Student Pharmacist Integration in an Ambulatory Service at a Rural Veterans Affairs Clinic
by Anna Lattos, PharmD, Erica Wagner, PharmD, BCACP, Mara Kieser, RPh, Stephanie Gruber, PharmD, BCACP, Edward Portillo, PharmD
Background: Proton pump inhibitors (PPIs) are commonly used for the management of gastroesophageal reflux disease (GERD) and heartburn; prophylaxis and treatment of gastrointestinal (GI) ulcers and bleeds; and in combination with antibiotics for treatment of Helicobacter pylori. 1-2 The Food and Drug Administration (FDA) and the American Gastroenterology Association (AGA) advise short-term length of therapy for these indications.3 However, it has been found that PPI prescriptions are often renewed for long-term therapy without clear or appropriate indications. Risks of long-term PPI use have been described in the literature, such as bone fracture, infection (Clostridium difficile and community acquired pneumonia), and micronutrient deficiencies of calcium, vitamin B12, iron and magnesium, all of which have been shown to affect patient health outcomes; and yet these medications are often overprescribed.1,2,4,7 Therefore, the opportunity exists to explore innovative models to ensure patients on PPIs are appropriately assessed for continued use. The primary objectives of this project were developed to reflect the integration of a student pharmacist into a PPI de-prescribing service. These objectives included (1) the development of tools and resources required to guide the student pharmacist, (2) processes completed by the student pharmacist to achieve service initiatives in a rural setting, and (3) evaluation of clinical pharmacist practitioner (CPP) time saved through incorporating the student pharmacist.
Methods: Tools were developed to pilot the PPI de-prescribing service in September 2019 by a third-year (P3) pharmacy student and reviewed by the CPP. Processes for chart review and phone call outreach were outlined by the CPP using a standardized decision support tool to determine appropriate PPI use. A chart review was performed by the student on 92 patients currently on long-term PPI therapy and receiving care at a rural outpatient clinic affiliated with the William S. Middleton Veterans Affairs (VA) Hospital. Patients were contacted by the P3 student between November 2019 and February 2020 under the supervision of the CPP. Project deliverables included the templates created by the student pharmacist, the use of these tools and other resources to complete service initiatives, and the time saved by the CPP per patient taper trial. The CPP time saved was determined by documenting student and CPP encounter time to complete service initiatives and taking the difference of the average time of these units.
Results: Note templates for this service were developed by the student and revised by the CPP. The student process of performing a baseline chart review demonstrated that 58% (53/92) of patients were on long-term PPI therapy for an inappropriate indication. Of the 9 patients that enrolled in the service, 2 patients completed a PPI taper, 4 patients were still in progress, and 3 patients stopped the taper trial due to return of GERD symptoms. The average time for patients who completed a PPI taper was 8-9 weeks (4-5 encounters). It is estimated that the integration of a student pharmacist in this service saved the pharmacist an average of 45 minutes per taper trial.
Conclusion: This project described and implemented the resources and processes needed to integrate a student pharmacist into the workflow of a PPI de-prescribing service. The project has demonstrated the potential benefit of using a student pharmacist to complete service initiatives in reaching rural patients. Student pharmacist outreach to eligible rural patients with pharmacist oversight provides a unique opportunity to achieve de-prescribing therapy in an effective and efficient manner in the ambulatory care setting. Future directions of this project are to package this service into other pharmacists’ and clinics’ workflows to help reach more patients through pharmacy services while also facilitating student learning.
Keywords: Pharmacists, Proton Pump Inhibitors, Calcium, Clostridioides difficile, Helicobacter pylori, Magnesium, Workflow, Students, Pharmacy, Gastroenterology, Heartburn, Ulcer, United States Food and Drug Administration, Veterans, Pharmaceutical Services, Gastroesophageal Reflux, Prescriptions, Ambulatory Care, Outcome Assessment, Health Care, Ambulatory Care Facilities, Fractures, Bone, Micronutrients, Anti-Bacterial Agents, Vitamin B 12, Pneumonia
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2022 March/April Table of Contents
Background: Proton pump inhibitors (PPIs) are commonly used for the management of gastroesophageal reflux disease (GERD) and heartburn; prophylaxis and treatment of gastrointestinal (GI) ulcers and bleeds; and in combination with antibiotics for treatment of Helicobacter pylori. 1-2 The Food and Drug Administration (FDA) and the American Gastroenterology Association (AGA) advise short-term length of therapy for these indications.3 However, it has been found that PPI prescriptions are often renewed for long-term therapy without clear or appropriate indications. Risks of long-term PPI use have been described in the literature, such as bone fracture, infection (Clostridium difficile and community acquired pneumonia), and micronutrient deficiencies of calcium, vitamin B12, iron and magnesium, all of which have been shown to affect patient health outcomes; and yet these medications are often overprescribed.1,2,4,7 Therefore, the opportunity exists to explore innovative models to ensure patients on PPIs are appropriately assessed for continued use. The primary objectives of this project were developed to reflect the integration of a student pharmacist into a PPI de-prescribing service. These objectives included (1) the development of tools and resources required to guide the student pharmacist, (2) processes completed by the student pharmacist to achieve service initiatives in a rural setting, and (3) evaluation of clinical pharmacist practitioner (CPP) time saved through incorporating the student pharmacist.
Methods: Tools were developed to pilot the PPI de-prescribing service in September 2019 by a third-year (P3) pharmacy student and reviewed by the CPP. Processes for chart review and phone call outreach were outlined by the CPP using a standardized decision support tool to determine appropriate PPI use. A chart review was performed by the student on 92 patients currently on long-term PPI therapy and receiving care at a rural outpatient clinic affiliated with the William S. Middleton Veterans Affairs (VA) Hospital. Patients were contacted by the P3 student between November 2019 and February 2020 under the supervision of the CPP. Project deliverables included the templates created by the student pharmacist, the use of these tools and other resources to complete service initiatives, and the time saved by the CPP per patient taper trial. The CPP time saved was determined by documenting student and CPP encounter time to complete service initiatives and taking the difference of the average time of these units.
Results: Note templates for this service were developed by the student and revised by the CPP. The student process of performing a baseline chart review demonstrated that 58% (53/92) of patients were on long-term PPI therapy for an inappropriate indication. Of the 9 patients that enrolled in the service, 2 patients completed a PPI taper, 4 patients were still in progress, and 3 patients stopped the taper trial due to return of GERD symptoms. The average time for patients who completed a PPI taper was 8-9 weeks (4-5 encounters). It is estimated that the integration of a student pharmacist in this service saved the pharmacist an average of 45 minutes per taper trial.
Conclusion: This project described and implemented the resources and processes needed to integrate a student pharmacist into the workflow of a PPI de-prescribing service. The project has demonstrated the potential benefit of using a student pharmacist to complete service initiatives in reaching rural patients. Student pharmacist outreach to eligible rural patients with pharmacist oversight provides a unique opportunity to achieve de-prescribing therapy in an effective and efficient manner in the ambulatory care setting. Future directions of this project are to package this service into other pharmacists’ and clinics’ workflows to help reach more patients through pharmacy services while also facilitating student learning.
Keywords: Pharmacists, Proton Pump Inhibitors, Calcium, Clostridioides difficile, Helicobacter pylori, Magnesium, Workflow, Students, Pharmacy, Gastroenterology, Heartburn, Ulcer, United States Food and Drug Administration, Veterans, Pharmaceutical Services, Gastroesophageal Reflux, Prescriptions, Ambulatory Care, Outcome Assessment, Health Care, Ambulatory Care Facilities, Fractures, Bone, Micronutrients, Anti-Bacterial Agents, Vitamin B 12, Pneumonia
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2022 March/April Table of Contents