Service Developments – Pharmacy Update Online

Innovative Remote Care Model Combines Tech and Pharmacists to Tame Stubborn Hypertension

Charlie King — Wed, 25 Sep 2024 16:00:19 +0000

Up to 74% of adults with treatment-resistant high blood pressure were able to get their blood pressure below 140/90 mm HG within one year through a program combining remote blood pressure monitoring with pharmacist interactions, according to preliminary research presented at the American Heart Association’s Hypertension Scientific Sessions 2024. The meeting is in Chicago, September 5-8, 2024, and is the premier scientific exchange focused on recent advances in basic and clinical research on high blood pressure and its relationship to cardiac and kidney disease, stroke, obesity and genetics.

The study targeted patients with blood pressure higher than 140/90 mmHg who were receiving care in clinics specializing in kidney conditions. The ConnectedCare365 Hypertension Management program provided people in central and northeast Pennsylvania communities with remote blood-pressure monitoring and other devices that transmit information to doctors. Patients were identified and enrolled through a centralized monitoring center, known as ConnectedCare365, to ensure consistent messaging and ample education on the devices and patient communication application. Doctors and pharmacists assigned by the program co-managed patient care and helped adjust medications for patients.

“In our study, we developed a program that builds off what others have done using telemonitoring and pharmacists,” said senior study author Alexander Chang, M.D., M.S., a nephrologist and associate professor in the department of nephrology and the department of population health sciences at Geisinger Health in Danville, Pennsylvania. “By deploying these extra resources to get blood pressure under control in high-risk patients and reducing hospitalizations, we are hoping that we can help provide more justification in expanding these types of programs.”

Notifications from the home blood pressure-monitoring devices were transmitted to the central monitoring center. During the first six months of the program, the notifications were first transmitted to doctors in collaboration with pharmacists through a virtual platform that connected to patients’ phones through an app, which connected to the devices over Bluetooth. Blood pressure measurements were assessed and blood pressure medications were prescribed and/or adjusted accordingly. During the second six months, the notifications were transmitted first to pharmacists, who co-managed blood pressure through a collaborative telehealth practice agreement. While patients were enrolled in the program, they also had real-time access to a nurse during business hours through a live chat feature in the central monitoring center.

Study results include:

67% of patients were able to achieve blood pressure control of <140/90 mm Hg at six months, and 74% of patients were able to achieve blood pressure control by 12 months. The 2017 clinical guideline from the American Heart Association and the American College of Cardiology set the threshold for stage 1 hypertension at 130/80 mm Hg and the threshold for stage 2 hypertension at 140/90 mm Hg.
Systolic blood pressure was lowered by an average of 3.3 mm Hg/month for those with initial blood pressure readings greater than 150/90 mm Hg; lowered by 2.4 mmHg/month for those with initial readings in the range of 140-149/90-99 mm Hg; and lowered by 0.6 mm Hg/month for those with initial readings lower than 140/90 mm Hg.
Pharmacist telehealth encounters, in which the patients talked directly with pharmacists about hypertension management, were documented in 65% of patients, and pharmacist interactions were associated with a 1.3 mm Hg/month decline in systolic blood pressure over time.
During the 12-month study period, 46% of patients had a blood pressure medication adjustment, and 37% were prescribed new blood pressure medication.
Patients experienced fewer hospitalizations during the study period compared to the previous 12 months; however, there was no difference in the number of reported emergency department visits.

“We know that home blood pressure monitoring can be done by patients accurately and can really help engage patients in their own health. However, we also know that these self-measured blood pressure readings often do not make it back to patients’ health care team, therefore, delays in adjusting medications are very common. This type of physician-pharmacist collaborative model with home blood pressure monitoring that is centrally received and monitored by the care team can help address these issues,” Chang said.

Study background and details:

The study included 205 adults, with an average age of 62 years; 48% self-identified as women and 52% as men.
87% of participants self-identified as non-Hispanic white adults, 6% as Black adults; 5% as Hispanic adults, and 1.5% as “other” for race/ethnicity.
53% of participants had a diagnosis of chronic kidney disease at the time of enrollment.
Participants’ blood pressure was tracked for up to 6-12 months between March 2022 and May 2024 with consistent improvements even after participation in the study ended.

The study’s strengths included its ability to review hospitalization data, inclusion of the pharmacists, the careful examination of the pharmacists’ role in this program and that it was conducted in a real-world setting, the authors noted. The study’s limitations included that patients were their own control group to determine the impact of the program and participants had to have internet access.

“This is an important program that allows for more efficient management of a high-risk patient group,” said Wanpen Vongpatanasin, M.D., FAHA, professor in the department of internal medicine at UT Southwestern Medical Center, director of UT Southwestern Medical Center’s Hypertension Section in the division of cardiology and clinical chair of the Hypertension Scientific Sessions 2024 Executive Committee. “This program’s team-based care approach including a pharmacist remotely makes it a feasible option to increase access. In addition, the study’s findings signal a way to reduce hospitalization and to improve blood pressure, which is very encouraging.”

Note: Moderated Poster Presentation MP11 in Session MPS02 New Paradigm and Lessons learn from Hypertension Clinical Trials in 2024 is Friday, September 6, 2024 at 9:35 a.m. CT.

New law regulating out-of-pocket drug spending saves cancer patients more than $7,000 a year, study finds

Charlie King — Sat, 21 Sep 2024 08:00:48 +0000

As prescription oral chemotherapies have become a common form of cancer treatment, some patients were paying more than $10,000 a year for medications. A new study finds that efforts to cap prescription drug spending are yielding significant out-of-pocket savings for these patients.

The Inflation Reduction Act, enacted in 2022, included establishing a cap on out-of-pocket spending for those enrolled in Medicare Part D prescription drug plans.

Researchers from the University of Michigan’s Institute for Healthcare Policy and Innovation and Rogel Cancer Center used the online Medicare Part D Plan Finder tool to assess how much patients were paying for the most commonly prescribed oral chemotherapies. They compared data from 2023, when no out-of-pocket cap was in place, to 2024, when the policy first took effect.

For Medicare Part D beneficiaries, annual out-of-pocket costs for oral cancer medications averaged $11,284 in 2023. In 2024, the average annual cost for the same medications is estimated to be $3,927. The median cost saving from 2023 to 2024 is estimated to be $7,260, demonstrating the policy’s effect on decreasing costs for patients. The study is published in JAMA Network Open.

“People with cancer are already vulnerable to financial distress and medical debt. Our analysis suggests that legislative policy can have a big impact on the cost of cancer care. This is especially critical as lawmakers now consider extending an out-of-pocket cap to commercial insurance,” said lead study author Benjamin Pockros, M.D., M.B.A., a urology resident at Michigan Medicine.

In 2025, an out-of-pocket cap will be set at $2,000, which the researchers predict will result in even greater savings for patients.

Additional authors: Chad Ellimoottil, M.D.; Belal Sbei; Megan Caram, M.D.; Kristian Stensland, M.D., M.P.H., M.S.

Funding for this work is from the University of Michigan Institute for Healthcare Policy and Innovation.

Disclosure: None

Paper cited: “Changes in Out-of-Pocket Spending for Common Oral Cancer Medications After the Inflation Reduction Act,” JAMA Network Open. DOI: 10.1001/jamanetworkopen.2024.32456

High doses of some prescription stimulants tied to increased psychosis risk

Charlie King — Fri, 20 Sep 2024 08:00:22 +0000

Prescribing rates for stimulants that treat attention-deficit/hyperactivity disorder (ADHD) have increased significantly over the past decade, with some of the largest increases reported during the COVID-19 pandemic. A new study of adult emergency department admissions at Mass General Brigham, led by McLean Hospital researchers, found that individuals who are taking high doses of amphetamine (e.g. Adderall) face more than a five-fold increased risk for developing psychosis or mania. Findings were published September 12^th in the American Journal of Psychiatry.

Overall, individuals with past-month prescription amphetamine use had a greater likelihood of new-onset psychosis or mania than individuals without past-month use. The risk was highest in those taking 30 mg or more of dextroamphetamine (which corresponds to 40 mg of Adderall), according to the study.

Previous studies have linked stimulants to psychosis and mania risk; however, information had been lacking on whether dosing impacted risk.

“Stimulant medications don’t have an upper dose limit on their labels, and our results show that it is clear that dose is a factor in psychosis risk and should be a chief consideration when prescribing stimulants,” said lead study author Lauren Moran, MD, a pharmacoepidemiology researcher at McLean Hospital. “This is a rare but serious side effect that should be monitored by both patients and their doctors whenever these medications are prescribed.”

Moran said the study was born out of her past clinical observations as an inpatient psychiatrist. She and her McLean colleagues would regularly see patients coming in experiencing first episodes of psychosis, and their medical records would reveal they were prescribed high doses of stimulants by their doctors.

Researchers reviewed electronic health records of Mass General Brigham patient encounters between 2005 and 2019, focusing on adults aged 16 to 35, the typical age of onset for psychosis and schizophrenia. All patients were admitted to McLean Hospital following referrals from other hospitals in the Mass General Brigham healthcare system. The researchers identified 1,374 cases of individuals presenting with first-episode psychosis or mania, compared to 2,748 control patients with a psychiatric hospitalization for other conditions like depression or anxiety. They conducted a comparison analysis of stimulant use over the preceding month and accounted for other factors, including substance use, in order to isolate the effects of stimulants.

They found the attributable risk percentage among those exposed to any prescription amphetamine was nearly 63% and for high dose amphetamine was 81%. These findings suggest that among people who take prescription amphetamine, 81% of cases of psychosis or mania could have been eliminated if they were not on the high dose. While a significant dose-related risk increase was seen in patients taking high doses of amphetamine, no significant risk increase was seen with methylphenidate (Ritalin) use, which is consistent with previous research, including a 2019 study led by Moran.

While the study does not prove causality, the researchers note there is a plausible biological mechanism in neurobiological changes that include a release of higher levels of the neurotransmitter dopamine from amphetamines, that parallel dopaminergic changes observed in psychosis.

Limitations of the study include inconsistencies with how electronic health records are kept. Additionally, with the research taking place in a psychiatric hospital in the Boston area that sees many patients with psychosis, it may make these findings less generalizable to other parts of the country.

Moran said the findings need not create alarm but should lead to extra caution when these medications are prescribed, especially for those who have risk factors for psychosis and mania.

“There’s limited evidence that prescription amphetamines are more effective in high doses,” said Moran. “Physicians should consider other medications our study found to be less risky, especially if a patient is at high risk for psychosis or mania.”

Authorship: In addition to Moran, Mass General Brigham co-authors included Joseph P. Skinner, BA (BWH), Ann K. Shinn MD, MPH (McLean), Kathryn Nielsen (McLean), Vinod Rao, MD, PhD (MGH), Trevor Taylor, MD, MPH (MGH), Talia R. Cohen (McLean), Cemre Erkol, MD (McLean), Jaisal Merchant, MA (McLean), Christin A. Mujica, MA (McLean), Roy H. Perlis, MD, MSc, (MGH) and Dost Ongur, MD, PhD (McLean).

Funding: This work was funded by a grant from the National Institute of Mental Health (NIMH), R01 MH122427.

Disclosures: Perlis received personal fees from Genomind, Burrage Capital, Psy Therapeutics Inc, Circular Genomics Inc, and Vault Health unrelated to the submitted work. Dr. Ongur received honorariums for scientific presentations to Neumora Inc. and Guggenheim LLC unrelated to the submitted work. Dr. Moran is employed by Sage Therapeutics (unrelated to this work and after study completed and submitted for publication). All other authors report no financial relationships with commercial interests.

Paper cited: Moran, LV et al. “Risk of Incident Psychosis and Mania with Prescription Amphetamines,” American Journal of Psychiatry. DOI: 10.1176/appi.ajp.20230329

Oxycodone use in Australia dropped 45% after policy changes to opioid prescribing

Charlie King — Wed, 18 Sep 2024 08:00:32 +0000

Between 2018 and 2020, Australia implemented policy changes to improve the quality and safety of opioid prescribing, with a specific focus on oxycodone. A new study led by The University of Queensland (UQ) using wastewater analysis has determined that oxycodone consumption in Australia dropped by 45% from 2019 to 2020, coinciding with those national policy changes.

In November 2019, the Australian National Prescribing Service launched a federal initiative to improve opioid prescribing. The initiative involved alerting high-prescribing clinicians that their opioid prescribing practices were outside typical ranges for that practitioner group (2019), providing training in opioid prescribing (2019), reducing the oxycodone package size (2020), and adding warning messages to oxycodone packaging (2020).

The study used wastewater-based epidemiology to estimate the quantity of oxycodone consumed by a community by sampling the community’s sewage as it flowed into a wastewater facility and measuring the levels of oxycodone and its metabolite, noroxycodone, excreted in urine.

For this study, the Australian National Wastewater Drug Monitoring program (NWDMP) collected and analysed 6,999 samples from over 50 wastewater treatment plants across Australia from April 2017 to April 2023. The results of the analysis are listed below.

Oxycodone use initially increased from 78 mg/day/1000 people in April 2017 to 120 mg/day/1000 people in August 2019. This 52% increase occurred before the federal initiative to improve opioid prescribing began.
Oxycodone use then decreased from 120 mg/day/1000 people in August 2019 to 65 mg/day/1000 people in December 2020. This 45% decrease coincided with the introduction of prescribing guidelines in 2019 and oxycodone packaging changes in 2020.
Oxycodone use showed a minor 2.4% increase from December 2020 to April 2023.

Lead author Dr. Rory Verhagen from UQ’s Queensland Alliance for Environmental Health Sciences explains, “The main finding from this study was that a big reduction in oxycodone use between 2019 and 2020 coincided with the introduction of national clinical and regulatory changes intended to reduce pharmaceutical opioid use. It is likely that the combination of smaller package sizes and educational initiatives in 2019 and early 2020 reduced consumption of oxycodone in Australia.”

The reduction in oxycodone use has not been offset by an increase in heroin or fentanyl use in Australia. NWDMP monitoring shows that throughout the study period, the consumption of heroin fluctuated without any clear trend while fentanyl followed a similar trend to oxycodone.

The study was conducted by researchers from The University of Queensland, the University of South Australia, and Queensland Health, Australia with primary funding from the Australian Criminal Intelligence Commission; it appears in the scientific journal Addiction.

Full citation for article: Verhagen R, Gerber C, Thai PK, Connor J, Loveday B, Bade R, O’Brien J, Jaunay EL, Simpson BS, Chan G, Hall W, Thomas KV, Mueller JF, Tscharke BJ. Wastewater-based evaluation of the efficacy of oxycodone regulations in Australia. Addiction. 2024. DOI: 10.1111/add.16653.

Primary funding: The Australian Criminal Intelligence Commission and Queensland Health Australia provided financial support for this research. Wastewater catchment mapping and sampling was conducted under an Australian Research Council Linkage Project (LP190101124, LP220100058).

Declaration of interests: None.

Opioid dose tapering before hip or knee surgery

Christine Clark — Mon, 16 Sep 2024 06:00:37 +0000

Patients who undergo total hip (THA) and total knee replacement surgery (TKA) can successfully reduce opioid doses before surgery with support from a pharmacy-led intervention, according to a randomised study led by Dr Shania Liu and Dr Jonathan Penm at the University of Sydney, Australia. In this series of short videos, they explain why opioid dose tapering is important and what the OpioidHALT pilot study found.

Why is opioid use before hip or knee replacement a problem?

Patients who require THA or TKA suffer from end stage osteoarthritis with chronic pain. Opioids often provide no better pain relief that simple analgesics and yet they carry the risk of additional side effects such as drowsiness and the risk of falls. Moreover, opioid use before surgery is linked to worse outcomes including slower recovery and persistent opioid use three months after surgery.

THA and TKA are among the most common elective surgical procedures performed around the world and numbers are expected to at least double over the next decade.

How OpioidHALT tackles pre-operative opioid use?

There is little published evidence for the effectiveness of opioid dose tapering. One previous retrospective study showed that patients who tapered their opioids before surgery might have better post-surgical outcomes. However, as the study was not randomised it was not known if there was something different about the patients who tapered their doses.

The OpioidHALT study involved video or telephone consultations with a pharmacist starting three months before the date of the operation. The pharmacist worked with each patient to develop an opioid tapering plan that was evaluated for safety by a pain specialist. Patients determined the level of opioid tapering that they wished within the framework of national guidelines i.e. 10 to 25% of the patient’s baseline opioid dose tapered per month.

What the OpioidHALT pilot study tells us

The initial consultations in the OpioidHALT study took about one hour. Follow-up appointments started one week after each dose reduction and were typically shorter, Patients were educated about how to identify and manage opioid withdrawal symptoms. “If necessary, the patient was put back on a higher opioid dose”, says Dr Liu.

OpioidHALT was a pilot study designed to determine whether the intervention delivered by pharmacists led to successful tapering of opioid doses. The results showed that in the intervention group 90% of patients tapered their opioid doses by at least 50% before surgery compared with17% in the usual care group.

Although the pilot study was not powered to evaluate other outcomes, some of the emerging findings suggest important impacts. In the intervention group there were –

Fewer opioids consumed in hospital
Smaller quantities of opioids supplied on discharge
Fewer days in hospital
Fewer patients taking opioids three months post-operation

Patients in the intervention group also had improved physical function and improved overall body pain intensity.

Why pharmacists should manage pre-operative opioid use

Recordings of the consultations showed that many patients were keen to discontinue opioid use but needed help with the process. “We’ve got patients who are crying [out] to have pharmacists to be more involved in their care …. and that’s something that a lot of pharmacists can do”, says Dr Penm. He adds that the whole multidisciplinary research team says “This is a really good intervention, we should be doing this, pharmacists should be leading it”

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care. He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

Why pharmacists should manage pre-operative opioid use

Christine Clark — Sun, 15 Sep 2024 06:00:35 +0000

Patients are “crying out” for help with opioid dose reduction according to evidence gathered during the OpioidHALT study and the impressive results have led to funding of $1.5 million to run the definitive trial, researchers Shania Liu and Jonathan Penm say.

Some 575 patients were screened for inclusion in the OpioidHALT study and 442 were excluded because of low opioid use. “That is the reality of clinical trials for you”, says Dr Shania Liu. “We know that approximately a quarter of patients in [this] population don’t use opioids on a regular basis”, she adds. Nevertheless, dosage tapering is still important for the many patients who are using opioids regularly.

OpioidHALT II

As a result of the impressive results from the OpioidHALT study Dr Jonathan Penm has now received funding of $1.5 million to run the definitive trial (OpioidHALT II). Recruitment started two months ago. “What’s great about it is all of the pilot sites were so impressed by the pilot that they’ve all stayed on for this definitive trial. Other sites have also expressed interest because they’ve been so excited about it”, says Dr Penm. “We’re going to have more pharmacists, a lot more patients – and [it] will be primarily powered to look at those pain and quality of life outcomes”, he explains.

Pharmacists often improve medication regimens but rarely find out how much of an impact the changes have on patients’ lives. One of the useful and important findings in the OpioidHALT study was that the early benefits of reduced opioid use were sustained for three months. “It just shows you the value that pharmacists can provide to their patients – that when we improve their medicines we could be improving it for much, much longer than you realise and having much, much stronger impact”, says Dr Penm.

All the opioid-tapering consultations were recorded and patients’ reactions made a profound impact on Dr Penm.

“Many of them were just so grateful to have someone listen to them, to validate what they’ve been going through with their pain and to support them through the opioids. In fact, most of them said, “I’ve never had any benefit from these but I just don’t know how to get off them – and I really would love some help”, so I think we’ve got patients who are crying [out] to have pharmacists to be more involved in their care, to be more present, to listen to them, to validate what they’re going through – and that’s something that a lot of pharmacists can do”, he says.

In summary Dr Penm says:

“Any work of this calibre is extremely difficult to do with one person and we have a very large team. One of the unique aspects is how multidisciplinary it was – we have pharmacists, we have nurses, we have GPs, we have anaesthetists, we have physiotherapists, we have orthopaedic surgeons – and we know how rare it is to get all these people together in one spot and for all of them to say, “This is a really good intervention, we should be doing this, pharmacists should be leading it”. It’s just beautiful to hear. You don’t always hear that the pharmacist is the most obvious choice but in this case they are. They’re happy, they’re competent, they’re capable – and everyone else doesn’t want to do this because it is not their area of expertise. Well, with pharmacy we’re very comfortable because we know this, we know opioids, we see tapering, we know how to taper, we know what to expect”.

About Dr Shania Liu and Dr Jonathan Penm

Read and watch the full series on our website or on YouTube.

What the OpioidHALT pilot study tells us

Christine Clark — Sat, 14 Sep 2024 06:00:37 +0000

The results of the OpioidHALT pilot study show that 90% of patients reduced their opioid doses by at least 50% compared with 17% in the control group and emerging findings hint at longer-lasting effects, Jonathan Penm explains.

The initial consultations in the OpioidHALT study – when the opioid tapering plans were developed took about one hour. Follow-up appointments started one week after each dose reduction to check on progress and safety; these were typically shorter, explains Dr Shania Liu. Opioid withdrawal symptoms were one obvious concern. Dr Liu emphasises that the tapering rate was very gradual to minimise the risks of opioid withdrawal and patients were educated about what to look out for and how to overcome withdrawal symptoms. “If necessary the patient was put back on a higher opioid dose to ….. ensure that patient safety came first”, she says. In fact, all adverse events were recorded during the study.

OpioidHALT findings

OpioidHALT was a pilot study designed to determine whether the intervention delivered by pharmacists led to successful tapering of opioid doses, explains Dr Jonathan Penm. “We also found that currently GPs or primary care physicians are generally responsible for opioid tapering, but that’s not their happy place – they were not comfortable, they did not want to spend their time on that”, he says. However, pharmacists were keen to undertake this work. The results showed that in the intervention group 90% of patients tapered their opioid doses by at least 50% before surgery compared with17% in the usual care group. “As a researcher it’s very rare to see such large differences – 17% versus 90%”, says Dr Penm.

Although the pilot study was not powered to evaluate other outcomes, some of the emerging findings suggest important impacts. Those patients whose opioid doses were tapered before surgery consumed fewer opioids in hospital and received smaller quantities of opioids at discharge. In addition, the length of hospital stay was shorter (4 days versus 5.6 days) in the intervention group. Three months after the surgery those in the intervention group were much less likely to be taking opioids than those in the control group. They also had improved physical function and improved overall body pain intensity. Dr Penm notes that “it’s not powered for that so we do have to be a bit cautious – but these are very promising results”.

About Dr Shania Liu and Dr Jonathan Penm

Read and watch the full series on our website or on YouTube.

How OpioidHALT tackles pre-operative opioid use

Christine Clark — Fri, 13 Sep 2024 06:00:25 +0000

The OpioidHALT intervention is tailored to the needs of individual patients and evaluated for safety by a pain specialist. Shared decision-making, with the patient, is an important feature of the scheme, according to researchers Shania Liu and Jonathan Penm.

The case for reducing opioid treatment slowly before total hip and knee replacements is compelling, according to Dr Jonathan Penm. Many patients with osteoarthritis are taking opioids but “we know opioids are not the most effective medicine for osteoarthritis, so we’ve got a cohort of people taking a medicine that doesn’t have much evidence, that’s not very effective and comes with a lot of side effects”, he explains. Reducing the opioid doses is unlikely to make pain any worse but it could reduce the risk of harms, he adds. He notes that there is little evidence for the effectiveness of opioid dose tapering. One previous retrospective study had shown that patients who tapered their opioids before surgery might have better post-surgical outcomes. However, as the study was not randomised it was not known if there was something different about the patients who tapered their doses. “They might just be patients who would naturally taper who weren’t as sick and so they have better outcomes – and so we just didn’t know if these harms were reversible”, he says.

OpioidHALT – objectives and methods

The objective of OpioidHALT study was to examine the feasibility and effectiveness of a pharmacist-led intervention to taper opioid dosage before hip and knee replacement surgery, compared with usual care. The intervention was delivered via a video or telephone consultation. “Pharmacists and patients met ‘one-on-one’ over a Zoom meeting or over a telephone call and discussed their pain management and opioid use before surgery – approximately three months before their joint replacement surgery – with the aim to gradually taper their opioid dose until the day of their surgery”, explains Dr Shania Liu.

For this pilot study a single pharmacist based in the community conducted all the consultations. The pharmacist was trained using freely available, online resources. “We recently published a training package summarising these resources so any pharmacist can access them”, says Dr Liu. The pharmacist worked with each patient to develop an opioid tapering plan that was evaluated for safety by a pain specialist. In addition, the GP was kept in the loop at all stages. Dr Liu emphasises the patient-centred nature of the consultations. “Patients could lead the level of opioid tapering that they wished. The opioid tapering rate, however, was guided by national guidelines on opioid tapering rates. So, this was, on average, 10 to 25% of the patient’s baseline opioid dose tapered per month – so quite gradual – and we did monitor for safety”, she says. Furthermore, patients were offered simple analgesics and non-pharmacological approaches to ensure that pain was managed whilst the opioid doses were being tapered.

About Dr Shania Liu and Dr Jonathan Penm

Read and watch the full series on our website or on YouTube.

Why is opioid use before hip or knee replacement a problem?

Christine Clark — Thu, 12 Sep 2024 06:00:13 +0000

Opioid doses can be successfully reduced by a pharmacy-led intervention, according to a randomised study led by Dr Shania Liu and Dr Jonathan Penm at the University of Sydney, Australia. IMI spoke to the researchers to find out more about the study and the wider research programme.

Patients who undergo total hip (THA) and total knee replacement surgery (TKA) suffer from end stage osteoarthritis with chronic pain. “We know from existing research that opioids are often no better than simple analgesics like paracetamol or acetaminophen or anti-inflammatory pain medicines for osteoarthritis-related pain – so these opioids are not providing any additional benefit and yet they carry the risk of additional side effects such as drowsiness and the risk of falls”, explains Dr Liu. Moreover, opioid use before surgery is linked to worse outcomes including slower recovery and persistent opioid use three months after surgery, she adds.

The OpioidHALT trial (Feasibility of responsible pre-operative opioid use for Hip and knee ArthropLasTy (OpioidHALT) pilot study) was designed to examine the feasibility and acceptability of an intervention to reduce opioid use before elective THA or TKA compared to usual practice. “Total hip and knee replacement surgeries are among the most common elective surgical procedures performed around the world with over 1 million of these procedures performed in the USA alone in 2021. As we know, the population as a whole is aging so these procedures are expected to at least double in volume over the next decade”, explains Dr Liu

About Dr Shania Liu and Dr Jonathan Penm

Read and watch the full series on our website or on YouTube.

Study finds nearly half of U.S. counties have at least one ‘pharmacy desert’

Charlie King — Mon, 09 Sep 2024 08:00:32 +0000

Nearly half of counties in the United States have at least one ‘pharmacy desert’ where there is no retail pharmacy within 10 miles, according to a new study published by researchers at The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC – James).

“As pharmacies close, more and more Americans are left without easy access to medications, with disproportionate consequences on certain communities. We found that patients in counties with higher social vulnerabilities and fewer primary care providers were up to 40% more likely to reside in a region with a pharmacy desert,” said Timothy Pawlik, MD, senior author of the study and holder of the Urban Meyer III and Shelley Meyer Chair for Cancer Research at the OSUCCC – James. Pawlik also serves as surgeon-in-chief at The Ohio State University Wexner Medical Center and as chair of the Department of Surgery in the Ohio State College of Medicine.

The U.S. Centers for Disease Control (CDC) defines social vulnerability as “potential negative effects on communities caused by external stresses on human health.”

“These findings highlight how disparities compound the lack of access to basic health care and how it can lead to many people not taking their prescribed medications and having worse health outcomes, especially for chronic conditions like diabetes and hypertension,” Pawlik added.

Study results were published today in JAMA Network Open.

Methods and Results
Researchers reviewed data on communities located less than 10 miles from the nearest retail pharmacy from the publicly available TelePharm Map. Counties were noted as having a high pharmacy desert density if the number of pharmacy deserts per 1,000 residents was in the 75th percentile. Social vulnerability index (SVI) and healthcare provider data were obtained from the CDC’s Agency for Toxic Substances and Disease Registry and the Area Health Resource File databases, respectively. The researchers used statistical methods to analyze the relationships between these factors.

The study found almost 46% of the 3,143 counties had at least one pharmacy desert. Counties with a high density of pharmacy deserts had higher social vulnerability and fewer primary care providers. People in these high-density pharmacy desert areas were more likely to face difficulties accessing medications and healthcare services.

Collaborators in this study include Giovanni Catalano, MD, Muhammad Muntazir Mehdi Khan, MBBS, and Odysseas P. Chatzipanagiotou, MD.

Remote monitoring and pharmacist helped improve hard-to-control blood pressure

Charlie King — Sun, 08 Sep 2024 08:00:34 +0000

Study results include:

67% of patients were able to achieve blood pressure control of <140/90 mm Hg at six months, and 74% of patients were able to achieve blood pressure control by 12 months. The 2017 clinical guideline from the American Heart Association and the American College of Cardiology set the threshold for stage 1 hypertension at 130/80 mm Hg and the threshold for stage 2 hypertension at 140/90 mm Hg.
Systolic blood pressure was lowered by an average of 3.3 mm Hg/month for those with initial blood pressure readings greater than 150/90 mm Hg; lowered by 2.4 mmHg/month for those with initial readings in the range of 140-149/90-99 mm Hg; and lowered by 0.6 mm Hg/month for those with initial readings lower than 140/90 mm Hg.
Pharmacist telehealth encounters, in which the patients talked directly with pharmacists about hypertension management, were documented in 65% of patients, and pharmacist interactions were associated with a 1.3 mm Hg/month decline in systolic blood pressure over time.
During the 12-month study period, 46% of patients had a blood pressure medication adjustment, and 37% were prescribed new blood pressure medication.
Patients experienced fewer hospitalizations during the study period compared to the previous 12 months; however, there was no difference in the number of reported emergency department visits.

Study background and details:

The study included 205 adults, with an average age of 62 years; 48% self-identified as women and 52% as men.
87% of participants self-identified as non-Hispanic white adults, 6% as Black adults; 5% as Hispanic adults, and 1.5% as “other” for race/ethnicity.
53% of participants had a diagnosis of chronic kidney disease at the time of enrollment.
Participants’ blood pressure was tracked for up to 6-12 months between March 2022 and May 2024 with consistent improvements even after participation in the study ended.

Note: Moderated Poster Presentation MP11 in Session MPS02 New Paradigm and Lessons learn from Hypertension Clinical Trials in 2024 is Friday, September 6, 2024 at 9:35 a.m. CT.

Survey: Most Americans comfortable with AI in healthcare

Charlie King — Fri, 23 Aug 2024 08:00:38 +0000

Artificial intelligence (AI) is all around us – from smart home devices to entertainment and social media algorithms. But is AI okay in healthcare? A new national survey commissioned by The Ohio State University Wexner Medical Center finds most Americans believe it is, with a few reservations.

The national poll of 1,006 people found:

75% believe using AI to minimize human errors is important.
71% would like AI to reduce wait times.
70% are comfortable with AI taking notes during an appointment.
66% believe AI should improve work-life balance for health care providers.

To address some of these issues, The Ohio State Wexner Medical Center is piloting the Microsoft Dragon Ambient eXperience (DAX) Copilot application. It uses conversational, ambient and generative AI to securely listen to a provider-patient visit and draft clinical notes in the patient’s electronic medical record. Rather than the provider typing the notes during the visit, they can focus on the patient then review and edit the notes afterward.

Ravi Tripathi, MD, chief health information officer at the Ohio State Wexner Medical Center, led the pilot program. From mid-January to mid-March this year, 24 physicians and advanced practice providers in primary care, cardiology and obstetrics and gynecology tested the technology during outpatient clinic visits. After obtaining the patient’s permission, the provider records the visit through the AI application. Once the visit is complete, the notes are organized and ready for review in less than a minute.

“We found it saved up to four minutes per visit. That’s time the physician can use to connect with the patient, do education and make sure they understand the plan going forward,” Tripathi said. “A few clinicians preferred their old workflow but, overall, 80% completed the pilot. In fact, we allowed them to keep using the AI solution afterward because it had significantly impacted their practices in the eight weeks of testing.”

One of the pilot participants was Harrison Jackson, MD, an internist who has been frustrated by the typing that has to take place during each patient visit.

“Documentation is necessary, but it takes away from the quality of patient interaction during a visit. I even apologize. I say, ‘I’m sorry, I know I’m making more eye contact with the computer than with you,’” Jackson said.

After testing AI documentation, Jackson reports some occasional missteps such as incorrect pronouns or mistaking one word for another – all things he said were easily fixed during his chart review. He supports the use of AI going forward in healthcare.

“I’m spending as much if not more time with each patient, and it’s higher quality time with more eye contact. I often mention aspects of a physical exam out loud for the AI program to capture, and it prompts a good conversation with my patient,” Jackson said. “I’ve also let our residents use the technology under my supervision, and we’ve noticed the quality of their patient interactions and the quality of plans they present have improved.”

While most Americans also see value in AI for healthcare, the survey found just over half (56%) still find it a little scary and 70% have concerns about data privacy.

“I know patients are concerned about the privacy and the security of their data, but we hold the artificial intelligence and this technology to the same standards that we hold our electronic medical record,” Tripathi said.

As of July 1, Ohio State expanded ambient documentation access to all providers in outpatient settings. In the first two weeks of expanded use, 100 clinicians regained 64 hours of time and satisfaction scores have improved from patients who say their conversations with their physicians were more valuable.

Survey Methodology

This study was conducted on behalf of The Ohio State University Comprehensive Cancer Center by SSRS on its Opinion Panel Omnibus platform. The SSRS Opinion Panel Omnibus is a national, twice-per-month, probability-based survey. Data collection was conducted from May 17 – 20, 2024, among a sample of 1,006 respondents. The survey was conducted via web (n=974) and telephone (n=32) and administered in English. The margin of error for total respondents is +/- 3.5 percentage points at the 95% confidence level. All SSRS Opinion Panel Omnibus data are weighted to represent the target population of U.S. adults ages 18 or older.

Video: Ohio State is thoughtfully implementing AI to help providers spend less time on the computer, and more time interacting with their patients.

view more Credit: The Ohio State University Wexner Medical Center