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Evaluation of cangrelor appropriateness and safety at a community hospital
MUE - PGY1 Pharmacy Residency at Memorial Hermann - KATY
Presented at: Vizient in New Orleans, LA (Dec 2024)
Madison Kalke, PharmD; Olivia Kreidler, PharmD, BCCCP
Background: Cangrelor, the only intravenous (IV) P2Y12 inhibitor, is preferred for rapid platelet inhibition due to its pharmacokinetic profile and reversibility. However, when oral options are available at a much lower cost, cangrelor continues to be a formulary-restricted drug within our health system. The health system reserves cangrelor for patients not pretreated with oral P2Y12 inhibitors before percutaneous coronary intervention (PCI) or as bridging therapy before cardiac surgery.
Objectives: The primary objective of this study is to evaluate the appropriateness of cangrelor utilization for PCI or as a bridging therapy option. Secondary outcomes include evaluating the proper transition from cangrelor to oral P2Y12 inhibitors and safety outcomes based on major bleeding events.
Methods: This retrospective chart review was conducted at a PCI-capable community hospital from August 2023 to August 2024. The study included inpatients aged 18 years or older who received at least one dose of cangrelor. Patients for whom cangrelor was ordered but not administered were excluded. The data were characterized using descriptive statistics.
Results: Among the 31 patients, cangrelor was used for anti-platelet therapy during PCI in 81%, for anti-platelet bridging in cardiac procedures in 16%, and for non-cardiac procedures in 3% of cases. The reasons for choosing IV over oral P2Y12 inhibitors included 38% for urgent PCI without pretreatment, 35% with no clear indication, 13% due to intubation, 6% because the patient was NPO, and 3% each for heavy sedation and vomiting. All patients were peri-procedurally anticoagulated with IV heparin, with one receiving a combination of heparin and eptifibatide. Two patients (6%) experienced major bleeding events that required packed red blood cells transfusion. One bleeding event was attributed to a pre-existing gastrointestinal bleed before hospital admission. Almost three-quarters (74%) of patients were appropriately transitioned from IV to oral P2Y12 inhibitors, with 19% not requiring a transition and only 7% experiencing inappropriate transitions.
Conclusions: While cangrelor was administered correctly to all patients, 35% had no clear justification for its selection. These findings suggest that IV cangrelor may be overused within our hospital, where more cost-effective oral P2Y12 inhibitors could have been selected. Major bleeding events occurred in 6% of cases, with one possibly linked to cangrelor. Most patients were successfully transitioned to oral P2Y12 inhibitors, with only 7% experiencing inappropriate transitions. There is an opportunity to optimize cangrelor use by reserving it for cases where oral P2Y12 inhibitors are unsuitable.
Comprehensive Review of SETMuPP
Comprehensive Review of SETMuPP's legislative, practice transformation, and education efforts
Presented at: ISHP- Fall Event 2023
Madison Kalke- PharmD Candidate 2024; Renee Robinson- PharmD, MPH, MSPharm, MBA; Brandy Seignemartin, PharmD, Thomas Wadsworth, PharmD
Purpose: Sustainable Education and Training Model under Pharmacist Provider Reimbursement (SETMuPP) was developed to support advancement of pharmacists compensation models and practice conditions.
Methods: The demonstration project had three aims: Advocacy, Practice Transformation, and Education. Developing and delivering education was the primary focus of each aim, with differing models and audiences. Advocacy: live, in-person, interactive training provided to pharmacists. Practice Transformation: online, case-based learning forum modeled utilizing the ECHO model, a peer-supported, virtual learning framework Education: PharmD curriculum adapted to engage student pharmacists in simulations of the medical billing process.
Results: Pharmacists authority to bill for patient care services was realized, 28 pharmacists were trained in medical billing, and 218 student pharmacists have experienced education and simulations in billing for services.
Conclusion: As a result of this project pharmacist’s were supported in billing the medical benefit with efforts being made to progress future generations of pharmacists into advanced clinical roles.
CONSTRUCT
CONSTRUCT- Creating an Online Network Site and Teaching Repository Utilizing Case-based Trainings: Utilizing Backwards Design and the ECHO Model
Presented at: ASHP- Mid Year 2022
Madison Kalke- PharmD Candidate 2024; Thomas Wadsworth- PharmD; Renee Robinson- PharmD, MPH, MSPharm, MBA
Purpose: Pharmacists remain the most accessible healthcare providers, continually evolving to meet the ever-changing health needs within their communities (1). In Idaho and Alaska, pharmacists provide select healthcare and prevention-related services not related to dispensing medication. However, pharmacists are often not compensated for these services because they lack the necessary training and technology to support billing of the medical benefit.
To support appropriate billing of the medical benefit, the SETMuPP Project team (Sustainable Education & Training Model under Pharmacist Provider Reimbursement) created an online learning platform (PharMBL) to increase pharmacist understanding of the coding and billing process.
Methods: The software used for this project was Wix.com, a subscription-based website builder. Wix provides measurable analytics support for co-creation and technology troubleshooting. Within this software, participant contact lists can be embedded and used to develop automated sequences to provide additional content and context to training resources posted.
PharmBL, developed using backwards design, was created to support learning and participant interaction and serve as a repository for pharmacists to access while submitting their claims for payment. The website layout, inspired by the ECHO training model, employs didactic lectures, case presentations, and Q&A.
The learning methodologies applied (backwards design and ECHO Model) were chosen to support independent billing of the medical benefit. Backward design is the process of designing a lesson, unit, or course by first determining what the final outcomes are and then planning assessment strategies, and finally determining methods of instruction and assignments. Inspired by how healthcare providers learn during clinical rotations and residencies, the ECHO Model® has evolved into an interdisciplinary, interactive, virtual learning framework. During the ECHO session, a small didactic training component is presented by a panel of specialists; participants present real (anonymized) cases to the specialists—and each other—for discussion, and recommendations are provided and discussed. Participants learn from one another, expanding best practices and reducing disparities, a true multiplier effect.
Results: Analytics available through Wix are used to monitor trac over time, page visits, and navigation flow. Trac over time reports show distinct peaks before and after each training session, and page visit reports show that following the homepage, the most viewed pages are session topics and resources. This data, combined with navigation flow reports, shows a trend of users first navigating to the site for session topics and sign-up with a return visit afterward to navigate resources and submit cases.
In addition to Wix analytics, the SETMuPP Youtube channel, where videos are uploaded for site members to view post-session, shows a record of multiple views on most videos.
Conclusion: We anticipate that the evidence-based online training forum will increase the number of claims submitted by the attendees for non-dispensing pharmacy services provided and foster sustainable clinical practice.
PHARM-BLT: Bringing in the bacon
PHARM-BLT: increasing Pharmacist's in Healthcare Access to Resources through Medical Learning/ Teaching Forum: Bringing in the Bacon.
Presented at: ISHP- Fall Event 2022
Awarded 1st place in the student division
Madison Kalke- PharmD Candidate 2024; Thomas Wadsworth- PharmD; Elaine Nguyen- PharmD, MPH; Amy Paul- PharmD; Brandy Seignemartin- PharmD; Renee Robinson- PharmD, MPH, MSPharm, MBA
Background: Pharmacists provide a number of health-services not directly linked to the dispensing of medications; however, reimbursement for these clinical services has been limited by a number of factors including technology to submit claims, and necessary billing knowledge.
Purpose: To develop, test, and implement a billing and coding training program to support sustainable delivery of health services not directly linked to the dispensing of medications.
Method: To address this unmet educational need of pharmacists, we created an online, case-based learning forum modeled utilizing the ECHO model, a peer-supported, virtual learning framework. Bimonthly synchronous training sessions included a didactic component, attendee-led application (coding and billing cases), and expert-led question support. All sessions were recorded, and an online learning platform was created to serve as a repository for pharmacist training and program resources for pharmacy staff to utilize to submit insurance claims.
This project was deemed exempt by IRB as non-research.
LEGI
LEGI: Leading advocacy Efforts using Geographic Information Systems
Presented at: KDHS Research Day (March 2023)
Mary Spatafore, PharmD Candidate 2025; Duane Wood, PharmD Candidate 2024; Madison Kalke, PharmD Candidate 2024; Keith Weber MS; Samuel Preston, PharmD 2026; Renee Robinson, PharmD, PharmD, MPH, MSPharm, MBA
Background: Pharmacists have the necessary insight to redesign healthcare systems, reduce spending, and design and/or re-design payment systems. To ensure equity, a deliberate attempt must be made to influence health policy and support evidence-based health system change.
Objective: The goal of this program is to establish an infrastructure to better identify and engage individual pharmacists across the state to influence health policy and support health equity.
Methods: Updated state Legislative District Data and the “who represents me” state application were used to link members with state representatives using home addresses of paid pharmacists, technicians, and student members. The Geocode Addresses tool in ArcGIS Pro was used to create two updated state legislative coverage maps to determine engagement opportunities and needs based on membership.
Results: All but one Senate district and five House districts were represented by the 140 paid members in the state. Approximately 52% of members reside in a Democratic Senate District; however, in the state House of Representatives, the percentage of members living in Republican and Democratic districts is equal (~42%), with ~15% residing in districts with “undefined” regions. Over half of members reside in the largest urban center (~63%).
Discussion: The use of GIS in this study allowed for the identification of geospatial gaps in access to care for children with special healthcare needs, which could inform policymakers in addressing disparities. Partnerships between academic institutions and public health departments could provide valuable insights into healthcare accessibility and contribute to efforts promoting health equity.
Conclusion: Geospatial analysis is an innovative approach to identifying advocacy opportunities, which can be leveraged to drive positive changes in the healthcare system. Information garnered from this assessment can be used to leverage individual members to support legislation efforts aimed at improving health access, health equity, and healthcare quality for the communities served.
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