University of Hawai'i System Repository

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Kapiʻolani Community College

University of Hawaiʻi at Hilo

University of Hawaiʻi - West Oʻahu

Leeward Community College

Honolulu Community College

Open Education Resources

Recent Submissions

Access status: Open Access ,
Facts About the Strike on Sugar Plantations in Hawaii
(1920) Hawaii Laborers' Association
This discusses the perspective of the Hawaiʻi Labor Association regarding the Oʻahu labor strikes in 1919-1920. The Hawaiʻi Laborersʻ Association was previously the Federation of Japanese Labor in Hawai'i, with collaborations with the Filipino Labor Union, and workers of Chinese, Portuguese, Puerto Rican and Native Hawaiian descent.
Access status: Open Access ,
Prescribing Trends of Loop Diuretics Among Medicare Beneficiaries in the United States (US) from 2021-2023
(2026-05-01) Lozano, Jayce; Meguro, Aryn
Purpose: Heart failure (HF) remains a leading cause of hospitalization and healthcare expenditures in the US, with volume overload being the primary indication for loop diuretics. The American Heart Association (AHA) lists furosemide, torsemide, and bumetanide as the most commonly prescribed loop agents. Furosemide has the poorest bioavailability (47-64%) and shortest half life (0.5-2 hrs). Torsemide offers more reliable absorption (~80%) and longer half life (~3.5 hrs). Bumetanide has high bioavailability (55-89%), but shorter duration (4-6 hrs). Despite these alternatives, furosemide remains dominant. This study evaluated recent national prescribing trends and relative utilization of these diuretics. Methods: Medicare Part D data of loop diuretic prescribing was obtained from the 2021–2023 Centers for Medicare and Medicaid Services “Part D Prescribers by Geography and Drug” files. Analysis included furosemide, torsemide, and bumetanide across all 50 states and the District of Columbia. For each state and year, total prescription claims and beneficiaries were extracted. Prescribing rates were standardized as claims per 100 beneficiaries to account for population differences. National totals were calculated by summing state claims. Proportional prescribing was determined annually to assess relative utilization. Analyses were descriptive and did not adjust for comorbidities, prescriber variation, or indication. Results: Between 2021 and 2023, furosemide dominated prescribing. In 2021, there were 23.3 million furosemide claims (5.72 per 100 beneficiaries; state range 3.70-9.53). Torsemide had 2.3 million claims (0.60 per 100) and bumetanide 2.0 million claims (0.44 per 100). In 2022, furosemide declined slightly to 22.6 million claims (5.28 per 100), while torsemide increased modestly to 2.5 million (0.62 per 100), bumetanide remained stable ( 2.0 million claims; 0.43 per 100). In 2023, furosemide remained steady at 22.8 million claims (4.94 per 100), with minimal change in torsemide (2.7 million claims; 0.60 per 100) and bumetanide (2.1 million claims; 0.44 per 100). Across all years, furosemide accounted for more than 80% of loop diuretic prescriptions. Conclusion: Between 2021 and 2023, furosemide represented the majority of Medicare Part D loop diuretic prescribing with limited uptake of torsemide or bumetanide despite reported pharmacologic advantages. National patterns remained stable over time. Claims data lack clinical context and adjustment for patient factors. Future studies should evaluate whether diuretic selection aligns with evidence based practice by linking prescribing patterns to HF outcomes like readmissions.
Access status: Open Access ,
Correlation of Medication Adherence and Heart Failure Readmission Rates at the State Level For Medicare Beneficiaries in 2023
(2026-05-01) Kuhnen, David. Benavente, Kiana.; Taira, Deborah
Purpose: Heart failure (HF) remains a significant cause of morbidity and mortality in the US, with hospital readmissions contributing significantly to both patients’ burden and system costs. Guideline-directed medical therapy (GDMT), is a cornerstone of evidence-based HF management, however, variations in medication access, possession, and adherence may influence patient outcomes long term. This study evaluates national and state-level differences in GDMT medication possession and compares it to the incidence of HF readmissions. This analysis seeks to emphasize the Pharmacist’s role in promoting medication adherence to reduce avoidable HF-related hospitalizations. Methods: This was a retrospective, cross sectional analysis of state-level possession rates of HF GDMT. GDMT possession data were obtained from the Centers for Medicare & Medicaid Services (CMS) Medicare Part D Prescribers by Geography and Drug dataset for the most recent available calendar year (2023). HF readmission rates, defined as 30-day all-cause readmissions following an index HF hospitalization, were collected from publicly available CMS Hospital Readmissions Reduction Program data. HF medications were angiotensin receptor-neprilysin inhibitors (ARNI), evidence-based beta-blockers (bisoprolol, carvedilol, metoprolol succinate), mineralocorticoid receptor antagonists (MRAs), or sodium-glucose cotransporter 2 (SGLT2) inhibitors. Medication adherence was estimated for each medication as the time of possession, and averaged across all HF medications. Descriptive statistics were used to summarize GDMT possession and HF readmission rates by state, and findings were presented in a comparative format to visualize possible trends. Results: In 2023, nationally, MPRs differed by agent, with evidence-based beta-blockers (bisoprolol, metoprolol succinate, carvedilol) being between 78% and 82%, ARNI (sacubitril/valsartan) at 66%, SGLT2 inhibitors (dapagliflozin, empagliflozin) between 63% and 67%, and mineralocorticoid receptor antagonists (spironolactone, eplerenone) between 70% and 73%. The highest level of HF readmissions per 10,000 medicare enrollees was Washington DC (149 per 10k enrollees) while the lowest was Idaho (27 per 10k enrollees). Average MPRs for key GDMT agents ranged between 0.57–0.72. Washington DC had the lowest average MPR for GDMT medications (57%) while Wisconsin showed the highest (72%). The correlation between MPR and HF readmissions was -0.26.These ranges exclude Washington DC, which fell an average of ~10% below them. State-level MPRs showed 16% variability and despite large differences in readmission rates across states, no strong patterns emerged between MPRs and readmission outcomes given the narrow range of possession values. Conclusion: The correlation between medication adherence and HF readmissions rates was negative, as expected, but weak. This suggests that factors beyond drug possession alone such as socioeconomic disparities, healthcare infrastructure, and adherence behaviors may play a role in driving differences in HF readmission rates. Medication access is important for improving patient outcomes and these results complement the complexity of Heart failure and reinforce the need for pharmacists in managing chronic disease states. Future work integrating clinical, demographic, and health system-level variables may provide more actionable insights into optimizing GDMT use and improving HF outcomes on a national scale.
Access status: Open Access ,
Comparison of Medicare Tirzepatide Prescribing and Cardiovascular Deaths by State
(2026-05-01) Corpuz, Zachary James. Sugimoto, Jace. Yu, Emily.; Fukunaga, Bryce
Purpose: Tirzepatide (Mounjaro) is a new antidiabetic drug effective in lowering A1C. The American Diabetes Association guideline does not have Mounjaro under the medications with cardiovascular (CV) benefits; however, a study conducted in 2023 highlighted the potential CV benefits of Mounjaro.1 According to the Centers for Disease Control and Prevention (CDC), roughly 919,032 people in the United States died from cardiovascular disease in 2023. Diabetes is linked to a higher risk of heart disease and cardiovascular (CV) death. This study aims to analyze the correlation between Mounjaro prescriptions and prevention of CV death rates among the 50 states. Methods: This study was a retrospective, evaluative study utilizing state prescription data from the 2023 Medicare Provider Utilization and Payment Data: Part D Prescriber Data. The data contained Mounjaro claims and beneficiaries for all 50 states from 2023 and CV death rates per 1,000 Medicare Beneficiaries ages 65 and older for each state during that year from the CDC. The raw data for Mounjaro claims were adjusted for population by dividing claims by the total beneficiaries for all medications then multiplied by 1000 and analyzed per 1000 beneficiaries in each state. Results: Based on the 2023 data, the top 10 states with the highest CV deaths include Oklahoma, Mississippi, Alabama, Arkansas, Louisiana, Tennessee, West Virginia, Michigan, Kentucky, and Missouri. The states with the highest Mounjaro prescription rates include Alabama, Louisiana, Oklahoma, Arkansas, Georgia, Kentucky, Indiana, Texas, West Virginia, and South Carolina. Of the top 10 states with the highest CV deaths, there were six states–Alabama, Louisiana, Oklahoma, Arkansas, Kentucky, West Virginia–that were among the top 10 states that had the highest Mounjaro prescribing rate. The top 10 states that had the lowest CV deaths were Minnesota, Hawaii, Colorado, Massachusetts, Connecticut, Alaska, Washington, California, Florida, and Oregon, none of which were among the top 10 states with the highest Mounjaro prescribing rates. Conclusion: There was no correlation between Mounjaro prescription rates and prevention of CV death rates in 2023. However, there was a possible correlation between Mounjaro prescription rates and states with the highest CV death rates. The major limitations of this study was the data was collected from only 2023 and Medicare Part D data. Further studies with larger sample sizes, broader ranges of age groups, and data across multiple years are needed to assess if there are long-term benefits in preventing cardiovascular deaths, especially in the states with the highest death rates.
Access status: Open Access ,
Evaluation of Sodium Glucose Cotransporter 2 Inhibitor Use in Patients with Type 2 Diabetes in a Primary Care Clinic
(2026-05-01) Le, Dalena. Kini-Lopes, Kamahaʻo.; Prudencio, Jarred
Purpose: This study aims to evaluate the utilization of sodium glucose cotransporter 2 (SGLT2) inhibitors in patients with type 2 diabetes within a primary care clinic and explore pharmacist-led interventions for optimization of medication management. Findings may inform interventions to improve evidence-based prescribing and maximize the cardiovascular and renal benefits of SGLT2 inhibitors in this patient population. Methods: A retrospective review of electronic medical records was conducted on patients with type 2 diabetes at a rural primary care clinic. The study included patients who were at least 18 years of age, had type 2 diabetes, and were current patients of the clinic as of March 2025. Data collected from the medical records included demographic data, past medical history, pharmacist involvement, hemoglobin A1c, weight, renal function, and diabetes medication prescribing history. The primary outcome of this study was to analyze the prescribing rates of SGLT2 inhibitors in patients with type 2 diabetes. Descriptive analysis methods were used to assess overall prescribing rates of SGLT2 inhibitors in this population, as well as subgroup analyses including patients managed by pharmacists, and patients with certain comorbidities such as clinical atherosclerotic cardiovascular disease (ASCVD) and heart failure. Results: A total of 499 patients met inclusion criteria and were included in the analysis. Of these, 164 patients (32.9%) were managed by pharmacists. A total of 152 patients (30.5%) had an active prescription for an SGLT2 inhibitor. Within the pharmacist-managed patient population, a total of 88 patients had an SGLT2 inhibitor, representing 53.7% of pharmacist-management patients. For those without a pharmacist, a total of 64 patients had an SGLT2 inhibitor, representing 19.1% of patients without a pharmacist. Of the 499 patients with type 2 diabetes, 58 patients had clinical ASCVD, and 35 of these patients had pharmacist management. Within this group managed by a pharmacist, 25 patients (71.4%) were prescribed an SGLT2 inhibitor. When compared to patients with type 2 diabetes and clinical ASCVD without a pharmacist, 12 patients (52.1%) were prescribed an SGLT2 inhibitor. A total of 43 patients had type 2 diabetes and heart failure, with 17 of them being managed by a pharmacist. A total of 14 of these patients (82.4%) managed by a pharmacist received an SGLT2 inhibitor, compared to 18 (69.2%) of patients who did not have a pharmacist on their care team. Conclusions: Patients being managed by a pharmacist were more likely to receive an SGLT2 inhibitor. Pharmacist-managed patients also had a higher rate of receiving SGLT2 inhibitors compared to patients without a pharmacist, for groups who had type 2 diabetes and either heart failure or clinical ASCVD. Results of this study support that the addition of a pharmacist in a primary care clinic can have a positive impact on prescribing rates of SGLT2 inhibitors, particularly in patients with clinical ASCVD or heart failure. Further studies will be conducted to expand pharmacy services to fill gaps of care and improve population-wide prescribing patterns.
Access status: Open Access ,
National Prescribing Trends of Metformin Before and After the 2022 Treatment Guideline Update
(2026-05-01) Lu, Scott. Yama, Kara.; Meguro, Aryn
Purpose: Prior to 2022, metformin was referenced as the first-line treatment option for Type 2 Diabetes Mellitus (T2DM) per the American Diabetes Association (ADA) Standards of Care in Diabetes guidelines. Since 2022, first-line treatment for T2DM is now centered around patient-specific factors like comorbidities, cost, and access considerations. The objective of this study was to compare the prescribing trends of metformin before and after the first-line therapy recommendations for T2DM management nationwide. Methods: This was an evaluative study conducted using a retrospective analysis on the Centers of Medicare and Medicaid Services public database from 2021 to 2023, which provided information on the prescribing rates nationwide. Data was aggregated by filtering each state’s total number of metformin claims and total beneficiaries who received Medicare or Medicaid services that year. All brand and generic formulations of monotherapy metformin were included. Territories and regions outside of the United States and combination medications with metformin were excluded. The estimated prescribing rates for each state were calculated by dividing the total number of metformin claims by the beneficiaries per 1000 for all medications. Then, the differences in estimated prescribing rates per state were calculated and extrapolated to a US heat map for further analysis. Results: Prior to the ADA guideline update, the top three states with the highest claims in 2021 were North Dakota (90), California (82), and Nebraska (81). With the first-line recommendation update in the ADA 2022 guidelines, the top three highest claims were in North Dakota (90), California (80), and Nebraska (79). In 2023, the top three states were North Dakota (85), California (77), and Minnesota (75). Overall, California and North Dakota continued to have the highest total number of metformin claims across all 3 years. Additionally, all states had a downward trend in prescribing rates of metformin from 2021 to 2023 with a difference ranging from -3 to -9. The states with the highest difference (-9) were Alaska and Iowa. Conclusion: Overall, a general downward trend in the prescribing rates indicated that metformin use has been gradually decreasing after the 2022 ADA guideline update. It should be noted that there was already a downtrend in prescribing rates before the guideline update. A limitation of this study was the lack of available data since the 2022 guideline update and the exclusion of combination therapies. Future research could assess combination therapies and extend the observation period beyond 2023.
Access status: Open Access ,
Structure-Activity Relationship Studies of Benzothiazole-Based FabK Inhibitors as New Anti-Clostridioides difficile Agents
(2026-05-01) Herman, Robert. Akintayo, Damilola. Hurdle, Julian. Hevener, Kirk.; Sun, Dianqing
Clostridioides difficile Infections (CDIs) remain a significant clinical challenge due to recurrence, antimicrobial resistance, and microbiome disruption associated with current therapies. The enoyl-acyl carrier protein reductase II enzyme (FabK) is essential for fatty acid biosynthesis in C. difficile and represents an attractive narrow-spectrum antibacterial target. We previously reported that a phenylimidazole-based inhibitor with a p-bromophenyl tail group demonstrated selective inhibition of CdFabK and low micromolar antibacterial activity. In this work, we aim to further expand the structure–activity relationship (SAR) of the phenylimidazole CdFabK inhibitor series in an effort to identify new scaffolds and improve biochemical potency, while maintaining whole-cell antibacterial activity. An expanded N-(benzo[d]thiazol-2-yl)-2-(2-(phenylamino)thiazol-4-yl)acetamide chemical series was designed and synthesized. Compounds were assessed for CdFabK enzymatic inhibition and in vitro antibacterial activity against C. difficile. A series of benzothiazole derivatives were synthesized following the Hantzsch thiazole synthesis, ester hydrolysis, and amide coupling of substituted carboxylic acids with 2-aminobenzothiazole derivative. Biological evaluation revealed that a compound with 6-ethoxybenzothiazole head group and phenylaminothiazole tail moiety exhibited CdFabK inhibition value of IC₅₀ = 4.40 μM, with minimum inhibitory concentration (MIC) of 1.60 μg/mL against C. difficile. Another close structural analog with the 3-chlorophenylaminethiazole tail showed excellent anti-difficile activity (MIC = 0.4 μg/mL) and low micromolar CdFabK inhibition of IC₅₀ = 4.90 μM. Systematic SAR exploration of phenylimidazole- and benzothiazole-based inhibitors led to improved anti–C. difficile activity while preserving CdFabK inhibition. These findings further validate FabK as a promising narrow-spectrum antibacterial target and support continued optimization of this class of new therapeutic agents for C. difficile infection.
Access status: Open Access ,
Comparison of Medicare Semaglutide Prescribing and End Stage Renal Disease by State
(2026-05-01) Guerrero, Kaitlyn. Kaʻanaʻana, Adam.; Fukunaga, Bryce
Purpose: Glucagon-like-peptide-1 (GLP-1) agonists are anti-diabetic drugs that are an efficacious and cost-effective option in achieving glycemic goals in type 2 diabetes. The American Diabetes Association (ADA) 2025 guidelines mention semaglutide’s potential benefits in reducing kidney disease progression. According to the Centers for Disease Control and Prevention (CDC), roughly 35.5 million people in the United States have chronic kidney disease (CKD). This study aims to analyze the correlation between semaglutide prescriptions and end stage renal disease diagnoses among the 50 states. Methods: This study was a retrospective, evaluative study utilizing state prescription data from the 2021 Medicare Provider Utilization and Payment Data: Part D Prescriber Data. This data was downloaded to obtain semaglutide claims and beneficiaries for all states from 2021. The data for 2022 ESRD prevalence rates was obtained from the National Institute of Diabetes and Digestive and Kidney Disease. Raw data for semaglutide claims were adjusted for population differences by dividing the claims per state by the total state beneficiaries, then multiplying by 1000. The ESRD rates were also adjusted for population differences by dividing the rate per state by the census state population, then multiplying by 100,000. Graphs and heat maps were generated utilizing Google Sheets to visually compare prescribing trends and ESRD diagnoses. Results: Based on the data collected from 2022, the top five states with the lowest rate of ESRD diagnoses include Vermont, Wyoming, Utah, New Hampshire, and Idaho. Of the top 10 states with the lowest rate of ESRD diagnoses, only Alaska and North Dakota were among the top 10 states with the highest semaglutide prescribing rate in 2021. Of the top 10 states with the highest rates of ESRD diagnoses, Utah, New Hampshire, and Colorado were among the top 10 states with the lowest semaglutide prescribing rate. Conversely, of the top 15 states with the lowest ESRD diagnoses, three states including Maine, Oregon, and Rhode Island, were among the top 15 states with the lowest semaglutide prescribing rate. Conclusion: There is a possible correlation between semaglutide prescription rates in 2021 and less ESRD diagnoses in 2022. The main limitation of this study was that semaglutide claims were only collected from the Medicare Part D data. Further studies with a larger sample size and greater variety of population are required to determine a possible correlation.
Access status: Open Access ,
Analysis of Prescribing Patterns of Incretin-Based Therapies in Patients with Type 2 Diabetes in a Primary Care Clinic
(2026-05-01) Kini-Lopes, Kamahaʻo, and Le, Dalena; Prudencio, Jarred
Purpose: The purpose of this study was to evaluate the use of glucagon-like peptide-1 (GLP-1) agonists in patients with type 2 diabetes in a primary care clinic. GLP-1 agonists have many benefits in patients with diabetes, including improving glycemic control, weight loss, and benefits in cardiovascular and renal outcomes in certain patient populations, such as those with clinical ASCVD. This study aims to analyze the use of GLP-1 agonists in a primary care clinic, and to assess the impact of pharmacist-managed diabetes care on these prescribing rates. Methods: A retrospective review of electronic medical records was conducted on patients with type 2 diabetes at a rural primary care clinic. The study included patients who were at least 18 years of age, had type 2 diabetes, and were current patients of the clinic as of March 2025. Data collected from the medical records included demographic data, past medical history, pharmacist involvement, hemoglobin A1c, weight, renal function, and diabetes medication prescribing history. The primary outcome of this study was to analyze the prescribing rates of GLP-1 agonists in patients with type 2 diabetes. Descriptive analysis methods were used to assess overall prescribing rates of GLP-1 agonists in this population, as well as subgroup analyses including patients managed by pharmacists, and patients with certain comorbidities such as clinical atherosclerotic cardiovascular disease (ASCVD). Results: A total of 499 patients met inclusion criteria and were included in the analysis. Of the 499 patients, 164 patients (32.9%) were managed by pharmacists. A total of 209 patients (41.9%) had an active prescription for an incretin-based medication. Within the pharmacist-managed patient population, a total of 86 patients had a GLP-1 agonist, representing 52.4% of pharmacist-management patients. For those without a pharmacist, a total of 123 patients had a GLP-1 agonist, representing 36.7% of patients without a pharmacist. Of the 499 patients with type 2 diabetes, 58 patients had clinical ASCVD, and 35 of these patients had active pharmacist management. Within the group of patients with type 2 diabetes and clinical ASCVD managed by a pharmacist, 21 patients (60%) were prescribed a GLP-1 agonist. When compared to patients with type 2 diabetes and clinical ASCVD without a pharmacist, 8 patients (34.8%) were prescribed a GLP-1 agonist. Conclusions: Patients managed by a pharmacist received GLP-1 agonists at higher rates than those without a pharmacist on their care team. Patients with clinical ASCVD were more likely to receive a GLP-1 agonist for cardiovascular benefits than those patients without a pharmacist. Results of this study support that the addition of a pharmacist in a primary care clinic can have a positive impact on prescribing rates of GLP-1 agonists, particularly in patients with clinical ASCVD. Further studies will be conducted to expand pharmacy services to fill gaps of care and improve population-wide prescribing patterns.
Access status: Open Access ,
The Impact of the 2022 Heart Failure Guidelines on National and Hawaii Prescribing Trends of Sacubitril/Valsartan (from 2015-2023)
(2026-05-01) Yama, Kara, Lu, Scott; Meguro, Aryn
Purpose: Sacubitril/valsartan was approved in 2015 and is now recommended as a first-line guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF), preferred over angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor II blockers (ARBs) in the 2022 American Heart Association/American Academy of Cardiology (AHA/ACC) Heart Failure Guidelines. In contrast to the 2016 guidelines, where sacubitril/valsartan was regarded as equivalent with ACEi & ARBs. The objective of this study was to evaluate national and Hawaii prescribing trends of sacubitril/valsartan in response to the 2022 guideline update. Methods: This was a retrospective evaluative study that utilized data from the Centers of Medicare and Medicaid Services public database from 2015 to 2023. Annual sacubitril/valsartan claims and total annual beneficiaries of Medicare and Medicaid services were collected. Territories and regions outside of the United States were excluded. Prescribing rates per year were calculated by dividing the total number of sacubitril/valsartan claims by all beneficiaries per 1,000 for each year. The estimated national average was determined by averaging all states’ claims and total beneficiaries per year. Yearly changes in sacubitril/valsartan claims was calculated by taking the difference in prescribing rates per 10,000 beneficiaries per year. This data was assessed using line graphs for visual examination and comparison. Results: Since 2015, there has been an increase in sacubitril/valsartan use each year both nationally and in Hawaii with a general trend upward showing increased prescribing rates. National trends and Hawaii trends followed a similar pattern, with slightly more claims per 1,000 beneficiaries nationally. The largest change in claims occurred in 2022, where for every 10,000 beneficiaries, there were 10.48 more sacubitril/valsartan claims for Hawaii and 10.45 for the estimated national average. The smallest change in claims was in 2015 with 0.09 more claims per 10,000 for Hawaii and 0.19 more claims per 10,000 nationally. Conclusion: Since the approval of sacubitril/valsartan in 2015, the prescription rate trends has been steadily increasing each year. A notable peak in sacubitril/valsartan claims occurred both in Hawaii and nationally after the 2022 guideline update. Limitations of this study include the lack of available data after 2023 and potential confounders such as cost and formulary changes. Future studies should evaluate a longer time period (after 2022) and assess the impact of the recently released generic formulation of sacubitril/valsartan in July 2025.