Introduction Bleeding is the major complication associated with warfarin therapy. Some antidepressants are also associated with increased bleeding risk. Warfarin and antidepressants are used frequently in combination, but it is unclear whether concomitant use increases the risk of bleeding beyond that with warfarin alone. The primary goal of this study was to determine whether use of warfarin and an antidepressant increases the risk for bleeding outcomes compared to warfarin use alone. The secondary goal was to characterize the risk of bleeding in warfarin-treated patients taking one specific class of antidepressant, selective serotonin reuptake inhibitors (SSRIs). Materials and Methods This was a retrospective, single-center, study of warfarin-treated patients prescribed (n=46) and not prescribed (n=54) an antidepressant. Medical records over six months were reviewed for INR values, medical history, bleeding type and incidence, and hospitalization due to bleeding. Patients were included in the antidepressant group if taking concomitant warfarin and antidepressant therapy consistently for a period of 6 months and in the control group if not taking an antidepressant with warfarin. Results Use of any antidepressant with warfarin was not associated with the incidence of any bleeding or major bleeding during the 6-month period. However, use of an SSRI with warfarin was associated with an increase in any bleeding event (OR 2.6, 95% CI, 1.01–6.4 p=0.04). Use of a SSRI remained a significant predictor of bleeding after accounting for other factors associated with bleeding risk. Conclusion This data suggest it is important to clarify the interaction between warfarin and SSRIs in regard to bleeding risk given the high frequency of their concomitant use.

The goal of this white paper is to provide direction for clinical pharmacists providing telehealth. Telehealth care is rapidly emerging to improve patient access to health care and optimize patient health outcomes. With the increasing ability to access electronic health record portals, as many as 75 million telehealth encounters are expected in North America annually. Although electronic "point of access" undoubtedly increases the use of medical and pharmacy services, the real value of telehealth lies in improved access to patients in remote areas lacking adequate medical and pharmacy services and to high-risk patients requiring frequent monitoring. This document is intended to serve as a guide for those interested in or already using telehealth to provide direct patient care. Specifically, it focuses on general concepts of telehealth and demonstrates how the delivery of comprehensive medication management (CMM) by telehealth aligns with the Standards of Practice for Clinical Pharmacists set forth by the American College of Clinical Pharmacy. Although clinical pharmacists must be appropriately credentialed and privileged to provide CMM, their process of care must also be adapted to suit the remote patient. Patient assessment, evaluation of medication therapy, development and implementation of a plan of care, follow-up, monitoring, and documentation of all processes of care are influenced by the technology available, the collaborations established, and the applicable regulations and requirements for telehealth practice.

The association of atrial fibrillation and resultant thromboembolic stroke is readily recognized in the published literature. However, the identification and weight of other risk factors that increase stroke risk are varied. To predict which patients are at greatest risk for thromboembolic stroke, numerous risk stratification schemas have been developed to guide thromboprophylactic treatment decisions. The well-known CHADS(2) scoring system incorporates risk factors such as congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, and previous stroke or transient ischemic attack. Recently, a novel risk stratification model, CHA2DS2 -VASc, has entered the literature and international guidelines, prompting further review of newly added risk factors-age 65-74 years, presence of vascular disease, and female sex-and the increased allotment of 2 points (vs 1 point in CHADS2) for age 75 years or older. The rationale for CHA2DS2 -VASc, as put forth by its authors, is that other risk assessment models omit important risk factors, have low predictive ability, and categorize too many patients as intermediate risk, leaving the choice of anticoagulant or antiplatelet therapy to the discretion of the clinician. Although CHA2DS2 -VASc readily identifies those patients truly at low risk, it classifies more patients as high risk who would then receive anticoagulation therapy. Therefore, implementation of this risk schema warrants further evaluation, especially when weighing the risk for bleeding and the risk for stroke. This critical review provides practitioners with an understanding of the literature that prompted the inclusion of these new risk factors and increased point allocations, compares and contrasts the risk schemas, and reviews national and international guidelines, thereby equipping the health care provider with the knowledge to aid clinical decision-making.

Purpose Health‐system pharmacists and community‐based pharmacists have long held professional relationships. However, the success of each group is often not interdependent and aligned. In 2018, the American College of Clinical Pharmacy (ACCP), CPESN USA, and the National Community Pharmacists Association (NCPA) Innovation Center led a meeting to build patient‐centered pharmacist teams to achieve medication optimization across care settings. Seven community pharmacists and health‐system/clinic‐based pharmacist teams participated in this meeting and left with the intentional commitment to build sustainable partnerships. This report describes the establishment of this partnership, and the subsequent application of Guiding Statements for these collaborations. This report also describes both the successes realized and the lessons learned, and to serve as practical recommendations for institutions interested in pursuing similar partnerships. Results Initial learnings from these partnerships have provided a proof of concept that an intentional approach to the relationship between a health‐system/clinic‐based pharmacist and community‐based pharmacist can lead to improvements in patient care as well as a professional collaboration. We experienced improved communication and closed‐loop care, improved professional relationships across care settings, and enhanced clinical services. However, these partnerships were not without challenges. For instance, lack of interoperability and limited electronic health record access made certain outcomes difficult to track. Conclusion The purposeful establishment of partnerships between health‐system/clinic‐based pharmacists and community‐based pharmacists, built upon the needs of both entities, allowed institutions to develop an aligned commitment to care for shared patients. Over the initial years of these partnerships, many successes were realized and lessons were learned. Both the successes and the challenges can serve as beneficial resources for institutions interested in developing similar partnerships.

Background Engaging residents in meaningful quality improvement (QI) is difficult. Challenges include competing demands, didactics which lack connection to meaningful work, suboptimal experiential learning, unclear accountability, absence of timely and relevant data, and lack of faculty coaches and role models. Various strategies to address these challenges for engagement have been described, but not as a unified approach. This paper describes a bundle of practical strategies to address common challenges to resident engagement in QI, illustrated through the experience of one residency education program. Methods 62 categorical residents in the University of Missouri Internal Medicine residency participated in a longitudinal QI curriculum integrated into residency clinic assignments with dedicated QI work sessions and brief just-in-time didactics with mentorship from faculty coaches. Residents completed at least two PDSA (Plan-Do-Study-Act) cycles for their projects. The experience included clear expectations and tools for accountability. Project criteria included importance to patients, residents, and the institution. Residents had access to data related to their own practice. A pre-post survey asked residents to self-assess their level of interest and engagement in QI on a 5-point Likert scale, with 1 = least desired and 5 = most desired result. Data were analyzed by paired t-test. Results All 62 residents participated in the program as members of ten QI teams. 40/62 residents completed both pre- and post-surveys. Items related to self-assessment of QI in clinical work all changed in the desired direction: likelihood of participation (3.7 to 4.1, p = 0.03), frequency of QI use (3.3 to 3.9, p = 0.001), and opinion about using QI in clinical work (3.9 to 4.0, p = 0.21). Resident assessment of QI priority in clinical work did not change. Conclusions We implemented a practical strategies bundle to overcome common challenges to successfully engaging residents in clinical quality improvement. These strategies included QI work integrated into routine clinical assignments, just-in-time didactics, experiential learning with clear expectations and strategic project selection, timely and pertinent data from the residents’ own practice, and real-time faculty coaching.

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BackgroundEngaging residents in meaningful QI is difficult. Challenges include competing demands, didactics which lack connection to meaningful work, suboptimal experiential learning, unclear accountability, absence of timely and relevant data, and lack of faculty coaches and role models. This paper describes practical strategies to address common challenges to resident engagement in QI, illustrated through the experience of one residency education program.Methods62 categorical residents in the University of Missouri Internal Medicine residency participated in a longitudinal QI curriculum integrated into residency clinic assignments with dedicated QI work sessions and brief just-in-time didactics with mentorship from faculty coaches. Residents completed at least two PDSA cycles for their projects. The experience included clear expectations and tools for accountability. Project criteria included importance to patients, residents and the institution. Residents had access to data related to their own practice. A pre-post survey asked residents to self-assess their level of interest and engagement in QI on a 5-point Likert scale, with 1=least desired and 5=most desired result. Data were analyzed by paired t-test. ResultsAll 62 residents participated in the program as members of ten teams. 40/62 residents completed both pre- and post-surveys. Items related to self-assessment of QI in clinical work all changed in the desired direction: likelihood of participation (3.7 to 4.1, p=0.03), frequency of QI use (3.3 to 3.9, p=0.001), and opinion about using QI in clinical work (3.9 to 4.0, p=0.21). Resident assessment of QI priority in clinical work did not change.ConclusionsWe implemented practical strategies to overcome common challenges to successfully engaging residents in clinical quality improvement. These strategies included QI work integrated into routine clinical assignments, just-in-time didactics, experiential learning with clear expectations and strategic project selection, timely and pertinent data from the residents’ own practice, and real-time faculty coaching.