Pharmacy News

Entries for February 2019

Different Year, Different Theme, Same Goal
Curtis Smith, Pharm.D., BCPS, FCCP

In 2018 the 115th Congress failed to pass the Pharmacy and Medically Underserved Areas Enhancement Act, the cornerstone of the federal pharmacist as provider movement. For many years the pharmacy profession, including MPA and MSHP, have promoted this legislation as a vitally important step in ensuring that pharmacists are paid directly for their clinical services. But the hope of that occurring in 2018 was dashed by other Congressional priorities. Although disconcerting, especially for those of us who put a lot of time and effort into the push for provider status, it should not discourage us as a profession. As I mentioned in my May 2018 MSHP Monitor article, we are in the midst of a major change in health care in the US from a primarily fee-for-service model to a value-based model of reimbursement. This change will ultimately highlight the fact that pharmacists are one of the most important healthcare providers to ensure quality outcomes in the US population.

That's why I'm excited that President Clark chose "Achieving Patient Care Outcomes" as the MSHP theme for 2019. Since quality of care rather than quantity of care/services will be the focus in the not too distant future, we need to demonstrate now the impact we have on those outcomes. A study last summer in AJHP did just that.1 The study evaluated the effect of pharmacists collaborating with physicians in an outpatient setting to improve outcomes in almost 2,500 patients and matched controls with at least two of seven specific chronic disease states, including hypertension, diabetes, hyperlipidemia, heart failure, asthma, COPD and depression and receiving at least four medications. They found statistically significant improvements in hemoglobin A1C and blood pressure lowering in patients who received pharmacists' care over the control patients who did not. They also found a significantly decreased rate of hospitalization for patients receiving pharmacy care (down 23.4 percent) vs. usual care (down 8.7 percent). This resulted in an overall savings of approximately $2,400 per patient per year. This savings amounted to five times the cost of the pharmacy services ($5.2 million savings vs. an approximately $1 million cost of the two-year program).

Another exciting thing that happened at the end of 2018 was a report published by the Trump administration entitled "Reforming America's Healthcare System Through Choice and Competition."2 This report recommends that states update scope of practice statutes so that everyone in the healthcare system is practicing at the top of their professional license. That should result in a higher quality and efficiency of care for all Americans. It also recommends that laws be updated so that non-physician healthcare providers can be paid directly for their services at the state and federal level. If implemented, these recommendations, combined with data on pharmacist-driven positive patient outcomes, position our profession as an important component of the move towards value-based care.

In light of the need for state law updates and data on pharmacist improved outcomes, California passed a law that went into effect in Jan. 2019 requiring pharmacy staff at hospitals with more than 100 beds to obtain an accurate medication history for each high-risk patient.3 Pharmacists and adequately trained pharmacy interns and technicians can perform this service, highlighting the importance of pharmacy trained individuals in the transitions of care process. This law was introduced by a pharmacist-legislator and unanimously supported by every other legislator. This demonstrates the need to promote pharmacists becoming legislators as well as pharmacy-related legislative action that improves patient outcomes.

So join with me in supporting and promoting President Clark's 2019 theme. It is vitally important to demonstrate how we achieve positive patient care outcomes, in order to be an integral part of the ongoing shift to value-based care and reimbursement. This year, as you consider ways that you can demonstrate and document the positive outcomes your services provide, consider also encouraging your representatives at the state and federal level to actively support legislation promoting pharmacists practicing at the top of their professional license - and receiving reimbursement accordingly. Our patients deserve it.
 
  1. Matzke GR, Moczygemba LR, Williams KJ, Czar MJ, Lee WT. Impact of a pharmacist-physician collaborative care model on patient outcomes and health services utilization. Am J Health Syst Pharm. 2018 Jul 15;75(14):1039-1047.
  2. U.S. Department of Health and Human Services, U.S. Department of the Treasury, U.S. Department of Labor. Reforming America's Healthcare System Through Choice and Competition. https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf. Accessed January 8, 2019.
  3. Thompson CA. California pharmacists to ensure accuracy of high-risk patients' admission medication lists. American Journal of Health-System Pharmacy October 2018, news180076; DOI: https://doi.org/10.2146/news180076. http://www.ajhp.org/content/early/2018/10/19/news180076. Accessed on Jan. 8, 2019.
Posted in: Member News
Western Michigan Society of Health-System Pharmacists Update
Stacy Brousseau, Pharm.D., BCPS, WMSHP president, emergency medicine clinical pharmacist, Bronson Methodist Hospital, Western Regional Society representative
 
The Western Michigan Society of Health-System Pharmacists (WMSHP) had exceptional continuing education offerings in 2018, with speakers who provided the membership with relevant, up-to-date information on an abundance of topics. WMSHP sponsored three different continuing education programs this past Fall. 

On Sept. 6, pharmacists Tiffany Jenkins and Rachel Walters presented on "The Role of the Pharmacist in Population Health" at Uccello's Ristorante in Grand Rapids. 

On Oct. 11, at Borgess Medical Center in Kalamazoo, Tracey Mersfelder provided some excellent and informative pain CE during her presentation titled, "A Painful Decision."

Finally, to round out 2018, pharmacist clinical coordinator Jim Curtis gave a forward-thinking presentation on "New Frontiers in Multiple Sclerosis" on Nov. 8 in Grand Rapids. WMSHP would like to extend a big thank you to all of our speakers for their outstanding educational contributions in 2018.
 
Keeping busy this fall, WMSHP also hosted its annual residency showcase on Oct. 4 at Ferris State University College of Pharmacy's GRx building in Grand Rapids. The showcase was coordinated along with the Ferris State University College of Pharmacy Career Fair. The event had a great student turnout, with residency programs from all across Michigan and several neighboring states participating in the event as well. WMSHP is looking forward to continuing to facilitate this showcase for years to come.
 
WMSHP also elected several new Board members for 2019. Incoming board members include:
 
President-elect 2019: Kyle Schmidt, Pharm.D., BCCP
Secretary 2019-2020: Brad Miller, Pharm.D.
Board Members 2019-2020:
  • Sarah Hoerner, Pharm.D. (incumbent)
  • Mitchell Stein, Pharm.D. (incumbent)
  • Shelby Kelsh, Pharm.D.
  • Derek Vander Horst, Pharm.D.
  • Andrea Borst, Pharm.D.
Posted in: Member News
New Indication for a "New" Oral Anticoagulant
Jenna Matelske, Pharm.D. candidate 2019, Ferris State University 
College of Pharmacy

Rivaroxaban (Xarelto®) is a factor Xa inhibitor regularly referred to as a "NOAC" meaning "new" or "novel" oral anticoagulant. Until recently, rivaroxaban was indicated for treatment/prevention of deep vein thrombosis and pulmonary embolism in addition to reduction of stroke risk in patients with atrial fibrillation. In October 2018, rivaroxaban gained a new indication for use in combination with aspirin to reduce the risk of major cardiovascular (CV) events (CV death, myocardial infarction, and stroke) in patients with chronic coronary artery disease (CAD) or peripheral artery disease (PAD).1,2 This additional indication stems from the investigations of the COMPASS trial published in 2017.3

Eikelboom and colleagues evaluated the efficacy of rivaroxaban alone and in combination with aspirin compared to the use of aspirin alone for secondary cardiovascular prevention. This multinational, double blind, double dummy, randomized trial was terminated early due to the demonstrated superiority of the rivaroxaban plus aspirin group compared to aspirin alone. The primary outcome of major CV events occurred in 4.1 percent of patients receiving the combination of aspirin and rivaroxaban versus 5.4 percent with aspirin alone (hazard ratio, 0.76; P<0.001). The trial conclusion led to the recommendation of adding rivaroxaban 2.5 mg twice daily to low dose aspirin for the prevention of secondary CV outcomes in patients with stable atherosclerotic vascular disease.3

As pharmacists, there are several major considerations of this new indication. First, the indication is only for the prevention of secondary CV events in CAD and PAD; primary prevention of CV events was not evaluated in the COMPASS trial. Uniquely, the trial evaluated adherence through the use of a 14 day run-in phase that identified patients who were unwilling or unable to adhere to the regimen.3 The recommended regimen does require the patient to take two different tablets on a different schedule (one twice daily and the other only once daily). The increased complexity of the regimen - from historical use of one aspirin tablet once daily - did not seem to be a barrier to efficacy. Recognition of the new dosage associated with this indication is vital. Rivaroxaban previously was only available as brand name Xarelto® in 10, 15, and 20 mg tablets.4 Following the most recent recommendation. a 2.5 mg tablet has come to the market - which is 25 percent the strength of the previous lowest available strength. The recommended regimen is also dosed twice daily, unlike the most common once daily dosing strategy for other rivaroxaban indications.4 These changes require vigilance as pharmacists to ensure safe and proper use. Finally, the major side effect of bleeding must be considered. The combination of rivaroxaban with aspirin did result in more major bleeding events (defined as events that led to patient presentation to an acute facility or hospitalization) than aspirin alone, 3.1 percent versus 1.9 percent respectively (hazard ratio, 1.70; P<0.001).3

Health system pharmacies also have important considerations regarding this new indication. At any given time, hospitals may have patients meeting the criteria for initiation of this indication as well as patients continuing home therapy of the combination. Health system pharmacists must work with multidisciplinary teams to evaluate the implementation of the new rivaroxaban indication. Cost of the addition of the 2.5 mg dosage to hospital formulary will have to be evaluated. Maintaining one patient on aspirin alone costs approximately $0.05/day, but with the addition of rivaroxaban 2.5 mg twice daily the price increases by $16.76/day based on average wholesale price. 4,5 The cost of rivaroxaban to the patient should also be considered as pharmacists may be involved in insurance and discount programs. Lastly, as many health systems are incorporating pharmacists in programs focused on educating patients initiated on oral anticoagulants, there is reason to include this new low dose indication in education programs.

Rivaroxaban is the only NOAC with an indication for secondary CV prevention in patients with CAD/PAD. We look to the future to see upcoming trials and evaluation of efficacy of the other oral anticoagulants in the pursuit of a similar indication.
 
ReferencesReferences
1. Global Janssen [Internet]. Titusville: Janssen Global Services, LLC. c2012-2019. U.S. FDA approves Xarelto (rivaroxaban) to reduce the risk of major cardiovascular events in patients with chronic coronary artery disease (CAD) or peripheral artery disease (PAD); 2018 Oct. 11 [cited 2019 Jan. 14]; [about 3 screens]. Available from: https://www.janssen.com/us-fda-approves-xareltor-rivaroxaban-reduce-risk-major-cardiovascular-events-patients-chronic
2. Xarelto® [packet insert]. Titusville, NJ: Janssen; 2018.
3. Eikelboom JW, et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med [Internet]. 2017 Aug. 27 [cited 2019 Jan. 14];377:1319-30. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa1709118 
4. Lexicomp Online [Internet]. Indianapolis: Wolters Kluwer Clinical Drug Information, Inc. 2013. Rivaroxaban; [cited 2019 Jan. 14]; Available from: http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/1275239#f_preparations
5. Lexicomp Online [Internet]. Indianapolis: Wolters Kluwer Clinical Drug Information, Inc. 2013. Aspirin; [cited 2019 Jan. 14]; Available from: http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/6388#fee
Posted in: Member News
Resident-at-Large 2019
Danielle Murphy, Pharm.D. Spectrum Health PGY1
 
WMSHP's monthly meetings resume this January in Kalamazoo with IU Health's clinical pharmacy manager and burn/critical care clinical pharmacy specialist Todd Walroth presenting on "Facilitating Pharmacy Residents and Technicians in Applying Project Management Skills in Clinical and Administrative Settings." 

For more information about WMSHP or our upcoming programming, please visitwww.wmshp.net .
Posted in: Member News
Retention and Recruitment Strategies for Pharmacy Technicians
Tisha Peterson, CPhT 

We've all been there. Short staffed, needing to find skilled pharmacy technicians. Where do we find them? How do we find them? Once we find them, how do we keep them?
 
The requirement of licensure for pharmacy technicians catapulted, what was once viewed as an entry-level job, to a profession. With that, came the challenge of finding licensed pharmacy technicians to fill current vacancies. Under the law requiring licensure, employers could apply to the state board of pharmacy for approval of an employer based training program. This would allow pharmacies to hire new pharmacy technicians while they study and train to become licensed. Many retail pharmacies took advantage of this opportunity. Currently, only a few hospitals have developed an approved training program.
 
An in-patient hospital in northern Michigan developed such a program. This allowed them to post open positions as pharmacy technician trainees. In advertising for trainees the number of candidates soared. The number of candidates went from two to three a week to having over 30 in a month. With new trainees, many with no pharmacy experience, came the need for trainers, mentors and teachers.
 
This need gave fruition to the Pharmacy Technician Preceptor Program. Current staff were given the opportunity to apply to be a preceptor and interview with pharmacy leadership. The candidates selected go through preceptor training, including teaching adult learners, documentation and the value of mentoring. The preceptors are also tasked with completing competency checklists and updating necessary changes. In addition to the preceptors evaluating the trainees, the trainees have the opportunity to evaluate the preceptor. This program allows an avenue for senior staff to advance, as well as maintain a consistent training program for new hires.
 
There seems to be two camps in the current workforce. You have your senior staff that have worked the same job for many years. They are content to come in, work hard, do the job and go home. Our second camp is made up of fresh faces ready to change the world. They are highly engaged in making changes for the better, but are ready to move on to the next challenge in a few short years. The challenge for employers is that both groups are motivated by different things, but want to be treated the same. A wage model was recently adapted by a northern Michigan hospital that attempts to do just that.
 
A technician is recognized monetarily for the skills they learn. Each skill is assigned points. High risk skills such as intravenous compounding would receive more points than a lower risk area such as a Pyxis machine refilling where products are barcode scanned. A new technician could potentially move up the wage scale, by becoming competent in many skills, much faster than a tiered model when longevity was the only factor affecting wage. This seems to satisfy the young technicians on the move and wanting to gain experience and skills quickly and be recognized for them.
 
The new wage model also recognizes longevity and experience. This seems to satisfy the other group of technicians. For every year of comparable experience a ratio of 1:1 is used in determining wage. For every year of pharmacy experience that is not in a hospital setting a 2:1 ration is used. This allows technicians that do not necessary want to learn new skills, because they are comfortable and happy in their current roles but should be recognized for their loyalty and longevity.
 
There are many ways to recruit and retain good pharmacy technicians. Only by sharing methods that work will the profession of pharmacy technicians continue to thrive. With new advancements happening every year it is more important now than ever to mold highly trained technicians and keep them.
Posted in: Member News
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