Kansas: Support and Development Center for Follow Through, Department of Human Development, University of Kansas, 1971), and Behavior Analysis and Education (G. Semb, Ed., Lawrence, Kansas: Support and Development Center for Follow Through, Department of Human Development, University of Kansas, 1972). Finally, as a test of the generality of the findings in the two applied behavior analysis sources, the current issue of each of 14 psychological and/or educational journals was reviewed. Thirty JABA studies reported academic permanent-product data, but only 14 reported reliability. Increasingly more product data through 1973 have been reported along with a greater proportion of authors reporting reliability. The review of the two conference proceeding publications revealed the same trend. In 1971, only three studies reported academic product data, none with reliability, while in 1972, 15 reported academic data, nine including reliability assessment. The review of 14 current education/psychology journal issues revealed four studies reporting academic data, none with reliability. Across all sources, about one-half of the studies reported reliability. Most of the studies reporting reliability described the frequency of reliability assessment, with approximately equal numbers of JABA studies reporting reliability for each paper or reliability for each session. The use of uninformed observers was reported in only three JABA studies and one conference study. Marks made on subjects' papers by either the teacher or the primary observer were reported masked for reliability purposes by only two JABA and two conference studies. Reliability was calculated on a session total basis in two JABA studies. Point-by-point agreement was given in nine JABA and three conference studies. Perfect reliability (mean agreement of 100%) was reported in only six JABA and three conference studies. Scores between 90 and 100% were reported in nine JABA and four conference studies. Scores below 80% were reported in three JABA studies. No other percentage agreement scores were reported, although one JABA study reported correlational reliability (Pearson r). In summary, recently more studies have dealt with academic data and, until 1974, a greater proportion of these studies reported reliability assessment, and relatively few studies reported either replicable methods, 100% agreement, or controls for maintaining rater independence.