Editor’s Choice Articles

Pharmacists report being less confident in their knowledge of direct acting oral anticoagulants (DOACs) than of vitamin K antagonists, which may influence their ability to detect and manage complications arising from DOAC use. In a mystery shopper study, patient agents were sent into community pharmacies with symptom or product-related requests related to common complications that might arise during treatment with oral anticoagulants, with each visit being assessed for the preferred outcome. Only 10/41 (24.4%) visits resulted in the preferred outcome. A complete history-taking process, obtaining a medical history, patient characteristics and pharmacist involvement were strong predictors of the preferred outcome being achieved. The preferred outcome was not consistently achieved without pharmacist involvement. The potential for strategies that support comprehensive pharmacist involvement in over-the-counter requests should be considered to ensure the provision of optimal care to patients taking high-risk medications such as DOACs. Full article

Since late December 2019, a novel, emerging coronavirus was identified as the infectious agent responsible for a generally mild but sometimes severe and even life-threatening disease, termed as “coronavirus disease 2019” (COVID-19). The pathogen was initially named as “2019 novel coronavirus” (2019-nCoV) and later renamed as “Severe Acute Respiratory Coronavirus type 2” (SARS-CoV-2). COVID-19 quickly spread from the first epicenter, the city of Wuhan, province of Hubei, mainland China, into neighboring countries, and became a global pandemic. As of July 15th 2020, the outbreak is still ongoing, with SARS-CoV-2 affecting 213 countries and territories. The coronavirus has caused a dramatic toll of deaths and imposed a severe burden, both from a societal and economic point of view. COVID-19 has challenged health systems, straining and overwhelming healthcare facilities and settings, including hospital and community pharmacies. On the other hand, COVID-19 has propelled several changes. During the last decades, pharmacy has shifted from being products-based and patient-facing to being services-based and patient-centered. Pharmacies have transitioned from being compounding centers devoted to the manipulation of materia medica to pharmaceutical centers, clinical pharmacies and fully integrated “medical-pharmaceutical networks”, providing a significant range of non-prescribing services. Moreover, roles, duties and responsibilities of pharmacists have paralleled such historical changes and have known a gradual expansion, incorporating new skills and reflecting new societal demands and challenges. The COVID-19 outbreak has unearthed new opportunities for pharmacists: community and hospital pharmacists have, indeed, played a key role during the COVID-19 pandemic, suggesting that a fully integrated, inter-sectoral and inter-professional collaboration is necessary to face crises and public health emergencies. Preliminary, emerging evidence seems to suggest that, probably, a new era in the history of pharmacies (“the post-COVID-19 post-pharmaceutical care era”) has begun, with community pharmacists acquiring more professional standing, being authentic heroes and frontline health workers. Full article

Community pharmacists (CPs) continue to have an important role in improving public health, however, advances in telehealth and digital technology mean that the methods by which they support their customers and patients are changing. The primary aim of this study was to identify which telehealth and digital technology tools are used by CPs for public health purposes and determine if these have a positive impact on public health outcomes. A systematic review was carried out using databases including PubMed and ScienceDirect, covering a time period from April 2005 until April 2020. The search criteria were the following: randomized controlled trials, published in English, investigating the delivery of public health services by community pharmacists using a telehealth or digital tool. Thirteen studies were included out of 719 initially identified. Nine studies detailed the use of telephone prompts or calls, one study detailed the use of a mobile health application, two studies detailed the use of a remote monitoring device, and one study detailed the use of photo-aging software. Public health topics that were addressed included vaccination uptake (n = 2), smoking cessation (n = 1), hypertension management (n = 2), and medication adherence and counseling (n = 8). More studies are needed to demonstrate whether or not the use of novel technology by CPs can improve public health. Full article

This case report details the five year journey of implementing, growing and optimizing a primary care pharmacist model in the ambulatory clinic setting within a health system. There is published evidence supporting the numerous benefits of including pharmacists in the primary care medical team model. This case report provides information regarding evolution of practice, the pharmacists’ roles, justification and financial models for the pharmacist services, as well as lessons learned and determined conclusions. Full article

In pharmacies in Sweden, a clinical decision support system called Electronic Expert Support (EES) is available to analyse patients’ prescriptions for potential drug-related problems. A nationwide intervention was performed in 2018 among all Swedish pharmacy chains to increase the use of EES among patients 75 years or older. The aim of this research was to study the use of EES in connection with the national intervention in order to describe any effects of the intervention, to understand how pharmacists use EES and to identify any barriers and facilitators for the use of EES by pharmacists for elderly patients. Data on the number and categories of EES analyses, alerts, resolved alerts and active pharmacies was provided by the Swedish eHealth Agency. The effects of the intervention were analysed using interrupted time series regression. A web-based questionnaire comprising 20 questions was sent to 1500 pharmacists randomly selected from all pharmacies in Sweden. The study shows that pharmacists use and appreciate EES and that the national intervention had a clear effect during the week of the intervention and seems to have contributed to a faster increase in pharmacists’ use of EES during the year to follow. The study also identified several issues or barriers for using EES. Full article

Preventable adverse drug events (ADEs) represent a significant public health challenge for the older adult population, since they are associated with higher medical expenditures and more hospitalizations and emergency department (ED) visits. This study examines whether a novel medication risk prediction tool, the MedWise Risk Score™ (MRS), is associated with ADEs and other pertinent outcomes in participants of the Programs of All-Inclusive Care for the Elderly (PACE). Unlike other risk predictors, this tool produces actionable information that pharmacists can easily use to reduce ADE risk. This was a retrospective cross-sectional study that analyzed administrative medical claims data of 1965 PACE participants in 2018. To detect ADEs, we identified all claims that had ADE-related International Classification of Diseases and Health Related Problems, 10th revision (ICD-10) codes. Using logistic and linear regression models, we examined the association between the MRS and a variety of outcomes, including the number of PACE participants with an ADE, total medical expenditures, ED visits, hospitalizations, and hospital length of stay. We found significant associations for every outcome. Specifically, every point increase in the MRS corresponded to an 8.6% increase in the odds of having one or more ADEs per year (OR = 1.086, 95% CI: 1.060, 1.113), $1037 USD in additional annual medical spending (adjusted R² of 0.739; p < 0.001), 3.2 additional ED visits per 100 participants per year (adjusted R² of 0.568; p < 0.001), and 2.1 additional hospitalizations per 100 participants per year (adjusted R² of 0.804; p < 0.001). Therefore, the MRS can risk stratify PACE participants and predict a host of important and relevant outcomes pertaining to medication-related morbidity. Full article

Competency-based education (CBE) “derives a curriculum from an analysis of a prospective or actual role in modern society and attempts to certify students’ progress on the basis of demonstrated performance in some or all aspects of that role”. This paper summarizes pertinent aspects of existing CBE models in health professions education; pharmacy education presented as an example. It presents a synthesis of these models to propose a new diagrammatic representation. A conceptual model for competency-based health professions education with a focus on learning and assessment is discussed. It is argued that various elements of CBE converge to holistically portray competency-based learning and assessment as essential in initial education and relevant to practitioners’ continuing professional development, especially in the context and importance of pursing lifelong learning practices. Full article

In recent years, a number of studies have examined tools to identify elderly patients who are at increased risk of drug-related problems (DRPs). There has been interest in developing tools to prioritise patients for clinical pharmacist (CP) review. This systematic review (SR) aimed to identify published primary research in this area and critically evaluate the quality of prediction tools to identify elderly patients at increased risk of DRPs and/or likely to need CP intervention. The PubMed, EMBASE, OVID HMIC, Cochrane Library, PsychInfo, CINAHL PLUS, Web of Science and ProQuest databases were searched. Keeping up to date with research and citations, the reference lists of included articles were also searched to identify relevant studies. The studies involved the development, utilisation and/or validation of a prediction tool. The protocol for this SR, CRD42019115673, was registered on PROSPERO. Data were extracted and systematically assessed for quality by considering the four key stages involved in accurate risk prediction models—development, validation, impact and implementation—and following the Checklist for the critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS). Nineteen studies met the inclusion criteria. Variations in study design, participant characteristics and outcomes made meta-analysis unsuitable. The tools varied in complexity. Most studies reported the sensitivity, specificity and/or discriminatory ability of the tool. Only four studies included external validation of the tool(s), namely of the BADRI model and the GerontoNet ADR Risk Score. The BADRI score demonstrated acceptable goodness of fit and good discrimination performance, whilst the GerontoNet ADR Risk Score showed poor reliability in external validation. None of the models met the four key stages required to create a quality risk prediction model. Further research is needed to either refine the tools developed to date or develop new ones that have good performance and have been externally validated before considering the potential impact and implementation of such tools. Full article

Pharmacists are at the forefront of dosing and monitoring medications eliminated by or toxic to the kidney. To evaluate the effectiveness and safety of these medications, accurate measurement of kidney function is paramount. The mainstay of kidney assessment for drug dosing and monitoring is serum creatinine (SCr)-based estimation equations. Yet, SCr has known limitations including its insensitivity to underlying changes in kidney function and the numerous non-kidney factors that are incompletely accounted for in equations to estimate glomerular filtration rate (eGFR). Serum cystatin C (cysC) is a biomarker that can serve as an adjunct or alternative to SCr to evaluate kidney function for drug dosing. Pharmacists must be educated about the strengths and limitations of cysC prior to applying it to medication management. Not all patient populations have been studied and some evaluations demonstrated large variations in the relationship between cysC and GFR. Use of eGFR equations incorporating cysC should be reserved for drug management in scenarios with demonstrated outcomes, including to improve pharmacodynamic target attainment for antibiotics or reduce drug toxicity. This article provides an overview of cysC, discusses evidence around its use in medication dosing and in special populations, and describes practical considerations for application and implementation. Full article

Recent advancements in molecular testing, the availability of cost-effective technology, and novel approaches to clinical trial design have facilitated the implementation of tumor genome sequencing into standard of care oncology practices. Current models of precision oncology practice include specialized clinics or consultation services based on a molecular tumor board (MTB) approach. MTBs are comprised of interprofessional teams of clinicians and scientists who evaluate tumors at the molecular level to guide patient-specific targeted therapy. The practice of precision oncology utilizing MTB-based models is an emerging approach, transforming precision genomics from a novel concept into clinical practice. This rapid shift in practice from cytotoxic therapy to targeted medicine poses challenges, yet brings exciting opportunities to clinical pharmacists practicing in hematology and oncology. Only a few precision genomics programs in the United States have a strong pharmacy presence with oncology pharmacists serving in leadership roles in research, interpreting genomic sequencing, making treatment recommendations, and facilitating off-label drug procurement. This article describes the experience of the precision medicine clinic at the Indiana University Health Simon Cancer Center, with emphasis on the role of the pharmacist in the precision oncology initiative. Full article