Amy N. Thompson

Medication Use and Associated Risk of Falling in a Geriatric Outpatient Population

BACKGROUND: Studies have shown that approximately one third of community-dwelling people aged 65 years and older will experience a fall each year. Many studies indicate that use of multiple medications may put patients at an increased risk of falling, but few studies have been conducted to correlate the number of medications with the risk of falls. OBJECTIVE: To determine the medications most frequently used in patients aged 65 years or older who have experienced a fall within the past year, with particular attention to type or number of medications most commonly associated with multiple falls or a fall with injury. METHODS: We conducted a chart review in an outpatient internal medicine clinic over a 13-month period. A total of 118 patients 65 years of age or older who were taking 4 or more medications and had experienced at least 1 fall in the previous 12 months were included. Data relating to sex, age, race, diagnoses, medications, and number and type of falls were obtained during the chart review. The primary end point of the study was number and type of medications most commonly used in patients experiencing a fall. RESULTS: A total of 116 patients were examined for trends in fall risk. A logistic regression model and receiver operating characteristic curve demonstrated significant fall risk with the addition of medications, with patients experiencing a 14% increase in fall risk with the addition of each medication beyond a 4-medication regimen (OR 1.14; 95% CI 1.02 to 1.27; p = 0.027). CONCLUSIONS: The addition of medications is associated with a significant increase in risk of falls in elderly patients, regardless of drug class. Further studies are needed to assess the possible increased risk of falls with increasing number of medications.

Pharmaceuticals in drinking water: local analysis of the problem and finding a solution through awareness.

OBJECTIVES To evaluate public awareness of pharmaceuticals in drinking water and to develop educational efforts to promote awareness in our community. METHODS A review of the literature was conducted to gain a full perspective of the current issue. Questionnaires, interviews, and website feedback were used to assess awareness of the problem and the most commonly used medication disposal methods. In addition, educational flyers were created to disseminate information to the public. RESULTS The questionnaires were completed by a total of 96 respondents. Of respondents employed in health care, 72% had previous knowledge of pharmaceutical medications being found in our local (Charleston, SC) water supply, and of respondents not employed in health care, 54% had previous knowledge. For those with previous knowledge, 7% disposed of medications in the toilet or sink, 38% used the trash, and 36% used multiple methods. Of respondents indicating no previous knowledge, 3% disposed of medications in the toilet or sink, 35% used the trash, and 42% used multiple methods. CONCLUSION Public awareness of pharmaceuticals in drinking water and educational efforts focusing on proper disposal of medications are essential in helping to reduce drinking water contamination.

Effectiveness of Pharmacy Run Anticoagulation Clinics Compared toLarge Clinical Trials of New Oral Anticoagulants

Abstract Purpose: The purpose of the study was to assess the quality of anticoagulation with warfarin in patients with non-valvular AF who were managed exclusively in pharmacy run anticoagulation clinics and to evaluate whether these patients would be expected to have the same efficacy and safety profiles as those patients in the RE-LY, ROCKET AF, and ARISTOTLE trials. Methods: This was a retrospective study of 146 patients in 3 pharmacy run anticoagulation clinics who were initiated on anticoagulation with warfarin therapy to prevent stroke associated with atrial fibrillation. International Normalized Ratio (INR) values were collected over a 1-year period and the quality of management was expressed as time in therapeutic range (TTR) calculated by Rosendaal’s linear interpolation method. Results: Forty-six patients from university internal medicine (UIM) clinic, 9 patients from family medicine (FM) clinic, and 91 patients from pharmacotherapy (PCT) clinic were studied. During the 1-year period, the overall mean TTR was 61.1%. The mean TTR in the UIM clinic, the FM clinic, and the PCT clinic was 60.1%, 62.5%, and 61.5%, respectively. Conclusion: The quality of anticoagulation with warfarin, as assessed by TTR, in the 3 pharmacy run anticoagulation clinics was similar to the mean TTR values reported for the warfarin-treated patients in the RE-LY, ROCKET-AF, and ARISTOTLE trials. The results of these studies are applicable to our patient population.

Olanzapine and baclofen for the treatment of intractable hiccups.

Intractable hiccups are a relatively uncommon condition characterized by involuntary, spasmodic contractions of the diaphragm. This type of hiccups generally has a duration of more than 1 month. We describe a 59‐year‐old kidney transplant recipient with a complicated medical history (atrial fibrillation, chronic renal failure, type 2 diabetes mellitus, gastroesophageal reflux, gout, hypertension, hyperlipidemia, and obstructive sleep apnea) who developed intractable hiccups that significantly affected his quality of life. Despite an extensive gastrointestinal and pulmonary evaluation, and treatment failures with several different drug regimens—metoclopramide, desipramine, amantadine, cyclobenzaprine, phenytoin, and lorazepam—his hiccups were eventually controlled with a combination of baclofen and low‐dose olanzapine therapy. Baclofen is a γ‐aminobutyric acid (GABA) analog that contains a phenylethylamine moiety. It is hypothesized that having both GABA and phenylethylamine properties activates inhibitory neurotransmitters, most notably GABA, which may in turn block the hiccup stimulus. The exact mechanism through which olanzapine is effective in patients with hiccups is not fully understood. It is thought that the effect is, in part, due to serotonin augmenting phrenic motoneuronal activity on the reflex arcs involved in the generation of hiccups within the spinal cord. In addition, since olanazapine is a dopamine antagonist, particularly a dopamine D2‐receptor antagonist, this could also have played a role in its effectiveness in treating our patient. Strong evidence for a specific treatment regimen for intractable hiccups is lacking in the primary literature. Our case report adds to the available literature, as there are currently no published data on the use of combination therapy for the treatment of intractable hiccups, and the combination of baclofen and olanzapine significantly improved our patients quality of life.

Evaluation of patient perceptions and outcomes related to anticoagulation point-of-care testing in ambulatory care clinics

Until recently, Prothrombin Time/International Normalized Ratio (PT/INR) measurements have typically been used to monitor patients on warfarin through institutional laboratories via venous puncture. The Point-of-Care Testing (POCT) device has revolutionized the patient care process by allowing for laboratory testing outside of the central laboratory. Objective: To analyze humanistic and clinical outcomes in patients currently treated with warfarin and monitored through a pharmacist-managed anticoagulation clinic using point-of-care testing (POCT) device versus venipuncture within ambulatory care clinics at our institution. Methods: All patients currently treated with warfarin therapy who were managed by clinical pharmacists for anticoagulation monitoring at the Medical University of South Carolina (MUSC) Family Medicine Center and University Diagnostic Center, were enrolled. Patients were asked to complete a satisfaction survey regarding their anticoagulation monitoring. In addition, data related to emergency department (ED) visits, hospitalizations and percent of time in the INR therapeutic range for 6 months pre- and post-implementation of POCT device was collected. This information was obtained through an electronic patient information database, Oacis. Results: A total of 145 patients were included in the data collection from the two clinics. The majority (41%) of these patients were taking warfarin for atrial fibrillation. Satisfaction surveys were completed by 86 (59 %) of patients. The surveys revealed that POCT device was preferred over venipuncture in 95% of patients. Reasons for the preference included more face-to-face interaction, less wait time, less pain, less blood needed, and quicker results. Of the 145 patients who were included in the objective data analysis, no significant differences were found in the number of hospitalizations, ED visits, or percent of time in the INR therapeutic range pre- and post-implementation of POCT device. Conclusion: The results of this study demonstrate improvement in patient satisfaction with POCT compared to venipuncture, with limited value in clinical outcomes.

Implementation of a Medication Reconciliation Process in an Internal Medicine Clinic at an Academic Medical Center

Discrepancies in medication orders at transitions of care have been shown to affect patient outcomes in a negative way. The Joint Commission recognizes the importance of medication reconciliation through their National Patient Safety Goals, with an emphasis placed on maintaining accurate medication information for each patient. The primary objective of this study was to assess the effectiveness of implementing a medication reconciliation process in an internal medicine clinic at an academic medical center. A retrospective chart review of patients seen at an Internal Medicine Clinic within and Academic Medical Center, a continuity and teaching clinic for Internal Medicine residents and faculty practice clinic, was conducted. Nursing staff were educated by PharmDs to perform a standardized medication history during the triage process. Medication reconciliation data was analyzed for 3263 patients from 1 August 2014 to 27 February 2015. A total of 4479 discrepancies were found through this process, with the majority (71%) of discrepancies being medications on the list that patient was no longer taking. This project illustrated to our nursing and physician staff the need for regular thorough review of the patient medication list.

Description of pharmacist-led quality improvement huddles in the patient-centered medical home model

OBJECTIVES This case study describes the implementation of pharmacist-led quality improvement team huddles in the patient-centered medical home clinic model. The purpose of these huddles is to have an impact on clinic-based quality metrics. SETTING Pharmacists embedded into primary care clinics at 2 separate health centers, within a large academic medical center, were funded by the clinics to lead their quality improvement (QI) team huddles. PRACTICE DESCRIPTION Huddle team members vary depending on the practice sites and can include physicians, pharmacists, advanced practice providers, nurses, administrative managers, social workers, and medical assistants. These huddles are typically held every 1-2 weeks for 15-20 minutes. Small rapid plan-do-check-act cycles allow the process to be quickly assessed and altered if needed. The quality metric that the team focused on changed based on clinic goals. Two case studies showcase successful examples of quality improvement initiatives that had a significant impact on the individual clinic-based metrics. INNOVATION The 2 case studies focus on pharmacist-led quality team huddles for controlled substance and asthma action plan metrics. The clinical pharmacists involved were pivotal to organizing and helping incorporate new processes within their clinics sites. RESULTS The work of the team huddles brought the clinics from a nonreimbursable status to reimbursable for these metrics. DISCUSSION Because pharmacists in the ambulatory care setting focus on chronic care disease management and QI, they are in an excellent position to lead team huddles focused on QI and registry management. By establishing interdisciplinary QI team huddles led by clinical pharmacists, these clinics were able to increase revenue for the clinic in the way of increasing pay-for-performance measures. CONCLUSION Pharmacist-led quality improvement team huddles can have a positive impact on quality metrics, population health, and reimbursement.

The Cleveland Clinic Pharmacy Population Health Management Summit

### KEY POINTS Population health and population health management (PHM) are relatively new terms. Despite a general understanding of the importance of PHM principles among pharmacists, we still lack a unifying professional vision of what we hope to achieve by PHM. In 2003, Kindig and Stoddart[1][1

Making the Transition from Student to Resident: A Method to Individualize a PGY1 Program

A Postgraduate Year One (PGY1) resident’s concerns, limitations, and strengths may be self-identified early in the residency year but are reliant on self-awareness and insight. Program directors commonly find difficulty in identifying a resident’s specific knowledge deficits at the beginning of the program. A standardized resident examination can identify limitations early in training and these results can be incorporated into a tailored resident development plan. A total of sixty-two PGY1 residents completed the examination pre- and post-training over a five-year timespan. Scores increased in most core disciplines in each of the five years, indicating an overall improvement in resident knowledge throughout their PGY1 year. The approach of utilizing the scores for the resident’s individualized plan allows for customization to ensure that the resident addresses knowledge gaps where necessary.

Assessment of Vitamin K Use in the Inpatient Treatment of Excessive Anticoagulation

Background: Guidelines from the Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy provide specific recommendations for the management of patients with supratherapeutic international normalized ratios (INRs). Objective: To assess the appropriateness of vitamin K administration in inpatients with excessive anticoagulation, according to existing guidelines. Methods: A retrospective chart review was performed for randomly selected patients on warfarin therapy who received vitamin K during hospitalization. Data were collected on patient demographics, vitamin K dose and route of administration, warfarin dose, alternative therapies, and INR values before and after vitamin K administration. The appropriateness of vitamin K use was evaluated based on indication, route, and dose. Results: A total of 136 patient charts were reviewed. The majority (71%, n = 97) of patients had a baseline INR of less than 5, with a mean INR of 4.4 ± 2.9 SD. Seventy-five patients had documented bleeding events on admission, 49% of which were considered major. Average time to repeat INR was 9.7 ± 6.8 SD hours. Seventy-one percent of patients had a documented appropriate indication for vitamin K, 42% received an appropriate dose, and 27% received vitamin K via the appropriate route of administration. Only 21% of patients received vitamin K for an appropriate indication, at an appropriate dose, via an appropriate route. Conclusions: At our institution, the current use of vitamin K for excessive anticoagulation is inconsistent and suboptimal with regard to route, dose, and monitoring parameters. Education of both medical and pharmacy staff is essential to improving compliance with ACCP recommendations.