Home medication inventory method to assess over-the-counter (OTC) medication possession and use: A pilot study on the feasibility of in-person and remote modalities with older adults

BACKGROUND

There is a need for reproducible methods to measure over-the-counter (OTC) medication possession and use. This is because OTC medications are self-managed, variably monitored by healthcare professionals, and in certain populations such as older adults some OTC medications may introduce risk and cause more harm than benefit.

OBJECTIVE

(s): To develop and assess the feasibility of the Home Medication Inventory Method (HMIM), a novel method to measure possession and use of OTC medications.

METHODS

We benchmarked, adapted, and standardized prior approaches to medication inventory to develop a method capable of addressing the limitations of existing methods. We then conducted a pilot study of the HMIM among older adults. Eligible participants were aged ≥60 years, reported purchasing or considering purchasing OTC medication, and screened for normal cognition. Interviews were conducted both in person and remotely. When possible, photographs of all OTC medications were obtained with participant consent and completion times were recorded for both in-person and remote modalities.

RESULTS

In total 51 participants completed the pilot study. Home medication inventories were conducted in-person (n = 15) and remotely (n = 36). Inventories were completed in a mean (SD) of 20.2 min (12.7), and 96 % of inventories completed within 45 min. A total of 390 OTC medications were possessed by participants, for a mean (SD) of 7.6 (6.3) per participant. No differences in duration of interviews or number of medications reported were identified between in-person and remote modalities. Anticholinergic medications, a class targeted in the pilot as potentially harmful to older adults, were possessed by 31 % of participants, and 14 % of all participants reported use of such a medication within the previous 2 weeks.

CONCLUSIONS

Implementing the HMIM using in-person and remote modalities is a feasible and ostensibly reproducible method for collecting OTC medication possession and use information. Larger studies are necessary to further generalize HMIM feasibility and reliability in diverse populations.

Adapting a community pharmacy intervention to improve medication safety

BACKGROUND

Community pharmacies are an ideal location to address challenges of over-the-counter medication safety, yet many successful interventions are only tested in a few pharmacies without expansion, creating unrealized opportunities to improve patient care on a larger scale. Scaling up to numerous pharmacies can be challenging because each community pharmacy has unique needs and layouts and requires individualized adaptation.

OBJECTIVES

This paper reports techniques for (a) adapting a community pharmacy intervention to fit the unique physical layout and patient needs of health system pharmacy sites without increasing staff workload, (b) identifying strategies to gather feedback on adaptations from stakeholders, and (c) developing materials to share with pharmacy champions for them to independently implement and sustain the intervention in their organization.

PRACTICE DESCRIPTION

The study team collaborated with Aurora Pharmacy, Inc to develop an intervention designed to increase awareness of safe over-the-counter medication use for older adults.

PRACTICE INNOVATION

Senior Safe, a community pharmacy-based intervention, was designed, implemented, and tested using the Exploration, Preparation, Implementation, and Sustainment implementation framework.

EVALUATION METHODS

Senior Safe was adapted through pilot testing and a randomized control trial. Feedback was collected from key stakeholders, including pharmacy staff, older adults, and a research advisory group.

RESULTS

A finalized version of Senior Safe, as well as an implementation package, was provided to Aurora Pharmacy to integrate into all 63 sites.

CONCLUSION

This multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but it requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.

CancelRx case study: implications for clinic and community pharmacy work systems

BACKGROUND

Medication prescribing and discontinuation processes are complex and involve the patient, numerous health care professionals, organizations, health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The health system also operates 15 outpatient community pharmacies.

OBJECTIVE

The goal of this qualitative study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations, before and after CancelRx implantation.

APPROACH

Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n = 3), employed by the health system were interviewed across 3-time periods between 2017 and 2018- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and conducted a hybrid analysis with deductive content analysis following the Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductive analysis to capture additional codes and themes.

KEY RESULTS

CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors.

CONCLUSIONS

This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Applying RE-AIM to examine the impact of an implementation facilitation package to scale up a program for Veterans with chronic obstructive pulmonary disease

BACKGROUND

US Veterans are four times more likely to be diagnosed with chronic obstructive pulmonary disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans' Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of five implementation strategies was designed and implemented.

METHODS

This evaluation utilized a mixed-methods approach to assess the impact of the Academy's implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians' perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted 8 to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items.

RESULTS

Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy session attendance (90%) and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians' significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation.

CONCLUSIONS

This evaluation found that the use of implementation facilitation paired with additional strategies enhanced the capacity of clinicians to implement COPD CARE. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

Applying RE-AIM to examine the impact of an implementation facilitation package to scale up a program for Veterans with Chronic Obstructive Pulmonary Disease

Background

U.S. Veterans are four-times more likely to be diagnosed with Chronic Obstructive Pulmonary Disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans' Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of four implementation strategies was designed and implemented.

Methods

This evaluation utilized a mixed-methods approach to assess the impact of the Academy's implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians' perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted eight to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items.

Results

Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy completion (97%), session attendance (90%), and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians' significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation.

Conclusions

This evaluation found that the use of implementation facilitation paired with additional strategies seemed to demonstrate positive implementation outcomes across all RE-AIM domains and identified areas for potential improvement. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

CancelRx Case Study: Implications for Clinic and Community Pharmacy Work Systems

Background

The medication prescribing, and de-prescribing process is complex with numerous actors, organizations, and health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy's dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017.

Objective

The goal of this study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations.

Approach

Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n =3), employed by the health system were interviewed across 3-time periods- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and analyzed via deductive content analysis.

Key Results

CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors.

Conclusions

This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis

Background

Prescription opioid misuse is a serious national crisis; in 2018 the top drugs involved in prescription overdose deaths included pain medications (opioids), benzodiazepines, and stimulants. Health information technology (health IT) provides a means to address this crisis through technologies that streamline the prescribing and discontinuation process. CancelRx is a health IT function that communicates when medications, such as controlled substances, are discontinued at the clinic and therefore should not be filled at the pharmacy. Prior to CancelRx, the communication of discontinued medications was a manual process, requiring the patient or a clinic staff member to personally contact the pharmacy to inform them of the change. The objective of this study was to assess how controlled substance medication discontinuations were communicated over time, before and after the implementation of CancelRx.

Methods

Secondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation. The study utilized an interrupted time series analysis (ITSA) to capture the percentage of controlled substance medications that were discontinued in the clinic’s electronic health record and discontinued in the pharmacy’s dispensing software. The ITSA plotted the percentage of successful discontinuation messages over time, particularly after the health system’s implementation of CancelRx, a novel technology.

Results

After CancelRx implementation there was an immediate (change = 77.7 percentage point) and significant (p < 0.001) increase in the number of controlled substance medications that were successfully discontinued at the pharmacy after being discontinued in the clinic. This change was sustained in the year following CancelRx (slope = 0.03 pp, 95% CI − 0.050 to 0.110) and did not revert to pre-CancelRx levels. The health IT functionality was able to effectively complete discontinuation tasks and potentially reduce workload for clinic staff.

Conclusions

Overall, this study demonstrates the role that technology can play in promoting communication between clinics and pharmacies, especially when medications such as controlled substances are discontinued.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01779-9.

CancelRx implementation: Observed changes to medication discontinuation workflows over time

Introduction

When patients are seen in an ambulatory outpatient clinic, such as their primary care provider's office, the prescriber often stops or discontinues medications. Although medication discontinuations are documented in the clinic's health record, this information may not be communicated to the pharmacy. Within the last decade, CancelRx has attempted to address this issue by sending a message from the clinic to the pharmacy when a medication has been discontinued or changed.

Objectives

This project studied pharmacy medication discontinuation workflows and pharmacists' perspectives at 3 UW Health outpatient pharmacies before and after implementation of CancelRx.

Methods

CancelRx was implemented at UW Health in October 2017. Pharmacists from 3 outpatient pharmacies were observed at 3 distinct time points. The research team conducted 9 observations 3-months before CancelRx implementation (July 2017). Additionally, 9 observations were completed at 3-months after CancelRx implementation (January 2018) and at 9-months after CancelRx implementation (July 2018). Collective case study and comparative workflow modeling were used in this study. Observation field notes were deductively coded and aggregated to determine task frequency, occurrence, and patterns using an interpretivist theoretical approach.

Results

During the study, 106 medication discontinuation instances (referred to as cases) were observed; 28 cases 3-months prior to CancelRx, 59 cases 3-months after CancelRx, and 16 cases 9-months after CancelRx. Medication discontinuation tasks aligned with the predetermined workflow: receiving and investigating the discontinuation messages, matching the message to the medication in the patient's profile and discontinuing it, documenting and communicating the message to others as necessary. After implementing CancelRx, the workflow changed as most pharmacists eliminated the investigating and documenting tasks.

Conclusions

This study provided insight into the medication discontinuation workflow in community pharmacies, especially after implementing CancelRx. Organizations are recommended to proactively consider the implications for novel health information technology before implementation to anticipate workflow and pharmacy practice changes and improve acceptance and effectiveness.

Quality of Handoffs in Community Pharmacies

OBJECTIVES

The aims of the study were to characterize handoffs in community pharmacies and to examine factors that contribute to perceived handoff quality.

METHODS

A cross-sectional study of community pharmacists in a Midwest State of the United States. Self-administered questionnaires were used to collect information on participant and practice setting characteristics. Data were analyzed using descriptive statistics and multivariate logistic regression.

RESULTS

A total of 445 completed surveys were returned (response rate, 82%). In almost half of the time, handoffs that occur in a community pharmacy setting were inaccurate or incomplete. Nearly half of the time handoffs occur in environments full of interruptions and distractions. More than 90% of the respondents indicated that they have undergone no formal training on proper ways of handing off information. Nearly 40% of respondents reported that their pharmacy dispensing technology does not have adequate functionality to support handing off information and that at least 50% of the time, poor handoffs result in additional work to the pharmacist because of the need for complete information before providing patient care. Multivariate analysis showed that being very familiar with patients, lower daily prescription volume, not having a 24-hour operation, and larger percentage of handoffs occurring in a synchronous fashion are all associated with better handoff quality.

CONCLUSIONS

Handoffs occur frequently and are problematic in community pharmacies. Current pharmacy environments offer limited support to conduct good handoffs, and as a result, pharmacists report loss of information. This could present as a significant patient safety hazard. Future interventions should target facilitating better communication during shift changes.

Impact of a pilot community pharmacy system redesign on reducing over-the-counter medication misuse in older adults

BACKGROUND

No interventions have attempted to decrease misuse of over-the-counter (OTC) medications for adults aged 65 years or older (older adults) by addressing system barriers. An innovative structural pharmacy redesign (the Senior Section) was conceptualized to increase awareness of higher-risk OTC medications. The Senior Section contains a curated selection of OTC medications and is close to the prescription department to facilitate pharmacy staff-patient engagement to reduce misuse.

OBJECTIVE

This pilot study examined the Senior Section's effectiveness at influencing OTC medication misuse in older adults.

METHODS

A pretest-post-test nonequivalent groups design was used to recruit 87 older adults from 3 pharmacies. Using a hypothetical scenario, the participants selected an OTC medication that was compared with their medication list and health conditions, and their reported use was compared with the product labeling. Misuse outcomes comprised drug-drug, drug-disease, drug-age, and drug-label, with 5 subtypes. Patient characteristics were compiled into a propensity score matching logistic regression model to estimate their effects on the Senior Section's association with misuse at pre- or postimplementation.

RESULTS

Patient characteristics were uniform between pre- and postimplementation, and, once entered into a propensity score matching model, drug-label misuse (exceeds daily dosage) statistically significantly lessened over time (z = -2.42, P = 0.015). In addition, the Senior Section reduced drug-label misuse (exceeds single dosage) for both the raw score model (z = -6.38, P = 0.011) and the model in which the patient characteristics propensity score was added (z = -5.82, P = 0.011). Despite these limited statistical effects, misuse was found to decrease after implementation for 7 of 11 comparisons.

CONCLUSION

These nascent outcomes begin providing an evidence base to support a well-conceived, pharmacy-based OTC medication-aisle redesign for reducing older adult OTC medication misuse. The Senior Section, when broadly implemented, creates permanent structures and processes to assist older adults to access risk information when selecting safer OTC medications.

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting

OBJECTIVE

Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software.

MATERIALS AND METHODS

CancelRx was implemented in October 2017 at an academic health system. For 12 months prior, and 12 months after CancelRx implementation, data were collected on discontinued medications in the health system's EHR and whether those prescriptions were successfully discontinued in the pharmacy's dispensing software. An interrupted time series analysis was conducted to model the occurrence of prescriptions successfully discontinued over time.

RESULTS

There was an immediate (lag = 0), significant (P < 0.001), and sustained (post-implementation slope 0.02) increase in the proportion of successful medication discontinuations after CancelRx implementation (from 34% to 93%). CancelRx had variable impact based on whether the clinic was primary care (71.4% change prepost) or specialty care (53.9% change prepost). CancelRx reduced the time between when a medication was discontinued in the clinic EHR and pharmacy dispensing software.

CONCLUSION

CancelRx automated a manual process and illustrated the role for health IT in communicating medication discontinuations between clinics and pharmacies. Overall, CancelRx had a marked benefit on medication list discrepancies and illustrated how health IT can be used across different settings to improve patient care.

Using a scenario-based hybrid approach to understand participant health behavior

BACKGROUND

Qualitative and mixed methods approaches are commonly used to understand participants' interactions with real-world settings and can help health services researchers to obtain realistic details about patients' health behaviors. However, interviews do not easily capture data about how patients perform health-related behaviors that are not part of their daily routine. A scenario-based approach is one method that can be used prospectively to explore how patients make decisions about their health-related behaviors. This approach is comprised of a set of small tailored probable circumstances with equally plausible situations, and are presented as narrative descriptions. To understand how older adults, a group at high-risk for OTC misuse, select over-the-counter (OTC) medication qualitative methods can be used.

OBJECTIVES

This study describes a scenario-based hybrid approach that included a simulation exercise and a situational interview to understand how older adults first select and then take OTC medication.

METHODS

The scenario-based hybrid approach consisted of 1) a simulation exercise to emulate participants' real-world experiences as they selected a medication in a store, followed by 2) a situational interview to capture how participants intended to take the medication they selected. Video recordings captured interview data as well as participants' body language, navigation patterns, and other nuanced data that would not have been captured in audio recordings.

RESULTS/CONCLUSION

The scenario-based hybrid approach not only yielded detailed information about behavior, but also allowed investigators to discern participants' decision-making, influences, and the rationales they use when selecting and taking OTC medications. Studies aiming to capture participants' behavior in naturalistic situations can use these techniques to draw inferences from direct and indirect visual references that may not be captured otherwise. In this study, the goal was to understand how older adult participants select and take OTC medications. This approach allowed the research team to expediently recreate situations in which participants would purchase an OTC medication, a task that may not occur frequently and thus may not be amenable to participant observation or accurately recalled using retrospective interviewing.

A pharmacy-based intervention to improve safe over-the-counter medication use in older adults

BACKGROUND

For older adults, health risks from inappropriate use of over-the-counter (OTC) medications represent a prevalent clinical and public health challenge. Focus groups with pharmacists led to the identification of a number of systems barriers to pharmacists supporting the safe selection and use of OTC medications by this population. Such feedback informed the development of the Senior Section™, a physical redesign that located a curated inventory of lower-risk OTC medications proximal to the prescription department.

OBJECTIVES

To determine whether implementation of the Senior Section resulted in improvements to the ability of pharmacy staff to engage with older adult patients to support OTC medication safety issues.

METHODS

A qualitative approach, in which pharmacy staff from 4 pharmacies within a single chain participated in a semi-structured interview, was used to evaluate the implementation of the Senior Section in their pharmacies. Interview transcripts underwent a deductive and iterative content analysis.

RESULTS

Eight pharmacists and 5 technicians were interviewed. They viewed the Senior Section as contributing to notable improvements in proximity, medication safety, convenience, and patient selection behaviors. The Senior Section's safer OTC inventory and its sectional layout, its relationship to the prescription department, and its signage served to enhance its usefulness as an OTC safety improvement intervention. Moreover, it functioned beneficially while streamlining the coordination of services with between pharmacists and technicians, and did not interfere with existing pharmacy workflows.

CONCLUSIONS

Pharmacy staff believed that the Senior Section facilitated their ability to engage with older adults to support safe OTC selection and use and thus to reduce OTC-related harms.

Evaluation of Patient Safety Culture in Community Pharmacies

OBJECTIVE

Medication errors are common in community pharmacies. Safety culture is considered a factor for medication safety but has not been measured in this setting. The objectives of this study were to describe safety culture measured using the Agency for Healthcare Research and Quality (AHRQ) Community Pharmacy Survey on Patient Safety Culture and to assess predictors of overall patient safety.

METHODS

This is a cross-sectional survey of community pharmacists practicing in Wisconsin measuring safety culture. Demographic variables collected included pharmacist and pharmacy characteristics. Data were analyzed using descriptive statistics, χ, and multivariate logistic regression analyses.

RESULTS

A total of 445 surveys were completed (response rate, 82%). Safety culture was positively associated with the following: an independent pharmacy (adjusted odds ratio [AOR], 1.69; 95% confidence interval [CI], 1.11-2.57), a health maintenance organization or clinic (AOR, 2.25; 95% CI, 1.34-3.78), being somewhat familiar with patients (AOR, 3.35; 95% CI, 1.82-6.19), or very/extremely familiar with patients (AOR, 8.8; 95% CI, 4.68-16.59). Five of the composite scores differed significantly from the results of the AHRQ pilot study (response to mistakes, communication openness, organizational learning-continuous improvement, communication about prescriptions across shifts, and overall patient safety). Consistent with the AHRQ pilot study, the composite describing staffing, work pressure, and pace had the lowest score (37.6%).

CONCLUSIONS

Understanding the safety culture of community pharmacies can help identify areas of strength and those that require improvement. Improvement efforts that focus on staffing, work pressure, and pace in community pharmacies may lead to better safety culture.

Understanding the Factors Influencing Older Adults' Decision-Making about Their Use of Over-The-Counter Medications-A Scenario-Based Approach

The potential risks of over-the-counter (OTC) medications are often aggravated in vulnerable populations, such as older adults. The elevated patterns of older-adult OTC medication use do not necessarily translate into a greater understanding of these medications or their safety implications. The objective of this study was to assess how older adults' knowledge, beliefs, and attitudes inform their decision-making regarding OTC use. Situational interviews were conducted in three community pharmacies with 87 older-adult participants to capture how they intended to use an OTC medication. The interviews were transcribed and qualitatively analyzed, generating seven key themes: (1) medication use concerns; (2) following label instructions; (3) wait time until medication effect; (4) responses to medication not working; (5) decision to stop medication; (6) sources of information; and (7) safety implications. This study shows substantial variations in older-adult OTC medication use while providing insight on factors that influence older adults' appropriate OTC medication use and, in some cases, the potential for harmful effects.

Improving Patient-Pharmacist Encounters with Over-The-Counter Medications: A Mixed-Methods Pilot Study

Background and Objectives:

Over-the-counter (OTC) medication use has increased safety risks for adults older than 65. Most older adults purchase OTC medications from community pharmacies, where the considerable distance or visual obstructions between the prescription area and OTC aisles undermine pharmacists’ ability to assist patients with OTC medication decisions. An innovative redesign of an abbreviated medication section specifically for older adults (called the Senior Section^TM ) can facilitate pharmacy staff/patient interaction, potentially improving safe medication selection and use. This study evaluated the impact of the Senior Section on the frequency and content of OTC encounters between pharmacy staff and patients.

Research Design and Methods:

An intervention mixed-methods design generated data from patient OTC encounters, and interviews with two pharmacists and two technicians, throughout the study. NVivo was used to code interview transcripts, and frequencies and chi-square analyses demonstrated pre/post-intervention comparisons for the OTC encounter variables.

Results:

After Senior Section implementation, pharmacy staff were more likely to initiate (and be involved in) patient encounters, address more topics or problem/symptoms, provide details about OTC products, discuss appropriateness of OTC use, and discuss medication classes highlighted in the Senior Section. Pharmacy staff were less likely to need to leave the prescription department for extended periods; they also had fewer prolonged encounters or encounters about product location. Importantly, the Senior Section did not impede pharmacy workflow.

Discussion and Implications:

The Senior Section prompted more frequent, effective, and efficient engagements between pharmacy staff and patients, which may substantially reduce OTC-related harms among older adults.

A pilot study of decision factors influencing over-the-counter medication selection and use by older adults

BACKGROUND AND OBJECTIVES

Despite their availability without prescription, OTC medications pose a risk for significant harm for older adults due to higher likelihood of polypharmacy, drug interactions, and age-related physiological changes. The purpose of this study is to identify the individual decision factors that influence how older adults select and use over-the-counter medications.

METHODS

A pilot study was conducted with 20 community-dwelling older adults. Older adults met the interviewer at a regional mass merchandise store where they were given both pain and insomnia standardized scenarios. Participants described how they would select and then hypothetically use a given medication to treat the problem described in the scenario.

RESULTS

OTC medication selection and reported use were influenced by several person-level decision-making factors including: personal beliefs/knowledge about OTCs, assessment of the ailment, and medical constraints.

CONCLUSION

The findings from this investigation provide direction for interventions to address unsafe OTC medication selection by older adults.

Differential Mobility Spectrometry of Ketones in Air at Extreme Levels of Moisture

The performance of a differential mobility spectrometer was characterized at ambient pressure and ten values of water vapor concentration, from 1.0 × 102 to 1.7 × 104 ppm using a homologous series of seven ketones from acetone to 2-dodecanone. Dispersion plots at 30 °C with separation fields from 35 to 123 Td exhibited increased alpha functions for the hydrated proton, protonated monomers, and proton bound dimers with increased moisture levels. Increases in the level of moisture were accompanied by decreased quantitative response with progressive suppression in the formation of the proton bound dimer first and then protonated monomer. Product ions for 2-octanone at 7 ppb were not observed above a moisture level of 4.0 × 103 ppm, establishing a limit for observation of analyte ion formation. The observation limit increased from 1.1 × 103 ppm for acetone to 5.7 × 103 ppm for 2-dodecanone. These findings demonstrate that ketones can be determined with a differential mobility spectrometry (DMS) analyzer near room temperature in the presence of elevated levels of moisture expected with the use of membrane inlets or headspace sampling of surface or ground waters. Moisture levels entering this DMS analyzer employed as an environmental monitor should be kept at 1.0 × 103 ppm or below and quantitative studies for individual ketones should be made at a fixed moisture level.

Interruptions in community pharmacies: Frequency, sources, and mitigation strategies

BACKGROUND

Interruptions constitute a key part of the communication strategy for healthcare providers, including community pharmacy personnel. Previous research in other healthcare environments has shown that interruptions are very common and may present as patient safety hazards. One 1999 study, conducted in community pharmacy settings, found that interruptions were prevalent and associated with dispensing errors. In the last 20 years, pharmacies have expanded patient services and implemented new technology. Yet, it is unknown how these changes have affected interruption sources and frequency.

OBJECTIVE

The objective was to characterize the frequency and sources of pharmacist task interruptions that occur in community pharmacies.

METHODS

A cross-sectional qualitative study design was used to evaluate the frequency and sources of pharmacist task interruptions in Wisconsin community pharmacies. The participants included 9 pharmacists and 9 technicians working in 2 independently-owned, 2 mass merchandise, and 2 hospital/clinical-affiliated pharmacies.

RESULTS

Interruption rates ranged from 3 to 7 per hour across the 6 pharmacies. Sources of interruptions included: patients, technicians, self-initiated interruptions, technology used in the pharmacy, and a second pharmacist.

CONCLUSIONS

Interruptions are common in community pharmacies and the causes are multifactorial. Prudent management of interruptions in these work environments may involve improved technician training and better designs of pharmacy technology.

Contextual factors influencing medication management by rural informal caregivers of older adults

BACKGROUND

Managing medications is an important part of the rural informal caregiver's role in the community setting, and the context within which care is provided plays an important role in shaping the work they perform. However, little is known about the intra- and interpersonal factors that impact the rural caregiver's involvement in and performance of medication management.

OBJECTIVES

To identify contextual factors influencing medication management by rural informal caregivers of older adults.

METHODS

Four separate focus groups with rural caregivers of older adults were conducted with 5-9 caregivers per group. Participants were asked to describe the medication management activities performed and problems they encountered while providing assistance. Focus groups were recorded, transcribed verbatim, and analyzed for themes using an inductive approach.

RESULTS

Care recipient independence, or their ability and preference to perform medication-related activities without supervision, was a key factor driving the caregiver's involvement in medication management and how it was performed. Many caregivers used a team-based approach to medication management that supported the care recipient's independence. Care recipient health and function was a driver behind the need for caregiving, and declines in physical and mental health led to changes in how medication management was carried out over time. Caregiver location also impacted the ways in which medication management was performed by caregivers.

CONCLUSIONS

Interventions and pharmacy services to support medication management by rural informal caregivers should be designed in a way that preserves and promotes the care recipient's independence, and should be tailored to the context within which caregiving is performed.

Human Factors in Pharmacy

Medication errors in the ambulatory setting are common and contribute to significant morbidity and mortality. Given the Institute of Medicine’s recommendation of adopting a systems-based approach to improving medication safety, research has been conducted utilizing human factors and ergonomics conceptual frameworks, approaches, and methods to study pharmacies and pharmacists. This panel will focus on how human factors principles and models have been adapted for contexts where medications are managed. Individual projects address pediatric patients’ medication-related needs, over-the-counter medication safety for older adults, anticoagulation management, automated prescription tracking, and medication safety-related decision making by healthcare professionals. These studies span settings from community pharmacies to inpatient pharmacies to specialty clinics and patients’ homes. By presenting a sample of the growing body of human factors work in pharmacy, this panel will offer unique implications for human factors theory, methods, and application in this important domain.

Medication management activities performed by informal caregivers of older adults

BACKGROUND

Medication management is commonly performed by informal caregivers, yet they are often unprepared and ill-equipped to manage complex medication regimens for their older adult care recipients. In order to develop interventions that will enhance the caregiver's ability to safely and confidently manage medications, it is critical to first understand caregiver challenges and unmet needs related to medication management.

OBJECTIVES

To explore how informal caregivers manage medications for their older adult care recipients by identifying the activities involved in medication management and the tools or strategies used to facilitate these activities.

METHODS

Four focus groups with caregivers of older adults were conducted with 5-9 caregivers per group. Participants were asked to describe the medication management activities performed and the tools or strategies used to facilitate these activities. Focus groups were recorded, transcribed verbatim, and analyzed for themes using an inductive approach.

RESULTS

Caregivers were commonly involved in 2 types of activities: direct activities requiring physical handling of medications such as obtaining medications, preparing pill boxes, and assisting with medication administration; and indirect activities that were more complex and required more of a cognitive effort by the caregiver, such as organizing and tracking medications, gathering information, and making treatment decisions. They utilized a variety of tools and strategies to support these medication management activities; however, these approaches often needed to be modified or personalized to meet the specific needs of their caregiving situation.

CONCLUSIONS

Informal caregivers play a vital role in ensuring safe and appropriate medication use by older adults. Medication management is complex and involves many activities that are supported through the use of a variety of tools and strategies that have been adapted and individualized to each specific caregiving scenario. Caregivers should be an important component of interventions that aim to improve medication use among older adults.

Population Pharmacokinetic/Pharmacodynamic Modeling of Tumor Size Dynamics in Pembrolizumab-Treated Advanced Melanoma

Pembrolizumab is a potent immune‐modulating antibody active in advanced melanoma, as demonstrated in the KEYNOTE‐001, ‐002, and ‐006 studies. Longitudinal tumor size modeling was pursued to quantify exposure‐response relationships for efficacy. A mixture model was first developed based on an initial dataset from KEYNOTE‐001 to describe four patterns of tumor growth and shrinkage. For subsequent analyses, tumor size measurements were adequately described by a single consolidated model structure that captured continuous tumor size with a combination of growth and regression terms, as well as a fraction of tumor responsive to therapy. This revised model structure provided a framework to efficiently evaluate the impact of covariates and pembrolizumab exposure. Both models indicated that exposure to the drug was not a significant predictor of tumor size response, demonstrating that the dose range evaluated (2 and 10 mg/kg every 3 weeks) is likely near or at the plateau of maximal response.

Disease Systems Analysis of Bone Mineral Density and Bone Turnover Markers in Response to Alendronate, Placebo, and Washout in Postmenopausal Women

A previously established mechanism-based disease systems model for osteoporosis that is based on a mathematically reduced version of a model describing the interactions between osteoclast (bone removing) and osteoblast (bone forming) cells in bone remodeling has been applied to clinical data from women (n = 1,379) receiving different doses and treatment regimens of alendronate, placebo, and washout. The changes in the biomarkers, plasma bone-specific alkaline phosphatase activity (BSAP), urinary N-telopeptide (NTX), lumbar spine bone mineral density (BMD), and total hip BMD, were linked to the underlying mechanistic core of the model. The final model gave an accurate description of all four biomarkers for the different treatments. Simulations were used to visualize the dynamics of the underlying network and the natural disease progression upon alendronate treatment and discontinuation. These results complement the previous applications of this mechanism-based disease systems model to data from various treatments for osteoporosis.

Model-Based Characterization of the Pharmacokinetics of Pembrolizumab: A Humanized Anti-PD-1 Monoclonal Antibody in Advanced Solid Tumors

Pembrolizumab, a potent antibody against programmed death 1 (PD-1) receptor, has shown robust antitumor activity and manageable safety in patients with advanced solid tumors. Its pharmacokinetic (PK) properties were analyzed with population PK modeling using pooled data from the KEYNOTE-001, -002, and -006 studies of patients with advanced melanoma, non-small cell lung cancer (NSCLC), and other solid tumor types. Pembrolizumab clearance was low and the volume of distribution small, as is typical for therapeutic antibodies. Identified effects of sex, baseline Eastern Cooperative Oncology Group performance status, measures of renal and hepatic function, tumor type and burden, and prior ipilimumab treatment on pembrolizumab exposure were modest and lacked clinical significance. Furthermore, simulations demonstrated the model has robust power to detect clinically relevant covariate effects on clearance. These results support the use of the approved pembrolizumab dose of 2 mg/kg every 3 weeks without dose adjustment in a variety of patient subpopulations.

A preliminary examination of over-the-counter medication misuse rates in older adults

BACKGROUND

Older adults are the largest consumers of over the counter (OTC) medications. Of the older adults who are at risk of a major adverse drug event, more than 50% of these events involve an OTC medication.

OBJECTIVE

To explore how older adults select and hypothetically use OTC medications and if the selected medications would be considered safe for use.

METHODS

Walking interviews were conducted with 20 community-dwelling older adults in a community pharmacy. Each participant selected an OTC medication for a hypothetical pain and sleep scenario. Data were analyzed for four types of misuse: drug-drug interaction, drug-disease interaction, drug-age interaction, and excess usage.

RESULTS

At least one instance of potential misuse was found in 95% of participants. For sleep medications, drug-drug interactions and drug-age interactions were more common, affecting 50% and 65% of participants respectively. The most common type of misuse noted in the pain products selected was that of drug-drug interaction, with a total of 39 occurrences, affecting 60% of the participants.

CONCLUSIONS

OTC misuse is common among older adults, and it is important for older adults to seek out resources, such as a pharmacist, to help them make safe OTC decisions.

Barriers and facilitators to recovering from e-prescribing errors in community pharmacies

OBJECTIVE

To explore barriers and facilitators to recovery from e-prescribing errors in community pharmacies and to explore practical solutions for work system redesign to ensure successful recovery from errors.

DESIGN

Cross-sectional qualitative design using direct observations, interviews, and focus groups.

SETTING

Five community pharmacies in Wisconsin.

PARTICIPANTS

13 pharmacists and 14 pharmacy technicians.

INTERVENTIONS

Observational field notes and transcribed interviews and focus groups were subjected to thematic analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) work system and patient safety model.

MAIN OUTCOME MEASURES

Barriers and facilitators to recovering from e-prescription errors in community pharmacies.

RESULTS

Organizational factors, such as communication, training, teamwork, and staffing levels, play an important role in recovering from e-prescription errors. Other factors that could positively or negatively affect recovery of e-prescription errors include level of experience, knowledge of the pharmacy personnel, availability or usability of tools and technology, interruptions and time pressure when performing tasks, and noise in the physical environment.

CONCLUSION

The SEIPS model sheds light on key factors that may influence recovery from e-prescribing errors in pharmacies, including the environment, teamwork, communication, technology, tasks, and other organizational variables. To be successful in recovering from e-prescribing errors, pharmacies must provide the appropriate working conditions that support recovery from errors.

The myth of standardized workflow in primary care

OBJECTIVE

Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns.

METHODS

This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic.

RESULTS

PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit.

DISCUSSION

PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice.

CONCLUSIONS

Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care.

Application of a Systems Pharmacology-Based Placebo Population Model to Analyze Long-Term Data of Postmenopausal Osteoporosis

Osteoporosis is a progressive bone disease characterized by decreased bone mass resulting in increased fracture risk. The objective of this investigation was to test whether a recently developed disease systems analysis model for osteoporosis could describe disease progression in a placebo-treated population from the Early Postmenopausal Intervention Cohort (EPIC) study. First, we qualified the model using a subset from the placebo arm of the EPIC study of 222 women who had similar demographic characteristics as the 149 women from the placebo arm of the original population. Second, we applied the model to all 470 women. Bone mineral density (BMD) dynamics were changed to an indirect response model to describe lumbar spine and total hip BMD in this second population. This updated disease systems analysis placebo model describes the dynamics of all biomarkers in the corresponding datasets to a very good approximation; a good description of an individual placebo response will be valuable for evaluating treatments for osteoporosis.

Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis

BACKGROUND

The U.S. Agency for Healthcare Research and Quality (AHRQ) developed a hospital patient safety culture survey in 2004 and has adapted this survey to other healthcare settings, such as nursing homes and medical offices, and most recently, community pharmacies. However, it is unknown whether safety culture dimensions developed for hospitals can be transferred to community pharmacies. The aim of this study was to assess the psychometric properties of the Community Pharmacy Survey on Patient Safety Culture.

METHOD

The survey was administered to 543 community pharmacists in Wisconsin, USA. Confirmatory factor analysis was used to assess the fit of our data with the proposed AHRQ model. Exploratory factor analysis was used to determine the underlying factor structure. Internal consistency reliabilities were calculated.

RESULTS

A total of 433 usable surveys were returned (response rate 80%). Results from the confirmatory factor analysis showed inadequate model fit for the original 36 item, 11-factor structure. Exploratory factor analysis showed that a modified 27-item, four-factor structure better reflected the underlying safety culture dimensions in community pharmacies. The communication openness factor, with three items, dropped in its entirety while six items dropped from multiple factors. The remaining 27 items redistributed to form the four-factor structure: safety-related communication, staff training and work environment, organisational response to safety events, and staffing, work pressure and pace. Cronbach's α of 0.95 suggested good internal consistency.

CONCLUSIONS

Our findings suggest that validation studies need to be conducted before applying safety dimensions from other healthcare settings into community pharmacies.

(De)synchronization of advanced visual information and ball flight characteristics constrains emergent information-movement couplings during one-handed catching

Advance visual information of a projection action and ball flight information is important for organizing dynamic interceptive actions like catching. However, how the central nervous system (CNS) manages the relationship between advance visual information and emerging ball flight information in regulating behavior is less well understood. Here, we sought to examine the extent that advance visual information to the CNS constrains regulation of catching actions by synchronizing and desynchronizing its relationship with ball trajectory characteristics. Novel technology was used to present video footage of an actor throwing a ball at three different speeds, integrated with information from a real ball projected by a machine set to the three speeds. The technology enabled three synchronized and six desynchronized conditions between advance visual information and subsequent ball flight trajectories. Catching performance, kinematic data from the catching hand and gaze behaviors were recorded. Findings revealed that desynchronization of video images of ball projection shaped emergent catching behaviors. Footage of slower throws, paired with faster ball projection speeds, caused catching performance decrements. Timing in early phases of action was organized by the CNS to match the advance visual information presented. In later phases, like the grasp, ball flight information constraints adapted and regulated behaviors. Gaze behaviors showed increased ball projection speed resulted in participants tracking the ball for a smaller percentage of ball flight. Findings highlighted the role of the two visual systems in perception and action, implicating the importance of coupling advanced visual information and ball flight to regulate emergent movement coordination tendencies during interceptive behaviors.

Implementation of quantitative and systems pharmacology in large pharma

Quantitative and systems pharmacology concepts and tools are the foundation of the model-informed drug development paradigm at Merck for integrating knowledge, enabling decisions, and enhancing submissions. Rigorous prioritization of modeling and simulation activities has enabled key drug development decisions and led to a high return on investment through significant cost avoidance. Critical factors for the successful implementation, examples on impact on decision making with associated return of investment, and drivers for continued success are discussed.

Facilitating collaboration between pharmacists and physicians using an iterative interview process

OBJECTIVE To elicit and describe mutually agreed upon common problems and subsequent solutions resulting from a facilitated face-to-face meeting between pharmacists and physicians. DESIGN Descriptive, exploratory, nonexperimental study. SETTING Wisconsin from October to December 2011. PARTICIPANTS Physicians and community pharmacists. INTERVENTION Face-to-face semistructured interviews with pharmacists and physicians from the same community, informed by previous individual interviews. MAIN OUTCOME MEASURES Methods to enhance collaboration and barriers to implementing collaboration between pharmacists and physicians. RESULTS Physicians and pharmacists generated ideas in which collaboration could improve patient care, including controlled substance monitoring, medication adherence, collaborative practice agreements for point-of-service issues, and a mechanism for urgent communication. Methods on how to collaborate on these issues also were discussed. CONCLUSION Bringing physicians and pharmacists together for a face-to-face interaction that was informed by information gained in previous individual interviews successfully stimulated conversation on ways in which each profession could help the other provide optimal patient care. This interaction appeared to dispel assumptions and build trust. The results of this project may provide pharmacists with the confidence to reach out to their physician colleagues.

Using a conflict conceptual framework to describe challenges to coordinated patient care from the physicians' and pharmacists' perspective

BACKGROUND

In an effort to increase cost-effectiveness of health care and reduce overall costs, patient-centered medical homes have been proposed to spur fundamental changes in the way primary care is delivered. One of the chief principles that describe a patient-centered medical home is that care is organized across all elements of the broader health care system, including community pharmacies.

OBJECTIVES

To identify and describe challenges derived from a conflict management framework to a physician-pharmacist approach to coordinating patient care.

METHODS

A descriptive, exploratory, non-experimental study was conducted in Wisconsin (U.S. State) from June to December, 2011. Data were collected through two rounds of face-to-face interviews with physicians and community pharmacists. The first round involved one-on-one interviews with pharmacists and physicians. The second round brought pharmacist-physician dyads together in an open-ended interview exploring issues raised in the first round. Content analysis was guided by a conflict management conceptual framework using NVivo 10 qualitative software.

RESULTS

A total of four major themes emerged from the conflict analysis of interviews that illustrate challenges to coordinated patient care: Scarce resources, technology design and usability, insurance constraints, and laws and policy governing patient care. The study findings indicate that both groups of health care professionals work within an environment of conflict and have to negotiate the challenges and strains that exist in the current health care system. Their need to work together, or interdependence, is primarily challenged by scarce resources and external interference.

CONCLUSIONS

Efforts to coordinate patient care through teams of inter-professional health care providers will be more successful if they acknowledge the inherent conflict that exists. Efforts should be made to provide an infrastructure for interdependence and to support interpersonal communication.

The prescription handoff in community pharmacy: a study of its form and function

OBJECTIVE

To describe and explore handoffs in community pharmacy.

DESIGN

Descriptive, exploratory, nonexperimental study.

SETTING

Wisconsin, August to October 2008.

PARTICIPANTS

Community pharmacists.

INTERVENTION

Brief, face-to-face, semistructured interviews.

MAIN OUTCOME MEASURE

Information on characteristics of handoffs, including the reasons for handoffs, what kind of information is shared during handoffs, and how information is shared.

RESULTS

The overarching reasons handoffs are done in community pharmacy are because some of the necessary information is confusing, contradictory, or absent, and/or the drug product is not in stock. Handoff information typically consists of a description of the problem, the current status of the problem, what information is still needed, and future steps to resolve the problem. Handoffs can occur synchronously during a shift change or asynchronously when one pharmacist signs out at the end of the day and another pharmacist opens the pharmacy the next morning. While synchronous handoffs are generally verbal in nature, asynchronous handoff information is primarily conveyed via paper or electronic notes on the dispensing computer system.

CONCLUSION

Our results suggest that handoffs do take place in community pharmacies and that the process is unstructured and variable. Future studies should fully characterize this process and explore possible strategies for improvement.

How do community pharmacies recover from e-prescription errors?

BACKGROUND

The use of e-prescribing is increasing annually, with over 788 million e-prescriptions received in US pharmacies in 2012. Approximately 9% of e-prescriptions have medication errors.

OBJECTIVE

To describe the process used by community pharmacy staff to detect, explain, and correct e-prescription errors.

METHODS

The error recovery conceptual framework was employed for data collection and analysis. 13 pharmacists and 14 technicians from five community pharmacies in Wisconsin participated in the study. A combination of data collection methods were utilized, including direct observations, interviews, and focus groups. The transcription and content analysis of recordings were guided by the three-step error recovery model.

RESULTS

Most of the e-prescription errors were detected during the entering of information into the pharmacy system. These errors were detected by both pharmacists and technicians using a variety of strategies which included: (1) performing double checks of e-prescription information; (2) printing the e-prescription to paper and confirming the information on the computer screen with information from the paper printout; and (3) using colored pens to highlight important information. Strategies used for explaining errors included: (1) careful review of patient's medication history; (2) pharmacist consultation with patients; (3) consultation with another pharmacy team member; and (4) use of online resources. In order to correct e-prescription errors, participants made educated guesses of the prescriber's intent or contacted the prescriber via telephone or fax. When e-prescription errors were encountered in the community pharmacies, the primary goal of participants was to get the order right for patients by verifying the prescriber's intent.

CONCLUSION

Pharmacists and technicians play an important role in preventing e-prescription errors through the detection of errors and the verification of prescribers' intent. Future studies are needed to examine factors that facilitate or hinder recovery from e-prescription errors.

Safeguarding older adults from inappropriate over-the-counter medications: the role of community pharmacists

PURPOSE OF THE STUDY

To elicit the thought process or mental model that community pharmacists use when making recommendations on over-the-counter (OTC) medications to older adults and to elicit the current practices of community pharmacists in providing information, advice, and counseling to older adults about potentially inappropriate OTC medications.

DESIGN AND METHODS

Three separate focus groups with pharmacists were conducted with 5 to 8 pharmacists per group. A vignette about an elderly woman seeking an OTC sleep aid was used to elicit information that pharmacists seek to establish when making a recommendation. Focus groups were recorded, transcribed verbatim, and analyzed for themes using the initial and focused coding methods of grounded theory.

RESULTS

Community pharmacists' mental models were characterized by 2 similarities: a similarity in what community pharmacists seek to establish about patients and a similarity in when community pharmacists seek to establish it--the sequence in which they try to learn key details about patients. It was identified that pharmacists gather specific information about the patient's medication profile, health conditions, characteristics of the problem, and past treatments in order to make a recommendation. Community pharmacists recommended behavioral modifications and seeing their physician prior to recommending an OTC sleep aid, primarily due to medication safety concerns.

IMPLICATIONS

Pharmacists can play a key role in assisting older adults to select and use OTC medications.

Rifampin's acute inhibitory and chronic inductive drug interactions: experimental and model-based approaches to drug-drug interaction trial design

We studied the time course for the reversal of rifampin's effect on the pharmacokinetics of oral midazolam (a cytochrome P450 (CYP) 3A4 substrate) and digoxin (a P-glycoprotein (P-gp) substrate). Rifampin increased midazolam metabolism, greatly reducing the area under the concentration-time curve (AUC(0-∞)). The midazolam AUC(0-∞) returned to baseline with a half-life of ~8 days. Rifampin's effect on the AUC(0-3 h) of digoxin was biphasic: the AUC(0-3 h) increased with concomitant dosing of the two drugs but decreased when digoxin was administered after rifampin. Digoxin was found to be a weak substrate of organic anion-transporting polypeptide (OATP) 1B3 in transfected cells. Although the drug was transported into isolated hepatocytes, it is not likely that this transport was through OATP1B3 because the transport was not inhibited by rifampin. However, rifampin did inhibit the P-gp-mediated transport of digoxin with a half-maximal inhibitory concentration (IC(50)) below anticipated gut lumen concentrations, suggesting that rifampin inhibits digoxin efflux from the enterocyte to the intestinal lumen. Pharmacokinetic modeling suggested that the effects on digoxin are consistent with a combination of inhibitory and inductive effects on gut P-gp. These results suggest modifications to drug-drug interaction (DDI) trial designs.

Pharmacokinetics of raltegravir in individuals with UGT1A1 polymorphisms

Raltegravir is a human immunodeficiency virus-1 (HIV-1) integrase strand transfer inhibitor metabolized by glucuronidation via UDP-glucuronosyltransferase 1A1 (UGT1A1). In this study, 30 subjects with a UGT1A1*28/*28 genotype (associated with decreased activity of UGT1A1) and 27 UGT1A1*1/*1 control subjects (matched by race, age, gender, and body mass index) received a single 400-mg dose of raltegravir after fasting. No serious adverse experiences were reported, and there were no discontinuations due to adverse experiences. The geometric mean ratio (GMR) (UGT1A1*28/*28 to UGT1A1*1/*1) and 90% confidence interval (CI) were 1.41 (0.96, 2.09) for raltegravir area under the concentration-time curve (AUC(0-infinity)), 1.40 (0.86, 2.28) for maximum plasma concentration (C(max)), and 1.91 (1.43, 2.55) for concentration at the 12-h time point (C(12 h)). No clinically important differences in time to maximum concentration (T(max)) or half-life were observed. Plasma concentrations of raltegravir are modestly higher in individuals with the UGT1A1*28/*28 genotype than in those with the UGT1A1*1/*1 genotype. This increase is not clinically significant, and therefore no dose adjustment of raltegravir is required for individuals with the UGT1A1*28/*28 genotype.

Safety, Tolerability, and Pharmacokinetics of Raltegravir After Single and Multiple Doses in Healthy Subjects

Raltegravir is a novel human immunodeficiency virus-1 integrase inhibitor with potent in vitro activity (95% inhibitory concentration (IC95)=33 nM in 50% human serum). Three double-blind, randomized, placebo-controlled, pharmacokinetic, safety, and tolerability studies were conducted: (1) single-dose escalation study (10-1,600 mg), (2) multiple-dose escalation study (100-800 mg q12 h x 10 days), and (3) single-dose female study (400 mg). Raltegravir was rapidly absorbed with a terminal half-life (t1/2) approximately 7-12 h. Approximately 7-14% of raltegravir was excreted unchanged in urine. Area under the curve (AUC)(0-infinity) was similar between male and female subjects. After multiple-dose administration, steady state was achieved within 2 days; there was little to modest accumulation of raltegravir. Trough levels were >33 nM for dose levels of 100 mg and greater. Raltegravir is generally well tolerated at doses of up to 1,600 mg/day given for up to 10 days and exhibits a pharmacokinetic profile supportive of twice-daily dosing with multiple doses of 100 mg and greater achieving trough levels >33 nM.

Mobility resolution and mass analysis of ions from ammonia and hydrazine complexes with ketones formed in air at ambient pressure

Protonated ammonia and hydrazines (MH(+)) form complexes with ketones and the differences in masses and mobilities of the resulting ions, MH(+)(ketone)(n), are sufficient for separation in an ion mobility spectrometer at ambient pressure. The highest mass ion for any of the protonated molecules is obtained when the ketone is present at elevated concentrations in the supporting atmosphere of both the source and drift regions of the spectrometer so that an ion maintains a discrete composition and mobility. The sizes of the ion-molecule complexes were found to depend on the number of H atoms on the protonated nitrogen atom--four for ammonia, three for hydrazine, two for monomethylhydrazine, and one for 1,1-dimethylhydrazine, and the drift times of these ions were proportional to the size of the ion-molecule complex. Unexpected side products, including protonated hydrazones and azines, and associated ketone clusters, were isolated to a single drift tube containing ceramic parts and could not, from CID studies, be attributed to gas-phase ion chemistry. These findings illustrate that mobility resolution of ions in IMS and IMS/MS experiments can be enhanced through chemical modification of the supporting gas atmosphere without changes in the core ion.

Characterization of nelfinavir binding to plasma proteins and the lack of drug displacement interactions

OBJECTIVES

To determine the characteristics of the binding of nelfinavir and active M8 to alpha1-acid glycoprotein (AAG) and human serum albumin (HSA), and to examine the displacement effects of drugs binding extensively to AAG (ritonavir and saquinavir) or to HSA (salicylic acid and valproic acid).

METHODS

Free drugs were separated by equilibrium dialysis after incubation with human plasma or purified plasma proteins and after co-incubation with potential displacers. Association constants were estimated from double-reciprocal plots of the data.

RESULTS

Nelfinavir and M8 free fractions [fractions of unbound drug (fus)] were 0.42+/-0.08% (mean+/-standard deviation) and 0.64+/-0.07%, respectively. For the two analytes, respectively, association constants were 7.25 x 10(7)/m and 3.33 x 10(7)/m for AAG and 1.11 x 10(6)/m and 7.92 x 10(5)/m for HSA. Nelfinavir fu in an AAG solution was significantly (P < 0.01) increased by the addition of ritonavir or saquinavir, whereas it was unaltered by addition of these drugs to whole plasma. Similarly, fu in an HSA solution was significantly increased (P < 0.01) by the addition of salicylic acid or valproic acid, whereas there was no difference in the free fraction in plasma.

CONCLUSIONS

The affinity of nelfinavir for human plasma proteins was higher than that of M8, and both nelfinavir and M8 showed higher affinity to AAG than to HSA. The free fraction of nelfinavir was not affected by drugs that bind extensively to AAG or albumin when these drugs were added to whole plasma in combination, suggesting a compensatory effect of alternate binding proteins.

Exaggerated respiratory chemosensitivity and association with level at 3568m in obesity

To investigate whether obesity is associated with alterations in respiratory chemosensitivity, we compared the ventilatory response to hypoxia (HVR) and hypercapnia (HCVR) in 9 obese men (BMI: 37.0+/-4.3 kg m(-2)) and 10 lean men (BMI: 25.8+/-4.8 kg m(-2)). HVR (DeltaVE, L min(-1) per DeltaSaO2, %) was measured by a progressive isocapnic hypoxia technique, and HCVR (DeltaVE/DeltaPETCO2, L min(-1)Torr(-1)) was measured by a progressive hypercapnic method. HCVR, was greater (p<0.001) in the obese men (2.68+/-0.78) than in the lean men (1.4+/-0.45) as was HVR (p<0.05) (1.26+/-0.65 versus 0.71+/-0.43, respectively). The difference (DeltaSaO2, 4.30+/-3.69 and 10.54+/-3.45 in the lean and obese men, respectively, p<0.01) between daytime (86+/-1 and 86+/-1%) and nighttime SaO2 (81+/-3 and 76+/-4%) at a simulated altitude of 3658 m was significantly (p<0.05) correlated with both HVR (r=0.51) and HCVR (r=0.48). These results suggest that chemosensitivity in mildly obese men is increased, not blunted. Furthermore, otherwise healthy, obese individuals have the potential for significant desaturation during sleep at high altitude possibly due to exaggerated sleep-disordered breathing.

Effect of moisture on the field dependence of mobility for gas-phase ions of organophosphorus compounds at atmospheric pressure with field asymmetric ion mobility spectrometry

The electric field dependence of the mobilities of gas-phase protonated monomers [(MH+(H2O)n] and proton-bound dimers [M2H+(H2O)n] of organophosphorus compounds was determined at E/N values between 0 and 140 Td at ambient pressure in air with moisture between 0.1 and 15 000 ppm. Field dependence was described as alpha (E/N) and was obtained from the measurements of compensation voltage versus field amplitude in a planar high-field asymmetric waveform ion mobility spectrometer. The alpha function for protonated monomers to 140 Td was constant from 0.1 to 10 ppm moisture in air with onset of effect at approximately 50 ppm. The value of alpha increased 2-fold from 100 to 1000 ppm at all E/N values. At moisture values between 1000 and 10 000 ppm, a 2-fold or more increase in alpha (E/N) was observed. In a model proposed here, field dependence for mobility through changes in collision cross sections is governed by the degree of solvation of the protonated molecule by neutral molecules. The process of ion declustering at high E/N values was consistent with the kinetics of ion-neutral collisional periods, and the duty cycle of the waveform applied to the drift tube. Water was the principal neutral above 50 ppm moisture in air, and nitrogen was proposed as the principal neutral below 50 ppm.

Canadian guidelines for cardiac rehabilitation and atherosclerotic heart disease prevention: a summary

Atherosclerotic heart disease (AHD) is the leading cause of death in Canadian women and men. Cardiac rehabilitation has been repeatedly shown to reduce cardiac morbidity and mortality significantly among patients with documented AHD. The Canadian Association of Cardiac Rehabilitation (CACR) has defined cardiac rehabilitation as "the enhancement and maintenance of cardiovascular health through individualized programs designed to optimize physical, psychological, social, vocational and emotional status. This process includes the facilitation and delivery of secondary prevention through heart hazard (risk factor) identification and modification in an effort to prevent disease progression and the recurrence of cardiac events". This summary presents a limited amount of background information and the majority of clinical practice recommendations contained within the previously published CACR Guidelines. These evidence-based clinical recommendations are intended as guidelines to good clinical practice rather than as standards of care. The key focus of this summary is the need for complete and targeted intervention of all heart hazards in patients at high or very high risk for, or with documented, AHD. To achieve this goal, the CACR Guidelines and this summary present risk stratification strategies designed to determine unambiguously a patient's risk of exercise-related cardiac events (short term absolute risk or disease prognosis) and their risk of recurrent AHD events (long term absolute risk from disease progression). The establishment of the short term and long term absolute AHD risks can then be used to determine heart hazard targets and the type of exercise program prescribed for patients with AHD. Despite the use of evidence-based medical practices, none of the recommendations presented in this document can replace the expert judgment of properly trained and experienced cardiac rehabilitation professionals. Health care providers must always be free to choose where and when clinical practice guidelines are applied, modified or superceded, depending on individual patient circumstances.

An LC-MS-MS method for the determination of indinavir, an HIV-1 protease inhibitor, in human plasma

A method for the determination of indinavir (IDV) (L-735 524) in human plasma by LC-MS-MS is discussed, and the validation data is presented. The analyte and internal standard are isolated from plasma by a simple acetonitrile precipitation of plasma proteins followed by centrifugation. LC-tandem mass spectrometry in positive ion, multiple reaction monitoring mode used pairs of ions at m/z of 614/421 for indinavir and 628/421 for internal standard, respectively. The calibration curve had a linear range from 3.0 to 12320 ng/ml when linear least square regression weighing 1/x was applied to the concentration versus peak area plot. The advantages of this method are the fast sample preparation, wide dynamic assay range and quick analysis taking only 5 min for each sample run. The robust nature of this assay has been further verified during routine use over several months involving multiple analysts.

Malignant schwannoma of the trigeminal nerve

SUMMARY

We present the MR imaging, CT, and clinical findings of a patient with malignant schwannoma of the trigeminal nerve. Local tumor recurrence is frequent and may be mistaken for lymphatic spread. In this report, we emphasize the natural history of this rare tumor and discuss the importance of imaging in diagnosis and surveillance.

Demyelinating diseases, leukodystrophies, and other myelin disorders

Magnetic resonance (MR) imaging recently has become the most sensitive clinical test in the detection of white matter disorders, yet neuropathologic evaluation remains the most specific. This article describes the gross and microscopic pathology of various diseases primarily or selectively affecting white matter. The discussion should provide deeper insight into the nature of white matter disease and assist in the interpretation of CT and MR images. The subject of white matter damage caused secondarily by such entities as neoplasia, trauma, infarction, or neuronal degeneration is not included.