Comparative effectiveness research: evaluating pharmacist interventions and strategies to improve medication adherence

Pharmacoinformatics-enabled Interventions Improved Care Coordination and Identified Pharmacy-Related Safety Issues in a Multicultural Medicare Population

BACKGROUND

 Compared to White populations, multicultural older adults experience more gaps in preventive care (e.g., vaccinations, screenings, chronic condition monitoring), social determinants of health barriers (e.g., access to care, language, transportation), and disparities and inequities (e.g., comorbidities, disease burden, and health care costs).

OBJECTIVES

 This study aims to describe an informatics-based approach used to execute and evaluate results of a member-centric, pharmacoinformatics-informed engagement program to deliver culturally tailored microinterventions to close medication-related gaps in care utilizing multidisciplinary care coordination that leverages the expanded role of the pharmacist. The operational framework will be described, and the influence of the medication use processes will be reported in a multicultural Medicare Advantage cohort.

METHODS

 A pharmacoinformatics framework was leveraged to conduct a retrospective, observational cohort analysis of the program. Claims data were used to evaluate the influence of medication use process microinterventions from a large Medicare Advantage cohort of members who self-identify as Black and/or Hispanic, and have type 2 diabetes mellitus and/or hypertension, and meet eligibility criteria for multidisciplinary (e.g., nursing and pharmacy) care management (CM) and received pharmacy referral from January 1, 2022, through September 30, 2023.

RESULTS

 A total of 3,265 Medicare Advantage members (78.3% Black and 21.7% Hispanic) received CM and pharmacy referral. Pharmacovigilance reviews conducted during this timeframe identified 258 acute events that escalated member CM. Provider outreach (n = 185) informed of safety issues (drug duplication, n = 48; drug interactions, n = 21; drug-disease interactions, n = 5; noncompliance and/or dosing issues, n = 27). Outreach to members (n = 160) and providers (n = 164) informed of open quality-related measure gaps for medication adherence.

CONCLUSION

 The application of pharmacoinformatics by a payor-led multicultural clinical program demonstrated quality improvements in Medicare Advantage member identification including risk stratification, timely outreach for pharmacy-related safety issues, and improved efficiency of multidisciplinary care coordination involving medication use process workflows.

Systematic review of pragmatic randomised control trials assessing the effectiveness of professional pharmacy services in community pharmacies

BACKGROUND

Implementation of Professional Pharmacy Services (PPSs) requires a demonstration of the service's impact (efficacy) and its effectiveness. Several systematic reviews and randomised controlled trials (RCT) have shown the efficacy of PPSs in patient's outcomes in community pharmacy. There is, however, a need to determine the level of evidence on the effectiveness of PPSs in daily practice by means of pragmatic trials. To identify and analyse pragmatic RCTs that measure the effectiveness of PPSs in clinical, economic and humanistic outcomes in the community pharmacy setting.

METHODS

A systematic search was undertaken in MEDLINE, EMBASE, the Cochrane Library and SCIELO. The search was performed on January 31, 2020. Papers were assessed against the following inclusion criteria (1) The intervention could be defined as a PPS; (2) Undertaken in a community pharmacy setting; (3) Was an original paper; (4) Reported quantitative measures of at least one health outcome indicator (ECHO model); (5) The design was considered as a pragmatic RCT, that is, it fulfilled 3 predefined attributes. External validity was analyzed with PRECIS- 2 tool.

RESULTS

The search strategy retrieved 1,587 papers. A total of 12 pragmatic RCTs assessing 5 different types of PPSs were included. Nine out of the 12 papers showed positive statistically significant differences in one or more of the primary outcomes (clinical, economic or humanistic) that could be associated with the following PPS: Smoking cessation, Dispensing/Adherence service, Independent prescribing and MTM. No paper reported on cost-effectiveness outcomes.

CONCLUSIONS

There is limited available evidence on the effectiveness of community-based PPS. Pragmatic RCTs to evaluate clinical, humanistic and economic outcomes of PPS are needed.

Translation and validation of the Test of Adherence to Inhalers (TAI) questionnaire among adult patients with asthma in Malaysia

OBJECTIVE

The Test of Adherence to Inhalers (TAI) is a validated self-reported questionnaire that can reliably assess adherence to inhalers through patient self-report. However, it was not available in Bahasa Melayu (BM) language, nor has it been validated for use in the Malaysian population. The study aimed, therefore, to translate the 10-item TAI questionnaire into BM and evaluate its psychometric properties.

METHODS

The translation of the English version of the valid 10-item TAI questionnaire into BM was followed by subjecting it to a series of tests establishing factorial, concurrent and known group validities. Concurrent validity was assessed through Spearman's rank correlation coefficient against pharmacy refill-based adherence scores. Known group validity was assessed by cross-tabulation against asthma symptom control and using chi-square test. The internal consistency of the test scale was determined by a test-retest method using Cronbach's alpha (α) value and intraclass correlation coefficients.

RESULTS

A total of 120 adult asthma patients participated in the study. A 2-factor structure was obtained and confirmed with acceptable fit indices; CFI, NFI, IFI, TLI >0.9 and, RMSEA was 0.08. The reliability of the scale was 0.871. The test-retest reliability coefficient for the total sum score was 0.832 (p < 0.01), which indicated good reliability. The 10-item TAI-BM established concurrent and known group validities. The sensitivity and specificity of the tool were >85%.

CONCLUSIONS

The scale successfully translated into BM and validated. The 10-item TAI-BM appears fit for use in testing inhaler adherence of Malaysian patients with asthma.

Self-Reported Medication Adherence Measured With Morisky Medication Adherence Scales and Its Determinants in Hypertensive Patients Aged ≥60 Years: A Systematic Review and Meta-Analysis

Background: The aim of this systematic review and meta-analysis was to estimate medication adherence in hypertensive patients aged ≥60 years and to explore potential determinants of adherence with antihypertensive treatment in this age group.

Methods: A systematic search of the PubMed, Scopus, and Google Scholar using the Cochrane guidelines was performed. The analysis included articles published between 1 January 2000 and 30 June 2018. The patients were considered adherent if they scored ≥6 pts. on the Morisky Medication Adherence Scale (MMAS-8) or ≥3 pts. on the Morisky Green Levine Medication Adherence Scale (MGL). If available, also odds ratios (OR) with 95% confidence intervals (95% CI) for determinants of medication adherence were recorded.

Results: Thirteen studies including a total of 5,247 patients were available for the meta-analysis. The pooled percentage of adherence was 68.86% (95% CI: 57.80–79.92%). Subgroup analysis did not demonstrate a significant difference in the adherence measured with the MMAS-8 and the MGL (68.31 vs. 70.39%, P = 0.773). The adherence of patients from Western countries (Europe, United States) turned out to be significantly higher than in other patients (83.87 vs. 54.30%, P = 0.004). The significant determinants of better adherence identified in more than one study were older age, retirement/unemployment, duration of hypertension >10 years, and a lower number of prescribed drugs.

Conclusion: Medication adherence in the oldest old hypertensive patients seems to be higher than in younger persons. Adherence in older persons was associated with age, socioeconomic status, and therapy-related factors.

Hypertension and Frailty Syndrome in Old Age: Current Perspectives

Hypertension is both a health problem and a financial one globally. It affects nearly 30 % of the general population. Elderly people, aged ≥65 years, are a special group of hypertensive patients. In this group, the overall prevalence of the disease reaches 60 %, rising to 70 % in those aged ≥80 years. In the elderly population, isolated systolic hypertension is quite common. High systolic blood pressure is associated with an increased risk of cardiovascular disease, cerebrovascular disease, peripheral artery disease, cognitive impairment and kidney disease. Considering the physiological changes resulting from ageing alongside multiple comorbidities, treatment of hypertension in elderly patients poses a significant challenge to treatment teams. Progressive disability with regard to the activities of daily life, more frequent hospitalisations and low quality of life are often seen in elderly patients. There is discussion in the literature regarding frailty syndrome associated with old age. Frailty is understood to involve decreased resistance to stressors, depleted adaptive and physiological reserves of a number of organs, endocrine dysregulation and immune dysfunction. The primary dilemma concerning frailty is whether it should only be defined on the basis of physical factors, or whether psychological and social factors should also be included. Proper nutrition and motor rehabilitation should be prioritised in care for frail patients. The risk of orthostatic hypotension is a significant issue in elderly patients. It results from an autonomic nervous system dysfunction and involves maladjustment of the cardiovascular system to sudden changes in the position of the body. Other significant issues in elderly patients include polypharmacy, increased risk of falls and cognitive impairment. Chronic diseases, including hypertension, deteriorate baroreceptor function and result in irreversible changes in cerebral and coronary circulation. Concurrent frailty or other components of geriatric syndrome in elderly patients are associated with a worse perception of health, an increased number of comorbidities and social isolation of the patient. It may also interfere with treatment adherence. Identifying causes of non-adherence to pharmaceutical treatment is a key factor in planning therapeutic interventions aimed at increasing control, preventing complications, and improving long-term outcomes and any adverse effects of treatment. Diagnosis of frailty and awareness of the associated difficulties in adhering to treatment may allow targeting of those elderly patients who have a poorer prognosis or may be at risk of complications from untreated or undertreated hypertension, and for the planning of interventions to improve hypertension control.

Knowledge, Attitude and Advice-Giving Behaviour of Community Pharmacists Regarding Topical Corticosteroids

This study examines the relationship between community pharmacists’ knowledge, attitudes to information provision and self-reported counselling behaviours in relation to topical corticosteroids and adjunct therapy in atopic eczema. A mixed-methods approach was used whereby data from interviews with community pharmacists were used to design a structured questionnaire that a larger sample of community pharmacists completed anonymously. The questionnaire was completed and returned by 105 pharmacists (36% response rate). Pharmacists showed gaps in their knowledge on the use of topical corticosteroids in atopic eczema but had good understanding on the use of emollients. There was a significant correlation between pharmacists’ attitudes to information provision and their self-reported counselling behaviour for most themes except in relation to corticosteroid safety where less advice was given. Improving attitudes to information provision should correlate with increased counselling behaviour. However, for the theme of corticosteroid safety, further studies are needed to examine why in practice pharmacists are not providing patient counselling on this topic even though most agreed this is a topic patients should know about.

A mixed-methods evaluation of an Integrated Medication Management program and implications for implementation

BACKGROUND

Improving medication adherence is a common and challenging issue. Taking medications as prescribed becomes particularly difficult for individuals with multiple chronic conditions. Poor adherence can lead to exacerbated health issues and prolonged disease severity. Medication Therapy Management is increasingly being used to help clinics improve medication adherence and reduce adverse events, but factors that enable implementation of such programs are not well identified.

OBJECTIVE

To describe the factors associated with implementation of an innovative pharmacy program and to measure the impact of the intervention.

METHODS

This mixed-methods cohort study in a federal qualified health center with its own pharmacy examined the implementation and the impact of a broad program including MTM. The intervention included appointments with pharmacists, communication between pharmacists and physicians, and, for some, monthly pre-packaged medications. Semi-structured interviews with patients and staff were recorded, transcribed, and analyzed for themes relating to implementation, satisfaction, and challenges. Quantitative methods using data collected by the pharmacists at each visit were used to compare the first visit to those at later visits and provided measures of impact on diabetes control, statin use, and medication-related problems (MRPs).

RESULTS

Qualitative interviews identified enabling factors that contributed to successful implementation of this program, including: program factors such as data access, communication with patients, and dedicated staff; organizational factors such as culture of integration, leadership support, and staffing; and lastly, environmental factors such as the availability of 340B funding. Quantitative analyses were limited by poor retention and lack of a similarly-documented comparison group. Health outcomes were not found to be significantly better, though there was a significant decrease in some kinds of MRPs. This program was well received by patients and staff and demonstrated some clinical impact.

CONCLUSION

The program's implementation was enabled by design as well as organizational and external factors. Financial and leadership support allowed for flexibility and creativity, which contributed to successful implementation. Alternative delivery models beyond fee-for-service payments may make this kind of program more feasible.

Pharmacist contributions to the ten essential services of public health in three National Association of Boards of Pharmacy regions

BACKGROUND

Pharmacists have contributed to improved population health through the delivery of public health services, but their contributions often go unrecognized within the larger health care system.

OBJECTIVES

To determine pharmacist perceptions of their contributions to the 10 essential services of public health and to compare those contributions among pharmacists in Iowa, North Dakota, and Manitoba.

METHODS

Licensed pharmacists in Iowa, North Dakota, and Manitoba were sent an online survey of their perceived level of achievement of the 10 essential services of public health.

RESULTS

A total of 649 pharmacists completed the survey. The 3 essential services that scored the highest overall were enforce laws and regulations that protect health and ensure safety, inform and educate people about health issues, and participate in ongoing training beyond continuing education requirements. Contributions of pharmacists to the 10 essential services of public health were previously evaluated by frequency of citation in the published literature. There was relative agreement between what was reported in the literature and what was determined by survey. One exception was "enforce laws and regulations that protect health and ensure safety," which was rarely reported in the literature but was reported in the survey to be the most frequently delivered service.

CONCLUSION

Pharmacist contributions to improved population health should be reported with the use of the 10 essential services of public health. This will increase recognition of pharmacist contributions and better align the disciplines of pharmacy and public health. In particular, pharmacists should consider ways to increase their level of involvement in the community and in partnership with other health care professionals.

Selected factors affecting adherence in the pharmacological treatment of arterial hypertension

BACKGROUND

Low adherence to hypertension (HT) management is one of the major contributors to poor blood pressure (BP) control. Approximately 40%-60% of patients with HT do not follow the prescribed treatment. The aim of the study was to analyze the relationship between selected variables and adherence to hypotensive pharmacological treatment. Besides socioclinical variables, the study focused on the role of illness acceptance.

PARTICIPANTS AND METHODS

The study included 602 patients with HT. Adherence and acceptance of illness were assessed using the following validated instruments: the Acceptance of Illness Scale (AIS) and the Morisky Medication Adherence Scale (MMAS).

RESULTS

The high-adherence group comprised a significantly higher percentage of patients with high illness acceptance scale scores than that of patients with low-to-moderate scores (42.4 vs 31.8%; P=0.008<0.01). The odds ratio (OR) showed that high adherence to pharmacological treatment was >1.5 times as likely to occur in the high acceptance group as in the low-to-moderate acceptance group (OR =1.58, 95% CI 1.14-2.19). Spearman's rank correlation coefficients showed statistically significant correlations between adherence and sex (men ρ=-0.101; P=0.012), age >45-66 years (ρ=0.098; P=0.015), higher education level (ρ=0.132; P=0.001), grade ESC of HT (ρ=-0.037; P=0.057), receiving one-tablet polytherapy (ρ=0.131; P=0.015), and illness acceptance (ρ=0.090; P=0.024).

CONCLUSION

Acceptance of illness is correlated with adherence to pharmacological treatment, and consideration should be given to more widespread assessment of illness acceptance in daily practice. Male sex, age >45-66 years, duration of illness grade ESC of HT, and receiving one-tablet polytherapy are significant determinants of adherence to pharmacological treatment in HT.

The influence of frailty syndrome on medication adherence among elderly patients with hypertension

BACKGROUND

Hypertension affects about 80% of people older than 80 years; however, diagnosis and treatment are difficult because about 55% of them do not adhere to treatment recommendations due to low socioeconomic status, comorbidities, age, physical limitations, and frailty syndrome.

AIMS

The purposes of this study were to evaluate the influence of frailty on medication adherence among elderly hypertensive patients and to assess whether other factors influence adherence in this group of patients.

METHODS AND RESULTS

The study included 296 patients (mean age 68.8±8.0) divided into frail (n=198) and non-frail (n=98) groups. The Polish versions of the Tilburg Frailty Indicator (TFI) for frailty assessment and 8-item Morisky Medication Adherence Scale for adherence assessment were used. The frail patients had lower medication adherence in comparison to the non-frail subjects (6.60±1.89 vs 7.11±1.42; P=0.028). Spearman's rank correlation coefficients showed that significant determinants with negative influence on the level of adherence were physical (rho =-0.117), psychological (rho =-0.183), and social domain (rho =-0.163) of TFI as well as the total score of the questionnaire (rho =-0.183). However, multiple regression analysis revealed that only knowledge about complications of untreated hypertension (β=0.395) and satisfaction with the home environment (β=0.897) were found to be independent stimulants of adherence level.

CONCLUSION

Frailty is highly prevalent among elderly hypertensive patients. Higher level of frailty among elderly patients can be considered as a determinant of lower adherence. However, social support and knowledge about complications of untreated hypertension are the most important independent determinants of adherence to pharmacological treatment.

Evolution of Clinical Pharmacy in the USA and Future Directions for Patient Care

This paper describes key events in pharmaceutical education, training, practice, and research that have occurred over the past 55 years. Some of these events included the development of the doctor of pharmacy degree, residency training, and co-location of clinical pharmacists in patient care areas. These changes not only necessitated more specialized training but then led to board certification to ensure quality patient care. Specific examples of the research that have supported the involvement of clinical pharmacists in direct patient care will be discussed.

The influence of illness acceptance on the adherence to pharmacological and non-pharmacological therapy in patients with hypertension

BACKGROUND

The available publications show that 50% of patients with hypertension discontinue their medications within the first 12 months after the beginning of treatment.

AIM

The aim of the study was to analyse the relationship between the acceptance of illness and the adherence to pharmacological and non-pharmacological therapy in patients with hypertension.

METHODS

The study included 102 patients with hypertension examined with validated instruments: Acceptance of Illness Scale (AIS), Health Behavior Inventory (HBI) and Morisky Medication Adherence Scale (MMAS-8).

RESULTS

High (>30 points) and moderate (19-29 points) levels of AIS were presented respectively by 59 and 43 patients. In a univariate analysis, the level of AIS had a statistically significant, independent, positive influence on all domains of the HBI questionnaire: HBI (Spearman's coefficient of rank correlation (r_S) =+0.3997), healthy eating habits (r_S=+ 0.376), preventive behaviours (r_S=+0.242), positive mental attitude (r_S=+0.504), health practices (r_S=+0.264). In univariate analysis the level of MMAS-8 was influenced by female gender (r_S=+0.325; p=0.001), higher education level (r_S=+0.241; p=0.015), employment (r_S=+0.217; p=0.029) and short duration of illness (r_S=+0.229; p=0.022). Multiple regression analysis showed that female gender was an independent predictor of pharmacological adherence (β=+0.325; p=0.001). Illness acceptance was an independent predictor in two domains of the HBI: positive mental attitude HBI domain (β=+0.468; p<0.001) and healthy eating habits (β=+0.321; p=0.001).

CONCLUSIONS

(1) Correlation analysis shows that illness acceptance is an important factor contributing to a higher level of adherence to non-pharmacological therapy of hypertension (total index of health behaviours: healthy eating habits, preventive behaviours, positive mental attitude, health practice) but has no influence on adherence to pharmacological treatment. (2) Female gender, higher levels of education, and the short duration of the disease significantly improve patients' adherence to the prescribed pharmacological and non-pharmacological therapy of hypertension.

Cluster randomized trials for pharmacy practice research

Introduction Cluster randomized trials (CRTs) are now the gold standard in health services research, including pharmacy-based interventions. Studies of behaviour, epidemiology, lifestyle modifications, educational programs, and health care models are utilizing the strengths of cluster randomized analyses. Methodology The key property of CRTs is the unit of randomization (clusters), which may be different from the unit of analysis (individual). Subject sample size and, ideally, the number of clusters is determined by the relationship of between-cluster and within-cluster variability. The correlation among participants recruited from the same cluster is known as the intraclass correlation coefficient (ICC). Generally, having more clusters with smaller ICC values will lead to smaller sample sizes. When selecting clusters, stratification before randomization may be useful in decreasing imbalances between study arms. Participant recruitment methods can differ from other types of randomized trials, as blinding a behavioural intervention cannot always be done. When to use CRTs can yield results that are relevant for making "real world" decisions. CRTs are often used in non-therapeutic intervention studies (e.g. change in practice guidelines). The advantages of CRT design in pharmacy research have been avoiding contamination and the generalizability of the results. A large CRT that studied physician-pharmacist collaborative management of hypertension is used in this manuscript as a CRT example. The trial, entitled Collaboration Among Pharmacists and physicians To Improve Outcomes Now (CAPTION), was implemented in primary care offices in the United States for hypertensive patients. Limitations CRT design limitations include the need for a large number of clusters, high costs, increased training, increased monitoring, and statistical complexity.

The achievement of public health services in pharmacy practice: A literature review

BACKGROUND

It is known that pharmacists are currently contributing to public health; however, the extent of this contribution as reported in the literature has not been examined. Investigating the ways that pharmacists are currently participating in public health is critical for the profession of pharmacy, pharmacy educators, and the public health community.

OBJECTIVES

The purpose of this study was to determine the reported contributions of pharmacy to each of the ten essential services of public health, and which of the five core competencies of public health were most frequently utilized in those contributions.

METHODS

A PubMed search was used to extract references that included both the words pharmacy and services in the title or abstract, and the words public health in any part of the document. A total of 247 references were extracted and categorized into the essential services and core competencies.

RESULTS

The essential services Inform, Educate, and Empower, and Link to/Provide Care were more frequently represented in the literature, and the core competency of Health Policy and Administration was most frequently utilized.

CONCLUSION

To further contribute to and integrate their contributions within population health, pharmacists must consider ways to strategically contribute to the essential services of public health and seek to increase competency in public health.

Pharmacist-led intervention study to improve drug therapy in asthma and COPD patients

BACKGROUND

Pharmacists can play an important role in identifying and instructing pulmonary patients on their inhalation techniques in their patient contacts when dispensing inhalation medication. Pharmacy dispensing data can be used to identify inappropriate drug use in asthma and chronic obstructive pulmonary disease (COPD) patients. Recent studies found beneficial effects of pharmacy care services in improving drug adherence of pulmonary patients. However, large-scale and rigorous evaluations on pharmacist-led interventions in community care settings to enhance evidence-based drug treatment in patients with asthma and COPD seems to be lacking and results from studies on pharmacist-led interventions for pharmacotherapy improvements are inconsistent. This study evaluated the effectiveness of pharmacist-led interventions on suboptimal drug use patterns with asthma or COPD medication with substantial numbers of pharmacies and patients involved.

SETTING

A prospective cohort study in a group of community pharmacies (intervention group) with a matched control group of Dutch community pharmacies was conducted between May 2011 and February 2012. Algorithms on 19 potential problems with asthma or COPD medication in a national dispensing database were used to signal patients to pharmacists of the intervention group (IG).

METHODS

IG pharmacists selected patients for comprehensive care by a structured program. Changes in problems were measured during 10 months in selected and all users of asthma and COPD medication of IG pharmacies and in compared to a control pharmacies (CG) without the structured program. Primary outcome was reduction of oral high dosage corticosteroids or antibiotics (HDT). Secondary outcomes were changes in the persistence of 19 potential problems in the IG compared to CG.

RESULTS

In the 107 IG pharmacies, 3,757 patients were selected for comprehensive care from totally 102,497 asthma or COPD patients and compared with 105,507 patients from 105 CG pharmacies. The mean number of HDT decreased in selected IG patients by an additional 0.54 (95 % CI 0.21-0.86) HDT treatments. From the problems with specific COPD and asthma medication, all problems decreased additionally to the CG within the total asthma or COPD population from the IG. Within the selected IG population the following problems decreased additionally for obsolete medication by 35 % (95 % CI 6-54 %), contra-indicated medication by 61 % (95 % CI 38-75 %) and lower use of powder inhalers in elderly patients by 29 % (95 % CI 13-42 %).

CONCLUSION

Community pharmacists actively providing comprehensive pharmacy care could improve effective treatment in asthma and COPD patients and thereby decrease the number of prescriptions for exacerbations for these patients.

Improving refill adherence and hypertension control in black patients: Wisconsin TEAM trial

OBJECTIVE

To assess the effectiveness and sustainability of a 6-month Team Education and Adherence Monitoring (TEAM) intervention for black patients with hypertension in community chain pharmacies.

DESIGN

Cluster randomized trial.

SETTING

28 chain pharmacies (14 TEAM and 14 control) in five Wisconsin cities from December 2006 to February 2009.

PARTICIPANTS

576 black patients with hypertension.

INTERVENTION

Trained pharmacist-technician teams implemented a 6-month intervention using scheduled visits, Brief Medication Questionnaires (BMQs), and novel toolkits for facilitating medication adherence and pharmacist feedback to patients and physicians. Control participants received patient information only.

MAIN OUTCOME MEASURES

Refill adherence (≥80% days covered) and changes in systolic blood pressure (SBP), diastolic blood pressure, and blood pressure control using blinded assessments at 6 and 12 months.

RESULTS

At baseline, all patients had blood pressure of 140/90 mm Hg or more. Of those eligible, 79% activated the intervention (mean 4.25 visits). Compared with control participants at 6 months, TEAM participants achieved greater improvements in refill adherence (60% vs. 34%, P < 0.001), SBP (-12.62 vs. -5.31 mm Hg, P < 0.001), and blood pressure control (50% vs. 36%, P = 0.01). Six months after intervention discontinuation, TEAM participants showed sustained improvements in refill adherence ( P < 0.001) and SBP ( P = 0.004), though the difference in blood pressure control was not significant ( P < 0.05) compared with control participants. Analysis of intervention fidelity showed that patients who received the full intervention during months 1 through 6 achieved significantly greater 6- and 12-month improvements in refill adherence and blood pressure control compared with control participants.

CONCLUSION

A team-based intervention involving community chain pharmacists, pharmacy technicians, and novel toolkits led to significant and sustained improvements in refill adherence and SBP in black patients with hypertension.

The impact of family caregivers on potentially inappropriate medication use in noninstitutionalized older adults with dementia

BACKGROUND

The risk of potentially inappropriate medication (PIM), both prescription and over-the-counter, use in dementia patients is high. Informal caregivers often facilitate patients' use of medications, but the effect of caregiver factors on PIM use has not been a focus of previous research.

OBJECTIVE

The aim of this study was to examine PIM use in dementia patients and caregivers and identify caregiver risk factors for PIM use in dementia patients.

METHODS

We conducted a secondary data analysis of the baseline wave of the Resources for Enhancing Alzheimer's Caregiver's Health study. The sample comprised 566 persons with dementia aged 65 and older and their coresiding family caregiver. PIM was defined using the 2003 Beers criteria and was examined in both dementia patients and their caregivers. Caregiver and patient risk factors included a range of sociodemographic and health variables.

RESULTS

In dementia patients, 33% were taking at least 1 PIM, and 39% of their caregivers were also taking a PIM. In fully adjusted models, the following caregiver factors were associated with an increased risk of dementia patient PIM use: caregiver's own PIM use, spouse caregivers, Hispanic caregivers, and greater number of years that the caregiver has lived in the United States. Increased caregiver age was associated with a decreased risk of PIM use in patients.

CONCLUSIONS

PIM use may be higher in dementia patients and their informal caregivers compared with the general older adult population. Further, patterns of medication use in 1 member of the dyad may influence PIM risk in the other dyad member. These results suggest that interventions to increase appropriate medication use in dementia patients and their caregivers should target both members of the dyad and target over-the-counter agents along with prescription medications.

The hypertension team: the role of the pharmacist, nurse, and teamwork in hypertension therapy

Team-based care is one of the key components of the patient-centered medical home. Studies have consistently demonstrated that teams involving pharmacists or nurses in patient management can significantly improve blood pressure control. These findings have been demonstrated in several meta-analyses and systematic reviews. These reviews have generally found that team-based care can reduce systolic blood pressure by 4-10 mm Hg over usual care. However, these reviews have also concluded that many of the studies had various limitations and that additional research should be conducted. The present state of the art review paper will highlight newer studies, many of which were funded by the National Institutes of Health. Newer strategies involve telephone and/or web-based management which is an evolving area to improve blood pressure control in large populations. Social media and other technology is currently being investigated to assist pharmacists or nurses in communicating with patients to improve hypertension management. Few cost-effectiveness analyses have been performed but generally have found favorable costs for team-based care when considering the potential to reduce morbidity and mortality. The authors will suggest additional research that needs to be conducted to help evaluate strategies to best implement team-based care to improve blood pressure management.