Interdisciplinary Physician-Pharmacist Medication Review for Outpatients With Heart Failure: A Subanalysis of the PHARM-CHF Randomized Controlled Trial

Aims: Patients with chronic heart failure (CHF) require polypharmacy and are at increased risk for drug-related problems. Interdisciplinary physician-pharmacist medication review may improve drug treatment. Our goal was to analyze the changes from the physician-documented medication plan (MP) and patient-stated medication to an interdisciplinary consolidated MP (CMP).Methods: This pre-specified subanalysis of the PHARM-CHF randomized controlled trial analyzed the medication review of CHF patients in the pharmacy care group. Community pharmacists compared the MP with the drug regimen stated by the patient and consulted with physicians on identified discrepancies and other medication-related problems resulting in a CMP.Results: We analyzed 93 patients (mean 74.0 ± 6.6 years, 37.6% female), taking a median of ten (IQR 8–13) drugs. 80.6% of patients had at least one change from MP to CMP. We identified changes in 32.7% (303/926) of drugs. The most common correction was the addition of a drug not documented in the MP to the CMP (43.2%). We also determined frequent modifications in the dosing regimens (37.6%). The omission of a drug documented in the MP but left out of the CMP accounted for 19.1%. Comparing patient-stated medication to CMP, the current drug regimen of patients was changed in 22.4% of drugs.Conclusion: The medication review resulted in changes of medication between MP and CMP in most of the patients and affected one-third of drugs. Structured physician-pharmacist interdisciplinary care is able to harmonize and optimize the drug treatment of CHF patients.

Evaluation of An Inpatient Pharmacy Consult on Discharge Medications in Bariatric Surgery Patients

Purpose: To evaluate the impact of an inpatient pharmacy consult on discharge medications following bariatric surgery. Methods: A pharmacy consult for discharge medication review for bariatric surgery patients was instituted at an academic medical center. The intervention included conducting a medication history, reviewing home medications for updates post-bariatric surgery, creating and documenting a discharge medication plan, and providing patient education. The impact of the intervention was evaluated by comparing medication classes, doses, and formulations prescribed during the intervention relative to a historical control group. Results: The study included 85 patients who received pharmacist intervention and 167 patients who did not receive pharmacist intervention following bariatric surgery. The prescription of an extended-release medication at discharge in the intervention group was reduced by 19.3% (28.7% vs. 9.4%, p = 0.0005). For patients on hypertension medications, 94.0% had their regimen reduced in the intervention group compared with 37.5% of patients in the control group (p < 0.001). Of patients on insulin at baseline, 87.5% of patients in the intervention group had dose reductions at discharge vs. 66.7% of patients in the control group (p = 0.37). No patients in the intervention group were discharged with oral antihyperglycemic medications or non-insulin injectable medications vs. 33.3% (p = 0.12) and 20.0% (p = 0.47), respectively, in the control group. Readmission rates at 30 days were insignificantly lower in the intervention group (3.5% vs. 4.2%, p = 1). Conclusions: Clinical pharmacist involvement in the discharge medication reconciliation process for bariatric surgery patients reduced prescribing of unadjusted medication classes, doses, and drug formulations.

MO105TELEMEDICAL SURVEILLANCE AND OPTIMIZED TREATMENT OF BLOOD PRESSURE IN KIDNEY TRANSPLANT RECIPIENTS

Background and Aims Patients with chronic kidney disease suffer often from cardiovascular diseases, especially high blood pressure and its complications such as stroke and heart attack. After kidney transplantation, this condition persists and can in addition harm the graft. However, outpatient care surveillance is not ideal to treat high blood pressure sufficiently. mHealth solutions such as remote vital signs seem to have the potential to fill in this gap. Method To optimize the monitoring of kidney transplant recipients (KTR), the MACCS (Medical Assistant for Chronic Care Solution)-project offers participants an intensified control of home-measured vital signs via a smartphone app. Additionally, well-being and medical adherence can be forwarded. A telemedicine team reviews daily incoming data and takes action, if necessary. A self-programed telemedicine dashboard visualizes the data. KTR receive their updated medication plan and medical support. The pilot phase of project started in February 2020 and is ongoing. A randomized controlled trial will start in March 2021. The concept sticks to General Data Protection Regulation (GDPR) of European Union. Results Currently, 335 KTR participate in the project with 26 (7.76%) dropouts since beginning. Including the 26 dropouts, we received in total 15 973 blood pressure (BP) values (mmHg) (systolic BP [SBP] mean 128.56, standard deviation [SD] ±103.7, maximum (max) 220, minimum (min) 60; diastolic BP [DBP] mean 78.51, SD ±9.97, max 120, min 60) and 27 481 heart rate (HR) values in beats per minutes (bpm) (mean 70, SD ±14, max 200, min 40). For 278 times, an adaption of antihypertensive therapy took place. In total, 170/335 KTR were hospitalized, which made up for 338 hospitalizations (1.99 cases per patient, max 6, min 1), which led to 3 8547 days in hospital (mean 9.34, SD ±11.43, max 89, min 1). In 331 cases, the diagnosis (main or secondary diagnosis) was related to hypertension, and 196 cases the diagnosis may be a hypertension-related complication, e.g. myocardial infarct. Evaluation regarding significance is in process and requires further data. Conclusion mHealth solutions including remote vital signs and telemedicine personnel for regular evaluation have the potential to optimize blood pressure treatment. Acute onset of hypertensive crisis can be handled sufficiently at home and thus reduce treatment at emergency rooms. Since severe complications of high blood pressure levels manifest after years, long-term results are required to conduct conclusions.

Impact of provincial and national implementation strategies on P2Y12 inhibitor utilization for acute coronary syndrome in the elderly: an interrupted time series analysis from 2008 to 2018

Background Guidelines recommend both acetylsalicylic acid and ticagrelor following acute coronary syndrome (ACS), but appropriate prescription practices lag. We analyzed the impact of government medication approval, national guideline updates, and publicly funded drug coverage plans on P2Y12 inhibitor utilization. Methods Accessing provincial databases, we obtained data for elderly ACS patients in Ontario, Canada, between 2008 and 2018. Using interrupted-time series with descriptive statistics and segmented regression analysis, we evaluated types of P2Y12 inhibitors prescribed at discharge and changes to their utilization in patients managed with percutaneous intervention (PCI), coronary artery bypass grafting (CABG) or medically, following national antiplatelet therapy guidelines (by the Canadian Cardiovascular Society), ticagrelor’s national approval by Health Canada, and ticagrelor’s coverage by a publicly funded medication plan. Results We included 114,142 patients (49.4%-PCI; mean age 75.71±6.94 and 62.3% male and 7.7%-CABG; mean age 74.11±5.63 and 73.5% male). Among PCI patients, clopidogrel utilization declined monthly after 2010 national guidelines were published (p<0.0001) and within the first month after ticagrelor’s national approval by Health Canada (p=0.03). Among PCI patients, ticagrelor utilization increased within the first month (p<0.0001) and continued increasing monthly (p<0.0001) after its coverage by a publicly funded medication plan. Among PCI patients, clopidogrel utilization declined within the first month (p=0.003) and ticagrelor utilization increased monthly (p=0.05) after 2012 CCS guidelines. Among CABG patients, ticagrelor’s coverage was associated with a monthly increase in its utilization (p<0.0001). Conclusion National guideline updates and drug coverage by a publicly funded medication plan significantly improved P2Y12 inhibitor utilization. Barriers to appropriate antiplatelet therapy in the surgical population must be explored.

Improving Primary Care Medication Processes by Using Shared Electronic Medication Plans in Switzerland: Lessons Learned From a Participatory Action Research Study

Background Several countries have launched health information technology (HIT) systems for shared electronic medication plans. These systems enable patients and health care professionals to use and manage a common list of current medications across sectors and settings. Shared electronic medication plans have great potential to improve medication management and patient safety, but their integration into complex medication-related processes has proven difficult, and there is little scientific evidence to guide their implementation. Objective The objective of this paper is to summarize lessons learned from primary care professionals involved in a pioneering pilot project in Switzerland for the systemwide implementation of shared electronic medication plans. We collected experiences, assessed the influences of the local context, and analyzed underlying mechanisms influencing the implementation. Methods In this formative action research study, we followed 5 clusters of health care professionals during 6 months. The clusters represented rural and urban primary care settings. A total of 18 health care professionals (primary care physicians, pharmacists, and nurses) used the pilot version of a shared electronic medication plan on a secure web platform, the precursor of Switzerland’s electronic patient record infrastructure. We undertook 3 group interviews with each of the 5 clusters, analyzed the content longitudinally and across clusters, and summarized it into lessons learned. Results Participants considered medication plan management, digitalized or not, a core element of good clinical practice. Requirements for the successful implementation of a shared electronic medication plan were the integration into and simplification of clinical routines. Participants underlined the importance of an enabling setting with designated reference professionals and regular high-quality interactions with patients. Such a setting should foster trusting relationships and nurture a culture of safety and data privacy. For participants, the HIT was a necessary but insufficient building block toward better interprofessional communication, especially in transitions. Despite oral and written information, the availability of shared electronic medication plans did not generate spontaneous demand from patients or foster more engagement in their medication management. The variable settings illustrated the diversity of medication management and the need for local adaptations. Conclusions The results of our study present a unique and comprehensive description of the sociotechnical challenges of implementing shared electronic medication plans in primary care. The shared ownership among multiple stakeholders is a core challenge for implementers. No single stakeholder can build and maintain a safe, usable HIT system with up-to-date medication information. Buy-in from all involved health care professionals is necessary for consistent medication reconciliation along the entire care pathway. Implementers must balance the need to change clinical processes to achieve improvements with the need to integrate the shared electronic medication plan into existing routines to facilitate adoption. The lack of patient involvement warrants further study.

Computational Studies in Breast Cancer

Early detection of breast cancer is a worldwide need as many hospitals have appeared in commitment of research pathway. As per WHO (World Health Organisation), early detection of breast cancer boosts the choice of making corrective judgement on medication plan. This corrective choice helps women to save themselves from expensive and unwanted medical test and treatment. Physical observation and medical history play an important role in diagnosing this disease; however, for detailed understanding, some reliable and accurate methods are still required. This chapter reviews existing computational methods and need of novel algorithms that can help in accurately diagnosing this disease. Correct diagnosis and yield results devising treatment strategy. For correct diagnosis micro-array gene expression data is widely used, this chapter highlights various computational studies done on breast cancer microarray data. This review highlights the benefit of computational model being an impressive tool for discovery of cancer along with devising its therapies.

Improvement of Advanced Assisted gastro retentive floating tablet using TRZ and S

Definition advancement is a significant piece of medication plan and improvement. Bioavailability and bioequivalence are absolutely reliant on definition improvement. Presently a-days detailing advancement is finished by following Quality through Design. Floating drug conveyance frameworks are the gastro retentive structures that absolutely control the delivery pace of target medication to a particular site which encourage a tremendous effect on medical care. This can be accomplished by utilization of different polymeric substances. Trazodone-Hydrochloride (TRZ), is a notable substance aggravate that is utilized as an energizer that has a place with a particular serotonin repeated inhibitors (SARI). The delivery information was fitted to different numerical models, for example, higuchi, Korsmeyer-Peppas (KP), 1st request &0 request to assess the energy and system of the medication discharge. Arranged coasting tablets of TRZ may end up being a possible possibility for sheltered and successful controlled medication conveyance over an all-encompassing timeframe for gastro retentive medication conveyance framework. The oral assisted medication architecture conveyance has been confounded through confined habitation time gastric. Also, rapid gastro-intestinal transmission might predict overall discharge medication in zone of retention and diminish the handled portion adequacy, as many of medications have been invested on small digestive upper piece system. Also, it handles structure measurement at assimilation site & in this way updates bio-availability as stated in.

Abstract 14379: Implementation of Pharmacist-led Antithrombotic Medication Management for Elective Endoscopic Procedures

Introduction: Mismanagement of antithrombotic medications often leads to cancelled elective procedures. Pharmacist-led anticoagulation management prior to elective procedures is not well studied. Methods: We implemented a best practice advisory (BPA) that offered referral to a pharmacist-led medication management service prior to elective outpatient gastrointestinal endoscopies. Eligible patients were taking warfarin, a direct oral anticoagulant, and/or a P2Y12 inhibitor for management of atrial fibrillation (AF), venous thromboembolism (VTE), coronary artery disease (CAD), peripheral arterial disease (PAD), and/or mechanical heart valve. Patients referred to the antithrombotic service were compared to those managed by the ordering provider. Outcomes assessed included documentation of a medication management plan, guideline-appropriateness of drug cessation prior to endoscopy, and guideline-appropriate rates of enoxaparin bridging for high risk warfarin patients. Results: Seventy-four percent of patients (448/645) were referred to the antithrombotic service. These patients were more likely to have had VTE (33.0% vs. 18.2%), less likely to have CAD (31.9% vs. 40.9%; p=0.009 for indication category), and more likely to be prescribed warfarin (32.8% vs 20.9%, p<0.001). After adjusting for baseline differences, patients referred to the antithrombotic service were more likely to have had pre-procedure medication plan documentation (98.7% vs 56.1%, p <0.001), and pre-procedure antithrombotic management was more likely to follow guidelines (97.5% vs. 91.5%, p=0.024). Guideline-appropriate use of bridging enoxaparin for warfarin patients was not different (10/16 [62.5%] vs. 2/6 [33.3%], p=0.221). Conclusion: Pre-procedural antithrombotic medication management by a pharmacist-led team for elective endoscopies was associated with more guideline-adherent management and better documentation of the medication plans.

Antiplatelet therapy prescription patterns for acute coronary syndrome: a decade analysed

Background/Introduction Guidelines recommend dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and ticagrelor following acute coronary syndrome (ACS) regardless of management strategy. Despite this, prescription practices lag and appropriate DAPT is not utilized. Purpose We aimed to trend differences in P2Y12 inhibitor prescriptions between ACS patients managed with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). As well, we wanted to analyze the impact practice-changing trial publications, national guideline updates, and publicly funded drug coverage plans may have on prescription patterns. Methods From national databases, we obtained data for ACS patients in the province of Ontario, Canada between 2008 and 2018. Using an interrupted-time series with data aggregated monthly, we evaluated types of P2Y12 inhibitor prescribed at hospital discharge and changes to antiplatelet prescription patterns following publication of Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndrome (PLATO), Canadian Cardiovascular Society (CCS) antiplatelet therapy guidelines, and ticagrelor coverage by a publicly funded medication plan. Results We included 114,142 ACS patients; 49% underwent PCI and 8% required CABG. Between October 2008 and March 2018, the proportion of patients discharged on P2Y12 inhibitors increased from 73.4% to 87% (p&lt;0.0001) for PCI patients and 11.4% to 31.4% (p&lt;0.0001) for CABG patients. PLATO publication was associated with a 1.3% (p=0.002) monthly decline in clopidogrel prescriptions amongst PCI patients. The 2010 CCS antiplatelet therapy guidelines were associated with a 0.7% (p&lt;0.0001) monthly decline in clopidogrel prescriptions amongst PCI patients. The approval of ticagrelor by publicly funded medication plan was associated with an increase in ticagrelor prescriptions within the first month (24.5%; p&lt;0.0001) and a continued monthly increase (0.4%; p&lt;0.0001) in PCI patients. The approval was also associated with an increase in monthly ticagrelor prescriptions (0.2%; p&lt;0.0001) amongst CABG patients. The 2012 CCS antiplatelet therapy guidelines were associated with a decline in clopidogrel prescriptions within the first month (6.1%; p=0.003) and a monthly increase in ticagrelor prescriptions (0.3%; p=0.05) amongst PCI patients. Conclusion Drug coverage by a publicly funded medication plan and guideline updates had significant impact on P2Y12 inhibitor prescription practices. Despite improvements, P2Y12 inhibitor prescriptions for CABG patients are far behind PCI patients. Further research is necessary to address barriers to appropriate antiplatelet therapy in the ACS population. Antiplatelet Prescription Patterns Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): New Investigator Fund - Hamilton Health Sciences Foundation, Hamilton, Canada

P2Y12 Inhibitor Utilization for Acute Coronary Syndrome in the Elderly: A Provincial Analysis From 2008 to 2018

Background Guidelines recommend acetylsalicylic acid (ASA) and ticagrelor following acute coronary syndrome (ACS), but appropriate prescription practices lag. We analyzed the impact of government medication approval, national guideline updates, and publicly funded drug coverage plans on P2Y12 inhibitor utilization.Methods Accessing provincial databases, we obtained data for elderly ACS patients in Ontario, Canada between 2008 and 2018. Using an interrupted-time series, we evaluated types of P2Y12 inhibitors prescribed at discharge, and changes to their utilization following ticagrelor’s national approval by Health Canada, national antiplatelet therapy guidelines (by the Canadian Cardiovascular Society (CCS)), and ticagrelor's coverage by a publicly funded medication plan.Results We included 114,142 patients (49.4%-PCI and 7.7%-CABG). Proportion of PCI patients utilizing P2Y12 inhibitors increased from 73.4% to 86.9% (p<0.001) and 11.4% to 46.5% (p<0.001) for CABG patients. Among PCI patients, clopidogrel utilization declined monthly after 2010 national guidelines were published (0.7%; p<0.0001) and within the first month after ticagrelor’s national approval by Health Canada (5.3%; p=0.03). Among PCI patients, ticagrelor utilization increased within the first month (24.5%; p<0.0001) and continued increasing monthly (0.4%; p<0.0001) after its coverage by a publicly funded medication plan. Among CABG patients, ticagrelor’s coverage was associated with a monthly increase in its utilization (0.2%; p<0.0001). Among PCI patients, clopidogrel utilization declined within the first month (6.1%; p=0.003) and ticagrelor utilization increased monthly (0.3%; p=0.05) after 2012 CCS guidelines.Conclusion National guideline updates and drug coverage by a publicly funded medication plan significantly improved P2Y12 inhibitor utilization. Barriers to appropriate antiplatelet therapy in the surgical population must be explored.