American Journal of Health-System Pharmacy最新文献

Purpose: Introduction of new medications to health-system formularies is often not accompanied by assessments of their clinical impact on the local patient population. The growing availability of electronic health record (EHR) data and advancements in pharmacoepidemiology methods offer institutions the opportunity to monitor the medication implementation process and assess clinical effectiveness in the local clinical context. In this study, we applied novel causal inference methods to evaluate the effects of a formulary policy introducing tocilizumab therapy for critically ill patients with coronavirus disease 2019 (COVID-19).

Methods: We conducted a medication use evaluation utilizing EHR data from patients admitted to a large medical center during the 6 months before and after implementation of a formulary policy endorsing the use of tocilizumab for treatment of COVID-19. The impact of tocilizumab on 28-day all-cause mortality was assessed using a difference-in-differences analysis, with ineligible patients serving as a nonequivalent control group, and a matched analysis guided by a target trial emulation framework. Safety endpoints assessed included the incidence of secondary infections and liver enzyme elevations. Our findings were benchmarked against clinical trials, an observational study, and a meta-analysis.

Results: Following guideline modification, tocilizumab was administered to 69% of eligible patients. This implementation was associated with a 3.1% absolute risk reduction in 28-day mortality (odds ratio, 0.86; number needed to treat to prevent one death, 32) attributable to the inclusion of tocilizumab in the guidelines and an additional 8.6% absolute risk reduction (odds ratio, 0.65; number needed to treat to prevent one death, 12) linked to its administration. These findings were consistent with estimates from published literature, although the effect estimates from the difference-in-differences analysis exhibited imprecision.

Conclusion: Evaluating formulary management decisions through novel causal inference approaches offers valuable estimates of clinical effectiveness and the potential to optimize the impact of new medications on population outcomes.

Purpose: The establishment of a new outpatient pharmacy provided a strategic opportunity to repurpose and convert an existing outpatient pharmacy into a closed-door mail-order pharmacy within a health system. This article describes the steps taken to successfully make this change and evaluates the impact.

Summary: The mail-order pharmacy conversion project was divided into 3 phases: phase 1 (before conversion) from July through August 2022, phase 2 (conversion) from October through November 2022, and phase 3 (after conversion) from December 2022 through February 2023. Phase 1 included standardizing workflows with standard operating procedure (SOP) development, improving automation, determining staffing ratios, gathering baseline staff engagement data, and identifying primary and secondary outcomes of interest. Phase 2 encompassed SOP implementation and training of mail-order team members. Phase 3 involved evaluating available pharmacy floorspace, marketing mail-order services, and the second distribution of the staff engagement survey. The measured outcomes of this project were total prescription volumes, increase in total revenue, and staff engagement. Data collection was completed in phase 3.

Conclusion: The existing outpatient pharmacy was successfully converted to a closed-door pharmacy, and the associated prescription volume increased. Developing a strategic action plan to establish SOPs, calculate staffing performance metrics, and identify opportunities for growth and engaging frontline team members were essential to the success of this project.

Purpose: Impella microaxial ventricular assist devices require a dextrose-based purge solution in combination with heparin or sodium bicarbonate to prevent device dysfunction and stoppage, but the dextrose in these solutions can interfere with positron emission tomography (PET) scans, necessitating an alternative approach.

Summary: We describe the short-term use in 2 cases of an alternative purge solution for patients with an Impella 5.5 ventricular assist device undergoing PET scans to rule out infection and malignancy. Sodium chloride solutions cannot be used with Impella ventricular assist devices even for short periods of time due to the potential for motor corrosion. We therefore selected a sterile water-based sodium bicarbonate purge solution, incorporating a short dextrose-free period before and during the PET scan. Imaging was successfully performed with this alternative solution, with monitoring of Impella performance levels and purge parameters throughout the procedure indicating no adverse effects on pump function.

Conclusion: Our sterile water-based bicarbonate purge solution coupled with a short-term restriction of dextrose is a practical option for PET imaging in patients with an Impella ventricular assist device.

Purpose: Evidence has suggested that clevidipine may provide faster blood pressure (BP) reduction with less volume than nicardipine in stroke and cardiothoracic surgery patients, but its use in hypertensive crises has not been well established. The primary objective of this study was to compare the treatment success of clevidipine and nicardipine in hypertensive crisis.

Methods: This was a multicenter, retrospective cohort study including patients who received either clevidipine or nicardipine for treatment of hypertensive crisis. The primary outcome was the time from infusion start to attainment of goal BP, defined as the higher value of the guideline-directed 25% reduction in BP or the physician-ordered goal. Secondary outcomes were the time from infusion start to guideline-directed 25% reduction in BP, drug and total volume intake, the time from order entry to BP goal attainment, the number of BP and heart rate excursions, intensive care unit (ICU) length of stay, and study medication cost.

Results: In total, 182 patients were included in the study (103 receiving nicardipine and 79 receiving clevidipine). Time to goal BP was similar between the groups (35 vs 33 minutes for clevidipine vs nicardipine, respectively; P = 0.37). Time to guideline-directed 25% reduction was also similar (P = 0.42). Volume from study drug was significantly less with clevidipine (222 vs 518 mL; P = 0.01); however, the total volume received in the ICU was similar (3,370 vs 3,383 mL; P = 0.43). Percent time in the goal BP range was similar (43.1% vs 42.3%). The cost of clevidipine was $199.37 per vial (based on the average wholesale price as of June 2023). This cost was 682% higher than that for a bag of nicardipine.

Conclusion: Time to goal BP was similar for clevidipine and nicardipine in this population. Any decreases in medication-associated volume with clevidipine were no longer evident when all volume sources were considered. These results show that clevidipine may not provide meaningful benefit in this heterogenous population. The difference in cost does not seem justified given the lack of improvement in clinically relevant outcomes.

Purpose: An advisory panel of experts was convened by the ASHP Foundation as a part of its Medication-Use Evaluation Resources initiative to provide commentary on an approach to antibiotic stewardship in the treatment of skin and soft tissue infections (SSTIs), with a focus on oral antibiotics in the emergency department (ED) setting for patients who will be treated as outpatients. Considerations include a need to update existing guidelines to reflect new antibiotics and susceptibility patterns, patient-specific criteria impacting antibiotic selection, and logistics unique to the ED setting.

Summary: While national guidelines serve as the gold standard on which to base SSTI treatment decisions, our advisory panel stressed that institutional guidelines must be regularly updated and grounded in local antimicrobial resistance patterns, patient-specific factors, and logistical considerations. Convening a team of experts locally to establish institution-specific guidelines as part of a comprehensive antibiotic stewardship program can ensure patients receive the most appropriate oral therapy for the outpatient treatment of SSTIs in patients visiting the ED.

Conclusion: SSTI treatment considerations for antibiotic selection in the ED supported by current, evidence-based guidelines, including guidance on optimal oral antibiotic selection for patients discharged for outpatient treatment, are a useful tool to improve the quality and efficiency of care, enhance patient-centric outcomes and satisfaction, decrease healthcare costs, and reduce overuse of antibiotics.

Purpose: The 340B Drug Pricing Program is important to healthcare organizations that serve vulnerable communities. However, it is unknown whether healthcare providers in these organizations understand the 340B program and how it supports enhanced patient services. This study aims to characterize the knowledge, attitudes, and beliefs of healthcare providers toward the 340B program in a multisite federally qualified health center (FQHC).

Methods: This was a cross-sectional study. A 27-item survey designed to assess prescriber knowledge and perspectives toward the 340B program was developed and administered. Closed-ended items were summarized using descriptive statistics, and open-ended items were analyzed with qualitative methods.

Results: A total of 198 healthcare providers with prescribing authority received the survey; of those, 65 (32.8%) participated. The majority of respondents (66.2%) were female; 41.5% were 35 years of age or younger, and 49.2% were physicians. The majority of respondents agreed that patients benefited from access to the organization's 340B pharmacies (95.0%) and that 340B pricing is important to consider when prescribing medications (78.3%). However, knowledge of the 340B program was limited, with only half of respondents (54.0%) able to correctly answer at least 4 of 7 knowledge-focused items. Reponses to a patient case suggested that some providers may be unfamiliar with which drugs are available at reduced prices.

Conclusion: The findings suggest that providers believe the 340B program benefits patients and the organization but often lack a complete understanding of the program. Future research should focus on prescriber education as a strategy to help organizations optimize their 340B programs and facilitate patient access to medications.

Disclaimer: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose: The purpose of this retrospective study was to utilize existing data to (1) compare the characteristics of Board of Pharmacy Specialties (BPS) credentials successfully recertified vs those that were not successfully recertified in 2022 and (2) compare survey responses about maintaining board certification by continuing pharmacy education (CPE) vs examination among those who successfully recertified.

Summary: The characteristics of BPS credentials eligible for recertification in 2022 (n = 4,812) and survey responses from board-certified pharmacists who successfully recertified in 2022 (n = 3,629) were retrieved from the MyBPS database. Across all specialties, 75.4% of credentials were successfully recertified in 2022. Most credentials were recertified by CPE (92.1%). Successfully recertified credentials were predominately held by pharmacists practicing within the US (96.7%), those between the ages of 31 and 40 years (51.9%), and those completing the first 7-year certification cycle (73.9%). A significant difference was found between recertified credentials and those that were not recertified based on specialty, recertification pathway, credential holder practice location, and credential holder age. Over 89% of respondents reported that a primary benefit of maintaining board certification is to "expand knowledge and skills in pharmacy."

Conclusion: Several factors influence the decision and/or ability of board-certified pharmacists to recertify and maintain their credentials. Successfully recertified board-certified pharmacists report expanded competency, credibility, personal gratification, and increased confidence among the primary benefits of maintaining board certification. Board-certified pharmacists who successfully recertify also report a preference for a recertification process that is temporally and financially efficient.