2026 Southeastern Residency Conference

Title: Standardizing Local Inhaled Epoprostenol Use in Acute Respiratory Distress Syndrome: A Quality Improvement Project

Authors: Adelaine Hogan, Ryan Lally, Rachel Langenderfer, Brittany NeSmith

Background: Inhaled epoprostenol (iEPO), a prostacyclin analogue-type pulmonary vasodilator, is often used off-label to treat hypoxemia in patients with acute respiratory distress syndrome (ARDS). Without guideline direction for use, preferences for iEPO dosing, timing of administration, and duration of therapy can vary. A medication use evaluation (MUE) of iEPO utilization for treatment of ARDS was conducted at Bon Secours St. Francis Downtown Hospital from January 1, 2023, through June 1, 2025, which found variation in initial doses and inappropriate prolonged duration of therapy. The purpose of this quality improvement project is to establish safe and efficient iEPO utilization practices when treating patients with ARDS through trial of a respiratory therapy-driven iEPO dosing and weaning protocol.

Methods/Results: This was a single-center, quality improvement project conducted at a 245-bed hospital in Greenville, South Carolina. An iEPO dosing and weaning protocol was developed by the investigators for use within the intensive care unit (ICU) to guide lab obtainment, initiation dose, and weaning parameters for all iEPO patients. The protocol was informed by current literature and reviewed and approved by a pharmacy-led interdisciplinary team of ICU pulmonologists and respiratory therapists. Educational material regarding ARDS, disease management, and protocol implementation was developed by investigators and distributed to ICU staff.

Background: Significant challenges to medication continuity often occur when patients transition from inpatient to outpatient care. At discharge, patients may face medication access barriers (MABs), including high costs, prior authorizations, and medication shortages. These barriers can result in adverse events, delayed therapy initiation, suboptimal disease management, and increased hospital readmissions. Consequently, many institutions have adopted transitions of care strategies, such as pharmacy-led medication reconciliation, to address MABs. Pharmacists are uniquely positioned to identify and mitigate MABs prior to hospital discharge; however, standardized workflows for addressing these barriers remain limited. The purpose of this study is to evaluate current MAB processes, with results used to optimize pharmacist workflow in identifying and addressing MABs and potentially support the creation of a new medication access pharmacy position.  
 
Methods: This was a retrospective cohort study that characterized documented MABs at Prisma Health Richland Hospital and Prisma Health Children’s Hospital – Midlands between May 11th, 2025, and December 11th, 2025. MABs involving intravenous medications were excluded. The primary objective was to characterize documented MABs. Secondary objectives included describing pharmacist assignments, resolution of MABs, communication of MABs, discharge pharmacy practices, ambulatory care follow-up, hospital readmission rates, and time spent completing MAB interventions. 
 
Results: In Progress 
 
Conclusions: In Progress 

Authors: Alexander Leaman, Mary Tremaine, Sandrine Nelson

Background: Seizures have been reported in up to 25% of patients with traumatic brain injury (TBI) and 15.2% of patients with aneurysmal subarachnoid hemorrhage (aSAH). In TBI, seizures within 7 days of injury are associated with increased length of stay, mechanical ventilation, and worse functional outcomes. Neurocritical Care Society Guidelines from 2024 note that seizure prophylaxis may be considered, recommending levetiracetam over phenytoin, for a short duration (≤7 days). Early seizures in aSAH have not been associated with worse outcomes but may cause acute complications, such as increased intracranial pressure and aneurysmal re-rupture. The 2023 aSAH guidelines state that antiseizure medications (ASMs) may be used for seizure prophylaxis in patients with high-risk features for ≤7 days, avoiding phenytoin due to excess morbidity and mortality. Consequently, levetiracetam is commonly used to prevent seizures in both TBI and aSAH, often prescribed as 500 mg twice daily (BID). However, a retrospective study from 2023 found a lower seizure incidence with 750 to 1000 mg BID. Additionally, a prospective study comparing levetiracetam 20 mg/kg loading dose followed by 1000 mg BID to phenytoin found no difference in seizure incidence. This study investigated the incidence of seizures with levetiracetam 500 mg BID compared to 750 to 1000 mg BID in patients with moderate to severe TBI or aSAH with high-risk features for seizures.

Methods: This was a retrospective study of patients admitted to either of two neurosurgical intensive care units (ICUs) in our health system. Patients were at least 18 years of age admitted with TBI or aSAH with high-risk features for seizures and received at least one dose of levetiracetam between January 1, 2023, and September 1, 2025. Patients were excluded for history of seizure disorder or cerebral neoplasm, ASM use prior to admission, death or withdrawal of care within 7 days, hospital admission less than 7 days, seizures on presentation, pregnancy, incarceration, and estimated creatinine clearance less than 30 mL/min. Patients were analyzed in two groups, those receiving levetiracetam 500 mg BID and those receiving levetiracetam 750 to 1000 mg BID. The primary outcome was the incidence of clinical or electrographic seizures within seven days. Secondary outcomes included adverse effects associated with levetiracetam (anemia, leukopenia, thrombocytopenia, or dose reduction or change to another ASM attributed to somnolence or agitation) and evidence of treatment escalation for seizures (increased levetiracetam dose, treatment duration greater than seven days, or addition of another ASM). A power calculation found that 178 patients would be required to find a 10.2% lower seizure incidence with the higher dosing strategy. Baseline characteristics were reported using descriptive statistics, with nominal outcomes analyzed using the Fisher’s exact test.

Results: A total of 79 patients were included, with 47 in the 500 mg BID group and 32 in the 750 to 1000 mg BID group. Baseline weight, serum creatinine, and Glasgow Coma Scale were similar between groups. There was no difference in seizure incidence in the first 7 days between groups, with 7 patients (14.9%) in the 500 mg BID group and 4 patients (12.5%) in the 750 to 1000 mg BID group (p=0.54). There was also no difference in the incidence of adverse effects or treatment escalation between groups.

Conclusions: In this study, the use of levetiracetam 750 to 1000 mg BID did not result in a lower seizure incidence compared to 500 mg BID. Future studies may help to quantify if a true difference exists between these dosing strategies on the incidence of seizures.

Contact information: [email protected]

Background 
Intensive care unit (ICU) delirium affects approximately one-third to one-half of critically ill adults and is associated with prolonged mechanical ventilation, increased ICU and hospital length of stay, higher mortality, and long-term cognitive impairment [1]. Contemporary Society of Critical Care Medicine Guidelines for Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (SCCM PADIS) emphasize structured delirium assessment, non-pharmacologic prevention, and cautious sedation, while discouraging routine antipsychotic use based on neutral findings from major randomized trials such as MIND-USA and AID-ICU [2]. Despite these recommendations, antipsychotics remain frequently used, with variability in agent selection and route, including off-label intravenous ziprasidone, raising safety and monitoring concerns. This study aims to compare duration of first-episode ICU delirium in patients receiving scheduled quetiapine versus as needed (PRN) ziprasidone, and to evaluate safety and utilization outcomes, including baseline corrected QT interval (QTc) prolongation, ventilator days, and ICU and hospital length of stay. 
Methods 
A retrospective analysis was performed in critically ill adults admitted to the ICU who received newly initiated antipsychotic therapy for delirium at AdventHealth Winter Park from December 2023 to November 2025. Eligible patients were ≥18 years old, had an ICU admission, received scheduled quetiapine for >24 hours or PRN ziprasidone, and screened positive on Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Patients were excluded if pregnant, had QTc >500 msec, received antipsychotics prior to ICU admission, or had neurologic or psychiatric conditions confounding delirium assessment, including schizophrenia, bipolar disorder, Parkinson’s disease, traumatic brain injury, stroke, psychosis, dementia, neurosurgical conditions, alcohol withdrawal, or coma. Patients were stratified by regimen (scheduled quetiapine vs PRN ziprasidone). The primary endpoint was duration of first episode of delirium in hours. Secondary outcomes included adverse drug events, QTc prolongation, ventilator days, ICU/hospital length of stay, and an exploratory subgroup comparing intramuscular versus intravenous ziprasidone. Categorical variables were analyzed using chi-square testing, and continuous variables were assessed for normality with the Shapiro-Wilk test and compared using the Mann-Whitney U test when non-normally distributed. 
Results 
After screening 251 patients, 93 met inclusion criteria; 10 who received both agents were excluded, leaving 83 patients (scheduled quetiapine n=38; PRN ziprasidone n=45). There was no significant difference in duration of first-episode ICU delirium (median 35.0 hours [IQR 24.0-57.5] with quetiapine vs 28.4 hours [IQR 12.9-52.5] with ziprasidone; p=0.29). QTc prolongation >500 ms occurred in 11% of quetiapine and 27% of ziprasidone patients, without statistical significance (p=0.12). Median RASS at positive CAM-ICU was -1.5 (IQR -3.0 to 0.0) vs -1.0 (IQR -2.0 to 1.0), respectively (p=0.34). Subgroup analyses showed no differences in delirium duration or QTc prolongation between intravenous and intramuscular ziprasidone. 
Conclusion 
In this retrospective study, scheduled quetiapine and PRN ziprasidone were associated with similar durations of first-episode ICU delirium and comparable safety outcomes, including QTc prolongation. Subgroup analyses showed no differences between intravenous and intramuscular ziprasidone. However, this study was limited by an insufficient sample size to achieve adequate statistical power, which may have impacted the ability to detect differences. Overall, antipsychotic selection and route of administration showed no statistically significant difference between delirium duration or safety outcomes. 
 
References:  

1. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753-1762.   

1. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU (PADIS). Crit Care Med. 2018.   

Aidan Bush, Patrick Blankenship, Crystal Laudermilk, Susan Roberts, Rob Lucas 
Prisma Health Blount Memorial Hospital – Maryville, TN 

Background: According to the CDC, adverse drug reactions (ADRs) cause approximately 1.5 million emergency department (ED) visits annually in the United States and are often linked to recent medication changes. Medication reconciliation technicians (MRTs) profoundly impact the quality of patient care within the hospital by obtaining accurate medication histories. While their role in identifying adverse drug reactions is often implied, there is limited research directly demonstrating their impact on patient care through the early identification of ADRs. The purpose of this retrospective cohort study is to evaluate the impact on patient care by expanding the role of MRTs with the addition of a single, targeted question to their usual workflow. 

Methods: This single‑center retrospective cohort study evaluated the impact of a workflow adjustment involving MRT‑assisted medication history collection at Prisma Health–Blount Memorial Hospital. The intervention cohort included all patients interviewed by an MRT between September 1–30, 2025. Patients reporting medication changes within the preceding 30 days were referred to a pharmacist for ADR assessment. The primary outcome was the incidence of ADRs identified through the updated MRT process. Secondary outcomes included characterization of ADR types and associated pharmacist interventions.  

Results: During September 2025, the pharmacy team identified 17 ADRs, with 7 (41%) directly attributed to the updated MRT‑supported workflow. MRTs completed 1,163 interviews during this period, a slight decrease from 1,330 interviews in 2024, consistent with fewer hospital admissions (713 vs 757, respectively). Among 51 patients reporting a medication change within the previous 30 days, 7 (13.7%) were confirmed to have experienced a true ADR following a pharmacist review.  Secondary outcomes showed that ADRs identified through MRT interviews most often involved drug–disease interactions (5, 71.4%), followed by dose‑related events (2, 28.6%). Pharmacists completed 9 interventions in response to identified ADRs, most frequently discontinuing the offending medication (7, 77%) and initiating alternative therapy when indicated. 

Conclusions: Although adding the 30‑day medication‑change question did not substantially increase overall ADR interventions, the process meaningfully enhanced the MRT’s role in identifying medication‑related problems and highlighted opportunities to further expand MRT involvement in pharmacy‑led safety workflows.

Pharmacogenomics-Guided Statin Reinitiation in Veterans with History of Statin-Associated Muscle Symptoms
De’Vaughn Vaughn, Jennifer Clark
Fayetteville VA Health Care Center – Fayetteville, NC
 
Background/Purpose: Statin-associated muscle symptoms (SAMS) are a leading cause of statin discontinuation, leaving high-risk patients undertreated for atherosclerotic cardiovascular disease (ASCVD) prevention. Pharmacogenomic (PGx) testing can identify genetic variants that increase SAMS risk: SLCO1B1 encodes a hepatic uptake transporter affecting systemic exposure to all statins; ABCG2 encodes an efflux transporter modulating absorption and disposition of rosuvastatin; and CYP2C9 encodes a phase 1 metabolizing enzyme responsible for oxidation of fluvastatin and, to a lesser extent, other statins. Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines provide therapeutic recommendations for statin selection and dosing based on these genotypes to improve safety, adherence and effectiveness of statin therapy. The purpose of this quality improvement project is to evaluate the role of PGx-guided, clinical pharmacist led statin reinitiation in veterans with history of SAMS and high ASCVD risk.
Methodology: This single-center, prospective cohort study enrolled 91veterans at the Fayetteville, NC VA Coastal Health Care System who had previously discontinued statin therapy due to reported SAMS. Eligible patients were identified through a statin adverse drug event (ADE) dashboard and had high ASCVD risk (history of type 2 diabetes mellitus and/or coronary artery disease) with prior exposure to no more than 3 statins. Veterans were contacted by the pharmacy resident and project preceptor via telephone and provided informed consent for PGx testing through Baylor Genetics. Following receipt of genotype results for SLCO1B1, ABCG2, and CYP2C9, patients were re-contacted and their PGx results were reviewed. Individualized statin recommendations were provided based on identified genetic variants. The primary outcome was the percentage of Veterans successfully reinitiated on statin therapy following PGx-guided recommendations. Secondary outcomes included rate of statin adherence at 4-6-week follow-up, rate of SAMS recurrence, and percentage of Veterans with LDL goal attainment of < 100mg/dL. 
Results: Of 91 eligible Veterans, 50 (55%) consented to PGx testing. Among those tested, 33 (66%) were successfully reinitiated on statin therapy, meeting the primary outcome. PGx testing identified SLCO1B1 decreased function in 12/33 (36%), ABCG2 decreased function in 4/33 (12%), and no actionable variants in 17/33 (52%). At the time of analysis, 21/33 (64%) Veterans had completed 4–6-week CPP follow-up, with 21/21 (100%) reporting adherence to statin therapy. Five Veterans (15%) discontinued therapy prior to follow-up: 3 due to SAMS recurrence (9%), 1 due to headache, and 1 due to epistaxis in the setting of anticoagulation. Among 12 Veterans with paired lipid data who continued therapy, mean LDL decreased from 134 mg/dL to 79 mg/dL (mean reduction: 56 mg/dL). Nine of 12 (75%) achieved LDL <100 mg/dL post-reinitiation. Of the 10 Veterans with baseline LDL >100 mg/dL, 7 (70%) achieved LDL < 100 mg/dL following PGx-guided statin reinitiation. Lipid data collection remains ongoing, with 20 Veterans awaiting post-statin lipid panels.
Conclusions: PGx-guided statin reinitiation resulted in a 66% reinitiation rate among consented Veterans, with a SAMS recurrence rate of only 9% comparing favorably to published recurrence rates of up to 30% with empiric rechallenge. All Veterans who reached 4–6-week follow-up remained adherent to therapy, and 75% of those with paired lipid data achieved LDL < 100 mg/dL. These early findings suggest that PGx-guided, clinical pharmacist-led statin reinitiation is a feasible and effective strategy for closing the treatment gap in high-risk Veterans with prior SAMS. Limitations include incomplete lipid data, lack of standardized baseline labs, and a small sample size. Continued follow-up and lipid panel collection will further define the durability of these outcomes.

Authors’ Names: Victoria Creo, Rebecca Stone, Jordan Khail

Background
Micro-learning is an educational strategy that delivers brief, instructional content designed to improve learner engagement, knowledge retention, and accessibility of materials. Within pharmacy education, micro-learning may provide an effective method for reinforcing clinically relevant counseling points that can be applied in various practice settings. Limited data exists to evaluate the effectiveness of micro-learning modules as an adjunct educational tool within Doctor of Pharmacy curricula. This study aims to evaluate the impact of micro-learning modules on student knowledge and retention and to assess pharmacy student perceptions regarding usefulness of micro-learning in pharmacy education.

Methods
Doctor of Pharmacy students from all professional years enrolled in accredited pharmacy programs throughout the state of Georgia were invited to participate in this study. Participants completed brief microlearning modules designed to deliver counseling information related to pregnancy prevention and opioid harm reduction strategies relevant to pharmacy practice.

Knowledge assessments were administered before and after completion of the modules to evaluate learning outcomes. A second post survey was also administered to determine knowledge retention thirty days following module completion. Additionally, the pre-/post-surveys will assess student perceptions of relevance of clinical topics to pharmacy profession and confidence in providing counseling on module topics. Post-survey will also evaluate student perceptions of micro-learning modules, including ease of use and willingness to utilize similar modules in future pharmacy learning. Descriptive statistics will summarize participant characteristics and survey responses, and a paired t-test will be computed to assess the difference between the pre-test and post-test knowledge scores.

Results
To date, 50 student pharmacists have completed the pre-intervention survey and baseline knowledge assessment. Mean baseline knowledge scores were 69.4% for the questions related to women’s health topics (prescription and over-the-counter emergency contraception and over-the-counter contraception) and 70.9% for the questions related to opioids and harm reduction topics (naloxone, fentanyl test strips, medication disposal). Post-intervention data collection is ongoing to assess the impact of the microlearning modules on student knowledge and perceptions.

Conclusion
In progress

Authors: Faith White, Ah Lim Yoo, Erin Pace
Background:
Insulin glargine-yfgn (Semglee) is a recently approved interchangeable biosimilar to insulin glargine. Comparable cost and clinical efficacy between insulin glargine-yfgn and NPH insulin (Humulin N) prompted institution-wide conversion from its preferred basal insulin NPH to insulin glargine-yfgn. However, there is currently limited guidance regarding the conversion between insulin glargine-yfgn and other insulins due to recent approval. As a result, prescribing information for insulin glargine was utilized to guide the conversion initiative. This prompted either a 1:1 conversion for patients taking up to 50 units of NPH daily or a reduction in NPH total daily dose (TDD) by 20% for patients taking greater than 50 units daily or NPH twice daily. Therefore, this project aims to address the knowledge gap in conversion methods between NPH and insulin glargine-yfgn by evaluating real-world data in an outpatient setting, specifically TDD and changes in glycated hemoglobin (A1c) before and after conversion.
Methods:
This retrospective cohort study was designed to assess conversion methods from NPH to insulin glargine-yfgn within outpatient clinics throughout the study institution. The conversion date was defined as the initial fill date of the first insulin glargine-yfgn order following previous NPH orders. Demographic variables, A1c, and TDD values were collected from an electronic health record. A1c values were collected at baseline (within 6 months prior to conversion) and approximately 6 months after conversion. TDD of NPH was collected at baseline, TDD of insulin glargine-yfgn on the date of conversion, and TDD of insulin glargine-yfgn approximately 6 months after conversion. Inclusion criteria were age greater than or equal to 18 years, type 1 or 2 diabetes, and conversion from NPH to insulin glargine-yfgn between April 1, 2024 and April 1, 2025. Exclusion criteria were concurrent therapy with other insulins (e.g. short acting, rapid acting, premixed formulations), pregnancy, prediabetes diagnosis, titrate-to-target dosing, and discontinuation of insulin glargine-yfgn within 6 months from conversion. The primary outcome was the mean change in TDD of NPH from baseline to the TDD of insulin glargine-yfgn 6 months after conversion. The secondary outcome was the mean change in A1c from baseline to 6 months after conversion. A Wilcoxon Signed Rank test was completed to analyze the TDD and A1c variables among the included participants.
Results:
Of the 1,245 eligible individuals that were screened, a total of 892 patients were included in this study. The majority of the study population were African American (54%), female (53%), and mean age of 65 years. Type 2 diabetes (99.7%) was the more commonly observed diagnosis. The mean TDD of insulin prior to conversion was 43.5 units compared to 38.6 units approximately 6 months after conversion. This indicates a statistically significant reduction in mean TDD by 4.88 units (p < 0.0001). Additionally, there was a statistically significant reduction in A1c by 0.08% (p = 0.0204) from 8.13% prior to conversion to 8.05% after conversion.
Conclusion:
The transition from NPH to insulin glargine-yfgn yielded a slight decrease in TDD and A1c. While the approximate 10% decrease in TDD may be interpreted as clinically significant in some scenarios, the overall A1c reduction was minimal. Current conversion guidance may not provide substantial benefit in A1c control partially due to the recommendations for preemptive insulin dose reduction for safety purposes. However, it may be reasonable to consider an initial 1:1 conversion in appropriate circumstances to provide additional A1c lowering. Such instances may be patients with elevated A1C and those who have not experienced hypoglycemia with the original TDD prior to the conversion.

Closing the Immunization Gap: Using the RE-AIM Framework to Assess a Pharmacy-Led Initiative  
Lauren Mikell, Courtney E. Gamston, Greg Peden, Kimberly Braxton Lloyd Auburn University Clinical Health Services -Auburn, AL 

Background/Purpose: Vaccinations are critical to prevent illness and complications, while reducing the burden on the healthcare system.  Despite these known benefits, immunization uptake in Alabama remains low. Triggered in June 2025 by the CDC’s expanded recommendation for Respiratory Syncytial Virus (RSV) vaccination to individuals aged 50–59 years old with risk factors, an employer-based pharmacy implemented a targeted initiative to close immunization gaps in individuals identified based on pharmacy dispensing records and immunization history. 

Methodology: In a one closed-door pharmacy, dispensing records in combination with Alabama Immunization Patient Registry with Integrated Technology (ImmPRINT) were used to assess the need for immunization. In alignment with recommendations for RSV vaccine receipt, patients aged 50 to 74 years taking an SGLT-2 inhibitor, sacubitril/valsartan, insulin, or maintenance inhaler, and those aged 75 and older were identified and reviewed for need for immunization. Patients who had not received their recommended vaccinations were contacted via telephone and invited to the pharmacy for vaccination. Informed by the results, a second round of identification and review was completed for patients aged 50 to 59 years that had not received a pneumococcal immunization through the pharmacy. The RE-AIM implementation science framework was utilized to assess the implementation of this process. Outcomes included Reach: the number of patients identified, reviewed, and contacted; Effectiveness: the number and percentage vaccinated, number and types of vaccines administered; and Implementation: adherence to the protocol and opportunities for improvement.  

Results: From August 2025 to March 2026, 363 identified patients were reviewed. A total of 1,291 vaccines were identified as due. Contact was attempted for 284 patients, with 131 successfully contacted (46.1%). Among those reached, 63 (22.2%) expressed that they were either not interested in vaccination or not interested in receiving their vaccines at the clinic and 36 (12.6%) patients reported intention to call the clinic later to schedule their vaccinations. Out of the 252 vaccines recommended to patients via phone, 113 were accepted. As of April 1st, 52 vaccines have been administered in the clinic. 

Conclusions: This method was effective for identifying individuals with gaps in immunization receipt. However, the rate of filling those immunization gaps remains low. Over 40% of patients were unreachable via telephone, necessitating investigation of other models of informing patients of their immunization needs. The ability to contact patients to convey the need for vaccination and provide education simultaneously may aid in increasing rates of immunization and strengthen engagement with the service.  

Pharmacist Impact on Quality of Anticoagulation Management: A Before and After Study

Edward McPartland, Victoria Burnette, Kelley Baxter, Chris Larkin
Ascension Saint Thomas Hospital West

Background/Purpose: Labile International Normalized Ratios (INR), defined as a Time in Therapeutic Range (TTR) less than 60%, has been identified as a key modifiable risk factor for adverse anticoagulation outcomes such as thrombosis or hemorrhage1. Prior evidence demonstrates that even modest improvements in TTR are clinically significant, as increases of 7% and 12% have been associated with the prevention of one major bleeding or thromboembolic event per 100 patient-years, respectively. Within the Ascension Saint Thomas Market (STM), there are several anticoagulation clinics, with Ascension Saint Thomas Hospital West being home to a pharmacist-managed clinic (PMC). In 2024, restructuring within the STM resulted in patients transitioning from one nurse-managed clinic (NMC) to our PMC. This transition provided an opportunity to evaluate clinical outcomes based on differences in clinic structure, such as clinic protocols and scope of practice. 
Methodology: This single-center retrospective chart review utilized electronic medical records to evaluate patients managed in the NMC from February 1, 2024 to July 31, 2024, and who were subsequently transferred to the PMC and received care from February 1, 2025 to July 31, 2025. Patients were identified via a transfer list organized by pharmacists during the transfer of care across clinics. Identified patients were reviewed using CoagClinic software for both timeframes, including documented visits and relevant laboratory values. Reports were generated for the specified time periods. Eligible participants were adults (≥ 18 years) who had their INR managed by a healthcare professional at both clinics within the specified timeframe. Patients were excluded if they were pregnant or incarcerated during the study. The primary outcome assessed the difference in TTR between the NMC and PMC. Secondary outcomes included extended TTR (±0.2 INR); peri-procedural bridging with a parenteral anticoagulant; bridging due to subtherapeutic INR; and hospital admissions due to hemorrhagic event, thromboembolic event, or supratherapeutic INR.
Results: A total of 347 patients were screened, of whom 294 met inclusion criteria. Mean TTR was significantly higher in the PMC compared to the NMC (68.2% vs 61.7%, p < 0.001), representing a 6.5% increase. Extended TTR was also significantly improved in the PMC (83.0% vs 75.5%, p < 0.001), corresponding to a 7.5% increase. A clinically significant reduction in hospital admissions due to hemorrhagic events was observed in the PMC compared to the NMC (4 vs 12 events, p = 0.07), although this difference did not reach statistical significance. There were no statistically significant differences in peri-procedural bridging therapy (8 vs 17 events, p = 0.10), subtherapeutic INR bridges (16 vs 8, p = 0.14), hospital admissions due to thromboembolic events (2 vs 2, p = 1), or hospital admissions related to supratherapeutic INR (2 vs 1, p = 1). Additional findings demonstrated significantly more clinic visits in the PMC (13 vs 11 visits, p < 0.001) and improved TTR among high-risk patients with INR goals outside the standard intensity of 2-3 (65.1% vs 56.7%, p < 0.01). Additionally, within the PMC cohort, 8 patients (2.7%) had documented changes to their INR goal during transition from the NMC.
Conclusions: Management within a PMC was associated with significantly improved TTR and extended TTR. Although secondary clinical outcomes did not reach statistical significance, a clinically meaningful reduction in hemorrhagic admissions was observed. The PMC also demonstrated more frequent clinic visits per patient, guideline-recommended goal INR updates, and improved TTR among high-risk patients with INR goal ranges outside of 2–3. These results highlight the potential of pharmacist-managed anticoagulation services to improve anticoagulation quality and facilitate tailored patient care.

Title: Insulin Treatment Strategies for Emergent Hyperkalemia  
Authors: Margaret Brown, Matthew Bamber, William Markle
FirstHealth Moore Regional Hospital Emergency Department – Pinehurst, NC

Background: Hyperkalemia is a medical emergency that can cause cardiac abnormalities and lead to cardiac arrest. Intravenous (IV) bolus insulin regular is a standard medication used to treat emergent hyperkalemia. Insulin shifts potassium and glucose intracellularly, which can lead to hypoglycemia. The objective of this study is to evaluate the rate of hypoglycemia between different doses of IV insulin regular in managing hyperkalemia.


Methods: This retrospective chart review study evaluated the rate of hypoglycemia in hyperkalemic (K > 5 mEq/L) patients treated with 10 or 5 units of IV insulin regular in FirstHealth Moore Regional Hospital Emergency Department between June 2024 and June 2025. The study included patients 18 years and older, with serum potassium > 5 mEq/L, and treatment initiation in the emergency department. Exclusion criteria included initial glucose < 70 mg/dL or > 180 mg/dL and receipt of in-patient dialysis. The primary outcome is the incidence of hypoglycemia (glucose <70 mg/dL). Secondary outcomes include amount of dextrose administered, in-hospital mortality, decrease in serum potassium from baseline, time from insulin administration to serum potassium < 5 mEq/L, time from serum potassium > 5 mEq/L to administration of IV insulin regular, number of patients who received multiple doses of insulin, mean number of doses of insulin received per patient, mean total units of insulin received per patient.


Results: A total of 81 patients were included, with 30 in the group receiving an initial bolus of 10 units IV insulin regular, and 51 patients receiving 5 units IV insulin regular. The primary outcome of the incidence of hypoglycemia found no statistically significant difference between the 10-units and 5-unit groups (5/30 vs 3/51; p=0.12). Only one secondary outcome was statistically significant: the mean number of insulin doses received between the 10-unit and 5-unit groups (1.1 vs 1.5; p = 0.03). Both the 10-unit and 5-unit group produced similar mean potassium reduction (1.58 vs 1.60 mEq/L; p = 0.44).


Conclusions: When comparing the incidence of hypoglycemia between a high and low dose IV insulin regular regimen to treat emergency hyperkalemia, there was no statistically significant difference between the groups. The small sample size may underestimate the true incidence of hypoglycemia. This study did not adjust for administration of concomitant hyperkalemia medications, which could change the overall decrease in serum potassium. Further studies are needed to evaluate the impact of underweight and obesity on hypoglycemia.

Assessing the Prevalence of Inappropriate Insulin Prescribing at Hospital Discharge
Darci Conklin, Jack Handshaw
AdventHealth Celebration – Celebration, FL

Background/Purpose: To review current prescribing trends to assess whether patients with diabetes are receiving appropriate insulin therapy at hospital discharge.

Methodology: Retrospective chart review of patients prescribed insulin at discharge from Advent Health Celebration, spanning from March 1st, 2025, to July 31st, 2025. The primary endpoint of the study was a composite of patients deemed to have inappropriate insulin prescriptions at discharge; defined as having at least one of the following: Patients prescribed duplicate insulin therapy, patients prescribed a regimen of correctional insulin only, patients prescribed an insulin prescription with inappropriate instructions, patients not prescribed appropriate insulin administration devices such as pen needles or insulin syringes, patients prescribed insulin when previously controlled on non-insulin antidiabetic medications prior to admission or patients who did not require insulin therapy as per the 2026 ADA Standards of Care in Diabetes guidelines. Secondary endpoints included incidence of each component of the primary composite endpoint, incidence of 30-day and 90-day re-admission due to a diabetes-related cause, patients co-prescribed glucagon, and patients co-prescribed testing supplies. Patients were included in this review if they were aged 18 years or older, had a discharge disposition of self-care or home health, were diagnosed with diabetes prior to or during the reviewed admission, and had a recorded A1c within the 6 months prior to discharge.

Results: A total of 198 patients were initially extracted for retrospective review; however, 39 patients were excluded, leaving 158 patient encounters eligible for analysis. Of the 158 encounters, 70 encounters were found to have inappropriate insulin prescriptions at discharge (70/158, 44.3%). No patients reviewed were prescribed glucagon at discharge, and only 57 patient encounters had patients prescribed testing supplies at discharge (57/158, 36.08%). A total of 21 patients were readmitted within 30 days of discharge (21/158, 13.29%), with 7 of these 21 patients (33.33%) deemed to have an inappropriate insulin prescription at discharge. Similarly, a total of 30 patients were readmitted within 90 days of discharge (30/158, 18.99%), with 10 patients (33.33%) discharged with an inappropriate insulin prescription.

Conclusions: Nearly half of patient encounters reviewed were deemed to have improper prescribing of insulin or associated supplies at hospital discharge. The most common insulin prescription errors seen were prescriptions with incorrect sliding scale instructions and patients not prescribed appropriate administration devices. Readmissions at 30 and 90 days were not seen to be associated with receiving inappropriate insulin prescriptions at discharge. Encounters where patients received a prescription for testing supplies or glucagon were also substantially low to non-existent. Based on the results seen, there is an opportunity for targeted education of prescribing physicians and inpatient clinical staff on insulin at discharge. These results also highlight the importance of pharmacist review in the transitions of care space for management of diabetes upon discharge and for the facilitation of close outpatient follow-up.

Evaluating Emergency Department Order Set in Sickle Cell Pain Management
Katherine Weller PharmD, Kanaan Shah PharmD, Christele Francois PharmD, BCPS, Tonya Hershman PharmD, BCPS, Karen Clarke, MD, Alexandra Arges MD, Mohamad Moussa MD, Yoo Mee Shin MD, Nicholas Kurtzman MD, Krista Dumkow PharmD, BCEMP, BCPS; Emory University Hospital, Atlanta, GA 

Background: 

Vaso-occlusive crises (VOC) in patients with sickle cell disease (SCD) occur because of adhesion of red blood cells to small vessel walls, leading to obstruction of blood flow, pain, and ischemia1. VOC is the most common complication of SCD. Patients often present to the emergency department (ED) for acute pain management when their home pain regimens fail to adequately control the crisis2. To manage acute crises, the American Society of Hematology Clinical Practice Guidelines on SCD recommend administering opioids within 60 minutes of arrival to the ED3. The guidelines further recommend a tailored opioid regimen that is reassessed every 30 to 60 minutes and multi-modal pain regimens with non-opioid therapies such as non-steroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants, or acetaminophen. This study aimed to assess the utilization of a guideline-based order set for acute pain management of patients with SCD presenting to the ED in a VOC.   


Methods: 

This was an Institutional Review Board-approved, single center, retrospective observational study of patients presenting to the ED with a diagnosis of VOC between January 1, 2024, and January 31, 2025. A total of 289 patients were identified and 181 met inclusion criteria of age >18, presentation during the study period, and a final diagnosis of VOC. Exclusion criteria included active infection, chronic or acute pain due to alternative diagnosis or other causes, history of substance abuse, left against medical advice, and pregnancy. The primary outcome was the incidence of analgesia administered within 60 minutes of ED arrival. Secondary outcomes included incidence of inpatient admission, time to initial dose of analgesia from arrival to the ED, time spent in the waiting room, pain re-assessment within 15-30 minutes of pain medication administration, dose escalation by 25% every 15-30 minutes until pain is adequately controlled, reduction in pain intensity measured by a pain scale, adverse events associated with opioid use, use of adjunctive NSAIDs, and ED length of stay. 



Results: 

Of the 181 patients that were included in this study, 37 patients had medications ordered utilizing the SCD order set in the ED. The primary outcome of incidence of analgesia administered within 60 minutes of ED arrival was not statistically significant (order set group, 10.8%; non-order set group, 11.8%; p-value=0.56). The use of NSAIDs was significantly higher in the orderset group (order set group, 43.2%; non-order set group, 16%; p-value=0.0003). Inpatient admission rates, pain assessment, dose escalation, and reduction in pain intensity were similar between groups, with no statistically significant differences. Operational metrics such as average time to analgesia, time spent in the waiting room, or average ED length of stay were not statistically significant. For adverse events associated with opioid use, there was no difference between groups (order set group, 8.11%; non-order set group, 1.39%; p-value=0.99). Of patients that had the order set used upon ED arrival, 70% had analgesics ordered through the order set panel.  



Conclusions: 

Implementation of the order set did not significantly improve the or timeliness of analgesia within 60 minutes of ED arrival.  The greatest barrier to receiving analgesia within 60 minutes of ED arrival was delays in appropriate room placement and IV placement. Strategies to address this barrier include prioritizing triage for patients presenting with VOC and implementing bed prioritization protocols to expedite rooming. The order set promotes guideline driven, multimodal VOC management while further optimization is needed to enhance timely analgesia, pain reassessment, and operational metrics. Future efforts should educate providers about the order set and refine the order set to improve its effectiveness, such as ensuring that analgesics are ordered through the order set and enhance timely nursing communications for pain scores and dose escalation.

Background/Purpose: Asymptomatic bacteriuria (ASB) is defined as the isolation of quantifiable bacteria in the urine in the absence of urinary symptoms. Per 2019 IDSA guidelines for the management of asymptomatic bacteriuria, healthy nonpregnant women, patients with diabetes, and older adult women should not be screened or treated for asymptomatic bacteriuria. Despite most recent guideline recommendations, estimated incidence of inappropriate asymptomatic bacteriuria treatment range from 40-83% in the United States. Similarly, 2021 CDC guidelines recommend treating bacterial vaginosis in symptomatic women. Currently there is no data supporting the routine screening of bacterial vaginosis in healthy, nonpregnant women. This quality improvement initiative aims to evaluate the impact of provider education and order set optimization on the quality of symptom documentation for uncomplicated urinary tract infections and bacterial vaginosis in women's health clinics at the Fayetteville NC VA Coastal Health Care System (FNCVACHCS).
Methodology: This project will identify Veterans treated for uUTI and/or BV at FNCVACHCS during two periods: September 1–November 28, 2025 (pre-intervention) and a subsequent 2.5-month post-intervention period. Data collection will utilize Computerized Patient Record System (CPRS) and Microsoft Excel software to review women’s health providers’ notes, cultures, and labs. The primary objective assessed the difference in symptom documentation rates after intervention. The secondary outcome evaluated treatment of uUTI and BV 28 days before and after intervention implementation. Primary and secondary endpoint changes will be compared to assess the impact of provider education and order set adjustments.
Results: In progress
Conclusion: In progress

Name: Caroline McKenna
[email protected] 

Background/Purpose:
Anticholinergic medications block the effects of the neurotransmitter acetylcholine. These medications treat a variety of conditions, including seasonal allergies, Parkinson’s disease, chronic obstructive pulmonary disease, urinary incontinence, and more. Side effects of anticholinergic medications include urinary retention, blurred vision, confusion, altered mental status, dry eyes and mouth, flushing of skin, and tachycardia.1 Persistent use of anticholinergic medications are associated with cognitive dysfunction in older adults, including Alzheimer’s, Lewy body dementia, and delirium.2 Various scoring scales are able to quantify the risk of anticholinergic burden in a quick and reproducible way. The Anticholinergic Cognitive Burden (ACB) Scale compares a medication’s ability to bind to muscarinic receptors and the degree of serum anticholinergic activity, and is the most common scoring system used in clinical research.2 Medications are scaled from 0-3, with zero implying no anticholinergic activity and 3 implying high anticholinergic cognitive effect. Summative burden can be categorized into low (0), medium (1,2), or high (3+) risk. The purpose of this study was to reduce anticholinergic burden in older adults and lower the risk of cognitive impairment, by implementing pharmacist-led ACB scoring and medication review during Medicare Annual Wellness Visits (AWVs).

Methodology:
This prospective, quality improvement study included patients with Medicare Part B coverage scheduled with a clinical pharmacist for their AWV across two outpatient family medicine clinics. Scheduling was handled by office support staff and based on primary care provider availability and pharmacist schedule openings. Patients were excluded if younger than 65. Guidance from the American Academy of Family Physicians in combination with clinical judgement by pharmacists were incorporated to determine appropriate intervention. During the AWV, medication reconciliations were completed. Patients received paper handouts for applicable anticholinergic medications, including but not limited to medications for pain, sleep, anxiety, allergies, and reflux. Handouts reviewed both risk and benefit of the offending agent, which were discussed with the pharmacist. Additional appointments were scheduled for deprescribing on a case-by-case basis. Data of age, ACB score, risk category, offending agents, and intervention offered was collected and analyzed by hand on a spreadsheet. 

Results:
A total of 76 patients were evaluated, with 6 patients excluded given age <65. Of those included, 28 (40%) had a low ACB score, 28 (40%) had a medium ACB score, and 14 (20%) had a high ACB score. The most common offending agents were omeprazole/pantoprazole/lansoprazole (n=14), metformin (n=11), cetirizine/loratadine (n=6), and chlorthalidone (n=4). In terms of interventions, 28 patients (40%) had no intervention given low ACB score, 3 (4%) patients were no longer taking an anticholinergic medication, 14 (20%) patients declined pharmacist intervention, 18 (26%) patients medication benefit outweighed anticholinergic risk, and 7 (10%) patients were open to pharmacist intervention and scheduled follow-up for deprescribing. For patients open to pharmacist follow-up, 4 patients were on omeprazole/pantoprazole, 2 patients were on cetirizine, and 1 patient was on both omeprazole and cetirizine. For patients on proton-pump inhibitors, 2 patients were successful in stopping the agent with minimal reflux symptoms, 1 patient found that famotidine alone relieved symptoms, 1 patient agreed to esomeprazole switch (ACB score = 0), and 1 patient continued on omeprazole after trial off. For patients on anticholinergic allergy medications, 1 patient self-stopped use prior to AWV, one agreed to as needed use, and one agreed to switch to fexofenadine (ACB score = 0).

Conclusions:
Incorporating anticholinergic burden discussions during Medicare Annual Wellness Visits by pharmacists provided a seamless and meaningful impact. Of those reviewed, 60% had a medium or high ACB score. Through patient education and deprescribing efforts, a pharmacist was able to identify inappropriate anticholinergic use and support individualized deprescribing plans, promoting medication safety for older adults. Although only a subset of patients elected to pursue pharmacist follow-up, the majority saw success in either discontinuing the anticholinergic medication or switching to a safer medication alternative. Continued focus on anticholinergic deprescribing by pharmacists during AWVs may further enhance medication optimization, promote shared decision-making, and reduce long‑term risks associated with anticholinergic medications.

Title: Assessing the Implementation of a Community Health Worker Program at a Community Clinic
 
Authors: Ryan Grady, Pharm.D., Courtney E. Gamston, Pharm.D., Linda Gibson-Young, Ph.D., FNP-C, RHN-C, MBA, FAANP, Amy Pridemore BSN, MA, MSN, DNP, FNP-C, David Redden, Ph.D., Kimberly Braxton Lloyd, Pharm.D. 

Background:  
Community Health Workers (CHWs) serve as bridges between healthcare systems and underserved populations, helping connect individuals to preventive services, chronic disease management, and social resources. Underserved communities face barriers to healthcare access, continuity of care, and clinic-based services. To address this, a newly initiated (2022) primary care and women’s health clinic with dispensing pharmacy implemented a CHW program designed to extend the reach of clinical services through interacting with the community and providing education and referrals. Evaluating the implementation of this initiative is important for determining its potential to enhance community engagement and inform future expansion.
 
Methods:  
This project uses the RE-AIM framework to evaluate Reach, the extent to which the program engaged the community, and Effectiveness, evaluating how well the CHW were able to engage the local community. Data was collected from CHW field notes and clinic documentation. Community-based activity data included date, time, location, nature of touchpoint, number of interactions, types of interactions, educational or referral interventions, and challenges encountered. Clinic-level activities included the number of CHW-generated referral appointments,  total clinic visits before and after CHWs implementation, and the number and proportion of clinic events scheduled and/or staffed by the CHWs.  Descriptive analyses were used to summarize program activities and assess feasibility and effectiveness. 

Results:
In Progress

Conclusions:
In Progress

Title: Association between outpatient glucagon-like peptide-1 receptor agonist use and the incidence or severity of sepsis
Authors:

Primary: Mary Sizer
Secondary: Hanna Kim, Jinae Lee, Daniel B. Hall, John Carr, PharmD, Akshaya Arunkumar, Abigail Case. PharmD, Chelsea Keedy

Objective: To determine if outpatient GLP-1 RA is associated with a decreased risk of sepsis occurrence or severity.

Background:
Glucagon-like-peptide-1 receptor agonists (GLP-1 RAs) mimic the endogenous hormone involved in regulating blood glucose concentrations and appetite. These agents are approved in management of type 2 diabetes and have grown popular for weight management. Pre-clinical and clinical data found anti-inflammatory, antioxidant, and multiorgan protective effects from use, suggesting a potential protective effect in acutely ill patients. Inversely, preliminary data has also suggested an increase in mortality for critically ill patients on such agents. There is limited data that investigates this association. The purpose of this study is to evaluate the association between GLP-1 RA use and incidence and severity of sepsis.

Methods:
This retrospective cohort study investigated the association between outpatient GLP-1 RA therapy and both the incidence and severity of sepsis using Merative MarketScan Commercial Database insurance claims recorded between January 1, 2022 and December 31, 2024. The cohort included adults with BMI >30, hospitalization or emergency room visit, and diagnosis of pneumonia, urinary tract infection, diabetic foot infection or intraabdominal infection identified by ICD10 codes. Patients that were pregnant, had cancer, were on hospice, or diagnosed with diabetes or diabetic foot infection were excluded. Inclusion and exclusion criteria were examined for the 6-month period prior to the data of hospitalization/ER visit (the index date) and eligible patients were divided into a GLP-1 RA use group and a control group. Chronic therapy was defined as ≥ 90-day total supply filled within 6 months of the index date and identified using NDC codes. Those that did not meet this definition were placed in the control. For both sepsis incidence and severe sepsis incidence, propensity score weighted logistic regression was used with inverse probability of treatment weighting to estimate odds ratios quantifying the average treatment effects among the treated while controlling for baseline confounders including age, sex, BMI (30-39.9 vs. >=40), and all baseline comorbidities including chronic heart failure, chronic kidney disease, liver cirrhosis, AFib, dementia, chronic ischemic heart disease. Propensity scores were estimated using logistic regression and covariate balance was assessed using both the standardize mean difference (acceptable range of +/- 0.1) and Kolmogorov-Smirnov (<0.05) criteria. Statistical inference was based on the nonparametric bootstrap implemented using 500 resampled datasets.

Results:
Of the 634,718 patients identified with a hospitalization/emergency room visit and concurrent infection, 22,267 patients fit eligibility criteria for the study. GLP-1 RA use accounted for 640 of those enrolled (2.87%) and 21,627 (97.1%) were enrolled into the comparator group. Baseline characteristics were similar, with the exception of gender, for which there was a significantly higher proportion of males in the comparator group (26.7% vs 15.2%; p=<0.001). The proportion of enrollees with pneumonia also differed significantly between groups, favoring the comparator group (25% vs 18.4%; p=<0.001). Urinary tract infection proportion favored the GLP-1 RA use cohort (52.7% vs 42.4%; p=<0.01). Additionally, enrolled comorbidities varied only in heart failure between the two cohorts (3.2% comparator group vs 1.3% use of GLP-1 RA; p=0.0085). The odds ratio (OR) for sepsis was 1.17 [95% CI: 0.85-1.46] (p=0.789) and the OR for severe sepsis was 0.92 [95% CI: 0.37-1.63] (p=0.934), indicating that the occurrence of sepsis and severe sepsis did not differ significantly between the two groups after controlling for baseline confounders.

Conclusions:
GLP-1 RA use was not associated with any significant difference in the odds of sepsis, nor of severe sepsis, in acutely ill enrollees with concurrent infection. GLP-1 RA combination products with dual mechanisms were examined alongside sole GLP-1 RA use. Differences in therapy were not examined.  Overall, the evidence is not sufficient to conclude that there is a difference in sepsis risk with GLP-1 RA use.

Authors
Liz Lively, Amanda Stankowitz, Alexander Tunnell, Mallorie Vaughn

Background
A multitude of organizations have released guidelines to aid providers in the treatment of urinary tract infections in women based on pregnancy status. The Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: 2010 Update by the IDSA provide specific recommendations for drug therapy and treatment options for non-pregnant women. According to the 2019 IDSA guidelines for asymptomatic bacteriuria (ASB), antibiotics should not be prescribed to treat women who have ASB but are not pregnant. Conversely, according to the 2023 ACOG Clinical Consensus for urinary tract infection, pregnant women with bacteria in the urine should be prescribed antibiotics, regardless of symptoms. The goal of this study was to assess the current state of antibiotic prescribing practices for female patients diagnosed with ASB or uncomplicated cystitis at two outpatient primary care offices, WT Anderson Community Health Center (WTACHC) and Primary Care West Macon (PCWM).
 
Methods
Researchers utilized a database generated report to conduct a chart review of all women who had a primary diagnosis of ASB, UTI, or cystitis as documented by ICD-10 code. Females ages 18 and older were included if they were seen at WTACHC or PCWM from January 1, 2024 to December 31, 2024. The primary outcome of this study was the percent of women seen at WTACHC or PCWM who were diagnosed with ASB and treated appropriately per IDSA or ACOG guidelines. Secondary outcomes evaluated the percent of women who were diagnosed with ASB and treated appropriately based on pregnancy status and location. Additional secondary outcomes included the incidence of misdiagnosis of uncomplicated cystitis without documented symptoms of a UTI and a descriptive analysis of the antibiotics prescribed, duration of therapy, and whether they align with recommended practices for empiric treatment of ASB or uncomplicated cystitis per IDSA or ACOG guidelines.
 
Results
Of the 93 subjects included in the study, six were from WTACHC and 87 from PCWM. Regarding the primary outcome, 28.6% (4/14) of adult women seen at WTACHC or PCWM met criteria for ASB and were treated appropriately. For secondary outcomes, overall, 33.3% (4/12) of non-pregnant women and none (0/2) of the pregnant women who were diagnosed with ASB were treated appropriately. There were no patients seen at WTACHC diagnosed with ASB, all six at this location had uncomplicated cystitis. Therefore, it was not possible to assess this secondary outcome at WTACHC. At PCWM, 28.6% (4/14) met criteria for ASB and were treated appropriately. Of all patients diagnosed with uncomplicated cystitis, 22.9% (19/83) were misdiagnosed due to lack of documented UTI symptoms. A total of 83 patients were prescribed antibiotics, most commonly with nitrofurantoin at 62.7% (52/83) or SMX/TMP at 16.9% (14/83). Of the patients who were prescribed antibiotics, 90.4% (75/83) were prescribed an appropriate antibiotic per the IDSA or ACOG guidelines. However, only 55.4% (46/83) were treated with the appropriate duration, which varies from 5-10 days based on agent and pregnancy status. The overall average duration of prescribed therapy was 6.29 days. Among the entire sample, 44.1% (41/93) of patients were treated appropriately for uncomplicated cystitis or ASB.
 
Conclusion
A majority of patients seen at WTACHC and PCWM diagnosed with ASB in 2024 were not treated per guidelines. Most of the patients diagnosed with uncomplicated cystitis were prescribed an appropriate antibiotic, but many had treatment durations beyond IDSA and ACOG guidance. Lack of documentation of symptoms may have falsely elevated the number of patients with ASB. Additionally, a significant limitation was identified in using ICD-10 coding to identify ASB, which limited the study population. Future initiatives should instead utilize urine culture to fully capture patients with ASB.

Background: An estimated 12% of the United States population is living with diabetes. This specific patient population is at an increased risk of hospital admission with longer lengths of stay and higher rates of readmission. Patients with diabetes are often lost to follow-up due to lack of disease education, access to medication, or access to care. At Cone Health, ambulatory pharmacists are embedded within primacy care clinics and provide disease state management and have been able to contribute to improve disease state related quality metrics. Inpatient diabetes coordinators identified embedded pharmacists to assist in transitions of care outreach to high-risk patients with diabetes upon hospital discharge.  The purpose of this study was to evaluate the impact of ambulatory pharmacist transitions of care outreach on diabetes control in patients recently admitted to the hospital.

Methods: This was a single-center, multi-site, IRB-reviewed and determined exempt, retrospective cohort, pre-post matched analysis that included patients with uncontrolled type 2 diabetes who were referred to an ambulatory care pharmacist during hospital admission between February 2025 and December 2025 for transitions of care outreach.  Ambulatory care pharmacists were encouraged to outreach patients upon discharge to address immediate medication access concerns in an effort to prevent readmissions and ensure adequate follow-up. Patients were included in the final analysis if there was documented pharmacist engagement and were affiliated with a Cone Health primary care clinic. The primary outcome was percent of patients meeting A1c <8% from baseline to follow-up which was assessed utilizing a McNemar’s Chi-square test. Secondary outcomes include 30-day all-cause unplanned readmissions, frequency of pharmacist engagement, and pharmacist-documented medication therapy problems and interventions.

Results: There were 139 patients referred to ambulatory pharmacy services for transitions of care outreach. A total of 103 patients were excluded due to study criteria. Of the patients referred, a total of 36 patients were included in primary statistical analysis. The mean age was 49.7 years, 13 (36.1%) patients were female, and 16 (44.4%) patients identified as Black or African American. A total of 32 (88.8%) of patients had type 2 diabetes with an average A1C of 11.7%.  At baseline, 1 patient (2.7%) had an A1C <8%. After pharmacist outreach and PCP follow‑up, 17 patients (44.4%) achieved an A1C <8% (difference 41.6%, 95% CI 25.6 – 57.8, p < 0.0001). The average time between baseline and follow-up A1C measurements was four months. During initial pharmacist outreach, medication therapy problems were identified with adherence (33.3%) being a top concern for patients, frequently driven by medication affordability and medication access barriers. Pharmacists were able to assist patients proactively through enrollment in patient assistance programs, switching to cost effective medications, completing prior authorizations, or referring patients to health system free pharmacies when appropriate. Patients continued to engage with ambulatory pharmacists on average of three times throughout the study duration. Continuous engagement further improved disease state management, medication access, and glycemic control.

Conclusions: Embedded pharmacist transitions of care outreach were associated with improvements on uncontrolled diabetes outcomes upon hospital discharge. More importantly, pharmacists were able to fill in the gap in the transitions of care process for patients with uncontrolled diabetes through providing access of care, medication accessibility, and reinforcing chronic disease state education. In addition to glycemic improvement, 30-day all cause unplanned readmissions rates were low. Patients were able to achieve A1C <8% from baseline to follow-up and a low 30-day all cause unplanned readmission rate was seen.

Presentation objective: Recognize key interventions an ambulatory care pharmacist can provide to support patients with uncontrolled diabetes during transitions of care.

Self-assessment question: Which of the following interventions was most commonly identified and addressed by pharmacists during transitions of care outreach?

Evaluation of a Pharmacist-Led Levothyroxine Monitoring and Management Program at the Salisbury VA Health Care System

Authors: Kendra G. Hofler, Camille P. Robinette, Meghan Mark, and Aashish A. Shah

Background:
Hypothyroidism is an endocrine disorder and can contribute to fatigue, weight gain, cognitive impairment, and cardiovascular complications if inadequately managed.1 Veterans are at increased risk for this disease due to certain environmental exposures, frequency of iodine exposure, and having post-traumatic stress disorder. 2-4 Appropriate levothyroxine dosing and regular thyroid function test (TFT) monitoring are essential for optimizing therapy, yet patients may experience delayed dose adjustments or overdue labs due to limited follow-up and provider workload. Pharmacist involvement in chronic disease management has demonstrated benefits in improving medication adherence, lab monitoring, and patient outcomes in various therapeutic areas.5 However, a structured, pharmacist-led hypothyroidism management process has not been formally implemented or evaluated at the Salisbury VA Health Care System (SVAHCS). The purpose of this quality improvement project is to assess the impact of pharmacist-led levothyroxine monitoring on treatment optimization, laboratory follow-up rates, and patient education within the SVAHCS.

Methods:
This project will be conducted as a quality improvement initiative involving Veterans with a diagnosis of hypothyroidism and active levothyroxine prescription at the SVAHCS. Pharmacists will identify patients who are overdue for TFTs (>6 months) using population management tools within the Computerized Patient Record System (CPRS). Interventions will include recommending and/or ordering TFTs, evaluating laboratory results, making evidence-based dose adjustment recommendations, and providing patient education on proper levothyroxine administration (e.g., timing, drug–food interactions, and adherence). Pharmacists will also recommend endocrinology referral for complex or refractory cases. Primary outcomes will include the proportion of patients achieving euthyroid status (TSH within target range) and improvement in TFT follow-up compliance. Secondary outcomes will assess number of Veterans educated on proper levothyroxine administration, dosing, and side effects, number  educated on signs and symptoms of hypothyroidism, and number of patients referred to endocrinology clinic. Data will be analyzed to determine the effectiveness and feasibility of pharmacist-led hypothyroidism management at the SVAHCS and to identify opportunities for broader implementation across the VA system.
 
Results:
A total of 35 patients were included in the analysis, all of which received counseling on appropriate levothyroxine administration. Prior to intervention, 32 patients (91.4%) were identified as taking levothyroxine incorrectly. Pharmacist-led interventions were made in 9 cases (25.7%), including 3 dose decreases, 5 dose increases, and 1 discontinuation of levothyroxine therapy. Only 1 patient required referral to endocrinology for further management.

Discussion:
The high proportion of patients taking levothyroxine incorrectly highlights a significant gap in patient understanding of proper administration, which may impact therapeutic outcomes. Pharmacist-led counseling appears to play an important role in identifying and addressing these issues. The relatively low number of medication interventions suggests that improper administration, rather than inappropriate dosing, may be a primary contributor to suboptimal therapy in this population. Additionally, the minimal need for endocrinology referral indicates that most patients can be effectively managed within a primary care or pharmacy setting.

Conclusion:
This study demonstrates that incorrect levothyroxine administration is common among patients but can be effectively addressed through targeted counseling. Pharmacist involvement can improve medication use and optimize therapy, potentially reducing the need for specialist referral. Further studies are warranted to evaluate the long-term impact of counseling on clinical outcomes.

References
1. Chaker L, Papaleontiou M. Hypothyroidism: A Review. JAMA. Published online September 03, 2025. doi:10.1001/jama.2025.13559
2. O'Donovan A, Cohen BE, Seal KH, Bertenthal D, Margaretten M, Nishimi K, Neylan TC. Elevated risk for autoimmune disorders in iraq and afghanistan veterans with posttraumatic stress disorder. Biol Psychiatry. 2015 Feb 15;77(4):365-74. doi: 10.1016/j.biopsych.2014.06.015. Epub 2014 Jun 28. PMID: 25104173; PMCID: PMC4277929.
3. Inoue K, Guo R, Lee ML, Ebrahimi R, Neverova NV, Currier JW, Bashir MT, Leung AM. Iodinated Contrast Administration and Risks of Thyroid Dysfunction: A Retrospective Cohort Analysis of the U.S. Veterans Health Administration System. Thyroid. 2023 Feb;33(2):230-238. doi: 10.1089/thy.2022.0393. Epub 2023 Jan 25. PMID: 36173108.
4. Spaulding SW. The possible roles of environmental factors and the aryl hydrocarbon receptor in the prevalence of thyroid diseases in Vietnam era veterans. Curr Opin Endocrinol Diabetes Obes. 2011 Oct;18(5):315-20. doi: 10.1097/MED.0b013e32834a8764. PMID: 21825977.
5. Wang L, Zhang Y, Wei Q, Liang X, Zhou J, Ma A, Wang L. The effect of pharmacist intervention on medication adherence measured with proportion of days covered: a systematic review and meta-analysis. Int J Clin Pharm. 2025 Aug 7. doi: 10.1007/s11096-025-01974-4. Epub ahead of print. PMID: 40775483.

Contact for Follow-up: 
Kendra G. Hofler
[email protected]