President Jessica DiLeo
President Elect Virginia Boomershine
Past President Keith Boesen
Treasurer Lisa Tonrey
Secretary Jacob Schwarz
DIRECTORS AT LARGE
Community
Jaime Von Glahn
Health Systems
Aimee (Keller) Itaaehau
Technician
Kevin Reger
Directors at Large
Patrick Hryshko
Laura Moore
Nancy Costlow Amy Kennedy
Lanre Kolawole
Sienna Miller
Liason
Justin Spicer
Midwestern University Student Chapter Liaison
Kassie Notbohm
University of Arizona Student Chapter Liaison
Mitchell R. Emerson
Dean Midwestern University CPG
Rick G. Schnellmann
Dean University of Arizona COP-Tucson
John Murphy
Associate Dean University of Arizona COP-Phoenix
Roger Morris Legal Counsel
EDITOR
Kelly Fine, RPh, FAzPA
MANAGING EDITOR Cindy Esquer
CREATIVE COORDINATOR
Elizabeth Nelson, CAE
The interactive digital version of the Arizona Journal of Pharmacy is available for members only online at www.tinyurl.com/azjournal
(480) 838-3385
web@azpharmacy.org
EDITOR’S NOTE: Any personal opinions expressed in this magazine are not necessarily those held by the Arizona Pharmacy Association. “Arizona Journal of Pharmacy” (ISSN 1949-0941) is published quarterly by the Pharmacy Network of Arizona at: 1845 E. Southern Avenue, Tempe, AZ 85282-5831.
Dear AzPA Members,
I hope everyone had a fantastic 2018. Your Board of Directors and Arizona Pharmacy Association staff continue to work diligently and we are proud to close out the year strong. We are looking forward to what 2019 has to offer! As you settle into the New Year and reflect on your 2019 resolutions, I strongly encourage you all to get more involved by adding “advocate for my profession” to your list of resolutions. YOU are what keeps our association running and profession strong.
You may be asking yourselves, “How can I help AzPA prepare for a successful year?” GET INVOLVED!
• To start, we are asking all members update their membership profiles on the AzPA website. I promise you, it will only take three minutes of your time. Visit https://azpharmacy.org/, login into your profile and select “My Account.” Update your account with your affiliated primary practice setting, credentials and ways in which you would be interested in becoming more involved.
As you settle into the New Year and reflect on your 2019 resolutions, I strongly encourage you all to get more involved by adding “advocate for my profession” to your list of resolutions.
• Attend a monthly committee meeting. Most committee calls take place during lunch or after work hours and only last 30 to 60 minutes.
• Refer a friend to AzPA. Invite them to join a committee call with you or register for one of our upcoming conferences. We have some great events coming up, including:
• Arizona Pharmacy Foundation Annual Ball (February 2, 2019}
• Spring Clinical Seminar (February 22–24, 2019)
• Annual Convention (June 20–23, 2019)
The opportunities do not stop there! If you are looking to become even more involved, here are some other great ways:
• Interested in chairing an AzPA Committee? We are looking for Co-Chairs for Membership, Marketing/Communications and our American College of Clinical Pharmacy Chapter. If interested or know someone who would be interested, please reach out to myself and/or Kelly Fine.
• We will be calling for nominations for our next round of Directors at Large and President-Elect positions. Be on the lookout for additional information coming soon!
I look forward to an amazing 2019, meeting you all at our upcoming conferences, and hearing more ideas on how we can continue to grow as an organization. HAPPY NEW YEAR!
Jessica Dileo, PharmD, BCACP, BCGP AzPA President 2018-2019
Hiva Pourarsalan, PharmD – Aetna Medicaid Donna Lynn M. Obra, PharmD – Aetna Medicaid Rodney Hendershot, RPh – Aetna Medicaid
Conflicts of interest: None
This study was presented as a poster presentation at the 2017 Spring Annual Academy of Managed Care Pharmacy Meeting in Denver, Colorado
The Centers for Medicare and Medicaid Services has proposed a new measure called Statin Use in Persons with Diabetes Measure (SUPD) that measures the use of statin in diabetic patients. This new quality measure targets diabetic patients 40 to 75 years old who are taking greater than or equal to two diabetes medications. Current American Heart Association/American College of Cardiology guidelines recommend patients who are 40 to 75 years old with diabetes should be put on a statin in order to prevent an atherosclerotic cardiac disease. Primary end point: Increase in number of statin claims in diabetic patients who are 40 to 75 years old and are on two or more diabetes medications without a statin. Secondary end point: increase in Statin Use in Patients with Diabetes (SUPD) Part D STAR measure.
One thousand nineteen (1,019) members with two or more diabetes medications who were between the age of 40 and 75 years old were identified utilizing patient safety report provided by Centers for Medicare and Medicaid Services (CMS), SUPD-Bene_Denominator report in August 2016. Members who had a paid claim for statins between July 31, 2016 and November 15, 2016 were excluded (245). Pharmacy claims were utilized to identify the prescribers treating diabetic patients without statins. Members whose prescriber’s fax numbers were not available were excluded (68). The identified members were divided into 6 groups to assess the effectiveness of different provider and member interventions. Group A included members whose prescribers received fax only, group B included members whose prescribers received fax plus provider call, group C included members whose prescribers received fax plus prescriber in- service, Group D included members whose
prescribers received fax and received member letter, Group E included members whose prescribers received fax plus prescriber call and members received member letter, Group F included members whose prescribers received fax plus prescriber in-service and members received member letter. Prescriber faxes were sent on December 1, 2016. Prescriber calls were made mid to end of December. Member letters were mailed out in January. Prescriber in-services were provided mid-January to mid-February Member paid statin claims were assessed on May 3rd. All the groups were compared to group A. In addition, groups D, E, and F were compared to groups A, B and C respectively to assess the effectiveness of member letters.
There was an increase in statin claims after interventions. Out of 702 members targeted, 93 members filled a statin through pharmacy benefits between 12/1/2016 and 04/25/2017 leading to a 13.2%
increase in statin fill. Group E showed a significant increase in fills compared to group A (p=0.002), in addition group E statin claims were significantly increased compared to group B (p=0.005). Groups C, D and F did not show a significant increase in comparison to group A (p>0.05).In addition, the secondary end point of increase in SUPD measure cannot be calculated at this point as this score is calculated in 2019.
This pilot program showed an increase in the number of statin claims within the time frame allotted. Groups B, D, E showed an increase in the number of statin fills in comparison to group A. Group E (provider fax plus provider call plus member letter) showed a statistically significant increase in comparison to group A (provider fax only). Group E also showed a statistically significant increase in statin claims compared to group B (provider fax plus provider call), indicating that including member letters as an intervention can lead to an impact in statin use.
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in diabetic patients. American Heart Association (AHA) and American College of Cardiology (ACC) have identified 4 different statin benefit groups: Clinical ASCVD, LDL ≥ 190 mg/dL, Diabetes (Type 1 or 2) + age 40 to 75 + LDL 70 to 189 mg/dL, Age 40 to 75 + ≥ 7.5% estimated 10year ASCVD risk. Of interest to this study, is the second group: Diabetics (Type 1 or 2) + age 40 to 75 + LDL 70 to 189 mg/dL. In addition, the recommendation on what type of statin to use in these diabetic patients depends on the 10-year ASCVD risk calculator. For patients who have a ≥ 7.5% estimated 10-year ASCVD risk, a high intensity statin is recommended and patient who have a < 7.5% estimated 10 year ASCVD risk or cannot tolerate high intensity statin a moderate intensity statin is recommended.
The Centers for Medicare and Medicaid Services has proposed a new STAR measure endorsed by Pharmacy Quality Alliance (PQA) called Statin Use in Persons with Diabetes Measure (SUPD) that measures the use of statin in diabetic patients. This new quality measure targets diabetic patients 40 to 75 years old who are taking greater than or equal to two diabetes medications. This measure will be added as a STAR measure in 2019. Interventions need to be made by the start of 2017 to meet the standards in 2019.
Mercy Care Advantage (HMO SNP) is a coordinated care plan with a Medicare contract and a contract with the Arizona Medicaid Program that serves about 20,000 Medicare-Medicaid members as of January 2017.
One thousand nineteen members who had two or more diabetes medications and were between the age of 40 and 75 years old were identified based on patient safety report provided by Centers for Medicare and Medicaid Services (CMS), SUPD-Bene_Denominator generated in August 2016. CVS generated program RxNavigator was utilized to get provider information and to evaluate statin claims before and after interventions. This methodology was chosen based to identify subject population based on CMS methodology.
Medicare members enrolled in MCA who are 40 to 75 years old and have 2 or more diabetes medication claims.
Members who had statin claims filled between July 31, 2016 to November 15, 2016 (245 members). In addition, members whose prescribers’ fax numbers were not available (68 members).
Members were divided based into six groups. Group A included members whose prescribers received fax only (306 members), group B included members whose prescribers received fax plus provider call (306 members), group C: members whose prescribers received fax plus prescriber in service (92 members), Group D: members whose prescribers received fax and members received member letter (153 members), Group E: members whose prescribers received fax plus prescriber call and members received member letter (153), Group F: members whose prescribers received fax plus prescriber in-service and members received member letter (46).
Faxes were sent on December 1, 2016; provider calls are made mid to end of December and member letters were mailed out in January and provider in-services were performed in February. Member claims were assessed early May to assess the different intervention groups. All the different intervention groups were compared to group A to assess the effectiveness of each intervention. Of note, only half of the provider groups in groups C and E were able to get in-service. All groups were compared to group A (control group). Groups D, E, and F were compared to groups A, B and C respectively to assess the effectiveness of member letters.
Primary end point: Increase in number of statin claims
in diabetic patients who are 40 to 75 years old and are on two or more diabetes medications without a statin. Secondary end point: increase in Statin Use in Patients with Diabetes (SUPD) Part D STAR measure.
P-values were calculated using a Two-Sample Proportion Test to test for significance between: P-values less than 0.05 were considered to be statistically significant
Out of 702 members, 93 members filled a statin through pharmacy benefits between 12/1/2016 and 4/25/2017, leading to an increase in number of statin claims. Table 1 displays demographics for members of all groups. Majority (over 50%) of the members were females and were over the age of 60 years old. P values were used to assess statistical significance. Group E statin claims were significantly increased post intervention in comparison to group A (p<0.05). Groups B, C, D and F did not show statistical significance change in number of claims as compared to group A. Table 2 displays the p value of differences between groups based on paid statin claims. Table 3 displays calculated P value for groups that received member letters to groups that did not receive member letters. Group E had a significant increase in number of statin claims compared to group B (p<0.05).
The total number of statin claims across all groups increased by13.2% after interventions. Group E showed a significant increase in fills compared to group A (p=0.003). Additionally, the number of statin claims in group E were significantly increased compared to group B (p=0.032). Groups B, C, D groups did not show a significant increase in comparison to group
A (p>0.05). Overall, groups B and E had the highest increase in statin claims, indicating that pharmacistdriven provider calls can increase statin claims for members with diabetes. The number of statin claims did not statistically increase in groups E and F. Provider in-services were only scheduled for half of the provider groups in the allotted time frame. While there were no statistically significant increases in the number of statin claims in groups E and F in comparison to groups B and
TABLE 2: Comparison of Different groups to control group (A), P value of <0.05 indicates significance.
Groups Compared P Value
A vs B 0.277
A vs C 0.132
A vs D 0.936
A vs E 0.002
A vs F 0.12
C, Group E showed a significant increase in statin claims compared to group B, indicating that member letters can potentially make a difference in statin claims.
This pilot program served 702 of those members, causing an increase in overall statin claims for members who were 40 to 75 years old and on two diabetes medications. As indicated by the results, the statistically significant intervention was group E, combining provider faxes with provider calls and member letters. While inservices provide face to face time between the plan and providers, in-services may not be practical as only half of the provider groups were able to get scheduled for in-services in the allotted time frame.
Future quality improvement programs can utilize pharmacists to provide direct calls to provider offices to make intervention as groups B and E received the highest number of statin claims after interventions.
TABLE 3: Comparison of intervention groups that received member letters (D, E, F) to intervention groups that did not receive member letters (A, B, C).
Groups Compared
P Value
(Significant <0.05)
A vs D 0.936
B vs E 0.032 C vs F 0.544
1. Announcement of Calender Year 2017 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. https://www.cms.gov/Medicare/Health-Plans/ MedicareAdvtgSpecRateStats/Downloads/ Announcement2017.pdf. Accessed Sep 20, 2016.
2. Mozafarian D, Benjamin EJ, et al. Executive Summary: Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation 2016; 133(4):447-54.
3. Stone NJ, Robinson JG, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.
This 1.5 day seminar provides approximately eleven (11) hours of continuing education for pharmacy professionals focusing on clinical topics pertinent to institutional and ambulatory care settings.
Friday, February 22, 2019
8:00AM–5:00PM
APhA Pharmacy-Based Cardiovascular Disease Risk Management Certificate Program*
8:00AM–5:00PM
AzPA Anticoagulation Certificate Program*
*Separate registration is required.
Saturday, February 23, 2019
8:00AM–9:30PM: General Session I
A National Perspective on Current Issues in Ambulatory Pharmacy: Panel Discussion with Az-ASHP Delegates
Melanie Smith, PharmD, BCACP – ASHP, Director of Ambulatory Care Practitioners
Pharmacist/Pharmacy Technician learning objectives: TBD
9:45AM–11:00AM: General Session II
The Enigmatic Problem of Protracted Withdrawal from Benzodiazepines: What Pharmacists Need to Know Robert Raffa, PhD; Joseph Pergolizzi, MD; Steven Wright, MD 0100-0000-18-058-L01-P/T
Pharmacist learning objectives:
• Counsel patients and prescribers on the existence of protracted BZD withdrawal symptoms
• Correlate patients’ reports with possible BZD AEs or withdrawal symptoms
• Advise on best practices for BZD tapering
• Describe evolving basic science research into protracted withdrawal
• Advocate for better BZD labeling
Pharmacy Technician learning objectives:
• Describe protracted benzodiazepine withdrawal symptoms
• Recognize best practices for benzodiazepine tapering
• Describe basic science research concerning protracted benzodiazepine withdrawal
Hot
Juan Villanueva, PharmD, BCPS
0100-0000-18-059-L01-P/T
Pharmacist learning objectives:
• Describe current trends in antibiotic resistance and implications on public health
• Identify strategies to implement evidence-based practices for antimicrobial stewardship
• Recognize appropriate antibiotic management methods to improve quality of care
Pharmacy Technician learning objectives:
• Recognize current trends in antibiotic resistance and implications on public health
• List benefits of antimicrobial stewardship across healthcare settings
Risk of Medication Errors Associated with Drug Shortages
Carol Rollins, PharmD, MS, BCNSP, FASEPN, FASHP, FAzPA 0100-0000-18-060-L05-P/T
Pharmacist/Pharmacy Technician learning objectives:
• Describe present and historical drug shortages and the difference between data from the FDA and ASHP.org
• Discuss factors contributing to risk of error when attempting to conserve an injectable product in short supply.
• Determine potential risks associated with changing from your usual product to an alternative product during a drug shortage
1:30PM–2:30PM: General Session III
Arizona Opioid Law Update
TBD
Pharmacist/Pharmacy Technician learning objectives:
TBD
2:45PM–4:15PM: Breakout Sessions (3-4)
To Breathe or Not to Breathe?
Nicholas Ladziak, PharmD; Beth Zerr, PharmD, BCACP, AE-C 0100-0000-18-061-L01-P/T
Pharmacist learning objectives:
• Identify different inhaler devices and available drug combinations
• Counsel patients on proper administration for prescribed inhalers
• Anticipate and resolve administration issues based on device and patient characteristics
Pharmacy Technician learning objectives:
• Identify different inhaler devices and available drug combinations
• Describe proper administration for prescribed inhalers
• Recognize administration issues based on device and patient characteristics
Overview of Pharmacogenomics in Diabetes
Adrijana Kekic, PharmD, BCACP
Pharmacist learning objectives:
• Recognize genetic influence in development of diabetes
• Differentiate role of PGx in treatment selection, efficacy and safety
• Integrate PGx knowledge in clinical case
4:30PM–5:30PM: Breakout Sessions (5-6)
Need More Salt: Managing the Syndrome of Inappropriate Antidiuretic Hormone
Grace Lin, PharmD, PGY2
0100-0000-18-062-L01-P/T
Pharmacist learning objectives:
• Describe the pathophysiology of the syndrome of inappropriate antidiuretic hormone secretion
• Identify medications that can precipitate the syndrome of inappropriate antidiuretic hormone secretion
• Recommend potential treatment options for the syndrome of inappropriate antidiuretic hormone based on current guidelines and literatures
Pharmacy Technician learning objectives:
• Describe the pathophysiology of the syndrome of inappropriate antidiuretic hormone secretion
• Identify medications used in the syndrome of inappropriate antidiuretic hormone secretion
• Recognize best practices for the syndrome of inappropriate antidiuretic hormone secretion
A Syphilis Update
Kerry-Ann Fuller, PharmD, BCACP; Molly Larson-Wakeman, PharmD
0100-0000-18-063-L01-P/T
Pharmacist learning objectives:
• Discuss the changing prevalence and epidemiology of syphilis
• Describe transmission methods of syphilis
• Create syphilis treatment and follow-up plan
Pharmacy Technician learning objectives:
• Discuss the changing prevalence and epidemiology of syphilis
• Describe transmission methods of syphilis
• Recognize treatment options for syphilis
8:00AM–9:30AM: General Session IV
Pharmacy Law Update 2019
Roger Morris, RPh, JD
0100-0000-18-064-L03-P/T
Pharmacist/Pharmacy Technician learning objectives:
• Identify major developments in U.S. Pharmacy law and related fields
• Describe the practical ramifications of proposed state and national legislative initiatives
• Recognize emerging patterns that will broadly affect the healthcare profession and pharmacy practice
9:45AM–10:45AM: General Session V
New Cholesterol Guidelines: What You Need to Know
Virginia Boomershine, PharmD, BCACP, CDE, FAzPA; Zachary Brock, PharmD, PGY2
0100-0000-18-065-L01-P/T
Pharmacist learning objectives:
• Compare cholesterol treatment guidelines
• Apply cholesterol treatment guidelines to the care of individual patients
Pharmacy Technician learning objectives:
• Review new cholesterol treatment guidelines
• Recognize current cholesterol treatment for patients
11:00am–12:30pm: General Session VI
2019 New Drug Update
Robert J. Lipsy, PharmD, BCPS, FASHP
0100-0000-18-066-L04-P/T
Pharmacist learning objectives:
• Recommend appropriate drugs and biologics for the treatment of unique patients
• Compare and contrast new therapies with existing standards of care
• Recognize common adverse reactions for new therapeutic entities
Pharmacy Technician learning objectives:
• Assist pharmacists in preparing drugs for intravenous administration
• Assist pharmacist in the appropriate storage of medicines
• Alert pharmacist to potential ADRs for evaluation
Beginning January 1, 2019, a schedule II controlled substance that is an opioid in Maricopa, Pima, Pinal, Yavapai, Mohave, and Yuma counties may be dispensed only with an electronic prescription order as prescribed by federal law or regulation. This same requirement becomes effective on July 1, 2019 in Greenlee, La Paz, Graham, Santa Cruz, Gila, Apache, Navajo, Cochise, and Coconino counties.
This is a statutory mandate to all pharmacies receiving Schedule II opioid prescriptions, with the exception of federal facilities (Indian Health Service, Department of Veterans Affairs, and Department of Defense), as they are not subject to state law.
What is EPCS?
EPCS stands for Electronic Prescribing of Controlled Substances and may also be referred to as e-Prescribing of Controlled Substances.
In 2010, the Drug Enforcement Administration (DEA) issued regulations permitting prescribers to enter and send controlled substance prescriptions electronically to pharmacies and enables pharmacies to receive, dispense, and archive electronic prescriptions. In order to be certified, EPCS systems must meet strict DEA requirements for credentialing, software certification, and dual factor authentication.
Electronic prescribing, or “e-Prescribing,” allows pharmacies to securely receive electronic noncontrolled substances prescription information entered by a health care provider using a special software program and connectivity to a transmission network.
EPCS allows pharmacies to receive, dispense, and archive electronic prescriptions for schedule II-V controlled substances. EPCS systems are specialized
systems that must meet strict Drug Enforcement Administration (DEA) requirements for credentialing, software certification, and dual factor authentication.
Is it true that all Arizona pharmacies must be able to receive controlled substance prescriptions electronically?
Beginning January 1, 2019, a schedule II controlled substance that is an opioid in Maricopa, Pima, Pinal, Yavapai, Mohave, and Yuma counties may be dispensed only with an electronic prescription order as prescribed by federal law or regulation. This same requirement becomes effective in Greenlee, La Paz, Graham, Santa Cruz, Gila, Apache, Navajo, Cochise, and Coconino counties on July 1, 2019. This is a statutory mandate to all pharmacies receiving Schedule II opioid prescriptions, with the exception of federal facilities (Indian Health Service, Department of Veterans Affairs, and Department of Defense), as they are not subject to state law.
Is there a waiver for pharmacies that are currently unable to accept electronically submitted Schedule II opioid prescriptions?
Per Arizona Revised Statutes (A.R.S.)§36-2525(Q) the Arizona State Board of Pharmacy has established a process to grant a waiver for accepting controlled electronic prescription submissions to a pharmacy that lacks adequate access to broadband or faces other hardships that prevent the location from implementing electronic prescription orders.
A one-time waiver may be granted and is only meant to give the pharmacy additional time to get set up to be EPCS capable. The waiver will expire one year from the mandated start date for your county.
The waiver application can be found on the Arizona Board of Pharmacy website at https://bit.ly/2UVQhfG.
Is there a deadline for the waiver applications to meet compliance with the mandate?
The deadline for the waiver application for accepting controlled electronic prescription submissions in Maricopa, Pima, Pinal, Yavapai, Mohave, and Yuma counties is December 15, 2018. The deadline for the waiver application for accepting electronic prescription submissions in Greenlee, La Paz, Graham, Santa Cruz,
Gila, Apache, Navajo, Cochise, and Coconino counties is June 15, 2019
Can the waiver be extended?
The waiver is only good for up to one year from the mandated start date for your county. No extensions will be granted. You must be EPCS enabled upon the expiration of the waiver in order to continue dispensing schedule II opioids. If you are in Maricopa, Pima, Pinal, Yavapai, Mohave, or Yuma county, your waiver will expire December 31, 2019. If you are in Greenlee, La Paz, Graham, Santa Cruz, Gila, Apache, Navajo, Cochise, or Coconino county, your waiver will expire June 30, 2020
How will a pharmacy know if a prescriber was approved for a waiver?
A pharmacist is not required to verify with a medical practitioner or the Board whether the medical practitioner has received a waiver approval. For those pharmacists wanting to verify if a waiver has been approved for a prescriber, the Board of Pharmacy will have approved waiver tracking available on the ABOP website at: https://bit.ly/2Cmx7Zh
Updates will be made to the tracking sheet monthly. The
tracking sheet will allow the pharmacist to look up the prescriber by his or her name and/or NPI number. No DEA numbers will be posted.
Do Schedule II opioid prescriptions from out-of-state prescribers need to be electronically submitted?
Prescribers who are not licensed in Arizona are not necessarily required to electronically prescribe schedule II opioid medications. A prescriber must follow his or her state’s laws and regulations.
Can outpatient pharmacies fill handwritten prescriptions from federal facilities?
Yes. Even though a pharmacist is not required to verify with a medical practitioner or the Board whether the medical practitioner has received a waiver approval, the Board of Pharmacy is recommending to prescribers licensed federally to apply for the waiver to help pharmacists that may choose to view the waiver list.
What are the next steps for pharmacies if compliance is not met with becoming EPCS capable?
The Board of Pharmacy will enforce provisions through the opening of and receiving of complaints.
There is expected to be an emergency bill passed to address confusions with the EPCS waivers the first couple weeks of the 2019 legislative session. The Board has received over 40,000 waivers which is causing a lot of confusion with both prescribers and pharmacists. As a result, the new bill will move the deadline to comply with EPCS to January 1, 2020 and July 1, 2021 respectively and there will be no more waivers issued or needed. More information will be sent out by AzPA once the new laws are passed.
By Don. R. McGuire Jr., R.Ph., J.D.
This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.
The pharmacist at Anytown Pharmacy had prepared prescriptions for two pets and placed them in the refrigerator awaiting pickup. When Butch’s owner came in to pick up his prescription, the owner was given another dog’s prescription. Upon administration, the dog became lethargic and Butch’s owner took him to the vet. Unfortunately, Butch’s symptoms couldn’t be reversed and he died as a result of the incorrect drug’s effects. Butch’s owner subsequently made a claim for damages against the pharmacy.
Pharmacists are health care providers because they want to help their patients. This is true whether the patient is human or an animal. The differences in the law for damages as the result of an error should not influence the way that a pharmacist approaches the care that they provide.
As with any aspect of their practices, pharmacists should be well informed of the standards and risks for any activity undertaken.
What damages is Butch’s owner entitled to recover? In the majority of states, pets and other animals are considered personal property. As such, the owner is not entitled to recover damages for emotional pain and suffering or mental anguish, no matter how close the owner is to the pet or how much a part of their family they consider the pet to be. This can make these types of claims difficult to settle because the owner feels that the bond with their pet is not being considered. Under the law, they are correct. The bond with their pet is not compensable.
What is compensable is the market value of the animal and other costs resulting from the incident. These other costs could be the cost of treatment by a vet or in extreme cases, the cost of burial or cremation of the animal. The market value of an animal includes a number of factors, such as the original purchase price, the cost of replacement, and other elements that can enhance the animal’s value. For example, if the animal patient is a prize-winning race horse, the owner would be entitled to recover lost stud fees and other income derived from the horse’s performances. The cost to replace a winning race horse can also be substantial.
The potential vet bills for an injured pet could also be substantial. Because of the bond with their pet, the distraught owner might be willing to try any treatment, even those with only a small chance of success. It would not be unusual for vet bills to exceed the market value of an animal.
Because animals are considered property under the law, some states may have different procedures for these types of claims. States that have damage caps in medical negligence cases may not apply them here. These caps are generally applied to the injured patient’s damages for pain and suffering. Because animal claims are property claims and there are no emotional damages, these caps do not apply. Also, because these claims are property claims, they may not be eligible for the Medical Review Panel process if that is in place in your state. In the Medical Review Panel process, the negligence claim is reviewed and evaluated by a panel of practitioners
before the case can go to court. The case then only goes to court if one of the parties disagrees with the panel’s decision.
Pharmacists may not think much about the financial risks from an animal claim because there are no damages for emotional distress. While this is true, the other exposures can still be significant. Market values for race horses that have died as the result of prescription errors can reach six figure settlements. This can be multiplied if more than one animal is killed or injured. A case in Florida in 2009 resulted in the deaths of 21 polo ponies from a compounded nutritional supplement. A jury awarded the owners of the horses $2.5 million.
Pharmacists are health care providers because they want to help their patients. This is true whether the patient is human or an animal. The differences in the law for damages as the result of an error should not influence the way that a pharmacist approaches the care that they provide. There are groups advocating in several states for changes in these laws to allow for the owner to recover emotional damages. Pharmacists will need to verify the law in their state. All patients deserve the same processes and safeguards. As with any aspect of their practices, pharmacists should be well informed of the standards and risks for any activity undertaken.
© Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.
This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.
Mitchell R. Emerson, PhD Dean, Midwestern University CPG
won and helped raise money for the fraternity, but most importantly we helped educate patients and provide resources for better adherence. I enjoyed leading the process and being a part of that event.
Tell us about your role as the CPG Alumni Council President and the goals of the Council?
Tell us about your most memorable event/class/ experience at MWU?
There are a lot of great memories I have from my time at MWU. One of my favorites was helping to organize the Grassroots Adherence Initiative event for Kappa Psi. The event was a success and led to one of my first opportunities to present a poster, which happened to be an AzPA event. Our initiative
I’m really enjoying my role as the Alumni Council President. I’m lucky to have the opportunity to work with such a fantastic group of professionals on the council. The goal of the council is to foster alumni engagement with the College and University. We brainstorm ways to provide value to our CPG alumni, plan events that appeal to alumni and their families to encourage them to stay involved with each other, future pharmacists and our College. I’ve been extremely encouraged by the attendance and involvement I’ve seen at all the recent alumni events.
Tell us about your career and where you are now?
Since graduation in 2009, I have worked at Mayo Clinic
Hospital. I’ve always been a hard worker, I worked my way up from not matching for a residency to working on a decentralized Hem/Onc/BMT floor, becoming dual board certificated (BCPS and BCOP), to pharmacy Supervisor and now ultimately in the role of Pharmacy Education Supervisor and Residency Program Director. It’s a role I worked extremely hard for that didn’t exist when I started. I really enjoy education, especially working with the students and residents.
Tell us how AzPA have influenced your career?
I have been a member of AzPA since the beginning of my pharmacy career. AzPA has been most influential in my career for networking and connecting with former professors, preceptors, classmates and future pharmacists. Pharmacy is a small world and it’s always wonderful to reconnect or develop a new relationship with likeminded individuals.
Construction on the Skaggs Pharmaceutical Sciences Center at the University of Arizona began in September and progress is underway. After 36 years, the Center critically needed updates to its infrastructure as well as additional space to accommodate new laboratories and interprofessional work space for drug discovery and research. New construction is adding 21,000 square feet of space on two new floors and 12,000 feet of renovated space. The $26M expansion and renovation is funded with the generous support of The ALSAM Foundation, created by L.S. “Sam” Skaggs, the namesake of the building, as well as the University of Arizona and generous donors.
As of early December, construction of the two new floors was well underway, with the foundations of the new structure nearly finished. The new construction will change the footprint of the building on the health sciences campus. The new floors are north of the building and extend over a previous open air walkway. Renovation of existing interior spaces into new labs also began in early December and will continue into the new year.
Construction will take approximately 18 months and the target completion date is early 2020.
Rick G. Schnellmann, PhD Dean, University of Arizona COP—Tucson
Nancy A. Alvarez, PharmD, BCPS, FAPhA, has been named the Associate Dean for the College of Pharmacy Phoenix campus. Dr. Alvarez will be joining the College of Pharmacy in February 2019 and will fill the position currently held by John E. Murphy, PharmD, who is retiring from the College later this year.
Dr. Alvarez is an established national leader in pharmacy. She will be responsible for overseeing all aspects of our Phoenix site, from the PharmD program and students to alumni and community relations. Her experience at the national level will help position the College and she will strategically lead outreach efforts to create awareness in the region about the College and our PharmD program.
Dr. Alvarez is a 1992 graduate of the University of Arizona College of Pharmacy and is a board-certified pharmacotherapy specialist. Prior to joining the UA College of Pharmacy, Dr. Alvarez was a member of the leadership team and assistant professor of pharmacy practice at Chapman University School of Pharmacy in Irvine, CA. She also worked at Endo Health Solutions as Sr. Director, Medical Information; maintained a hospice/palliative care practice with Hospice Pharmacia (now excelleRx); and a community practice with Walgreen’s.
Dr. Alvarez has completed diverse service experiences such as Phi Lambda Sigma National President, inaugural Pharmacy Technician Certification Board Certification Council member and Phi Delta Chi Grand Vice President for Collegiate Affairs. For the American Pharmacists Association, her service ranges from APhA-ASP National Member-at-Large to two terms on the APhA Board of Trustees, and in 2017–18, was the 162nd President. She participates in leader development for the Pharmacy Leadership and Education Institute as a facilitator, content developer and program director. She was named an APhA Fellow in 2004.
Renju Abraham
Anthony M. Albert
Daniel Avery
Jaimee Avery
Raymond M. Barone
Jason Barnes
Donald J. Boles
David Buck
Michael Castillo
Reasol Agustin Chino
Ashley Comstock
Tam Thanh Dao
Monika Debski
Hanh Do
Susan Emmerson
Blanca Guerra
Jessica Guthrie
Cliff Hardesty
Martia Hunt
Omar Jamjoom
Jo-Ann U. Linson
Rebecca Magee
Alicia Newkirk
Maya Patel Ashley Pendrick
Natalie Ann Perkins
Gary Pinkley
Vicki Pohl
Christina Reding
Cara Russo
Edna Sandoval
Bronwyn Simone Smith
Daniel Tetteh
Nina Vadiei
Scott M Waldrop Eric J. YanceyHee Ju
Molly Larson-Wakeman Pooja Patel
Lilian Balyan
Kevin Bekemeyer
Jason Boanca
Alexander Bowman Amber Brandon
Nancy Catalan Carley Ceglio
Juwon Cho Michael Ciurro Ciera Cooley
Anthony Dao Adam Denney
Samuel Duso Caslyn Duval April Graybill
Teresita Holmes Alison Huynh
Robert Kanouse Marquiah Ladd Heather Langer
Angel Malabanan
Adryanna Mercado Felicia Munoz Maria Namou Nicole Nguyen
Miriam Perez
Shaghayegh Pirasteh
Kian Pourkay
Priyanga Radjassegarane
Robert Salinas
Mark Seo
Ranya Shrourou
Essam Soomro
Tiffany Tam
Shriya Thakrar
Cullan Tidwell
John Vardian
Jennifer Ah Rum Yang Tori Zizek
Jana Baum
Jimi Bellina
Lindsay Berger Adilene Betancourt
Debra Cave
Teresa Chairez
Lea Cozzens
Andrea Esquivel Oswaldo Guevara
Laurin Hawkins
Jelina Ip Brenda Jensen
Henry Mendoza Lopez Veronica Ortiz
Shriji Shah Nichole Stark
Siyu Wan Samantha Zimmerman
Sonya Collins
The world is changing rapidly. Disruption is the norm, and technology will continue to advance. Medicines will become more complex. And humans will need humans to provide care. To prepare the profession for new opportunities in the future, APhA is collaboratively advancing multiple puzzle pieces simultaneously to get pharmacists on the health care team—and in the game. It’s time to put all those pieces together and look at the big picture.
Advocacy is at the heart of what pharmacy associations offer. The centerpiece of APhA’s advocacy is the pursuit of consumer access to, and coverage for, pharmacists’ quality patient care services, often referred to as “provider status.” The Pharmacists Provide Care campaign (www.pharmacistsprovide care.com) is central to APhA’s provider status activities and facilitates grassroots advocacy efforts with supporting resources, according to Pharmacy Today in January. As this year ends, APhA continues its multifaceted push for progress on recognition of pharmacists at the state and federal levels and is preparing an advocacy strategy for the new Congress. APhA wants to reiterate its thanks and appreciation to the thousands who reached out to their legislators in 2018 asking for the passage of the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 109) and for related language to be added in opioid legislation. At press time, H.R. 592/S. 109 had 296 cosponsors in the House and 54 cosponsors in the Senate. The lack of passage in this Congress is not indicative of the value of the profession’s efforts nor of APhA’s efforts to inform legislators and the Trump administration of the importance of covering pharmacists’ services. State-level “provider status” encompasses provider designation, scope of practice, and/or payment for pharmacists’ patient care services, wrote Rebecca Snead, RPh, executive vice president and CEO of the National Alliance of State Pharmacy Associations (NASPA), in February. National and state pharmacy associations are working with state and private payers along several avenues.
Reprinted with permission from the Provider Status column in the December 2018 issue of Pharmacy Today (www.pharmacytoday. org). For more information about ways for pharmacists and student pharmacists to follow and influence the profession’s efforts to achieve provider status, access the provider status recognition section of APhA’s website (www.pharmacist.com/ providerstatusrecognition) and APhA’s Pharmacists Provide Care website (PharmacistsProvideCare. com).
Copyright © 2018, American Pharmacists Association. All rights reserved.
continued
Pharmacists need to integrate into new care models. An important tool for increasing patient access to care, collaborative practice agreements create a formal relationship between a pharmacist and a prescriber that allows the prescriber to delegate certain additional patient care functions to the pharmacist, explained Krystalyn K. Weaver, PharmD, NASPA vice president of policy, in March.
The Joint Commission of Pharmacy Practitioners in 2014 released the Pharmacists’ Patient Care Process (PPCP), the profession’s systematic approach for pharmacist provision of care. Consisting of five steps, the PPCP (https:// jcpp.net/patient-care-process/) at its core is the establishment of a patient–pharmacist relationship, with care delivered using a patient-centered approach, wrote Anne Burns, RPh, APhA vice president of professional affairs, in April.
Preparing today’s pharmacy school graduates to practice as a member of the health care team, interprofessional education (IPE) occurs when students from two or more health professions learn together with a goal of collaborating effectively and improving health outcomes, Today wrote in May.
After graduation, postgraduate training helps pharmacists demonstrate an advanced knowledge of topics and equips them to provide patient care, continued the series in June. Pharmacists increasingly are being asked by employers, and required by state boards of pharmacy and payers, to provide an expanding range of patient care services. Meanwhile, as pharmacy practice evolves, it’s becoming more specialized. A broad range of credentialing processes available to pharmacists recognize specialized knowledge and skills, while privileging processes allow employers to verify pharmacists’ qualifications for their patient care role, according to July’s article. APhA is working on several fronts in this area; more information will be released in 2019.
As health care moves toward team-based care and value-based payment, pharmacists need more use of technology for their patient care services. The Pharmacy Health Information Technology (HIT) Collaborative, of which APhA is a founding member, focuses on ensuring that the pharmacist’s role of providing services is integrated into the national HIT infrastructure, according to August’s article.
Value-based models use a team-based approach to care, Today wrote in September and October. To be included, pharmacists should be aware of quality measures and understand how contributing their skills can make an impact. A multispecialty team lets each provider bring something different to the table. Practice research and innovation spark pharmacists’ expanding roles, continued the series in November.
Pharmacists are easy to reach and ready to help. APhA is on a shared mission to improve medication use, advance patient care, and transform and position the pharmacy profession for what lies ahead.
At 62 years old, “Eileen” was finally on the other side of a long history of sexual violence. But the ordeal had left her with both chronic anxiety and chronic pain. To treat it, she took high doses of oxycodone—a medication that isn’t appropriate for the pain caused by trauma-induced nervous system damage. But, because the opioid painkiller relieved her anxiety, Eileen was reluctant to stop taking it.
“That’s part of the trouble with opioids,” said Amy Kennedy, PharmD, a clinical pharmacist at El Rio Community Health Center in Tucson, AZ. “Patients who have that type of pain like the [anxiety-reducing] effects, but it does nothing to improve their long-term function, so they end up on very high doses because the assumption is they just need more.” Kennedy provides pain consultations at El Rio, where she ensures that patients receive the safest, most effective medication for their particular type of pain.
Last year, Arizona saw a 10% increase in drug overdose deaths. Nationwide, drug overdoses overwhelmingly involve opioids. At El Rio, Kennedy helps stem the tide of the epidemic by identifying patients with pain for whom opioids would not be appropriate and recommending a safer, more effective pain regimen.
As valuable as this service is in a country that lost 72,000 people to drug overdoses in 2017, health insurance does not reimburse pharmacists for these consultations. CMS does not recognize pharmacists as health care providers. As a result, they cannot bill most health insurance plans for most of the clinical care they are qualified to provide. Kennedy’s salary at El Rio is instead covered by grant funding that is earmarked for specific services and must be renewed regularly. She can see some pain patients, but until pharmacists have provider status, the clinic can’t expand the much-needed pain consultation program.
When she met with Eileen, Kennedy suggested duloxetine as an alternative to opioids for pain. The SNRI, while marketed to treat depression, addresses anxiety and pain as well. As a medication expert, Kennedy explains the benefits of nonopioid medications to patients who are reticent to give up a well-known pain medication, however ineffective it may be.
“With a drug like duloxetine, patients look up what it’s for and tell me that’s not what they need, so I explain what we know about how this drug works,” she said.
With Kennedy’s counseling, Eileen agreed to stop opioids and try an SNRI. She also started counseling with therapists at El Rio. As Eileen tapered off opioids and transitioned to an SNRI, Kennedy checked in with her regularly by phone. Today, Eileen takes only duloxetine and an occasional Tylenol. “She has two grandkids that she can now play with,” says Kennedy. “And she even has a new relationship, which I never thought would happen.”
El Rio serves 100,000 low-income patients—about one-fifth of Tucson’s population. Kennedy would like to bring a pharmacist’s expertise to the way all these patients are treated for pain. But, until pharmacists can bill for each patient visit, expanding their reach is unsustainable, regardless of the added value.
“Physicians are great diagnosticians, but our health care system isn’t built for them to have time during their patient visits to answer these questions around the nuances of pain medications,” she said. “Pharmacists can help attack the opioid crisis, in addition to all the steps we’ve already taken to restrict the supply chain, through this other avenue, while also providing very effective pain care.”
By: Dennis B. Worthen, PhD, Cincinnati, OH
• “Health Security Act” was introduced in early years of Clinton presidency. Amendments sought to include pharmacists’ services. Bill failed to garner support and was not passed.
• Alejandro Zaffaroni formed ALZA Corporation (the name is the first two letters of his first and last names) to pioneer new technologies for drug delivery leading to the introduction of dermal patch delivery systems.
• Denton Cooley performs the first successful heart transplant in the United States.
• Mary Hunt, known as “Moldy Mary” was a lab technician at the Agricultural Research Station in Peoria, IN in 1943 when she discovered a cantaloupe with a Penicillium chrysogenum strain that was far more productive than earlier strains and was partially responsible for the increased output of penicillin.
• Johnson & Johnson produced sterilized components of CarrelDakin solution which was used to irrigate wounds received in the trenches on the Western Front during WW I. This was the most effective way to fight infection in the pre-antibiotic era.
One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America’s history. Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out: www.aihp.orgAt the completion of this activity, the participant will be able to:
1. Describe the role of each in a comprehensive quality assurance program 2. Describe at least 2 differences between peer review and a systems analysis 3. Compare and contrast the key steps in conducting each type of investigation.
4. List 3 factors to consider when deciding whether to conduct a Systems Analysis investigation 5. Describe the role of the Patient Safety Act in protecting the confidentiality of your investigation.
Target Audience: Pharmacists & Pharmacy Technicians
Credits: CE is 0.5 hour (0.05 CEU)
1. Go to www.GoToCEI.org 2. Log in or create a profile (will not be able to complete CE without a profile) 3. Once logged in, locate and click the light green box labeled “MY PROFILE” 4. This will take you to your dashboard (list of activities still active). Enter the Access Codes(pharmacist or technician) in the “PARTNER CODE” box and press “APPLY”
Pharmacists: 2016RPH Technicians: 2016TECH 5. You will be directed to the Activity Summary, click “CONFIRM” 6. Once you have applied the code, you should be able to complete the activity. It will be in your “TO DO ACTIVITIES” dashboard at the bottom of the page 7. Locate the activity title you wish to complete within your profile and click the Exam 8. Complete the exam and evaluation as prompted, click SUBMIT to send your information to CPE Monitor
Questions? Please contact Christy Lodge at CEI by calling 515-270-8118 or christy@CEImpact.com
Provided by Alliance for Patient Medication Safety – your partner in quality assurance
