To assess the rates of therapeutic international normalized ratio (INR) levels between pharmacist-managed clinics compared to traditional physician-management and to determine the variation in rates of therapeutic INR levels between pharmacist-managed clinic data compared to physician-management. Retrospective, randomized, chart review. Referral only, outpatient, pharmacist based anticoagulation clinic under a community based tertiary care health system. Sixty-four patients with at least 1 year's worth of visits to the pharmacist managed clinic were reviewed for INR stability. The average percentage of visits within the defined therapeutic range, was 71.1% for the physician-managed group versus 81.1% for the pharmacist-managed group (P < 0.0001). The estimated variance in average therapeutic INR rates was double for the physician-managed group (365.7) versus the pharmacist-managed group (185.2) (P = 0.004). The pharmacist-managed anti-coagulation clinic had higher rates of INRs determined to be therapeutic and also exhibited significantly less variability in therapeutic INR rates relative to the physician-managed service.
Background Penicillin skin testing (PST) is a novel way to reduce the use of broad-spectrum agents in penicillin-allergic patients. This study evaluated the outcomes of patients with antimicrobials prescribed with and without PST in a community health system. Methods We performed a quasi-experimental study that compared an intervention group of 100 patients who completed PST over an open enrollment period beginning January 2016 with a matched control group of 100 patients who were penicillin allergic. Patients in the control group were matched to infection diagnosis codes of members of the PST group and randomly selected and matched on a 1:1 basis. The primary outcome was noncarbapenem beta-lactam days of therapy (DOT). The secondary outcome assessed the average cost of antimicrobial therapy for the intervention group before and after PST. Results Seventy of the 98 patients (71%) who tested negative had changes directly made to their antimicrobial regimens. Beta-lactam DOT for the PST group were 666/1094 (60.88%, with 34.82% being a penicillin specifically). Beta-lactam DOT for the control group consisted of 386/984 (39.64%, with 6.4% being a penicillin specifically). The chi-square test of homogeneity for beta-lactam DOT between the 2 groups was significant ( P < .00001). Changes to the antimicrobial regimen after PST saved the average patient $353.03 compared with no change in the pre-PST regimen ( P = .045). Conclusions PST led to immediate antimicrobial de-escalation in the majority of patients who tested negative. This led to a significant increase in beta-lactam usage, specifically penicillins. These benefits were also associated with significant cost savings to patients.
Background Pharmacists can optimize outcomes related to diabetes mellitus (T2DM) by taking advantage of telehealth opportunities despite the COVID-19 Public Health Emergency (COVID-19 PHE). Objective Identify and compare changes in T2DM outcomes prior to (August 2019 through February 2020) and during (March 2020 through October 2020) the COVID-19 PHE. Secondary objectives were to identify and compare pay-for-performance metrics and additional fee-for-service submitted in these patients. Methods This study examined changes in T2DM outcomes at one primary care office within a community health system. Pharmacists started regularly using Remote Patient Monitoring (RPM) services during the COVID-19 PHE to reduce in-person visits. Patients with an initial A1C greater than or equal to 8% were included. Data collected included comorbidities, change in A1C, and diabetes and statin medication therapy adherence. Percentage of Healthcare Effectiveness Data and Information Set (HEDIS) and Merit-Based Incentive Payment System (MIPS) measures met, and billing code frequencies were also assessed. Results In the pre COVID-19 PHE group (N=30), the average three and six month A1C reductions were 1.3% and 1.2%, respectively, while the reductions were 2.0% and 2.2% in the during COVID-19 PHE group (N=61). The percentage of patients appropriately initiated or maintained on statins was 96.2% in the pre COVID-19 PHE group versus 82.6% in the during COVID-19 PHE group. Related to HEDIS, statin adherence was 95.2% in the pre COVID-19 PHE group and 84.2% in the during COVID-19 PHE group while A1C control was 41.7% versus 54%, respectively. A1C control related to MIPS was 60% pre COVID-19 PHE versus 73.8% during the COVID-19 PHE. Diabetes medication adherence related to HEDIS and medication reconciliation related to MIPS was 100% for both groups. Conclusion Data demonstrates the opportunity for pharmacists to maintain and improve clinical outcomes related to T2DM despite the ongoing COVID-19 PHE through implementation of telephonic monitoring.
This qualitative study explores key patient experience impressions responsible for driving quality. Differences between primary and specialty care patient perspectives were analyzed using a mixed-methods design in high-, median-, and low-quality performing practices. We found that primary care patients highly value provider listening, time spent with provider, and consistent and effective coordination of care. Specialty care patients were found to highly value provider clinical skill acumen/outcomes, being kept informed with timely updates and care instructions, and a stress- and pain-free experience. We conclude that differing patient types attach greater value to different elements of their health care experiences.
BackgroundPenicillin skin testing (PST) is a novel way to reduce the use of broad-spectrum agents, potentially resulting in unnecessary overuse and cost savings. This study evaluated clinical and economic outcomes of antimicrobials prescribed with and without PST in a community health system.MethodsThis quasi-experimental study compared an experimental group of 100 adult patients who completed PST for a self-reported penicillin allergy over an open enrollment period beginning January 2016 to a matched control group of 100 patients over the same time frame that had a listed penicillin allergy as well as consultation with infectious diseases. Patients in the control group were matched to the infection diagnosis codes of the members of experimental group and then randomly selected and matched on a 1:1 basis. The primary outcome was β-lactam days of therapy (DOT) defined as either a penicillin or cephalosporin (not carbapenem). The secondary outcome assessed the average cost of antimicrobial therapy before and after PST.ResultsThe control group consisted of 436 patients who met inclusion criteria with 100 patients from that group matched to the 100 patients in the PST group by diagnosis code. The most common self-reported allergy consisted of IgE-mediated (52%) and unknown (30%) in the PST group and IgE-mediated (33%), unknown (20%), and rash (32%) in the control group. Ninety-eight of 100 patients who underwent PST tested negative, with 71 out of 98 (73%) having changes directly made to their antimicrobial regimens immediately after PST. Β-lactam DOT for the PST group were 666 out of 1,094 (60.88%, with 34.82% being a penicillin specifically). Β-lactam DOT for the control group consisted of 386 out of 984 (39.64%, with 6.4% being a penicillin specifically). Chi-square test of homogeneity for β-lactam DOT between the two groups was significant (P < 0.00001). Changes to the antimicrobial regimen after PST saved the average patient $353.03 compared with no change in pre-PST regimen (P = 0.045).ConclusionPST led to immediate antimicrobial de-escalation in the majority of patients who tested negative. This led to a significant increase in β-lactam usage, specifically penicillins. These benefits were also associated with significant cost savings to patients, justifying the cost of performing PST.Disclosures B. M. Jones, ALK: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Grant recipient and Speaker honorarium. C. Bland, ALK: Grant Investigator and Speaker’s Bureau, Grant recipient and Speaker honorarium.
Background The modified Dundee classification has recently been validated in various studies for non-purulent skin and soft tissue infections. This has yet to be applied in the United States and within community hospital settings to optimize antimicrobial stewardship and ultimately patient care. Methods A retrospective, descriptive analysis was performed of 120 adult patients admitted to St. Joseph’s/Candler Health System for non-purulent skin and soft tissue infections between January 2020 to September 2021. Patients were classified into their modified Dundee classes, and frequencies of concordance of their empiric antimicrobial regimens with this classification scheme in the emergency department and inpatient settings were compared, along with possible effect modifiers and possible exploratory measures associated with concordance. Results Concordance with the modified Dundee classification for the emergency department and inpatient regimens was 10% and 15%, respectively, with broad-spectrum antibiotic use and concordance positively associated with illness severity. Due to substantial broad-spectrum antibiotic use, possible effect modifiers associated with concordance were unable to be validated, and overall no statistically significant differences among exploratory analyses across classification status were observed. Conclusion The modified Dundee classification can help identify gaps in antimicrobial stewardship and excessive broad-spectrum antimicrobial usage toward optimizing patient care.
BackgroundCommonly reported penicillin allergies result in limited treatment options, increased healthcare costs, and increasing resistance with the use of broad-spectrum agents. By providing penicillin skin testing (PST) to patients with a penicillin allergy, there is potential to reduce the use of carbapenems, aztreonam, vancomycin, and other broad-spectrum agents, resulting in cost savings and unnecessary overuse. This study examined clinical and economic outcomes of antimicrobials prescribed before and after PST.MethodsThis nonrandomized, observational chart review examined adult patients admitted over an open enrollment period of 100 patients who completed PST for a self-reported penicillin allergy. The study included all patients who met inclusion criteria and completed the test per protocol. Administration of the test utilized a stewardship pharmacist-driven, nursing administered, protocol that has three phases: puncture, intradermal, and oral challenge (optional phase). The primary outcome assessed was change made to antimicrobial regimen directly related to PST. A secondary outcome assessed was cost savings associated with PST.ResultsOver 13 months, 116 patients were consulted for PST with 100 patients completing PST per protocol. Self-reported allergies consisted of IgE-mediated and unknown in 52% and 30% of patients respectively. Seventy-one of 98 patients who tested negative (73%) had changes directly made to their antimicrobial regimens related to PST after intervention from the stewardship pharmacist. Thirty-four patients who had received carbapenems were changed directly to a penicillin or cephalosporin. A previous evaluation at our institution showed an average total antimicrobial acquisition cost savings per patient to be $314.75, which would result in $22,347.25 in direct savings for all patients evaluated.ConclusionPST led to immediate antimicrobial de-escalation in the majority of patients who tested negative. Most of these patients were transitioned to optimal therapy or de-escalated from carbapenem therapy. A total direct cost savings for the institution over the course of 13 months exceeded $20,000. Our study confirmed the overall utility of PST as a cost effective antimicrobial stewardship tool, especially as a carbapenem-sparing strategy.Disclosures B. Jones, ALK: Consultant, Grant Investigator and Scientific Advisor, Consulting fee, Grant recipient and Speaker honorarium; C. Bland, ALK: Grant Investigator and Scientific Advisor, Grant recipient and Speaker honorarium
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