Kristen Coppock, MA

Could pharmacist-led medication reconciliation improve inpatient continuity of care in individuals with HIV? Researchers at a California medical center are seeking to find out.

In a 2-part study, a research team with Desert Regional Medical Center (DRMC) in Corona, CA is analyzing the need for pharmacist intervention for patients with HIV. The goal of the study is to ultimately find a way to improve continuity of care for these individuals at a higher rate than what the center currently sees.

“We have a lot of HIV-positive patients,” said primary author Vi Thai, PharmD, a PGY1 pharmacy resident at DRMC. "Thirty-eight percent did not continue the regimen when they could have."

Thai presented the study Wednesday in a poster session at the 2018 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in Anaheim, CA. She said medication adherence is extremely important to patients with HIV, since the virus can become drug-resistant when there are changes in the regimen.

According to researchers, there are more than 5,500 individuals with HIV/AIDS in DRMC’s Riverside County and more than half of those patients are residing in the Coachella Valley that the health system serves.

Researchers are utilizing retrospective medication reconciliation data of patients with HIV who were admitted to DRMC, from July 2017 through July 2018, to determine a possible need for pharmacist intervention. These patients are defined as having an International Classification of Diseases (ICD-10) diagnosis of HIV documented from their inpatient stay and were admitted from home, according to researchers.

According to an analysis of the retrospective data, Thai said, the researchers found that 38% of HIV-positive patients that had been admitted to DRMC were considered ‘fallouts.’ Another 51% of HIV-positive patients continued their regimens at home, and the remainder had provider support for not having a home regimen. 

In an effort to increase the number of those continuing their medications at home, admittance of HIV-positive patients to the general medicine units at DRMC will trigger an automatic pharmacy consult, during the study period from November 2018 to March 2019. A pharmacy resident or a student trained in medication reconciliation will be tasked with gathering patient information through insurance claims, outpatient pharmacies, and patient or caregiver interviews.

Using this newly collected data, the researchers will compare the continued home use of HIV medication in the group who received pharmacist-led consultation compared with the retrospective group.

Pharmacist Intervention and Continued HIV Care: Examining the Connection

," originally appeared on PharmacyTimes.com.

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Could pharmacist-led medication reconciliation improve inpatient continuity of care in individuals with HIV?

As of September 2018, there were 139 new national drug shortages during this year alone, and a total of 238 overall, according to University of Utah (UA) Drug Information Service data. 

"It’s a lot,”  Erin R. Fox, PharmD, BCPS, FASHP, Senior Director for Drug Information and Support Services at UA Health, told an audience at a satellite symposium at the 2018 American Society of Health-Systems Pharmacists (ASHP) Midyear Clinical Meeting in Anaheim, CA, this week. The session, which was supported by an educational grant from Baxter Healthcare Corporation, centered on best practices pharmacists can utilize to respond to ongoing drug shortage issues.

Drug shortages have a tremendous impact on the health care system; in the United States, $209 million was spent in 2013 for the purchase of more expensive substitutes, according to ASHP estimates. That estimate does not include other significant costs, such as the added labor required to identify available alternative products and to ensure operational changes to accommodate the product changes.

Data from the Drug Information Service, which provides drug shortage content to ASHP, show the top 5 drug classes with active shortages on September 30, 2018 were antimicrobials, chemotherapy products, cardiovascular and central nervous system medications, and E-lytes, nutrition and fluids. The data presented by Fox showed that many of these active shortages were injectable, including 34 of the 36 items in the E-Lytes, nutrition and fluids category.

In her presentation, Fox said some of most basic products required for patient care are often subject to shortage. She noted bupivacaine, lidocaine, hydromorphone, morphine, fentanyl, ketamine, ondansetron, saline, and sterile water as examples.

Many drug shortages have been related to quality issues at manufacturing facilities, Fox said. While most factories are running at capacity, some also are utilizing aging facilities or producing medications ‘just in time.’ In addition, business decisions impact drug availability, she explained.

“Over the years, manufacturing has become more lean,” said Fox. “It’s expensive to add manufacturing lines, and it takes time. It may not be worth the money to keep those factories up to date.”

Meanwhile, a lack of transparency can pose a problem for ensuring quality, Fox told the audience. Often, companies hire other companies to make their products, and "they just put a label on it,” said Fox.

For injectables, there is also is a fragile supply chain to consider, Fox said. Often, a single firm is producing 90% of the total supply and it is common for that firm to have a sole source of raw materials, she added. Competition for manufacturing these drugs is low, especially when companies consider a low return on investment for certain products.

During her presentation, Fox acknowledged challenges pharmacists face with drug shortages, but said the goal of these health care professionals should be to minimize the impact of drug shortages on patients. These shortages may be not be seen by other professionals on a patient’s health care team, she emphasized, so it is imperative that pharmacists take on this role.

Citing ASHP Guidelines on Managing Drug Product Shortages, which she developed, Fox said a key strategy for pharmacists is to plan for drug availability challenges. “Do as much work ahead as you can,” said Fox. “If you can be well-prepared and make your checklist, you’re already ahead of the game."

Planning ahead includes having a team in place, assessing operational and therapeutic needs, conducting impact analysis, and devising an action plan, Fox said. Having that plan in place extends to disaster response, such as preparedness and recovery.

Gathering data and monitoring a shortage and maintaining contact with local representatives of the manufacturer are part of the pharmacy team's work to mitigate the impact of less drug availability, Fox said. Making decisions for purchasing and rationing drugs; storing, preparing and dispensing these products; and communicating the information to patients also are crucial for managing a drug shortage.

In situations when there is not enough product, Fox urged pharmacists not to ration alone and suggested having a resource allocation committee in place to make those decisions. “There might be days where you lose your entire supply. You have to have a plan for dealing with that,” she said.

Overall, coping with drug shortages comes down to communication. Every team member should know his or her role and be proactive in sharing that information.

Pharmacists Play a Role in Responding to Drug Shortages

Keeping communities safe from potentially deadly viruses is everyone’s responsibility, and vaccination is crucial to protecting people from the flu, pneumococcal pneumonia, and other preventable conditions, according to the National Foundation for Infectious Diseases (NFID).

 This week marks the start of the 2018-2019 flu season.

On behalf of the NFID, a panel of health care experts spoke at a live event in Washington, DC, about the importance of immunization against 

. “We should all know by now that the flu is unpredictable. I predict there will be a flu season,” said William Schaffner, MD, an NFID board member and medical director at Vanderbilt University School of Medicine. “Vaccination will make it less likely that you spread the virus to others. No one wants to be the ‘dreaded spreader.’ ”

In the United States, about 80,000 deaths and 900,000 hospitalizations reported to the US Centers for Disease Control and Prevention (CDC) during the 2017-2018 flu season were attributed to the influenza virus and related complications such as heart attack and stroke.

 The majority of those deaths occurred in patients aged 65 years and older.

“Last year, more than 90% of adults hospitalized with influenza had an underlying condition that placed them at high risk,” said Dr. Schaffner during the live event. "Flu can exacerbate chronic conditions."

Chronic conditions, such as asthma, heart disease, obesity, and HIV, all can contribute to more severe reactions to the influenza virus. Patients who have had their spleen removed, those with inner ear implants, and smokers also face higher risks, Dr. Schaffner said.

In a separate, prepared statement, US Food and Drug Administration (FDA) Commissioner Scott Gottlieb said that a seasonal flu vaccine is one of the most effective and safest ways to protect self, family, and community from the flu and serious flu-related complications.

"Flu vaccines work by preparing the body’s immune system when exposed to multiple strains of influenza viruses circulating during the influenza season. When a person gets vaccinated, their body’s immune system is able to recognize and respond to a future exposure of the disease-causing agent to prevent that disease," Gottlieb stated.

Among the flu-related deaths last year were 180 children

, about half of whom had underlying chronic conditions that put them at higher risk for serious cases of influenza. According to US Surgeon General Jerome M. Adams, MD, MPH, most of the children who died from influenza last year were unvaccinated.  “As a father of 3 young children, this hits me hard,” Dr. Adams added. “One flu death is too many.”

According to the NFID, the vaccination rate among children slightly declined, from 59% in 2016-2017 to 57.9% in 2017-2018, and falls well below the national public health goal of 80%. Vaccination was highest in 2017-2018 among children aged 6 months to 4 years, at 67.8%, but this group’s rate fell 2.2% from the previous year, which poses a concern to the organization.

Pediatrician Wendy Sue Swanson, MD, MBE, chief of digital innovation and digital health at Seattle Children’s Hospital, said parents can utilize regular check-ups with a doctor to have their children vaccinated. She recommended children receive influenza immunization as soon as possible.

“Kids have a lot of snot, and a lot of drool, and they go to school. When they go to school, they share those secretions,” said Dr. Swanson, a mother to 2 boys. “One hundred-eighty families put a child in a grave last year because of a preventable virus.”

Immunization also is crucial to pregnant women, another population group at higher risk for serious cases of influenza. According to Laura E. Riley, MD, a Given Foundation professor and chair of the department of obstetrics and gynecology at Weil Cornell Medicine, a woman’s immune system changes when she becomes pregnant, and her lung function decreases as the pregnancy advances, which both make her more vulnerable to a viral illness.

“In every (flu) epidemic, we’ve seen that as you get into the second and third trimesters, you’re more likely to die or end up hospitalized,” said Dr. Riley. 

Women with influenza tend to deliver their babies prematurely, Dr. Riley added, which can result in lifelong complications for the child. In addition, influenza-related fever in a pregnant woman can cause birth defects, she added. On the other hand, vaccinations administered to pregnant women cross into the placenta, providing virus protection to mothers and their babies that lasts for months following birth.

“There is a huge protection here,” Dr. Riley said. “We’re protecting women from death. We’re protecting women from hospitalization. We’re protecting babies from prematurity.”

The influenza vaccine is available as an injection or nasal spray this year. In addition to doctor visits, health care experts said vaccinations are being administered in pharmacies, hospitals, and clinics, as well as in many workplaces, provided by employers.

Officials with the NFID emphasized that everyone aged 6 months and older should receive an influenza vaccine. In addition, other preventive measures can be taken to avoid getting the virus or passing it on to others, such as the “3 Cs”: Keeping hands clean, covering coughs and sneezes, and containing the virus. “If you’re sick, stay home,” said Dr. Adams. “If you think you have the flu, go to your doctor.”

Dr. Riley noted that many individuals don’t realize how sick the flu can make a person. “It’s a really nasty virus. That’s the message that needs to get out,” she said.

Health care experts also urged patients aged 65 years and older to get the pneumococcal virus vaccine. According to the NFID, pneumococcal disease most often causes pneumonia and can lead to sepsis, a common complication of influenza. Patients with underlying conditions are at higher risk for hospitalization or death from pneumococcal disease.

“Influenza and pneumococcal vaccination are an important part of managing chronic diseases,” said Dr. Schaffner in a prepared statement.

 “By getting vaccinated against flu and pneumococcal disease, we can all do our part to stay healthy and interrupt the spread of these serious diseases.”

This article was originally published as, “

NFID: More Vaccinations Needed to Better Protect Families and Communities

Influenza and Pneumococcal disease can be serious, health officials urge vaccination [news release]. Washington, DC; September 27, 2018: NFID website. http://www.nfid.org/newsroom/news-conferences/2018-nfid-influenza-pneumococcal-news-conference/press-release.pdf. Accessed September 27, 2018.

Statement by FDA Commissioner Scott Gottlieb, M.D., on preparations for the upcoming flu season and vaccinations [news release]. Silver Spring, MD; September 27, 2018: FDA website. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm621785.htm. Accessed September 27, 2018.

Keeping communities safe from potentially deadly viruses is everyone’s responsibility.

Kristen Coppock, MA

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