Community Pharmacist and Family Medicine Collaboration for Pre-Visit Planning for Shared Patients Receiving Chronic Care Management Services

Background: Pre-visit planning entails completing necessary tasks prior to clinic appointments. Community pharmacists (CPs) have unique knowledge about patients' medication use but do not routinely provide drug therapy reviews before clinic visits. Objectives: (1) Create and implement a business partnership between a CP and family medicine clinic (FMC) for CP provision of pre-visit medication reviews, and (2) describe the billing experience for shared patients in the FMC chronic care management (CCM) program. Methods: A prospective 8-month study in one community pharmacy and FMC in Iowa. Eligible patients were enrolled in the clinic CCM program and received their prescriptions at the CP. CPs were granted access to the clinic electronic health record (EHR), performed medication reviews, and recorded drug therapy recommendations (DTRs) in the clinic EHR. FMC physicians reviewed CP DTRs before the patient encounter. Time tracking software in the EHR recorded CP and FMC time performing CCM services. CCM revenue was prorated between parties. FMC physicians completed a survey about their experience. Results: Overall, there were 129 CP reviews performed for 95 patients. These reviews resulted in 169 DTRs and 76% were accepted by the physician. There were 71 CCM claims billed and CCM revenue was $3596 ($1796 FMC, $1800 CP). More than 90% of physicians (N = 11) indicated they reviewed CP DTRs before the patient encounter and agreed they were helpful to their practice. Conclusion: CPs completed pre-visit medication reviews and made accepted medication therapy recommendations. CCM billing provided a mechanism for CPs to receive revenue for their services.

Evaluation of an enhanced depression and anxiety screening with targeted pharmacist intervention

BACKGROUND

Depression is a significant source of morbidity but often goes undiagnosed. Broader screening is recommended, and pharmacists could contribute.

OBJECTIVES

Assess the feasibility of community pharmacy depression and anxiety screening and describe the medication-related problems (MRP) identified, pharmacist interventions, and provider responses for high-risk patients.

METHODS

This pilot was conducted between October 2022 and January 2023 at an independently owned community pharmacy in the Midwest U.S. Patients aged 18-45 with ready prescriptions were identified through weekly reports and tags were placed on prescription bags. A convenience sample of patients fluent in English were offered the the Patient Health Questionnaire (PHQ2) and Generalized Anxiety Disorder (GAD2), with follow-up PHQ9 and GAD7 for at-risk individuals. High-risk individuals met with the pharmacist for consultation and recommendations were discussed. Descriptive statistics were calculated for participant demographics, questionnaire responses, MRPs, and provider responses. Patient profiles were examined 2 months after the workup to identify medication changes.

RESULTS

A total of 29 patients volunteered to be screened for anxiety and depression, of these, 41% scored in the high-risk category for depression and/or anxiety and met with the pharmacist for the consultation. The pharmacist identified multiple MRPs. The most common was the need for additional therapy and inadequate dosages. Patients were reluctant for the pharmacist to follow up with their prescriber and were unreachable for telephone follow-up. Profiles reviewed two months post-assessment showed half of the at-risk patients had one or more mental health medication changes.

CONCLUSION

Community pharmacists may have a role in the screening and management of patient mental health, although there were challenges with screening uptake and follow-up. The pharmacist identified multiple MRPs for this high-risk group for which greater routine monitoring and follow-up may be beneficial. More work appears needed to engage both patients and prescribers.

Examining the case for direct contracting: A multistakeholder case study

BACKGROUND

Employers and pharmacies are challenged by a complex system for prescription payment. Cost plus direct contracts for prescriptions and bundled services may yield benefits.

OBJECTIVES

This study aimed to (1) explore direct contracting using multistakeholder interviews, (2) compare employer costs and employee copays for 6 months of prescription charges under their pharmacy benefit manager (PBM) with projected costs under a pharmacy direct contract, (3) project pharmacy revenue, costs, and net profit had these prescriptions been processed through the direct contract, and (4) assess employee satisfaction under the direct contract.

METHODS

Semistructured stakeholder interviews were recorded transcribed and analyzed to identify different perspectives on direct contracting. Employer PBM invoices for 412 employee prescriptions over 6 months were analyzed to calculate employer and employee costs and reanalyzed for the invoice cost plus $12 professional fee direct contract. For the pharmacy financial analysis projection, invoice costs and a $9.82 cost of dispensing were subtracted from total revenue to yield an estimated profit had the parties been under the arrangement. A 34-item satisfaction survey was mailed using a 4-contact design with cash incentives to the 20 employees serviced by the direct contract that were analyzed descriptively.

RESULTS

Eight stakeholder interviews described the benefits and potential challenges of such direct contracts. The financial analysis suggested the employer costs would be $5664 lower and employee copays would have been $1918 lower had all prescriptions been paid using the direct contract. The estimated profit for the pharmacy was projected at $899. Survey respondents were generally satisfied with the direct contract, but few used the bundled services.

CONCLUSION

The direct contract may be financially beneficial for all parties. It also may offer more transparent pricing that may be desirable for the employer and pharmacy. Greater uptake of bundled services may increase the value to the employer.

Evaluation of medication disposal behaviors after counseling by a community pharmacist and provision of a home medication disposal kit

OBJECTIVES

To evaluate providing an at-home medication disposal kit on opioid disposal behaviors. Self-report of prior disposal behaviors also was assessed to describe the sample.

DESIGN

Pilot study with randomization. Surgery outpatients were counseled on medication disposal by a pharmacist from the outpatient community pharmacy at the bedside and given an informational pamphlet detailing recommended disposal methods. Patients on even-numbered dates also received an at-home medication disposal system, creating a quasi-randomized assignment.

SETTING

Hospital outpatient surgery center.

PARTICIPANTS

Ambulatory surgery outpatients filling an opioid prescription.

OUTCOME MEASURES

Patients were called one month after discharge to answer a structured interview about their disposal behaviors. Responses were recorded. Descriptive statistics were calculated to describe disposal behaviors, and chi-squared and t-tests were used to assess group differences.

RESULTS

A total of 45 patients participated, with 24 receiving a disposal packet. Of the 23 patients that had left-over tablets, 8 patients disposed of them. Seven (30.4%) of patients with leftovers disposed of their medication safely as recommended by the pharmacist during counseling. Rates of appropriate disposal were statistically similar. Of the 14 patients who had left-over opioids and received a disposal packet, 5 (35.7%) patients used the provided packet. Of the 9 patients with left-over opioids who did not receive the disposal packet, 2 (22.2%) patients disposed of their left-over opioids appropriately.

CONCLUSION

This pilot provides insight into the implementation of medication disposal services in the ambulatory surgery setting and the potential impact that a community pharmacist can have in promoting safe medication disposal. While the study demonstrated similar rates of disposal, those with the disposal packet exclusively reported using the packet as their method of disposal, suggesting having the packet on-hand simplified decision-making.

"There Is Method to This Madness" A Qualitative Investigation of Home Medication Management by Older Adults

OBJECTIVES

This paper explores (1) the systems and processes older adults use to manage medications at home, and (2) the well-being goals of personal interest that motivate them.

METHODS

Qualitative interviews were conducted in the homes of 12 older adults in a small city in the Midwest United States. Interviews were analyzed using inductive template analysis.

RESULTS

The average age of older adults in this study was 74.2 years (SD = 10.5), 66.7% were women. The most prominent home medication management tools used were pill boxes, containers and vials, and medication lists. Routines were often aligned with activities of daily living such as teeth brushing and eating. Their medication management work occurred in contexts of other household members and budget constraints. Routines and practices were sometimes idiosyncratic adaptations and supported goals of maintaining control and decreasing vulnerability.

CONCLUSION

In developing routines for home medication management, older adults developed systems and deliberate processes to make sense of their medication experiences in the context of their home environment and based on available resources.

Community pharmacists' counseling regarding nicotine replacement therapy: A secret shopper study

BACKGROUND

Nicotine replacement therapy (NRT) is a safe and effective non-prescription tobacco cessation treatment. While most community-based pharmacists periodically provide patient education regarding NRT, there is a gap in real-world evidence assessing the counseling provided.

OBJECTIVES

To assess community pharmacist counseling regarding NRT in a real-world setting.

METHODS

A cross-sectional secret shopper audit was conducted to collect data regarding NRT counseling from 120 community pharmacist encounters. Seventeen trained college of pharmacy students presented to community pharmacies using a standardized script asking about 1 of 3 common NRT products (patch, gum, and lozenge). Pharmacies were randomly selected from a list of all community pharmacies open to the public in Bexar County, Texas. A standardized assessment form was used to document product availability, counseling length, whether or not the 7 counseling points and 6 assessment questions that could help guide the pharmacist's counseling regarding NRT products were provided without prompting, and potential inaccuracy of any recommendations and counseling points. Descriptive statistics were calculated, and analysis of variance and Fisher's exact test were used to test for variation across site type and time of day.

RESULTS

NRT was available for purchase without speaking to pharmacy staff in 99 of 120 (83%) pharmacies. The mean length of counseling was 136 (standard deviation = 91) seconds. The most common points discussed were recommended strength (72%), tapering schedule (58%), and assessment of the daily number of cigarettes smoked (56%). Forty-one (34%) pharmacists provided one or more potentially inaccurate counseling points, the most common being inaccurate tapering schedule (provided during 31 (26%) encounters). Only 15% of pharmacists referred auditors for additional help or recommended a follow-up.

CONCLUSION

NRT was commonly accessible in community pharmacies outside of the pharmacy area. Opportunities for pharmacists to provide more complete and accurate information to better assist patients with safe and effective smoking cessation were identified.

Provider perspectives and experiences following the integration of the prescription drug monitoring program into the electronic health record

Prescription drug monitoring programs (PDMPs) are a public health tool for prescribers and pharmacists to monitor controlled substance use at the patient level. The objectives of this study were to (1) assess attitudes about the PDMP and perceived changes in experience and decision-making following integration into the electronic health record (EHR), and (2) identify barriers to optimal PDMP use and user recommendations for improvement. This descriptive study used an electronic survey to obtain feedback from prescribers and pharmacists at a single academic medical center. Descriptive statistics were calculated, and textual data were analyzed. Of 1480 PDMP users 208 responded (14.1%). Responses demonstrated the integration of the PDMP into the EHR simplified log-in and access to PDMP information resulting in more frequent access and perceived improvement of care quality. Barriers included technical issues accessing the PDMP within the EHR and the lack of integration of other state PDMPs. Overall, the benefit of integrating the PDMP into the EHR was positive but largely limited to streamlining log-in and patient selection. Recommendations for improvement include addressing technological issues and education on PDMP interpretation and integrating new features that may modify prescribing, referral, and co-prescribing behaviors.

Ensuring quality qualitative research reporting in community pharmacy: a systematic literature review

OBJECTIVES

To evaluate the reporting quality for a sample of community pharmacy qualitative research articles based on the Standards for Reporting Qualitative Research (SRQR) guidelines, data interpretation and use of theory.

METHODS

A systematic literature search was conducted using Ovid MEDLINE to identify qualitative research related to community pharmacy. Data were extracted and evaluated based on the SRQR standards, data interpretation level and use of theory. Adherence to standards was analysed using descriptive statistics.

KEY FINDINGS

Eighty-one studies were retrieved through the database search (n = 81). Then, 31 studies met the inclusion criteria after screening abstracts and full texts. Twelve out of 21 SRQR were present in more than 80% of the studies. However, essential standards, such as research approach, reflexivity and trustworthiness techniques, were absent or partially present in 30 (97%) studies, 30 (97%) studies and 21 (68%) studies, respectively. Data interpretation level was descriptive in 27 (87%) studies and interpretive or partially interpretive in 4 (13%) studies. Theory was absent in 19 (60%) and implied, partially integrated or retrospectively applied in 12 (40%) of the studies.

CONCLUSION

Trustworthiness and quality of qualitative inferences within community pharmacy research could be enhanced with increasing awareness about reporting; the approach and paradigm, reflexivity, trustworthiness techniques, data interpretation level and theoretical use.

Pharmacist counseling when dispensing naloxone by standing order: A secret shopper study of 4 chain pharmacies

BACKGROUND

Texas has passed legislation to increase access to naloxone, the opioid overdose antidote, allowing pharmacists to dispense by standing order without an outside prescription. Given this added responsibility, there is a need to assess real-world counseling provided by pharmacists when dispensing naloxone.

OBJECTIVES

Assess naloxone accessibility and counseling provided by community pharmacists when dispensing naloxone by standing order.

METHODS

A total of 11 student pharmacists (mean age 25 years; 63.6% female; primarily Hispanic [36.4%], Asian [27.3%], and white [27.3%]) audited community pharmacies by presenting to purchase naloxone. Variables included naloxone availability and price, counseling duration, and whether 13 predetermined counseling points were provided unprompted. Shoppers were prepared with a background story if asked so that each answered questions consistently. All shoppers participated in two 1-hour training sessions, including verification of their ability to accurately assess naloxone counseling. Pharmacies in Bexar County, TX were selected randomly from 4 pharmacy chains, each of which have implemented statewide standing orders within their chain. Descriptive statistics were calculated. A Fisher exact test and linear mixed-effects regression model were used to assess variation across chains in whether naloxone was dispensed and the mean total number of counseling points provided, respectively.

RESULTS

The shoppers audited 45 pharmacies. Naloxone was dispensed in 31 of 45 (68.9%) encounters (mean cost: $129.59). The mean counseling duration was 89 seconds. The most common counseling points included: administration technique (24 of 31), readministration of second dose (22 of 31), and calling 9-1-1 (20 of 31). All other points were included in less than one-third of pharmacists' counseling. Across the 4 chains, there was significant variation in naloxone dispensing and the number of counseling points provided.

CONCLUSION

Secret shoppers were unable to access naloxone from nearly one-third of pharmacies. Counseling often excluded concepts pertinent to patient safety and effectiveness, suggesting opportunities remain to promote consistent, high-quality naloxone counseling in community pharmacies.

Student pharmacist personal and work experiences with people displaying warning signs of suicidal ideation

Introduction

Student pharmacists, in their roles as trainees, technicians, and peers, may interact with people displaying suicide warning signs. Providing suicide gatekeeping training to student pharmacists may prepare them to engage people at risk. Measuring the extent to which student pharmacists have encountered people displaying warning signs of suicide may help contextualize the potential importance of training student pharmacists in suicide gatekeeping. The objective was to describe student pharmacists' awareness of someone they know having attempted or died by suicide and whether they have heard statements suggesting suicide risk in their personal and work life.

Methods

An anonymous electronic survey was administered to 111 student pharmacists before engaging in question-persuade-refer training as part of their second-year pharmacy curriculum. Respondents were asked for demographics and if Someone ever told you something concerning where you wondered if they were thinking about suicide for both work and one's personal life. Descriptive statistics and chi-squared tests were used to compare items by gender.

Results

There were 111 responses to the survey for a 100% response rate. Concerning statements related to suicide were reported by 71.2% of respondents in their personal life and by 34.2% of students while at work. There were no differences based on gender.

Discussion

A significant proportion of student pharmacists have personal, peer, and professional exposure related to people with potential suicidal ideation. These findings emphasize the need for broad approaches for training students and pharmacists in suicide gatekeeping as a new public health role.

Evaluation of participant reluctance, confidence, and self-reported behaviors since being trained in a pharmacy Mental Health First Aid initiative

In the U.S., an estimated one in five individuals experience a mental illness annually which contribute to significant human and economic cost. Pharmacists serving in a public health capacity are positioned to provide first aid level intervention to people experiencing a mental health crisis. Research on pharmacy professionals (pharmacists, technicians, students) undergoing training in Mental Health First Aid (MHFA) can provide evidence of the potential benefits of such training. The objectives of this study were to 1) describe the reluctance and confidence to intervene in mental health crises of pharmacy professionals previously trained in MHFA, 2) describe their self-reported use of MHFA behaviors since becoming trained, and 3) describe participant open-ended feedback on their MHFA training. Materials and methods: An electronic survey was disseminated in May and June, 2019 using a four-email sequence to pharmacy professionals who had completed MHFA training from one of five pharmacist MHFA trainers throughout 2018. Domains included demographics, six Likert-type reluctance items, seven Likert-type confidence items for performing MHFA skills, and frequency of using a set of nine MHFA skills since being trained. Prompts collected open-ended feedback related to MHFA experiences and training. Descriptive statistics were used for scaled and multiple-choice items and a basic content analysis was performed on the open-ended items to group them into similar topics. Results: Ninety-eight out of 227 participants responded to the survey yielding a response rate of 44%. Participants reported high levels of disagreement to a set of reluctance items for intervening and overall high levels of confidence in performing a range of MHFA skills. Participant self-reported use of a set of MHFA skills ranged from 19% to 82% since being trained in MHFA. Almost half (44%) of participants had asked someone if they were considering suicide. A majority (61%) also had referred someone to resources because of a mental health crisis. Open-ended responses included positive experiences alongside important challenges to using MHFA in practice and recommendations including additional training focused on the pharmacy setting. Conclusions: Pharmacy professionals in this evaluation reported little reluctance and high confidence related to using MHFA training and reported use of MHFA skills since being trained.

Pharmacist Segments Identified from 2009, 2014, and 2019 National Pharmacist Workforce Surveys: Implications for Pharmacy Organizations and Personnel

Background/Objective: Findings from the 2009 and 2014 National Pharmacist Workforce Surveys showed that approximately 40% of U.S. pharmacists devoted their time primarily to medication providing, 40% contributed a significant portion of their time to patient care service provision, and the remaining 20% contributed most of their time to other health-system improvement activities. The objective of this study was to characterize the U.S. pharmacist workforce into segments based on the proportion of time they spend in medication providing and patient care services and compare changes in these segments between 2009, 2014, and 2019. Methods: Data from 2009, 2014, and 2019 National Pharmacist Workforce Surveys were analyzed. Responses from 1200 pharmacists in 2009, 1382 in 2014, and 4766 in 2019 were used for analysis. Respondents working in the pharmacy or pharmacy-related fields reported both their percent time devoted to medication providing and to patient care services. Medication providing included preparing, distributing, and administering medication products, including associated professional services. Patient care services were professional services designed for assessing and evaluating medication-related needs, monitoring and adjusting patient's treatments, and other services designed for patient care. For each year of data, pharmacist segments were identified using a two-step cluster analysis. Descriptive statistics were used for describing the characteristics of the segments. Results: For each year, five segments of pharmacists were identified. The proportions of pharmacists in each segment for the three surveys (2009, 2014, 2019) were: (1) medication providers (41%, 40%, 34%), (2) medication providers who also provide patient care (25%, 22%, 25%), (3) other activity pharmacists (16%, 18%, 14%), (4) patient care providers who also provide medication (12%, 13%, 15%), and (5) patient care providers (6%, 7%, 12%). In 2019, other activity pharmacists worked over 45 hours per week, on average, with 12 of these hours worked remotely. Patient care providers worked 41 hours per week, on average, with six of these hours worked remotely. Medication providers worked less than 40 hours per week, on average, with just one of these hours worked remotely. Regarding the number of patients with whom a respondent interacted on a typical day, medication providers reported 18 per day, patient care providers reported 11 per day, and other activity pharmacists reported 6 per day. In 2009, 8% of patient care providers worked in a setting that was not licensed as a pharmacy. In 2019, this grew to 17%. Implications/Conclusions: The 2019 findings showed that 34% of U.S. pharmacists devoted their time primarily to medication providing (compared to 40% in 2009 and 2014), 52% contributed a significant portion of their time to patient care service provision (compared to 40% in 2009 and 2014), and the remaining 14% contributed most of their time to other health-system improvement activities. Distinguishing characteristics of the segments suggested that recent growth in the pharmacist workforce has been in the patient care services, with more being provided through remote means in organizations that are not licensed as pharmacies. The findings have implications for pharmacist training, continuing education, labor monitoring, regulations, work systems, and process designs. These changes will create new roles and tasks for pharmacy organizations and personnel that will be needed to support emerging patient care services provided by pharmacists.

Provider beliefs on the Barriers and Facilitators to Prescription Monitoring Programs and Mandated Use

Background: Underutilization of Prescription monitoring programs (PMP), especially in states where participation is voluntary could limit their impact against opioid epidemic. Objectives: To (1) examine PMP use among Iowa healthcare providers (HCPs); (2) identify factors prompting and impeding PMP use, and (3) assess beliefs toward mandating PMP use. Methods: A cross-sectional survey of Iowa HCPs was conducted using a 12-item questionnaire. Survey domains include demographics, current PMP utilization, conditions and barriers associated with PMP use, and perspectives on use mandates. Analyses were based on descriptive statistics, proportional odds and poisson regression models. Results: There were 704 usable responses. Almost all respondents were registered with the PMP with dentists having the lowest rate (p < .001). Nurse practitioners consulted the PMP for the largest proportion of prescriptions, while pharmacists and dentists used significantly less (p < .001). Lack of time was the most common reported barrier impeding PMP use. Red flag behaviors and unfamiliarity with patient were the most common conditions prompting PMP review. HCPs estimated their use of the PMP would significantly increase if integrated into their electronic health records (p < .001). Almost half of HCPs held the opinion that PMP use should never be mandated, although inter-provider variation was present with nurse practitioners most amenable to mandates. Discussion: HCPs displayed variation in PMP use. EMR integration appears to be a strategy for increasing PMP use. There was resistance to mandating PMP use for all controlled substances prescribed and dispensed, with some interest in mandates for new patients only or new controlled substance prescriptions only.

Pilot and Feasibility of Combining a Medication Adherence Intervention and Group Diabetes Education for Patients with Type-2 Diabetes

Introduction: Controlling diabetes typically requires self-management and medications. Community pharmacists are positioned to support patients with both. Methods: This study assessed the feasibility and potential benefit of combining pharmacist-provided group diabetes education (up to eight sessions) and medication synchronization using a three-group design. Data were collected using pre-post paper surveys and electronic health record data. One group received both education and synchronization services, another group received medication synchronization only, and a third served as control. Results: Of 300 contacted patients, eighteen patients participated in group diabetes education, 14 had medication synchronization only, and 12 comprised a control group. There was little change in HbA1c over the study period. Medication adherence appeared to be positively aided by medication synchronization, although all groups started with high adherence. Some medication beliefs and self-care activities may have been positively impacted by group diabetes education. Both groups receiving medication synchronization were satisfied. Conclusions: Participants strongly agreed they would recommend group diabetes education from the study pharmacy to a friend and were satisfied with medication synchronization; however, it was difficult to tell if there was a synergistic effect by combining the two services. Reimbursement for diabetes education was not obtained despite multiple attempts, hindering sustainability.

Analysis of oral dietary supplement use in rural older adults

AIMS AND OBJECTIVES

To describe and explore characteristics associated with oral dietary supplement use and identify potential interactions with prescription medications in a sample of rural community-dwelling older adults.

BACKGROUND

Older adults use polypharmacy to help manage chronic diseases. Due to healthcare access disparities, rural older adults may consider dietary supplement use as an alternative approach to maintain health and manage disease. Oral dietary supplement use is expected to increase among ageing adults; placing them at risk for potential interactions and adverse events.

DESIGN

A secondary analysis was conducted on oral dietary supplement, medication and health characteristic data collected on N = 138 participants. The original study was adherent to STROBE guidelines.

RESULTS

Researchers found that 83% of the rural older adults used oral dietary supplements in addition to their prescribed medications. Participants took additional single-dose vitamins along with their multivitamin; 57% took vitamin D, 52% took calcium, 15% took vitamin C and 13% took additional potassium and vitamin E. Participants also used oral dietary supplements with medications that had a potential for interaction.

CONCLUSIONS

Compared with national samples of older adults, a high percentage of rural older adults used oral dietary supplements in addition to their prescribed medications. In the rural setting, older adults are at risk for potential drug-oral dietary supplement interactions.

RELEVANCE TO CLINICAL PRACTICE

Nurses can conduct vigilant medication reconciliation that includes documenting characteristics of oral dietary supplement use. Nurses can assist with providing appropriate dietary supplements education that promotes patient knowledge and prevent inappropriate use; particularly when caring for older adults from rural settings.

The Association Between Technology Use and Health Status in a Chronic Obstructive Pulmonary Disease Cohort: Multi-Method Study

Background

Telemedicine and electronic health (eHealth) interventions have been proposed to improve management of chronic obstructive pulmonary disease (COPD) for patients between traditional clinic and hospital visits to reduce complications. However, the effectiveness of such interventions may depend on patients’ comfort with technology.

Objective

The aim was to describe the relationship between patient demographics and COPD disease severity and the use of communication-related technology.

Methods

We administered a structured survey about the use of communication technologies to a cohort of persons in the COPDGene study at one midwestern hospital in the United States. Survey results were combined with clinical and demographic data previously collected as part of the cohort study. A subsample of patients also completed eHealth simulation tasks. We used logistic or linear regression to determine the relationship between patient demographics and COPD disease severity and reported use of communication-related technology and the results from our simulated eHealth-related tasks.

Results

A total of 686 patients completed the survey and 100 participated in the eHealth simulation. Overall, those who reported using communication technology were younger (P=.005) and had higher incomes (P=.03). Men appeared less likely to engage in text messaging (P<.001) than women. Patients who spent more time on tasks in the eHealth simulation had greater odds of a COPD Assessment Test score >10 (P=.02) and walked shorter distances in their 6-minute walk tests (P=.003) than those who took less time.

Conclusions

Older patients, patients with lower incomes, and less healthy patients were less likely to report using communication technology, and they did not perform as well on our simulated eHealth tasks. Thus, eHealth-based interventions may not be as effective in these populations, and additional training in communication technology may be needed.

Analysis of a Community Pharmacy Intervention to Improve Low Adherence Rates to Oral Diabetes Medications

For patients with diabetes, suboptimal medication adherence contributes to disease progression, complications, and increased healthcare costs. Identification of, and intervention for patient-identified reasons for nonadherence are essential to improving medication adherence. This prospective, quality improvement study was conducted at an independent community pharmacy in the Mid-West United States. Patients with a proportion of days covered (PDC) for their oral antidiabetic medications of less than 80% were contacted by telephone and interviewed by a clinical pharmacist. The interviews and corresponding adherence interventions were guided by an abbreviated version of the Drug Adherence Work-Up (DRAW©) tool that focused on oral medications for diabetes. The change in PDC 120-days post-interview was assessed to determine the change in adherence rates. Patients receiving the pharmacist-delivered adherence intervention had significantly higher 120 day PDC values which are likely to indicate more regular medication-taking at home. Almost half of study patients signed up for medication synchronization and these patients trended toward higher PDC values, although the relative difference was not statistically significant from those receiving the intervention and not opting to have their medications synchronized.

Community Pharmacist Attitudes on Medication Synchronization Programs

Background: Medication synchronization is a service offered by an increasing number of community pharmacies that aligns refilling of a patient’s multiple medications. Purported benefits include increased adherence and improved dispensing efficiency. Objective: To assess community pharmacist agreement with a set of declarative statements about medication synchronization programs and to identify variation related to pharmacist characteristics. Methods: In 2015, a cross-sectional survey was mailed to 1,000 pharmacists from 5 Midwestern U.S. states using 4-contacts and an online option. Respondents used a 7-point Likert scale to agree or disagree with 5 statements about medication synchronization. Demographic and workplace characteristics were collected. Data were analyzed using descriptive statistics and factor analysis. Multiple linear regression tested the relationship between pharmacist characteristics and a 4-item attitude composite. Results: There were 258 usable responses for a response rate of 28.8%. About half (45.0%) reported their pharmacy offered medication synchronization. Most pharmacists (82.6%) agreed this service has a positive impact on patient adherence but 57% agreed that a “significant change to workflow” was or would be required. Pharmacist agreement that the program provides financial benefits to the pharmacy was higher than agreement that the service provides more opportunities for patient interactions (p<0.001). In the multiple regression analysis, having a PharmD and working at a pharmacy offering Medication Therapy Management were associated with more positive scores on the medication synchronization benefits composite whereas working in a staff role (rather than a manager/owner) was lower. No demographic predictors were significantly associated with agreeing that a significant change to workflow would be required for implementation. Conclusions: Pharmacists generally were positive about medication synchronization programs, although some negative views were present, especially regarding the need for workflow change. Research is needed to understand barriers and facilitators to how medication synchronization programs are implemented and maintained and their effects on outcomes. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties.   Type: Original Research

The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange

INTRODUCTION

Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment.

MATERIALS AND METHODS

Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences.

RESULTS

Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD.

CONCLUSIONS

This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.

Medication List Discrepancies and Therapeutic Duplications Among Dual Use Veterans

A concerning level of discrepancies exists between the VA and non-VA medication lists of dual use veterans, raising the risk of adverse drug events.

Patient Education for Consumer-Mediated HIE. A Pilot Randomized Controlled Trial of the Department of Veterans Affairs Blue Button

OBJECTIVES

Consumer-mediated health information exchange (HIE) is one of the three types of HIE designated by the Office of the National Coordinator. HIE is intended to improve the quality of care while reducing cost, yet empirical support for this claim is mixed. Future research should identify the contexts whereby HIE is most effective.

METHODS

This study was conducted as a pilot two-arm randomized controlled trial. In the intervention arm, 27 veterans were taught how to generate a Continuity of Care Document (CCD) within the Blue Button feature of their VA patient portal and were then asked to share it with their community non-VA provider. In the attention control condition, 25 Veterans were taught how to look up health information on the Internet. The impact of this training on the next non-VA medical visit was examined.

RESULTS

Nineteen (90%) veterans in the intervention arm shared their CCD with their non-VA provider as compared with 2 (17%) in the attention control arm (p<0.001). Both veterans and non-VA providers indicated high satisfaction with the CCD. Comparison of medical records between the VA and non-VA providers did not indicate improved medication reconciliation (p=0.72). If veterans shared their CCD prior to their non-VA providers ordering laboratory tests, the number of duplicate laboratories was significantly reduced (p=0.02).

CONCLUSIONS

In this pilot randomized controlled trial, training 52 veterans to share their CCD was feasible and accepted by both patients and providers. Sharing this document appeared to reduce duplicate laboratory draws, but did not have an impact on documented medication list concordance.

Investigation of Simulated Pharmacist Decision Making Involving Prescriptions With a High Probability of Causing Patient Harm

Background: Medication errors pose a significant risk to patients, resulting in morbidity, mortality, and unnecessary health care utilization. Pharmacists, using their professional judgment, have an important role as a final check for identifying and resolving these problems. Little is known, however, about pharmacist perspectives and experiences with dispensing or withholding potentially dangerous prescriptions. Objectives: To (a) evaluate the extent to which pharmacists would not dispense a likely harmful prescription which has been confirmed by the prescriber and (b) assess pharmacist attitudes and experiences with dispensing likely harmful prescriptions. Methods: An anonymous, self-administered, 25-item survey was emailed to members of a state pharmacy association and a pharmacy college alumni list. A series of static prescription vignettes (1 reasonable and 4 likely dangerous doses) were presented and asked if they would fill each prescriber-confirmed prescription. Pharmacists also were asked a series of Likert-type, open-ended, multiple choice, and demographic items regarding their professional experiences and role perceptions. Results: There were 497 usable responses. Three of the 4 dangerous prescriptions were withheld by the majority of pharmacists (sumatriptan as the exception). No demographic variable was universally associated with filling dangerous vignette prescriptions; rather, there were vignette-specific differences. The majority of pharmacists reported refusing to fill a potentially harmful prescription during their career. Conclusions: There appears to be meaningful variation in how pharmacists react when presented with likely harmful prescriptions. More research is needed to better understand this role, its determinants, and the potential effects on patient safety.