Professional Practice


Professional Practice

Information relevant to pharmacy practice such as expanded roles of pharmacists, advancements in pharmacy practice, professional resources to share with patients or enhance practice knowledge and more.

Marketers adjust to pharmacist’s expanded role in COVID-19 era

When COVID-19 forced the shutdown of doctors’ offices across the country last spring, community pharmacies remained open — and pharmacists stepped up, taking on more patient counseling, immunizations and testing. And as COVID-19 vaccines have become more widely available, pharmacies — and pharmacists — have played a critical role in their distribution.

“Society is realizing that pharmacies are literally saving the world with immunizations,” notes Scott Knoer, CEO of the American Pharmacists Association (APhA). “The access point of the community pharmacy is very significant.” 

The medical marketing community has finally taken notice. While pharmacists have long been an important audience, their increasing responsibilities and rising profile as healthcare providers have made them an even more crucial group for marketers to reach, not to mention busier than ever before.

The resulting shift has prompted marketers to experiment with new channels as they try to cut through the noise. As they do so, questions have emerged as to whether pharmacists’ expanded scope of care, and subsequent increase in contact with patients, will outlast the current crisis. Either way, many consumers are unlikely to ever again view their local chain pharmacy as a mere convenient destination for M&M’s and paper towels. 

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Overworked, understaffed: Pharmacists say industry in crisis puts patient safety at risk

From the moment Marilyn Jerominski walks into her pharmacy every morning, her time is in demand. As pharmacy manager of a busy 24-hour Walgreens in Palm Desert, California, she is responsible for the safety and accuracy of the thousands of prescriptions the store dispenses every week.

"There's so much stress," Jerominski said. "You're not only running to the drive-thru but to the front, to the vaccination station to give a vaccination, then to the phone. ... It's almost impossible for any human to keep that momentum day in and out."

It wasn't always that way. When she began working as a pharmacist 13 years ago, it was a very different environment, Jerominski said. There were more staff members and more time to counsel patients about their medications. These days, she is exhausted and often overwhelmed, worried about making a mistake when someone's health is on the line. She is far from alone.

Jerominski is one of an estimated 155,000 pharmacists working at chain drugstores who, over the past decade, have found themselves pushed to do more with less. They're working faster, filling more orders and juggling a wider range of tasks with fewer staff members at a pace that many say is unsustainable and jeopardizes patient safety. Now Covid-19 vaccinations are raising new concerns about what will happen if they aren't given enough additional support for yet another responsibility.

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Small Pharmacies Are Crucial to Vaccine Distribution. But It Could Cost Them.

Michigan Pharmacist in National News

To read the article, click here.

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COVID-19 Testing and Caveats

In a recent webinar from TRC Healthcare Healthcare’s Emerging Recommendations Panel on July 16, 2020, an expert panel discussed COVID-19 types of tests and caveats. The panel consisted of Lori Dickerson, Pharm.D., FCCP as the moderator, joined by Reid Blackwelder, M.D., FAAFP, Jehan Budak, M.D., Steven Nissen, M.D., MACC and Craig Williams, Pharm.D., FNLA, BCPS. They noted that pharmacists are getting more involved with testing as pharmacists in every state are authorized to order and administer SAR-COV-2 testing.

The first set of tests is the diagnostic tests. These tests use swabs to obtain specimen from the nasopharyngeal, nasal or oropharyngeal cavity. One type of most common diagnostic tests is polymerase chain reaction (PCR) testing. PCR is a molecular test that detects viral RNA presence in a sample. Most tests must show a 95 percent sensitivity and 100 percent specificity in order to be eligible for the emergency use authorization (EUA). Although during some cross studies, some tests were shown to be only 79 percent sensitive but results may have been from faults with the transport media being utilized. Point of care (POC) antigen testing is another diagnostic test that tends to have a turnaround time under 30 minutes verses hours for a PCR test. While being faster to generate an answer, they tend to only be 80 percent sensitive. PCR testing is more accurate, but POC antigen testing provides quicker results. Some institutions are screening with the antigen testing and confirming negative tests with PCR in order to rule out false negatives. For patients who test negative in the community but are still experiencing symptoms, TRC Healthcare recommended retesting immediately if an antigen test was used originally or to retest two-three days after a molecular test. Dr. Budak recommended utilizing molecular testing as the preferred retest if at all possible.

The sample collection can also lead to false negatives as the different tests can be difficult to perform. Nasopharyngeal is preferred, but harder to collect. Dr. Budak’s practice considers oropharyngeal the lowest tier sample to collect. Sputum tests in the pipeline were mentioned. This expert panel acknowledged that many physicians and pharmacists are not always able to pick which test their facility is utilizing, but recommends any test over not testing.. It is also worth noting that the tests can return a false negative if swabbed too early in the viral process where the viral load is too low as the nasal viral load can vary for each individual.

They recommended against re-testing a patient who had previously tested positive for SARS-COV-2 to see if the virus has cleared. This is because the dead virus may still be present in the nares for some time after the infection has completed. Consistent with the Centers for Disease Control and Prevention, TRC Healthcare recommended and the panel agreed that isolation can end after 10 days of symptom onset if symptom free for at least 72 hours.

The other type of testing is the antibody test to determine if someone had a previous infection. It is collected by blood sample or venipuncture. Obtaining a EUA from the Food and Drug Administration for antibody testing assumes 90 percent sensitivity and 95 percent specificity. A negative test indicates that a patient likely did not have COVID-19. The positive test from antibody testing cannot guarantee that a patient had COVID-19 specifically is exposure is uncertain due to false positives. When disease presence is low, the chance for false positives is high. There is not currently an area in the U.S. where the disease is common enough to make the positive predictive value much over 50 percent. With this, patients are cautioned against assuming immunity due to a presumed true positive test.

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Pharmacy’s Role in Addressing Stewardship in Dentistry

Elaine M. Bailey, Pharm.D., Executive Director, Michigan Antibiotic Resistance Reduction Coalition

Antibiotic resistance is a serious public health threat requiring a multifaceted approach. Approximately 10 percent of outpatient antibiotics in the U.S. are prescribed by dentists, amounting to nearly 25 million courses each year.1 Approximately 1.5 million additional antibiotic courses are prescribed to patients presenting in emergency departments with dental pain.2. There are increasing reports of inappropriate antibiotic prescribing in dental patients as well as dental patients experiencing Clostridiodes (formerly Clostridium) difficile diarrhea. 3,4. Given these findings, the American Dental Association (ADA) committed to the U.S. Antimicrobial Resistance Challenge by creating and disseminating guidance to help clinicians appropriately prescribe antibiotics. 5 The American Academy of Orthopedic Surgeons (AAOS) also committed to increase awareness of when antibiotics should and should not be used for patients with hip and knee implants who are undergoing dental procedures. (https://www.cdc.gov/drugresistance/intl-activities/amr-challenge.html

The ADA guideline for treatment of oral infections addresses many stewardship principles. The guideline encourages a paradigm shift in the use of antibiotics in dentistry from a “just in case” approach to using only when absolutely necessary. For example, when the patient is able to obtain interventional treatment (e.g. pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage) within 24 hours, antibiotics are generally not recommended. The ADA suggests practicing “Delayed Prescribing/Watchful Waiting” in situations where antibiotic treatment is unlikely to be of benefit. If a decision is made to prescribe antibiotics, then the maximum duration is seven days and the patient should discontinue antibiotics after they have been symptom-free for 24 hours. The ADA has also attempted to curb the use of clindamycin, which has been shown to be highly associated with Clostridiodes Difficile Infection (CDI)6, by following the guidance of the CDC in terms of evaluating penicillin allergy and suggesting the use of azithromycin as an alternative to prescribing clindamycin in the face of a true (anaphylactic) penicillin allergy. 

For infective endocarditis prophylaxis in patients undergoing dental procedures, current guidelines support premedication for only a small subset of patients.7 Unfortunately, in the case of patients with prosthetic joint replacements who are undergoing dental procedures, the guidelines developed by the ADA and AAOS have changed over the past 17 years, at times being incongruent particularly related to how long after the implant the patient should continue to receive prophylaxis before a dental procedure. The AAOS Appropriate Use Criteria (AUC) online tool indicates that it is rarely appropriate to prophylax patients who have undergone joint replacement more than one year before the dental procedure. The antibiotics prescribed are generally aligned with the American Hospital Association (AHA) guidelines with the exception of the removal of clindamycin as a choice (Table 2). Unfortunately, several dental providers in Michigan have shared that their orthopedic colleagues are often not in compliance with the AAOS guidance. 

Comprehensive guidelines exist for the development of stewardship programs in inpatient settings but despite the majority of antibiotics being prescribed in the outpatient setting, stewardship guidelines are generally lacking. The CDC include dentists in their list of intended audiences in the Core Elements of Antibiotic Stewardship for outpatient settings. 8 However, guidance is not provided on how to implement the Antimicrobial Stewardship Program (ASP) in the unique setting of dental offices.

Dentists have little opportunity to observe firsthand the adverse events associated with antibiotic prescribing, such as CDI, so they are generally unaware of the impact of their prescribing habits. The majority of dentists are solo practitioners with variably trained support staff and collectively the dental office has limited knowledge of antibiotic pharmacology. 9 Here are just a few suggestions of how our profession can support dentists, their staff and patients, to be better antibiotic stewards:

  1. Talk to all the staff in your dentist’s office about their important role in antibiotic stewardship. Advise them about the resources available through the Michigan Antibiotic Resistance Reduction (MARR) Coalition and other organizations (Table 3).
  2. When filling an outpatient prescription for treatment of an oral infection, insure that it is consistent with the ADA guideline.5 In particular, focus on the duration of therapy and the prescribing of clindamycin. Provide patients with information on how to dispose of unused antibiotics in the event that their symptoms resolve before completing seven days of therapy.
  3. Advise patients with prosthetic devices that in many cases the risk of antibiotics outweigh the benefits of taking them before dental manipulation and therefore they should consider discussing the need for antibiotics not only with their dentists but with their other healthcare providers. In some cases, their general practitioner (GP) may have assumed the responsibility for writing the prescription if the patient is over a year out of their implant and the GP may not be aware of the change in the guidelines. Dentists have shared that referring their medical colleagues to the AAOS AUC tool has been a helpful communication tactic.
  4. Incorporate dental stewardship principles, particularly regarding prophylaxis, in systemwide ASPs. Focus on educating orthopedic surgeons on the increasing incidence of community-associated CDI and the association with dental antibiotics. Policies should be implemented in emergency departments and urgent care centers consistent with the ADA treatment guidelines.
  5. Critically evaluate cases of penicillin allergy since the majority of dental patients with a penicillin allergy are prescribed clindamycin. If the patient’s allergy history is dated, recommend that they discuss with their regular physician.

 

Given the numerous stakeholders involved, implementing antibiotic stewardship in dentistry is going to be challenging. Pharmacy has an opportunity to positively influence dental stewardship by educating all the stakeholders, particularly the patients. Please review these helpful resources.

References:

  1. Roberts RM, Bartoces M, Thompson SE, Hicks LA, Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc 2017;148(3) :172-178
  2. Roberts RM, Hersh AL, Shapiro DJ, Fleming- Dutra KE, Hicks LA. Antibiotic prescriptions associated with dental-related emergency department visits. Ann Emerg Med. 2019;74(1):45-49.
  3.  Suda KJ, Calip GS, Zhou J, Rowan S, Gross AE, Hershow RC, Perez RI, McGregor JC, Evans CT. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open. 2019 May 3;2(5):e193909
  4. Bye M, Whitten T, Holzbauer S. Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009–2015. Open Forum Infect Dis. 2017;4(Suppl 1):S1. Published 2017 Oct 4. doi:10.1093/ofid/ofx162.001
  5. Lockhart PB, Tampi MP, Abt E et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc.2019;150:906-921.
  6. Guh AY, Adkins SH, Li O, et al. Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study. Open Forum Infect Dis. 2017 Oct 26;4(4):ofx171
  7. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2008;139 Suppl:3S-24S.
  8. Center for Disease Control and Prevention. Core Elements of Outpatient Antibiotic Stewardship. Available at: https://www.cdc.gov/antibiotic-use/community/pdfs/16_268900-A_CoreElementsOutpatient_508.pdf Accessed 3/28/20.
  9. American Dental Association, Survey Center. 2012 Distribution of Dentists survey. Chicago: American Dental Association, 2011.
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