The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma

Assessing the knowledge to practice gap: The asthma practices of community pharmacists

Background

Community pharmacists are well positioned to identify patients with poorly controlled asthma and trained to optimize asthma therapy. Yet, over 90% of patients with asthma live with uncontrolled disease. We sought to understand the current state of asthma management in practice in Alberta and explore the potential use of the Chat, Check and Chart (CCC) model to enhance pharmacists' care for patients with asthma.

Methods

An 18-question survey was used to examine pharmacists' monitoring of asthma control and prior use of the CCC tools. Descriptive statistics were used to characterize the response rate, sample demographics, asthma management and CCC use. Survey validity and reliability were established.

Results

One hundred randomly selected pharmacists completed the online survey with a 40% (100/250) response rate. A third of responding pharmacists reported talking to most patients about asthma symptoms and medication, with a greater focus on talking with patients on new prescriptions over those with ongoing therapies. Fewer than 1 in 10 pharmacists routinely talked to most patients about asthma action plans (AAPs). The majority of pharmacists (76%) were familiar with the CCC model, and 83% of those reported that the CCC model influenced their practice anywhere from somewhat (45%) to a great deal (38%). Both scales had good reliability, and factor analysis provided support for scale validity.

Conclusions

There was considerable variability in pharmacists' activities in monitoring asthma. Pharmacists rarely used AAPs. The CCC model had a high level of self-reported familiarity, use and influence among pharmacists.

Improving Chronic Disease Outcomes Through Medication Therapy Management in Federally Qualified Health Centers

INTRODUCTION

Appropriate management of chronic diseases, including proper use of medications, can lead to better disease control, decrease disease-related complications, and improve overall health. Pharmacists have been shown to positively affect chronic disease outcomes through medication therapy management (MTM). The primary objectives of this project are to increase the number of patients with (1) A1c in control and (2) blood pressure in control; secondary objectives are to (3) describe number and type of medication-related problems identified and resolved by pharmacists providing MTM in Federally Qualified Health Centers (FQHCs), (4) identify potential (pADEs) and actual adverse drug events (ADEs), and refer patients to diabetes self-management education classes, as needed.

METHODS

This multisite, prospective, descriptive pilot study engaged three FQHC sites with distinct models of established pharmacist MTM services to care for patients with uncontrolled diabetes and/or hypertension. Data were reported in aggregate regarding primary and secondary outcomes.

RESULTS

As of December 2015, 706 patients were enrolled in the project. Of the 422 with uncontrolled diabetes, 52.84% (n = 223) had an A1c <9%; 72 patients (17.06%) achieved an A1c between 8% and 9%, 19.19% (n = 81) of patients achieved an A1c <8% and ≥7%, and 16.59% (n = 70) of patients achieved an A1c <7%. The percentage of patients with blood pressure <140/90 mm Hg improved to 65.21%.

CONCLUSION

Pharmacist-provided MTM can improve chronic disease intermediate outcomes for medically underserved patients in FQHCs.

A pharmacy management service for adults with asthma: a cluster randomised controlled trial

BACKGROUND

Although clinical guidelines are available for the management of asthma, this health condition is still poorly managed in many countries.

OBJECTIVES

To assess the effects of a Pharmacy Management Service (PharMS) on asthma control of adult patients.

METHODS

This study comprised of a cluster randomised controlled trial (RCT) that was conducted from April 2014 to July 2015 at four government health clinics. The control participants received usual pharmacy service, while the intervention participants were recruited into the PharMS. Each participant was monitored for 6 months, and the outcome measures included asthma control using the Asthma Control Test (ACT), inhaler technique using a checklist and medication adherence using the Malaysian Medication Adherence Scale.

RESULTS

A total of 157 participants were recruited: 77 in the control and 80 in the intervention group. At the end of the study, 90% of the intervention participants achieved well-controlled asthma compared to 28.6% in the control group (P < 0.001). The differences in the proportion of participants with correct inhaler technique was also significant, with an adjusted effect size of 0.953 (P < 0.001). In addition, the intervention participants showed significantly higher medication adherence than the control group (92.5% versus 45.5%, P < 0.001). The Generalised Estimated Equation analysis further confirmed that the PharMS (P < 0.001) was significantly related to an improvement in the ACT scores.

CONCLUSION

A community-based asthma management program, the PharMS, that provided asthma education and skill training by a trained pharmacist, resulted in positive and significant improvements in clinical and management outcomes of adult asthma patients.

Social and economic value of Portuguese community pharmacies in health care

Background

Community pharmacies are major contributors to health care systems across the world. Several studies have been conducted to evaluate community pharmacies services in health care. The purpose of this study was to estimate the social and economic benefits of current and potential future community pharmacies services provided by pharmacists in health care in Portugal.

Methods

The social and economic value of community pharmacies services was estimated through a decision-model. Model inputs included effectiveness data, quality of life (QoL) and health resource consumption, obtained though literature review and adapted to Portuguese reality by an expert panel. The estimated economic value was the result of non-remunerated pharmaceutical services plus health resource consumption potentially avoided. Social and economic value of community pharmacies services derives from the comparison of two scenarios: “with service” versus “without service”.

Results

It is estimated that current community pharmacies services in Portugal provide a gain in QoL of 8.3% and an economic value of 879.6 million euros (M€), including 342.1 M€ in non-remunerated pharmaceutical services and 448.1 M€ in avoided expense with health resource consumption. Potential future community pharmacies services may provide an additional increase of 6.9% in QoL and be associated with an economic value of 144.8 M€: 120.3 M€ in non-remunerated services and 24.5 M€ in potential savings with health resource consumption.

Conclusions

Community pharmacies services provide considerable benefit in QoL and economic value. An increase range of services including a greater integration in primary and secondary care, among other transversal services, may add further social and economic value to the society.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2525-4) contains supplementary material, which is available to authorized users.

Evaluation of a pharmacist-managed asthma clinic in an Indian Health Service clinic

OBJECTIVES

To observe whether American Indian and Alaskan Native (AI/AN) patients at the Yakama Indian Health Service seen at the pharmacist-managed asthma clinic improved asthma outcomes.

DESIGN

Retrospective chart review, single group, preintervention and postintervention.

SETTING

Pharmacist-managed asthma clinic at an Indian Health Service ambulatory care clinic.

PATIENTS

Sixty-one AI/AN patients who were seen at least once in the asthma clinic from 2010 to 2014.

INTERVENTION

Pharmacist-provided asthma education and medication management.

MAIN OUTCOME MEASURES

Asthma-related hospitalizations and emergency department or urgent care (ED) visits.

RESULTS

The total number of asthma-related hospitalizations and ED visits between the 12-month periods preceding and following the initial asthma clinic visit were 11 versus 2 hospitalizations (P = 0.02) and 43 versus 25 ED visits (P = 0.02), respectively. Over the same period, asthma-related oral corticosteroid use showed a nonsignificant decrease in the number of prescriptions filled (n = 59, P = 0.08). In contrast, inhaled corticosteroid prescription fills significantly increased (n = 42, P = 0.01).

CONCLUSION

A reduction of asthma-related hospitalizations and ED visits were observed during the course of the intervention. Increased access to formal asthma education and appropriate asthma care benefit the Yakama AI/AN people. A controlled trial is needed to confirm that the intervention causes the intended effect.

Pharmacist home visits: A 1-year experience from a community pharmacy

OBJECTIVE

To provide experience on the methods and costs for delivering a large-scale community pharmacist home visit service.

SETTING

Independent urban community pharmacy, Buffalo, NY.

PRACTICE DESCRIPTION

Mobile Pharmacy Solutions provides traditional community pharmacy walk-in service and a suite of clinically oriented services, including outbound adherence calls linked to home delivery, payment planning, medication refill synchronization, adherence packaging, and pharmacist home visits. Pharmacist daily staffing included three dispensing pharmacists, one residency-trained pharmacist, and two postgraduate year 1 community pharmacy residents.

PRACTICE INNOVATION

A large-scale community pharmacy home visit service delivered over a 1-year period.

EVALUATION

Pharmacist time and cost to administer the home visit service as well as home visit request sources and description of patient demographics.

RESULTS

A total of 172 visits were conducted (137 initial, 35 follow-up). Patients who received a home visit averaged 9.8 ± 5.2 medications and 3.0 ± 1.6 chronic disease states. On average, a home visit required 2.0 ± 0.8 hours, which included travel time. The percentages of visits completed by pharmacists and residents were 60% and 40%, respectively. The amounts of time to complete a visit were similar. Average home visit cost including pharmacist time and travel was $119 ($147 for a pharmacist, $77 for a resident).

CONCLUSION

In this community pharmacy-based home visit service, costs are an important factor, with each pharmacist visit requiring 2 hours to complete. This experience provides a blueprint and real-world perspective for community pharmacies endeavoring to implement a home visit service and sets a foundation for future prospective trials to evaluate the impact of the service on important indicators of health and cost.

Pharmacists' perspectives of the current status of pediatric asthma management in the U.S. community pharmacy setting

Objective To explore community pharmacists' continuing education, counseling and communication practices, attitudes and barriers in relation to pediatric asthma management. Setting Community pharmacies in Michigan, United States. Methods Between July and September 2015 a convenience sample of community pharmacists was recruited from southeastern Michigan and asked to complete a structured, self-reported questionnaire. The questionnaire elucidated information on 4 general domains relating to pharmacists' pediatric asthma management including: (1) guidelines and continuing education (CE); (2) counseling and medicines; (3) communication and self-management practices; (4) attitudes and barriers to practice. Regression analyses were conducted to determine predictors towards pharmacists' confidence/frequency of use of communication/counseling strategies. Main outcome measure Confidence in counseling skills around asthma. Results 105 pharmacists completed the study questionnaire. Fifty-four percent of pharmacists reported participating in asthma related CE in the past year. Over 70% of pharmacists reported confidence in general communication skills, while a lower portion reported confidence in engaging in higher order self-management activities that involved tailoring the regimen (58%), decision-making (50%) and setting short-term (47%) and long-term goals (47%) with the patient and caregiver for managing asthma at home. Pharmacists who reported greater use of recommended communication/self-management strategies were more likely to report confidence in implementing these communication/self-management strategies when counseling caregivers and children with asthma [Beta (B) Estimate 0.58 SE (0.08), p < 0.001]. Female pharmacists [B Estimate -2.23 SE (1.01), p < 0.05] and those who reported beliefs around doctors being the sole provider of asthma education [B Estimate -1.00 SE (0.32), p < 0.01] were less likely to report confidence in implementing communication/self-management strategies. Conclusion A pharmacists' confidence may influence their ability to implement recommended self-management counseling strategies. This study showed that community pharmacists are confident in general communication. However pharmacists are reporting lower confidence levels in counseling on higher order self-management strategies with patients. More appropriate and targeted continuing education programs for pharmacists around asthma self-management education are recommended.

A cluster randomised control trial to evaluate the effectiveness and cost-effectiveness of the Italian medicines use review (I-MUR) for asthma patients

Background

The economic burden of asthma, which relates to the degree of control, is €5 billion annually in Italy. Pharmacists could help improve asthma control, reducing this burden. This study aimed to evaluate the effectiveness and cost-effectiveness of Medicines Use Reviews provided by community pharmacists in asthma.

Methods

This cluster randomised, multi-centre, controlled trial in adult patients with asthma was conducted in 15 of the 20 regions of Italy between September 2014 and July 2015. After stratification by region, community pharmacists were randomly allocated to group A (trained in and delivered the intervention at baseline) or B (training and delivery 3 months later), using computerised random number generation in blocks of 10. Each recruited up to five patients, with both groups followed for 9 months.

The intervention consisted of a systematic, structured face-to-face consultation with a pharmacist, covering asthma symptoms, medicines used, attitude towards medicines and adherence, recording pharmacist-identified pharmaceutical care issues (PCIs). The primary outcome was asthma control, assessed using the Asthma-Control-Test (ACT) score (ACT ≥ 20 represents good control). Secondary outcomes were: number of active ingredients, adherence, cost-effectiveness compared with usual care. Although blinding was not possible for either pharmacists or patients, assessment of outcomes was conducted by researchers blind to group allocation.

Results

Numbers of pharmacists and patients enrolled were 283 (A = 136; B = 147) and 1263 (A = 600; B = 663), numbers completing were 201 (A = 97; B = 104) and 816 (A = 400; B = 416), respectively. Patients were similar in age and gender and 56.13% (458/816) had poor/partial asthma control. Pharmacists identified 1256 PCIs (mean 1.54/patient), mostly need for education, monitoring and potentially ineffective therapy. Median ACT score at baseline differed between groups (A = 19, B = 18; p < 0.01). Odds ratio for improved asthma control was 1.76 (95% CI 1.33–2.33) and number needed to treat 10 (95% CI 6–28). Number of active ingredients reduced by 7.9% post-intervention (p < 0.01). Adherence improved by 35.4% 3 months post-intervention and 40.0% at 6 months (p < 0.01). The probability of the intervention being more cost-effective than usual care was 100% at 9 months.

Conclusions

This community pharmacist-based intervention demonstrated both effectiveness and cost-effectiveness. It has since been implemented as the first community pharmacy cognitive service in Italy.

Trial registration

TRN: ISRCTN72438848 (registered 5^th January 2015, retrospectively).

Physician-reported factors that encourage collaboration with community pharmacists

OBJECTIVE

To determine factors that encourage physicians to establish collaborative practice agreements with community pharmacists.

METHODS

A 20-item cross-sectional survey was mailed to a random sample of 1000 family medicine physicians practicing in North Carolina. Two weeks after the initial mailing, a reminder was sent to physicians. Physicians were entered into a drawing to receive a gift card as an incentive for survey completion. The questionnaire collected demographic information, factors important to physicians for collaboration with a community pharmacist, and physician perceptions of pharmacist qualifications. Descriptive statistics were used to analyze patterns in the Likert scale survey responses.

RESULTS

Of the 1000 mailed surveys, 67 were returned as undeliverable, resulting in a final sample size of 933 surveys. One hundred forty-six family medicine physicians responded to the survey, yielding a 15.6% response rate. Respondents were 58% male, 73% had been practicing longer than 10 years, and 60% had an academic affiliation. Our results indicate that an established relationship with a community pharmacist is the most important factor when considering a collaborative practice agreement. At least 90% of physicians reported that the most important pharmacist contributions were drug therapy adverse effect management, drug interaction management, medication access assistance, prescription counseling, and medication adherence. A majority of physicians reported that community pharmacists improve quality outcomes and metrics (74% and 72%, respectively).

CONCLUSION

Physicians in North Carolina recognize the value of the services a pharmacist can provide to their patients. Developing relationships between community pharmacists and physicians and describing the value of additional credentialing in the provision of patient care will be integral in establishing collaborative practice agreements in the community setting.

Impact of telepharmacy services as a way to increase access to asthma care

OBJECTIVE

To demonstrate that real-time, telepharmacy-based asthma educational services are feasible and to support the efforts of local primary care prescribers to improve patient outcomes.

METHODS

The lead investigator (a pharmacist, physician assistant, and certified asthma educator) identified an independent community pharmacy with telehealth capabilities in a rural area with a high prevalence of asthma. Working with the pharmacy, an asthma education program was developed based on the National Asthma Education and Prevention Program guidelines. It consisted of three monthly education visits, with subsequent visits every three months for one year. The Asthma Control Test (ACT) was administered at baseline and at each visit to assess a patient's perception of asthma control.

RESULTS

Eighteen of 20 patients (90%) with reversible airway disease completed all six visits in this year-long study. For the 18 patients, the mean ACT scores of 18 at baseline (initiation of intervention) did not meet the threshold for "well-controlled" asthma. By the third educational visit (3 months), 16 patients met ACT criteria for well-controlled asthma (mean score = 20), and they maintained control for the remaining 9-month follow-up period (ACT ≥ 21). Local prescribers authorized medication changes recommended by the asthma educator 20 times and also requested six direct consults with the asthma educator over the study period.

CONCLUSION

Using the local community pharmacy as a vehicle to deliver asthma education services by telepharmacy was utilized by local prescribers. The findings show this is an effective means to engage patients to gain and maintain asthma control.

Pharmacist Critique Was Ill-Informed

Pharmacists’ ability to exercise “professional right of conscience” in dispensing emergency contraception, as well as the professionalism of pharmacists, has fallen under attack recently by the media, by state governments, and even by other healthcare professionals in published commentaries. This editorial discusses the controversy surrounding emergency contraceptives, the right of pharmacists to refuse to fill prescriptions that they consider morally objectionable, and the responsibility of pharmacists to provide medications in a timely and professional manner. The professionalism of pharmacy is also examined in light of the expanded scope of practice in which pharmacists increasingly find themselves practicing.

Economic Evidence for US Asthma Self-Management Education and Home-Based Interventions

The health and economic burden of asthma in the United States is substantial. Asthma self-management education (AS-ME) and home-based interventions for asthma can improve asthma control and prevent asthma exacerbations, and interest in health care-public health collaboration regarding asthma is increasing. However, outpatient AS-ME and home-based asthma intervention programs are not widely available; economic sustainability is a common concern. Thus, we conducted a narrative review of existing literature regarding economic outcomes of outpatient AS-ME and home-based intervention programs for asthma in the United States. We identified 9 outpatient AS-ME programs and 17 home-based intervention programs with return on investment (ROI) data. Most programs were associated with a positive ROI; a few programs observed positive ROIs only among selected populations (eg, higher health care utilization). Interpretation of existing data is limited by heterogeneous ROI calculations. Nevertheless, the literature suggests promise for sustainable opportunities to expand access to outpatient AS-ME and home-based asthma intervention programs in the United States. More definitive knowledge about how to maximize program benefit and sustainability could be gained through more controlled studies of specific populations and increased uniformity in economic assessments.

Racial and ethnic disparities in meeting MTM eligibility criteria among patients with asthma

BACKGROUND

Asthma is one of the most frequently targeted chronic diseases in the medication therapy management (MTM) programs of the Medicare prescription drug (Part D) benefits. Although racial and ethnic disparities in meeting eligibility criteria for MTM services have been reported, little is known about whether there would be similar disparities among adults with asthma in the United States.

METHODS

Adult patients with asthma (age ≥ 18) from Medical Expenditure Panel Survey (2011-2012) were analyzed. Bivariate analyses were conducted to compare the proportions of patients who would meet Medicare MTM eligibility criteria between non-Hispanic Blacks (Blacks), Hispanics and non-Hispanic Whites (Whites). Survey-weighted logistic regression was performed to adjust for patient characteristics. Main and sensitivity analyses were conducted to cover the entire range of the eligibility thresholds used by Part D plans in 2011-2012.

RESULTS

The sample included 4,455 patients with asthma, including 2,294 Whites, 1,218 Blacks, and 943 Hispanics. Blacks and Hispanics had lower proportions of meeting MTM eligibility criteria than did Whites (P < 0.001). According to the main analysis, Blacks and Hispanics had 36% and 32% lower, respectively, likelihood of MTM eligibility than Whites (odds ratio [OR]: 0.64, 95% confidence interval [CI]: 0.45-0.90; OR: 0.68, 95% CI: 0.47-0.98, respectively). Similar results were obtained in sensitivity analyses.

CONCLUSIONS

There are racial and ethnic disparities in meeting Medicare Part D MTM eligibility criteria among adult patients with asthma. Future studies should examine the implications of such disparities on health outcomes of patients with asthma and explore alternative MTM eligibility criteria.

United States Health Care System: A Pharmacy Perspective

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The relationship between return on investment and quality of study methodology in workplace health promotion programs

OBJECTIVE

To determine the relationship between return on investment (ROI) and quality of study methodology in workplace health promotion programs.

DATA SOURCE

Data were obtained through a systematic literature search of National Health Service Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Database (HTA), Cost Effectiveness Analysis (CEA) Registry, EconLit, PubMed, Embase, Wiley, and Scopus.

STUDY INCLUSION AND EXCLUSION CRITERIA

Included were articles written in English or German reporting cost(s) and benefit(s) and single or multicomponent health promotion programs on working adults. Return-to-work and workplace injury prevention studies were excluded.

DATA EXTRACTION

Methodological quality was graded using British Medical Journal Economic Evaluation Working Party checklist. Economic outcomes were presented as ROI.

DATA SYNTHESIS

ROI was calculated as ROI = (benefits - costs of program)/costs of program. Results were weighted by study size and combined using meta-analysis techniques. Sensitivity analysis was performed using two additional methodological quality checklists. The influences of quality score and important study characteristics on ROI were explored.

RESULTS

Fifty-one studies (61 intervention arms) published between 1984 and 2012 included 261,901 participants and 122,242 controls from nine industry types across 12 countries. Methodological quality scores were highly correlated between checklists (r = .84-.93). Methodological quality improved over time. Overall weighted ROI [mean ± standard deviation (confidence interval)] was 1.38 ± 1.97 (1.38-1.39), which indicated a 138% return on investment. When accounting for methodological quality, an inverse relationship to ROI was found. High-quality studies (n = 18) had a smaller mean ROI, 0.26 ± 1.74 (.23-.30), compared to moderate (n = 16) 0.90 ± 1.25 (.90-.91) and low-quality (n = 27) 2.32 ± 2.14 (2.30-2.33) studies. Randomized control trials (RCTs) (n = 12) exhibited negative ROI, -0.22 ± 2.41(-.27 to -.16). Financial returns become increasingly positive across quasi-experimental, nonexperimental, and modeled studies: 1.12 ± 2.16 (1.11-1.14), 1.61 ± 0.91 (1.56-1.65), and 2.05 ± 0.88 (2.04-2.06), respectively.

CONCLUSION

Overall, mean weighted ROI in workplace health promotion demonstrated a positive ROI. Higher methodological quality studies provided evidence of smaller financial returns. Methodological quality and study design are important determinants.

Evaluation of the implementation process and outcomes of a professional pharmacy service in a community pharmacy setting. A case report

Pharmacist-led medication review services are recognized as a key to medicines management. This case study describes the implementation process of a medication review with follow-up service in a community pharmacy setting and evaluates its initial outcomes. An implementation-effectiveness hybrid study was undertaken in a community pharmacy setting. The implementation process was divided into four different phases: Exploration and adoption, program installation, initial implementation, and full operation. A core set of implementation outcomes was measured, including penetration, implementation costs, feasibility, fidelity, acceptability, appropriateness and efficiency. The penetration rate of the service was nearly 62.5%, and the implementation costs were 57,359.67€. There was a high retention-participation rate of patients. For every month of service provision, there was a 1.27 increase in the number of patients requesting the service, compared to the number of patients being offered the service. The time spent on service provision was 171.7 min per patient. Average patient satisfaction with the service was 4.82 (SD: 0.39, scale 1-5), and the acceptance rate of care plans by patients and general medical practitioners were 96.99% and 96.46%, respectively. There were 408 negative outcomes associated with the use of medications were identified during the study (3.09 per patient), of which 96.3% were resolved. The average time per patient spent on service provision significantly decreased along the 18 months of service provision. This case report can assist individual pharmacists and professional organizations interested in implementing evidence-based services by offering an example on how to approach the implementation process in a systematic way.

Pediatric asthma medication therapy management through community pharmacy and primary care collaboration

OBJECTIVES

To design and implement a collaborative medication therapy management (MTM) program targeting pediatric patients with high-risk asthma in a community pharmacy.

SETTING

Underserved inner city of Cincinnati, OH.

PRACTICE DESCRIPTION

A large national grocery store chain pharmacy and an academic hospital developed a partnership aimed at improving asthma care for shared patients. An interdisciplinary project team was formed, including 2 clinical pharmacists, 1 pharmacy district clinical coordinator, 1 pharmacy division clinical coordinator, 1 associate professor at a college of pharmacy, 1 pharmacy resident, and 3 pediatric physicians. This pilot project involved 2 Kroger Pharmacy sites and Cincinnati Children's Hospital Medical Center's (CCHMC) 3 pediatric primary care centers.

PRACTICE INNOVATION

Kroger and CCHMC staff identified shared high-risk asthma patients (those cared for at the included primary care centers who used Kroger for their medication fills) with the use of information from validated symptom assessments (Asthma Control Test), refill history, and recent health care utilization. Community pharmacists recruited jointly identified patients and provided a targeted MTM intervention. Education focused on asthma diagnosis, types of asthma medications, appropriate medication administration, and environmental triggers. Pharmacists suggested medication changes to prescribers via facsimile. Pharmacists followed up with patients in 30 days to assess asthma control, provide additional education, and propose further recommendations.

EVALUATION

Outcomes evaluated included the average number of recommendations made to patients and prescribers and acceptance rates for each of those measures.

RESULTS

Six patients completed the project. Pharmacists provided an average of 3.7 recommendations to each patient and 1.5 to prescribers for each patient; 77.3% and 100% recommendations were accepted, respectively.

CONCLUSION

This pilot project describes the design and implementation of a pharmacist-physician collaborative program for high-risk pediatric asthma patients. The greatest outcome of this project was the formation of a collaborative team between pharmacists and physicians that continues to work together on additional family-centered initiatives.

Integrating Medication Therapy Management Education into a Core Pharmacy Curriculum

Objective. To describe the design of a core course directed at improving confidence and competence of students to perform medication therapy management (MTM) services. Design. Using the American Pharmacists Association (APhA) certificate training program framework, a core course was developed to teach MTM concepts to third-year student pharmacists. Using deep learning and authentic assignments, course instructors attempted to improve student confidence and readiness to provide MTM services. Assessment. Student ability to meet course objectives was evaluated by examinations and the APhA MTM program self-assessment. Students had an overall success rate of 93% on all three assessments. Student perceptions of confidence, competence, and importance of performing MTM services were measured using a survey instrument with 56 Likert-type items. Students completing both surveys reported significantly increased confidence and competence. Conclusion. Integrating MTM-specific education into the core curriculum increased student pharmacists' perceived competence and confidence to perform MTM services.

Comparison of two Medication Therapy Management Practice Models on Return on Investment

Objective:

To compare the return on investment (ROI) of an integrated practice model versus a “hub and spoke” practice model of pharmacist provided medication therapy management (MTM).

Methods:

A cohort retrospective analysis of MTM claims billed in 76 pharmacies in North Carolina in the 2010 hub and spoke practice model and the 2012 “integrated” practice model were analyzed to calculate the ROI.

Results:

In 2010, 4089 patients received an MTM resulting in 8757 claims in the hub and spoke model. In 2012, 4896 patients received an MTM resulting in 13 730 claims in the integrated model. In 2010, US$165 897.26 was invested in pharmacist salary and $173 498.00 was received in reimbursement, resulting in an ROI of +US$7600.74 (+4.6%). In 2012, US$280 890.09 was invested in pharmacist salary and US$302 963 was received in reimbursement, resulting in an ROI of +US$22 072.91 or (+7.9%).

Conclusion:

The integrated model of MTM showed an increase in number of claims submitted and in number of patients receiving MTM services, ultimately resulting in a higher ROI. While a higher ROI was evident in the integrated model, both models resulted in positive ROI (1:12-1:21), highlighting that MTM programs can be cost effective with different strategies of execution.

Quasi experimental designs in pharmacist intervention research

Background In the field of pharmacist intervention research it is often difficult to conform to the rigorous requirements of the "true experimental" models, especially the requirement of randomization. When randomization is not feasible, a practice based researcher can choose from a range of "quasi-experimental designs" i.e., non-randomised and at time non controlled. Objective The aim of this article was to provide an overview of quasi-experimental designs, discuss their strengths and weaknesses and to investigate their application in pharmacist intervention research over the previous decade. Results In the literature quasi experimental studies may be classified into five broad categories: quasi-experimental design without control groups; quasi-experimental design that use control groups with no pre-test; quasi-experimental design that use control groups and pre-tests; interrupted time series and stepped wedge designs. Quasi-experimental study design has consistently featured in the evolution of pharmacist intervention research. The most commonly applied of all quasi experimental designs in the practice based research literature are the one group pre-post-test design and the non-equivalent control group design i.e., (untreated control group with dependent pre-tests and post-tests) and have been used to test the impact of pharmacist interventions in general medications management as well as in specific disease states. Conclusion Quasi experimental studies have a role to play as proof of concept, in the pilot phases of interventions when testing different intervention components, especially in complex interventions. They serve to develop an understanding of possible intervention effects: while in isolation they yield weak evidence of clinical efficacy, taken collectively, they help build a body of evidence in support of the value of pharmacist interventions across different practice settings and countries. However, when a traditional RCT is not feasible for logistical and/or ethical reasons researchers should endeavour to use the more robust of the quasi experimental designs.

Comprehensive Medication Management and Medication Adherence for Chronic Conditions

BACKGROUND

The beneficial clinical effects of medication adherence have been consistently reported across most chronic diseases. Medication nonadherence carries significant economic and clinical burden. Medication therapy management (MTM) services aim to optimize pharmacotherapy and improve medication adherence.

OBJECTIVE

To evaluate the impact of exposure to face-to-face comprehensive medication management (CMM) services on medication adherence across 4 classes of chronic disease medications: oral diabetes medications, statins, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), and beta-blockers.

METHODS

Pharmacy claims of continuously enrolled employees of a large Midwest integrated health system were retrieved for the period 2007-2011. Retrospective analysis was used to compare medication adherence measured using proportion of days covered (PDC) in employees who received CMM with employees who did not (control group). The pharmacy MTM program used the Patient-Centered Primary Care Collaborative standard of care. The CMM group's index date was the date of the first CMM visit; the non-CMM group's index date was randomly chosen from all therapeutic class-specific prescription claims dates. For each therapeutic class, patients with at least 1 prescription fill in both the measurement period (365 days post-index) and the baseline period (365 days pre-index) were included. The primary outcome measure was the PDC.

RESULTS

The CMM group had consistently higher and statistically significant PDC levels across all the therapeutic classes in the measurement period (P < 0.05) when looking at the unadjusted comparison. In the multivariate models, CMM exposure was associated with higher PDC; the difference between groups was statistically significant in all therapeutic classes except for oral diabetes medications (oral diabetes medications: 0.0403, 95% confidence limits [CL] = -0.0050, 0.0850; statins: 0.0769, 95% CL = 0.0480, 0.1050; ACEIs/ARBs: 0.1083; 95% CL = 0.0710, 0.1450; and beta-blockers: 0.0484; 95% CL = 0.0060, 0.0910). Logistic regression showed that the CMM group had an increased probability of meeting the 80% PDC cut-point for statins (3.36, 95% CL = 0.048, 0.105); ACEIs/ARBs (3.57, 95% CL = 2.35, 5.42); and beta-blockers (2.56, 95% CL = 1.57, 4.18).

CONCLUSIONS

Exposure to face-to-face CMM services resulted in improvement of medication adherence. CMM is a powerful practice model that should be encouraged by insurers and health plan administrators to increase rates of medication adherence.

Perceptions of British Columbia residents and their willingness to pay for medication management services provided by pharmacists

BACKGROUND

Across Canada, pharmacists have expanded their scope of practice by performing medication management (MM) services. However, little is currently known about the opinions and attitudes of patients and the general population toward MM services.

METHODS

A cross-sectional online survey, including a best-worst scaling task, was designed to understand the general public's opinions, preferences and willingness-to-pay with respect to MM services in British Columbia.

RESULTS

Of 977 individuals contacted, 819 responded to the questionnaire (84% response rate). The mean age was 45 years (standard deviation [SD] 16 years), and 37% were male. Overall, 93% of respondents felt that the medication advice from their pharmacist resulted in improvement in patient outcomes and/or medication use. This was also selected as the "best" attribute of MM, while other preferred attributes of MM included being able to obtain an appointment with the pharmacist on the same day or via walk-in, improved patient-physician relationships and MM sessions able to be completed in 15 minutes with the pharmacist. The average willingness to pay for MM was $24.55 (SD $21.44). Younger males with higher household income and those who had had MM in the past were willing to pay more for MM services out of pocket.

DISCUSSION AND CONCLUSION

The accessibility of pharmacists was valued highly by respondents who, overall, were supportive of MM services and recognized the potential of pharmacists' involvement in drug therapy management to improve patient outcomes and medication use. Alternative models of funding are worth considering for the sustainability of MM service provision.

Pharmacy workforce to prevent and manage non-communicable diseases in developing nations: The case of Nepal

Non-communicable diseases (NCDs, e.g. cardiovascular diseases, cancer, chronic respiratory diseases and diabetes mellitus) are the main causes of mortality and morbidity in developing countries, including Nepal. Nearly half of the deaths in Nepal are caused by NCDs. Nepal lacks adequate human resources to prevent and manage NCDs, but the skills and expertise of pharmacists in Nepal are underused. There is evidence from many countries that pharmacists can contribute substantially to the prevention and management NCD. We aim to describe the opportunities and challenges for pharmacists to prevent and manage NCDs in Nepal. Pharmacists can contribute by screening and monitoring NCDs; counseling on lifestyle; providing medication therapy management services; promoting public health; and providing other pharmaceutical services. Challenges to the implementation of some of these activities in the current context include inadequate training of pharmacists in NCD prevention and management, the cost of pharmaceutical services to patients and government, and the existing health care service delivery model. There is a need for health services research to determine how pharmacists can be best used to prevent and manage NCDs in Nepal.

Estimating the Fiscal Effects of Public Pharmaceutical Expenditure Reduction in Greece

The purpose of the present study is to estimate the impact of pharmaceutical spending reduction on public revenue, based on data from the national health accounts as well as on reports of Greece’s organizations. The methodology of the analysis is structured in two basic parts. The first part presents the urgency for rapid cutbacks on public pharmaceutical costs due to the financial crisis and provides a conceptual framework for the contribution of the Greek pharmaceutical branch to the country’s economy. In the second part, we perform a quantitative analysis for the estimation of multiplier effects of public pharmaceutical expenditure reduction on main revenue sources, such as taxes and social contributions. We also fit projection models with multipliers as regressands for the evaluation of the efficiency of the particular fiscal measure in the short run. According to the results, nearly half of the gains from the measure’s application is offset by financially equivalent decreases in the government’s revenue, i.e., losses in tax revenues and social security contributions alone, not considering any other direct or indirect costs. The findings of multipliers’ high value and increasing short-term trend imply the measure’s inefficiency henceforward and signal the risk of vicious circles that will provoke the economy’s deprivation of useful resources.

Improving adherence to asthma therapies

PURPOSE OF REVIEW

Adherence to asthma therapies is poor leading to unnecessary morbidity and increased use of emergency and hospital resources. Strategies to improve adherence have not been successful.

RECENT FINDINGS

Asthma adherence disease management is a clinical method to improve adherence for asthma patients. The method includes: diagnosing adherence status; identifying patient barriers leading to nonadherence; selecting specific strategies for the clinician for each barrier identified; use of patient-centered communication skills to enhance the effectiveness of the strategies employed. This approach is now being tested in multiple controlled trials.

SUMMARY

Clinicians may want to consider these strategies, in whole or in part, to improve asthma patient adherence.

Implementation of medication review with follow-up in a Spanish community pharmacy and its achieved outcomes

BACKGROUND

Despite many research studies demonstrating the benefit in clinical, economic, and humanistic outcomes of professional pharmacy services, there is a paucity of evidence when these services become incorporated into the usual practice of a community pharmacy.

OBJECTIVE

The objective of the present study was to evaluate the clinical, economic, and humanistic impact of a pharmacist-conducted medication review with follow-up following 18 months implementation.

SETTING

Community pharmacies in Spain.

METHOD

The study used an effectiveness-implementation hybrid design. During the follow-up, patients attended the pharmacy on a monthly basis and received the medication review with follow-up service.

MAIN OUTCOME MEASURE

Economic, clinical, and humanistic measures were used to assess the impact of the service.

RESULTS

132 patients received the service. During the 18 months of follow-up, 408 negative outcomes related to medicines (which are uncontrolled health problems) were identified, of which 393 were resolved. The average number of medicines used by patients significantly decreased from 6.1 (SD: 2.9) to 3.3 (SD: 2.2). A significant decrease was also observed in hospitalizations [OR = 0.31 (IC 95% = 0.10-0.99)] and in emergency department visits [OR = 0.16 (IC 95% = 0.05-0.55); p = 0.001]. A general trend to increase all quality of life domains was observed over time. The higher increase was observed in the construct health transition [mean increase: 30.7 (SD: 25.4)], followed by bodily pain [mean increase: 22.3 (SD: 25.4)], and general health [mean increase: 20.7 (SD: 23.7)]. Medication knowledge significantly increased in terms of aggregated domains of dose, frequency, drug indication [from 8.9 (SD: 17.5) to 87.9 (SD: 25.0)], and dose and frequency [from 9.3 (SD: 17.9) to 92.5 (22.1)]. Although a slight improvement was observed in terms of drug indication, this increase was not statistically significant. 68 out of 132 patients (51.5%) were non-adherent to their treatment. This number decreased to 1 (0.8%) after the follow-up [OR = 0.007 (IC 95%: 0.001-0.053) p < 0.001].

CONCLUSION

A community pharmacy based medication review with follow-up service delivered by a trained pharmacist, has positive effects across clinical, economic, and humanistic outcomes. These results are consistent with previous studies. Incorporating community pharmacists into the multidisciplinary team is a reliable solution to improve health care.

Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies

BACKGROUND

Asthma self-management remains poorly implemented in clinical practice despite overwhelming evidence of improved healthcare outcomes, reflected in guideline recommendations over three decades. To inform delivery in routine care, we synthesised evidence from implementation studies of self-management support interventions.

METHODS

We systematically searched eight electronic databases (1980 to 2012) and research registers, and performed snowball and manual searches for studies evaluating implementation of asthma self-management in routine practice. We included, and adapted systematic review methodology to reflect, a broad range of implementation study designs. We extracted data on study characteristics, process measures (for example, action plan ownership), asthma control (for example, patient reported control questionnaires, days off school/work, symptom-free days) and use of health services (for example, admissions, emergency department attendances, unscheduled consultations). We assessed quality using the validated Downs and Black checklist, and conducted a narrative synthesis informed by Kennedy's whole systems theoretical approach (considering patient, practitioner and organisational components and the interaction between these).

RESULTS

We included 18 studies (6 randomised trials, 2 quasi-experimental studies, 8 with historical controls and 3 with retrospective comparators) from primary, secondary, community and managed care settings serving a total estimated asthma population of 800,000 people in six countries. In these studies, targeting professionals (n = 2) improved process, but had no clinically significant effect on clinical outcomes. Targeting patients (n = 6) improved some process measures, but had an inconsistent impact on clinical outcomes. Targeting the organisation (n = 3) improved process measures, but had little/no effect on clinical outcomes. Interventions that explicitly addressed patient, professional and organisational factors (n = 7) showed the most consistent improvement in both process and clinical outcomes. Authors highlighted the importance of health system commitment, skills training for professionals, patient education programmes supported by regular reviews, and on-going evaluation of implementation effectiveness.

CONCLUSIONS

Our methodology offers an exemplar of reviews synthesising the heterogeneous implementation literature. Effective interventions combined active engagement of patients, with training and motivation of professionals embedded within an organisation in which self-management is valued. Healthcare managers should consider how they can promote a culture of actively supporting self-management as a normal, expected, monitored and remunerated aspect of the provision of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (registration number: CRD42012002898 ) Accessed 24 May 2015.

The pharmacy-level asthma medication ratio and population health

BACKGROUND AND OBJECTIVES

Community pharmacies may be positioned for an increased role in population health. We sought to develop a population-level measure of asthma medication fills and assess its relationship to asthma-related utilization.

METHODS

We conducted a retrospective, ecological study (2010-2012). Medication data from a chain of pharmacies (n = 27) within 1 county were used to calculate a Pharmacy-level Asthma Medication Ratio (Ph-AMR), defined as controller fills divided by controller plus rescue fills. Higher values are superior because they indicate more controller compared with rescue fills. The outcome was the asthma-related utilization rate among children in the same census tract as the pharmacy, calculated by dividing all emergency visits and hospitalizations by the number of children in that tract. Covariates, including ecological measures of poverty and access to care, were used in multivariable linear regression.

RESULTS

Overall, 35 467 medications were filled. The median Ph-AMR was 0.53 (range 0.38-0.66). The median utilization rate across included census tracts was 22.4 visits per 1000 child-years (range 1.3-60.9). Tracts with Ph-AMR <0.5 had significantly higher utilization rates than those with Ph-AMR ≥0.5 (26.1 vs 9.9; P = .001). For every 0.1 increase in Ph-AMR, utilization rates decreased by 9.5 (P = .03), after adjustment for underlying poverty and access. Seasonal variation in fills was evident, but pharmacies in high-utilizing tracts filled more rescue than controller medications at nearly every point during the study period.

CONCLUSIONS

Ph-AMR was independently associated with ecological childhood asthma morbidity. Pharmacies may be a community-based leverage point for improving population-level asthma control through targeted interventions.

Defining and advancing ambulatory care pharmacy practice: it is time to lengthen our stride

PURPOSE

This paper reviews the basic tenets of ambulatory care pharmacy practice, including (1) the historical development of patient-centered care provided by pharmacists, (2) the need for and value of comprehensive medication management, (3) the education, training, and qualifications of pharmacists, and (4) demonstrated improvement in health and healthcare outcomes from pharmacists' services.

SUMMARY

When ambulatory care pharmacists engage in patient care to their full capacity, physician time is saved, access to care is improved, and clinical and economic outcomes are enhanced. There is a need for ambulatory care pharmacists to work toward optimizing safe medication use and optimizing medication therapy for patients with diabetes, asthma, cardiovascular disease, and renal disease. Other opportunities for the development of ambulatory care pharmacy services exist in preventive care, precision therapeutics, medication therapy management, mitigation of healthcare disparities, and implementation of national healthcare reform. Interprofessional patient care teams should include ambulatory care pharmacists in patient-centered medical homes and accountable care organizations. Ambulatory care pharmacy practice would benefit by enhancing specialty residency training and by creating a residency/fellowship for advanced subspecialty clinical practice and research. Provider status is essential to recognize pharmacists as an integral part of the patient care team.

CONCLUSION

By assertively advancing ambulatory care practice, pharmacy will help achieve the national priorities of improving patient care, patient health, and affordability of care.

Elder and caregiver solutions to improve medication adherence

Medication mismanagement is a growing public health concern, especially among elders. Annually, it is a major contributor to emergency hospitalization and nursing home placement. Elders and their caregivers, as healthcare consumers and stakeholders in this issue, are uniquely qualified to inform strategies to improve medication adherence. We conducted a qualitative study to ascertain caregiver and elder perceptions of barriers to medication management and to identify community-derived solutions to improve medication management. Nine focus groups (N = 65, mean age = 71) were conducted with caregivers or elders from five communities. Participants were recruited by key informants utilizing snowball sampling methodology. The following themes were identified in the participant-recommended proposed solutions improving medication adherence: (i) use of personal systems to overcome barriers to medication adherence, (ii) various solutions to address cost concerns, (iii) the need for regular review of medications by doctors or pharmacists to eliminate unnecessary medications, (iv) desire for community-driven support systems, and (v) using medical advocates. Elders and caregivers recognized medication non-adherence as a community-wide issue and were eager to offer solutions they thought would work in their communities. These solutions can lend credibility to strategies currently being developed/utilized and offer innovative recommendations for future interventions.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

Background

Despite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.

Aim

To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.

Methods

Self-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.

Results

We included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.

Conclusions

Supporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.

Study registration

This study is registered as PROSPERO CRD42012002898.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Historical trend of racial and ethnic disparities in meeting Medicare medication therapy management eligibility in non-Medicare population

BACKGROUND

Prior research examining racial and ethnic disparities in meeting Medicare medication therapy management (MTM) eligibility criteria among the non-Medicare population suggests minorities have lower likelihood of being eligible than non-Hispanic Whites (Whites). However, such research has not examined trends in disparities and whether these disparities may be expected to decrease over time based on historical data.

OBJECTIVES

To examine trends in MTM eligibility disparities among the non-Medicare population from 1996-1997 to 2009-2010.

METHODS

This retrospective observational analysis used Medical Expenditure Panel Survey data from the two study periods. The MTM eligibility criteria used by health insurance plans in 2008 and 2010 were analyzed. Trends in disparities were examined by including interaction terms between dummy variables for 2009-2010 and non-Hispanic Blacks (Blacks)/Hispanics in a logistic regression. Interaction effects were estimated on both the multiplicative and additive terms. Main and sensitivity analyses were conducted to represent the ranges of the Medicare MTM eligibility thresholds used by health insurance plans.

RESULTS

According to the main analysis, Blacks and Hispanics were less likely to be eligible than Whites for both sets of eligibility criteria in 1996-1997 and in 2009-2010. Trend analysis for both sets of criteria found that on the multiplicative term, there were generally no significant changes in disparities between Whites and Blacks/Hispanics from 1996-1997 to 2009-2010. Interaction on the additive term found evidence that disparities between Whites and Blacks/Hispanics may have increased from 1996-1997 to 2009-2010 (e.g., in the main analysis between Whites and Hispanics for 2010 eligibility criteria: difference in odds = -0.03, 95% CI: [-0.03]-[-0.02]).

CONCLUSIONS

Racial and ethnic minorities in the non-Medicare population experience persistent and often increasing disparities in meeting MTM eligibility criteria. Drug benefit plans should take caution when using elements of Medicare MTM eligibility criteria.

Validation of a survey tool assessing effectiveness of an educational intervention on the caring behaviors and referral activities of community pharmacists for migraineurs

BACKGROUND

Community pharmacists are in an ideal position to ameliorate migraineur under-consulting, under-diagnosis, and under-treatment. Contemporary education/training on developing therapeutic alliances with patients and in advanced pharmacotherapy may further motivate pharmacists to impact the care of migraineurs.

OBJECTIVES

The objectives of this study were to assess pharmacists' perceptions of a migraine training program and their self-assessment of subsequent impact on patient care and to develop and assess a tool evaluating the impact of the training program from the patients' perspectives: (1) for patients diagnosed with migraines - identify perceptions of care by pharmacists who have undergone specialty training in migraine vs. pharmacists who have not; and (2) for patients with recurrent headaches and not diagnosed with migraines - identify perceptions of pharmacist effectiveness and thoroughness, after specialty training, to identify a potential migraine diagnosis and referral for advanced care vs. pharmacists that have not undergone specialty training.

METHODS

This study employed a mixed method survey design using community pharmacies from the Tulsa, Oklahoma and Pittsburgh, Pennsylvania greater metropolitan areas. Pharmacists from intervention pharmacies received specialty training on migraine and were surveyed on their current practices and about the education program. Approximately 1 month after the training, control and intervention pharmacists were surveyed on current practices. Additionally, patients from both pharmacies were surveyed to assess Migraine Disability Assessment (MIDAS) and pharmacists' delivery of care derived from the Pharmacists' Care of Migraineurs Scale (PCMS). Surveys were handed out for a period of 3-months.

RESULTS

There were 16 pharmacists and 61 patients recruited. There was no difference in patient perceptions of pharmacists' care or in patient self-perceptions between migraineurs and recurrent headache sufferers. Ninety-two percent of pharmacists agreed that the program could be transferred to an internet-based educational program. The 14-item patient survey, however, demonstrated good internal consistency reliability, with each question having a Cronbach's alpha 0.80 or higher.

CONCLUSIONS

There are few studies evaluating the role and potential impact community pharmacists can have on patients suffering from migraines or recurrent headaches. While no difference was found between the groups, the internal reliability of the survey questions and the need to address needs of migraineurs warrants tool dissemination and a larger-scale study.

A randomized, controlled pragmatic trial of telephonic medication therapy management to reduce hospitalization in home health patients

OBJECTIVE

To evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing hospitalizations among home health patients.

SETTING

Forty randomly selected, geographically diverse home health care centers in the United States.

DESIGN

Two-stage, randomized, controlled trial with 60-day follow-up. All Medicare- insured home health care patients were eligible to participate. Twenty-eight consecutive patients within each care center were recruited and randomized to usual care or MTM intervention. The MTM intervention consisted of the following: (1) initial phone call by a pharmacy technician to verify active medications; (2) pharmacist-provided medication regimen review by telephone; and (3) follow-up pharmacist phone calls at day seven and as needed for 30 days. The primary outcome was 60-day all-cause hospitalization.

DATA COLLECTION

Data were collected from in-home nursing assessments using the OASIS-C. Multivariate logistic regression modeled the effect of the MTM intervention on the probability of hospitalization while adjusting for patients' baseline risk of hospitalization, number of medications taken daily, and other OASIS-C data elements.

PRINCIPAL FINDINGS

A total of 895 patients (intervention n = 415, control n = 480) were block-randomized to the intervention or usual care. There was no significant difference in the 60-day probability of hospitalization between the MTM intervention and control groups (Adjusted OR: 1.26, 95 percent CI: 0.89-1.77, p = .19). For patients within the lowest baseline risk quartile (n = 232), the intervention group was three times more likely to remain out of the hospital at 60 days (Adjusted OR: 3.79, 95 percent CI: 1.35-10.57, p = .01) compared to the usual care group.

CONCLUSIONS

This MTM intervention may not be effective for all home health patients; however, for those patients with the lowest-risk profile, the MTM intervention prevented patients from being hospitalized at 60 days.

Economic evaluation of enhanced asthma management: a systematic review

OBJECTIVES

To evaluate and compare full economic evaluation studies on the cost-effectiveness of enhanced asthma management (either as an adjunct to usual care or alone) vs. usual care alone.

METHODS

Online databases were searched for published journal articles in English language from year 1990 to 2012, using the search terms '"asthma" AND ("intervene" OR "manage") AND ("pharmacoeconomics" OR "economic evaluation" OR "cost effectiveness" OR "cost benefit" OR "cost utility")'. Hand search was done for local publishing. Only studies with full economic evaluation on enhanced management were included (cost consequences (CC), cost effectiveness (CE), cost benefit (CB), or cost utility (CU) analysis). Data were extracted and assessed for the quality of its economic evaluation design and evidence sources.

RESULTS

A total of 49 studies were included. There were 3 types of intervention for enhanced asthma management: education, environmental control, and self-management. The most cost-effective enhanced management was a mixture of education and self-management by an integrated team of healthcare and allied healthcare professionals. In general, the studies had a fair quality of economic evaluation with a mean QHES score of 73.7 (SD=9.7), and had good quality of evidence sources.

CONCLUSION

Despite the overall fair quality of economic evaluations but good quality of evidence sources for all data components, this review showed that the delivered enhanced asthma managements, whether as single or mixed modes, were overall effective and cost-reducing. Whilst the availability and accessibility are an equally important factor to consider, the sustainability of the cost-effective management has to be further investigated using a longer time horizon especially for chronic diseases such as asthma.

Impact of the pay-for-performance-for-patients program for diabetes management

OBJECTIVES

To determine whether patients with diabetes who used a financial rewards program in a grocery chain pharmacy had increased rates of self-reported healthy behaviors, to measure the impact of the program on glycosylated hemoglobin (A1C), and to measure the impact of the program on grocery store sales.

METHODS

This prospective study took place at one location of a grocery chain pharmacy in Cincinnati, OH. Adult patients with diabetes on at least one diabetes medication were eligible to participate. Participants received a $5 incentive for each weeklong behavior log completed and reviewed with the pharmacist, who provided counseling on improving healthy behaviors. Change in self-reported healthy behaviors, A1C, grocery store expenditure, and program satisfaction were measured.

RESULTS

During the 12-week study, 25 patients enrolled in the program. A total of 13 participants completed the poststudy survey and reported increased rates of self-monitoring of blood glucose and blood pressure and increased exercise frequency. Differences in A1C and grocery store expenditures were unable to be detected. Satisfaction with the pay-for-performance-for-patients (P4P4P) program was favorable (8.6 on a 10-point scale).

CONCLUSION

Participants given small, frequent financial incentives had increased frequency of healthy behaviors and were satisfied with the P4P4P program.

Asthma management and inhalation techniques among community pharmacists in 2009: a comparison with the 1999 survey

OBJECTIVE

In a 1999 survey, community pharmacists from the Alsace region of France had a reasonably good knowledge of asthma treatment and prevention, but their skill in the use of asthma inhalation devices left room for improvement. Since then, health authorities have encouraged the involvement of community pharmacists in patient care and education in order to improve asthma control. The aim of this study was to assess the change in the knowledge of asthma management and inhaler technique skills of community pharmacists in the same geographic area after a 10-year interval.

METHODS

In 2009, 86 randomly selected community pharmacists from the Alsace region answered a standardized questionnaire about their theoretical knowledge of and practical attitude toward asthma management and inhaled delivery systems, following which their skills in the use of four inhalation devices (pressurized metered-dose inhaler (pMDI) with/without a spacer, breath-actuated pMDI and dry powder inhaler (DPI)) were evaluated.

RESULTS

Very few pharmacists were required to manage an acute asthma exacerbation at the pharmacy, but all responded well by administering a short-acting inhaled β2-agonist. Theoretical knowledge of asthma management (criteria of severity of asthma exacerbation, guidelines and drugs triggering asthma exacerbations) was still average. Compared with 1999, they were twice as confident in demonstrating inhaler use, and their skills in using the pMDI, breath-actuated pMDI and DPI had improved significantly (p < 0.001).

CONCLUSIONS

Since 1999, pharmacists' skill in the use of inhalers has improved, but theoretical knowledge of asthma management is still average, pointing to the importance of continuing pharmaceutical education.

Pharmaceutical care for asthma patients: A Developing Country's Experience

Objective:

This study aims at the outcome of providing pharmaceutical care service for asthma patients through an active partnership between clinical pharmacist and patients, for an optimal pharmacotherapy and a better quality of life (QoL).

Methods:

In this controlled clinical trial, which was conducted for 8 months (2009) in the Institute of Pulmonary Medicine and Research Centre of a 550-bedded multispecialty tertiary care teaching hospital in India, all patients diagnosed with asthma at least 6 months before getting enrolled in this study were included (n = 66). Patients were divided into the intervention group who received pharmaceutical care through asthma education, medication counselling, instructions on lifestyle modifications, asthma care diary, etc., and the control group who were not provided any pharmaceutical care. Asthma control in the two groups was assessed using Asthma Control Test (ACT) at regular intervals. QoL in both groups was assessed at regular intervals using standardized Asthma Quality of Life Questionnaire (AQLQ).

Findings:

The mean AQLQ scores for the intervention group at the baseline were changed to significantly higher amounts in the final visit indicating overall, activity, symptoms, emotional, and environmental domains, respectively (P < 0.05). The mean ACT scores for intervention group at baseline were also increased in statistically significant amounts in the final visit for all the five ACT questions (P < 0.05).

Conclusion:

Our pharmaceutical care program showed a positive impact in improving patient's asthma-related QoL, lung function, and asthma control. By providing structured pharmaceutical care, clinical pharmacists can help asthma patients to achieve desired health outcomes.

Incorrect use of peak flow meters: are you observing your patients?

BACKGROUND

Monitoring peak expiratory flow (PEF) values is one option as part of asthma action plans per national guidelines. PEF assessment is also recommended in emergency department and hospitalized patients. Incorrect use of peak flow meters (PFM) has obvious implications for appropriate decisions by patients and clinicians.

METHODS

We searched the English literature via PubMed and SCOPUS using the following search terms: PEF maneuver; incorrect use of PFM. When pertinent articles were found, we assessed publications cited in those papers. All studies related to incorrect use of PFM in patients with asthma were included.

RESULTS

Nine studies have reported errors in performing the PEF maneuver, including three pediatric and six adult studies. Errors were found at most steps of the maneuver, and inability to perform all steps correctly was common in these investigations. Examples of errors included failure to inhale fully or give maximum effort on exhalation, accelerating air with the tongue and buccal musculature, and performing only one attempt versus three. Gender differences in correct use of PFM are suggested by three adult studies. One study described falsifying PEF values by manipulating the PFM indicator, and another investigation assessed the PEF maneuver in two positions in bed versus the correct posture of standing.

CONCLUSION

Many pediatric and adult patients do not use PFM correctly. Clinicians should regularly observe patients use PFM to detect errors and help ensure correct use and accurate PEF measurements.

Pharmacy students' attitudes toward pharmaceutical care in Qatar

OBJECTIVES

The study objectives were to investigate Qatar pharmacy students' attitudes toward pharmaceutical care (PC), to identify the factors that influence their attitudes, and to recognize their perceived barriers for PC provision.

METHODS

A cross-sectional and online survey of Qatar pharmacy students was conducted.

RESULTS

Over 4 weeks, 46 surveys were submitted (88% response rate). All respondents agreed that the pharmacist's primary responsibility is to prevent and resolve medication therapy problems. Most respondents believed that PC provision is professionally rewarding and that all pharmacists should provide PC (93% and 91% of respondents, respectively). Highly perceived barriers for PC provision included lack of access to patient information (76%), inadequate drug information sources (55%), and time constraints (53%). Professional year and practical experience duration were inversely significantly associated with four and five statements, respectively, out of the 13 Standard Pharmaceutical Care Attitudes Survey statements, including the statements related to the value of PC, and its benefit in improving patient health and pharmacy practitioners' careers.

CONCLUSION

Qatar pharmacy students had positive attitudes toward PC. Efforts should be exerted to overcome their perceived barriers.

Value-based insurance design: aligning incentives and evidence in pulmonary medicine

When consumers are required to pay the same out-of-pocket amount for pulmonary services for which clinical benefits depend on patient characteristics, clinical indication, and provider choice, there is an enormous potential for both underutilization and overutilization. Unlike most current one-size-fits-all health plan designs, value-based insurance design (V-BID) explicitly acknowledges clinical heterogeneity across the continuum of care. By adding clinical nuance to benefit design, V-BID seeks to align consumer and provider incentives with value, encouraging the use of high-value services and discouraging the use of low-value interventions. This article describes the concept of V-BID; creates a framework for its development in pulmonary medicine; and outlines how this concept aligns with research, care delivery, and payment reform initiatives.

Patient-centered health care using pharmacist-delivered medication therapy management in rural Mississippi

OBJECTIVE

To describe and provide preliminary clinical and economic outcomes from a pharmacist-delivered patient-centered health care (PCHC) model implemented in the Mississippi Delta.

SETTING

Mississippi between July 2008 and June 2010.

PRACTICE DESCRIPTION

13 community pharmacies in nine Mississippi Delta counties.

PRACTICE INNOVATION

This PCHC model implements a comprehensive medication therapy management (MTM) program with pharmacist training, individualized patient encounters and group education, provider outreach, integration of pharmacists into health information technology, and on-site support in community pharmacies in a medically underserved region with a large burden of chronic disease and health disparities. The program also expands on traditional MTM services through initiatives in health literacy/cultural competency and efforts to increase the provider network and improve access to care.

MAIN OUTCOME MEASURES

Criteria-based clinical outcomes, quality indicator reports, cost avoidance.

RESULTS

PCHC services have been implemented in 13 pharmacies in nine counties in this underserved region, and 78 pharmacists and 177 students have completed the American Pharmacists Association's MTM Certificate Training Program. Preliminary data from 468 patients showed 681 encounters in which 1,471 drug therapy problems were identified and resolved. Preliminary data for clinical indicators and economic outcome measures are trending in a positive direction.

CONCLUSION

Preliminary data analyses suggest that pharmacist-provided PCHC is beneficial and has the potential to be replicated in similar rural communities that are plagued with chronic disease and traditional primary care provider shortages. This effort aligns with national priorities to reduce medication errors, improve health outcomes, and reduce health care costs in underserved communities.