A narrative review of the well-being and burnout of U.S. community pharmacists

OBJECTIVES

The purpose of this narrative review is to summarize the literature on well-being and burnout among community pharmacists in the U.S. and provide recommendations for future research.

METHODS

Relevant literature was identified by searching PubMed for combinations of keywords such as "burnout" and "well-being" combined with "pharmacists." Titles and abstracts were reviewed for relevancy, and full text articles were reviewed when applicable.

RESULTS

While burnout is defined by its 3 core symptoms of emotional exhaustion, depersonalization, and low personal accomplishment, well-being is more challenging to define and measure, which has led to it being less studied. Community pharmacists faced high rates of burnout, low quality of life (QOL), and extreme fatigue prior to the COVID-19 pandemic, a situation that has likely only worsened. Factors such as workload, the type of community pharmacy, the level of education or training of the pharmacist, and stress may be some of the contributors to high rates of burnout. Clinician burnout may be related to high rates of mental health disorders seen in pharmacists, may impact patient safety and satisfaction, and may affect productivity and costs to employers and the healthcare system overall. There has been no research into interventions or strategies to support well-being and reduce burnout among community pharmacists, but having a workplace that is perceived as supporting well-being may have some impact. Recommendations for future research include the following: (1) define well-being, (2) explore why various factors support well-being or contribute to burnout, (3) determine the impact of community pharmacists experiencing well-being or burnout, and (4) develop strategies to support well-being and reduce burnout that are specific to community pharmacy.

CONCLUSION

There is a sparsity of evidence regarding community pharmacist well-being and burnout. Further research is needed to generate the evidence needed to support interventions that are specific to the unique work setting of community pharmacists.

An examination of the emerging field of community paramedicine: a national cross-sectional survey of community paramedics

BACKGROUND

Community Paramedicine is an evolving community-based model that expands paramedic roles from emergency and transport care to a focus on non-emergent and preventive health services tailored to local community needs. Though community paramedicine is a growing field and acceptance is gradually increasing, there is limited information on community paramedics (CPs) perceptions of their expanded roles. The study's aim is to assess CPs' perceptions about their training, roles, role clarity, role readiness, role satisfaction, professional identity, interprofessional collaboration, and the future of the community paramedicine care model.

METHODS

Using the National Association of Emergency Medical Technicians-mobile integrated health (NAEMT-MIH) listserv, a cross-sectional survey was conducted in July/August 2020 using a 43-item web-based questionnaire. Thirty-nine questions evaluated CPs' training, roles, role clarity, role readiness, role satisfaction, professional identity, interprofessional collaboration, and program/work characteristics. Four open-ended questions examined perceptions of the future of community paramedicine care models and challenges/opportunities encountered during the COVID-19 pandemic. Data was analyzed using Spearman's correlation, Wilcoxon Mann-Whitney U, and Kruskal-Wallis tests. Open-ended questions were analyzed using qualitative content analyses.

RESULTS

Responses from fifty-seven CPs were analyzed. Most (80%) completed didactic and/or clinical training. Nearly all respondents (96.5%) performed health assessments; only 38.6% administered vaccines. Overall, participants were neutral about their role readiness with a mean score of 3.3/5.0. The mean role clarity was 15.5 (range 4-29; higher scores = higher clarity), professional identity was 46.8 (range 30-55; higher scores = higher identity), role satisfaction was 4.4/5 with 5 = very satisfied, and interprofessional collaboration was 9.5/10 (10 = very important). Role clarity training (rho = 0.4, p = 0.0013) and higher interprofessional collaboration (rho = 0.4, p = 0.0015) were found to be significantly associated with the enhancement of professional identity. Respondents who completed training showed higher role satisfaction compared to those who did not (p = 0.0114). COVID-19 challenges included keeping up with emerging policies/procedures, CPs' well-being, and inadequate funding to meet service needs; opportunities identified included service delivery expansion and CPs meeting community needs in a flexible manner. Respondents reported that sustainable payment models, expanding services, and geographic reach were important to the future of community paramedicine.

CONCLUSIONS

Interprofessional collaboration is important to fulfill CPs roles. Role clarity and readiness could be improved, which aligns with the emerging nature of community paramedicine. The future of the community paramedicine care model is dependent on funding and expanding reach of services.

Evaluating the relationship between patient activation and health-related quality of life (HRQOL) in patients with pancreatic cancer (PwPC)

PURPOSE

Advanced pancreatic cancer is synonymous with a high mortality rate, debilitating symptom profile, and minimal prolongation in overall survival. Therefore, health-related quality of life (HRQOL) is important in patients with pancreatic cancer (PwPC). In chronic conditions, patient activation is positively associated and higher HRQOL. However, no known study has evaluated patient activation, HRQOL, and their association in PwPC.

METHODS

A 43-item cross-sectional survey assessed patient activation and HRQOL of patients with locally advanced and metastatic pancreatic cancer undergoing chemotherapy. Variables were analyzed descriptively, and relationships were assessed using bivariate statistics (sig p < 0.05).

RESULTS

Fifty-six patients participating in the study had an average age of 69.5 ± 11.1 years, and the majority were females (51.8%), Caucasians (61.8%), married/partnered (64.3%), and had at least a college degree (59%). Almost half were at stage 4 (48.2%), and most were newly diagnosed (66.1%). Mean patient activation score was 63.5 ± 17.2 (scale range: 0-100), with most at higher activation levels of 3 or 4 (66.7%). Mean HRQOL score of 41.0 ± 12.7 (scale range: 0-72) was low. Patient activation levels, age, education level, and gender explained 21% of variation in overall HRQOL scores. Patients at activation level 4 had significantly higher overall HRQOL versus those at lower activation (level 1 or 2). Higher patient activation was significantly associated with having either private insurance only or multiple insurances and being partnered.

CONCLUSION

Patient activation significantly predicted HRQOL in PwPC despite the low sample size. Initiatives to increase patient activation should focus on patients of low socioeconomic status and those without partner support.

Comparing survival outcomes between neoadjuvant and adjuvant chemotherapy within breast cancer subtypes and stages among older women: a SEER-Medicare analysis

BACKGROUND

This study aimed to compare survival outcomes of neoadjuvant (NAC) and adjuvant chemotherapy (AdC) within each breast cancer subtype and stage among older women.

METHODS

Older (≥ 66 years) women newly diagnosed with stage I-III invasive ductal breast cancer during 2010-2017 and treated with both chemotherapy and surgery within one year were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Analyses were performed within each of six groups, jointly defined based on subtype (hormone receptor [HR]-positive/human epidermal growth factor receptor 2 [HER2]-negative, HER2 + , and triple-negative) and stage (I-II and III). Kaplan-Meier curves and multivariable Cox models were used to compare overall and recurrence-free survival between NAC and AdC, with optimal full matching performed for confounding adjustment.

RESULTS

Among 8,495 included patients, 8,329 (20.6% received NAC) remained after matching. Before multiple testing adjustment, Cox models showed that NAC was associated with a lower hazard for death among stage III HER2 + patients (hazard ratio = 0.347, 95% confidence interval CI 0.161-0.745) but a higher hazard for death among triple-negative patients (stage I-II: hazard ratio = 1.558, 95% CI 1.024-2.370; stage III: hazard ratio = 2.453; 95% CI 1.254-4.797). A higher hazard for death/recurrence was associated with NAC among stage I-II HR + /HER2- patients (hazard ratio = 1.305, 95% CI 1.007-1.693). No significant difference remained after multiple testing adjustment.

CONCLUSIONS

The opposite trends (before multiple testing adjustment) of survival comparisons for advanced HER2 + and triple-negative disease warrant further research. Caution is needed due to study limitations such as cancer stage validity.

Perceived Discrimination in the Community Pharmacy: A Cross-Sectional, National Survey of Adults

BACKGROUND

Discrimination experiences have been documented in various health care settings; little is known about discrimination experiences in the community pharmacy setting.

OBJECTIVES

This study aimed to (1) describe perceived everyday discrimination, including racial discrimination, in community pharmacies, (2) examine factors associated with perceived everyday discrimination, (3) examine the relationship between perceived racial discrimination and delays in picking up prescriptions, and (4) examine the relationship between perceived racial discrimination and forgoing prescriptions.

METHODS

A cross-sectional survey was conducted in 2021 with a U.S. Qualtrics research panel. The 9-item Everyday Discrimination Scale (EDS) was used to assess perceived discrimination (range 9-45, higher scores indicate higher perceived discrimination). One question asked whether respondents perceived racial discrimination. Two questions asked whether respondents delayed or forwent getting a prescription(s) in the past year. Descriptive statistics were calculated for all variables. A generalized linear model examined factors associated with perceived discrimination; logistic regression examined the relationships between perceived racial discrimination and delays in getting or forgoing prescription(s).

RESULTS

Participants (n = 578) were 40.2 (±16.5) years old. Most were white (55.5%), 24.4% were black, and 29.4% were Hispanic or Latino. The mean EDS score was 16.5 (±8.8); 18.7% perceived racial discrimination. Overall, 36.3% and 33.0% reported a delay in getting and forgoing their prescriptions, respectively. Age (P < 0.0001), sexual identity or orientation (P = 0.010), ethnicity (P = 0.049), annual income (P = 0.012), and prescription insurance (P = 0.008) were associated with perceived discrimination. Those with perceived racial discrimination had significantly higher odds of a delay in getting their prescription(s) than those without perceived racial discrimination (odds ratio 2.6 [95% CI 1.3-5.3]).

CONCLUSIONS

Study findings elucidate discrimination experiences in the community pharmacy and the impact of racial discrimination on individuals' decision in obtaining their medications in a timely manner. Community pharmacy staff need to recognize their implicit biases and obtain training on best practices that promote equitable treatment of diverse patients.

Using the Theory of Planned Behavior to Assess Oregon community pharmacists' intention to prescribe using the Formulary and Protocol Compendia

BACKGROUND

Oregon pharmacists can autonomously prescribe hormonal contraception, naloxone, and various medications and devices from a Formulary and Protocol Compendia (FPC). Prescribing using the FPC has seen limited uptake.

OBJECTIVES

(1) Assess Oregon community pharmacists' intention to prescribe using the FPC; (2) Determine the impact that attitudes, subjective norms (SN), perceived behavioral control (PBC), perceived obligation, and past prescribing behavior have on pharmacists' intention to prescribe; (3) Examine the relationship between beliefs and pharmacists' attitudes, subjective norms, and perceived behavioral control.

METHODS

This study was conducted as a cross sectional survey, which was developed based on the results of a previously conducted research project. A modified version of the Theory of Planned Behavior (TPB) was the study framework. All Oregon community pharmacists with a public email address were invited to participate. The questionnaire collected information on TPB constructs as well as demographic and practice information. TPB constructs were measured directly (intention, attitudes, SN, PBC, perceived obligation, and past prescribing behavior) and indirectly (attitudes, SN, and PBC). Descriptive statistics were used for all items. Multiple linear regression was used to assess Objectives 2 and 3.

RESULTS

There were 175 useable responses included in the analysis of the estimated 1015 community pharmacists that received the survey invitation (17%). Respondents had 16.5 ± 13.3 years in practice, 60% held a PharmD degree, and 69% had prescribed in some manner before. Mean intention to prescribe using the FPC was 5.0 ± 1.5 (7-point scale with 7 indicating higher intention). Attitudes, SN, PBC, and PO were significant predictors of intention to prescribe, while past prescribing behavior was not (Adj R² = 0.741, p < .0001). Attitudes were explained by beliefs about increasing patient access (p = .0179). PBC was explained by beliefs about having policies and procedures in place (p = .004) and feeling comfortable prescribing (p = .008).

CONCLUSIONS

Oregon community pharmacists have a positive intention to prescribe using the FPC, but actual uptake remains low. Efforts to increase uptake should focus on the beliefs that contribute most strongly to pharmacist intention.

Neoadjuvant chemotherapy use trends among older women with breast cancer: 2010-2017

PURPOSE

This study assessed chemotherapy use trends before (neoadjuvant chemotherapy [NAC]) or after surgery (adjuvant chemotherapy [AdC]) among older women with breast cancer and examined factors related to NAC receipt.

METHODS

Women (> 65 years) diagnosed with stage I-III breast cancer during 2010-2017 who received NAC or AdC were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. All patients were stratified into six strata based on subtype (hormone receptor-positive/human epidermal growth factor receptor 2-negative [HR + /HER2-], HER2 + , and triple-negative breast cancer [TNBC]) and stage (I-II and III). Cochran-Armitage tests were performed to test temporal trends of NAC use in each stratum. Multivariable logistic regression analyses were performed to identify factors (sociodemographic and clinical) related to NAC use.

RESULTS

Among included older (mean ± standard deviation: 72.3 ± 5.2 years) women (N = 8,495) with stage I-III breast cancer, NAC use increased from 11.7% (2010) to 32.6% (2017). Significant increases in NAC were found in all strata (p < .0001) with more substantial increases in HER2 + disease and TNBC compared to HR + /HER2- disease. Multivariable logistic regressions identified the youngest age category (66-69 years) and later stage as significant (p < 0.05) predictors of NAC receipt in most strata, in addition to diagnosis year.

CONCLUSION

Similar to the overall breast cancer population, NAC use increased among a population of older women. NAC was received by most patients with stage III HER2 + disease or TNBC in more recent years and was more common among younger elderly women and those in stage III.

Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice

Background: Harm reduction includes treatment and prevention approaches rather than abstinence, as a public health strategy for mitigating the opioid epidemic. Harm reduction is a new strategy for many healthcare professionals, and gaps in knowledge and practices may lead to barriers to optimal treatment. Our objective was to identify and describe gaps in physicians' knowledge, education, and practice in harm reduction strategies related to opioid overdose. Methods: We searched the PubMed, CINAHL, and Web of Science databases for articles published between 2015 and 2021, published in English, containing empirical evidence, addressing opioid harm reduction, and identifying gaps in physicians' knowledge, education, or practice. Results: Thirty-seven studies were included. Studies examined how physicians' perceptions or stigma influenced harm reduction efforts and addressed clinical knowledge gaps in overdose treatment and prevention and OUD treatment. Less than half of the studies addressed access issues at the system level, above the individual healthcare professional. Conclusion: Individual-level interventions should be addressed with professional continuing education and curricular-based changes through experiential and interprofessional education. System-level gaps can be remedied by increasing patient access to care, creating policies favorable to harm reduction, and extending resources to provide harm reduction strategies.

General versus disease-specific health literacy in patients with breast cancer: a cross-sectional study

Health literacy is recognized as a critical factor affecting communication across the continuum of cancer care and plays a key role in patients' ability to meaningfully discuss their condition with healthcare providers. However, there is no consensus on the best approach to measure health literacy in clinical practice. The aims of this study were to compare general and disease-specific measurements of health literacy in patients with breast cancer as well as examine their relationships with patient-provider communication. During office visits, patients with HER-2 + breast cancer who received care at oncology clinics with value-based models of care completed a survey including the 6-item cancer health literacy tool (CHLT-6), 6-item newest vital sign (NVS), 2 items measuring difficulty of patient-provider communication, and 11 demographic/clinical items. The mean age of 146 participants was 57.1 ± 10.8 years. Most participants had adequate general health literacy as measured by the NVS (79%) and a high probability of adequate cancer health literacy (≥ 0.7) as measured by the CHLT-6 (92%). Most patients easily communicated with healthcare providers (90.2%) and understood information they provided (83.5%). However, there was no significant relationship between patient-provider communication and health literacy. Both the CHLT-6 and NVS may be useful tools to assess the health literacy of patients with cancer in clinical practice. Study findings of adequate health literacy and ease of communication might have been influenced by the value-based care models adopted by participating clinics. Further research in more diverse samples of patients with cancer and different types of oncology practice settings is warranted.

Faith-based Health and Social Services for People Experiencing Homelessness in the United States: A Scoping Review of the Literature

Across the U.S., faith communities play a crucial role in delivering services to people experiencing homelessness (PEH). However, factors influencing faith communities' provision of health and social services to PEH and related outcomes are unclear. The purpose of this scoping review of the literature, therefore, was to investigate the provision of health and social services for PEH by faith communities across the U.S.: how those services are coordinated, funded, and sustained, and associated outcomes. Eleven articles met inclusion criteria and were included in this review. Findings suggest that while faith communities provide critical services for PEH, further research is necessary in order to understand how, when, and with whom they work; how programs are funded and sustained; and outcomes associated with these services. We suggest that academic-community partnerships may enhance our understanding of faith-based services for PEH and increase capacity of faith communities for providing them.

GPS Mobile Health Intervention Among People Experiencing Homelessness: Pre-Post Study

BACKGROUND

People experiencing homelessness are at risk for gaps in care after an emergency department (ED) or hospital visit, which leads to increased use, poor health outcomes, and high health care costs. Most people experiencing homelessness have a mobile phone of some type, which makes mobile health (mHealth) interventions a feasible way to connect a person experiencing homelessness with providers.

OBJECTIVE

This study aims to investigate the accuracy, acceptability, and preliminary outcomes of a GPS-enabled mHealth (GPS-mHealth) intervention designed to alert community health paramedics when people experiencing homelessness are in the ED or hospital.

METHODS

This study was a pre-post design with baseline and 4-month postenrollment assessments. People experiencing homelessness, taking at least 2 medications for chronic conditions, scoring at least 10 on the Patient Health Questionnaire-9, and having at least 2 ED or hospital visits in the previous 6 months were eligible. Participants were issued a study smartphone with a GPS app programmed to alert a community health paramedic when a participant entered an ED or hospital. For each alert, community health paramedics followed up via telephone to assess care coordination needs. Participants also received a daily email to assess medication adherence. GPS alerts were compared with ED and hospital data from the local health information exchange (HIE) to assess accuracy. Paired t tests compared scores on the Patient Health Questionnaire-9, Medical Outcomes Study Social Support Survey, and Adherence Starts with Knowledge-12 adherence survey at baseline and exit. Semistructured exit interviews examined the perceptions and benefits of the intervention.

RESULTS

In total, 30 participants were enrolled; the mean age was 44.1 (SD 9.7) years. Most participants were male (20/30, 67%), White (17/30, 57%), and not working (19/30, 63%). Only 19% (3/16) of the ED or hospital visit alerts aligned with HIE data, mainly because of patients not having the smartphone with them during the visit, the smartphone being off, and gaps in GPS technology. There was a significant difference in depressive symptoms between baseline (mean 16.9, SD 5.8) and exit (mean 12.7, SD 8.2; t₁₉=2.9; P=.009) and a significant difference in adherence barriers between baseline (mean 2.4, SD 1.4) and exit (mean 1.5, SD 1.5; t₁₇=2.47; P=.03). Participants agreed that the app was easy to use (mean 4.4/5, SD 1.0, with 5=strongly agree), and the email helped them remember to take their medications (mean 4.6/5, SD 0.6). Qualitative data indicated that unlimited smartphone access allowed participants to meet social needs and maintain contact with case managers, health care providers, family, and friends.

CONCLUSIONS

mHealth interventions are acceptable to people experiencing homelessness. HIE data provided more accurate ED and hospital visit information; however, unlimited access to reliable communication provided benefits to participants beyond the study purpose of improving care coordination.

Smartphone Technology to Empower People Experiencing Homelessness: Secondary Analysis

BACKGROUND

In the United States, the number of people experiencing homelessness has continually increased over the last 3 years. Homelessness is associated with poor health, and people experiencing homelessness are often burdened with high rates of chronic and mental health conditions, functional limitations, and cognitive impairment. Despite the high burden of chronic illness and functional limitations, there is limited literature exploring self-management among homeless populations.

OBJECTIVE

This study aims to investigate how access to smartphone technology facilitates self-management, including the attainment of social needs within the context of homelessness.

METHODS

A secondary analysis of 33 exit interviews from 2 feasibility studies related to mobile health interventions among people experiencing homelessness was conducted. Iterative thematic analysis was used to identify themes representative of participants' experiences using smartphone technology.

RESULTS

Collectively, participants revealed not only how the context of homelessness constrained their ability to engage in activities necessary to self-manage health and meet social needs but also how consistent and predictable access to the tools available through a smartphone changed their behaviors and outlook. The global theme of empowered by technology was identified and defined as how having a smartphone with a plan for unlimited text, calling, data, and transportation allowed participants to navigate homelessness and facilitated self-management.

CONCLUSIONS

People experiencing homelessness used the tools on a smartphone to make decisions, take action, solve problems, and use the resources-skills necessary for fulfilling tasks required for effective self-management. Further, consistent access to smartphone technology and transportation empowered participants to meet the requirements for the attainment of social needs.

"It's Time to Represent": shifting the paradigm to improve the quality of inputs into value assessment frameworks

"It's Time to Represent" integrates 2 strategies that challenge the status quo to increase the diversity of populations that participate in research and address drivers of health disparities to better inform value assessment. The first, a community-engaged campaign, proposes to develop authentic, long-term partnerships with community members, their health care providers, and researchers to tailor recruitment and retention methods for underrepresented groups and hold researchers accountable for equitable selection of study participants. The second proposes to create an expectation for researchers to routinely collect patient-reported, actionable social determinants of health data to generate enhanced real-world evidence and thereby improve the quality of inputs utilized in value assessment frameworks. DISCLOSURE: No specific funding was received for this manuscript. The authors report no potential conflicts of interest.

"It's Time to Represent": shifting the paradigm to improve the quality of inputs into value assessment frameworks

"It's Time to Represent" integrates 2 strategies that challenge the status quo to increase the diversity of populations that participate in research and address drivers of health disparities to better inform value assessment. The first, a community-engaged campaign, proposes to develop authentic, long-term partnerships with community members, their health care providers, and researchers to tailor recruitment and retention methods for underrepresented groups and hold researchers accountable for equitable selection of study participants. The second proposes to create an expectation for researchers to routinely collect patient-reported, actionable social determinants of health data to generate enhanced real-world evidence and thereby improve the quality of inputs utilized in value assessment frameworks. DISCLOSURE: No specific funding was received for this manuscript. The authors report no potential conflicts of interest.

"Without my medication, I'm a wreck": Photo-elicitation to explore medication use among people experiencing homelessness

BACKGROUND

People experiencing homelessness (PEH) live with a high burden of chronic illness, functional and cognitive impairments, and serious mental illness. Many PEH are prescribed complex medication regimens to manage symptoms and improve health and functioning. However, medication use within the context of homelessness is complicated, and adherence is often suboptimal.

OBJECTIVE

To document medication use within the context of homelessness and explore experiences of medication use among people experiencing homelessness (PEH).

METHODS

This study used mixed methods including photo-elicitation interviews. Participants were given a digital camera and asked to take pictures of people, places, things, and situations that represented every day medication use. Participants were also asked to write down reasons for taking the pictures. After two weeks, participants returned the camera and notes. At a subsequent interview, the photographs and notes were reviewed and discussed. Demographic and health-related information was also collected for each participant. An interpretive description approach was used for qualitative data analysis. Quantitative data were analyzed using descriptive statistics in order to describe the sample.

RESULTS

Seven PEH completed this study. Mean age was 45 years (SD = 11.3) and length of homelessness was 6.1 years (SD = 11.3). All reported multiple chronic conditions (≥2) and reported taking 6.6 (SD = 2.6) medications. Participants reported medication adherence barriers with mean score of 37 (SD = 5.5) on the ASK-12, a 12-item scale with a range of 12-60 (higher scores indicate more barriers). Qualitative analysis identified four categories: medication-related burdens, medication-related beliefs, connectedness, and stigmatizing encounters.

CONCLUSIONS

Medication use among PEH is complex and cannot be considered separately from daily life or from struggles to meet basic needs. Multi-level interventions are needed to optimize medication use among PEH, and healthcare professionals including community pharmacists should reinforce beliefs that medication-related benefits outweigh the burdens and then tailor services to the context of homelessness.

Are Health Literacy and Patient Activation Related to Health Outcomes in Breast Cancer Patients?

Background:

Assessing health literacy and patient activation at the beginning of care could facilitate the provision of appropriate information to patients with breast cancer and increase the effectiveness of interventions geared toward improving patient involvement in self-managing their health and, consequently, their quality of life.

Objective:

The aim of this study was to evaluate cancer health literacy and patient activation in patients with breast cancer as well as examine their relationships to health-related quality of life (HRQoL) and resource use.

Methods:

Patients with breast cancer positive for human epidermal growth factor receptor 2 (HER2+) receiving care at 12 oncology clinics in Texas were offered participation in the study via convenience sampling. The survey consisted of the 6-item Cancer Health Literacy Tool, the 13-item Patient Activation Measure, the 27-item Functional Assessment of Cancer Therapy – General (version 4), and single-item measures for number of emergency department visits and hospitalizations as well as clinical and demographic characteristics.

Key Results:

The mean age of the 146 study participants was 57.1 ± 10.8 years; 92% (n = 134) had a high probability (≥0.7) of adequate cancer health literacy whereas 68% percent (n = 99) had high patient activation (level 3 or 4). Cancer health literacy had significant positive relationships with education and household income. Patient activation, education, and number of treatment types received explained 23% of the variation in HRQoL, and all except cancer health literacy were positive and significant predictors. No bivariate/multivariate analysis was conducted for emergency department visits and hospitalizations because there were few reported incidents.

Conclusions:

Interventions that aim to improve HRQoL in patients with breast cancer could target modifiable factors like patient activation. The homogeneity of cancer health literacy among study participants might have influenced its nonsignificant relationship with HRQoL and patient activation. Further assessments of health literacy and patient activation in larger and more diverse populations of patients with breast cancer are warranted. [HLRP: Health Literacy Research and Practice. 2021;5(3):e171–e178.]

Plain Language Summary:

In this study, the majority of patients with breast cancer were found to have high levels of cancer health literacy, patient activation, and health-related quality of life (HRQoL). The significant relationship between patient activation and HRQoL implies that patients with breast cancer who are able to actively participate in managing their health and health care are more likely to have higher HRQoL. Interventions that aim to improve HRQoL in patients with breast cancer could target modifiable factors like patient activation.

Over-the-counter medication use in residents of senior living communities: A survey study

BACKGROUND

Self-medication with over-the-counter (OTC) products is common among older adults. Although OTC self-medication is a convenient way to manage some health issues, older persons may be at higher risk of experiencing medication-related problems. This study examines the prevalence, practices, and preferences associated with OTC medication use in older adult residents of senior living communities.

OBJECTIVES

The study aimed to examine the characteristics of OTC medication users and to quantify the prevalence, attitudes, perceptions, preferences, and practices regarding OTC medication use and decision-making in 2 senior living communities in central Virginia.

METHODS

The study used survey methodology. A 51-item semistructured questionnaire was designed by the research team of geriatrics specialists, and mixed-methods and evaluation researchers. The questionnaire was administered in-person to participants (N = 88). Descriptive analyses were conducted using SAS 9.4. Characteristics of those using OTC medications as directed by a health professional were compared with those of whom were self-medicating with OTC medications.

RESULTS

Most of the sample were women (55%), black (61%) and had less than or equal to a high school education (55%). Analgesics were the most (76%) prevalent OTC therapeutic category used, and aspirin was the most (65%) prevalent OTC medication. A greater (82%) proportion of respondents reported self-recommended OTC medication use (self-medication with OTC medications) rather than physician recommended use (18%). A high (41%) prevalence of inappropriate use of OTC medications was observed in this sample of older adults. Most (80%) considered OTC medications safe and effective. The pharmacy was the most (93%) commonly reported purchase location to buy an OTC medication. Physicians were the most (90%) commonly reported information source for OTC medications.

CONCLUSION

Considering the high percentage of self-reported self-medication, inappropriate use, and experiences of adverse effects, steps should be taken to develop consumer education and relationships with pharmacists to encourage the responsible use of OTC medications in this population.

Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting

BACKGROUND

Pharmacists are increasingly fulfilling roles on primary care teams, yet business models for pharmacist services in these settings have not been optimized. This study describes how an ambulatory care pharmacy department implemented various billing methods to generate revenue for pharmacist services.

OBJECTIVES

(1) Describe pharmacist-delivered billable and non-billable services; and (2) Assess the impact of various billing methods on the return-on-investment (ROI) for billable services.

METHODS

This study was conducted from September 2016 to August 2017 in Virginia. Pharmacist time spent performing billable encounters using current procedural technology (CPT) codes (e.g., incident-to a physician, annual wellness visits) was calculated. Encounters eligible for the hospital-based facility (G0463) and chronic care management (CCM) codes were considered to be potentially billable services. The ROI was calculated for billable and potentially billable services.

RESULTS

A total of 948.3 hours (0.46 full-time equivalents (FTE)), 17% of all clinical services, were billed using CPT codes. This resulted in a total revenue of $173,638.66. Missed revenue from not billing for the G0463 and CCM codes was $68,268.37. The cost of pharmacist services for 0.46 FTE was $78,613.08, resulting in a ROI for billed pharmacist services of 1.2:1. The ROI increased to 1.6:1 when considering potentially billable services.

CONCLUSION

It is feasible to have a positive ROI for billable pharmacist services. To achieve a sustainable business model, there must be a high volume of billable services. G0463 and CCM codes are often underutilized, yet represent significant opportunities in revenue for pharmacist services and should be pursued.

Perceptions and predictors of intention to receive the COVID-19 vaccine

Background

The control of the Coronavirus Disease 2019 (COVID-19) pandemic may be dependent on widespread receipt of an effective vaccine. It is important to understand patient health-related behaviors and perceptions to guide public health vaccination strategies.

Objectives

To examine perceptions of COVID-19 and vaccination beliefs, and identify predictors of intention to receive the COVID-19 vaccine in the US.

Methods

A cross-sectional, web-based survey guided by the Health Belief Model was conducted using a web-based Qualtrics survey panel of US adults. The main outcome was the intention to receive the COVID-19 vaccine if offered. Additional measures included: demographics, perceptions of COVID-19 severity, risk and susceptibility, views of a potential COVID-19 vaccine, virus and vaccine information sources, vaccine beliefs and behaviors, and seasonal flu vaccine history.

Results

A total of 1047 complete responses were included. Females had lower odds of intending to receive the COVID-19 vaccine than males (AOR = 0.54, 95% CI: 0.36–0.80). Those with a two-year degree/some college had lower odds of intending to receive the COVID-19 vaccine compared to those with a high school degree/GED (AOR = 0.59, 95% CI: 0.36–0.97). Respondents who perceived the severity of the virus to be higher, perceived a greater COVID-19 vaccine benefit, and perceived greater general vaccine benefits had higher odds of intending to receive a COVID-19 vaccine (AOR = 1.44, 95% CI: 1.09–1.91; AOR = 2.82, 95% CI: 2.24–3.56; AOR = 1.77, 95% CI 1.41–2.21, respectively).

Conclusions

In this study, intention to receive the COVID-19 vaccine varied across demographics, perceived virus severity, COVID-19 vaccine and general vaccine beliefs. Successful implementation of a COVID-19 immunization strategy by healthcare providers and public health officials will need to incorporate diverse COVID-19 vaccination education strategies tailored to patients' health beliefs.

Use of patient assessment skills in advanced pharmacy practice experiences

INTRODUCTION

Pharmacy programs are required to teach patient assessment (PA) skills. However, pharmacist workforce survey data indicates that limited opportunities exist for students to practice PA skills in real-world settings. The study objectives were to (1) assess how often PA skills are utilized by fourth-year pharmacy (P4) students on advanced pharmacy practice experiences (APPEs), (2) determine perceived competence in performing PA skills, and (3) examine relationships between grade-point average or post-graduation plans and the number of skills performed and between skill use frequency and self-reported competency.

METHODS

P4 students completed a questionnaire assessing 13 PA skills. Respondents performing a skill indicated frequency of use and rated their competence using a 5-point scale. Descriptive and bivariate statistics were reported.

RESULTS

The response rate was 81%. Measuring blood pressure (BP) (76%) and evaluating metered-dose inhaler (MDI) technique (74%) were most commonly performed. Peak-flow meter evaluation (6%) and lymph node examination (2%) were least commonly performed. Measuring BP and evaluating MDI technique had the highest competency ratings (4.6 + 0.7 for both). Lung (3.4 + 0.7) and heart (2.8 + 1) auscultation had the lowest competency ratings. Positive correlations were found between the frequency of skill use and self-reported competence for assessing MDI technique, peripheral pulses, and peripheral edema. No other findings were significant.

CONCLUSIONS

P4 students reported high perceived competency for PA skills performed frequently during APPEs. Preceptor education, requiring skill use, and encouraging students to proactively identify situations to use skills could increase opportunities for use of PA skills.

Pulmonary Health Effects of Electronic Cigarettes: A Scoping Review

BACKGROUND

There is global concern regarding the public health impact of electronic cigarettes (ECs). ECs are commonly promoted as safer than conventional cigarettes (CCs), however there is limited knowledge of the long-term health effects. This scoping review examined the pulmonary health effects of ECs reported in the literature from 2009 to 2019.

METHOD

PubMed, CINAHL, and Science Direct databases were used. Search terms included "vaping, electronic nicotine delivery systems, electronic cigarettes, lung diseases, respiratory diseases, and pulmonary." Original research articles in English that used human subjects between January 1, 2009 and January 31, 2020 and reported pulmonary outcomes were included.

RESULTS

Forty-five studies met the inclusion criteria. There were 14 (31.1%) randomized experimental, 7 (15.6%) nonrandomized experimental, 6 (13.3%) cohort, and 18 (40.0%) cross-sectional studies. Sixteen (35.6%) studies were conducted in the United States; the rest were conducted across 11 other countries. The total number of subjects was 1,465,292 and ages ranged from 12 to 99 years across studies. Eligible studies demonstrated an association between EC use and pulmonary symptoms, asthma and chronic obstructive pulmonary disease diagnosis and exacerbations. The degree of this association varied based on the use of additional tobacco products. EC use resulted in worse outcomes than nonsmoking, but resulted in improved outcomes when compared with CC use or dual use of CC and EC.

CONCLUSION

Evidence indicates that EC use, especially dual use, leads to negative pulmonary effects and adverse outcomes. Education on the potential risks and publishing of EC ingredients on labels could help improve public health safety communication and reduce EC use.

Perceptions of collaborative care team members on facilitators and barriers to care and glycosylated hemoglobin level as a diabetes quality metric at a federally qualified health center in Texas

OBJECTIVES

Facilitators and barriers to collaborative patient care have been explored in previous studies. Few studies provide information about collaborative care team (CCT) members' roles in treating patients with diabetes and how CCT members should be evaluated for their contributions to diabetes care. To describe the roles and responsibilities of CCT members at CommUnityCare (CUC), a federally qualified health center in Central Texas; identify the facilitators and barriers affecting referrals to other CCT members within CUC; explore the facilitators and barriers to collaborative patient care at CUC; and assess CCT members' perceptions of quality metrics for diabetes care.

METHODS

A cross-sectional design was used. Data was collected by a survey and semistructured interviews of CCT members. The survey (32 questions) assessed roles and responsibilities, including the percentage of time spent on clinic activities, referral criteria, perceptions of quality diabetes care, and facilitators and barriers to care. The interview (32 questions) gathered a description of the CCT member's role, referral process, and ideas for diabetes quality metrics. Descriptive statistics and content analysis were used for data analysis.

RESULTS

Twenty-two CCT members (4 diagnosticians, 4 clinical pharmacists, 4 behavioral health professionals, 4 registered dietitians, 2 community health workers, and 4 care managers) participated in this study. Co-location (54%) and professional relationships with coworkers (32%) facilitated referrals to other CCT members. Appointment availability (32%) and lack of referral criteria knowledge (27%) were barriers to other CCT member referrals. Seventy-five percent of the dietitians and care managers thought that the glycosylated hemoglobin (A1C) level was a good quality metric for diabetes care, followed by 50% of the clinical pharmacists, 25% of the behavioral health counselors, and 0% of the community health workers and diagnosticians.

CONCLUSION

Co-location and professional relationships facilitated referrals to CCT members, whereas lack of CCT member availability and lack of referral criteria knowledge were barriers to CCT referrals. Metrics other than the lowering of the A1C level should be further explored to assess the quality of diabetes care.

Assessment of basal insulin adherence using 2 methodologies among Texas Medicaid enrollees with type 2 diabetes

BACKGROUND: Basal insulin is often recommended as the initial therapy for patients with type 2 diabetes who require insulin treatment. Adequate adherence is critical to diabetes management, yet suboptimal insulin adherence has been reported. Second-generation long-acting (SGLA) insulin has higher dosing flexibility and lower hypoglycemia risk and may improve adherence. However, little is known regarding adherence to SGLA insulin and how adherence to SGLA insulin compares with intermediate-acting neutral protamine Hagedorn (NPH) and first-generation long-acting (FGLA) insulin. Measurement of insulin adherence is challenging because of the inaccuracies of recorded days supply of insulin, and traditional medication possession ratio (MPR) may be negatively affected. Adjusted MPR (aMPR) has been developed in an effort to address this issue. OBJECTIVE: To examine the unadjusted and adjusted associations between basal insulin type and adherence to basal insulin using MPR and aMPR. METHODS: This retrospective database study used Texas Medicaid prescription claims from January 1, 2014, through June 30, 2017. The index date was the date of the first basal insulin prescription without the same prescription 6 months before (pre-index), and all patients were followed for 12 months (post-index). Patients aged 18-63 years with ≥ 1 pre-index prescription of an oral hypoglycemia agent (OHA) or a glucagon-like peptide-1 receptor agonist (GLP-1 RA), without any post-index prescription of premixed insulin or a basal insulin different from index insulin, and with continuous enrollment throughout the pre- and post-index periods, were included. The dependent variable was basal insulin adherence over 12 months, measured using MPR and aMPR. Unadjusted and adjusted adherence comparisons were conducted by basal (background) insulin type (NPH, FGLA, and SGLA). Covariates included age, gender, baseline use of basal insulins and comorbid medications, total number of medications, OHA adherence, post-index number of OHAs, and use of bolus insulins and GLP-1 RAs. Analysis of variance, chi-square tests, and multiple logistic regression analyses were performed. RESULTS: Of the 5,034 patients included, NPH, FGLA, and SGLA insulin users accounted for 3.7%, 89.8%, and 6.5%, respectively. The overall mean (SD) age was 50.9 (9.9) years, and 65.9% were female. In the unadjusted bivariate analyses, SGLA insulin users had significantly higher adherence, using either MPR (SGLA 0.68 [0.25] vs. FGLA 0.59 [0.27] vs. NPH 0.55 [0.27]; P < 0.0001) or aMPR (0.83 [0.23] vs. 0.78 [0.26] vs. 0.73 [0.28]; P = 0.0001). After controlling for covariates, insulin type was not significantly associated with the likelihood of being adherent (MPR or aMPR ≥ 0.8) using either measure. CONCLUSIONS: Adherence to SGLA insulin was not different from adherence to other basal insulins after controlling for patient characteristics. Yet, MPR and aMPR have limitations and warrant further confirmation of the study findings. Before new adherence measures for insulin therapy are developed, MPR and aMPR should be used with caution. DISCLOSURES: No specific funding was received for this manuscript. The authors report no potential conflicts of interest. Part of the data from this study was presented as posters at the American Pharmacists Association 2020 Annual Meeting & Exposition, March 20-23, 2020, in National Harbor, MD, and at the International Society for Pharmacoeconomics and Outcomes Research 2020 Conference, May 16-20, 2020, in Orlando, FL.

Opioid-Related Education Provided by Continuing Education Divisions at US Pharmacy Schools

Objective. To quantify the number and type of new opioid-related continuing pharmacy education (CPE) activities offered by continuing education divisions (CEDs) at US schools and colleges of pharmacy from 2015 through 2018, and to determine the number of pharmacists who completed opioid-related CPE activities. Methods. Data was derived from the database of CPE activities maintained by the Accreditation Council for Pharmacy Education (ACPE), which is the sole accreditation agency for all providers of CPE, including pharmacy schools. Data were filtered to include only pharmacy school CPE providers. A search for six keywords (opiates, opioids, pain, pain management, drug overdose, and opioid antagonist) was conducted for the years 2015-2018. The data extracted included title of the CPE activity, contact hours, activity type, activity format, and the number of pharmacists who participated in the activity. Descriptive statistics were used. A content analysis of activity titles was performed. Results. Overall, the CEDs of US schools and colleges of pharmacy delivered 20.3% of all ACPE-approved opioid-related CPE activities from 2015-2018. A total of 1,237 unique opioid-related CPE activities were identified. The number of new CPE activities increased from 249 in 2015 to 297 in 2016 to 349 in 2017, then decreased to 342 in 2018. These activities reached 149,373 pharmacists and were most commonly affiliated with the following keywords: opioids (34.8%) and pain management (30.2%). Conclusion. The opioid epidemic creates an opportunity for pharmacists to increase their role in public health, but education and training are necessary. The study findings indicate that many pharmacists participate in opioid-related CPE provided by ACPE-accredited CEDs of pharmacy schools. This number is likely to increase as a growing number of states are beginning to require opioid-related CPE for pharmacist license renewal.

Priority community engagement strategies for cardiovascular health: A checklist for community pharmacists

OBJECTIVE

The objective of this study was to identify essential strategies for use by community pharmacists seeking to establish community partnerships to prevent and manage cardiovascular disease (CVD) in their local communities.

METHODS

A multistep process was used to develop and refine the Community-Clinical Linkages for Cardiovascular Health (CCL-CVD) checklist. First, the authors reviewed the extant literature related to community pharmacists' community engagement and identified evidence-based recommendations for community pharmacists from the Centers for Disease Control and Prevention's guidance documents and linkage framework. Next, the authors developed a 9-item checklist of community engagement strategies for use by practicing community pharmacists with an interest in health promotion and partnership development. The authors then surveyed 15 content experts from across the United States and asked them to evaluate each of the 9 checklist items on a 3-point scale: (1) essential; (2) useful, but not essential; or (3) not necessary. On the basis of the survey results, the authors calculated a content validity ratio (CVR) for each of the 9 strategies and performed a content analysis of the qualitative responses provided by the content experts.

RESULTS

Eleven content experts completed the survey for a response rate of 73%. The CVR for 3 strategies from the initial CCL-CVD checklist reached statistical significance, and these 3 strategies were considered essential strategies for community pharmacists to use when working to develop community partnerships to improve CVD. The following strategies were considered essential: (1) gathering data to support the need for pharmacists' services, (2) identifying preferred communication strategies, and (3) creating mechanisms for documentation and establishing an evaluation plan. An additional strategy-develop goals and objectives for the partnership-neared statistical significance and was included as a second-tier strategy.

CONCLUSION

The multistep process resulted in a practical, 2-tiered checklist for use by community pharmacists who are interested in community engagement and developing sustainable CCLs to improve CVD health.

Patient experience with clinical pharmacist services in Travis County Federally Qualified Health Centers

Background

Positive patient experiences with care have been linked to improved health outcomes. Patient experience surveys can provide feedback about the level of patient-centered care provided by clinical pharmacists and information about how to improve services.

Objectives

Study objectives are: 1) To describe patient experience with clinical pharmacist services in a federally qualified health center (FQHC). 2) To determine if demographic or health-related factors were associated with patient experience.

Methods

This cross-sectional survey included adult patients who were English or Spanish speaking, and completed a clinical pharmacist visit in March or April 2018. Patient experience was evaluated, on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with 10 items using four domains: pharmacist-patient interaction information provision, support for self-care, and involvement in decision making. In addition, one item was used to rate the overall experience. Demographic and health-related variables were also collected. Eligible patients completed the survey after their clinical pharmacist visit. Descriptive and inferential statistics, as well as Cronbach's alpha for scale reliability, were employed.

Results

Respondents (N=99) were 55.4 (SD=12.1) years and 53.1% were women. Overall, patients rated their experiences very high with the 10-item scale score of 4.8 (SD=0.4) out of 5 points and the overall experience rating of 4.9 (SD=0.4) out of 5 points. With the exception of race, there were no differences between patient experience and demographic and health-related variables. African Americans had significantly (p=0.0466) higher patient experience scores compared to Hispanics.

Conclusions

Patients receiving care in a FQHC highly rated their experience with clinical pharmacists. This indicates that clinical pharmacists provided a high level of patient-centered care to a diverse group.

A scoping review of community paramedicine: evidence and implications for interprofessional practice

Community paramedicine (CP) is an evolving method of providing community-based health care in which paramedics function outside of their traditional emergency response roles in order to improve access to primary and preventive health care and to basic social services. Early evidence indicates that CP programs have contributed to reducing health care utilization and improving patient outcomes leading some to call for a transformation of EMS into value-based mobile healthcare fully integrated within an interprofessional care team. The purpose of this scoping review was to understand the evidence base of CP in order to inform the further evolution of this model of care. Following the PRISMA extension for Scoping Reviews, 1,163 titles were screened by our research team. Eligibility criteria were publication in English after January 1, 2000; description of a CP program located in a Western nation; and inclusion of a discussion of outcomes. Twenty-nine publications met the criteria for inclusion. The literature was varied in terms of study design, program purpose, and target audience. The lack of rigorous, longitudinal studies with control groups makes rendering conclusions as to the value and effectiveness of CP programs difficult. Further, the extent to which community paramedics operate within interprofessional teams remains unclear. However, some programs demonstrated improvement in both health services and patient outcomes. As stakeholders continue to explore the potential of CP, results of this review highlight the importance of further investigation of outcomes, the professional identity of the community paramedic, and the role of the community paramedic on interprofessional teams.

Comprehensive health management pharmacist-delivered model: impact on healthcare utilization and costs

OBJECTIVES

To (1) examine the impact of the Comprehensive Health Management Patient Service (CHaMPS) on unplanned hospital admissions and emergency department (ED) visits in patients with chronic conditions, (2) describe the number and type of pharmacist interventions, and (3) determine the cost savings of CHaMPS.

STUDY DESIGN

Retrospective, cross-sectional design with a matched comparator group.

METHODS

CHaMPS integrated pharmacists within family medicine clinics to optimize medication use among patients with chronic conditions. Outcomes were the change in unplanned hospital admissions and ED visits from baseline to 180- and 365-day postintervention periods between the CHaMPS and propensity-matched comparator groups. Descriptive, bivariate (t tests and McNemar tests), and multivariate (general linear models) statistical analyses were used. Pharmacist interventions are reported and a cost-benefit analysis was conducted.

RESULTS

A total of 624 patients (312 in the CHaMPS group and 312 in the comparator group) were included. Unplanned hospital admissions decreased in the CHaMPS group and increased in the comparator group (not significant). ED visits remained stable in the CHaMPS group but increased significantly in the comparator group, resulting in a significant mean change in ED visits between the groups at the 180- and 365-day postintervention periods (P = .03 for both periods). Pharmacists provided a total of 5705 medication-related problem, education, and medication reconciliation interventions (18.3 per patient). The benefit-cost ratio ranged from 2.1:1 to 2.6:1.

CONCLUSIONS

CHaMPS achieved its goals by demonstrating a positive impact on ED visits and a benefit-cost ratio greater than 1.0. The cost savings of the embedded pharmacist model are most beneficial from a payer perspective or an accountable care organization approach to healthcare.

Educational Outcomes Resulting From Restructuring a Scholarship Course for Doctor of Pharmacy Students

Objective. To compare educational outcomes between two iterations of a scholarship and research course for Doctor of Pharmacy (PharmD) students at Virginia Commonwealth University's School of Pharmacy. Methods. The first iteration of a course intended to teach pharmacy students the knowledge and skills necessary to design and conduct research involved lectures and application exercises, including limited guided questions about different aspects of the research process. In the fall of 2015, multiple structured activities and accompanying grading rubrics, each designed around the structure and content of a section of a research proposal, were introduced to the course to supplement lectures. Both iterations of the course culminated with students submitting a research proposal. After establishing interrater reliability, faculty members graded a random sample of 20 research proposals, 10 from each version of the course, and section-specific and overall proposal scores were compared. Results. In the proposals submitted after the course revisions, significant improvements in three areas were identified: the overall score, the section-specific scores for research hypothesis/specific aims, and institutional review board (IRB) discussion/informed consent. Nominal, though not statistically significant, improvements were observed in other sections. Conclusion. Additional research is needed regarding the best instructional strategies to reinforce data analysis and statistical testing knowledge and skills in PharmD students. Overall, our findings support the hypothesis that a more formalized, guided approach for teaching research methods improves learning outcomes for PharmD students.

Pharmacist documentation of gaps in care identified during diabetes coaching

OBJECTIVES

1) To identify the number of gaps, type of gaps, and contributing factors to gaps in diabetes care reported by pharmacists in the Diabetes Gaps in Care Portal (Gaps Portal). 2) To understand how pharmacists used the Gaps Portal and the implications for quality diabetes care.

DESIGN

The Alliance for Patient Medication Safety developed an online Gaps Portal as a tool for pharmacists to identify and document gaps in care when managing patients with diabetes.

SETTING

Pharmacists from across the United States in community pharmacy and ambulatory care settings who were engaged in diabetes coaching activities participated.

MAIN OUTCOME MEASURES

Pharmacists entered gaps in diabetes care into the Gaps Portal from April 2016 to June 2017. Descriptive statistics were used to determine the type and number of gaps and contributing factors. A qualitative analysis of pharmacist interviews was conducted to identify themes related to pharmacist perceptions of the portal.

RESULTS

Ten pharmacists entered 528 gaps in diabetes care (n = 469; 565 encounters). The most common category of gaps in diabetes care was drug therapy (n = 420/528; 79.6%). Of the drug therapy gaps reported, the most common gap occurred in patients with or at risk for atherosclerotic cardiovascular disease and not on a high-intensity statin (122/420), followed by those not on a moderate statin (106/420). Themes focused on during interviews included integration of diabetes coaching and documentation, impact of Gaps Portal on workflow, and prioritization of gaps.

CONCLUSION

Pharmacists most commonly identified drug therapy gaps, predominantly pertaining to statin use, which coincides with a change in the guidelines for statin use in diabetics. Telephone interviews indicated that the Gaps Portal template served as a useful checklist to identify gaps in care during diabetes coaching activities and that the Gaps Portal was useful for reporting and monitoring purposes.

Learning Activities to Build Population Health Management Skills for Pharmacy Students

Objective. To describe the implementation and evaluation of population health management learning activities in a second-year Doctor of Pharmacy (PharmD) course. Methods. Population health learning sessions were implemented in a step-wise manner: population needs assessment activity to identify priority programs for implementation given a specific patient population; didactic materials to introduce program evaluation foundational knowledge; program evaluation design activity to evaluate implemented programs using the Centers for Disease Control and Prevention's Program Evaluation Framework; and evaluation of program outcome data. Students' self-rated abilities (grouped into Bloom's Taxonomy classifications) and perceptions before and after program evaluation activities were assessed. Qualitative analyses evaluated student feedback on learning sessions. Results. Students' self-rated abilities for all Bloom's classifications increased after the learning sessions. Student perceptions on importance of program evaluation also improved (from 71% reporting "agree" or "strongly agree" pre-activities to 79% post-activities). Students found the application to case scenarios and the opportunity to integrate each component of program evaluation into a complete process useful. Conclusion. Step-wise population health management learning sessions were implemented, culminating in skill-based program evaluation activities. The activities improved students' self-rated abilities and perceptions regarding program evaluation. Areas for improvement for the learning sessions were also identified and will inform future instructional design.

Predictors of Emergent Emergency Department Visits and Costs in Community-Dwelling Older Adults

BACKGROUND

The number of yearly emergency department (ED) visits by older adults in the United States has been increasing.

PURPOSE

The objectives were to (1) describe the demographics, health-related variables, and ED visit characteristics for community-dwelling older adults using an urban, safety-net ED; (2) examine the association between demographics, health-related variables, and ED visit characteristics with emergent vs nonemergent ED visits; and (3) examine the association between demographics, health-related variables, ED visit characteristics, and ED visit costs.

METHODS

A cross-sectional, retrospective analysis of administrative electronic medical record and billing information from 2010 to 2013 ED visits (n = 7805) for community-dwelling older adults (⩾65 years old) from an academic medical center in central Virginia was conducted.

RESULTS

Most of the ED visits were by women (62%), African Americans (75%), and approximately 50% of ED visits were nonemergent (n = 3871). Men had 1.2 times the odds of an emergent ED visit (95% confidence interval [CI]: 1.02-1.37). The ED visits by white patients had 1.3 times the odds of an emergent ED visit (95% CI: 1.09-1.57) and 14% higher costs (white race: 95% CI: 1.07-1.21) compared with African American patients. Emergent ED visits were 60% more likely to have higher costs than nonemergent visits (95% CI: 1.52-1.69). White race and arrival by ambulance were associated with both emergent ED visits and higher total ED visit costs in this sample of ED visits by community-dwelling older adults.

CONCLUSIONS

Strategies to maximize opportunities for care in the primary care setting are warranted to potentially reduce nonemergent ED utilization in community-dwelling older adults.

Impact of a pharmacist-physician collaborative care model on patient outcomes and health services utilization

PURPOSE

The impact of a pharmacist-physician collaborative care model on patient outcomes and health services utilization is described.

METHODS

Six hospitals from the Carilion Clinic health system in southwest Virginia, along with 22 patient-centered medical home (PCMH) practices affiliated with Carilion Clinic, participated in this project. Eligibility criteria included documented diagnosis of 2 or more of the 7 targeted chronic conditions (congestive heart failure, hypertension, hyperlipidemia, diabetes mellitus, asthma, chronic obstructive pulmonary disease, and depression), prescriptions for 4 or more medications, and having a primary care physician in the Carilion Clinic health system. A total of 2,480 evaluable patients were included in both the collaborative care group and the usual care group. The primary clinical outcomes measured were the absolute change in values associated with diabetes mellitus, hypertension, and hyperlipidemia management from baseline within and between the collaborative care and usual care groups.

RESULTS

Significant improvements (p < 0.01) in glycosylated hemoglobin, blood pressure, low-density-lipoprotein cholesterol, and total cholesterol were observed in the collaborative care group compared with the usual care group. Hospitalizations declined significantly in the collaborative care group (23.4%), yielding an estimated cost savings of $2,619 per patient. The return on investment (net savings divided by program cost) was 504%.

CONCLUSION

Inclusion of clinical pharmacists in this physician-pharmacist collaborative care-based PCMH model was associated with significant improvements in patients' medication-related clinical health outcomes and a reduction in hospitalizations.

Low-Income Senior Housing Residents' Emergency Department Use and Care Transition Problems

Older adults may be at risk of adverse outcomes after emergency department (ED) visits due to ineffective transitions of care. Semi-structured interviews were employed to identify and categorize reasons for ED use and problems that occur during transition from the ED back to home among 14 residents of low-income senior housing. Qualitative thematic and descriptive analyses were used. Ambulance use, timely ED use or a wait-and-see approach, and lack of health-care provider contact before ED visit were emergent themes. Delayed medication receipt, no current medication list, and medication knowledge gaps were identified. Lack of a personal health record, follow-up care instruction, and worsening symptoms education emerged as transition problems from ED to home. After an ED visit, education opportunities exist around seeing primary care providers for nonurgent conditions, follow-up care, medications, and worsening condition symptoms. Timely receipt of discharge medications and medication education may improve medication-related transition problems.

Homeless patients' perceptions about using cell phones to manage medications and attend appointments

OBJECTIVES

The objectives of this study were to (1) describe homeless persons' access and use of cell phones and their perceptions about using cell phone alerts to help manage medications and attend health care appointments and (2) identify demographic characteristics, medication use and appointment history and perceptions associated with interest in receiving cell phone alerts to manage medications and appointments.

METHODS

A cross-sectional survey was conducted in 2013 at a homeless clinic in Virginia. The questionnaire comprised items about cell phone usage, ownership and functions such as text messaging. Participants reported medication use and appointment history, perceptions about cell phone alerts and interest in receiving alerts to manage medications and appointments. Descriptive statistics for all variables are reported. Logistic regression was used to examine predictors of interest in using a cell phone to manage medications and appointments.

KEY FINDINGS

A total of 290 participants completed the survey; 89% had a cell phone. Seventy-seven percent were interested in appointment reminders, whereas 66%, 60% and 54% were interested in refill reminders, medication taking reminders and medication information messages respectively. Those who believed reminders were helpful were more likely to be interested in medication taking, refill and appointment reminder messages compared to those who did not believe reminders were helpful. A history of running out of medicine and forgetting appointments were predictors of interest in refill and appointment reminders.

CONCLUSIONS

Mobile technology is a feasible method for communicating medication and appointment information to those experiencing or at risk for homelessness.

Development and Implementation of Clinical Pharmacist Services Within an Integrated Medical Group

Background:

In 2012, pharmacists were integrated into a medical group to provide direct patient care, drug information activities, and health care provider education. The medical group encompasses 40 primary care and 60 specialty offices in Virginia.

Objective:

To describe the development and implementation of clinical pharmacist services integrated within a medical group.

Methods:

Pharmacists’ roles and responsibilities, type and number of patient encounters, and identification of strategies to facilitate implementation are described.

Results:

From June 2012 to December 2014, pharmacists had 809 patient encounters, which included patient-centered education, medication consults, Medicare annual wellness visits, senior care visits, and comprehensive medication reviews. Pharmacists addressed 403 drug information requests from nurse navigators, providers, and administrators. Pharmacists also have roles in risk management, quality improvement initiatives, and operations that benefit the medical group. Strategies to facilitate implementation include working with organizational leadership, identifying a physician champion, and establishing credibility by being responsive to practice needs and responding to requests in a timely manner to build trust within the health care team.

Conclusion:

Integration of pharmacists within health care teams involves more than direct patient care activities. Pharmacists should be involved at the organizational level to have a broader impact on patient and practice levels.

Antimicrobial Stewardship Program Members' Perspectives on Program Goals and National Metrics

PURPOSE

This study compares antimicrobial stewardship program (ASP)-stated goals and outcomes collected as well as opinions regarding national metric establishment.

METHODS

Twenty-one ASP members underwent telephone interviews answering open-ended questions about ASP goals, outcomes collected, and opinions about national metrics. Content analysis was used to code responses into predefined ASP-metric categories.

FINDINGS

The most common ASP goal was antimicrobial appropriateness (76%), outcomes tracked were use and microbial outcomes (both 71%), and desired national metric was use (67%).

IMPLICATIONS

Stated-goals, outcomes tracked, and opinions regarding national metric establishment did not fully align. With ASP-related regulations looming, it is important that alignment is increased.

Medication adherence challenges among patients experiencing homelessness in a behavioral health clinic

BACKGROUND

Behavioral health medication nonadherence is associated with poor health outcomes and increased healthcare costs. Little is known about reasons for nonadherence with behavioral health medications among homeless people.

OBJECTIVES

To identify reasons for medication nonadherence including the sociodemographic, health-related factors, and behavioral health conditions associated with medication nonadherence among behavioral health patients served by a Health Care for the Homeless center (HCH) in Virginia.

METHODS

The study sample was selected from an existing database that included sociodemographic, health-related information, and medication-related problems identified during a pharmacist-provided medication review conducted during October 2008-September 2009. Patients experiencing or at risk of homelessness who were ≥18 years old with at least one behavioral health condition who had a medication review were eligible for the study. A qualitative content analysis of the pharmacist documentation describing the patient's reason(s) for medication nonadherence was conducted. The Behavioral Model for Vulnerable Populations was the theoretical framework. The outcome variable was self-reported medication nonadherence. Descriptive and multivariate (logistic regression) statistics were used.

RESULTS

A total of 426 individuals met study criteria. The mean age was 44.7 ± 10.2 years. Most patients were African-American (60.5%) and female (51.6%). The content analysis identified patient-related factors (74.8%), therapy-related factors (11.8%), and social or economic factors (8.8%) as the most common reasons for patients' medication nonadherence. Patients with post-traumatic stress disorder (PTSD) (adjusted odds ratio: 0.4; 95% CI: 0.19-0.87) were less likely to have a medication adherence problem identified during the medication review.

CONCLUSIONS

The content analysis identified patient-related factors as the most common reason for nonadherence with behavioral health medications. In the quantitative analysis, patients with a PTSD diagnosis were less likely to have nonadherence identified which may be related to their reluctance to self-report nonadherence and their diagnosis, which warrants further study.

An evaluation of the association between an antimicrobial stewardship score and antimicrobial usage

OBJECTIVES

To determine whether an antimicrobial stewardship 'intensity' score predicts hospital antimicrobial usage.

METHODS

An antimicrobial stewardship score for 44 academic medical centres was developed that comprised two main categories: resources (antimicrobial stewardship programme personnel and automated surveillance software) and strategies (preauthorization, audit with intervention and feedback, education, guidelines and clinical pathways, parenteral to oral therapy programmes, de-escalation of therapy, antimicrobial order forms and dose optimization). Multiple regression analyses were used to assess whether the composite score and also the categories were associated with either total or antimicrobial stewardship programme-target antimicrobial use as measured in days of therapy.

RESULTS

The mean antimicrobial stewardship programme score was 55 (SD 21); the total composite score was not significantly associated with total or target antimicrobial use [estimate -0.49 (95% CI -2.30 to 0.89)], while the category strategies was significantly and negatively associated with target antimicrobial use [-5.91 (95% CI -9.51 to -2.31)].

CONCLUSIONS

The strategy component of a score developed to measure the intensity of antimicrobial stewardship was associated with the amount of antimicrobials used. Thus, the number and types of strategies employed by antimicrobial stewardship programmes may be of particular importance in programme effectiveness.

Community Pharmacist-Provided Osteoporosis Screening and Education: Impact on Patient Knowledge

Objective: To evaluate the impact pharmacist-provided screening and education had on patient knowledge of osteoporosis and preventive strategies. Methods: A prospective, randomized, controlled study was conducted at 16 locations of a national supermarket chain pharmacy in the Richmond, Virginia area. Women 30 years and older with no history of osteoporosis were enrolled in the study. Patients self-selected into the study by agreeing to the bone density screening, pharmacist-provided education, and completion of a knowledge survey. Subjects were randomized to complete the osteoporosis-related knowledge survey either before (Group A) or after (Group B) the screening and education session. The survey was developed after guideline and literature evaluation and was pretested with a group of patients for content and clarity. The survey evaluated knowledge of osteoporosis, risk factors for the disease, appropriate age for testing, and preventive strategies. Groups A and B were compared using t-tests. Results: A total of 110 women were enrolled in the study. The mean (±SD) age was 52.5 ± 13.1 years in Group A (n=52) and 52.7 ± 11.5 years in Group B (n=58). Knowledge scores were higher in the group who received pharmacist-provided education prior to completing the survey in each category (knowledge of the disease, risk factors, preventive strategies, and appropriate age for testing) and overall (p<0.001). Conclusions: Community pharmacist-provided osteoporosis screening and education increased patient knowledge about osteoporosis and preventive strategies. Community pharmacist involvement with increasing patient knowledge may empower patients to engage in prevention strategies to improve bone mass.   Type: Original Research

Concordance of Pharmacist Assessment of Medication Nonadherence With a Self-Report Medication Adherence Scale

OBJECTIVE

To evaluate the concordance of the Modified Morisky Scale (MMS) with a pharmacist assessment of medication adherence during a medication review.

METHODS

This retrospective study examined the electronic medical records (EMRs) of patients ≥18 years who received a medication review by a pharmacist from October 2008 to September 2009 at a homeless behavioral health clinic. In addition to the 6-item MMS, adherence was assessed using the first 4 items of the MMS, which comprise the original Morisky Scale. A final pharmacist assessment of adherence based upon the medication review was documented in the EMR. The McNemar test was used to assess the agreement between the MMS (6 and 4 items) and the pharmacist assessment of medication adherence.

RESULTS

A total of 288 patients were eligible for the study, which included 449 medication reviews. Nonadherence was identified in 61.7% and 49.7% of medication reviews using the 6 and 4 items of the MMS. The pharmacist assessment determined nonadherence in 23.8% of medication reviews. There were significant differences between the pharmacist adherence assessment and the 6 (P < .0001) and 4 (P < .0001) items of the MMS.

CONCLUSION

A combination of methods including self-report and pharmacist assessment may provide the greatest insight into adherence.

Facilitators and barriers to implementing antimicrobial stewardship strategies: Results from a qualitative study

BACKGROUND

Many hospitals have implemented antimicrobial stewardship programs (ASPs) and have included in their programs strategies such as prior authorization and audit and feedback. However there are few data concerning the facilitators and barriers that ASPs face when implementing their strategies. We conducted a qualitative study to discern factors that lead to successful uptake of ASP strategies.

METHODS

Semistructured telephone interviews were conducted from June-July 2013 with 15 ASP member pharmacists and 6 physicians representing 21 unique academic medical centers.

RESULTS

Successful implementation of ASP strategies was found to be related to communication style, types of relationships formed between the ASP and non-ASP personnel, and conflict management. Success was also influenced by the availability of resources in the form of adequate personnel, health information technology personnel and infrastructure, and the ability to generate and analyze ASP-specific data. Types of effective strategies commonly cited included audit and feedback; prior authorization, especially with an educative component; and use of real-time alert technology and guidelines.

CONCLUSIONS

Several factors may influence ASP success in the implementation of their strategies. ASP members may use these findings to improve upon the success of their programs.

Adherence to behavioral therapy and psychiatry visits in a safety-net setting in Virginia, USA

Little is known about predictors of adherence to outpatient behavioural therapy and psychiatry visits in those who experience homelessness. Yet, consistent receipt of services in the community is critical to preventing use of acute care psychiatric services, which cause a significant cost burden to the mental health system. This retrospective study examined sociodemographic, housing instability and health-related factors associated with adherence to behavioural therapy and psychiatry appointments among 1711 clients served by an urban healthcare for the homeless centre in Virginia, USA. Clients ≥18 years old with a behavioural health condition who had an intake assessment and at least one behavioural therapy or psychiatry appointment scheduled during October 2005-September 2009 were eligible for the study. Of those with scheduled behavioural therapy visits, 27.7% were high adherers and 19.3% did not attend any appointments, whereas of those with scheduled psychiatry visits, 13.6% were high adherers and 22.1% did not attend any appointments. African Americans, when compared with whites, and those with a primary diagnosis of bipolar disorder were less likely to be high adherers to behavioural therapy. Women and being ≥35 years old were associated with a decreased likelihood of failing to attend psychiatry appointments, whereas African Americans, when compared with whites, and those with co-occurring disorders were more likely to not attend any psychiatry appointments. Understanding factors related to adherence to behavioural health services can help homeless care providers tailor strategies for improving visit adherence.

Integrating Components of Medication Therapy Management Services into Community Pharmacy Workflow

Objective: The objective of this study was to develop and evaluate a process for integrating components of medication therapy management services into a community pharmacy workflow. Secondary objectives were to evaluate outcomes as well as patient and pharmacist satisfaction with this change. Methods: This prospective, 3-month observational study took place in a small, independent community pharmacy. This intervention included a redesigned work system that included a seated private desk area and focus on the pharmacist, rather than the technician, being the first contact when patients entered the pharmacy. Pharmacists participated in a focus group before and after the implementation of the new workflow to better understand the delivery of the intervention and assess satisfaction. Process outcomes included time spent with the patient, the number of medication-related problems identified and recommendations made, the type of disease education provided, type and number of immunizations administered, and health monitoring tests performed. Patient satisfaction surveys were distributed after completing the intervention during the third month of the study. Results: A total of 56 patients were enrolled in this study resulting in 82 encounters. Forty medication-related problems, including experiencing an adverse drug reaction and ineffective therapy, were identified with recommendations made to patients or prescribers. Disease education, such as goals of therapy, was provided 46 times. Health monitoring tests, such as blood pressure, were performed 16 times and eight immunizations were administered. The revised workflow incorporating components of MTM services was successful in that 39% of encounters were less than two minutes and 49% of encounters were between two and five minutes in length. Only 12% of encounters were greater than five minutes. Overall, patients were very satisfied with the intervention. Pharmacists responded positively, but expressed concern that the changes to the work system prevented them from overseeing technician functions. Conclusion: Pharmacists in community practice are able to provide components of medication therapy management services during a brief, face-to-face interaction with patients. Overall, patients and pharmacists were satisfied with the changes to the pharmacy work system and that additional work system changes are needed to further expand the role of the community pharmacist and facilitate patient-pharmacist interactions.   Type: Original Research

Preparation of faculty members and students to be citizen leaders and pharmacy advocates

To identify characteristics and quality indicators of best practices for leadership and advocacy development in pharmacy education, a national task force on leadership development in pharmacy invited colleges and schools to complete a phone survey to characterize the courses, processes, and noteworthy practices for leadership and advocacy development at their institution. The literature was consulted to corroborate survey findings and identify additional best practices. Recommendations were derived from the survey results and literature review, as well as from the experience and expertise of task force members. Fifty-four institutions provided information about lecture-based and experiential curricular and noncurricular components of leadership and advocacy development. Successful programs have a supportive institutional culture, faculty and alumni role models, administrative and/or financial support, and a cocurricular thread of activities. Leadership and advocacy development for student pharmacists is increasingly important. The recommendations and suggestions provided can facilitate leadership and advocacy development at other colleges and schools of pharmacy.

Characteristics of Social and Administrative Sciences graduate programs and strategies for student recruitment and future faculty development in the United States

BACKGROUND

The rising demand of faculty in Social and Administrative Sciences (SAS) in pharmacy in the United States heightens the need to increase the number of Doctor of Philosophy (PhD) graduates in SAS who choose to pursue an academic career.

OBJECTIVES

To describe the characteristics of SAS graduate programs and graduate students and identify strategies for student recruitment and future faculty development.

METHODS

An Internet survey (phase I) with key informants (graduate program officers/department chairs) and semistructured telephone interviews (phase II) with phase I respondents were used. Items solicited data on recruitment strategies, number of students, stipends, support, and other relevant issues pertaining to graduate program administration. Descriptive statistics were tabulated.

RESULTS

Of the 40 SAS graduate programs identified and contacted, 24 completed the Internet survey (response rate [RR]=60.0%) and, of these, 16 completed the telephone interview (RR=66.7%). At the time of the survey, the median number of graduate students with a U.S.-based PharmD degree was 3. An average annual stipend for graduate assistants was $20,825. The average time to PhD degree completion was 4.57 years, and approximately 31% of PhD graduates entered academia. Various strategies for recruitment and future faculty development were identified and documented.

CONCLUSIONS

Findings allow SAS graduate programs to benchmark against other institutions with respect to their own achievement/strategies to remain competitive in student recruitment and development. Additional research is needed to determine the success of various recruitment strategies and identify potential new ones.