A 3-Year Chronic Disease Public Health Intervention Focused on a Network of Rural Pharmacies Supported by Student Pharmacists

OBJECTIVE

To retrospectively analyze and report various tracked outcomes of a 3-year collaboration offering chronic disease management services in diabetes and cardiovascular disease in pharmacies across 12 rural communities supported year-round by fourth-year student pharmacists.

METHODS

Individualized medication therapy management services were provided to patients with cardiovascular disease and diabetes in a 6-month series based upon national guidelines standards of care. Objective laboratory measurements, adherence rates, goals set for patients, vaccination rates, and routine maintenance examinations were all tracked as part of the program. Provider acceptance of recommendations from student pharmacists were tracked, and patients completed a 3-question survey regarding satisfaction with services.

RESULTS

A total of 430 student pharmacists rotated through these pharmacy sites providing care to 779 unique patients across 3 years. Statistically significant improvements in A1C (-0.8%, P < .001) and systolic and diastolic blood pressure (5 mm Hg, 3 mm Hg, respectively, P < .01) were associated with the pharmacy care. Adherence issues were identified and addressed with 44% of these patients. In all, 70% of patients reported successful goal attainment of >50% from baseline. Providers accepted student therapy change recommendations 56% of the time. Patients reported satisfaction with services provided in the pharmacies (average scores of 4.22-4.67 on a 1-5 Likert-type scale).

CONCLUSIONS

A 3-year pharmacy intervention in 12 rural areas made positive impacts on patients' adherence rates and self-management in diabetes and cardiovascular disease and was associated with statistically significant improvements in A1C and blood pressure while challenging fourth-year student pharmacists to perform at a high level on community pharmacy rotations.

Strategy to Improve Efficiency of Comprehensive Medication Reviews in a Community Pharmacy

Background: Comprehensive medication reviews (CMRs) provide opportunities for pharmacists to perform clinical services to their patients. However, pharmacists are often not able to perform CMRs due to time constraints. Studies have shown that incorporating support staff into the CMR workflow may lead to increases in the completion of CMRs. Objective: The primary objective was to examine the change in the number of CMRs completed at the pharmacy after a new strategy was implemented to perform and prepare for CMRs. The secondary objective was to examine the changes in the revenue generated from CMRs. Methods: This study was a pre-post retrospective, observational study performed at an independent pharmacy. Data were collected and analyzed 10 months before and after implementation of a new strategy. The new strategy called for pharmacy interns to use a template for working up patients prior to CMRs. Wilcoxon signed-rank tests were run on IBM SPSS, Version 24.0, to determine the significance of the changes. Results that generated P values <.05 were considered statistically significant. Results: The total number of CMRs completed increased from 29 before the intervention to 158 after the intervention (P = .009). The revenue generated from CMRs improved statistically (P = .007). Conclusions: Implementing a strategic workflow that uses pharmacy interns and a patient workup template can significantly increase the number of CMRs completed in a community pharmacy. Appropriate delegation of such tasks may allow more time for pharmacists to deliver more CMRs. Additional benefits include increased compensation from delivering more CMRs.

Older persons' experiences regarding evaluation of their medication treatment-An interview study in Sweden

BACKGROUND

Older persons with polypharmacy are at increased risk of harm from medications, and this issue is a global patient safety challenge. Harm may arise at all stages of medication use and may cause hospital admission, additional resource utilization and lower patient satisfaction. Older persons' participation in their own care may increase patient safety. Their views on the evaluation of their medication treatment, and their own involvement in it, are crucial yet poorly understood.

OBJECTIVES

To identify opportunities to make the medication use process safer, we explored and described older persons' experiences of evaluation of their medication treatment.

DESIGN

Semi-structured interviews were performed with 20 community-dwelling older persons (age 75-91 years) in Sweden. Data were analysed using inductive qualitative content analysis.

RESULTS

These older persons reported having a responsibility to engage in their medication evaluations, although some felt unable to do so or considered themselves unconcerned. Evaluation, in their experience, was facilitated by continuity of care and an invitation to participate. However, some older persons experienced not receiving a comprehensive medication evaluation.

DISCUSSION AND CONCLUSION

Older persons want to be actively involved in their medication evaluations, and this may represent an underutilized resource in the pursuit of patient safety. Their trust in physicians to undertake evaluations on a regular basis, although that does not necessarily occur, may cause harm. Patient safety could benefit from a co-production approach to medication evaluations, with health-care professionals explicitly sharing information with older persons and agreeing on responsibilities related to on-going medication treatment.

Multimorbidity and medication complexity: New challenges in heart transplantation

INTRODUCTION

Multimorbidity and therapeutic complexity are a recognized problem in the heart transplant (HTx) population. However, little is known about how best to quantify this complexity or the strategies that could reduce its burden.

METHODS

This single-center, observational study included adult heart transplant recipients (HTxR) >1.5 years from transplant. We assessed multimorbidity (>2 comorbidities) and the patient-level Medication Regimen Complexity Index Spanish version (pMRCI-S) score. We also analyzed the independent predictors of pMRCI-S and the impact of the index score on specific clinical variables.

RESULTS

We included 135 chronic-stage HTxR. Comorbidities significantly increased after HTx (6 ± 3 vs 2 ± 2, P-value < .001). Patients took 12 ± 3 chronic drugs/d, 58% of them to treat comorbidities. The mean total pMRCI-S score was 42 ± 11, higher than in several other chronic diseases. The medication category drugs to treat comorbidities predicted a higher total pMRCI-S score (OR = 3.12, 95% CI 2.8-3.43, P-value < .001). Therapeutic complexity after HTx had an impact on solid malignancies (OR = 1.1, 95% CI 1.02-1.18, P-value = .02) and renal function (OR=-0.81, 95% CI -1.21-(-0.42), P-value < .001).

CONCLUSIONS

The multimorbidity and pMRCI-S scores obtained in HTx population were worrisomely high. The pMRCI score is a sensitive method that allows identification of the factors determining therapeutic complexity after HTx and selection of strategies to reduce pMRCI-S values.

Clinical Impact of a Comprehensive Medication Management Service in Primary Health Care

OBJECTIVE

To evaluate the clinical impact of a comprehensive medication management (CMM) service in a Brazilian primary health-care setting.

METHODS

A quasi-experimental study has been carried out between July 2014 and November 2016 with patients who received the service in the primary care setting of a Brazilian city (n = 1057). Factors associated with drug therapy problems (DTP) detection in the initial assessment were evaluated by performing univariate and multivariate analyzes. To evaluate the impact of the CMM service, a linear regression model was constructed from the difference between the initial and final values of the clinical and laboratory parameters adjusted by multiple variables.

RESULTS

A total of 1642 DTPs was identified, the most prevalent one being "nonadherence" (31.9%) and the "need for additional drug therapy" (22.9%). The use of 5 or more medications and the presence of 3 or more diseases were positively associated with the identification of 3 or more DTPs during the initial assessment. Even after multiple adjustments, a statistically significant reduction has been observed in the values of glycated hemoglobin, systolic blood pressure, low-density cholesterol, and total cholesterol.

CONCLUSION

The CMM service contributed to the resolution of DTP and showed positive clinical impact in primary health care in the studied setting.

Training and Toolkit Resources to Support Implementation of a Community Pharmacy Fall Prevention Service

Community pharmacies are an ideal setting to manage high-risk medications and screen older adults at risk for falls. Appropriate training and resources are needed to successfully implement services in this setting. The purpose of this paper is to identify the key training, tools, and resources to support implementation of fall prevention services. The service was implemented in a network of community pharmacies located in North Carolina. Pharmacies were provided with onboard and longitudinal training, and a project coach. A toolkit contained resources to collect medication information, identify high-risk medications, develop and share recommendations with prescribers, market the service, and educate patients. Project champions at each pharmacy received a nine-question, web-based survey (Qualtrics) to identify usefulness of the training and resources. The quantitative data were analyzed using descriptive statistics. Thirty-one community pharmacies implemented the service. Twenty-three project champions (74%) completed the post-intervention survey. Comprehensive onboard training was rated as more useful than longitudinal training. Resources to identify high-risk medications, develop recommendations, and share recommendations with prescribers were considered most useful. By providing appropriate training and resources to support fall prevention services, community pharmacists can improve patient care as part of their routine workflow.

Using the Theory of Planned Behavior to Understand Factors Influencing South Asian Consumers' Intention to Seek Pharmacist-Provided Medication Therapy Management Services

The study purpose was to use the theory of planned behavior to understand factors influencing South Asian consumers’ intention to seek pharmacist-provided medication therapy management services (MTMS). Specific objectives were to assess effects of attitude, subjective norm (SN), perceived behavioral control (PBC), and socio-demographics on South Asian consumers’ intention to seek MTMS. Participants who were ≥18 years of age, of South Asian origin, with a previous visit to a pharmacy in the US for a health-related reason, and with ability to read and comprehend English were recruited from independent pharmacies in New York City. Responses were obtained through a self-administered survey. Descriptive statistics were performed, and multiple linear regression analysis was conducted to assess the study objective. SPSS was used for data analyses. Out of 140 responses, 133 were usable. Mean scores (standard deviation) were 4.04 (0.97) for attitude, 3.77 (0.91) for SN, 3.75 (0.93) for PBC, and 3.96 (0.94) for intention. The model explains 80.8% of variance and is a significant predictor of intention, F (14,118) = 35.488, p < 0.05. While attitude (β = 0.723, p < 0.05) and PBC (β = 0.148, p < 0.05) were significant predictors of intention, SN (β = 0.064, p = 0.395) was not. None of the socio-demographics were significant predictors of intention. Strategies to make South Asians seek MTMS should focus on creating positive attitudes and removing barriers in seeking MTMS.

Alignment of Community Pharmacy Foundation Grant Funding and the Evolution of Pharmacy Practice in the United States of America

The Community Pharmacy Foundation is a non-profit organization dedicated to the advancement of community pharmacy practice and patient care delivery through grant funding and resource sharing. Since 2002, CPF has awarded 191 grants and over $9,200,000 (US dollars) in research and project grants. The purpose of this manuscript is to highlight the evolution of pharmacy practice and pharmacy education in the United States through the presentation of exemplary cases of Community Pharmacy Foundation funding that is aligned with new care delivery models and approaches to the advancement of patient-centered pharmacy care. Pharmacy began in colonial America as the United States of America was just beginning to form with apothecary shops and druggists. Over time, the pharmacy industry would be revolutionized as America became urbanized, and drug products became commercially produced. The role of the pharmacist and their education evolved as direct patient care became a clear expectation of the general public. By the 1990s, the pharmacy profession had carved out a new path that focused on pharmacist-led, patient-centered pharmaceutical care and medication therapy management services. The Community Pharmacy Foundation grant funding has aligned with this evolution since its founding in 2000, and multiple exemplary grants are presented as support. As the role of pharmacists again transitions from a fee-for-service model to a value-based model, the Community Pharmacy Foundation continues to provide grant funding for research and projects that support the advancement of community pharmacy practice, education, and expanded training of pharmacists.

A Study to Identify Medication-Related Problems and Associated Cost Avoidance by Community Pharmacists during a Comprehensive Medication Review in Patients One Week Post Hospitalization

Objectives: To determine the numbers of medication discrepancies and medication-related problems (MRPs) identified and resolved when providing a transitions of care comprehensive medication review (CMR) after hospital discharge within a community pharmacy; and to estimate the cost-avoidance value of this service. Methods: Community pharmacists provided CMRs to covered employees and dependents of a self-insured regional grocery store chain who were discharged from the hospital. Data was collected prospectively over 4 months. Discrepancies were identified among patients’ medication regimens by comparing the hospital discharge record, the pharmacy profile, and what the patient reported taking. MRPs were categorized into ten categories, as defined by the OutcomesMTM^® Encounter Worksheet. Interventions were categorized using the severity scale developed by OutcomesMTM^®, a Cardinal Health company. Data were analyzed using descriptive statistics and bivariate correlations. Results: Nineteen patients were enrolled in the program. Pharmacists identified 34 MRPs and 81 medication discrepancies, 1.8 and 4.3 per patient, respectively. The most common type of MRP was underuse of medication (70.6%). Significant positive correlations were found between the number of scheduled prescription medications and the number of medications with discrepancies (p ≤ 0.01; r = 0.825) and number of scheduled prescription medications and the number of MRPs (p ≤ 0.01; r = 0.697). Most commonly, the severity levels associated with the MRPs involved the prevention of physician office visits or addition of new prescription medications (n = 10 each); however, four emergency room visits and three hospitalizations were also avoided. The total estimated cost avoidance was $92,143, or $4850 per patient. Extrapolated annual cost savings related to this service would be $276,428. Conclusions: This transitions of care service was successful in identifying and addressing MRPs and discrepancies for this patient population. By providing this service, community pharmacists were able to prevent outcomes of various severities and to avoid patient care costs.

Effectiveness and safety of mepolizumab in severe refractory eosinophilic asthma: results in clinical practice

Background

Asthma is an inflammatory disease of the airways with symptoms that vary over time and intensity, sometimes leading to disability or even death. Eosinophilic asthma accounts for 25% of cases of severe asthma. It is mediated by eosinophils regulated by interleukin-5 (IL-5), the target of mepolizumab, which has been recently licensed as an add-on treatment of severe refractory eosinophilic asthma. The aim of this study was to evaluate the effectiveness and safety of mepolizumab in clinical practice.

Methods

A multicentre, retrospective, and descriptive study covering a year was conducted in a province of Spain with more than 500,000 inhabitants. Every patient prescribed with mepolizumab since its introduction into the hospital was included in the study. Clinical parameters were collected from the pharmacists' counselling reports from electronic prescription software and electronic patient records. Effectiveness was assessed as a decrease in the exacerbation frequency and/or a reduction in the use of oral corticosteroids (OCS) compared to the previous year.

Results

A total of 25 patients were studied, but only 23 could be evaluated by the cut-off date. A decrease in the exacerbation frequency was observed in 19 (82.6%) patients, 11 of them without any exacerbation during the treatment. A relative reduction of 87% in the exacerbation rate per year was obtained. A total of 15 patients were on regular OCS - 9 patients (60%) reduced their average dose, whilst 4 (26.7%) patients completely abandoned OCS. Safety was evaluated based on reported adverse effects. Adverse events were observed in 12 patients, the most common being headache, arthralgia, and dizziness/nausea.

Conclusion

Mepolizumab has been shown to be effective based on the high decrease in the exacerbation frequency and reduced use of OCS. Reported adverse effects were mostly mild and appeared in half of the patients; some of the adverse events had not been previously described in pivotal trials.

Medication therapy disease management: Geisinger's approach to population health management

PURPOSE

Pharmacists' involvement in a population health initiative focused on chronic disease management is described.

SUMMARY

Geisinger Health System has cultivated a culture of innovation in population health management, as highlighted by its ambulatory care pharmacy program, the Medication Therapy Disease Management (MTDM) program. Initiated in 1996, the MTDM program leverages pharmacists' pharmacotherapy expertise to optimize care and improve outcomes. MTDM program pharmacists are trained and credentialed to manage over 16 conditions, including atrial fibrillation (AF) and multiple sclerosis (MS). Over a 15-year period, Geisinger Health Plan (GHP)-insured patients with AF whose warfarin therapy was managed by the MTDM program had, on average, 18% fewer emergency department (ED) visits and 18% fewer hospitalizations per year than GHP enrollees with AF who did not receive MTDM services, with 23% lower annual total care costs. Over a 2-year period, GHP-insured patients with MS whose pharmacotherapy was managed by pharmacists averaged 28% fewer annual ED visits than non-pharmacist-managed patients; however, the mean annual total care cost was 21% higher among MTDM clinic patients.

CONCLUSION

The Geisinger MTDM program has evolved over 20 years from a single pharmacist-run anticoagulation clinic into a large program focused on managing the health of an ever-growing population. Initial challenges in integrating pharmacists into the Geisinger patient care framework as clinical experts were overcome by demonstrating the MTDM program's positive impact on patient outcomes.

Implementation of postdischarge follow-up telephone calls at a comprehensive cancer center

PURPOSE

The development and implementation of a pharmacy-driven, postdischarge follow-up telephone call program to assess medication adherence, provide education, and address medication-related concerns are discussed.

SUMMARY

Many readmissions are avoidable through effective discharge planning and patient follow-up after hospitalization. However, there is limited information on how to effectuate this process. To address this barrier, a team consisting of a clinical pharmacy specialist, a clinical pharmacy manager, a postgraduate year 1 pharmacy resident, and an education specialist at The University of Texas MD Anderson Cancer Center collaborated to create a postdischarge telephone call program within a transitions-of-care (TOC) pilot program. Various education and training materials were created to ensure trainees were competent. As of February 2016, 23 outpatient pharmacists and students have completed training, earning a median pretest and posttest score of 6 and 9, respectively, out of 10. There have been 206 calls completed; 150 patients (73%) were successfully reached, and 20 patients (9%) declined the telephone call. Medication adherence assessed during the telephone follow-up identified that 134 patients (89%) received their new medications within 72 hours, and 87 patients (58%) were recognized as having one or more discrepancies.

CONCLUSION

Developing a TOC program similar to this pilot program requires several resources including time, collaboration, and support from the management team. Pharmacy is well positioned to complete an accurate medication review and conduct postdischarge telephone calls to address medication-related issues. By providing these services, patients will receive continuity of care and positively impact emergency room visitation rates and hospital readmission rates.

Implementation of an Interprofessional Medication Therapy Management Experience

Objective. To measure the impact of an interprofessional experience (IPE) in medication therapy management (MTM) on students' attitudes and skills regarding interprofessional collaboration (IPC). Methods. This interprofessional MTM experience spanned three weeks, with health science students (medicine, nursing, nutrition, and pharmacy) meeting once weekly. The IPE facilitated interprofessional student collaboration via small-group sessions to conduct MTM consultations for patients with complex chronic conditions. Student learning and attitudinal changes were evaluated by comparing pre- and post-IPE survey responses and a qualitative summary of the students' clinical recommendations. Efficacy of student groups was measured via patient satisfaction surveys and was reported by frequency of response. Results. Twenty-seven students participated in the program and 22 completed both pre- and post-IPE surveys (81% response rate). The survey included open-ended and Likert-type items assessing students' attitudes and skills regarding the IPE as well as their reactions to the experience. Significant changes were observed for two attitudinal items regarding interprofessional teams: maintaining enthusiasm/interest and responsiveness to patients' emotional and financial needs. Patient-reported satisfaction and students' complex clinical recommendations provided further evidence of student learning. Conclusion. This novel IPE in MTM promoted interprofessional collaboration and education in this unique patient care area. Students' attitudes toward and skills in interprofessional collaboration improved, and the patients who received care reported positive experiences. Many health professions programs face challenges in meeting IPE requirements. The results of our study may provide the impetus for other institutions to develop similar programs to meet this urgent need.

Implementation of a Pilot Pharmacist Testosterone Therapy Management Service

BACKGROUND

Recent literature findings suggest that opportunities exist to optimize testosterone replacement therapy management.

OBJECTIVE

To evaluate the impact of a pilot clinical pharmacist testosterone therapy management service in a Veterans Affairs primary care setting.

METHODS

A 6-month, single-clinic, prospective cohort quality improvement project included male patients with an active prescription for testosterone. Patients were excluded if they switched primary care providers or were managed by a specialty clinic. After diagnosis, primary care providers had the option of referring patients for clinical pharmacist testosterone replacement therapy management. The project investigated the impact of pharmacist management on adherence to guideline-defined baseline and therapeutic monitoring, prior authorization workload, time saved by primary care providers, and clinical pharmacist interventions.

RESULTS

Sixty patients split between pharmacist management (N = 35) and nonpharmacist management (N = 25) cohorts. Monitoring of baseline parameters was significantly improved with clinical pharmacist management (54% vs 20%, P = 0.0006). Improved baseline monitoring decreased prior authorization team workload as requests were approved on the first submission at a higher rate (100% vs 75.4%, P = 0.06). Pharmacist management increased therapeutic monitoring for assessing symptom improvement (96% vs 26%, P < 0.001), monitoring of testosterone levels (96% vs 61%, P = 0.003), and safety monitoring with complete blood counts (100% vs 83%, P = 0.04). A total of 42 pharmacist-patient encounters saved over 600 minutes of primary care provider time.

CONCLUSION

Clinical pharmacist involvement enhances therapeutic monitoring for male hypogonadism leaving room for expansion of clinical pharmacy services within testosterone replacement therapy management.

Consultant Pharmacist⁻Provider Collaboration in U.S. Assisted Living Facilities: A Pilot Study

The purpose of this pilot study was to explore the impact of pharmacist-provided recommendations to general practitioners (GPs) of patients living in assisted living facilities (ALFs). A secondary objective of this study was to explore prescriber and ALF staff perceptions. This was a mixed-method, quasi experimental 1-group pre/post-test study with an explanatory qualitative arm using in-depth semi-structured interviews at five regional ALFs and one independent community pharmacy in East Tennessee. Residents older than 65 years of age, with confirmed diagnosis of Type II diabetes in the pharmacy’s medical record, taking anti-diabetic medication for at least 14 days and resident of affiliated ALF for at least past 30 days were enrolled. Phase 1 demonstrated a 35.1% (13/37 recommendations) acceptance rate of pharmacist recommendations. Phase 2 demonstrated a similar 31.3% acceptance rate of pharmacist recommendations (5/16 recommendations). The mean pre–post difference in average 30-day FBG was greater in the accepted group than the rejected recommendation group (−9.1 vs. −2.3 mg/dL). Pharmacist–GP collaboration in the ALF population was feasible and may improve the quality of patient care of these residents.

Comparative Effectiveness of Medication Therapy Management Eligibility Criteria Across Racial/Ethnic Groups

BACKGROUND/OBJECTIVES

Previous research indicates that eligibility criteria for medication therapy management (MTM) services in Medicare prescription drug (Part D) plans, defined under the Medicare Modernization Act (MMA), are associated with racial/ethnic disparities and ineffective in identifying individuals with medication utilization issues. Our study's objective was to determine the comparative effectiveness of MTM eligibility criteria under MMA and in the Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial/ethnic groups.

DESIGN

ACA and MMA MTM eligibility criteria were compared on proportions of eligible individuals among patients with medication utilization issues. Multinomial logistic regression was conducted to control for patient/community characteristics. Need-based and demand-based analyses were used to determine disparities due to need and demand for healthcare. Main/sensitivity analyses were conducted for the range of eligibility thresholds.

SETTING

Medicare data (2012-2013) linked to Area Health Resources Files.

PARTICIPANTS

A total of 964 610 patients 65 years or older.

MEASUREMENTS

Medication safety/adherence measures, developed primarily by the Pharmacy Quality Alliance, were used to determine medication utilization issues.

RESULTS

Higher proportions of patients were eligible based on ACA than MMA MTM eligibility criteria. For example, in 2013, proportions based on ACA and MMA MTM eligibility criteria would be 99.7% and 26.2%, respectively, in the main analysis (p < .001); in the demand-based main analysis, ACA criteria were associated with 13.6% and 9.8%, respectively, higher effectiveness than MMA criteria among non-Hispanic blacks and Hispanics than non-Hispanic whites.

CONCLUSION

ACA MTM eligibility criteria are more effective than MMA criteria in identifying older patients needing MTM, particularly among minorities. J Am Geriatr Soc 67:581-587, 2019.

Disaster Health Management: Do Pharmacists Fit in the Team?

BACKGROUND

In addition to the traditional logistics role, pharmacists are undertaking important new roles in disasters. Despite this, little is known about the level of acceptance of these activities by other providers.

PROBLEM

The aim of this study was to determine the international opinion of disaster and health professionals regarding the emerging roles of pharmacists in disasters.

METHODS

Delegates at the World Association for Disaster and Emergency Medicine's (WADEM; Madison, Wisconsin USA) 20th Congress in Toronto, Canada (April 2017) were invited to complete an anonymous survey posing eight questions regarding attitudes towards pharmacists' roles in disasters. Quantitative data were analyzed using IBM (IBM Corp.; Armonk, New York USA) SPSS statistical software version 23, and qualitative data were manually coded.

RESULTS

Of the 222 surveys handed out, 126 surveys were completed yielding a 56.8% response rate. Of the respondents, 96.8% (122/126) believed pharmacists had a role in disasters additional to logistics. Out of 11 potential roles pharmacists could perform in a disaster, provided on a 5-point Likert scale, eight roles were given a rating of "Agree" or "Strongly Agree" by 72.4% or more of the participants. Lack of understanding of a pharmacist's roles and capabilities was the highest described barrier to pharmacists' roles in disaster management.

CONCLUSIONS

This multi-disciplinary disaster health "community" agreed pharmacists have roles in disasters in addition to the established role in supply chain logistics. Participants accepted that pharmacists could possibly undertake numerous clinical roles in a disaster. Several barriers were identified that may be preventing pharmacists from being further included in disaster health management planning and response.WatsonKE, TippettV, SingletonJA, NissenLM. Disaster health management: do pharmacists fit in the team?Prehosp Disaster Med. 2019;34(1):30-37.

GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention for Emergency Department Patients - A Qualitative Evaluation

Background:

Three million US emergency department (ED) visits occur for falls each year. The mortality of falls is increasing and only one fourth of older adults report their fall to their primary care provider, suggesting that valuable preventative opportunities are missed. A fall prevention intervention initiated in the ED immediately after a fall has the potential to reduce subsequent falls, but ED providers lack the time and resources to complete fall risk assessments on their patients. GAPcare, the Geriatric Acute and Post-Acute Fall Prevention Intervention, was developed to address this need.

Methods:

GAPcare combines a pharmacist-led medication therapy management intervention with a physical therapist (PT)-administered fall risk assessment and disposition planning. A key objective of this pilot randomized controlled trial (RCT) was to create a patient and caregiver-centric intervention. This manuscript reports on the results of the qualitative companion study in which we conducted in-depth interviews with patients and caregivers to determine their lived experience with the intervention, barriers and perceived impact of the intervention, and to obtain their recommendations for the improvement of GAPcare. We recruited patients and their caregivers from the RCT into 30 minutes interviews in the participants’ home singularly or in dyads (patient and caregiver together). Interviews were audio-recorded, transcribed, and double-coded. We used applied thematic analysis to guide the data analysis.

Results:

We conducted 20 interviews; patients (n=12), caregivers (n=11). Patients were on average 83 years old, 7/12 were female, and 2/14 had cognitive impairment. 6/11 caregiver interviews were in reference to a patient with dementia. Patients and caregivers reported they embraced the experience of motivational interviewing elements, citing its collaborative and inclusive nature. Caregivers in particular said they felt that PT helped their loved one recognize and overcome functional limitations. Barriers included lack of time, the burden of coordinating multiple service providers once home, and concerns that PT would be ineffective or increase pain. Areas for improvement included better screening for those who would benefit from the individual components (pharmacy vs. PT consultation), improving identification of GAPcare pharmacists and PTs vs. other hospital staff in the ED, and expanding the role of GAPcare personnel to provide culturally competent, comprehensive care to improve adherence and medication education.

Conclusions:

We found that GAPcare, a new team-based intervention for fall prevention in the ED, was welcomed by patients and their caregivers. Several suggestions to improve the intervention were made that will inform the screening, content, and communication with patients in GAPcare.

Accurate Therapeutic Response Assessment of Pancreatic Ductal Adenocarcinoma Using Quantitative Dynamic Contrast-Enhanced Magnetic Resonance Imaging With a Point-of-Care Perfusion Phantom: A Pilot Study

OBJECTIVES

The aim of this study was to test the feasibility of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with concurrent perfusion phantom for monitoring therapeutic response in patients with pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

A prospective pilot study was conducted with 8 patients (7 men and 1 woman) aged 46 to 78 years (mean age, 66 years). Participants had either locally advanced (n = 7) or metastatic (n = 1) PDAC, and had 2 DCE-MRI examinations: one before and one 8 ± 1 weeks after starting first-line chemotherapy. A small triplicate perfusion phantom was imaged with each patient, serving as an internal reference for accurate quantitative image analysis. Tumor perfusion was measured with K using extended Tofts model before and after phantom-based data correction. Results are presented as mean ± SD and 95% confidence intervals (CIs). Statistical difference was evaluated with 1-way analysis of variance.

RESULTS

Tumor-size change of responding group (n = 4) was -12% ± 4% at 8 weeks of therapy, while that of nonresponding group (n = 4) was 18% ± 15% (P = 0.0100). Before phantom-based data correction, the K change of responding tumors was 69% ± 23% (95% CI, 32% to 106%) at 8 weeks, whereas that of nonresponding tumors was -1% ± 41% (95% CI, -65% to 64%) (P = 0.0247). After correction, the data variation in each group was significantly reduced; the K change of responding tumors was 73% ± 6% (95% CI, 64% to 82%) compared with nonresponding tumors of -0% ± 5% (95% CI, -7% to 8%) (P < 0.0001).

CONCLUSIONS

Quantitative DCE-MRI measured the significant perfusion increase of PDAC tumors responding favorably to chemotherapy, with decreased variability after correction using a perfusion phantom.

The Impact of Technology on Safe Medicines Use and Pharmacy Practice in the US

For decades it has been suggested that pharmacists are under-utilized and could better use their knowledge and experience to improve the use of medicines. The traditional roles for pharmacists have been preparing and distributing medicines, but this has limited both the location where they work and the available time to work more closely with other healthcare professionals to improve both the effectiveness and safety of medicines. Newly emerging technologies have made this possible. Examples include robotics that automate preparation and distribution of medicines, electronic health information, clinical decision support systems, and machine readable coding on medicine packaged. As a result of the use of these technologies, pharmacists in hospitals are working outside the hospital pharmacy and spending more time in medication therapy management activities compared to traditional distribution roles.

Senior PharmAssist: Less Hospital Use with Enrollment in an Innovative Community-Based Program

OBJECTIVES

To evaluate changes in acute health services use of Senior PharmAssist participants.

DESIGN

Retrospective analysis.

SETTING

Community-based, nonprofit program in Durham County, North Carolina.

PARTICIPANTS

Adults aged 60 and older with income of 200% of the federal poverty level or less who enrolled in the Senior PharmAssist program (N = 191) between August 1, 2011, and March 15, 2017.

INTERVENTION

Medication therapy management (MTM), customized community referrals, Medicare insurance counseling, and medication copayment assistance provided by Senior PharmAssist.

MEASUREMENTS

Primary outcomes were self-reported emergency department (ED) visits and hospital admissions in the previous year, assessed at baseline and every 6 months for up to 2 years.

RESULTS

Mean number of ED visits declined over time (0.83 visits per year at baseline to 0.53 visits per year at 24 months, P = .002), as did the percentage of participants reporting an ED visit in the past year (49% at baseline to 31% at 24 months, P = .003). Mean hospital admissions also decreased (0.56 admissions per year at baseline to 0.4 admissions per year at 24 months, P = .02). There was no significant change in percentage of participants reporting a hospital admission in the past year (33% at baseline to 25% at 24 months, P = .23).

CONCLUSION

Older adults who enrolled in a community-based program that helps them manage medications, connect with community resources, and overcome barriers to medication access experienced reductions in acute health services use. J Am Geriatr Soc 66:2394-2400, 2018.

Protocol for a feasibility study of an Indigenous Medication Review Service (IMeRSe) in Australia

INTRODUCTION

The age-adjusted rate of potentially preventable hospitalisations for Aboriginal and Torres Strait Islander people is almost five times the rate of other Australians. Quality use of medicines has an important role in alleviating these differences. This requires strengthening existing medication reviewing services through collaboration between community pharmacists and health workers, and ensuring services are culturally appropriate. This Indigenous Medication Review Service (IMeRSe) study aims to develop and evaluate the feasibility of a culturally appropriate medication management service delivered by community pharmacists in collaboration with Aboriginal health workers.

METHODS AND ANALYSIS

This study will be conducted in nine Aboriginal health services (AHSs) and their associated community pharmacies in three Australian states over 12 months. Community pharmacists will be trained to improve their awareness and understanding of Indigenous health and cultural issues, to communicate the quality use of medicines effectively, and to strengthen interprofessional relationships with AHSs and their staff. Sixty consumers (with a chronic condition/pregnant/within 2 years post partum and at risk of medication-related problems (MRPs) per site will be recruited, with data collection at baseline and 6 months. The primary outcome is the difference in cumulative incidence of serious MRPs in the 6 months after IMeRSe introduction compared with the 6 months prior. Secondary outcomes include potentially preventable medication-related hospitalisations, medication adherence, total MRPs, psychological and social empowerment, beliefs about medication, treatment satisfaction and health expenditure.

ETHICS AND DISSEMINATION

The protocol received approval from Griffith University (HREC/2018/251), Queensland Health Metro South (HREC/18/QPAH/109), Aboriginal Health and Medical Research Council of New South Wales (1381/18), Far North Queensland (HREC/18/QCH/86-1256) and the Central Australian HREC (CA-18-3090). Dissemination to Indigenous people and communities will be a priority. Results will be available on the Australian Sixth Community Pharmacy Agreement website and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12618000188235; Pre-results.

Evaluation of mobile phone applications to support medication adherence and symptom management in oncology patients

Mobile phone applications (apps), may support pediatric oncology patients with medication and disease management. A scoping review of the literature, a search of the iTunes App and Google Play Stores, was conducted to identify medication and symptom management apps for adult and pediatric oncology patients. Pooled results yielded 28 apps which were assessed for quality using the Mobile Application Rating Scale, with mean overall scores ranging from 2.8 to 4.3. Most apps received low scores in the Engagement domain. Our study assessed the quality of available mobile oncology apps and identified areas for improvement in design and function.