As laws, regulations, and paradigms change and affect healthcare provision, pharmacists are expanding their scope of practice.

Clinical pharmacists have been tapped to lead chronic care management (CCM) services, as pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits.

Research reveals pharmacists are one of the most accessible medical care professionals, as patients report interacting with a pharmacist nearly nine times more frequently than a primary care provider or specialist.

As medication experts, pharmacists are uniquely positioned to prevent medication errors and drug interactions and minimize side effects and adverse medication events.

This makes them well-suited to manage patients with chronic conditions and complex medical pictures.  

Pharmacist-led CCM solutions:

• Mitigate medication-related risks
• Effectively manage chronic conditions between physician visits
• Improve medication and care plan adherence
• Reduce overall healthcare expenditure
• Improve patient’s quality of life
• Improve quality metrics
• Reduce physician workload and administrative burden

In addition to managing and preventing chronic conditions and diseases, such as chronic obstructive pulmonary disease, pain, diabetes, congestive heart failure, hypertension, cancer, and chronic kidney disease, clinical pharmacists are equipped to make high-level clinical decisions.

This enables them to reduce physician workload and on-call burden in a third-party CCM arrangement.  

With the national shift to value-based care, leveraging pharmacist-led care will assist medical practices in meeting quality metrics, reducing physician workload, minimizing administrative burden, and improving clinical and commercial outcomes.

PharmD Live®’s pharmacist-led CCM services integrate with physician practices and care teams to fortify clinical and commercial outcomes.

To learn more about the benefits of pharmacist-led care, contact Ellery Plowman.

Eltaki, Sara M., PharmD, BCPS; Gernant, Stephanie A., PharmD, MS; Hale, Genevieve M., PharmD, BCPS; Jones, Renee, PharmD, CPh; Joseph, Tina, PharmD, BCACP; Moreau, Cynthia, PharmD; Prados, Yesenia, PharmD; and Seamon, Matthew J., PharmD, JD. Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations: A Report from the Accountable Care Organization Research Network, Services, and Education. Academy of Managed Care Pharmacy. May, 2017. https://www.jmcp.org/doi/pdf/10.18553/jmcp.2017.23.5.541

Moose, Joseph PharmD, and Branham, Ashley PharmD, BCACP. Pharmacists as Influencers of Patient Adherence. Pharmacy Times. August 24, 2014. https://www.pharmacytimes.com/publications/directions-in-pharmacy/2014/august2014/pharmacists-as-influencers-of-patient-adherence-

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The social determinants of health—economic and social factors that impact health status—have received considerable attention from Health and Human Services (HHS) Secretary Alex Azar. In his November 14th speech at The Hatch Foundation for Civility and Solutions, Secretary Azar names the social determinants of health as the root cause of much of today’s healthcare spending.

Azar states, “We believe we could spend less money on healthcare—and, most important, help Americans live healthier lives—if we did a better job of aligning federal health investments with our investments in non-healthcare needs.”

As a clinical pharmacist delivering chronic care management (CCM) services, I have seen many patients whose health conditions are impacted or solely caused by social and economic factors. Ongoing medication therapies, emergency room visits, and extended hospital stays are often underpinned by factors outside of clinical care. The well-being of patients and families is thwarted, health outcomes compromised and a plethora of wasteful spending that ignores root cause and common sense. Asthma patients living in homes contaminated with mold, non-adherence to life-dependent medications due to cost, and diabetics without access to healthy food are commonplace.

Sweeping changes to healthcare delivery are expected in 2019, as the journey to a value-based healthcare economy continues. One of these changes will likely be an uptick in chronic care management services provided to Medicare patients with two or more chronic conditions. Addressing the social determinants of health is a compulsory aspect of Medicare-reimbursable CCM services—so it is reasonable to assume more patients will be adequately screened. Community resources (with paper-thin budgets) will likely be tapped for resource provision—healthy meals, transportation or funding for electricity bills. Addressing social determinants of health through CCM services is promising for Medicare patients; however, much work will need to be done to ensure adequate funding for resources.

In his November speech, Azar stated, “Just like how every patient is different in healthcare, every person has unique social service needs—and we are intent on designing models that connect them to the services they need, rather than offering a one-size-fits-all approach.”

A 2014 study by Dr. Seth Berkowitz evaluated the relationship between material need insecurities, control of diabetes mellitus and the use of healthcare resources. Berkowitz concluded, “Health care systems are increasingly accountable for health outcomes that have roots outside of clinical care. Because of this development, strategies that increase access to health care resources might reasonably be coupled with those that address social determinants of health, including material need insecurities. In particular, food insecurity and cost-related medication underuse may be promising targets for real-world management of diabetes mellitus.”

In the context of the study, addressing the social determinants of health is aligned with The Quadruple Aim: improved population health, reduced care cost, satisfied patients and satisfied providers. And Secretary Azar seems to agree: “What if we provided [sic] solutions for the whole person, including addressing housing, nutrition and other social needs? What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford nutritious food? If that sounds like an exciting idea…I want you to stay tuned to what CMMI is up to.”

Yes, Secretary Azar, our curiosity is piqued!

Dr. Nwaubani is Founder and CEO of PharmD Live®, an emerging digital health company focused on pharmacist-led innovative solutions to improve patient outcomes and ease the transition to value-based care. This article originally appeared as a guest post on healthcareguys.com.

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Drug Treatment Options Are Limited:

Currently, there are no treatment options available that can cure or alter the disease progression in the brain. While researchers are working to find a breakthrough drug that can reverse or stop the progression of this debilitating disease, healthcare providers must also focus their efforts on disease prevention. Although some risk factors in developing the disease, such as age and genetics, are not controllable, there are a variety of healthy lifestyle choices shown to promote brain health and preserve its function, including a combination of regular exercise, social interactions, mental stimulation, quality sleep, stress management, and healthy diet.

In May 2019, the World Health Organization issued guidelines to aide in globally reducing the risk of dementia. The new recommendations emphasize healthy lifestyle choices including regular physical exercise, abstaining from tobacco, drinking less alcohol, maintaining a normal blood pressure, and eating a healthy diet.

Healthy Dietary Recommendations Can Help Slow Cognitive Decline.

Healthcare providers can help patients lower their risk of cognitive decline as they continue to age by recommending dietary changes that have proven success. One such diet, called MIND, also known as the Mediterranean-DASH Intervention for Neurodegenerative Delay, combines aspects of the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet. MIND was developed by Martha Clare Morris, a nutritional epidemiologist, and her research team at Rush University Medical Center in Chicago. While both the Mediterrean and the DASH diets may also offer protection against cognitive decline, the MIND diet was developed specifically to address neurodegeneration and to determine the effect of nutrition on the brain as people age.

Morris and her team designed MIND with an emphasis on natural whole foods and nutrients that promote neuroprotection. Unlike the other two diets, MIND emphasizes berries over other fruits, separates green leafy vegetables from “other” vegetables, and recommends fish at least once weekly. It promotes foods rich in antioxidants as well as foods that have high amounts of omega 3 fatty acids, which may promote overall brain health and function.

Components Of The Mind Diet:

The MIND diet has 15 dietary components broken into two groups including 10 foods that promote brain health and five unhealthy food groups foods to avoid or limit due to high amounts of trans and saturated fats and sugar.

“Brain healthy” foods include:

• Green, leafy vegetables: at least six servings per week of vegetables like kale, spinach, cooked greens, and salads for their antioxidant effects;
• All “other” vegetables: at least one serving per day; aim for non-starchy vegetables;
• Berries: blueberries, blackberries, strawberries, and raspberries for their antioxidant effects at least twice per week;
• Nuts: especially those high in omega 3 fatty acids, such as walnuts, most days;
• Olive oil as the main cooking oil;
• Whole grains: oatmeal, quinoa, brown rice, whole wheat pasta, and 100% whole wheat bread at least three servings per day;
• Fish: at least one serving per week; aim for fish high in omega 3 fatty acids such as salmon, sardines, trout, tuna, and mackerel;
• Beans: beans, lentils, and soybeans at least four servings per week;
• Poultry: chicken or turkey at least twice per week; and
• A glass of wine daily.

“Unhealthy foods”:

• Butter and margarine: less than one tablespoon per day;
• Cheese: less than one serving per week;
• Red meat: limit to no more than three servings per week; this includes all beef, pork, lamb, and any products made from these meats;
• Fried food: less than one serving per week;
• Pastries and sweets: limit to no more than four times per week.

MIND Diet Study Results:

To determine the benefits of the MIND diet with respect to brain health, Morris and her team conducted an observational study which followed 923 individuals, ages 58 to 98, over a period of five years. The study enrolled volunteers already participating in the ongoing Rush Memory and Aging Project in Chicago. Researchers used an optional food frequency questionnaire to observe what people in the study were already eating to assign points based on their food choices in order to calculate a MIND score that correlated to their risk reduction.

The study found that closely adhering to the MIND diet could lower the risk of developing Alzheimer’s by as much as 53%. Of the 923 enrolled participants, only 144 of them developed Alzheimer’s disease. Even when the diet was only modestly followed, the risk of Alzheimer’s was reduced by as much as 35%. According to Morris, “One of the more exciting things about this is that people who adhered even moderately to the MIND diet had a reduction in their risk for AD.”

The study also suggests that the longer a person follows the MIND diet, the better the chance of preventing cognitive decline.

Continuing Dietary Research:

In a follow up study, Morris and her team compared the MIND diet with the DASH and Mediterrean diets. When strictly followed, the DASH and Mediterrean diets offered similar protection against cognitive decline and prevention of Alzheimer’s disease. However, when either diet was only modestly followed, the risk reduction was negligible.

While the observational study did show a strong relationship between adherence to the MIND diet and protection against Alzheimer’s disease, a causal relationship could not be determined due to the limitations of an observational study design.“We devised a diet and it worked in this Chicago study. The results need to be confirmed by other investigators in different populations and also through randomized trials.That is the best way to establish a cause-and-effect relationship between the MIND diet and reductions in the incidence of Alzheimer’s disease,” said Morris.

In order to confirm her results from the previous studies and determine the effectiveness of the MIND diet in preventing Alzheimer’s disease, Morris and her research team are in the process of conducting a three year intervention study consisting of 604 individuals aged 65 to 84. The study includes participants who are considered overweight, have poor eating habits and no cognitive decline. The participants have been randomly separated into two groups: the MIND diet group and the mild calorie restriction group (250 fewer calories per day). The trial concludes in 2021 with the hopes of finding the MIND diet has a direct impact on brain health and Alzheimer’s prevention.

REFERENCES:

Alzheimer’s Association. (2019). 2019 Alzheimer’s disease facts and figures [PDF]. Retrieved from https://www.alz.org/media/Documents/alzheimers-facts-and-figures-infographic-2019.pdf

Smith, M., Robinson, L., Segal, J. (2018). Preventing Alzheimer’s disease: What you can do to prevent dementia. HelpGuide.org. Retrieved from https://www.helpguide.org/articles/alzheimers-dementia-aging/preventing-alzheimers-disease.htm/

Hunt K. (2019). Eat well, exercise more: New global guidelines to reduce the risk of dementia. CNN Health. Retrieved from https://www.cnn.com/2019/05/14/health/who-guidelines-dementia-intl/index.html

Rush University Medical Center. (2015). New MIND Diet May Significantly Protect Against Alzheimer’s Disease. Retrieved from https://www.rush.edu/news/press-releases/new-mind-diet-may-significantly-protect-against-alzheimers-disease

Rush University Medical Center. (2015). Diet may help prevent Alzheimer’s. Retrieved from https://www.rush.edu/news/diet-may-help-prevent-alzheimer

Morris MC, Tangney CC, Wang Y, Sacks FM, Bennett DA, Aggarwal NT. ( 2015). MIND diet associated with reduced incidence of Alzheimer’s Disease. Alzheimers Dement. 11(9): 1007-1014. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4532650/

Barba, C. (2018). Can you beat Alzheimer’s with diet? An interview with the MIND diet creator. Being patient. Retrieved from https://www.beingpatient.com/can-you-beat-alzheimers-with-diet-an-interview-with-the-mind-diet-creator/

The MIND diet intervention to prevent Alzheimers’s disease. Retrieved from http://mind-diet-trial.org/

Bradford, A. (2016). What is the MIND diet? LiveScience. Retrieved from https://www.livescience.com/57132-mind-diet.html

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By Elliot Sternberg, MD

PharmD Live®, Chief Medical Officer

The Center for Medicare and Medicaid Services (CMS) has embraced a framework created by the Institute for Health Improvement (IHI) designed to optimize the American healthcare system:

• Improve Patient Care
• Reduce Healthcare Costs         
• Improve Population Health

CMS has aligned its Quality Payment Program metrics to increase (up to 7%), or reduce (down to 7%), physician reimbursements, tied to performance in pursuit of these goals. The Merit-Based Incentive Payment System (MIPS) has 4 performance categories (with weighting noted):

• Quality 45%
• Cost 15%
• Improvement Activities 15%
• Interoperability 25%

In addition, CMS has created a customized Advanced Payment Model (APM), featuring an overall financial risk component while requiring the use of a  certified electronic health record (CEHRT) to receive a 5% incentive payment for groups of eligible clinicians focusing on specific clinical conditions, care episodes, or populations:

• Quality 50%
• Improvement Activities 20%
• Promoting Interoperability 30%

Though well intended, this initiative has placed a significant burden on primary care providers (PCP) who, for the most part, are paid on a productivity basis. The added administrative burden of detailed documentation, data collection and submission, in the setting of adoption of an electronic health record, has come at significant cost, time and stress for the health care provider and staff. It is not surprising that some older physicians have opted for early retirement, while others have joined larger organizations that can seemingly ease administrative burden.  But the fact still remains – to be paid one must see patients and complete all of the necessary documentation, thus the pressure remains regardless of practice environment.  

Consequently, physicians face  a very “STEEEP” hill to climb in  providing care to an increasingly aging  and complex group of patients:

Is It Any Wonder Physicians Are Experiencing Burnout? 

In response, healthcare providers should focus their  efforts on realizing their own “Quadruple Aim”: 

While The Solution To These Challenges May Be Complex, One Concept Rises  To The Top:

The Primary Care Provider does not need to climb this very “STEEEP hill alone!”

The PCP should be finding greater personal and professional satisfaction when he/she practices to the maximum of their privileges and license. This strongly suggests the necessity of offloading many mundane tasks.  This can be accomplished through collaboration with ancillary providers (pharmacists, behavioral medicine specialists, dietitians, and educators among others) which will enable the physician to focus on the diagnosis and management of more challenging clinical problems. Embracing a collaborative team approach, supported by effective technology  and clinical apps, will help to overcome many of the STEEEP challenges they are forced to meet. Allowing others to assist will help improve and promote increased patient access, delivery of preventive services and education, and optimization of medication management while providing chronic disease management services between between physician visits. 

 The Result?

• Increased health of the patient and physician population;
• Enhanced experience of delivering and receiving care;
• Reduced per capita cost of care while rewarding primary care services.

For their own health and welfare, PCPs must explore different ways of meeting the needs of their patient population. Collaborating with others, embracing a team approach and adoptingsophisticated software solutions would be an effective start. 

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The Importance Of Glucose Monitoring:

Glucose monitoring is an essential tool to evaluate a patient’s response to therapy and determine if glycemic targets are being achieved.

1. Glucose monitoring can help detect and alert to episodes of hypoglycemia and hyperglycemia as well as offer insight into how stress, diet, exercise, and medication impact blood glucose fluctuations and levels throughout the day.
2. It can offer healthcare providers information to optimize medication therapy in an effort to reach overall treatment goals.

Not that long ago, self monitoring blood glucose (SMBG) meters were the only available devices for home blood sugar monitoring for the millions of patients living with diabetes. Since these allow for the patient to decide when to test his or her blood sugar level, the data provided is both intermittent and time specific. Many times overnight and post-prandial blood glucose levels go unchecked, making it difficult for patients and their practitioners to identify fluctuations in blood glucose levels.

Positive Aspects Of Continuous Glucose Monitoring Systems:

The introduction of personal continuous glucose monitoring systems has revolutionized diabetes management for both type 1 and type 2 diabetic patients that rely on exogenous insulin for blood glucose control. Because these patients are dependent on exogenous insulin as part of their diabetes management, they are more susceptible to episodes of blood glucose fluctuations and hypoglycemia. Studies have shown that CGM can improve long-term glucose control, increase the amount of time blood glucose levels are in a healthy range, and reduce episodes of hypoglycemia. The American Diabetes Association states, “Our position on CGM is that this new technology can offer diabetic patients a major advance in improving A1C values and reducing the occurrence of disruptive hypoglycemia.”

While the currently available CGM models may differ with respect to device features, they all share similarities in functionality. They are all composed of 3 basic parts: a sensor, a transmitter, and a receiver.

• The sensor continuously monitors blood glucose readings in the interstitial fluid under the skin.
• A small wire in the sensor connects to a reusable transmitter that gathers and interprets the glucose level and transmits the reading wirelessly to an insulin pump, smartphone, tablet, or a device monitor depending on the model.
• Daily activities such as meal times, exercise, or take insulin can also be entered and tracked on the receiver.

Unlike SMBG meters, CGM technology captures blood glucose levels in real time throughout the day, usually in five minute intervals. This allows patients to see how their levels fluctuate over the course of a few hours or even days in response to diet, periods of physical activity or exercise, and medication. CGM systems can identify trends in blood glucose fluctuations as well as episodes of hyper- and hypoglycemia. Depending on the model, an alarm feature may be available to alert the user when blood glucose levels are quickly falling or rising.

Limitations Of Personal CGM Systems:

Personal CGM systems are not without limitations. Even though blood glucose levels are continuously monitored, a finger stick is still required on many of the models for the purpose of calibration or treatment decisions. The high cost associated with CGM systems and limited healthcare coverage can be prohibitive, limiting patient access. Researchers and developers continue to work on improving features such as accuracy, easy of use, and increased life span of device sensors, all of which are concerns with many models available on the market today.

Current Impacts On Diabetes Management:

Regardless of some design limitations of currently available CGM systems, the detailed information these systems gather and provide to both patients and their healthcare providers can significantly impact diabetes management. Patients are able to gain valuable insight into their glucose levels and rates of fluctuations. This can help patients, along with their practitioners, to proactively manage their diabetes through drug therapy as well as lifestyle and dietary modifications.

CGM is an advanced way for people living with diabetes to keep track of their blood glucose levels in real time and monitor levels over a period of time. These systems will likely evolve to play a vital and central role in diabetes management and blood glucose control, helping patients achieve glycemic targets and maintain near normal blood glucose levels. CGM technology can help patients and healthcare providers make significant improvements in treatment outcomes as well as greatly reduce the incidence of diabetes-related complications.

Stay Tuned For Continuous Blood Glucose Monitoring Systems Part 2: How One Company Is Leading The Way In Technology Innovation And Advances In Patient Care.

References:

Russel SJ. (2017). Continuous Glucose Monitoring. U.S. Department of Health and Human Services. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from: https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes/continuous-glucose-monitoring

.ADA: American Diabetes Association. (2019). Diabetes Technology: Standards of Medical Care in Diabetes-2019. Diabetes Care. 42(Supplement 1): S71-S80. Retrieved from https://doi.org/10.2337/dc19-S007

Slattery D, Choudhary P. (2017). Clinical Use of Continuous Glucose Monitoring in Adults with Type 1 Diabetes. Diabetes Technol Ther. 1; 19(Suppl 2): S-55–S-61. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444504/

Rodbard D. (2017). Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes. Diabetes Technol Ther. 1; 19(Suppl 3): S-25–S-37.. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467105/

American Diabetes Association. (2019). Fast Facts: Data and statistics about diabetes. Retrieved from https://professional.diabetes.org/sites/professional.diabetes.org/files/media/sci_2019_diabetes_fast_facts_sheet.pdf

Healthwise staff. (2018). Continuous Glucose Monitoring: Topic Overview. Kaiser Foundation Health Plan of Washington. Retrieved from https://wa.kaiserpermanente.org/kbase/topic.jhtml?docId=abk4683

American Diabetes Association. (2008). Continuous glucose monitoring: The future of diabetes management. Diabetes Spectrum. 21(2): 112-119. Retrieved from https://doi.org/10.2337/diaspect.21.2.112

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Gender and age are the most significant risk factors for developing breast cancer, with approximately 95% of all cases occurring in women 40 and older. It is a leading cause of death among women in the United States, second only to skin cancer. 

Breast cancer is considered a disease of aging. The median age of women who develop breast cancer is 62, with over 24% of cases occurring in women between the ages of 70 -84. Additionally, the number of diagnosed invasive breast cancer cases is expected to more than double by 2030 for this age group.

Mammogram Recommendations:

The U.S. Preventive Services Task Force recommends biennial mammogram screenings for women ages 50-74.  However, screening guidelines for women 75 years and older are less clear. The task force does not offer any guidance for or against mammogram screenings for this population due to lack of evidence demonstrating benefits outweighing risks. Thus, the decision to continue having mammograms should be personal, based on current health and medical history. The benefits of continued screenings should be discussed with a physician who can aid in developing a preventative screening plan. For some older, healthy women with a life expectancy greater than 10 years, it may be reasonable to continue getting mammograms once every 2 years; whereas breast cancer monitoring through physical exams may be more beneficial for older women who have serious health issues or reduced life expectancy.

Treatment Options For Older Women:

Even though older women represent the majority of breast cancer patients, treatment-based guidelines for this patient population are limited mainly due to lack of representation in clinical trials which are used to form the basis of the standards of care guidelines. While usual treatment regimens for younger patients often involve a combination of chemotherapy, surgery, and radiation, treatment for older women, who present with early breast cancer, is likely to be considerably less invasive and is mostly dependent upon the type of breast cancer diagnosed. For example, it is estimated that 80% of women in their 70s, and 90% of women in their 80s, have hormone receptor positive breast cancer. These types of tumors can often be treated effectively with surgery and adjuvant hormone therapy without the need for additional radiation or chemotherapy.  

Hormone therapy has been shown to prevent cancer cells from getting the hormones necessary to grow, either by lowering estrogen levels, or by stopping the action of estrogen on tumor cells. The following hormone based therapy is often used to treat breast cancer in post-menupausal women:

• Aromatase inhibitors, including anastrozole, exemestane, and letrozole, which help lower estrogen levels in the body.  
• Selective estrogen receptor modulators (SERMs), including tamoxifen and toremifene,which block estrogen receptors on the tumor cells surface.  This prevents estrogen from acting on cancer cells and giving the cells instructions to grow and divide.

A study published in the  August 1st, 2019 edition of “International Journal of Radiation Oncology” looked at women 70 years of age and older with hormone receptor positive, HER-2 negative breast cancer. The research team conducted a matched cohort observational study that included 2995 patients from the National Cancer Database. The study compared overall survival in otherwise healthy women treated with lumpectomy and adjuvant hormone therapy versus lumpectomy followed by radiation therapy. The study found no difference in the 5 year overall survival rate between the two groups. Women who underwent lumpectomy and hormone therapy lived just as long as those who received radiation, although radiation therapy did result in a somewhat reduced risk of recurrence.  (https://www.redjournal.org/article/S0360-3016(19)33556-4/abstract)

For a small percentage of older women who have advanced metastatic breast cancer or estrogen negative breast cancer, treatment with chemotherapy may warrant consideration. Chemotherapy drugs are often selected based on their ability to target tumor cell genes and proteins as well as the patient’s ability to tolerate the treatment regimen. The risks of potential side effects that can impact the patient’s daily life must be weighed against the benefits of treatment. Women should work closely with their oncologist to develop a personalized treatment plan that addresses the following:

• Health and life expectancy
• Risks and benefits of treatment
• Treatment goals- reduced side effects versus lower likelihood of recurrence

Risk Of Breast Cancer Related Death:

While older women are more likely to get breast cancer, their risk of dying from the disease is not significantly higher than that of younger women. Studies show more deaths from breast cancer in older women simply because most diagnoses occur in older women; however, the cause of death for many of these women is unrelated to their breast cancer. For women of any age, survival rates are dependent on the stage and subtype of cancer. The facts show many women of advanced age have positive results when treated for breast cancer. 

References:

U.S. Preventive Services Task Force.  (2016). Breast Cancer: Screenings. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1?ds=1&s=breast%20can

National Cancer Institute.  Study Forecasts New Breast Cancer Cases by 2030. https://www.cancer.gov/news-events/cancer-currents-blog/2015/breast-forecast

BreastCancer.Org. U.S. Breast Cancer Statistics. https://www.breastcancer.org/symptoms/understand_bc/statistics

Breast Friends., (2017) Breast Cancer Signs, Symptoms, and Facts. https://www.breastfriends.org/cancer-facts/breast-cancer-facts/?gclid=Cj0KCQjw8svsBRDqARIsAHKVyqEs0se5AsFMU6UTliXXdrzL5CnIXNZ49s2S-r4iGG98D-gLFth8qmUaAio8EALw_wcB

American Cancer Society. Hormone Therapy for Breast Cancer. Retrieved from https://www.cancer.org/cancer/breast-cancer/treatment/hormone-therapy-for-breast-cancer.html#references

Harvard Women’s Health Watch. (2015).  Good New About Early Stage Breast Cancer for Older Women. Harvard Health Publishing Harvard Medical School. Retrieved from https://www.health.harvard.edu/cancer/good-news-about-early-stage-breast-cancer-for-older-women

Freedman RA.  (2015). What Older Women Should Know About Breast Cancer.  Dana-Farber Cancer Institute. Retrieved from https://blog.dana-farber.org/insight/2015/08/what-older-women-should-know-about-breast-cancer/

Buszek, SM, Lin HY, Bedrosian I, Tamirisa N Babiera GV, Shen Y, Shaitelman SF.  (2019). Lumpectomy Plus Hormone or Radiation Therapy Alone for Women Aged 70 Years or Older With Hormone Receptor–Positive Early Stage Breast Cancer in the Modern Era: An Analysis of the National Cancer Database. 

DOI: https://www.redjournal.org/article/S0360-3016(19)33556-4/abstract

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Over the years, clinical pharmacists have become crucial members of the multidisciplinary teams who treat breast cancer patients. 

Cancer treatment can be more challenging and complicated for older women due to a progressive decline in organ function.

This can reduce the elimination of cancer drugs through renal excretion and liver metabolism, increasing the risk for side effects and treatment-related toxicities as well as normal tissue tolerance.

Clinical pharmacists can provide expert knowledge on cancer treatment pharmacokinetic properties including drug absorption, the volume of distribution, renal elimination, and liver metabolism to help guide treatment decisions and options.  

Medication Expertise:

Clinical pharmacists are medication experts poised to deliver a wide variety of services to breast cancer patients, including education, monitoring adverse drug effects, and evaluating drug-drug, drug-gene, and drug-disease interactions.

The increased occurrence of comorbidities and polypharmacy in elderly women increases the risk for drug-drug, drug-gene, and drug-disease interactions as well as cumulative adverse effects. 

Pharmacists are uniquely qualified to reconcile a patient’s medication list and identify potential interactions associated with the patient’s use of dietary and nutritional supplements, herbals, and over-the-counter medications and how these interactions can increase the risk of treatment complications and/or toxicities.     

Resource And Education:

Additionally, clinical pharmacists can be key resources in educating and managing the adverse effects and toxicities of breast cancer treatment. 

Many adverse effects of chemotherapy can be managed with patient education and supportive care, thereby increasing medication adherence and regimen tolerance. 

Supportive care services may include treatment for nausea and vomiting, pain management, constipation and diarrhea, anemia, anticoagulation, and treatment with anti-infectives. 

Elderly women on chemotherapy for advanced or hormone receptor-negative breast cancer are at increased risk of developing myelosuppression secondary to their anticancer regimen.

Through laboratory monitoring, clinical pharmacists can help identify women who should be prescribed hematopoietic growth factors to combat the myelotoxicity of chemotherapy. 

From treatment recommendations and patient education to side effects and drug interaction management, clinical pharmacists play an integral role in ensuring optimal treatment outcomes and improved quality of life for older women fighting breast cancer. 

References:

Powers J. (2018).  The Role of the Pharmacist as Part of a Multidisciplinary Cancer Care Team.  Pharmacy Times. 19: 12: 27. 

Retrieved from https://www.pharmacytimes.com/publications/specialty-pharmacy-times/2018/may-2018/the-role-of-the-pharmacist-as-part-of-a-multidisciplinary-cancer-care-team

Lewis JA.  (2017). The Oncology Care Pharmacist in Health System Pharmacy.  Pharmacy Times. 20: 41: 32. 

Retrieved from https://www.pharmacytimes.com/publications/health-system-edition/2017/january2017/the-oncology-care-pharmacist-in-healthsystem-pharmacy

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Top Trend #1: Virtual Health

Consumers are plugged in. With the rising use of digital technology, healthcare wearables, and virtual care, the concepts of going online or using an app to manage health have rapidly gone mainstream. Consumer advantages, ranging from convenience to cost to real-time data flow, mean that virtual health will continue to gain acceptance. However, significant barriers to entry and reasonable doubts about these technologies still present major challenges to the digital health industry. Lack of understanding about the technology and concerns about privacy, combined with a preference for face-to-face interaction, suggest that a segment of consumers will remain disengaged with virtual health. Also, access to virtual care delivery is not universally available to all patients, due to variations in background, demographics, and socioeconomic status.

Our take: Virtual healthcare has numerous benefits for patients and healthcare providers, but it is not a universal approach. The ideal scenario employs technology to provide all patients with access to personalized, adaptable care that equals the quality of treatment they would receive in a clinical setting.

Top Trend #2: Healthcare Data Utilization

Harnessing the power of information, from a single patient to an entire population, is a major topic in the healthcare industry today. Proponents envision a future where data insights and predictive analytics can increase the efficiency of healthcare delivery and train AI to accurately improve health outcomes, but reaching these goals is a formidable challenge. The promise established by the HITECH Act and requirements for interoperability between electronic data systems has – so far – fallen short of its potential. Data privacy and cybersecurity are ongoing dilemmas in the proper storage and usage of electronic health information. Although technologies exist to support these processes, industry-wide cooperation, common technical standards, and secure verification methods are yet to be achieved.

Our take: We will see healthcare data systems continue to improve, standards develop, security improve, and regulations evolve. Data analysis to drive better care is a worthy ambition, and investment in this sector will begin to produce results for individuals and overall population health.

Top Trend #3: Patient Engagement

Now more than ever, many patients are willing and able to take an active part in their own care. Direct-to-consumer care, self-diagnostic services, genetic testing, and pharmacogenomics are leading trends among health-savvy consumers. Increasing numbers of wearables, health & fitness apps are making digital health more accessible. 

Our take: Healthcare does not occur in a vacuum. Consumers will continue to rely on guidance and communication with a traditional healthcare team, including physicians and pharmacists. Consumer engagement channels are a complement, rather than a threat, to conventional healthcare models, and should be embraced by providers looking to better coordinate with patients.

Top Trend #4: Pharmacy Integration

Patient care settings that rely on decision-making by one provider are fading in favor of team-based models that deliver coordinated care and better health. Pharmacists, as experts in disease state management and medication therapy, are at the forefront of this evolution. With anticipated changes to federal regulations that will both ease limitations and provide incentives for coordinated care, healthcare practitioners are coming together in unprecedented arrangements that streamline healthcare delivery and deliver improved health outcomes.

Our take: Proposed reforms, including strong safeguards to protect patients from fraud and abuse, are long overdue to enable providers to better coordinate high-quality healthcare. Team-based approaches, with pharmacists as central partners, provide better health outcomes and improved value in healthcare delivery.

The future of healthcare starts with what is happening now. Changes in technology, consumer behavior, and healthcare regulation today will drive the delivery methods of tomorrow. With our commitment to patient empowerment and improved health outcomes, PharmD Live® is positioned at the forefront of coordinated care. Learn more today at pharmdlive.com. 

Sources

• Health apps and wearable devices
• Receptiveness to virtual care
• AI / virtual doctors

• Big data
• Virtual access to health care

• Direct to consumer healthcare
• Focus on social determinants of health

• Patient empowerment
• Precision medicine
• Interoperability and data exchange standards for EHRs (FHIR)
• Healthcare wearables
• Patient self-diagnostics
• Predictive analytics
• PGx

• Data security, cyber attacks, and patient privacy

Technology Trends in Healthcare in 2021: The Rise of AI

• Telemedicine
• Wearables
• Cloud computing
• Augmented and Virtual Reality
• AI
• Chatbots
• Data science and predictive analytics
• Blockchain / interoperability

• Pharmacists integration into clinical team- bigger role as part of the healthcare team  especially to care for patients with chronic and debilitating diseases.
• Regulatory:-HHS Releases Proposal to Reform Stark Law, Antikickback Rules To Support Value-Based Care

The post On The Horizon For 2020: PharmD Live®’s Review Of Top Healthcare Trends appeared first on Pharmdlive.

Firstly, in “Integrating Telehealth into A Clinical Pharmacy Telephonic Diabetes Management Program” (Journal of Diabetes Science and Technology 2011), 28 patients entered an observation trial over four months to determine if a telephonic diabetes management program utilizing clinical pharmacists could improve mean hemoglobin A1C (HbA1c) as well as lower blood glucose (BG) levels. During the trial, a clinical pharmacist scheduled telephone follow-ups to review the patients’ blood glucose, and  provided drug therapy management, education, and lifestyle changes. The patients’ baseline mean HbA1c was 9.8% and the resulting mean HbA1c was 8.5%; these results show a statistically significant reduction of -1.3% (p=0.001). The baseline mean BG was 178 mg/dl (SD 67) and the resulting mean BG was 163 mg/dl (SD 64); these results show a statistically significant reduction of -15 (p=0.0002). The patients also participated in surveys at the end of the trial and the results showed that most patients were overall comfortable in the care they received, found value in the device used to measure their BG, and would recommend the program to others. To summarize this trial, HbA1c values improved significantly, mean blood glucose values decreased significantly, and patients were mostly satisfied. 

The second trial, “The Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Control” (JAMA 2013), assessed if pharmacist-managed home blood pressure (BP) telemonitoring improves blood pressure compared to standard of care. The trial was a 2-group cluster, randomized, clinical trial involving 450 patients in 16 primary care clinics in Minneapolis over 18 months. The primary outcome was control of systolic BP to <140 mm Hg and diastolic BP to < 90 mm Hg (< 130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 and 12 months. 228 patients received telemonitoring intervention while 222 patients received standard of care. Pharmacists had an introductory meeting with the telemonitoring group in which they reviewed their medications, medical history, educated the patient on hypertension, instructed the patient on how to use the home BP telemonitoring system, and helped each patient set individualized goals. The primary outcome results showed a statistically significant difference between the telemonitoring group compared to standard of care. The proportion of patients with controlled BP in the telemonitoring group at 6 months was 71.8% vs 45.2% in the standard of care (P<0.001). At 12 months, the proportion of patients with controlled BP in the telemonitoring group was 71.2% vs 52.8% in standard of care (P<0.005). Lastly, the proportion of patients at 18 months with controlled BP in the telemonitoring group was 71.8% vs 57.1% (P<0.003). To summarize, blood pressure telemonitoring with pharmacist management resulted in large improvements in blood pressure control for 6, 12, and 18 months compared to standard of care. 

Some limitations of these trials should be addressed. Although the trials discussed above are older, there are very few trials addressing the outcomes of telepharmacy. These trials are also on the smaller side, however, with the increased use of telepharmacy there should be more of a push to increase both the number and size of trials for telepharmacy. 

In conclusion, telepharmacy can improve patient outcomes for both diabetes and hypertension, and pharmacists can have a major impact on patient outcomes through telepharmacy. Additionally, with the increased use of telepharmacy, we will likely see more clinical trials displaying improved outcomes for other disease states as well. Although Covid-19 has brought telepharmacy to the forefront, it is likely here to stay. 

References:

1. Omboni S, Tenti M. Telepharmacy for the management of cardiovascular patients in the community. Trends Cardiovasc Med. 2019;29(2):109-117. doi:10.1016/j.tcm.2018.07.002.
2. Alexander E, Butler CD, Darr A, et al. ASHP statement on telepharmacy. Am J Health Syst Pharm. 2017;74(9):e236-e241. doi:10.2146/ajhp170039.
3. Shea S, Weinstock RS, Starren J, et al. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus. J Am Med Inform Assoc. 2006;13(1):40-51. doi:10.1197/jamia.M1917.
4. Klug C, Bonin K, Bultemeier N, et al. Integrating telehealth technology into a clinical pharmacy telephonic diabetes management program. J Diabetes Sci Technol. 2011;5(5):1238-1245. Published 2011 Sep 1. doi:10.1177/193229681100500533.
5. Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA. 2013;310(1):46-56. doi:10.1001/jama.2013.6549.
6. Alltucker, K. and Weintraub, K., 2020. Virtual care may be here to stay – LUBBOCK AVALANCHE-JOURNAL, 7/7/2020. [online] Digital.olivesoftware.com. Available at: <http://digital.olivesoftware.com/Olive/ODN/LubbockAvalancheJournal/shared/ShowArticle.aspx?doc=LAJ%2F2020%2F07%2F07&entity=Ar01701&sk=55279277&mode=text> [Accessed 14 July 2020].

The post Who You Gonna Call? Telepharmacy And Patient Outcomes appeared first on Pharmdlive.

• Cooking- Many recipes add extra sugar and fat that are unnecessary. Try using less sugar or low sodium options. Consider using fat free yogurt, sour cream, or even sugar substitutes. Olive and canola oils can be used as a substitute for butter. If you are a guest at a Thanksgiving dinner, offer to bring a healthy dish. There are so many healthy Thanksgiving recipes online. For example, the Mayo Clinic posted a recipe book of healthy Thanksgiving dishes that are delicious and won’t break your diet.
• Meal Time-Try to stick to your regular meal times. Many people may skip breakfast to “save room for turkey”, but eating beforehand may help, control your appetite and curtail overeating. If your Thanksgiving meal is later on in the day, have a small snack. This is especially important if you are on diabetic medications so that you can make sure your blood sugar doesn’t get dangerously low. 
• Choosing the Right Foods– Start with vegetables or a salad that can help to curb your appetite. Next,  pick a few of your favorite Thanksgiving foods that you most look forward to eating. If you choose to have dessert, consider limiting your other carbs which can include potatoes, bread, stuffing, candied yams, etc. Lastly, drink plenty of water with your meal and throughout the day and pass on the soda or other sugary beverages.
• Portion Control- You may not always have a lot of control over what is served, but you do have control over how much you eat. Try making a small plate of food. Choose to make a plate with extra vegetables then for the rest of your meal, have a small portion of your choice of protein, and a small portion of carbohydrates. Focus on truly enjoying your food and eat slowly; This will give your brain time to recognize that you are full and allow you to savor all the flavors of the holidays. For dessert, choose a smaller dessert such as mini muffins, a small cookie, or slice of pie. Lastly, pass on getting seconds. It can be very tempting, but you will be happy you did the day after Thanksgiving. 
• Avoid Alcohol- Drinking alcohol can lower your blood sugar so it’s best to avoid. If you have alcohol, drink it with your meal. 
• Diabetes Tips– If you are diabetic, we recommend checking your blood sugar more often on Thanksgiving day. Also, if you are planning on eating a larger meal than normal, calorie counting and increasing your insulin dose at mealtime can help prevent your blood sugar from spiking.
• Stay Active– Keeping a regular exercise routine during the holidays is the best way to stay healthy and keep off the extra pounds. There are also special Thanksgiving day events, that can be done indoors with the family (Ideas Here) . Involve your family in your exercise routine. It ‘s a great way to bond and encourage one another.
• Try Again- If you slip up and eat more than intended, start again the next day. Having a healthy lifestyle is about choosing the best options each day.
• Remember the meaning behind Thanksgiving– Although a lot of emphasis is put on food, Thanksgiving is not about the meals. It is a time to give thanks for family and friends and cherish those you love. So if you are struggling to eat healthy this Thanksgiving, try to refocus on your loved ones and be thankful for all you have. 

From all of us at PharmD Live®, we wish you a safe and healthy Thanksgiving!

References

1. Medicalwesthospital.org. 2020. 9 Tips For A Healthy Thanksgiving. [online] Available at: <https://www.medicalwesthospital.org/9-tips-for-a-healthy-thanksgiving.php> [Accessed 13 November 2020].
2. Mayo Clinic. 2020. Thanksgiving Recipes: Delicious And Healthy Options. [online] Available at: <https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/thanksgiving-recipes/art-20048258> [Accessed 13 November 2020].
3.  HealthyWomen. 2020. Registered Dietitians Offer Tips For A Healthier Thanksgiving. [online] Available at: <https://www.healthywomen.org/content/article/registered-dietitians-offer-tips-healthier-thanksgiving> [Accessed 13 November 2020].
4. Centers for Disease Control and Prevention. 2020. 5 Healthy Eating Tips For The Holidays. [online] Available at: <https://www.cdc.gov/diabetes/library/features/holidays-healthy-eating.html> [Accessed 13 November 2020].

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