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Independent pharmacist prescribing of statins for patients with type 2 diabetes: An analysis of enhanced pharmacist prescriptive authority in Idaho
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2020) 1e7
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Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Independent pharmacist prescribing of statins for patients with type 2 diabetes: An analysis of enhanced pharmacist prescriptive authority in Idaho Nathan Spann*, Jeffrey Hamper, Robert Griffith, Kevin Cleveland, Timothy Flynn, Katie Jindrich a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 November 2019 Accepted 18 December 2019
Objectives: This study describes the development and patients’ perceptions of a community pharmacisteled, statin-prescribing service for patients with diabetes and aims to identify why patients indicated for statin therapy were not prescribed therapy at the time of pharmacist consultation. Setting: This pilot service began in 4 community-based Albertsons Companies pharmacies located in western Idaho. Patients eligible for the statin-prescribing service had a current diagnosis of type 2 diabetes, were aged between 40 and 75 years, were currently taking medications to manage their diabetes and had no contraindications to statin therapy. Practice description: Due to recent law changes in Idaho, pharmacists can now prescribe statins and certain other medications without oversight from a medical provider or the need for a collaborative practice agreement. Practive innovation: Patients were identified and contacted by their local community pharmacist to discuss the statin-prescribing service. Once statin therapy was initiated, patients completed a brief, 7-question survey regarding their perceptions of the service. Evaluation: This study evaluated the following: number of patients eligible for the prescribing service, number of patients who received a pharmacist-written statin prescription, and patients’ perceptions regarding the service. Methods: Of the 64 patients screened, 18 (28%) were eligible for statin therapy. Of those eligible, 6 (33%) accepted pharmacist services and 4 patients started statin treatment. Two patients were prescribed a statin by the community pharmacist, whereas the other 2 patients contacted their primary care provider and requested a statin prescription at the pharmacist’s recommendation. Results: Overall, participating patients (n ¼ 4) reported feeling comfortable and satisfied with all aspects of the protocol and their pharmacist’s role as a prescriber. Conclusion: This pilot was the first example of community pharmacists independently prescribing statins outside of the clinic setting. The service could target an important health initiative. Published by Elsevier Inc. on behalf of the American Pharmacists Association.
Community-based pharmacists do not have regular national prescriptive authority for 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors, also known as statin
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. * Correspondence: Nathan Spann, PharmD, Clinical Assistant Professor, Idaho State University, College of Pharmacy, 1311 East Central Drive, Meridian, ID 83642. E-mail address: [email protected] (N. Spann).
medications, with the exception of pharmacists in the U.S. Department of Veteran Affairs and those in military settings1 or under collaborative practice agreements.2,3 To ensure that patients are properly prescribed a statin medication, community pharmacists can identify statin-eligible patients through medication therapy management (MTM) platforms and contact primary care providers with statin recommendations.4-6 Pharmacists can play an important role in improving the prescription and overall patient outcomes through the completion of MTM.5,6 However, a recent study showed that
https://doi.org/10.1016/j.japh.2019.12.015 1544-3191/Published by Elsevier Inc. on behalf of the American Pharmacists Association.
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Key Points Background: Many patients who are eligible for statin treatment are not on an appropriate therapy. Attempts to contact primary providers to start statin treatment in indicated patients have been lacking. Findings: The ability of community pharmacists to prescribe statin medications has the potential to reduce this care gap.
pharmacists must contact, on average, 9 providers for every 1 new statin prescription issued and that, on average, a total of 13 provider contacts are needed to ultimately dispense 1 new statin medication.4 Patients who are indicated to receive a statin based on guideline recommendations are often not prescribed one. A study that evaluated pharmacist-identified gaps in diabetes management found that of the 420 patients screened, 122 (29%) and 106 (25%) patients who needed highand moderate-intensity statins, respectively, had not received a prescription.7 Independent prescribing of statins by pharmacists has the potential to improve these gaps in care. To address this care gap, Idaho pharmacy laws and administrative rules were updated in July 2018 to allow all pharmacists licensed in Idaho to independently prescribe statin medications to eligible patients. Before the official rule activation, community pharmacies, such as Albertsons, were permitted by the Idaho State Board of Pharmacy to begin a pilot statin-prescribing service, mirroring the policies set forth in the updated law and administrative rules. Albertsons’ pilot service began identifying and engaging eligible patients starting in May 2018, 3 months before the official state laws took effect. The original iteration of Idaho law did not explicitly name drugs or drug devices eligible to be independently prescribed by pharmacists.8 The Idaho State Board of Pharmacy supplemented the rule with prescribing protocols written in formal meetings that were open to public input. Drugs with protocols approved and published by the Board of Pharmacy eligible to be prescribed independently by pharmacists included the following: treatment and short-term prevention of cold sores, treatment of uncomplicated urinary tract infections (UTIs), short-acting beta agonists for patients with asthma, seasonal influenza prophylaxis and treatment, Group A streptococcal pharyngitis treatment, and statin medications for patients with diabetes. Albertsons Companies began by piloting services for cold sores, uncomplicated UTIs, and statins. The emphasis on improving statin prescribing for patients with diabetes was the result of the Centers for Medicare and Medicaid Services’ (CMS) value-based purchasing initiatives to match guideline treatment recommendations. Statins have been demonstrated to reduce morbidity and mortality from stroke and heart attack, particularly in patients with diabetes.9,10 The most current guidelines at the time of this study, the 2017 American Diabetes Association Standards of Medical Care in Diabetes Guideline and the 2013 American College of
2
Cardiology/American Heart Association (ACC/AHA) Cholesterol Guideline, agree that all patients with diabetes, despite their cholesterol levels, should be recommended at least moderate-intensity statin therapy. Patients with a higher atherosclerotic risk factor score qualify for high-intensity statin therapy.11,12 Furthermore, the addition of “statin use in persons with diabetes (SUPD)” to Medicare Part D quality measures in 2018 provided an additional rationale for new legislation and incentive for pharmacists to offer independent statinprescribing services. Community pharmacists often interact with patients on a more frequent basis than primary providers, and they have access to the medication and refill history of patients.13 In addition, pharmacists are widely considered to be an integral part of the health care team and are trained experts in managing complicated medication profiles.14-17 Moreover, pharmacists can assist health plans aimed at meeting quality measures by closing the gap in care for patients with diabetes through appropriate statin prescriptions. Assurance that patients are prescribed and adherent to appropriate-intensity statins could also help improve physician-specific treatment metrics, such as CMS’s Medicare Access and Chip Reauthorization Act and Merit-Based Incentive Payment System, which have important ties to billable services and reimbursement. The statin-prescribing service at Albertsons Companies was aimed at (1) identifying patients with diabetes who had indications for treatment but were not yet prescribed statin therapy, (2) having a trained pharmacist screen each identified patient for statin initiation criteria, and (3) prescribing a moderate-intensity statin after eligibility was established. This prescribing service intended to close the care gap for patients in need of statin treatment as per guideline recommendations.
Objectives The objectives of this study were to describe the development and measure patients’ perceptions of an independent pharmacist-prescribed statin service and identify reasons why patients were not prescribed statin therapy when indicated at the time of pharmacist consultation.
Setting and participants Pilot locations The pilot prescribing service was initiated in 4 Albertsons community pharmacies located in Boise, Nampa, Caldwell, and Emmett (Idaho). The pilot stores were selected in part because they serviced the highest number of eligible patients as identified by Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPP), a quality improvement program capable of tracking CMS star measures. At the start of the pilot, Boise, the state’s capital, had a population approaching a quarter million, whereas Nampa and Caldwell, larger suburbs of Boise, had populations of approximately 100,000 and 50,000, respectively. Emmett, a rural farming town located 30 miles outside of Boise, had about 7000 people at the start of the service. Idaho is in the bottom 25% with regard to the prevalence of diabetes (8.1% of the population) in the country;
SCIENCE AND PRACTICE Pharmacist prescribing of statins for diabetes
however, Canyon County, home to Nampa and Caldwell, is closer to the national average at 9.2%.18 Training and service initiation All 11 pharmacists working full-time in the pilot pharmacies completed internal company training to provide the statinprescribing service. Undistributed (float) pharmacists (n ¼ 6) expected to staff the pilot pharmacies during the pilot period (May 2018 to July 2018) also completed training. Training included (1) studying the Idaho State Board of Pharmacy statinprescribing protocol and the company’s statin-prescribing service outline and (2) completing a practice fingerstick blood test used to check patients’ alanine aminotransferase (ALT) values. Albertsons created a document called the statin prescribing service outline for trainees to review and discuss with trainers. The document discussed all aspects of statin prescription, including guideline recommendations, required monitoring, and statin class characteristics. Pharmacists scheduled patients for appointments over the phone and trained all pilot certified pharmacy technicians (CPhTs) to alert pharmacists when eligible patients returned calls about participating in the service. Unsuccessful attempts to reach patients by phone were recorded on an Excel spreadsheet so that 3 contact attempts could be tracked. Pharmacists also left medication profile notes and written messages on medication bags to be picked up, if applicable, to best ensure that contact was made. Recruitment EQuIPP was used to identify eligible patients for the service. Using the SUPD measure, EQuIPP identified patients with a diagnosis of diabetes with no current billed prescription claim for a statin medication. These potentially eligible patients were then contacted by their local pharmacy to discuss the prescribing service and confirm their eligibility. Patient eligibility Eligible patients included those who had a current diagnosis of type 2 diabetes, were aged between 40 and 75 years, and were currently taking medication(s) to manage their diabetes. Patients who were ineligible for the service included those who reported a history of statin intolerance or who were contraindicated to statin treatment, such as patients with active liver disease, unexplained ALT elevation at or more than 3 times above the upper limit of normal reference range, pregnant (or intending to become pregnant) or breastfeeding women, a history of statin-induced rhabdomyolysis, on hemodialysis or peritoneal dialysis, New York Heart Association class II-IV ischemic systolic heart failure, or a history of cognitive impairment. Eligibility was determined using clinical guidelines such as the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults; the 2017 American Diabetes Association Standards of Medical Care in Diabetes; the National Heart, Lung, and Blood Institute guidelines; and statin package inserts from manufacturers. These resources also guided the monitoring and follow-up policies of the service. Before contacting any patient, pharmacists first conducted a medication review to identify suspected contraindications or
potential drug interactions. Patients’ self-reports were used to confirm or deny contraindications. Confirmation of a diagnosis of diabetes was required from either the patients’ or their health care provider. Patients with diabetes other than type 2 (e.g., prediabetes, gestational, type 1) were excluded.
Practice innovation Potentially eligible patients identified by EQuIPP were contacted by their community pharmacist (a postgraduate year-1 community pharmacy resident) after a medication profile review to discuss statin use. Patients were called a total of 3 times, typically no more than once per week, at their listed primary phone number. When it was possible to leave a voicemail, a request was made for the patient to call the pharmacy. Patients who could not be contacted after 3 attempts had notes placed with their filled prescriptions and technicians were trained to request a pharmacist’s consult on the receipt of the written note. When the pharmacist was able to contact the patient, whether it was over the phone or in person, the pharmacist discussed the reason for the statin indication and the prescribing process. Interested patients were then scheduled for an appointment with the pharmacist at the pilot pharmacy or, if time permitting, completed the appointment immediately. Reasons for ineligibility or refusal were documented. Pharmacists began consultations by completing an intake form to further establish eligibility. The intake form gathered basic contact information and primary care provider information and asked questions specific to the history of statin treatment. Patients were also asked if they had ever received a diagnosis of type 2 diabetes, if they were currently takingmedication(s)totreatdiabetes,and severalmorequestions to rule out contraindications. After patients were deemed eligible, they were asked to consent to a fingerstick test to ensure that their ALT level was not elevated. This blood test was completed in accordance with the National Heart, Lung, and Blood Institute guidelines recommendation that ALT be checked at baseline when initiating statin treatment.12 Albertsons determined that the most cost-effective way to measure ALT was through a contract with an off-site laboratory and mailing of patients’ samples. The device provided by the laboratory collected 100 mL of blood using a lancet and pipette or the hanging blood drop approach. The device containing the blood sample was mailed and processed, and the result was available within 3 to 5 business days. Statin-prescribing decisions were made once the ALT result was received and evaluated by the pharmacist. Pharmacists were prepared to refer patients in the setting of an elevated ALT result. After the receipt of an ALT value within normal reference range, patients returned to the pilot pharmacy where pharmacists prescribed, processed, and dispensed an appropriate statin with up to 12 months of refills. ACC/AHA guidelines recommend statin therapy for eligible patients with diabetes even with normal cholesterol levels; therefore, low-density lipoprotein (LDL) was not assessed at baseline. Patients were prescribed the lowest moderate-intensity statin dose that was compatible with all other relevant health information collected. Although many patients eligible for the service may have been indicated for a high-intensity statin, this pilot sought to establish statin tolerance, and 3
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further patient assessment to determine overall atherosclerotic cardiovascular disease (ASCVD) risk was not sought; this was done to contain the overall cost of the service. Patientspecific factors such as drug-drug interactions, grapefruit consumption, kidney function, morning versus evening dosing preference, affordability, and fear of muscle pain were also taken into account in choosing the most appropriate statin for each patient. The most appropriate and cost-effective statin was selected, without any regard to reimbursement to the pharmacy. The prescribed statins were filled at the pharmacy and billed to the patient's prescription insurance company using the prescribing pharmacist’s individual National Provider Identifier without incident. At the time of dispensing, pharmacists delivered their regular counseling to patients taking statin therapy for the first time, including an in-depth review of the statin’s indication, its benefits, how to take the medication, and monitoring and potential adverse effects. After a statin was prescribed and dispensed, the primary care provider (or when the patient did not have a primary care provider, the provider of record responsible for the diabetes medications) was notified within 24 hours of the newly issued prescription. If the prescribing service resulted in a prescription, a nominal fee was assessed to the patient. This fee covered all costs associated with the pharmacist’s time and ALT test. Prescribing pharmacists followed up with patients 4 weeks after the initial prescription through a face-to-face visit or phone call to assess tolerance and adherence and to address any questions or concerns from patients. LDL was not assessed as part of the 4-week follow-up visit. ALT would only be reassessed if patients displayed any signs or symptoms of liver injury, such as yellowing of the skin or eyes, upper right quadrant pain, or vomiting.19 An electronic record of the handwritten prescription was kept on file as per the requirements of the State. Of note, if the
Contact paent to further determine eligibility
prescription needed to be transferred, all applicable transfer laws with regard to noncontrolled medications applied. Figure 1 presents the workflow process. Survey design Patients who completed the intake process and received the ALT test were asked to complete a written 7-question survey (Appendix 1) regarding their perceptions of the service. This survey asked for demographic information; patients’ history with statins, if applicable; their comfort with the pharmacists’ recommendations; and their perceptions of the pharmacists’ communication. Patients who completed the survey were incentivized with a 10%-off grocery coupon as a token of appreciation for their time. Patients who were screened but did not move forward with the service did not complete the survey. A total of 60 patients were ineligible, declined service, or were lost to follow-up (Figure 2). Evaluation Of the 64 patients who were identified as eligible for statin therapy by EQuIPP, 21 (33%) had contraindications for statins, 17 (27%) could not be contacted, and 12 (19%) refused (Figure 2). Of the 6 (9%) patients who agreed to the service, 4 (66.7%) successfully received a statin medication. Of the 4 patients who were successfully started on statin treatment, 2 were pharmacist prescribed. The other 2 patients were recommended a statin by their pharmacist but ultimately solicited a prescription from their primary care provider because of a delay in the ALT results. The demographic data for these patients are detailed in Table 1. The inability to contact patients directly (n ¼ 17) was the main reason that patients were not further evaluated for statin eligibility. Another major reason for the inability to prescribe
Complete intake form & perform POCT - ALT for paents meeng inclusion criteria with no contraindicaons
Evaluate ALT value. Refer when elevated, connue service when normal
Prescribe, counsel & dispense appropriate stan. Follow up in 4 weeks.
Eligibility screening (EQuIPP + medicaon profile review) Figure 1. Statin service workflow. Abbreviations used: ALT, alanine aminotransferase; EQuIPP, Electronic Quality Improvement Platform for Plans and Pharmacies; POCT, point-of-care testing.
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SCIENCE AND PRACTICE Pharmacist prescribing of statins for diabetes
64 paents idenfied
58 did not complete the service
6 agreed to the service
2 were prescribed a stan by the PharmD
2 were prescribed a stan by another medical provider
2 were lost to follow-up
21 were contraindicated
17 were unable to be contacted
12 paents refused
8 already had a stan
Figure 2. Statin eligibility and service completion.
was previous intolerance or contraindication (n ¼ 21) to statins reported by the patients. Most patients who noted intolerance could not recall the specific symptoms. Of the 12 patients who refused the service, one stated that they “wanted all treatment decisions to go through their primary care provider” and another stated that “they did not understand the purpose of a statin and had no interest in starting one.” The remaining refusals simply stated “I do not think I need the medication.” In other words, the patients questioned the benefit of the treatment. Motivational interviewing techniques were used to prompt the patients to reconsider. All 4 patients who successfully started statin treatment completed a survey at the end of the service provision. These 4 patients had never taken a statin because they had cholesterol values within the normal reference range and agreed on the following statements: My pharmacist explained the proper use of the medication, including adverse effects and what to do if they occur. I feel comfortable with my pharmacist’s recommendation of starting statin therapy. My pharmacist described the reasons why statin therapy is recommended for me. I feel my pharmacist was able to adequately answer all of my questions. I would recommend this pharmacy service to an eligible family member or friend with diabetes.
Discussion No previous study has examined the development and patients’ perceptions of pharmacists independently prescribing statins. In our study, patients were comfortable with their Table 1 Demographic information of patients who were prescribed statins Demographic Sex Age (y) Income ($) Education Race Ethnicity
Patient response (n) Female (1); male (3) 51e55 (1); 56e60 (3) 20,000e34,999 (3); 35,000e49,999 (1) High school or GED (3); undergraduate (1) White or Caucasian (3); Hispanic or Latino (1) Not Hispanic or Latino (3); Hispanic or Latino (1)
Abbreviation used: GED, General Educational Development.
pharmacist in a prescriptive role. Studies have demonstrated positive patient perceptions of pharmacist services such as community pharmacyebased services,20 pharmacist-led diabetes management services,21 and pharmacist-provided Medicare annual wellness visits.22 Previous studies into independent pharmacist prescribing have shown similar positive patient perceptions. For example, a study on the public perception of community pharmacisteprescribed nonemergency hormonal contraception showed “generally positive” viewpoints because of increased health care access, avoidance of inadvertent pregnancies, and more freedom to women for obtaining the medications. However, this same study reported patients’ concerns regarding the safety and logistics of offering the service in a community setting.23 Similarly, medical organizations have opposed independent pharmacist prescribing, claiming that pharmacists are unqualified, will cause harm to patients, and that pharmacists do not have the proper information available to prescribe, such as a patient chart.24 This service could be expanded in several ways. The pilot service used a single patient identification resource (EQuIPP) and 4 pilot stores to identify potentially eligible patients. With expansion of the service, more MTM platforms can be used to identify patients with diabetes who need a statin. Screening during the dispensing workflow can also identify eligible patients. Additional marketing of expanded pharmacy services will bring new patients. In addition, many patients were excluded from the service based on reported previous intolerance to statins. Reattempting statin treatment in those with reported intolerances may be a future opportunity for the prescribing service. Challenging patients who are intolerant to 1 statin is consistent with guideline recommendations and could be possible for a pharmacist with access to a patient chart.12,14 An inability to directly contact patients was the largest barrier to initiating patient screening. This was more of an issue when the screening took place outside of standard workflow, as it often did during the pilot phase. With workflow-based screening (nonappointment), the communication was easier to establish with the patient and may have been more effective than phone-based interactions. Pharmacists provide better patient care when complete medical history is available for review, such as in an electronic health record.25-27 Many community pharmacists in Idaho do not have access to a patient’s medical record. Had an electronic medical record been available during the pilot phase of this
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service, prescribing pharmacists could have calculated an ASCVD risk score and distinguished between the need for moderate- versus high-intensity statin treatment, a limitation of the service. In the future, a greater emphasis could be placed on contacting providers’ offices to gather more details on intolerance and to explore other treatment options for patients who report intolerance. Although not directly measured, the pharmacists were enthusiastic about using their clinical training and taking advantage of their newfound prescriptive authority. They were also pleased to see patients react positively to participating in the service. Concerns and suggestions for improvement from the pharmacists were centered on time available to complete the service and making the service affordable. During the pilot phase, a postgraduate year-1 community-based pharmacy resident was responsible for contacting patients, describing the service, setting up appointments, and completing the consultations. The resident was an “extra” worker in the pharmacy so time constraints and workflow stoppage could not be truly experienced. Each consultation took roughly 20 minutes, which could be quite burdensome in the middle of a busy day. Most of the time was spent answering the patients’ questions and describing the background information on statins, diabetes, guideline recommendations, and in the case of the first 2 patients, why their primary care provider did not prescribe a statin earlier and why the pharmacist was able to do so. Pharmacists can save time by training CPhTs to assist the patient in not only filling out the intake form independently but also in completing the ALT test. The cost of the service was an explicitly mentioned barrier for some patients who refused the service for this reason. Charging patients out of pocket for the pharmacist’s time and the supplies used in the screening process will likely continue to serve as a barrier for patients in the future. Despite charging a fee for the service, patients may use it for the sake of convenience and for the fact that they trust the professional consultation of their pharmacist. However, to ensure that the program is sustainable, third-party reimbursement would likely be necessary. Future studies should look at the success of this expanded service in addition to the success of pharmacist-prescribed statins in other settings. Of particular interest would be settings with immediate access to electronic medical records, which would allow for full ASCVD risk assessment, and those with more robust laboratory services, which would allow for easier monitoring and titration. Two of 4 patients who agreed to complete the prescribing service requested a statin prescription from their primary care provider while awaiting the return of the mail-away ALT test result. If a device that could give an immediate result had been used, the pharmacist would have prescribed these 2 patients their medications. The mail-away option also requires patients to return to the pharmacy on a separate day to pick up their prescription, providing another chance to lose patients to follow-up. Newer guideline recommendations should also be considered, as there have been numerous updates published after this research concluded.
Conclusion This pilot was the first example of community pharmacists independently prescribing statins without the need for a 6
collaborative practice agreement or other medical provider oversight to patients outside of the clinic setting. The service could target an important health initiative.
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24. Pojskic N, MacKeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists. Res Social Adm Pharm. 2014;10(2): 341e354. 25. Weddle SC, Rowe AS, Jeter JW, Renwick RC, Chamberlin SM, Franks AS. Assessment of clinical pharmacy interventions to reduce outpatient use of high-risk medications in the elderly. J Manag Care Spec Pharm. 2017;23(5):520e524. 26. Hensler D, Richardson CL, Brown J, et al. Impact of electronic health record-based, pharmacist-driven valganciclovir dose optimization in solid organ transplant recipients. Transpl Infect Dis. 2018;20(2): e12849. 27. Polen CB, Judd WR, Ratliff PD, King GS. Impact of real-time notification of Clostridium difficile test results and early initiation of effective antimicrobial therapy. Am J Infect Control. 2018;46(5):538e541.
Nathan Spann, PharmD, Clinical Assistant Professor, College of Pharmacy, Idaho State University, Meridian, ID Jeffrey Hamper, PharmD, BCACP, Manager, Academic Relations, Albertsons Companies, Boise, ID Robert Griffith, PharmD, Pharmacy Manager and Residency Preceptor, Albertsons Companies, Boise, ID Kevin Cleveland, PharmD, ANP, Assistant Dean and Associate Professor, College of Pharmacy, Idaho State University, Meridian, ID Timothy Flynn, PharmD, Patient Care Pharmacist and Residency Program Director, Albertsons Companies, Boise, ID Katie Jindrich, PharmD, Residency Program Coordinator, Albertsons Companies, Boise, ID
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Appendix 1. 7-Question Statin Satisfaction Survey Statin Prescription Satisfaction Survey I am starting my pharmacist prescribed statin (cholesterollowering) medication today. , Yes , No If no, skip questions 1 and 2. 1. My pharmacist explained the proper use of the medication, including side effects and what to do if they occur. , Agree , Disagree 2. Before receiving a statin medication from my pharmacist, I was not taking one because: , My provider recommended one but I did not want to take it at the time. , My provider recommended one but I could not afford it. , My provider did not recommend one for me to the best of my knowledge. , My provider did not recommend one to me because my cholesterol levels were normal. , I had either a contraindication to treatment, a prior allergic reaction or I did not tolerate the medication. , I do not / did not have a primary care provider to recommend one to me. , Other: ___________________________________________ 3. I feel comfortable with my pharmacist’s recommendation of starting statin therapy. , Agree , Disagree 4. My pharmacist described the reasons why statin therapy is recommended for me. , Agree , Disagree 5. I feel my pharmacist was able to adequately answer all of my questions. , Agree , Disagree 6. I would recommend this pharmacy service to an eligible family member or friend with diabetes. , Agree , Disagree If you disagree with any of the above items, please indicate why: ________________________________________________
7.e1
7. Which of the following applies to you? Check all that apply. , I have not taken a statin medication before. , I have tried a statin medication in the past but stopped due to side effects. , I have tried a statin medication in the past but stopped due to cost, inconvenience, or forgetfulness. , I have tried a statin medication in the past but stopped because it was deemed no longer medically necessary by my provider. , I have tried a statin medication in the past but stopped because I believed it was no longer medically necessary. , Other: ___________________________________________. Demographic information Gender , Female , Male Age group , 40 e 45 , 46 e 50 , 51 e 55 , 56 e 60 , 61 e 65 , 66 e 70 , 71 e 75 Income , < $20,000 , $20,000 - $34,999 , $35,000 - $49,999 , $50,000 - $74,999 , $75,000 - $99,999 , $100,000 or more Education , Part high school , High school / GED , Undergrad college , Graduate / professional Employment , Full-time , Part-time , Seasonal , Volunteer , Retired , Unemployed Race , Asian / Pacific Islander , Hispanic / Latino , Black / African American , American Indian / Native American , White / Caucasian , Other: _________________________ Ethnicity , Hispanic or Latino , Not Hispanic / Latino , Other Thank you very much for completing this survey. Please enjoy this 10% off grocery coupon as a sign of appreciation for your time and effort.
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Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Independent pharmacist prescribing of statins for patients with type 2 diabetes: An analysis of enhanced pharmacist prescriptive authority in Idaho Nathan Spann*, Jeffrey Hamper, Robert Griffith, Kevin Cleveland, Timothy Flynn, Katie Jindrich a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 November 2019 Accepted 18 December 2019
Objectives: This study describes the development and patients’ perceptions of a community pharmacisteled, statin-prescribing service for patients with diabetes and aims to identify why patients indicated for statin therapy were not prescribed therapy at the time of pharmacist consultation. Setting: This pilot service began in 4 community-based Albertsons Companies pharmacies located in western Idaho. Patients eligible for the statin-prescribing service had a current diagnosis of type 2 diabetes, were aged between 40 and 75 years, were currently taking medications to manage their diabetes and had no contraindications to statin therapy. Practice description: Due to recent law changes in Idaho, pharmacists can now prescribe statins and certain other medications without oversight from a medical provider or the need for a collaborative practice agreement. Practive innovation: Patients were identified and contacted by their local community pharmacist to discuss the statin-prescribing service. Once statin therapy was initiated, patients completed a brief, 7-question survey regarding their perceptions of the service. Evaluation: This study evaluated the following: number of patients eligible for the prescribing service, number of patients who received a pharmacist-written statin prescription, and patients’ perceptions regarding the service. Methods: Of the 64 patients screened, 18 (28%) were eligible for statin therapy. Of those eligible, 6 (33%) accepted pharmacist services and 4 patients started statin treatment. Two patients were prescribed a statin by the community pharmacist, whereas the other 2 patients contacted their primary care provider and requested a statin prescription at the pharmacist’s recommendation. Results: Overall, participating patients (n ¼ 4) reported feeling comfortable and satisfied with all aspects of the protocol and their pharmacist’s role as a prescriber. Conclusion: This pilot was the first example of community pharmacists independently prescribing statins outside of the clinic setting. The service could target an important health initiative. Published by Elsevier Inc. on behalf of the American Pharmacists Association.
Community-based pharmacists do not have regular national prescriptive authority for 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors, also known as statin
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. * Correspondence: Nathan Spann, PharmD, Clinical Assistant Professor, Idaho State University, College of Pharmacy, 1311 East Central Drive, Meridian, ID 83642. E-mail address: [email protected] (N. Spann).
medications, with the exception of pharmacists in the U.S. Department of Veteran Affairs and those in military settings1 or under collaborative practice agreements.2,3 To ensure that patients are properly prescribed a statin medication, community pharmacists can identify statin-eligible patients through medication therapy management (MTM) platforms and contact primary care providers with statin recommendations.4-6 Pharmacists can play an important role in improving the prescription and overall patient outcomes through the completion of MTM.5,6 However, a recent study showed that
https://doi.org/10.1016/j.japh.2019.12.015 1544-3191/Published by Elsevier Inc. on behalf of the American Pharmacists Association.
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Key Points Background: Many patients who are eligible for statin treatment are not on an appropriate therapy. Attempts to contact primary providers to start statin treatment in indicated patients have been lacking. Findings: The ability of community pharmacists to prescribe statin medications has the potential to reduce this care gap.
pharmacists must contact, on average, 9 providers for every 1 new statin prescription issued and that, on average, a total of 13 provider contacts are needed to ultimately dispense 1 new statin medication.4 Patients who are indicated to receive a statin based on guideline recommendations are often not prescribed one. A study that evaluated pharmacist-identified gaps in diabetes management found that of the 420 patients screened, 122 (29%) and 106 (25%) patients who needed highand moderate-intensity statins, respectively, had not received a prescription.7 Independent prescribing of statins by pharmacists has the potential to improve these gaps in care. To address this care gap, Idaho pharmacy laws and administrative rules were updated in July 2018 to allow all pharmacists licensed in Idaho to independently prescribe statin medications to eligible patients. Before the official rule activation, community pharmacies, such as Albertsons, were permitted by the Idaho State Board of Pharmacy to begin a pilot statin-prescribing service, mirroring the policies set forth in the updated law and administrative rules. Albertsons’ pilot service began identifying and engaging eligible patients starting in May 2018, 3 months before the official state laws took effect. The original iteration of Idaho law did not explicitly name drugs or drug devices eligible to be independently prescribed by pharmacists.8 The Idaho State Board of Pharmacy supplemented the rule with prescribing protocols written in formal meetings that were open to public input. Drugs with protocols approved and published by the Board of Pharmacy eligible to be prescribed independently by pharmacists included the following: treatment and short-term prevention of cold sores, treatment of uncomplicated urinary tract infections (UTIs), short-acting beta agonists for patients with asthma, seasonal influenza prophylaxis and treatment, Group A streptococcal pharyngitis treatment, and statin medications for patients with diabetes. Albertsons Companies began by piloting services for cold sores, uncomplicated UTIs, and statins. The emphasis on improving statin prescribing for patients with diabetes was the result of the Centers for Medicare and Medicaid Services’ (CMS) value-based purchasing initiatives to match guideline treatment recommendations. Statins have been demonstrated to reduce morbidity and mortality from stroke and heart attack, particularly in patients with diabetes.9,10 The most current guidelines at the time of this study, the 2017 American Diabetes Association Standards of Medical Care in Diabetes Guideline and the 2013 American College of
2
Cardiology/American Heart Association (ACC/AHA) Cholesterol Guideline, agree that all patients with diabetes, despite their cholesterol levels, should be recommended at least moderate-intensity statin therapy. Patients with a higher atherosclerotic risk factor score qualify for high-intensity statin therapy.11,12 Furthermore, the addition of “statin use in persons with diabetes (SUPD)” to Medicare Part D quality measures in 2018 provided an additional rationale for new legislation and incentive for pharmacists to offer independent statinprescribing services. Community pharmacists often interact with patients on a more frequent basis than primary providers, and they have access to the medication and refill history of patients.13 In addition, pharmacists are widely considered to be an integral part of the health care team and are trained experts in managing complicated medication profiles.14-17 Moreover, pharmacists can assist health plans aimed at meeting quality measures by closing the gap in care for patients with diabetes through appropriate statin prescriptions. Assurance that patients are prescribed and adherent to appropriate-intensity statins could also help improve physician-specific treatment metrics, such as CMS’s Medicare Access and Chip Reauthorization Act and Merit-Based Incentive Payment System, which have important ties to billable services and reimbursement. The statin-prescribing service at Albertsons Companies was aimed at (1) identifying patients with diabetes who had indications for treatment but were not yet prescribed statin therapy, (2) having a trained pharmacist screen each identified patient for statin initiation criteria, and (3) prescribing a moderate-intensity statin after eligibility was established. This prescribing service intended to close the care gap for patients in need of statin treatment as per guideline recommendations.
Objectives The objectives of this study were to describe the development and measure patients’ perceptions of an independent pharmacist-prescribed statin service and identify reasons why patients were not prescribed statin therapy when indicated at the time of pharmacist consultation.
Setting and participants Pilot locations The pilot prescribing service was initiated in 4 Albertsons community pharmacies located in Boise, Nampa, Caldwell, and Emmett (Idaho). The pilot stores were selected in part because they serviced the highest number of eligible patients as identified by Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPP), a quality improvement program capable of tracking CMS star measures. At the start of the pilot, Boise, the state’s capital, had a population approaching a quarter million, whereas Nampa and Caldwell, larger suburbs of Boise, had populations of approximately 100,000 and 50,000, respectively. Emmett, a rural farming town located 30 miles outside of Boise, had about 7000 people at the start of the service. Idaho is in the bottom 25% with regard to the prevalence of diabetes (8.1% of the population) in the country;
SCIENCE AND PRACTICE Pharmacist prescribing of statins for diabetes
however, Canyon County, home to Nampa and Caldwell, is closer to the national average at 9.2%.18 Training and service initiation All 11 pharmacists working full-time in the pilot pharmacies completed internal company training to provide the statinprescribing service. Undistributed (float) pharmacists (n ¼ 6) expected to staff the pilot pharmacies during the pilot period (May 2018 to July 2018) also completed training. Training included (1) studying the Idaho State Board of Pharmacy statinprescribing protocol and the company’s statin-prescribing service outline and (2) completing a practice fingerstick blood test used to check patients’ alanine aminotransferase (ALT) values. Albertsons created a document called the statin prescribing service outline for trainees to review and discuss with trainers. The document discussed all aspects of statin prescription, including guideline recommendations, required monitoring, and statin class characteristics. Pharmacists scheduled patients for appointments over the phone and trained all pilot certified pharmacy technicians (CPhTs) to alert pharmacists when eligible patients returned calls about participating in the service. Unsuccessful attempts to reach patients by phone were recorded on an Excel spreadsheet so that 3 contact attempts could be tracked. Pharmacists also left medication profile notes and written messages on medication bags to be picked up, if applicable, to best ensure that contact was made. Recruitment EQuIPP was used to identify eligible patients for the service. Using the SUPD measure, EQuIPP identified patients with a diagnosis of diabetes with no current billed prescription claim for a statin medication. These potentially eligible patients were then contacted by their local pharmacy to discuss the prescribing service and confirm their eligibility. Patient eligibility Eligible patients included those who had a current diagnosis of type 2 diabetes, were aged between 40 and 75 years, and were currently taking medication(s) to manage their diabetes. Patients who were ineligible for the service included those who reported a history of statin intolerance or who were contraindicated to statin treatment, such as patients with active liver disease, unexplained ALT elevation at or more than 3 times above the upper limit of normal reference range, pregnant (or intending to become pregnant) or breastfeeding women, a history of statin-induced rhabdomyolysis, on hemodialysis or peritoneal dialysis, New York Heart Association class II-IV ischemic systolic heart failure, or a history of cognitive impairment. Eligibility was determined using clinical guidelines such as the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults; the 2017 American Diabetes Association Standards of Medical Care in Diabetes; the National Heart, Lung, and Blood Institute guidelines; and statin package inserts from manufacturers. These resources also guided the monitoring and follow-up policies of the service. Before contacting any patient, pharmacists first conducted a medication review to identify suspected contraindications or
potential drug interactions. Patients’ self-reports were used to confirm or deny contraindications. Confirmation of a diagnosis of diabetes was required from either the patients’ or their health care provider. Patients with diabetes other than type 2 (e.g., prediabetes, gestational, type 1) were excluded.
Practice innovation Potentially eligible patients identified by EQuIPP were contacted by their community pharmacist (a postgraduate year-1 community pharmacy resident) after a medication profile review to discuss statin use. Patients were called a total of 3 times, typically no more than once per week, at their listed primary phone number. When it was possible to leave a voicemail, a request was made for the patient to call the pharmacy. Patients who could not be contacted after 3 attempts had notes placed with their filled prescriptions and technicians were trained to request a pharmacist’s consult on the receipt of the written note. When the pharmacist was able to contact the patient, whether it was over the phone or in person, the pharmacist discussed the reason for the statin indication and the prescribing process. Interested patients were then scheduled for an appointment with the pharmacist at the pilot pharmacy or, if time permitting, completed the appointment immediately. Reasons for ineligibility or refusal were documented. Pharmacists began consultations by completing an intake form to further establish eligibility. The intake form gathered basic contact information and primary care provider information and asked questions specific to the history of statin treatment. Patients were also asked if they had ever received a diagnosis of type 2 diabetes, if they were currently takingmedication(s)totreatdiabetes,and severalmorequestions to rule out contraindications. After patients were deemed eligible, they were asked to consent to a fingerstick test to ensure that their ALT level was not elevated. This blood test was completed in accordance with the National Heart, Lung, and Blood Institute guidelines recommendation that ALT be checked at baseline when initiating statin treatment.12 Albertsons determined that the most cost-effective way to measure ALT was through a contract with an off-site laboratory and mailing of patients’ samples. The device provided by the laboratory collected 100 mL of blood using a lancet and pipette or the hanging blood drop approach. The device containing the blood sample was mailed and processed, and the result was available within 3 to 5 business days. Statin-prescribing decisions were made once the ALT result was received and evaluated by the pharmacist. Pharmacists were prepared to refer patients in the setting of an elevated ALT result. After the receipt of an ALT value within normal reference range, patients returned to the pilot pharmacy where pharmacists prescribed, processed, and dispensed an appropriate statin with up to 12 months of refills. ACC/AHA guidelines recommend statin therapy for eligible patients with diabetes even with normal cholesterol levels; therefore, low-density lipoprotein (LDL) was not assessed at baseline. Patients were prescribed the lowest moderate-intensity statin dose that was compatible with all other relevant health information collected. Although many patients eligible for the service may have been indicated for a high-intensity statin, this pilot sought to establish statin tolerance, and 3
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further patient assessment to determine overall atherosclerotic cardiovascular disease (ASCVD) risk was not sought; this was done to contain the overall cost of the service. Patientspecific factors such as drug-drug interactions, grapefruit consumption, kidney function, morning versus evening dosing preference, affordability, and fear of muscle pain were also taken into account in choosing the most appropriate statin for each patient. The most appropriate and cost-effective statin was selected, without any regard to reimbursement to the pharmacy. The prescribed statins were filled at the pharmacy and billed to the patient's prescription insurance company using the prescribing pharmacist’s individual National Provider Identifier without incident. At the time of dispensing, pharmacists delivered their regular counseling to patients taking statin therapy for the first time, including an in-depth review of the statin’s indication, its benefits, how to take the medication, and monitoring and potential adverse effects. After a statin was prescribed and dispensed, the primary care provider (or when the patient did not have a primary care provider, the provider of record responsible for the diabetes medications) was notified within 24 hours of the newly issued prescription. If the prescribing service resulted in a prescription, a nominal fee was assessed to the patient. This fee covered all costs associated with the pharmacist’s time and ALT test. Prescribing pharmacists followed up with patients 4 weeks after the initial prescription through a face-to-face visit or phone call to assess tolerance and adherence and to address any questions or concerns from patients. LDL was not assessed as part of the 4-week follow-up visit. ALT would only be reassessed if patients displayed any signs or symptoms of liver injury, such as yellowing of the skin or eyes, upper right quadrant pain, or vomiting.19 An electronic record of the handwritten prescription was kept on file as per the requirements of the State. Of note, if the
Contact paent to further determine eligibility
prescription needed to be transferred, all applicable transfer laws with regard to noncontrolled medications applied. Figure 1 presents the workflow process. Survey design Patients who completed the intake process and received the ALT test were asked to complete a written 7-question survey (Appendix 1) regarding their perceptions of the service. This survey asked for demographic information; patients’ history with statins, if applicable; their comfort with the pharmacists’ recommendations; and their perceptions of the pharmacists’ communication. Patients who completed the survey were incentivized with a 10%-off grocery coupon as a token of appreciation for their time. Patients who were screened but did not move forward with the service did not complete the survey. A total of 60 patients were ineligible, declined service, or were lost to follow-up (Figure 2). Evaluation Of the 64 patients who were identified as eligible for statin therapy by EQuIPP, 21 (33%) had contraindications for statins, 17 (27%) could not be contacted, and 12 (19%) refused (Figure 2). Of the 6 (9%) patients who agreed to the service, 4 (66.7%) successfully received a statin medication. Of the 4 patients who were successfully started on statin treatment, 2 were pharmacist prescribed. The other 2 patients were recommended a statin by their pharmacist but ultimately solicited a prescription from their primary care provider because of a delay in the ALT results. The demographic data for these patients are detailed in Table 1. The inability to contact patients directly (n ¼ 17) was the main reason that patients were not further evaluated for statin eligibility. Another major reason for the inability to prescribe
Complete intake form & perform POCT - ALT for paents meeng inclusion criteria with no contraindicaons
Evaluate ALT value. Refer when elevated, connue service when normal
Prescribe, counsel & dispense appropriate stan. Follow up in 4 weeks.
Eligibility screening (EQuIPP + medicaon profile review) Figure 1. Statin service workflow. Abbreviations used: ALT, alanine aminotransferase; EQuIPP, Electronic Quality Improvement Platform for Plans and Pharmacies; POCT, point-of-care testing.
4
SCIENCE AND PRACTICE Pharmacist prescribing of statins for diabetes
64 paents idenfied
58 did not complete the service
6 agreed to the service
2 were prescribed a stan by the PharmD
2 were prescribed a stan by another medical provider
2 were lost to follow-up
21 were contraindicated
17 were unable to be contacted
12 paents refused
8 already had a stan
Figure 2. Statin eligibility and service completion.
was previous intolerance or contraindication (n ¼ 21) to statins reported by the patients. Most patients who noted intolerance could not recall the specific symptoms. Of the 12 patients who refused the service, one stated that they “wanted all treatment decisions to go through their primary care provider” and another stated that “they did not understand the purpose of a statin and had no interest in starting one.” The remaining refusals simply stated “I do not think I need the medication.” In other words, the patients questioned the benefit of the treatment. Motivational interviewing techniques were used to prompt the patients to reconsider. All 4 patients who successfully started statin treatment completed a survey at the end of the service provision. These 4 patients had never taken a statin because they had cholesterol values within the normal reference range and agreed on the following statements: My pharmacist explained the proper use of the medication, including adverse effects and what to do if they occur. I feel comfortable with my pharmacist’s recommendation of starting statin therapy. My pharmacist described the reasons why statin therapy is recommended for me. I feel my pharmacist was able to adequately answer all of my questions. I would recommend this pharmacy service to an eligible family member or friend with diabetes.
Discussion No previous study has examined the development and patients’ perceptions of pharmacists independently prescribing statins. In our study, patients were comfortable with their Table 1 Demographic information of patients who were prescribed statins Demographic Sex Age (y) Income ($) Education Race Ethnicity
Patient response (n) Female (1); male (3) 51e55 (1); 56e60 (3) 20,000e34,999 (3); 35,000e49,999 (1) High school or GED (3); undergraduate (1) White or Caucasian (3); Hispanic or Latino (1) Not Hispanic or Latino (3); Hispanic or Latino (1)
Abbreviation used: GED, General Educational Development.
pharmacist in a prescriptive role. Studies have demonstrated positive patient perceptions of pharmacist services such as community pharmacyebased services,20 pharmacist-led diabetes management services,21 and pharmacist-provided Medicare annual wellness visits.22 Previous studies into independent pharmacist prescribing have shown similar positive patient perceptions. For example, a study on the public perception of community pharmacisteprescribed nonemergency hormonal contraception showed “generally positive” viewpoints because of increased health care access, avoidance of inadvertent pregnancies, and more freedom to women for obtaining the medications. However, this same study reported patients’ concerns regarding the safety and logistics of offering the service in a community setting.23 Similarly, medical organizations have opposed independent pharmacist prescribing, claiming that pharmacists are unqualified, will cause harm to patients, and that pharmacists do not have the proper information available to prescribe, such as a patient chart.24 This service could be expanded in several ways. The pilot service used a single patient identification resource (EQuIPP) and 4 pilot stores to identify potentially eligible patients. With expansion of the service, more MTM platforms can be used to identify patients with diabetes who need a statin. Screening during the dispensing workflow can also identify eligible patients. Additional marketing of expanded pharmacy services will bring new patients. In addition, many patients were excluded from the service based on reported previous intolerance to statins. Reattempting statin treatment in those with reported intolerances may be a future opportunity for the prescribing service. Challenging patients who are intolerant to 1 statin is consistent with guideline recommendations and could be possible for a pharmacist with access to a patient chart.12,14 An inability to directly contact patients was the largest barrier to initiating patient screening. This was more of an issue when the screening took place outside of standard workflow, as it often did during the pilot phase. With workflow-based screening (nonappointment), the communication was easier to establish with the patient and may have been more effective than phone-based interactions. Pharmacists provide better patient care when complete medical history is available for review, such as in an electronic health record.25-27 Many community pharmacists in Idaho do not have access to a patient’s medical record. Had an electronic medical record been available during the pilot phase of this
5
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service, prescribing pharmacists could have calculated an ASCVD risk score and distinguished between the need for moderate- versus high-intensity statin treatment, a limitation of the service. In the future, a greater emphasis could be placed on contacting providers’ offices to gather more details on intolerance and to explore other treatment options for patients who report intolerance. Although not directly measured, the pharmacists were enthusiastic about using their clinical training and taking advantage of their newfound prescriptive authority. They were also pleased to see patients react positively to participating in the service. Concerns and suggestions for improvement from the pharmacists were centered on time available to complete the service and making the service affordable. During the pilot phase, a postgraduate year-1 community-based pharmacy resident was responsible for contacting patients, describing the service, setting up appointments, and completing the consultations. The resident was an “extra” worker in the pharmacy so time constraints and workflow stoppage could not be truly experienced. Each consultation took roughly 20 minutes, which could be quite burdensome in the middle of a busy day. Most of the time was spent answering the patients’ questions and describing the background information on statins, diabetes, guideline recommendations, and in the case of the first 2 patients, why their primary care provider did not prescribe a statin earlier and why the pharmacist was able to do so. Pharmacists can save time by training CPhTs to assist the patient in not only filling out the intake form independently but also in completing the ALT test. The cost of the service was an explicitly mentioned barrier for some patients who refused the service for this reason. Charging patients out of pocket for the pharmacist’s time and the supplies used in the screening process will likely continue to serve as a barrier for patients in the future. Despite charging a fee for the service, patients may use it for the sake of convenience and for the fact that they trust the professional consultation of their pharmacist. However, to ensure that the program is sustainable, third-party reimbursement would likely be necessary. Future studies should look at the success of this expanded service in addition to the success of pharmacist-prescribed statins in other settings. Of particular interest would be settings with immediate access to electronic medical records, which would allow for full ASCVD risk assessment, and those with more robust laboratory services, which would allow for easier monitoring and titration. Two of 4 patients who agreed to complete the prescribing service requested a statin prescription from their primary care provider while awaiting the return of the mail-away ALT test result. If a device that could give an immediate result had been used, the pharmacist would have prescribed these 2 patients their medications. The mail-away option also requires patients to return to the pharmacy on a separate day to pick up their prescription, providing another chance to lose patients to follow-up. Newer guideline recommendations should also be considered, as there have been numerous updates published after this research concluded.
Conclusion This pilot was the first example of community pharmacists independently prescribing statins without the need for a 6
collaborative practice agreement or other medical provider oversight to patients outside of the clinic setting. The service could target an important health initiative.
References 1. Ourth H, Groppi J, Morreale AP, Quicci-Roberts K. Clinical pharmacist prescribing activities in the Veterans Health Administration. Am J Health Syst Pharm. 2016;73(18):1406e1415. 2. Merten JA, Shapiro JF, Gulbis AM, et al. Utilization of collaborative practice agreements between physicians and pharmacists as a mechanism to increase capacity to care for hematopoietic stem cell transplant recipients. Biol Blood Marrow Transplant. 2013;19(4):509e518. 3. Villeneuve J, Lamarre D, Lussier MT, et al. Physician-pharmacist collaborative care for dyslipidemia patients: knowledge and skills of community pharmacists. J Contin Educ Health Prof. 2009;29(4):201e208. 4. Renner HM, Hollar A, Stolpe SF, Marciniak MW. Pharmacist-to-prescriber intervention to close therapeutic gaps for statin use in patients with diabetes: a randomized controlled trial. J Am Pharm Assoc (2003). 2017;57(3S):S236eS242.e1. 5. Holland R, Desborough J, Goodyer L, Hall S, Wright D, Loke YK. Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. Br J Clin Pharmacol. 2008;65(3):303e316. 6. Lowrie R, Mair FS, Greenlaw N, et al. Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction. Eur Heart J. 2012;33(3):314e324. 7. Moczygemba LR, Bhathena S, DiPiro CV, Snead R. Pharmacist documentation of gaps in care identified during diabetes coaching. J Am Pharm Assoc (2003). 2019;59(1):57e63. 8. Idaho Board of Pharmacy. Law book with Idaho pharmacy code & administrative rules. Available at: https://bop.idaho.gov/wp-content/ uploads/sites/99/code_rules/2018-07-02_2018_IDBOP_LawBook.pdf. Accessed September 13, 2018. 9. Brunner NW, Ramanathan K, Wang H, Quan H, Khan NA. Effectiveness of statin prescribing on reducing mortality in South Asian, Chinese, and White patients with diabetes. Can J Cardiol. 2013;29(8):920e926. 10. Wang W, Zhang B. Statins for the prevention of stroke: a meta-analysis of randomized controlled trials. PLoS One. 2014;9(3):e92388. 11. Marathe PH, Gao HX, Close KL. American Diabetes Association standards of medical care in diabetes 2017. J Diabetes. 2017;9(4):320e324. 12. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2889e2934. 13. Maningat P, Gordon BR, Breslow JL. How do we improve patient compliance and adherence to long-term statin therapy? Curr Atheroscler Rep. 2013;15(1):291. 14. American Diabetes Association. Standards of medical care in diabetesd2012. Diabetes Care. 2012;35(suppl 1):S11eS63. 15. Nkansah N, Mostovetsky O, Yu C, et al. Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Data Syst Rev. 2010;7:CD000336. 16. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10):923e933. 17. Michot P, Catala O, Supper I, et al. Cooperation between general practitioners and pharmacists: a systematic review. Sante Publique. 2013;25(3):331e341. 18. Centers for Disease Control and Prevention. Diabetes: Data and Statistics. Atlanta, GA: Centers for Disease Control and Prevention; 2019. 19. DiPiro CV, Schwinghammer TL, DiPiro JT, Wells BG. Pharmacotherapy Handbook. New York, NY: McGraw-Hill; 2017. 20. Ekenga V, Bailey-Wheeler J, Hart T, Sarpong D, Earls M. Patients’ perception of community pharmacists as healthcare providers and willingness to participate in pharmacist services: a pilot study. J Pharm Health Serv Res. 2018;9(4):297e300. 21. Siaw MYL, Toh JH, Lee JY. Patients’ perceptions of pharmacist-managed diabetes services in the ambulatory care and community settings within Singapore. Int J Clin Pharm. 2018;40(2):403e411. 22. Sherrill CH, Cavanaugh J, Shilliday BB. Patient satisfaction with Medicare annual wellness visits administered by a clinical pharmacist practitioner. J Manag Care Spec Pharm. 2017;23(11):1125e1129. 23. Irwin AN, Stewart OC, Nguyen VQ, Bzowyckyj AS. Public perception of pharmacist-prescribed self-administered non-emergency hormonal contraception: an analysis of online social discourse. Res Social Adm Pharm. 2019;15(6):650e655.
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24. Pojskic N, MacKeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists. Res Social Adm Pharm. 2014;10(2): 341e354. 25. Weddle SC, Rowe AS, Jeter JW, Renwick RC, Chamberlin SM, Franks AS. Assessment of clinical pharmacy interventions to reduce outpatient use of high-risk medications in the elderly. J Manag Care Spec Pharm. 2017;23(5):520e524. 26. Hensler D, Richardson CL, Brown J, et al. Impact of electronic health record-based, pharmacist-driven valganciclovir dose optimization in solid organ transplant recipients. Transpl Infect Dis. 2018;20(2): e12849. 27. Polen CB, Judd WR, Ratliff PD, King GS. Impact of real-time notification of Clostridium difficile test results and early initiation of effective antimicrobial therapy. Am J Infect Control. 2018;46(5):538e541.
Nathan Spann, PharmD, Clinical Assistant Professor, College of Pharmacy, Idaho State University, Meridian, ID Jeffrey Hamper, PharmD, BCACP, Manager, Academic Relations, Albertsons Companies, Boise, ID Robert Griffith, PharmD, Pharmacy Manager and Residency Preceptor, Albertsons Companies, Boise, ID Kevin Cleveland, PharmD, ANP, Assistant Dean and Associate Professor, College of Pharmacy, Idaho State University, Meridian, ID Timothy Flynn, PharmD, Patient Care Pharmacist and Residency Program Director, Albertsons Companies, Boise, ID Katie Jindrich, PharmD, Residency Program Coordinator, Albertsons Companies, Boise, ID
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Appendix 1. 7-Question Statin Satisfaction Survey Statin Prescription Satisfaction Survey I am starting my pharmacist prescribed statin (cholesterollowering) medication today. , Yes , No If no, skip questions 1 and 2. 1. My pharmacist explained the proper use of the medication, including side effects and what to do if they occur. , Agree , Disagree 2. Before receiving a statin medication from my pharmacist, I was not taking one because: , My provider recommended one but I did not want to take it at the time. , My provider recommended one but I could not afford it. , My provider did not recommend one for me to the best of my knowledge. , My provider did not recommend one to me because my cholesterol levels were normal. , I had either a contraindication to treatment, a prior allergic reaction or I did not tolerate the medication. , I do not / did not have a primary care provider to recommend one to me. , Other: ___________________________________________ 3. I feel comfortable with my pharmacist’s recommendation of starting statin therapy. , Agree , Disagree 4. My pharmacist described the reasons why statin therapy is recommended for me. , Agree , Disagree 5. I feel my pharmacist was able to adequately answer all of my questions. , Agree , Disagree 6. I would recommend this pharmacy service to an eligible family member or friend with diabetes. , Agree , Disagree If you disagree with any of the above items, please indicate why: ________________________________________________
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7. Which of the following applies to you? Check all that apply. , I have not taken a statin medication before. , I have tried a statin medication in the past but stopped due to side effects. , I have tried a statin medication in the past but stopped due to cost, inconvenience, or forgetfulness. , I have tried a statin medication in the past but stopped because it was deemed no longer medically necessary by my provider. , I have tried a statin medication in the past but stopped because I believed it was no longer medically necessary. , Other: ___________________________________________. Demographic information Gender , Female , Male Age group , 40 e 45 , 46 e 50 , 51 e 55 , 56 e 60 , 61 e 65 , 66 e 70 , 71 e 75 Income , < $20,000 , $20,000 - $34,999 , $35,000 - $49,999 , $50,000 - $74,999 , $75,000 - $99,999 , $100,000 or more Education , Part high school , High school / GED , Undergrad college , Graduate / professional Employment , Full-time , Part-time , Seasonal , Volunteer , Retired , Unemployed Race , Asian / Pacific Islander , Hispanic / Latino , Black / African American , American Indian / Native American , White / Caucasian , Other: _________________________ Ethnicity , Hispanic or Latino , Not Hispanic / Latino , Other Thank you very much for completing this survey. Please enjoy this 10% off grocery coupon as a sign of appreciation for your time and effort.