Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis.

BACKGROUND: Prescription opioid misuse is a serious national crisis; in 2018 the top drugs involved in prescription overdose deaths included pain medications (opioids), benzodiazepines, and stimulants. Health information technology (health IT) provides a means to address this crisis through technologies that streamline the prescribing and discontinuation process. CancelRx is a health IT function that communicates when medications, such as controlled substances, are discontinued at the clinic and therefore should not be filled at the pharmacy. Prior to CancelRx, the communication of discontinued medications was a manual process, requiring the patient or a clinic staff member to personally contact the pharmacy to inform them of the change. The objective of this study was to assess how controlled substance medication discontinuations were communicated over time, before and after the implementation of CancelRx. METHODS: Secondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation. The study utilized an interrupted time series analysis (ITSA) to capture the percentage of controlled substance medications that were discontinued in the clinic's electronic health record and discontinued in the pharmacy's dispensing software. The ITSA plotted the percentage of successful discontinuation messages over time, particularly after the health system's implementation of CancelRx, a novel technology. RESULTS: After CancelRx implementation there was an immediate (change = 77.7 percentage point) and significant (p < 0.001) increase in the number of controlled substance medications that were successfully discontinued at the pharmacy after being discontinued in the clinic. This change was sustained in the year following CancelRx (slope = 0.03 pp, 95% CI - 0.050 to 0.110) and did not revert to pre-CancelRx levels. The health IT functionality was able to effectively complete discontinuation tasks and potentially reduce workload for clinic staff. CONCLUSIONS: Overall, this study demonstrates the role that technology can play in promoting communication between clinics and pharmacies, especially when medications such as controlled substances are discontinued.

Impact of a pilot community pharmacy system redesign on reducing over-the-counter medication misuse in older adults.

BACKGROUND: No interventions have attempted to decrease misuse of over-the-counter (OTC) medications for adults aged 65 years or older (older adults) by addressing system barriers. An innovative structural pharmacy redesign (the Senior Section) was conceptualized to increase awareness of higher-risk OTC medications. The Senior Section contains a curated selection of OTC medications and is close to the prescription department to facilitate pharmacy staff-patient engagement to reduce misuse. OBJECTIVE: This pilot study examined the Senior Section's effectiveness at influencing OTC medication misuse in older adults. METHODS: A pretest-post-test nonequivalent groups design was used to recruit 87 older adults from 3 pharmacies. Using a hypothetical scenario, the participants selected an OTC medication that was compared with their medication list and health conditions, and their reported use was compared with the product labeling. Misuse outcomes comprised drug-drug, drug-disease, drug-age, and drug-label, with 5 subtypes. Patient characteristics were compiled into a propensity score matching logistic regression model to estimate their effects on the Senior Section's association with misuse at pre- or postimplementation. RESULTS: Patient characteristics were uniform between pre- and postimplementation, and, once entered into a propensity score matching model, drug-label misuse (exceeds daily dosage) statistically significantly lessened over time (z = -2.42, P = 0.015). In addition, the Senior Section reduced drug-label misuse (exceeds single dosage) for both the raw score model (z = -6.38, P = 0.011) and the model in which the patient characteristics propensity score was added (z = -5.82, P = 0.011). Despite these limited statistical effects, misuse was found to decrease after implementation for 7 of 11 comparisons. CONCLUSION: These nascent outcomes begin providing an evidence base to support a well-conceived, pharmacy-based OTC medication-aisle redesign for reducing older adult OTC medication misuse. The Senior Section, when broadly implemented, creates permanent structures and processes to assist older adults to access risk information when selecting safer OTC medications.

A pharmacy-based intervention to improve safe over-the-counter medication use in older adults.

BACKGROUND: For older adults, health risks from inappropriate use of over-the-counter (OTC) medications represent a prevalent clinical and public health challenge. Focus groups with pharmacists led to the identification of a number of systems barriers to pharmacists supporting the safe selection and use of OTC medications by this population. Such feedback informed the development of the Senior Section™, a physical redesign that located a curated inventory of lower-risk OTC medications proximal to the prescription department. OBJECTIVES: To determine whether implementation of the Senior Section resulted in improvements to the ability of pharmacy staff to engage with older adult patients to support OTC medication safety issues. METHODS: A qualitative approach, in which pharmacy staff from 4 pharmacies within a single chain participated in a semi-structured interview, was used to evaluate the implementation of the Senior Section in their pharmacies. Interview transcripts underwent a deductive and iterative content analysis. RESULTS: Eight pharmacists and 5 technicians were interviewed. They viewed the Senior Section as contributing to notable improvements in proximity, medication safety, convenience, and patient selection behaviors. The Senior Section's safer OTC inventory and its sectional layout, its relationship to the prescription department, and its signage served to enhance its usefulness as an OTC safety improvement intervention. Moreover, it functioned beneficially while streamlining the coordination of services with between pharmacists and technicians, and did not interfere with existing pharmacy workflows. CONCLUSIONS: Pharmacy staff believed that the Senior Section facilitated their ability to engage with older adults to support safe OTC selection and use and thus to reduce OTC-related harms.

Using a scenario-based hybrid approach to understand participant health behavior.

BACKGROUND: Qualitative and mixed methods approaches are commonly used to understand participants' interactions with real-world settings and can help health services researchers to obtain realistic details about patients' health behaviors. However, interviews do not easily capture data about how patients perform health-related behaviors that are not part of their daily routine. A scenario-based approach is one method that can be used prospectively to explore how patients make decisions about their health-related behaviors. This approach is comprised of a set of small tailored probable circumstances with equally plausible situations, and are presented as narrative descriptions. To understand how older adults, a group at high-risk for OTC misuse, select over-the-counter (OTC) medication qualitative methods can be used. OBJECTIVES: This study describes a scenario-based hybrid approach that included a simulation exercise and a situational interview to understand how older adults first select and then take OTC medication. METHODS: The scenario-based hybrid approach consisted of 1) a simulation exercise to emulate participants' real-world experiences as they selected a medication in a store, followed by 2) a situational interview to capture how participants intended to take the medication they selected. Video recordings captured interview data as well as participants' body language, navigation patterns, and other nuanced data that would not have been captured in audio recordings. RESULTS/CONCLUSION: The scenario-based hybrid approach not only yielded detailed information about behavior, but also allowed investigators to discern participants' decision-making, influences, and the rationales they use when selecting and taking OTC medications. Studies aiming to capture participants' behavior in naturalistic situations can use these techniques to draw inferences from direct and indirect visual references that may not be captured otherwise. In this study, the goal was to understand how older adult participants select and take OTC medications. This approach allowed the research team to expediently recreate situations in which participants would purchase an OTC medication, a task that may not occur frequently and thus may not be amenable to participant observation or accurately recalled using retrospective interviewing.

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

OBJECTIVE: Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software. MATERIALS AND METHODS: CancelRx was implemented in October 2017 at an academic health system. For 12 months prior, and 12 months after CancelRx implementation, data were collected on discontinued medications in the health system's EHR and whether those prescriptions were successfully discontinued in the pharmacy's dispensing software. An interrupted time series analysis was conducted to model the occurrence of prescriptions successfully discontinued over time. RESULTS: There was an immediate (lag = 0), significant (P < 0.001), and sustained (post-implementation slope 0.02) increase in the proportion of successful medication discontinuations after CancelRx implementation (from 34% to 93%). CancelRx had variable impact based on whether the clinic was primary care (71.4% change prepost) or specialty care (53.9% change prepost). CancelRx reduced the time between when a medication was discontinued in the clinic EHR and pharmacy dispensing software. CONCLUSION: CancelRx automated a manual process and illustrated the role for health IT in communicating medication discontinuations between clinics and pharmacies. Overall, CancelRx had a marked benefit on medication list discrepancies and illustrated how health IT can be used across different settings to improve patient care.

Improving Patient-Pharmacist Encounters with Over-The-Counter Medications: A Mixed-Methods Pilot Study.

BACKGROUND AND OBJECTIVES: Over-the-counter (OTC) medication use has increased safety risks for adults older than 65. Most older adults purchase OTC medications from community pharmacies, where the considerable distance or visual obstructions between the prescription area and OTC aisles undermine pharmacists' ability to assist patients with OTC medication decisions. An innovative redesign of an abbreviated medication section specifically for older adults (called the Senior SectionTM ) can facilitate pharmacy staff/patient interaction, potentially improving safe medication selection and use. This study evaluated the impact of the Senior Section on the frequency and content of OTC encounters between pharmacy staff and patients. RESEARCH DESIGN AND METHODS: An intervention mixed-methods design generated data from patient OTC encounters, and interviews with two pharmacists and two technicians, throughout the study. NVivo was used to code interview transcripts, and frequencies and chi-square analyses demonstrated pre/post-intervention comparisons for the OTC encounter variables. RESULTS: After Senior Section implementation, pharmacy staff were more likely to initiate (and be involved in) patient encounters, address more topics or problem/symptoms, provide details about OTC products, discuss appropriateness of OTC use, and discuss medication classes highlighted in the Senior Section. Pharmacy staff were less likely to need to leave the prescription department for extended periods; they also had fewer prolonged encounters or encounters about product location. Importantly, the Senior Section did not impede pharmacy workflow. DISCUSSION AND IMPLICATIONS: The Senior Section prompted more frequent, effective, and efficient engagements between pharmacy staff and patients, which may substantially reduce OTC-related harms among older adults.