2023 Update to the American College of Clinical Pharmacy Pharmacotherapy Didactic Curriculum Toolkit

The 2023 ACCP Publications Committee was charged with reviewing the 2019 Update to the ACCP Pharmacotherapy Didactic Curriculum Toolkit. 1 The committee was composed of 11 pharmacists, 1 pharmacy resident, and 1 student. Pharmacist members represented diverse areas of expertise on the basis of clinical practice area, geographic location, and teaching experience, including, but not limited to, academia, critical care, drug information, family medicine, and internal medicine. The committee met face-to-face at the 2022 ACCP Global Conference in San Francisco. A designated virtual weekly meeting time was established. A cloud file-sharing folder was created to house resources, minutes, virtual meeting recordings, external feedback, ongoing committee work, and a committee calendar. The chair assigned topics for the toolkit review on the basis of clinical expertise and teaching experience using information that was solicited before the Global Conference. Areas where expertise was lacking were assigned to members who had been on the 2019 ACCP Publications Committee or on a volunteer basis. The committee performed literature searches and used resources similar to those cited in the 2016 and 2019 toolkits including, but not limited to, national accreditation standards for colleges and schools of pharmacy, 7 licensing examination competency statements, 8 competency areas from residency training programs, 9 pharmacotherapy textbooks, 10 – 15 related clinical practice guidelines, and literature on disease burden and the pharmacist’s role in optimizing pharmacotherapy. 16 All topics were approached with generalist pharmacy practitioners in mind. Each section of the toolkit was reviewed by a subcommittee composed of at least two committee members before a weekly meeting. Recommendations were collected in a shared spreadsheet that was reviewed by the entire committee. On average, two or three sections of the toolkit were reviewed at each weekly meeting. In addition, all committee members were advised to collect comments/input on the 2019 edition from pharmacists and faculty within their institutions and professional networks. External feedback was collected on a spreadsheet and reviewed during the weekly meetings. All topics were voted on by a simple majority rule during the virtual meetings. There were three meetings when the committee did not have a quorum. Those able to join listened to reviewer comments and shared feedback, all of which were presented in an electronic vote that was conducted by the chair. Thirteen 1-hour weekly meetings occurred over a 4-month period. Four additional meetings were deemed necessary by the chair to discuss outstanding reviews. Officers of the ACCP Practice and Research Networks were invited to review and provide input on the updated draft of the toolkit. The final toolkit was reviewed and approved by the ACCP Board of Regents in August 2023.

The committee reviewed the competency-based tier definitions from the 2019 toolkit during the face-to-face meeting. The committee discussed the number of topics and concern for curricular hoarding and the role of the toolkit in curricular evaluation and revision. The primary audience and users of the toolkit were also considered. The committee identified several topics within the 2019 toolkit that required additional training to varying degrees to practice independently or to understand the complexities of disease states. In fact, many accredited postgraduate year two (PGY2) residency programs provide topic lists that include highly specialized conditions that may not require a direct patient care experience. 9 Including these conditions in the toolkit could contribute to curricular hoarding. For these reasons, the committee agreed that the 2023 toolkit would focus on content for the Pharm.D. curriculum. A historical overview of tier designations was reviewed ( Table 1 ), and the committee ultimately determined that updated definitions were necessary to enhance the practicality of the toolkit as well as to mitigate curricular hoarding. 1 – 3 The committee referred to published models and frameworks that consider the relevancy and criticality to describe a topic as “need to know,” “nice to know,” or “as needed.” 17 The committee commented that this language was helpful but that, if used, many topics would likely be reclassified as tier 1. Further discussions identified the importance of assigning tier 1 classification for conditions in which students receive sufficient knowledge and skills to enable them to be “practice-ready.” 7 These conditions are highly prevalent, and pharmacotherapy plays a significant role in management. The committee also discussed that there are prevalent conditions for which students receive foundational knowledge and skills, but additional training is needed in order to be “practice-ready.” These would be deemed tier 2. Conditions designated as tier 1 and tier 2 are all topics that should receive sufficient contact time in curricula. Tier 3 conditions are those in which students receive limited education, and substantial knowledge or training is required after graduation to provide person-centered care. Tier 3 conditions may be rare or have a low prevalence and may have limited or no specific treatment, and/or pharmacotherapy may have a limited role. Topics designated as tier 3 are recommended to be included in curricula but have less time or materials devoted to teaching. Although tier 3 from the 2019 toolkit was designed to be comprehensive and would have included these topics, the 2023 committee agreed that any other conditions not meeting the tier designations would not appear in the updated toolkit. Accordingly, topics that instructors may view as “elective-only” and that are not covered in the core curriculum are not likely to be found in this version of the toolkit. Although the toolkit is intended to provide guidance, the degree to which tier topics are taught is at the discretion of individual colleges and schools of pharmacy and their faculties. During the revision process, the American Association of Colleges of Pharmacy published the 2022 Curricular Outcomes and Entrustable Professional Activities (COEPA). 18 COEPA introduced “person-centered care” to describe pharmacists providing whole-person care to individuals as the medication specialist. It was proposed and agreed on to use the updated terminology in the tier definitions. The committee also addressed that the additional training required to be practice-ready is not limited to traditional residency and fellowship experiences, but also includes equivalent “on-the-job” experiences, board certifications, and various certificate training programs. 19 – 23 The committee voted unanimously to approve the following tier designation language for the 2023 update. Students receive sufficient education and training on this condition to prepare them to be practice-ready pharmacists providing collaborative, person-centered care upon graduation and licensure. Students receive foundational education and training on this condition, but some additional knowledge and/or training will be required after graduation (e.g., residency, fellowship, or other experiences) to prepare them to be practice-ready pharmacists providing collaborative, person-centered care. Students receive limited education on this condition, and substantial knowledge or training will be required after graduation (e.g., residency, fellowship, or other experiences) to prepare them to provide collaborative, person-centered care.

There are a total of 231 topics in the 2023 toolkit ( Table 2 ), a decrease of 77 (23.2%) from the 2019 edition. Topics in each tier are as follows: 68 as tier 1 (29%), 111 as tier 2 (48%), and 52 as tier 3 (23%). Appendix 1 includes topics that were removed. Of note, although certain topics were removed completely, others were retained through combinations or revisions of line items. In most instances, topics involving minimal or highly specialized pharmacotherapy were removed from the toolkit. In addition to pharmacotherapy textbooks, the committee consulted the American Society of Health-System Pharmacists PGY2 competency areas and external feedback from educators and direct patient care pharmacists. Various hematologic disorders, for instance, are PGY2 elective topics and may only receive case-based application if the program’s patient population does not support a direct patient care experience. 9 Palliative care and hospice care were also removed from the toolkit. The pharmacotherapy goals of hospice care are captured under toolkit entry “End-of-life care and symptom management.” However, palliative care is not limited to terminal illness and should be considered when managing any serious illness because it involves medical decision-making that is based on individual patient needs. Drug-induced diseases and conditions were first introduced in the 2016 version of the toolkit, with a total of 9 appearing in the 2019 edition. 1 , 2 These topics are usually introduced when discussing a medication that causes the condition, with an explanation of the drug-induced mechanism and adverse effects. Because management of these adverse events is typically limited to dose reduction or removal of the offending agent and provision of supportive care, the committee believed these topics were duplicative with the conditions they caused (e.g., acute kidney injury, heart failure). It was decided to remove all drug-induced diseases and conditions except for selected dermatologic and hematologic conditions for which significant prevention and treatment pharmacotherapy exists. Ultimately, heparin-induced thrombocytopenia, drug-induced hemolytic anemias, Stevens-Johnson syndrome, and toxic epidermal necrolysis were retained. The committee generally considered it unnecessary to include preventive efforts in the toolkit because they are assumed to be taught under specific disease states. For example, because of changes in aspirin recommendations and the lack of obvious pharmacotherapy, primary prevention of atherosclerotic cardiovascular disease (ASCVD) is assumed to be adequately covered when teaching hypertension, dyslipidemia, tobacco/nicotine use disorder, and diabetes. 24 Stable ischemic heart disease, acute coronary syndromes, peripheral artery disease, and stroke should also satisfy the intent of ASCVD secondary prevention. Although some of these topics include acute care management, all topics are likely taught with the inclusion of secondary prevention. The committee also made several modifications to nomenclature for clarity and to reflect updates with modernized terminology. This was addressed with many kidney conditions (formerly renal conditions) according to preferred terminology from the Kidney Disease: Improving Global Outcomes Consensus Conference in 2020. 25 The section addressing individuals older than 65, previously known as geriatrics , is now Older people , a term adopted by the American Geriatrics Society. 26 The 2023 toolkit continues to exclude topics under medicinal chemistry, pharmacology, adverse drug events, drug-drug and drug-nutrient interactions, pharmacokinetics, pharmacodynamics, pharmacogenomics/pharmacogenetics, therapeutic drug monitoring, pharmacoeconomics, and integrative and functional medicine. Other specific skills and processes of care such as antimicrobial stewardship (including antimicrobial resistance), patient assessment, digital health tools and other technology used to assist with medication management (e.g., glucose monitoring devices), medication delivery systems (e.g., inhalers, insulin pumps), and other OTC tests and devices are not addressed in the 2023 toolkit. The 2023 committee supports the statement made by the 2019 committee, expecting that these excluded topics will be covered in required courses for relevant conditions and disease states. An additional topic removed from the 2023 toolkit is basic life support (BLS). Although training is essential and required before experiential placements, there is no pharmacotherapy in BLS. Transgender health, pregnancy termination, and physician-assisted dying first appeared in the 2016 toolkit. These were retained in 2019, and transgender health and physician-assisted dying were renamed as gender-affirming hormone therapy and medical aid in dying, respectively. All three topics were classified as tier 3 in the 2019 toolkit, meaning students and residents may not receive education and training on these topics. Gender-affirming care and pregnancy termination have gained significant attention through political conversations and legislative changes and are areas where pharmacists are involved in person-centered care. A recent commentary examined the gaps in pharmacy practice and research for transgender and gender-diverse (TGD) individuals and explained how pharmacy curricula can incorporate and enhance future and practicing pharmacists’ ability to provide high-quality care to TGD individuals. 27 To increase access to medication abortion, the mifepristone risk evaluation and mitigation strategy was modified in January 2023 to allow certified pharmacies to dispense mifepristone if prescribed by a certified prescriber for terminating a pregnancy. 28 These topics are now classified as tier 2, denoting that all pharmacists should receive foundational education and training on these topics. Medical aid in dying was retained as a tier 3 classification because legal authorization is limited and guidelines to standardize medical aid in dying did not exist at the time of this writing. 29 Autonomous pharmacist prescribing continues to expand, but what can be prescribed varies greatly from state to state. For example, since 2019, several states have gained direct prescribing authority for HIV preexposure and postexposure prophylaxis. 30 The committee considered that the expansion of pharmacist prescribing in this and other areas has been authorized in a limited number of states to date and that, in many cases, pharmacists are required to complete continuing education or training programs in order to meet the criteria for independent prescribing. Therefore, a tier 2 placement was determined to be appropriate at this time. 31 Colleges and schools of pharmacy may choose to place more emphasis on these topics because of state and regional practices. Future committees should review these topics to ensure appropriate tier classification.

The 2023 Pharmacotherapy Didactic Curriculum Toolkit is designed to be a guide for individual institutions and faculty when teaching the pharmacotherapy of conditions and disease states. It is also useful in curricular design to assist in selecting appropriate topics and the appropriate breadth and depth of content delivery. Several toolkit topics were removed to encourage optimization of curricular efficiencies and minimization of curricular overload. Toolkits should be reviewed every 3 years to identify needed revisions on the basis of the pharmacist’s evolving role, advances in therapeutics and pharmacy practice, and changes to accreditation standards and recognized professional competencies.

The committee’s scope of pharmacy practice was broadly general, with strong representation from ambulatory care and acute care settings. The lack of certain specialties, such as hematology/oncology and infectious diseases, was identified early on, and external input was heavily relied on as described previously. Although the committee relied on multiple objective sources, subjective opinions may have influenced toolkit entries and tier designations. The definition of “practice-ready” is not universal among pharmacists and educators, as recently described by Trujillo and Cain. 5 It may be acceptable for a program to focus only on foundational knowledge and skills. Conversely, a program may seek to provide more advanced or in-depth instruction on certain disease states. The wording used to describe the tiers was designed to emphasize what all student pharmacists should minimally receive, allowing individual institutions and individual faculty to determine when it may be acceptable to move beyond the foundational limits. The committee decided against providing recommendations on content time because they would likely be biased with subjective opinions, and it is difficult to quantify content time solely on the basis of tier levels. For example, a tier 1 topic could require minimal instruction time if treatment is not complex. As stated earlier, regional and global perspectives may dictate topic coverage and prioritization.

The American College of Clinical Pharmacy (ACCP) Pharmacotherapy Didactic Curriculum Toolkit is intended to serve as a guide to colleges and schools of pharmacy navigating curricular revisions. The inaugural publication of the toolkit was issued in 2009, followed by complete revisions prepared in 2016 and 2019. 1 – 3 Subsequent to the 2016 update, the ACCP Board of Regents established that the toolkit revision process should occur every 3 years to account for rapid advances in health care and evolving evidence for pharmacotherapy. At the time of writing the current publication, the 2019 toolkit had been cited 46 times and downloaded more than 4000 times, indicating both its value to the College and its need for revisions. Since the 2019 publication, curricular hoarding has become a topic of concern across many colleges and schools of pharmacy. 4 , 5 Curricular hoarding is when new content is added to existing curricula without adequately reducing outdated, irrelevant, or otherwise extraneous coursework, which can perpetuate curriculum overload. 4 , 6 Colleges and schools of pharmacy must work to teach the most relevant and critical diseases, conditions, and treatments at the appropriate depth within the constraints of allotted credit hours. Including all disease states or conditions for which there is an FDA-approved medication in a resource like the toolkit is not only challenging, but also impractical. The need for teaching of specialized pharmacotherapy topics in colleges and schools of pharmacy has further been called into question because of the availability of additional knowledge and training opportunities, including residencies, fellowships, board certifications, and certificate programs for those interested in specialized areas of practice. This edition of the toolkit provides guidance on which disease states to include in a pharmacy school’s curriculum and direction on the level of breadth and depth needed to prepare an entry-level, graduating pharmacist.