Pharmacy student involvement in population health management of statin quality measures

Pharmacists have demonstrated their value in population health management (PHM). With appropriate training, advanced pharmacy practice experience (APPE) students are also well positioned to participate in PHM.


| INTRODUCTION
Healthcare has gradually shifted to a value-based model, placing more emphasis on the quality of care provided to improve health outcomes. 1 In order to measure the quality of healthcare, certain quantifiable standards have been developed, which are also known as quality measures. 2 Many institutions utilize population health management (PHM) and enlist various members of their healthcare team to help improve their quality measures. 3 The role of the pharmacy team in improving quality measures is constantly evolving with the expansion of collaborative practice agreements. 4 For example, pharmacists have demonstrated value in reducing preventable hospital readmissions and emergency department visits as well as improving chronic disease outcomes, such as hemoglobin A1C and blood pressure. 5 They have also proved to be useful in PHM tasks, such as improving statin-related quality mea-

sures, including Statin Use in Persons with Diabetes (SUPD) and Statin
Therapy for Patients with Cardiovascular Disease (SPC). 6,7 Within the ambulatory care clinic at Providence Medical Foundation in Orange County, California, clinical pharmacists actively participate in improving the SPC, SUPD, and Statin Therapy for Patients with Diabetes (SPD) measures from National Committee for Quality Assurance (NCQA) and Pharmacy Quality Alliance (PQA). 8,9 The patients who are not meeting these SPC, SUPD, and SPD measures are determined by insurance plans. However, pharmacists are just one part of the larger pharmacy team, which also consists of technicians and pharmacists in training, such as residents and students.
Advanced pharmacy practice experience (APPE) students are trained in a wide range of clinical topics, such as diabetes, dyslipidemia, and cardiovascular diseases, both in the classroom and in experiential education. The Accreditation Council for Pharmacy Education (ACPE) Standards also require pharmacy students to learn how population-based care influences patient-centered care. 10  Also, both studies determined the need for future research to review student perceptions of their participation and impact on their learning. 11,12 A new learning activity, which was driven by institutional goals to improve patient care and quality, was developed and implemented in 2021. The activity incorporated APPE students at Providence Medical Foundation into PHM, specifically the statin quality measure improvement process. APPE students are well-positioned at this point of their training to make recommendations on statin therapy and address clinical concerns. This activity aligns with the ACPE Standards for educational outcomes in population-based care. 10 This hands-on practice can also enrich the students' learning experience and better prepare them for the current job market.
This retrospective study reviews the process of the newly implemented activity and contributes two novel aspects to the literature, including feedback from the participating students and better measurement of student-led work compared to pharmacist-led work. This study shares the lessons learned from this experience, in hopes of helping other individuals who serve as experiential pharmacy preceptors.

| METHODS
This retrospective study describes results from a quality improvement initiative that was implemented at Providence Medical Foundation.
The study was approved by Providence St. Joseph Health Institutional Review Board. The primary objective of this study was to retrospectively analyze the process and impact of a new workflow, which incorporates pharmacy students into PHM at the institution. The secondary objective was to describe student feedback on the experience. The reporting of this study was guided by the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. 13

| Overview
On an annual basis, Providence Medical Foundation receives insurance claims data of patients not meeting the statin quality measures (SPC, SPD, SUPD). The traditional workflow was for clinical pharmacists to review this data from August to December of that year and work to initiate statin medications for eligible patients. This includes a clinical review of patient charts and determination for statin eligibility for each patient. If a patient was deemed eligible to start a statin, clinical pharmacists reached out to the primary care physician (PCP) for approval through email or a message on the electronic medical record (EMR). Once approval was obtained from the PCP, the patients were outreached telephonically to start the statin.
The clinical pharmacists were residency trained with an active pharmacy license. They received instructions on this process from the managed care pharmacist, which included a 1 h meeting to review the statin measures, exclusion criteria, past performance, and how to improve the measure. The pharmacists were familiar with this type of initiative from previous experience. They had 1 day per week dedicated to PHM and some pharmacists utilized some assistance from students to chart review while other pharmacists completed every step independently.
In 2021, members of the clinical pharmacy team remodeled this traditional workflow. The goals were to better standardize this workflow and reach more patients, incorporate APPE students into the core pharmacy team, and enrich their learning with a hands-on activity.
This remodeled workflow is depicted in Figure 1. The steps of the workflow were similar between the 2 years, with some parts gaining more standardization. APPE students were incorporated into each step and received appropriate training and supervision. In the first 3 weeks of their 6-week rotation, students reviewed patient charts and made recommendations for statin eligibility for each patient. This information was then reviewed by a pharmacist, who agreed or disagreed with the recommendations. If appropriate, the patient's PCP was contacted through email or a message on the EMR for approval to start a statin. During the last 3 weeks of the rotation, students completed telephonic outreach with pharmacist oversight for the approved patients, to either start a new statin or counsel on adherence if they were already taking a statin. Students participated in this experience for 4 h per week for 6 weeks. Each 6-week rotation had 5-7 students participating and there were 3 rotation blocks from August through December. Students documented the outcomes of their chart review and telephonic outreach (as shown in Table 1 and   Table 2) in a password protected cloud-based service.
At the end of the rotation, feedback regarding students' experi-

| Training sessions for students
Properly training students for this experience was a crucial step as it helps with student understanding of the initiative and helps maintain consistency in student work. Three separate training sessions were designed and implemented. The first session was an overview of PHM, the second was a review of the statin measures, and the third was a clinical refresher and hands-on practice with motivational interviewing. The concepts that were discussed in the training sessions were similar to what the pharmacists reviewed with the managed care pharmacist, but more rigorous and designed for students.

| Data collection and statistical analysis
Claims data, containing age, gender, and statin measure, was provided by the insurance plans. Additional relevant data, such as presence of type 2 diabetes, clinical history of ASCVD, history of previous statin use (if applicable), history of statin intolerance (if applicable) and presence of active liver disease, were collected by students from diagnoses documented by physicians in patient charts (Table 1).
Next, statin initiation rates from 2021 with the remodeled workflow were compared to statin initiation rates from 2020 with the traditional workflow ( Table 2). Official exclusion criteria are set for each statin measure by Centers for Medicare & Medicaid Services (CMS) and these criteria were followed by both pharmacists and students. 14 Some of these official exclusions include end-stage renal disease, pregnancy, hospice, and others. Patients were marked as "not clinically appropriate" as determined by the primary care physician or pharmacist for reasons including: the patient was prediabetic (for SPC or SPD), LDL under 40 mg/dL, or had an intolerable gastrointestinal, muscle, or cognitive adverse effect with previous statin use that did not meet an official exclusion. 14 In 2020, the pharmacists made an average of two outreach attempts for each patient, but this occasionally varied based on pharmacist workload. In 2021, in a more standardized approach, students attempted to reach patients three times prior to marking them as "unable to reach." Furthermore, some patient charts were marked as   Table 1. In 2020, pharmacists started with more patients who have previously tried at least one statin and had an intolerance to it, when compared to students in 2021. This could be due to different patients being included between the 2 years based on their insurance plan.
Patient outreach results are included in Table 2 Out of 20 students who participated in this experience, 16 students (80%) responded to the student feedback survey upon completion of their rotation. All 16 students (100%) answered that the training was helpful in preparing them for this experience. Among these students, six students (38%) specifically noted the utility of the third session (clinical review and motivational interviewing) in preparing them to speak with patients. The responses also included 13 students (81%) mentioning an improvement in clinical knowledge about lipid management, 9 students (56%) mentioning an improvement in counseling skills, and 7 students (44%) mentioning an improvement in their confidence and/or comfort speaking with patients. A total of 10 students (63%) mentioned they enjoyed the opportunity to improve a patient's health while 7 students (44%) noted they enjoyed working as a team with their peers and pharmacists. A total of 5 students (31%) provided constructive feedback that having more time for calls/chart review would have been helpful and 4 students (25%) suggested adding additional training on navigating the EMR.

| DISCUSSION
Ambulatory care pharmacists are incorporated into primary care clinics to help improve patient outcomes, resolve drug information questions, and promote higher quality of care. 16,17 In addition to these clinical and PHM duties, ambulatory care pharmacists often have to balance student precepting responsibilities.
Previous projects have demonstrated that student pharmacists can effectively participate in PHM alongside their clinical pharmacist preceptors. 11,12 Cannon et al showed that 46 APPE students were able to make 3774 interventions over the study period and offset 765.6 h of clinical pharmacist time. 12 Another study demonstrated that motivational interviewing-based telephone interventions by pharmacy students resulted in significantly improved medication adherence and less medication discontinuation. 18 From the limited studies available, pharmacy students have proven capable of participating in PHM activities and documenting their interventions. But results from students' work in PHM activities have not been directly compared to results from pharmacists' work in PHM activities.
This retrospective study evaluated an institutional initiative that incorporated APPE students into PHM duties and builds on existing research by investigating two new aspects. One aspect was the direct retrospective comparison of how effective students were in the new experiential PHM activity, as compared to pharmacists in the previous year. The second aspect was reporting the value that students find in this work.

| CONCLUSION
Student involvement in PHM activities can be beneficial for the students, pharmacists, patients, and the institution. There was no difference in statins started or declined between the traditional workflow led by pharmacists and the remodeled workflow led by APPE students. These similar findings between the two groups suggest APPE students can also be valuable members of the healthcare team when reviewing patient charts to assess eligibility for statins and outreaching to eligible patients. This could possibly extend to other medication-related quality measures and future research is warranted in this area. Overall, students found this experience beneficial and had positive perceptions of their contributions to PHM.
Incorporating students into PHM can ease the burden of resource shortage within a healthcare team and help train the next generation of pharmacists.

ACKNOWLEDGMENTS
The authors thank the following individuals for their contributions to this project: Angel Ta, Pharm.D., Megan Eclevia, Pharm.D., and Ray Tan, Pharm.D. for assisting with data collection and analysis; Richard Beuttler, PsyD, M.S. for assisting with data analysis; Providence Medical Foundation pharmacy team for assisting with student training.

FUNDING INFORMATION
There was no external funding for this research.

CONFLICT OF INTEREST STATEMENT
Neeloufar Fakourfar and Hindu Rao have no conflicts of interest to disclose.