Effects of caregiver counselling on medication persistence and adherence in patients with dementia at a pharmacist-managed clinic: A pilot study.

WHAT IS KNOWN AND OBJECTIVE: Low treatment persistence and adherence in patients with dementia results in a rapid loss of disease control. This pilot study evaluated the impact of pharmacist-provided caregiver counselling on treatment persistence, adherence, quality of life (QoL) in patients with dementia, as well as caregiver's knowledge of dementia, and caregiver burden. METHODS: This prospective, randomized controlled study was performed at a hospital-based pharmacist-managed clinic from December 2017 to December 2019. Patients with mild-to-moderate Alzheimer's disease (AD), initiating cholinesterase inhibitors within 3 months, and coming with their caregivers were included and randomized 1:1 to intervention or control group. The intervention group received pharmacist counselling and education sheets about AD, whereas the control group only received standard of care. Patients' treatment persistence and adherence were assessed at months 3, 6, 9, and 12; QoL, and caregiver burden were assessed at baseline and month 12. Caregiver's knowledge of dementia was assessed at baseline and 2 weeks after counselling in the intervention group. Nonparametric statistics and generalized estimating equation models were used for statistical analysis. RESULTS AND DISCUSSION: A total of 40 patients and 40 caregivers were included, with 20 pairs for each group. One-year medication persistence (16/20 vs. 16/20) and adherence rates (87%-99%) were high in both groups without significant differences. Dementia knowledge scores improved significantly after counselling in the intervention group (77.5 vs. 95.8, p < 0.01). Although the change of caregiver burden was non-significant between groups, the score decreased in the intervention group (-0.89; p = 0.78) but increased in the control group (+6.01; p = 0.07). WHAT IS NEW AND CONCLUSION: In this pilot study, pharmacist's counselling for patients with dementia and their caregivers is feasible and can enhance caregiver knowledge of dementia. Further study with larger scale is needed to confirm the impact on these outcomes.

A qualitative study on the development of pharmacist-managed clinics in Taiwan.

WHAT IS KNOWN AND OBJECTIVE: Pharmacist-managed clinics (PMCs) are established to solve drug-related problems and enhance the quality of care of ambulatory patients. Although the benefits of such services have been demonstrated, little is known about PMC operations, especially outside the United States. The aim of this study was to explore how PMCs were established and to discuss implementation issues of PMCs in Taiwan. METHODS: A purposive sample of pharmacists, pharmacy administrators and physicians involved with PMCs was recruited from hospitals of varying scales across Taiwan. Semi-structured, individual interviews were conducted to understand the perceptions of the clinical service of PMCs. Interviews were transcribed verbatim and analysed by thematic analysis to find underlying themes. RESULTS: A total of 12 pharmacists, 5 pharmacy administrators and 3 physicians from 8 institutions were interviewed. Pharmacists spent 4 to 20 h per week at PMCs, and the practice experiences of PMC ranged from 1 to 6 years. PMCs have been provided in these institutions for 4 to 11 years with an average volume of 28 h and 25 patient visits weekly. Study participants described influential factors in establishing PMCs, including clinical expertise, attitude towards patient care and trust building with collaborating physicians. Operational concerns in implementing PMCs included role clarifications, manpower shortage, inadequate advanced training or certification, regulatory issues and a lack of service promotion. WHAT IS NEW AND CONCLUSION: This research broadens the understanding of operating PMC services and reveals key requirements and concerns regarding the care model, which can be useful for other countries. Resolving perceived barriers and collecting other stakeholders' perspectives may reinforce the integration of PMCs into patient care in the future.

An investigation of the determinants for community pharmacists' positive image and the needs for community pharmacists' services in Taiwan.

OBJECTIVES: To examine the specific factors that the general public believes have an effect on the image of community pharmacists and also to identify community pharmacists' services that truly fulfill people's needs. METHODS: A convenient sample of 401 community pharmacy customers completed the questionnaire. RESULTS: When asked about the factors that help establish a positive image for a community pharmacist, 98.3% of the respondents reported accurate dispensing as the most important factor, followed by cordial attitude (95.5%), and wearing clothes showing pharmacist's license with a photo (94.6%). Among the services provided by community pharmacies, most people think that the most needed service is a consultation explaining drug-drug interactions (93.8%). Furthermore, 312 (77.8%) respondents indicated that there is a need for comprehensive pharmaceutical services. As for the amount that the respondents were willing to pay for such service, many (42.9%) chose 100 NT dollars (≈ 3USD). CONCLUSION: The results of this study showed that correct dispensing is the most important factor that helps establish a positive image of community pharmacists and that the most needed services were those that required pharmacists' professional competence. Moreover, nearly 80% of the respondents reported that they needed comprehensive pharmaceutical services and were willing to pay for it.

Development and validation of a Chinese medication literacy measure.

BACKGROUND: Despite the impact of medication literacy (ML) on patients' safe use of medications, existing instruments are mostly for general health literacy measurement or designed for specific disease populations, with few specifically designed for ML. OBJECTIVE: To develop and validate the first Chinese medication literacy measure (ChMLM). METHODS: The ChMLM was developed by a multidisciplinary and bilingual expert panel and subsequently pilot-tested. The final version had 17 questions in four sections: vocabulary, non-prescription drug, prescription drug and drug advertisement. Face-to-face interviews were administered in a convenience sample of adults with diverse sociodemographic characteristics. Internal consistency was assessed by Cronbach's alpha. Content validity was confirmed by the expert panel, and hypothesis testing was performed to assess construct validity. RESULTS: A total of 634 adults were interviewed. The mean (SD) total ChMLM score was 13.0 (2.8). The internal validity was acceptable (Cronbach's alpha=0.72). Nine of the ten a priori hypotheses were fulfilled. Younger age, higher income and higher education levels were significantly associated with a higher ChMLM score. Furthermore, higher scores on the ChMLM were associated with higher confidence or less difficulty in writing, reading, speaking and listening abilities in a health-care encounter. No association was found between ChMLM total scores and frequency of doctor's visits. CONCLUSION: The ChMLM is a valid and reliable ML measure. It may help pharmacists and other health-care providers to target patients and problem areas that need interventions with the ultimate goal of preventing medication errors and harm.

Understanding the medication experience of patients with advanced non-small cell lung cancer taking epidermal growth factor receptor-tyrosine kinase inhibitors: A phenomenological study.

BACKGROUND AND OBJECTIVE: Patients with cancer taking oral antineoplastic medications may encounter problems including suboptimal adherence as well as physical and psychological disease burden. Despite increase in the use of oncology pharmacy services, there are wide variations between healthcare professionals and patient perceptions of patients' medication experiences. The objective of the study was to explore the medication experience of taking oral targeted therapy in patients with advanced non-small cell lung cancer (NSCLC). METHOD: We purposively sampled advanced stage (stage III or IV) NSCLC patients taking epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) in a medical center in Taiwan. Face-to-face interviews using semi-structured interview guides were conducted. Interviews were transcribed verbatim and thematic analysis was applied. A phenomenological methodology was adopted to explore the underlying meaning of patients' lived experience. RESULTS: A total of 19 participants with a mean age of 68.2 years were interviewed. The duration of EGFR-TKIs use ranged from 2 weeks to 5 years. When first learned about the unexpected yet 'treatable' cancer, participants expressed strong emotional responses based on their intrinsic beliefs of the terminal disease and therapy. They walked along an unfamiliar trail while confronting physical and psychological challenges and made compromises to treatment. Gaining experiences from cancer journey, patients with cancer continuously seek the ultimate goals-'return to normal'. CONCLUSIONS: This study also revealed medication experiences of participants' journey from seeking information in the initial phase and living with cancer, to taking back control of their own lives. Healthcare professionals could better empathize with patients' loss of control and understand their perspectives when making clinical decisions. These findings can guide interdisciplinary teams to integrate patients' beliefs and conduct pre-screening assessments of health literacy levels to tailor communication. Subsequent interventions should be developed to identify barriers to medication self-management and empower patients by building social networks.

Living with Parkinson's disease: disease and medication experiences of patients and caregivers.

PURPOSE: Symptoms and medication use in patients with Parkinson's disease (PD) affect the quality of life of patients and caregivers, yet prior research seldom focused on their experiences with medications. This study explored comprehensive living and medication experience from patients with PD and their caregivers. METHODS: Patients diagnosed with PD for ≥2 years, with or without their caregivers, were recruited from an outpatient clinic in Taiwan. Semi-structured in-depth interviews were conducted based on the Common Sense Model. A qualitative content analysis was used to identify salient themes from verbatim transcripts. RESULTS: In total, 15 patients and eight caregivers were interviewed. Five themes were derived: (1) symptoms and help-seeking behaviours before a diagnosis, (2) emotional impacts and life adaptations after a PD diagnosis, (3) life affected by medications, (4) experiences of caregivers in taking care of PD patients, and (5) communication between doctors and patients. CONCLUSIONS: Patients frequently adjusted their daily schedules to live with PD and the medication side effects. Caregivers struggle to overcome caring burdens and to stay positive to support patients. More attention on providing medication information, mental support, and communication between stakeholders is needed to improve the quality of life of patients and caregivers.

Effectiveness of collaboration between oncology pharmacists and anaesthesiologists for inpatient cancer pain management: A pilot study in Taiwan.

OBJECTIVE: To evaluate the effectiveness of the collaboration between oncology pharmacists and anaesthesiologists for improving pain control management in cancer patients. METHODS: This retrospective case-control pilot study enrolled inpatients with active cancer and a pain score of >3 at least once per day for 3 consecutive days. The study group was selected from June 2018 to January 2019. Patients with the same inclusion criteria were selected between November 2017 and May 2018 to serve as the comparison group. The primary outcome was the percentage of patients that experienced pain relief within 7 days from initial pain attack. RESULTS: A total of 71 and 77 patients were enrolled in the study and comparison groups. More patients in the study group experienced pain relief within 7 days from the index date (78.9% [56 of 71 patients] versus 72.7% [56 of 77 patients], respectively). The service increased the rate of intervention from attending physicians within 4 days from index date and quality of opioid management. CONCLUSION: The collaboration between oncology pharmacists and anaesthesiologists for cancer pain management may be associated with an increase in the rate of pain relief in cancer patients with poor pain control.

Efficacy of AST-120 for Patients With Chronic Kidney Disease: A Network Meta-Analysis of Randomized Controlled Trials.

AST-120, an oral spherical activated carbon, may delay the need for kidney dialysis and improve uremia symptoms because it can adsorb acidic and basic organic compounds, especially small-molecule uremic toxins. However, previous studies produced no conclusive evidence regarding the benefits of AST-120 in delaying the progression of chronic kidney disease (CKD). Therefore, this systematic review and network meta-analysis evaluated the effects of AST-120 in patients with CKD. Related keywords of CKD and AST-120 were used to search four databases to obtain potential evidence on this topic, and two authors individually completed evidence selection, data extraction, and quality assessment. Network meta-analysis was performed for mortality, end-stage renal disease, composite renal outcomes, and laboratory outcomes based on a frequentist approach. In total, 15 randomized controlled trials (n = 3,763) were included in the present synthesis, and the pooled results revealed non-significant differences in mortality among the treatment strategies. Low- and high-dose AST-120 were not superior to no AST-120 treatment regarding renal outcomes. However, the event rates of end-stage renal disease (risk ratio [RR] = 0.78, 95% confidence interval [CI] = 0.62-0.99) and composite renal outcomes (RR = 0.78, 95% CI: 0.63-0.97) were significantly lower in the tailored-dose AST-120 group than in no AST-120 group. The results did not reveal a small-study effect on the outcomes. Tailored dosing of AST-120 appeared to represent an optimal treatment strategy because it resulted in lower rates of composite renal outcomes and end-stage renal disease.

Development of the Chinese Version of Medication Adherence Reasons Scale (ChMAR-Scale).

Medication non-adherence is a concern in chronic disease management. Currently, there is no scale that characterizes sufficient non-adherent reasons for practical use in the Chinese population. This study developed and validated the Chinese version of the Medication Adherence Reasons Scale (ChMAR-Scale) and described non-adherence reasons in adult patients taking blood pressure medicine in Taiwan. A forward-backward procedure was used to translate the original MAR-Scale, and new items pertinent to cultural differences were added. Patients aged above 20 years old who were taking blood pressure medicine were recruited from a regional hospital and eight community pharmacies in the Taipei metropolitan area. Data analyses were conducted with IBM SPSS 19 (Armonk, NY, USA). Exploratory factor analysis revealed six domains, including belief, self-perception, forgetfulness, management, availability, and miscellaneous issues, with Cronbach's alphas ranging from 0.649 to 0.852, item-total correlations ranging from 0.362 to 0.719, and factor loadings ranging from 0.365 to 0.775. Criterion-related validity with the visual analog scale and two global items were 0.525, 0.436, and 0.502. Forgetfulness, belief issues, and self-perception issues were the most common non-adherence reasons. In conclusion, the ChMAR-Scale showed good psychometric properties and identified more reasons for medication non-adherence than other existing scales. Healthcare providers should be vigilant of these problems while consulting patients.

Conceptualization, Development and Psychometric Evaluations of a New Medication-Related Health Literacy Instrument: The Chinese Medication Literacy Measurement.

There is a need for valid and reliable instruments to focus on medication aspects of health literacy and help healthcare professionals address patients' barriers to medication use. This cross-sectional study describes the conceptualization, development, and psychometric properties of the first Chinese Medication Literacy Measurement (ChMLM) to assess the level of health literacy on medication use. The 17-item ChMLM (ChMLM-17) and its short form, 13-item ChMLM (ChMLM-13), consist of four sections (vocabulary, over-the-counter labels, prescription labels, and advertisements) to cover six domains of medication-related health literacy. Multistage stratified quota sampling was attempted to recruit a representative sample in Taiwan. Receiver operating characteristic curves were used to identify the cut-off point for differentiating high and low medication literacy. Psychometric analyses were performed (n = 1410) to assess the reliability and validity separately on all samples and sociodemographic subgroups. The 17- and 13-item versions both had high construct validity among all patients and patients with low medication literacy. The developed ChMLM-17 and ChMLM-13 is expected to help healthcare providers and researchers to accurately measure medication-related health literacy and improve medication use in the real-world practice.

Translation, revision, and validation of the Chinese version of the Satisfaction with Oral Anti-Diabetic Agent Scale (C-SOADAS) in patients with type 2 diabetes mellitus.

OBJECTIVE: The aim of this study was to translate, adapt, and validate the Satisfaction with Oral Anti-Diabetic Agent Scale (SOADAS) in type 2 diabetes mellitus (DM) patients taking oral antidiabetic drugs (OADs) in Taiwan. PATIENTS AND METHODS: The SOADAS was translated to Chinese and was modified based on reviews of two physicians, five diabetes educators, and two patient focus groups. A cross-sectional interviewer-administered survey was conducted in adult patients with type 2 DM who were taking OADs. The Chinese version of the SOADAS (C-SOADAS), the EuroQol 5 dimensions 3-level (EQ-5D-3L) questionnaire, and a demographic questionnaire were administered to participants. Instrument structure, internal consistency, convergent validity, and known-group validity were assessed. RESULTS: A total of 260 DM patients were recruited. The mean score of an individual item ranged from 3.6 to 3.9, while the mean total score (out of 25 possible points) was 18.7 points. Overall, floor and ceiling effects were negligible. The Cronbach's α value was 0.81. All the four predetermined hypotheses for known-group validity assessment were fulfilled. In convergent validity testing, the C-SOADAS total scores were found to be correlated with EuroQol-Visual Analog Scale (EQ-VAS) scores (r = 0.2; p < 0.01) but not with EuroQol 5 dimensions (EQ-5D) index scores (r = 0.02; p = 0.81). CONCLUSION: The 5-item C-SOADAS appears to be a psychometrically acceptable measure of OAD treatment satisfaction among type 2 DM patients in Taiwan. The tool may be incorporated into clinical practice to quickly assess treatment outcomes from patients' perspectives.

Using modified information delivery to enhance the traditional pharmacy OSCE program at TMU - a pilot study.

BACKGROUND AND OBJECTIVE: Objective Structured Clinical Examination (OSCE) has been used in many areas of healthcare training over the years. However, it constantly needs to be upgraded and enhanced due to technological and teaching changes. We aim at implementing an integrative OSCE method which employs informatics via the virtual patient within the pharmacy education curriculum at Taipei Medical University to enhance the pharmacy students' competence for using and disseminating information and to also improve critical thinking and clinical reasoning. METHODS: We propose an integrated pharmacy OSCE which uses standardized patients and virtual patients (DxR Clinician). To evaluate this method, we designed four simulated stations and pilot tested with 19 students in the first year of the Master in Clinical Pharmacy program. Three stations were simulated as the inpatient pharmacy: 1) History and lab data collection; 2) Prescription review; 3) Calling physician to discuss potential prescription problems. The fourth was simulated as the patient ward station to provide patient education. A satisfaction questionnaire was administered at the end of the study. RESULTS: Students rated their ability of 2.84, 2.37, 2.37, and 3.63 of 5 for each of the four stations, with the second and third being the most difficult stations. The method obtained an average rating of 4.32 of 5 for relevance, 4.16 for improving clinical ability, 4.32 for practicality in future healthcare work, and 4.28 for willing to have another similar learning experience. CONCLUSION: The integration of Virtual Patient in this study reveals that this assessment method is efficient and practical in many aspects. Most importantly, it provides the test taker with a much closer real-life clinical encounter. Although it is in many ways more difficult, it also provides for better "learning from mistakes" opportunities for test-takers.

Preliminary physician and pharmacist survey of the National Health Insurance PharmaCloud system in Taiwan.

BACKGROUND: The PharmaCloud system, a cloud-based medication system, was launched by the Taiwan National Health Insurance Administration (NHIA) in 2013 to integrate patients' medication lists among different medical institutions. The aim of the preliminary study was to evaluate satisfaction with this system among physicians and pharmacists at the early stage of system implementation. METHODS: A questionnaire was developed through a review of the literature and discussion in 6 focus groups to understand the level of satisfaction, attitudes, and intentions of physicians and pharmacists using the PharmaCloud system. It was then administered nationally in Taiwan in July to September 2015. Descriptive statistics and multiple regression were performed to identify variables influencing satisfaction and intention to use the system. RESULTS: In total, 895 pharmacist and 105 physician questionnaires were valid for analysis. The results showed that satisfaction with system quality warranted improvement. Positive attitudes toward medication reconciliation among physicians and pharmacists, which were significant predictors of the intention to use the system (ß= 0.223, p < 0.001). Most physicians and pharmacists agreed that obtaining signed patient consent was needed but preferred that it be conducted by the NHIA rather than by individual medical institutions (4.02 ± 1.19 vs. 3.49 ± 1.40, p < 0.01). CONCLUSIONS: The preliminary study results indicated a moderate satisfaction toward the PharmaCloud system. Hospital pharmacists had a high satisfaction rate, but neither are physicians and community pharmacists. Continuously improvement on system quality has been performing based on the results of this preliminary survey. Policies and standardization processes, including privacy protection, are still warranted further actions to make the Taiwan PharmaCloud system a convenient platform for medication reconciliation.

Pilot evaluation of a continuing professional development tool for developing leadership skills.

BACKGROUND: Strategies are needed to assure essential nonclinical competencies, such as leadership, can be gained using a continuing professional development (CPD) framework. OBJECTIVE: The objective of this study was to explore student pharmacists' utilization and perceived effectiveness of a CPD tool for leadership development in an elective course. METHODS: Students completed 2 CPD cycles during a semester-long leadership elective using a CPD tool. A questionnaire was used to measure students' perceptions of utility, self-efficacy, and satisfaction in completing CPD cycles when using a tool to aid in this process. RESULTS: The CPD tool was completed twice by 7 students. On average, students spent nearly 5 hours per CPD cycle. More than half (57.1%) scored themselves as successful or very successful in achieving their learning plans, and most (71.4%) found the tool somewhat useful in developing their leadership skills. Some perceived that the tool provided a systematic way to engage in leadership development, whereas others found it difficult to use. CONCLUSIONS: In this pilot study, most student pharmacists successfully achieved a leadership development plan and found the CPD tool useful. Providing students with more guidance may help facilitate use and effectiveness of CPD tools. There is a need to continue to develop and refine tools that assist in the CPD of pharmacy practitioners at all levels.

Development and initial assessment of the medication user self-evaluation (MUSE) tool.

BACKGROUND: Using patient-reported data to supplement claims-based indicators may be helpful in identifying Medicare beneficiaries likely to benefit from medication therapy management (MTM) services. OBJECTIVE: Our objective was to develop and initially assess a patient medication user self-evaluation (MUSE) tool to identify Medicare Part D beneficiaries who would benefit from a comprehensive medication review. METHODS: A random sample of 225 patient medication profiles was created from a survey of Medicare beneficiaries; the survey also included demographic characteristics, responses to adherence questions, and reported symptoms. Three clinical pharmacists used the patient profiles to make judgments regarding the likelihood (low, moderate, or high) that each patient would benefit from an MTM visit in the next 3 months. A total of 150 cases were used for model calibration, and 75 were used for validation. Ordinal logistic regression models were fit to predict the likelihood of benefit from an MTM visit by using different combinations of potential MUSE items. Final model selection was based on the Akaike information criterion and the percent agreement between model prediction and expert judgments in the validation data. Measures considered for inclusion in the MUSE tool were related to medication use, medical conditions, and health care utilization. RESULTS: The final MUSE items incorporated number of medications, number of physicians, number of pharmacies, number of hospitalizations in the past 6 months, having forgotten to take medications, cost-related problems, and number of medical conditions. CONCLUSION: The 7-item MUSE tool could be used in targeting MTM services, such as comprehensive medication reviews, among Medicare beneficiaries.

A leadership elective course developed and taught by graduate students.

OBJECTIVE: To develop and implement a flexible-credit elective course to empower student pharmacists to develop lifelong leadership skills and provide teaching practice opportunities for graduate students. DESIGN: An elective course focusing on leadership development for second- and third-year doctor of pharmacy (PharmD) students was designed and taught by 4 graduate students under the mentorship of 2 faculty members. Student pharmacists could enroll in a 1-, 2-, or 3-credit-hour version of the course. ASSESSMENT: Attainment of course objectives was measured using student pharmacist reflection papers and continuing professional development portfolios. Additionally, self-assessments of graduate students and faculty members delivering the course were conducted. In their responses on course evaluations, student pharmacists indicated they found the course a valuable learning experience. Graduate students found course development to be challenging but useful in developing faculty skills. CONCLUSION: This flexible-credit elective course taught by graduate students was an innovative way to offer formal leadership instruction using limited college resources.

Practice characteristics of bachelor of science and doctor of pharmacy degreed pharmacists based on the 2009 National Workforce Survey.

OBJECTIVE: To compare practice settings and activities of pharmacists with bachelor of science (BS) in pharmacy and doctor of pharmacy (PharmD) degrees. METHODS: Data from the 2009 National Pharmacist Workforce Survey instrument were analyzed. Multivariate regression was used to examine the association of the PharmD degree with time spent in dispensing and patient care. RESULTS: The survey response rate by pharmacists was 52%, and 562 usable responses met our inclusion criteria. Sixty-three percent of BS and 39% of PharmD pharmacists were employed in community pharmacies, compared with 21% of BS and 38% of PharmD pharmacists employed in hospital pharmacy settings. Practicing in a community setting had the strongest influence on time spent in dispensing and time spent in patient care. Among respondents with PharmD degrees, a residency was associated with less time in dispensing and more time in patient care. CONCLUSION: Time spent in dispensing and patient care were influenced more by practice setting than by educational degree and residency training.