TY - JOUR
AU - MacDonald, Nancy, C
AB - Abstract Purpose The Delphi method was used to develop best practice recommendations (BPR) for safe use of pulmonary hypertension (PH) pharmacotherapies and to describe the pharmacist’s role in provision of care. Methods A core group reviewed PH medication-safety literature and developed initial BPR. Pharmacists practicing at PH-accredited Centers of Comprehensive Care who met defined PH expert criteria were invited to participate on an expert panel. In round 1 of a 4-round Delphi process, expert input was provided on the BPR. Feedback was incorporated into BPR for the next round. Round 2 proceeded in identical fashion to round 1. In round 3, BPR were deliberated in a teleconference and underwent voting at the cessation of the round using a 5-point Likert scale. Median scores of < 2.5, 2.5–3.75, and > 3.75 resulted in a best practice statement being rejected, reviewed in round 4, or accepted in the final BPR, respectively. In round 4, the remaining BPR were discussed and underwent voting. BPR were assigned a level of evidence and strength of recommendation based on voting results. Results Eleven PH experts agreed to participate and met expert inclusion criteria, along with 2 pharmacists from the core group, bringing the total number of expert panel members to 13. To guide safe use of PH pharmacotherapies, 26 BPR were developed, categorized into 5 practice domains, comprising the PH Care Center accreditation process, inpatient practice, formulary management, diagnostics, and ambulatory care. BPR included provisions for safe use of parenteral prostacyclin agents and healthcare practitioner education. Conclusion The Delphi method was used to develop BPR to guide safe use of PH pharmacotherapies. Delphi technique, patient safety, pharmacist, practice guidelines, pulmonary hypertension, safety management KEY POINTS A panel of pharmacists with expertise in pulmonary hypertension (PH) developed a list of best practice recommendations (BPR) to ensure the safe use of PH pharmacotherapies. The BPR identify opportunities to guide development of PH medication practice policies, procedures, and guidelines to mitigate errors. The BPR can be used at all facilities to develop or evaluate current practices in an effort to provide safe care for the PH population. Pulmonary hypertension (PH) is defined by an elevated mean pulmonary artery pressure at rest (measuring at least 25 mm Hg) and is separated into five groups according to the underlying etiology of disease.1,2 Group 1, pulmonary arterial hypertension (PAH), is associated with significant morbidity and mortality.3 PAH symptoms are non-specific, and the time between symptom onset and definitive diagnosis is frequently delayed.4,5 The Pulmonary Hypertension Association (PHA) was established in 1991 to foster patient support groups, highlight the importance of early diagnosis, develop educational programs, and advocate for research to prevent and cure PH.6 The Pulmonary Hypertension Care Center (PHCC) program was developed in 2013 to form a network of accredited centers to improve overall quality of care and patient outcomes.7 Accreditation requires an institution to meet outlined criteria, submit an application, and complete a site visit conducted by two members of the PHCC Review Committee. Institutions are designated as either Centers of Comprehensive Care (CCC) or Regional Clinical Programs (RCP).8 A CCC is able to provide the highest level of care, including management of parenteral prostacyclin therapies and infusion devices. This includes specialty-trained healthcare staff and specific institutional procedures for managing PH.8 PH-specific pharmacotherapies target the prostacyclin, endothelin, or nitric oxide pathway.9,10 These medications have unique complexities and challenges pertaining to their safe use in both inpatient and outpatient settings (Appendix A).9,11 Due to these complexities, related errors have led to increased levels of care, harm, and death.12 It is recommended that health care facilities establish procedures to ensure safe prescribing, order verification, dispensing, and administration of these agents.13-16 There is a paucity of literature to guide safe medication practices for PH-targeted therapies.12 Best practice recommendations (BPR) developed by experts have been established to guide the safe use of other high-risk medications.17-19 The purpose of this study was to (1) develop a consensus of BPR for the safe use of PH pharmacotherapies by recruiting an expert panel of pharmacists and (2) describe the pharmacist’s role in the care of this patient population. Methods The modified Delphi method was used to identify best practices and to formulate statements to ensure the safe use of PH pharmacotherapies at facilities caring for patients with PH. The Delphi method is used to develop consensus recommendations using a group of experts in a subject area where there is no definitive evidence.20-27 The modified Delphi method used in this study consisted of the following steps: identification and recruitment of experts by the core group, development of initial BPR by the core group, and expert panel review of BPR to reach consensus and vote on proposed BPR over 4 independent rounds. This approach allowed for expert interaction in the third and fourth rounds.27 This study was approved by the institutional review board at Henry Ford Hospital. The core group consisted of the research coordinator and 2 pharmacists with expertise in PH. The core group invited the pharmacist expert candidates to participate and coordinated all rounds of the study. Directors of pharmacy from all PHA CCC (as of October 1, 2016) were asked to recommend at least 1 pharmacist within their respective center, who possessed expertise related to PH pharmacotherapy, to serve on the expert panel. If no response was received, there was a follow-up email and telephone call at 7 and 10 days, respectively. The respective institution was excluded if no referral was received. The recommended PH pharmacists were invited to participate in the study via email. The email included the expert panel member criteria, the purpose of the study, and time commitment. To be included in the expert panel, pharmacists had to meet two of the following criteria: (1) be recognized as the pharmacy point person for adult PH within their institution; (2) provide direct care to adult PH patients; or (3) be involved in developing policies, procedures, guidelines, presentations, or publications pertaining to use of PH pharmacotherapies. If no response was received, the recommended pharmacist received a follow-up email and telephone call at 7 and 10 days, respectively, and was excluded if no response was received. Panel members who agreed to participate were required to complete an electronic survey (SurveyMonkey Inc., Palo Alto, CA) which collected demographic information. To devise the initial draft of BPR, the core group conducted a literature search using PubMed with the combined headings and keywords for “pulmonary hypertension” and “medication safety” or “medication errors” or “medication policy.” Guidelines and statements from the American Society of Health-System Pharmacists (ASHP), American College of Clinical Pharmacy (ACCP), PHA, and the Institute for Safe Medication Practices (ISMP) regarding medication safety or PH medications were reviewed.8,15-17,28-39 Literature was included if it was written in English and described strategies to guide safe practices regarding the use of PH medications. Literature was reviewed to identify scenarios that resulted in patient harm or potential for harm in those receiving PH medications due to medication errors. The core group developed initial BPR which focused on the prevention of medication errors, medication access, transitions of care, and the pharmacist’s role.40-42 Best practice statements were formatted with supporting rationale and references. Each best practice statement recognized a documented or perceived safety concern or barrier with PH medications with a corresponding solution to mitigate risk in the scenario. Best practice statements were then categorized into practice domains (e.g., inpatient practice, ambulatory care practice). This first BPR draft was titled version 1 of the BPR document (BPR version 1). The document was revised after each modified Delphi round; this occurred four times. Round 1 Version 1 of the BPR was sent to each expert panel member via email for anonymous review. The expert panel was given instructions on the process to provide input on BPR version 1. Expert panel contribution (e.g., modification of content, wording, applicability, feasibility, intent) was requested on any component (best practice statement, rationale, or domain) of BPR version 1. Expert panel members could also recommend general modifications to the BPR (e.g., combining similar statements, adding a new best practice statement, suggest new domains, add references, pose anonymous questions to the group). The reviewed document was emailed back to the core group. Panel members who did not respond were emailed and then called at 10 and 14 days, respectively. A similar method of follow-up was used for each subsequent round. All expert panel comments and suggested changes were individually reviewed by the core group. The feedback was used to modify and produce BPR version 2. Expert panel comments that the core group felt required group input were de-identified and included in BPR version 2 for expert panel review. Round 2 Round 2 proceeded in identical fashion to the first round with the BPR version 2 document being emailed to expert panel members for anonymous review and expert panel feedback being incorporated to develop BPR version 3 by the core group. Round 3 Round 3 consisted of a 2-hour teleconference meeting in which all expert panel members were introduced, un-blinding the process. Prior to the teleconference, the expert panel was sent BPR version 3 and an agenda for the meeting. The intent of this meeting was to finalize the wording and intent of all BPR. The discussion for this meeting was limited to the best practice statements only. Each best practice statement was reviewed using the following steps: (1) the statement was displayed on-screen, (2) the statement was read aloud, (3) there was discussion to clarify the wording and intent of the statement amongst panel members, (4) the statement was modified in real-time during the discussion based on panel member feedback, and (5) the revised statement was read aloud. Best practice recommendations that could not be reviewed due to time constraints were sent via email to the expert panel. Expert panel members were asked to select from one of the following statements for BPR that were not discussed during the teleconference: “agree as written,” “combine with another statement and proposed change,” “disagree with intent of statement and suggest removal,” and “disagree with wording of statement and proposed change.” Panel members were asked to provide literature support where appropriate. The core group consolidated the feedback and modified the BPR accordingly. Round 3 concluded with voting by the expert panel members on all BPR. To reduce individual practice bias, each institution that was represented in the expert panel was allowed one vote. The contact person for the respective site was responsible for coordinating a single consensus vote for their site. To be eligible to vote on the BPR, the panel member must have participated in at least one of the first three rounds. Panel members voted anonymously using an electronic survey tool. Panel members were instructed to base their voting solely on the best practice statement. Voting was conducted using a 5-point Likert scale. The responses on this scale ranged from 1 (“I strongly disagree that this statement should be accepted as a BPR”) to 5 (“I strongly agree that this statement should be accepted as a BPR”). The median Likert score was used to determine if the best practice statement would be included in the final BPR version as follows: panel consensus agreement (score of > 3.75), equivocal (score of 2.5–3.75), or consensus disagreement (score of < 2.5). The consensus agreement strategy was based on previous studies.43 Statements reaching consensus agreement were accepted in the final BPR version with a strong level of recommendation (Appendix B). Statements with consensus disagreement were rejected from the final BPR version. Statements categorized as equivocal were reviewed in round 4. Round 4 Round 4 consisted of a teleconference in which each panel member was given the opportunity to present his or her point of view on equivocal BPR. Round 4 concluded with voting by panel members on the equivocal BPR, using an electronic survey tool. Voting in round 4 used dichotomous statements of either “I accept this statement as a BPR” or “I reject this statement as a BPR.” Majority decision was used to determine if an equivocal statement would be accepted in the final BPR version. Equivocal statements accepted were given a weak level of recommendation. After voting was completed in round 4, all BPR were assigned a level of evidence rating that ranged from Level 1 to 5 based on the supporting literature with the highest quality of evidence supporting the best practice statement (Appendix B).27,44 Demographic information was collected on the expert panel members. Collected information included inclusion criteria met, training, years of practice, practice setting, and Board of Pharmaceutical Specialties (BPS) certification status. Additional data collected included the voting results from rounds 3 and 4. Data was reported using descriptive statistics expressed as either mean or median with interquartile range. Statistics were analyzed using Microsoft Excel version 2013 (Microsoft Corp. Redmond, WA). The core group drafted the initial manuscript and incorporated revisions based on expert panel comments. Results In total, 30 directors of pharmacy from CCC were contacted (Figure 1), of which 14 (46.7%) responded with the name and contact information of 16 pharmacists (one site provided 3 recommendatons). Of the 16 referred pharmacists, 11 (68.8%) agreed to participate in the development of the BPR. In addition, 2 pharmacists from the core group were included, bringing the total number of expert panel members to 13. These individuals represented 11 different PHA-accredited CCC. Figure 1. View largeDownload slide Flow diagram of included expert pharmacistsa aPHA = Pulmonary Hypertension Association, CCC = Centers of Comprehensive Care, PH = pulmonary hypertension. bAn additional 2 pharmacists from the core group are included with the 11 pharmacists who agreed to participate in this panel Figure 1. View largeDownload slide Flow diagram of included expert pharmacistsa aPHA = Pulmonary Hypertension Association, CCC = Centers of Comprehensive Care, PH = pulmonary hypertension. bAn additional 2 pharmacists from the core group are included with the 11 pharmacists who agreed to participate in this panel All referred pharmacists who agreed to participate met at least two of the criteria to be included as an expert panel member with 92% meeting all three criteria. The demographics of the expert panel are shown in Table 1. Of the panel members, 92% had received post-graduate training and 85% were BPS-certified. Evolution of the BPR, practice domains, and expert panel participation by BPR version are listed in Table 2. Table 1. Pharmacist Expert Panel Demographicsa Characteristic Pharmacist, no. (%) (n = 13) Panel inclusion criteria met Involved in developing policies, presentations, or publications pertaining to use of PH pharmacotherapies 13 (100) Recognized as pharmacy point person for adult PH within respective institution 12 (92) Provide direct care to adult PH patients 12 (92) Doctor of pharmacy degree 13 (100) Post-graduate training PGY1 residency 11 (85) PGY2 residency 9 (69) BPS certification 11 (85) Pharmacotherapy 11 (85) Added qualifications in cardiology 2 (15) Critical care 2 (15) Professional title Clinical pharmacist 10 (77) Pharmacy coordinator 2 (15) Academia 1 (8) Years providing care as a pharmacist 5–10 6 (46) 11–15 2 (15) > 15 5 (39) Years providing care to patients with PH 5–10 7 (54) 11–15 4 (31) > 15 2 (15) Description of practice site (n = 11) University hospital 10 (91) Community hospital 1 (9) Characteristic Pharmacist, no. (%) (n = 13) Panel inclusion criteria met Involved in developing policies, presentations, or publications pertaining to use of PH pharmacotherapies 13 (100) Recognized as pharmacy point person for adult PH within respective institution 12 (92) Provide direct care to adult PH patients 12 (92) Doctor of pharmacy degree 13 (100) Post-graduate training PGY1 residency 11 (85) PGY2 residency 9 (69) BPS certification 11 (85) Pharmacotherapy 11 (85) Added qualifications in cardiology 2 (15) Critical care 2 (15) Professional title Clinical pharmacist 10 (77) Pharmacy coordinator 2 (15) Academia 1 (8) Years providing care as a pharmacist 5–10 6 (46) 11–15 2 (15) > 15 5 (39) Years providing care to patients with PH 5–10 7 (54) 11–15 4 (31) > 15 2 (15) Description of practice site (n = 11) University hospital 10 (91) Community hospital 1 (9) aPH = pulmonary hypertension, BPS = Board of Pharmaceutical Specialties, PGY = post-graduate year. View Large Table 1. Pharmacist Expert Panel Demographicsa Characteristic Pharmacist, no. (%) (n = 13) Panel inclusion criteria met Involved in developing policies, presentations, or publications pertaining to use of PH pharmacotherapies 13 (100) Recognized as pharmacy point person for adult PH within respective institution 12 (92) Provide direct care to adult PH patients 12 (92) Doctor of pharmacy degree 13 (100) Post-graduate training PGY1 residency 11 (85) PGY2 residency 9 (69) BPS certification 11 (85) Pharmacotherapy 11 (85) Added qualifications in cardiology 2 (15) Critical care 2 (15) Professional title Clinical pharmacist 10 (77) Pharmacy coordinator 2 (15) Academia 1 (8) Years providing care as a pharmacist 5–10 6 (46) 11–15 2 (15) > 15 5 (39) Years providing care to patients with PH 5–10 7 (54) 11–15 4 (31) > 15 2 (15) Description of practice site (n = 11) University hospital 10 (91) Community hospital 1 (9) Characteristic Pharmacist, no. (%) (n = 13) Panel inclusion criteria met Involved in developing policies, presentations, or publications pertaining to use of PH pharmacotherapies 13 (100) Recognized as pharmacy point person for adult PH within respective institution 12 (92) Provide direct care to adult PH patients 12 (92) Doctor of pharmacy degree 13 (100) Post-graduate training PGY1 residency 11 (85) PGY2 residency 9 (69) BPS certification 11 (85) Pharmacotherapy 11 (85) Added qualifications in cardiology 2 (15) Critical care 2 (15) Professional title Clinical pharmacist 10 (77) Pharmacy coordinator 2 (15) Academia 1 (8) Years providing care as a pharmacist 5–10 6 (46) 11–15 2 (15) > 15 5 (39) Years providing care to patients with PH 5–10 7 (54) 11–15 4 (31) > 15 2 (15) Description of practice site (n = 11) University hospital 10 (91) Community hospital 1 (9) aPH = pulmonary hypertension, BPS = Board of Pharmaceutical Specialties, PGY = post-graduate year. View Large Table 2. Evolution of Best Practice Recommendations by Versiona Characteristic Version 1 Version 2 Version 3b Final Version Number of participating panelist, no. (%) 11 (85) 8 (62) 13 (100) 13 (100) Total BPR statements, no. 24 26 29 26 BPR statements by domain, no. Accreditation process 2 3 3 3 Inpatient practice 18 20 20 18 Inpatient formulary management 1 1 1 1 Diagnostic and procedural 0 0 3c 2 Ambulatory care 3 2 2 2 Characteristic Version 1 Version 2 Version 3b Final Version Number of participating panelist, no. (%) 11 (85) 8 (62) 13 (100) 13 (100) Total BPR statements, no. 24 26 29 26 BPR statements by domain, no. Accreditation process 2 3 3 3 Inpatient practice 18 20 20 18 Inpatient formulary management 1 1 1 1 Diagnostic and procedural 0 0 3c 2 Ambulatory care 3 2 2 2 aBPR = best practice recommendations. bThe wording and intent of 8 best practice statements were finalized outside of the teleconference. cIndicates a new domain was added during the version. View Large Table 2. Evolution of Best Practice Recommendations by Versiona Characteristic Version 1 Version 2 Version 3b Final Version Number of participating panelist, no. (%) 11 (85) 8 (62) 13 (100) 13 (100) Total BPR statements, no. 24 26 29 26 BPR statements by domain, no. Accreditation process 2 3 3 3 Inpatient practice 18 20 20 18 Inpatient formulary management 1 1 1 1 Diagnostic and procedural 0 0 3c 2 Ambulatory care 3 2 2 2 Characteristic Version 1 Version 2 Version 3b Final Version Number of participating panelist, no. (%) 11 (85) 8 (62) 13 (100) 13 (100) Total BPR statements, no. 24 26 29 26 BPR statements by domain, no. Accreditation process 2 3 3 3 Inpatient practice 18 20 20 18 Inpatient formulary management 1 1 1 1 Diagnostic and procedural 0 0 3c 2 Ambulatory care 3 2 2 2 aBPR = best practice recommendations. bThe wording and intent of 8 best practice statements were finalized outside of the teleconference. cIndicates a new domain was added during the version. View Large All 11 sites participated in the voting on the final BPR version in round 3. In round 3, 25 (96%) best practice statements reached consensus agreement and were assigned a strong level of recommendation (Table 3). No statements reached consensus disagreement. One (4%) best practice statement was voted equivocal in round 3 but was subsequently accepted in the final BPR version with a weak level of recommendation after reaching majority consensus (70%) in round 4. The BPR were developed over 6 months from initial contact of pharmacy directors to analysis of round 4 voting. The 26 final BPR are listed in Appendix C with level of evidence, grade of recommendation, supporting rationale, and supporting references. Table 3. Voting Results on Best Practice Statements by Practice Domain From Round 3a Panel Consensus on BPR, no. (%) Inpatient Practice (n = 18) Inpatient Formulary Management (n = 1) Diagnostic and Procedural Areas (n = 2) Ambulatory Care Practice (n = 2) Accreditation Process (n = 3) Agreement 17 (94) 1 (100) 2 (100) 2 (100) 3 (100) Equivocal 1 (6) 0 (0) 0 (0) 0 (0) 0 (0) Disagreement 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Panel Consensus on BPR, no. (%) Inpatient Practice (n = 18) Inpatient Formulary Management (n = 1) Diagnostic and Procedural Areas (n = 2) Ambulatory Care Practice (n = 2) Accreditation Process (n = 3) Agreement 17 (94) 1 (100) 2 (100) 2 (100) 3 (100) Equivocal 1 (6) 0 (0) 0 (0) 0 (0) 0 (0) Disagreement 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) aBPR = best practice recommendations. View Large Table 3. Voting Results on Best Practice Statements by Practice Domain From Round 3a Panel Consensus on BPR, no. (%) Inpatient Practice (n = 18) Inpatient Formulary Management (n = 1) Diagnostic and Procedural Areas (n = 2) Ambulatory Care Practice (n = 2) Accreditation Process (n = 3) Agreement 17 (94) 1 (100) 2 (100) 2 (100) 3 (100) Equivocal 1 (6) 0 (0) 0 (0) 0 (0) 0 (0) Disagreement 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Panel Consensus on BPR, no. (%) Inpatient Practice (n = 18) Inpatient Formulary Management (n = 1) Diagnostic and Procedural Areas (n = 2) Ambulatory Care Practice (n = 2) Accreditation Process (n = 3) Agreement 17 (94) 1 (100) 2 (100) 2 (100) 3 (100) Equivocal 1 (6) 0 (0) 0 (0) 0 (0) 0 (0) Disagreement 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) aBPR = best practice recommendations. View Large Discussion The expert panel reached consensus on 26 BPRs. Of these, one statement was accepted with a weak level of recommendation and 25 were accepted with a strong level of recommendation. The BPR were categorized into five separate practice domains, comprising inpatient practice, inpatient formulary management, ambulatory care practice, diagnostic and procedural areas, and PHA accreditation process. The BPR were developed to identify scenarios for which delineated procedures should exist to optimize PH medication safety and access but allow for individual sites to develop processes for their practice given differences in resources and personnel that exist at PHA-accredited CCC, RCP, and non-accredited centers. The expert panel represented a diverse group of pharmacists with varying years of clinical practice, similar to previous Delphi studies.59 A wide geographic area across the United States was represented. No preferred method for expert identification exists and heterogeneity can be seen in the literature.17,24,26,27,59-61 Our approach identified PHA-accredited CCC, then requested referrals from directors of pharmacy for pharmacists considered to possess expertise in PH. Referred experts met at least two of the 3 proposed criteria, similar to an approach used for defining what constituted an expert in previous studies.18 A panel size of 5 to 10 experts is considered to be adequate for consensus development, but the range of panel members has been documented to exceed 100 in some Delphi studies.43,62 The participation and response rate observed in our study was high with at least 60% participation in all rounds, similar to other studies.18,43,61 The initial development of the BPR used a literature search that was similar to previous Delphi studies.18,59,60 In addition, both new best practice statements and supporting references could be added by expert panelists during review, a method previously described.59 In rounds 1 and 2, experts provided anonymous feedback, to reduce the chances that individuals would influence one another. In rounds 3 and 4, live teleconferences were used to allow interaction and sharing of rationale. The interactive nature of this approach afforded experts the opportunity to shape and hone their viewpoints over a period of time, refining the practicality, utility, and precision of the statements while concurrently developing consensus.27,63,64 The BPR expand on previous PH medication safety recommendations, particularly parenteral prostacyclins.12-16,46 The BPR addressing inpatient practice focus on the development and implementation of standardized policies or guidelines in regard to accuracy of order entry, verification, dispensing, preparation, and administration. No literature exists to guide the optimal approach for inpatient administration of parenteral prostacyclin analogues with respect to selection of infusion device (e.g., continuation of home ambulatory infusion pump, conversion to hospital supplied ambulatory infusion pump, or conversion to hospital smart pump). For this reason, a best practice statement focused on standardizing inpatient infusion device practices was developed, given variable practices used among institutions. The importance of education and standardized competencies for healthcare professionals involved in the use of these therapies and respective administration devices (e.g., ambulatory infusion pump, inhaled devices) was felt to be instrumental. The remaining aspects of inpatient practice addressed in the BPR included the importance of maintaining an appropriate inpatient formulary to ensure that admitted patients are able to continue their PH pharmacotherapies in an effort to optimize patient outcomes.46 Transitions of care activities were felt to be important due to the medication access complexities that exist with PH-targeted therapies. Particularly, inpatient initiations of these medications or titration of home therapies are opportunities for gaps in access or errors in medication reconciliation at discharge. Best practice recommendations are targeted towards new inpatient initiations of medications with a Risk Evaluation and Mitigation Strategy (REMS) program and those which require insurance prior authorization. Additionally, facilitating effective communication surrounding PH pharmacotherapies between inpatient pharmacists and outpatient clinicians was felt to be important. The statement addressing this point was accepted with a weak level of recommendation due to variation in practice site workflow (e.g., established methods of communication not involving a pharmacist or limitations with the current pharmacist staffing model). Pharmacist involvement in these activities may improve safety and facilitate a multidisciplinary approach in the management of these therapies.7,13 The BPR also address the importance of managing these therapies in the ambulatory care setting. The integration of pharmacists in the management of PH pharmacotherapies in the outpatient setting allows for a multidisciplinary approach which may facilitate optimization of patient safety.13,14 The panel members reached consensus agreement on the BPR that emphasize the value of pharmacists to provide patient and provider education and help to improve patient access to PH pharmacotherapies. Lastly, the BPR address the importance of pursuing accreditation by the PHA. The expert panel members reached consensus that PHA accreditation would help to ensure that institutions caring for adult patients with PH would be proficient with all PH pharmacotherapies and the respective delivery devices. Accreditation ensures appropriate training for healthcare staff and also that specific protocols exist for managing PH pharmacotherapies.12 Although it is a widely-accepted and robust process for reaching consensus on best practices when there are no empirical data, the Delphi method is not without shortcomings. These include a lack of criteria for selecting the expert panel, determining optimal panel size, participation bias, and persuasion of panel members by strongly opinionated participants.23,25,63 There are no definitions that define a PH expert pharmacist; therefore, for our study, a pragmatic definition was developed. The criteria developed models the aspects that would be expected of an expert in his or her respective field, such as being recognized by peers as an expert and developing publications that provide added insight into the respective subject area. Most studies using the Delphi method have between 15 and 20 expert panelists.63,65 A panel size of 10 to 15 is considered adequate provided that the knowledge and experience of all members are similar.20 Our study included 13 experts and met the panel size considered adequate to reach consensus. An additional limitation may be that our expert panel was a pharmacist-only panel. The PH pharmacotherapies addressed by these BPR involve a number of healthcare personnel, including physicians, nurses, advanced practice providers, and pharmacy technicians. Although BPR address the importance of staff education and training, the perspective is limited to that of the pharmacists. Participation bias was minimized by contacting pharmacy directors for a referral of pharmacists possessing expertise in PH. Anonymity of panel feedback in rounds 1 and 2 and during the voting process minimized persuasion of the panelist by opinionated participants.59 Currently, there are no empirically validated standards for what constitutes consensus. Several methods of establishing whether a consensus was achieved have been described. For our study, we used a median value of greater than 75% to determine consensus agreement, which is consistent with previous studies.64,66 It is also recommended to have a response rate of at least 70% in all rounds of the Delphi method in order to preserve the rigor of the process.63 In our study, the average participation per round was 87%, with the lowest round having 62% participation. Lastly, all panel members in our study practice at a PHA-accredited CCC, which may limit the applicability of the BPR to non-accredited centers. The intent in formulating the BPR was to ensure applicability to any institution, regardless of practice setting or PHA accreditation status, to guide the safe use of PH pharmacotherapies. Overall, the BPR developed by this study can facilitate the safe use of PH pharmacotherapies. In addition to guiding therapies at institutions currently caring for patients with PH, these BPR can also serve as a template for safe practices at institutions that currently do not maintain these therapies on formulary but are considering adding them. Conclusions The Delphi method was used to develop 26 BPRs to guide safe use of PH pharmacotherapies. Disclosures James C. Coons, PharmD, FCCP, BCCP declares the following conflict of interest: Research Grant Support, United Therapeutics. All other authors have declared no potential conflicts of interest. Acknowledgments The authors would like to acknowledge Lindsey Federle, Pharm.D., BCPS for her participation on the expert panel and contributions during the development of the best practice recommendations. References 1. Simonneau G , Gatzoulis MA , Adatia I et al. Updated clinical classification of pulmonary hypertension . J Am Coll Cardiol . 2013 ; 62 : D34 – 41 . Google Scholar Crossref Search ADS PubMed 2. Galiè N , Humbert M , Vachiery JL et al. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT) . Eur Heart J . 2016 ; 37 : 67 – 119 . Google Scholar Crossref Search ADS PubMed 3. Ling Y , Johnson MK , Kiely DG et al. 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Google Scholar Crossref Search ADS PubMed Appendix A—Safety Concerns and Access Considerations Surrounding the use of Pulmonary Hypertension Medicationsa Prostacyclin analogue or receptor agonist Epoprostenol is an ISMP High Alert Medication Specialized administration devices for parenteral and inhaled agents Parenteral and inhaled agents require drug preparation Need for back-up supply with parenteral therapies Need for continuous therapy without interruption for parenteral therapies Prior authorization required Outpatient dispensing from a specialty pharmacy Endothelin receptor antagonists REMS program (teratogenicity and/or hepatotoxicity) Prior authorization required Outpatient dispensing from a specialty pharmacy Soluble guanylate cyclase stimulator REMS program (teratogenicity) Prior authorization required Outpatient dispensing from a specialty pharmacy Phosphodiesterase-5 inhibitors Prior authorization often required Specialty pharmacy may be required for outpatient dispensing Appendix B—Levels of Evidence and Strength of Recommendation Definitions27, 32 Level of evidence Level 1: Very high quality High-quality randomized controlled trials High-quality prospective studies Systematic review of level 1 randomized controlled trials Level 2: High quality Lesser-quality prospective studies Lesser-quality randomized controlled trials Retrospective studies Prospective comparative studies Systematic review of level 2 studies or level 1 studies with inconsistent results Level 3: Moderate quality Case–control studies Retrospective cohort studies Systematic review of level 3 studies Level 4: Low quality Case series Case–control studies with poor reference standard Level 5: Very low quality Expert opinion Strength of recommendation Strong recommendation Best practice statement voted as a consensus agreement amongst expert panel in round 3 Weak recommendation Best practice statement voted as equivocal amongst expert panel in round 3 and accepted with a majority vote in round 4 Appendix C—Best Practice Statement (Strength of Recommendation; Level of Evidence) With Rationale Inpatient practice Institutional policies with procedures or guidelines should be developed to guide the safe use of parenteral, inhaled, and oral prostacyclin agents and their respective administration devices.12, 13, 15-17, 28, 30, 31, 45, 46(Strong recommendation, moderate-quality evidence) The risk of medication errors and adverse events associated with intravenous prostacyclin agents, specifically epoprostenol, led to its inclusion on the Institute for Safe Medication Practices (ISMP) list of high-alert medications. A survey of Unites States pulmonary hypertension (PH) centers reported that the majority of centers have experienced medication errors, including accidental bolus administering (flushing the dedicated line), incorrect administering (calculation, compounding, or ordering errors), and pump-related errors. Standardizing the ordering, storage, preparation, and administration processes of these products can reduce risk of error. Prostacyclin ambulatory infusion device- (e.g. CADD Legacy, CADD MS 3, Crono 5) related errors can lead to serious adverse outcomes for hospitalized patients therefore, standardized policies and procedures detailing the appropriate use of either the home ambulatory infusion device, a hospital-supplied ambulatory infusion device or conversion to a hospital-supplied IV smart pump is warranted. Designated drug-specific inhalation devices used to administer inhaled treprostinil and iloprost require careful step-by-step instructions for preparation and handling to ensure safe and appropriately administered medication. Additionally, these devices have specific cleaning steps in order to preserve the integrity of the device, including the use of distilled water. Institutions should have a standardized policy and procedure in place addressing the use of these medications/devices. This policy should address whether patient and/or hospital staff operate the device and provide directions to healthcare staff if the patient-specific inhalation device is not available. Given the complexities in administration of parenteral prostacyclin analogues, centers caring for adult patients with PH should designate inpatient healthcare professional staff trained to administer and monitor these therapies. This care may be provided by designating specific hospital locations or coordination of the availability of healthcare professionals that have expertise in the use of these therapies.7, 12, 13, 15-17, 28, 31, 45, 46(Strong recommendation, moderate-quality evidence) Errors in administration of parental prostacyclin therapies can lead to severe morbidity and mortality. Due to the high-risk nature of parenteral prostacyclin therapy, only staff trained in the correct administration and monitoring procedures should be assigned to care for patients receiving therapy. To ensure appropriately trained personnel are managing these therapies, patients receiving parenteral prostacyclin therapies should be located in specific areas within the inpatient units or have a policy and process in place to ensure coordination of the availability of healthcare professionals that have expertise in the use of these therapies to provide care if not confined to specific inpatient locations. For patients continuing on home infusion devices during hospital stay, a policy with procedures or guideline should be in place to address the following scenarios: patients unable to operate their home pump, hospital staff not trained to use the home device, home device malfunction, and central line malfunction. In addition, a process should be in place for expeditious ordering of necessary equipment for medication infusions (i.e. tubing, subcutaneous starter kits).12, 15-17, 45, 47 (Strong recommendation, very low quality evidence) Patients presenting to institutions utilizing home ambulatory infusion pumps have been described as a possible source of medication errors. An ISMP survey reported that a minority of respondents had a procedure in place to describe a structured approach to patient infusion device management. Given the availability of multiple parenteral infusion devices for parenteral prostacyclin analogues (CADD Legacy pump, Crono 5 pump, CADD MS 3 pump), a procedure should be in place to manage the aforementioned scenarios. An institutional policy with procedures or guideline for managing patients that require emergent initiation of a prostacyclin infusion should be developed.12, 13, 45(Strong recommendation, very low quality evidence) In certain emergent situations (critical illness), patients may require initiation of a prostacyclin infusion without the availability of a CADD pump or central access. In these cases, a process should be developed which addresses appropriate prostacyclin use and administration. Pharmacist expertise is essential in helping to create an effective procedure which ensures safe use in this extenuating circumstance. An institutional procedure should be developed for managing an unexpected interruption in prostacyclin analogue infusion. This should address interruptions in therapy due to malfunctions of medication cassette/syringe, infusion device, and parenteral access.12, 13, 15-17, 45, 46(Strong recommendation, moderate-quality evidence) Abrupt discontinuation of parenteral prostacyclin therapy can result in severe rebound pulmonary hypertension and significant harm, including death. Preventing and reducing interruptions in therapy may decrease risk of significant patient harm. A procedure should be in place that outlines strategies to address unanticipated interruptions in parenteral prostacyclin analogue therapy. This procedure may include keeping a patient specific backup epoprostenol cassette/bag on the nursing unit or in the pharmacy. However, errors have occurred with this approach due to the incorrect epoprostenol cassette/bag being given to the wrong patient when there are multiple epoprostenol infusions on the same unit. Another approach is having procedures in place for communication between nursing and pharmacy that allow for pharmacy personnel to prepare an epoprostenol cassette/bag in this scenario. To address infusion line related complications, an alternate peripheral IV line should be placed to allow immediate prostacyclin analogue administration in the event that the primary infusion site malfunctions. Standardized order sets should be developed for each of the prostacyclin analogue infusions used in the inpatient setting.12, 13, 17, 38, 45(Strong recommendation, very low quality evidence) Electronic order sets (or standardized written order sets in institutions without electronic order entry) should be developed in conjunction with the pharmacist to guide appropriate ordering of prostacyclin analogue infusions and to minimize error potential. The dosage, titration, and administration of prostacyclin infusions is complex. Several variables must be taken into consideration, including but not limited to: route, infusion pump, dosing weight, current dose, diluent, and infusion rate. This recommendation is supported by the Pulmonary Hypertension Association (PHA). Centers should have a designated frequency for changing the parenteral tubing used to administer prostacyclin analogue infusions.13, 30(Strong recommendation, very low quality evidence) Errors related to improper equipment have been reported via the ISMP Medication Errors Reporting Program (MERP). Changing the parenteral tubing at a scheduled frequency helps to ensure that proper equipment is in place to reduce risk to patients. A standardized pharmacy policy with procedures or guideline should be developed for preparing parenteral prostacyclin analogues to ensure accurate order verification, preparation, and dispensing.8, 12, 13, 15-17, 31, 45, 46(Strong recommendation, moderate-quality evidence) Administering of prostacyclin therapies is highly individualized to the patient, based on disease severity, dosing weight, tolerance, previous therapies, and the length of time they have been maintained on current therapy. Parenteral prostacyclin agents have a narrow therapeutic window, and sudden increases or decreases in dose can lead to life-threatening consequences. Each institution should have a standardized workflow process. Upon receipt of a parenteral prostacyclin analogue order this process may include contacting the patient’s specialty pharmacy, pulmonary hypertension healthcare provider, or conducting a medication history (i.e., verification of dosing weight, cassette concentration, medication dose, infusion rate), to ensure appropriate administering, and product preparation pursuant to the manufacturer recommendations upon hospital admission. Initial training and annual competency should be required for inpatient nurses who provide care for patients requiring parenteral prostacyclin analogues, including appropriate monitoring and, if applicable, their infusion devices.8, 12, 13, 15, 16, 45, 46(Strong recommendation, moderate-quality evidence) Error reports from the ISMP MERP indicate that a frequent cause of medication errors during drug administration is unfamiliarity with devices by healthcare professionals. Incorrect utilization of prostacyclin infusion devices has led to errors relating to incorrect dose and infusion rate secondary to improper pump programming. Annual competencies for nursing staff ensure a standardized education process that facilitates appropriate training to reduce the safety risk for patients. Initial training and competencies should be developed for newly hired pharmacists and pharmacy technicians who either provide direct patient care, develop policies and procedures, or are involved with the distribution of PH pharmacotherapies. This competency should focus on medication safety and proper distribution of PH pharmacotherapies. Additionally, pharmacy staff competencies should be repeated at a frequency sufficient to maintain proficiency regarding the safe use and distribution of PH pharmacotherapies.7, 12–14, 30, 31, 36, 37, 45, 46, 48, 49(Strong recommendation, moderate-quality evidence) Initial and ongoing training with competencies are an important medication error prevention strategy that has been recommended and utilized by many pharmacy associations. Initial training ensures that all pharmacists and pharmacy technicians in either direct patient care or distribution roles are adequately trained and educated in a standardized manner consistent with institutional guidelines, policies, and procedures for use of PH pharmacotherapies. Competencies ensure that all members of pharmacy staff remain up to date on any new policies or updates to existing policies associated with the utilization of these medications at the respective centers. Annual competencies regarding other disease state specific pharmacotherapy are currently recommended for pharmacists practicing at institutions with specialized certifications (i.e., comprehensive stroke center). An institutional policy with procedures or guideline should be developed to outline the safe conversion of oral PH medications on inpatient formulary to parenteral PH medications, and vice versa, when patients are not able to take such medications by mouth and where alternative administration routes exist (e.g., treprostinil diolamine to parenteral treprostinil) guided by specific manufacturer recommendations.50, 51(Strong recommendation, very low quality evidence) Several oral PH medications cannot be crushed. Clinical scenarios where patients are unable to take medications by mouth (e.g., mechanical ventilation), therapeutic options available are to either hold the oral medication, initiate a new alternate therapy, or convert to an alternate route of administration (e.g., treprostinil diolamine to IV treprostinil). With select oral PH medications, pharmaceutical manufacturers have recommendations for the conversion of an oral PH medication to a parenteral agent. This oral to parenteral conversion is complex and poses a risk for medication errors (e.g., calculations converting oral dosing to IV, selection of a dosing weight, medication dose, medication concentration, etc.). For this reason, it is suggested to have a protocol in place to standardize the process to prevent medication errors in scenarios in which manufacturer recommendations exist for product conversion. A policy with procedures or guideline should be developed for managing an unexpected interruption in U.S. Food and Drug Administration-approved inhaled prostacyclin analog therapy. This should address interruptions in therapy due to lack of availability of inhalation device, device malfunction, or clinical scenarios not compatible with the administration device (e.g., mechanical ventilation or altered mental status).11, 13, 52, 53(Strong recommendation, very low quality evidence) Abrupt stoppage of inhaled prostacyclin therapy has the potential to result in adverse consequences to the patient, including rebound PH. Preventing and reducing interruptions in therapy may decrease significant patient harm. Depending on the practice at each institution, a procedure should be in place that outlines strategies to address unanticipated interruptions in inhaled prostacyclin analogue therapy. Adult patients newly initiated on a PH pharmacotherapy which requires a Risk Evaluation and Mitigation Strategy (REMS) program should be under the care of a physician enrolled in the respective REMS program associated with PH targeted therapies.8, 11, 14, 54(Strong recommendation, very low quality evidence) Many of the oral PH medications, including the endothelin receptor antagonists and riociguat have specific REMS program requirements. For these agents, it is mandated that prescribers and patients be enrolled into specific REMS programs to ensure regulatory compliance for the prescribing of these agents. Having physicians enrolled in REMS programs ensures proper compliance with manufacturer requirements and streamline prescribing for inpatient use. An inpatient procedure should be developed for dispensing PH medications with a REMS program. This should include verification of patient REMS enrollment when a home medication is continued upon admission for inpatient care and upon inpatient initiation of the aforementioned therapies. Additionally, this should include verification that the patient is under the care of a healthcare provider certified in the respective medication’s REMS program.11, 14, 54, 55(Strong recommendation, very low quality evidence) Required regulatory compliance programs (REMS programs) are components of prescribing and dispensing many of the oral agents, including the endothelin receptor antagonists and riociguat. Development of policies, procedures, and guidelines are necessary to ensure a standardized process for the utilization, storage, preparation, monitoring, and administration of these medications with their respective administration devices (if applicable). PH pharmacotherapies with a REMS program outline specific criteria for prescribing and dispensing of these medications for physicians and inpatient pharmacies. In order to be compliant with these REMS programs inpatient pharmacies must ensure pharmacists dispensing or verifying medication orders are knowledgeable about REMS requirements. Centers should designate a pharmacist/pharmacists, with PH expertise to collaborate with the PH team for provision of direct patient care.7, 12-14, 17, 28, 34, 35, 45, 56(Strong recommendation, very low quality evidence) Professional organizations recommend that pharmacists be included in collaborative, team-based practice. The pharmacy specialist should have post-graduate residency training or equivalent experience and, when eligible, board certification. Serious medication errors have been reported with PH pharmacotherapies, some of which have resulted in fatalities. The presence of pharmacists with additional training or expertise in the use of PH pharmacotherapies may help to reduce medication errors through direct patient-care activities and the development of related inpatient policies and procedures (e.g., administration errors, development of monitoring plans, drug–drug interactions, and medication contraindications). Pharmacists have been mandated to be part of the medical team for other high-risk patient populations (i.e., solid organ transplantation, ventricular assist device) as their expertise has proven to reduce medication errors and improve patient outcomes. A pharmacist should provide input on medication safety events reported in the inpatient and ambulatory care setting. Additionally, quality assurance initiatives should be in place for evaluation of PH-medication-related guidelines, policies, and procedures to ensure that practices are being followed.7, 12-14, 17, 30, 32, 33, 45(Strong recommendation, very low quality evidence) Pharmacists are an integral part of any medication safety assessment process. Pharmacist involvement in medication use from procurement through administration and monitoring can help to identify areas of improvement for the reduction of adverse events. As the medication experts, pharmacists can also provide leadership in the development, maintenance, and ongoing evaluation of adverse drug reporting programs to ensure patient safety and proper utilization of these therapies. In order to continually assess compliance with institution procedures and address areas for improvement, quality assurance initiatives should take place at a time-frame determined by the organization. A process should in place for submitting a prior authorization (PA) to the patient’s insurance or an application for assistance programs, to ensure timely access to medications at discharge when new PH medications are initiated in the inpatient setting.8, 11, 13, 14(Strong recommendation, very low quality evidence) The majority of prescription insurance providers require PA for pharmacotherapies used to treat PH, due to their significant cost. A delay in processing a PA may negatively impact a patient’s access to medications in a timely manner. A process for submitting PAs can help expedite the process and identify any gaps in insurance coverage at an earlier stage. Centers should have a communication system between the inpatient pharmacist and the outpatient clinician for appropriate follow up after hospital discharge.7, 8, 11, 14(Weak recommendation, very low quality evidence) Transitions of care from the inpatient to outpatient setting have been shown to be associated with an increased risk of medical errors due to suboptimal coordination. Considering the high risks associated with PH pharmacotherapies, a specific, step-by-step process for a handoff between inpatient and outpatient clinician helps to safeguard the potential for adverse events experienced by patients on these therapies Inpatient formulary management A process should be in place to continue home PH medications in the event a medication is not stocked in the inpatient pharmacy.11, 12, 14, 28, 45(Strong recommendation, very low quality evidence) PH medications are an essential component to optimal patient outcomes. Continuation of these medications is important to maintain patient care. If home PH medications are not available on the inpatient formulary, pharmacy policies, and procedures must be in place to ensure continuation of therapies (e.g., utilizing home medication process while inpatient or one-time non-formulary approval pathway, transitioning to available equivalent therapy per policy). Diagnostic and procedural areas A policy with procedures or guideline should be developed for managing patients on prostacyclin analogue infusions that require magnetic resonance imaging (MRI) or other diagnostic imaging studies.12, 13, 45, 57(Strong recommendation, very low quality evidence) Safety risks exist in patients that receive prostacyclin analogue infusions who require MRI testing due to the incompatibility of ambulatory infusion pumps with MRI. In order to keep the infusion pumps outside the MRI room, additional tubing and connectors are typically required. Alternatively, the infusion may be changed to an MRI-compatible pump. In addition, errors have been reported due to discontinuation of prostacyclin analog infusions to allow for the MRI to be completed due to pump incompatibility. Patients undergoing imaging studies requiring an extended period of time may be at risk for inadvertent interruptions of therapy due to inadequate medication reservoir volume. Policies and procedures should be in place to ensure adequate medication supply prior to diagnostic imaging study. This recommendation is supported by the PHA. A policy with procedures or guideline should be developed for managing patients on prostacyclin analogue infusions that undergo surgical or diagnostic procedures.12, 45(Strong recommendation, very low quality evidence) Errors have been reported due to inadvertent discontinuation of prostacyclin analog infusions related to inadequate medication infusion supply and device or line malfunction. Additional errors have been reported in the operating room related to use of dedicated prostacyclin analogue infusion line for concomitant medication administration and surgical incision adjacent to subcutaneous infusion site. Policies and procedures should be in place for prostacyclin analog therapy related to: adequate medication supply, distribution of additional medication supply, initiation of new intraoperative therapy, administration of therapy, and delineation of appropriate staff members to operate the administration device and monitor the therapy. Ambulatory care practice Pharmacy services should be integrated into the multidisciplinary team to manage PH patients in the ambulatory care setting.7, 8, 9, 11, 13, 14(Strong recommendation, very low quality evidence) As the medication experts, pharmacists possess a wide breadth of knowledge about the effectiveness and safety of PH medications. Pharmacists can provide valuable services in areas of patient and provider education, medication access, transitions of care support, and side effect management. Centers caring for adult patients with PH in the outpatient setting should develop a central data collection program for tracking required tests associated with REMS medications (i.e.: pregnancy tests or liver transaminases).8, 11, 14, 58(Strong recommendation, very low quality evidence) Medications including the endothelin receptor antagonists and riociguat require close monitoring as mandated by the manufacturers’ REMS programs. Components of existing REMS programs may include, but are not limited to, monitoring liver function tests (LFT) and pregnancy tests. A central data collection accessible to pharmacists and prescribers facilitates effective communication between healthcare providers to optimize patient care and reduce the safety risk associated with these therapies. Accreditation process Centers caring for adult patients with PH should pursue accreditation by the PHA as either Centers of Comprehensive Care (CCC) or a Regional Clinical Program (RCP).7, 8, 11(Strong recommendation, very low quality evidence) The criteria outlined by the PHA to be accredited as a CCC or RCP highlight the importance of expertise with PH pharmacotherapy. As it pertains to PH medication use, CCC are required to (1) be proficient in disease state and with all PH pharmacotherapies (oral, inhaled, intravenous, subcutaneous) and delivery devices; (2) have specially-trained staff on inpatient wards and intensive care units; (3) have specific protocols for managing PH, including prostacyclin analogue infusions; (4) have pharmacy personnel with immediate access to and proficiency in the preparation of parenteral prostacyclin analogue infusions; and (5) be knowledgeable about the approval, initiation, and maintenance of all PH pharmacotherapies. RCP are required to be proficient and knowledgeable about the approval, initiation, and maintenance of all non-parenteral PH pharmacotherapies. Centers should include a pharmacist in the PHA accreditation process.7, 11, 14, 28, 29, 39(Strong recommendation, very low quality evidence) Pharmacists are integral patient-care team members with a specific skill set required to care for complex patient populations and possess in-depth knowledge of medications. Additionally, pharmacists are often responsible for the development and maintenance of center-specific drug use guidelines, policies, and procedures to guide safe inpatient medication use. Given that the PHA criteria for a CCC mandates an institution have specific protocols for managing prostacyclin infusions, pharmacists are key members that should be involved in the preparation of PHA accreditation and re-accreditation visits. In addition, pharmacists need to have dedicated time to meet with the accrediting group for the single day CCC accreditation visit. Pharmacists should be involved in PH-related education for patients and healthcare professionals.7–9, 45(Strong recommendation, very low quality evidence) Pharmacists are recognized as medication experts. They are an important component to providing continuing education to healthcare professionals and professional trainees. In addition, community outreach programs for patients with PH may allow a more convenient access to care. Community outreach programs also afford opportunities for additional education for patients in regard to their PH pharmacotherapies. Footnotes a IV = intravenous, REMS = Risk Evaluation and Mitigation Strategy, ISMP = Institute for Safe Medication Practices. © American Society of Health-System Pharmacists 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Development of best practice recommendations for the safe use of pulmonary hypertension pharmacotherapies using a modified Delphi method
JF - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/zxy020
DA - 2019-01-25
UR - https://www.deepdyve.com/lp/oxford-university-press/development-of-best-practice-recommendations-for-the-safe-use-of-mPYcgnE9vD
SP - 153
VL - 76
IS - 3
DP - DeepDyve
ER -