2025 Southeastern Residency Conference

Title: Assessing Academic Detailing on Pharmacogenomic Utilization in the Primary Care and Menth Health Settings
Authors: Jenna K. Brophy, Justin Davis
James H. Quillen VA Medical Center (JHQVAMC) PGY1– Mountain Home, TN
Background/Purpose:  Pharmacogenomics is the study of how interindividual variations in genes can influence the response to medications.  Pharmacogenomic (PGx) testing is a clinical tool to improve the safety and efficacy of medication prescribing. The Food and Drug Administration (FDA) currently has 397 medications with genomic testing discussed in their package insert, 58 medications with data supporting pharmacogenomic associations, 20 with potential pharmacogenomic impact on safety and response, and 40 that may have pharmacogenomic impact on kinetics.  A 2019 cross-sectional study of 7.7 million veterans across VHA determined that roughly 55% of patients were prescribed at least one actionable, level A medication informed by PGx testing. Despite published guidance to facilitate implementation of pharmacogenomic information, it can take as many as 17 years for research to be incorporated into clinical practice.   Surveys of schools and colleges of medicine in the United States show efforts in recent years to increase the incorporation of pharmacogenomics within their curriculum; however, the depth and extent of education varies, and most respondents believe that physicians and other healthcare professionals do not possess an appropriate level of knowledge in this area.  Academic detailing (AD) is an outreach intervention that delivers non-biased education to bridge the gap between provider knowledge, prescribing practices, and evidence-based, recommended clinical guidance.  In a clinical trial assessing Technology Enabled Academic Detailing (TEAD), it was perceived as effective in terms of content delivery as traditional AD interventions (as determined by end-user feedback); however, there is limited information whether TEAD is as effective as traditional AD in promoting change in clinical practice.  This quality improvement initiative aims to assess the receptiveness and impact of academic detailing on pharmacogenomic utilization in the primary care and mental health settings.
Methodology: This is a prospective cohort study that enrolled healthcare providers in the primary care and mental health settings at the James H Quillen VA Medical Center between April 2024 and December 2024. All providers were enrolled after delivery of service-level educational outreach on the availability of PGx testing.  Written education was disseminated quarterly to provide updates and facilitate implementation of pharmacogenomics within these respective practice areas. During the study period, three attempts were made to offer individualized academic detailing (AD) sessions to all providers. Options for in-person and TEAD were made available.  Providers could self-schedule through a calendar link or contact the academic detailer if alternative scheduling options were required.  The primary outcome was to compare the utilization of pharmacogenomics between AD-exposed v. non-exposed providers. Secondary endpoints aimed to evaluate differences in acceptance of detailing between services (mental health v. primary care) and providers (physician vs. non-physician provider). A survey was utilized to identify barriers associated with academic detailing and PGx implementation.  
Results: In progress
Conclusions: In progress

Title: Direct oral anticoagulants and potential inconsistencies with recommended dosing in atrial fibrillation


Authors: Kelsey Maynard, Melissa Johnson, David Cruse, Cody Veal, Chelsea Keedy


Background: Direct oral anticoagulants are commonly recommended in atrial fibrillation patients to prevent thromboembolism. Anticoagulant dosing not aligned with approved labeling has been associated with increased risk of cardiac hospitalization, stroke, all-cause mortality, and bleeding. Previous studies have reported 20 to 32 percent of atrial fibrillation patients have their direct oral anticoagulants dosed outside labeling recommendations. The objectives of this study were to determine the rate of direct oral anticoagulant dosing that is outside of approved labeling for patients with atrial fibrillation at three outpatient primary care clinics of a community health system and determine the characteristics of those inappropriately dosed.


Methods: This was a retrospective, cross-sectional analysis evaluating adult patients diagnosed with atrial fibrillation treated with direct oral anticoagulants from January 1^st, 2023 to December 31^st, 2023. Patients were excluded if they were less than 18 years old or greater than 89 years old, pregnant or experienced childbirth within study period, or if they had been previously diagnosed with a clotting disorder.  Patients were also excluded if they were treated for venous thromboembolism, hip/knee replacement, left ventricular thrombus or heparin induced thrombocytopenia during the study period. The primary outcome is to determine the percentage of atrial fibrillation patients with direct oral anticoagulant dosing that is not consistent with the Food and Drug Administration approved labeling. Secondary analyses were completed to determine the percentage of atrial fibrillation patients with particular clinical or demographic characteristics who were inappropriately dosed. Characteristics evaluated included age, sex, race, drug name, drug dose, drug dosing instructions, body weight, serum creatinine, concomitant CYP450/PGP drug-drug interactions, concomitant medications, hemodialysis status, primary care office location, prescriber, social deprivation index, CHA₂DS₂-VASc, HAS-BLED, and history of bleeding.


Results: Two hundred and twenty-two patients met inclusion criteria for analysis. Thirty-six of these patients had their direct oral anticoagulant inappropriately dosed (16.2%). Of the inappropriately dosed patients, the average age was 81 years old, 20 patients were female (55.6%), 29 were Caucasian (80.6%), 2 patients were on dialysis (5.6%), and 11 patients had a history of bleeding (30.6%). Twenty-five patients were prescribed apixaban (69.4%) and 11 patients were prescribed rivaroxaban (30.6%). Ten of these patients (27.8%) had their direct oral anticoagulant prescribed by their primary care provider, the average CHA₂DS₂-VASc score was 3.5, and the average HAS-BLED score was 2.1. Eight patients (22.2%) were also prescribed a CYP450/PGP medication and 16 patients (44.4%) were also prescribed a nonsteroidal inflammatory drug, glucocorticoid, antiplatelet, or selective serotonin reuptake inhibitor. Nineteen of the inappropriately dosed patients (52.8%) had their direct oral anticoagulant under dosed, nine patients (25%) did not have their direct oral anticoagulant adjusted for their creatinine clearance appropriately, six patients (16.7%) met two of the three dose adjustment criteria for apixaban dose adjustment, and two patients (5.6%) were on dialysis and were not greater than 80 years old or less than 60 kg.


Conclusion: The majority of the atrial fibrillation patients in three of our community health system’s outpatient primary care clinics have their direct oral anticoagulants dosed appropriately per the Food and Drug Administration’s approved dosing. The atrial fibrillation patients in our primary care clinics at highest risk of having their direct oral anticoagulants inappropriately dosed are patients who are elderly, female, Caucasian, and prescribed apixaban. These patients are more often under dosed. 

Implementing A Practical and Effective Approach to Expand Naloxone Access for Geriatric Veterans at the Salisbury VA Health Care System (SVAHCS)

Authors: Elizabeth Martinez Delgado, Allison E. Strain, Chelsea McDonnell, Camille Robinette, Sarah J. Hopper
Salisbury Veterans Affairs Health Care System – Salisbury, NC

Objective: Compare percentage of naloxone prescriptions initiated by pharmacist and primary care provider (PCP) to older adult high-risk Veterans. 

Self-Assessment Question: Based on the objective of this quality improvement project, which of the following Veterans would be more likely to accept a supply of naloxone spray?
 
Background/Purpose: Veterans aged 65 years and older, due to physiological changes experienced through the aging process, are at an increased likelihood of developing enhanced side effects to opioids and sedatives. Due to these concerns, access to naloxone in older adults prescribed a combination of opioid prescriptions plus sedatives is important to reduce the risk of opioid overdose. The purpose of this quality improvement project is to assess whether pharmacist led prescribing increases naloxone access to older adult Veterans in comparison to naloxone prescribing by a primary care provider at the SVAHCS.  

Methodology: Older adult Veterans with an active opioid prescription plus a sedative (barbiturates, benzodiazepines, medications for opioid use disorder, non-benzodiazepines, and skeletal muscle relaxants) will be included. To further assess risk, the Stratification Tool of Opioid Risk Mitigation (STORM) will also be utilized. Through the Opioid Overdose Education & Naloxone Distribution (OEND) dashboard one hundred Veterans meeting these criteria will be identified. Fifty Veterans will be contacted and offered a naloxone prescription alongside naloxone education. A retrospective chart review will be completed to assess if 50 Veterans with scheduled PCP appointments from December 1st, 2024 to February 28th, 2025 were prescribed naloxone by their PCP.

Results: The baseline characteristics of this project include average age 73 years old ± 5.4,  94.6% (n=88) male sex,  75.3% (n=70) white race, and predominant comorbidities were obstructive sleep apnea 45.2% (n=42) and chronic obstructive pulmonary disease 34.4% (n=32). 94.6% (n=88) of Veterans included had a commitment opioid + sedative hypnotic prescription, 6.5% (n=6) included had concomitant opioid + benzodiazepine prescription, 93.5% (n=87) were chronic opioid users, average morphine equivalent daily dose 35.7 ± 38.2, and on average each Veteran had an average of 1.6 ± 1 additional CNS active medications. The primary objective was met in 88.7% (n=42) of Veterans who were initiated on a naloxone prescription by a pharmacist in comparison to 8.3% (n=4) of Veterans receiving a naloxone prescription after their PCP appointment. The secondary objectives resulted 75.6% (n=34) chronic opioid users, 82.2% (n=37) low STORM risk, 17.8% (n=8) medium STORM risk for the targeted pharmacist initiation component and 93.8% (n=45) chronic opioid users, 79.2% (n=38)  low STROM risk, 20.8% (n=10) medium STORM risk for the standard of care, PCP initiation component.

Conclusions: Targeted pharmacist naloxone prescribing yielded positive results. Results are attributed to personalized conversations tailored to Veteran’s medications which increased the acceptance of naloxone supply, opioid overdose education, and medication burden counseling. Overall, naloxone acceptance was unrelated to chronic opioid use, STORM risk, or specific CNS depressant medication. Additionally, naloxone under-prescribing during standard of care in comparison to targeted pharmacist prescribing is likely multifactorial.

Contact Information: elizabeth.martinezdelgado@va.gov

Title: Comparing Fall Risk in Older Adults on Chronic Opioids versus Buprenorphine Therapy


Authors: A. Garrett Allegra, Olivia Caron, Tasha Woodall


Objective: To analyze potential differences in fall risk in older adults on chronic full-agonist opioid therapy versus chronic buprenorphine therapy


Self Assessment Question: What correlation, if any, was seen in this study between buprenorphine use and fall risk reduction when compared to full-agonist opioids?


Background: Minimizing fall risk in older adults is a pillar of geriatric medicine, and pharmacists play an important role in decreasing the use of fall-risk-increasing drugs (FRIDs) in this population1. One such class of medications is opioids, which have been shown to significantly increase fall risk, injury from falls, and fractures in older adults2. Some data suggest that buprenorphine, a partial opioid agonist, increases fall risk as well; however, buprenorphine and full-agonist opioids have not been directly compared3. The objective of this study was to examine the rate of positive fall screenings among older adults prescribed opioids versus those prescribed buprenorphine.


Methods: Eligible patients met the following inclusion criteria: family medicine patient at Mountain Area Health Education Center (MAHEC) in Asheville, NC; age > 65 years at time of fall screen; and active buprenorphine, full-agonist opioid, or partial-agonist opioid on medication list at time of fall screen. Patients taking both buprenorphine and a full-agonist opioid and patients whose opioid was prescribed for an acute injury related to a fall were excluded. A retrospective chart review of eligible patients was conducted to compare the rate of positive fall screenings among patients who take chronic opioids versus patients who take chronic buprenorphine. Data collected during these chart reviewed included opioid product on medication list, duration of therapy, milligram morphine equivalents (MMEs), fall risk screening score, renal function, and concomitant FRIDs for comparison.


Results: A pre-existing registry of 733 patients who take chronic opioids was analyzed to identify 211 older adults who were taking chronic opioid therapy at the time of their most recent fall screening. An additional registry was compiled listing 80 patients taking chronic buprenorphine. This list was analyzed via chart review to identify 29 older adults who were taking buprenorphine at the time of their most recent fall screening. Data analysis was performed and yielded no significant difference in positive fall risk screening rates between individuals taking buprenorphine and those taking full agonist opioids (69% vs 58%, p-value not reported). There was also no difference seen in rates of injuries from fall between groups (24% for buprenorphine, 25% for opioids). There was a statistically significant difference in fall rate between all female patients enrolled in the trial (65%) compared to male patients (48%, p=0.037) and between all patients under 75 years old (52%) and those 75 years or older (69%, p=0.026). 


Conclusion: This trial showed no statistical difference in fall risk between buprenorphine and full agonist opioids in adults aged 65 years or older. There was, however, a significant increase in fall risk among women and patients 75 years or older who take an opioid product of any kind. The association between various opioid products and fall risk among subpopulations warrants further investigation with larger sample sizes.

Implementation and Analysis of a Pharmacist-Managed Heparin Infusion Service at an Academic Medical Center 
Abigail Mason, Brittany White, Emily Goodwin, Ashley Williams, Jesse Briscoe, Kyle Knapp

Background
Unfractionated heparin is widely used as a first-line anticoagulant for hospitalized patients due to its rapid onset of effect and short duration. Given the inherent risk of bleeding with heparin administration, frequent lab monitoring is required to maintain target lab levels and to minimize risk of adverse effects. An internal analysis of a historic nurse-led heparin infusion protocol revealed frequent protocol non-compliance and deviations resulting in a facility change to a pharmacist-led protocol in December 2023. This project compares historic lab outcomes and safety events between nurse-driven and pharmacy-driven heparin protocols.

Methods
This IRB-approved, retrospective cohort analysis compared laboratory and safety outcomes between historic nurse-led protocol and pharmacist-led protocol. Patients meeting the following criteria were identified for inclusion in the pharmacist-led cohort: age greater than 18 years, admission to Erlanger Baroness Hospital, and receipt of the standard, reduced-dose, or low-dose Heparin Infusion Protocols between March 1, 2024 and March 30, 2025. Patients were excluded if they received heparin therapy for less than 24 hours or if the baseline activated partial thromboplastin time (aPTT) exceeded 40 seconds. The primary outcome of this study was difference between cohorts in mean time, in hours, to first aPTT result at or above the protocol-specified target range. Results were stratified by heparin infusion protocol. Secondary outcomes included pharmacist-led heparin protocol adherence, mean number of aPTT checks in therapeutic range, and documented bleeding events during the hospitalization. Adherence to heparin protocols in the pharmacist-led group was assessed in three domains. This included selection of correct initial heparin bolus dose, correct initial infusion rate, and correct subsequent rate adjustments as specified by the ordered heparin protocol. Additionally, the mean time from aPTT result to pharmacist order change and time from pharmacist order change to nurse medication administration was analyzed.

Results: The implementation of a pharmacist-managed heparin service at Erlanger resulted in a statistically significant reduction in the median time to achieve the primary outcome of first therapeutic aPTT or higher, decreasing from 10.1 hours in the nurse-managed group to 6.3 hours (p<0.0001). This significant improvement was observed across standard-dose (10.4 to 6.3 hours, p<0.0001), reduced-dose (10.0 to 6.4 hours, p=0.0207), and low-dose protocols (9.0 to 6.2 hours, p=0.0099). Regarding secondary outcomes, the pharmacist-managed group demonstrated a statistically significant decrease in the percentage of sub-therapeutic aPTT checks per patient (40% to 31%, p=0.0003) and a significant increase in therapeutic checks (p=0.0180) compared to the nurse-managed group. Notably, there were no significant differences between groups in the rates of supratherapeutic aPTT checks or aPTTs exceeding 150 seconds. Pharmacist adherence to the protocol was high at 95.4%, with a median time of 4.5 minutes from lab result to order entry and 18 minutes to rate change documentation.

Conclusions: In conclusion, the pharmacist-managed heparin service at Erlanger effectively improved the time to therapeutic anticoagulation and improved the proportion of therapeutic aPTTs without increasing the risk of excessive anticoagulation.

Title: Improving Antimicrobial Stewardship Through Penicillin Allergy Verification in a Rural Setting


Authors: Nicole M Kochmann, Abigail J. White, Bryan “Russ” Gunter


Objective: Decrease the number of incorrectly documented penicillin allergies in a rural population.  

Background: Approximately 10% of patients report a penicillin allergy, however, up to 90% of these are not true allergies. Inaccurate allergy documentation contributes to unnecessary use of broad-spectrum antibiotics, increasing the risk of antimicrobial resistance, adverse events, and healthcare costs. This project aimed to review current penicillin allergy documentation, identify areas for improvement, and determine patient eligibility for allergy testing or delabeling using the PEN-FAST tool. This tool helps identify low-risk patients who may be eligible for a direct oral challenge without the need for referral or skin testing.

Methods: 
A total of 101 adult patient charts with documented allergies to penicillin,amoxicillin, or ampicillin were reviewed and PEN-FAST scores calculated. Patients were excluded if they lacked a primary care provider, had no visits in the past three years, or had a history of severe reactions.

Results: Eight charts were excluded due to intolerance rather than allergies. With the remaining 93 charts: 86 lacked sufficient information to calculate a PEN-FAST score, while only seven had complete information. These results highlight gaps in our allergy documentation process, limiting use of the PEN-FAST tool.

Conclusion: The current allergy documentation process lacks necessary information, making it difficult to accurately assess PEN-FAST scores. There is a need for improved education on documenting allergies beyond just the reaction itself. Next steps for this project include implementing multidisciplinary education, developing educational tools, creating an in-house oral challenge protocol for low-risk patients (PEN-FAST < 3), and establishing a referral process for higher-risk patients (PEN-FAST ≥ 3).

Title: Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitor Prescribing in Black/African American Veterans with Chronic Kidney Disease (CKD) and Type 2 Diabetes Mellitus (T2DM) Living in a Rural Area   

Authors: Madison Barrier, Camille Robinette, Meghan Mark, Allison Strain  

Objective: Evaluate and initiate SGLT-2 inhibitors in Black/African American Veterans with T2DM and CKD 

Self-Assessment Question: 
Which patient should be initiated on an SGLT-2 inhibitor?
A: 50 year old with T1DM and CKD, eGFR 45
B: 70 year old with T2DM and CKD, eGFR 15
C: 67 year old with T2DM and CKD, eGFR 35
D: 59 year old with T2DM and CKD, on dialysis

Background: SGLT-2 inhibitors reduce intraglomerular pressure and improve tubuloglomerular feedback resulting in delayed CKD progression in Veterans with and without T2DM.  Approximately 1 in 3 adults with T2DM also have CKD with higher rates of Black/African American individuals experiencing CKD. Based on the 2022 Kidney Disease Improving Global Outcomes (KDIGO) guidelines, an SGLT-2 inhibitor is recommended for Veterans with CKD, T2DM, and eGFR greater than or equal to 20 mL/min/1.73m2. 
Many Veterans at the Salisbury Veterans Affairs Health Care System (SVAHCS) are impacted by both T2DM and CKD. Approximately 20% of Veterans served by the SVAHCS live in rural areas and may have challenges accessing care. Offering telephone visits and mailing educational materials to rural Veterans may improve access to preventative healthcare without the need for traveling to a physical location.  

Methods: This quality improvement project will be conducted by enrolling Veterans via chart review to conduct telephone visits for SGLT-2 inhibitor education, prescribing, and follow-up. Veterans will be identified using the VA Academic Detailing Diabetes Patient Report with parameters for rurality, race, disease states (T2DM and CKD), and exclusion criteria. Veterans identified will be reviewed and assessed for inclusion in the project. Veterans will be contacted for an introduction to the population health clinic, project intention, and scheduling an initial visit with a pharmacist. The initial population health clinic visit will be conducted via telephone by a pharmacist to provide patient education and initiation of an SGLT-2 inhibitor, empagliflozin, in accordance with VA national formulary. A telephone follow-up scheduled for approximately one month after SGLT-2 inhibitor initiation will be used to assess tolerability and medication adherence. Further follow-up and management will be transitioned back to the Veterans’ established primary care teams.  

Results: A total of 45 Veterans were contacted based on the initial chart review, 20 agreed to appointments with a pharmacist to discuss the use of SGLT-2 inhibitors for CKD and T2DM and were subsequently included in the quality improvement project. The majority of patients were male 19 (95%) with an average eGFR of 51.85 mL/min/1.73m2 and A1c of 6.9%. During the initial visit with a pharmacist, 11 (55%) Veterans agreed to starting an SGLT-2 inhibitor. During all scheduled appointments, Veterans were provided verbal medication counseling, offered a pill box and/or testing supplies to assist with T2DM care if needed, and educational material was mailed after the conclusion of the visit for further review. Of the 11 patients who initiated an SGLT-2 inhibitor, 10 reported medication adherence (missing 2 or fewer days per week). At the time of follow-up, one Veteran reported an adverse effect (urinary tract infection) that resolved at subsequent follow-up.  Follow-up renal function testing was performed between weeks 3 and 10 from medication initiation. Average eGFR decreased by 2.1 mL/min/1.73m2 as expected based on documented literature.  

Conclusion: Based on the results of this quality improvement project, many Veterans are willing to initiate an SGLT-2 inhibitor for CKD and T2DM management. The most common reason for declining initiation was patient preference, followed by patients wanting to discuss with their primary care provider.  Due to the small sample size and limited project duration, no direct therapeutic effect was measured in the results of this project.  

Title: Assessing Renal Function After Hepatitis C Treatment with a Pangenotypic Direct-Acting Antiviral: Sofosbuvir/Velpatasvir and Glecaprevir/Pibrentasvir

Authors: Chloe McGee, Charity Nora, Karli Nelson

Background: The 2023 American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) guidelines for the treatment of hepatitis C virus (HCV) recommend the use of pangenotypic direct acting antivirals (DAAs), such as sofosbuvir/velpatasvir (SOF/VEL) and glecaprevir/pibrentasvir (GLE/PIB), for all six major HCV genotypes. Treatment success is defined as undetectable HCV RNA levels at twelve weeks after treatment end, also known as sustained virologic response (SVR). In addition to impacting the liver, HCV has been associated with other negative effects including an increased risk of developing chronic kidney disease (CKD). While DAAs have been studied for safety and efficacy among patients with diagnosed CKD, there is a lack of data on the impact of HCV treatment with a pangenotypic DAA on renal function. The purpose of this study is to determine if successful treatment of HCV with a pangenotypic DAA leads to an improvement in renal function.

Methods: This was an IRB approved, observational, single center, retrospective chart review, which included adults eighteen years and older who achieved a twelve-week SVR after treatment of HCV with a pangenotypic DAA (GLE/PIB or SOF/VEL) between January 1, 2017 and January 1, 2024. Exclusions included non-compliance to the treatment regimen, history of kidney or liver transplant, end stage renal disease, or previous HCV treatment. The primary outcome was the change in serum creatinine from baseline to twelve-week SVR. Secondary endpoints included change in estimated glomerular filtration rate, percentage of patients achieving a 0.3 mg/dL or greater decrease in serum creatinine and change in chronic kidney disease classification. Data analysis to include descriptive statistics and paired t-tests as appropriate.

Results: A total of seventy-seven patients were included (44 in the SOF/VEL group and 30 in the GLE/PIB group). At baseline, over 90% of patients had an eGFR >60 ml/min/1.73m2. The median serum creatinine increased from 0.82 mg/dL at baseline to 0.88 mg/dL at 12 week SVR (p < 0.001). The median eGFR decreased from 95.5 mL/min/1.73 m2 to 88.0 mL/min/1.73 m2 at 12 week SVR (p < 0.001). 60% of patients did not have a change in their CKD eGFR category from baseline to 12 week SVR.

Conclusion: While a statistically significant worsening of renal function was detected, the clinical significance of a 0.6 mg/dL increase in serum creatinine is low. Additionally, when reviewing the change in CKD eGFR category, the majority of patients did not have a change in category. Based on these results, successful treatment of HCV with SOF/VEL or GLE/PIB did not result in a clinically significant change in renal function.

Title: Evaluation of Outpatient Parenteral Antimicrobial Therapy and Antimicrobial Stewardship Program Practices at a Veterans Affairs Medical Center


Authors: Alley Minton, Bailey Guest, Cassidy Prewitt, Galina Wang


Objective: To evaluate the efficacy of OPAT.


Self Assessment Question:  Which of the following is an example of a patient who would likely qualify for OPAT through SVAHCS?


Background: Outpatient parenteral antimicrobial therapy (OPAT) refers to the delivery of parenteral antimicrobial treatment in at least two doses on different days without requiring hospitalization. Many individuals are eligible for OPAT with the intent to effectively treat the ongoing infection with medical oversight, reduce or offset hospitalization, decrease healthcare costs and improve quality of life. Antimicrobial stewardship plays a crucial role in promoting the safe and appropriate use of antimicrobials to combat the rise of antibiotic resistance. Hospitals that have implemented antimicrobial stewardship programs (ASP) have reported significant reductions in unnecessary antibiotic prescriptions and improved patient outcomes. At the Salisbury Veterans Affairs Health Care System (SVAHCS), the OPAT program is overseen by a full-time Infectious Diseases physician assistant, with essential support from the Infectious Diseases (ID) clinical pharmacist practitioner (CPP), an ID/Acute Care CPP, and rotating ID physician oversight. This OPAT program is unique due to majority of requests for OPAT originate from surrounding non-VA healthcare facilities. In 2023, OPAT maintained a consistent enrollment of 149 patients, compared to 158 in 2022 and 122 in 2021, with various treatment regimens and durations.


Methods: This quality improvement project will be conducted as a retrospective cohort study. The main objective is to assess the efficacy of OPAT. Primary outcomes will focus on readmission rates to a hospital while receiving OPAT due to complications, adverse events, treatment failure or for reasons unrelated to infection or OPAT regimen. Secondary objectives include evaluating safety, antimicrobial stewardship interventions, the reduction of hospital bed days of care (BDOC) and intravenous (IV) line days avoided associated with OPAT. Secondary outcomes will include rate of OPAT completion, potential cost savings, 30-day readmissions post-OPAT (including reasons), and 30-day mortality following OPAT.


Results: 567 patient were extracted from data from January 2022 to December 2024. 398 patients were included, 122 patients did not meet inclusion criteria, and 47 were excluded by the exclusion criteria. 53 patients were readmitted during OPAT therapy, accounting for 13% of the total amount of patients included. The primary reason for readmission was due to concomitant disease which included 27 patients and 51% of the patients readmitted. Antibiotic failure was the second most common at 15 patients (28%), followed by adverse effects at 11 patients (21%). The readmission rate 30 days after OPAT completion only included 9 patients, 2% of the total patient population included. Comparable to the readmission rate, the primary reason for readmission was concomitant disease at 6 patients (66%) followed by 2 patients for antibiotic failure and 1 patient with C. difficile infection. The total OPAT completion rate was 97% with 386 patients. Mortality 30 days after OPAT was 1% with 5 patients. The average number of bed days of care avoided were 3,337 per year. The average number of IV-line days avoided were 134 per year. Over the 3-year span, there were 4,575 documented interventions. Aside from a high number of evaluations and follow-up reviews, laboratory monitoring, nonformulary requests, drug information, duration change, and medication change were the top 5 ASP interventions.


Conclusion: OPAT at the SVAHCS is an efficacious alternative to prolonged hospitalization to complete antimicrobial treatment. OPAT data that was collected over the past 3 years has shown improvement since OPAT was last evaluated in 2017 at SVAHCS. Readmission rates are comparable to current literature with approximately half being unrelated to infection. Almost all patients who initiated OPAT with the SVAHCS completed therapy successfully with minimal complications and low overall 30-day mortality. SVAHCS ASP is integrally involved in OPAT routinely recommending and now documenting interventions and potential cost savings through TheraDoc.

Contact Information: alley.minton@va.gov

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.

Submission Type: Resident Poster
Submission Category: Research-In-Progress
Submission Topic: Primary Care
Title: 
Pharmacist-Led Optimization of Sodium-Glucose Cotransporter-2 inhibitors in Veterans with Chronic Kidney Disease and Type 2 Diabetes Mellitus at the Carl Vinson VA Medical Center  
Purpose: 
Sodium-Glucose Cotransporter-2 inhibitors (SGLT2i) have been shown to reduce Chronic Kidney Disease (CKD) progression and cardiovascular events in patients with type 2 diabetes mellitus (T2DM) and comorbid CKD. Use of SGLT2i are recommended by both the American Diabetes Association (ADA) and Kidney Disease – Improving Global Outcomes (KDIGO). At the Carl Vinson VA Medical Center (CVVAMC), it is estimated that only 35% of Veterans with T2DM and CKD are prescribed a SGLT2i. The purpose of this project is to optimize the usage of SGLT2i in Veterans diagnosed with T2DM and CKD via a pharmacist-led medication management model. 
Self Assessment Question:
Which component of the nephron do SGLT2 inhibitors exert their mechanisms of action?
A. Loop of Henle
B. Distal convoluted tubule
C. Proximal tubule
D. Collecting duct
Methods:  
This performance improvement project was approved by the local P&T Committee on 01/24/25. The primary objective will be to increase the percentage of Veterans with T2DM and CKD who are prescribed an SGLT2i. Veterans will be identified via the National Academic Detailing Diabetes dashboard and contacted by a clinical pharmacist practitioner (CPP) to provide education about the benefits of SGLT2i; the CPP will offer and prescribe SGLT2i using shared-decision making.  Veterans will be included using the following criteria:  Diagnosis of T2DM and CKD, Primary Care Assignment at Dublin Main Campus,  Veteran resides in an area considered rural and high poverty, and male sex at birth.  Veterans will be excluded if they have Type 1 Diabetes Mellitus, active prescription for any SGLT2i (empagliflozin, dapagliflozin, canagliflozin), documented allergy or contraindication to a SGLT2i including frequent urinary tract or genital yeast infections, active prescription for foley catheter or diapers, receiving hemodialysis, or EGFR <20 ml/min/1.73m2. Empagliflozin is on the VA National formulary and will be the preferred SGLT2i. If the Veteran agrees to empagliflozin trial, the prescription will be mailed and they will be scheduled with a CPP within 4-6 weeks to monitor change in renal function and symptoms of urinary tract/genital yeast infections. 
Results:
A total of 243 Veterans were reviewed between July 2024 and March 2025. Of the 243, the majority were white (55.5%) with an average age of 74 years old.  Out of the 243 eligible veterans, 82 were eligible to receive treatment. The veterans were excluded for the following reasons: 14 veterans had an eGFR < 20 ml/min, 45 veterans did not have an active diagnosis of CKD, 22 veterans did not have an active diagnosis of Type 2 Diabetes Mellitus, 31 veterans had an anion gap value > 12, 7 veterans had a documented allergy to an SGLT2, 9 had urinary issues, 11 veterans were deceased, and 17 veterans were initiated on an SGLT2i prior to review. Of the 82 veterans eligible for treatment, 20 veterans were initiated on treatment (24.39%). Veterans were not initiated on treatment for the following reasons: primary care providers not agreeable to initiation, unable to reach, hypotension, dual care and following non-va providers, and declining treatment due to shared decision making. Empagliflozin was well tolerated in those in which it was initiated, and no adverse effects have been reported to date.
Conclusion:
This pharmacist-led performance improvement project met its primary objective by increasing the usage of SGLT2i in Veterans diagnosed with T2DM and CKD. Upon completion of the project 38.5% of patient were on SGLT2i which is an increase from the start of the project (35%).  The modest increase in the percentage of patients initiated on empagliflozin is attributed to the relatively low number of patients who met inclusion criteria for the project and the unscheduled nature of initial contact.  

Title: Are Healthcare Workers Ready to Tackle Social Determinants of Health? A Look at Current Practices and Preparedness
Author: Ariel Ford, Courtney E. Gamston, Lena McDowell, Lindsey Hohmann, Kimberly Braxton Lloyd
Background: Social determinants of health (SDoH) are non-medical factors that significantly impact health outcomes. A substantial portion of the United States adults have negative SDoH, or social risks, as reflected in key population statistics: 65.2 million live below or near the poverty line, with rural areas facing a higher poverty rate (15.4%) than the national average (12.8%) with a population of 46,108,315 living in rural areas. Additionally, 10.2% lack a high school diploma or equivalent and 26.2 million people of all ages are uninsured. A 2023 survey of Alabama pharmacists revealed that only 28% of their practice sites currently screen for SDoH, with most reporting discomfort and a lack of preparedness to assess and address these factors. This study aims to evaluate SDoH screening, referral practices, and provider readiness across healthcare disciplines in Alabama to inform strategies for improving current practices. 
Methods: A 2025 anonymous survey was distributed to pharmacists, physicians, and nurses in Alabama to assess how each profession currently addresses SDoH, including screening, referrals, and follow-ups. The survey also examined provider interest in screening and managing SDoH, previous training, and perceived comfort and preparedness in identifying social needs and connecting them with local resources. Descriptive statistics were used to characterize participants, practice settings, and current approaches. Comparisons across the three provider groups were conducted using ANOVA for continuous data and Chi-square analysis for categorical variables, offering a more comprehensive understanding of SDoH screening and referral practices in Alabama.
Results: In progress
Conclusion: In progress

Title: Contraception on Demand, Increasing Patient Access to Contraceptives Within the Gulf Coast Veterans Health Care System
 
Authors: Annelle L. Drake, Hayley R. McCarron, Tiffany D. Jagel
 
Background: In 2018, approximately 9% of the Veteran population was female and is expected to increase to 17% by 2040. The general population has a 6% chance of developing Post-Traumatic Stress Disorder (PTSD) at some point in their lives, but female Veterans have a 13% chance. PSTD increases the risk of gestational diabetes, preeclampsia, preterm births, prolonged hospitalizations surrounding delivery, and increases the risk of rehospitalization. Beginning in 2021 at the VA clinics in Puget Sound and Pittsburgh, Clinical Pharmacy Practitioners (CPPs) started the Contraception on Demand program that was later awarded the VHA Shark Tank Diffusion and Excellence Promising Practice. Their CPPs then saw 74 Veterans in 6 months and counseled Veterans on contraceptive options. Veterans were able to receive either a 3-month supply of a new contraceptive or a 12-month supply of their established contraception. 77% of patients agreed to some form of contraception, and 90% of the eligible Veterans elected to receive a 12-month supply. Data also suggested that a 12-month supply would save $87.12 per patient per year, while improving patient outcomes. On March 11, 2024, the diffusion of Contraception on Demand to the Gulf Coast Veterans Health Care System (GCVHCS) was approved.
 
Methods: A list was compiled from within the GCVHCS, and patients who were eligible were offered a clinic visit with a PACT Clinical Pharmacy Specialist to discuss a 12-month supply of contraception. Data was captured and analyzed on the percentage of patients who agree to an appointment, those who transition to a 12-month supply, reasons for denial, and other pharmacist interventions. In addition, data was captured on the referrals for IUDs, contraindications identified, and the percentage of patients who switched to a different form of contraception. The “PharmD Tool” within CPRS was utilized to track any additional pharmacist interventions.
 
Results: Of 320 patients with active prescriptions for contraception, 214 (66.88%) were eligible for enrollment. 144 (67.29%) patients agreed to have an appointment scheduled, 4 (1.87%) agreed to schedule an appointment but were not contacted by scheduling assistants, 45 (21.03%) Veterans declined the appointment offer, and 21 (9.81%) Veterans were mailed letters after three unsuccessful attempts to contact. The most common reason for declining an appointment was a lack of interest. Of the 144 Veterans who agreed to an appointment, 118 (81.94%) agreed to transition to a 12-month supply of their contraceptive. 16 (11.11%) Veterans declined transitioning. 10 (6.94%) patients did not attend their appointments. During these appointments, 29 additional interventions were captured via the PharmD tool within the electronic health record. One of the most frequent intervention made was discontinuing estrogen-containing oral contraceptives, which occurred during 9 appointments. The other most frequent intervention was conducting a Veteran's annual suicide screening questionnaire, which occurred during 9 appointments as well. Other interventions included medication reconciliation, contraceptive counseling, dispensing of pregnancy tests, referrals to specialists, and recruitment to primary care clinics for disease state management.
 
Conclusion: Overall, female Veterans were interested in receiving a 12-month supply and expressed great satisfaction with the implementation of Contraception on Demand. One unforeseen limitation to implementing Contraception on Demand related to the expiration date of the stock at the Central Mail Order Pharmacy used by the GCVHCS. Through identifying contraindications to estrogen-containing contraceptives, stroke risks were reduced and safety improved. By converting to a 12-month supply, between 468-1,404 refill requests were eliminated for the upcoming year, depending on whether Veterans were prescribed a 1-month or a 3-month supply on their original prescription. This reduction improves Veteran's access to medication, reduces potential lapses in care due to delays in mail, and saves Veteran's time from having to request refills from the VA.

Title: Impact of Pharmacist Intervention on Optimizing Guideline Directed Medication Therapy Prescribing of GLP-1 Agonists and/or SGLT2 Inhibitors in High-Risk Patients with Diabetes


Authors: Holly Johnson, Min Chul Kim, Amanda Stankowitz, Alexander Tunnell, TiShay Perry


Objective: To determine if targeted pharmacist interventions could effectively address identified barriers and optimize the prescribing of GDMT in this patient population.


Self-assessment Question: True or False: Targeted pharmacist interventions optimized the prescribing of GDMT in this patient population.


Background: The 2024 American Diabetes Association guidelines recommend glucagon-like peptide-1 receptor agonists (GLP-1RA) or sodium-glucose cotransporter-2 inhibitors (SGLT2i) as first-line agents for adult type 2 diabetic patients at high-risk of or with a history of atherosclerotic cardiovascular disease (ASCVD). Per these guidelines, high-risk for ASCVD is defined as those with end organ damage or multiple cardiovascular risk factors. A medication use evaluation was conducted from January 1st, 2024 to March 31st, 2024 at WT Anderson Community Health Center (WTACHC) and revealed that only 45% of high-risk type two diabetic patients were prescribed recommended guideline directed medication therapy (GDMT) of either a GLP-1 agonist or SGLT2i. Potential barriers to prescribing were identified. The purpose of this study was to determine if targeted pharmacist interventions could effectively address identified barriers and optimize the prescribing of GDMT in this patient population.


Methodology: For this single-centered, IRB-approved, prospective comparative study investigators assessed all adult type two diabetic patients seen at the WTACHC for ASCVD risk status. The pre-intervention cohort included patients from January 1st, 2024 to March 31st, 2024, and the post-intervention cohort included patients from October 1st, 2024 to December 31st, 2024. A daily list of targeted pharmacist interventions to initiate a GLP-1RA or SGLT2i for eligible patients was then generated and presented to physicians for review. The primary outcome of this study was the rate of appropriately prescribed GDMT of either a GLP-1RA or SGLT2i following provider education and pharmacist intervention. Secondary outcomes included the percent of patients with a documentation for not receiving GDMT, percent of patients without documentation but with a presumed reason for not receiving GDMT, and percent of pharmacist interventions accepted. Statisical analysis included independent chi-square tests. 


Results: A total of 180 patients were included in the pre-intervention cohort and 266 in the post-intervention cohort. The primary outcome of the rate of appropriately prescribed GDMT in high-risk patients increased by 10% (95% CI, 0.59% to 19.41%, p=0.078), from 45% (95% CI, 37.7% to 52.3%) in the pre-intervention cohort to 55% (95% CI, 49% to 61%) in the post-intervention cohort. An 8% decrease was seen for the secondary outcome of patients with a documented reason for not receiving GDMT (95% CI, -3.84% to 19.84%, p=0.23), dropping from 34% (95% CI, 24.6% to 43.4%) in the pre-intervention cohort to 26% (95% CI, 18.7% to 33.3%) in the post-intervention cohort. However, there was a 1% increase in the percentage of patients without a documented reason but with a presumed appropriate reason for not receiving GDMT (95% CI -4.81% to 6.81%, p=0.96), increasing from 5% (95% CI, 0.7% to 9.3%) in the pre-intervention cohort to 6% (95% CI, 2.1% to 9.9%) in the post-intervention cohort. Overall, 142 targeted pharmacist interventions were made, with an acceptance rate of only 14%.


Conclusions: The rate of appropriately prescribed GDMT did increase in the post intervention cohort but was not determined to be a statistically significant difference. Additionally, the interventions did not result in a significant increase in the percentage of patients with a documented reason for not receiving GDMT. Despite the educational efforts, there was a decrease seen in documentation for this population. There was also no significant change in the percentage of patients without a documented reason but with a presumed appropriate reason for not receiving GDMT, and most pharmacist interventions were not accepted. The lack of statistically significant results in this study may be attributed to the interventions being conducted on paper rather than in face-to-face interactions. Future studies could consider more personalized, individualized interventions to improve outcomes for each patient.

Title: Does corrected calcium adequately reflect calcium levels in critically ill patients?


Authors: Allison Krueger, Caitlin Thomas


Objective: Review methods to assess patients’ calcium status and whether corrected calcium accurately represents the status of critical care patients.


Self Assessment Question: Which of the following is TRUE regarding the original Payne corrected calcium equation?


Background: Abnormalities in calcium status are common among critically ill patients, and disturbances in calcium status have been linked with increased mortality and morbidity. Accurate representation of calcium status is key in managing patients in the intensive care unit (ICU). There are two main ways of measuring calcium in a blood sample: total serum calcium (totCa) and ionized calcium (measurement of unbound calcium). Since only approximately half of the serum calcium is biologically active under normal conditions, equations were developed to estimate that value using serum calcium levels before labs were capable of directly testing ionized calcium. The most well know adjustment is the modified Payne equation that “corrects” totCa from reduced albumin levels. A formula by Pftizenmeyer et al. in 2007 was designed to “correct” totCa for very elderly patients in a facility that does not utilize iCa. The purpose of this study is to evaluate the accuracy of albumin corrected calcium and total serum calcium compared to ionized calcium at discerning calcium homeostasis in patients requiring critical care.


Methods: This is a single-center, retrospective cohort study that was deemed exempt from Institutional Review Board approval. It was conducted in a large, tertiary level, community teaching hospital with patients across seven adult ICUs. The electronic medical record was reviewed for inclusion in the study. Patients were included if the following labs were collected with 10 minutes of each other: ionized calcium, serum calcium, and serum albumin. Patients were excluded if they received albumin within the 24 hours prior to the lab collection and/or received intravenous calcium within the 12 hours prior to lab collection. The primary outcome is to assess total calcium and modified Payne corrected calcium for noninferiority to ionized calcium.  


Results: A total of 25 patients were included in this study. The mean levels for iCa, totCa, and corCa were 1.12 mmol/L, 8.4 mg/dL, and 9.5 mg/dL respectively. There was a statistical difference between the three mean levels (F = 11.35, p < 0.001). There was a statistical difference between the three methods at categorizing calcium status (Q = 7.98, p = 0.0185). Total calcium was found to be the outlier. Bland-Altman analysis of totCa shows a mean difference of 0.13 mmol/L (95% CI -0.06 – 0.32). Bland-Altman analysis of corCa shows a mean difference of 0.01 mmol/L (95% CI -0.15 – 0.17).


Conclusion: Total calcium was inferior to iCa when it comes to assessing patient calcium status. This study found that corCa compared to iCa was noninferior at predicting normocalcemia. Furthermore, the Bland-Altman analysis shows that, when comparing methods for getting an accurate value, both total calcium and corrected calcium have too wide of variations to accurately rely on them.

Title: Evaluating the safety of transitioning to an adalimumab biosimilar from the reference product (Humira®) in adult patients with rheumatic conditions 


Authors: Riya Shah, Michelle Morales, Ava Afshar, Katina Tsagaris


Objective: To compare the difference between treatment emergent adverse events (TEAE) in patients on brand Humira® (adalimumab) compared to when switched to an adalimumab biosimilar for a non-medical reason. The goal is to provide real world, timely reference data for clinical practice regarding any safety differences. 


Background: Biosimilars are highly similar to an FDA-approved biologic medication, known as the reference product, and are expected to have no clinically meaningful differences in terms of efficacy and safety. Biosimilars were introduced to increase market competition and offer efficacy that is not clinically different from the reference product but at lower cost, thus increasing access. Since 2023, ten FDA-approved adalimumab (ADA) biosimilar products have entered the US market. Insurance companies have adjusted their prescription formularies since the launch of these biosimilars, with many now mandating patients switch from the reference product, Humira®, to an adalimumab biosimilar instead. 
Given the recent introduction of adalimumab (ADA) biosimilars, their real-world safety profile in a US population with rheumatic conditions remains unclear.


Methods: A single center, paired-sample, retrospective study was conducted at the two outpatient Emory Rheumatology Clinics at Emory University Hospital Midtown (EUHM) in Atlanta, GA. Eligible patients were identified via the electronic medical record. Inclusion criteria consisted of adults managed and prescribed Humira® by an EUHM rheumatologist. Patients must have been on Humira® for at least 3 months before switching to an ADA biosimilar for a non-medical reason by an EUHM rheumatologist. In addition, the switch must have occurred between 1/1/2024 and 9/1/2024 with one or more documented clinical follow-up(s) by 11/30/2024, the end of the study period, following the ADA biosimilar initiation. The primary outcome was the differences of TEAE in patients on Humira® compared to an ADA biosimilar. This was determined by comparing the number of TEAE reported on Humira® the 3 months before the ADA biosimilar switch and the number of TEAE reported while on ADA biosimilar through 11/30/2024. Secondary outcomes included ADA biosimilar discontinuation rate by the end of the study period, reason for biosimilar discontinuation (if applicable), and the type of TEAE experienced. 


Results: A total of 177 patients switched from Humira® to an ADA biosimilar between 1/1/2024 and 9/1/2024 of which 94 met inclusion criteria. Of these, 9 patients (9.6%) reported TEAE with 7 reported side effects while on Humira® and 12 while on an ADA biosimilar. Two patients had TEAE on both
Humira® and 12  while on an ADA biosimilar. Two patients had TEAE on both Humira® and the ADA biosimilar, four patients had TEAE on Humira® but none with the ADA biosimilar, and three patients had no TEAE on Humira® but did on the ADA biosimilar (p = 1.000, 0.75 (95% CI 0.110- 4.433)). The following TEAE were reported with Humira®: pruritus (n=2), itchy eyes (n=1), injection site reactions (n=3), and abdominal pain (n=1). Patients reported the following on the ADA biosimilar: pruritus (n=1), scaly skin (n=1), sores on scalp (n=1), inner ear itch (n=1), spreading rash (n=1), malaise (n=1), dizziness (n=1), nausea (n=1), peeling skin (n=1), injection site reaction/redness and swelling (n=1), burning upon injection (n=1), and genital itching (n=1). In addition, 11 of 94 patients (11.7%) discontinued the ADA biosimilar for reasons like insurance preference (2/11, 1.8%), adverse events (3/11, 2.7%), decreased efficacy (3/11, 2.7%), pregnancy (1/11, 0.9%), treatment de-escalation (1/11, 0.9%), and unclear (1/11, 0.9%). 
  
Conclusion: No statistically significant difference was found between the number of reported TEAE when patients were on Humira® versus when switched to an ADA biosimilar. The majority of patients tolerated both Humira® and the ADA biosimilars, however, there were numerical differences in the amount of TEAE on each of the medications. A larger sample is needed to determine if a difference exists in TEAE amongst patients on Humira® versus when switched to an ADA biosimilar.  

Title: Development and Implementation of a Web-based Escape Room with Embedded Principles of Pharmacist Independent Prescribing

Authors: Christy Sherrill, Haley Simkins, Meg Parmelee

Objective: The primary objective of this pilot study is to assess change in pre/post acceptance and knowledge of ambulatory care and pharmacist prescribing, as well as diabetes-related knowledge following educational intervention utilizing a web-based escape room format. 

Background: As the plain of education advances, there arises an increased need for the development of new and adaptable teaching strategies to enhance learning outcomes across a variety of platforms that speak to all learning styles and settings. In this current era, we have many advances in technology to employ, including the idea of gamification, which has been identified as a creative strategy to give learners real-life, hands-on experience in a virtual platform. Over recent years, the utilization of the virtual escape room has become a popular educational tool in medical education. In this research study, ambulatory care and pharmacist prescribing are the two key content focuses, and students will be exposed to these concepts through a web-based escape room utilizing diabetes as the clinical topic. This escape room will teach ambulatory care and pharmacist prescribing processes initially in the context of diabetes, with the hopes to expand to other disease states as a “plug and play” option.

Methods: The primary research aims of this study are to assess the impact that simulation using gamification has on student pharmacists’ acceptability and knowledge of the pharmacist’s scope of practice, to investigate the effect of simulation using gamification on student pharmacists’ diabetes-related knowledge and confidence, and to analyze student pharmacists’ perceptions of simulation using gamification for educational purposes. To accomplish these aims, after initial focus group and beta testing, a finalized escape room was piloted among pharmacy students from varying years of study completing didactic coursework on the University of North Carolina Asheville campus and experiential education in the Asheville area. Students completed a pre-survey, then conducted the escape room in 30-minute time slot, followed by a debrief and 10 minute immediate-post survey. Results of the pre and post surveys were analyzed for quantitative and qualitative data. The pre-survey and post-survey contained a 12-item knowledge assessment on diabetes management principles and a 12-item confidence assessment on the principles of independent prescribing. Results were compared pre- and post-escape room activity.

Results:  After completing the activity, average scores on the diabetes-related knowledge assessment improved from 76.75% to 89.82%. This was a significant improvement as evidenced by a p-value <0.05 (two-tailed paired t-test). Four questions performed the same pre and post activity. Seven questions performed better post-activity. One question performed worse, with only 4 students answering correctly. Participants answered 7 out of 12 questions 100% correctly post-activity. All questions were answered correctly by at least 80% of students, aside from Q2 as an outlier. In regard to confidence levels, students saw improvement in confidence level on every one of the 12 confidence questions.

Conclusions: Participants in this pilot study saw statistically significant improvement in overall knowledge of diabetes management principles and increases in confidence with regards to principles of independent prescribing immediately after completion of the escape room. Participants overall were happy with the virtual escape room as a fun and more engaging learning platform, citing room for improvement in the usability of the interface, as well as future considerations for expanding the potential uses of the platform.

Title: Retrospective Review of Dual CGRP Targeted Treatment Regimens for Acute and Preventive Treatment of Migraines 
Authors: Amanda Forrest,  Alison Martin, Dallin Billow
Objective: The purpose of this project will be  to assess the safety and efficacy of dual CGRP-targeting therapies for the use in preventive and acute migraine treatment in a Veteran population.
Self-Assessment Question:
KJ is a 35 yo F experiencing severe, frequent migraines. Her past medical history includes CAD and DM. Currently she is complaining of 20 migraine days per month, with an average pain intensity of 7-9/10. She is currently utilizing erenumab 70 mg SC monthly for migraine prevention with limited benefit. She comes to your clinic requesting something for acute treatment. Which of the following would you recommend?

• Ubrogepant 100 mg as needed
• Atogepant 60 mg daily
• Sumatriptan 100 mg as needed
• None of the above since she has CAD and is already taking a CGRP targeting medication

Background:
Several medications targeting calcitonin gene-related peptide (CGRP) have been approved for acute treatment and prevention of migraines. Controversy exists in utilizing the concomitant use of these agents given their similarities in mechanism, and limited data to support concurrent use. Current guidelines/position statements recommend these medications given their established efficacy, but do not address using them concurrently. Limited literature is available to assess their current place in therapy when used concomitantly.
Methods: 
This project was a medication use evaluation, utilizing electronic patient prescribing records and retrospective chart review. The primary objective was to assess the safety of dual CGRP-targeting therapies when used in combination for the prevention and acute treatment of migraines. Secondary exploratory objectives sought to assess the efficacy of these combination treatment regimens. Patients were included if they had a documented diagnoses of migraine and were concomitantly using a preventive CGRP-targeting regimen and gepant for acute migraine treatment between April 1, 2023 and January 15, 2025. Patients were excluded if they no longer received care from the VA healthcare system or the VA neurology team. Safety and efficacy outcomes were collected via retrospective chart review and analyzed and reported using descriptive statistics.
Results:
Of the 96 patients screened, 89 were included in the final analysis. Majority of patients were female (60.7%), with a mean age of 46.8 years and had a diagnosis of chronic migraines (75.3%). 149 unique dual CGRP targeting regimens were identified and included in the safety analysis, 59 of which were eligible for the exploratory efficacy analysis. 14 regimens were excluded from the efficacy analysis, leaving a total of 45 regimens included in the efficacy analysis. No new and or concerning adverse reactions were identified. Only 7 adverse drug reactions were reported in total per subjective patient reporting. There was no median change in migraine intensity or duration found in the efficacy analysis (0.0, p=0.184, 0.0, p=.917 respectively). Subjectively, 10 patients on dual CGRP therapy reported the addition of a gepant for acute treatment was effective, 20 reported ineffective and 29 had a lack of documentation.
Conclusions: The use of concomitant dual CGRP targeting agents for migraine treatment and prevention, appear safe and well tolerated. Efficacy data was limited in this study and more large scale, randomized controlled trials are needed to fully assess this endpoint.

Title: What Medications Are Most Prescribed but Never Filled? Predictors of Nonadherence in Medicare 5-Star Population


Authors: Caleb Williams, Nadia Hason, Naomi Yates


Contact: Caleb.x.williams@kp.org


Objective: 
Primary: Evaluate the most abandoned therapies within the Medicare 5-Star population
Secondary: Compare the different demographic factors (gender, age, race, ethnicity) and measurable factors (PCP relationship, mail order utilization, comorbidities, lab values) and how they influence first fill adherence in the Medicare 5-Star population


Self-Assessment Question: 
Which factor was consistently associated with increased medication adherence across all therapeutic categories (hypertension, diabetes, and high cholesterol)?
a) Age
b) Female gender
c) Mail order pharmacy (answer)
d) Race (black vs white)


Background:
Medication adherence significantly impacts patient outcomes and healthcare costs in the United States, particularly for chronic conditions such as diabetes, hypercholesterolemia and hypertensions. The first fill of a new maintenance medication is critical for establishing long-term therapy success, as failure to initiate treatment can indefinitely delay care, increase the risk of complications, and contribute to over $170 billion in annual healthcare expenditures. Identifying and addressing barriers is essential for improving early adherence and optimizing patient outcomes.


Methods:
This is a retrospective, IRB-exempt cohort study that included all Medicare 5-Star patients who were prescribed but did not fill generic oral diabetes, antihypertensives and/or statin medications from May 31^st, 2023, to June 1^st, 2024. Patients not enrolled at Kaiser Permanente through the full study duration were excluded. The primary outcome was to identify the most frequently abandoned therapies within the Medicare 5-Star population. The secondary outcome was to compare the different demographic factors, such as gender, age, race, ethnicity or measurable factors such as a lack of PCP relationship, underutilization of mail order, comorbidities, laboratory values and how they influence first fill adherence.


Results:
Between 5/31/2023 and 6/1/2024, a total of 27,674 Medicare 5-Star patients were included in the analysis of first-fill adherence for diabetes, hypertension, and statin medications. Among these, 6,408 were prescribed an oral diabetes medication, 17,714 were prescribed a hypertension medication, and 17,305 were prescribed a statin medication. The overall first-fill rates were highest for hypertension medications (97.9%), followed by statins (96.5%) and diabetes medications (95.0%).
Several factors were significantly associated with higher odds of filling a first prescription across all three medication classes. A recent primary care provider (PCP) visit within the last 12 months was the strongest predictor of first-fill adherence, with odds ratios (OR) of 3.08 (95% CI: 2.47–3.83) for hypertension medications, 2.30 (95% CI: 1.92–2.75) for statins, and 1.81 (95% CI: 1.39–2.35) for diabetes medications (p < 0.0001 for all). Enrollment in kp.org was also associated with increased adherence, with ORs of 1.61 (95% CI: 1.24–2.09) for hypertension medications, 1.36 (95% CI: 1.09–1.71) for statins, and 1.48 (95% CI: 1.09–2.02) for diabetes medications (p < 0.05 for all).
Conversely, depression or the use of antidepressants was associated with lower adherence. Patients with depression had lower odds of filling their initial antihypertensive (OR 0.72, 95% CI: 0.56-0.91) or antidiabetic prescriptions (OR 0.64, 95% CI: 0.49 – 0.833, p < 0.05 for both). Additionally, racial disparities were observed, as Black/African American patients were significantly less likely to fill their first prescription compared to White patients for both diabetes (OR 0.72, 95% CI: 0.55–0.95) and statin medications (OR 0.74, 95% CI: 0.61–0.90, p < 0.05 for both).
Use of mail order pharmacy was strongly associated with first-fill adherence across all medication groups. Patients who used mail order had significantly higher odds of filling their first prescription compared to those using retail pharmacy, with ORs of 2.35 (95% CI: 1.89–2.93) for hypertension medications, 2.28 (95% CI: 1.92–2.71) for statins, and 1.78 (95% CI: 1.40–2.28) for diabetes medications (p < 0.0001 for all).
 
Conclusion:
This study aimed to identify key factors associated with first-fill adherence for diabetes, hypertension, and statin medications among Medicare 5-star patients. The findings suggest that patients with recent PCP visits, kp.org enrollment, and mail order pharmacy use were significantly more likely to fill their first prescription, while those with depression or taking antidepressants and certain racial/ethnic backgrounds exhibited lower adherence rates.

Title: Impact of Required Stop Times for Continuous Intravenous Fluid on Duration of Fluid Therapy

 Authors: 
Lauren Hudson
Jessica Briscoe
Christopher Wilson
 
Background: 
While continuous intravenous (IV) fluids are widely administered, inappropriate use is associated with significant adverse effects, including increased risk of fluid overload, electrolyte disturbances, and mortality. Despite these complications, recommendations regarding continuous IV fluids are lacking. At the study institution, a required IV fluid duration was implemented in the electronic medical record, which mandates a provider to schedule a stop time on continuous IV fluids when placing the initial order. This study aimed to determine the effect of preemptive stop times for continuous IV fluids on duration of fluid therapy and patient outcomes.
 
Methods: 
This single center, retrospective, observational study was approved by the Institutional Review Board. Adult patients admitted to the general ward on a hospitalist service for at least 24 hours with orders for continuous IV fluids for at least 12 hours were included. Exclusion criteria included requirement for renal replacement therapy prior to admission or receipt of continuous fluids for cancer-related complications (i.e. tumor lysis syndrome), dysnatremias, pancreatitis, rhabdomyolysis, diabetic ketoacidosis, high output fistulas, total parenteral nutrition, or sepsis. The primary outcome of this study was to compare the duration of fluid therapy pre-and post-implementation of required stop times on continuous IV fluid orders. Duration of fluid therapy was assessed until hospital discharge or through 30 days after initiation. Secondary outcomes of this study included comparison of total volume of continuous fluids administered through day 5, hospital length of stay (LOS), incidence of intensive care unit (ICU) admission related to fluid overload, and any incidence of electrolyte disturbances throughout fluid administration. Nominal data was analyzed using a Chi-square or Fischer’s exact test. Continuous data was analyzed via Student’s t-test or Mann-Whitney U.
 
Results: 
A total of three hundred and fifty patients were included. Median duration of fluid therapy at 30 days was shorter in the post-protocol group compared to the pre-protocol group (1 day vs 2 days, p-value < 0.001). Median maintenance fluid volume at day 5 was lower in the post-protocol group compared to the pre-protocol group (1875 mL vs 3100 mL, p-value < 0.001). There were statistically significant reductions in the incidence of electrolyte disturbances, fluid overload, diuretic requirement, and increased oxygen requirements in the post-protocol group.
 
Conclusions: 
Implementation of a required stop time on continuous IV fluids orders reduced the duration of fluid therapy and volume of fluids administered. Further evaluations should be performed to assess the role that required stop times play in reducing hospital costs.

Background: 
Effective communication skills are essential for pharmacy students, as they directly impact patient care and counseling quality. Traditional methods such as role-playing, simulated patients, and virtual patient interactions are commonly used in pharmacy education to enhance these skills. However, these approaches have notable limitations, including increased faculty workload, the need for trained standardized patients, and the high cost and potential technical challenges of virtual simulation software. The integration of artificial intelligence (AI) presents an innovative solution to address these challenges. The purpose of this study was to assess first-year pharmacy student confidence gains in communicating with patients using an AI chatbot in a communications course. 


Methods: 
First-year pharmacy students at the University of Georgia College of Pharmacy participated in this study. ChatGPT prompts were developed to simulate patient interactions, guiding the chatbot to engage with students as if they were patients picking up a new prescription. Embedded rubrics assessed students' soft skills, accuracy of medication counseling, and use of PRIME questions. The chatbot provided real-time feedback on strengths and areas for improvement. 
Electronic surveys measured students' confidence before and after a graded standardized patient activity. Confidence was assessed across seven domains: patient introduction, patient interviewing, use of probing questions, active listening, nonverbal communication, patient-centered education, and provision of accurate medication information. Students initially registered for ChatGPT and completed a pre-survey capturing demographics and baseline counseling confidence. They then engaged in a chatbot-guided counseling session before a week-long independent practice period. A post-survey followed the first graded standardized patient session to evaluate changes in confidence. Students had the option to use the chatbot again before a second graded encounter, after which they completed the same post-survey. Descriptive statistics analyzed demographic data, and a Wilcoxon Signed Rank Test assessed changes in confidence based on pre- and post-survey results following chatbot utilization. 


Results
A total of 145 first-year pharmacy students enrolled in the Pharmacy Intercommunications course at the University of Georgia. Of these, 117 completed all components of pre- and both post-surveys. Among pre-survey respondents (n=126), 70.3% reported pharmacy work experience, with 60.7% (n=88) having experience in a community setting. Additionally, 57% (n=72) had at least one year of work experience. Prior to the study, 62.8% had used ChatGPT, while 35.9% reported feeling comfortable using it. A Wilcoxon Sign-Rank Test indicated that median post-survey ranks for confidence across all 7 confidence domains were statistically significantly higher than the pre-survey ranks. The largest changes were seen in confidence introducing oneself to the patient and stating the purpose of the interview (Z=6.82, p<0.001), interviewing and assessing patient knowledge by using PRIME questions (Z= 6.954, p<0.001), using probing questions to clarify information (Z=6.941, p<0.001), tailoring counseling to meet patient specific needs (Z= 5.457, p<0.001), and providing complete and accurate information during the counseling session (Z= 5.19, p<0.001). A Wilcoxon Sign-Rank Test comparing confidence between the first post-survey and the second post-survey indicated that median post-survey ranks for confidence were statistically significant across all domains with the exception of confidence in the ability to demonstrate active listening (Z=0.885, p=0.376) and confidence in communicating interest and confidence through body language (Z=1.825, p=0.068).  


Conclusions
Incorporating an AI chatbot as a counseling tool in the classroom resulted in a statistically significant increase in first-year pharmacy students’ confidence when counseling a graded simulated patient. These findings highlight the potential of AI as an effective educational tool to enhance student learning.

Title: Clinical Impact of GLP-1 and GIP/GLP-1 Receptor Agonist Access Issues in a Primary Care Setting

Authors: Alexandra Cochran, Laura Schalliol, Savannah Owen, Holly Lowe, and Gabriella V Rosellini

Objective: 
The primary objective is to evaluate the percent change in HbA1c for the prescribed GLP-1 or GIP/GLP-1 receptor agonist for the treatment group compared to the control group. 
The secondary objectives are to evaluate the change in weight and BMI for the prescribed GLP-1 or GIP/GLP-1 receptor agonist for the treatment group compared to the control group and to observe the medication adjustments made to maintain glycemic control in the absence of a GLP-1 and GIP/GLP-1 receptor agonist therapy.

Self Assessment Question: What are some potential strategies to mitigate the impact of GLP-1 and GIP/GLP-1 receptor agonist access issues on patient outcomes?
A. Expanding patient assistance programs
B. Utilizing SGLT2 inhibitors or insulin as alternatives
C. Implementing clinic-based sample programs
D.  All of the above

Background: Type 2 diabetes mellitus (T2DM) is a growing global health concern that requires comprehensive management to minimize complications. The complications of T2DM, including cardiovascular disease, chronic kidney disease, neuropathy, and retinopathy, can significantly impact a patient’s quality of life and overall health outcomes. Effective management of T2DM includes not only controlling blood glucose levels but also promoting weight management. However, despite significant advancements in diabetes therapies, many patients still struggle to achieve optimal control due to barriers such as medication costs, accessibility, and adherence.
The introduction of glucagon-like peptide-1 (GLP-1) receptor agonists, such as liraglutide, semaglutide, dulaglutide, and exenatide, revolutionized T2DM treatment by providing both glycemic control and weight reduction. The widespread use of GLP-1 receptor agonists has led to improved health outcomes, especially in patients with comorbid cardiovascular disease, and have become a cornerstone in the management of T2DM. Moreover, the recent advent of dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonist, tirzepatide, has shown significant metabolic effects as well.
Despite the efficacy of these therapies, challenges in accessing GLP-1 and GIP/GLP-1 receptor agonists have emerged as a significant issue for many patients. Medication shortages, delays in prior authorization, and high out-of-pocket costs can impede timely access to these treatments, disrupting the continuity of care. Access barriers are particularly concerning, as they can lead to periods of inadequate glycemic control. Furthermore, patients who experience these disruptions may need to rely on less effective therapies

Methods: This study is a single-center, retrospective cohort analysis that utilizes medical records accessed via the electronic health record. Medical records were screened for patients prescribed any of the studied medications between January 1, 2022, and July 31, 2024. Inclusion criteria included adult patients aged eighteen years or older and having a T2DM diagnosis. Once included, patients were further divided into a treatment group and a control group. Exclusion criteria included patients who were younger than 18 years of age, with either no follow-up documentation or a medication discontinuation due to adverse effects.
 
Results: A total of 379 patients were reviewed for this study, with 247 patients meeting the inclusion criteria. Of these, 51 patients experienced an access issue with the prescribed GLP-1 or GIP/GLP-1 receptor agonists while 196 were included but did not experience any of the studied access issues. Of the 247 patients included, the average age was 59.5 years with 49% of the patient population being male.
The average change in HbA1c was -0.42% in the treatment group and -0.75% in the control group (p = 0.2128), indicating no statistically significant difference. Similarly, the average weight change was -1.91 kg in the treatment group and -2.13 kg in the control group (p = 0.7022). BMI changes followed a comparable trend, with an average reduction of -0.7 kg/m2 in the treatment group and -0.75 kg/m2 in the control group (p = 0.812).
 
Conclusion: Access issues for GLP-1 and GIP/GLP-1 receptor agonists can lead to clinically significant changes in glycemic control, weight, and BMI in patients with T2DM. This study reinforces the need for proactive management strategies and a collaborative approach among healthcare providers to mitigate the effects of access issues on patient health outcomes. Further research is needed to explore the long-term effects of medication access interruptions, including their impact on diabetes-related complications and overall patient outcomes. Additionally, studies should investigate the efficacy of alternative therapies, such as SGLT2 inhibitors or insulin regimens, in maintaining glycemic control when GLP-1 and GIP/GLP-1 receptor agonists are unavailable.

Title: Evaluation of the Impact of a Pharmacist-led Smoking Cessation Clinic Within a Primary Care Setting


Authors: Tiffany Gilchrist, Victoria McCarthy, Zil Tyler, Regan Wilson


Objective: To evaluate the effectiveness of a pharmacist-led smoking cessation clinic over a three-year period at the Piedmont Athens Regional Clay Community Care Clinic (CCCC)

Background: Smoking cessation plays a critical role in disease prevention and can significantly improve patient health outcomes. Pharmacists can be a great resource to assist individuals with smoking cessation due to their extensive background in pharmacotherapy and easy accessibility. This retrospective study aimed to evaluate the effectiveness of a pharmacist-led smoking cessation clinic over a three-year period at the Piedmont Athens Regional Clay Community Care Clinic (CCCC). This study hypothesized that patients who establish care with a pharmacist will demonstrate higher quit rates compared to patients who do not establish care with a pharmacist.
  
Methodology: This was a single-center, retrospective chart review of adult patients with a history of cigarette smoking referred to the CCCC pharmacist-led smoking cessation clinic from July 1, 2021 to June 30, 2024. Patients interested in smoking cessation are referred to the pharmacist-led smoking cessation clinic by their primary care provider. However, some patients do not establish care despite pharmacist outreach efforts. The primary outcome of this study is the percentage of patients who successfully quit smoking. Secondary outcomes include the percentage of patients who relapsed after quitting and the percentage of patients who successfully quit after previous unsuccessful quit attempts. Pre-specified subgroup analyses were evaluated for patients who established care with a pharmacist which included time to quit, percentage of patients who adhered to pharmacotherapy if prescribed, percentage reduction of cigarettes smoked from baseline, the percentage of patients who quit after receiving medication and behavioral counseling vs percentage of patients who quit with behavioral counseling alone, and the total number of follow-up visits completed with a pharmacist in patients who quit. Data collected included current cigarette usage at each encounter, pack-year history, pharmacological agents if prescribed, number of follow-up visits, reason for discharge, previous quit attempts, and if patients relapsed after quitting. Continuous data was analyzed using the Mann-Whitney U test and presented as an interquartile range (IQR) or medians. Categorical data was analyzed using the Chi-Square test and presented as percentages or numbers. Statistical significance was met for the primary and secondary outcomes of the study if the p < 0.05. 
  
Results: A total of 171 eligible patient referrals were reviewed, with 150 patients meeting the inclusion criteria. Baseline characteristics were similar between groups, with an average age of 53.5 years and 51.5% male patients. Among the 75 patients who did not establish care with a pharmacist, 67 (89%) did not receive smoking cessation pharmacotherapy. In the intervention group, the most commonly utilized pharmacotherapy was nicotine replacement therapy, prescribed in 54.6% of cases. The primary outcome—patients who quit smoking—was achieved in 14.7% of patients managed through the pharmacist-led smoking cessation clinic, compared to 1.3% of patients who did not establish care (p = 0.003). For secondary endpoints, there was a significant difference in patients who quit smoking after previous unsuccessful quit attempts (13.3% vs. 0%, p = 0.02). No significant difference in patients who relapsed after quitting was found between both groups (5.3% vs. 0%, p = 0.46).
  
Conclusions: In conclusion, patients who established care with a pharmacist had a statistically significant improvement in successful smoking cessation. 

Title: Evaluation of a Pharmacist-Led Cardiovascular-Kidney-Metabolic (CKM) Initiative 


Objective: To evaluate the impact of a pharmacist-led cardiovascular-kidney-metabolic (CKM) initiative to assist in early detection in management of CKD to slow disease progression and prevent cardiovascular disease. 


Background: In 2023, the American Heart Association (AHA) published a presidential advisory on Cardiovascular- Kidney-Metabolic (CKM) Health, which defines CKM syndrome as a health disorder attributable to connections among obesity, diabetes, chronic kidney disease (CKD), and cardiovascular disease (CVD), including heart failure, atrial fibrillation, coronary heart disease, stroke, and peripheral artery disease. The AHA recommends that patients be screened across their life span with the main aim to reduce the risk of CKD progression and prevent associated cardiovascular outcomes. This wholistic approach includes patient-centered pharmacologic and nonpharmacologic therapy which may include treatment of obesity, diabetes, hypertension, hyperlipidemia, and CKD to reduce cardiovascular disease risk factors. In order to slow progression and prevent associated adverse outcomes of CKM, it requires an interdisciplinary team of nephrology, cardiology, endocrinology, and primary care. However, there are barriers to this wholistic approach which include provider difficulty managing risk factors, provider concerns about adverse drug reactions , patient acceptance, affordability of treatment, and lack of comprehensive integrated clinical information systems. The inclusion of a clinical pharmacist in this multidisciplinary team can help address these barriers to increase the number of patients on guideline-directed therapy with the ultimate goal to reduce CKD and CVD risk in CKM. Pharmacists at our institution have implemented a CKM initiative to assist in early detection in management of CKD to slow disease progression and prevent cardiovascular disease. 


Methods: A single-center retrospective chart review was conducted at Piedmont Columbus Regional Midtown Family Medicine Center and Piedmont Community Health Clinic to evaluate the impact of the pharmacist-led CKM initiative conducted between October 1, 2024, through February 28, 2025. The study included patients screened by clinical pharmacists at Piedmont Columbus Community Health and Piedmont Columbus Family Medicine and excluded patients on renal replacement therapies and renal transplant patients. The primary outcome was the percent of patients receiving CKM screening with an actionable recommendation by the pharmacist [obtainment of a laboratory assessment, addition of guideline directed therapy, adjustment in guideline directed therapy doses, or referral to the pharmacist managed clinic for chronic disease state management (DM, HTN, HLD, CKD, obesity management, smoking cessation)]. Secondary outcomes included percent of patients on guideline-recommended therapies for CKM pre- and post-intervention, percent of patients diagnosed with CKD through screenings, percent of patients with a positive clinical outcome, and number of medications obtained through patient assistance programs. Descriptive statistics were used to analyze the primary objective and both chi-square and descriptive statistics were used to analyze the secondary outcomes.  


Results: In progress


Conclusion: In progress

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.

Title: Implementation of the Pharmacogenomic Testing for Veterans (PHASER) Program among High Suicide-Risk Veterans: A quality improvement project


Authors: Adirika Obiako, Christina Laird, Shari Brown, Tiffany Jagel


Objective: The primary objective of this quality improvement project is to increase testing and evaluate the impact of implementing PHASER in patients that are at a high risk of suicide who are on a mental health medication impacted by the PHASER panel.


Background: PHASER is an initiative designed to provide patients and providers access to high quality, evidence-based pharmacogenomic laboratory testing and recommendations that help optimize medication efficacy and reduce trial and error prescribing. The PHASER panel tests 15 different genes and multiple alleles that impact drug metabolism of over 73 commonly prescribed medications.


Methods: Patients flagged for a high risk for suicide have been identified from the High-Risk Flag Patient Tracking Report. Once these patients were identified, patients’ mental health medication regimen was reviewed to see if they were taking any mental health medications that were impacted by the PHASER testing panel. Patients on the high suicide risk dashboard were contacted and offered testing. Testing was ordered and scheduled for patients that were agreeable. Patients completed a one-time blood draw which was sent to a third-party testing facility where the test was performed and analyzed. Results were uploaded to patient medical records. The results highlight the type of metabolizer for each of the 15 genes and which of the 73 medications may require dose modification. Medications impacted were listed. When required, evidence-based dose adjustments were advised to prescribers based on Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. 


Results: 19.7% of candidates completed testing and their appointment with the pharmacogenomics pharmacist to review results for potential medication changes. Variants for cytochrome enzymes involved in pharmacogenomics influenced major depressive disorder medication metabolism were common. CYP2B6 and CYP2C19 had 53.6% variance present. CPY2D6 had 54% variance present. All of the patients included in the project had 1 of 3 cytochrome enzymes impacted and 51.3% who had 2 or more impacted. An average of 4.6 of the panel's 16 pharmacogenomic influenced major depressive disorder medications were impacted. 33.3% of patients had an actionable variant for a currently prescribed major depressive disorder medication and 20% required a pharmacogenomic guided dosage adjustment due to patient reported adverse drug event. These patients had been on their major depressive disorder medication for less than 3 months. 46.3% had been on major depressive disorder therapy for 3 months or more with no issues reported with adverse drug events or efficacy.

Conclusion: Definitive conclusions cannot be draw outside of the objective data reported, but some interesting parallels with what has been reported in the literature were noted. The literature reports Veterans carry at least 1 pharmacogenomic variant that can impact therapy decisions. We found these patients averaged 6 variants that impacted an average of 16 medications on the 73-medication panel. 1.6 of those variants were for a cytochrome enzyme involved in processing of pharmacogenomic influenced medications for major depressive disorder. Literature reports patients fail an average of 2-3 medications before finding symptom relief with depression. For 80% of the patients that completed testing this was true. These patients failed an average of 2.5 trials and this included pharmacogenomic influenced major depressive disorder medication trials only, it did not include trials for major depressive disorder medications that are not influenced by pharmacogenomics.

Title: A Dose of Change: Advancing Buprenorphine Induction Practices in the ED
Authors: Samantha Keen, Rebecca Maloney
Objective:  Final pending
Self Assessment Question: Final pending
Background: 
Opioid use disorder (OUD) continues to be one of the most pressing public health crises in the United States, claiming thousands of lives each year through overdose and contributing to a wide range of social, health, and economic burdens. Emergency departments (EDs) often serve as critical initial points of care for veterans in acute opioid-related crises, yet many leave without access to evidence-based treatment. This initiative aims to improve care quality by implementing standardized buprenorphine induction protocols in the ED, focusing on reducing barriers to treatment initiation and facilitating transitions to outpatient care. Despite the strong evidence and growing support for buprenorphine induction in the ED, our facility does not currently offer this service to veterans presenting with OUD. This gap in care is significant, as veterans who come to the ED for issues related to opioid use often leave without being connected to ongoing treatment, leading to continued cycles of misuse and repeated ED visits. Implementing standard buprenorphine induction protocols in the ED would help bridge this gap, providing veterans with immediate access to life-saving treatment and significantly improving their chances of long-term recovery.  By addressing logistical challenges, enhancing care coordination, and fostering staff engagement, the project seeks to improve patient outcomes, reduce ED recidivism, and promote continuity of care for veterans with OUD.
Methods: 
This prospective interventional cohort study will be conducted in the emergency department at the James H Quillen VA Medical Center.  The study will consist of two phases: a baseline period (pre-implementation) and an intervention period (post-implementation).  During the baseline period, data will be collected retrospectively on patients presenting with OUD to the ED and treated with standard care.  During the intervention period, a buprenorphine induction protocol with an order set will be implemented.  Education on appropriate use of the protocol will be provided to the ED mental health providers.  This intervention will be implemented as part of standard of care treatment for this quality improvement project.  Following implementation and education, this intervention will be considered standard of care for management of OUD in the ED.  Data collection for both phases will include the number of patients screened, buprenorphine inductions performed, and rates of successful outpatient referrals.   Following evaluation of the data collected, continuous monitoring of outcomes and quality metrics will occur.   Outcomes measured will be the number of patients who receive a buprenorphine prescription through the ED and referrals the SUD clinic.  
Results: In progress
Conclusions: In progress

Title: 
Pharmacist-Led Deprescribing of Inappropriately Prescribed Inhaled Corticosteroids in Veterans with Chronic Obstructive Pulmonary Disease


 Authors:
Jessica Parks, Amber Jefferson, Lauren Howard, Cassandra Warsaw


Introduction:
Chronic obstructive pulmonary disease (COPD) management consists of bronchodilators and inhaled corticosteroid (ICS). ICS use is recommended with a history of COPD hospitalizations, two or more moderate COPD exacerbation within the last two years, eosinophil (EOS) count of 300 cells/µL or higher, or if the patient is diagnosed with concomitant asthma. ICS should be considered as a last-line option due to increased risk for oral candidiasis, hoarse voice, and pneumonia. Previous studies have shown benefits of pharmacist-led clinics for the management of chronic disease states. The purpose of this quality improvement initiative was to investigate the impact of pharmacist-led deprescribing of inappropriately prescribed inhaled corticosteroids in Veterans with COPD, regardless of initial ICS-containing regimens.


Methods:
Retrospective chart reviews were completed for the initiative. A total of 123 Veterans, identified using the COPD Dashboard, were included in the review. Descriptive statistics were used for data analysis. Veterans were included if assigned to the designated primary care clinic, diagnosed with COPD, and had an active ICS prescription. A total of 54 Veterans met inclusion criteria. Charts were reviewed for an appropriate indication for ICS use. Updated pulmonary function tests (PFTs) and complete blood cell counts (CBC) were scheduled with consent. If the ICS was deemed inappropriate, then the pharmacist contacted the Veteran via telephone to provide education and utilized Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines to determine appropriate therapy. Veterans were contacted via telephone to conduct a COPD management appointment, and based on patient-specific factors, the pharmacist recommended to either discontinue or continue the ICS-containing inhaler. If an ICS was discontinued, a long-acting muscarinic antagonist (LAMA) or LAMA/long-acting bronchodilator agonist (LABA) was prescribed as alternative therapy. Interventions were documented in the electronic health record using a specified note template. Data collection occurred between July and November 2024. The project was approved by the Pharmacy and Therapeutics committee as a quality improvement initiative, which is exempt from IRB approval.


Results:
Upon examination of charts, it was noted that PFT results and CBC lab work were outdated in accordance to GOLD guidelines for COPD therapeutic management. A total of 21 Veterans obtained updated PFTs and 9 Veterans obtained updated CBC labs. There were a total of 54 Veterans that met inclusion criteria and there were a total of 33 Veterans deemed appropriate for ICS deprescribing. Overall, 76% (N=25) of Veterans agreed to ICS de-escalation.


Conclusions:
The data collected further supports the necessity of pharmacist-led clinics to ensure appropriate medications are prescribed and monitoring parameters are upheld. Additionally, pharmacist-led deprescribing of inappropriate ICS inhalers reduces the risk of adverse effects and enables pharmacists to identify patients requiring updated COPD monitoring.

Title: Impact of a Remote Continuous Glucose Monitoring Service in an Ambulatory Care Setting
Authors: Alexa Williams, Matthew Holt, Ryan Cromer, TJ Henderson, Aayush Patel
Background: Continuous glucose monitoring (CGM) offers an alternative to the traditional self- monitoring blood glucose methods. Traditional methods, which may negatively impact patient satisfaction, cannot account for glycemic excursions and hypoglycemic unawareness. CGM provides more data points to assess glycemic variation and generates an ambulatory glucose profile (AGP) which provides calculated percentages of time in range (TIR), time below range (TBR), and time above range (TAR) for glucose levels in a measured time period as well as hourly. The reported glycemic trends can be used by providers to better understand the time and frequency glucose levels are out of the recommended range and customize diabetes regimens appropriately. At the Piedmont Columbus Family Medicine Center, many patients have begun using CGMs to share data with their providers. Based on glycemic trend data, providers can make informed decisions on customizing patient-specific regimens and continue to monitor their patient’s blood glucose levels closely. The purpose of this retrospective chart review was to compare the mean difference in A1c improvement between patients managed with remote CGM and those managed without this service in a multidisciplinary family medicine practice. 
Methods: A retrospective chart review was completed of patients with diabetes at Piedmont Columbus Family Medicine Center with a baseline A1c ≥7, comparing those utilizing CGMs with those not utilizing CGMs. Improvement in A1c was determined from the baseline A1c at the beginning of the study to the final A1c level recorded for each patient. The mean difference in A1c was determined from all patients within each group and the overall improvement in A1c between the control group and the treatment group was compared. The LibreView® and Dexcom Clarity® systems were used to store patient’s blood glucose levels from their CGM to determine TIR, TBR, and TAR within various date ranges. Baseline TIR, TBR, and TAR were determined at the beginning of the study time period and then again around the time of each A1c measured for each patient. Improvement in TIR, TBR, and TAR were determined from baseline to the final values measured at the end of the study. Data was collected from patients beginning on January 1, 2024 until February 28, 2025.
Results: There was a total of 78 patients included in the study, 39 patients that utilized CGM and 39 patients that did not utilize CGM. Baseline characteristics were similar between groups, with the largest difference seen in race and diabetes type. For the primary objective of mean difference in A1c, the CGM patients had a baseline A1c of 9.3% and a final A1c of 8.1% with an average reduction of 1.2% and the non-CGM patients had a baseline A1c of 8.0% and a final A1c of 6.7% with an average reduction of 1.3%. The mean difference in A1c was not statistically significant between groups. For secondary objectives, the CGM patients had a total baseline TIR of 53.8% and a final TIR of 57.2% with an average increase of 3.3%, a total baseline TBR of 0.5% and a final TBR of 0.6% with an average increase of 0.1%, and a total baseline TAR of 45.7% and a final TAR of 42.2% with an average reduction of 3.5%. These secondary objectives were not statistically significant. There was a total of 189 pharmacy interventions, 172 in the CGM group and 17 in the non-CGM group.
Conclusion: Continuous glucose monitoring offers an alternative to traditional finger stick monitoring, providing glucose trends and reports such as the ambulatory glucose profile including detailed analysis of time in, above, and below range. The impact of A1c was similar between groups, however the duration of patient inclusion for non-CGM patients was higher, offering more time for patients to better control their diabetes. While there was not a statistically significant difference seen between groups, average A1c was improved when utilizing a CGM, which may provide a good option for patients with uncontrolled diabetes.
Contact: alexa.williams@piedmont.org

Title: A Retrospective Evaluation of an Electronic Medical Record Alert to Pharmacists on the Incidence of Inappropriate Medication Administration in Patients with Feeding Tubes 

Authors: Devin O'Brien, Rosemary Garbowski, Matthew Lane, Saumil Vaghela

Background: Medication administration is an important part of the foundation for medication safety and efficacy. Various studies have demonstrated the frequency of inappropriate administration of medications through a feeding tube. Many of these studies have shown that pharmacist interventions can positively impact the percentage of medications administered appropriately in patients with feeding tubes. Few studies have evaluated the effectiveness of a pharmacist-directed alert on the appropriate administration of medications. The purpose of this study was to evaluate the effectiveness of an electronic medical record alert to pharmacists on the incidence of inappropriate medication administration in patients with feeding tubes.  

Methods: A retrospective chart review was conducted using the electronic medical record (EMR) at an acute care community hospital. Chart reviews were conducted on patients with tube feeding (TF) orders who were admitted prior to and following implementation of the EMR alert. The pre-implementation period was between June 1, 2024 and August 31, 2024. The post-implementation period was between October 1, 2024 and December 31, 2024. A wash-out period was designated between September 1, 2024 and September 30, 2024 to ensure that all patients with a TF order triggered the alert to pharmacists in the EMR. Patients were included if they had a TF order placed and had at least one scheduled medication ordered to be administered enterally. Patients were excluded if they were covered by a service that participated in daily multidisciplinary team rounding, as the medications for these patients were individually evaluated regardless of the pharmacist-directed alert. The primary outcome for this study was the composite incidence of inappropriate medication administration and medication administration omissions in patients with feeding tubes (for example: crushed medications that should not be crushed per the package insert or a liquid administered through the feeding tube that has potential for binding to the feeding tube). The secondary outcome for this study was inappropriate administration of high risk medications. All data points collected for each patient were compiled in an electronic spreadsheet. 

Results: A total of 52 patients were included in the study, 29 in the pre-implementation group and 23 in the post-implementation group. For the primary endpoint of composite incidence of inappropriate medication administration and medication administration omissions,122 errors were found in the pre-implementation group and 71 in the post-implementation group. For the secondary outcome of inappropriate administration of high risk medications, there were zero patients in both groups. 

Conclusion: An EMR alert to pharmacists to evaluate medications in patients with feeding tubes may help to decrease the number of inappropriate medication administrations