Cost-Effectiveness of Intranasal Naloxone Distribution to High-Risk Prescription Opioid Users.

OBJECTIVES: To determine the cost-effectiveness of pharmacy-based intranasal naloxone distribution to high-risk prescription opioid (RxO) users. METHODS: We developed a Markov model with an attached tree for pharmacy-based naloxone distribution to high-risk RxO users using 2 approaches: one-time and biannual follow-up distribution. The Markov structure had 6 health states: high-risk RxO use, low-risk RxO use, no RxO use, illicit opioid use, no illicit opioid use, and death. The tree modeled the probability of an overdose happening, the overdose being witnessed, naloxone being available, and the overdose resulting in death. High-risk RxO users were defined as individuals with prescription opioid doses greater than or equal to 90 morphine milligram equivalents (MME) per day. We used a monthly cycle length, lifetime horizon, and US healthcare perspective. Costs (2018) and quality-adjusted life-years (QALYs) were discounted 3% annually. Microsimulation was performed with 100 000 individual trials. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: One-time distribution of naloxone prevented 14 additional overdose deaths per 100 000 persons, with an incremental cost-effectiveness ratio (ICER) of $56 699 per QALY. Biannual follow-up distribution led to 107 additional lives being saved with an ICER of $84 799 per QALY compared with one-time distribution. Probabilistic sensitivity analyses showed that a biannual follow-up approach would be cost-effective 50% of the time at a willingness-to-pay (WTP) threshold of $100 000 per QALY. Naloxone effectiveness and proportion of overdoses witnessed were the 2 most influential parameters for biannual distribution. CONCLUSION: Both one-time and biannual follow-up naloxone distribution in community pharmacies would modestly reduce opioid overdose deaths and be cost-effective at a WTP of $100 000 per QALY.

Classifying intervention modifications in the community pharmacy context: A demonstration study.

OBJECTIVES: The objectives of this study were to apply the Stirman and colleagues' framework to identify modifications made to a motivational interviewing (MI)-based intervention for medication nonadherence and to determine whether the locally modified intervention affected expected patient medication adherence outcomes in community pharmacies. METHODS: Pharmacists at 4 pharmacies were trained to provide a brief MI intervention to 50 patients per pharmacy who were nonadherent to antihypertensive medications. The training included a 3-hour online course in MI and in-pharmacy training on patient identification and documentation. Semistructured interviews were conducted to determine modifications to the patient identification processes, MI interventions, and documentation of interventions. Directed content analysis was guided by the Stirman and colleagues' framework. Preintervention and 6 months postintervention adherence rates for the patients who received the intervention were calculated. Paired samples t tests were used to assess the impact of the intervention on adherence rates. RESULTS: Modifications were made to the context of the intervention (e.g., via telephone instead of in-pharmacy). Additionally, content modifications included "loosening the structure" (e.g., reordering intervention steps), "drifting or departing" (e.g., too busy to attempt), "adding elements" (e.g., reminder cards), and "repeating elements" (e.g., patient identification). There were statistically significant improvements in adherence from preintervention to 6 months postintervention (74.1% to 84.5%; P < 0.05) at each pharmacy regardless of the modifications applied. CONCLUSION: Modifications made during intervention implementation were classified using Stirman and colleagues' framework. Despite the modifications, adherence rates improved and were consistent with expectations based on prior studies of similar interventions. These findings support previous implementation research on adaptability and suggest that the ability to tailor, modify, or refine an intervention to meet the needs of the provider or setting may allow for intervention success. Future research on the impact of specific modifications will help determine which are detrimental or beneficial to patient outcomes and sustainability of services.

Development and implementation of a collaboration between a patient-centered medical home and community pharmacy.

OBJECTIVES: This study aimed to describe the development and implementation strategies used in the collaboration between a patient-centered medical home (PCMH) and a grocery pharmacy chain and to evaluate the effectiveness of a community pharmacist's clinical integration in reducing hemoglobin A1c levels at clinic and patient levels. SETTING: The Kroger Co and Catholic Health Initiative St. Vincent. PRACTICE DESCRIPTION: The Kroger Co is a large grocery store that operates 27 pharmacies in the state of Arkansas, with 20 locations in the central Arkansas area. PCMH is part of a large health system in central Arkansas with 10 primary-care clinics in the area. PRACTICE INNOVATION: With the transition to value-based payment models, pharmacists are being utilized in settings outside of the pharmacy. This project demonstrates a partnership between a community pharmacy and PCMH. The community pharmacist spent 20 h/week in the PCMH providing medication therapy and disease state management services. Services were focused on patients with uncontrolled diabetes. EVALUATION: Descriptive statistics were used to describe the distribution of the pharmacists' time. A patient-level pre-post analysis of the mean changes in hemoglobin A1c (HbA1c) was conducted for patients who interacted directly with the pharmacist. A clinic-level analysis was conducted to evaluate changes in HbA1c compared to that in a nonequivalent control group using a standard quality measure. RESULTS: In total, 312 individual patients interacted with the pharmacist. Of those patients, 228 had diabetes. A total of 111 patients underwent pre-post HbA1c analysis. In those patients, there was a statistically significant reduction in mean HbA1c . There was no difference in clinic-level results between the intervention and control locations. CONCLUSION: Collaboration between a community pharmacy and PCMH is feasible and may improve patient care. Future research should include pharmacy-based visits and development of a process for improved communication.

Pharmacist-provided services and community pharmacist integration into a patient-centered medical home: A qualitative study of primary care clinic staff perceptions.

OBJECTIVES: To describe patient-centered medical home (PCMH) staff members' views toward community pharmacist involvement in patient care within the PCMH and to identify areas in which pharmacist-provided services can improve the quality of care in their clinics. DESIGN: Qualitative semistructured interview study. SETTING: One primary care clinic. PARTICIPANTS: Multidisciplinary clinic staff members. OUTCOME MEASURES: Views of staff toward implementing a community pharmacist into their clinic and top pharmacist services to help improve medication management within the clinic. RESULTS: A total of 14 staff members of the clinic participated in the study. Participants included physicians, clinical staff members such as registered nurse assistants, licensed practical nurses, and medical assistants, and clinic management. Key themes included the following: the clinic was open to implementing pharmacy services; the providers would be very receptive to pharmacist recommendations; the clinic is willing to try different pharmacist integration models to see what works best within the workflow; the pharmacist must be readily available for consultation; the pharmacist should hold an introductory meeting with the clinic; opinions vary on the best timing of pharmacist appointments with patients; and ideas vary about the best location for pharmacist consultations. The top 5 pharmacist services mentioned by participants included chronic condition management, medication reconciliation training, Beers List education, diabetes education, and adherence counseling. CONCLUSION: Primary care clinic staff support the integration of pharmacy services. Further research is needed to apply the results to other clinics and to identify barriers and opportunities in the implementation process.

Community pharmacy owners' views of star ratings and performance measurement: In-depth interviews.

OBJECTIVES: The star rating system implemented by Medicare has the potential to positively affect patient health and may have financial implications for community pharmacies. Learning from owners of community pharmacies with high performance on these quality measures may help us to identify and further understand factors contributing to their success. This study described high-performing community pharmacy owners' current awareness and knowledge of star ratings, attitudes toward star ratings and performance measurement, and initiatives being offered in pharmacies that aim to improve the quality of care. METHODS: Qualitative interviews with owners of independent community pharmacies were conducted in Spring 2015. Fifteen community pharmacies with high performance on the star rating measures were invited to participate. Recruitment did not end until the saturation point had been reached. All interviews were transcribed verbatim. Interview data were analyzed with the use of ATLAS.ti by 2 coders trained in thematic analysis. Krippendorf's alpha was calculated to assess intercoder reliability. RESULTS: Ten high-performing pharmacy owners participated. Analysis identified 8 themes, which were organized into the following categories: 1) current awareness and knowledge (i.e., superficial or advanced knowledge); 2) attitudes toward star ratings (positive perceptions, skeptical of performance rewards, and lack a feeling of control); and 3) pharmacy initiatives (personal patient relationships, collaborative employee relationships, and use of technology). Intercoder reliability was good overall. CONCLUSION: Interviews with high-performing pharmacies suggested that awareness of the star rating measures, overall positive attitudes toward the star ratings, the relationships that pharmacy owners have with their patients and their employees, and the use of technology as a tool to enhance patient care may contribute to high performance on the star rating measures. Future research is needed to determine if and how these constructs are associated with pharmacy performance in a larger population.

Adoption of a biometric screening service in community pharmacies: a qualitative study.

OBJECTIVE: To explore differences in perceived attributes of biometric screening services and organization characteristics among community pharmacies that adopt, outsource, or do not adopt biometric screening services that assess patients' blood pressure, blood glucose, serum cholesterol, and body mass index. DESIGN: Qualitative, comparative analysis. SETTING: Independently owned community pharmacies in Alabama. PARTICIPANTS: 25 key informants from community pharmacies were classified as adopters, outsourced adopters, and nonadopters of biometric screening services. Pharmacies using in-house staff to conduct screenings are referred to as adopters; those using external staff are referred to as outsourced adopters. MAIN OUTCOME MEASURES: Perceived attributes of the screening service and organizational characteristics identified through emergent theme analysis based on the Diffusion of Innovations Model and Model of Innovation Assimilation. RESULTS: The screening service was perceived differently by adopters, outsourced adopters, and nonadopters. Adopters saw the opportunity to increase revenue and expand the role of the pharmacist in health care by offering the service. Adopters also perceived the service to be compatible with their pharmacy layout and organizational identity; simple to implement; modifiable in terms of experimentation with models of service delivery; and visible by external constituencies (which positively affects pharmacy image). In contrast, nonadopters felt the amount of time, investment, and lack of potential patients associated with the service influenced their decision not to adopt it. Adopters and nonadopters differed in regard to their innovativeness in patient care services, their connectedness in professional networks, and how they make sense of and deal with the uncertainty of new programs. Outsourced adopters were similar to adopters but were more cautious in their decision making. CONCLUSION: Perceived attributes of the screening service and organizational characteristics differed among adopters, outsourced adopters, and nonadopters.

Rural Americans' COVID-19 Vaccine Perceptions and Willingness to Vaccinate against COVID-19 with Their Community Pharmacists: An Exploratory Study.

In early 2022 in the U.S., rural adults were the least likely to vaccinate against COVID-19 due to vaccine hesitancy and reduced healthcare access. This study explored the factors influencing rural adults' COVID-19 vaccine perceptions and their acceptance of pharmacist-administered vaccination. We utilized phone-based semi-structured interviews with 30 adults living in rural regions of one southwestern state and analyzed the data using a team-based thematic analysis approach. Vaccine-willing participants described knowing other people affected by the virus and their desired protection from the virus. They reported trusting scientific institutions and the government to provide safe vaccines. Vaccine-hesitant populations, however, feared that the COVID-19 vaccine development process had been rushed, compromising the safety of these newer vaccines. Although they differed in the news sources they preferred for receiving COVID-19 vaccine information, both vaccine-willing and vaccine-hesitant participants described trusting local authorities, such as healthcare providers and county government officials, to provide accurate COVID-19 vaccine information. Regarding the acceptability of pharmacist-administered COVID-19 vaccinations, all but one participant described their acceptance of this healthcare delivery approach. Future outreach should leverage rural adults' trust in local sources, including community pharmacists, deemed more convenient access points to healthcare, when addressing vaccine hesitancy.

U.S. adults' reasons for changing their degree of willingness to vaccinate against COVID-19.

Introduction: COVID-19 vaccines significantly reduce the risk of complications and hospitalizations due to this virus. When COVID-19 vaccines first became commercially available, roughly 30% of U.S. adults reported being hesitant to receive these newly developed vaccines, and 15% said they would not receive the vaccine. However, by May 2021, 19% of adults were vaccine-hesitant, and 13% refused to vaccinate against COVID-19. It is critical to understand why adults' degree of willingness to vaccinate against COVID-19 changed over time to plan for future pandemics and vaccination campaigns. Methods: We conducted two waves of survey research over five months (January and May 2021) with a panel of 890 U.S. adults. One survey question assessed willingness to vaccinate against COVID-19. The response option included a slider scale ranging from 0 (signifying complete unwillingness) to 10 (complete willingness). We asked participants whose willingness score changed by more than one point to report their rationale for their change in perceptions. We conducted a conventional content analysis on all qualitative responses. Results: We analyzed qualitative responses for 289 participants, 54.7% of whom had not been vaccinated against COVID-19 by May 2021. Among those who remained unvaccinated, 36.1% reported increased willingness to vaccinate. The most commonly cited reasons for becoming more willing to receive the vaccine include believing that COVID-19 vaccines are safe and effective, protecting against the pandemic, and desiring to return to pre-pandemic life. Reasons for increased COVID-19 vaccine hesitancy include vaccine safety concerns, the low perceived need for the vaccine, distrust in how COVID-19 vaccines are made and of larger institutions such as the government and pharmaceutical companies, and concerns about vaccine effectiveness. Conclusion: Findings illuminate the rationale behind individuals' changes in their degree of willingness to vaccinate against COVID-19. It is critical to incorporate these considerations in future vaccine rollout initiatives to increase the public's vaccine confidence.

Evidence-Based Quality Improvement (EBQI) in the pre-implementation phase: key steps and activities.

Background: Evidence-Based Quality Improvement (EBQI) involves researchers and local partners working collaboratively to support the uptake of an evidence-based intervention (EBI). To date, EBQI has not been consistently included in community-engaged dissemination and implementation literature. The purpose of this paper is to illustrate the steps, activities, and outputs of EBQI in the pre-implementation phase. Methods: The research team applied comparative case study methods to describe key steps, activities, and outputs of EBQI across seven projects. Our approach included: (1) specification of research questions, (2) selection of cases, (3) construction of a case codebook, (4) coding of cases using the codebook, and (5) comparison of cases. Results: The cases selected included five distinct settings (e.g., correction facilities, community pharmacies), seven EBIs (e.g., nutrition promotion curriculum, cognitive processing therapy) and five unique lead authors. Case examples include both community-embedded and clinically-oriented projects. Key steps in the EBQI process included: (1) forming a local team of partners and experts, (2) prioritizing implementation determinants based on existing literature/data, (3) selecting strategies and/or adaptations in the context of key determinants, (4) specifying selected strategies/adaptations, and (5) refining strategies/adaptations. Examples of activities are included to illustrate how each step was achieved. Outputs included prioritized determinants, EBI adaptations, and implementation strategies. Conclusions: A primary contribution of our comparative case study is the delineation of various steps and activities of EBQI, which may contribute to the replicability of the EBQI process across other implementation research projects.

Perceptions of HPV vaccination and pharmacist-physician collaboration models to improve HPV vaccination rates.

BACKGROUND: Human Papillomavirus (HPV) is the most common sexually transmitted disease in the United States (US), with 12 cancer causing strains. Vaccination rates in the southern US fall below the national average. Pharmacists provide an opportunity to improve vaccination rates. OBJECTIVES: The objectives of this study were to 1) identify barriers and facilitators to providing the HPV vaccine and Vaccines for Children (VFC) program participation in pharmacies and clinics, and 2) assess pharmacy staff, clinic staff, and parent perceptions of 3 collaboration models to improve HPV vaccination. METHODS: A developmental formative evaluation was conducted with pharmacy staff, primary care clinic staff, and parents of adolescent children. Interview guides were informed by the Consolidated Framework for Implementation Research (CFIR). Barriers and facilitators to HPV vaccination and VFC participation were explored. Additionally, acceptability of 3 collaboration models were explored: 1) a shared-responsibility model in which a physician provides the first dose of HPV vaccine with the second provided in the pharmacy, 2) a pharmacy-based model in which a clinic refers patients to the pharmacy to receive both doses, and 3) an insourced model in which pharmacists schedule days to provide the vaccine in the collaborating clinic. RESULTS: Twenty-nine interviews were conducted between August 2019 and June 2020. Both pharmacy and clinic staff had positive views toward the HPV vaccine and vaccinations in general. Pharmacists and physicians reported parental awareness and education as a barrier to HPV vaccination. Counseling about HPV vaccine was reported as being more time-consuming because of the stigma associated with the vaccine. Parents were willing to have their children vaccinated for HPV in the pharmacy but desired their child's physician be involved in the immunization process. The shared-responsibility model was the most favored of the 3 collaboration models. CONCLUSION: Perceptions of the HPV vaccine and vaccination in pharmacies were positive. Collaboration between clinics and pharmacies to improve HPV vaccination rates is viewed positively by pharmacy staff, clinic staff, and parents. This study will guide implementation of pharmacist-physician collaborative models to improve vaccination through pharmacy participation in the VFC program and HPV vaccination.

Opioid overdose counseling and prescribing of naloxone in rural community pharmacies: A pilot study.

INTRODUCTION: Fatal overdoses from opioids increased four-fold from 1999 to 2009, and they are now the leading cause of death among Americans under 50. Legislation has been passed by every state to increase access to naloxone but dispensing by community pharmacies remains low. OBJECTIVES: The objective of this study was to pilot test a proactive opioid overdose counseling intervention and a passive naloxone intervention, and the implementation strategies developed to support their delivery, in rural community pharmacies on relevant implementation outcomes. METHODS: The interventions, implementation strategies, and the overall pilot study approach were developed in a collaborative partnership with a regional supermarket pharmacy chain. They selected 2 rural pharmacies to participate in the pilot study and 2 non-intervention pharmacies to serve as comparison sites. Two interventions were pilot tested in the 2 intervention pharmacies: 1)a proactive opioid overdose counseling intervention and 2) a passive naloxone intervention. An explanatory sequential mixed-methods design was utilized to evaluate adoption, feasibility, acceptability, and appropriateness outcomes after the 3-month observation period. RESULTS: Between the 2 intervention pharmacies, 130 patients received the opioid overdose counseling intervention. 44 (33.8%) were prescribed and dispensed naloxone. Zero naloxone prescriptions were written or dispensed at the comparison pharmacies. Interviews with pharmacy staff found the interventions to be feasible, acceptable, and appropriate in their settings. CONCLUSION: This small scale pilot study in partnership with a regional supermarket pharmacy chain had positive results with a third of patients who received the opioid overdose counseling intervention being dispensed naloxone. However, the majority of patients did not receive naloxone indicating additional revisions to the intervention components and/or implementation strategies are needed to improve the overall impact of the interventions.

Improving HPV vaccination using implementation strategies in community pharmacies: Pilot study protocol.

BACKGROUND: Nearly 80 million people in the United States have contracted the Human Papillomavirus (HPV), and it is currently the most common sexually transmitted disease. Each year approximately 14 million people are newly infected. OBJECTIVE(S): This study will address increasing the HPV vaccination rates by initiating a research agenda focusing on how best to utilize community pharmacies as Vaccines For Children (VFC) vaccination sites. Community pharmacies are highly accessible when compared to traditional vaccination sites due to extended evening and weekend business hours, no copays for visits, and no appointment required to speak with a pharmacist. METHODS: We will conduct a Developmental Formative Evaluation using semi-structured interviews with key informants (pharmacists, pharmacy managers, technicians) from 5 Harps pharmacies to identify barriers and facilitators to community pharmacies' provision of HPV vaccine through a mixed methods design with pharmacy staff members and local physicians. We will follow that by selecting a pharmacist-physician collaborative model and identify implementation strategies through an Evidence Based Quality Improvement (EBQI) process with key stakeholders. This will be followed by piloting the selected pharmacist-physician collaborative model and implementation strategies in two Harps pharmacies (1 rural, 1 urban) on relevant implementation outcomes. PROJECT IMPACT: This study will examine the current model of HPV vaccinations and how to improve HPV vaccination rates among adolescents by utilizing community pharmacy services.

Student Pharmacists' Use of Patient-Centered Communication Skills During an Introductory Pharmacy Practice Experience.

Objective. To assess how Doctor of Pharmacy (PharmD) students use patient-centered communication (PCC) during a community pharmacy introductory pharmacy practice experience (IPPE). Methods. All first-year student pharmacists at the University of Arkansas for Medical Sciences completed a required course in patient-centered communication that included training in motivational interviewing. After subsequently completing their first IPPE, the students submitted written reflections on their use of PCC during the experience. The reflections were de-identified and template analysis was conducted. With this method, predetermined codes are established, and a constant comparison method is used to finalize overarching themes. The students' overall level of reflection was assessed and each reflection was coded. Discrepancies were resolved through in-depth discussion and negotiated consensus. Results. Of the 116 student reflections submitted, 951 codes were applied. Six overarching themes were identified: acknowledgement of motivational interviewing skills/components; philosophy of patient-centeredness; barriers to using PCC or motivational interviewing; benefits from use of PCC; demonstration of good general communication skills; and perceptions of patient encounters. Approximately 46% of students reflected at a level three or higher (ie, personal insight or intended behavior change). Conclusion. First-year student pharmacists successfully used PCC skills during their IPPE. These findings demonstrate the impact that a PCC course can have on students' overall patient-centeredness and highlights barriers that students struggle to overcome. Other pharmacy schools may benefit from implementing a similar PCC course. Activities that reiterate these skills and provide additional opportunities to practice PCC are necessary throughout the curriculum.

Communication between pharmacists and primary care physicians in the midst of a U.S. opioid crisis.

BACKGROUND: Effective communication between prescribers of opioids and community pharmacists can contribute to maximizing appropriate pain management and reducing opioid misuse and diversion. While much of the education and training available on reducing opioid misuse and diversion stresses the importance of interprofessional communication between prescribers and pharmacists, few studies have been explored those communication patterns directly. OBJECTIVE: The objectives of this manuscript are to present and explore key emergent themes from a qualitative study around the nature, frequency, and content of communication between primary care physicians (PCPs) and pharmacists focusing on opioids. METHODS: Interviews were conducted with 48 PCPs and 60 community pharmacists across four states in the U.S.: Washington, Idaho, Kentucky and Arkansas. RESULTS: Convergent results from both samples indicated that the content of communication usually centers on questions of dosing, timing of the prescription, and/or evidence of potential misuse/diversion. When communication was focused on relaying information about a patient and/or clarifying questions around the prescription, it appeared positive for both parties. Results also indicated that close physical proximity between PCPs and dispensing pharmacists contributed to more positive and useful communication, especially when the clinics and pharmacies were part of the same healthcare system. Many pharmacists reported hesitancy in "questioning" a physician's judgement, which appeared related to commonly held beliefs of both pharmacists and physicians about the respective roles of each in providing patient care. Pharmacists reported difficulty in reaching PCPs for discussion, while PCPs reported it was easy to reach pharmacists. CONCLUSIONS: Physician and pharmacist communication around opioids can be mutually beneficial. When prescribers and pharmacists are co-located, higher levels of trust and teamwork are reported, which in turn seems to be related to more open and positive communication. Additional research is needed to identify interventions to increase mutually-valued communication that improves the quality of decision-making around opioids.

Utilization of prescription drug monitoring programs for prescribing and dispensing decisions: Results from a multi-site qualitative study.

BACKGROUND: Prescription drug monitoring programs (PDMPs) track the dispensing of prescription-controlled substances with the goal of mitigating misuse and diversion. Authorized users query the PDMP for controlled substance prescription histories at the point of care. Despite widespread implementation of PDMPs, there is much not known about how PDMPs influence prescribing and dispensing decisions. OBJECTIVES: The objective of this study was to investigate how primary care providers (PCPs) and pharmacists utilize PDMPs when making prescribing and dispensing decisions. METHODS: Data from in-depth, qualitative interviews with PCPs (n = 48) and community pharmacists (n = 60) across four states- Arkansas, Idaho, Kentucky, and Washington were analyzed for themes around PDMP use. RESULTS: Both PCPs and pharmacists reported that PDMPs are key tools for aiding prescribing and dispensing decisions. PCPs reported variable use of PDMPs with most querying the PDMP when there are "red flags" and fewer reporting having clinic policies that direct PDMP use. Primary care providers in Kentucky reported more consistent and routine use of the PDMP as a result of a state law that mandates query prior to the initial prescribing of Schedule II controlled substances. Community pharmacists practicing in chain pharmacies reported formal policies requiring PDMP query prior to dispensing opioids, while utilization of PDMPs by pharmacists practicing in independently-owned pharmacies was more variable. Pharmacists and PCPs reported barriers to PDMP use, such as having to "log in on a separate machine" and perceived that PDMP utility could be improved by integrating it within pharmacy dispensing systems and electronic health records. CONCLUSIONS: Pharmacists and PCPs reported the importance of PDMP information to aid their prescribing and dispensing decisions. Efforts to enhance state PDMP programs should consider processes that seamlessly integrate all available controlled substance prescription history for a given patient at the point of care so that PDMP utility for prescribing and dispensing decisions is maximized.

Application of the Consolidated Framework for Implementation Research to community pharmacy: A framework for implementation research on pharmacy services.

BACKGROUND: Community pharmacies are an increasingly important health care setting with opportunities for improving quality and safety, yet little is understood about determinants of implementation in this setting. OBJECTIVE: This paper presents an implementation framework for pharmacy based on the Consolidated Framework for Implementation Research (CFIR). METHODS: This study employed a critical review of 45 articles on professional services provided in community pharmacies, including medication therapy management (MTM), immunizations, and rapid HIV testing. RESULTS: The relevant domains and associated constructs for pharmacy services were as follows. Intervention Characteristics ultimately depend on the specific service; of particular note for pharmacy are relative advantage and complexity. The former because implementation of services can pose a cost-benefit challenge where dispensing is the primary role and the latter because of the greater challenge implementing multi-faceted services like MTM compared to a discrete service like immunizations. "In terms of Outer Setting, pharmacies are affected by patient needs and acceptance, and external policies and incentives such as reimbursement and regulations. For Inner Setting, structural characteristics like pharmacy type, size and staff were important as was pharmacists' perception of their role and available resources to provide the service. Key Characteristics of Individuals include training, preparedness, and self-efficacy of the pharmacist for providing a new service. Few studies revealed relevant Process constructs, but if they did it was primarily related to engaging (e.g., champions). CONCLUSIONS: As pharmacists' roles in health care are continuing to expand, a framework to inform implementation research in community pharmacy (and other) settings is crucially needed.

Parental acceptance of human papillomavirus vaccinations and community pharmacies as vaccination settings: A qualitative study in Alabama.

PURPOSE: To determine parents' knowledge and attitudes regarding human papillomavirus (HPV) vaccinations in their adolescent children and to describe parents' perceptions of adolescent vaccinations in community pharmacies. METHODS: In-depth interviews were completed with parents or guardians of children ages 11-17 years from Alabama's Lee and Macon counties. One-hour long, open-ended telephonic or in-person interviews were conducted until the saturation point was reached. Using ATLAS.ti software and thematic analysis, interview transcripts were coded to identify themes. RESULTS: Twenty-six parents were interviewed, most of whom were female (80.8%) and white (50%). A total of 12 themes were identified. First, two themes emerged regarding elements facilitating children's HPV vaccination, the most common being positive perception of the HPV vaccine. Second, elements hindering children's vaccination contained seven themes, the top one being lack of correct or complete information about the HPV vaccine. The last topic involved acceptance/rejection of community pharmacies as vaccination settings, and the most frequently cited theme was concern about pharmacists' clinical training. CONCLUSIONS: Physician-to-parent vaccine education is important, and assurances of adequate pharmacy immunization training will ease parents' fears and allow pharmacists to better serve adolescents, especially those who do not see physicians regularly.

Pharmacists' Attitudes and Perceived Barriers to Human Papillomavirus (HPV) Vaccination Services.

Use of non-traditional settings such as community pharmacies has been suggested to increase human papillomavirus (HPV) vaccination uptake and completion rates. The objectives of this study were to explore HPV vaccination services and strategies employed by pharmacies to increase HPV vaccine uptake, pharmacists' attitudes towards the HPV vaccine, and pharmacists' perceived barriers to providing HPV vaccination services in community pharmacies. A pre-piloted mail survey was sent to 350 randomly selected community pharmacies in Alabama in 2014. Measures included types of vaccines administered and marketing/recommendation strategies, pharmacists' attitudes towards the HPV vaccine, and perceived system and parental barriers. Data analysis largely took the form of descriptive statistics. 154 pharmacists completed the survey (response rate = 44%). The majority believed vaccination is the best protection against cervical cancer (85.3%), HPV is a serious threat to health for girls (78.8%) and boys (55.6%), and children should not wait until they are sexually active to be vaccinated (80.1%). Perceived system barriers included insufficient patient demand (56.5%), insurance plans not covering vaccination cost (54.8%), and vaccine expiration before use (54.1%). Respondents also perceived parents to have inadequate education and understanding about HPV infection (86.6%) and vaccine safety (78.7%). Pharmacists have positive perceptions regarding the HPV vaccine. Barriers related to system factors and perceived parental concerns must be overcome to increase pharmacist involvement in HPV vaccinations.

Telephone-based motivational interviewing for medication adherence: a systematic review.

Adherence to prescribed medications continues to be a problem in the treatment of chronic disease. Motivational interviewing (MI) has been shown to be successful for eliciting patients' motivations to change their medication-taking behaviors. Due to the constraints of the US healthcare system, patients do not always have in-person access to providers. Because of this, there is increasing use of non-traditional healthcare delivery methods such as telephonic counseling. A systematic review was conducted among published studies of telephone-based MI interventions aimed at improving the health behavior change target of medication adherence. The goals of this review were to (1) examine and describe evidence and gaps in the literature for telephonically delivered MI interventions for medication adherence and (2) discuss the implications of the findings for research and practice. The MEDLINE, CINAHL, psycINFO, psycARTICLES, Academic Search Premier, Alt HealthWatch, Health Source: Consumer Edition, and Health Source: Nursing/Academic Edition databases were searched for peer-reviewed research publications between 1991 and October 2012. A total of nine articles were retained for review. The quality of the studies and the interventions varied significantly, which precluded making definitive conclusions but findings among a majority of retained studies suggest that telephone-based MI may help improve medication adherence. The included studies provided promising results and justification for continued exploration in the provision of MI via telephone encounters. Future research is needed to address gaps in the current literature but the results suggest that MI may be an efficient option for healthcare professionals seeking an evidence-based method to reach remote or inaccessible patients to help them improve their medication adherence.

Exploration of heterogeneity in distributed research network drug safety analyses.

Distributed data networks representing large diverse populations are an expanding focus of drug safety research. However, interpreting results is difficult when treatment effect estimates vary across datasets (i.e., heterogeneity). In a previous study, risk estimates were generated for selected drugs and potential adverse outcomes. Analyses were replicated across eight distributed data sources using an identical analytic structure. To evaluate heterogeneity of risk estimates across data sources, the estimates were combined with summary-level data characterizing the population of each data source. Meta-analysis, meta-regression, and plots of the influence on overall results versus contribution to heterogeneity were examined and used to illustrate an approach to heterogeneity assessment. Heterogeneity, as measured by the I-squared statistic, was high with variability across outcomes. Plots of the relationship between influence on overall results and contribution to heterogeneity suggest that certain datasets and characteristics were influential but there was variability dependent on the drug and outcome being assessed. Exploratory meta-regression identified many possible influential factors, but may be subject to ecological bias and false positive conclusions. Distributed data network drug safety analyses can produce heterogeneous risk estimates that may not be easily explained. Approaches illustrated here can be useful for research that is subject to similar problems with heterogeneity.