Measuring implementation of medication optimization services: Development and validation of an implementation outcomes questionnaire

Revisiting the opioid and naloxone education (ONE) program: Program evaluation using the RE-AIM model four years later

OBJECTIVE

The Opioid and Naloxone Education (ONE) Program focuses on community pharmacy-based patient screening and interventions to improve population health with regard to opioid use. The purpose of this paper is to reevaluate the ONE Program performance using the RE-AIM model, in comparison to the review performed in 2019.

METHODS

The program performance of the ONE Program was evaluated from January 1, 2021 to December 31, 2022 was evaluated using the five domains of the RE-AIM model. Reach was defined as the proportion of patients receiving opioid prescriptions who completed the screening. Efficacy was defined as the proportion of individuals identified as at risk who received a pharmacist intervention. Adoption was defined as the proportion of community pharmacies who enrolled in the ONE Program. Implementation was defined as the proportion of pharmacies that enrolled that provided at least five patient screenings. Maintenance was defined as the proportion of pharmacies that completed at least one screening three months. These results were compared against evaluation of the program from October 12, 2018 to June 1, 2019.

RESULTS

Approximately 7.28 % of patients receiving opioid prescriptions were screened for risk of opioid misuse and accidental overdose (Reach). Of the patients screened, 97.4 % of patients at risk for opioid misuse or accidental overdose received a pharmacist-led intervention (Efficacy). Additionally, 49.6 % of the pharmacist that enrolled in the ONE Program completed at least five screenings (79 %) and of those, 86.4 % maintained the program three months later.

CONCLUSIONS

In years four and five of implementation, the ONE Program demonstrated improvement in four of the five domains of the RE-AIM model compared to years one and two. However, Reach declined over time. This reevaluation has demonstrated the importance of longitudinal program assessment, and the possibility of improved program performance over time.

Integrating design thinking and implementation science principles in delivering a medication review service in the community pharmacy setting-An implementation testing study

BACKGROUND

Medication review (MR) services are evidenced-based practices in which a systematic assessment of a patient's medication is conducted, primarily aiming to optimize drug therapy and minimize adverse drug events through pharmacist interventions. Although studies show that MR services are effective, the implementation of MR services in Malaysia has been challenging due to several barriers. An MR services blueprint was developed to be adapted to the Malaysian community pharmacy setting as part of tailoring strategies.

OBJECTIVE

Through utilizing the design thinking triple diamond model and implementation science principles, a powerful guide for healthcare researchers and stakeholders to assist with effective service implementation, this study aimed to evaluate the implementation testing and observe the effectiveness of the developed MR service blueprint.

METHOD

The study utilizes an effectiveness-implementation Type 3 hybrid implementation science framework conducted from May 2021 to April 2022. Employing a qualitative ethnographic approach, researchers observed pharmacy study sites during the implementation of MR services. Both qualitative and quantitative data were collected across exploration, preparation, testing, and operational phases. Implementation outcomes evaluated include phases, reach, fidelity, acceptability, as well as implementation barriers and strategies. MR intervention outcomes included service characteristics and the number and type of drug-related problems and interventions offered.

RESULTS

17 community pharmacists were invited to pilot the MR service blueprint for six months in their setting. Of this, 78.5% (n = 11) of the pharmacies reached the testing phase, and 36% (n = 4) reached the implementation phase. Fifty-four patients were in the study, giving an implementation reach of 70%. The majority of surveyed patients expressed satisfaction with the service. The total DRP identified was 133, and 64 interventions were provided by the pharmacists. Facilitation strategies such as "Engage stakeholders by creating ownership of the change" and "Equip stakeholders with training" are needed to overcome the barriers.

CONCLUSION

This study marked the beginning of successful MR service implementation at Malaysian community pharmacies. Future studies with multi-level partnered strategies are required to reach full implementation and sustainability.

Implementation of medication reviews in community pharmacy: reaching consensus on stakeholders' recommendations for mechanisms of change using the nominal group technique

BACKGROUND

Since 2022, patients with five or more medicines are eligible for a medication review (MR) in a community pharmacy remunerated by the German health system. However, implementation has been slow, with few pharmacies providing MRs. Stakeholders' input is necessary to detail how implementation strategies can be executed effectively on a national level. Prior research identified "external facilitation" and "altering incentives" as crucial strategies to achieve implementation outcomes.

AIM

To gather stakeholders' recommendations for, and obtain consensus on, mechanisms of change that allow implementation strategies to work in practice.

METHOD

The consensus method used was the nominal group technique (NGT) with NGT-discussions held separately with pharmacy owners and pharmacy chambers employees. Votes were summed and the relative importance (rI) calculated, defined as (score achieved for a mechanism)/(maximum possible score) × 100. Content analysis provided context for the highest ranked mechanisms and allowed linking to implementation outcomes.

RESULTS

Four NGT-discussions were held in 2023 (n = 2 owners; n = 2 chamber employees) with a total of 17 participants. The overall highest ranked mechanisms were fit-for-purpose software (rI = 154.7) detailed process support (rI = 104.9) and an expert support line (rI = 77.7). These together with financial viability (rI = 40.0) were prioritised by both participant groups. Three mechanisms were favoured for both implementation strategies, namely software, process support and materials (rI = 34.3).

CONCLUSION

This study identified stakeholders' priorities for mechanisms of change to implement MRs in community pharmacies. Focusing efforts on the prioritised mechanisms is likely to significantly advance a national implementation plan for countries which are at an early implementation stage.

Community pharmacist intervention to close statin gaps in diabetes care: The GuIDE-S study

BACKGROUND

Statin therapy is recommended for people with type 2 diabetes (T2D) to lower cardiovascular risk; however, evidence suggests that significant gaps in statin therapy exist.

OBJECTIVE

To evaluate (1) the impact of a community pharmacist-led model for initiating statin therapy in people with type 2 diabetes (T2D) on statin initiation and (2) pharmacists' self-reported perceptions of the intervention feasibility and fidelity to the intervention.

METHODS

This was a type 1 hybrid effectiveness-implementation study of 9 intervention and 18 control pharmacies within a community pharmacy chain. Pharmacy staff proactively identified patients with T2D not taking a statin and prescribed a statin via a collaborative practice agreement or facilitated acquisition of a prescription from the patient's preferred prescriber. The eligible population included patients aged 18-84 years with T2D, who had filled ≥60 days' supply of one, noninsulin, diabetes medication in a rolling 6-month period, and who had not filled a statin during the same period. A Cox proportional hazards model was used to compare time to statin initiation. Pharmacists at intervention pharmacies completed a survey at 6 and 12 months after implementation (March and August 2019, respectively) to assess intervention feasibility and fidelity.

RESULTS

For the statin initiation analysis, 1670 intervention patients were matched to 3358 control patients. Overall, 26.3% (n=442) of intervention patients and 25.4% (n=854) of control patients initiated a statin within 12 months of their index date. There was no difference in statin initiation likelihood between intervention and control patients (hazard ratio: 1.00; 95% CI: 0.83, 1.21). Fifteen pharmacists completed the 6-month survey (33% response rate), and 12 completed the 12-month survey (26%). The intervention's feasibility score was 4.0 at 6 months and 4.2 at 12 months, indicating an increase in perceived feasibility. Fidelity decreased from 6 to 12 months.

CONCLUSION

The community pharmacist-led intervention resulted in more patients initiating statin therapy as compared to usual care; however, the differences were not statistically significant. Pharmacists perceived the intervention to be feasible; however, fidelity decreased over time.

The PharmNet Harm Reduction Intervention for Community Pharmacies: Protocol for a Pilot Randomized Controlled Trial

Background

The overdose epidemic in the United States has continued to worsen despite substantial efforts to mitigate its harms. The opioid antagonist naloxone has been identified as a key means of reducing the prevalence of fatal overdoses. An important evidence-based approach to optimizing naloxone’s impact is to seed it throughout the community, because bystanders are often able to reverse overdoses more quickly than first responders and sometimes are the only possible means of overdose reversal. As part of a multipronged approach to distributing naloxone nationwide, community pharmacies have been identified as ideal venues for naloxone dispensing, especially under standing orders. However, dispensing rates remain surprisingly low, and there is a need to understand how best to engage community pharmacies in naloxone-based harm reduction services.

Objective

The objective of this trial is to determine whether a tailored, pragmatic pharmacy intervention (PharmNet) results in greater naloxone dispensing relative to baseline (the prior 3 months) compared to a control condition. This pilot trial is intended to determine whether it is appropriate to invest the substantial resources that would be required to conduct a full-scale, randomized controlled study of PharmNet.

Methods

We will conduct a 3-month randomized controlled pilot trial consisting of 2 parallel groups with a 4:3 allocation ratio. A group of 7 independent pharmacies from rural areas in Indiana will be randomly assigned to either the PharmNet intervention arm (n=4) or the control arm (n=3). The primary outcome will be overall naloxone dispensing (both at cost and free), and secondary outcomes will include the distribution of referral cards and multiple variables at the level of individual staff members. Dispensing data will be collected for the 3 months prior to the intervention and the 3 months of the intervention, and all other data will be collected using a pretest-posttest design. The primary analysis will be a generalized linear mixed model with a Poisson distribution with fixed effects for group, time, and their interaction and a random effect for pharmacy ID to account for repeated measures within pharmacies.

Results

This study was approved by the Indiana University institutional review board in 2 phases (August 2, 2021, and April 26, 2022) and was funded by the Indiana University Grand Challenge: Responding to the Addictions Crisis.

Conclusions

If this study produces evidence that the PharmNet intervention results in increased naloxone dispensing relative to control pharmacies, it will be both appropriate and important to study it in a large, full-scale randomized controlled trial.

International Registered Report Identifier (IRRID)

PRR1-10.2196/42373

Readiness as a precursor of early implementation outcomes: an exploratory study in specialty clinics

Background

Readiness has been identified as an essential precursor of successful implementation. However, evidence supporting its value is sparse. Empirical studies exploring the relationship between the application of readiness interventions, readiness levels, and implementation outcomes are lacking. The purpose of this study was twofold: (1) to evaluate the effectiveness of a readiness intervention (based on increases in readiness levels, changes in early implementation outcomes (i.e., acceptability, appropriateness, feasibility, and intent to adopt), and qualitative insights into the types of perceived outcomes) and (2) to assess the role of readiness as a predictor of these early implementation outcomes.

Methods

Seven healthcare specialty clinics engaged in a structured process to assess and build readiness for implementing a comprehensive medication management (CMM) service over a 10-month period. A mixed methods approach, which included surveys with healthcare stakeholders at each clinic (N = 27) and interviews with the lead pharmacists (N = 7), was used to evaluate the effectiveness of the readiness intervention (aim 1). Survey data were also used to conduct multiple regression models to assess the role of readiness as a predictor of early acceptability, appropriateness, feasibility, and intent to adopt CMM (aim 2).

Results

Significantly higher readiness levels, as well as higher scores on acceptability, appropriateness, feasibility, and intent to adopt, were reported as a result of engaging in the readiness intervention. However, upon closer examination, the direction of this association seemed to be dependent on the type of clinic. Qualitative data on the types of perceived outcomes resulting from engaging in the readiness intervention provided further insights into the potential reasons for these findings. Furthermore, post-readiness levels predicted between 44 and 68% of the variance in the early implementation outcomes. When accounting for clinic membership, readiness remained critical for service acceptability, feasibility, and intent to adopt but not for appropriateness.

Conclusion

These findings provide insights into the relationship between use of a readiness intervention, readiness levels, and early implementation outcomes. Engaging healthcare settings in a readiness intervention was beneficial in ways more complex than a simple positive linear relationship, highlighting the opportunity to broaden its purpose and expand definitions of readiness success. In addition, the importance of readiness levels in predicting early implementation outcomes, while critical, also seems to be highly dependent on context, particularly for appropriateness (fit).

A mixed methods evaluation of the implementation of pharmacy services within a team-based at-home care program

BACKGROUND

Sub-optimal medication use results in significant avoidable morbidity, mortality, and costs. Programs, such as comprehensive medication management (CMM), can help to optimize medication use, improve outcomes, and reduce costs. However, implementing programs like CMM can be challenging and differences in how CMM has been implemented may be responsible for observed heterogeneity in the outcomes associated with CMM.

OBJECTIVE(S)

Describe the implementation strategies utilized in implementing CMM telephonically within a team-based at-home care program and evaluate the implementation process.

METHODS

The implementation of CMM was facilitated using various implementation strategies including: develop educational material and conduct training, change record system, audit and feedback, learning collaborative, quality monitoring, readiness assessment, and implementation team formation. The impact of these strategies as well as pharmacist and team member perspectives on the implementation of CMM were examined using mixed methods and guided by Proctor's conceptual model for implementation.

RESULTS

The pharmacists felt that most of the implementation strategies used to facilitate consistent delivery of CMM were useful, but were unable to successfully implement all of them. Despite this, significant increases in fidelity to steps of the patient care process was achieved. The pharmacists felt that CMM was acceptable, appropriate for patient population, and feasible, but barriers (e.g., the telephonic and remote nature of the practice, the evolving nature of the program, and the difficulty in coordinating care between the patients primary care team and the care team affiliated with the program) affected the feasibility and organizational fit of CMM within this team-based, at-home care program. General pharmacy services, however, were seen as acceptable, appropriate, and feasible.

CONCLUSION

Deliberately designing and utilizing a variety of implementation strategies can facilitate the implementation of CMM and significantly increase fidelity to the patient care process. To improve feasibility and organizational fit of CMM, additional barriers and challenges need to be addressed.