North Carolina Pharmacist Volume 104 Number 4

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North Carolina Pharmacist Volume 104 Number 4

Advancing Pharmacy. Improving Health.

Official Journal Of The North Carolina Association Of Pharmacists

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@

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

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 4 EDITOR-IN-CHIEF Tina Thornhill

A Few Things Inside

LAYOUT/DESIGN Rhonda Horner-Davis

• From the Executive Director...................................................................................4


• From the President..............................................................................................6

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

• Comparison ofAUC/MIC Vancomycin Dosing Versus Trough-Based Dosing.......10 • PAAS National: USP 800 Sets New “National Professional Standard”....................17 • HIV Preexposure Prophylaxis Update...................................................................18 • Evaluation of Return on Investment as a Sustainability Measure..............................24


• Op-ed Submission...............................................................................................32


• NCAP News.......................................................................................................34


North Carolina Pharmacist is supported in part by:


• Alliance for Patient Medication Safety ...................................................7


• Working Advantage..................................................................................7

SECRETARY Beth Caveness 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 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.

• Pharmacy Technician Certification Board (PTCB) .................................9 • NCAP Career Center .............................................................................21 • Pharmacy Quality Commitment.............................................................22 • Pharmacists Mutual Companies ............................................................23

Convention Sponsorship Ads: • Pfizer .....................................................................................................16 • Founders Wellness ................................................................................30 CORRECTIONS AND ADVERTISING For rates and deadline information, please contact Rhonda Horner-Davis at

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•From the Executive Director• Penny Shelton, PharmD, FASCP, FNCAP

Windshields & Rearview Mirrors

clearly what lies ahead until things are upon us. Not too unlike my mornings when I’m driving east to work each day, I’m squinting through the glare, rain, bug residue, or sometimes all three on my When I get time to really relax, windshield. However, when I look breathe, and appreciate the big up into the rearview mirror it’s a and little moments in life, I would picture-perfect scene. Yes, the fusay that I enjoy reflection. I might ture can be blurry, even opaque, even say I can be quite the ponder- with trepidation and uncertainer when time permits. I, like you, ty. Yet, here at NCAP we are conprobably don’t reflect enough. If stantly pushing for a difference you’re like me, it’s because we’re that will better the profession and too busy taking care of business those we serve. or others. And if I’m honest about the reflection I do, I must admit I This year has been another amazprefer thinking about the future ing year for the Association. Your rather than the past. Howev- outgoing President, Ouita Gatton, er, if my age has any correlation has served admirably; and in her with wisdom, I then need to put column this issue, she touches an addendum on this statement, on how quickly 2023 has come because we cannot really ponder and gone. She also alludes to the the future without recalling or general work and value of NCAP. drawing upon our past, at least Much of the work by the Associato some degree. You know what tion takes place behind the scenes, I’m referring to—just think about and as your Executive Director, I all those quotes—about how our believe one of our greatest sucpast shapes or informs both our cesses this year comes from our commitment to relationship depresent and future. velopment. Not all partnerships I sat down to write this column pan out as first envisioned, but on the topic of reflecting on 2023 some take surprising turns during since this year will soon be in our the year that can lead to new oprearview. Par for the norm with portunities. Look no further than me, my thoughts soon turned to the announcement made by North 2024 and what’s on the horizon Carolina Medicaid on December for NCAP. Maybe my fascination 20th. with what is to come stems from my love of a good journey and a Since 2018, only pharmacists with challenge. The future is always a the advanced credential, clinical challenge because we cannot see pharmacist practitioner, were allowed to enroll as a provider, Page 4

but beginning in early January 2024, that agency will begin allowing any pharmacist providing care via SL 2021-110 authorized statewide protocols to enroll as a provider. NCAP will continue to work with NC Medicaid in the coming weeks and months to assist pharmacists in this transition. Also, NCAP remains committed to doing the work needed to secure provider enrollment and payment for pharmacist-provided services, permitted by legal scope of practice, among all health plans doing business in our state.

Another exciting relationship that fully developed in 2023, and one that will be an important part of NCAP’s operations in 2024, involves a new behavioral health grant provided by Alliance Health. The NCAP Board of Directors and staff are ready to get started on this two-year initiative in which we will work to develop a behavioral health services model for pharmacies. Also, NCAP is one of several partners working in concert with Blue Cross and Blue Shield of North Carolina to begin piloting hypertension and diabetes care services in community pharmacies in 2024. Both of these projects have the potential to shift the landscape of covered services for beneficiaries of health plans in the future. Meanwhile, each of NCAP’s practice academies has been working on strategic plan components

throughout 2023. The New Practitioner and Student Pharmacist Forums were also extremely busy this year. In 2024, NCAP sees several opportunities for shaping a new direction for our academies and forums. In this issue, you can read a brief summary provided by each of these groups.

Next year, we will again be busy running legislation. We have three bills that still have some life coming out of the 2023 long session and heading into the 2024 short session. In January we will begin preparing for the short session, which should start in May. We have had huge victories on the legislative front since 2021. Yet, we cannot rest, we have more pivotal work to do. Regarding some of our more recent legislative battles, earlier this week, a pharmacist member asked me: “Why do you think, with all the proof that exists that pharmacists add value and save money in the care of patients, that you still have such an uphill battle trying to convince health plans, agencies, and legislators to pay pharmacists for their care?” I could talk about this all day, but my answer is there are multiple reasons. We can point to the major oppositions, such as physician organizations, pharmacy benefit managers, health plans, and others; but honestly, one of the greatest contributing factors is that we did this to ourselves, and we are still our own worst enemy.

What do I mean by this? Let’s go back in history to when the Social Security Act was amended to define healthcare providers and healthcare settings. Now

that rearview mirror, or Monday-morning quarterbacking, is going to rear its head in what follows and may be viewed as controversial by some. I feel our profession was asleep at the wheel back then. We either were not at the table at all, or we didn’t fight hard enough in the 1960s when those amendments were made. Of course, pharmacy practice has evolved significantly since that time, and it can be easy to point fingers. Today, at the state level, we have our greatest opportunity to upend things and get pharmacists recognized, enrolled, and paid for services. But not if most of the profession is disengaged. There’s power in numbers. Yet, less than 15% of licensed pharmacists join the state pharmacy association, and NCAP is the entity tasked with fighting this fight in the halls of the legislative building and agencies.

NCAP’s mission is to unite, serve, and advance the profession. Unity is essential for us to succeed in undoing the things where history has not been on our side. This had me thinking about a line that I saved from Amanda Gorman’s inaugural poem, The Hill We Climb. That line is, “That doesn’t mean we are striving to form a union that is perfect; we are striving to forge a union with purpose.” We look around at what is happening in our profession and we see imperfections everywhere. There are poor work environments, constant turnover in pharmacy personnel, low reimbursement for medications, unclear regulations, long hours, little reward, inability to be paid for patient care, and so on. How do we expect to fix these issues if we do not come

together? NCAP will always lead with purpose, but our union is too small to wield the power we need to succeed sooner rather than later; and history is watching!

In the future, I’m sure there will be new battles of uncertainty muddying up the metaphorical windshields of those pharmacists. When they are looking back in time, what side of history do we want to be on? In another sixty to seventy years, I don’t know if the Social Security Act will still be in place, but when pharmacists in 2085 are reflecting, will they point to us and say, why wasn’t our profession more vocal? Why didn’t they organize and fight harder? Why couldn’t they see this coming? When we are in the historical rearview mirror, I don’t want these questions to be our legacy. You shouldn’t either!

In 2024, the NCAP Board of Directors and staff will be focused on changes to increase membership and member engagement. Improved unity, which means stronger membership, is imperative for our success. To our members reading this column, I view you as an army, and when we reach out to mobilize our efforts, I hope you will do everything in your power to take action to help us form a true union, one with both purpose and power. Meanwhile, I hope you all had the happiest of holidays; taking time to relax and celebrate the reason for the season with family and friends. Pharmacy Proud, Penny

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

With Gratitude and Thanksgiving!

Wow! It seems like yesterday, when I introduced myself to all of you, excited at the anticipation and planning of a new NCAP year. Fast forward to now, and it is time to say farewell as your current NCAP president. As I reflect upon this year, I want to express my gratitude and thanksgiving to the Association for all that has taken place in 2023. As the holidays conclude and New Year begins, we all have to remember to breathe, here is my pause to thank NCAP leadership, staff, members, and others.

Serving as your NCAP president this year has been one of the greatest blessings and joys of my professional career. It has been filled with pleasure working side by side each month with our board of directors, executive director, and NCAP staff. Each board member is an expert in their area of practice, has a passion for pharmacy, and serves tirelessly on the volunteer board to make the state pharmacy association the best it can be. Lifetime friendships have been made because of our mutual service together. It is a true statement that “no man is an island,” especially when it comes to working as a team to benefit the phar-

macists of North Carolina. We just need more of you to serve in your area of pharmacy passion!!

Penny Shelton works tirelessly and selflessly every single day as your Executive Director of NCAP. I have appreciated her expertise and leadership as I have listened, learned, and watched how she has navigated various happenings that affected our profession this past year. We are beyond blessed in North Carolina to have a leader who exemplifies quality and excellence in how she leads and manages the affairs of the Association. All I can say is thank you for the opportunity to serve with you, Penny.

forts concerning state networking events and payor programming. It was a joy to serve with her. Jennifer Plair is our new executive fellow and has already shown her maturity and passion for our profession. It has been a blessing to serve with both of these emerging pharmacy leaders this year.

Another thank you is extended to our lobbyists, Tony Solari and Debra Conrad, as they worked round the clock to educate legislators about our pharmacy bills. Though the successes were not as robust as they had been in previous years, we maintained technician immunization privileges, expanded ACIP vaccine recommendations, and simplified childNo one does a better job of day- hood vaccines. to-day management and program coordination for the pharmacy We continue to have successful inassociation than the NCAP staff. terest and attendance at the qualiCheryl, Angie, Grant, Teressa, ty CE programs we offer as a state and Rhonda work beyond regu- organization and through our lar hours to ensure members are various forums and academies. A provided with quality service and huge thank you to all of those who expert programming. The mem- have served and continue to serve bership gets its money’s worth by in these areas. A debt of gratisuch an incredible team! Thank tude goes to all the leaders and you for a year of camaraderie and members of the various forums, friendship with you. committees, and academies that continue to contribute and serve This year, NCAP said “so long” to to show excellence for the profesour two-year executive fellow, sion. Megan Witkowski. She worked tirelessly to coordinate various ef- Student pharmacists, technicians, Page 6

interns, and residents are integral to the success and continuation of our association. NCAP looks forward every year to hosting the annual residency conference, providing technician awards, and involving students in leadership roles. It has been a delight working with students from all four pharmacy schools in North Carolina. Thank you for continuing to teach me something new every day. And technicians…thank you for all you do to keep the pharmacy running smoothly. Thank you to all of you who contributed to the advocacy fund drive held at our annual convention in Beaufort, North Carolina. The “Under the Sea” fundraising campaign was different and inclusive and produced a unique picture-taking opportunity with the victory. (See photo below) To date, it has raised more money for the advocacy fund at one time than any other event for NCAP.

o If you are not a member of NCAP, we need you…NOW. If we do not work together, we will not be as successful as we have the potential to be.

o Please get involved in the legislative process. Just remember…we must advocate for ourselves. No one will do it for us. Thank you for a great year! Until next time…

A new BOD will begin in January 2024. We will have new leadership, passion, and expertise working together to create and pursue benefits for the pharmacy profession in North Carolina. A continual push for membership increase will be a main focus for the 2024 BOD.

Toll Free: (866) 365-7472

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All NCAP members can unlock the best life has to offer with exclusive savings on: Theme Parks, Attractions and Shows; Hotels, Flights and Rental Cars; Concerts, Sports and Live Events; Movie Tickets; Electronics and much more. Visit the Membership Benefits tab at to find out more!

In closing, I leave you with these final thoughts.

o If you are a member of NCAP, thank you, and make sure you lend us your leadership for a season. Please sign up for the committee of your interest or run for office on the BOD. We need you!!

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We Can’t Do This Without You

Membership Dues Increase The North Carolina Association of Pharmacists (NCAP) was formed by merging four separate pharmacy organizations. NCAP was created to unite the profession, better utilize available resources, provide strength in numbers, and to generate a collective voice for our profession. On January 1, 2024, NCAP will celebrate 24 years of dedicated service on behalf of pharmacy professionals in all practice settings. In all this time, the Association has not raised the price of membership dues. Given the importance of the work that the Association is conducting, and the recognition that there are many more initiatives that we need to produce or advocate for on behalf of our profession, the NCAP Board of Directors has identified a need for a dues adjustment. Our members are the lifeblood of the Association, and we trust that each of you has found value in the tremendous work conducted by our state pharmacy association. Thank you for your continued support. NCAP is eager to bring even more resources and services to our members. The following membership types and dues will go into effect on March 1, 2024.

One Year Membership Dues Pharmacist: $275 Sustaining Pharmacist - *Annual: $225 (Save $50) Sustaining Pharmacist - *Monthly: $21 (Save $23) Sustaining Joint Household - *Annual: $360 (Save $190) Retired Pharmacist: $125 Resident/Fellow: $50 Technician: $35 Student Pharmacist: $10 Associate Member: $225

*must be on auto-renewal to receive savings

Comparison of AUC/MIC Vancomycin Dosing Versus Trough-Based Dosing in Patients with Extremes of Body Weight By: Dr. Taylor M. Felton, Dr. Riley Bowers, Dr. Brock Dorsett, and Dr. Emily Johnson ABSTRACT Background: Updated vancomycin dosing and monitoring guidelines state that trough-only monitoring is no longer recommended. They instead recommend an individualized target AUC/MIC ratio be attained to achieve clinical efficacy and minimize adverse events compared to trough-based dosing. However, vancomycin dosing in obese and underweight patients can be challenging due to the physiological changes that alter pharmacokinetics. There is limited data regarding AUC/ MIC-based vancomycin in obese patients, and data pertaining to dosing in the underweight population are lacking.

weighing at least 100 kg or a BMI of at least 30 kg/m2, and underweight was described as weighing 50 kg or less or 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: Two hundred twenty patients met the inclusion criteria, with 114 patients in the troughbased dosing group and 106 in the AUC/MIC-based dosing group. AUC/MIC-based dosing yielded a higher rate of initial therapeutic concentrations than troughbased dosing, 50.0% vs. 17.5%, respectively. The underweight Objective: We aimed to assess population primarily drove this the attainment of initial therapeu- difference, with 62.5% of the tic concentration in patients with AUC/MIC-based dosing group extreme body weights receiving achieving initial therapeutic conAUC/MIC-based dosing versus centrations versus only 9.3% in trough-based vancomycin dosing. the trough-based dosing.

Methods: Adult inpatients who were considered obese or underweight and who received vancomycin therapy with at least one documented vancomycin concentration were retrospectively reviewed in this single-center cohort study. Obese was defined as

Conclusion: AUC/MIC-based vancomycin dosing resulted in greater achievement of initial therapeutic concentration than trough-based vancomycin dosing in patients with extreme body weight. Page 10

INTRODUCTION The tricyclic glycopeptide antibiotic vancomycin is commonly used as a component of most empiric antibiotic regimens in hospitalized patients and treats serious gram-positive infections such as methicillin-resistant Staphylococcus aureus (MRSA).1 Since 2009, the mainstay of therapeutic drug monitoring for vancomycin focused on keeping trough concentrations between 10-20 mg/L as a surrogate marker for an area under the curve to a minimum inhibitory concentration (AUC/ MIC) ratio of 400-600. However, this was primarily if the MIC was ≤1 mg/mL in patients with normal renal function.2 New research has suggested that an AUC/MIC dosing strategy could improve trough-based dosing given inter-individual variability between a measured trough concentration and the corresponding AUC/MIC ratio.3 In 2020, the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists updated the therapeutic monitoring of vancomycin guideline to no longer recommend trough-only monitoring. Instead,

the updated guidelines recommend an individualized AUC/MIC ratio target between 400-600 to achieve clinical efficacy and decrease the risk of nephrotoxicity.1

body weight ≥ 100 kg or a BMI ≥ 30 kg/m2 or ≤18.5 kg/m2 that a peak and a trough both be drawn at steady state to assess the efficacy of the vancomycin regimen. The purpose of this study was to It is already established that dos- evaluate the achievement of iniing vancomycin in obese patients tial therapeutic concentration in can be difficult, given that the vol- obese and underweight patients ume of distribution and clearance receiving trough-based dosing are larger in this patient popula- versus AUC/MIC-based vancomytion.4 It is recommended to have cin dosing. early and frequent monitoring of AUC exposure to guide dose ad- METHODS justments for obese patients, especially when empiric vancomy- This was a single-center, retrocin doses exceed 4 grams/day.1 spective cohort study granted Studies have shown that trough- exempt status by the Cape Fear based dosing can overestimate Valley Health Institutional Review the total daily vancomycin dose Board. The primary objective was compared to AUC/MIC dosing to compare the number of obese which not only leads to a lower and underweight patients achievvancomycin exposure but also ing initial therapeutic concenlowers the risk of acute kidney in- tration in those receiving AUC/ jury.5 Although there is some data MIC-based dosing versus troughregarding dosing vancomycin in based dosing. Obese was defined obese patients, data and studies as weighing at least 100 kg or pertaining to vancomycin dosing with a BMI of at least 30 kg/m2, in the underweight population are and underweight was described lacking. One study demonstrated as weighing 50 kg or less or with that underweight patients were a BMI of 18.5 kg/m2 or less. likely to be under-dosed when using trough-based nomograms, but Secondary objectives were to the data are limited.6 compare the number of obese patients achieving initial therThis study aimed to address a gap apeutic concentration for AUC/ in current research by comparing MIC-based dosing versus troughtraditional trough-based vanco- based, the number of undermycin dosing to AUC/MIC-based weight patients achieving initial dosing in patients of extreme therapeutic concentration for body weight, including over- AUC/MIC-based dosing versus weight and underweight patients. trough-based, compare the rate of Cape Fear Valley Medical Center, acute kidney injury, to assess suba large community teaching hos- sequent vancomycin concentrapital, transitioned from a trough- tions for accumulation in patients based nomogram to AUC/MIC- initially achieving therapeutic based vancomycin in December concentrations, and to compare 2021. The current AUC/MIC van- the total daily vancomycin doses comycin policy at this institution needed to achieve initial theraspecifies for patients with a total peutic concentrations in patients Page 11

receiving AUC/MIC-based vancomycin dosing versus troughbased dosing.

This study defined acute kidney injury as at least a 0.3 mg/dL increase in serum creatinine or at least 1.5 times the baseline serum creatinine.7 After an initial therapeutic concentration, accumulation was defined as a subsequent vancomycin AUC/MIC >600 mg*h/L or a trough concentration >20 mg/L.

This study was performed at Cape Fear Valley Medical Center, a 670bed community hospital in Fayetteville, North Carolina. Vancomycin dosing and monitoring are conducted via a pharmacy consult service at this institution. Patients at least 18 years old hospitalized at Cape Fear Valley Medical Center, who were considered obese or underweight, and who received vancomycin therapy with at least one documented vancomycin concentration were retrospectively reviewed in this single-center cohort study. Patients were excluded if they required renal replacement therapy, had unstable renal function before the initiation of vancomycin, were pregnant, had burns covering more than 20% of total body surface area, had significant ascites requiring paracentesis, or had cystic fibrosis. Patients deemed eligible were identified via EPIC, the electronic health record utilized at the institution. Eligible patients who were admitted between January 1, 2021, and December 31, 2021, were included in the trough-based dosing group, and those admitted between January 1, 2022, and December 31, 2022, were includ-

ed in the AUC/MIC-based dosing group. Patients included in the troughbased dosing vancomycin group were dosed using a nomogram based on weight and creatinine clearance (Figure 1). Therapeutic trough concentrations were linked to the specific vancomycin indication. Therapeutic trough concentrations for skin and soft tissue infections were between 10-15 mg/L and 15-20 mg/L for the remaining indications. Trough concentrations were approximately drawn an hour before administering the fourth dose. Patients in the AUC/MIC-based group were considered therapeutic if they had an AUC/MIC ratio between 400 to 600 mg*h/L. AUC/MIC-based vancomycin dosing was assessed using two steady-state vancomycin concentrations. This consisted of having a level drawn two hours post-administration of the third dose of vancomycin and another level drawn one-hour pre-administration of the fourth dose. ClinCalc, a validated free online vancomycin calculator, was used to determine AUC/MIC dosing and assess levels to determine AUC/MIC ratios.8

The primary endpoint of achievement of initial therapeutic concentration was compared using a chi-square analysis. Secondary endpoints of the percentage of patients in each group achieving initial therapeutic concentration, rate of acute kidney injury, and the percentage of patients accumulating were also compared using a chi-square analysis. The total daily vancomycin dose was analyzed using a t-test. An alpha of <0.05 was considered statisti-

cally significant. Statistical analy- concentrations in the AUC/MICses were performed using JMP-15 based dosing group (39.7%) than (SAS. Cary, NC). the trough-based dosing group (25.0%), but this was not statistically significant. RESULTS After the screening, a total of 220 patients met the inclusion criteria. Of those patients, 114 patients were included in the trough-based dosing group, and 106 patients were included in the AUC/MICbased dosing group. The mean age of the study population was 55.3 + 16.4 years for the entire patient population. In the obese population, the mean weight was 125.0 + 25.3 kg, and the mean body mass index was 41.7 + 9.2 kg/m2 in the obese population. The underweight population had a mean weight of 46.2 + 6.6 kg and a mean body mass index of 17.1 + 2.1 kg/m2. The majority of patients in both groups were receiving vancomycin therapy for sepsis (36.0% versus 29.2% in the trough-based and AUC/MICbased groups, respectively), skin and soft tissue infections (24.5% versus 20.8%) and osteomyelitis (15.8% versus 15.1%). Further baseline characteristics are described in Table 1. Initial therapeutic concentration was achieved in 20 patients (17.5%) in the trough-based dosing group and 53 patients (50.0%) in the AUC/MIC-based dosing group (P<0.0001). The underweight population primarily drove this, with 62.5% of patients in the AUC/MIC-based dosing group achieving initial therapeutic concentration compared to 9.3% of patients in the trough-based dosing group (P<0.0001). Obese patients also had a higher achievement of goal Page 12

Obese patients in the troughbased group required higher doses of vancomycin needed to achieve initial therapeutic concentrations compared to the AUC/MIC-based group. Underweight patients required higher daily doses of vancomycin in the AUC/MIC-based group compared to the trough-based group. Rates of acute kidney injury were lower in the AUC/MIC-based group, and accumulation was similar between the two groups. These results were not statistically significant (Table 2). DISCUSSION

The findings of our study demonstrated that AUC/MIC-based vancomycin dosing led to greater attainment of initial therapeutic concentration compared to trough-based vancomycin dosing in obese and underweight patients. The results of our study support the vancomycin dosing and monitoring guidelines recommendation to target an AUC/ MIC ratio of 400-600 mg*h/L. Additionally, the findings of this study also align with the idea proposed by Covey et al. that AUC/ MIC-based vancomycin dosing lowers the risk of developing an acute kidney injury.

Furthermore, the results align with previous studies describing that underweight patients were likely to be under-dosed with weight-based dosing using trough-based nomograms.6 The

findings also align with a previous study that demonstrated that trough-based dosing can overestimate the total daily dose in patients with a BMI ≥ 30 kg/m2 compared to AUC/MIC-based dosing.5 The differences in total daily doses needed to achieve initial therapeutic concentration could be attributed to the differences in dosing strategies.

Patients in the trough-based group were started on regimens based on weight and creatinine clearance from a dosing nomogram. Therefore, the trough-based group patients received approximately similar daily doses of vancomycin until trough levels could be assessed. On the other hand, patients in the AUC/MIC-based dosing group received an initial vancomycin regimen that was not just based on weight and creatinine clearance but individualized based on other patient-specific factors, including gender, height, and if they are critically ill.

also allows for inaccurate and in- 2. Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Vancomycin therapeutic consistent patient weights. Lastguidelines: a summary of consensus ly, accumulation could only be recommendations from the Infecassessed in five patients in the tious Diseases Society of America, trough-based group and 16 in the the American Society of Health-System Pharmacists, and the Society AUC/MIC-based dosing group due of Infectious Diseases Pharmacists to the absence of second levels [published correction appears in Clin and further vancomycin dosing. Infect Dis. 2009 Nov 1;49(9):1465]. CONCLUSION


AUC/MIC vancomycin dosing resulted in greater achievement of initial therapeutic concentration compared to trough-based vancomycin dosing in patients with extremes in body weight. Two steady-state concentration levels were used for patients receiving 4. AUC/MIC-based vancomycin dosing to provide the most accurate AUC/MIC calculation.

Authors: Taylor M Felton1,2, 5. PharmD; Riley Bowers1,2, PharmD, BCCP, BCPS; Brock Dorsett1, PharmD, BCPS; Emily Johnson1, PharmD, BCPS. 1: Cape Fear Valley Health; 1638 Owen Drive, Fayetteville, NC, United States 28304; 2: Campbell University College of Pharmacy and Health Sciences; 6. 217 N. Main Street, Buies Creek, NC, United States 27506. Corresponding author: Dr. Felton at

Our study was not without limitations. Approximately 25% of patients in both the trough-based and AUC/MIC-based groups received vancomycin for skin and soft tissue infection. As a result, this could have reduced vancomycin exposure in the patients REFERENCES 7. belonging to the trough-based dosing group, given the therapeu- 1. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin tic goal for skin and soft tissue for serious methicillin-resistant infections is 10-15 mg/L. Serum Staphylococcus aureus infections: A revised consensus guideline and level collection is performed by review by the American Society of phlebotomy lab technicians and Health-System Pharmacists, the Innurses at Cape Fear Valley Medifectious Diseases Society of Americal Center; therefore, the timing ca, the Pediatric Infectious Diseases of vancomycin concentrations Society, and the Society of Infectious 8. Diseases Pharmacists. Am J Health was not controlled, and concenSyst Pharm. 2020;77(11):835-864. trations might not reflect true doi:10.1093/ajhp/zxaa036 troughs. Variability in bed scales Page 13

Clin Infect Dis. 2009;49(3):325-327. doi:10.1086/600877 Neely MN, Kato L, Youn G, Kraler L, Bayard D, van Guilder M, Schumitzky A, Yamada W, Jones B, Minejima E. Prospective Trial on the Use of Trough Concentration versus Area under the Curve To Determine Therapeutic Vancomycin Dosing. Antimicrob Agents Chemother. 2018 Jan 25;62(2):e02042-17. doi: 10.1128/ AAC.02042-17 Durand C, Bylo M, Howard B, Belliveau P. Vancomycin Dosing in Obese Patients: Special Considerations and Novel Dosing Strategies. Ann Pharmacother. 2018;52(6):580-590. doi:10.1177/1060028017750084 Covey JR, Erickson O, Fiumara D, et al. Comparison of Vancomycin Area-Under-the-Curve Dosing Versus Trough Target-Based Dosing in Obese and Nonobese Patients With Methicillin-Resistant Staphylococcus aureus Bacteremia. Ann Pharmacother. 2020;54(7):644-651. doi:10.1177/1060028019897100 Colin PJ, Allegaert K, Thomson AH, et al. Vancomycin Pharmacokinetics Throughout Life: Results from a Pooled Population Analysis and Evaluation of Current Dosing Recommendations. Clin Pharmacokinet. 2019;58(6):767-780. doi:10.1007/ s40262-018-0727-5 Stevens PE, Levin A; Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013;158(11):825-830. doi:10.7326/0003-4819-158-11201306040-00007 Kane, SP. Vancomycin Calculator – Vancomycin. Updated November 20, 2022.

Figure 1. Trough-Based Dosing Nomogram

Table 1. Baseline Characteristics Parameter

Trough-Based (N = 114)

AUC/MIC (N = 106)

56.7 (16.0)

53.8 (16.7)

Mean Age, years (SD)a

Mean Weight (overweight), kg (SD) Mean Weight (underweight), kg (SD)

Mean BMIb (overweight), kg/m2 (SD) Mean BMI (underweight), kg/m2 (SD)

Vancomycin Indication, n (%)

Mean Initial SCre, mg/dL (SD)

Mean Initial CrCl , mL/min (SD) f

Sepsis SSTIc Osteomyelitis Bacteremia Pneumonia Meningitis Infective Endocarditis UTId Septic Joint Intraabdominal Infection

Standard Deviation Body Mass Index Skin and Soft Tissue Infection d. Urinary Tract Infection e. Serum Creatinine f. Creatinine Clearance a.



Page 14

127.7 (25.5) 44.5 (5.48)

122.2 (25.0) 47.8 (7.62)

41 (36.0) 28 (24.5) 18 (15.8) 9 (7.9) 9 (7.9) 3 (2.7) 2 (1.7) 2 (1.7) 1 (0.9) 1 (0.9)

31 (29.3) 22 (20.8) 16 (15.1) 12 (11.3) 16 (15.1) 0 (0) 3 (2.8) 1 (0.9) 2 (1.9) 3 (2.8)

42.0 (9.41) 17.6 (2.37)

0.88 (0.36)

90.5 (43.2)

41.3 (9.06) 16.6 (1.79)

0.82 (0.27)

113.0 (61.0)

Table 2. Primary and Secondary Endpoints Endpoint Achievement of initial therapeutic concentration, n (%)

Achievement of initial therapeutic concentration, (underweight) n (%) Achievement of initial therapeutic concentration, (obese) n (%)

TDDa needed to achieve initial therapeutic concentrations, (obese) mg (SD) TDD needed to achieve initial therapeutic concentrations, (underweight) mg (SD) Accumulation, n (%)

Acute Kidney Injury (obese), n (%) Acute Kidney Injury (underweight), n (%) a.

Total Daily Dose

Trough-Based (N = 114)

AUC/MIC (N = 106)

P-value (95% CI)

20 (17.5)

5/54 (9.3)

53 (50.0)

30/48 (62.5)


15/60 (25.0)

23/58 (39.7)


3116.6 (838.1)

2869.6 (849.0)

0.3839 (-323.66, 817.73)

1120 (705.9)

1891.6 (797.9)

0.069 (-1626.6, 83.4)

2/5 (40.0)

7/16 (43.8)

5/60 (8.3) 2/58 (3.5)

1/54 (1.9)

1/48 (2.1)

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true effect of this exposure is unknown for many, and may result in both acute and chronic health issues due to trace exposure to hazardous drugs. Acute toxicity may present as nausea, rashes, hair loss, kidney damage, hearing loss and cardiac toxicity. Long term effects may include cancer, infertility, and other reproductive health issues. Certain populations, including, those that are immunosuppressed, and women and men of childbearing age may therefore be more at risk.

USP 800 Sets New “National Professional Standard” The United States Pharmacopeia (USP) revealed that more than 8 million U.S. healthcare workers are exposed to hazardous drugs each year and that more than 12 billion doses of hazardous drugs are handled by U.S. providers each year, with pharmacists and pharmacy technicians at the top of the list.

Community pharmacies have been dispensing hazardous drugs long before the potential for harm (due to low dose, long term exposure) was known. Exposure to a hazardous drug is often inadvertent and unknown to the employee. There is some surprise when presented with the list of hazardous drugs which includes pharmaceuticals that you may handle on a daily basis including; fluconazole, fluoxetine, carbamazepine, warfarin and oral contraceptives. There are more than 400 hazardous drugs and their unique dosage forms. Occupational exposure to hazardous drugs, or their residue, can be an everyday experience and the

This occupational exposure extends to everyone working in the pharmacy, from the pharmacists and pharmacy technicians who handle HDs, to those who work at the pharmacy counter or in the receiving and delivery areas. The exposure risk extends to anyone who may come into contact with HD particles or residue. Exposure can occur: • thru the skin or oral mucosa when counting and pouring

• by inhalation of dust particles when splitting a tablet or when working with an uncoated tablet that simply creates a lot of dust • by ingestion if eating or with hand to mouth contact without cleaning or hand washing

• by injection, as is the case with an accidental needlestick Different activities in the pharmacy come with different levels of potential risk: • dispensing a unit of use or a blister package of a hazardous drug may have a very low risk of Page 17


• counting and pouring an uncoated hazardous drug tablet or capsule increases the risk • splitting a hazardous drug tablet where dust can be created creates potential for increased exposure

• cleaning a spill of a liquid hazardous drug introduces another level of risk

The key is developing good practices to contain or greatly reduce risk. Per OSHA, the safe handling of hazardous drugs in accordance with USP 800 is now considered a “national professional standard” as a pharmacy process “to protect the safety and health of employees”. A USP 800 compliance program is a necessary step to protect the health and safety of your employees, patients in your pharmacy, and the environment. It can also help reduce employer liability from frivolous lawsuits through employee training, competency documentation and employee acknowledgements. PAAS National® is committed to serving community pharmacies and helping keep hard-earned money where it belongs. Contact PAAS today at (608) 873-1342 or to see why PAAS USP 800 Compliance Program membership might be right for you. By Trenton Thiede, PharmD, MBA, President at PAAS National®, expert third party audit assistance and FWA/HIPAA compliance. Copyright © 2023 PAAS National, LLC. Unauthorized use or distribution prohibited. All use subject to terms at https://paasnational. com/terms-of-use/.

HIV Preexposure Prophylaxis Update and the Potential Role of Pharmacists By: Maggie Fogle, PharmD Candidate

In late August 2023, the United States Preventive Services Task Force (USPSTF) issued an update to their 2019 guidance on human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP).1 While North Carolina (NC) is not one of the 17 states where pharmacists can prescribe PrEP, there is still value in all pharmacists in NC being aware of the update. This article will review the changes in the USPSTF’s guidance and discuss how this information can be applied in community and ambulatory care pharmacy settings to care for adult at-risk patients.

Per the NC Department of Health and Human Services (DHHS), there were 723 newly diagnosed cases of HIV in NC between January and June of 2023.2 Based on historical trends; this means the state is on track to maintain its rank as having the eighth-highest rate of new HIV cases in the United States.3,4 Even without accounting for underdiagnosing, patients living in poverty or rural areas are more likely to be HIV positive.4 Pharmacists are among the most accessible healthcare providers, with 96.5% of the US population

having a pharmacy within 10 miles of their home.5 This means pharmacists, especially community and ambulatory care pharmacists, are well positioned to help provide HIV preventative care and counseling to those who need it most. This was the reason why, in 2021, NC pharmacists were given the authority to provide HIV postexposure prophylaxis (PEP), a time-sensitive treatment that can prevent lifelong HIV.6

medications. TAF/FTC (Descovy®) is a prodrug combination with the same active metabolites as TDF/FTC and was approved for PrEP by the FDA in October 2019. Both medications are nucleotide analogue reverse transcriptase inhibitors that work inside CD4+ T cells. These analogues compete with endogenous nucleotides, blocking the conversion of HIV RNA to DNA and thus preventing HIV’s incorporation into the host’s DNA.7 The TAF form of tenofovir is absorbed differently than TDF, allowing it to distribute more selectively to lymphocytes and reducing the drug’s impact on renal function and bone integrity compared to the TDF form.8

The two main changes in the USPSTF guidance are the criteria for a patient at high risk of HIV acquisition and the drugs with an indication for PrEP.1 The provided flowchart (Figure 1) summarizes the risk assessment update, which was created based on the A thirty-day supply of brandwritten USPSTF guidance. name Truvada® or Descovy® costs approximately $2000, dependPreviously, tenofovir disoproxil ing on the wholesaler. However, a fumarate/emtricitabine (TDF/ generic form of Truvada® (TDF/ FTC) under the brand name Tru- FTC) became available in October vada® was the only medication 2020, and many county health deindicated for PrEP.1 Tenofovir partments in NC offer it for a realafenamide/emtricitabine (TAF/ duced cost compared to the usual FTC) and injectable cabotegravir out-of-pocket cost at a pharmacy.9 for PrEP, respectively named De- The initial patent for Descovy® scovy® and Apretude, have been does not expire until 2025, and added to the list of preventative insurance plans often only cover Page 18

Descovy® for patients with renal disease or other medical conditions for which TDF/FTC is not recommended.10 Thus, TDF/FTC is still widely used for HIV PrEP despite its higher rate of adverse effects. Although NC pharmacists cannot prescribe PrEP, they have been authorized to prescribe postexposure prophylaxis (PEP). As PEP providers, pharmacists can identify high-risk patients and use the opportunity to counsel patients on the benefits of PrEP. The most common barriers to PrEP initiation and adherence are stigma, access, affordability, and perceived adverse effects.11

Pharmacists can provide education for patients and address side effects known to derail adherence. Pharmacists can also help facilitate patients’ access to PrEP by assisting with prior authorization requirements and recommending patient assistance programs.

The other medication added to the USPSTF guidance is cabotegravir. Cabotegravir is an HIV-1 integrase strand transfer inhibitor, and when used for PrEP, patients must have a negative HIV test before initiating treatment.12 Cabotegravir has two different formulations approved for PrEP: oral (Vocabria®) and intramuscular (IM) injection (Apretude®). Oral cabotegravir can be administered as a lead-in to assess tolerability before initiating the long-acting IM formulation or as bridge therapy for missed IM cabotegravir injections.7 For HIV PrEP, when oral cabotegravir is used as lead-in therapy,

patients take 30 mg once daily for at least 28 days. IM cabotegravir (Apretude) can be initiated within three days of the last oral dose. Apretude® 600 mg (3 mL) is administered as a gluteal injection one month apart for two consecutive injections and then every two months thereafter.12 Missing a scheduled injection by more than 7 days can negatively affect the medication’s efficacy, and the manufacturer provides dosing recommendations for oral cabotegravir as a bridge for reinitiating the injectable.12 The dosing schedule of long-acting cabotegravir can be easier for patients to adhere to compared to daily pills.

ance.13,14 Most health plans do not guarantee reimbursement, so claims can be denied after cabotegravir is administered.15,16 Even when reimbursement is obtained, pharmacies may not fully recoup the acquisition cost, as can happen with other non-specialty medications. NC Medicaid pays pharmacists a fee for administering long-acting injectables, which can help offset the difference in acquisition cost and reimbursement.17 There is also a pathway for NC pharmacists with a clinical pharmacist practitioner (CPP) certification to bill Medicaid directly for patient care.13,17 Policymakers, health plans, and pharmacy associations continue Immunizing pharmacists have the to work on recognizing and reimauthority to administer long-act- bursing pharmacists for the care ing injectables. According to the they provide. NC Board of Pharmacy, a long-acting injectable is a “drug product Given the complexity of HIV anformulated to produce sustained tiviral therapies and the medirelease and gradual absorption of cation expertise of pharmacists, the active pharmaceutical ingre- patients can greatly benefit from dient over an extended period af- pharmacist-provided HIV-relatter subcutaneous or intramuscu- ed care. With this latest USPSTF lar injection administration.”6 By update, there are now more opthis definition, pharmacists can portunities for NC pharmacists administer cabotegravir for PrEP to help patients who are at risk of if a patient receives a prescription HIV exposure and assist in lowfrom their provider. The medica- ering the annual rate of new HIV tion needs to be refrigerated un- cases in North Carolina. til use. It must be acquired via a specialty pharmacy, so medical Author: Maggie Fogle is a 2024 offices are unlikely to stock cabo- PharmD Candidate at UNC Coltegravir, creating an opportunity lege of Pharmacy. mmfogle@live. for pharmacists to provide and administer long-acting injectable PrEP.13 REFERENCES The annual acquisition cost of Barry MJ, Nicholson WK, Silvercabotegravir for one patient is 1. stein M, et al. Preexposure Prophylaxis $22,000 and must be done via the to Prevent Acquisition of HIV: US Pre“buy and bill” process, in which ventive Services Task Force Recommenthe medication is purchased be- dation Statement. JAMA - J Am Med Asfore the claim is sent to insur- soc. 2023;330(8):736-745. doi:10.1001/ Page 19

jama.2023.14461 2. North Carolina HIV/STD/Hepatitis Surveillance Unit. North Carolina HIV/STD Quarterly Surveillance Report.; 2023. 3. Centers for Disease Control and Prevention. North Carolina - 2015 State Health Profile. Published online 2015. 4. North Carolina HIV/STD/Hepatitis Surveillance Unit. 2021 North Carolina HIV Surveillance Report HIV/STD/ Hepatitis.; 2021. 5. Berenbrok LA, Tang S, Gabriel N, et al. Access to community pharmacies: A nationwide geographic information systems cross-sectional analysis. J Am Pharm Assoc. 2022;62(6):1816-1822. e2. doi:10.1016/j.japh.2022.07.003 6. North Carolina Board of Pharmacy. Protocols for Post Exposure Prophylaxis for Human Immunodeficiency Virus.; 2023.

7. Wolters Kluwer. Facts and Comparisons. 8. Di Perri G. Tenofovir alafenamide (TAF) clinical pharmacology. Infez Med. 2021;29(4):526-529. doi:10.53854/liim-2904-4 9. GoodRx. Truvada. https://www. 10. Gilead. Descovy for PrEP Cost. 11. Wood S, Gross R, Shea JA, et al. Barriers and Facilitators of PrEP Adherence for Young Men and Transgender Women of Color. AIDS Behav. 2019;23(10):2719-2729. doi:10.1007/ s10461-019-02502-y 12. ViiV Healthcare Company. Apretude Package Insert.; 2021. 13. ViiV Connect. Apretude Reimbursement Guide.; 2022. 14. North Carolina Medicaid. Ad-

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ministration of Long-Acting Injectable Medications. https://medicaid.ncdhhs. gov/blog/2021/11/02/administration-long-acting-injectable-medications. 15. Cigna. Apretude Drug and Biologic Coverage Policy.; 2023. 16. United Healthcare. Long-Acting Injectable Antiretroviral Agents for HIV. Vol D00103I.; 2023. doi:10.3947/ ic.2021.0136 17. NC Medicaid Division of Health Benefits. Cabotegravir Extended-Release Injectable Suspension Billing Guidelines. NCDHHS. Published 2022. cabotegravir-extended-release-inj e c t a b l e - s u s p e n s i o n - i n t ra m u s c u lar-use-apretude-hcpcs-code-j3490

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Evaluation of Return on Investment as a Sustainability Measure for Ambulatory Care Pharmacy Services By: Dr. Casey Wells, Dr. Irene Park Ulrich, Dr. Anne Carrington Warren ABSTRACT Background: Essential factors for pharmacy services in physician practices have been identified: full team integration, electronic health record access, physician champion support, appropriate equipment, private clinic room, and focus on team-based care. Return on investment (ROI) was not identified as a key factor. Objectives: The purpose of this project was to analyze past pharmacy residents’ proposed ROI for ambulatory care pharmacist services and determine whether the aforementioned factors were important for position sustainability.

Practice Description: Mountain Area Health Education Center (MAHEC) is a large multi-disciplinary practice, graduate medical education program, and Level 3 Patient-Centered Medical Home in North Carolina. The pharmacy department houses two post-graduate year 1 ambulatory care pharmacy residents, two post-graduate year 2 (PGY2) geriatric pharmacy residents, and one PGY2 ambulatory care and academia pharmacy resident.

Practice Innovation: The PGY2 residency in ambulatory care and academia at MAHEC has a core focus on practice site development with the goal of creating sustainable and replicable ambulatory pharmacy services.

pharmacist position. Data from the twelve practice sites where pharmacist services were developed support prior findings for the essential factors for sustainability.

Key Words: ambulatory care, Evaluation Methods: A retro- primary care, sustainability spective review of past business plans and a survey of prior residents were performed. Practice BACKGROUND site ROIs were calculated using business plan proposals for phar- With growing healthcare costs macy services. The survey ob- and primary care provider shorttained information about the key ages, pharmacists are well suited practice site characteristics. to act as physician extenders and help meet the demands of providResults: Twelve PGY2 residents ing optimal patient care. A variety (100%) completed the survey. of ambulatory care settings exist Of these twelve, ten completed for clinical pharmacists such as business plans for the implemen- practicing in physician’s offices, tation of pharmacist services. All community pharmacies, and hosprojected ROIs for an ambulato- pital-based ambulatory environry care pharmacist position were ments.1 However, few resources positive. Five practice sites sus- exist to support pharmacists and tained an ambulatory care phar- describe the needed conditions macist. All six essential factors for to establish new ambulatory care establishing ambulatory services pharmacy services that expand were present at four practice access to care. Past studies highsites, three of which sustained an light the need for novel pharmaambulatory care pharmacist posi- cy services based on their clinical outcomes as opposed to financial tion. outcomes.2 A previous ambulaConclusion: Projected positive tory care expert panel identified ROI alone was not indicative of six essential factors that should sustaining an ambulatory care be considered when establishing Page 24

ambulatory care services in primary care practices.3 The six factors identified were (1) full integration into the team, (2) access to the electronic health record (EHR), (3) a physician or administrative champion, (4) appropriate equipment provided by the clinic, (5) a private room to see patients, and (6) a practice that is open to team-based care.3 Return on investment (ROI) was not one of the factors considered by this study group; however, it can be difficult to obtain funding for a new clinical pharmacy service without a positive ROI to show identifiable revenue gains or cost savings to the organization.4,5

The purpose of this project was to analyze past pharmacy residents’ proposed ROI for ambulatory care pharmacist services and determine whether the aforementioned factors were important for position sustainability. PRACTICE DESCRIPTION

Mountain Area Health Education Center (MAHEC) is a large multi-disciplinary practice, graduate medical education program, and Level 3 Patient-Centered Medical Home in western North Carolina. MAHEC has national recognition for its innovative team-based primary care and has embedded clinical pharmacist practitioners (CPP) across the organization. In North Carolina, CPPs work at the top of their license under collaborative practice agreements with physicians to independently initiate, adjust, and discontinue medications. The pharmacy department houses two post-graduate year 1 (PGY1) ambulatory care pharmacy residents, two post-graduate year 2 (PGY2) geriatric pharmacy residents, and one PGY2 ambulatory care and academia pharmacy resident. The PGY2 ambulatory care and academia pharmacy residency had two residents during its first five years and reduced its residency class size to one resident in 2020 to promote practice site partnership sustainability around the uncertainty of the pandemic.

Prior reviews of pharmacist medication therapy management (MTM) programs, a common service offered by ambulatory care pharmacists, have demonstrated an ROI as high as 12:1,6 with an average of 3:1 or 5:1.7 An economic evaluation of clinical pharmacy services across fifteen studies in hospital, ambulatory care and community pharmacies found a median benefit to cost ratio of 4.81 to 1.2 When advocating for a new ambulatory care pharmacist position, it can be helpful to provide organization leaders with anticipated ROI supporting continued evidence of sustainability in the long term. ROI could also be used in the planning process to show how a pharmacist position will affect net financial gains and how long it will take for this position to break even. ROI allows clinics to see how much is gained PRACTICE INNOVATION from each dollar invested in a pharmacist service.8 Since its initiation in 2015, the PGY2 residency in ambulatory OBJECTIVES care and academia at MAHEC has had a core focus on practice Page 25

site development for ambulatory pharmacy services in the outpatient clinic setting. Residents in the program partner with a medical practice that does not have existing pharmacy services and over the course of the year, seek to create a sustainable and replicable ambulatory pharmacy service. Resident practice sites are recruited based primarily on the presence of a physician champion and openness to team-based care. The didactic curriculum of the program supports residents as they prepare a detailed business plan for their ambulatory services, including expected revenue generation and investment cost. Business plans are pitched to the partnered practice sites, and they determine if they would like to continue to fund a non-resident, ambulatory care pharmacist position to maintain the pharmacy services developed during the residency year. EVALUATION METHODS

The primary objective was to evaluate the relationship between a positive projected ROI and the sustainment of ambulatory pharmacy services. The secondary objective was to assess the relationship between the number of essential factors previously identified and sustaining ambulatory pharmacy services. The local Institutional Review Board exempted this project. For the primary objective, a retrospective review of past resident business plans was completed to calculate projected ROIs. Twelve pharmacy residents have completed the program. Hard copies and/or electronic copies of busi-

ness plans maintained by the residency program were available for review. Each business plan included a proposed cost (financial investment of adding an ambulatory care pharmacist to the practice site) and the projected financial returns (an anticipated benefit that the clinic will receive). Financial investments included the summation of salary, benefits, continuing medical education, licensures, certifications, professional memberships, and supplies needed during the first year of clinical pharmacist services. Financial returns were calculated based on reimbursement levels for projected visit types for the anticipated number of pharmacy clinic half-days. The primary investigator reviewed each business plan to determine financial investment and returns. ROI was calculated using the following equation from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Toolkit:8

latory pharmacy services. The six essential factors are identified above. The final survey item was an open-ended question to allow respondents to share any other pertinent information about their practice site. The survey was administered to residency program graduates using an online platform. The survey was open for four weeks. If survey responses were not received in the originally specified time period, respondents received a single reminder email to seek participation. Survey responses were analyzed for potential patterns suggestive of clinic sustainability. RESULTS

Twelve PGY2 residents completed the survey. Practice site characteristics were obtained (Table 1). Four practice sites were located in non-health system outpatient clinics, four in health system outpatient clinics, and four in Federally Qualified Health ROI = Net financial returns from improvement actions Centers (FQHCs). Financial investment in improvement actions Seven clinic sites had To evaluate the secondary objec- the geographic des- ignation of tive, project leads developed a rural, three were suburban and 19-item survey to evaluate char- two were urban. Four clinics had acteristics of previous medical between 3-5 physicians, five had practice sites at the time they between 6-10 physicians, and were partnered with a resident. three had greater than 11 physiThe survey questions evaluated cians. The most common types of the size, location, governance, and other providers who worked in scope of services for each practice the clinic were physician assissite to further expand upon resi- tants (PAs), nurse practitioners dent business plans. One section (NPs), and behavioral health/soof the survey asked respondents cial work providers. One proposed to evaluate the presence or ab- clinic had an onsite pharmacy; sence of each of the six essential however, they did not sustain a factors for the success of ambu- pharmacist position. Additionally, Page 26

two clinics were associated with a school of health sciences.

Of the program’s 12 past residents, ten resident business plans were available to review. All calculated ROIs for a proposed clinical pharmacist position had positive projections and ranged from 1.06 to 1.40 (mean 1.20). Five practice sites sustained clinical pharmacy services following the residency program. ROIs calculated from the business plans of these five practices were 1.10, 1.12, 1.16, 1.27, and 1.36 (mean 1.20). The mean ROI for practices that did not sustain clinical pharmacy services was 1.17. Table 2 displays the ROI, prevalence of the six essential factors for establishing pharmacy services care, and whether the practice site sustained an ambulatory care pharmacist position. All six essential factors for establishing pharmacy services in ambulatory care settings were present at four practice sites, three of which sustained one fulltime pharmacist position. The final two sites that sustained were each missing one factor; they did not have access to a private room to see patients or lacked appropriate equipment from the clinic for part of the time. The site that had all factors but did not sustain had challenges with cost and revenue attribution in a large health system. Notably, a later resident did sustain a position within the same health system.

Two commonly missing factors for sites that did not sustain were the lack of full integration into the team and the perception that the practice was not for team-based

care. Three out of the five sites that sustained a pharmacist position were in a clinic that had been established for 10+ years. The fourth clinic site was open for one year and the final site was open between 2-5 years. Three sites out of the 12 surveyed had medical residents training in the clinic, all of which sustained a pharmacist position. For the sites that did not sustain a pharmacist position, they all lacked partnerships with medical residents or schools of health sciences. PAs and NPs were team members at four of the sites that sustained a pharmacist position. In general, practice sites with a smaller number of physicians did not sustain an ambulatory care pharmacist position. PRACTICE IMPLICATIONS

This evaluation builds on previous knowledge regarding potentially important characteristics of primary care practices when considering the addition of pharmacy services. All projected ROIs were positive, and the magnitude of ROI did not appear to impact the sustainability of ambulatory care pharmacist positions. These results offer important insight regarding the financial considerations of outpatient clinics when determining whether to invest in an ambulatory care pharmacist position.

pharmacy services with a median $4.81 cost return for every $1 invested in clinical pharmacy services.2 The range of ROI in this systematic review is valued from 1.02 to 34.61 for ambulatory, community, hospital, and longterm care clinical pharmacy services.2 The two ambulatory care studies included in this review had comparable ROIs to our study at 1.02 and 2.89.2 They hypothesized that the time to benefit for hospital-based clinical pharmacy services is much shorter, possibly explaining why their ROI is significantly larger than ambulatory care service ROI.2 The 20062010 systematic review of clinical pharmacy services by ACCP noted a shift from hospital-focused economic reviews to outpatient clinic or community-based services with calculated ROI ranging from 1.05-25.95.9 The most recent 2011-2017 systematic review of clinical pharmacy services by ACCP called for further studies demonstrating cost-effectiveness as too few studies utilized financial outcomes that a pooled ROI could not be calculated in their systematic review for this time period.5

In the ambulatory care setting, MTM services in Minnesota demonstrated significant cost savings with an ROI of $12.15 per $1 in MTM costs.6 Their significantly larger ROI could be due to Over time, the median pooled es- the scale of their project spanning timates of the cost-benefit ratio over six clinics as well as including for clinical pharmacy services prescription savings costs within have increased.2 In the 2000- their health care expenditures.6 2005 systematic review of clinical The proposed business plans inpharmacy services by the Ameri- cluded in this study only include can College of Clinical Pharmacy net financial returns based on (AACP), there was a positive eco- billable clinic encounters by the nomic impact for 69% of clinical pharmacist when calculating ROI. Page 27

National pharmacy organizations provide supplemental resources to promote the development and expansion of clinical pharmacy services.10,11 These resources include processes and guidance for how to build pharmacy services in ambulatory care without much focus on how to select a site for practice readiness. The six essential characteristics found by the ambulatory care expert panel from Carrington et al. were separated into two broad groups: foundational elements and operational elements.3 Three out of the six essential elements require strong relationships and are considered the “foundational” elements (full integration into the team, a physician or administrative champion, and a practice that is open to team-based care).3 The remaining “operational” elements include access to an EHR, appropriate equipment, and a private room to see patients.3 These three foundational elements could be considered surrogate markers for practice site culture and readiness for team-based care as all three of these foundational elements were present in all of the practice sites that sustained an ambulatory care pharmacist. Three out of five of the sites that sustained a position exhibited all six essential factors for establishing pharmacy services. The final two sites that were sustained were missing one operational factor each: the pharmacist did not have access to a private room to see patients and lacked appropriate equipment from the clinic part of the time. This may suggest that the foundational elements, more so than the operational elements, better predict the sustainability

of ambulatory pharmacy services. However, there were two pharmacy residents who had all three foundational elements but did not sustain a pharmacist position. As noted above, one site did not sustain because of challenges with cost and revenue attribution in a large health system, though these issues were resolved for a later resident who was able to sustain a position. Another site with all the foundational elements that was not sustained was during a transition period for the organization. The site opted to partner with the residency program for another year and, ultimately, two fulltime clinical pharmacist positions were sustained the following year.

Additionally, identifying a well-established clinic may be an important factor to consider as three out of five practices that sustained were established more than 10 years prior. A clinic with a medical residency program may be associated with sustaining pharmacist positions due to interdisciplinary learning opportunities between pharmacy and medicine. Three out of the five of our practice sites that sustained had medical residents. This could be a significant factor moving forward as family medicine residency programs with an integrated clinical pharmacist increased from 27.9% in 2000 to 52.5% in 2015.12

An interesting aspect not reviewed within our study would be the evaluation of clinical pharmacy service ROI over time compared to the original valuation to determine productivity and verify projected ROIs. Further research is needed to determine other characteristics that could

increase ambulatory pharmacy service sustainability rates to attenuate the healthcare shortages in primary care. This study had many strengths. First, the residency program requires that each resident follow a standardized business plan format which increases data accessibility and comparability. Second, there was even representation of the type of practice sites, including non-health system and health system clinics, and FQHCs. Lastly, a variety of clinic sizes were represented based on the number of physicians. This study was limited by the small sample size of past pharmacy residents so the practice site characteristics for sustainability may not be generalizable. Additionally, ROI calculations were based on estimated business plan projections and not actual revenue generated. The scope of the ROIs evaluated was limited to the services proposed by each pharmacy resident for one pharmacist position. The timeline of the ROIs evaluated was limited to the twelve-month PGY2 residency calendar (July-June for respective years). Since each ROI used a time horizon of 1 year, the cost calculations do not consider the issues of inflation or depreciation.8 Due to the retrospective nature of this survey, recall bias may have affected responses regarding practice sites. CONCLUSION

A projected positive ROI alone was not indicative of sustaining an ambulatory care pharmacist position, suggesting that potential financial gain was not a motivating consideration for primary care Page 28

practices considering the addition of clinical pharmacy services. Data from the twelve practice sites where clinical pharmacist services were developed support prior survey results for key characteristics needed for sustainability: full team integration, access to the EHR, presence of a physician champion, availability of appropriate equipment, private clinic room, and team-based care.

Authors: Casey Wells1, PharmD, CPP, Clinical Pharmacist at Mountain Area Health Education Center; Irene Park Ulrich2,1,3, PharmD, BCACP, CPP, Clinical Pharmacist, PGY2 Ambulatory Care Residency Program Director at Mountain Area Health Education Center; Anne Carrington Warren2,3, PharmD, BCPS, CPP, Clinical Pharmacist at Mountain Area Health Education Center. 1Pharmacotherapy Division; Mountain Area Health Education Center, Asheville, NC; 2Department of Family Medicine; Pharmacotherapy Division; Mountain Area Health Education Center, Asheville, NC; 3 Practice Advancement and Clinical Education; University of North Carolina at Chapel Hill Eshelman School of Pharmacy; Chapel Hill, NC. Corresponding author: Dr. Wells at REFERENCES

1. American College of Clinical Pharmacy., Harris IM, Baker E, Berry TM, Halloran MA, Lindauer K, Ragucci KR, McGivney MS, Taylor AT, Haines ST. Developing a business-practice model for pharmacy services in ambulatory settings. Pharmacotherapy. 2008 Feb; 28(2):285. 2. Perez A, Doloresco F, Hoffman JM, Meek PD, Touchette DR, Vermeulen LC, Schumock GT; American College of Clinical Pharmacy. ACCP: economic

evaluations of clinical pharmacy services: 2001-2005. Pharmacotherapy. 2009 Jan;29(1):128. doi: 10.1592/ phco.29.1.128. 3. Carrington A, Pokallus A, Ulrich IP, Scott MA, Fay AE, Drake ES, Wilson CG. Essential factors demonstrating readiness of primary care practices for clinical pharmacy services. Am J Health-Syst Pharm - Volume 75, Issue 21, 1 November 2018, Pages 1708– 1713, https:// 4. Evoy K, Fischer J, Mably M. Development of ambulatory care pharmacist positions under financial constraints. Frontline Pharmacist. Am J HealthSyst Pharm - Vol 72 Aug 15, 2015. DOI 10.2146/ajhp140501 5. Talon, B, Perez, A, Yan, C, et al. Economic evaluations of clinical pharmacy services in the United States: 2011-2017. J Am Coll Clin Pharm. 2020; 3:793–806.

DOI: 10.1002/jac5.1199 6. Isetts BJ, Schondelmeyer SW, Artz MB, Lenarz LA, et al. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc. 2008;48:203211. 7. Cipolle R, Strand L, Morley P. Pharmaceutical care practice: The clinician’s guide. McGraw-Hill; 2004. 8. Return on Investment Estimation. Toolkit for Using the AHRQ Quality Indicators - How to Improve Hospital Quality and Safety. Tool F1. Last reviewed March 2017. Accessed 8/20/2021. https:// hospital/resource/qitool/index.html 9. Touchette DR, Doloresco F, Suda KJ, Perez A, Turner S, Jalundhwala Y, Tangonan MC, Hoffman JM. Economic evaluations of clinical pharmacy services: 2006-2010. Pharmacotherapy.

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2014 Aug;34(8):771-93. doi: 10.1002/ phar.1414. Epub 2014 Mar 19. 10. Harris IM, Baker E, Berry TM, Halloran MA, Lindauer K, Ragucci KR, McGivney MS, Taylor AT, and Haines ST. (2008), Developing a Business-Practice Model for Pharmacy Services in Ambulatory Settings. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 28: 285-285. https:// phco.28.2.285 11. Kliethermes MA, Brown TR. Building a successful ambulatory care practice: a complete guide for pharmacists. Bethesda, MD: American Society of Health-System Pharmacists; 2012 12. Lounsbery JL, Jarrett JB, Dickerson LM et al. Integration of clinical pharmacists in family medicine residency programs. Fam Med. 2017; 49:430-6.

Table 1: Practice Site Characteristics This table displays the characteristics from past practice sites where ambulatory care pharmacy services were being developed. Responses were obtained via survey. Resident Responses 1












Practice site description Federally Qualified Health Center Non HealthSystem Outpatient Clinic Non HealthSystem Outpatient Clinic Federally Qualified Health Center

Geographic designation Urban

Number of physicians 6-10

Number of medical residents 11+

How long practice had been established (yrs) 0-1

Onsite pharmacy? No

Associated with a school of health sciences? Yes






PA, NP, BH/SW, Nutrition





PA, NP, RN, BH/SW, Nutrition, Care Managers PA, NP, BH/SW, Care Managers














Other provider types RN, BH/SW, Nutrition







HealthSystem Outpatient Clinic HealthSystem Outpatient Clinic Non HealthSystem Outpatient Clinic HealthSystem Outpatient Clinic Federally Qualified Health Center

























Federally Qualified Health Center Non HealthSystem Outpatient Clinic HealthSystem Outpatient Clinic



PA, NP, RN, DDS, BH/SW, Nutrition, Care Managers, CHW, Diabetes Health Coach PA, RN, BH/SW, Care Manager



















BH/SW (Behavioral Health/Social Work), CHW (Community Health Workers), DDS (Dentist), NP (Nurse Practitioner), PA (Physician Assistant/Associate), RN (Registered Nurse)

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Table 2: Primary and Secondary Objectives This table displays the return on investment, prevalence of all six factors for establishing clinical pharmacist services in primary care and whether the practice site sustained a clinical pharmacist position. ROI & Sustainability

Resident Responses 1 2 3 4 5 6 7 8 9 10 11 12

Site Position Return on Sustained Investment ? 1.27 (+) Y 1.36 (+) Y 1.10 (+) Y 1.16 (+) Y 1.12 (+) Y n/aa N 1.22 (+) N n/aa N 1.11 (+) N 1.06 (+) N 1.40 (+) N 1.07 (+) N

Six Essential Factors for Establishing Clinical Pharmacy Services

Yes to all six factors? Y Y Y N N Y N N N N N N

Full integration into the team Y Y Y Y Y Y P P Y Y P Y

Access to the EHR Y Y Y Y Y Y Y Y Y Y P Y

Physician or administrative champion with influence Y Y Y Y Y Y Y Y Y N Y P

Appropriate equipment provided by clinic Y Y Y Y P Y Y Y Y Y Y Y

Private room to see patient s Y Y Y N Y Y Y Y P Y Y Y

Business plans to pitch for implementation of pharmacist services were not a residency requirement at this time Y= yes; N = no; P= part of the time


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Practice that is open to teambased care Y Y Y Y Y Y P P Y Y P Y

Op-ed Submission: Call to Action from Oregon on Reproductive Health

By: Paige Clark, RPh

Amidst the challenging landscape for reproductive rights, North Carolina is close to being a national leader in reproductive healthcare access. You will no doubt find this distinction unexpected, especially when bestowed by an Oregonian, but I affirm it. Your state has embarked on a journey to enhance access to reproductive healthcare through a pragmatic and patient-centered initiative: pharmacist-initiated contraception. While 28 other states and the District of Columbia can claim similar initiatives, North Carolina has the potential to set the gold standard. Pharmacist-initiated contraception can increase access, reduce unintended pregnancies, and result in cost savings for insurers. Such initiatives also increase the bonds between pharmacists and primary care providers and help support the tapestry of a robust reproductive health environment. Seeing how North Carolina is carefully approaching implementation, I am confident it will be the


From my po sition as a lessons from Oregon’s implementation of PharmacistǦ lead regulato ry and imple Ǥ mentation/ education North Carolina Pharmacist Ǧ ǡ pharmacist, I witnessed the transforma Ǥ tive impact that expand ing the role of pharmacists in providing birth control can have on enhanc- a comprehensive implementation ing reproductive health access for roadmap. communities. From my experience, I also know the components I was thrilled to learn that critical of successful implementation. components to successful impleThis summer, I shared these les- mentation are already organized. sons learned from Oregon with I am not aware of another state stakeholders at the North Caro- which has displayed such efficienlina Summit on Pharmacist Initi- cy in putting these together. Speated Contraception. The Summit, cifically, I noted cooperation and organized by the UNC Eshelman partnership among major stakeSchool of Pharmacy, is part of a holders (pharmacists, clinicians, reproductive health advocates, statewide initiative to coordinate Page 32

and state health officials), support, encouragement, and collaboration between the state association of pharmacists and the state board of pharmacy, their joint offer for state-sponsored training and plans for a public awareness campaign and a broader reproductive health landscape primed to support their goals. I was particularly inspired that regional Pharmacist Champions will liaise closely with other healthcare professionals to promote the availability of pharmacist-initiated contraception and support community pharmacists as they begin to offer the service. Collaboration among these regional champions and coalition building with key stakeholders and community groups will be key to successful widespread implementation.

women, but if they find their local pharmacist is not trained, it will negatively stymie the effort and become the main headline.

other states at this stage in its journey toward pharmacist-initiated contraception, and its focus on collaborative implementation indicates its commitment to accessible and comprehensive reproductive healthcare. I know intimately the pivotal role pharmacists can play in bridging gaps in care, especially in areas where healthcare resources are limited. With the agreement of the state’s pharmacists to get trained and the commitment of all stakeholders to support the initiative, North Carolina will become a model for reproductive healthcare access and create a more equitable future for all.

Experience has shown that success hinges on creating sustainable compensation mechanisms that acknowledge the value of pharmacists’ expanded role. In an exciting development, Medicaid is rolling out a reimbursement model for pharmacists who are providing contraception services beginning Jan 8, 2024. A Medicaid bulletin outlining this change is forthcoming in the next few weeks, and NCAP will host a webinar on how to enroll and how to bill in February 2024. Now that Medicaid is investing in pharma- Paige Clark, RPh, is the Vice cists, private payors must follow President of Pharmacy Programs suit. and Policy at Prescryptive, based in Portland, Oregon. Even in my enthusiasm, I caution North Carolina is steps ahead of that there are challenges ahead. The first is ensuring pharmacists get trained to offer this service. I learned that via a grant to the NC Association of Pharmacists, the NC Board of Pharmacy has paid 6,000 pharmacists to receive the state-approved contraceptive training, but only 2,600 have registered. I urge pharmacists to embrace this opportunity, become birth control pharmacists, and do their part to increase contraceptive access. Their colleagues from other states tell them they will be glad they did! Pharmacists are consistently ranked among the most trusted professions and are sought for healthcare because of their convenience. In fact, 60% of women not on a highly effective method would start if available at the pharmacy. The UNC project includes plans for a public awareness campaign to educate Page 33

Thank You for Your Support

Save the Date – NCAP’s 2024 Annual Convention

The staff of your North Carolina Association of Pharmacists extends a heartfelt thank you for your support by being a member of NCAP during 2023. There is no way we could accomplish all of the positive work on behalf of the profession of pharmacy without you. We hope your holiday celebrations brought you peace and happiness with loved ones, and we wish you a successful 2024.

As you begin to map out big events for 2024 on your calendar. Make sure to mark this one and prepare to join NCAP for our Annual Convention on June 24 - 26, 2024 at the Embassy Suites Raleigh-Durham/Research Triangle Park. We will announce when the convention website is open and all the details as they are confirmed. For now, mark your calendars and plan to join us!

Each year NCAP has new opportunities for members to get involved. Whether you want to serve on a committee or chair one, we have lots of options. Use this form to share your contact information with us and tell us what your areas of interest are. We look forward to hearing from you and helping match you with a volunteer opportunity that suits you best.

It’s time to nominate that colleague who always gives 110%. They work hard to give the best care to their patients and support their fellow staff and community. Nominate that awesome pharmacist or pharmacy technician for one of the awards described here. Nominees need to be a member of NCAP. Award recipients will be announced at the 2024 Annual Convention, June 24 – 26.

NCAP’s Call for Volunteers

NPF Leadership Buzz Book Club

For those enjoying this year’s Leadership Buzz Book Club, your next book discussion will be Tuesday, February 27, 2024 from 6 – 7 pm. Make sure you read Permission to Care: Building a Healthcare Culture That Thrives in Chaos by Cory Jenks and be ready to discuss with Sarah Kokosa, PharmD, MHA, CPP. Southeastern Pharmacy Leadership Weekend

The North Carolina Association of Pharmacists is proud to be a partnering state for SCPhA’s SE Pharmacy Leadership Weekend! Because of this partnership, NCAP members are invited to register for this event at the member rate when registering as a full registrant. Check your email for more information on a coupon code to receive this offer! Here’s the presenter line-up for this year’s event - we promise, it won’t disappoint! To register and learn more, click here:

Call for Awards

Call for Posters

The 9th Annual Scientific Posters Showcase will be presented during our annual convention, June 24 – 26, 2024. The exact date and details for the session are still being decided. Here is the information you need regarding how and when to submit your abstract along with an example of an abstract.

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Find more at

Thank you to our generous donors for supporting the NCAP Advocacy Fund! Alberto Augsten Jordon Baker Sarah Bridges Jennifer Burch Elizabeth Caveness Heather Coleman Kira Durr Fred Eckel Brian Faulconer Allie Fay Anna Ferguson Stefanie Ferreri Ouita Gatton Myra Greene Justin Han Deborah Hewitt A. Hudson

Kevin Isaacs Gina Joy Matthew Kelm Rachel Kestin Stephanie Kiser Elizabeth Locklear Erica Mabry Macary Marciniak Patricia Mashburn Brooke Masten Amber McLendon Chelsea McGee Lindsey Miller Elizabeth Mills Ann Marie Nye Madison Onstott Ritesh Patel Veel Patel

David Phillips Allison Presnell Laura Rhodes Christopher Sain Mollie Scott Eduardo Seijo Penny Shelton Laura Skaff Benjamin Smith Brent Talley William Taylor Keith Vance Gregory Vassie Charles Whitehead Christen Wilhight Dawn Wilson Dustin Wilson

and 4 Anonymous Donors These contributors have helped us to achieve success during the 2023 legislative session. We were able to get S206, preserving PREP Act immunization authorities, signed into law, allowing pharmacists and technicians to administer all ACIP-recommended vaccines to adults and flu/COVID-19 vaccines to children with parental consent. Our provisions to modernize collaborative practice and payment for pharmacist-provided health care services has passed in the House and Senate, moving H125 closer to becoming law; H246, our PBM bill, has passed in the House. We still have a lot to get done this session. If you have not yet given, we hope you will join these individuals in supporting NCAP's legislative work.

Your support drives positive change in our profession!

Click to Visit and Donate! Or Text GIVE2NCAP to (202) 858-1233

Ronald Hugh Small

September 8, 1942 — October 29, 2023 Ronald H. Small, 81, of Bermuda Run, NC passed away Sunday, October 29, 2023. He was born September 8, 1942 to the late Willie H. Small and Anna Belle H. Small of Burlington, NC. Ron had a passion for his family, living life to the fullest and his career. He received his BS Pharmacy degree and a Masters of Business Administration from the University of North Carolina. In recognition of his many contributions to the Pharmacy profession he was awarded an honorary Doctor of Science degree from Campbell University. Previously, Ron was VP of Quality, Safety and Service Excellence and Chief Pharmacy Officer at Wake Forest Baptist Health. Ron served as the Interim CIO for the Medical Center’s Informatics Center and for two years as Chief Procurement Officer. Following over 36 years at Wake Forest, he worked with the Joint Commission Resources and Joint Commission International. Ron was a Fellow in the APhA and ASHP and a member of the Faculty of the ASHP Foundation’s Leadership Academy. He was a Certified Executive Coach with the International Coaching Federation (ICF) and a Yellow Belt in Six Sigma. Additional certifications include Quality Improvement Trainer by the Juran Institute and certification from the Intermountain Institute for Healthcare Delivery Research. Utilizing his Certified Executive Coach designation with his own company Eagle Strategic Alliance, Ron fully retired in 2022. He is survived by his loving wife of 47 years, Pamela Small; his daughter, Kimberly Myers (Tim) of Advance; two grandchildren, Jordan Myers of Wilmington and Joseph Myers of Advance; a brother, Larry Small (Karen) of Burlington; a sister-in-law, Vicki Ridenhour; an aunt Garnett Coble of Burlington and many loving nieces, nephews and cousins. Page 43

CLASSIFIEDS Business TARHEEL FLAGS • Flags (American, Christian, State, College Logo, etc.) • Clocks (Battery Operated with Logos, etc.) • Crosses with US Flag Motif Made from Recycled Wooden Shipping Pallets See Photos at TarHeel Flags on Facebook/Market Place Contact Jim Knowles, PharmD (Retired) 704-835-1042 – Please Leave Message


Complete SynMed XF System including Calibrated Containers, Dell OptiPlex 7040 with monitor, Wireless Honeywell bar code scanner, Lexmark laser printer model MA810, Zebra thermal printer model TLP2824 Plus, 4 positioning tray for two sets of blister cards, complete set of calibrated covers for containers, SynMed Image Module, SynMed Assist with includes Touch screen 23" Dell Computer. This unit was bought new when starting up a pharmacy in 2020. It was never used! The unit and all are in pristine condition. This would be like buying a new unit for tens of thousands less. Total Cost new was over $300,000. For Sale for $190,000. Purchase price does not include shipping charges, any tax and site preparation. Contact Tom D’Andrea 919-629-4900

Order A Classified Ad Free For NCAP Members or $1.00 a word with a $25.00 Minimum Contact Rhonda Horner-Davis at

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