RESUMEN
BACKGROUND: Electronic consults (eConsults) allow for asynchronous, consultative, provider-to-provider communication. A pharmacy run eConsult service was initiated in a group of primary care clinics composed of 60 attending internal medicine primary care physicians (PCP), 100 internal medicine residents, and 10 pharmacists serving more than 60,000 patients. This study aims to describe (1) the number and types of eConsults placed to pharmacists; (2) the number of eConsults completed, converted to an office visit, or declined by a pharmacist; (3) the number of pharmacist recommendations made and implemented within 30 days of eConsult placement; and (4) PCP perceptions of the eConsult service. DESIGN: A retrospective chart review of all pharmacy eConsults placed between February 25, 2020, and July 6, 2021, was completed to describe eConsult utilization. In addition, an electronic survey was used to assess attending physician perceptions of pharmacy eConsults. RESULTS: A total of 513 eConsults were placed during the study period. The most common type of eConsult placed was "cost savings/formulary med questions" (110, 21.4%). Of the 435 eConsults completed by a pharmacist, 339 (78%) eConsults resulted in specific recommendations for medication therapy and 332 (98%) of these recommendations were implemented by the PCP. A total of 17 PCPs completed the survey assessing the perceived benefits of pharmacy eConsults. The top perceived benefits were improvement in patient outcomes (15, 88%) and ability to save provider time spent on patient care (14, 82%). CONCLUSIONS: eConsults to pharmacists resulted in specific drug therapy recommendations that were routinely implemented by PCPs and perceived as a benefit to both providers and patients.
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Farmacéuticos , Consulta Remota , Humanos , Estudios Retrospectivos , Atención Primaria de Salud/métodos , Derivación y Consulta , Atención Dirigida al Paciente , Consulta Remota/métodosRESUMEN
INTRODUCTION: Patients taking warfarin require frequent international normalized ratio (INR) monitoring in healthcare settings, putting them at increased risk of Coronavirus disease 2019 (COVID-19) exposure during the pandemic. Thus, strategies to limit in-person visits to healthcare facilities were recommended by the Anticoagulation Forum. The objective of this study was to describe the number and types of changes made to anticoagulation therapy as a result of pharmacist intervention during the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective chart review of patients included in a primary care COVID-19 anticoagulation intervention was conducted. During this intervention, pharmacists provided individualized recommendations for anticoagulation changes in patients taking warfarin to limit their healthcare facility exposure while also maintaining safe anticoagulation management practices. RESULTS: As a result of pharmacist intervention, 83 (55.7 %) of the 149 patients included in the intervention had changes in anticoagulation including: switching to a direct oral anticoagulant (n = 12), extending the INR monitoring interval (n = 48), switching to home INR monitoring (n = 21), or stopping anticoagulation (n = 2). For those patients who were taking warfarin for the entire 6 months pre- and post-intervention, the total number of healthcare facility and laboratory visits with an INR completed decreased from 8.8 to 6.4 (p < 0.001) per patient without a statistically significant decrease in time in therapeutic range (p = 0.76). CONCLUSIONS: This study depicts rapid implementation of a population health-based approach to assess all patients taking warfarin for options to minimize healthcare visits and decrease risk for COVID-19 exposure. Methods to reduce healthcare visit burden while maintaining patient safety should be considered as a regular component of anticoagulation management post-pandemic.
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COVID-19 , Warfarina , Anticoagulantes/efectos adversos , Monitoreo de Drogas/métodos , Humanos , Relación Normalizada Internacional/métodos , Pandemias , Farmacéuticos , Estudios Retrospectivos , Warfarina/efectos adversosRESUMEN
OBJECTIVE: To assess pharmacy preceptors' perceptions of the benefits of and barriers to a layered learning practice model (LLPM) at their practice site. METHODS: An online survey was created using Qualtrics and sent to experiential directors at all colleges [or schools] of pharmacy in Ohio and at Big Ten universities. The experiential directors were asked to send the survey to all preceptors affiliated with their program. The survey assessed the perceived or actual benefits of and barriers to a layered learning model. Benefits and barriers to patient care, student or resident learning, and the practice site were assessed. RESULTS: In total, 304 surveys were initiated by precepting pharmacists. Survey respondents reported precepting introductory pharmacy practice experience students (n = 113, 37.1%), advanced pharmacy practice experience students (n = 184, 60.5%), and residents (n = 176, 57.9%) throughout a given year. Survey respondents' most commonly identified benefits of a LLPM included an increase in patient access to pharmacy team members (n = 97, 42.3%), an increase in the number of precepting opportunities for learners (n = 80, 34.9%), and improvement in patient education (n = 76, 33.2%). The top identified barriers to a LLPM included performing precepting duties that may interfere with preceptor job responsibilities (n = 158, 72.1%), having inadequate workspace for learners (n = 120, 54.8%), and being unable to effectively teach or oversee multiple learners simultaneously (n = 77, 35.1%). CONCLUSIONS: This research provides insight into pharmacy preceptor perception of how a LLPM impacts practice sites, patient care, and training of pharmacy learners. This information may be valuable in the design of preceptor development for colleges of pharmacy and residency programs.
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Educación en Farmacia , Farmacia , Estudiantes de Farmacia , Humanos , Ohio , PreceptoríaRESUMEN
RATIONALE: Reconstructing stable isotope (SI) ratios at the base of paleo-food webs is often challenging. For coastal systems, the SI ratios of organic matter in archeological shell represents a possible solution, providing a direct record of primary consumer SI ratios in the littoral zone. However, shell is often porous, with organic compounds susceptible to diagenetic alteration or contamination. If molecular isotopic information is well preserved, compound-specific amino acid isotope analysis (CSI-AA) has the potential to provide direct proxies for baseline SI ratios, bypassing many contamination issues, and to allow assessment of the diagenetic state. METHODS: We collected shell from both archeological middens and nearby littoral zones in coastal Alaska, and used a simple organic extraction approach based on decalcification with sequential weak HCl additions to liberate organic material. We measured CSI-AA patterns, molar AA distributions, and the CSI-AA degradation parameter (ΣV), in the context of bulk SI ratios in fossil shell, modern shell, and soft tissue from five common taxa (urchin, limpet, mussel, periwinkle, chiton). RESULTS: CSI-AA patterns in both soft tissue and shell were consistent with primary consumers, and were indistinguishable in most modern and fossil shell pairs, showing that amino acid δ15 N values can be well preserved in archeological shell. AA molar distributions were also similar, although most fossil shell was enriched in Asx and Gly. Comparison between CSI-AA results from modern specimens confirmed that the source AA group (tracking isotopic baselines) are transferred without substantial modification into the shell record. In contrast, the Trophic AA group had elevated δ15 N values in shell versus soft tissue for all taxa examined, suggesting that a correction factor will be required for any CSI-AA proxies using these AAs. CONCLUSIONS: Overall, this new data indicates that the CSI-AA analysis of fossil shell represents a promising new approach to determining isotopic baselines in coastal paleo-ecosystems.
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Aminoácidos/química , Exoesqueleto/química , Fósiles , Isótopos de Nitrógeno/análisis , Animales , Arqueología , Ecosistema , Cromatografía de Gases y Espectrometría de Masas , MariscosRESUMEN
BACKGROUND: Persons with multiple chronic conditions and disability face access barriers to office-based primary care and have very high rates of emergency department (ED) use and hospital admissions. Home-based primary care (HBPC) has been proposed as a way to improve disease management and prevent health crises. HYPOTHESIS: Enrollment of patients with disability and multiple chronic conditions in a HBPC program is associated with a subsequent decrease in ED visits and hospital admissions. METHODS: We abstracted electronic medical record (EMR) data among patients receiving HBPC and compared rates per 1000 patient days for ED visits, admissions, 30-day readmissions, and inpatient days for up to three years before and after enrollment. RESULTS: Of 250 patients receiving HBPC, 153 had admission data recorded in our EMR prior to enrollment. One year after HBPC enrollment, the rate of admissions dropped by 5.2 (95% confidence interval 4.3, 6.0), 30-day readmissions by 1.8 (1.3, 2.2) and inpatient days by 54.6 (52.3, 56.9) per 1000 patient-days. Three years post-enrollment, rates remained below baseline by 2.2 (1.3, 3.1) for admissions, 0.5 (0.04, 1.0) for 30-day readmissions and 32.2 (29.8, 34.7) for inpatient days. Among 91 patients with pre-enrollment ED data, the rate of ED visits also dropped at one and three years by 5.5 (4.6, 6.4) and 2.7 (1.7, 3.7), respectively. CONCLUSION: Provision of HBPC for persons with multiple chronic conditions and disability is associated with a persistent reduction in ED and hospital use.
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Personas con Discapacidad , Servicio de Urgencia en Hospital/estadística & datos numéricos , Accesibilidad a los Servicios de Salud , Servicios de Atención de Salud a Domicilio , Hospitales/estadística & datos numéricos , Afecciones Crónicas Múltiples/terapia , Atención Primaria de Salud , Adulto , Anciano , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Aceptación de la Atención de SaludRESUMEN
BACKGROUND: Population health management uses proactive, targeted interventions to improve health outcomes. OBJECTIVES: To compare the effectiveness of and time required for 2 pharmacist-driven population health management interventions to improve vitamin B12 monitoring in patients taking metformin. METHODS: Physicians were randomized to 1 of 2 population health management interventions. For all patients of physicians assigned to the patient portal intervention, a pharmacist communicated need for vitamin B12 monitoring directly to the patient using an electronic patient portal. For all patients of physicians assigned to the office visit intervention, a pharmacist communicated monitoring recommendations to the physician prior to a scheduled office visit through the electronic health record. The proportion of patients in each group who received vitamin B12 monitoring 30 days after the intervention was quantified. RESULTS: A total of 489 patients of 26 physicians within 5 general internal medicine clinics who had taken metformin for at least 1 year and had not received vitamin B12 monitoring within the past year were identified. The intervention delivered as part of an office visit resulted in increased serum vitamin B12 monitoring compared with the intervention using electronic communication through a patient portal (odds ratio = 4.05; 95% CI = 1.22, 13.46; P = 0.03). The office visit intervention and the patient portal intervention took an average of 8.2 and 0.9 minutes per patient, respectively. CONCLUSIONS: Population health management completed during the course of office visits was more effective at increasing vitamin B12 monitoring and required more time than an intervention delivered through an electronic patient portal.
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Monitoreo de Drogas/métodos , Hipoglucemiantes/efectos adversos , Metformina/efectos adversos , Farmacéuticos/organización & administración , Médicos/organización & administración , Vitamina B 12/sangre , Citas y Horarios , Monitoreo de Drogas/normas , Registros Electrónicos de Salud , Femenino , Humanos , Hipoglucemiantes/uso terapéutico , Relaciones Interprofesionales , Masculino , Metformina/uso terapéutico , Rol Profesional , Calidad de la Atención de Salud , Distribución AleatoriaRESUMEN
Objective. To determine the impact of an elective course on students' perception of opportunities and of their preparedness for patient care in community and ambulatory pharmacy settings. Design. Each course meeting included a lecture and discussion to introduce concepts and active-learning activities to apply concepts to patient care or practice development in a community or ambulatory pharmacy setting. Assessment. A survey was administered to students before and after the course. Descriptive statistics were used to assess student responses to survey questions, and Wilcoxon signed rank tests were used to analyze the improvement in student responses with an alpha level set at 0.05. Students felt more prepared to provide patient care, develop or improve a clinical service, and effectively communicate recommendations to other health care providers after course completion. Conclusion. This elective course equipped students with the skills necessary to increase their confidence in providing patient care services in community and ambulatory settings.
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Atención Ambulatoria , Servicios Comunitarios de Farmacia , Educación en Farmacia , Evaluación Educacional , Servicio de Farmacia en Hospital , Estudiantes de Farmacia , Curriculum , HumanosRESUMEN
PURPOSE: The purposes of this population management intervention were to identify patients with stage 3, 4, or 5 chronic kidney disease (CKD) and to improve care in a patient-centered medical home (PCMH). Objectives of the intervention were to (i) increase the identification of CKD, (ii) increase the use of aspirin and angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin II receptor blockers (ARBs) in patients with CKD, and (iii) ensure that all medications prescribed to patients with CKD were dosed appropriately based on renal function. SETTING: This intervention was completed at a National Committee for Quality Assurance tier 3 PCMH associated with a major, academic health system. PATIENTS: A list of 328 patients with an estimated glomerular filtration rate of < 60 mL/min per 1.73 m(2) was generated using the electronic medical record; 146 patients underwent the intervention. MEASUREMENTS AND OBSERVATIONS: A pharmacist review of the electronic medical record was completed to confirm stage 3, 4, or 5 CKD based on estimated glomerular filtration rate, to ensure that ACE-Is/ARBs and aspirin were prescribed, and to ensure that all medications were dosed appropriately based on renal dosing adjustment recommendations. Recommendations were made to improve medication use and safety in patients with CKD. Before intervention, 73% of patients were prescribed an ACE-I/ARB and 72% of patients were prescribed aspirin. After the intervention, use of these medications increased to 77% and 82% of patients, respectively. Pharmacist recommendations to adjust medication dosing based on Cockcroft-Gault calculated creatinine clearance were made for 138 medications (0.95 medication per patient); 90 (65.2%) recommendations were accepted by the patients' physicians. CONCLUSION: These results demonstrate the impact of a pharmacist-driven renal medication dosing intervention within a PCMH on medication use and safety for patients with CKD.
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Fallo Renal Crónico/tratamiento farmacológico , Evaluación de Resultado en la Atención de Salud , Farmacéuticos/normas , Anciano , Antagonistas de Receptores de Angiotensina/administración & dosificación , Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , Aspirina/administración & dosificación , Femenino , Servicios de Salud para Ancianos , Humanos , Fallo Renal Crónico/prevención & control , Masculino , Casas de Salud , Inhibidores de Agregación Plaquetaria/administración & dosificación , Atención Primaria de Salud , Estados UnidosRESUMEN
OBJECTIVES: (1) To determine if antenna coupling occurs in common operating room scenarios. (2) To define modifiable clinical variables that reduce the magnitude of antenna coupling. BACKGROUND: Mechanisms of electrosurgical burns where monitoring devices contact the surgical patient are unclear. Antenna coupling occurs when the "bovie" active electrode (electrically active transmitting antenna) emits energy, which is captured by a nonelectrically active wire (electrically inactive receiving antenna) in close proximity without direct contact. METHODS: Monopolar radiofrequency energy was delivered to a laparoscopic instrument (electrically active transmitting antenna), whereas other nonelectrically active wires (electrically inactive receiving antenna) including electrocardiogram (EKG) lead, nonactive "bovie" pencil, and nerve electrode monitor were placed in proximity. Temperature changes of tissue placed adjacent to the electrically inactive receiving antennae were measured. RESULTS: Nonelectrically active wires (receiving antenna) increase tissue temperature when lying parallel to the active electrode cord: EKG pad 2.4°C ± 1.2°C (P = 0.002), "bovie" pencil tip 90°C ± 9°C (P < 0.001), and nerve electrode monitor 106°C ± 12°C (P < 0.001). Factors that reduced the heat generated by antenna coupling included the following: increasing angulation between transmitting and receiving antennae (parallel = 90°C ± 9°C; 45° angle = 53°C ± 10°C; perpendicular = 35°C ± 11°C; P < .001), increasing separation distance between parallel transmitting and receiving antenna (<1 cm = 90°C ± 9°C; 15 cm = 44°C ± 18°C; 30 cm = 39°C ± 2°C; P < .001); and decreasing generator power setting (15 W = 59°C ± 11°C; 30 W = 90°C ± 9°C; 45 W = 98°C ± 8°C; P < .001). CONCLUSIONS: Antenna coupling occurs in common operating room scenarios. Simple, practical measures by the surgeon, such as orienting the receiving antenna at a greater angle and with greater separation to the active electrode cord, or lowering the generator power setting reduce antenna coupling.
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Quemaduras por Electricidad/etiología , Electrocirugia/efectos adversos , Laparoscopía/efectos adversos , Temperatura Corporal , Quemaduras por Electricidad/prevención & control , Electrodos , Humanos , Complicaciones Intraoperatorias , QuirófanosRESUMEN
OBJECTIVE: To investigate changes in and the impact of grading scales from 2005 to 2010 and explore pharmacy faculty and student perceptions of whole-letter and plus/minus grading scales on cumulative grade point averages (GPAs) in required courses. METHODS: Grading scales used in 2010 at the University of Cincinnati College of Pharmacy were retrospectively identified and compared to those used in 2005. Mean GPA was calculated using a whole-letter grading scale and a plus/minus grading scale to determine the impact of scales on GPA. Faculty members and students were surveyed regarding their perceptions of plus/minus grading. RESULTS: Nine unique grading scales were used throughout the curriculum, including plus/minus (64%) and whole-letter (21%) grading scales. From 2005 to 2010 there was transition from use of predominantly whole-letter scales to plus/minus grading scales. The type of grading scale used did not affect the mean cumulative GPA. Students preferred use of a plus-only grading scale while faculty members preferred use of a plus/minus grading scale. CONCLUSIONS: The transition from whole-letter grading to plus/minus grading in courses from 2005 to 2010 reflects pharmacy faculty members' perception that plus/minus grading allows for better differentiation between students' performances.