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PURPOSE: To assess the impact of a clinical pharmacy specialist (CPS) embedded within a rheumatology clinic at a large academic medical center on the prescription capture rate at the health-system specialty pharmacy. METHODS: Initially low prescription capture rates for the health-system specialty pharmacy led to the integration of a CPS in the main campus rheumatology clinic. Benchmarking was completed by assessing the prior prescription capture rate using electronic medical record analytics and Loopback Analytics (a database of prescription capture for the health-system specialty pharmacy). The existing workflows for both the rheumatology clinic and specialty pharmacy were observed with regard to biologic medication ordering and processing. Strategies for an updated workflow for biologic ordering with the incorporation of an embedded CPS in the rheumatology clinic were designed. This new workflow was established with key stakeholders, including the CPS, rheumatology providers, clinic staff, and pharmacy technicians. Once the workflow was established, all parties were educated and updated, including rheumatology providers, nursing staff, and specialty pharmacy staff. Prescription capture rate was monitored on a monthly basis. RESULTS: Prescription capture increased from 13.16% before pharmacist implementation (October to December 2021) to 35.42% after pharmacist implementation (October to December 2022) (P = 0.019). During the same periods, the revenue generated increased from $43,222.89 to $135,198.70 (P = 0.224) and the proportion of prescriptions initially sent to the health-system specialty pharmacy compared to other specialty pharmacies increased from 37% to 79% (P < 0.001) with CPS implementation. CONCLUSION: Expansion and implementation of pharmacy services by integrating a CPS in a rheumatology ambulatory clinic increased prescription capture and pharmacy revenue while optimizing patient care. We hope to expand similar CPS services to other clinics within the health system.

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Background: Diabetes mellitus has become increasingly prevalent and a considerable health risk in the United States. Early introduction of insulin can improve overall health outcomes of patients with diabetes. With the development of long-acting insulin analogs, such as insulin glargine, limitations such as variable absorption and hypoglycemia were reduced. Majority of reported adverse drug effects secondary to insulin glargine include injection site reaction and hypoglycemia. There is limited data on gastrointestinal adverse effects, including nausea, of insulin glargine. Case Presentation: A 51-year-old female with a past medical history of type 2 diabetes was referred to the collaborative drug therapy management pharmacist for diabetes education and management. The patient was initiated on insulin glargine (Lantus®) and began to experience episodes of nausea and emesis over a 9 week period. Once the patient was switched from insulin glargine (Lantus®) to insulin detemir, symptoms subsided. Upon re-trial of insulin glargine (Lantus®), nausea and emesis-like symptoms resumed. A probable relationship between insulin glargine (Lantus®) and the reaction was estimated using the Naranjo Adverse Drug Reaction Probability Scale. Conclusion: Potential mechanisms behind the relationship of insulin glargine (Lantus®) and nausea are hypothesized, however there is limited literature supporting this claim and further investigation is warranted.

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INTRODUCTION: Telemedicine has become a critical aspect of healthcare provision during the coronavirus pandemic (COVID-19). However, healthcare providers' utilization of and satisfaction with telemedicine technologies could have a significant impact on the quality of care provided to patients during COVID-19. The current study explores the key factors that could affect healthcare providers' satisfaction with telemedicine in ambulatory care during the pandemic. OBJECTIVES: This research study aims at identifying the factors that could influence the healthcare providers' satisfaction level with the use of telemedicine in ambulatory care services in Saudi Arabia during COVID 19. METHODS: This is a descriptive quantitative cross-sectional study. The research team has utilized the Service Quality Model (SERVQUAL) to assess the healthcare providers' satisfaction with telemedicine in ambulatory care through a questionnaire that was adapted from previous studies. This questionnaire includes the following dimensions: tangibility, reliability, responsiveness, assurance, and empathy. It was distributed to all ambulatory care physicians in a public hospital-based ambulatory health center in Eastern Region, Saudi Arabia. RESULTS: The study findings showed that Saudis are significantly more satisfied with telemedicine compared to non-Saudis. Age, gender, experience, medical specialty, and computer literacy skills were not found to have any significant effects on the level of the provider's satisfaction. CONCLUSION: This research provides new insight and understanding of the relationship between the frequent use of the health information system and the level of physician satisfaction. This major finding puts more emphasis on the importance of education and training when it comes to the adoption of telemedicine through the frequent use of health information systems and applications. These encouraging findings provide a vital piece of information for healthcare organizations interested in a further adoption of telemedicinal practices and applications.

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Background: Modern hepatitis C virus (HCV) treatment regimens yield cure rates greater than 90%. However, obtaining approval for treatment through the prior authorization (PA) process can be time consuming and require extensive documentation. Lack of experience with this complex process can delay HCV medication approval, ultimately increasing the amount of time before patients start treatment and in some cases, prevent treatment altogether. Objectives: Assess the impact of incorporating clinical pharmacists into specialty pharmacy and hepatology clinic services on medication access, patient adherence, and outcomes in patients being treated for HCV. Methods: We performed a retrospective cohort exploratory study of patients seen in an academic medical center hepatology clinic who had HCV prescriptions filled between 8/1/15 and 7/31/17. Patients were categorized by whether they filled prescriptions prior to (Pre-Group) or after (Post-Group) the implementation of a pharmacist in clinic. The Post-Group was further divided according to whether the patient was seen by a pharmacist in clinic (Post-Group 2) or if the patient was not seen by the pharmacist, but had their HCV therapy evaluated by the pharmacist before seeking insurance approval (Post-Group 1). Results: The mean time from the prescription being ordered to being dispensed was longer in the Pre-Group (50.8 ± 66.5 days) compared to both Post-Groups (22.2 ± 27.8 days in Post-Group 1 vs 18.9 ± 17.7 days in Post-Group 2; P < .05). The mean time from when the prescription was ordered to when the PA was submitted was longer in the Pre-Group (41.6 ± 71.9 days) compared to both Post-Groups (6.3 ± 16 in Post-Group 1 vs 4.1 ± 9.7 in Post-Group 2; P < .05). Rates of medication adherence and sustained virologic response were similar between all groups. Conclusion: Incorporation of clinical pharmacists into a hepatology clinic significantly reduced the time patients waited to start HCV treatment. In addition to improving access to medications, implementation of the model helped to maintain excellent medication adherence and cure rates.

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Dialysis patients are often iron deficient due to a multiple factors. Ferric pyrophosphate citrate is a complex iron salt that can be given via dialysate allowing maintenance of hemoglobin (Hgb) concentration and iron balance while reducing the need for IV iron. The purpose of this study is to perform a cost evaluation of FPC and the effect it has on lowering the dose/use of ESAs and IV iron therapy. This study reviewed the same 100 hemodialysis patient's charts before and after the use of FPC. The data points that were collected and analyzed are as follows: hemoglobin, ferritin levels, average weekly ESA dosing, and IV iron replacement therapy dose. Out of 100 patients, there was no statistical difference in the average hemoglobin, ferritin, and iron saturation levels observed in the patients before and after FPC use. The average weekly dose of darbepoetin alfa per patient was 52.74 µg before the FPC group compared to 39.27 µg in the post FPC group (P < .0001). The total dose of ferric gluconate per patient was 3290.01 mg in the before FPC group and 585.60 mg in the post FPC group (P < .0001). The average total iron sucrose dose per patient in the before FPC group was 3097.92 mg versus 1216.67 mg in the post FPC group (P < .1563). When comparing FPC's cost and implementation into both of our outpatient dialysis centers, this yielded a net savings of $296 751.49.

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Purpose: The Coronavirus 2019 (COVID-19) pandemic created a significant disruption in healthcare. In our health-system located in New York City, the provision of care in the ambulatory care setting moved to a remote model virtually overnight. We describe interventions made during the pandemic to transform ambulatory care pharmacy through expansion of telehealth services. Summary: In March of 2020, the closure of primary care clinics and provider appointment cancellations due to inpatient redeployment created a void. Collaboration with other health care providers and development of standardized telehealth workflows served as a conduit for creating new roles and opportunities for pharmacy team members. Three main interventions where the pharmacy team filled gaps include; (1) Expansion of pharmacist telemedicine visits for high-risk patients to improve access to primary care visits, (2) Partnership with nursing to create a centralized refill call center workflow, (3) Integration of pharmacy extenders into the prior authorization process to prevent medication access issues. Existing collaborative practice agreements for chronic disease management were utilized. A virtual pharmacist model for patient care contributed to an increase in telehealth visits from 51 in 2019 to 2997 total visits in 2020. In addition, the health-system refill call center expanded its services through collaboration with our pharmacy team. Pharmacists and pharmacy interns partnered with nurse practitioners to improve the call center workflow and address the significant increase in refill requests during the outbreak. Furthermore, a prior authorization process was created across multiple ambulatory care clinics to expedite medication access and prevent delays in therapy. Conclusion: Our ambulatory care pharmacy team leveraged technology, innovative workflows, and collaborative teamwork to catalyze a shift in pharmacists' and pharmacy extenders' roles in healthcare delivery to expeditiously meet patients' needs during a pandemic.

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Background: Patient satisfaction with outpatient pharmacy services at our institution was below the target level, due mainly to long waiting times. A lean management strategy to reduce patient waiting time and increase the satisfaction of both patients and staff was developed and implemented. Methods: The project was conducted in the outpatient pharmacy of a comprehensive cancer center in Amman, Jordan. The process started with formation of a multidisciplinary team and A3 problem-solving, which is a 10-step scientific method with measurable patient-centered outcomes. Average patient waiting time and level of patient satisfaction were compared before and after full implementation of the process. In addition, a survey was conducted among the pharmacy staff who worked in the outpatient pharmacy during the process to determine its impact on staff satisfaction. Results: Patient waiting time for prescriptions of fewer than 3 medications and of 3 medications or more decreased significantly (22.3 minutes vs 8.1 minutes, P < .001, and 31.8 minutes vs 16.1 minutes, P < .002, respectively), and patient satisfaction increased (62% vs 69%; P = .005) after full implementation of the project. The majority of the pharmacy staff reported that the process motivated them in their work and that both their jobs and their relationships with their managers and colleagues had improved. Conclusion: Application of lean management in an outpatient pharmacy was effective in reducing patient waiting time and improving the satisfaction of both patients and employees.

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Background: Since 2013 there have been cholesterol guideline changes impacting pharmacists' clinical practice in managing lipid disorders. For more than a decade, cholesterol management was based on the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol Adult Treatment Panel III guideline, highlighting non-high-density lipoprotein cholesterol (non-HDL-C) as a secondary target in persons with triglycerides ≥200 mg/dL, after low-density lipoprotein cholesterol goal attainment. The 2013 American College of Cardiology and American Heart Association (ACC/AHA) guideline differed from the traditional management of dyslipidemia, in part no longer emphasizing the utilization of non-HDL-C levels. Objective: To measure pharmacists' attitudes and behavior regarding utilization of non-HDL-C level calculation before and after the inception of the 2013 ACC/AHA cholesterol guideline. Methods: Pharmacists in the American College of Clinical Pharmacy ambulatory care listserv participated in an electronic survey in November 2013, before the inception of the 2013 ACC/AHA guideline, and again in October 2018. Results: We collected 391 usable responses from participants; 212 responses in 2013 and 179 responses in 2018. The before and after comparison revealed that respondents in 2013 reported significantly higher frequency of calculating non-HDL-C levels (mean = 1.88, SD = 0.80) than respondents in 2018 (mean = 1.66, SD = 0.79) (P ≤ .001). Also, the frequency that non-HDL-C level calculation alters decisions regarding course of treatment was lower in the 2018 (mean = 3.50, SD = 1.06) in comparison with 2013 (mean = 3.77, SD = 0.88) (P ≤ .05). Furthermore, pharmacists were more favorable toward the inclusion of non-HDL-C level calculation in 2018 (mean = 3.77, SD = 1.05) than in 2013 (mean = 3.13, SD = 1.33) (P ≤ .001). Conclusion and Relevance: Clinical pharmacists' utilization of non-HDL-C levels in the clinical management of patients with hypercholesterolemia has decreased, highlighting the need for further education on the importance of evaluating non-HDL-C levels in the very high-risk atherosclerotic cardiovascular disease population.

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Hospital pharmacies may not have the necessary resources, tools, or policies in place to implement a valuable opioid stewardship program. Meanwhile, the number of opioid prescriptions and medication use has increased nationwide. The overuse of opioids is due to the challenging nature of pain management, drug diversion prevention, and opioid abuse, as well as difficulty in recognizing and implementing best practices regarding opioid stewardship. The purpose of this review is to describe the components and executional strategy of an effective opioid and pain stewardship program. Opioid and pain stewardship programs can help identify opportunities for better adherence to best practice recommendations such as standardization of opioid dosing strategies, prescription of multimodal and opioid-sparing regimens, identification of substance misuse, review of patient history information, recognition of pain as a disease state, and increased dispensing of opioid reversal medications.

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Background: The impact of pharmacist-led transition of care services with collaborative drug therapy management has shown to improve patients' outcomes and decrease health costs. Compelling statistics show higher readmission rates for under-insured patients compared with insured patients at primary health care clinics. Methods: This is a single center, prospective, cohort study designed to examine team-based collaborative drug therapy management and its effect on therapeutic outcomes of under-insured patients with target chronic diseases managed in a primary health center. Targeted chronic diseases included dyslipidemia, diabetes, hypertension, anticoagulation disorders, chronic obstructive pulmonary disease, and heart failure. The primary outcome measures included percentage of time in therapeutic international normalized ratio (INR) and percentage of patients at targeted goals of blood pressure, lipids, and hemoglobin A1c (HbA1c). Secondary outcomes included reduced emergency department visits, number of patient encounters, hospital readmissions within 30 days of discharge, and disease exacerbation rates. Results: Patients were at INR goal 58% of the time compared with 52% at baseline (P = .66). There was a 9% improvement in mean HbA1c in the intervention group when compared with baseline (9.6% vs 10.9%, P = .03). With pharmacist intervention, 73.8% of the patients had their blood pressure at goal compared with 50% at baseline (P = .14). A limited number of patients were readmitted for different reasons, including uncontrolled disease states. Conclusions: The pharmacist-physician collaborative drug therapy management led to improved blood pressure control, average HbA1c, and time in therapeutic INR range. A decrease in health care utilization was also identified.

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OBJECTIVES/HYPOTHESIS: To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS). STUDY DESIGN: Cross-sectional analysis. METHODS: Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared. RESULTS: Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes). CONCLUSIONS: RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E311-E319, 2020.

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Purpose: This study evaluated the comparative effectiveness of different pharmacist visit types on reducing readmission rates. Method: A single-center, retrospective cohort study was conducted from January 2015 to July 2017. Patients were 18 years or older with an index heart failure (HF) exacerbation admission. Upon hospital discharge, patients were seen in clinic by a clinical pharmacy specialist (CPS) with collaborative practice agreement (CPA) (High Intensity Bundle), medication therapy management (MTM) pharmacist without CPA (Low Intensity Bundle), or no pharmacist (Standard of Care [SOC]). The primary outcome was 30-day all-cause readmission rate. Secondary outcomes included rate of 30-day HF readmissions and average number of days until readmission in those who were readmitted. Results: Totally, 98 patients were included in the final analysis (35 High Intensity Bundle, 28 Low Intensity Bundle, and 35 SOC). The primary outcome of all-cause readmissions was lower in both the pharmacist groups compared with SOC (CPS 8.6% [3/35] vs SOC 25.7% [9/35], P = 0.046 and MTM 7.1% [2/28] vs SOC 25.7% [9/35], P = 0.057). Incremental differences were seen between visit types for the secondary outcome of 30-day HF readmissions (CPS 2.9% vs MTM 7.1% vs SOC 17.1%, P = 0.039). The average number of days until readmission was longer in the CPS versus the MTM and SOC (26.7 days vs 12.5 days vs 14.1 days, respectively). Conclusion: Post-hospital discharge pharmacist visits were associated with lower 30-day all-cause readmission. In particular, clinic visits with a Higher Intensity Bundle may be more effective in reducing HF readmissions. These exploratory findings warrant further investigation.

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Purpose: As health care progresses toward pay for performance reimbursement models and focus is placed on the patient as a consumer, health care systems must adapt by initiating new programs and services. This institution responded by implementing a "Meds 2 Beds" program integrating clinical services with dispensing and medication delivery during transitions of care. This study evaluates outcomes relevant to patients, health care providers, pharmacists, and administrators. Methods: This observational chart review evaluated the effectiveness of a "Meds 2 Beds" program from May 1, 2014, through December 1, 2015. Patients who participated in this program were matched 1:1 with controls who did not. The primary outcome was 30-day hospital readmission. Secondary outcomes included 30-day emergency department (ED) visits, patient satisfaction, and financial impact. Results: In this sample, 185 "Meds 2 Beds" patients were matched to 185 controls. Thirty day readmission occurred in 16 (8.7%) "Meds 2 Beds" cases and 19 (10.3%) controls (P = .71). Rates of 30-day ED visits were nonsignificantly reduced in cases (22 [11.9%] vs 33 [18.1%]; odds ratio = 0.62, P = .11) and occurred significantly later (11 vs 7 days, P = .03). Conclusions: This study showcases a creative medication delivery and discharge counseling program. The program provides financial benefit to the institution creating a direct revenue stream from prescription dispensing while highlighting a potential for reduced readmissions and ED visits (although a statistically significant difference was not demonstrated in this analysis). A similar model can be adopted by other health care institutions to improve the quality of patient care.

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BACKGROUND: Patients with prolonged length of hospital stay (LOS) not only increase their risks of nosocomial infections but also deny other patients access to inpatient care. Hepatobiliary (HPB) malignancies have some of highest incidences in East and Southeast Asia and the management of patients undergoing HPB surgeries have yet to be standardized. With improved neurosurgery techniques for intracranial aneurysms and tumors, neurosurgeries (NS) can be expected to increase. Elective surgeries account for far more operations than emergencies surgeries. Thus, with potentially increased numbers of elective HPB and NS, this study seeks to explore perioperative factors associated with prolonged LOS for these patients to improve safety and quality of practice. METHODS: A retrospective cross-sectional medical record review study from January 2014 to January 2015 was conducted at a 1250-bed tertiary academic hospital in Singapore. All elective HPB and NS patients over 18 years old were included in the study except day and emergency surgeries, resulting in 150 and 166 patients respectively. Prolonged LOS was defined as above median LOS based on the complexity of the surgical procedure. The predictor variables were preoperative, intraoperative, and postoperative factors. Student's t-test and stepwise logistic regression analyses were conducted to determine which factors were associated with prolonged LOS. RESULTS: Factors associated with prolonged LOS for the HPB sample were age and admission after 5 pm but for the NS sample, they were functional status, referral to occupational therapy, and the number of hospital-acquired infections. CONCLUSION: Our findings indicate that preoperative factors had the greatest association with prolonged LOS for HPB and NS elective surgeries even after adjusting for surgical complexity, suggesting that patient safety and quality of care may be improved with better pre-surgery patient preparation and admission practices.

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There is a need to better coordinate services for children in urban settings who are at risk for communication disorders. This article addresses the barriers to obtaining services and discusses the process for creating a model for interprofessional practice to better serve patients from lower socioeconomic backgrounds.

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OBJECTIVE: To evaluate outcomes following a state-wide implementation of post arthroplasty review (PAR) clinics for patients following total hip and knee arthroplasty, led by advanced musculoskeletal physiotherapists in collaboration with orthopaedic specialists. DESIGN AND SETTING: A prospective observational study analysed data collected by 10 implementation sites (five metropolitan and five regional/rural centres) between September 2014 and June 2015. MAIN OUTCOME MEASURES: The Victorian Innovation and Reform Impact Assessment Framework was used to assess efficiency, effectiveness (access to care, safety and quality, workforce capacity, utilisation of skill sets, patient and workforce satisfaction) and sustainability (stakeholder engagement, succession planning and availability of ongoing funding). RESULTS: 2362 planned occasions of service (OOS) were provided for 2057 patients. Reduced patient wait times from referral to appointment were recorded and no adverse events occurred. Average cost savings across 10 sites was AUD$38 per OOS (Baseline $63, PAR clinic $35), representing a reduced pathway cost of 44%. Average annual predicted total value of increased orthopaedic specialist capacity was $11,950 per PAR clinic (range $6149 to $23,400). The Australian Orthopaedic Association review guidelines were met (8/10 sites, 80%) and patient-reported outcome measures were introduced as routine clinical care. High workforce and patient satisfaction were expressed. Eighteen physiotherapists were trained creating a sustainable workforce. Eight sites secured ongoing funding. CONCLUSIONS: The PAR clinics delivered a safe, cost-efficient model of care that improved patient access and quality of care compared to traditional specialist-led workforce models.

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PURPOSE: To determine the degree to which ambulatory physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services are available in hospitals with designated rehabilitation beds (DRBs) in Ontario, and to explore the structure of delivery and funding among services that exist. METHODS: Questions regarding ambulatory services were included in the System Integration and Change (SIC) survey sent to all hospitals participating in the Hospital Report 2005: Rehabilitation initiative. RESULTS: The response rate was 75.9% (41 of 54 hospitals). All hospitals surveyed provide some degree of ambulatory rehabilitation services, but the nature of these services varies according to rehabilitation client groups (RCGs). The majority of hospitals continue to deliver services through their employees rather than by contracting out or by creating for-profit subsidiary clinics, but an increasing proportion is accessing private sources to finance ambulatory services. CONCLUSIONS: Most hospitals with DRBs provide some degree of ambulatory rehabilitation services. Privatization of delivery is not widespread in these facilities.