North Carolina Pharmacist Volume 104 Number 2

North Carolina Pharmacist Volume 104 Number 2

Advancing Pharmacy. Improving Health.

Look inside for 2023 NCAP Convention Highlights

Official Journal Of The North Carolina Association Of Pharmacists ncpharmacists.org

Call for Articles North Carolina Pharmacist (NCP) is currently accepting articles for publication consideration.

We accept a diverse scope of articles, including but not limited to: original research, quality improvement, medication safety, case reports/case series, reviews, clinical pearls, unique business models, technology, and opinions.

NCP is a peer-reviewed publication intended to inform, educate, and motivate pharmacists, from students to seasoned practitioners, and pharmacy technicians in all areas of pharmacy.

Articles written by students, residents, and new practitioners are welcome. Mentors and preceptors – please consider advising your mentees and students to submit their appropriate written work to NCP for publication.

Don’t miss this opportunity to share your knowledge and experience with the North Carolina pharmacy community by publishing an article in NCP. Click on Guidelines for Authors for information on formatting and article types accepted for review.

For questions, please contact Tina Thornhill, PharmD, FASCP, BCGP, Editor, at tina.h.thornhill@ gmail.com.

North Carolina Pharmacist is the official journal of the North Carolina Association of Pharmacists Located at: 1101 Slater Road, Suite 110 Durham, NC 27703 Phone: (984) 439-1646 Fax: (984) 439-1649 www.ncpharmacists.org

Official Journal of the North Carolina Association of Pharmacists 1101 Slater Road, Suite 110 Durham, NC 27703 Phone: (984) 439-1646 Fax: (984) 439-1649

North Carolina Pharmacist Volume 104 Number 2

www.ncpharmacists.org EDITOR-IN-CHIEF Tina Thornhill LAYOUT/DESIGN Rhonda Horner-Davis

EDITORIAL BOARD MEMBERS Anna Armstrong Jamie Brown Lisa Dinkins Jean Douglas Brock Harris Amy Holmes John Kessler Angela Livingood Bill Taylor

A Few Things Inside • From the President..................................................................................................4 • From the Executive Fellow......................................................................................6

• Resist the Resistance..............................................................................................8 • Attitudes and Perceptions.....................................................................................15

• Utilization of Pharmacists....................................................................................23 • Impact of a Five-Part Certificate Program..............................................................28

• PGY1 Community-Based Pharmacy Residency...................................................36

BOARD OF DIRECTORS

• Convention Highlights........................................................................................41

EXECUTIVE DIRECTOR Penny Shelton

• Legislative News.................................................................................................61

PRESIDENT Ouita Gatton PRESIDENT-ELECT Bob Granko PAST PRESIDENT Matthew Kelm TREASURER Ryan Mills

• 2023 Poster Abstracts..........................................................................................50

North Carolina Pharmacist is supported in part by: • Edupharmtech .........................................................................................6

• Alliance for Patient Medication Safety ...................................................6 • Pharmacy Technician Certification Board (PTCB) ..............................14

SECRETARY Beth Caveness

• Pharmacy Quality Commitment............................................................22

Madison Wilson, Chair, SPF Anita Yang, Chair, NPF Katie Trotta, Chair, Community Jeff Reichard, Chair, Health-System Dave Phillips, Chair, Chronic Care Andy Warren, Chair, Ambulatory Riley Bowers, At-Large Elizabeth Locklear, At-Large Macary Weck Marciniak, At-Large

• Pharmacists Mutual Companies ...........................................................35

North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists.

An electronic version is published quarterly. The journal is provided to NCAP members through allocation of annual dues. Opinions expressed in North Carolina Pharmacist are not necessarily official positions or policies of the Association. Publication of an advertisement does not represent an endorsement. Nothing in this publication may be reproduced in any manner, either whole or in part, without specific written permission of the publisher.

• NCAP Career Center ............................................................................27

• Working Advantage...............................................................................60

Convention Sponsorship Ads: • Pfizer .......................................................................................................7 • Founders Wellness ................................................................................13 CORRECTIONS AND ADVERTISING For rates and deadline information, please contact Rhonda Horner-Davis at rhonda@ncpharmacists.org

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•From the President• Ouita Gatton, R.Ph.

Pharmacists Represented Well On Legislative Day 2023

Happy Summer, Everyone!

The time began as a practically perfect spring day in downtown Raleigh. The sun was bright, the sky nearly cloudless, and the temperature delightful for the beginning of a robust time in the North Carolina legislature on behalf of the pharmacy profession. Traveling from the mountains, coast, and many places in between, over 90 pharmacists, pharmacy technicians, pharmacy students, NCAP board members, and leadership flooded the legislative halls on Jones Street in Raleigh on April 19 this year to provide a united voice centered on expanded collaborative practice, immunization authority, and appropriate reimbursement for pharmacy services.

To prepare for the legislative invasion, all attendees were asked to attend an NCAP-hosted webinar on the Thursday before the legislative day. Penny Shelton, NCAP Executive Director, provided detailed information on all the bills NCAP had in play at the time. She also reviewed the talking points document NCAP created to direct any conversations that were had with legislators. Those who attended the training were also

provided an easy navigation tool to determine their own senator and representative for their local areas.

the day was when Representative Wayne Sasser shared progress and hopes surrounding the various bills that will benefit pharmacy. He was particularly focused On legislative day, strategy ses- on the passage of bills related to sions were held by team leaders transparency and fair reimburseand their assigned group mem- ment for pharmacy services. bers prior to visits with legislators. A debt of gratitude goes to The PLD attendees were well-repTony Solari, Debra Conrad, Mike resented by all four pharmacy James, Bobby Rawls, Ritesh Pa- schools. Future pharmacists from tel, Penny Shelton, and Michelle UNC, Wingate, High Point, and Fritsch, who served as the team Campbell were learning how to leaders for these groups. NCAP advocate for the profession early lobbyists Tony and Debra, as well in their careers. High Point Unias Penny and other key state lead- versity surprised everyone when ers, prepared the best strategies a purple and white bus arrived, to share with each unique phar- carrying their student pharmamacy team ahead of time. This cists, eager and ready to learn. advanced readiness enabled conversations much easier to nav- PLD 2023 set up great momenigate the often-misunderstood tum toward much success for our world of pharmacy for the legis- profession in this North Carolina lators. Profession advocates vis- lawmaker assembly. Fortunately, ited committee meetings, thanked NCAP is a healthy organization bill sponsors on both sides of the with strong leadership. But it political aisle, and echoed each takes dollars from many pockets other in their common messages to ensure appropriate candidates once engagement began. that understand pharmacy are on ballots and elected. Because The date of the legislative day Wayne Sasser is a pharmacist, was timely. Members had just he serves not only in his legislareturned from the General As- tive capacity but as an advisor to sembly’s spring break; the energy many of his non-pharmacy colwas high, and their attention was leagues that serve alongside him focused on pharmacy legislative in both chambers. He told our day (PLD) attendees who sought group he cannot serve forever; an appointment. A highlight of he encouraged the untried in the Page 4

room to think about running to fill his shoes. He also challenged us to think about how we currently support candidates and issues pertinent to pharmacy.

NCAP has always had a fund that focuses on raising money solely dedicated to advocacy efforts.

Never has funding been more important than these last several years of successful advocacy efforts on behalf of North Carolina pharmacy. There now exists a convenient way for NCAP members and non-members to give to support this advocacy fund. While most other NCAP fund-raising efforts do not allow businesses to contribute, businesses can give to the NCAP Advocacy Fund.

Upcoming Events

More events to watch for:

Mark your calendars for the following upcoming events and continuing education opportunities.

Visit the NCAP website, www.ncpharmacists.org, often for details as they are confirmed and to register for these events.

Sunday Evening Webinars for the remainder of 2023

9:00 am to 3:00 pm Novant Health Conference Center Winston-Salem, NC Details and Registration

If you are not a member of NCAP, please join today! If we do not advocate for ourselves, no one else will. No one tells our story as well as we do!

Friday, October 27, 2023

Ouita

Introducing the New NCAP Executive Fellow

Friday, July 21, 2023

This year’s goal is to raise $10,000 to help fund our grassroots work and help with the cost of NCAP’s lobbyists. It is very easy to give. Simply text “Give2NCAP” to (202) 8581233 or give directly to the NCAP website (www.ncpharmacists.org); click on ‘Donate to NCAP Advocacy Fund’ under the ‘Advocacy’ tab on the home page to make a one-time donation or to pledge a sustaining donation.

Let’s meet this monetary goal this year!

Until next time…

2023 Student Pharmacist Conference

2023 NCAP Residency Conference

Sunday, July 30, 2023 July Sunday Evening Webinar 6:00 pm to 7:00 pm Live Webinar Details and Registration

25th Annual Anti-Infective Conference 8:30 am to 3:30 pm Greensboro Country Club Greensboro, NC Details Coming Soon Page 5

Jennifer Plair, PharmD, MSPH, will begin her Executive Fellowship with NCAP on July 10, 2023. Dr. Plair is from Hampton, Virginia. She earned a BS in Biology from Saint Augustine’s University in Raleigh, NC, completed a Masters Degree in Public Health from Campbell University, and recently graduated from East Tennessee State University with her Doctor of Pharmacy degree. She has an interest in pharmacy management, community pharmacy, and pharmacy practice advancement.

She looks forward to transitioning to North Carolina and joining the NCAP team.

•From the Executive Fellow• Megan Witkowski, PharmD, MSPH

A Farewell from NCAP’s First Executive Fellow

As my time as the Executive Fellow with NCAP comes to an end, I take this opportunity to reflect on the incredible experiences and growth I have gained during this transformative journey over the past two years. Being NCAP’s first Executive Fellow came with its fair share of challenges. There was no one before me to lay out the blueprints or to model the path forward. At times, it was difficult, but looking back, I am filled with gratitude for the chance to forge my own way.

My fellowship with NCAP provided me with the platform to excel, collaborate, and advocate for the advancement of pharmacy practice in North Carolina. I learned from and worked closely with pharmacy leaders from across the state. Not only was this invaluable to my professional pursuits, but it has also been instrumental in helping me develop my skills and grow as an individual. This immense personal growth was unexpected for me. I owe many thanks to the mentors for the guidance I have received, which has profoundly influenced my development as a pharmacist and a leader.

One of my primary responsibilities during my fellowship involved acting as the Managing Network Facilitator for the CPESN North Carolina network. This position allowed me to work alongside passionate independent pharmacists from our state and around the country who are constantly pushing our profession forward by practicing in new and innovative ways. This experience taught me many things about leadership, project management, and implementation, but above all, it showed me the boundless potential we possess when we unite in pursuit of a common purpose.

As I embark on the next chapter of my career, I carry with me the lessons learned, the passion ignited, and the commitment to making a meaningful impact in the field of pharmacy. I am proud to have been an NCAP Executive Fellow and will forever cherish the memories and experiences that have shaped my journey.

Thank you, NCAP, for this remarkable opportunity and for the lasting impact you have made on my professional life. Farewell (for now) with heartfelt gratitude and anticipation for the bright future that lies ahead.

Megan

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Resist the Resistance: A Summary of the IDSA Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections By: Dr. Joseph T. Martinez, PharmD Introduction Clinicians and researchers have observed a continual rise in antimicrobial resistance (AMR). In collaboration with other international agencies, the World Health Organization (WHO) offers estimations about the health and economic cost of the current resistance trajectory. Drug-resistant infections and diseases may cause ten million deaths annually by 2050, damaging the economy and livelihood of millions worldwide.1

two versions of the Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections in March 2022. Version 1.0 covers infections caused by extended-spectrum β-lactamaseproducing enterobacterales (ESBL-E), carbapenem-resistant enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTRPA). Version 2.0 covers infections caused by AmpC β-lactamaseproducing Enterobacterales (AmpC-E), carbapenem-resistant Acinetobacter baumannii species (CRAB), and Stenotrophomonas maltophilia.2 This document reviews Version 1.0, with these infections designated as urgent or serious threats by the Centers for Disease Control and Prevention.3 This review discusses the resistant pathogens of concern, the approach to treatment, current resistance to novel treatment, and approaches to reduce/delay resistance to therapy.

To address this concern in a timely manner, the Infectious Diseases Society of America (IDSA) sought to provide guidance on the rapidly changing treatment of resistant infections. Due to the time it takes to develop a treatment guideline and the timeliness of this issue, the IDSA instead provided a focused update on difficult-to-treat infections. As a result, a comprehensive review was developed, mainly composed of clinical experience and expert opinion, to guide decision-making and to Resistant Pathogens provide an annual update.

ESBL-Es are gram-negative bacteria that are resistant to most The IDSA, in addressing a few se- β-lactams. Resistance occurs by lect types of infections, released opening the cyclic amide backPage 8

bone of most penicillin, cephalosporins, and aztreonam. This resistance is commonly found in Escherichia coli, Klebsiella spp, and Proteus mirabilis. Although not considered a first-line treatment, most carbapenems show activity against ESBL-Es. Testing for this resistance is not routine; ceftriaxone susceptibility with a minimum inhibitory concentration of ≥2mg/L is often used as a proxy for ESBL production. However, the high rates of false positives due to the high sensitivity and low specificity of this method should caution healthcare providers.4,5

CREs present with resistance to at least one carbapenem or produce a carbapenemase, a type of β-lactamase that is effective in opening the β-lactam ring of a carbapenem. These examples include Klebsiella pneumoniae carbapenemase (KPC) and Metallo-β-lactamases (MBL). Oxacillinases (OXA), another type of β-lactamase, have also shown resistance to carbapenems. In addition to the opening of the cyclic amide ring, CREs maintain resistance through the disruption of outer membrane

porins, preventing the entry of The duration of each medication antibiotics into the bacterium is provided in Tables 1-3.6 through passive diffusion.

If able, the most effective agents DTR-PA is a more significant form should be preserved to delay resisof resistance than is typically seen tance and maintain their effectivewith P. aeruginosa. A difference is ness for future use. These agents noted between DTR and multi- include carbapenems and the drug resistance, which is resis- novel β-lactams (ceftolozane-tatance to at least one antibiotic in zobactam, ceftazidime-avibactam, ≥3 of the following drug classes; and imipenem-cilastatin-relebacpenicillins, cephalosporins, fluo- tam). Additionally, fluoroquinoloroquinolones, aminoglycosides, nes should be limited to preserve and carbapenems. DTR is defined their efficacy and avoid toxicities as resistance to piperacillin-ta- such as QT prolongation, C. diffizobactam, ceftazidime, cefepime, cile infections, tendonitis/tendon aztreonam, meropenem, imipen- rupture, seizures, and peripheral em-cilastatin, ciprofloxacin, and neuropathy. Finally, combination levofloxacin. This occurs through therapy should be avoided due to multiple mechanisms: decreased the greater risk of toxicity withexpression of outer membrane out improvement of outcomes. porins, excess AmpC cephalospo- Exceptions to this include empiric rinases, excess efflux pumps, and treatment, tetracycline regimens, mutations in the penicillin-bind- and non-urinary alternatives for CRE. ing proteins.

Treatment Approach Many considerations are universal for all three types of infections.

First, susceptibility testing must be performed to direct therapy, along with consideration for the recommended agents for each infection. This should be repeated if the patient does not improve or worsens. The exception to this rule is if a CRE organism tests positive for carbapenemases, no carbapenem should be given, even if they are found susceptible.

Uncomplicated Cystitis The first-line agents from the IDSA 2010 guideline on uncomplicated cystitis may be considered if susceptibility is found, except in the case of P. aeruginosa (Table 1).7 Fluoroquinolones may be considered for CRE as firstline options. If a patient resists ertapenem, standard infusion meropenem can be used; CRE resistance to one carbapenem does not correlate with all carbapenems. However, they should not be used if carbapenemase testing Second, the duration of treatment is positive, regardless of suscepvaries based on the type of infec- tibility results. Single-dose amition, patient sex, and agent. The noglycosides are effective while total time should include empiric reducing the risk of toxicity from and narrowed regimens, includ- prolonged use. ing a change from intravenous to oral therapy. The clinical re- Complicated UTIs and Pyelonesponse must be considered when phritis deciding if a range is provided. For the progression to complicatPage 9

ed infections, the IDSA guidance recommends the earlier introduction of more-effective agents compared to cystitis (Table 2).7 Many of these options can include a combination of parenteral and oral therapy if a transition is appropriate. Compared to the cystitis recommendations, once-daily (not single-dose) aminoglycosides may be used with proper renal, otic, and neurotoxicity monitoring. Extended infusion meropenem (not standard) may be used for ertapenem resistance if carbapenemase testing is unknown or negative. Fosfomycin may still be used for E. coli prostatitis; fosfomycin is not recommended for other complicated infections, even in confirmed E. coli patients.

Although not listed as guidance recommended options, piperacillin-tazobactam, and cefepime may be continued if used empirically and the patient improves.

There is no need to change or extend therapy for these two medications. However, neither agent is recommended outside of the urinary tract due to decreased efficacy, even if susceptibility is found; other agents would be preferred.

Non-Urinary Infections Carbapenems are first-line agents for all three types of infections, with a β-lactamase inhibitor used in combination to treat CRE and DTR-PA (Table 3).

In the case of CRE, determining the kind of carbapenemase resistance that is present (if any) can help to guide therapy. KPC-producing or ertapenem/meropenem-resistant CRE may be treated with ceftazidime-avibactam, meropenem-vaborbactam, or

imipenem-cilastatin-relebactam. MBL-producing CRE may be treated with ceftazidime-avibactam plus aztreonam or cefiderocol monotherapy. OXA-48-producing CRE may be treated with ceftazidime-avibactam or cefiderocol.

Tetracyclines (tigecycline and eravacycline) may be used with other agents as an alternative to β-lactams. Standard doses may be used for intra-abdominal infections, with other infections being considered at high doses.

Polymyxins and aminoglycosides should be avoided due to the risk of toxicity. Inhaled antibiotics are not recommended due to the risk of bronchoconstriction and no outcome/survival benefit.

bactam in isolates previously susceptible to both medications without exposure to ceftazidime-avibactam.9

Approaches to prevent or delay resistance to the novel β-lactams have been suggested. First, prevention of infection and source 3. control has been shown to be effective across all types of infections. Next, the use of suscep4. tibility testing and repeating as needed is recommended to guide therapy. Pharmacists can play an influential role by providing recommendations to maintain 5. the effectiveness of these agents, whether their role is focused on infectious disease or not.

Conclusion 6.

AMR will continue to challenge healthcare providers for years to come. This will require diligence to stay up to date on the evi- 7. denced-based guidance and expert opinion to direct treatment plans. Combining the current evidence, the use of susceptibility testing, and preserving the most effective agents, pharmacists can play a vital role in reducing antibiotic resistance rates to improve patient outcomes.

Emergence of Resistance to Novel β-lactams Despite antimicrobial stewardship efforts, resistance has been documented in some of the newest agents available. Currently, ceftolozane-avibactam and ceftazidime-avibactam are the most concerning. One of the potential factors is that ceftazidime-avibactam was the first FDA-approved novel β-lactam for CRE, which led to its extensive use before other medications became available.

However, resistance will begin to Author: Joseph T. Martinez, 8. develop more with other treat- PharmD, is a PGY1 Community-Based Pharmacy Resident at ments the longer they are used.

Walgreens Pharmacy and an AdTo illustrate this, ceftazidime-avi- junct Clinical Instructor at Campbactam has been shown to have bell University in Buies Creek, NC. 20% resistance after clinical ex- jmartinez@campbell.edu 9. posure to CRE.8 Additionally, ceftolozane-avibactam has shown up to 50% resistance after clinical References 1. New report calls for urgent action to exposure to DTR-PA. There has avert antimicrobial resistance crisis. also been documented resistance World Health Organization. Apr 29 2019. to ceftazidime-avibactam (80%) 2.

Tamma PD, Aitken SL, Bonomo RA, after exposure to ceftolozane-aviPage 10

et al. Infectious Diseases Society of America 2022 Guidance on the Treatment of Extended-Spectrum β-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa). Clin Infect Dis. 2022 Aug 25;75(2):187-212.

Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2019, 2019.

Villegas MV, Esparza G, Reyes J. Should ceftriaxone-resistant Enterobacterales be tested for ESBLs? A PRO/CON debate. JAC Antimicrob Resist. 2021 May 7;3(2):dlab035.

Tamma PD, Humphries RM. PRO: Testing for ESBL production is necessary for ceftriaxone-non-susceptible Enterobacterales: perfect should not be the enemy of progress.

JAC Antimicrob Resist. 2021 May 7;3(2):dlab019.

Lexicomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc. https://online.lexi.com. Accessed May 5, 2023.

Gupta K, Hooton TM, Naber KG, et al.

Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e10320.

Karaiskos I, Daikos GL, Gkoufa A, et al. Hellenic Ceftazidime/Avibactam Registry Study Group. Ceftazidime/ avibactam in the era of carbapenemase-producing Klebsiella pneumoniae: experience from a national registry study. J Antimicrob Chemother. 2021 Feb 11;76(3):775-783.

Rubio AM, Kline EG, Jones CE, et al. In Vitro Susceptibility of MultidrugResistant Pseudomonas aeruginosa following Treatment-Emergent Resistance to Ceftolozane-Tazobactam. Antimicrob Agents Chemother.

2021 May 18;65(6):e00084-21.

Table 1: Uncomplicated Cystitis Treatment Recommendations 2

1st line

ESBL-E

Nitrofurantoin Monohydrate/macrocrystals: 100mg twice daily Macrocrystals: 50-100mg every six hours Duration: 5 days (females); 7 days (males) Sulfamethoxazole-trimethoprim 800mg-160mg twice daily Duration: 3 days (females); 7 days (males)

Fosfomycin* 3g single dose Single-dose aminoglycoside Ceftazidime-avibactam 2.5g every 8 hours Duration: 5-14 days

Nitrofurantoin Sulfamethoxazole-trimethoprim

CRE

Alternative

Amoxicillin-clavulanate 500mg-125mg twice daily Duration: 5-7 days

Ciprofloxacin Immediate release: 250mg every 12 hours Extended-release: 500mg every 24 hours Duration: 3 days (females); 5 days (males) Levofloxacin 250mg once daily Duration: 3 days (females); 5 days (males) Single-dose aminoglycoside

Meropenem-vaborbactam 4g every 8 hours Duration 5-14 days Imipenem-cilastatin-relebactam 1.25g every 6 hours Duration: 5-14 days Cefiderocol 2g every 8 hours Duration: 5-14 days Colistin (Polymyxin E) 300mg CBA loading dose, then 150-180mg CBA twice daily starting 12 hours later

Ceftolozane-tazobactam 1.5g every 8 hours Duration: 5-14 days

DTR-PA

Ceftazidime-avibactam

Colistin (Polymyxin E)

Imipenem-cilastatin-relebactam Cefiderocol

Single-dose aminoglycoside *E. Coli only Abbreviations: ESBL-E, extended-spectrum β-lactamase-producing enterobacterales; mg, milligrams; g, grams; CRE, carbapenemase-producing enterobacterales; CBA, colistin base activity; DTR-PA, Pseudomonas aeruginosa with difficult-to-treat resistance.

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Table 2: Pyelonephritis and Complicated Urinary Tract Infection Treatment Recommendations 2 1st Line Alternative Sulfamethoxazole-trimethoprim 800mg-160mg twice daily Duration: 14 days Ertapenem 1g once daily Duration: 5-14 days Meropenem 1g every 8 hours Duration: 5-14 days

ESBL-E

Imipenem-cilastatin 500mg every 6 hours Duration: 5-14 days

Once-daily aminoglycoside

Ciprofloxacin Oral immediate release: 500mg every 12 hours Oral extended release: 1g every 12 hours Intravenous: 400mg every 12 hours Duration: 5-7 days Levofloxacin 750mg once daily Duration: 5-7 days Ceftazidime-avibactam Meropenem-vaborbactam

Sulfamethoxazole-trimethoprim

CRE

Imipenem-cilastatin-relebactam

Ciprofloxacin

Cefiderocol

Levofloxacin

Once-daily aminoglycoside Ceftolozane-tazobactam Ceftazidime-avibactam

DTR-PA

Once-daily aminoglycoside

Imipenem-cilastatin-relebactam Cefiderocol

Abbreviations: ESBL-E, extended-spectrum β-lactamase-producing enterobacterales; mg, milligrams; g, grams; CRE, carbapenemase-producing enterobacterales; DTR-PA, Pseudomonas aeruginosa with difficult-to-treat resistance.

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Table 3: Non-Urinary Infection Treatment Recommendations2 1st Line

Alternatives

Carbapenems

ESBL-E

Step down to oral fluoroquinolone or sulfamethoxazole-trimethoprim

Not applicable

Extended-infusion meropenem 1-2g over 3 hours every 8 hours (may give loading dose over 30 minutes)

CRE

Ceftazidime-avibactam

Ceftazidime-avibactam plus aztreonam Aztreonam: 1-2g every 6-8 hours, depending on the location

Meropenem-vaborbactam

Cefiderocol

Imipenem-cilastatin-relebactam Ceftolozane-tazobactam

DTR-PA

Ceftazidime-avibactam Imipenem-cilastatinrelebactam

Cefiderocol

Abbreviations: ESBL-E, extended-spectrum β-lactamase-producing enterobacterales; CRE, carbapenemase-producing enterobacterales; g, grams; DTR-PA, Pseudomonas aeruginosa with difficult-to-treat resistance.

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Attitudes and Perceptions Towards COVID-19 Vaccine Uptake Among Pharmacy Students By: Dr. Edward T. Chiyaka, Dr. Carrie L. Griffiths, and Dr. Andrew J. Woods Abstract Introduction: Pharmacists are essential to patients’ systems for managing their medications and can also provide vaccine recommendations and counsel vaccine-hesitant patients. During the COVID-19 public health emergency, all frontline healthcare workers were mandated to get vaccinated; however, not all were fully vaccinated. This study evaluated COVID-19 vaccine hesitancy, uptake, and perceptions among pharmacy students.

Methods: Pharmacy students from three private pharmacy schools in the United States were invited to participate in an anonymous online cross-sectional survey distributed using QualtricsXM to answer questions about their attitudes and perceptions toward the COVID-19 vaccine.

Results: There were 182 respondents. Among them, 87% had received at least one dose of either Moderna, Pfizer-BioNTech, or Johnson & Johnson’s Janssen vaccine, and 13% had not been vaccinated or were vaccine-hesitant. The vaccine-hesitant group was likely to cite vaccine side effects (61%) and religious beliefs (30%) as some of the reasons for not getting vaccinated. Furthermore, 65% of the hesitant group were extremely unlikely to consider taking the vaccine even if it received full approval from the Food and Drug Administration.

Conclusion: Most pharmacy students have already received the COVID-19 vaccine, but there is a significant proportion who have not been vaccinated, citing concerns about effectiveness, side effects, and religious beliefs. Given the expanded role of pharmacists in patient care and their potential influence in improving vaccine uptake in their communities, there is a need to improve vaccine uptake among

them.

Keywords: COVID-19, pharmacy students, vaccine hesitancy, vaccine uptake, COVID-19 vaccine Introduction Pharmacists play a significant role in the drug therapy management framework of patients.1 In addition to processing prescriptions and providing patient care activities, pharmacists in the community, hospital, ambulatory, and managed care settings may also offer outreach or additional services to prescribers and patients. While pharmacists had previously provided vaccines in select states, their roles were expanded during the COVID-19 public health emergency, including giving the COVID-19 vaccination.2 This means that pharmacists, like other healthcare providers, can also provide vaccine recommendations, vaccinate patients, and counsel vaccine-hesitant patients. According to research on vaccine acceptance among healthcare workers, the propensity of healthcare workers to recommend COVID-19 vaccination to their patients was found to be positively correlated with their vaccination rates3. Additionally, studies have demonstrated that the involvement of pharmacists in administering immunizations has improved vaccination rates.4-6

Vaccine hesitancy is one of the significant barriers to COVID-19 vaccine uptake, as identified by the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC).7,8 While all frontline healthcare providers have been prioritized, and many are being mandated to get vaccinated, not all have been fully vaccinated. The literature has evaluated vaccine uptake in college students and medical and dental students but not pharmacy

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students.9-13 The purpose of this study was to assess other survey questions, such as frequencies and perCOVID-19 vaccine hesitancy, uptake, and percep- centages. The items on the Likert scale were reclassified as strongly disagree or disagree and strongly tions among pharmacy students. agree or agree. Proportions of vaccine hesitancy and vaccine acceptance were computed and compared.

Methods Chi-square tests were used to identify statistically A cross-sectional study was conducted among phar- significant differences between the vaccine-hesitant macy students from private pharmacy schools in and vaccine-acceptance groups on various survey North Carolina from September 27 to November 2, items. Statistical significance was established at an 2021. The anonymous online survey was distributed alpha of p < 0.05. to potential participants via email using QualtricsXM. Informed consent was obtained before the respon- Results dent entered the survey. The University’s Institu- A total of 182 pharmacy students completed the survey, a 19% response rate. Most of the participants tional Review Board approved the study protocol. were: females (79.7%), white (72.5%), and aged between 18 – 24 years (60.4%) (Table 1). There was a Survey Instrument Survey items were developed based on research on similar distribution of participants across years in attitudes and perceptions toward the COVID-19 vac- pharmacy school (22% to 28.6%). About 87% of the cine for different health professions.9,10,14 Most of the participants received at least one dose of Moderna, questions came from the Vaccine Confidence Survey Pfizer-BioNTech, or Johnson & Johnson’s Janssen Question Bank, which contains CDC’s recommend- vaccine. Among the vaccinated, approximately 16% ed COVID-19 vaccine confidence and uptake sur- indicated that they got vaccinated because their vey items.15 Authors made some adjustments and school mandated vaccination, while the other 84% added more questions to the validated templates had been voluntarily vaccinated. Statistically signifto adequately examine the identified themes. The icant differences in vaccine hesitancy were found survey assessed different factors, including partici- based on sex and year in pharmacy school (p-values pants’ personal vaccine behavior; general attitudes .022 and .046, respectively). We observed the highand perception towards COVID-19 vaccines; current est prevalence of COVID-19 vaccine hesitancy among knowledge about COVID-19 vaccines; the perceived female students (60.9%) and students in their first likelihood of COVID-19 infection; personal experi- year of pharmacy school (43.5%) compared to their ence with COVID-19 as well as demographic factors corresponding groups. such as age, sex, race, and year of study. We assessed vaccine uptake and hesitancy for the COVID-19 vac- About 13% of the participants had not been vaccine with the question, “The U.S. Food and Drug Ad- cinated at the time of survey completion. Among ministration (FDA) issued an emergency use autho- these, approximately 65% indicated they were exrization (EUA) for three vaccines, Pfizer-BioNTech, tremely unlikely to consider taking the vaccine even Moderna, and Johnson & Johnson’s Janssen in the if it received full approval from the FDA. Only 17.4% United States to prevent COVID-19. Have you been were somewhat likely or extremely likely to receive vaccinated using any of the three vaccines? (Select the vaccine after full approval. Also, about 61% of yes if you have received at least one dose)”. Partici- the vaccine-hesitant group indicated that they were pants who responded “no” were asked the following concerned about the vaccine’s side effects as the reaquestion: “The Pfizer COVID‐19 vaccine has received son for not getting vaccinated; 30% cited religious full approval from the FDA. If you were offered the beliefs as the reason for not getting vaccinated. Not enough long-term studies assessing side effects and Pfizer vaccine, how likely are you to take it?” fertility issues were cited by the vaccine-hesitant group as some of the most concerning issues about Data Analysis Data were analyzed using IBM SPSS Statistics for the COVID-19 vaccines.

Windows, version 26 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics were used to describe Fewer participants agreed to have experience with the study participants’ demographic features and COVID-19. About 10% of the participants indicated Page 16

they had a COVID-19 infection, while nearly a quarter had cared for someone who had a COVID-19 infection at some point. Only two-thirds (59.9%) had personally known someone with a COVID-19 infection. Most participants agreed that they were likely to be exposed to COVID-19 as future pharmacists, and they considered the COVID-19 vaccination important as healthcare providers (Table 2).

The majority of the pharmacy students (87.9%) agreed that vaccines are essential for them to stay healthy as future pharmacists; the development of a COVID-19 vaccine is important to decrease the spread of the disease (80.8%); and COVID-19 vaccination is important for the overall public health of our communities (81.9%). However, fewer pharmacy students agreed that COVID-19 vaccination should be mandatory for all healthcare providers (58.5%) and the general public (38.5%). Among those unwilling to take the vaccine, only 4.3% agreed that the COVID-19 vaccination should be mandatory for healthcare providers and the public.

Interestingly, of those hesitant to vaccinate, more than 78% indicated that they planned on getting the influenza vaccine this season. Furthermore, less than 30% of the vaccine-hesitant group indicated that they would be motivated to receive a COVID-19 vaccination to protect the health of family/friends, the health of coworkers, or the health of the community. Only 30.4% of this group indicated they would be motivated to receive a COVID-19 vaccine to protect their health.

and social networks.16-19 The current study evaluated the attitudes and perceptions towards COVID-19 vaccine uptake among pharmacy students from three private pharmacy schools in North Carolina.

Despite most respondents acknowledging an inherent increased risk of contracting SARS-CoV-2 because of providing direct patient care, 13% of participating pharmacy students reported COVID-19 vaccine hesitancy/refusal. Our study found a lower rate of COVID-19 vaccination hesitancy/refusal among pharmacy students than previously reported rates of COVID-19 vaccine hesitancy/refusal among nursing, medical, and dental students in the United States, which varied from 21.6 percent to 44.5 percent.9,10,20,21 A global study of COVID-19 vaccination hesitancy among students or trainees in healthcare professions revealed an average of 19 percent vaccine hesitancy rate.22 While the vaccine hesitancy rate from our study is lower than previously reported vaccine hesitancy rates for other healthcare professionals, the findings are particularly concerning because pharmacists are widely regarded as the most influential healthcare workers and key sources of vaccine information for patients and caregivers.

Similar to published data regarding vaccine hesitancy among healthcare professionals and students, our results suggest pharmacy students who are younger in age or female are more hesitant to accept a COVID-19 vaccination.3,9,23-25 Contrary to similar published studies, our results indicate that non-Hispanic white pharmacy students are less accepting of a COVID-19 vaccination than their minority counterparts.23 Each pharmacy school involved in this study offered free COVID-19 vaccination on campus, thereby minimizing or eliminating barriers to COVID-19 vaccination access within their respective student populations, unlike the general population.

Thus, lack of access did not factor in receiving the COVID-19 vaccine.

In the bivariate analyses, students in the vaccine acceptance group were statistically significantly different (p < .05) compared to those in the vaccine-hesitant group on most of the survey items except for the following items: I had COVID-19 infection; I cared for someone with COVID-19 infection; and I personally know someone who has died from COVID-19 infection. Also, no statistical differences between the vaccine acceptance and vaccine-hesiCOVID-19 vaccination hesitancy data published tant groups were observed by age and race. before or in the early stages of the widespread availability of the vaccines indicate that safety and Discussion As trusted healthcare providers, pharmacists’ potential adverse effects were at the crux of healthunderstanding and acceptance of vaccination care worker and student disinclination. Almost against SARS-CoV-2 is paramount in combating the 90% of pharmacy students expressing vaccinaCOVID-19 pandemic. Healthcare providers are the tion hesitancy in our study noted general concern principal source of vaccine information and directly about COVID-19 vaccination safety and adverse efinfluence the vaccination decisions of their patients fects approximately a year after vaccinations were Page 17

made available to healthcare providers. Similar to previously reported data, participating pharmacy students identifying as female indicated concerns about the COVID-19 vaccination’s potential impact on fertility. These findings add to the need to continue assessing the long-term effects of COVID-19 vaccinations, specifically in women of childbearing age. A surprising proportion of vaccine-hesitant respondents cited insufficient evidence for vaccine efficacy, a somewhat concerning finding given that the survey population expected to have a basic understanding of scientific evidence generation. This result suggests that perhaps greater emphasis related to the analysis of medical literature is warranted within pharmacy curricula.

First-year pharmacy students were significantly less likely to accept a COVID-19 vaccination when compared to second, third-, and fourth-year pharmacy students. This finding correlates to other published studies indicating that less healthcare education and experience increases the likelihood of vaccine hesitancy or refusal.3,24-26 Healthcare professionals entering practice in the past decade are more likely to lack sufficient vaccine-related knowledge and thus certainty in initiating and leading vaccine-related conversations with patients.14,27,28 A lack of vaccine-related understanding and confidence in navigating discussions with other providers and patients related to vaccination could translate to decreased vaccine uptake within the communities pharmacists serve. Pharmacy students receive immunization education and training through pharmacy curricula.

As a result, pharmacy students demonstrate better than average vaccine-related knowledge than other healthcare professional students.14 Over 78% of pharmacy students in the vaccine-hesitant group and about 90% of all respondents stated they plan on receiving the flu vaccine this season. However, enhanced educational opportunities exist throughout pharmacy curricula – certainly regarding the use of mRNA-based vaccinations considering the advent of their efficacy. Research on vaccine acceptance among healthcare workers has revealed that the propensity of healthcare workers to recommend COVID-19 vaccination to their patients was positively correlated with their vaccination rates.3 Therefore, promoting vaccination uptake among healthcare providers has been suggested to increase vaccine uptake in patients. While the COVID-19 pandemic

continues to slow, our study findings may indicate future behavior if additional vaccines are required.

Even though our study’s vaccine hesitation rate of 13% is lower than previously reported hesitancy rates among other students and healthcare workers, the vaccination rate is alarming. Using trusted voices and leaders to advocate for vaccination(s), giving convenient access to vaccines, and a greater focus on raising awareness and education have all been suggested as possible measures to increase vaccination rates among students in healthcare professions.22

Strengths and Limitations Participants were selected from three private pharmacy schools in one state. As a result, the findings may not apply to other schools or communities. As with any survey-based study, our findings are influenced by recall bias, reliance on self-reported habits, and the inability to demonstrate cause-andeffect correlations. The survey response rate was low across all three participating institutions, which could have skewed the study’s findings. Furthermore, non-responding students may have been vaccination hesitant, resulting in an underestimating vaccine hesitancy among pharmacy students. Despite these limitations, to our knowledge, this is the first study to evaluate the attitudes and perceptions toward COVID-19 vaccine uptake among pharmacy students in the United States. Additionally, the number of respondents is on par with similar published studies.9,13 Vaccinations available for approximately one year at the time of survey distribution, and information related to efficacy and safety are more robust than previously published studies.

Conclusion The present study evaluated pharmacy students’ attitudes and perceptions toward COVID-19 vaccine uptake. Most students expressed positive attitudes toward COVID-19 vaccines and the value of the vaccines for themselves, their families, and the communities they serve. They also had strong positive perceptions of the role of vaccines in decreasing the spread of diseases and improving the overall public health of communities. Despite most of the students having been vaccinated, some expressed concern about potential side effects or were concerned that the vaccines may not be effective. Pharmacists are frontline healthcare practitioners who can play a

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port. 2021;70(20):759. http://dx.doi.org/10.15585/ pivotal role in advocating for and providing vaccinammwr.mm7020e3 tions. With the recent authorization for pharmacists 8.

Silva J, Bratberg J, Lemay V. COVID-19 and influto administer vaccines, including the COVID-19 vacenza vaccine hesitancy among college students. cines, they must demonstrate their confidence that Journal of the American Pharmacists Associathe benefits of COVID-19 vaccination exceed the tion. 2021;61(6):709-714. e701. http://dx.doi. risks.

Authors: Edward T. Chiyaka, Ph.D., is an Assistant Professor of Pharmacy at Wingate University School of Pharmacy in Wingate, NC. e.chiyaka@wingate. edu. Carrie L. Griffiths, PharmD, is an Associate Professor of Pharmacy at Wingate University School of Pharmacy. Andrew J. Woods, PharmD, is an Associate Professor of Pharmacy at Wingate University School of Pharmacy.

References

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2016;34(47):5708-5723. http://dx.doi. org/10.1016/j.vaccine.2016.08.085 6. Rhodes LA, Williams DM, Marciniak MW, Weber DJ. Community pharmacists as vaccine providers. International Journal of Health Governance. 2017. http:// dx.doi.org/10.1108/IJHG-05-2017-0020 7. Murthy BP, Sterrett N, Weller D, et al. Disparities in COVID-19 vaccination coverage between urban and rural counties—United States, December 14, 2020– April 10, 2021. Morbidity and Mortality Weekly Re-

org/10.1016/j.japh.2021.05.009 9. Kelekar AK, Lucia VC, Afonso NM, et al. COVID-19 vaccine acce e American Dental Association.

2021;152(8):596-603. http://dx.doi.org/10.1016/j. adaj.2021.03.006 10. Lucia VC, Kelekar A, Afonso NM. COVID-19 vaccine hesitancy among medical students. Journal of Public Health. 2021;43(3):445-449. http://dx.doi. org/10.1093/pubmed/fdaa230 11. Morris JL, Baniak LM, Luyster FS, et al. Covid-19 vaccine confidence and hesitancy in nursing students and faculty at a large academic medical center. Nursing outlook. 2021. http://dx.doi.org/10.1016/j.outlook.2021.10.010 12. Saied SM, Saied EM, Kabbash IA, Abdo SAEF. Vaccine hesitancy: Beliefs and barriers associated with COVID‐19 vaccination among Egyptian medical students. Journal of medical virology. 2021;93(7):42804291. http://dx.doi.org/10.1002/jmv.26910 13. Sharma M, Davis RE, Wilkerson AH. COVID-19 vaccine acceptance among college Students: a theory-based analysis. International Journal of environmental research and public health. 2021;18(9):4617. http://dx.doi.org/10.3390/ijerph18094617 14. Dybsand LL, Hall KJ, Carson PJ. Immunization attitudes, opinions, and knowledge of healthcare professional students at two Midwestern universities in the United States. BMC medical education. 2019;19(1):19. http://dx.doi.org/10.1186/s12909-019-1678-8 15. Prevention CfDCa. Building Confidence in COVID-19 Vaccines. https://www.cdc.gov/vaccines/covid-19/ vaccinate-with-confidence/rca-guide/downloads/ CDC_RCA_Guide_2021_Tools_AppendixD_Surveys-508.pdf. Accessed 25 April 2023.

16. Department of Health and Human Services. Guidance for Licensed Pharmacists and Pharmacy Interns Regarding COVID-19 Vaccines and Immunity under the PREP Act. In: Services HaH, ed2021. https://www. phe.gov/Preparedness/legal/prepact/Pages/PREPAct-Guidance.aspx. Accessed 25 April 2023.

17. Kasting ML, Wilson S, Dixon BE, et al. A qualitative study of healthcare provider awareness and informational needs regarding the nine-valent HPV vaccine.

Vaccine. 2016;34(11):1331-1334. http://dx.doi. org/10.1016/j.vaccine.2016.01.050 18. Lau M, Lin H, Flores G. Factors associated with human papillomavirus vaccine-series initiation and healthcare provider recommendation in US adoles-

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cent females: 2007 National Survey of Children’s Health. Vaccine. 2012;30(20):3112-3118. http://dx. doi.org/10.1016/j.vaccine.2012.02.034 19. Siddiqui M, Salmon DA, Omer SB. Epidemiology of vaccine hesitancy in the United States. Human vaccines & immunotherapeutics. 2013;9(12):26432648. http://dx.doi.org/10.4161/hv.27243 20. Manning ML, Gerolamo AM, Marino MA, et al.

COVID-19 vaccination readiness among nurse faculty and student nurses. Nursing Outlook.

2021;69(4):565-573. http://dx.doi.org/10.1016/j. outlook.2021.01.019 21. Mascarenhas AK, Lucia VC, Kelekar A, et al. Dental students’ attitudes and hesitancy toward COVID‐19 vaccine. Journal of Dental Education. 2021;85(9):15041510. http://dx.doi.org/10.1002/jdd.12632 22. Mustapha T, Khubchandani J, Biswas N. COVID-19 vaccination hesitancy in students and trainees of healthcare professions: A global assessment and call for action. Brain, Behavior, & Immunity-Health. 2021. http://dx.doi.org/10.1016/j.bbih.2021.100289 23. Shaw J, Stewart T, Anderson KB, et al. Assessment of US healthcare personnel attitudes towards coronavirus disease 2019 (COVID-19) vaccination in a large university healthcare system. Clinical Infectious Diseases. 2021;73(10):1776-1783. http://dx.doi.

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2013;31(41):4591-4595. http://dx.doi. org/10.1016/j.vaccine.2013.07.039

Table 1 Socio-demographic characteristics of participants All respondents N=182 (%)

Vaccine Hesitant (%)

Vaccine Acceptance (%)

p-value

60.4 33.5 6.0

73.9 26.1 0.0

58.5 34.6 5.7

.42

79.7 20.3

60.9 39.1

82.4 17.6

.02*

25.3 22.0 28.6 24.2

43.5 26.1 26.1 4.3

22.6 21.4 28.9 27.0

.05*

72.5 27.5

73.9 26.1

72.3 27.7

.64

Age 18 -24 years (n=110) 25 – 34 years (n=61) 35 years and above (n=11) Sex Female (n=145) Male (n=37) Year P1 (n=46) P2 (n=40) P3 (n=52) P4 (n=44) Race White (n=132) Non-White (n=50)

*Chi-square was used to determine significance, defined as p<.05, between vaccine-hesitant and vaccine acceptance groups.

P1=first professional year; P2=second professional year; P3=third professional year; P4=fourth professional year

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Table 2 Survey responses among COVID-19 vaccine acceptance and hesitant pharmacy students Participants that responded affirmatively (agree/strongly agree) All students N=182 (%)

Vaccine Hesitant (%)

Vaccine Acceptance (%)

p-value

I had COVID-19 infection I cared for someone with COVID-19 infection

10.4 24.2

4.3 17.4

11.3 25.2

.27 .30

I personally know someone who has had COVID-19 infection

59.9

21.7

65.4

<.001*

I personally know someone who has died from COVID-19 infection

39.6

30.4

40.9

.24

85.7 76.4 36.8 57.7 44.0 41.8

60.9 21.7 69.6 17.4 87.0 78.3

89.3 84.3 32.1 63.5 37.7 36.5

.001* <.001* .001* <.001* <.001* <.001*

63.7

13.0

71.1

<.001*

80.2 70.9 75.3 75.8 63.2 68.1 27.5 62.1

26.1 26.1 26.1 30.4 17.4 17.4 0.0 34.8

88.1 77.4 82.4 82.4 69.8 75.5 31.4 66.0

<.001* <.001* <.001* <.001* <.001* <.001* <.001* .004*

17.0 87.9

47.8 56.5

12.6 92.5

<.001* <.001*

80.8

39.1

86.8

<.001*

81.9 38.5

43.5 4.3

87.4 43.4

<.001* <.001*

55.5

4.3

62.9

<.001*

21.4 89.6

47.8 78.3

17.6 91.2

.004* .034*

Experience with COVID-19

Personal views on COVID-19 vaccine I am likely to be exposed to COVID-19 as a future pharmacist COVID-19 vaccination is important for me as a healthcare provider I am concerned that a COVID-19 vaccine may not be effective I am concerned that I may infect family or friends with COVID-19 I am concerned about serious side effects from a COVID-19 vaccine I need more information about the COVID-19 vaccine I trust the information I am receiving about the COVID-19 vaccine from the public health experts

General attitudes to vaccine Protect health of family/friends Protect health of co-workers Protect health of community Protect my health To get back to work/school To resume social activities Others encouraged me to get vaccinated It is required in my profession

General perceptions to COVID-19 vaccines People receive more vaccines than are good for them Vaccines are important for me to stay healthy as a future pharmacist Development of a COVID-19 vaccine is important to decrease spread of the disease COVID-19 vaccination is important for the overall public health of our communities The COVID-19 vaccination should be mandatory for the general public The COVID-19 vaccination should be mandatory for all healthcare providers

Personal vaccination behavior Have you ever delayed receiving a vaccine for reasons other than illness or allergy?

Do you plan on receiving a flu vaccine this season? *p-value indicates a level of alpha for statistical significance.

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Utilization of Pharmacists in Physical Therapy Didactic Curricula in the United States By: Dr. Dustin Wilson, Dr. Brock Woodis, and Dr. Scot Sawyer

Introduction Pharmacists have been recognized as ideal candidates for teaching the core concepts of pharmacology and pharmacotherapeutics in health sciences curricula.1-4 However, there is scarce data on pharmacists’ use in those curricula.3-5 A recent survey of US physician assistant (PA) programs reported that 83% of programs responding utilized pharmacists in their didactic curricula to deliver pharmacology and pharmacotherapeutics content.5 Pharmacists could ensure that health sciences students receive a solid foundation in pharmacology and pharmacotherapeutics to reduce serious ADEs and excessive healthcare costs.6 In addition, accreditation standards for some health sciences programs now require that curricula prepare students to work in interprofessional environments.7-9 Incorporating pharmacists early in the didactic curricula could enhance students’ knowledge of the role of the pharmacist on the healthcare team.

Currently, 277 US physical therapy (PT) programs are accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE).10 The CAPTE standards require a program’s curriculum to include instruction in pharmacology to be accredited.7 They also state that PT program academic faculty (core and associated) can include medical practitioners from other healthcare disciplines

as long as they have the expertise to meet specific curricular needs.7 Literature is not currently available on which medical practitioners are delivering the pharmacology content in these programs. The purpose of our study was to describe the scope of utilization of pharmacists to teach pharmacology/ pharmacotherapeutics in accredited PT programs in the United States.

Methods This was an Institutional Review Board (IRB)-approved, prospective, cross-sectional, cohort survey.

All accredited PT programs listed on the CAPTE website in which the email address of the Chair/Director was identified were recruited for the study.

Programs were evaluated for inclusion from November 27, 2019, to December 11, 2019.

The primary objective of this study was to describe the percentage of PT programs that utilize pharmacists to lecture on pharmacology and pharmacotherapeutics content. Secondary objectives were to describe the percentage of pharmacology and pharmacotherapeutics lectures pharmacists deliver, the percentage of PT programs that employ a full-time pharmacist to coordinate the Pharmacology and Pharmacotherapeutics courses, and the inclusion of pharmacists in other courses in the curricula.

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The investigators created an online survey (Qualtrics®, Provo, UT). The survey included twelve multiple-choice questions, with one question having a free text option if answered in the affirmative. Data collected in the survey included program characteristics (type of institution; first-year class size; length of graduate program; the presence of a school of pharmacy at the institution; years of establishment), how pharmacology and pharmacotherapeutics content was delivered, and if pharmacists were used elsewhere in the curriculum. The Director of Assessment of the investigators’ institution evaluated survey questions for ambiguity and readability.

The survey link was emailed to programs that met inclusion criteria on February 19, 2020. A reminder email with a survey link was sent two weeks after the first email. The survey closed after four weeks on March 18, 2020. All data collected from the surveys were exported to Microsoft Excel (Version 2016, Redmond, WA). Descriptive statistics were used for all analyses.

faculty to coordinate these courses in the curriculum. Less than 10% (5/59) of respondents commented that pharmacists were involved in other courses in the PT curriculum, including biology of disease/pathophysiology and interprofessionalism.

Discussion To our knowledge, this is the first study to describe the scope of utilization of pharmacists in physical therapy didactic curricula. A similar study was conducted in PA programs throughout the US.5 The majority of published literature discusses the utilization of pharmacists on patient care teams and clinical training of mainly physicians and physician assistants.11-14 Considering physical therapists are often the first healthcare providers patients see after hospital discharge, having solid drug therapy knowledge to identify and monitor ADEs could prove invaluable in reducing healthcare costs and patient morbidity.15

Our study showed that of the 59 PT programs responding to the survey, 49% were utilizing pharmacists to deliver pharmacology and pharmacotherapeutics content. This observation is promising, considering the recent commentaries by Lerchenfeldt and Lloyd advocating that pharmacists should have a larger role in medical education.2,4 However, the percentage of programs utilizing pharmacists was much lower than what was recently reported in PA programs (49% vs. 83%).5 A possible explanation for this observation is the number of pharmacology and pharmacotherapeutics credit hours in each program. In the present study, most programs responding averaged two credit hours, while PA programs often have at least four or more credit hours.

More credit hours in the PA programs are necessary since PAs have prescribing authority.

Results Of the 253 programs listed on the CAPTE website at the time of the study, the email addresses of the Chair/Director of 240 programs were identified (95%). Of these programs, the survey was delivered to 229 (11 emails were undeliverable). Of the 229 surveys delivered, 59 programs completed the survey for a 26% response rate. The majority of programs responding had been established for more than 15 years (76%). The type of institution was well balanced (public: 49% vs. private: 51%), as well as whether the university had a school of pharmacy (yes: 51% vs. no: 49%). Seventy-six percent reported that the pharmacology and pharmacotherapeutics content was delivered as individual courses. The individual courses totaled 1-4 credit hours in the didactic curricula, with most programs responding to 2 credit hours (67%). Program char- It is also encouraging to observe that in our study, acteristics on class size and length of the program pharmacists delivered more than 50% of the pharmacology and pharmacotherapeutics lectures in 19 can be found in Table 1. of the 29 programs (66%). This is a similar finding Forty-nine percent (29/59) of programs responding as compared to PA programs (83%) which suggest reported that pharmacists were utilized to deliver that when pharmacists are utilized, they deliver pharmacology and pharmacotherapeutics content. most of the content. Only 8% of programs employed Of those programs that utilized pharmacists, 66% a pharmacist as a full-time faculty member. This is (19/29) reported pharmacists teaching more than not surprising since most programs reported phar50% of the lectures. However, only five (8%) pro- macology and pharmacotherapeutics courses were grams reported having a full-time pharmacist on two credit hours in their curriculum. Justifying the Page 24

cost of a pharmacist to serve as a full-time faculty macology and pharmacotherapeutics content in responsible for a two-credit hour course may not be their curricula. Furthermore, 66% of programs usfeasible. ing pharmacists reported that pharmacists deliver more than 50% of the lectures on pharmacology and Another potential advantage of utilizing pharma- pharmacotherapeutics. This study suggests that cists to deliver pharmacology and pharmacothera- pharmacists are being used to teach the core conpeutics content in the curricula is the early exposure cepts of pharmacology and pharmacotherapeutics to interprofessional education (IPE). The CAPTE in PT curricula. Pharmacists should consider purstandards state, “The didactic and clinical curricu- suing opportunities to become involved in didactic lum includes interprofessional education; learning teaching in PT programs. activities are directed toward the development of interprofessional competencies including, but not lim- Authors: Dustin Wilson, PharmD, BCPS, is an Asited to, values/ethics, communication, professional sociate Professor of Pharmacy Practice (dwilson@ roles and responsibilities, and teamwork.”7 Theo- campbell.edu) at the Campbell University College of retically, students could better understand pharma- Pharmacy & Health Sciences (CPHS) in Buies Creek, cists’ role on the healthcare team if pharmacists de- NC. C. Brock Woodis, PharmD, BCACP, BC-ADM, livered pharmacology and pharmacotherapeutics CDCES, and Scot Sawyer, PT, DPT, were affiliated lectures early in the curriculum. Whether this early with CPHS at the time of the study. exposure would translate to improved student attitudes and collaboration in practice is unknown and REFERENCES warrants further study.

1.

There are limitations to our study worth noting.

First, only 59 (26%) programs completed the survey, which is a lower response rate than the response rates of health professionals reported in a recent systematic review (51%).16 Several programs were excluded due to the inaccessibility of the email address Chair/Director. Targeting other faculty with broad knowledge of their respective program (e.g., didactic coordinator) may have led to a higher response rate. In addition, the title alone could have decreased the response rates for programs that do not utilize pharmacists. Second, we should have surveyed whether programs had access to or were affiliated with an academic medical center. Proximity and affiliation to an academic medical center could improve the program’s ability to recruit pharmacists to participate in the curriculum. Lastly, we did not evaluate the academic or clinical impact of pharmacists lecturing in the PT curricula. Whether PT curricula that utilize pharmacists have better National Physical Therapy Examination passage rates could be evaluated in future studies. However, considering drug therapy knowledge is likely a small portion of the exam, this endeavor may be futile.

2.

3.

4.

5.

6.

7.

8.

Conclusions 9.

In this study, nearly 50% of programs responding to the survey utilize pharmacists to deliver pharPage 25

McBane S, Mesaros J. Teaching pharmacology in a physician assistant program. J Physician Assist Educ 2010;21(3):1822. doi:10.1097/01367895-201021030-00003 Lerchenfeldt S, Hall L. Pharm. D.s in the midst of M.D.s and Ph. D.s: the importance of pharmacists in medical education. Med Sci Educ 2018;28:259-261. doi:https://doi. org/10.1007/s40670-017-0520-3 D’Epiro G, Trout M. Importance of pharmacists in medical education. Med Sci Educ 2018;28:263. doi:https://doi. org/10.1007/s40670-018-0550-5 Lloyd N. Pharmacist-led teaching as a longitudinal theme for medical school curriculums – a solution for reducing prescribing errors in junior doctors. BMC Med Educ 2019;19(173). https://doi.org/10.1186/s12909-0191632-9 Wilson D, Fenn P. Utilization of pharmacists in physician assistant didactic curricula in the United States. Curr Pharm Teach Learn 2022;14(2):153-158. doi: 10.1016/j. cptl.2021.11.024 Wiernik P. A dangerous lack of pharmacology education in medical and nursing schools: a policy statement from the American College of Clinical Pharmacology. J Clin Pharmacol2 015;55(9):953-954. doi:10.1002/jcph.539 Commission on Accreditation in Physical Therapy Education. Accreditation handbook website. Accessed 20 July 2022. https://www.capteonline.org/globalassets/captedocs/capte-pt-standards-required-elements.pdf Accreditation Review Commission on Education for the Physician Assistant, Inc. Accreditation standards for physician assistant education 5th edition website. Accessed 22 July 2022. http://www.arc-pa.org/accreditation/standards-of-accreditation/ Commission on Osteopathic College Accreditation. Accreditation of colleges of osteopathic medicine: COM continuing accreditation standards website. Accessed 22 July

2022. https://osteopathic.org/accreditation/standards/ 10. Commission on Accreditation in Physical Therapy Education. Aggregate program data website. Accessed 20 July 2022. https://www.capteonline.org/about-capte/data-and-research/aggregate-program-data 11. Lisenby K, Scarbrough C, Pinner N, et al. Innovative utilization of pharmacist-led board review in a family medicine residency curriculum. Curr Pharm Teach Learn 2018;10:1501-1506. doi:10.1016/j.cptl.2018.08.006 12. Kim S, Willett L, Hughes F, et al. Pharmacist-led workshops to enhance pharmacotherapy knowledge for medical students. Teach Learn Med 2013;25(2):118-121. doi:10.1080 /10401334.2013.770744 13. Hale L, Morton J, Albers J, et al. Physician assistant student exposure to the long-term care setting by working with a

consultant pharmacist. J Interprof Care 2020;34(3):315323. doi:10.1080/13561820.2019.1663160 14. Hamilton L, Behal M, Metheny W. Impact of pharmacist education on incoming medical residents. Hosp Pharm.

2021;57(4):442-447 doi:10.1177/00185787211046860 15. Medications and physical therapy practice. American Physical Therapy Association website. Accessed 20 July 2022. Medications and Physical Therapy Practice 2019. pdf (homehealthsection.org) 16. Meyer V, Benjamens S, Moumni M, et al. Global overview of response rates in patient and health care professional surveys in surgery: a systematic review. Ann Surg 2022;275(1):e75-e81. doi: 10.1097/ SLA.0000000000004078

Table 1. Program characteristics Characteristic Type of institution Public Private

Total n = 59 n (%) 29 (49) 30 (51)

First-year class size <26 26-50 51-75 >75

1 (2) 38 (64) 14 (24) 6 (10)

School of pharmacy at university Yes No

30 (51) 29 (49)

Length of program, months <25 25-29 30-34 35-39 >39 Years of establishment <5 5-10 11-15 >15

Delivery format for pharmacology and pharmacotherapeutics Individual courses Integrated with other courses

2 (3) 2 (3) 15 (26) 38 (65) 2 (3)

6 (10) 7 (12) 1 (2) 45 (76) 45 (76) 14 (24)

Page 26

Page 27

Impact of a Five-Part, Student Pharmacist-Led Advocacy Certificate Program

By: Dr. Anita Yang, Dr. Kevin Rhash, Dr. Andrew Cartwright, and Dr. Adam Persky ABSTRACT Objectives: Evaluate the impact of a five-part, student pharmacist-led “Student Pharmacist Advocate Certificate’’ program on students’ pharmacy legislation interest, knowledge, and comfortability speaking with legislators compared to baseline prior to the advocacy program.

Methods: Retrospective review of pre- and post-surveys of students who completed the “Student Pharmacist Advocate Certificate” program in the spring of 2021. Surveys were based on a Likert scale to assess impact through paired t-tests.

Results: After completing the advocacy program, student pharmacists’ legislation interest, knowledge, and comfortability speaking with legislators significantly increased, while there was no significant change in perceptions of the importance of understanding pharmacy legislation. Students’ knowledge and comfortability speaking to legislators on all four core topics significantly improved: PBMs, CPAs, prescriptive authority, and pay parity.

Conclusion: With proper instruction, knowledge, and experience, student pharmacists can effectively advocate for advancing the pharmacy profession.

Thus, pharmacy schools should consider implementing more robust opportunities into curricula to better prepare student pharmacists as life-long advocates.

Introduction As healthcare evolves, the pharmacist’s role be-

comes more prominent and essential in patient care.1-3 Pharmacists are well-positioned to be accessible clinicians as they can offload physician burden in inpatient and outpatient clinics.4,5 Despite apparent benefits, pharmacists must be more utilized due to federal and state laws and regulations and the inability to reimburse compensation for direct patient care services.3 Concerted and effective advocacy efforts from other healthcare professions, such as physician assistants, nurse practitioners, and optometrists, have successfully advanced their scope and field of practice.6-8 Therefore, legislative pharmacy advocacy from students and practicing pharmacists is essential to proactively engage with legislation, legislators, and the bill-making process to see positive changes in pharmacy practice ultimately. However, there is currently a lack of integration of legislative advocacy into didactic, experiential, and co-curricular experiences in colleges and schools of pharmacy.9,10 Thus, pharmacy schools may be missing the opportunity to stress the impact and importance of self-advocacy early in students’ pharmacy careers, which is crucial to ensure patients receive optimal and quality healthcare.

Developing effective advocacy knowledge and skills as a student pharmacist provides foundational skills that can extend into becoming a pharmacy practitioner and leader. Current literature displays positive outcomes in advocacy-based classroom simulations for pharmacy students and that structured advocacy events tailored towards pharmacy students can increase comfortability.11-13 Since many pharmacy schools still need to incorporate advocacy into their curricula formally, there continues to be an increased demand for investigating effective hands-

Page 28

on approaches to engage students in pharmacy ad- tient care. vocacy outside the classroom setting through state and national pharmacy associations.9 A “Student Pharmacist Advocate Certificate” was offered through NCAP for students who attended Currently, an ongoing objective of the North Caroli- required events and completed pre- and post-adna Association of Pharmacists (NCAP) is to immerse vocacy series surveys. The series examined four students in advocacy efforts through active partic- pertinent pharmacy legislation topics identified by ipation in state legislation. Student leaders of the NCAP in greater detail: pharmacy benefit managers NCAP Student Pharmacists Forum (NCAP SPF) cre- (PBMs), collaborative practice agreements (CPAs), ated a large-scale, five-part advocacy series and a prescriptive authority, and pay parity.

“Student Pharmacist Advocate Certificate” to offer students from all four pharmacy schools in North The impact of this advocacy initiative was assessed Carolina. This study aims to assess the impact of through pre- and post-initiative surveys on a 1 (lowthe student-led, five-part advocacy series for stu- est) to 5 (highest) point Likert scale. Post-initiative dent pharmacists in North Carolina to facilitate best surveys had to be completed within one week of practices in integrating advocacy efforts within and certificate completion. The pre-and post-initiative beyond the pharmacy school curriculum. The study surveys assessed the impact of the initiative’s effect hypothesis is that students who complete the “Stu- on students’ pharmacy legislation interest, knowldent Pharmacist Advocate Certificate’’ program will edge, and comfortability speaking with state legisexperience increased levels of pharmacy legislation lators (Appendix 1). The surveys also assessed the interest, knowledge, comfortability speaking with importance of understanding pharmacy legislation state legislators, and the importance of understand- as a student pharmacist and if pharmacy advocacy ing compared to their baseline. is only beneficial in certain areas of pharmacy. Additionally, students could note topics discussed with Methods their state legislators within the post-advocacy iniThis study was a retrospective review of pre- and tiative survey. post-surveys from students who successfully participated in the five-part advocacy series and complet- Baseline characteristics included pharmacy school, ed the “Student Pharmacist Advocate Certificate” in class year, and North Carolina House and Senate the spring of 2021. NCAP SPF representatives co- District. Student characteristics are presented as ordinated this student-led, five-part student advoca- percentages of categorical variables and mean ± cy series from four pharmacy schools within North standard deviation (SD). The impact of pre- and Carolina: Campbell University, Wingate University, post-advocacy series surveys was analyzed through High Point University, and the University of North paired t-tests. Statistical significance was set at Carolina. First-year through fourth-year pharma- p<.05. The University of North Carolina Institutional cy students enrolled in a North Carolina pharmacy Review Board exempted this study. school were eligible to participate in the advocacy series.

Results From January 2021 to April 2021, 87 student pharDue to the SARS-CoV-2 (COVID-19) pandemic, all macists in North Carolina expressed initial interest events occurred via a virtual platform. This five-part in attaining further information regarding the fiveseries included the following events: 1) Why Ad- part advocacy series. Ultimately, by May 2021, 50 vocate as a Student Pharmacist, 2) State Pharmacy pharmacy students completed the requirements to Legislation Information Session, 3) State Pharmacy earn NCAP’s “Student Pharmacist Advocate CertifiLegislation - Hot Topics Discussion, 4) Legislation cate.” All four North Carolina pharmacy schools had Meetings Preparatory Session, and 5) Virtual Meet- student representation, with the majority (98%; ings with State Legislators. The final event allowed n=49) of students within the first three years of students to engage in meaningful conversations their respective four-year programs (Table 1). with state legislators and discuss pertinent issues regarding pharmacy practice and its effect on pa- NCAP Student Pharmacist Forum leaders schedPage 29

uled virtual meetings with fourteen state legislators through the advocacy program. Student pharmacists had virtual meetings with eleven state legislators: six from the House of Representatives and five senators. Three representatives were “no-shows” due to scheduling conflicts. The eleven state legislators represented districts across North Carolina (Figure 1). During student-led meetings with state legislators, most students expressed their passion for the pharmacy field and the importance of advocating, personal patient care stories, PBMs, CPAs, prescriptive authority, and the evolving pharmacist’s role considering COVID-19 (Figure 2).

Administer Injectable Drugs,” which also tied provisions from Senate Bill 575, “Pharmacists Improving Public Health Needs,” was discussed to provide insight into the breadth of pharmacy expertise. House Bill 96 was passed following this advocacy initiative in August 2021. Similarly, PBMs align with Senate Bill 257, “Medication Transparency Act,” and were also recently passed following this advocacy initiative in September 2021. Currently, in progress, CPAs align with House Bill 862, “Improving Access to Patient Care,” and “Fair and Equitable Reimbursement for Pharmacists,” regarding pay parity. Student pharmacists were integral in advancing pertinent pharmacy legislation by speaking directly with state This program significantly increased students’ phar- legislators. macy legislation, knowledge, and comfortability speaking with state legislators (Table 2). Addition- Despite the COVID-19 pandemic, student leaders ally, students’ knowledge and comfortability speak- were able to leverage a virtual platform between the ing with state legislators significantly increased on four pharmacy schools to provide an informative all four focused topics: PBMs, CPAs, prescriptive au- and impactful advocacy series. Because meetings thority, and pay parity (Table 3). Students’ percep- with state legislators took place virtually rather than tions of the importance of understanding pharmacy in-person at the state capitol, physical and translegislation as a student pharmacist were well-re- portation barriers were eliminated. This increased ceived before the advocacy series. While insignif- student accessibility to participate in live meetings icant, these perceptions still increased favorably with state legislators without compromising the upon completing the advocacy series. quality or effectiveness of those meetings. Similarly, Yu and colleagues successfully utilized a virtual platDiscussion form for a COVID-19-focused state advocacy day for Due to the need for consistent advocacy instruction medical students and residents.14 Their study found in the didactic coursework of pharmacy schools, that medical trainees understand the importance of students in North Carolina initiated an advocacy effectively attaining the skills and knowledge to adcertificate through the state pharmacy association. vocate for health policy with proper education and This retrospective analysis of pre-and post-advoca- guidance.14 cy initiative surveys highlights the impact of educational and hands-on experience speaking directly Dr. Elizabeth Griffiths indicates that “our patients’ with state legislators regarding pertinent pharmacy access to care as well as their health and wellbeing legislation. Additionally, pharmacy students were depend on our willingness to become advocates on shown to successfully execute an impactful advo- their behalf,” thus, successful legislative advocacy is cacy initiative by increasing their knowledge and imperative across all healthcare professions.15 The comfortability on relevant pieces of pharmacy leg- positive results of this retrospective study strengthen the current literature on the significant benefits of islation. didactic and experiential advocacy efforts in healthThe four relevant pieces of pharmacy legislation care professional students.11-13, 16, 17 The education identified by NCAP aligned with specific bills NCAP students receive while attending pharmacy school was actively lobbying at the state level. While North should ideally help them become advocates through Carolina does not have the legislation to provide specific coursework with real-life experiences and pharmacists with prescriptive authority, legislation participation in professional organizations.12,13,18 has been enacted to increase patient care access and As pharmacy practice continues to expand and adadvance pharmacy practice to improve public health vance, it is crucial to involve student pharmacists in needs. Thus, House Bill 96, “Allow Pharmacists to advocacy early on to understand its value and gain Page 30

knowledge and tools to be successful advocates for the field. Adequate legislation is necessary to allow pharmacists to practice at the top of their licenses to overcome reimbursement and scope of practice barriers impeding patient care.19

cussions always focused on improving patient outcomes.

Conclusion Implementing and completing a “Student Pharmacist Advocate Certificate” increased student pharmaLimitations of this study include a retrospective cists’ pharmacy legislation interest, knowledge, and analysis of self-reported data utilizing a numerical comfortability speaking with legislators. Advocating Likert scale with small sample size. Strengths of this for advancing pharmacy practice can effectively bestudy include evaluating the impact of a student-led gin as a student pharmacist. With adequate instrucinitiative through the state pharmacy association, tion and training, student pharmacists can execute the viability of leveraging a virtual platform, and the meaningful conversations with state legislators rereal-world implications of state legislator meetings garding pertinent pieces of pharmacy legislation. on pharmacy practice. With sessions being transitioned to a virtual platform, accessing legislators Authors: Anita Yang, PharmD, is a PGY2 Ambuwas more convenient than having students com- latory Care Pharmacy Resident in the Department mute in person from across the state to the General of Pharmacy Services at UNC Health Care, anita.

Assembly in Raleigh, North Carolina. yang2@unchealth.unc.edu. Kevin Rhash, PharmD, Pharmacy schools have a considerable opportunity is a PGY1 Acute Care Pharmacy Resident in the Deto integrate pharmacy advocacy into their curricu- partment of Pharmacy Services at Duke University lum as critical actions and conversations with state Health. Andrew Cartwright, PharmD, is a Staff legislators can directly impact their future practice Pharmacist at Atrium Health Wake Forest Bapand patients in their community. Since students tist Medical Center and High Point Medical Cenhave diverse experiential, extracurricular, and work ter. Adam Persky, Ph.D., is an Associate Dean of experiences, they are well-positioned to educate Professional Education at the University of North others on pharmacists’ different roles and the im- Carolina Eshelman School of Pharmacy. pact of student pharmacists. Students also have the knowledge and skills to communicate unique pa- References tient-care stories effectively to the public and state 1. Dolovich L, Austin Z, Waite N, et al. Pharmacy in the 21st century: Enhancing the impact of the pharmacy profession legislators. Advocacy for the pharmacy field is not on people’s lives in the context of health care trends, evisolely limited to speaking directly with state legisdence and policies. Can Pharm J (Ott). 2018;152(1):45-53. lators; it is a skill that requires continuous practice Published 2018 Dec 25. doi:10.1177/1715163518815717 in various settings to master advocating for the ser- 2. Adams AJ, Weaver KK. The Continuum of Pharmacist Prescriptive Authority. Ann Pharmacother. 2016;50(9):778vices, resources, versatility, and knowledge pharma784. doi:10.1177/1060028016653608 cists bring to healthcare teams.

3. Isai F, Krofah E. The expanding role of pharmacists in a By creating this advocacy certificate program and showing positive outcomes, we hope other pharmacy schools and state and national pharmacy organizations will increase their role in developing strong student advocates. Whether that be through advocacy training, certificates, or workshops – it is evident that students are more comfortable and knowledgeable regarding pharmacy legislation after increased engagement. Furthermore, because clinical pharmacy services improve patient outcomes, advocating for pharmacy expansion may positively impact patient care. Several of the topics discussed during legislative meetings revolved around expanding pharmacy services, with the end goal of these dis-

4.

5.

6.

7.

8.

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transformed health care system. National Governors Association. Published 2015 January 25.

Valliant SN, Burbage SC, Pathak S, Urick BY. Pharmacists as accessible health care providers: quantifying the opportunity. J Manag Care Spec Pharm. 2022;28(1):85-90. doi:10.18553/jmcp.2022.28.1.85 Jain SH. Can pharmacists help reinvent primary care in the United States? Forbes. Published October 10, 2018.

Ross LA, Janke KK, Boyle CJ, et al. Preparation of faculty members and students to be citizen leaders and pharmacy advocates. Am J Pharm Educ. 2013;77(10):220. doi:10.5688/ajpe7710220 Jungnickel PW, Kelley KW, Hammer DP, Haines ST, Marlowe KF. Addressing competencies for the future in the professional curriculum. Am J Pharm Educ. 2009;73(8):156.

Fincham JE, Ahmed A. Dramatic need for cooperation and advocacy within the academy and beyond. Am J Pharm

Educ. 2012;76(1):1.

9. Murphy EM, Hagy N, Miller J, Rodis JL. The Integration, Perceptions, and Implementation of Legislative Advocacy Within U.S Colleges and Schools of Pharmacy [published online ahead of print, 2021 Oct 25]. Am J Pharm Educ.

2021;8668. doi:10.5688/ajpe8668 10. Gohlke AL, Murphy KM, Cannell ME, Ray DB, Burnworth MJ. Igniting the fire within: a primer on political advocacy for pharmacy professionals. J Pharm Pract. 2013;26(3):165170. doi:10.1177/0897190013482333 11. Mospan CM, Gillette C. Impact of a Simulated Legislative Visit on Student Pharmacists’ Political Skill Inventory Scores. AJPE. 2021;85(5): 8259. Published 2021 May 1. doi: 10.5688/ajpe8259 12. Pace AC, Flowers SK. Students’ perception of professional advocacy following a political advocacy course. Elsevier Inc. 2021;4(1):34-38. doi: 10.1016/j.cptl.2011.10.005 13. Adams AJ, Matzke GR, McCall KL. A Novel Education and Training Program to Enhance Student Advocacy. AJPE. 2015;76(7):95. Published 2015 Sep 25. doi: 10.5688/ ajpe79795 14. Yu Z, Moustafa D, Kwak R, et al. Engaging in advocacy

during medical training: assessing the impact of a virtual COVID-19-focused state advocacy day. Postgrad Med J. 2022;98(1159):365-368. doi:10.1136/postgradmedj-2020-139362 15. Griffiths EP. Effective Legislative Advocacy - Lessons from Successful Medical Trainee Campaigns. N Engl J Med. 2017;376(25):2409-2411. doi:10.1056/NEJMp1704120 16. Press VG, Fritz CD, Vela MB. First year medical student attitudes about advocacy in medicine across multiple fields of discipline: analysis of reflective essays. J Racial Ethn Health Disparities. 2015;2(4):556-564. doi:10.1007/ s40615-015-0105-z 17. Blake EW, Powell PH. A pharmacy political advocacy elective course. Am J Pharm Educ. 2011;75(7):137. doi:10.5688/ajpe757137 18. Legal and Regulatory Developments Affecting Pharmacy in 2020. Pharmacy Today. https://www.pharmacytoday. org/article/S1042-0991(20)31209-3/fulltext. Published January 2021.

19. Sin J. Advocating for pharmacy: Role of the student pharmacist. Am J Health Syst Pharm. 2014 Nov 1;71(21):18367. doi: 10.2146/ajhp130531. PMID: 25320132.

Table 1 Participants of the “Student Pharmacist Advocate Certificate” All Students N=50 (%) Pharmacy School Campbell University University of North Carolina High Point University Wingate University

21 (42) 12 (24) 9 (18) 8 (16)

School Year P1 P2 P3 P4

10 (20) 27 (54) 12 (24) 1 (2)

P1=first profession year P2=second profession year P3=third profession year P4=fourth profession year

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Table 2 Impact of the Five-Part Advocacy: Pharmacy Legislation Pre-Advocacy Initiative M (SD)

Post-Advocacy Initiative M (SD)

p-value

Interest

3.9 (0.80)

4.4 (0.64)

<.001

Knowledge

2.5 (0.89)

3.5 (0.79)

<.001

Comfortability Speaking with Legislators

2.6 (1.12)

3.5 (0.91)

<.001

Importance as a Student Pharmacist

4.7 (0.56)

4.9 (0.34)

.004

Pharmacy Legislation

Table 3 Impact of the Five-Part Advocacy: Pharmacy Legislation Topic Knowledge and Speaking Comfortability Pre-Advocacy Initiative M (SD)

Post-Advocacy Initiative M (SD)

p-value

PBMs

2.3 (1.00)

3.4 (0.93)

<.001

CPAs

2.5 (1.20)

3.8 (1.08)

<.001

Prescriptive Authority

2.4 (1.11)

3.7 (1.05)

<.001

Pay Parity

2.1 (0.84)

3.5 (0.97)

<.001

Knowledge and Speaking Comfortability to State Legislators

PBM=pharmacy benefit managers; CPAs=collaborative practice agreements

Figure 1 Highlighted North Carolina Districts of Completed Student-Led Legislative Meetings

Highlighted districts of the following 11 virtual student-led legislative meetings in North Carolina: Representative Cecil Brockman (District 60), Senator Chuck Edwards (District 48), Representative Cynthia Ball (District 49), Representative Erin Pare’s Assistant (District 37), Senator Jim Burgin (District 12), Senator Natalie Murdock (District 20), Representative Verla Insko (District 56), Representative Wesley Harris (District 105), Representative Zack Hawkins (District 31), Senator Valerie Foushee (District 23), and Senator Wiley Nickel (District 16).

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Figure 2 Topics Discussed During State Legislator Meetings

Appendix 1 Pre- and Post-Advocacy Initiative Survey Pre-Advocacy Initiative Survey

Post-Advocacy Initiative Survey

Student Information Name, E-mail, Pharmacy School, Class Year

Student Information Name, E-mail, Pharmacy School, Class Year

Likert Scale – Pharmacy Legislation (1-No interest; 3-Some interest, 5 – Very High interest) Baseline interest Baseline knowledge Baseline speaking comfortability Baseline speaking comfortability to state legislators on: Pharmacy Benefit Managers, Collaborative Practice Agreements, Prescriptive Authority, Pay Parity

Likert Scale – Pharmacy Legislation (1-No interest; 3-Some interest, 5 – Very High interest) Current interest Current knowledge Current speaking comfortability Current speaking comfortability to state legislators on: Pharmacy Benefit Managers, Collaborative Practice Agreements, Prescriptive Authority, Pay Parity

Likert Scale – Pharmacy Legislation (1-Not important; 3-Somewhat important; 5 – Very important) Importance of understanding pharmacy legislation as a student pharmacist

Likert Scale – Pharmacy Legislation (1-Not important; 3-Somewhat important; 5 – Very important) Importance of understanding pharmacy legislation as a student pharmacist Legislator Meeting Information Legislator’s name Select all the following topics discussed Passion for the pharmacy profession Personal pharmacy/patient story Importance of advocating for the pharmacy profession County-specific related issues Pharmacy Benefit Managers Collaborative Practice Agreements Pay Parity Prescriptive Authority Pharmacist Role in Light of COVID-19 [Free Text]

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Page 35

PGY1 Community-Based Pharmacy Residency: A Door to Endless Possibilities

By: Dr. Taylor Mitchell and Dr. Geena Eglin ABSTRACT Pharmacy resident candidates are often overwhelmed with various postgraduate year 1 (PGY1) residency opportunities nationwide.

Yet, candidates may not be fully informed about their options during the application process. The PGY1 Community-Based Pharmacy Residency Programs (CPRP) are one of three PGY1 residency types formally recognized by the American Society of Health-System Pharmacists (ASHP); however, each PGY1 CPRP is unique when comparing their learning experiences. This article highlights the benefits of a candidate pursuing a PGY1 CPRP in North Carolina.

INTRODUCTION Pharmacy residency programs have become integral to a pharmacist’s training to aid in the fasttrack development of advanced clinical skills and knowledge needed to practice at the top of one’s license. Formal pharmacy residency training programs and accreditation standards were developed in the early 1960s. (1) Since its establishment, residency training programs have dramatically changed to incorporate to-

day’s dynamic clinical field. The American Society of Health-System Pharmacists (ASHP) formally recognizes three types of PGY1 residency programs: PGY1 Pharmacy, PGY1 Community-Based Pharmacy (CPRP), and PGY1 Managed Care Pharmacy. (2) Pharmacy residency candidates interested in ambulatory care, chronic disease state management, or other outpatient pharmacy practices often find themselves at a crossroads when deliberating on which type of first-year residency program to pursue. Although PGY1 CPRP and PGY1 pharmacy residency programs expose pharmacists to various clinical experiences, some students may misunderstand the depth a PGY1 CPRP offers candidates based on its nomenclature. In this article, the different types of North Carolina PGY1 CB pharmacy residency programs CPRP are further discussed while evaluating the unique opportunities that may arise from each.

opportunity where cutting-edge pharmacists mentor postgraduate pharmacists in a community-based pharmacy setting.” (3) A community-based program allows pharmacists to care for patients in various outpatient settings through longitudinal experiences by incorporating disease state management, medication therapy management (MTM), immunizations, wellness services, and collaborative and integrative team-based care models. (3) All PGY1 CPRPs have the resident concentrate the majority of their time in patient care, including a focus on at least three chronic disease states (e.g., diabetes, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, etc.), and many programs offer experiences with a specific disease state or patient population such as oncology, HIV, or hepatitis C virus. (4) This allows the PGY1 CPRP resident to see a variety of common and specialty chronic diseases over their training year.

A PGY1 CPRP allows pharmacists PGY1 CPRP TYPES to gain skills in four competency The American Pharmacists As- areas defined by ASHP in partnersociation (APhA) defines a PGY1 ship with APhA, including patient CPRP as “an advanced training care, advancing community-based Page 36

practice, leadership and management, and teaching, education, and dissemination of knowledge.

(4) These are similar to competencies described for PGY1 Pharmacy but will be completed in different settings offering other unique characteristics and projects. Where these competencies and skills will be developed may vary as community-based settings provide direct patient care in locations outside of the inpatient or acute care health-system setting. (3) This may include specialty pharmacies, patient-centered medical homes, free clinics, and federally qualified health centers, to highlight a few.

The PGY1 CPRP settings in North Carolina are based in chain and independent pharmacies, ambulatory care centers, and hospital/ health-system outpatient pharmacies. Each program’s definitions are outlined in Table 1.

(5,6) The 2022 ASHP Directory advertises that 30 PGY1 CPRP positions were available from nine different ASHP-accredited programs across North Carolina (Figure 1). While accredited programs are surveyed against a set of best practice standards, how they train residents and the patient care opportunities provided may differ significantly between residency programs. This allows programs to capitalize on the unique aspects of their organization and patient population as a part of the residency design, including their physical locations and service areas.

Retail pharmacies, including large national or regional chains and independent and grocery-based pharmacies, are a common location for PGY1 CPRPs and may

have unique advantages to the type of practice and opportunities offered. Chain pharmacies or other organizations with multiple pharmacy locations often provide residents with the opportunity to obtain regional or national management experience. As a result, such involvement could lead the resident to be hired into a management position upon graduation from the program. Although the opportunities to obtain chronic disease management experiences may vary across such pharmacies, residents may still provide patient education regarding medications and perform blood sugar, blood pressure, and lipid screenings during volunteer community events. Independent pharmacy programs uphold similar opportunities and may allow for further creativity in developing and marketing business programs due to their differences in management and policy-making procedures. Independent pharmacies may enable residents to see all aspects of a pharmacy’s operational and ownership requirements from a business perspective and learn about various payment models. A resident commonly has longitudinal MTM service responsibilities in chain and independent pharmacy environments. These locations continuously provide pharmacy residents with patient education opportunities, given the high demand for such pharmacies to fill prescriptions for their community. Chain and independent pharmacy PGY1 CPRPs are dispersed throughout the central, western, and eastern regions of North Carolina. As a result, each of the pharmacies in these locations will have access to various resources they can direct Page 37

patients to for additional assistance, including those supporting mental health, preventative medical care, laboratory tests, and more.

Ambulatory care centers are another setting for PGY1 CPRPs. Ambulatory care pharmacy provides integrated, accessible healthcare services by pharmacists to assist patients in their medication needs and practice in the context of family and community. (7) More interdisciplinary opportunities can be available for ambulatory care residents. Experience may be available in various services, such as pharmacist-run anticoagulation clinics, transitions of care practices, and population health management. Patient appointments focusing on congestive heart failure, oncology, hepatitis C, HIV, and cystic fibrosis would also likely be available. Depending on the center’s physical location, funding source, and structure, residents may have a greater focus of care centered around underserved, uninsured, and rural populations. Within ambulatory care centers, a resident may obtain less retail experience than one might get from an independent and chain-based pharmacy residency program. Yet, residents still fulfill patient-centered medication dispensing via evening and weekend clinical shifts in their respective program’s associated hospitals. One institution currently offers a PGY1 CPRP opportunity focused in the ambulatory care center setting in the North Carolina Piedmont region.

The final area for a PGY1 CPRP is within a hospital/health-system outpatient pharmacy. These

organizations offer residents a combination of retail and ambulatory care pharmacy settings. An additional advantage is access to patients leaving the inpatient setting, thus allowing for a robust transition of care experience.

Such programs encourage their residents to simultaneously uphold longitudinal responsibilities over the year with the possibility of transitioning between shortterm rotational requirements.

Longitudinal responsibilities may focus on patient care activities in transitions of care, discharge, specialty pharmacy, and chronic disease management. In contrast, others focus on projects in population health, business planning, pharmacy management, and research.

Often, residents can expect preceptor(s) of such programs to be credentialed as Clinical Pharmacist Practitioners (CPP). North Carolina CPPs, defined as “licensed pharmacists authorized to initiate, modify, and discontinue drug therapy and order specific laboratory tests under the supervision of one or more physicians,” may practice in various outpatient settings. (8) However, fewer CPPs are seen in community pharmacies (both retail and independent) due to many physicians and providers prescribing for the larger patient population served.

(8) While many states have some form of collaborative practice laws, prescribing authority for pharmacists is limited, thus making programs that allow residents to work under CPPs highly valued.

(9) Residency programs in health systems may include the PGY1 CPRP resident in a larger residency class and provide more phar-

macy students to precept. Opportunities such as patient care with CPPs, population health, specialty pharmacy, and discharge services are not secluded to just a health-system PGY1 CPRP; however, these examples highlight how they might be incorporated into such a program.

date a solid foundation for further PGY2 training. While most often this is within the ambulatory care setting, graduates from a PGY1 CPRP are also well equipped for other specialties such as cardiology, geriatrics, informatics, or medication-use safety and policy, to name a few. Depending on affiliations with schools of pharmacy or Outpatient health-system res- health systems, candidates may idency programs comprise the also have the opportunity to early most significant portion of PGY1 commit to such a PGY2 program CPRP positions across North Car- within the same hospital/health olina. As a result, careful consid- system via early commitment or a eration is warranted when select- different program. ing a PGY1 CPRP in a hospital/ health-system outpatient phar- CONCLUSION macy program to match one’s The decision of which PGY1 CPRP personal and professional goals to pursue can be difficult to navbest. igate and is often not a “one size fits all” approach. PGY1 CPRP canTHE BENEFITS OF A PGY1 CPRP didates must review programs Upon completing a PGY1 CPRP, within North Carolina carefully to pharmacists are exceptionally ensure the learning experiences equipped with various clinical offered align with their personal and operational skill sets. Job op- and professional goals. All PGY1 portunities may include manage- CPRPs offer experiences in patient ment, specialty pharmacy, tran- care, leadership, management, sitions of care, value-based care advancement of community pracmodels, continuing community tice, and education. Nevertheless, pharmacy services, or a faculty there may be unique advantagposition at a pharmacy school. es in one or more of these areas The extraordinary clinical skillset based on the program’s setting. also fully prepares the pharmacist Retail chain and independent to practice at the top of their li- pharmacy programs allow resicense through CPP credentialing. dents to gain skills in managing a pharmacy while sharpening medGraduates of a PGY1 CPRP may ication knowledge, performing also consider pursuing a special- patient education sessions, and ized PGY2 residency position. completing MTM interventions.

Candidates completing a PGY1 Ambulatory care centers enable CPRP hold skill sets developed residents to clinically manage pawithin the aforementioned four tients through scheduled appointmain competency areas of patient ments and population health incare: advancing community-based terventions while still obtaining practice, leadership and manage- medication dispensing skills. This ment, and teaching, education, setting continues to support lonand dissemination of knowledge. gitudinal patient relationships in These skill sets give the candi- various geographical locations.

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Standards for PGY1 Pharmacy Hospital/health-system outpaResidencies. ASHP. Accessed Febtient pharmacy programs comruary 28, 2023. https://www. bine both experiences by encourashp.org/professional-developaging residents to obtain a broad m e n t / re s i d e n c y- i n fo r m a t i o n / range of experiences in providing residency-program-resources/ residency-accreditation/accreditapatient care from managerial, amtion-standards-for-pgy1-pharmabulatory care, retail, and outpacy-residencies?loginreturnUrl=SSOtient pharmacy perspectives. For CheckOnly those who desire to pursue any 3. Community-Based Pharmacy Respharmacy career in the outpaidency Programs (CPRPs) For Interested Candidates. American tient setting or obtain a PGY2 in Pharmacists Association. Accessed ambulatory care, a PGY1 CPRP is February 28, 2023. https://www. the best way to develop an array pharmacist.com/Career/Residenof clinical skills and knowledge to cies/CPRP/Interested-Candidates prepare one for such longitudinal 4. American Society of Health-System Pharmacists (ASHP), Amerpatient care opportunities. With ican Pharmacists Association the diversity of outpatient-fo(APhA). Accreditation Standard cused learning experiences availfor Postgraduate Year One (PGY1) able for PGY1 CPRP residents, Community-Based Pharmacy Resthey are set up for success when idency Programs. Published April 2017. Accessed February 28, 2023. pursuing additional residency https://www.ashp.org/-/media/ training or their dream career in assets/professional-development/ pharmacy. residencies/docs/pgy1-community-based-pharmacy-2017.ashx

cessed February 28, 2023. https:// www.ashp.org/-/media/assets/ products-services/ASHP-Accreditation-Programs/docs/ASO-ModelTypes.pdf 7. Ashjian E, Dzwierzynski E, Padilla M, et al. Ambulatory Care Career Tool Document. American Society of Health-System Pharmacists. Published 2017. Accessed February 28, 2023. https://www.ashp.org/-/ media/assets/pharmacy-practice/ resource-centers/ambulatory-care/ ambulatory-care-career-tool.ashx 8. Clinical Pharmacist Practitioners.

North Carolina Board of Pharmacy.

Accessed February 28, 2023. http:// www.ncbop.org/pharmacists_cpp. htm 9. A. Prescribing Authority for Pharmacists: Rules and Regulations by State. GoodRx Health. Published July 22, 2022. Accessed February 28, 2023. https://www.goodrx.com/ hcp/pharmacists/prescriber-authority-for-pharmacists 10. Company Information. Novant Health. Updated December 31, 2021. Accessed February 28, 2023. https://www.novanthealth.org/ home/about-us/company-information.aspx#:~:text=Novant%20 Health%20is%20a%20not,and%20 community%20health%20outreach%20programs

Authors: Taylor Mitchell, PharmD, 5. American Society of Health-System Pharmacists. Residency Direcis a PGY1 Community-Based Restory. Accessed February 28, 2023. ident at Novant Health New Hahttps://accreditation.ashp.org/dinover Regional Medical Center, rectory/#/program/residency Taylor.Mitchell@novanthealth. 6. American Society of Health-System org. Geena Eglin, PharmD, BCACP, Pharmacists. ASO Model Types. AcCSP, CPP, is the PGY1 Community-Based Residency Director at Novant Health New Hanover RePERSONAL PERSPECTIVES gional Medical Center in Wilmington, NC. ACKNOWLEDGEMENT The authors thank Michelle Rager, PharmD, BCPS, BCACP, for the helpful discussion and comments on this manuscript.

REFERENCES 1.

2.

Letendre DE, Brooks PJ, Degenhart ML. The evolution of pharmacy residency training programs and corresponding standards of accreditation. Pharm Pract Manag Q. 1995;15(2):30-43.

American Society of Health-System Pharmacists. Accreditation

Geena Eglin, PharmD, BCACP, CSP, CPP, secured her PGY2 ambulatory care residency position at Novant Health NHRMC in 2019-2020 after completing a PGY1 CPRP in Springfield, Massachusetts. After completion of her postgraduate training, Dr. Eglin was well prepared for her job in a specialty CPP position and is now transitioning into her newly appointed role as the Novant Health NHRMC PGY1 CPRP residency director. Dr. Eglin states, “Candidates completing a PGY1 CPRP are exposed to the best range of experiences, setting up graduates to be successful in many different practice areas, including traditional operations, specialty pharmacy, ambulatory care, and population health.”

This was the case for Samantha Seivert, PharmD, BCPS, a graduate of the University of Illinois at Chicago. “I looked heavily at programs in North Carolina because of the opportunity for a CPP license, which is a unique opportunity this state provides for pharmacists to practice at the top of their license,” states Dr. Seivert, a Novant Health NHRMC PGY1 CPRP graduate. Due to her advanced and unique learning experiences obtained during her PGY1 CPRP residency, Dr. Seivert received her Board-Certified Pharmacotherapy Specialist certificate and transitioned into a CPP role focusing on cardiology.

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Table 1 PGY1 CPRPs Definitions as Adapted from ASHP PGY1 CPRPs

Description

Independent Pharmacy

A privately owned retail pharmacy that is not directly affiliated with any chain of pharmacies and is not owned/operated by a publicly traded company.

Hospital/Health-System Outpatient Pharmacy

The organization or department of the hospital is responsible for the procurement, storage, preservation, packaging, compounding, preparation, and dispensing of medications to patients preparing to be discharged from the hospital or outpatients.

Chain Pharmacy

Acute Care/Hospital/ Ambulatory Care Center

A group of four or more community pharmacies are part of the same company/organization.

Teaching Hospital: Hospital with an accredited medical residency-training program and affiliation with a medical school.

General Community: Non-federal, short-term hospital where diagnostic or therapeutic services are available to the public.

Rural Hospital (includes Critical Access Hospitals): Hospital outside the U.S. Census-designated Metropolitan Statistical Area.*

Government Hospital: Federal government hospital (Veterans Affairs, Department of Defense, Public Health Service, Indian Health Service, and Bureau of Prisons).

Children’s Hospital: A hospital that offers services exclusively to infants, children, adolescents, young adults up to age 18, and adults in special cases.

Long-Term Care Hospital: A hospital that provides medical and skilled nursing services to patients with long-term illnesses who are not in an acute phase but require a level of service not available in a nursing home.

Psychiatric Hospital: A hospital that provides diagnostic/ treatment services to patients with mental and emotional disorders.

Rehabilitation Hospital: A hospital that provides medical, health-related, social, and vocational services to disabled individuals to help them attain their max functional capacity.

Ambulatory Care Center: Care provided by health care professionals in outpatient settings such as medical offices and clinics, hospital outpatient departments, and federally qualified health centers.

University/College of Pharmacy/School of Pharmacy-sponsored program: Residency program sponsored by one of these entities responsible for administering and coordinating the program.

*Area delineated by the U.S. OMB as having >1 urbanized area and a population >50,000.

Figure 1 Location of North Carolina PGY1 CB Pharmacy Residency Programs

Note: Each pin shows the general areas where PGY1 CB Pharmacy Residency Programs are offered and may represent multiple practice sites or available positions.

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2023 Poster Abstracts

1. Utilization of Video-Based Interactive Tools as a Lecture Replacement and Supplementation in an Integrated Pharmacotherapy Course Authors: Jennifer Wood, PharmD, BCPS; Rebecca Grand; Devin Olden; Scott Perkins, PharmD; Riley Bowers, PharmD, BCPS, BCCP

Institution: Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC Objectives: The primary objective of this study was to evaluate results from the implementation of interactive video-based tools as a replacement and supplement to in-class lectures in an integrated cardiovascular pharmacotherapy course.

Methods: Faculty members created an abbreviated interactive lecture accompanied by two interactive video-based supplemental tools, which were uploaded into the learning management system.

This was offered as an alternative to the standard two-hour lecture and provided students with the opportunity to review pharmaco-

therapy for arrhythmias. The first supplemental tool focused on atrial arrhythmias and was comprised of five case-based vignettes. The second supplemental tool focused on ventricular arrhythmias and was comprised of four case-based vignettes, along with an abbreviated asynchronous lecture with added instructor commentary. It was not mandatory for students to complete the supplemental tools, with students being able to select how many modules within the tools to complete. After exposure to course material and the interactive video-based materials, all learners completed an assessment with material from the lecture replacement and material covered in traditional lectures.

These assessment scores were compared between serious users of the new tool versus non-users.

Results: At least one module within the optional supplemental tool was utilized by 39 (56.2%) students in the class. Serious attempts at completing the tool were made by 22 (32.8%) learners. Mean assessment score for questions related to the optional interactive video tools for serious Page 50

users was 81.5% versus 72.1% for non-users (P=0.0026). Scores related to non-interactive topics showed no difference when comparing serious users of the tool versus non-users (81.2% vs.

77.8%; P=0.1401). Overall, utilization of optional video-based learning tools was correlated with improved performance on targeted disease states compared to non-supplemented material.

Conclusion: Results indicate that implementation of interactive video-based supplemental material is an effective approach to enhance learning outcomes in an integrated pharmacotherapy course.

2. Implementation of a HFpEF/ HFmrEF medication order set to improve evidence-based therapies at hospital discharge Authors: Jacklyn Rispin, PharmD, Carrie Baker, PharmD, MBA, BCPS, Riley Bowers, PharmD, BCCP, BCPS

Institution: Cape Fear Valley Medical Center, Fayetteville NC

Objective: The objective of this study was to compare the percentage of patients optimized on guideline-directed medical therapy (GDMT) based on the 2022 ACC/AHA/HFSA Heart Failure guideline updates at discharge before and after the implementation of an order set.

of HFmrEF, and 100 had HFpEF. At admission, 43.5% were receiving an ACEi/ARB/ARNI, 60.9% a BB, 7% an MRA, and 6.1% were on an SGLT2i. There were 5 patients (4.3%) receiving appropriate therapy at discharge with the opportunity for further optimization in 11 patients with HFmrEF, and 68 patients with HFpEF. The Methods: This retrospective co- order set was utilized by providhort study examined adult pa- ers on 9 patients (7.8%). tients hospitalized with a heart failure diagnosis, ejection fraction Conclusion: Appropriate GDMT (EF) ≥ 41%, and NYHA class II-IV, at discharge increased by 3% afreceiving medical treatment pre ter the implementation of an orand post-order set implementa- der set; however, opportunities tion. The primary objective was for further optimization of therato compare the percentage of pa- py remain. tients fully optimized on GDMT before and after order set imple- 3. Direct Oral Anticoagulants: mentation. Full optimization was A Retrospective Evaluation of defined as patients receiving all Prescribing Practices clinically appropriate agents for heart failure with mildly reduced Authors: Lyric Chaplin, PharmD; ejection fraction (HFmrEF)/heart Hau Le, PharmD​ ; Kristen Mckfailure with preserved ejection night, PharmD, BCPS, CDCES, CPP; fraction (HFpEF) prior to dis- Justin Arnall, PharmD BCOP; Paige charge.

Carson, PharmD, CDCES, BCPS, CPP;​Andrew Clark, PharmD, Preliminary Results: There BCPS, CDCES, CPP; Laura Skaff, were 372 patients included in PharmD, BCACP, CPP ​ the pre-order set group. A total of 41 patients had a diagnosis of Institution: Atrium Health CabarHFmrEF, and 330 had HFpEF. At rus, Concord NC admission, 43.3% were receiving an ACEi/ARB/ARNI, 63.4% a Objective: The purpose of this beta-blocker (BB), 9.9% a min- study is to review current drug eralocorticoid receptor antago- utilization and identify prescripnist (MRA), and 7.5% were on a tion trends that may indicate sodium-glucose co-transporter-2 needed interventions. inhibitor (SGLT2i). Overall, 5 patients (1.3%) received appropri- Methods: This medication use ate therapy at discharge, with 20 evaluation was a retrospective, patients in the HFmrEF group and multicenter chart review with a 248 patients in the HFpEF group data collection period from Janqualifying for additional therapy. uary 1st, 2021, to June 30th, 2021.

There were 115 patients included Data was collected from identiin the post-order set group. A to- fied inpatient hospitals and outtal of 15 patients had a diagnosis patient clinics in the Charlotte, Page 51

NC Metro region from patients who were started on therapeutic apixaban, rivaroxaban, or dabigatran. Patients were included in the study if they were aged 18 or older and who were initiated on a DOAC by a prescriber within the Atrium Health system. Primary outcomes included the number of major bleeding events, major adverse cardiovascular events (MACE), venous thromboembolism (VTE) events, stroke, emergency department/hospital admissions, and adverse reactions to a DOAC. Secondary outcomes included the type of drug therapy problem which prevented the appropriate use of DOACS, the number of patients with pharmacy intervention/consults regarding their DOAC dose, and which disease state or DOAC had the most frequent inappropriate dosing.

Results: A total of 200 patients were included in the medical use evaluation. The mean age was 62.3, apixaban was prescribed in 79% of the patients, while the other 21% were prescribed rivaroxaban. Patients were being treated for atrial fibrillation (35%), pulmonary embolism (33%), or deep vein thrombosis (29%). 14.5% of patients experienced a primary outcome related to a DOAC within 6 months after starting. 32% of patients experienced a drug therapy problem within 6 months of starting a DOAC.

Conclusion: Patients who are started on DOAC therapy need routine monitoring to ensure they are maintained on the correct dose. Pharmacists can evaluate DOAC therapy to assess proper dosing and adjust as necessary through routine outpatient mon-

itoring.

4. Impact of a Clinical Decision Support System on Antibiotic Prescribing Durations Authors: Marcus Mize, PharmD; Nicolo Vargas, PharmD, BCPS; Vickie Malloy, PharmD; Jennifer Wood, PharmD, BCPS; Serina Tart, PharmD Institution: Cape Fear Valley Medical Center, Fayetteville NC Objective: The primary objective of this study was to compare the number of patients who received evidence-based antimicrobial duration for urinary tract infection (UTI) and community-acquired pneumonia (CAP) before and after implementation of clinical decision support systems with indication-specific, guideline-directed durations of therapy. Secondary objectives included the number of patients who received evidence-based antimicrobial durations for UTI or CAP and the mean overall durations of therapy before and after the implementation of clinical decision support systems.

Methods: The medical records of 994 patients receiving antibiotics for CAP and/or UTI from October 1, 2022, to November 30, 2022, and January 1, 2023, to February 28, 2023, were reviewed. Patients who had COVID-19 infections, concomitant bacterial infections requiring prolonged antibiotics, were discharged to another facility, left against medical advice, or expired during admission were excluded. Data collected included patient demographics, antibiotic allergies, indication for antibiotics, as well as name and duration

of prescribed antibiotic(s).

millions of Americans. The primary purpose of this study is to dePreliminary Results: 125 pa- termine whether a presentation tients with CAP and 111 patients on signs and symptoms of opioid with UTI were included in the overdose and naloxone use inpre-implementation group, and creases attendee knowledge and 76 patients with CAP and 98 pa- confidence pre-and post-intertients with UTI were included in vention. the post-implementation group.

The duration-appropriate du- Methods: A presentation on opirations were 115/213 in the oid overdose and its treatment pre-implementation group and was delivered to undergraduate 104/164 in the post-implementa- and graduate students, facultion group. The mean total dura- ty, staff, and guests of a private tions for CAP were 7.9 days prior university. Participants 18 years to implementation and 7.8 days of age and older were included. after implementation. The mean Pre- and post-presentation surtotal duration for UTI was 7.0 veys assessed attendee baseline days prior to implementation and knowledge of opioid overdose 6.9 days after implementation. signs and symptoms and gauged understanding regarding using Conclusion: Although the im- naloxone in overdose situations. plementation of a clinical deci- Survey questions included multision support tool increased the ple-choice and open-ended quespercentage of patients receiving tions. Additionally, students were guideline-directed durations of asked to rate their confidence in therapy for UTI and CAP, the over- recognizing signs and symptoms all duration was not significantly of an opioid overdose (scale of 1 different before and after imple- to 10, 10 = very confident). Particmentation. Further interventions ipants who completed both surmay be necessary to reduce veys were included in the study. the duration of antibiotics prescribed to hospitalized patients Results: Fifty-three attendees to improve adherence with guide- (n=11 [21%] graduate students, line-recommended durations. n=42 [79%] undergraduate students) completed both surveys.

The mean pre- and post-presen5. Assessing self-perceived rec- tation confidence of attendees in ognition of opioid overdose recognizing overdose signs and signs and symptoms and use symptoms was 4.5 and 7.9, reof naloxone through the use of spectively (p<0.001). Prior to the an open-ended survey pre- and presentation, 9% (n=5) of particpost-educational encounter ipants correctly identified signs and symptoms of an overdose Authors: Rama Shamieh, PharmD which improved to 34% (n=18) Candidate; Susan M. Smith, BS, post-presentation. When asked PharmD, BCPS if a prescription was needed for naloxone, most participants statObjective: Misuse of opioids af- ed they were unsure (n=22, 42%). fects the health and well-being of After the presentation, 92% Page 52

(n=49) of participants stated that a prescription was not needed. In response to the open-ended question, “What is naloxone used for?”

57% (n=30) correctly stated “opioid overdose reversal;” this improved to 85% (n=45) post-presentation.

Conclusion: A presentation on opioid overdose and naloxone use can significantly improve attendee knowledge as well as improve self-perceived confidence in recognizing overdose situations.

Educational efforts geared specifically toward undergraduate students can be very impactful.

6. System Integration of P&T and Policies and Procedures across Managed Entities Authors: Ryan Mills, PharmD, MBA, MHA, BCPS, CSP, Toni Currin, PharmD, MBA, MSCR Institution: UNC Health – UNC Health Johnston and UNC Health REX

Policies and Procedures were cataloged and ranked based on key protocols, clinical documentation paths, and medication selection processes that are common to all four hospitals. We chose one or two to tackle each week using the catalog summary comparing UNC Health Johnston and UNC Health Rex policies. The policies that are coming up for review at local P&T were prioritized. Policies were meshed together based on likeness, removing what was no longer relevant. Then we prepared a draft for stakeholder feedback.

The goal was to begin aligning the Policies and Procedures to facilitate the transition to a regional P&T, which helped address barriers such as different sites practicing differently. The regional P&T serves as the approval committee of regional policies and procedures.

Conclusion: Standardizing Policies and Procedures while building the framework for regionalizing P&T is a beneficial model addressing barriers and challengObjective: This review aims to es of aligning managed hospitals describe the regionalization of across a health system.

P&T and Policies and Procedures across UNC Health Johnston and UNC Health REX. 7. Antipsychotic utilization, healthcare resource use, costs, Methods: The first step in align- and quality of care among all ing our local P&T and Policies fee-for-service Medicare beneand Procedures across four hos- ficiaries with schizophrenia in pitals in the region was designing North Carolina a structure, cadence, and bylaws agreed upon across the region. Authors: Jalpa A. Doshi1, SanMultiple stakeholders were in- ghyuk Seo2, Charmi Patel2, Zhi volved in the design, creating Geng1, Carmela Benson2, Brianne ownership and buy-in. Simultane- Brown2, Pengxiang Li1 ously while designing our region- Institution: 1University of Pennal P&T, Policies, and Procedures sylvania, Philadelphia, PA, USA; were reviewed locally for regional 2Janssen Scientific Affairs, LLC, Titusville, NJ, USA alignment.

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Objective: To describe antipsychotic use, healthcare resource use (HRU), costs, and quality of care among all fee-for-service (FFS) Medicare beneficiaries with schizophrenia in North Carolina and examine county-level variations in these measures.

Methods: The sample included all adult Medicare beneficiaries in North Carolina with continuous FFS Medicare Parts A, B, and D coverage and 1 inpatient and/ or ≥2 outpatient claims with a diagnosis for schizophrenia in the 2019 100% Medicare data files. Summary statistics on antipsychotic use, HRU and cost, and quality measures were reported.

Results: In our final sample of 11,457 beneficiaries, 92% received Part D low-income subsidies, and 87% were dually eligible for Medicare and Medicaid. About 91% used any antipsychotic, 23% used any long-acting injectable (LAI), and 16% used atypical LAIs. About 27% of patients had ≥1 hospitalization, and 50% had ≥1 emergency room (ER) visits, with the majority of both related to mental health. Mean total annual all-cause, mental health, and schizophrenia-related costs were $23,015, $14,431, and $12,109, respectively. Among patients with hospitalizations, 15% and 24% had readmission within 7 and 30 days, and 56% and 70% had a physician visit and an antipsychotic fill 30 days post-discharge, respectively. Large county-level variations were found in LAI use (14% [Stanly and Iredell] to 36% [Franklin]), all-cause hospitalizations (19% [Randolph and Rutherford] to 48% [Granville]), all-

cause ER visits (32% [Watauga] to 69% [Pender]), all-cause total costs ($11,871 [Currituck] to $ 35,316 [Jones]), and 30-day hospital readmissions (17% [Gaston] to 38% [Cumberland]).

as stable ischemic heart disease (SIHD), minor stroke/transient ischemic attack (TIA), or acute coronary syndrome (ACS) receiving antithrombotic medications during hospitalization between June 1, 2020 – June 1, 2021. DisConclusions: In this study ex- charge summaries and outpatient amining all 2019 FFS Medicare fill histories at 1 month, 3 months, beneficiaries with schizophre- 6 months, or 12 months were nia in North Carolina, we found used to assess antithrombothigh levels of hospital admis- ic prescribing appropriateness sions, readmissions, and ER vis- based on the indication. its, suggesting a high burden of schizophrenia. Large county-level Results: A total of seventy-six pavariations found in LAI use, HRU, tients were included in the study. cost, and quality measures across The majority of patients had a North Carolina call for additional past medical history significant targeted quality improvement ini- for hypertension (87%), hypertiatives by state and local policy- lipidemia (71%), and diabetes makers.

(59%). There was no difference in the primary endpoint of the 8. Evaluation of appropriate an- percentage of appropriate antitithrombotic prescribing in pa- thrombotic medication prescribtients with primary ASCVD in a ing in patients with ASCVD based community hospital on the initial event, defined as SIHD, minor stroke/TIA, or ACS Authors: Sarah McGrath, PharmD, (p = 0.155). The percentage of MSCR, Carrie Baker, PharmD, appropriate antithrombotic preMBA, BCPS, Riley Bowers, scribing in patients by indication PharmD, BCCP, BCPS was SIDH: 13/25 (50%), minor Institution: Cape Fear Valley stroke/TIA: 6/12 (50%), and Health Systems, Fayetteville, NC, ACS: 21/38 (55%). No difference Campbell University College of in appropriate antithrombotic Pharmacy, Buies Creek, NC prescribing was seen based on the patient’s self-identified race Objective: The primary objective (p=0.793) or insurance status was to compare the percentage (p=0.111). of appropriately prescribed antithrombotic medications based on Conclusion: Despite the lack of guideline-recommended medica- statistically significant results, tions and durations of therapy in DAPT duration remained incorpatients with ASCVD based on the rect in approximately 50% of the initial event. patient population. This highlights the necessity for additional Methods: This single-center ret- prescriber education for the most rospective cohort study identified effective patient outcomes. patients through a computer-generated report based on a diag- 9. Comparison of AUC/MIC Vannosis of primary ASCVD defined comycin Dosing Versus TroughPage 54

Based Dosing in Patients with Extremes of Body Weight Authors: Taylor Felton, PharmD; Emily Johnson, PharmD, BCPS; Riley Bowers, PharmD, BCCP, BCPS; Brock Dorsett, PharmD, BCPS Institution: Cape Fear Valley Medical Center- Fayetteville, NC

Objective: The purpose of this study was to assess the attainment of initial therapeutic concentration in patients with extremes of body weight receiving AUC/MIC-based dosing versus trough-based vancomycin dosing.

Methods: Adult patients hospitalized at Cape Fear Valley Medical Center, who were considered obese or underweight, that received vancomycin therapy with at least one documented vancomycin concentration, were retrospectively reviewed in this single-center cohort study. Obese was defined as weighing at least 100 kilograms or with a BMI of at least 30 kg/m2, and underweight was described as weighing 50 kilograms or less or with a BMI of 18.5 kg/m2 or less. The primary endpoint was the percentage of obese and underweight patients achieving initial therapeutic concentration for AUC/MIC-based vancomycin versus trough-based vancomycin dosing.

Results: 220 patients met the inclusion criteria, with 114 patients in the trough-based dosing group and 106 patients in the AUC/MICbased dosing group. AUC/MICbased dosing yielded a higher rate of initial therapeutic concentrations than trough-based dosing, 50.0% vs. 17.5%, respectively (p<0.0001). This difference was

the minimal monitoring group, had entirely virtual visits during treatment. Both groups received telephonic touchpoints from a Clinical Pharmacist Practitioner (CPP) and Nurse Care Coordinator (NCC) throughout DAA treatConclusion: AUC/MIC vancomy- ment. The primary outcome was cin dosing is superior to trough- the SVR12 rate. Student t-tests based vancomycin dosing in were conducted for continuous patients with extremes of body variables and chi-square tests for categorical variables. weight. primarily driven by the underweight population, with 62.5% of the AUC/MIC-based dosing group achieving initial therapeutic concentrations versus only 9.3% in the trough-based dosing.

10. Standard Versus Minimal Monitoring for Hepatitis C Direct Acting Antiviral (DAA) Therapy at an Academic Medical Center

Authors: Anita Yang, PharmD1; Neel Swamy, MPH, PharmD Candidate2, Jane Giang, PharmD, BCPS, BCGP, CPP1

Institutions: 1University of North Carolina Health Care, Chapel Hill, North Carolina, USA 2 University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA

Results: From 5/1/2020 to 4/30/2021, 133 HCV patients met inclusion criteria and were treated with DAA (Cohort 1: n=56; Cohort 2: n=77). There were no differences in baseline demographics, and most patients received Epclusa or Mavyret for 8-12 weeks. Total encounters remained significantly higher in Cohort 1 compared to Cohort 2 (Cohort 1: 3.1 ± 1.0 vs. Cohort 2: 2.8 ± 1.2; p=0.047), whereas Cohort 2 had higher telephonic CPP and NCC touchpoints (Cohort 1: 2.1 ± 1.2 vs Cohort 2: 2.5 ± 1.9; p=0.045). Although Cohort 2 had a higher loss to follow-up rates (Cohort 1: 7.1% vs. Cohort 2: 18.2%; p=0.06), ultimately, there were no differences in SVR rate between cohorts (Cohort 1: 91.1% vs. Cohort 2: 77.9%; p=0.13),

Objective: The purpose of this study was to assess minimal monitoring approaches in Hepatitis C virus (HCV) direct-acting antiviral (DAA) therapy to overcome the burden for clinic and patient while maintaining undetectable Conclusion: This single-center HCV RNA 12 weeks after the end study demonstrates that minimal monitoring during HCV treatment of treatment (SVR12). through post-treatment week Methods: A 12-month, single-cen- 12 is more effective in achievter retrospective chart review ing SVR cure rates than standard was conducted in treatment-naïve monitoring. Eliminating required HCV-infected adults who received in-person clinic visits during DAA DAA therapy between 5/1/2020 therapy alongside a collaborative to 4/30/2021. Patients in Cohort approach may play a major role in 1, the standard monitoring group, overcoming barriers to HCV care had > 1 in-person clinic visit in select patients. during DAA treatment. Cohort 2, Page 55

11. Community Health Outreach: Sugary Beverage Consumption and Obesity & Type 2 Diabetes Mellitus Authors: Audrey Shulz, Kennedy Bradsher, Eric Melton, Chad Staunton, Semya Thompson, and Amie J. Dirks-Naylor Institution: Wingate University School of Pharmacy, Wingate, North Carolina Objective: The Healthy People 2030 established that over-consumption of sugary beverages has caused an increase in the prevalence of obesity & type 2 diabetes mellitus (T2DM) in the U.S. Thus, the overarching goal of this project was to reduce the prevalence by educating college students on sugary beverage consumption (SBC) and risks of developing obesity and T2DM. The specific objective was to determine if a pharmacy student-led educational session, delivered via Zoom or a tri-fold display booth, could improve knowledge regarding SBC and T2DM/obesity and increase the likelihood of reducing SBC among college students.

Methods: An educational session was delivered using two different formats; one developed using PowerPoint and delivered via Zoom in a group setting, and the other utilizing a tri-fold display with content delivered via oneon-one walk-up discussions. Both types of sessions were held on a college campus and presented to mainly undergraduate students by five second-year student pharmacists. Both formats included the same educational content.

Links to online pre- and post-surveys were provided to partici-

pants. Responses were recorded the structures and processes of using Qualtrics. billed care coordination notes for youth with intellectual and develResults: Sixty-two and 64 par- opmental disabilities, psychiatric ticipants completed the pre-sur- conditions, and complex medical vey and post-survey, respectively. conditions. This study seeks to Approximately 79% attended the describe elements of billed care Zoom session vs. the alternative. coordination to facilitate broadParticipants were mostly female er billing for care coordination in (61%) and split evenly between practices and research using reexercisers and non-exercisers. al-world administrative data.

Approximately 70% consume 1-2 sugary drinks daily, while 20% Methods: Billed medical notes inconsume three or more daily. volving care coordination for chilNearly 97% stated that the educa- dren with intellectual and develtional session changed their per- opmental disabilities, psychiatric spective on SBC, with 86% likely conditions, and three or more to change their SBC. The interven- complex chronic conditions seen tion improved knowledge of the annually from 2015-2019 were topic, including recommended extracted (N=36). A literature redaily maximum sugar intake, how view was conducted to identify to read a nutrition label to deter- common features of care coormine sugar consumption, conver- dination services. Medical notes sion of grams to teaspoons of sug- were coded for potential strucar, and characteristics of T2DM/ ture and process aspects of a care obesity. coordination visit. Illustrative quotes were collected, and medConclusion: The pharmacy stu- ical notes were analyzed for key dent-led educational sessions themes. Two team members deincreased awareness and knowl- veloped a coding manual, coded edge of SBC and T2DM/obesity each record, and met periodically and increased the self-reported to discuss and reconcile differenclikelihood of a change in SBC. es. Co-authors provided input to describe the sample, clinical prac12. Care Coordination for High tice, and research implications of Need Children: Structure and the data.

Process from EPIC Billed Medical Notes Results: Structures of care coordination notes involved timAuthors: Cassie Twisdale, ing, billing codes, and standard PharmD Candidate1, Catherine phrasing. Key themes of proAllen, PharmD Candidate1, Neal cesses identified include medical DeJong M.D. 2, Izabela Annis, MS,1 specialists, identification of famiKathleen C Thomas, Ph.D. 1 ly structure, addressing the chal1 Institution: UNC Eshelman lenges of moving, assessment for School of Pharmacy, 2UNC School state and federal benefits, school of Medicine communication, parent communication, assessment of basic Objective: The primary objec- needs, mental health, vaccines, tive of this study was to examine and direct patient follow-up.

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Some themes were linked to billing requirements, while others involved addressing medical and non-medical needs.

Conclusion: Findings provide insight into the structures and processes of real practice care coordination that have not been well described before. Billed care coordination medical notes involve themes that support high-quality care coordination. The inclusion of key themes related to structure and process of care coordination to support billing of these services has the potential to help provide high-need children with holistic care.

13. Impact of a pharmacist-led “Every Try Counts” smoking cessation appointments on quit attempts in a primary care clinic

Authors: Danielle McGlynn, PharmD, Erika McClain, PharmD, BCPS, BCACP, CPP, and Elizabeth Hudson, PharmD, MBA, BCACP, CPP Institution: Cape Fear Valley Health System, Fayetteville, NC

Objective: The primary purpose of this study was to describe the impact of “Every Try Counts” in a primary care clinic on patients’ ability to have at least one successful quit attempt, defined as abstaining from smoking for at least 24 hours in a 30-day period. Secondary objectives were to describe the mean number of successful quit attempts per patient in a 30-day period, the impact of implementing “Every Try Counts” on patients’ ability to abstain from smoking for 3 and 5

days, patient perceptions of “Every Try Counts” evaluated during 1-month follow-up survey, and the rate of pharmacologic therapies utilized in combination with “Every Try Counts” to assist with smoking cessation.

macists prescribing hormonal contraceptives in North Carolina

Authors: Joseph Martinez, 1,2 PharmD ; Katie Trotta, PharmD, BCACP2; James Honeycutt, 1 PharmD, MBA ; Charles Herring, Methods: From November 1, PharmD, BCPS, CPP2.

2022, to March 30, 2023, 18 patients saw a Clinical Pharmacist Institution: 1Walgreen Co, DeerPractitioner at a primary care field, IL; 2Campbell University clinic for a smoking cessation ap- College of Pharmacy and Health pointment where strategies from Sciences, Buies Creek, NC. the FDA campaign “Every Try Counts” were utilized. A 1-month Objective: North Carolina House follow-up phone call and survey Bill 96 allows an immunizing were completed to quantify quit pharmacist to provide hormonal attempts and patient satisfaction. contraceptives (HCs). The purpose of this study was to gather Results: Of the 18 patients at- and collate information regarding tending the initial smoking ces- successes/challenges from pharsation appointment, 6 scheduled macists who have provided HCs follow-up visits, 2 attended fol- in an outpatient practice to assist low-up visits, and 6 completed others in the implementation of the 1-month follow-up survey. At this service. The primary objecleast one successful quit attempt tive was to assess the proportion in a 30-day period was had by 4 of NC pharmacists who developed of 6 patients (66.7%). The mean this service and provided HCs in number of quit attempts per pa- an outpatient setting. The secondtient over a 30-day period was ary objectives were to address the 2. Although only 50% of patients outcomes/barriers during the rewere able to abstain from smok- quired training/ implementation ing for 3 days and 33.3% of pa- of this service. tients were able to abstain from smoking for 5 days, all 6 patients Methods: A cross-sectional, webfelt “Every Try Counts” was help- based survey was sent in Deful, rating it at least a 3, on a scale cember 2022 to NC pharmacists from 1 to 5. Half of the patients enrolled in the required North Carolina Association of Pharmautilized pharmacologic therapy. cists (NCAP) HC training, with Conclusion: Patient perceptions all responses between December of the “Every Try Counts” smok- 2022 and January 2023 considing cessation method were pos- ered. Inclusion criteria included itive; however, barriers exist to pharmacists licensed in NC and implementing smoking cessation performed at least 50% of their clinical practice in an outpatient services. setting. The primary endpoint 14. Implementation and per- was the percentage of pharmaception of outpatient phar- cists who had prescribed HCs out Page 57

of pharmacists surveyed. All endpoints were analyzed using descriptive statistics.

Results: The survey was sent to a total of 1633 pharmacists. 96 completed surveys were included in the analysis (5.88% completion rate). 19 pharmacists (19.8%) developed a HC service, with 15 of these pharmacists having provided HCs (15/96, 15.63%). All 15 respondents reported positive patient feedback, while 7 reported improved job satisfaction. The barriers reported include a lack of appropriate reimbursement, cost prohibitions for patients, and time constraints. 11 (11.5%) respondents had yet to complete the NCAP training, while 66 respondents had completed the training without implementing the service (66/96, 68.75%).

Conclusions: A small proportion of advanced-trained NC outpatient pharmacists are providing HCs to their patients, mostly in rural independent pharmacies.

Addressing the numerous barriers would expand the scope of this service and innovate the outpatient pharmacy setting.

15. Impact of Therapeutic Carbohydrate Reduction on Weight, Cardiometabolic Laboratory Markers, and Medication Requirements in Patients with Type 2 Diabetes Authors: Kendrick Murphy, PharmD, BCACP; Amy Thompto, MS, RD/N; Kaitlyn Quinn, PharmD Institution: Charles George VA Medical Center, Asheville NC Objective: The primary objective

of this project is to evaluate the impact of adopting a low or very low-carbohydrate diet on weight loss, cardiometabolic laboratory markers, and medication requirements in patients with type 2 diabetes.

HgbA1c = 7.7%; fasting blood glucose = 177; total cholesterol = 150 mg/dL; LDL = 89 mg/dL; HDL = 37 mg/dL; triglycerides = 215 mg/dL; AST = 23 U/L; ALT = 40 IU/L; ALP = 86 U/L; albumin = 3.8 g/dL. Average BMI = 38.7. In all patients, eGFR > 45 mL/min/1.73 Methods: Twenty-seven partic- m2 and serum creatinine < 2.0 ipants initially enrolled in the mg/dL. C-peptide was within norsixteen-week Therapeutic Carbo- mal limits for all patients. hydrate Reduction (TCR) Aspire Conclusion: To be determined. program. All participants were asked to obtain pre-program labs 16. Impact of Clinical Pharwithin one month of the class macist Practitioner Service start date or up to two weeks af- Implementation on Hormone ter the class start date. Ordered Therapy Adherence in Horlabs include HbA1c, fasting blood mone-Positive Breast Cancer glucose, lipid panel, serum creat- Patients inine/eGFR panel, liver function panel, and C-peptide. Participants Authors: Lainey Vargo, PharmD, are asked to regularly check their Dustin Bryan, PharmD, BCPS, blood glucose and blood pres- Paige Perez, PharmD, BCPS, CPP sure and report their weight on Institution: Cape Fear Valley Meda weekly basis. A registered di- ical Center, Fayetteville, NC etitian will lead a weekly virtual group class helping participants Objective: The primary purpose successfully reduce carbohydrate of this study was to evaluate the consumption. A Clinical Pharma- impact of a Clinical Pharmacist cist Practitioner and PGY1 phar- Practitioner (CPP) on the adhermacy resident will make medi- ence rates in hormone-positive cation interventions as indicated breast cancer patients referred to manage hypoglycemia, hypo- for suboptimal adherence at Cape tension, and other side effects of Fear Valley Cancer Treatment and carbohydrate reduction. Partic- Cyberknife Center. This research ipants will complete repeat labs will also identify and describe adduring the final two weeks of the herence barriers commonly seen program. Any labs obtained two among this patient population. weeks after the last session will be included for review.

Methods: The medical records of 92 patients with hormone-posiResults: The TCR Aspire program tive breast cancer who have filled will conclude in late April 2023. an oral hormone therapy within As of week 12, several patients the Cape Fear Valley Health Syshave had antihyperglycemic & tem between May 2022 and Octoantihypertensive medications re- ber 2022 were reviewed. Patients duced or discontinued. Eighteen who filled more than a 30-day participants obtained baseline supply at a time and whose adlabs. Average baseline laborato- herence at baseline was identified ry results include the following: to be > 90% utilizing proportion Page 58

of days covered (PDC) were excluded. Data collection included patient demographics, hormone medication, duration of therapy, baseline and follow-up PDC, and patient-described adherence barriers.

Results: Nine patients with a mean age of 59 years, and a mean baseline PDC of 0.68 were included. Majority of patients were on letrozole (33%), followed by anastrozole (22%), tamoxifen (22%), abemaciclib (11%), and palbociclib (11%). Three-month analysis after the intervention with a CPP showed that PDC increased by an average of 0.09. Post-intervention mean PDC was 0.76. Survey results for patient-described adherence barriers revealed that the most common adherence barrier in this patient population was due to adverse effects. Other common adherence barriers included poor health literacy, and medication non-compliance.

Conclusions: In hormone positive breast cancer patients identified to have sub-optimal adherence an appointment with a CPP increased patients PDC on average by 0.09.

17. Outcomes of Student Pharmacist-Led Educational Interventions on Medication Reconciliation Process

Authors: Lauren Fasth, PharmD Candidate1, Chelsea Atkins, MS, MPH2, Nancy Kubiak, MD, FACP2, Casey Wells, PharmD, CPP1,2 1 Institution: UNC Eshelman School of Pharmacy, Asheville NC; 2 Mountain Area Health Education Center (MAHEC), Asheville NC

Objective: To determine if student pharmacist-led educational interventions improved the thoroughness of medication reconciliations completed by certified medical assistants (CMAs) over extended time periods.

Methods: Over a 4-month period, seven CMAs within an Internal Medicine Clinic were observed conducting 100 medication reconciliations. First, an initial observation of 25 medication reconciliations was completed by two investigators (LF, CW). Then, CMAs attended three 30-minute lectures over the course of a fourmonth period: T1 = teaching one on medication reconciliation best practices, T2 = teaching two on the top 50 medications prescribed by providers in internal medicine, T3 = teaching three on over-thecounter products. Each was conducted by the student-pharmacist and developed based on best practices for medication reconciliations outlined in the 2018 ASHP Medication Reconciliation Guidance Document for Pharmacists.

Post-education observations were conducted after 1-month, 3-month, and 4-month intervals.

Results: The overall number of questions CMAs asked during their medication reconciliations increased by 12.6% over the 4-month period after attending three teaching sessions. In addition, the overall number of questions CMAs omitted decreased by 40.5%. However, an increase was observed in the number of questions omitted between months 1 and 3, in which no educational intervention occurred.

cists can effectively provide educational interventions to CMAs to improve the thoroughness of medication reconciliations completed in outpatient clinical settings. However, due to the decline in performance seen between months 1 and 3, regular training is needed for sustained improvement. Future research should consider the impact of an embedded medication reconciliation checklist in the EHR to further improve CMA performance.

18. The Effect of Semaglutide on Insulin Requirements and Overall Diabetes Control in Patients with Type 2 Diabetes at the Charles George VA Medical Center Authors: Diana Loffgren, PharmD, MHPA, BCACP, CDCES, and Lindsey Baugham, PharmD Institution: Charles George Veterans Affairs Medical Center, Asheville NC

Objective: The purpose of this project was to assess changes in insulin regimens and overall diabetes control in patients on semaglutide and insulin at the Charles George VA Medical Center. The primary outcome was any change in insulin doses 6 and 12 months after the initiation of semaglutide.

The secondary outcomes were any changes in A1c or weight at the same time points.

Patients were excluded if they had Type 1 Diabetes, had prior semaglutide use, used semaglutide for less than 6 months, or were on hospice or pregnant at the time of semaglutide initiation.

Results: 161 patients were included in the final analysis. The most common reason for exclusion was less than 6 months of semaglutide use (95%), with the next most common reason being prior semaglutide use (5%). On average, patients were taking 77 units of basal insulin at baseline and had a subsequent dose reduction of 4 and 6 units at 6 and 12 months, respectively (p<0.01 for both time points). This correlates roughly to a 5-8% dose reduction.

Patients were taking an average of 80 units of bolus insulin at baseline and had a subsequent dose reduction of 6 and 8 units at 6 and 12 months, respectively (p<0.01 for both time points). This correlates roughly to an 8-10% dose reduction. Patients lost an average of 8 pounds and had an average 1% reduction in A1c over 12 months.

Conclusion: The use of semaglutide was associated with statistically significant reductions in insulin doses. The clinical significance of these results will vary depending on a patient’s initial insulin dose.

19. Medication Use Evaluation Methods: 201 patients with of Dipeptidyl-Peptidase 4 InType 2 Diabetes were identified hibitors (DPP4-I) in Primary for chart review. Patients were Care Patients at Atrium Health included if they received a new prescription for semaglutide be- Authors: Luis Trejo, PharmD; tween October 2020 and October Paige Carson, PharmD, CDCES, 2021 and were already on insulin BCPS, CPP, DPLA; Jessica Cole, Conclusions: Student pharma- prior to semaglutide initiation. PharmD, BCACP, CPP; Maeghan Page 59

Troyer, PharmD, BCACP, CDCES, CPP Institution: Atrium Health Cabarrus, Concord NC

Objective: The purpose of this study was to evaluate the use of dipeptidyl-peptidase 4 inhibitors (DPP4-I), assess safety and efficacy, and identify opportunities to optimize diabetes regimens.

Methods: This was a retrospective medication use evaluation.

Patients were identified via reports from electronic medical records and included adults with an Atrium Health primary care provider who was prescribed a DPP4-I between October 1, 2021, and March 31, 2022. Data collected included demographics, DPP4-I and prescriber information, adverse effects, dosing errors, drug interactions, baseline

and follow-up A1c values, and pharmacist involvement in diabetes management. Data were analyzed using descriptive statistics.

Results: One hundred patients with a mean age of 64 years were included. There were 52% female, 61% White, 27% Black, 5% Hispanic/Latino, 23% had atherosclerotic cardiovascular disease, 15% had chronic kidney disease, and 13% had heart failure. The most prescribed DPP4-I was sitagliptin, with 68% receiving sitagliptin and 19% sitagliptin-metformin. Four adverse effects were attributed to DPP4-I, hypoglycemia, vomiting, hypotension, and leg pain and swelling. There were three dosing errors with patients prescribed sitagliptin 100 mg once daily with an eGFR <45 mL/ min/1.73m2. Ten patients were on concomitant glucagon-like

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peptide 1 (GLP-1) agonists, with subcutaneous semaglutide and dulaglutide being the most common (three each). There was an average A1c lowering of 0.91%.

There were 11 patients who had a pharmacist involved in their diabetes management; There were no dosing errors and no concomitant GLP-1 agonist use in these patients. The mean follow-up A1c of the patients who had a pharmacist involved was lower at 7.80% compared to 7.95% of the overall study group.

Conclusion: DPP4-Is are relatively safe and have minimal drug interactions; however, there is room for medication optimization, given that 10% of the patients were concomitantly on a GLP-1 agonist.

Pharmacist involvement appears to be beneficial in diabetes management.

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