Comparing algorithms for composite measures of intra-disease multiple medication adherence: The case of diabetes.

BACKGROUND: Adherence to multiple medications (i.e., separate dosage forms) intended for a disease can be measured by different single estimators, termed as composite estimators of intra-disease multiple medication adherence: 80% days covered (a) by at least one medication ("at least one"); (b) by both medications ("both"); (c) by each medication measured separately ("all"); and (d) computing an average of the individual medication adherence estimates ("average"). OBJECTIVES: (a) Assess different composite adherence estimators regarding their ability to predict healthcare utilization; (b) compare and contrast composite estimators. METHODS: Using MarketScan 2002-2003 data, 6043 nonelderly patients who filled separate prescriptions of sulfonylurea [SU] and thiazolidinedione [TZD] were identified. Adherence was measured by the proportion of days covered (PDC) over periods of 90 days, 30 days, and cumulatively over such periods. Cox proportional hazards models analyzed all-cause and diabetes-related emergency room (ER) visits as the outcome variables. RESULTS: All composite measures predicted hazards of all-cause or diabetes ER visits (P < 0.001) and each measure showed statistically significant discriminatory power (concordance statistics from 0.55 to 0.58). Cox regression was performed multiple times in which composite estimators measured on a continuous scale (e.g., 'average') were dichotomized using several cut-points. In the majority of cases (≤3 out of 8 times in analyses of ER outcomes), optimal results did not occur when the dichotomization cut-point was set at 80%. CONCLUSIONS: Each composite estimator showed the fundamental quality of a good measure. Although 'average' and 'all' approaches offer ease of measurement, there was no clear trend in superiority of one measure over the others. Clinical and practical considerations should dictate the choice of measure.

Development of the medication adherence estimation and differentiation scale (MEDS).

OBJECTIVES: To develop a self-reported measure for medication adherence and compare its ability to predict the proportion of days covered (PDC) with contemporary scales. METHODS: Retrospective prescription fill data from three community pharmacies in the Southeastern US were assessed to identify patients that were 18 years of age or older, and had received at least one medication for diabetes, hypertension, or dyslipidemia. A cross-sectional survey containing the Medication adherence Estimation and Differentiation Scale (MEDS) was administered among these pharmacy patrons. The MEDS assessed the extent and reasons for non-adherence. Survey responses were anonymously linked with retrospective prescription fill data. A total of 685 patients were sampled. The proportion of days covered (PDC) was used as the criterion measure. The Morisky, Green, and Levine Adherence Scale (1986 Morisky scale) and the Medication Adherence Reasons Scale (MAR-Scale) were used as comparators. RESULTS: The MEDS presented a five-factor solution-worries about side-effects, worries about addiction, worries about cost, lack of perceived need, and unintentional non-adherence (CFI = 0.97; RMSEA = 0.06; SRMR = 0.03; standardized factor loadings greater than 0.5, and statistically significant). The relationship between MEDS scores and PDC was statistically significant (unstandardized regression coefficient = -0.50, p < .01). The MEDS performed better than the 1986 Morisky scale (R2 = 0.02 vs 0.05, standardized regression coefficient = -0.13 vs -0.21) and the MAR-Scale (R2 = 0.02 vs 0.05, standardized regression coefficient = -0.12 vs -0.21) in predicting PDC. CONCLUSIONS: The MEDS demonstrated good psychometric properties and performed better than the comparator scales in the prediction of PDC.

The Relationship Between Prior Experiences in Mathematics and Pharmacy School Success.

Objective. To assess students' pre-pharmacy math experiences, confidence in math ability, and relationship between experiences, confidence, and grades in math-based pharmacy courses. Methods. A cross-sectional survey of first year to third year pharmacy students was conducted. Students reported type of pre-pharmacy math courses taken, when they were taken [high school (HS) vs. college] and year of HS and college graduation. Students rated their confidence in math ability using the previously validated 11-item Fogerty Math Confidence Scale (Cronbach alpha=0.92). Math grade point average (GPA), Pharmacy College Admission Test quantitative (PCAT quant) scores, and grades (calculations and kinetics) were obtained from transcripts and school records. Spearman correlation and multivariate linear regression were used to compare math experiences, confidence, and grades. Results. There were 198 students who reported taking math courses 7.1 years since HS graduation and 2.9 years since their last schooling prior to pharmacy school. Students who took math courses with more time since HS/last schooling had lower calculations and kinetics grades. Students reporting having taken more HS math courses had better calculations grades. Students with higher math GPA, and PCAT quant scores also had higher calculations and kinetics grades. Greater confidence in math ability was associated with higher calculations grades. In multivariate regressions, PCAT quant scores and years since HS independently predicted calculations grades, and PCAT quant scores independently predicted kinetics grades. Conclusion. The number of pre-pharmacy math courses and time elapsed since they were taken are important factors to consider when predicting a pharmacy student's success in math-based pharmacy school courses.

Hospital pharmacists' perceived beliefs and responsibilities in indication-based off-label prescribing.

Background Off-label prescribing is prevalent in healthcare. There is a lack of understanding of pharmacists' attitudes toward the practice of off-label prescribing, especially those that are prescribed for other indications than approved ones (termed as indication-based off-label prescribing). Objective Explore hospital pharmacists' attitudes toward and perceived responsibility in off-label and indication-based off-label prescribing in hospital pharmacy practice. Setting Pharmacists practicing in hospitals in the United States were investigated. Method Pharmacists were contacted via email through State affiliates of the American Society of Health-System Pharmacist. The survey described an indication-based off-label medication order for a hospitalized patient and the prescribing physician. Data were collected via Qualtrics. Main outcome measure Questions focused on awareness, beliefs, and responsibility-including, risk assessment and monitoring outcomes-related to off-label and indication-based offlabel prescribing. Results Of 107 pharmacist respondents, about 79% and 98% reported being familiar with offlabel and indication-based off-label prescribing, respectively. While 77.6% pharmacists believed that patients should be informed, only 37.4% agreed that they had responsibility of informing physicians; presence of policy was associated (p < 0.02) with pharmacist agreeing to inform physicians. Over 70% agreed that patients should be closely monitored for outcomes and 43.1% believed physicians had predominant responsibility of monitoring outcomes. Conclusion Pharmacists' perceived responsibility and beliefs regarding off-label prescribing are insightful that can be utilized for improving patient care.

Preliminary development of the Medication Nonpersistence Scale.

OBJECTIVES: To develop the Medication Nonpersistence Scale (MNPS)-a multi-item self-reported scale to measure medication persistence. SETTING: Six hundred seventy-five patients patronizing 3 separate independent community pharmacies in the southeastern United States participated in this research. PRACTICE INNOVATION: The MNPS, a self-reported measure, developed to provide an estimate of, and reasons for, medication nonpersistence. EVALUATION: Cross-sectional survey data were linked with retrospective prescription fill data obtained from 3 independent community pharmacies in the southeastern United States. The MNPS factor structure was studied by means of confirmatory factor analysis (CFA), and its scale reliability and convergent validity were evaluated with the use of the results of this analysis. Its concurrent validity was tested against a standardized days-to-discontinuation measure calculated over the past 12 months, and an attempt was made to arrive at an optimum cutoff point to identify patients who have been nonpersistent with their medications. RESULTS: The survey yielded 675 usable patients. The CFA confirmed a single-factor solution with good model fit (root mean square error of approximation = 0.06 [90% CI 0.05-0.07]; comparative fit index = 0.96). Moderate to strong evidence of scale reliability (Cronbach alpha = 0.75; construct reliability = 0.94; index of composite reliability developed for binary items = 0.91), convergent validity (standardized factor loadings >0.5 and statistically significant), and concurrent validity (unstandardized regression coefficient = -3.97; P = 0.03) was observed. Individuals who score 1 or higher on the MNPS were considered to be nonpersistent. CONCLUSION: The MNPS demonstrated good psychometric properties and offers a useful first step toward the self-reported measurement of medication persistence in clinical practice and research.

The role of perceived impact on relationship quality in pharmacists' willingness to influence indication-based off-label prescribing decisions.

Little is known about factors that affect pharmacists' roles in off-label prescribing. This study examined the effect of perceived impact on relationship quality (IRQ) on hospital pharmacists' willingness to influence a physician's decision regarding an indication-based off-label medication order (WTIP) (i.e., beyond FDA-approved indications) and the moderating roles of the appropriateness of the medication order and the relative expert power of the pharmacist. Pharmacists practicing in U.S. hospitals, recruited from membership rolls of state affiliates of the American Society of Health-System Pharmacists, were sent an electronic link to a questionnaire via their respective affiliates. A cross-sectional, randomized, 2 × 2 experimental design was used; participants were assigned to one of the indication-based off-label medication order scenarios. Relative expert power (i.e., power differential between the pharmacist and the physician) and appropriateness of the prescription were manipulated. Perceived IRQ was measured with multiple items. Pharmacists' WTIP in the scenario was the outcome variable. A total of 243 responses were included in multiple linear regression analyses. After controlling for dependence power, information power, communication effectiveness, perceived responsibility, and attitude, pharmacists' WTIP was negatively affected by perceived IRQ (estimate = -0.309, P < 0.05). This effect was more pronounced in groups exposed to the scenario where the pharmacist had lower relative expert power (estimate = -0.438, P < 0.05) and where the medication was less appropriate (estimate = -0.503, P < 0.05). Although willing to ensure rationality of off-label prescribing, pharmacists' WTIP was affected by a complex array of factors - the perceived impact of influence attempts on relationship quality between the pharmacist and the prescriber, the pharmacist's relative expert power, and the appropriateness of the off-label prescription. Increasing pharmacists' expert power and collaboration with physicians and promoting pharmacists' multifaceted contribution, collaborative or independent, to patient care may facilitate pharmacist services in off-label pharmaceutical care.

Store and prescription characteristics associated with primary medication nonadherence.

BACKGROUND: Primary medication nonadherence (PMN) is any instance whereby patients fail to initiate a pharmacotherapy regimen after receiving a prescription for new therapy. The Pharmacy Quality Alliance (PQA) has proposed a standardized definition for PMN and a quality measure to assess the rates of PMN in community pharmacies. OBJECTIVES: To (a) measure PMN using the proposed PQA measure with data available from a pharmacy dispensing system and (b) identify the prescription-level (patient, prescriber, and medication) and store-level (store and neighborhood) characteristics associated with PMN. METHODS: This study was approved by a southern university institutional review board, and a data use agreement was in place. A large national pharmacy grocery chain provided de-identified, transactional data for 2010 through January 2012, for 100 pharmacies (de-identified unique patient and store codes were available). The proposed PQA-PMN measure was used, and PMN rates were calculated. Investigators examined adult individuals with a new electronic prescription for any of the included medications during the measurement period and determined whether the medication or an appropriate alternative was claimed within 30 days. Multilevel logistic regression with a random intercept was used to evaluate prescription-level and store-level predictors of PMN. Prescription-level variables included prescriber type, PQA-defined drug class, patient gender and age, whether the prescription was accompanied by another prescription on the same day, payment source, and out-of-pocket costs. A daily average prescription volume variable was calculated for each pharmacy as a store-level variable. Additional store-level variables were derived from the 2007-2011 American Community Survey, available from the U.S. Census Bureau (median household income, educational level, percentage of minorities, and percentage aged 65 years and over in the census tracts where the pharmacies are located).  RESULTS: Of the e-prescriptions during the 1-year measurement period, 29,238 were for new therapies as defined by the PMN measure, and 3,570 (12.2%) of those new prescriptions were not claimed within a 30-day period. There was significant variability among the pharmacies (intraclass correlation coefficient=0.140). In the adjusted multilevel model, the estimated odds of an unclaimed prescription were significantly different among drug classes comprising the PQA-PMN measure and were higher as out-of-pocket costs increased, when the prescription was accompanied by another prescription on the same day, and for primary care physicians relative to physician assistants and advanced practice nurses. The estimated odds were slightly higher for younger individuals, when originating at stores with lower prescription volumes and when originating at stores located in neighborhoods with higher household incomes. Although neither the gender of the patient nor the payment source were related to whether the prescription went unclaimed in the multivariable model, these variables, along with out-of-pocket costs and the accompaniment of the prescription with another prescription on the same day, were involved in cross-level interactions with household income and educational level.  CONCLUSIONS: This study is one of the first to use pharmacy prescription data to calculate PMN using the PQA standardized measure and to identify prescription-level and store-level factors associated with PMN. PMN remains a significant challenge in this setting, and there is significant variation in the outcome among pharmacies in the same chain, even after accounting for several potential store-level predictors. There is considerable opportunity for quality improvement to reduce the number of unclaimed prescriptions. Efforts directed at further understanding this behavior and how to design tailored interventions to reduce its occurrence are warranted.

Factors that physicians find encouraging and discouraging about electronic prescribing: a quantitative study.

To determine factors that physicians find encouraging and discouraging about e-prescribing and to compare these factors based on physicians' adoption status, a cross-sectional study was conducted using an internet-based survey administered to a national convenience sample of primary care physicians. A scale was developed to measure factors related to the adoption of e-prescribing. Analysis procedures included exploratory factor analysis, multivariate analysis of variance, and Tukey's post-hoc tests. 443 surveys were received and seven e-prescribing factors were identified. Pre-implementation and cost factors were found to be most discouraging, while software features were found to be most encouraging. The fact that current e-prescribers found e-prescribing factors to be more encouraging than future or non-e-prescribers suggests that 'fear of the unknown' may play a role in prescribers' perceptions of e-prescribing and associated software. These findings will enable consultants, vendors, and policymakers to facilitate the adoption of e-prescribing by directly targeting the factors that are most salient to physicians.

Adoption of and experience with e-prescribing by primary care physicians.

BACKGROUND: The impetus of electronic prescribing (e-prescribing) is the reduction of preventable medication errors by generating a legible prescription checked via e-prescribing software for drug-drug and other interactions. Although the adoption of e-prescribing among physicians is growing, the Institute of Medicine's recommendations that all prescriptions be routed electronically by 2010 certainly has not been met. OBJECTIVES: To provide an update on e-prescribing use among primary care physicians (PCPs), describe their experience with e-prescribing, and provide insight into prescribers' decisions to implement e-prescribing in their practices. METHODS: An Internet-based survey was administered to a national convenience sample of physicians. The respondents were categorized into e-prescribers or non-e-prescribers. Data to describe demographic characteristics, respondents' experiences with e-prescribing, and respondents' decision to implement e-prescribing were collected. Nonparametric tests were used to test differences in the factors influencing e-prescribers' and traditional prescribers' decisions about electronic prescription implementation. RESULTS: Four hundred forty-three PCPs participated in the study. There were no significant differences in the demographic characteristics of e-prescribers and non-e-prescribers. Most e-prescribers (83%) reported satisfaction with their e-prescribing system and a preference for e-prescribing over traditional prescribing. Although 22% of respondents indicated that they have started and stopped e-prescribing, most have resumed or intended to resume e-prescribing in the near future. More than half of the respondents reported that they are experiencing problems with their e-prescribing software. CONCLUSIONS: E-prescribing appears to be present in many types of primary care practices and geographic areas of the country. Despite their satisfaction with and preference for e-prescribing, PCPs still appear to be experiencing problems with e-prescribing software. Implications of these study results for the pharmacy profession are discussed.

The influence of symbols on the short-term recall of pharmacy-generated prescription medication information in a low health literate sample.

The effect of symbols on conveying health information has been studied in a variety of contexts and populations. This investigation assessed whether short-term recall of prescription medication information could be enhanced in a low health literate population through the use of symbols. Participants recruited from various nonpharmacy educational service locations were randomly assigned to receive a prescription medication information leaflet in either a text-only, text with symbols, or symbols-only format and then administered the Rapid Estimate of Adult Literacy in Medicine (REALM). Only those with REALM scores indicative of a sixth grade or lower reading level were included in data analysis. An 8-item, interviewer-administered questionnaire was used to assess participants' recall of information contained in the leaflet. A fictitious medication was used to control for participants' past experiences with medications. Results of statistical testing revealed that the three groups did not differ with respect to their ability to recall the medication information, F(2, 157) = 0.943, p = .392. The symbols used in this investigation were not found to enhance the short-term recall of the medication information presented. These findings should not be considered a wholesale indictment of the use of symbols within health care and in pharmacies. Rather, they should serve as a caution to their widespread use without careful consideration.

Health literacy in the pharmacy setting: defining pharmacotherapy literacy.

OBJECTIVE: All currently available definitions of health literacy may be considered quite general. Given the complex nature of the patient-pharmacy encounter and the varying tasks required to properly and successfully consume or administer medication or to adhere to a pharmaceutical care regimen, these available definitions may describe inadequately a patient's health literacy for the purpose of pharmacotherapy and pharmacist intervention. Therefore, the objective of this research was to conceptualize the Pharmacotherapy Literacy construct. METHODS: Licensed pharmacists (n=2,368) were mailed a questionnaire providing them with the Healthy People 2010 definition of health literacy and asked, "Given this definition, how would you define Pharmacotherapy Literacy?" A total of 420 usable surveys were returned of which 176 (42%) included responses to the open-ended question concerning pharmacotherapy literacy. Responses were reviewed independently and collectively by the authors. Common themes were identified, compared and discussed until consensus was reached. An initial definition was formulated and distributed to six doctoral-trained academicians and practicing pharmacists who were asked to offer their opinions of the definition as well as suggestions for its improvement. The definition was modified and subjected to further review from 15 additional doctoral-trained academicians and practicing pharmacists who provided feedback concerning its improvement. RESULTS: BASED ON THE RECOMMENDATIONS RECEIVED FROM THE ACADEMICIANS AND PHARMACISTS, THE FOLLOWING, FINAL DEFINITION WAS FORMULATED BY THE AUTHORS: Pharmacotherapy Literacy - An individual's capacity to obtain, evaluate, calculate, and comprehend basic information about pharmacotherapy and pharmacy related services necessary to make appropriate medication-related decisions, regardless of the mode of content delivery (e.g. written, oral, visual images and symbols). CONCLUSIONS: As the ever-changing pharmacy environment continues to advance and become more complex in nature, a definition of health literacy specific to the pharmacy setting - thereby providing a name and a focus - may improve medication consumption, medication safety, and the patient-pharmacist relationship.

The role of the medial prefrontal cortex in the play fighting of rats.

Although decorticated rats are able to engage in play, their play is abnormal in three ways. First, decorticates do not display the normal, age-related shifts in defensive strategies during development. Second, decorticates do not modify their defensive tactics in response to the social identity of their partners. Third, decorticates display a global shift in defensive tactics from more complex to less complex strategies. It has been shown that lesions of the motor cortex (MC) selectively produce the abnormal developmental effects on play, and that lesions of the orbitofrontal cortex (OFC) selectively produce the deficits in behavioral discrimination between social partners. In the current set of experiments, we demonstrate that lesions of the medial prefrontal cortex (mPFC) produce the shift from more complex to less complex defensive tactics, while leaving intact the age-related and partner-related modulation of defensive strategies. Thus, we have evidence for a triple dissociation of function between the MC, the OFC, and the mPFC with respect to social play behavior.

Pharmaceutical product withdrawal: attributions of blame and its impact on trust.

BACKGROUND: Six major pharmaceutical products were withdrawn from the market from 2000 to 2006. Little evidence exists in understanding consumer reactions to such events and the influence the withdrawal has on its competitors. OBJECTIVE: To explore consumers' attribution of blame after pharmaceutical product market withdrawal (PPMW) and its effect on trust. METHODS: Subjects were assigned randomly to 4 groups and provided a unique hypothetical PPMW scenario and asked to imagine themselves in the situation described. Each scenario represented a different "distance" from the PPMW (eg, whether subjects were asked to assume they were taking the withdrawn drug or a therapeutic substitute). Blame of and trust in several key professionals/groups were measured. RESULTS: Closer "distance" to the PPMW resulted in higher blame attributions for the Food and Drug Administration (FDA), pharmaceutical company (Pharma), and the physician. Although the pattern of trust scores did not differ based on "distance," insurance companies and Pharma suffered from low trust, whereas pharmacists and physicians received higher trust ratings. Blaming appeared to be no different between consumers on a withdrawn product and those consumers on a product in the same therapeutic class ("substitute" product). CONCLUSION: Substitute products (drugs in the same therapeutic class) appear to be affected in the event of a PPMW, although drugs used to treat the same disease do not appear to be so affected. The difficult-to-explain findings with respect to trust may be accounted for by the fact that trust is more downstream than blame (based on the scenario presentations) and that trust is a complex construct with multiple antecedents. Although the bonds of interpersonal trust remain stronger than those of institutional trust, the likelihood of situational trust versus overall trust may complicate this picture of understanding trust. It may be possible that trust is impervious to this one negative instance versus many positive interactions.

The psychosocial work environment and maternal postpartum depression.

BACKGROUND: Postpartum depression is a debilitating mental disorder affecting women after childbirth. This study examined the correlates of postpartum depression at 11 weeks after childbirth, focusing on work-related stressors and applying the job demand-control-support model. METHOD: Investigators recruited a prospective cohort of 817 employed Minnesota women when hospitalized for childbirth in 2001. Trained interviewers collected data in person and by telephone at enrollment and 5 and 11 weeks postpartum from three Minneapolis and St. Paul hospitals. RESULTS: Results of hierarchical regression analysis showed that worse depression scores (Edinburgh Postnatal Depression Scale) were associated with higher psychological demands, lower schedule autonomy, and lower perceived control over work and family. Perceptions of control mediated the relationships of coworker support and schedule autonomy with postpartum depression scores. Study findings showed no significant buffering effects for decision latitude; however, coworker support and decision latitude appear to act as functional substitutes in reducing postpartum depressive symptoms. CONCLUSION: These findings raise questions about the applicability of the job demand-control-support model to postpartum women or to postpartum depression. Future research could assess the impact of the interaction between the work and home environment on maternal postpartum depression.

Ratings of journals for the dissemination of pharmacy-related social and administrative science.

BACKGROUND: It has been over a decade since a journal quality rating study has been conducted in the social and administrative sciences (SAdS). This study sought to reevaluate perceptions of journal quality. OBJECTIVES: To develop a list of journals that are suitable publication venues for SAdS scholars and compare the quality of these journals as rated by school of pharmacy deans, SAdS department/division chairs, and SAdS faculty. METHODS: A list of journals was assembled and presented to a Delphi panel of 15 SAdS scholars. Using a modified Delphi technique, the panel refined the list by judging the suitability of each journal as a publication venue for scholars. This list was used in a survey administered via the Internet. Journal quality was rated on a 7-point Likert-type scale with the option of indicating unfamiliarity with each journal. Differences in quality ratings between faculty, chairs, and deans were explored. Adjusted rating scores were calculated based on familiarity with journals. Ratings from the current study were compared to previous studies. RESULTS: One hundred and twelve journals emerged from the modified Delphi technique. Kruskal-Wallis analysis of variance found no significant difference in perceived journal quality across all journals evaluated by the 3 groups (KW=3.91). Groups did differ in their familiarity (KW=11.71, P<.01), with faculty being the most familiar with the journals and deans being the least familiar. Journal rankings were highly correlated with journal rankings from previously published studies. CONCLUSIONS: Results of this study have implications for scholars choosing publication venues and those who make decisions contingent on scholars' publication records. These differences may represent a positive or negative bias that affects hiring as well as tenure and promotion decisions. This study provides guidance for decisions reliant on publication records, but should not be used exclusively as such an indicator.