Impact of pharmacist prescribing through direct pharmacy access policies on access to hormonal contraception.

BACKGROUND/OBJECTIVE: This study assesses the impact of direct pharmacy access (DPA) policies that allow pharmacists to prescribe hormonal contraceptives on women's access by comparing access among 3 groups: (1) women in a state without DPA (Indiana), (2) women in a state with DPA, but not using DPA, and (3) women in a state with DPA and using DPA. METHODS: This cross-sectional survey, including a scale to measure access to contraceptives, perception items, and demographics, was distributed through Amazon Mechanical Turk (Amazon.com, Inc). Kruskal-Wallis tests and linear regression analysis were used. RESULTS: The sample size was 316. When controlling for education, income, and age, the women not using DPA (in Indiana and a DPA state, respectively) reported significantly higher levels of approachability (P < 0.001 and P < 0.001, respectively), acceptability (P < 0.001 and P < 0.001, respectively), availability and accommodation (P < 0.001 and P = 0.009, respectively), affordability (P < 0.001 and P < 0.001, respectively), and appropriateness (P < 0.001 and P < 0.001) access than the women using DPA. The women using DPA reported significantly lower levels of privacy access than those not using DPA in a DPA state (P = 0.004) when controlling for education, income, and age. However, 78.9% of women using DPA agreed DPA made obtaining contraceptives easier. Most of the women who had never used DPA were previously unaware of DPA (81.1% in DPA states and 86.2% in Indiana) but felt that it would improve access (82.8% and 80.0%, respectively). CONCLUSION: Understanding the effects of DPA policies on women's access to contraceptives can inform future policies and support implementation. Lower levels of access across all dimensions among those using DPA may be influenced by imperfect implementation and failure to legislatively enable the sustainability of this service rather than pharmacists' ability to improve women's access.

A mixed-methods study of pharmacy instructors' early experiences with a teaching electronic medical record.

INTRODUCTION: As use of electronic medical records (EMRs) increases in healthcare, multiple accreditation organizations recommend training future clinicians on EMRs as part of the academic curriculum. Therefore, some pharmacy programs now utilize an academic EMR. Our objective was to examine pharmacy instructors' early experiences with a commercially available teaching EMR (tEMR) in order to identify current and future priorities along with benefits and barriers to academic EMR use in pharmacy education. METHODS: We conducted semi-structured interviews and a web-based survey with pharmacy instructors. Interview and survey data analyses consisted of hybrid inductive/deductive approaches to coding data and descriptive statistics, respectively. We mapped themes to the Pharmacists' Patient Care Process (PPCP). RESULTS: Seven instructors participated in interviews, and 10 completed the survey. We identified 25 interview themes that were generally congruent with survey responses. A noted benefit of the tEMR was providing a large repository of real-life patient data. Instructors' current priorities for tEMR activities primarily aligned with "collect," "assess," and "plan" steps of the PPCP. One reported barrier was insufficient training regarding the tEMR capabilities. Instructors offered innovative ideas for future academic EMR use, including pharmacokinetics, incident reporting, and longitudinal cases. CONCLUSIONS: Study findings are most applicable to pharmacy programs in the early stages of academic EMR adoption. We identified opportunities for pharmacy programs to facilitate innovative, future use of academic EMRs, including curriculum planning, so pharmacy students gain experience using EMR functions for each PPCP step and develop more advanced EMR skills.

Perceptions of working conditions and safety concerns in community pharmacy.

BACKGROUND/OBJECTIVE: Working conditions within community pharmacy can impact pharmacists and their ability to provide safe patient care. The objective of this study was to determine pharmacists' perceptions of working conditions while controlling for respondent (years of experience, degree, work status) and workplace variables (prescription volume, type of community setting). METHODS: This mixed-methods study used a cross-sectional survey to investigate community pharmacists' perceptions of company climate (at the store level, corporate level, as well as fear of discipline), workflow issues, and career satisfaction. Items utilized a seven-point Likert-type response format (1 = strongly disagree to 7 = strongly agree). Linear regression was used to assess relationships between perceptions and years of experience, degree, work status, prescription volume, and type of community setting. A free-response question captured perceptions of safety concerns. An adapted version of the Agency for Healthcare Research and Quality integrative model of health care working conditions on organizational climate and safety was used as a framework for this analysis. RESULTS: Respondents working in national chains had significantly more fear of being disciplined for following policies to promote safety and addressing patient safety concerns than respondents in independent (P < 0.001) and grocery and big box stores (P < 0.001), when controlling for years of experience in community pharmacy, degree, and prescription volume. Most participants (n = 805, 96.9%) indicated organizational or company level factors were the most substantial threat to safety, with work design and quality emphasis being the second most frequently mentioned hazards. CONCLUSION: Company climate and workflow were perceived negatively in all community settings but were perceived the most negatively by those working in chain pharmacies. A majority of pharmacists feared being disciplined for addressing safety concerns with management, which may be detrimental to patient safety. Further research on how to improve working conditions is warranted.

Opioid prescribing and health outcomes in opioid-naive patients: Analysis of a statewide health information exchange.

BACKGROUND: Widespread use of prescription opioids is associated with adverse outcomes. OBJECTIVE: To identify factors associated with adverse health outcomes and health care use using a statewide health information exchange. METHODS: This is a retrospective cohort study using the Indiana Network for Patient Care. Adult opioid-naive patients who received an opioid prescription between January 2012 and December 2017 were included. The outcomes included (1) a composite outcome of any combination of opioid abuse, dependence, or overdose, (2) all-cause mortality, and (3) health care use. Independent variables included opioid dosage, dispensed amount, days supply, concurrent use of short-acting (SA) and long-acting (LA) opioids, and concurrent use with benzodiazepine or gabapentinoids. Additional variables included patients' age, sex, race, modified Charlson Comorbidity Index score, mental health conditions, and medications for opioid use disorders. Factors associated with composite outcome and mortality were identified using Cox proportional hazards and reported as adjusted hazard ratio (aHR) and 95% CI. Factors associated with health care use were identified using Poisson regression and reported as adjusted incidence rate ratio (aIRR) and 95% CI. RESULTS: 1,328,287 opioid prescriptions were identified for 341,722 patients. Opioid-related factors associated with the composite outcome, mortality, and hospitalizations, respectively, included opioid dosage (aHR 1.003 [95% CI 1.001-1.006]; aHR not applicable; aIRR 1.07 [1.06-1.08]), opioid days supply (aHR 1.03 [1.02-1.03]; aHR 1.009 [1.005-1.014]; aIRR 0.94 [0.92-0.96]), concurrent SA/LA opioids (aHR 2.12 [1.78-2.54]; aHR 1.40 [1.14-1.70]; aIRR 1.40 [1.37-1.42]), and use of benzodiazepines/gabapentinoids (aHR 1.68 [1.38-2.04]; aHR 1.23 [1.01-1.51]; aIRR 1.25 [1.23-1.27]). CONCLUSION: Many factors are associated with poor health outcomes, especially concurrent use of SA and LA opioids and overlapping prescriptions of opioids with benzodiazepines or gabapentinoids. Identification of factors associated with adverse outcomes may help identify patients at risk for poor outcomes and could inform possible interventions.

Policy solutions to address community pharmacy working conditions.

OBJECTIVE: Increasing attention has been drawn to poor working conditions in community pharmacy, the impact on patient safety, and the role of pharmacy benefit managers (PBMs) in the United States. This study assessed community pharmacists' perceptions of potential solutions to improve working conditions. METHODS: This mixed-methods, survey-based study explored pharmacists' proposed solutions for improving working conditions. The participants' perceptions of solutions at the company and state or national levels were assessed using a 7-point Likert-type response format (from 1 = strongly disagree to 7 = strongly agree). Multiple regression assessed the relationships between participant perceptions and pharmacy type (e.g., national chain, grocery, or independent), pharmacy degree, age, average number of prescriptions processed daily (prescription volume), and years of experience. The participants' perceptions of how to improve working conditions were explored to provide more depth and nuance to the understanding of these issues. RESULTS: The sample size was 1222 participants. Respondents working for national chains were statistically significant more in favor of limiting the number of prescriptions verified per pharmacist and less in favor of addressing reimbursement issues than those working for grocery or big-box stores (P = 0.001 and P = 0.006, respectively) and independent pharmacies (P < 0.001 and P < 0.001, respectively), when controlling for years of experience, degree, and prescription volume. Although addressing staffing issues and changing corporate priorities were immediate concerns, the participants felt that regulating PBM reimbursement practices should be the first priority. CONCLUSION: Identifying solutions from employee stakeholders may be an effective way to inform actions that both employers and extraorganizational entities can take to improve pharmacist working conditions and patient care. Restricting PBMs was the most preferred solution, followed by direct and indirect reimbursement for nondispensing services. However, working conditions in community pharmacy are influenced by multiple factors that often are dependent on one another. Thus, a multifaceted approach will likely be required to improve working conditions.

Pharmacy students' perspectives on the initial implementation of a teaching electronic medical record: results from a mixed-methods assessment.

BACKGROUND: Electronic medical records (EMRs) have been used for nearly three decades. Pharmacists use EMRs on a daily basis, but EMRs have only recently been incorporated into pharmacy education. Some pharmacy programs have implemented teaching electronic medical records (tEMRs), but best practices for incorporating tEMRs into pharmacy education remain unknown. The objectives of this study were to 1) assess pharmacy students' views and experiences with a tEMR; and 2) identify current learning activities and future priorities for tEMR use in pharmacy education. METHODS: We used a mixed-methods approach, including three, two-hour student focus groups and a 42-item web-based survey to examine student perspectives of the tEMR. All first, second, and third year professional pharmacy students were eligible to participate in the survey and a focus group. Web-based survey items were measured on a 7-point Likert scale, and quantitative analyses included descriptive statistics. Two researchers independently coded transcripts using both deductive and inductive approaches to identify emergent themes. These analysts met and resolved any coding discrepancies via consensus. RESULTS: Focus groups were conducted with 22 total students, with 6-8 students represented from each year of pharmacy training. The survey was completed by 156 students: 47 first year, 55 second year, and 54 third year. Overall, 48.7% of survey respondents altogether agreed or strongly agreed that using the tEMR enhanced their learning in pharmacy classes and laboratories. Qualitative data were organized into four major themes regarding tEMR adoption: current priorities for use within the pharmacy curriculum; tEMR benefits; tEMR barriers; and future priorities for tEMR use to prepare students for pharmacy practice. CONCLUSIONS: This study reveals pharmacy students' perspectives and attitudes towards using a tEMR, the types of classroom activities that incorporate the tEMR, and students' future suggestions to enhance the design or application of the tEMR for their learning. Our research findings may aid other pharmacy programs and promote more effective use of tEMRs in pharmacy education. In the long-term, this study may strengthen pharmacy education on EMRs and thus increase the efficacy and safety of pharmacists' EMR use for patients' medication management.

Pharmacists' impact on older adults' access to vaccines in the United States.

OBJECTIVE: The purpose of this systematic review was to explore pharmacists' impact on older adults' access to vaccines in terms of realized accessibility, financial accessibility, and vaccine availability. METHODS: Five databases were searched using a search strategy developed in PubMed and translated to other databases. Included studies were English-language, United States-based primary literature published between 1994 to present day. Studies were excluded if they were incomplete studies or did not focus on at least one of three dimensions of access to immunizations: realized accessibility, availability, and financial accessibility. The following data were gathered: title, authors, year published, sub-dimension of accessibility, health care setting, intervention or data source, pharmacist role, type of immunization, duration of study, sample size, and main outcome measures. RESULTS: Twenty-five studies met the inclusion criteria. Of those, the majority evaluated realized accessibility (n = 22, 88%). Eleven studies evaluated vaccine availability, and one study addressed financial accessibility. Pharmacists had a variety of roles in the immunization process, including screener, educator, immunizer, or documenter, and often played more than one role (n = 10, 40%). Pharmacists participated in the vaccination process across multiple health care settings, including in community pharmacies (n = 8, 32%) and hospitals (n = 7, 28%). In the majority (n = 21, 84%) of studies, pharmacists positively impacted older adults' access to vaccines. The most common vaccinations studied were pneumococcal and influenza vaccinations (n = 20, 80%). CONCLUSION: Vaccinations are important in protecting and maintaining the health of older adults. Pharmacists improved access to vaccinations and served many roles in the vaccination process. Future research should explore how pharmacists impact access to vaccines beyond vaccination rates, especially regarding the financial impact on patients.

Pharmacy Student Perceptions and Preferences of In-person Versus Video-Recorded Evaluations in Skills-Based Courses.

Objective. To determine pharmacy students' preferences for and perceptions of in-person and video evaluations.Methods. A mixed methods survey was administered to 447 first-, second-, and third-year students enrolled in a public US Doctor of Pharmacy program. A survey instrument with 14 quantitative items and four qualitative items was used to measure student perceptions. Eight response choice items measured preferences. Paired t tests were used to compare students' perceptions. Independent t tests were used to compare perceptions between students who experienced and had not experienced video evaluations. Two researchers performed thematic content analysis of the qualitative responses.Results. Students (n=444, 99.3% response rate) perceived in-person evaluations more positively for all items except nervousness. Students who experienced video technology felt significantly more positive about video evaluations than students who had little or no experience using video technology on nine items. The students who experienced video technology felt significantly less positive toward video evaluations in terms of quality (1.24 vs. 0.83) and amount (1.14 vs 0.77) of written feedback. Although students valued the interaction with a larger, more diverse pool of evaluators that was made possible by video evaluations, they did not view video technology as applicable to their future practice.Conclusion. Students viewed in-person evaluations significantly more positively than video evaluations. This effect was mitigated by greater exposure to video technology, suggesting that concerns regarding video evaluations are based on conjecture rather than experience. This study highlights the need to reduce the technological issues associated with video evaluations and improve the written feedback provided to students.

Social and legislative shaping of access to contraceptives and the pharmacist's role: A literature review.

BACKGROUND: Despite years of research and numerous policies, access to contraceptives in the United States remains imperfect. Largely due to lack of access to contraceptives, unintended pregnancy rates remain high. OBJECTIVE: To provide researchers and policy-makers with a comprehensive review of the legislative and social landscape that has shaped contraceptive access in the United States, which may help to guide future research and policies. METHODS: A narrative overview of existing literature on policies and research regarding women's access to contraceptives was compiled, with a focus on the role of pharmacists. RESULTS: Contraceptive access has been heavily influenced by laws and policies throughout the years, and disparities remain in underserved populations. Pharmacists are beginning to play a role in improving access to contraceptives through provision of contraceptives using direct pharmacy access policies. CONCLUSIONS: Continued research and new policies aimed at improving contraceptive access are warranted.