North Carolina Pharmacist Volume 104 Number 2

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

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

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

BOARD OF DIRECTORS

EXECUTIVE DIRECTOR

Penny Shelton

PRESIDENT

Ouita Gatton

PRESIDENT-ELECT

Bob Granko

PAST PRESIDENT

Matthew Kelm

TREASURER

Ryan Mills

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.

A Few Things Inside

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

Pharmacists Represented Well On Legislative Day 2023

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

On legislative day, strategy sessions were held by team leaders and their assigned group members prior to visits with legislators. A debt of gratitude goes to Tony Solari, Debra Conrad, Mike James, Bobby Rawls, Ritesh Patel, Penny Shelton, and Michelle Fritsch, who served as the team leaders for these groups. NCAP lobbyists Tony and Debra, as well as Penny and other key state leaders, prepared the best strategies to share with each unique pharmacy team ahead of time. This advanced readiness enabled conversations much easier to navigate the often-misunderstood world of pharmacy for the legislators. Profession advocates visited committee meetings, thanked bill sponsors on both sides of the political aisle, and echoed each other in their common messages once engagement began.

The date of the legislative day was timely. Members had just returned from the General Assembly’s spring break; the energy was high, and their attention was focused on pharmacy legislative day (PLD) attendees who sought an appointment. A highlight of

the day was when Representative Wayne Sasser shared progress and hopes surrounding the various bills that will benefit pharmacy. He was particularly focused on the passage of bills related to transparency and fair reimbursement for pharmacy services.

The PLD attendees were well-represented by all four pharmacy schools. Future pharmacists from UNC, Wingate, High Point, and Campbell were learning how to advocate for the profession early in their careers. High Point University surprised everyone when a purple and white bus arrived, carrying their student pharmacists, eager and ready to learn.

PLD 2023 set up great momentum toward much success for our profession in this North Carolina lawmaker assembly. Fortunately, NCAP is a healthy organization with strong leadership. But it takes dollars from many pockets to ensure appropriate candidates that understand pharmacy are on ballots and elected. Because Wayne Sasser is a pharmacist, he serves not only in his legislative capacity but as an advisor to many of his non-pharmacy colleagues that serve alongside him in both chambers. He told our group he cannot serve forever; he encouraged the untried in the

Happy Summer, Everyone!

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.

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!

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!

Until next time…

Upcoming Events

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.

More events to watch for:

Sunday Evening Webinars for the remainder of 2023

2023 Student Pharmacist Conference

Ouita

Friday, July 21, 2023

2023 NCAP Residency Conference

9:00 am to 3:00 pm

Novant Health Conference Center

Winston-Salem, NC

Details and Registration

Sunday, July 30, 2023

July Sunday Evening Webinar

6:00 pm to 7:00 pm

Live Webinar

Details and Registration

Friday, October 27, 2023

25th Annual Anti-Infective Conference

8:30 am to 3:30 pm

Greensboro Country Club

Greensboro, NC

Details Coming Soon

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.

Introducing the New NCAP 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.

Megan Witkowski, PharmD, MSPH

A Farewell from NCAP’s First Executive Fellow

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.

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

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 provide an annual update.

The IDSA, in addressing a few select types of infections, released

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.

Resistant Pathogens

ESBL-Es are gram-negative bacteria that are resistant to most β-lactams. Resistance occurs by opening the cyclic amide back-

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 antibiotics into the bacterium through passive diffusion.

DTR-PA is a more significant form of resistance than is typically seen with P. aeruginosa. A difference is noted between DTR and multidrug resistance, which is resistance to at least one antibiotic in ≥3 of the following drug classes; penicillins, cephalosporins, fluoroquinolones, aminoglycosides, and carbapenems. DTR is defined as resistance to piperacillin-tazobactam, ceftazidime, cefepime, aztreonam, meropenem, imipenem-cilastatin, ciprofloxacin, and levofloxacin. This occurs through multiple mechanisms: decreased expression of outer membrane porins, excess AmpC cephalosporinases, excess efflux pumps, and mutations in the penicillin-binding 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.

Second, the duration of treatment varies based on the type of infection, patient sex, and agent. The total time should include empiric and narrowed regimens, including a change from intravenous to oral therapy. The clinical response must be considered when deciding if a range is provided.

The duration of each medication is provided in Tables 1-3.6

If able, the most effective agents should be preserved to delay resistance and maintain their effectiveness for future use. These agents include carbapenems and the novel β-lactams (ceftolozane-tazobactam, ceftazidime-avibactam, and imipenem-cilastatin-relebactam). Additionally, fluoroquinolones should be limited to preserve their efficacy and avoid toxicities such as QT prolongation, C. difficile infections, tendonitis/tendon rupture, seizures, and peripheral neuropathy. Finally, combination therapy should be avoided due to the greater risk of toxicity without improvement of outcomes. Exceptions to this include empiric treatment, tetracycline regimens, and non-urinary alternatives for CRE.

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 is positive, regardless of susceptibility results. Single-dose aminoglycosides are effective while reducing the risk of toxicity from prolonged use.

Complicated UTIs and Pyelonephritis

For the progression to complicat-

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.

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 develop more with other treatments the longer they are used.

To illustrate this, ceftazidime-avibactam has been shown to have 20% resistance after clinical exposure to CRE.8 Additionally, ceftolozane-avibactam has shown up to 50% resistance after clinical exposure to DTR-PA. There has also been documented resistance to ceftazidime-avibactam (80%) after exposure to ceftolozane-avi-

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 control has been shown to be effective across all types of infections. Next, the use of susceptibility testing and repeating as needed is recommended to guide therapy. Pharmacists can play an influential role by providing recommendations to maintain the effectiveness of these agents, whether their role is focused on infectious disease or not.

Conclusion

AMR will continue to challenge healthcare providers for years to come. This will require diligence to stay up to date on the evidenced-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.

Author: Joseph T. Martinez, PharmD, is a PGY1 Community-Based Pharmacy Resident at Walgreens Pharmacy and an Adjunct Clinical Instructor at Campbell University in Buies Creek, NC. jmartinez@campbell.edu

References

1. New report calls for urgent action to avert antimicrobial resistance crisis. World Health Organization. Apr 29 2019.

2. Tamma PD, Aitken SL, Bonomo RA,

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.

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

4. 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.

5. 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.

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

7. 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.

8. 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.

9. 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

Nitrofurantoin Monohydrate/macrocrystals:

100mg twice daily

Macrocrystals: 50-100mg every six hours

Duration: 5 days (females); 7 days (males)

ESBL-E

Sulfamethoxazole-trimethoprim

800mg-160mg twice daily

Duration: 3 days (females); 7 days (males)

Alternative

Amoxicillin-clavulanate

500mg-125mg twice daily

Duration: 5-7 days

Fosfomycin*

3g single dose

Single-dose aminoglycoside

Ceftazidime-avibactam

2.5g every 8 hours

Duration: 5-14 days

Nitrofurantoin

Sulfamethoxazole-trimethoprim

Ciprofloxacin

Immediate release: 250mg every 12 hours

Extended-release: 500mg every 24 hours

CRE

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

DTR- PA

Ceftolozane-tazobactam

1.5g every 8 hours

Duration: 5-14 days

Ceftazidime-avibactam

Imipenem-cilastatin-relebactam

Cefiderocol

Single-dose aminoglycoside

Colistin (Polymyxin E)

*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.

Table 2: Pyelonephritis and Complicated Urinary Tract Infection Treatment Recommendations 2 1st Line

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

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

Sulfamethoxazole-trimethoprim

CRE

Ciprofloxacin

Levofloxacin

Ceftolozane-tazobactam

Ceftazidime-avibactam

DTR -PA

Alternative

Once-daily aminoglycoside

Ceftazidime-avibactam

Meropenem-vaborbactam

Imipenem-cilastatin-relebactam

Cefiderocol

Once-daily aminoglycoside

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.

Table 3: Non-Urinary Infection Treatment Recommendations 2

1st Line Alternatives

ESBL-E

Carbapenems

Step down to oral fluoroquinolone or sulfamethoxazole-trimethoprim

Extended-infusion meropenem

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

CRE

DTR -PA

Ceftazidime-avibactam

Meropenem -vaborbactam

Imipenem-cilastatin-relebactam

Ceftolozane-tazobactam

Not applicable

Ceftazidime-avibactam plus aztreonam

Aztreonam: 1-2g every 6-8 hours, depending on the location

Cefiderocol

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.

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

students.9-13 The purpose of this study was to assess COVID-19 vaccine hesitancy, uptake, and perceptions among pharmacy students.

Methods

A cross-sectional study was conducted among pharmacy students from private pharmacy schools in North Carolina from September 27 to November 2, 2021. The anonymous online survey was distributed to potential participants via email using QualtricsXM. Informed consent was obtained before the respondent entered the survey. The University’s Institutional Review Board approved the study protocol.

Survey Instrument

Survey items were developed based on research on attitudes and perceptions toward the COVID-19 vaccine for different health professions.9,10,14 Most of the questions came from the Vaccine Confidence Survey Question Bank, which contains CDC’s recommended COVID-19 vaccine confidence and uptake survey items.15 Authors made some adjustments and added more questions to the validated templates to adequately examine the identified themes. The survey assessed different factors, including participants’ personal vaccine behavior; general attitudes and perception towards COVID-19 vaccines; current knowledge about COVID-19 vaccines; the perceived likelihood of COVID-19 infection; personal experience with COVID-19 as well as demographic factors such as age, sex, race, and year of study. We assessed vaccine uptake and hesitancy for the COVID-19 vaccine with the question, “The U.S. Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for three vaccines, Pfizer-BioNTech, Moderna, and Johnson & Johnson’s Janssen in the United States to prevent COVID-19. Have you been vaccinated using any of the three vaccines? (Select yes if you have received at least one dose)”. Participants who responded “no” were asked the following question: “The Pfizer COVID-19 vaccine has received full approval from the FDA. If you were offered the Pfizer vaccine, how likely are you to take it?”

Data Analysis

Data were analyzed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics were used to describe the study participants’ demographic features and

other survey questions, such as frequencies and percentages. The items on the Likert scale were reclassified as strongly disagree or disagree and strongly agree or agree. Proportions of vaccine hesitancy and vaccine acceptance were computed and compared. Chi-square tests were used to identify statistically significant differences between the vaccine-hesitant and vaccine-acceptance groups on various survey items. Statistical significance was established at an alpha of p < 0.05.

Results

A total of 182 pharmacy students completed the survey, a 19% response rate. Most of the participants were: females (79.7%), white (72.5%), and aged between 18 – 24 years (60.4%) (Table 1). There was a similar distribution of participants across years in pharmacy school (22% to 28.6%). About 87% of the participants received at least one dose of Moderna, Pfizer-BioNTech, or Johnson & Johnson’s Janssen vaccine. Among the vaccinated, approximately 16% indicated that they got vaccinated because their school mandated vaccination, while the other 84% had been voluntarily vaccinated. Statistically significant differences in vaccine hesitancy were found based on sex and year in pharmacy school (p-values .022 and .046, respectively). We observed the highest prevalence of COVID-19 vaccine hesitancy among female students (60.9%) and students in their first year of pharmacy school (43.5%) compared to their corresponding groups.

About 13% of the participants had not been vaccinated at the time of survey completion. Among these, approximately 65% indicated they were extremely unlikely to consider taking the vaccine even if it received full approval from the FDA. Only 17.4% were somewhat likely or extremely likely to receive the vaccine after full approval. Also, about 61% of the vaccine-hesitant group indicated that they were concerned about the vaccine’s side effects as the reason for not getting vaccinated; 30% cited religious beliefs as the reason for not getting vaccinated. Not enough long-term studies assessing side effects and fertility issues were cited by the vaccine-hesitant group as some of the most concerning issues about the COVID-19 vaccines.

Fewer participants agreed to have experience with COVID-19. About 10% of the participants indicated

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.

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-hesitant groups were observed by age and race.

Discussion

As trusted healthcare providers, pharmacists’ understanding and acceptance of vaccination against SARS-CoV-2 is paramount in combating the COVID-19 pandemic. Healthcare providers are the principal source of vaccine information and directly influence the vaccination decisions of their patients

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.

COVID-19 vaccination hesitancy data published before or in the early stages of the widespread availability of the vaccines indicate that safety and potential adverse effects were at the crux of healthcare worker and student disinclination. Almost 90% of pharmacy students expressing vaccination hesitancy in our study noted general concern about COVID-19 vaccination safety and adverse effects approximately a year after vaccinations were

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

pivotal role in advocating for and providing vaccinations. With the recent authorization for pharmacists to administer vaccines, including the COVID-19 vaccines, they must demonstrate their confidence that the benefits of COVID-19 vaccination exceed the 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

1. Kehrer JP, Eberhart G, Wing M, et al. Pharmacy’s role in a modern health continuum. Canadian Pharmacists Journal/Revue Des Pharmaciens Du Canada. 2013;146(6):321-324. http://dx.doi. org/10.1177/1715163513506370

2. Aruru M, Truong H-A, Clark S. Pharmacy Emergency Preparedness and Response (PEPR): a proposed framework for expanding pharmacy professionals’ roles and contributions to emergency preparedness and response during the COVID-19 pandemic and beyond. Research in Social and Administrative Pharmacy. 2021;17(1):1967-1977. http://dx.doi. org/10.1016/j.sapharm.2020.04.002

3. Shekhar R, Sheikh AB, Upadhyay S, et al. COVID-19 vaccine acceptance among healthcare workers in the United States. Vaccines. 2021;9(2):119. http://dx. doi.org/10.3390/vaccines9020119

4. Adams AJ, Desselle SP, McKeirnan KC. Pharmacy technician-administered vaccines: on perceptions and practice reality. Pharmacy. 2018;6(4):124. http:// dx.doi.org/10.3390/pharmacy6040124

5. Isenor J, Edwards N, Alia T, et al. Impact of pharmacists as immunizers on vaccination rates: a systematic review and meta-analysis. Vaccine. 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-

port. 2021;70(20):759. http://dx.doi.org/10.15585/ mmwr.mm7020e3

8. Silva J, Bratberg J, Lemay V. COVID-19 and influenza vaccine hesitancy among college students. Journal of the American Pharmacists Association. 2021;61(6):709-714. e701. http://dx.doi. 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-

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.

Table 1

Socio-demographic characteristics of participants

org/10.1093/cid/ciab054

24. Tavolacci MP, Dechelotte P, Ladner J. COVID-19 vaccine acceptance, hesitancy, and resistancy among university students in France. Vaccines. 2021;9(6):654. http://dx.doi.org/10.3390/vaccines9060654

25. Unroe KT, Evans R, Weaver L, et al. Willingness of long-term care staff to receive a COVID-19 vaccine: a single state survey. Journal of the American Geriatrics Society. 2021;69(3):593-599. http://dx.doi. org/10.1111/jgs.17022

26. Baniak LM, Luyster FS, Raible CA, et al. COVID-19 vaccine hesitancy and uptake among nursing staff during an active vaccine rollout. Vaccines. 2021;9(8):858. http://dx.doi.org/10.3390/vaccines9080858

27. Betsch C, Wicker S. E-health use, vaccination knowledge and perception of own risk: drivers of vaccination uptake in medical students. Vaccine. 2012;30(6):1143-1148. http://dx.doi. org/10.1016/j.vaccine.2011.12.021

28. Mergler MJ, Omer SB, Pan WK, et al. Association of vaccine-related attitudes and beliefs between parents and health care providers. Vaccine. 2013;31(41):4591-4595. http://dx.doi. org/10.1016/j.vaccine.2013.07.039

*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

Survey responses among COVID -19 vaccine acceptance and hesitant pharmacy students

Participants that responded affirmatively (agree/strongly agree)

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.

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.

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 characteristics on class size and length of the program can be found in Table 1.

Forty-nine percent (29/59) of programs responding reported that pharmacists were utilized to deliver pharmacology and pharmacotherapeutics content. Of those programs that utilized pharmacists, 66% (19/29) reported pharmacists teaching more than 50% of the lectures. However, only five (8%) programs reported having a full-time pharmacist on

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.

It is also encouraging to observe that in our study, pharmacists delivered more than 50% of the pharmacology and pharmacotherapeutics lectures in 19 of the 29 programs (66%). This is a similar finding as compared to PA programs (83%) which suggest that when pharmacists are utilized, they deliver most of the content. Only 8% of programs employed a pharmacist as a full-time faculty member. This is not surprising since most programs reported pharmacology and pharmacotherapeutics courses were two credit hours in their curriculum. Justifying the

cost of a pharmacist to serve as a full-time faculty responsible for a two-credit hour course may not be feasible.

Another potential advantage of utilizing pharmacists to deliver pharmacology and pharmacotherapeutics content in the curricula is the early exposure to interprofessional education (IPE). The CAPTE standards state, “The didactic and clinical curriculum includes interprofessional education; learning activities are directed toward the development of interprofessional competencies including, but not limited to, values/ethics, communication, professional roles and responsibilities, and teamwork.”7 Theoretically, students could better understand pharmacists’ role on the healthcare team if pharmacists delivered pharmacology and pharmacotherapeutics lectures early in the curriculum. Whether this early exposure would translate to improved student attitudes and collaboration in practice is unknown and warrants further study.

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.

Conclusions

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

macology and pharmacotherapeutics content in their curricula. Furthermore, 66% of programs using pharmacists reported that pharmacists deliver more than 50% of the lectures on pharmacology and pharmacotherapeutics. This study suggests that pharmacists are being used to teach the core concepts of pharmacology and pharmacotherapeutics in PT curricula. Pharmacists should consider pursuing opportunities to become involved in didactic teaching in PT programs.

Authors: Dustin Wilson, PharmD, BCPS, is an Associate Professor of Pharmacy Practice (dwilson@ campbell.edu) at the Campbell University College of Pharmacy & Health Sciences (CPHS) in Buies Creek, NC. C. Brock Woodis, PharmD, BCACP, BC-ADM, CDCES, and Scot Sawyer, PT, DPT, were affiliated with CPHS at the time of the study.

REFERENCES

1. 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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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/

9. 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

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.

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.

Introduction

As healthcare evolves, the pharmacist’s role be-

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-

on approaches to engage students in pharmacy advocacy outside the classroom setting through state and national pharmacy associations.9

Currently, an ongoing objective of the North Carolina Association of Pharmacists (NCAP) is to immerse students in advocacy efforts through active participation in state legislation. Student leaders of the NCAP Student Pharmacists Forum (NCAP SPF) created a large-scale, five-part advocacy series and a “Student Pharmacist Advocate Certificate” to offer students from all four pharmacy schools in North Carolina. This study aims to assess the impact of the student-led, five-part advocacy series for student pharmacists in North Carolina to facilitate best practices in integrating advocacy efforts within and beyond the pharmacy school curriculum. The study hypothesis is that students who complete the “Student Pharmacist Advocate Certificate’’ program will experience increased levels of pharmacy legislation interest, knowledge, comfortability speaking with state legislators, and the importance of understanding compared to their baseline.

Methods

This study was a retrospective review of pre- and post-surveys from students who successfully participated in the five-part advocacy series and completed the “Student Pharmacist Advocate Certificate” in the spring of 2021. NCAP SPF representatives coordinated this student-led, five-part student advocacy series from four pharmacy schools within North Carolina: Campbell University, Wingate University, High Point University, and the University of North Carolina. First-year through fourth-year pharmacy students enrolled in a North Carolina pharmacy school were eligible to participate in the advocacy series.

Due to the SARS-CoV-2 (COVID-19) pandemic, all events occurred via a virtual platform. This five-part series included the following events: 1) Why Advocate as a Student Pharmacist, 2) State Pharmacy Legislation Information Session, 3) State Pharmacy Legislation - Hot Topics Discussion, 4) Legislation Meetings Preparatory Session, and 5) Virtual Meetings with State Legislators. The final event allowed students to engage in meaningful conversations with state legislators and discuss pertinent issues regarding pharmacy practice and its effect on pa-

tient care.

A “Student Pharmacist Advocate Certificate” was offered through NCAP for students who attended required events and completed pre- and post-advocacy series surveys. The series examined four pertinent pharmacy legislation topics identified by NCAP in greater detail: pharmacy benefit managers (PBMs), collaborative practice agreements (CPAs), prescriptive authority, and pay parity.

The impact of this advocacy initiative was assessed through pre- and post-initiative surveys on a 1 (lowest) to 5 (highest) point Likert scale. Post-initiative surveys had to be completed within one week of certificate completion. The pre-and post-initiative surveys assessed the impact of the initiative’s effect on students’ pharmacy legislation interest, knowledge, and comfortability speaking with state legislators (Appendix 1). The surveys also assessed the importance of understanding pharmacy legislation as a student pharmacist and if pharmacy advocacy is only beneficial in certain areas of pharmacy. Additionally, students could note topics discussed with their state legislators within the post-advocacy initiative survey.

Baseline characteristics included pharmacy school, class year, and North Carolina House and Senate District. Student characteristics are presented as percentages of categorical variables and mean ± standard deviation (SD). The impact of pre- and post-advocacy series surveys was analyzed through paired t-tests. Statistical significance was set at p<.05. The University of North Carolina Institutional Review Board exempted this study.

Results

From January 2021 to April 2021, 87 student pharmacists in North Carolina expressed initial interest in attaining further information regarding the fivepart advocacy series. Ultimately, by May 2021, 50 pharmacy students completed the requirements to earn NCAP’s “Student Pharmacist Advocate Certificate.” All four North Carolina pharmacy schools had student representation, with the majority (98%; n=49) of students within the first three years of their respective four-year programs (Table 1).

NCAP Student Pharmacist Forum leaders sched-

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).

This program significantly increased students’ pharmacy legislation, knowledge, and comfortability speaking with state legislators (Table 2). Additionally, students’ knowledge and comfortability speaking with state legislators significantly increased on all four focused topics: PBMs, CPAs, prescriptive authority, and pay parity (Table 3) Students’ perceptions of the importance of understanding pharmacy legislation as a student pharmacist were well-received before the advocacy series. While insignificant, these perceptions still increased favorably upon completing the advocacy series.

Discussion

Due to the need for consistent advocacy instruction in the didactic coursework of pharmacy schools, students in North Carolina initiated an advocacy certificate through the state pharmacy association. This retrospective analysis of pre-and post-advocacy initiative surveys highlights the impact of educational and hands-on experience speaking directly with state legislators regarding pertinent pharmacy legislation. Additionally, pharmacy students were shown to successfully execute an impactful advocacy initiative by increasing their knowledge and comfortability on relevant pieces of pharmacy legislation.

The four relevant pieces of pharmacy legislation identified by NCAP aligned with specific bills NCAP was actively lobbying at the state level. While North Carolina does not have the legislation to provide pharmacists with prescriptive authority, legislation has been enacted to increase patient care access and advance pharmacy practice to improve public health needs. Thus, House Bill 96, “Allow Pharmacists to

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 legislators.

Despite the COVID-19 pandemic, student leaders were able to leverage a virtual platform between the four pharmacy schools to provide an informative and impactful advocacy series. Because meetings with state legislators took place virtually rather than in-person at the state capitol, physical and transportation barriers were eliminated. This increased student accessibility to participate in live meetings with state legislators without compromising the quality or effectiveness of those meetings. Similarly, Yu and colleagues successfully utilized a virtual platform for a COVID-19-focused state advocacy day for medical students and residents.14 Their study found that medical trainees understand the importance of effectively attaining the skills and knowledge to advocate for health policy with proper education and guidance.14

Dr. Elizabeth Griffiths indicates that “our patients’ access to care as well as their health and wellbeing depend on our willingness to become advocates on their behalf,” thus, successful legislative advocacy is imperative across all healthcare professions.15 The positive results of this retrospective study strengthen the current literature on the significant benefits of didactic and experiential advocacy efforts in healthcare professional students.11-13, 16, 17 The education students receive while attending pharmacy school should ideally help them become advocates through specific coursework with real-life experiences and participation in professional organizations.12,13,18

As pharmacy practice continues to expand and advance, it is crucial to involve student pharmacists in advocacy early on to understand its value and gain

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

Limitations of this study include a retrospective analysis of self-reported data utilizing a numerical Likert scale with small sample size. Strengths of this study include evaluating the impact of a student-led initiative through the state pharmacy association, the viability of leveraging a virtual platform, and the real-world implications of state legislator meetings on pharmacy practice. With sessions being transitioned to a virtual platform, accessing legislators was more convenient than having students commute in person from across the state to the General Assembly in Raleigh, North Carolina.

Pharmacy schools have a considerable opportunity to integrate pharmacy advocacy into their curriculum as critical actions and conversations with state legislators can directly impact their future practice and patients in their community. Since students have diverse experiential, extracurricular, and work experiences, they are well-positioned to educate others on pharmacists’ different roles and the impact of student pharmacists. Students also have the knowledge and skills to communicate unique patient-care stories effectively to the public and state legislators. Advocacy for the pharmacy field is not solely limited to speaking directly with state legislators; it is a skill that requires continuous practice in various settings to master advocating for the services, resources, versatility, and knowledge pharmacists bring to healthcare teams.

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-

cussions always focused on improving patient outcomes.

Conclusion

Implementing and completing a “Student Pharmacist Advocate Certificate” increased student pharmacists’ pharmacy legislation interest, knowledge, and comfortability speaking with legislators. Advocating for advancing pharmacy practice can effectively begin as a student pharmacist. With adequate instruction and training, student pharmacists can execute meaningful conversations with state legislators regarding pertinent pieces of pharmacy legislation.

Authors: Anita Yang, PharmD, is a PGY2 Ambulatory Care Pharmacy Resident in the Department of Pharmacy Services at UNC Health Care, anita. yang2@unchealth.unc.edu. Kevin Rhash, PharmD, is a PGY1 Acute Care Pharmacy Resident in the Department of Pharmacy Services at Duke University Health. Andrew Cartwright, PharmD, is a Staff Pharmacist at Atrium Health Wake Forest Baptist Medical Center and High Point Medical Center. Adam Persky, Ph.D., is an Associate Dean of Professional Education at the University of North Carolina Eshelman School of Pharmacy.

References

1. Dolovich L, Austin Z, Waite N, et al. Pharmacy in the 21st century: Enhancing the impact of the pharmacy profession on people’s lives in the context of health care trends, evidence and policies. Can Pharm J (Ott). 2018;152(1):45-53. Published 2018 Dec 25. doi:10.1177/1715163518815717

2. Adams AJ, Weaver KK. The Continuum of Pharmacist Prescriptive Authority. Ann Pharmacother. 2016;50(9):778784. doi:10.1177/1060028016653608

3. Isai F, Krofah E. The expanding role of pharmacists in a transformed health care system. National Governors Association. Published 2015 January 25.

4. 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

5. Jain SH. Can pharmacists help reinvent primary care in the United States? Forbes. Published October 10, 2018.

6. 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

7. 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.

8. 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 Table

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.

Impact of the Five-Part Advocacy: Pharmacy Legislation

Impact of the Five-Part Advocacy: Pharmacy Legislation Topic Knowledge and Speaking Comfortability

PBM=pharmacy benefit managers; CPAs=collaborative practice agreements

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).

Table 2

Table 3

Figure 1

Topics Discussed During State Legislator Meetings

Appendix 1

Pre- and Post-Advocacy Initiative Survey

Pre-Advocacy Initiative Survey

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-Not important; 3-Somewhat important; 5 – Very important)

Importance of understanding pharmacy legislation as a student pharmacist

Post-Advocacy Initiative Survey

Student Information

Name, E-mail, Pharmacy School, Class Year

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

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]

ABSTRACT

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

By: Dr. Taylor Mitchell and Dr. Geena Eglin

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.

PGY1 CPRP TYPES

The American Pharmacists Association (APhA) defines a PGY1 CPRP as “an advanced training

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 to gain skills in four competency areas defined by ASHP in partnership with APhA, including patient care, advancing community-based

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

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.

Outpatient health-system residency programs comprise the most significant portion of PGY1 CPRP positions across North Carolina. As a result, careful consideration is warranted when selecting a PGY1 CPRP in a hospital/ health-system outpatient pharmacy program to match one’s personal and professional goals best.

THE BENEFITS OF A PGY1 CPRP

Upon completing a PGY1 CPRP, pharmacists are exceptionally equipped with various clinical and operational skill sets. Job opportunities may include management, specialty pharmacy, transitions of care, value-based care models, continuing community pharmacy services, or a faculty position at a pharmacy school. The extraordinary clinical skillset also fully prepares the pharmacist to practice at the top of their license through CPP credentialing.

Graduates of a PGY1 CPRP may also consider pursuing a specialized PGY2 residency position. Candidates completing a PGY1 CPRP hold skill sets developed within the aforementioned four main competency areas of patient care: advancing community-based practice, leadership and management, and teaching, education, and dissemination of knowledge. These skill sets give the candi-

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 health systems, candidates may also have the opportunity to early commit to such a PGY2 program within the same hospital/health system via early commitment or a different program.

CONCLUSION

The decision of which PGY1 CPRP to pursue can be difficult to navigate and is often not a “one size fits all” approach. PGY1 CPRP candidates must review programs within North Carolina carefully to ensure the learning experiences offered align with their personal and professional goals. All PGY1 CPRPs offer experiences in patient care, leadership, management, advancement of community practice, and education. Nevertheless, there may be unique advantages in one or more of these areas based on the program’s setting. Retail chain and independent pharmacy programs allow residents to gain skills in managing a pharmacy while sharpening medication knowledge, performing patient education sessions, and completing MTM interventions. Ambulatory care centers enable residents to clinically manage patients through scheduled appointments and population health interventions while still obtaining medication dispensing skills. This setting continues to support longitudinal patient relationships in various geographical locations.

Hospital/health-system outpatient pharmacy programs combine both experiences by encouraging residents to obtain a broad range of experiences in providing patient care from managerial, ambulatory care, retail, and outpatient pharmacy perspectives. For those who desire to pursue any pharmacy career in the outpatient setting or obtain a PGY2 in ambulatory care, a PGY1 CPRP is the best way to develop an array of clinical skills and knowledge to prepare one for such longitudinal patient care opportunities. With the diversity of outpatient-focused learning experiences available for PGY1 CPRP residents, they are set up for success when pursuing additional residency training or their dream career in pharmacy.

Authors: Taylor Mitchell, PharmD, is a PGY1 Community-Based Resident at Novant Health New Hanover Regional Medical Center, Taylor.Mitchell@novanthealth. org. Geena Eglin, PharmD, BCACP, CSP, CPP, is the PGY1 Community-Based Residency Director at Novant Health New Hanover Regional 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. 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.

2. American Society of Health-System Pharmacists. Accreditation

Standards for PGY1 Pharmacy Residencies. ASHP. Accessed February 28, 2023. https://www. ashp.org/professional-development/residency-information/ residency-program-resources/ residency-accreditation/accreditation-standards-for-pgy1-pharmacy-residencies?loginreturnUrl=SSOCheckOnly

3. Community-Based Pharmacy Residency Programs (CPRPs) For Interested Candidates. American Pharmacists Association. Accessed February 28, 2023. https://www. pharmacist.com/Career/Residencies/CPRP/Interested-Candidates

4. American Society of Health-System Pharmacists (ASHP), American Pharmacists Association (APhA). Accreditation Standard for Postgraduate Year One (PGY1) Community-Based Pharmacy Residency Programs. Published April 2017. Accessed February 28, 2023. https://www.ashp.org/-/media/ assets/professional-development/ residencies/docs/pgy1-community-based-pharmacy-2017.ashx

5. American Society of Health-System Pharmacists. Residency Directory. Accessed February 28, 2023. https://accreditation.ashp.org/directory/#/program/residency

6. American Society of Health-System Pharmacists. ASO Model Types. Ac-

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

PERSONAL PERSPECTIVES

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.

Table 1

PGY1 CPRPs Definitions as Adapted from ASHP

PGY1 CPRPs Description

Independent Pharmacy

Chain Pharmacy

Hospital/Health-System Outpatient Pharmacy

Acute Care/Hospital/ Ambulatory Care Center

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.

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

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.

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.

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.

Figure 1

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

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.

Methods: This retrospective cohort study examined adult patients hospitalized with a heart failure diagnosis, ejection fraction (EF) ≥ 41%, and NYHA class II-IV, receiving medical treatment pre and post-order set implementation. The primary objective was to compare the percentage of patients fully optimized on GDMT before and after order set implementation. Full optimization was defined as patients receiving all clinically appropriate agents for heart failure with mildly reduced ejection fraction (HFmrEF)/heart failure with preserved ejection fraction (HFpEF) prior to discharge.

Preliminary Results: There were 372 patients included in the pre-order set group. A total of 41 patients had a diagnosis of HFmrEF, and 330 had HFpEF. At admission, 43.3% were receiving an ACEi/ARB/ARNI, 63.4% a beta-blocker (BB), 9.9% a mineralocorticoid receptor antagonist (MRA), and 7.5% were on a sodium-glucose co-transporter-2 inhibitor (SGLT2i). Overall, 5 patients (1.3%) received appropriate therapy at discharge, with 20 patients in the HFmrEF group and 248 patients in the HFpEF group qualifying for additional therapy. There were 115 patients included in the post-order set group. A total of 15 patients had a diagnosis

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 order set was utilized by providers on 9 patients (7.8%).

Conclusion: Appropriate GDMT at discharge increased by 3% after the implementation of an order set; however, opportunities for further optimization of therapy remain.

3. Direct Oral Anticoagulants: A Retrospective Evaluation of Prescribing Practices

Authors: Lyric Chaplin, PharmD; Hau Le, PharmD; Kristen Mcknight, PharmD, BCPS, CDCES, CPP; Justin Arnall, PharmD BCOP; Paige Carson, PharmD, CDCES, BCPS, CPP; Andrew Clark, PharmD, BCPS, CDCES, CPP; Laura Skaff, PharmD, BCACP, CPP

Institution: Atrium Health Cabarrus, Concord NC

Objective: The purpose of this study is to review current drug utilization and identify prescription trends that may indicate needed interventions.

Methods: This medication use evaluation was a retrospective, multicenter chart review with a data collection period from January 1st, 2021, to June 30th, 2021. Data was collected from identified inpatient hospitals and outpatient clinics in the Charlotte,

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-

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).

Preliminary Results: 125 patients with CAP and 111 patients with UTI were included in the pre-implementation group, and 76 patients with CAP and 98 patients with UTI were included in the post-implementation group. The duration-appropriate durations were 115/213 in the pre-implementation group and 104/164 in the post-implementation group. The mean total durations for CAP were 7.9 days prior to implementation and 7.8 days after implementation. The mean total duration for UTI was 7.0 days prior to implementation and 6.9 days after implementation.

Conclusion: Although the implementation of a clinical decision support tool increased the percentage of patients receiving guideline-directed durations of therapy for UTI and CAP, the overall duration was not significantly different before and after implementation. Further interventions may be necessary to reduce the duration of antibiotics prescribed to hospitalized patients to improve adherence with guideline-recommended durations.

millions of Americans. The primary purpose of this study is to determine whether a presentation on signs and symptoms of opioid overdose and naloxone use increases attendee knowledge and confidence pre-and post-intervention.

Methods: A presentation on opioid overdose and its treatment was delivered to undergraduate and graduate students, faculty, staff, and guests of a private university. Participants 18 years of age and older were included. Pre- and post-presentation surveys assessed attendee baseline knowledge of opioid overdose signs and symptoms and gauged understanding regarding using naloxone in overdose situations. Survey questions included multiple-choice and open-ended questions. Additionally, students were asked to rate their confidence in recognizing signs and symptoms of an opioid overdose (scale of 1 to 10, 10 = very confident). Participants who completed both surveys were included in the study.

5. Assessing self-perceived recognition of opioid overdose signs and symptoms and use of naloxone through the use of an open-ended survey pre- and post-educational encounter

Authors: Rama Shamieh, PharmD Candidate; Susan M. Smith, BS, PharmD, BCPS

Objective: Misuse of opioids affects the health and well-being of

Results: Fifty-three attendees (n=11 [21%] graduate students, n=42 [79%] undergraduate students) completed both surveys. The mean pre- and post-presentation confidence of attendees in recognizing overdose signs and symptoms was 4.5 and 7.9, respectively (p<0.001). Prior to the presentation, 9% (n=5) of participants correctly identified signs and symptoms of an overdose which improved to 34% (n=18) post-presentation. When asked if a prescription was needed for naloxone, most participants stated they were unsure (n=22, 42%). After the presentation, 92%

(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

Objective: This review aims to describe the regionalization of P&T and Policies and Procedures across UNC Health Johnston and UNC Health REX.

Methods: The first step in aligning our local P&T and Policies and Procedures across four hospitals in the region was designing a structure, cadence, and bylaws agreed upon across the region. Multiple stakeholders were involved in the design, creating ownership and buy-in. Simultaneously while designing our regional P&T, Policies, and Procedures were reviewed locally for regional alignment.

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 challenges of aligning managed hospitals across a health system.

7. Antipsychotic utilization, healthcare resource use, costs, and quality of care among all fee-for-service Medicare beneficiaries with schizophrenia in North Carolina

Authors: Jalpa A. Doshi1, Sanghyuk Seo2, Charmi Patel2, Zhi Geng1, Carmela Benson2, Brianne Brown2, Pengxiang Li1 Institution: 1University of Pennsylvania, Philadelphia, PA, USA; 2Janssen Scientific Affairs, LLC, Titusville, NJ, USA

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]).

Conclusions: In this study examining all 2019 FFS Medicare beneficiaries with schizophrenia in North Carolina, we found high levels of hospital admissions, readmissions, and ER visits, suggesting a high burden of schizophrenia. Large county-level variations found in LAI use, HRU, cost, and quality measures across North Carolina call for additional targeted quality improvement initiatives by state and local policymakers.

8. Evaluation of appropriate antithrombotic prescribing in patients with primary ASCVD in a community hospital

Authors: Sarah McGrath, PharmD, MSCR, Carrie Baker, PharmD, MBA, BCPS, Riley Bowers, PharmD, BCCP, BCPS

Institution: Cape Fear Valley Health Systems, Fayetteville, NC, Campbell University College of Pharmacy, Buies Creek, NC

Objective: The primary objective was to compare the percentage of appropriately prescribed antithrombotic medications based on guideline-recommended medications and durations of therapy in patients with ASCVD based on the initial event.

Methods: This single-center retrospective cohort study identified patients through a computer-generated report based on a diagnosis of primary ASCVD defined

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. Discharge summaries and outpatient fill histories at 1 month, 3 months, 6 months, or 12 months were used to assess antithrombotic prescribing appropriateness based on the indication.

Results: A total of seventy-six patients were included in the study. The majority of patients had a past medical history significant for hypertension (87%), hyperlipidemia (71%), and diabetes (59%). There was no difference in the primary endpoint of the percentage of appropriate antithrombotic medication prescribing in patients with ASCVD based on the initial event, defined as SIHD, minor stroke/TIA, or ACS (p = 0.155). The percentage of appropriate antithrombotic prescribing in patients by indication was SIDH: 13/25 (50%), minor stroke/TIA: 6/12 (50%), and ACS: 21/38 (55%). No difference in appropriate antithrombotic prescribing was seen based on the patient’s self-identified race (p=0.793) or insurance status (p=0.111).

Conclusion: Despite the lack of statistically significant results, DAPT duration remained incorrect in approximately 50% of the patient population. This highlights the necessity for additional prescriber education for the most effective patient outcomes.

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

9. Comparison of AUC/MIC Vancomycin Dosing Versus Trough-

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.

Conclusion: AUC/MIC vancomycin dosing is superior to troughbased vancomycin dosing in patients with extremes of body weight.

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

2University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA

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 HCV RNA 12 weeks after the end of treatment (SVR12).

Methods: A 12-month, single-center retrospective chart review was conducted in treatment-naïve HCV-infected adults who received DAA therapy between 5/1/2020 to 4/30/2021. Patients in Cohort 1, the standard monitoring group, had > 1 in-person clinic visit during DAA treatment. Cohort 2,

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 treatment. The primary outcome was the SVR12 rate. Student t-tests were conducted for continuous variables and chi-square tests for categorical variables.

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),

Conclusion: This single-center study demonstrates that minimal monitoring during HCV treatment through post-treatment week 12 is more effective in achieving SVR cure rates than standard monitoring. Eliminating required in-person clinic visits during DAA therapy alongside a collaborative approach may play a major role in overcoming barriers to HCV care in select patients.

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 using Qualtrics.

Results: Sixty-two and 64 participants completed the pre-survey and post-survey, respectively. Approximately 79% attended the Zoom session vs. the alternative. Participants were mostly female (61%) and split evenly between exercisers and non-exercisers. Approximately 70% consume 1-2 sugary drinks daily, while 20% consume three or more daily. Nearly 97% stated that the educational session changed their perspective on SBC, with 86% likely to change their SBC. The intervention improved knowledge of the topic, including recommended daily maximum sugar intake, how to read a nutrition label to determine sugar consumption, conversion of grams to teaspoons of sugar, and characteristics of T2DM/ obesity.

Conclusion: The pharmacy student-led educational sessions increased awareness and knowledge of SBC and T2DM/obesity and increased the self-reported likelihood of a change in SBC.

12. Care Coordination for High Need Children: Structure and Process from EPIC Billed Medical Notes

Authors: Cassie Twisdale, PharmD Candidate1, Catherine Allen, PharmD Candidate1, Neal DeJong M.D. 2, Izabela Annis, MS,1

Kathleen C Thomas, Ph.D. 1

Institution: 1UNC Eshelman

School of Pharmacy, 2UNC School of Medicine

the structures and processes of billed care coordination notes for youth with intellectual and developmental disabilities, psychiatric conditions, and complex medical conditions. This study seeks to describe elements of billed care coordination to facilitate broader billing for care coordination in practices and research using real-world administrative data.

Methods: Billed medical notes involving care coordination for children with intellectual and developmental disabilities, psychiatric conditions, and three or more complex chronic conditions seen annually from 2015-2019 were extracted (N=36). A literature review was conducted to identify common features of care coordination services. Medical notes were coded for potential structure and process aspects of a care coordination visit. Illustrative quotes were collected, and medical notes were analyzed for key themes. Two team members developed a coding manual, coded each record, and met periodically to discuss and reconcile differences. Co-authors provided input to describe the sample, clinical practice, and research implications of the data.

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 objective of this study was to examine

Results: Structures of care coordination notes involved timing, billing codes, and standard phrasing. Key themes of processes identified include medical specialists, identification of family structure, addressing the challenges of moving, assessment for state and federal benefits, school communication, parent communication, assessment of basic needs, mental health, vaccines, and direct patient follow-up.

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.

Methods: From November 1, 2022, to March 30, 2023, 18 patients saw a Clinical Pharmacist Practitioner at a primary care clinic for a smoking cessation appointment where strategies from the FDA campaign “Every Try Counts” were utilized. A 1-month follow-up phone call and survey were completed to quantify quit attempts and patient satisfaction.

Results: Of the 18 patients attending the initial smoking cessation appointment, 6 scheduled follow-up visits, 2 attended follow-up visits, and 6 completed the 1-month follow-up survey. At least one successful quit attempt in a 30-day period was had by 4 of 6 patients (66.7%). The mean number of quit attempts per patient over a 30-day period was 2. Although only 50% of patients were able to abstain from smoking for 3 days and 33.3% of patients were able to abstain from smoking for 5 days, all 6 patients felt “Every Try Counts” was helpful, rating it at least a 3, on a scale from 1 to 5. Half of the patients utilized pharmacologic therapy.

Conclusion: Patient perceptions of the “Every Try Counts” smoking cessation method were positive; however, barriers exist to implementing smoking cessation services.

macists prescribing hormonal contraceptives in North Caroli-

Authors: Joseph Martinez, PharmD1,2; Katie Trotta, PharmD, BCACP2; James Honeycutt, PharmD, MBA1; Charles Herring, PharmD, BCPS, CPP2.

Institution: 1Walgreen Co, Deerfield, IL; 2Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC.

Objective: North Carolina House Bill 96 allows an immunizing pharmacist to provide hormonal contraceptives (HCs). The purpose of this study was to gather and collate information regarding successes/challenges from pharmacists who have provided HCs in an outpatient practice to assist others in the implementation of this service. The primary objective was to assess the proportion of NC pharmacists who developed this service and provided HCs in an outpatient setting. The secondary objectives were to address the outcomes/barriers during the required training/ implementation of this service.

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.

14. Implementation and perception of outpatient phar-

Methods: A cross-sectional, webbased survey was sent in December 2022 to NC pharmacists enrolled in the required North Carolina Association of Pharmacists (NCAP) HC training, with all responses between December 2022 and January 2023 considered. Inclusion criteria included pharmacists licensed in NC and performed at least 50% of their clinical practice in an outpatient setting. The primary endpoint was the percentage of pharmacists who had prescribed HCs out

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.

Methods: Twenty-seven participants initially enrolled in the sixteen-week Therapeutic Carbohydrate Reduction (TCR) Aspire program. All participants were asked to obtain pre-program labs within one month of the class start date or up to two weeks after the class start date. Ordered labs include HbA1c, fasting blood glucose, lipid panel, serum creatinine/eGFR panel, liver function panel, and C-peptide. Participants are asked to regularly check their blood glucose and blood pressure and report their weight on a weekly basis. A registered dietitian will lead a weekly virtual group class helping participants successfully reduce carbohydrate consumption. A Clinical Pharmacist Practitioner and PGY1 pharmacy resident will make medication interventions as indicated to manage hypoglycemia, hypotension, and other side effects of carbohydrate reduction. Participants will complete repeat labs during the final two weeks of the program. Any labs obtained two weeks after the last session will be included for review.

Results: The TCR Aspire program will conclude in late April 2023. As of week 12, several patients have had antihyperglycemic & antihypertensive medications reduced or discontinued. Eighteen participants obtained baseline labs. Average baseline laboratory results include the following:

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 m2 and serum creatinine < 2.0 mg/dL. C-peptide was within normal limits for all patients. Conclusion: To be determined.

16. Impact of Clinical Pharmacist Practitioner Service Implementation on Hormone Therapy Adherence in Hormone-Positive Breast Cancer Patients

Authors: Lainey Vargo, PharmD, Dustin Bryan, PharmD, BCPS, Paige Perez, PharmD, BCPS, CPP Institution: Cape Fear Valley Medical Center, Fayetteville, NC

Objective: The primary purpose of this study was to evaluate the impact of a Clinical Pharmacist Practitioner (CPP) on the adherence rates in hormone-positive breast cancer patients referred for suboptimal adherence at Cape Fear Valley Cancer Treatment and Cyberknife Center. This research will also identify and describe adherence barriers commonly seen among this patient population.

Methods: The medical records of 92 patients with hormone-positive breast cancer who have filled an oral hormone therapy within the Cape Fear Valley Health System between May 2022 and October 2022 were reviewed. Patients who filled more than a 30-day supply at a time and whose adherence at baseline was identified to be > 90% utilizing proportion

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

Institution: 1UNC Eshelman School of Pharmacy, Asheville NC; 2Mountain 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.

Conclusions: Student pharma-

Methods: 201 patients with Type 2 Diabetes were identified for chart review. Patients were included if they received a new prescription for semaglutide between October 2020 and October 2021 and were already on insulin prior to semaglutide initiation.

19. Medication Use Evaluation of Dipeptidyl-Peptidase 4 Inhibitors (DPP4-I) in Primary Care Patients at Atrium Health

Authors: Luis Trejo, PharmD; Paige Carson, PharmD, CDCES, BCPS, CPP, DPLA; Jessica Cole, PharmD, BCACP, CPP; Maeghan

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

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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