2025 Southeastern Residency Conference

Authors: Abby McCurry, Emma Williams, Tasha Woodall
Background: Patients who have had Medicare Part B for over 12 months are eligible for a yearly “Wellness” visit to create or update a personalized prevention plan. These annual wellness visits (AWVs) are generally covered by the Medicare plan at no cost to the patient, making it an easier and more affordable process for eligible patients to access critical preventive screenings and address medication and health-related problems. The reimbursement for these visits ranges from $120-160, making this beneficial as well for the providers to complete. Despite this, completion rates of AWVs tend to be suboptimal, particularly for homebound patients. The objective of this quality improvement study was to determine if pharmacists can increase the AWV completion rate for eligible patients by creating chart reminders for providers.
Methods: Patients met criteria to be included in this quality improvement study by being a home-based primary care (HBPC) patient at Mountain Area Health Education Center (MAHEC), being eligible and due for a Medicare Annual Wellness Visit, and having an appointment for a HBPC visit scheduled in the selected time frame. HBPC patients who had upcoming visits had their charts reviewed the weekend before their visit to determine if they met eligibility criteria. If criteria were met, a note was added in the "reason for visit" portion of the note and a message was sent to the providers performing the visit to alert the providers that the patient was due for an AWV. At the end of each week, a retrospective chart review was performed to determine if AWVs were completed and track overall completion rate.
Results: There were a total of 4 AWV due in the 17-day time frame with 2 (50%) being completed. This was an increase from the control time frame where 20% (1 of 5) AWV were completed.
Conclusion: Putting notes in the "reason for visit" section in addition to messaging involved providers were successful ways to increase the number of AWV completed for home-based primary care patients at MAHEC.

Title: Implementing a Pharmacist Driven Proton Pump Inhibitor (PPI) Deprescribing Intervention in a Veteran Patient Population
Authors: Kristin Allen, Marisa Strychalski, Kye Grooms

Background: 
Proton pump inhibitors (PPIs) are among the most commonly prescribed medications in the VA to treat acid-related stomach disorders. The American College of Gastroenterology (ACG) recommends up to an 8-week course of a PPI for symptomatic relief of gastroesophageal reflux disease (GERD). The PPI should then be tapered off and discontinued or switched to a histamine 2 receptor antagonist (H2RA) for maintenance therapy. The long-term use of PPIs can potentially lead to adverse events such as osteoporosis and bone fractures. Due to these potential long-term risk, they are also included on the American Geriatric Society (AGS) Beers Criteria for potentially inappropriate medication use in older adults. Furthermore, Veterans on long-term PPIs with a low BMI (defined as a BMI of 19 kg/m2 and lower) are at even higher risk of osteoporosis and bone fractures, as low BMI is an independent risk factor in and of itself. The purpose of this study was to limit the potentially inappropriate continuation of formulary PPIs in a geriatric Veteran patient population most vulnerable to developing or worsening osteoporosis by reducing the PPI dose, stopping the PPI, and/or switching to a formulary preferred H2RA.

Methods:  
A data query identified geriatric Veterans (>75 years old) who have an active prescription for omeprazole or pantoprazole for at least 2 years and had at least one of the following: a low BMI, a diagnosis of osteoporosis, or were on osteoporosis prevention/treatment in the last 2 years. Veterans who were deemed appropriate for intervention based on chart review were contacted by phone. Through shared decision-making, the Veteran either continued the PPI at their current dose, reduced the dose, discontinued the PPI, and/or switched to an H2RA and were then scheduled for telephone follow-up for any interventions made. The primary endpoint was the percent difference in PPI utilization following pharmacist intervention. The secondary endpoint was the difference in the total daily dose of the PPI and H2RA for all patients on therapy following pharmacist intervention. The tertiary endpoint was to determine if the results of the DEXA scans performed show new/clinically relevant findings and require intervention. Data collected also included baseline characteristics such as age, weight (in kilograms), body mass index, serum creatinine, sex, and if the patient had a DEXA scan on file with the VA. 

Results:
25 patients were contacted and 72% of patients agreed to the deprescribing intervention. The utilization of low dose PPIs and high dose PPIs decreased by 8% and 24% and the utilization of as needed famotidine and non-pharmacologic strategies increased by 24% and 8% following pharmacist intervention. In total, 20% of Veterans were able to de-escalate PPI therapy and 32% were able to successfully discontinue the PPI and switch to as needed famotidine or non-pharmacologic strategies only. The total daily dose of PPIs decreased by 370 mg and the famotidine dose increased by 120 mg in total across 25 patients. One patient was started on a non-formulary PPI due to uncontrolled GERD symptoms on the formulary agents. Three out of four DEXA scans showed osteopenia/osteoporosis and two patients were started on treatment while one was referred to Endocrinology for further management.

Conclusion:
The pharmacist driven deprescribing intervention was able to de-escalate and discontinue PPI therapy, reduce the total daily dose of PPIs, increase the total daily dose of famotidine, and initiate osteopenia/osteoporosis treatment in those with new/clinically relevant DEXA scan results which illustrates the important role pharmacist play in reducing the risk of adverse drug events and pill burden as well as improving the overall health of the geriatric Veteran patient population.