Pharmacy News

The pharmacy news section of the MPA Web site is designed to provide members with immediate access to timely and relevant information about pharmacy and our Association. In this section, you will find information on MPA activities, Association members, the latest issues impacting the pharmacy profession and press releases from MPA and its affiliates.

Members are also encouraged to join the conversation by following MPA on Twitter @MIPharmacists for the latest breaking news. For more information on MPA's presence on social networking sites, visit our social media page.

Western Michigan Society of Health-System Pharmacists Update
Stacy Brousseau, Pharm.D., BCPS, WMSHP president, emergency medicine clinical pharmacist, Bronson Methodist Hospital, Kalamazoo, Mich.

Western Michigan Society of Health-System Pharmacists (WMSHP) has been busy in 2019, with continuing education programming offered every month so far this year. WMSHP kicked off the year on Jan. 10 with a fantastic, interactive presentation from Todd Walroth, Pharm.D., BCPS, BCCCP, on facilitating pharmacy residents and technicians in applying project management skills. In February, Mark Wilson, Pharm.D., BCPS, kept us laughing while educating us on the newest recommendations and up-and-coming treatment options for heart failure patients. Then, in March, Dr. Graham Carlos gave a remarkable, captivating presentation on evading healthcare burnout. He spoke on the science behind burnout and offered valuable commentary and advice on managing the stressors encountered while working in health care. Rounding out the winter/spring monthly meetings, in April, pharmacy residents Alice Chen and Jessica Hirsch presented their yearlong research projects on fixed-dose 4-factor prothrombin complex concentrate (PCC) for warfarin reversal and on the effect of postoperative ketamine on opioid consumption in abdominal surgery patients, respectively. WMSHP would like to extend a big thank you to all of the amazing speakers!

WMSHP also held their 50th Annual Spring Seminar on May 14 at the Prince Conference Center in Grand Rapids. Programming for the conference included five hours of live continuing education on a wide range of topics, including pain management, infectious diseases, pharmacy law, critical care and cardiology. Special giveaways for attendees, as well as two student scholarships, were awarded at the conference! Thank you to all of the speakers and attendees!
 
WMSHP will be on summer break for programming through August and will resume monthly meetings in September. However, mark your calendars for the annual WMSHP Summer Outing on July 25 with West Michigan Whitecaps baseball at Fifth-Third Ballpark! WMSHP will again be offering an all-you-can-eat BBQ dinner on the Altogas Patio. The event will be free for WMSHP members, with an additional $15 per person cost for accompanying friends or family. Registration for the event is now available! For more information about WMSHP or upcoming programming, please visit www.wmshp.net.
Posted in: Member News
IV to PO Levothyroxine Dose Conversion Update
Priya Verma, Pharm.D., PGY-1 pharmacy resident, Sparrow Health System,
Lansing, Mich.

Levothyroxine (Synthroid®) is a synthetic form of thyroxine, which is an endogenous hormone secreted by the thyroid gland. Thyroxine (T4) is converted to the active thyroid hormone, L-triiodothyronine (T3). The thyroid hormones exert the metabolic effects involving normal metabolism, promoting gluconeogenesis and stimulating protein synthesis.1 The 2014 American Thyroid Association (ATA) Guidelines recommend initiating levothyroxine as the first line treatment for primary hypothyroidism.2 Levothyroxine is available in both an oral and intravenous (IV) formulation. For the treatment of hypothyroidism, it is recommended to initiate oral levothyroxine, whereas the IV formulation is often reserved for patients who are temporarily unable to receive oral therapy. Historically, when converting from a parenteral to enteral route, the dose conversion was 1:2. The dose conversion has been updated in the ATA Guidelines, which recommend a dose conversion of 0.75:1 when converting from a parenteral to enteral route. This updated dose conversion is based on recent literature which has shown that the bioavailability of levothyroxine is estimated to be around 79-81 percent.3 Based on this data, the ATA Guidelines and Lexicomp recommend administering an IV dose that is 75 percent of the oral dose when converting from a parenteral to enteral route. At Sparrow, we have updated the parenteral to enteral drug conversion policy to include the new levothyroxine conversion to match the updated guidelines.
 
References

1. Levothyroxine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed February 7, 2019.
2. Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid 2014; 24: 1670-751.
3. Dickerson RN, Maish GO, Minard G, et al. Clinical Relevancy of the Levothyroxine-Continuous Enteral Nutrition Interaction. Nutr Clin Pract 2010; 25: 646-52.
Posted in: Member News
Physician Adherence to 2017 ACC/AHA/HFSA Clinical Practice Guidelines in Patients with Heart Failure with Reduced Ejection Fraction (HGrEF) in a Community Teaching Hospital
Tawnie McGraw, Pharm.D. candidate 2019, Ferris State University College of Pharmacy, Grand Rapids, Mich.; Kali VanLangen, Pharm.D., BCPS, Ferris State University College of Pharmacy and Mercy Health Saint Mary's Hospital, Grand Rapids, Mich.; and Julie Belfer, Pharm.D., BCCCP, BCPS, Mercy Health Saint Mary's Hospital, Grand Rapids, Mich.

The prevalence of heart failure continues to rise with the aging population in the United States, as do the costs associated.1 It is estimated that by year 2035, more than 130 million adults in the United States (45.1 percent) are expected to have some form of cardiovascular disease and the costs associated are expected to reach 1.1 trillion dollars.1 It is also important to note that more than 20 percent of patients with heart failure are readmitted to the hospital within 30 days and up to 50 percent within months.2 Although heart failure cannot be cured, the burdens associated with the disease can be reduced with appropriate pharmacotherapy. By targeting this population with guideline recommended pharmacotherapy we can slow heart failure progression, reduce mortality and morbidity and improve symptoms to prevent hospitalizations.
 
The primary purpose of this study, the Physician Adherence to 2017 ACC/AHA/HFSA Clinical Practice Guidelines in Patients with Heart Failure with Reduced Ejection Fraction (HGrEF) in a Community Teaching Hospital study, was to evaluate physician adherence to guideline recommended medications that have shown morbidity and mortality benefit as well as reduce heart failure related hospitalizations in patients with HFrEF at Mercy Health Saint Mary's. Physician adherence was based on the adherence score for prescribed medications at discharge for patients within the cardiology consult group and the primary care services group.
 
There are multiple studies that utilize an adherence score to evaluate the appropriateness of medications prescribed to patients with HFrEF. The adherence score was originally developed and used in the QUALIFY study which aimed to understand the impact of physician adherence to guidelines from the European Society of Cardiology.3 The adherence score provides an objective assessment and is calculated by obtaining the ratio of the evidenced-based medications prescribed to the evidenced-based medications that theoretically should have been prescribed. The medications that theoretically should have been prescribed are chosen based on their significant improvement in morbidity and mortality as well as reduction in heart failure hospitalizations as supported by the current guidelines. Each medication is reviewed for appropriateness based on the current guidelines4 and then given a score of either zero points for the lack of prescribing of an evidenced-based medication in the absence of contraindications, 0.5 points for the use of evidenced-based medication at < 50 percent target dosage or one point for the use of evidenced-based medication > 50 percent target dosage or for not prescribing in the presence of contraindications, intolerances or allergies.
 
This was a retrospective chart review that included adult patients admitted between June 1, 2017 and June 1, 2018 with a discharge diagnosis of heart failure with reduced ejection fraction (ejection fraction < 40% measured on echocardiogram) confirmed by documentation within the past one year from date of admission. Two cohorts of patients were identified for comparison: patients with a cardiology consult and patients managed by a primary care service. The primary care services group comprised of patients admitted to one of the following three services: the family medicine resident service, internal medicine resident service or the hospitalist service. The primary outcome was to compare the average physician adherence score between the cardiology consult group and the primary care services group. The secondary outcome was to compare the average physician adherence score between the internal medicine resident service, family medicine resident service and the hospitalist service. The reasons for not prescribing guideline recommended medications was also explored.
 
The mean physician adherence score was significantly higher for the cardiology consult group versus the primary care services group, which was 0.59 and 0.47 respectively (p = 0.0279). Contraindications was the most commonly inferred reason for not prescribing guideline recommended medications as it was present in 67 percent of patients in the cardiology consult group and 87 percent of patients in the primary care services group (p = 0.008). However, contraindications were accounted for when calculating the adherence score.
 
This study showed a statistically significant difference in the mean physician adherence scores between the cardiology consult group and the primary care services group. Based on our evaluation, this indicates that if a cardiology consult was obtained, patients were more likely to be discharged on guideline recommended medications at appropriate target doses based on our evaluation. However, there were multiple patient baseline characteristics that were different among the two cohorts which might have contributed to the difference seen in the mean physician adherence score. There was no difference in the mean physician adherence scores between the primary care services. A larger patient population may be needed to further assess the clinical significance of physician adherence scores between the cardiology consult group and primary care services group.
 
There is potentially room for improvement in physician adherence to evidenced-based medications for HFrEF. The unique skillset of a pharmacist readily optimizes medication regimens and identifies gaps in adherence. We can assess for true allergies and recommend alternative medications when appropriate, assess for physician and patient hesitancy to the prescribed medications and provide education to reduce hesitancy. We can also provide close follow up and assist in medication titration. A prospective study would be valuable to provide further insight to reasons for not prescribing evidenced-based medications in the absence of allergies, contraindications or adverse events.

References
 

1. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation [Internet]. 2018 Jan 31 [cited 2018 Mar 31];137(13): e67-e493. Available from: http://circ.ahajournals.org/content/early/2018/01/30/CIR.0000000000000558 

2. O'Conner CM. High heart failure readmission rates: is it the health system's fault? JACC Heart Fail [Internet]. 2017 May [cited 2018 Mar 31];5(5):393. Available from: http://heartfailure.onlinejacc.org/content/5/5/393

3. Komajda M, Cowie MR, Tavazzi L et al. Physicians' guideline adherence is associated with better prognosis in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. Eur J Heart Fail [Internet]. 2017 Nov [cited 2018 Feb 22];19(11):1414-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28463464

4. Yancy CW, Jessup M, Bozkurt B et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Failure Society of America. J Am Coll Cardiol [Internet]. 2017 Aug 8 [cited 2018 Mar 4];70(6):776-803. Available from: https://www.ahajournals.org/doi/10.1161/cir.0000000000000509

Posted in: Member News
Use of Telemedicine for Medication History Interviews

Amy Pouillon, Pharm.D., supervisor, medication history and coordinator, 
Spectrum Health Hospitals, Grand Rapids, Mich.

 

Amy Pouillon, Pharm.D., at Spectrum Health Butterworth preparing to interview a patient remotely.

Accurate patient medication histories are a critical piece of the hospital admission process helping ensure patient safety during the inpatient stay and after discharge. Historically, emergency room nurses or other healthcare professionals were responsible for completing this detailed work during the complex admitting process. Variations in practice and lack of time during the admission process resulted in medication histories not validated with available outpatient prescription records which contributed to medication safety events (adverse drug reactions, medication errors and/or near misses).1,2,3
Spectrum Health is a multihospital system which continues to incorporate new hospitals across West Michigan. As new hospitals integrate, systems are standardized; best practices are shared, including the opportunity to spread this best practice around medication history acquisition. As the hospital system expands, the standardization of patient care across entities has required innovative thinking to provide consistent high quality care at the lowest cost. An internal assessment of medication history processes across multiple hospitals revealed significant variability. Standard interview scripting and medication validation with outpatient prescription records were not a consistent part of the medication history process. The smaller community hospitals relied on support from nursing, pharmacy or providers to update the medication history prior to reconciliation. Patient safety, system standardization, quality outcomes and provider satisfaction were the primary drivers for developing a highly reliable medication history service across the multiple hospitals. The team recognized that a new health solution was required to improve the process for how medication histories were obtained at the hospitals within the system.
Utilizing medication history pharmacy technicians from the central large teaching hospital, telemedicine and the common electronic health record, a pilot program connected the medication history team from the central campus with the patients in a small regional hospital providing 24 hours a day, seven days a week medication history service.
During the pilot phase of the program, the team was able to show improvements in all metrics identified in the plan phase of the project. Improved quality metrics were observed by a reduced medication history error rate from 11 percent to less than one percent in charts retrospectively audited by rounding pharmacists. Nursing efficiency improved by approximately 10 minutes of time per patient as they were no longer required to complete the medication history and enter the information in the electronic health record. Removing the medication history task from the nurse allowed the practitioner to devote more time to other patient care activities. The nurses reported spending approximately one minute per patient helping transfer the telemedicine hardware into the patient room and facilitating the interview process with the pharmacy technician team. The medication history turnaround time to completion improved from 27 minutes to 20.6 minutes which benefited the provider by having an accurate patient home medication list earlier in the admission process. The pharmacy team also gained efficiencies, reducing the time required to obtain the best possible medication history from 22 minutes to 11.2 minutes. Provider satisfaction improved from a baseline score of 2.1 to 3.32. Refer to Table 1 for a detailed breakdown of the results.
By leveraging these resources between entities, the health system was able to avoid an estimated $200,000 of pharmacy technician labor expense showing the value of system integration. The pilot program has become an established working model for the organization and has fully integrated four hospitals with plans for expansion to three additional hospitals by summer 2019.
Table 1: Pilot Project Metrics
 
Baseline
Goal
30 days
90 days
120 days
Medication history error rate
11%
< 5%
2.6%
1.4%
<1%
Nurse time with medication history process
10 minutes
< 5 minutes
1 minute
1 minute
< 1 minutes
Turnaround time
27 minutes
≤27 minutes
17.8 minutes
26.1 minutes
20.6 minutes
Pharmacy technician completion time
22 minutes
22 minutes
14.1 minutes
13.3 minutes
11.2 minutes
Provider Satisfaction Survey
2.1
> 2.1
3.4
3.31
3.32

References

1. Kwan JL, Lo L, Sampson M, et al. Medication reconciliation during transitions of care as a patient safety strategy: A systematic review. Ann Intern Med. 2013; 158(5_Part_2): 397-403.
2. Hellstrom LM, Bondesson A, Hoglund P et al. Errors in medication history at hospital admission: Prevalence and predicting factors. BMC Clin Pharmacol. 2012; 12(9): 1-9.
3. Meuller SK, Sponsler KC, Kripalani, S, et al. Hospital-based medication reconciliation practices: A systematic review. Arch Intern Med. 2012; 172(14): 1057-69.
Posted in: Member News
Applying the Pharmacists' Patient Care Process to Transitions of Care
Devin Schmidt, Pharm.D., BCACP, ambulatory care pharmacist, Mercy Health Muskegon, Muskegon, Mich.

In 2014, the Pharmacists' Patient Care Process was created by the Joint Commission of Pharmacy Practitioners (JCPP) after a need was recognized for a consistent process in the delivery of patient-centered care across various practice settings of the pharmacy profession. Supported by 13 national pharmacy organizations, this process set out to engage patients and caregivers using effective communication to promote comprehensive approaches to deliver care in collaboration with other members of the healthcare team.1 Since the publication of this process, many pharmacists and student pharmacists have begun using these steps to employ consistent patient care to their practices.

Recently, the American Pharmacists Association (APhA) highlighted implementing this process in transitions of care.2 This guide serves to provide specific guidance, directly related to patient care during a healthcare transition, within each of the principles defined in the Pharmacists' Patient Care Process.

Collect - A pharmacist should collect the necessary subjective and objective information to enable safe and efficient care transitions. Collected information should include, but not be limited to, data to optimize medication reconciliation, medication counseling, medication delivery and/or dispensing, and post discharge follow up via telephone or face-to-face visit. Depending on the care transition, this would include a comparison of the existing and previous medication regimens, patient's personal medication list and patient provided history.

Assess - Using the information collected, assessment of the indication, efficacy, safety and ease of adherence for each medication should be performed at each care transition. Assessing both acute and chronic disease states is important during a care transition, even though it may have been an acute concern that lead to this change in level of care. Attention should also be given to health literacy, the patient's social support system, potential barriers, such as transportation or financial barriers, and the need for assistance in setting up follow up care.

Plan - When creating a care plan during various care transitions, each medication related problem needs to be addressed to optimize the patient's medication regimen, prioritizing resolving barriers and ensuring safety. Care plans should align with the therapy goals established by the healthcare team. Engaging the patient with effective communication is important to educate and empower the patient to self-manage their health when discussing the plan.

Implement - Effective collaboration between pharmacists and other members of the healthcare team is imperative to address identified barriers to safe and efficient transitions. Potential collaborations might include utilizing other disciplines to help address barriers with home health, transportation, insurance enrollment, culture, language differences or various levels of health literacy. Pharmacists are uniquely suited to provide patient specific education on their complete medication list at transitions and empower self-management. Providing information to other members of the healthcare team that were not involved in the care transition is also an integral component for implementing a successful plan.

Follow-up: Monitor and Evaluate - Once a patient completes a care transition, it is important that the implemented plans are monitored and evaluated to determine its efficacy, as well as providing effective hand-offs to ensure continuity of care throughout transitions. Follow up phone calls, home or office visits and medication reviews aide in the assessment of adherence and self-care of the implemented plan.

Overall, various care transitions can involve different disciplines, tasks and responsibilities depending on the location of transition. However, utilizing the five steps of the Pharmacists' Patient Care Process provides a framework by which a consistent level of care across the pharmacy profession is provided during healthcare transitions.

References 

1. The Pharmacists' Patient Care Process [Internet]. JCPP. 2014 [cited 2019Feb23]. Available from: https://jcpp.net/patient-care-process
2. American Pharmacists Association. Applying the Pharmacists' Patient Care Process to Care Transitions Services. February 2019.
Posted in: Patient Safety
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