North Carolina Pharmacist Volume 99 Number 3 Summer 2018 Advancing Pharmacy. Improving Health.
2018 NCAP Annual Convention Benton Convention Center Winston-Salem September 21-22, 2018
Inside this issue: Convention Schedule • Roundtable Discussions • Poster Abstracts • Remembering Stan Haywood • “Right to Try” Legislation • Lyme Disease • Policy Analysis Official Journal of the North Carolina Association of Pharmacists ncpharmacists.org
Official Journal of the North Carolina Association of Pharmacists 1101 Slater Road, Suite 110 Durham, NC 27703 Phone: (984) 439-1646 Fax: (984) 439-1649
www.ncpharmacists.org
North Carolina Pharmacist Volume 99 Number 3 Summer 2018
Inside
EDITOR-IN-CHIEF Tina Thornhill
• From the President ......................................................................................................3
LAYOUT/DESIGN Rhonda Horner-Davis
• From the Executive Director ...................................................................................4
EDITORIAL BOARD MEMBERS Anna Armstrong Jamie Brown Lisa Dinkins Jean Douglas Brock Harris Amy Holmes John Kessler Angela Livingood Ronald Small Bill Taylor
BOARD OF DIRECTORS EXECUTIVE DIRECTOR Penny Shelton PRESIDENT Stefanie Ferreri PRESIDENT-ELECT Debra Kemp PAST PRESIDENT Stephen Eckel TREASURER Thomas D’Andrea BOARD MEMBERS Olivia Bentley Jamie Brown Lisa Dinkins Kira Harris Kevin Helmlinger Macary Marciniak Cortney Mospan Jason Moss Dave Phillips Sophie DeBerry Jennifer Wilson 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.
• Convention Schedule.......................................................................................6 • Roundtable Discussions.................................................................................17 • Poster Session Abstracts.................................................................................24 • Policy Analysis: Pharmacy and Medically Underserved Areas Enhancement Act...39 • Lyme Disease: The Forgotten Vector-Borne Disease of North Carolina..........43 • Factors Associated with the Incidence of Lyme Disease in North Carolina.........50 • Call for Peer Reviewers and Peer Reviewer Recognition..................................................58 • “Right to Try” Legislation – Implications for Pharmacists and Pharmacies...59 • Pharmacy Technology Program Receives Accreditation..................................63 • Honoring Stan Haywood.....................................................................65 • News to Use.......................................................................................................................67
North Carolina Pharmacist is supported in part by: • EPIC Pharmacies Network..........................................................................16 • MedsOnCue ................................................................................................37 • Pharmacists Mutual Companies..................................................................38 • Pharmacy Technician Certification Board...................................................49 • VIP Pharmacy Systems...............................................................................57 • NCAP Career Center...................................................................................62 • EPIC Pharmacies, Inc..................................................................................64 • Pharmacy Quality Commitment..................................................................68
ADVERTISING For rates and deadline information, please contact
Rhonda Horner-Davis at rhonda@ncpharmacists.org
Click Here to Follow us!
•From the President • Stefanie Ferreri, PharmD
Positioning for Influence: From Patient Stories to Pharmacy Vision is the theme of this year’s
annual meeting. Please join me in Winston-Salem on September 21st and 22nd at the Benton Convention Center for the NCAP annual meeting. North Carolina has been a leader in pharmacy by influencing the profession’s vision and the annual meeting is a great way to continue to move our profession forward and to learn from others. This year’s annual meeting has several roundtables and posters that demonstrate successful practices. There are also a variety of continuing education and networking activities that you will find beneficial. If you have not attended a meeting in recent years, now is the time to see the changes that have been made. On day one of the meeting, you will have the opportunity to participate in different workshops and roundtable discussions. You will gain more insight into the opioid epidemic by “dismantling stigma to transform practice” with perspectives provided by the patient, family, physician, and pharmacist. You will learn more about Medicaid managed care in NC. For our student attendees, you can also participate in OTC Jeopardy and network with many NC residency programs. On day two of the meeting, we will focus on important pharmacy issues within different sectors of the profession. The sectors we want to highlight include health-system, ambulatory care, public health, academia, community, long-term care, technicians and students. The format
for this day will be a combination of facilitated discussions and short presentations to advance each of these sectors of practice. These sessions will be highly interactive, and the information gleaned will serve to shape the strategic plan and advocacy agenda for 2019. For this day to be the most successful, we not only need you to attend, but we need for you to invite your co-workers and colleagues to attend as well. I promise - your voices will be heard! Our Executive Director, Penny Shelton, has been working tirelessly on behalf of the association. It has been my pleasure to work with her and the board on behalf of the members of NCAP for the past year. In my first column addressing the membership of NCAP, I stated I had two initiatives for my presidential term. The first was to increase membership. I am happy to report that July 2018 marks the first time since November 2015 that NCAP had an increase in the monthly dues compared to the same month in the previous year. We reached a steady state and now we need to rebuild. I assure you NCAP is in a great place and we need ideas from our members and those in pharmacy who are not yet members to make it even greater! So, I challenge all our members to recruit just one nonmember to join. Remember that membership is open to pharmacists, pharmacy technicians, and student pharmacists. My second initiative, advocacy, can be better facilitated by increasing membership. So many innovative practices require an advocate to seek public support for a cause or policy. NCAP needs your help to continue this advocacy role. In the past year we have made strides to increase our presence with advocacy. Our lobbyist, Tony Adams, has been meeting with legislators in Raleigh on our behalf. He and Executive Director Shelton have been working with the
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NCAP Policy and Advocacy Committee to develop a bill to improve the existing collaborative practice authority for pharmacy. The Committee has also been working on talking points to help pharmacists and others advocate for these improvements. We will be launching two initiatives in order to help members advance their practice and to assist them in the care of their patients. The first initiative is the opioid regional workshops scheduled on Sundays throughout this fall. These workshops are designed to be practical and interactive providing you with information, resources, and tools to transform your practice and better equip you to help your patients and your community. You can register for these workshops at https://www. ncpharmacists.org/calendar_list.asp. For the second initiative, NCAP has engaged in several meetings with the NC Division of Public Health (DPH) and NC Medicaid regarding advancing the role of pharmacists to provide tobacco cessation counseling. Recent meetings have addressed enabling pharmacists who complete training to bill for tobacco cessation counseling services. NCAP is currently at work using a team of pharmacists and members of the DPH Tobacco Prevention and Control Branch to develop a curriculum and service implementation training program. Our hope is to be able to bring this important training and new reimbursement payment option to pharmacists in first part of 2019. NOW I NEED TO HEAR FROM YOU! What ideas do you have for membership benefits? What can we do to promote advocacy? What changes do you want to see? How do you want to get involved? Feel free to let me know your thoughts via email at stefanie_ferreri@unc.edu or follow me on Twitter @stefanieferreri I look forward to seeing you in Winston-Salem at the NCAP Annual Convention!
Volume 99 Number 3 Summer 2018
•From the Executive Director• Penny Shelton, PharmD, BCGP, FASCP
Every Voice Matters In the late 1990’s individuals in leadership for our profession discussed the advantages of forming a merged, single pharmacy association, and in 2000 NCAP was formed. Although individuals may have had different perceptions, the primary reason for the merger was to strengthen the profession by uniting and generating one voice for pharmacy, a voice that would serve to advance the profession. Today there are > 12,000 pharmacists licensed, living and working in North Carolina, > 19,000 registered pharmacy technicians, and > 1,150 student pharmacists in training. Yet, the collective voice of our profession is represented by a vast minority, the equivalent of what some might describe as a collective whisper. Why? I believe it is because the majority are not utilizing the conduit, NCAP, that was established and exists to represent our profession. NCAP is working hard to change this and to bring to fruition the original vision for our merged Association (i.e., that strong collective voice). The Board of Directors, staff and I are focused on creating greater value and establishing mechanisms for bringing our profession together. One such
example is the upcoming 2018 Annual Convention. The second day of the Convention will be unlike any event that NCAP has ever attempted to host. We are devoting the entire day to the issues that are impacting our profession. In the morning we will have individual summits for those who work in hospitals, community, long-term care, ambulatory care, public health, and academia. We will also have specific summits for technicians and student-pharmacists. Each group will identify, prioritize and begin problem-solving discussions around the issues, concerns and opportunities that are viewed as being the most impactful or potentially profession-changing in nature. In the afternoon, we will all come together for a highly interactive session where all the issues identified in the morning summits will be prioritized. Today our profession is being challenged, even threatened, by many outside influences. Just as true, there are many new opportunities that if we are not engaged, pharmacy may be left behind. Change is inevitable, but historically pharmacy has been somewhat passive, allowing change to happen to us. We have been amazing adaptors over the years, figuring out how to survive, but we need to be more organized and more proactive in order to influence and drive the type of change that we want and need for our profession and patients to thrive. Are you concerned about the job market, unfair business practices
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by pharmacy benefit managers, NC Medicaid’s transition to managed care, the work environment, payment for services, or quality performance ratings? Do you see risk or do you see opportunities for the profession through advanced roles and education for technicians, remote verification, telehealth clinical services, and collaborative practice. Have you thought of ways that we can collectively tackle any of these issues? Have you wondered about whether there is something NCAP can do or provide to help with any of these issues or opportunities?
Whether you are a pharmacist, a technician or a student pharmacist, if you have an opinion, if you care about the future of our profession, if you want your voice to be heard, if you want to be a part of the solution to the problems and the opportunities our profession faces, well then, you need to attend the NCAP Annual Convention this year. The theme for Convention will be “Positioning for Influence: From Patient Stories to Pharmacy Vision.” Come set the direction for our profession and be a part of strengthening and positioning your state’s pharmacy association (NCAP) as an influencer—the entity that gets the job done for pharmacy—in North Carolina. Pharmacy Proud, Penny
Volume 99 Number 3 Summer 2018
Scan or click on the QR code to register today!
2018 NCAP Annual Convention “Positioning for Influence: From Patient Stories to Pharmacy Vision”
Come Join Us
September 21-22, 2018 at the
Benton Convention Center in
Winston-Salem, NC Click here for Convention details or go to our website at ncpharmacists.org Exhibitors Contact Rhonda Horner-Davis at rhonda@ncpharmacists.org
2018 NCAP Annual Convention “Positioning for Influence: From Patient Stories to Pharmacy Vision”
Two Days of Empowering Sessions If Pharmacy is a part of who you are, then the 2018 NCAP Convention is a “Must Be There Event” for you! Regardless of where you work, your practice setting, or whether you are a pharmacist, technician, student pharmacist, or other pharmacy advocate, there is something important going on for you at Convention this year. Our theme, “Positioning for Influence: From Patient Stories to Pharmacy Vision,” is sure to resonate, motivate and empower those who attend any of the day-long workshops, 12+ continuing education sessions, or numerous interactive round tables and scientific posters. From the Keynote session to the Networking Reception with Exhibitors, the patient stories shared and the information gained are destined to influence. Also, for the first time, NCAP will be devoting an entire day of Convention to important issues impacting our profession. All pharmacists, technicians and student pharmacists are encouraged to lend their voice to this unique event designed to advance pharmacy and better position our profession for influencing change. Important, yet controversial issues and practices, are shaping our profession. Change is inevitable-- for better or worse--and becoming more proactive as NC pharmacy professionals can be the difference in setting the direction and controlling the impact.
Friday, September 21 - Workshops 7:00 am - 8:00 am
Registration/Continental Breakfast/Silent Auction Opens
8:00 am - 5:00 pm
NCAP Advanced Opioid Workshop
Opioid Epidemic: Pharmacists Transforming Practice to Save Lives
NC-CE #NC092118101 (8 hrs) (accredited by NCAP)
Lunch and Breaks Provided
8:00 am - 5:00 pm
APhA Diabetes Certificate Program
ACPE #0202-0000-18-122-L01-P (8 hrs) (accredited by APhA)
Friday, September 21 7:00 am - 8:30 am
Registration/Continental Breakfast/Silent Auction Opens North Carolina Pharmacist
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7:30 am - 8:30 am
Product Theater--Breakfast Symposium (No CE)
Sponsored by Novo Nordisk Jamie Pantelokis – jpnk@novonordisk.com
8:30 am - 8:45 am
Welcome/Introductions (No CE)
Convention Planning Co-Chairs and Moderators: Courtney L. Bradley, PharmD, BCACP Assistant Professor of Clinical Sciences High Point University Fred Wilson School of Pharmacy
Irene Park Ulrich, PharmD, BCACP, CPP Clinical Pharmacist, Mountain Area Health Center Assistant Professor of Clinical Education UNC Eshelman School of Pharmacy
8:45 am -10:30 am
Keynote Session (1.75 hours)
ACPE# 0046-9999-18-299-L01-P/T Opioid Epidemic: Dismantling Stigma to Transform Practice: Patient, Family, Physician and Pharmacist Perspectives Moderator Udobi Campbell, PharmD, MBA Associate Chief Pharmacy Officer Ambulatory Services, Duke University Hospital
Keynote Panel Donald McDonald, MSW, LCAS Executive Director, Addiction Professionals of North Carolina
Betsy Ragone Founder & President, Michael’s Voice Jana Burson, MD Addiction Medicine Specialist and Medical Director Wilkesboro Comprehensive Treatment Center Cheryl Viracola, PharmD Pharmacy Program Manager Community Care of Wake and Johnston Counties Learning Objectives: •
Identify the impact of the opioid epidemic on North Carolina citizens, families and existing public health/healthcare resources (P/T)
•
Describe how addiction stigma perpetuates the problem and impedes progress or solutions to addressing the epidemic (P/T)
•
Determine how the profession of pharmacy can step up and take on greater roles to help reduce stigma, improve care, and reduce the negative impact of opioid addiction (P)
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10:30 am -10:45 am
Break
10:45 am -12:15 pm
CONCURRENT SESSIONS (Choose one to attend) (1.5 Hours) (A) Deprescribing Best Practices
ACPE# 0046-9999-18-300-L04-P/T Speaker: Tasha Woodall, PharmD Learning Objectives: •
Define and identify risks posed by polypharmacy, particularly in older adults (P/T)
•
Explain benefits of reducing polypharmacy (P/T)
•
Describe a rational approach to deprescribing (P/T)
•
Identify target drugs for deprescribing and develop a regimen for discontinuation when given a patient case (P/T)
(B) Pharmacy Audits: PBM Tactics and Prevention Strategies ACPE# 0046-9999-18-301-L04-P
Speaker: Jason Walker-Crawford, PharmD Pharmacist Analyst, PAAS National Learning Objectives: •
Describe the most common detrimental outcomes of PBM-related audits (P)
•
Review tactics and strategies to increase your audit confidence and reduce risk of penalties (P)
•
Identify strategies to increase compliance with HIPAA, fraud, waste and abuse regulations (P)
(C) Opioid Safety, Regulatory Compliance, and Recent Legislation: What you need to know ACPE# 0046-9999-18-302-L01-P/T
Speaker: Angela Livingood, PharmD Learning Objectives: •
Review recently approved or enacted opioid-related federal and state legislation and regulations (P/T)
•
Identify those opioid-related pieces of legislation and regulations most pertinent to pharmacy practice (P/T)
•
Discuss beneficial clinical and operational policies and procedures to assist pharmacies in complying with newer opioid legislation and regulation (P)
(D) Taking Control of Your Financial Future ACPE# 0046-9999-18-303-L04-P
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Speakers: Todd Bailey Owner & Financial Advisor, KRB Financial Daniel Lee, RPh, MBA Financial Advisor, Navigon Financial Group Learning Objectives: •
Review common misperceptions and mistakes that individuals make that jeopardize their financial future (P)
•
Describe financial principles that pharmacists can implement to effectively manage pharmacy school debt while also saving for retirement (P)
12:15 pm -1:30 pm Lunch with Awards & Recognitions NCAP Awards 50+Recognition Rite of Roses Installation of NCAP Officers 1:30 pm -2:30 pm Collaborating for Excellence—Round Table Discussions (1 Hour) ACPE# 0046-9999-18-304-L04-P Specific Topics and Facilitators: Refer to pages 17-22 for details Poster Session (No CE) Poster presenters may also leave their poster up for display during the afternoon break and at the 5:30 pm networking reception 2:30 pm - 3:45 pm
The Times They Are A Changin’—Getting Ready for Medicaid Managed Care in North Carolina (1.25 Hours) ACPE# 0046-9999-18-305-L04-P/T Speakers:
John C. Stancil, Jr., R.Ph. Director of Pharmacy, DMEPOS, Home Care and Ancillary Services--Division of Medical Assistance NC Department of Health and Human Services Sue Lynn Ledford, RN, BSN, DrPH Public Health Division Director, Wake County
Learning Objectives: •
Review the status and timeline of where North Carolina Medicaid currently stands with regards to the steps in transitioning to managed care (P/T)
•
Differentiate how pharmacy services and clinical services will be managed and reimbursed in the new system vs. the current system for NC Medicaid (P)
•
Describe how pharmacists and pharmacies can take on greater roles in patient care under the new managed care structure (P)
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OTC Jeopardy (1.25 Hours) ACPE# 0046-9999-306-L040-P/T Teams from the four schools of pharmacy in NC will compete. Learning objectives: •
Identify principles of pharmacology and pharmacotherapy for common OTC classes and products (P/T)
•
Identify important patient education points for common OTC classes and products (P)
3:45 pm
Residency Showcase opens for Fourth-Year Student Pharmacists
3:45 pm - 4:00 pm 4:00 pm - 5:30 pm
Break CONCURRENT SESSIONS (Choose one to attend) (1.5 hours) (A) DEA-led discussion on Long-term Care ACPE# 0046-9999-18-307-L04-P/T
•
Speaker: David Hargroder, Manager DEA Atlanta Field Office Learning Objectives: Discuss the unique needs and nature of operations for controlled substances in long-term care as compared to the community or hospital settings (P/T)
•
Identify the most common DEA administered violations, penalties, and sanctions seen in long-term care (P/T)
•
Discuss best practices, policies and procedures which help ensure compliance with DEA enforced regulations (P/T)
(B) Chronic Care Management: Making the Service a Reality in Your Practice ACPE# 0046-9999-18-308-L04-P
Moderator: Andria Eker, PharmD Speakers: Cody Clifton, PharmD Desiree Gaines, PharmD Learning Objectives: •
Examine the role of chronic care management in quality payment programs (P)
•
Review what constitutes a chronic care management service (P)
•
Describe how pharmacists, technicians and other team members can work together to implement and maintain chronic care management services (P)
•
Determine the type of agreement (contractual or collaborative practice) that needs to be implemented for chronic care management services (P)
•
Identify resources available to assist pharmacists in establishing chronic care management services in their pharmacy, clinic or facility (P)
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(C) IV Sterile Compounding: Safety and Risks; Sterility Testing ACPE# 0046-9999-18-309-L07-P/T Speaker: Scarlett Eckert, PharmD Learning Objectives: •
Review the severity of IV compounding errors (P/T)
•
Describe the components of IV compounding errors (P/T)
•
Review the ‘proposed’ USP <797> requirements addressing IV compounding safety (P/T)
•
Review the USP <800> personnel, environment and patient safety requirements (P/T)
•
Identify which risk factors and safety issues can be mitigated (P/T)
•
Discuss how to mitigate risk factors and improve safety of your cleanroom practices and compounded sterile products (P/T)
4:45 pm - 5:45 pm
Residency Showcase opens for all Student Pharmacists
5:30 - until
Networking Reception with Exhibitors
NCAP extends a special pre-meeting thank you to our exhibitors and sponsors. Convention-goers, come walk the exhibit showcase on Friday evening while enjoying a drink and tasty hors d’oeuvres. In a fun networking environment, come learn about the latest resources and products available from our exhibitors. Then be sure to join us for “Lunch with the Exhibitors” on Saturday when select exhibitors will take to the speaker platform to share important information.
Saturday, September 22 For the first time, NCAP will devote this entire second day of Convention to important issues impacting our profession. All pharmacists, technicians and student pharmacists are welcome to lend their voice to this unique event designed to help better position our profession for influencing change. Are issues such as such as advanced roles for technicians, work environment, business transparency, star ratings, Medicaid reform, telehealth clinical services, remote verification, provider designation, collaborative practice, or the job market important to you? Then you don’t want to miss out on this new NCAP event. 7:00 am -7:30 am
Registration/Silent Auction Opens
7:30 am - 8:30 am
Breakfast With the Practice Forums (1 Hour)
ACPE# 0046-9999-18-310-L04-P Chronic Care Practice Forum Update Speaker: Jason Moss, Chair Community Care Practice Forum Update Speaker: Courtney Mospan, Chair Health Systems Practice Forum Update North Carolina Pharmacist
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Speaker: Kira Brice, Chair
New Practitioner Network Update Speaker: Kevin Helmlinger, Chair Learning Objectives: •
Describe recent activities and initiatives for the Practice Forums and New Practitioner Network (P)
•
Identify two to three ways to become more involved with the Practice Forums and New Practitioner Network (P)
8:30 am - 8:45 am
Business Break and Time to Transition to Specific Summits
8:45 am - 12:00 pm
Identifying the Five Most Impactful and Potential Profession-Changing Issues That Pharmacy Faces (Choose one of the following Summit Groups) (3 hours) ACPE# 0046-9999-18-311-L04-P/T Academia Summit Long-Term Care Summit Ambulatory Care/Public Health Summit
Student Pharmacists Summit
Community Care Summit
Technicians Summit
Health-System Summit Facilitators: NCAP Board of Directors and Summit Planning Teams Groups will take a 10-15 minute Break when appropriate for individual Summits between 10:00-10:30am Learning Objectives:
Noon - 1:30 pm
•
Identify areas of concern, important issues, and opportunities impacting our profession (P/T)
•
Discuss and prioritize the identified issues based on the level of impact today versus five years from now (P/T)
•
Identify what changes are needed to address the five most impactful or potentially profession-changing issues or problems (P/T)
•
Describe how the NC Association of Pharmacists can be better utilized as a conduit for change, influence and action (P/T)
Lunch with “Did You Know” Information by Exibitors
Select Exhibitors will have the opportunity to present information about their company, a product or resource as part of a short platform presentation during lunch. 1:30 pm - 3:30 pm
Every Voice Matters! Collectively Setting the Vision for North Carolina Pharmacy North Carolina Pharmacist
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ACPE# 0046-9999-18-312-L04-P/T Moderator Krystalyn Weaver, PharmD Vice President, Policy & Operations National Alliance of State Pharmacy Associations Facilitators: NCAP Officers and Executive Director Learning Objectives: Identify areas of concern, important issues, and opportunities impacting our profession (P/T) • Discuss and prioritize the identified issues based on the level of impact today versus five years from now (P/T) •
Identify what changes are needed to address the five most impactful or potentially profession-changing issues or problems (P/T)
•
Describe how the NC Association of Pharmacists can be better utilized as a conduit for change, influence and action (P/T)
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STUDENT PROGRAMMING Students are welcome to attend both days of Convention. Students registered for convention on Day 1 are encouraged to attend the regular programming including the plenary and concurrent sessions of their choice. Students may participate in any of the roundtable discussions and browse the scientific posters. All programming during Convention is open to students, but student specific programming includes:
Friday, September 21 2:30 pm – 3:45 pm
OTC Jeopardy
Teams of four from Campbell University, High Point University, University of North Carolina and Wingate University compete for bragging rights as the school of pharmacy with the most OTC ‘gotcha factor.’ All students and other attendees are encouraged to attend this session to cheer on their favorite school. 3:45 pm – 5:45 pm
Residency Showcase
Dress for success and bring your networking skills, business cards and CVs to this annual event where students have an opportunity to interact with representatives from residency programs across North Carolina and few even from neighboring states. The first hour of showcase is open only to fourth-year pharmacy students. Any students may browse the showcase during the second hour. 5:30 pm – Until
Networking Reception with Exhibitors
Join the fun after a day of learning! Spend time with other attendees networking and browsing the exhibits. Complete your exhibit card and enter the raffle. Refuel with a beverage and heavy hors d’oeuvres. Try your luck at our games of chance.
Saturday, September 22 7:30 am – 8:30 am
Registration / Breakfast
For 4th Year Students 8:30 am - 10:30 am
Companies will provide presentations describing their organization, the culture, what it is like to work for them, career-long opportunities within their company, expectations for pharmacists when they hire, cur rent job market status and other information.
10:30 am - 12:30 pm
Career Fair Part I: Presentations
Career Fair Part II: Showcase
Time for students to interact with companies and organizations present. Time to ask follow-up questions and to exchange business cards and CVs. North Carolina Pharmacist
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12:30 pm - 1:30 pm 1:30 pm - 3:30 pm
Lunch and Networking Career Fair: Professional Development Sessions
Choose to Participate in 2 of 3 available sessions Session A Session B Session C
Becoming a Networking Ninja—Session designed to help you learn how to take advantage of networking opportunities and how to network effectively. Enhancing Your Digital Footprint—Session designed to help you improve your digital presence and how to always look and present yourself the best way possible. Atypical Use of Your Doctor of Pharmacy Degree—Session designed to help you think through non-traditional uses of your Doctor of Pharmacy degree. When the job market is tight, what other opportunities might be out there that are right for you?
For 1st - 3rd Year Students 8:30 am – 12:00 pm
(Includes Break)
All P1-P3 students will participate in a leadership summit on “The Issues Impacting our Professionion.” Just like the hospital, community, long-term care, ambulatory care, academia, and technician attendees on this day, the student-pharmacists will be engaged in their own summit centered on identifying and problem-solving around issues impacting our profession. Through discussions and activities facilitated by members of the NCAP Student Pharmacist Network and the New Practitioner Network, the student pharmacists will: Ø Identify areas of concern, important issues, and opportunities impacting our profession Ø Discuss and prioritize the identified issues based on the level of impact today versus five years from now Ø Identify what changes are needed to address the five most impactful or potentially profession-changing issues or problems Ø Describe how the NC Association of Pharmacists can be better utilized as a conduit for change, influence and action 12:30 pm – 1:30 pm Lunch & Networking 1:30 pm – 3:30 pm Every Voice Matters! Collectively Setting the Vision for North Carolina Pharmacy Moderator Krystalyn Weaver, PharmD Vice President, Policy & Operations National Alliance of State Pharmacy Associations Facilitators NCAP Officers and Executive Director The students pharmacists will join all other convention attendees for a session designed to help set vision and direction for the profession of pharmacy in our state. The theme for the Annual Convention is “Positioning for Influence: From Patient Stories to Pharmacy Vision.” Information gleaned from the individual morning summits will be placed on the floor for further discussion and prioritization in this afternoon session. This session is all about everyone who cares about our profession coming together to lend their voice to help advance and better position our profession for influencing change. Important and controversial issues and practices are shaping our profession. The issues include: enhanced technician roles and education, work environment, business transparency, performance metrics, the job market, value-based payment, Medicaid reform, remote clinical services and telehealth/telepharmacy, provider designation and collaborative practice. Change is inevitable, but helping lead and being proactive can make all the difference in setting the direction and controlling the impact. Every voice matters, including the student-pharmacist voice, in the future of our profession. North Carolina Pharmacist
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NCAP Annual Convention 2018 - Positioning for Influence: from Patient Stories to Pharmacy Vision “Collaborating for Excellence” Roundtable Discussions, Impactful Patient Stories, Innovative Best Practices, Clinical Pearls
Convention attendees will have the opportunity to attend up to 3 roundtables that will be 18 minutes each during a 60-minute roundtable session. A description of each roundtable is provided below: 1.
“Diabetes management services in the community pharmacy” Ashley Abode, PharmD, Clinical Service Coordinator, Realo Discount Drugs, aabode@ realodiscountdrug.com
hance your retirement portfolio today. 3.
Janna Beavers, PharmD, BCPS-AQ Cardiology, Cardiology Clinical Specialist, WakeMed Health & Hospitals, jbeavers@wakemed.org
Overview: This roundtable discussion will center around diabetes management and the unique opportunity within a community pharmacy to engage your patients.
Overview: Transitions of care is a hot topic in healthcare, particularly in the world of pharmacy. The impact parmacists can have on transitions of care will be discussed.
Objectives: •
•
2.
Review reimbursable opportunities for diabetes prevention and management within a community pharmacy
Objectives:
Review and discuss available curriculum
•
Discuss recruitment strategies
•
Identify barriers to delivering these services
•
Share success stories and challenges
“Avoiding the most common and destructive retirement planning mistake” Todd Bailey, Financial Advisor, KRB Financial, todd@krbfinancialnc.com Overview: Perhaps you’re doing a good job of saving for retirement, but have you considered the role of taxes in your plan? Objectives: •
Learn the function of taxation within the various types of investing vehicles.
•
Understand the most effective ways to withdrawal income in order to minimize the impact of taxes in retirement.
•
Identify new strategies that will enNorth Carolina Pharmacist
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“Impact of Pharmacists on Transitions of Care”
4.
•
Define transitions of care and how it applies to individual practice settings.
•
Understand the role of the pharmacist in transitions of care services.
•
Discuss clinical pearls, current practices, and perceived barriers from various healthcare settings.
“Tips and Tricks for Practice-Based Research” Marianne Billeter, Pharm.D, BCPS, Pharmacy Manager, Direct Patient Care, New Hanover Regional Medical Center, marianne.billeter@ nhrmc.org Overview: Pharmacists and pharmacy technicians play a vital role in assuring patients receive the most benefit from their medications. Practice-based research is used to determine the ‘Best’ medication use processes and ‘Best’ medications in different patient care settings. Ultimately, practice-based research will demonstrate real world use of medications that cannot be determined from clinical trials. The facilitator will discuss how to get started with practice-based research and give examples of projects that could be studied. Objectives:
Volume 99 Number 3 Summer 2018
5.
•
Identify practice-based research topics
•
Describe a process to get started with practice-based research
ity Improvement Organization for this brief, but interactive introduction to the basics of healthcare quality improvement. Objectives:
“Emergency Preparedness and Disaster Management”
•
Simple hands-on activity as a problem-solving warm-up
Udobi Campbell, PharmD, MBA, Associate Chief Pharmacy Officer, Ambulatory Pharmacy Services, Duke University Hospital, Udobi. campbell@duke.edu
•
Short overview of opioid safety at pharmacy for content and the model for improvement.
•
Provide and review the activity sheets corresponding to steps in quality improvement methodology.
Jennifer Mando-Vandrick, PharmD, BCPS Clinical Pharmacist, Emergency Department, Duke University Hospital, jennifer.mando@ duke.edu
7.
Overview: Disaster incidents are events that may happen at a moment’s notice and easily overwhelm a health system’s ability to provide care to all patients. This session will discuss strategies that incorporate pharmacy practice support to the front lines in a disaster incident. The facilitator will review available evidence, processes, and lead discussion on how best to ensure pharmacy services are available to support staff and patient responses in a disaster incident.
Amy Hallisey, RPh, FASCP, Clinical Pharmacy Manager, NC Medicare & Retirement, United HealthCare, amy.hallisey@uhc.com Overview: As a pharmacist for United Health Care’s Medicare & Retirement Division, my job is to help providers improve their PartD medication adherence stars scores. This is often accomplished by calling on local pharmacies to partner with these providers. The roundtable discussion will include information on what classes of medications are included, what patients are excluded, how is proportion of days (PDC) calculated, how we can help improve our pharmacies star ratings, what insurance companies have to offer, and how pharmacies can get reimbursed for their contributions.
Objectives:
6.
•
Discuss strategies to ensure ongoing patient care during a disaster incident
•
Identify techniques to maintain staff involvement and motivation during a disaster incident
Objectives:
“Quality Improvement at the Pharmacy: Solving Problems and Advancing Practice” Michael Crooks, PharmD, Alliant Quality, Michael.Crooks@area-F.hcqis.org Jennifer Massey, PharmD, Alliant Quality, Jennifer.Massey@area-F.hcqis.org Overview: Healthcare Quality Improvement is the applied science of systematic and continuous action that leads to measurable improvement in health services and health outcomes. As our health care systems continue to emphasize quality over quantity, the skills of quality assurance, process improvement and performance measurement become more integral to our daily activities. Pharmacists are well-positioned in the healthcare system to both effect better process to improve health outcomes and evaluate the impact of those changes through measurement, tracking and reporting. Join the medication safety team from Alliant Quality, North Carolina’s Medicare Quality Innovation Network – QualNorth Carolina Pharmacist
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“Into the STARS: Boosting PartD Measures Higher”
8.
•
Discuss the importance of claims data, how pill splitting, sampling, and price matching affects Part D adherence ratings
•
Illustrate how enhanced services pharmacies can partner with provider groups with the goal of helping patients achieve a PDC>80%
“Implementation of CMS Mega Rule in Long-Term Care Facilities” Ted Hancock, PharmD, BCACP, BCGP Consultant Pharmacist, Blue Ridge Pharmacy, thancock@blueridgerx.com Overview: Consolidated Medicare and Medicaid requirements for participation for Long Term Care (LTC) facilities (42 CFR part 483, subpart B) were first published in the Federal Register on February 2, 1989 (54 FR 5316). The requirements were recently revised to reflect the substantial advances that have been made over the past several years in the
Volume 99 Number 3 Summer 2018
theory and practice of service delivery and safety. The revisions were published in a final rule that became effective on November 28, 2016. This session is intended to review the reform of pharmacy services, discuss F-Tag renumbering, explore new interpretive guidance and share experiences with the new survey process. Objectives: •
•
9.
Discuss each participant’s experience with the new Interpretive Guidance including electronic MRR, signing and documentation Share experience with the new state survey process focusing on changes and unexpected outcomes
naloxone dispensing, and provide naloxone as appropriate. The Realo stores have been guided to find ways to maximize their current workflow process to incorporate identification of patients, provide education to patients and/ or caregivers, and track dispensing of naloxone. This roundtable will provide examples from three Realo pharmacy locations regarding how they have participated in this quality improvement initiative to improve opioid safety in North Carolina. Objectives: •
Discuss three approaches to improving opioid safety within a community pharmacy setting by assessment of current workflow, identifying patients at risk for opioid overdose, educating patients and caregivers, and tracking dispensing of naloxone.
•
Describe lessons learned and data gathered during the quality improvement process at these three community pharmacies.
“Use of Simulation for Pharmacist Education” John Brock Harris, PharmD, BCPS, BCPPS, Associate Professor of Pharmacy at Wingate University School of Pharmacy, Clinical Pharmacy Specialists at Novant Health Hemby Children’s Hospital, b.harris@wingate.edu Overview: Simulation activities allow healthcare professionals to be trained in low risk environments. Using low and/or high-fidelity simulation gives the user(s) the opportunity to practice a skill without directly impacting patient care or pharmacy processes. Simulation may use technology to deliver or enhance the experience. However, a simulation activity does not need to include technology to flourish. The facilitator will lead a discussion of the roles of simulation in training processes as well approaches to include simulation in various pharmacy environments. Objectives: •
•
To discuss the role of both low and high-fidelity simulation in pharmacist training as a pharmacy learner and practicing pharmacist. To explore avenues to include simulation in pharmacist training.
10. “Strategies to Impact Opioid Safety in a
Community Pharmacy”
Christy Holland, PharmD, Residency Site Coordinator, Realo Discount Drugs, cholland@ realodiscountdrug.com Overview: Realo Discount Drugs has supported the involvement of some of its stores in a quality improvement initiative with Alliant Quality to improve opioid safety by developing an efficient process to increase communication with patients regarding opioid risk, identify patients that would benefit from North Carolina Pharmacist
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11. “Reducing Re-Hospitalizations Through
Pharmacist-Physician Collaboration”
Jennifer Kim, PharmD, BCPS, BCACP, CPP, Assistant Director of Pharmacy Education, Cone Health, Greensboro Area Health Education Center, University of North Carolina Eshelman School of Pharmacy, jen.kim@ conehealth.com Overview: Although readmission rates appear to have plateaued over the past few years, penalties to hospitals continue. The discussion will include an open dialogue about best practices for pharmacist-physician collaboration in the interest of reducing hospital re-admissions. The facilitator will encourage sharing of experiences, workflows, and success strategies from various practice settings. Objectives: •
Develop a collaborative service with physicians to reduce hospital readmissions at your practice setting
•
Document activities, monitor patient outcomes, measure the impact of your pharmacist-physician collaborative
12. “Tobacco Cessation – Keep it Simple”
Peter Koval, PharmD, BCPS, CPP, Associate Professor of Clinical Education at UNC Eshelman School of Pharmacy, Director of Pharmacy Education at Greensboro AHEC, peter. koval@conehealth.com Overview: This roundtable will provide an opVolume 99 Number 3 Summer 2018
using evidence-based medicine, best practices, and proper monitoring and follow-up
portunity to discuss techniques to effectively counsel patients on tobacco cessation. Objectives: •
Efficiently provide counseling and support
•
Concisely express drug therapy knowledge of useful therapeutic agents
ing Pharmacy Profession”
ment…But is $1M Enough to Retire On? Daniel J. Lee, RPh, MBA, Financial Advisor, Navigon Financial Group, dlee@navfin.com Overview: This session will provide an overview of budgeting, understanding debt, establishing credit, setting up an emergency fund, protecting yourself, saving for the future (retirement and college savings), preparing for retirement, and creating a plan and strategy. Objectives: •
Understand the reasons for saving and investing as well as appreciate the power of compounding interest
•
Know the importance of diversification and asset allocation in determining your investment profile Identify the factors that may affect your quality of life and financial portfolio when you’re living in retirement
14. “Community Pharmacists’ Role in Mental
Health Screening and Care”
Cortney Mospan, PharmD, BCACP, BCGP, Assistant Professor of Pharmacy, Wingate University School of Pharmacy, c.mospan@ wingate.edu Overview: Suicide is now the 10th leading cause of death, and many patients with mental health conditions such as depression are undiagnosed and left without treatment and support for their condition. This session will review strategies for community pharmacists to become an engaged partner in the care of patients with mental health conditions. The facilitator will review validated screenings that can be used in the community pharmacy setting, how to identify resources in your community to support patients’ mental health, and best practices for implementation. Objectives: •
Employ mental health screenings within community pharmacy workflow North Carolina Pharmacist
Summarize necessary triage, support, and connection to care for patients with potential mental health conditions
15. “Advanced Pharmacy Laws for the Chang-
13. “What it Takes to Save $1M for Retire-
•
•
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Geoffrey Mospan, PharmD, BCPS, Assistant Professor of Pharmacy Practice, Wingate University School of Pharmacy, g.mospan@ wingate.edu Overview: While pharmacists are usually well versed on pharmacy practice laws, including prescription, labeling, and recordkeeping requirements, understanding the Learned Intermediary Doctrine and the pharmacist’s Duty to Warn may be more difficult. For Clinical Pharmacist Practitioners, the Learned Intermediary Doctrine plays an important role in their daily practice when prescribing medications. Furthermore, the pharmacist’s Duty to Warn may have never been as important as it is now during the Opioid Epidemic. This roundtable discussion will provide an overview of both legal concepts followed by a discussion utilizing case scenarios and strategies for compliance to reduce personal liability. Objectives: •
Describe the applicability of the Learned Intermediary Doctrine to Clinical Pharmacist Practitioners and dispensing pharmacists
•
Describe the pharmacist’s Duty to Warn and apply this concept to current practice.
16. “The Use of Nonpharmacological Interven-
tions to Reduce Behavioral and Psychological Symptoms of Dementia”
Jason M. Moss, PharmD, BCGP, CPP, Assistant Professor of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Clinical Pharmacist, Dunn Medical Services, mossj@campbell.edu Overview: Behavioral and psychological symptoms of dementia (BPSD) continue to challenge both family and health care providers. Pharmacotherapy is problematic due to the risk of serious adverse effects and lack of efficacy. The discussion will include an open dialogue on evidence-based strategies for the use and implementation of nonpharmacological interventions to manage BPSD. The facilitator will encourage sharing of experiences with nonpharmacological Volume 99 Number 3 Summer 2018
strategies and how facilities have successfully incorporated these strategies into practice and the role of the pharmacist. Objectives: •
Discuss nonpharmacological interventions using evidence-based medicine in the management of behavioral and psychological symptoms of dementia.
•
Review strategies to implement nonpharmacological interventions to manage behavioral and psychological symptoms of dementia at your practice setting.
17. “Pharmacist Burnout and Resiliency”
Michael W. Neville, PharmD, BCPS, FASHP, Assistant Dean for Students & Professor, Wingate University School of Pharmacy, m.neville@wingate.edu Overview: Years ago, technological advances promised to shorten our work weeks, lighten our loads and decrease our stress. Those predictions didn’t work out as expected. Rather, expectations for tighter time lines, greater efficiencies and increased expectations have been born. Pharmacists have not escaped this reality, and many find themselves in work environments with greater demands than ever. Objectives: •
Summarize common practices that result in burnout and lead to decreased resiliency
•
Discuss methods to immunize against stress and its harmful effects
18. “Changing the Rules of the Telephone
Game: Transparent Dialogue to Improve Team Member Engagement” Randi B. Raynor, PharmD, BCPS, Pharmacy Operations Manager, Novant Health Presbyterian Medical Center, rbridges@novanthealth.org Overview: The foundation of team member engagement is the confidence that the team member is being heard and is actively involved in the decision-making process. Members of our organizations have professional goals, and leaders aren’t the only people who can positively impact change and innovation. How do we as leaders ensure that we are establishing an environment that allows our team members to have an active voice in the ongoing conversations related to excellent patient care? By using transparent dialogue, we can go beyond the normal North Carolina Pharmacist
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methods of communication and discussion. This can be accomplished through visual/tactile resources; small group interactions, and Topic Talks that allow discussions to expand beyond day-to-day workflow. What happens when a suggestion board is placed in break rooms, Thursday’s Thoughtful Topics discussion days, televisions share key information on a repetitive reel, or a small group of team members come together as mini-governance to tackle the tough issues of the department? The organization/department has a more engaged team member who directly enhances the dialogue with leadership. Objectives: •
To share ideas for two-way communication to promote team member engagement.
•
To share non-traditional communication tools to reach all team members.
19. “Screening Older Adults for Falls in the
Community Pharmacy Setting”
Jessica Robinson, PharmD, Community Pharmacy Practice Fellow, UNC Eshelman School of Pharmacy, robinje@email.unc.edu Overview: Falls and fall-related injuries represent a significant burden for older adults, caregivers, and the healthcare system, with falls serving as the leading cause of injuryrelated death for this population. The Centers for Disease Control and Prevention (CDC) estimates that fall-related injuries contribute to more than $50 billion in annual healthcare costs and that the rate of fall-related mortality is increasing by 3% annually in the United States. The CDC has developed Stopping Elderly Accidents Deaths and Injuries (STEADI) to educate patients, caregivers, and healthcare providers to identify risk factors and take necessary steps to reduce an individual’s risk of falling. While many factors contribute to falls, medications with sedative, anticholinergic, and antihypertensive mechanisms are a modifiable risk factor that pharmacists are uniquely positioned to impact. Within the community setting, pharmacists can identify older adults at risk, review medications, recommend safer alternatives, and provide education on how to reduce the risk of falling. Objectives: •
Learn how to screen older adults using the three STEADI questions
•
Identify medication classes that contribute to falls, and
•
Identify local and state-wide resources for engagement.
Volume 99 Number 3 Summer 2018
20. “Sail into Savings: Best Practices to Re-
duce Cost-Related Medication Non-adherence” Jeanie Schepisi, Piedmont Regional Manager - SHIIP, North Carolina Department of Insurance, Jeanie.schepisi@ncdoi.gov Julie Cooper, PharmD, BCPS AQ-Cardiology, Associate Professor, Clinical Sciences High Point University, jcooper2@highpoint.edu Overview: Rising drug prices are a barrier to medication adherence. Seniors, especially those with changing medication use, are at a high risk for cost-related medication nonadherence. Throughout the year, the Seniors’ Health Insurance Information Program (SHIIP) provides neutral, objective, and unbiased counseling and assistance to persons navigating Medicare, including the aged and the disabled, at no cost. At this table talk, pharmacists will learn about how SHIIP serves North Carolina Medicare beneficiaries and best practices to partner with SHIIP to prevent cost-related medication non-adherence. Objectives: •
List services offered to Medicare beneficiaries by the Seniors’ Health Insurance Information Program
•
Create a model for pharmacists to connect patients to the Seniors’ Health Insurance Information Program during the Medicare Open Enrolment Period.
21. “Engaging Student Pharmacists in Com-
munity-based Pharmacy Practice”
Kelci Trahms, PharmD, PGY1 Communitybased Pharmacy Resident, UNC Eshelman School of Pharmacy and Moose Pharmacy, kelci@moosepharmacy.com Shantel Houston, PharmD, PGY1 Community-based Pharmacy Resident, UNC Eshelman School of Pharmacy and Moose Pharmacy, shantel@moosepharmacy.com Cody Clifton, PharmD, Residency Site Coordinator and Clinical Pharmacist at Moose Pharmacy and Coordinator of Quality Assurance and Best Practices at CPESN USA, cody@moosepharmacy.com
no easy task. In this session, we will discuss how to begin each rotation experience so that you and your students are set-up for success. We will also provide examples of how student pharmacists are engaged in clinical practice at a community-based pharmacy. Lastly, we will explore ways you can immerse student pharmacists into learning at your practice setting. Objective: •
Explain how to conduct site orientation and review necessary information to discuss with student pharmacists when they start at your site.
•
Provide concrete ideas for student pharmacist activities which both directly and indirectly involve you as a preceptor.
•
Engage in peer-led discussion to solve problems at your communitybased pharmacy site.
22. “Successful Sleep in the Older Adult”
Tasha Woodall, PharmD, BCGP, CPP, Associate Director of Pharmacotherapy – Geriatrics at Mountain Area Health Education Center, Assistant Professor of Clinical Education at UNC Eshelman School of Pharmacy, tasha. woodall@mahec.net Overview: Evidence of substantial harms from the use of sedative-hypnotics, particularly for older adults, continues to mount. Despite this, in addition to studies suggesting the benefits of these drugs are minimal, use continues to be widespread. During this session, the facilitator will guide a discussion about best practices for deprescribing hypnotics and which alternative treatments may be used instead. Objectives: •
Describe risks vs. benefits of agents commonly used for sleep, in particular the benzodiazepines and benzodiazepine receptor agonists.
•
Summarize advantages and disadvantages of alternative sleep agents.
Overview: Precepting pharmacy students is a rewarding way to influence the future of pharmacy, improve the provision of quality patient care, and remain current in clinical knowledge. Incorporating precepting into your community practice can enhance your pharmacy, but keeping students engaged during the entirety of their practical experience is North Carolina Pharmacist
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Volume 99 Number 3 Summer 2018
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NCAP Annual Convention 2018 - Positioning for Influence: from Patient Stories to Pharmacy Vision Poster Session Abstracts Category: Original Research Title: A Retrospective Review of Factors that Impact Performance in a Year-Long Top 200 Drug Course Authors: Sophia DeBerry, Cortney Mospan, PharmD, BCACP, BCGP; Christopher Gillette, PhD Objectives: To assess the impact of pre-requisite GPA, semester that Introductory Pharmacy Practice Experience (IPPE) occurred, IPPE practice location, completion of practice quizzes (PQs), and campus attended on student performance in a Top 200 Drug course. Methods: A retrospective observational analysis of performance in a Top 200 course was completed. Students were included if they were enrolled in both semesters of the course and completed their Community IPPE in 2016 -2017. Linear regression models were created to examine how pre-requisite GPA, semester that IPPE occurred, type of IPPE site, completion of >80% of practice quizzes, and campus location were associated with final course grade in both semesters. Results: Students were significantly more likely to have higher fall final course grades when they had a higher pre-requisite GPA (b=8.75, p<0.0001), were enrolled in IPPE (b=2.81, p=0.034), and completed >80% of PQs (b=4.15, p=0.005). Students who had higher pre-requisite GPAs (b=3.75, p=0.03), completed >80% of PQs (b=3.47, p=0.002), attended the satellite campus (b=-3.22, p=0.009), had completed IPPE at a grocery store or mass merchant (b=2.63, p=0.026), and had higher scores in the fall semester (b=0.35, p<0.0001) had higher spring course grades. Conclusion: Several factors were identified that impacted student performance, some of which may not be expected. Students with a higher pre-requisite GPA and those who completed >80% of PQs performed better. Campus location and IPPE location also impacted student performance. Further investigations should assess how these factors improved student performance and if they can impact student performance in other courses. Category: Original Research Title: Implementation and Evaluation of a Pharmacist-led Hypertension Management Clinic Authors: Andrew P. Clark, PharmD, BCPS, CDE, CPP; North Carolina Pharmacist
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Kristie D. Clark, PharmD, CDE, CPP; Nick Wilkins, PharmD, BCPS, CDE, CPP Institution: Carolinas HealthCare System NorthEast – Concord Internal Medicine Objective: The primary objective was to assess the impact of pharmacist intervention on patients with hypertension. Secondary outcomes included systolic and diastolic blood pressure values and medication interventions including the number and type of medication-related problem interventions and percentage resolved by the clinical pharmacist, and average number of antihypertensive medications at three months after the last pharmacist office visit. Methods: Medical records of 106 patients with hypertension from January 1, 2017 to December 31, 2017 were reviewed. Patients were included in the blood pressure outcome data if they had an office visit with the pharmacist at least once, and had at least one documented blood pressure at any visit three months after the last pharmacist visit. Medication-related problems were reported for all patients seen in 2017. Results: 78 patients met criteria and were included in the analysis. The average systolic blood pressure in the study group improved from 145.5 mmHg to 140.4 mmHg (p < 0.0417) and the average diastolic blood pressure improved from 81.5 mmHg to 77.7 mmHg (p < 0.0210). 52.6% of patients met their age specific goals three months after meeting with the pharmacist, compared with 35.9% before intervention. Pharmacists made a total of 141 medication-related problem recommendations, of which 133 recommendations were implemented by the pharmacist. A total of 106 unique patients were seen for 153 visits by pharmacists in 2017. Patients did not take significantly more antihypertensive medications on average after meeting with the pharmacist – 2.14 medications per patient initially versus 2.31 medications on average at three months. Conclusion: Patients who were seen by a clinical pharmacist at least once showed a statistically significant improvement in systolic and diastolic blood pressures. A greater percentage of patients achieved their age-appropriate BP goals without significantly increasing medication burden. Category: Original Research Volume 99 Number 3 Summer 2018
Title: Reducing 30-Day Hospital Readmission Rates by Utilizing Embedded Pharmacists for Discharge Follow-up in an Internal Medicine Practice Authors: Amanda Woods, PharmD, BCACP, CDE, CPP; Kayla Morgan, PharmD, BCACP, CDE, CPP; Lindsay Sheehan, PharmD, CDE, CPP Institution: Kannapolis Internal Medicine, Atrium Health Objective: Medication-related problems (MRPs) are a significant cause of hospital readmissions and emergency room (ER) visits. This project aimed to decrease 30-day hospital readmission rates and ER visits by utilizing outpatient clinical pharmacists to conduct hospital follow-up visits. Methods: This project consisted of three separate prospective, single-center, controlled, IRB-approved studies conducted at a hospital-owned internal medicine practice. Adult patients scheduled for a pharmacist hospital followup were compared to patients who only received routine hospital follow-up with their primary care provider. Patients were offered an in person, phone, or virtual followup visit with a pharmacist. The primary endpoint was 30-day hospital readmissions and ER visits. Secondary endpoints included MRPs identified items that required provider intervention, and patient-identified barriers to care. Results: A total of 239 patients were included in the study. The majority of the patients were >65 years of age with multiple chronic disease states and medications. There were statistically and clinically significant reductions in 30-day hospital readmissions for patients in the PharmD intervention group compared to the standard hospital follow-up group (7% vs 18%, p=0.0104) and ER visits (8% vs 20%, p=0.0054). There was an overall 65% reduction in readmissions or ER visits in the PharmD intervention group (12% vs 34%, p<0.001). The potential savings to the health system exceeded $137,500. The pharmacist identified an average of 3.1 MRPs per visit and 72% were resolved by the pharmacist. Conclusion: Clinical pharmacists can identify and resolve a variety of MRPs surrounding hospital discharge. Pharmacist intervention after hospital discharge potentially prevented one in five hospital readmissions or ER visits within thirty days, which was associated with a potential cost savings exceeding $137,500 over the course of the study periods. These results are further proof of concept for the use of clinical pharmacists to improve transitions of care. Category: Quality Improvement Evaluations Title: Efficacy and safety of sodium glucose co-transporter-2 inhibitors at three clinics within an educational health system North Carolina Pharmacist
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Authors: Casey Wells, BS, PharmD Candidate; Jennifer Kim, PharmD, BCPS, BCACP, CPP Institution: Moses H. Cone Memorial Hospital, Greensboro NC; UNC Eshelman School of Pharmacy Objective: To assess the efficacy and safety of sodium glucose co-transporter-2 inhibitors (SGLT2i) in diabetic patients in terms of glycosylated hemoglobin (A1c), blood glucose (BG), blood pressure (BP) and weight (Wt) reductions at three indigent clinics within an educational health system. Methods: This was a deidentified, retrospective chart review medication use evaluation. Patients of one of three clinics prescribed Invokana (canagliflozin), Farxiga (dapagliflozin), or Jardiance (empagliflozin) before March 9th, 2018 were included. Of 139 patients screened, 42 were excluded for not having at least one of the following: PostA1c, Post-BG, Post-BP, or Post-Wt due to recent initiation or loss of follow up. Results: Of 97 patients, 49 (50.52%) were prescribed canagliflozin, 25 (23.71%) empagliflozin, and 23 (23.71%) dapagliflozin. The mean baseline A1c was 9.88% and BG was 232.51 mg/dL. The overall mean post-A1c was 8.83%, (-1.05%, p=0.0005). The overall post-BG was 179.29 mg/dL (-53.22mg/dL, p < 0.0001). There was no significant difference in BP [(systolic p=0.4605), (diastolic p=0.6644)] or Wt (p=0.7699). Dapagliflozin showed the greatest reduction in A1c (-1.44%) and BG (-91.83 mg/ dL), followed by canagliflozin (-1.12%, -40.82mg/dL). Fifteen (15.46%) had concomitant heart failure while taking an SGLT2i for diabetes. Four patients on an SGLT2i had renal impairment contraindications. Four patients (4.12%) had a history of urinary tract infections prior to starting the SGLT2i. Four patients (4.12%) had amputations prior to starting SGLT2i. There were no reports of UTI or amputation after starting SGLT2i. Eleven patients (11.34%) developed vaginal candidiasis or yeast infections. Conclusion: This study found a statistically and clinically significant reduction in A1c and blood glucose. Dapagliflozin was found the most effective SGLT2i. There was no significant difference in blood pressure or weight reductions after starting SGLT2i in this population. Category: Original Research Title: Characterization of Dormant Tumor Cells in Pancreatic Ductal Adenocarcinoma and Therapeutic Strategies Authors: Sonya L Anderson, BA, PharmD Candidate1; Limei Shen, PhD2; Leaf Huang, PhD2 Institution: 1University of North Carolina at Chapel Hill Eshelman School of Pharmacy; 2University of North Carolina in Chapel Hill Department of Pharmacoengineering
Volume 99 Number 3 Summer 2018
and Molecular Pharmaceutics Objective: Pancreatic Ductal Adenocarcinoma (PDAC) is often resistant to most systemic/targeted therapies, facilitating the need for novel drug delivery. One such novel therapeutic treatment option is traps. Traps are fusion proteins that bind to chemokines in a manner similar to monoclonal antibodies. The traps are then formulated into nanoparticles which can be delivered to the pancreas. The trap can be formulated to target chemokines like CXCL13 which have been implicated in the suppression of the anti-tumor response through B-reg recruitment. The primary purpose of this study was to prove the CXCL13 trap (OT1) decreases PDAC tumor growth by reducing B-reg differentiation through analysis of known markers of B-reg expression. Methods: To analyze OT1’s effect on PDAC tumor growth and B-reg differentiation, a well-validated, clinically relevant mouse model (KPC) was used. KPC98207 cells (1x106) were injected into the tail of the pancreas. Mice were randomized into two treatment groups: PBS or OT1 (50 μg of plasmid). IV injections were performed every 3 days for a total of 3 doses. Tumor tissues were then harvested to be analyzed through western blot (WB) and flow cytometry (FC) for the presence of certain cytokines (pSTAT3, IL-35, IL-10) and vimentin. Results: Through WB band intensity quantification, PDAC tumors treated with OT1 had significantly reduced presence of pSTAT3 (p<0.05), IL-35 (p<0.01), and vimentin (p<0.01) as compared to GAPDH control. Additionally, through FC quantification, PDAC tumors treated with OT1 had significantly reduced presence of IL-10 (0.79%) as compared to PBS control (8.91%) (p<0.01). Conclusion: OT1 works to decrease tumor burden in PDAC by reducing differentiation of B-cells into B-reg cells, shown by the reduction of cytokines involved in suppressing the anti-tumor immune response (pSTAT3, IL-35, IL-10) and vimentin. Thus, OT1 represents a new PDAC treatment option to be used in conjunction with current chemotherapeutic drugs. Category: Original Research Title: Evaluation of Generational Influences Among 4th Year Pharmacy Students and Experiential Preceptors Authors: Susan M Smith, BS, PharmD, BCPS; Megan Coleman, PharmD, BCPS, CPP Institution: Wingate University School of Pharmacy, Wingate, NC Objective: The purpose of this study was to evaluate the influence generational categories may have on patterns and commonalities that exist among pharmacy students and their respective experiential pharmacist preceptors during advanced pharmacy practice experiences (APPE). North Carolina Pharmacist
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Methods: Two hundred fifty-two multiple-choice surveys aimed at evaluating generational characteristics were sent to 87 pharmacy students during their first three APPE rotations and to their respective experiential preceptors. The questions focused on six key areas: preferred learning/teaching style, view on the role of career/ work, communication style, view of technology, outlook on life, and personal characteristics. Each response option corresponded to a generational category (Veteran, Baby Boomer, Generation X, and Millennial) to which students and preceptors were blinded. Students and preceptors were instructed to apply each question to themselves. Students were then instructed to apply the question to their preceptor, while preceptors applied the questions to students. Results: Twenty-three of 87 students (26%) completed 45 generational surveys (18% response rate), and 61 of 172 preceptors (35%) completed 75 generational surveys (30% survey response rate). Students selected the option that corresponded to their actual generational category significantly more often compared to preceptors (2.133±0.815 versus 1.632± 1.132, p <0.05). Although none of the respondents were born in the years covered by the Veteran category, responses corresponding to this generation represented the second highest number of responses selected by students and preceptors alike. Conclusions: Students and preceptors identified with characteristics outside of their actual generational category. In addition, both groups selected options such as having a grateful outlook on life and working to make a difference that may correlate more with people who have chosen pharmacy as a profession rather than their generational category. Pharmacist awareness of these generational similarities is vital to the success of the preceptor-student relationship as well as the overall learning experience. Category: Original Research Title: Assessing the Impact of Pharmacists in Improving Quality Measures that Affect Physician Payment Authors: Jessica Sinclair, PharmD; Olivia Bentley, PharmD, CFTS, AAHIVP; Amina Abubakar, PharmD, CFTS, AAHIVP; Laura Rhodes, PharmD, BCACP; Macary Weck Marciniak, PharmD, BCPS, BCACP, FAPhA Objective: To assess the impact of pharmacists in a primary care practice on quality measures of MIPS and PCMH through the provision of face-to-face annual wellness visits and via phone calls for chronic care management Methods: A retrospective analysis of specific quality measures was conducted by utilization of reports and by manual collection of data within the electronic healthcare record, AthenaNet. This data was reported by AthenaNet as the percentage of patients who have satisfied each Volume 99 Number 3 Summer 2018
measure, and descriptive statistics were utilized to analyze the data. Patients were included in the study if they were seen at the clinic between January 1, 2017 and February 2, 2018 and care provided met criteria for one of seven selected MIPS or PCMH quality measures. Patients were excluded if they were less than 18 years of age, deceased, or discharged from the practice during the study period. Results: A total of 193 patients were seen by the clinical pharmacist for an annual wellness visit, chronic care management, or both services. For the first assessment of quality measures before and after pharmacist integration, improvements were only seen in two quality measures: the hepatitis C screening and influenza vaccination rate. When the population of patients seen by the pharmacist was compared to the entire Medicare population at the practice, the pharmacist cohort met more criteria for quality measure satisfaction; the greatest improvement was seen in hepatitis C screening (31%), influenza vaccination (29%), and colorectal cancer screening (23%) Conclusions: The pharmacist integration model in clinic filled gaps in care and improved quality measures, which may contribute to higher potential reimbursement. Annual wellness visit services may increase the likelihood of quality measure satisfaction due to an increased number of patient interactions. Category: Quality Improvement Evaluation Title: Medication Reconciliation: Incorporating Resident Education and Discharge Instructions Thereby Lowering Errors (MR. IncREDIBLE) Authors: Heather Kehr, PharmD, BCPS; Angela Pegram, PharmD, BCPS, CDE; Lara Pons, MD, FAACP Objective: Complaints regarding inaccuracy on discharge medication instructions from the inpatient service sharply increased. The purpose of this study was to investigate errors on discharge instructions in our family medicine inpatient service, both in number and type to ascertain if there is a problem in this area. Methods: For academic year 2017-2018, 3 charts were randomly chosen from different blocks of inpatient service for each first and second year resident (n=15) in our program. The discharge summary was compared with the patient discharge medication instructions for accuracy in medication name, dosage and instructions. Errors were recorded by residency year, week of service and type of error made for each incident found on review. Results: Forty errors were found on the 45 charts reviewed, giving an error rate of 0.89 errors per chart reviewed. Omissions (n=30 or 75%) comprised the largest number of errors, which included omitting a new medicine on instructions, not addressing a dosage change or continuing a home medication, or not including the North Carolina Pharmacist
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medication changes in the discharge summary. Week 2 (n=14 or 35%) and week 4 (n=20 or 50%) of our monthly service block correlated with the most errors. Residency year seemed to have no correlation with number of errors, with the interns having 52% (n=21) and the second-year residents having 48% (n=19) errors found on review. Conclusions: Based on the findings of our pilot study, an intervention was needed right away to fix erroneous discharge medication instructions. As our new intern class begins, education on refreshing the discharge medication reconciliation was emphasized. Additionally, our attendings will be very closely checking the discharge summary and discharge medication instructions of all residents to catch errors before they reach the patient. Our review will be repeated to check for improvement and look for other possible problem areas in the discharge medication instruction process. Category: Original Research Title: Comparison of a two-phase pulmonary function test activity: Using learner self-confidence to determine activity revisions Authors: Courtney L. Bradley, PharmD, BCACP; Christopher Houpt, PharmD Candidate; Kelly Odegaard, PharmD Candidate; Peter Gal, PharmD, BCPS, FCCP, FASHP, FPPAG Institution: High Point University Fred Wilson School of Pharmacy, High Point, NC Objectives: To evaluate whether pharmacy student confidence administering a pulmonary function test (PFT) after a skills laboratory session is further enhanced by adding a second laboratory session. Methods: A two-week educational activity was designed. For week one, students prepared by completing readings and watching videos on proper PFT procedures. In skills lab, each student completed a PFT with an instructor coaching to assure proper performance. Week two occurred one week later, and, in pairs, students again completed a PFT, but the paired student served as the coach. Instructors were present but only interjected when necessary. Students completed three surveys, a baseline before training, and after completing the laboratory sessions in week 1 and week 2, to assess confidence in performing PFT steps and interpreting PFT results. Surveys assessed confidence using a 0 to 10 scale and were statistically analyzed using the sign test. Results: Forty-five students completed and consented to all surveys (78.9% inclusion rate). There was a significant increase in confidence for all items between the first and second surveys. However, between the second and third surveys, only two items increased significantly. Conclusion: The educational intervention was successful in improving student self-confidence in performing Volume 99 Number 3 Summer 2018
PFTs and interpreting results. However, limited additional confidence was gained by adding a second week of training, especially in context of resource allocation required. These findings inform instructors that a 1-week PFT training session is sufficient and that resources needed for a second PFT training week would be better invested in another teaching opportunity. Category: Original Research Title: Student Pharmacist Attitudes Towards and Perceptions of the Role of the Pharmacist in Suicidal Ideation Assessment Authors: Brandi Pierce, PharmD candidate; Miranda Johnson Benfield, PharmD candidate; Chris Gillette, PhD; Cortney Mospan, PharmD Institution: Wingate University School of Pharmacy Objective: To investigate first-year student-pharmacist attitudes toward suicide, perceived role of the pharmacist in assessing for suicidal ideation, and whether previous pharmacy work experience or gender are associated with attitudes toward suicide or the perceived pharmacist’s role. Methods: An anonymous online survey was administered to first-year student-pharmacists at one pharmacy program in North Carolina. Measures included gender, previous pharmacy work experience, personal contact with suicide, the perceived pharmacist’s role in assessing for suicide, and Attitudes Towards Suicide (ATTS). Data are presented as medians or proportions, where appropriate. Bivariate associations were investigated using nonparametric statistical tests. Results: Seventy-three student-pharmacists had usable survey data (response rate=75%). The median ATTS score was 69 (IQR = 7), indicating student-pharmacists were generally undecided in attitudes toward suicide. However, 91.78% (n=67) of student-pharmacists agreed or strongly agreed that suicide was a real disease. The majority of students (56.17%, n=41) agreed or strongly agreed that patients do not want to discuss suicide with a pharmacist; however, almost 80% (79.45%, n=58) agreed or strongly agreed that pharmacists have a professional responsibility to assess for suicidal ideation. A majority (53.43%, n=39) of students disagreed (or strongly disagreed) that patients with suicidal ideation receive all necessary information from a primary care provider or psychiatrist/psychologist. The majority of students (53.42%, n=39) were not aware of Mental Health First Aid, and a small minority (12.33%, n=9) had completed Mental Health First Aid training. There was no association in attitudes toward suicide nor the perceived pharmacist’s role in suicide based on genders or previous pharmacy work experience. Conclusion: First-year student-pharmacists, while being North Carolina Pharmacist
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undecided on his/her personal attitudes toward suicide, overwhelmingly agree that suicide is a disease and pharmacists are important in assessing for suicidal ideation. Schools and colleges of pharmacy should provide Mental Health First Aid training to support suicide intervention skills. Category: Original Research Title: A unique role for utilization of student pharmacists to assess pharmacokinetic quality improvement in a community hospital Authors: Mason Holt; Daryl Blackburn RPh, MBA; Michael Willis, PharmD, MHA, BCPS; April Cooper, PharmD, Duke Regional Hospital, Department of Pharmacy and Campbell University, College of Pharmacy & Health Sciences Objective: In 2017, Duke Regional Hospital (DRH) and Campbell University, College of Pharmacy & Health Sciences (CPHS) entered into an agreement which significantly increased the number of student pharmacists receiving clinical training at DRH. The purpose of this study was to utilize student pharmacists during an experiential rotation in a community hospital to assess pharmacokinetic quality improvement in an on-going Department of Pharmacy initiative. Methods: A pharmacist provided orientation and training related to pharmacokinetic dosing, the DRH pharmacokinetics policy and the QI project to students completing an Advanced Professional Practice Experience. A report was developed to identify patients. Students underwent a 30-minute orientation to the project and a 2-hour pharmacokinetic training session. Twenty patients were randomly selected every month for review by each student. Utilizing REDCaps, a secure web application for building and managing an online database, students retrospectively captured information related to dosing and attainment of targeted goals. One student was selected to analyze the data and present the results to the pharmacy department. Results: Ten pharmacy students collected data on 200 patients. Each student spent approximately 5 hours on data collection. One pharmacy student was involved with the data analysis and presentation of the results to the department. Conclusions: With the help of pharmacy students we were able to double the number of patients reviewed in one year for our community hospital’s pharmacokinetics QI initiative. Category: Original Research Title: Evaluation of Antibodies (NMDA, CASPR2, AMPA, LGI1, DPPX, and GABAB) Associated with Human Immune-Mediated Encephalitides in Canine Cerebrospinal Fluid Volume 99 Number 3 Summer 2018
Authors: Emma G. Stafford PharmD, FSVHP; Amanda Kortum; Jeffery Yoder PhD; Natasha Olby Vet MB, PhD, MRCVS, DACVIM (Neurology) Institution: North Carolina State University College of Veterinary Medicine Objective:The primary purpose of this study was to ascertain the underlying etiology of canine meningoencephalitis of unknown etiology (MUE) by evaluating autoimmune antibodies known to be predictive in human encephalitides including three receptor targets (NMDA, AMPA, GABAB) and three voltage-gated potassium channel-associated protein targets (CASPR2, LGI1, DPPX). Methods: Cerebrospinal fluid (CSF) from thirty five (n=35) dogs was tested for against six possible antigenic targets (NMDA, GABAB, AMPA, DPPX, CASPR, LGI1) using a commercially available test kit that utilizes indirect immunofluorescent assay. Briefly, CSF samples were pipetted onto a proprietary TITERPLANE tray that recognizes IgA, IgG, and IgM antigens. In the second step, attached antibodies are stained with fluorescein-labelled anti-dog antibodies and visualized on a fluorescence microscope. Results: Testing indicated that N-methyl-D-aspartate (NMDA) receptor antibodies were present in the CSF of three dogs (n=3/35). Control CSF from a clinically normal dog was included and was negative against all antigenic targets. No other antibody targets (AMPA, GABAB, CASPR2, LGI1, DPPX) were positive in any of the dogs evaluated. Conclusion: To the best of our knowledge, this is the first published report of NMDA receptor encephalitis in the dog and only the second published report on this disease in veterinary medicine. Identification of the underlying autoantibody responsible for MUE in dogs leads to the potential for development of targeted therapies as well as the use of dogs as a naturally occurring animal model. Category: Quality Improvement Evaluation Title: Prothrombin complex concentrate (human) Kcentra® Medication Use Evaluation Authors: Ashton Lee, PharmD Candidate; Rebecca Szymanski, PharmD, BCPS; Christopher Barringer, RPh Institution: Carolinas Healthcare System Northeast, Concord NC Objective: The purpose of this medication use evaluation was to evaluate the appropriateness of the prescribing of Prothrombin complex concentrate (human) Kcentra® (PCC) at Atrium Health facilities. Methods: Retrospectively, the electronic medical records North Carolina Pharmacist
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(EMR) of eighty-four patients at ten facilities who received PCC were reviewed. Data collected included indication for use, individual entering the order into the EMR, ordering provider, utilization of correct order set, dose, and utilization of vitamin K. Results: Eighty-four patients at ten Atrium Health facilities who received PCC were included in the analysis. PCC was ordered for forty patients who were on warfarin (47.6%), nineteen who were on rivaroxaban (22.6%), fourteen on apixaban (16.7%), and three on enoxaparin (3.6%). PCC was ordered and administered to eight patients who were not on any medications requiring reversal with PCC. (9.5%). Six patients on warfarin (15%) had PCC ordered and administered despite an INR less than 2.0. Three patients who were on warfarin (7.5%) did not receive vitamin K concurrently with PCC. The correct order set, warfarin or direct oral anticoagulant reversal, was utilized for 79 patients (94%). The appropriate dose based on package insert recommendations was ordered for 55 patients (65.5%). Three facilities had 100% correct order set utilization including correct dosing. Conclusion: This evaluation indicates that there is room for improvement within Atrium Health facilities with prescribing PCC according to the FDA approved dosing strategies. Proper utilization of the facility’s mandatory order sets would facilitate improved usage. Provider and pharmacist education following this MUE will focus on utilization of the proper order set, FDA approved dosing, appropriate INR limits, and the importance of providing vitamin K concurrently with PCC when reversing warfarin. Optimization of the use of PCC could reduce unnecessary costs at individual locations. Category: Original Research Title: Advancing Precision Medicine: Improving Attitudes and Confidence in Pharmacogenomics with Educational Programming and Personalized Genotyping Authors: Deanna Rubin, PharmD Candidate; Olivia Dong, MPH; Rachel Howard; Oscar Suzuki, PhD; Cristina Benton, PharmD, PhD; Tim Wiltshire, PhD; Amber Frick, PharmD, PhD Institution: University of North Carolina Eshelman School of Pharmacy Objective: As pharmacogenomics (PGX) testing becomes increasingly widespread, it is vital for pharmacists to become proficient in applying this information to optimize pharmacotherapy and influence key healthcare stakeholders. This study sought to examine conference attendees’ attitudes regarding the use of PGX and to discover how those attitudes change following educational programming, including personalized genotyping. Methods: The 2017 UNC Pharmaceutical Sciences Conference focused on the role of pharmacy in precision medicine. Prior to the conference, 76 participants Volume 99 Number 3 Summer 2018
completed a survey and PGX testing with DNA2Rx. At the conference, participants received their PGX results for 18 relevant pharmacogenes. Twenty-eight participants also completed a post-conference survey. Demographic information and personal attitudes regarding PGX were collected and paired data was assessed with the Wilcoxon signed rank test using SAS.
personal best for FVC, FEV1, FEV1/FVC, and FEF25-75. Phase two occurred one week later and participants that wore a nose clip in phase one did not wear a nose clip in phase two, and vice versa. The results were analyzed using a paired t-test to compare using a nose clip versus not using a nose clip, as well as week one versus week two to ensure there was no practice bias.
Results: Participants self-identified as 41% female, 21% Asian, and 75% white with a median age of 41. Most participants had prior genetics training (61%), but only 2% had previously completed PGX testing despite many experiencing medication-related side effects (67%). Participants worked in healthcare (29%), academia (61%), and industry (13%). Following the conference, participants were significantly more likely (p<0.05) to believe PGX information should be stored in the patient’s medical record and that PGX testing companies provide accurate results. They were also more confident in their ability to identify therapeutic areas where PGX testing is required, discuss benefits of PGX testing, and interpret PGX results (p<0.05). Agreement rates that most physicians, pharmacists, or patients can accurately interpret PGX results remained low (<20%).
Results: Thirty-seven participants reported results and met the study criteria (64.9% response rate). There was no statistically significant difference between participants results when they wore a nose clip or not, or between week one and two.
Conclusion: With the rise of personalized medicine in healthcare, PGX education is critical for pharmacists to remain influential leaders in this field. Utilizing personal genomic testing could be a useful way to actively engage healthcare stakeholders in PGX and improve attitudes surrounding the use of PGX testing for the future.
Authors: Laura Bobbitt, PharmD Candidate; Jacqueline McLaughlin, PhD
Category: Original Research Title: Comparison of a Two-Phase Pulmonary Function Test Activity Utilizing Nose Clips and Not Utilizing Nose Clips Authors: Kelly Odegaard, PharmD Candidate 2020; Christopher Houpt, PharmD Candidate 2020; Courtney L. Bradley, PharmD, BCACP; Peter Gal, PharmD, BCPS, FCCP, FASHP, FPPAG Institution: Fred Wilson School of Pharmacy, High Point University Objectives: To determine whether a difference exists in pulmonary function test (PFT) results when participants wear a nose clip versus not wearing a nose clip. Our null hypothesis is that when participants do not use a nose clip while performing a PFT their results will be more variable and differ significantly from PFTs performed with nose clips. Methods: A two-phase intervention was designed for which each participant served as their own reference. For phase one, participants either wore a nose clip to complete a PTF or did not. Participants completed PFTs three times; the values were compared to assure reproducibility. Values that were recorded included percent predicted and North Carolina Pharmacist
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Conclusions: This study demonstrated that PFT results do not vary widely if a participant does or does not wear a nose clip. These findings may be used by clinicians when writing protocols or developing clinics to avoid unnecessary spending and resource allocation on nose clips. Category: Original Research Title: Pay to Play: How Much It Costs to Complete the Prepharmacy Curriculum
Institution: UNC Eshelman School of Pharmacy, Chapel Hill, NC Objective: To characterize current prepharmacy curricula and model the associated financial costs. Methods: Prepharmacy course requirements for every Doctor of Pharmacy degree program accredited by the Accreditation Council for Pharmacy Education were collected from each school’s website. Course cost data for community colleges, public in-state universities, and private non-profit universities were collected from the College Board, Trends in College Pricing 2017. The cost per credit hour was multiplied by the number of credits required by each school to estimate the costs of prepharmacy curricula for various pathways (e.g. community college, university). Results: On average, schools require 67±8 (range 41 to 94) semester hours of prepharmacy coursework. At least 85% of programs require General Biology, General Chemistry, Organic Chemistry, and Calculus. Courses such as Anatomy & Physiology, Microbiology, Physics, Statistics, English Literature/Composition, Communication/Public Speaking, and Economics are required by approximately 60% to 80% of programs. Requirements for Biochemistry, Cellular Biology, Molecular Biology, Genetics, and Psychology vary widely. There is also large variation in liberal arts requirements, with some schools requiring courses in History, Philosophy, Political Science, Business/Accounting, and Critical Thinking. The cost to complete the prepharmacy curriculum can vary, Volume 99 Number 3 Summer 2018
depending on the student’s pathway to pharmacy school. Students who completed the prepharmacy curriculum at a community college in 2017 paid on average $17,890 ± $2,259 (range $11,029 - $25,286) for tuition, fees, and room and board. At the other end of the spectrum, students who completed a bachelor’s degree at a private university and later completed prepharmacy requirements at a public university paid on average $137,937 ± $5,843 (range $122,398 - $153,772).
ered education to hospital staff (UNC 75%, Other 100%). However, fewer pharmacy interns at UNC had a drug monograph project (UNC 12.5%, Other 67%).
Conclusion: There appears to be little agreement on what is core to the prepharmacy curriculum across PharmD programs in the United States. Consideration should be given to the extent to which the prepharmacy curriculum financially burdens prospective students.
Title: Impact of Pharmacist-Led Anemia Management for Non-Dialysis-Dependent Renal Disease Patients
Category: Quality Improvement Evaluations Title: Assessment of Student Pharmacy Internship Programs from Intern and Preceptor Perspectives Authors: Sally Jagielski, PharmD Candidate 20191; Jonathan Cicci, PharmD, BCPS1,2; Ashley Pappas, PharmD, BCPS1,2; Megan Clarke, PharmD, BCPS, AQ Cardiology1,2 Institutions: 1University of North Carolina Eshelman School of Pharmacy – Chapel Hill, NC; 2Department of Pharmacy, University of North Carolina Medical Center – Chapel Hill, NC Objective: To characterize the roles and experiences of pharmacy interns in a variety of pharmacy settings. Methods: Two 13-question surveys were emailed via Google forms. The first survey (S1) was sent to known pharmacy interns from the University of North Carolina (UNC) Eshelman School of Pharmacy (n=33). The second survey (S2) was sent to preceptors of pharmacy internships at the UNC Medical Center and to preceptors of external pharmacy internships from interns who completed S1 or those found via a web search (n=19). Results: Thirteen pharmacy interns (39%) responded to S1, including nine (69%) UNC interns and four (31%) from other programs. Internship sites included acute care (15%), ambulatory care (46%) and administration (39%). Pharmacy interns completed an average of 4.9 projects (range 1-10). Eleven preceptors (58%) responded to S2 (UNC 73%, Other 27%). Sites included acute care (UNC 18%, Other 9%), ambulatory care (UNC 9%, Other 9%) and administration (UNC 46%, Other 9%). Interns had been accepted for an average of 3.9 years (UNC; 1 - 10 years) or 9.7 years (Other; 3 - 16 years) and completed an average of 6.2 projects (UNC; range 2 - 9) or 3 projects (Other; range 3 - 3). Pharmacy interns primarily shadowed preceptors (UNC 87.5%, Other 100%) and participated in administrative roles (UNC 100%, Other 100%). In general, students frequently completed quality improvement projects (UNC 75%, Other 67%) and delivNorth Carolina Pharmacist
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Conclusion: Pharmacy interns participate in both administrative and clinical roles. Additional opportunities may exist for UNC interns to work on drug monographs. Category: Original Research
Authors: Jolynn Sessions, PharmD, BCOP; Nowshin Islam, PharmD Candidate; Ebose Ikheloa, PharmD Candidate Institution: Mission SECU Cancer Center, Asheville, NC; UNC Eshelman School of Pharmacy – Asheville Campus, Asheville, NC Objective: The primary purpose of this study was to evaluate the percentage of visits where Hb was maintained above 10 g/dl and the percentage of patients who required blood transfusions. Secondarily, the cost-effectiveness of pharmacist’s intervention will be assessed. Methods: A retrospective chart review of patients’ electronic medical records (EMR) with start period of April 1, 2015 through May 25, 2018 was conducted. Patients who did not present for initial clinic visit and patients who did not present for a follow-up appointment after their initial clinic visit were excluded. Data collected included patient demographics, initial ESA dose per protocol, baseline and follow-up hemoglobin levels, iron studies, type of insurance, time between follow-up visits, number of actual visits, as well as other comorbid factors. Results: Fifty-three patients with a mean baseline Hb of 8.9 g/dL were included and seen for a cumulative 436 visits. They were able to maintain a Hb level above 10 g/dL for 32.8% percent of visits. Hb fell below 8 g/dL for 10.8% percent of visits and five patients required blood transfusions during their care. Of the fifty-three patient, twelve are still being seen by the pharmacist for anemia management. 21% percent of patients were lost due to lack of follow-up and 37% were released from the clinic either because they started dialysis, receive a transplant, or no longer needed ESA. Conclusion: Anemia, in the setting of renal disease, may result in fatigue, myalgia, decreased concentration, cold intolerance, and poor appetite. Clinical pharmacists can help ensure non-dialysis dependent renal disease patients receive effective management of their anemia by appropriately monitoring Hb, initiating supportive- and therapeutic modalities, and adjusting doses of ESA. Category: Quality Improvement Evaluation Title: Identification of High-Impact Drug Classes durVolume 99 Number 3 Summer 2018
ing Formulary Standardization across a Multi-Institution Health Care System Authors: Chelsea Day, PharmD Candidate, B.S.; Gregory Heindel, PharmD, BCPS; Jennifer Cruz, PharmD, BCPS Institution: University of North Carolina Medical Center, Chapel Hill NC Objective: The primary objective of this evaluation was to identify drug classes with significant impact on formulary standardization efforts across a multi-institution health care system. The common qualities of high impact drug classes were also described. Methods: Data were gathered from class reviews standardized between August 2017 and June 2018 by the UNC Health Care System Pharmacy and Therapeutics Committee, as part of a health care system drug formulary standardization initiative. The health care system drug formulary regulates 11 hospitals (including academic, community, and rural) and numerous outpatient clinics and infusion centers. Few drug formulary standardization efforts were completed prior to August 2017. The number of line items reviewed, total line items included in the system drug formulary, and number of existing ERX’s removed were collected from each class review. A line item was defined as a single drug, dosage form, and strength. ERXs represent institution specific, individual drug files that were built within the electronic health record. Most line items equate to 1 ERX, however, some line items translate to multiple ERXs. Class reviews with greater than 50% ERXs removed were considered high impact. The percent of ERX’s removed was calculated as the number of ERX’s removed divided by the total line items reviewed for each class. Results: Forty class reviews containing 939 line items were evaluated. As a result of standardization, 341 line items were included in the system drug formulary, while 346 ERX’s were removed. High impact drug classes included amino and antipseudomonal penicillins (55%), non-iron phosphate binders (55%), amphotericin (67%), 5-alpha reductase inhibitors (75%), carbapenems (100%), natural and antistaphylococcal penicillins (100%) and echinocandins (217%). Conclusion: Certain drug classes may contain more unnecessary site variability than others. It may be reasonable for health care systems to begin with these drug classes when initiating formulary standardization. Category: Quality Improvement Evaluation Title: Evaluation of Appropriate Anticoagulant Use and Monitoring in a Family Medicine Center Authors: Sarah Mislan, PharmD Candidate; Kelsy Combs, PharmD, BCPS; Peter Koval, PharmD, BCPS, North Carolina Pharmacist
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CPP Institution: Family Medicine Center, Greensboro NC; UNC School of Pharmacy, Chapel Hill NC Objective: The purpose of this medication use evaluation was to characterize anticoagulation use in a family medicine teaching clinic. The primary objectives were to evaluate direct-acting oral anticoagulant (DOAC) patients for appropriate indication, dosing, and to identify candidates for switching from warfarin to a DOAC. Secondary objectives included examining time within INR goal, monitoring for hemoglobin, yearly primary care physician visits (PCP), and compliance with INR monitoring. Methods: The medical records of 105 patients receiving either warfarin or DOAC therapy were reviewed. Patients not seen by a PCP within the past year were excluded. Data collected for DOAC patients included patient demographics, anticoagulation indication, serum creatinine, and dose. Data collected for warfarin patients included anticoagulation indication, frequency of INR follow-up, percent time within a specific INR goal, and frequency of hemoglobin monitoring and PCP visits. Results: A total of 59 patients were identified to be taking a DOAC, and one patient was identified as having an incorrect dose prescribed. For the DOAC patients, 69% had hemoglobin monitoring within the past 12 months. A total of 46 patients were identified to be taking warfarin, with 76% receiving hemoglobin monitoring within the past 12 months. The 44 patients identified to have an INR goal of 2-3 had an average percent time within goal of 55.7%. The 2 warfarin patients with an INR goal of 2.5-3.5 had an average percent time within goal of 70%. There were 28 warfarin patients identified as potential candidates for switching to a DOAC. Conclusion: Patients taking a DOAC at the family medicine teaching clinic are prescribed correct doses and are receiving appropriate monitoring of hemoglobin. A large number of warfarin patients are candidates for converting to DOAC therapy. Category: Original Research Title: Geriatric Task Force: How an Interprofessional Medication Self-management Program Can Impact Blood Pressure and Diabetes Goals in an Aging Population Authors: Paige Cawley, UNC Eshelman School of Pharmacy PharmD Candidate; Jennifer Kim, PharmD, BCPS, BCACP CPP Institution: Moses Cone Internal Medicine Center, Greensboro NC Objective: To determine the impact of an interprofessional medication adherence support program for older adults with both uncontrolled hypertension (HTN) and diabetes Volume 99 Number 3 Summer 2018
(DM). Methods: An internal medicine primary care residency clinic implemented an interprofessional medication selfmanagement program including physicians, nurses, certified medical assistants, nurse technicians, a pharmacist, a social worker, and a dietician. The pharmacist identified patients 60 years or older with both uncontrolled HTN and DM. Six-month medication refill histories were obtained from pharmacies. Nurses evaluated adherence and provided findings to physicians prior to patient appointments. After each appointment, team members called patients every 1-3 months for ongoing medication self-management support. The primary outcome is the comparison of mean baseline blood pressure (BP) and A1C values. Secondary outcomes included percentage of patients achieving individualized goal BP and A1C values. Results: A total of 32 patients completed the study, with a mean age of 67 years, 61% were female, 88% were Black or African American, 15.6% were smokers, 46.9% had a cardiovascular disease diagnosis, and 28.1% had chronic kidney disease. The mean systolic BP at baseline was 161.1mmHg and the mean A1C was 9.7%. At 6 months, mean systolic BP was decreased to 139.1mmHg (P < 0.001 compared to baseline), and at 12 months was maintained at 140.03 (P < 0.001 compared to baseline). Likewise, 6-month mean A1C was reduced to 8.79% (P=0.0068 compared to baseline), and by 12-months was down to 7.96% (P < 0.001 compared to baseline). At 12-month follow up, 69.6% of patients reached their systolic BP goal and 59.3% reached their personalized A1C goal. Conclusions: Practicing in an interprofessional framework can enhance patient care by providing more thorough and coordinated care. The use of follow-up allowed both A1C and SBP to be lowered in the 12-month followup by addressing barriers to medication adherence. Category: Original Research Title: Transitions of care for chronic obstructive pulmonary disease: a pharmacist’s collaborative service Authors: Amy Lin, PharmD Candidate; Jennifer Kim, PharmD; Randy Absher, PharmD; Tanya Makhlouf, PharmD Candidate; Casey Wells, PharmD Candidate Objective: The purpose of this study is to assess the impact of a clinical pharmacist led COPD transitions of care service within an internal medicine teaching team. The transitions of care services encompass therapy recommendations and implementation, discharge counseling, medication access help, and post-discharge telephone and clinic follow-up. Methods: A retrospective cohort study was conducted from June 2015 to May 2018 with adult patients with a primary care provider in the practice site admitted with North Carolina Pharmacist
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COPD exacerbation as the primary diagnosis. A matched cohort of patients receiving usual care was compared to the pharmacist intervention group using a Fischer’s exact test. The primary outcomes were COPD readmissions and ED visits within 30 days of discharge from the index admission. Secondary outcomes included associated cost savings and a description of pharmacist interventions. Results: A total of 38 usual care and 36 transitions of care patients admitted for a COPD exacerbation were identified. The transitions of care program significantly reduced 30-day COPD related readmissions from 26.3% to 2.8% (p=0.0068) and 30-day ED visits from 28.9% to 5.5% (p=0.0127). Furthermore, the reduction of the total number of 30-day COPD readmissions and ED visits can be attributed to an overall average cost savings of $81,478. Conclusions: The clinical pharmacist led transitions of care service for COPD admissions within an internal medicine teaching team can significantly reduce 30-day readmissions and ED visits. This reduction is associated with improving patient mortality risk and healthcare system costs. Category: Original Research Title: Community Pharmacist Attitudes, Perceptions, and Barriers in Performing Suicidal Ideation Assessment Authors: Miranda Johnson Benfield, PharmD candidate; Cortney Mospan, PharmD; Chris Gillette, PhD; Brandi Pierce PharmD candidate Institution: Wingate University School of Pharmacy Objective: To investigate community pharmacists’ attitudes toward suicide and perceived role in assessing for suicidal ideation, identify whether practice location or gender are associated with attitudes toward suicide, and describe pharmacist-reported barriers towards assessing for suicidal ideation. Methods: An anonymous online survey was sent to all licensed pharmacists residing in North Carolina. Measures included gender, pharmacy practice setting, personal contact with suicide, perceived role in assessing for suicide, the Attitudes Towards Suicide (ATTS), and barriers in performing suicidal ideation assessment. Data are presented as means or proportions, where appropriate. Bivariate associations were investigated using nonparametric statistical tests. Results: Two hundred fifty-eight pharmacists completed the survey (response rate=2.14%). Two did not consent, and 125 were excluded (non-community pharmacy practice), providing 131 participants. The majority agreed or strongly agreed (n=121, 93.08%) that suicidal ideation and mental health conditions are real diseases. The Volume 99 Number 3 Summer 2018
average ATTS score was 69.79 (SD=6.20, range 31-89), indicating pharmacists are generally undecided towards suicide. A plurality (n=57, 43.85%) agreed or strongly agreed it is a community pharmacist’s responsibility to assess for suicide, but many were undecided (n=47, 35.34%). Suicidal ideation assessment is uncommon with most rarely or never assessing (n=116, 87.22%). Mental Health First Aid training is rare (n=6, 4.51%), but most (n=106, 83.46%) would be interested if continuing education credit was offered. Practice location and gender were not significantly associated with ATTS score (p>0.05). Common barriers were lack of education in mental health screening (n=104), lack of knowledge and self-efficacy in suicidal ideation assessment (n=99), and lack of time to provide individual attention to patients (n=87). Conclusion: Community pharmacists in North Carolina are undecided on personal attitudes towards suicide, but overwhelmingly agree that suicide is a disease. Barriers to suicidal ideation assessment were identified, with the majority of pharmacists being interested in continuing education to address these barriers. Category: Original Research Title: Comparison of Acute Kidney Injury in Hospitalized Patients Receiving Traditional- Versus Extended-Infusion Piperacillin/Tazobactam Authors: David M. Laurent, PharmD1,2 ; Robert Tunney, PharmD, BCPS2,3 ; Ruthanne Baird, PharmD, BCPS1 ; Amy Pope, PharmD, BCPS1 ; Kristen Keen, PharmD1 ; Jason M. Moss, PharmD, BCGP, CPP1,2 ; Kimberly Kelly, PharmD, BCPS1,2 Institution: 1Department of Pharmacy, Harnett Health System, Lillington, North Carolina; 2Campbell University College of Pharmacy & Health Sciences, Buies Creek, North Carolina; 3Vidant Medical Center, Greenville, North Carolina Objective: To compare the incidence of acute kidney injury (AKI) between patients receiving piperacillin/tazobactam (P/T) either by traditional- or extended-infusion. Methods: A retrospective, cohort study of patients admitted to a two-hospital, rural health system was performed. Demographic, comorbidity, and antibiotic use data were collected from adult patients without pre-existing renal dysfunction receiving P/T for at least 48 hours for the traditional- and extended-infusion cohorts from January to September 2016 and January to September 2017, respectively. The primary endpoint was the occurrence of AKI utilizing a chi-squared analysis for comparisons between the two cohorts. Secondary objectives, assessed by univariate analysis, evaluated for the effect of AKI in hospitalized patients with the following risk factors: concurrent use of select nephrotoxic agents, total number of nephrotoxic agents used, age > 60 years, and preexisting renal dysfunction. North Carolina Pharmacist
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Results: Among the 130 patients enrolled in each cohort, AKI was observed in 8.5% and 17.7% of patients in the traditional- and extended-infusion groups, respectively (p=0.027). Among patients experiencing AKI, the mean (± standard deviation) number of nephrotoxins per patient was 3.0 ± 1.1 versus 1.8 ± 1.0 in each cohort, respectively (p = 0.002). The univariate analysis of risk factors did not demonstrate a significantly higher risk of AKI between patients who developed and those who did not develop AKI. Conclusion: We observed a higher incidence of AKI in the extended-infusion P/T cohort, suggesting nephrotoxicity may be associated with infusion duration. Future prospective studies should further evaluate our findings that extended-infusion piperacillin/tazobactam increases the incidence of AKI. Category: Original Research Title: Incidence of Nephrotoxicity and Readmission Rates in Patients Receiving Vancomycin-containing OPAT regimen Authors:Heysel Lam, PharmD Candidate1,2; Cassie Kuppelweiser, PharmD, CPP2 Institution: 1 University of North Carolina Eshelman School of Pharmacy, Chapel Hill NC; 2Moses H. Cone Memorial Hospital, Cone Health, Greensboro NC Objective: The primary purpose of this study is to determine the rates of nephrotoxicity and hospital readmission for patients receiving a vancomycin-containing outpatient parenteral antimicrobial therapy (OPAT) regimen. The secondary objectives are to determine the rates of OPAT pharmacy consults and vancomycin trough levels checked prior to discharge. Methods: This retrospective analysis consists of reviewing data of Advanced Home Care (Cone Health-affiliated home health care) patients who received a vancomycin-containing OPAT regimen between July 2017 and May 2018. Through Advanced Home Care databases, changes in SCr throughout OPAT regimen are tracked to determine the incidence of vancomycin-associated nephrotoxicity. Through Cone Health’s EHR, the readmission rates as well as the rates of OPAT pharmacy consults and vancomycin trough levels checked prior to discharge are evaluated. Patients on hemodialysis are excluded in this study. Data to be collected includes, but is not limited to: concomitant nephrotoxic agents (diuretics, ACE inhibitors/ ARBs, NSAIDs), vancomycin dosing interval, baseline SCr, and timing of SCr changes throughout OPAT regimen. Results: Data is currently being collected and analyzed. Of 382 total patients receiving any OPAT regimen, 79 patients with a mean age of 61 years receiving vancomycin-containing OPAT regimen are included in the study. Volume 99 Number 3 Summer 2018
Most patients received combination regimen (54%), with ceftriaxone being the most common antibiotic added to a vancomycin-containing OPAT regimen (30%). One patient received combination regimen of vancomycin and piperacillin/tazobactam at discharge. 32% patients on vancomycin-containing OPAT regimen received OPAT pharmacy consults prior to discharge.
education and process changes to optimize immunization practices in obstetric patients within the health-system.
Conclusion: Currently, across Cone Health, IV vancomycin is the most common antibiotic used. Vancomycinassociated nephrotoxicity remains an ongoing challenge for many patients receiving vancomycin-containing OPAT regimen, often requiring suboptimal dosing or discontinuation of the antibiotic. The implication of this study can help guide current practice and establish future considerations when initiating vancomycin in an outpatient setting.
Authors: Sarah Shockley, PharmD Candidate1; Jessica Robinson, PharmD1; Chelsea Renfro, PharmD2; Stefanie Ferreri, PharmD 1
Category: Quality Improvement Evaluation Title: Evaluation of compliance with obstetric related vaccinations within a health-system Authors: John Brock Harris, PharmD, BCPS, BCPPS1,2; Amy P. Holmes, Pharm.D., BCPPS3 ; Rebecca Rainess, Pharm.D. candidate1 Institution: 1Wingate University School of Pharmacy, Wingate, NC, 2Novant Health Hemby Children’s Hospital, Charlotte, NC, 3Novant Health Forsyth Medical Center, Winston-Salem, NC Objective: The aim of this project is to determine the level of adherence with the Centers for Disease Control recommendations for Tdap and varicella vaccine administration in pregnant/postpartum women within a health-system. Methods: A selection of patients >17 years old who gave birth in January or December 2017 within a health-system were evaluated in this Institutional Review Board exempt review of Tdap and varicella vaccine administrations (VVA) compared to CDC recommendations. Data collected included institution, maternal age, birth gestation, immunity documentation, and vaccine administration dates. Selected patients were evaluated for VVA and only patients with health-system-based obstetricians were evaluated for Tdap administrations. Results: 204 patients were evaluated for VVA; 127 were also included in the Tdap evaluation. The only difference between groups administered vaccines versus groups that did not, was gestational age in the Tdap subgroups (p=0.0095). 29% of patients in VVA groups had documented immunity. 71% of VVA patients should have received the varicella vaccine. None were given. 78% of patients received the Tdap vaccine with 64.6% receiving the vaccine between 27-36 weeks gestation. Conclusions: Areas of improvement in pregnancy/ postpartum immunizations within a single health-system exist. This review will be used as the basis for potential North Carolina Pharmacist
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Category: Original Research Title: Development and Implementation of a Community Pharmacy-Based Falls Prevention Service
Institution: 1University of North Carolina at Chapel Hill, Chapel Hill, NC; 2University of Tennessee Health Science Center, Memphis, TN Objective: The purpose of this project is to (1) develop the processes, tools, and training resources for a community pharmacy-based falls prevention service, (2) validate their use in the community setting, and (3) develop a toolkit for public dissemination. Methods: The Evidence-Based System for Innovation Support (EBSIS) Logic Model was used to guide the development of the processes, tools, and training for a falls prevention service. EBSIS focuses on four components of innovation delivery: tools, training, technical assistance, and quality improvement. Focus groups were conducted with community pharmacy and primary care stakeholders to develop workflow and communication processes, as well as tools for service implementation. These resources were used by pharmacy staff participating in a randomized-controlled trial within a North Carolina community pharmacy network. Participants will complete an online survey and participate in a semi-structured interview to identify key characteristics and challenges to guide the development of a community pharmacy falls prevention toolkit. Preliminary Results: Thirty-one community pharmacies implemented the falls prevention service during their participation in a randomized-controlled trial from October 2017 to June 2018. Tools and resources underwent minor modification throughout the intervention, based on participant feedback. Surveys will be distributed in July 2018, with results to be analyzed in August 2018. Semi-structured interviews will be conducted in September-October 2018, with analysis completed by December 2018. Final results and the community pharmacy falls prevention toolkit are expected to be complete by December 2018. Preliminary Conclusion: Initial results suggest that procuring pharmacy and primary care feedback led to the development of tools and resources that required minimal modification for effective use in the community setting. By gathering feedback via survey and semi-structured interviews, investigators will be able to develop a robust toolkit for dissemination to community pharmacists who wish to develop a falls prevention program in their own pharmacies. Volume 99 Number 3 Summer 2018
Category: Quality Improvement Evaluations
Category: Original Research Title: Impact of a pharmacogenomics educational intervention utilizing a next-generation sequencing platform on future pharmacists Authors: Clara Kim, PharmD Candidate 2020; Olivia Dong, MPH; Rachel Howard, BS; Cristina Benton, PharmD, PhD; Robert Dupuis, PharmD; Tim Wiltshire, PhD; Amber Frick, PharmD, PhD Institution: UNC Eshelman School of Pharmacy, Chapel Hill, NC Objective: As leading discoveries in precision medicine are expected to transform healthcare, educating student pharmacists in pharmacogenomics (PGX) knowledge and its impact is becoming increasingly important. We examined the change of perception of student pharmacists in PGX after an educational intervention including optional PGX testing. Methods: Second-year student pharmacists (N=142) were enrolled in an applied clinical pharmacology course at the UNC Eshelman School of Pharmacy in fall of 2017 and completed an educational intervention consisting of lectures with active learning exercises, navigation of PGX resources, and voluntary PGX testing with DNA2Rx free of charge. DNA2Rx is an in-house, next-generation sequencing panel testing for 22 genes associated with the actionable genome and specific drug dosing guidelines. A report was generated for each student detailing responses to over 100 drugs. Students were surveyed on their attitudes and confidence regarding PGX in clinical practice before and after the educational intervention. Paired pre- and post-intervention Likert responses were analyzed with the Wilcoxon signed-rank test. The results of this educational intervention were also compared to the previous year’s educational intervention. Of note, this year’s class had improvements in the genotyping process (e.g., received more advanced results for more genes and alleles). Results: Of the 142 student pharmacists surveyed, 106 (75%) indicated their learning experience was enhanced by undergoing personal genotyping. Several self-efficacy indicators related to PGX testing were also significant from pre- to post-educational intervention in comparison to the previous year. For instance, there were significant increases in discussing the benefits (p=0.0002) and risks (p<0.0001) of PGX and interpreting the results of PGX testing for patients (p<0.001). Conclusion: PGX testing is a unique opportunity for student pharmacists to learn and engage in PGX. Results from this study affirm the positive impact of personal genome testing and more comprehensive reporting on perceptions of PGX. North Carolina Pharmacist
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Title: Evaluation of Patient Adherence in a Medicare Advantage COPD Population Authors: Brittany Stone, PharmD Candidate; Dawn Pettus, PharmD, BCACP Institution: Triad Healthcare Network, Greensboro, NC Objective: The primary purpose of this study was to determine patient adherence to long-acting inhaled bronchodilator agents in a Medicare Advantage plan COPD population. Secondary objectives were to determine availability of rescue inhaler, concomitant steroid use, and compliance with recommended immunizations. Methods: The study was a retrospective chart review of 518 patients with COPD from January 1, 2016 through March 31, 2018. To be included patients must have been part of the Triad Healthcare Network Accountable Care Organization, have insurance coverage through the HealthTeam Advantage Medicare Advantage Plan, have a diagnosis of COPD, and be participating in the CCIP COPD project. Insurance claims data was provided by the quality department at HealthTeam Advantage. Fill dates and days’ supply were reviewed for all COPD-related medications to determine patient adherence. Results: Patients were prescribed long-acting bronchodilators in varying combinations or alone, including 62 patients (12%) on LAMA alone, 17 patients (3%) only LABA/LAMA combo, 140 patients (27%) on LABA/ICS, 48 patients (9%) on triple therapy with LABA/LAMA/ICS, and 1 patient on LAMA/ICS. Overall, long-acting bronchodilators were prescribed to 268 of the 518 patients (52%) as part of their COPD regimen, and only 108 of those patients (21%) were adherent. Only 299 patients (58%) were prescribed a rescue inhaler, 178 patients (34%) received an oral steroid despite having a long-acting bronchodilator prescribed, 147 patients (28%) received their 2017 influenza vaccine, 59 patients (11%) received the Prevnar13 vaccine, and 27 patients (5%) received the Pneumovax vaccine. Conclusion: Many patients in our COPD population are not prescribed appropriate guideline-based therapy with a long-acting bronchodilator, and those who are continue to show poor adherence. Further intervention needs to be made to determine the cause of non-adherence, as well as the reason for such a low proportion of long-acting bronchodilator prescribing in this progressively worsening population. Category: Quality Improvement Evaluation Title: Implementing a Formalized Antimicrobial Stewardship Program in a Small Community Hospital Author: Sara Shearin, PharmD, MSCR, BCPS Volume 99 Number 3 Summer 2018
Institution: Carteret Health Care, Morehead City, NC Objective: To improve the use and prescribing of antimicrobial agents through the formalization of existing antimicrobial stewardship efforts by decentralized pharmacists in a small community hospital. Methods: During the initial planning phases of the formalization process, a gap analysis was conducted using the Core Elements of a Hospital Antimicrobial Stewardship Program (ASP) checklist published by the Centers for Disease Control. Other primary reference tools used in the process included the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Results: The gap analysis was presented to hospital administration, and multiple needs were identified, as our hospital had limited infectious disease resources. A hospital policy was then drafted describing the roles and responsibilities of the ASP. Administrative support was obtained, and a wide range of options were explored. As a result, a formalized multidisciplinary ASP committee was developed. Conclusions: Currently, ASP committee meetings are held monthly. A variety of ongoing improvement efforts are in place, many of which have already been implemented, including empiric treatment algorithms for sepsis and non-sepsis indications, and indication specific order sets. Additionally, multiple pharmacy driven policies and protocols are in place, including automatic renal dose adjustment, automatic IV to PO conversion, preferred antimicrobials, and dose optimization. Ongoing real-time data collection has also been made available, which has further aided pharmacists in antimicrobial therapeutic recommendations. As the concern for antimicrobial resistance and increasing antimicrobial related adverse effects continues to increase, the ASP at our hospital will continue to be stewards for our patients and community in combating this epidemic of inappropriate antimicrobial use.
Letters to North Carolina Pharmacist – The Editorial Board and Editor welcome your comments regarding the journal and any of its contents. In particular, we would like to hear from you concerning professional issues related to practice/professional dilemmas/potential conflicts of interest. If you have comments, please send to Tina Thornhill, Editor, at tina.h.thornhill@gmail.com. North Carolina Pharmacist
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Volume 99 Number 3 Summer 2018
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Policy Analysis: Pharmacy and Medically Underserved Areas Enhancement Act By Ryan Mills Overview of the Health Problems While the Affordable Care Act (ACA) provided health coverage for more Americans, it also increased the demand for health services. Despite the implementation of the ACA, over 20% of Americans do not have access to primary care physicians (PCPs) largely due to the fact that the current supply of PCPs does not meet the market’s demand, especially in rural areas. In the rural North Carolina county of Columbus, for example, the County Health Ranking report states that the ratio of PCPs to patients is 2,620:1. (1) According to Health Workforce Analysis conducted by Health Resources and Services Administration (HRSA), the projected shortage of PCPs will be 20,400 in 2020. (2) Of note, this is the national average and does not account for the disparity between rural and urban areas. The supply of PCPs in rural areas is forecasted to be well below the national average. Due to the aging of the baby boomer generation and the implementation of the ACA,
the demand for primary care services will sharply increase through 2020. The HRSA projects the demand for care will be far greater than the supply of PCPs and increased optimal use of non-physician providers can help mitigate the PCP shortage and bridge the gap in care for patients. Pharmacists are an integral part of the healthcare team, and when integrated, patients, providers, community, and healthcare systems all benefit. (3) Granting pharmacist’s provider status in medically underserved areas is one way of increasing access to care. H.R. 592 and S. 109 seeks to amend the Social Security Act in which Medicare would recognize pharmacists as healthcare providers enabling coverage for pharmacist-provided clinical services. Passage of H.R. 592 and S. 109 into law would mean pharmacy services consistent with state laws, provided to Medicare beneficiaries in medically underserved areas, and would be reimbursable under Medicare Part B. In North Carolina, pharmacists can administer most vac-
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cines designated by the CDC without a prescription. North Carolina pharmacists, with appropriate training and experience, can obtain their Clinical Pharmacist Practitioner (CPP) credential and enter into collaborative practice agreements with physicians, whereby the physician grants authority to the pharmacist to provide specific patient care services. Physician-pharmacist collaborative practice authority has been used in North Carolina since 1998 as a means to provide improved care for patients with conditions such as diabetes, hyperlipidemia, hypertension, hypothyroidism, osteoporosis, chronic pain and smoking cessation. (4)
Severity of the Health Problem Access to PCPs is vastly different in rural communities in comparison to urban areas. Rural communities across the U.S. face many contributing factors that create disparity in the delivery of healthcare. According to the National Rural Health Association report, living in remote areas correlates with poorer health due to social and economic factors such as educational shortcomings, health behaviors, and lack of access to care. Table 1 illustrates the disparity between urban and rural areas in the US. The increasing demand for healthcare services coupled with the vast difference in the percentage of physicians in rural compared to urban areas magnifies the importance of passing H.R. 592/S.109.
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Table 1: National Rural Health Snapshot (1) Health Snapshot (1) Rural
Urban
Percentage of USA Population
20%
79%
Percentage of USA Physicians
10%
90%
Number of Specialists per 100,000 population
40.1
134.1
Population aged 65 and older
18%
15%
Population below the poverty level Average per capita income Population who are non-Hispanic Whites
14% $19K 83%
11% $26K 69%
Adults who describe health status as fair/poor
28%
21%
Adolescents (Aged 12-17) who smoke
19%
11%
80
60
Female death rate per 100,000 (Ages 1-24) Population covered by private insurance Population who are Medicare beneficiaries
40 64% 23%
30 69% 20%
Medicare beneficiaries without drug coverage
45%
31%
Medicare spends per capita compared to USA average
85%
106%
Medicare hospital payment-to-cost ratio
90%
100%
Percentage of poor covered by Medicaid
45%
49%
Male death rate per 100,000 (Ages 1-24)
Overview of the Bill In 2018, House Bill 592 and Senate Bill 109 was reintroduced and assigned to a congressional committee who will decide if the bill will be passed in the House and Senate. Sponsors of this bill are Sen. Charles Grassley (R-Iowa), Rep. Brett Guthrie (R-Kentucky), Rep. G.K. Butterfield (D-North Carolina), Tom Reed (R-New York), and Ron Kind (D-Wisconsin). The probability of these bills being enacted as standalone bills is 3%. (5)
Both bills are titled “The Pharmacy and Medically Underserved Areas Enhancement Act” and follow 2014 House Bill 4190. The scope of the bill would serve to recognize pharmacists as providers under Medicare Part B. The patient populations targeted include those in Medically Underserved Areas, Health Professional Shortage Areas, and the Medically Underserved Populations. The reason this bill is limited to only medically underserved communities is that it fulfills a nationwide gap in medical care. Pharmacists have the appropriate education and training to help fill this void and
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focusing on this gap is a means by which pharmacists can draw attention to the need for our profession to be included as physician extenders. Nurse practitioners and physician assistants used similar approaches to gaps in care when seeking their provider status designation. Reimbursement, as established by the Social Security Act, would be consistent with Medicare’s payment for nurse practitioners and physician assistants. The rate is 85% of a physician’s fee. The authorized pharmacy services would be in accordance
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with the state’s scope of practice laws. If passed, the bill would increase patient access to quality care by allowing pharmacists to render services consistent with their level of education, training, and licensing. Most importantly, the legislation would not expand the scope of pharmacy services, but it would allow services to be rendered that are already authorized under state laws. The bill is a cost-effective solution to health care by increasing patient access to care. It offers the opportunity for early intervention, such as drug therapy management, to help minimize long-term cost.
Proponents The Patient Access to Pharmacists’ Care Coalition’s (PAPCC) is an inclusive multi-stakeholder group that represents a wide range of pharmacy professionals and other stakeholders who want to improve access to patient care services offered by pharmacists in the outpatient settings. Medicare Part B already encompasses all outpatient settings in which pharmacists work, such as medical homes, hospital clinics, physician offices, health systems, urgent care centers, community pharmacies, and other ambulatory care settings. Also, national pharmacy associations such as the American Pharmacy Association (APhA), American Society of Health-System Pharmacists (ASHP), National Community Pharmacy Association (NCPA), and the National Association of Chain Drug Stores (NACDS), support this legislation. The “provider status legislation” is the
one issue in which all of pharmacy has rallied to support as one collective voice. This legislation has tremendous bi-partisan support as well. H.R. 592 / S.109 currently has 282 cosponsors (165 Republicans/117 Democrats) for the House bill and 52 cosponsors (28 Republicans/25 Democrats/1 Independent) for the Senate bill. Both North Carolina Senators have endorsed their support of S. 109. In the House, 11 of our 13 Representatives endorsed H.R. 592. The two remaining NC legislators in need of signing on are Rep. Virginia Foxx (R-District 5) and Rep. Patrick McHenry (R-District 10). The PAPCC is also implementing long-term strategies to educate the public on the pharmacy profession’s potential to improve medication therapy outcomes and overall public health. The most recent initiatives include an advertisement campaign targeting seniors about the role of the pharmacist, providing education to House and Senate members, and including the bill in the opioid legislation to improve the likelihood of approval.
Opponents H.R. 592 or S. 109 as written still have many hurdles
to overcome with competing priorities. The main challenge the bill faces is the cost to the Medicare program. The PAPCC is working on that issue, and although better medication use will save the healthcare system money in the long run, convincing
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the Congressional Finance Committees will be difficult. One of the reasons the earlier House Bill
(HR.4190) did not pass is that it did not have a Congressional Budget Office (CBO) “score.” In the current session, the CBO has not scored the bill, but additional cost analysis based on a score produced during the previous 114th Congress has projected the cost to be less than $1 billion per year over the next ten years.
Congress is looking at the parallels between provider status and fee-for-service. They are primarily focused on cost savings rather than new additional costs. Data analysis to show future cost savings by improving population health will increase the probability of approval. In addition, data showing how this legislation can help with the opioid epidemic is likely to also be viewed favorably. Concerns voiced by members of the House and Senate are centered around the position of the American Medical Association (AMA), the cost of the bill, and level of support. At this time, the AMA neither opposes nor supports the bill and bipartisan support in both the House and Senate are strong. Furthermore, physician members in the House of Representatives, Roe (R‐Tennessee) and Bera (D‐California), are cosponsors of the bill.
Unintended Consequences Since the bill focuses on the underserved and is not viewed as
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an attempt to compete with other health professionals, it is hard to argue against the proposed legislation; however, two potential problems with this bill have been identified. First, there could be an increase in cost of Medicare Part B which could increase premiums for beneficiaries. Second, the AMA could oppose the legislation because as the supply of providers increases, the demand for services may decrease which could threaten provider salaries and wages. The cost of Medicare Part B is the biggest hurdle, but limiting pharmacy provider services to the medically underserved areas will limit the rise in costs billed to Medicare. Moreover, experts forecast a reduction in the costs to Medicare Part A (hospital coverage) because of preventive care. Data collected over the first few years can determine if a new bill to grant broader coverage into other healthcare areas would be beneficial. Historically the AMA has opposed nurse practitioners and physician assistants practicing medicine without physician supervision. The AMA’s position has been to “oppose legislation allowing non-physician groups to encroach on the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO) supervision; and (we) continue to encourage state medical societies to oppose state legislation allowing nonphysician groups to encroach on the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO)
supervision.” (6)
A Call for Action: Widespread action includes joining and supporting your state association such as North Carolina Association of Pharmacists (NCAP) because the enacting of services at the state level will be critically important. NCAP is the only organization in North Carolina whose primary focus is the profession of pharmacy; it is affiliated with national associations as well. In order to gain passage of the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 109) increased outreach efforts by pharmacy advocates is necessary. If you live or work in either Representative Foxx or McHenry’s districts, you should write to encourage them to sign-on to support H.R. 592. All others should write your Representative and thank them for their support and encourage their action on moving the H.R. 592 or S. 109 forward. Many national associations have predrafted letters that can be used by pharmacists and student pharmacists to facilitte a message to your legislator. Click on the “Take Action” hyperlink (below) for quick access to ASHP’s online advocacy center that has a pre-drafted letter that is connected to your elected officials based on your zip code.
TAKE ACTION References 1. North Carolina. (2018). Retrieved from http://www.countyhealthrankings.org/app/northcarolina/2018/overview
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2. Projecting the Supply and Demand for Primary Care Practitioners Through 2020. (2018). Retrieved from http:// bhpr.hrsa.gov/healthworkforce/ supplydemand/usworkforce/primarycare/ 3. Choucair, J. (2015, January 28). PAPCC Applauds Introduction of H.R. 592. The Patient Access to Pharmacists’ Care Coalition (PAPCC). Retrieved from http:// pharmacistscare.org/papcc-applauds-introduction-of-h-r-592 4. Clinical Pharmacist Practitioners. (2018). Retrieved from http://www.ncbop.org/pharmacists_cpp.htm 5. H.R. 592: Pharmacy and Medically Underserved Areas Enhancement Act. (2018). Retrieved from https://www. govtrack.us/congress/bills/114/ hr592 6. Allen, R. (2018). Physician and Nonphysician Licensure and Scope of Practice. Retrieved from http://www.ama-assn.org/ meetings/public/interim00/reports/rcc/cme1i00.rtf 7. The American Society of Health-System Pharmacists (ASHP). (2015). Retrieved from http://connect.ashp.org 8. What’s Different about Rural Health Care? (2018). Retrieved from http://www.ruralhealthweb. org/go/left/about-rural-health
Ryan Mills, PharmD, MBA, MHA, BCPS, is the Pharmacy Manager at Novant Health in Kernersville, NC. rsmills@novanthealth.org
Volume 99 Number 3 Summer 2018
Lyme Disease: The Forgotten Vector-Borne Disease of North Carolina By Katherine S. Adams, William J. Taylor, Peter Ahiawodzi, and Mark Moore
of the 230 cases of Lyme disease in 2016 were recorded in Wake County. (1) The number of cases in Wake County is quite disturbing as it is one of the fastest growing areas in the nation and second-most populous county in North Carolina with approximately 1,025,000 residents. (7) Symptoms
Background Transmitted by blacklegged ticks (species: Ixodes Scapularis; family: Ixodidae), Lyme disease is a multisystem bacterial infection caused by the spiral-shaped bacterium, Borrelia burgdorferi. It is important to note that blacklegged ticks are commonly referred to as “deer ticks.” First documented in 1975 as childhood arthritis, Lyme disease received its name from the small town of Lyme, Connecticut. According to the Centers for Disease Control and Prevention (CDC), Lyme disease is the most commonly reported vector-borne illness in the United States and was the fifth most common nationally notifiable disease in 2014. (1) Even though the majority of cases are reported in the northeast and north central states, in recent years, the geographical magnitude of disease has expanded raising the prospect of Lyme disease becoming endemic in the southeast. (2)
Recent research suggests that regions across the United States where Lyme disease was previously uncommon are now experiencing a growth in blacklegged tick populations (Appendix A). (3) Ominously, people living in these newly affected areas may be unaware of the associated health risks and appropriate prevention techniques since they previously had no reason to worry. (3) Data from the CDC indicates the state of North Carolina is experiencing a drastic increase in the number of Lyme disease cases per year (Appendix B). (1) For surveillance purposes, five counties within the state were classified as endemic for Lyme disease in 2015: Alleghany, Haywood, Guilford, Wilkes and Wake. (4,5) For a county to be classified as endemic there must be at least two confirmed cases of Lyme disease acquired within the county or a population of infected blacklegged ticks must have been previously documented within the county. (6) According to the CDC, 27
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Symptoms of Lyme disease resemble other common illnesses, thus making diagnosing arduous; however, there is one characteristic symptom associated with Lyme disease, the “bull’s eye” rash (erythema migrans). Located at the site of attachment, the small circle grows over time reaching the dimension of a penny or larger. Other symptoms that often co-occur with the rash include: fatigue, chills, fever, headache, lymphadenopathy, neck stiffness, myalgia, and arthralgia. (8) Lyme disease has three clinical stages: early-localized, earlydisseminated, and late Lyme disease. Early symptoms usually occur 3 to 30 days following the tick bite. The rash, erythema migrans (EM), is characterized within the first stage of early-localized Lyme disease. (9) Multiple EM, as well as cardiac and neurological findings, are often observed in the early-disseminated stage of the illness. Cardiac findings include carditis with second-or third-degree heart block, while neurologic findings include cranial neuritis, lymphocytic meningitis, or mo-
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tor/sensory radiculoneuritis. (9) In late Lyme disease, patients typically suffer from rheumatologic complications that can be intermittent or chronic; with the knees being the most commonly affected joints. (9,10) Diagnosis Diagnosing Lyme disease is often extremely challenging for physicians if an individual infected with the disease does not develop a rash or show signs of a tick bite and only presents flulike symptoms. If EM is not present, but the patient shows other symptoms, then serologic testing analyzing blood samples for antibodies can be completed to confirm the diagnosis. (11) Following the initial infection, several weeks are needed for the antibodies to build to measurable levels before serologic testing can be conducted. (11) Even though false-positives occasionally occur, the CDC recommends two-tiered serologic testing. The enzyme-linked immunosorbent assay (ELISA) is conducted first, followed by a western blot. If patients present with nonspecific symptoms and have no history of tick exposure in Lyme-endemic areas, serologic testing is not recommended. (12) When diagnosing Lyme disease, clinicians typically rely on patient history and physical examination, with consideration
given to the time of year, work and living environment, locations recently visited, and common recreational activities. (12) Most people who are diagnosed with Lyme disease do not recall being bitten by a tick. (3) Unfortunately, the most common reason for failure of treatment is misdiagnosis by clinicians. Prophylaxis and Treatment The sooner Lyme disease is diagnosed and treated, the greater probability of complete recovery. Once an attached tick has been removed, prophylaxis may be considered in the following cases: 1) all patients, 2) only patients believed to be at an increased risk for developing Lyme disease (especially attachment of more than 36 hours), 3) patients who develop EM or other clinical symptoms, and 4) all patients who seroconvert from a negative to a positive serum antibody test result. (14) National treatment guidelines for Lyme disease published by the Infectious Diseases Society of America (IDSA) advise either 100 mg of doxycycline twice per day, 500mg of amoxicillin three times per day, or 500 mg of cefuroxime twice per day (See Appendix C). (13,14) These agents are inexpensive and seldom cause any serious adverse side effects. (13) If the patient cannot take medication orally, then 2 grams of ceftriaxone is recommended parenterally once per day. (14) The recommended
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duration of therapy for either oral or parenteral administration is 14 days. (14) When treated with antibiotics, early-localized and early-disseminated Lyme disease is eliminated in 90% of infected patients. (12) While more serious symptoms of early-disseminated Lyme disease can be treated with antibiotics, arthritis seen in the late stages of Lyme disease is often impossible to eradicate with antibiotics alone. Unfortunately, an estimated 20% of patients do not recover following antibiotic treatment and continue to experience chronic arthritis symptoms. (16) Prevention, Patient Education, and the Role of the Pharmacist The pharmacist can serve to educate people in the prevention of Lyme disease (Appendix D). The best method to control and prevent Lyme disease occurrence is for individuals to avoid blacklegged ticks and their natural habitats; however, for individuals who live and work in endemic areas, it is imperative that insect repellants containing the chemical DEET or the insecticide permethrin be applied to clothing. (11) The concentration of DEET ranges from less than 10 percent to over 30 percent; however, concentrations of more than 30 percent are not recommended for children. (17) The duration of protection increases as the concentration of DEET increases. (17) DEET has been proven to be a nontoxic and efficient means of
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protection against ticks. Providing education on the importance of wearing lightcolored clothing as well as tick identification and prompt removal (e.g., within the first 24 hours of attachment) can reduce the risk of infection. (12) The tick should be grasped with tweezers as close to the skin as possible, and then pulled away from the site of attachment steadily until detached (Appendix E). (11) A study conducted in Connecticut demonstrated that body checks within 36 hours and baths within 2 hours following exposure are effective strategies in reducing the risk of Lyme disease. (18) Pets (e.g., cats and dogs) also serve as host for Ixodes scapularis in high-risk areas. Treating pets with a tick-preventative can reduce the risk of encountering an infected tick. (19) Patient education on common symptoms of Lyme disease can also increase awareness and help patients to get prompt medical attention. Furthermore, when antibiotic therapy is initiated, the pharmacist can play a critical role in educating the patient about the importance of medication adherence and potential adverse side effects. (16) The annual update released by the State Epidemiologist and the Head of the Communicable Disease Branch encourages
providers to be mindful of the patients who present with symptoms of the disease. North Carolina residents must be made aware of appropriate prevention techniques. While the mortality rate for Lyme disease is low, its lingering symptoms can be quite debilitating. Katherine S. Adams is a Doctor of Pharmacy Candidate, MSPH Candidate, and MBA Candidate at the Campbell University College of Pharmacy & Health Sciences. William J. Taylor, PharmD, is an Associate Professor of Public Health at the Campbell University College of Pharmacy & Health Sciences. Peter Ahiawodzi, PhD, MPH, CPH, is an Assistant Professor of Epidemiology at the Campbell University College of Pharmacy & Health Sciences. Mark Moore, PharmD, MS, MBA is an Associate Dean for Student Affairs & Admissions at the Campbell University College of Pharmacy & Health Sciences. taylorw@campbell.edu
48.6% of U.S. Counties. Entomology Today. 2016. URL: https://entomologytoday. org/2016/01/18/ticks-thattransmit-lyme-disease-reported-in-fifty-percent-of-u-scounties/. 4.
Paul M. Lantos, Lise E. Nigrovic, Paul G. Auwaerter, Vance G. Fowler Jr., Felicia Ruffin, R. Jory Brinkerhoff, et el., Geographic Expansion of Lyme Disease in the Southeastern United States, 2000–2014. Open Forum Infectious Diseases, December 2015, Volume 2, Issue 4. https://doi.org/10.1093/ofid/ ofv143
5.
Davies, M. (2015). Annual Update on Surveillance for Lyme Disease in North Carolina. Retrieved from https:// www.buncombecounty.org/ common/health/nc-dhhs-annual-update-on-surveillancefor-lyme-disease-in-northcarolina.pdf
6.
Centers for Disease Control. (2011). Lyme Disease 2011 Case Definition. Accessed on July 16, 2018. Retrieved from https://wwwn.cdc.gov/ nndss/conditions/lyme-disease/case-definition/2011/.
7.
Walston S. Learn About Wake County. Accessed on June 22, 2018. URL: http:// www.wakegov.com/about/ facts/Pages/default.aspx.
8.
Mead P. Epidemiology of Lyme Disease. Infectious Disease Clinics of North America. URL: https://www. id.theclinics.com/article/ S0891-5520(15)00024-0/abstract.
9.
Johnson, M. (2010). Chronic Lyme Disease: A Survey of Connecticut Primary Care Physicians. J Pediatr, 157(6), 1025-1029.e2. doi:10.1016/j. jpeds.2010.06.031
References 1.
Centers for Disease Control. Lyme disease. Accessed on June 22, 2018. URL: https:// www.cdc.gov/lyme/index. html.
2.
Lantos M, Pan K, Gaines N, et al. Geographic Expansion of Lyme Disease in the Southeastern United States, 2000-2014. Open Forum Infectious Diseases. 2015.
3.
Foster H. Ticks that Transmit Lyme Disease Reported in
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10.
11.
12.
Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis. Accessed on June 28, 2018. Retrieved from http://www. idsociety.org/Guidelines/Patient_Care/IDSA_Practice_ Guidelines/Infections_By_ Organism-28143/Bacteria/ Lyme_Disease/
Jen C, Dorado V, Lu B, Nguyen S. Lyme Disease: The Pharmacist’s Role in Treatment and Prevention. U.S. Pharmacist. 2016. URL: https://www.uspharmacist.com/article/lyme-disease-the-pharmacists-rolein-treatment-and-prevention. Tran M, Waller L. Effects of Landscape Fragmentation and Climate on Lyme Disease Incidence in the Northeastern United States. EcoHealth. 2013; 2014;10(4):394-404. Ziegler M, Didas M, Smith S. Diagnosing and Managing Lyme Disease. Journal of the American Academy of Physician Assistants. 2013;26(11):21-26.
13.
Hayes B, Piesman J. How Can We Prevent Lyme Disease? N Engl J Med. 2003;348(24):24242430. URL: https://doi. org/10.1056/NEJMra021397.
14.
Infectious Disease Society of America. (2007). The Clinical
15.
Centers for Disease Control and Prevention. (2017). Research on Doxycycline and Tooth Staining. Accessed on July 16, 2018. Retrieved from https://www.cdc.gov/ rmsf/doxycycline/index.html
16.
Knisley J, Johnson M. Lyme disease: Knowledge is the Best Prevention. Nurse Pract. 2004;29(8):34-43.
17.
North Carolina Department of Health and Human Services. (2018). Safe Use of Insect Repellents. Accessed on July 16, 2018. Retrieved from http://epi.publichealth. nc.gov/cd/diseases/deet.html
18.
Brisson D, Dykhuizen E, Ost-
feld S. Conspicuous Impacts of Inconspicuous Hosts on the Lyme Disease Epidemic. Proceedings of the Royal Society B: Biological Sciences. 2008;275(1631):227-235. 19.
Hamer A, Tsao I, Walker D, Mansfield S, Foster S, Hickling J. Use of Tick Surveys and Serosurveys to Evaluate Pet Dogs as a Sentinel Species for Emerging Lyme Disease. J Am Vet Med Assoc. 2009;234(2):244-244.
20.
New Era Pest Control Inc. How to Remove a Tick. Accessed on June 28, 2018. Retrieved from http://www. newerapestcontrol.com/ web/2014/07/01/remove-tick/
Appendix A (Reference 4) The first map (A) reveals I. scapularis distribution in 1998,0 and the second map (B) reveals distribution in 2015. Counties reporting six or more ticks were classified as established (red and green) and counties reporting at least one tick were classified as reported (blue and yellow).
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Appendix B (Reference 1) The graph shows the increasing incidence of Lyme disease cases from 2010 to 2016 in the state of North Carolina.
Appendix C (Reference 14) Infectious Disease Society of America guidelines for treating Lyme disease.
Preferred Oral Regimens for Treating Lyme Disease Drug Dosage Dosage Duration of Therapy (Pediatrics) (Adults & Pediatrics) Amoxicillin 500 mg BID 50 mg/kg TID 14 (14-21) days Doxycycline
100 mg BID
If > 8 yo, 4 mg/kg BID
14 (14-21) days
Cefuroxime 500 mg BID 30 mg/kg BID 14 (14-21) days Axetil Preferred Parenteral Regimens for Treating Lyme Disease Ceftriaxone
2 g Daily
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14 (10-28) days
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Appendix D
Opportunities for the Pharmacist • Increase awareness of tick-borne illnesses • Counsel on potential risks of Lyme disease • Make recommendations for preventive measures o Bug-repellent clothing (ex. ElimiTick™, Insect Shield©, etc.) o Repellent selection for clothing applications (i.e. Permethrin) o Repellent selection for skin application (i.e. DEET) • Educate on proper tick removal technique and storage for testing • Monitor post-exposure for early identification of a tick-associated rash • Provide assistance with early referral to a physician provider • Assist providers with selection of appropriate therapeutic management • Counsel on importance of medication adherence, drug-drug and drug-food interactions, and possible adverse events (e.g. photosensitivity) • Recognition symptoms of Lyme disease at all stages of progression
Appendix E (Reference 20)
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Factors Associated with Incidence of Lyme Disease in North Carolina By Katherine S. Adams, William J. Taylor, Mark Moore, and Peter Ahiawodzi
Introduction Transmitted by Ixodes scapularis (blacklegged ticks), Lyme disease is a multisystem bacterial infection caused by the spiralshaped bacterium, Borrelia burgdorferi. First documented in 1975 as childhood arthritis, Lyme disease received its name from the small town of Lyme, Connecticut. According to the Centers for Disease Control and Prevention (CDC), Lyme disease is the most commonly reported vector-borne illness in the United States and the fifth most common Nationally Notifiable disease. (2) Recent inquiry suggests that Lyme disease is greater and more widespread across the nation than formerly assumed. According to a recent survey, blacklegged ticks are now discoverable in twice the number of counties as in 1998 (Appendix A). (3) More than 36,000 confirmed cases were reported nationally in 2013; however, the actual number of cases is predicted to be approximately 300,000 per year, costing the U.S. healthcare system between $712 million and $1.3 billion a year – or nearly $3,000 per patient on average. (3-5)
In 2014, 96% of confirmed Lyme disease cases were reported from the following 14 states: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia and Wisconsin (Appendix B). (2) While most cases are located in the northeast and north central United States, in recent years, the geographical magnitude of disease has expanded raising the prospect that Lyme disease is becoming endemic in the southeast as well. (6) Some states have not always considered Lyme disease to be a serious health concern; therefore, not educating their residents on the possible repercussions of infection and recommended measures to prevent the onset of disease. Consequently, the state of North Carolina, sharing a sizeable boundary with Virginia (1 of the 14 states mentioned previously), has experienced a concerning increase in Lyme disease cases. The conclusions of a geographical study conducted by medical providers associated with Duke University Hospital revealed, “the geographic distribution of Lyme
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disease cases significantly expanded in Virginia between 2000 and 2014, particularly southward in the Virginia mountain ranges. If these trends continue, North Carolina can expect autochthonous Lyme disease transmission in its mountain region in the coming years.” (6) North Carolina reported 173 (39 confirmed and 134 probable) cases in 2013 and 601 (134 confirmed and 467 probable) cases during the 5-year period from 2009 to 2013.1 Four North Carolina counties were classified as endemic for Lyme disease in 2013: Alleghany, Haywood, Guilford and Wake (Appendix C). (1) For a county to be classified as endemic there must be at least two confirmed cases of Lyme disease acquired within the county or an established population of infected blacklegged ticks documented in the county. According to the CDC, 24 of the 173 cases of Lyme disease in 2013 were recorded in Wake County. (2) The number cases in Wake County is quite disturbing given it is one of the fastest growing areas in the nation and secondmost populous county in North Carolina with approximately 1,025,000 residents. (7)
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The geographic distribution of Lyme disease is sporadic in North Carolina, ranging from the eastern shore to the western mountains. Maps reveal several instances where counties considered endemic or having an elevated number of cases of Lyme disease have no reported cases in their bordering counties; thereby, causing suspicion on the accuracy of reporting as county borders do not create an impassable barrier for blacklegged ticks. By understanding the distribution of Lyme disease and the factors that contribute to its occurrence, public health officials may be successful in controlling and preventing the problem. The purpose of this study was to examine the geographic distribution of Lyme’s disease in North Carolina and to evaluate what factors influence the reporting of the disease.
a population of less than 112,000 residents while more dense counties had a population of greater than or equal to 112,000 residents. Statistical Analysis Independent sample t-tests were used to demonstrate associations between study variables and county categorization. Simple linear regression modeled the relationship between Lyme disease and explanatory variables individually considered in the study. Additionally, multiple linear regression modeled Lyme disease as a function of multiple explanatory variables. Statistical Package for the Social Sciences (SPSS) software was used to analyze the secondary data. All analysis was considered significant with a p-value of 0.05.
Study Design Results This was an ecological study of 100 counties in North Carolina. For the purposes of this study, individual county characteristics were collected. Data was gathered from the CDC, North Carolina Wildlife Resources Commission and the United States Census Bureau. Variables analyzed in the study included: population, gender, race, education, income, and the number of whitetail deer harvested in each county in North Carolina. Cumulative percent of population per square mile was used to identify fifty counties as less dense and fifty counties as more dense. Less dense counties had
As seen in Table 1, the population was significantly different between the less dense and more dense counties (P <0.0001). The number of individuals living in more dense counties was significantly larger (M = 160,410.68, S.D. = 177,851.589) than the number living in less dense counties (M = 30,292.24, S.D = 18003.169). A notably higher percentage (P = 0.047) of women lived in the denser counties (M = 51.148, S.D. = 1.2082) than less dense counties (M = 50.560, S.D. = 1.8964). A significant difference was found in the
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racial demographics between less dense and more dense counties. The percent of white and African-American residents was higher in less dense than more dense counties (P=0.008 and P<0.0001, respectively). No significant difference was found between less dense and more dense counties in terms of the percentage of Hispanic or Latino citizens (P = 0.803). The percentage of high school graduates did not differ significantly between less dense and more dense counties (P= 0.237); however, the percentage of those who held a bachelor’s degree or higher in less dense counties (M = 12.4972, S.D. = 6.8197) was considerably lower (P= 0.003) compared to those residing in more dense counties (M= 22.890, S.D. = 9.8798). There was no significant difference in the percentage of individuals living in poverty between less dense and more dense counties (P= 0.177). The results revealed a significant variance between the number of whitetail deer harvested in less dense counties compared to more dense counties (P= 0.001). Finally, the results showed a significant difference in the number of Lyme disease cases for the 14-year period of 2000-2014 between less dense and more dense counties (P < 0.0001). Considerably fewer cases of Lyme disease were reported in less dense counties (M= 5.00, S.D. = 4.785) than more dense counties (M= 23.42, S.D = 33.444). Population per square mile in North Carolina counties was found to be significantly as-
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sociated with Lyme disease (P < 0.0001) in the unadjusted regression estimates displayed in Table 2. As the population of people per square mile increased, the number of cases increased by 64 per 1,000 persons (B = 0.064, S.E = 0.007); however, gender as well as race were not found to be significant in the regression analysis. The results showed that the incidence of Lyme disease increased as educational background level increased (High School: B =0.765; S.E. = 0.270, P= 0.006; Bachelor’s: B =1.641; S.E. = 0.236 P= 0.000). In that same accord, those who were impoverished had a lowered reported incidence of Lyme disease (B = -1.802; S.E. = 0.511, P = 0.001). Lastly, whitetail deer harvest reports for individual North Carolina counties was not significantly associated with the prevalence of Lyme disease (P= 0.501). As illustrated in Table 3, the multivariable adjusted model, population per square mile was found to be significantly associated with Lyme disease cases (P < 0.0001). As the population of people per square mile increased, the number of cases increased by 44 per 1,000 persons (B= 0.044, S.E. = 0.010, P < 0.0001). Also, the percentage of women in a county was found to be significantly inversely associated with Lyme disease (B = -2.385, S.E. = 1.1.84, P=0.047), suggesting that as the female population decreased, Lyme disease cases increased. Race was
not significantly associated with Lyme disease in North Carolina. The percentage of high school graduates or higher was also not significant in the analysis; however, an association between the percentage of individuals who held bachelor’s degrees or higher and Lyme disease was found to be significant (B= 0.843, S.E.= 0.320, P= 0.010). Indicating as percentages of individuals who held bachelor’s degrees or higher increased, the number of Lyme disease cases also increased. The results also suggested that the percentage of persons living in poverty was not significantly associated with Lyme disease occurrence in North Carolina. Finally, whitetail deer harvest reports were found to be significantly associated with Lyme disease cases (P= 0.010). As the number of whitetail deer harvested increased the number of Lyme disease cases increased by 6 cases per 1,000 persons (B =0.006, S.E.= 0.002, P= 0.010). Discussion Once the counties were divided into less dense and more dense categories, the analysis revealed significant differences between the defined categories. The number of reported Lyme disease cases was found to be higher in more dense North Carolina counties. Furthermore, the adjusted regression analysis found population per square mile to be significantly associated with Lyme disease. As the population increased, the number of Lyme disease cases increased
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by 44 per 1,000 people. The t-test found that larger percent of women occupied more dense counties than less dense counties. Additionally, multiple regression analysis indicated a significant inverse relationship between percent of women and reported Lyme disease cases; suggesting that Lyme disease is more prevalent in men in North Carolina. Since men are more likely to engage in forestry, agriculture, or construction-related occupations, future research should analyze occupational data for each county to potentially determine the association between Lyme disease cases and occupation by county in North Carolina. White and African American individuals were found to occupy less dense counties than more dense counties; however, racial differences among the counties had no correlation to the number of Lyme disease cases reported. The number of residents who held bachelor’s degrees were noticeably higher in more dense counties. Counties with residents possessing a higher education level had higher rates of reporting likely attributable to heightened awareness and medical attention. Medical providers specializing in infectious disease are also more likely to practice in more dense counties which could potentially explain why more dense counties had higher reporting of Lyme disease. The percentage of persons living in poverty did not significantly differ between less dense and more dense counties. No association was found between percentage of persons in poverty and reported cases by county from the regression
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analysis. The number of whitetail deer harvested in less dense counties was significantly higher than the number harvested in more dense counties. Counties occupied by fewer residents tend to have larger areas of preferred habitat for wildlife and hunting which explains why less dense counties have more whitetail deer harvested. Furthermore, the results suggested as the number of whitetail deer harvested increased in North Carolina the number of Lyme disease cases increased by 6 cases per 1,000 persons. This variable was selected because whitetail deer are known to host blacklegged ticks; therefore, possibly indicating areas with larger deer populations would have elevated numbers of Lyme disease cases. The study found that more dense counties in North Carolina experienced higher cases of Lyme disease, implying perhaps, hunters who reside in more dense counties traveled to less dense counties to harvest deer and got exposed and became infected with Borrelia burgdorferi. This study is not without limitations. First, the data used was secondary, and, hence, we were limited to variables available in the reports we used for our analysis. Second, the analyses performed in this study were performed on county level rather than on an individual level. Although we found associations between various factors and Lyme disease, the associations may be applicable at the county level and not necessarily at the individual level. Third, the design and analysis of this study only
allows us to talk about associations and not causation; however, the findings form an important step in hypothesis formulation for further testing. Conclusion On par with the vaccine-preventable diseases varicella and pertussis, Lyme disease ranks among the top 10 most reportable illnesses in the United States. Lyme disease is a serious and growing public health concern in the United States as well as the state of North Carolina. Governor Roy Cooper released a statement on May 11, 2018 written by the state public health veterinarian, Carl Williams, to all North Carolina medical providers. (1) The statement encourages providers to remain aware of patients who present with Lyme symptoms since the incidence has increased considerably in North Carolina. By obtaining a better understanding of the sporadic reporting of Lyme disease in North Carolina, public health officials have the potential to reduce the number of infections. Considering the economical and health repercussions of Lyme disease on North Carolina and its residents, future precautions should be taken. Since Lyme disease was found to be more common in male North Carolina residents, occupations and hobbies traditionally dominated by men could be significant in determining prevalence of Lyme disease by county in North Carolina; therefore, ad-
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ditional research should be conducted to determine association of occupation and Lyme disease reporting by county in North Carolina. If an association is found, then extensive education of prevention methods for those commonly exposed to vectors or their host would be beneficial in reducing the occurrence Lyme disease. Education of appropriate prevention techniques would also be advantageous to whitetail deer hunters who spend time in deciduous forests since they have an elevated risk for Lyme disease. By understanding the geographic distribution of Lyme disease and contributing county characteristics, additional work can be done to develop effective prevention. Future research should be conducted to analyze additional county characteristics.
Katherine S. Adams is a Doctor of Pharmacy Candidate, MSPH Candidate, and MBA Candidate at the Campbell University College of Pharmacy & Health Sciences. William J. Taylor, PharmD, is an Associate Professor of Public Health at the Campbell University College of Pharmacy & Health Sciences. Mark Moore, PharmD, MS, MBA is an Associate Dean for Student Affairs & Admissions at the Campbell University College of Pharmacy & Health Sciences. Peter Ahiawodzi, PhD, MPH, CPH, is an Assistant Professor of Epidemiology at the Campbell University College of Pharmacy & Health Sciences. taylorw@ campbell.edu
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Table 1
Descriptive Characteristics of the Less Dense and More Dense Counties in North Carolina Variables Total Population Population per square mile % Women % White % African American % Hispanic or Latino % High school diploma % Bachelor’s degree or higher % At poverty level # of whitetail deer harvested Lyme disease cases, 2000-2014
Less Dense Counties (N=50) M (S.D)
More Dense Counties (N = 50) (M (S.D)
P-value
30,292.24 (18003.169)
160,410.68 (177,851.589)
< 0.0001
63.536 (25.6109)
325.782 (318. 5523)
< 0.0001
50.560 (1.8964)
51.148 (1.2082)
0.047
71.940 (20.0822)
70.750 (15.2430)
0.008
21. 614 (19.9817)
19.850 (12.4972)
< 0.0001
5.160 (4.0189)
7.888 (3.1901)
0.803
79.430 (11.7983)
83.862 (4.6147)
0.273
17.154 (6.8197)
22.890 (9.8798)
0.033
20.750 (4.8121)
17.908 (4.2773)
0.177
1579.84 (1116.719)
1472.74 (707.216)
0.001
5.00 (4.785)
23.42 (33.444)
< 0.0001
Table 2
Unadjusted Estimates of Factors Associated with Lyme Disease
Variables Population per square mile % Women % White % African American % Hispanic or Latino % High school diploma % Bachelor’s degree or higher % At poverty level # of whitetail deer harvested North Carolina Pharmacist
Estimate (B) 0.064 0.756 -0.072 -0.004 1.790 0.765 1.641 -1.802 0.002 Page 54
Std. Error 0.007 1.599 0.145 0.155 0.642 0.270 0.236 0.511 0.003
P-value < 0.0001 0.637 0.622 0.982 2.787 0.006 < 0.0001 0.001 0.501
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Table 3 Adjusted Estimates of Factors Associated with Lyme Disease Variables Population per square mile Percent female Percent white Percent African American Percent Hispanic or Latino Percent high school graduates or higher Percent Bachelor’s degree or higher Percent persons in poverty Number white-tail deer harvested
Estimate (B) 0.044 -2.385 -0.453 -0.325 -0.063 0.102 0.843 -0.810 0.006
Std. Error 0.010 1.184 0.375 0.386 0.571 0.219 0.320 0.544 0.002
P-value <0.0001 0.047 0.230 0.402 0.912 0.644 0.010 0.140 0.010
References 1.
North Carolina Department of Health and Human Services. Lyme Disease in North Carolina. Accessed on June 22, 2018. URL: http://epi.publichealth.nc.gov/cd/lyme/docs/lyme_fs.pdf.
2.
Centers for Disease Control. Lyme disease. Accessed on June 22, 2018. URL: https://www. cdc.gov/lyme/index.html.
3.
Foster H. Ticks that Transmit Lyme Disease Reported in 48.6% of U.S. Counties. Entomology Today. 2016. URL: https://entomologytoday.org/2016/01/18/ticks-that-transmit-lyme-diseasereported-in-fifty-percent-of-u-s-counties/.
4.
Mead P. Epidemiology of Lyme Disease. Infectious Disease Clinics of North America. URL: https://www.id.theclinics.com/article/S0891-5520(15)00024-0/abstract.
5.
Johns Hopkins Bloomberg School of Public Health. (2015). Lyme disease costs up to $1.3 billion per year to treat, study finds. Retrieved from http://www.jhsph.edu/news/news-releases/2015/lyme-disease-costs-more-than-one-billion-dollars-per-year-to-treat-study-finds.html
6.
Lantos M, Pan K, Gaines N, et al. Geographic Expansion of Lyme Disease in the Southeastern United States, 2000-2014. Open Forum Infectious Diseases. 2015.
7.
Walston, S. (2016). Learn about Wake County. Retrieved from http://www.wakegov.com/ about/facts/Pages/default.asp
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Appendix A (Reference 3) The first map (A) reveals I. scapularis distribution in 1998 and the second map (B) reveals distribution in 2015. Counties reporting six or more ticks were classified as established (red and green) and counties reporting at least one tick were classified as reported (blue and yellow).
Appendix B (Reference 2)
Appendix C (Reference 1)
The map shows the distribution of probable and
The lightest colored counties indicate zero re-
confirmed cases of Lyme disease in the United
ported cases of Lyme disease. Meanwhile, the
States in 2014.
darkest colored counties indicate greater than five reported cases of Lyme disease. The four counties colored in red have been classified as endemic for the disease.
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The NCAP On-Demand E-Learning library of offerings is expanding! These webinars are a member benefit as CE is FREE TO MEMBERS ONLY. Several clinical and other topics are now available. There is also a dedicated project team that is working this year to increase our E-Learning offerings.
Go to ncpharmacists.org and log-in for full access
Call for Peer Reviewers The North Carolina Pharmacist is currently seeking pharmacist volunteers to serve as peer reviewers. The journal is published online quarterly and is intended to inform, educate, and motivate pharmacists, from students to seasoned practitioners, and pharmacy technicians in all areas of pharmacy. Peer review helps to validate research and increases networking possibilities. We are especially interested in pharmacists with expertise in the following areas: Hospice/Palliative Care Pharmacy Law / Legislative Issues Statistical Methods Surgery Don’t miss this opportunity to share your knowledge and experience with the North Carolina pharmacy community by serving as a peer reviewer for the North Carolina Pharmacist. If you wish to be considered as a reviewer and/or want more information, please email Linda Goswick at linda@ncpharmacists.org or Tina Thornhill, PharmD, FASCP, BCGP, Editor, at tina.h.thornhill@gmail.com.
The North Carolina Association of Pharmacists and the North Carolina Pharmacist wishes to thank the following individuals for serving as peer reviewers: Dawn Battise, PharmD, BCACP Courtney Bradley, PharmD, BCACP Rebecca Chater, BSPharm, MPH, FAPhA Andrew Clark, PharmD, BCPS, CDE, CPP Stephanie Craycroft-Andrews, PharmD, BCACP Elizabeth Farrington, PharmD, FCCP, FCCM, FPPAG, BCPS, BCNSP Zachary Hecox, PharmD Thomas Henry, PharmD, BCPS Tracy M. Hudson, PharmD, BCPS Heather Kehr, PharmD, BCPS Jennifer Kim, PharmD, BCPS, BCACP Caleb Little, PharmD Jacqueline Olin, MS, PharmD, BCPS, CDE Susan Smith, PharmD, BCPS Zachary Tyler Tackett, PharmD Lydia Wang, PharmD, CPP John W. Watson, BS, MBA, DBA MaryBeth Welch, PharmD Catherine Lewis Wente, PharmD, CACP, BCPS Yolanda D. Williams, PharmD, PhD Jenn Wilson, PharmD, BCACP North Carolina Pharmacist
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“Right to Try” Legislation – Federal and North Carolina Laws: Implications for Pharmacists and Pharmacies By John M. Kessler A recently enacted 2018 federal law and a 2015 North Carolina (NC) state law have established a new pathway for patients with a terminal illness (defined as a life-threatening disease or condition) to obtain investigational drugs, biologics, or devices under certain conditions. This “right to try” (RTT) pathway is significantly different from the existing procedures for obtaining these treatments under the FDA’s Emergency Use regulations, Expanded Access (compassionate use) programs, or single-patient investigational new drug (IND) procedures. This brief review summarizes key parts of the federal and state law and provides empiric guidance on how pharmacists can help keep patients as safe as possible. Because pharmacies and pharmacists are not specifically included in the RTT pathway for obtaining and using these investigational drugs, this may pose new risks for patients. Federal and NC RTT laws allow
patients to access investigational products that have passed through Phase I testing and are still in the research development process. While this appears to be a benefit to patients, a closer examination reveals that the RTT laws add nothing to the options that patients already have via existing FDA regulated pathways. The laws neither shorten the time to access an investigational medication, nor do they increase the number of medications available or the number of eligible patients. While the RTT laws provide a legal pathway for access, no manufacturer is required to participate. Instead, the new RTT laws appear to remove important safety and ethical oversight in our current system and to disregard the value of scientific information (for future patients) when these investigational medications are used. The RTT “movement” originated largely from the work of the Goldwater Institute, whose legislative and judicial agenda
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included limiting federal control over access to investigational drugs. However, in their efforts to improve patients’ rights to investigational therapies, the new RTT laws bypass existing patient safety protections and remove the FDA, as well as Institutional and Ethics Review Boards (IRB) from the oversight of investigational products. The RTT laws also bypass the FDA’s existing pathways for providing investigational products to individual patients, outside of the usual clinical trial process. Arguments, over the past five years, supporting and opposing RTT legislation are well documented in the literature. While the “access” provision in the RTT laws is the most commonly referred to benefit, the laws have a number of lesser known provisions of importance to pharmacists, patients and families - some of which are potentially harmful. Government: The RTT laws state that the federal government shall not take any action to
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prohibit or restrict access to an RTT medication and no official, employee, or agent of the State shall block or attempt to block an eligible patient’s access to an investigational drug, biological product, or device. NC law further clarifies, however, that counseling, advice, or a recommendation consistent with medical standards of care from a licensed health care provider does not constitute a violation of this section. Pharmacists and others working for the federal government or the state should carefully read this part of the RTT laws to remain in compliance. Eligibility: Federal law provides those with a terminal illness access to investigational products and is further defined by each state. NC law requires that patients must have a terminal illness attested to by a treating physician; have considered all other FDA-approved options; have received a recommendation from the treating physician for use of an investigational product; have given informed consent in writing; have documentation from the treating physician that the individual meets all of the criteria for this definition, and that the physician was consulted in the creation of the written informed consent document. Restrictions on Liability: Both federal and NC laws include a “no liability” clause that states that no liability shall lie against individuals and entities that manufacture, distribute, prescribe, dispense, possess, or use investigational products via the RTT pathway, with the NC law specifically mentioning
any harm caused to the eligible patient if the effort was made in good faith and with reasonable care. This restriction on liability is in marked contrast to nonRTT pathways in which patients retain their full legal rights to seek compensation for injury. Loss of Scientific Data: The federal law includes a “no outcomes” clause that prohibits the FDA or other federal agencies from using any information about RTT use that may adversely impact the review or approval of the investigational product. This is in stark contrast to the collection, analysis, and use of safety data for investigational medications obtained via the current pathways. Loss of Benefits and Potential New Costs: The NC law includes specific language that eligibility for hospice care may be withdrawn if the eligible patient begins treatment via the RTT pathway. In addition, the NC laws states that the patient’s health benefit plan or third-party administrator and provider are not obligated to pay for any care or treatments consequent to the use of the RTT product, including for complications and side effects, which would generally be covered if the investigational product were administered under existing FDA-regulated pathways. Cost Burden for RTT treatment: The NC law includes specific language that the patient is liable for all expenses consequent to the use of the RTT product and that this liability extends to the eligible patient’s estate unless specifically negotiated differently with the manufacturer in advance of
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the RTT treatment. The costs of the RTT product and any associated costs (e.g. professional fees, product fees, shipping, and markup) may be charged to the patient without limit. The RTT laws do not require the patient’s health benefit/insurance plan to provide coverage, unless specified in the contract. Furthermore, if a patient dies while under RTT treatment, their heirs are not liable for any debt or outstanding costs. According to Bloomberg News (Michelle Cortez, June 20, 2018), at least one small biotechnology company has implied that it will make its unproven stem-cell therapy available to ALS patients at a price of $300,000 despite the company’s earlier Phase 2 study which did not demonstrate any benefit over placebo in slowing the rate of ALS progression. Under existing FDAregulated pathways, costs of the investigational product are often covered either by the sponsor of the clinical trial or the manufacturer of the product. Pharmacy’s Role: RTT laws bypass the protections, oversight, and professional role that pharmacists have in their covenant with patients and with society. Arguably, in practice they do more than bypass pharmacist oversight. The laws could realistically create an obstacle to patient care and safety by excluding pharmacists from the RTT pathway. In the community setting, including nursing homes and hospice facilities, RTT laws bypass the usual dispensing process, such that pharmacists may be unaware that the patient is using an RTT medication; therefore,
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increasing the risk of drug-drug interactions. Since RTT medications are investigational, it is very likely that pharmacists will find it more difficult, if not impossible, to access drug information to inform appropriate patient monitoring or to provide patient counseling. In the health-system setting, RTT laws enable these medications to bypass the Formulary system, IRB/Ethics Board review, investigational drug service oversight, and integration with electronic medical records and pharmacy information systems. Unless internal policies and procedures are implemented to create a safety net around patients using RTT meds, the risks to patients may go unchecked. Given that RTT laws bypass many of the protections and benefits offered by pharmacists, our profession is now challenged to develop new ways to imagine and deliver the care that is needed, especially in this vulnerable patient group. There are no published “best practices” for the use of RTT medications. Pharmacists can empirically mitigate the risk and support their patients by 1) ensuring the medication history includes asking about the use of investigational medications and documenting this in the patient profile; 2) helping patients access drug information about proper administration and use; 3) monitoring for known and unforeseen side effects that emerge after treatment starts; 4) reporting suspected side effects to the prescriber, manufacturer, and FDA; and 5) assuring the patient has been fully consent-
ed, with special emphasis on their loss of benefits, costs burden, and restrictions on liability. Drug information centers and clinical research pharmacists across NC could provide an invaluable service in helping to connect their colleagues to the necessary information about RTT drugs and to existing nonRTT pathways offered by the manufacturer. Moreover, prior to a patient starting down the RTT pathway, if and when the opportunity presents, pharmacists are positioned to advise patients about the existing procedures for obtaining these same medications under the FDA’s Emergency Use regulations, Expanded Access (compassionate use) programs, or single-patient IND procedures. In addition to direct contact with the manufacturer, the Expanded Access Navigator (http://navigator.reaganudall. org/) is one online tool that can be useful. Some RTT proponents have created a false public narrative that these existing pathways are slow or nonresponsive to patient needs. In fact, depending on the clinical condition being treated, investigational treatments can be obtained within 24 hours, with minimal regulatory requirements. Importantly, patients maintain their legal rights, do not lose benefits to which they are otherwise entitled, and do not incur potentially significant costs. RTT laws present new challenges in the appropriate use of medications not proven to be safe or effective. Pharmacists should position themselves to respect and support patient
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autonomy by helping individuals and their families access and properly use investigational medications via traditional or RTT pathways. When this involves the RTT pathway, it will likely require new clinical safety nets, new policies and procedures, and a heightened awareness of the benefits and risks. References: (NC ) SESSION LAW 2015-137 HOUSE BILL 652 AN ACT ESTABLISHING A RIGHT TO TRY ACT TO PROVIDE EXPANDED ACCESS TO INVESTIGATIONAL DRUGS, BIOLOGICAL PRODUCTS, AND DEVICES FOR PATIENTS DIAGNOSED WITH TERMINAL ILLNESS. www.ncleg.net/Sessions/2015/ Bills/House/PDF/H652v4.pdf (Federal) Right to Try Act of 2017. https://www.congress. gov/115/bills/hr878/BILLS115hr878ih.pdf John M. Kessler, B.S. Pharm, Pharm.D. Chief Clinical OfficerSecondStory Health, LLC jkessler@secondstoryhealth. com
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Pharmacy Technology Program Receives Accreditation By Tonya Welch and Jean Douglas Guilford Technical Community College’s (GTCC) Pharmacy Technology Program received accreditation from the Pharmacy Technician Accreditation Commission (PTAC). With this achievement, GTCC becomes the 11th academic institution in North Carolina with an accredited program for pharmacy technicians. The PTAC is a collaboration between ASHP and ACPE and serves both boards of directors as the accrediting review committee for pharmacy technician education and training programs. “Our program trains people to be well-rounded pharmacy technicians. Students are offered opportunities to receive hands-on experience with clinical rotations at pharmacy retail and hospital settings,” said Tonya Welch, director of the program. Representatives from the PTAC conducted a site visit in 2017 and granted full accreditation of GTCC’s program in February 2018 for a six-year term. The program curriculum includes a mix of online,
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classroom and lab coursework. Students receive hands-on skill development, computer and tablet experience, and gain real-world experience training with retail pharmacies, home health care and hospitals. “We have a simulation lab where students learn how to operate in both retail pharmacy and hospital environments,” said Welch. GTCC’s national accreditation comes in advance of a new requirement announced by the Pharmacy Technician Certification Board (PTCB). Effective January 1, 2020, pharmacy technicians will be required to complete a PTCB-recognized education or training program. For more information on GTCC’s pharmacy technology program, contact Tonya Welch at tpwelch@gtcc.edu or 336-334-4822 x55079. Jean Douglas, PharmD, Associate Professor and Director of Standardized Client Program at High Point University
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Honoring Stan Haywood
A Mentor, A Coach, and A Friend By Ashley Duggins work part-time at Prevo Drug was a perfect fit for me. I was thrilled to be joining Stan and his staff! After having my second child, Sydney, in 2006, my part-time job quickly developed into a full-time job. I first met Stan Haywood as a student in pharmacy school in 2001. I was excited by the opportunity to spend a month at his pharmacy, Prevo Drug, in my hometown of Asheboro, North Carolina. I remember being quite impressed by Stan and the love and respect his customers and employees had for him. Never having worked in an independent pharmacy, I found the family atmosphere and the amount of time Stan was able to spend with his customers appealing. This experience affirmed that retail pharmacy was the right course for my career. The following year, 2002, I graduated from pharmacy school and went to work for Eckerd Pharmacy. When my son, Carson, was born I took some time off work. In the summer of 2003, I received a call from Stan asking if I would be interested in working for him part-time. By that time, I was ready to return to work, and the chance to
Always one to think outside the box, Stan was on the cutting edge of pharmacy and was constantly presenting me with new challenges for career growth. These new challenges were exciting and advanced both our profession and our pharmacy. Stan provided me with the opportunity and the freedom to explore new ideas and new projects. He was always supportive and welcomed new ideas. If I made mistakes and got ahead of myself, he would put things into perspective and encourage me to keep going. Stan was so much more than my boss; he was my mentor, my coach and my friend! In 2012 he began talking about retirement and asked if I would be interested in taking over the pharmacy. I was beyond thrilled, as I could think of no greater honor than to carry on the legacy of Prevo Drug. In December of 2013, my husband Ken and I purchased
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Prevo Drug from Stan. What an amazing yet terrifying day! Always faithful, Stan was with me every step of the way, promising to help me in any way that I needed. Trust me when I say I needed him often! I would call him at least four to five times a day with questions; however, he never got frustrated. He accepted the fact he was on my speed dial! He continued to work parttime for me two days a week. Even though I became more comfortable with my new role as owner, I still needed Stan. Sometimes just his presence at Prevo Drug or in my office would bring me comfort. Like a sponge, I soaked-up his wisdom on every possible occasion.
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In July 2017, Stan was diagnosed with stage 4-pancreatic cancer. It was such a devastating blow to so many people; however, he handled it with grace, as he did all things in his life. After he started treatment, he was unable to work. He missed it greatly, as he loved to be with his customers and they with him. Although he did not come to Prevo Drug as often, I would talk to him on the phone, sit with him while he was getting chemotherapy or just have a glass of tea on his back porch. Spending time with him made me feel instantly wiser. His passing has left a void, and I find myself needing him and his wisdom often in both my pharmacy career and in my daily life as well. Stan’s pharmacy was his mission field. He was passionate about advancing pharmacy, but, most importantly, his customers came first. He would always say to me, “When you take care of your customers, everything else falls into place.” In the day of low reimbursement, DIR fees and prior authorizations, Stan’s philosophy was “think about the ‘I cans’ instead of the ‘I cant’s’.” He has big shoes to fill! I do my best to honor him every day and to carry on his legacy. Here is an excerpt from his obituary. A lifetime Tar Heel, Stan graduated from the University of North Carolina at Chapel Hill in 1968 with a Bachelor of Science degree in Pharmacy. He opened Prevo Drug, Inc., with
business partner, Jim Prevo, in 1972. He was the owner and chief pharmacist of Prevo Drugs, Inc., in Asheboro for 40 years and continued to work parttime after selling Prevo. He was a certified compounding pharmacist and a certified diabetic educator with the Greensboro AHEC. He served as a Randolph County Commissioner for three terms, on the Randolph County Board of Health, and on the North Carolina Board of Pharmacy. He worked tirelessly to advance the goals of Randolph County as well as those of the pharmaceutical profession. In April, the North Carolina Board of Pharmacy established the $1.1 million L.
Stanley Haywood Recovery Fund. The fund will provide assistance to pharmacy professionals battling substance abuse problems. He has been a member of N.C. Mutual Drug Company since 1972 and has served on both the Mutual Drug Legislative Affairs Committee and the Mutual Drug Retail Advisory Committee. Haywood is a member of the N.C. Association of Pharmacists and was serving his third term as a member of the N.C. Board of Pharmacy. Ashley Duggins, PharmD is the owner of Prevo Drug in Asheboro, NC. ashley@prevodrug.com
Pictured (L to R): Chip Owen, Ken Duggins, Julie Allsbrook, Stan Haywood, Megan Morgan and Adam Misenheimer (front row) Ashley Duggins and Sara Beth Brown
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By Tina Thornhill
To Use Tdap in Pregnancy A new study found that when the Tdap vaccine is given during pregnancy, the occurrence of infant pertussis is reduced. The Centers for Disease Control (CDC), with support from the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives, recommends that women between 27 (preferred) and 36 weeks of pregnancy receive the Tdap vaccine. The aim is to provide the infant with some shortterm protection against whooping cough. The antibodies produced by the mother when the vaccine is given in the third trimester was thought to bridge protection for the infant until they can receive their immunization at the age of two months. In the retrospective analysis, there was a 75% reduction of pertussis hospitalizations and a 46% reduction of any pertussis cases. Some previous immunological studies reported that mothers receiving the vaccine have a less effective response to their own pertussis vaccine series; however, this most recent study did not find this to be the case. The incidence of pertussis is increasing leading to an increase in infant mortality. The CDC recommends the Tdap vaccine with every pregnancy. The side effects are minimal, but may include injection site reactions, headache, body aches, and fatigue.
Reference: https://www.ajpmonline.org/article/S07493797(18)31696-9/pdf
Dietary Supplement Use on the Rise in US Children and Adolescents Analysis of the National Health and Nutrition Examination Surveys (NHANES) data revealed that one out of every three children and adolescent uses dietary supplements. Products most commonly used are: multivitamins, iron, calcium, vitamin D, body-building supplements, melatonin and omega-3 fatty acid supplements. Boys were more likely to take body-building and omega-3 supplements. Since these products report some benefit to cognition and sleep, researchers attributed the rise in melatonin and omega-3 fatty acid use especially in those with attention-deficit hyperactivity disorder (ADHD). The researchers warn about the use of these and other supplements that have potentially adverse cardiovascular side effects (e.g., arrhythmias) – especially when combined with ADHD products. Reference: Qato DM, Alexander GC, Guadamuz JS, et al.Prevalence of Dietary Supplement Use in US Children and Adolescents, 2003-2014. JAMA Pediatrics; Published online June 18, 2018.
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Vaccination Errors – the 2017 Report from ISMP The Institute for Safe Medication Practices (ISMP) reported that errors related to vaccinations remain a problem – especially in outpatient medical and public health clinics where over half of the errors occurred. A third of errors occurred in physician offices. The most frequently cited errors were the administration of the wrong vaccine, the wrong dose, and using expired or contaminated vaccines. Pharmacies accounted for 2% of the errors, the lowest incidence cited. The vaccinations with the most errors were Hepatitis A, DTaPIPV, and Influenza. The ISMP has developed a teaching tool that can be used to increase awareness and reduce the number of errors made. Pharmacists can be an excellent education resource to medical and nursing staff and help with policy and procedure development that may reduce the incidence of vaccination errors. (https://www.ismp.org/sites/default/files/attachments/2018-06/ Teaching-table.pdf). Reference: https://www.ismp. org/sites/default/files/attachments/2018-06/20180614.pdf Tina Thornhill, PharmD, FASCP, CGP Editor-in-Chief
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