Implementation of an interprofessional medication adherence program for chronic patients in community pharmacies: how much does it cost for the provider?

BACKGROUND: The implementation of an innovative and sustainable professional pharmacy service in routine care requires substantial resources borne by the pharmacy owner. Although a community pharmacy is a business setting, few studies have examined cost as a potential barrier to widespread implementation. Implementation costs, as the cost impact of an implementation effort, can be significant and hamper the decision to invest from the provider perspective. Traditional financial planning tools can be used to analyse and support business decision to implement a service by assessing the net impact of a new service on the provider's budget. This study aimed to estimate the implementation costs and the break-even point of an interprofessional medication adherence program for chronic patients in Switzerland. The program combines motivational interviews, medication adherence electronic monitoring and feedback reports to patient and physicians. METHODS: We used a 3-step approach: (i) micro-costing analysis: identification of implementation activities, quantification and valuation of required resources. Implementation costs, including service support costs and direct delivery costs, were analysed according to the implementation phase (installation, initial implementation, and full operation); (ii) break-even analysis: estimation of the required number of patients to follow up with to ensure that the generated revenue exceeded the total cost; and (iii) univariate sensitivity analyses. RESULTS: The estimated total cost of the installation phase was 8481 CHF, more than half of which represented the cost of the equipment. Direct delivery costs were 666 CHF per patient per year, with 68% of this value associated with the cost of workforce time. According to the Swiss national reimbursement system, a minimal of 16 [10-27] patients was required to cover the implementation costs of the installation phase. This break-even point decreased to 13 patients in the initial and full operation phases. CONCLUSIONS: These estimates lead to a better understanding of the real cost of implementing a professional pharmacy service in routine care. In a Swiss context, the current medication adherence support fee-for-service system allows pharmacists to reach the break-even point. Such information is important for community pharmacists to guide their implementation strategies. The replication of similar analyses in other settings and countries is paramount.

DEVRIESEASIS IN A PLUMED BASILISK (BASILISCUS PLUMIFRONS) AND CHINESE WATER DRAGONS (PHYSIGNATHUS COCINCINUS) IN A ZOOLOGIC COLLECTION.

Devriesea agamarum is a Gram-positive bacterium that was first described in 2008 as a causative agent of disease in lizards. Until today, reports from several countries reported the presence of this bacterium in various lizard species, which suggests a wide distribution among lizard collections. Pathologic lesions ranged from proliferative dermatitis and cheilitis to abscesses in multiple organs and septicemia in single animals, as well as entire groups. Until now, disease caused by D. agamarum has been reported in several lizard species. Because the bacterium is only identified by 16S rRNA sequencing and no commercially available identification systems contain the agent in their database, it may be underdiagnosed. This report describes a series of fatal devrieseasis in plumed basilisks (Basiliscus plumifrons) and Chinese water dragons (Physignathus cocincinus) from a zoologic collection and extends the range of susceptible species. In 3 mo, five animals died with pyogranulomatous lesions in the subcutis, the coelomic cavity, or multiple organs. In all cases, diffuse swelling or focal skin elevations of different body parts were observed. Devriesea agamarum could be isolated from lesions in all animals. A subsequent clinical survey of the lizard collection including bacteriologic investigation of oral cavity swabs indicated that bearded dragons (Pogona vitticeps) were carriers of D. agamarum, which suggests that this species could be a source of infection with this pathogen.

Computed tomography-guided bone biopsies for evaluation of proliferative vertebral lesions in two boa constrictors (Boa constrictor imperator).

Two boa constrictors (Boa constrictor imperator) presented with paresis of the trunk originating cranial to the cloaca. Radiographs were consistent with proliferative bone lesions involving several vertebrae. Computed tomography (CT) demonstrated the presence of lytic/expansile lesions. Computed tomography-guided biopsies of the lesions were performed without complications. Histology was consistent with bacterial osteomyelitis and osteoarthritis. Gram-negative bacteria (Salmonella sp. and Pseudomonas sp.) were isolated from cultures of the biopsies. Medical treatment with specific antibiotics was attempted for several weeks in both cases without clinical or radiographic improvements. The animals were euthanized, and necropsy confirmed the findings observed upon CT. To the authors' knowledge, this is the first report of the use of CT-guided biopsies to evaluate proliferative vertebral lesions in snakes. In the present report, CT-guided biopsies were easily performed, and both histologic and microbiologic results were consistent with the final diagnosis.

Building Interprofessional Collaborative Practices Through a Support Program for Patients With Type 2 Diabetes in Primary Care.

INTRODUCTION: The building of interprofessional collaborative practices throughout the implementation process of a patient support program (Siscare) in primary care for patients with type 2 diabetes was assessed. Siscare included regular patient-pharmacist motivational-based interviews; medication adherence, patient-reported, and clinical outcomes monitoring; and physician-pharmacist interactions. METHOD: This investigation was a prospective, multicenter, observational, mixed-methods cohort study. Interprofessionality was operationalized through four progressive levels of interrelationship practices between the health care professionals. The target number of patients per pharmacy was 10 among 20 pharmacies. RESULTS: The project started with the recognition of Siscare by stakeholders, the creation of an interprofessional steering committee, and the adoption of Siscare by 41 pharmacies among 47 pharmacies in April 2016. Nineteen pharmacies presented Siscare at 43 meetings attended by 115 physicians. Twenty-seven pharmacies included 212 patients; however, no physician prescribed Siscare. Collaboration primarily occurred through the unidirectional transmission of information from the pharmacist to the physician (level 1: 70% of pharmacists transmitted interview reports to physicians), bidirectional exchange of information sometimes occurred (level 2: 42% received physician responses), and concerted measures of treatment objectives took place occasionally (level 3). Twenty-nine of 33 physicians surveyed were in favor of this collaboration. DISCUSSION: Despite multiple implementation strategies, physician resistance and lack of motivation to participate exists, but Siscare was well received by pharmacists, patients, and physicians. Barriers to collaborative practice (financial and IT) need to be further explored. Interprofessional collaboration is a clear need to improve type 2 diabetes adherence and outcomes.

Diagnosis of gastrointestinal parasites in reptiles: comparison of two coprological methods.

BACKGROUND: Exotic reptiles have become increasingly common domestic pets worldwide and are well known to be carriers of different parasites including some with zoonotic potential. The need of accurate diagnosis of gastrointestinal endoparasite infections in domestic reptiles is therefore essential, not only for the well-being of captive reptiles but also for the owners. Here, two different approaches for the detection of parasite stages in reptile faeces were compared: a combination of native and iodine stained direct smears together with a flotation technique (CNF) versus the standard SAF-method. RESULTS: A total of 59 different reptile faeces (20 lizards, 22 snakes, 17 tortoises) were coprologically analyzed by the two methods for the presence of endoparasites. Analyzed reptile faecal samples contained a broad spectrum of parasites (total occurence 93.2%, n = 55) including different species of nematodes (55.9%, n = 33), trematodes (15.3%, n = 9), pentastomids (3.4%, n = 2) and protozoans (47.5%, n = 28). Associations between the performances of both methods to detect selected single parasite stages or groups of such were evaluated by Fisher's exact test and marginal homogeneity was tested by the McNemar test. In 88.1% of all examined samples (n = 52, 95% confidence interval [CI] = 77.1 - 95.1%) the two diagnostic methods rendered differing results, and the McNemar test for paired observations showed highly significant differences of the detection frequency (P < 0.0001). CONCLUSION: The combination of direct smears/flotation proved superior in the detection of flagellates trophozoites, coccidian oocysts and nematode eggs, especially those of oxyurids. SAF-technique was superior in detecting larval stages and trematode eggs, but this advantage failed to be statistically significant (P = 0.13). Therefore, CNF is the recommended method for routine faecal examination of captive reptiles while the SAF-technique is advisable as additional measure particularly for wild caught animals and individuals which are to be introduced into captive collections.

Mycobacterium avium Subsp. avium infection in four veal calves: differentiation from intestinal tuberculosis.

Mycobacterium avium subsp. avium (Maa) is an intracellular pathogen belonging to the Mycobacterium avium-intracellulare complex (MAC). Reservoirs of MAC are the natural environment, wildlife and domestic animals. In adult bovine, MAC infections are typically caused by Mycobacterium avium subsp. paratuberculosis (Map). Maa infections in bovine are rarely reported but may cause clinical disease and pathological lesions similar to those observed in paratuberculosis or those induced by members of the Mycobacterium tuberculosis complex (MTBC). Therefore, differentiation of MAC from MTBC infection should be attempted, especially if unusual mycobacterial lesions are encountered. Four veal calves from a fattening farm dying with clinical signs of otitis media, fever, and weight loss were submitted for necropsy. Samples from affected organs were taken for histologic investigation, bacteriologic culture, and bacterial specification using PCR. Macroscopic thickening of the intestinal mucosa was induced by granulomatous enteritis and colitis. Intracytoplasmic acid-fast bacteria were detected by Ziehl-Neelsen stains and PCR revealed positive results for Mycobacterium avium subsp. avium. Clinical and pathological changes of Maa infection in veal calves had features of Mycobacterium avium subsp. paratuberculosis and the MTBC. Therefore, Mycobacterium tuberculosis complex infection should be considered in cases of granulomatous enteritis in calves.

Impact and cost of a 2-week community-based screening and awareness program for diabetes and cardiovascular risk factors in a Swiss canton.

BACKGROUND: Community-based diabetes screening programs can help sensitize the population and identify new cases. However, the impact of such programs is rarely assessed in high-income countries, where concurrent health information and screening opportunities are common place. INTERVENTION AND METHODS: A 2-week screening and awareness campaign was organized as part of a new diabetes program in the canton of Vaud (population of 697,000) in Switzerland. Screening was performed without appointment in 190 out of 244 pharmacies in the canton at the subsidized cost of 10 Swiss Francs per participant. Screening included questions on risk behaviors, measurement of body mass index, blood pressure, blood cholesterol, random blood glucose (RBG), and A1c if RBG was ≥7.0 mmol/L. A mass media campaign promoting physical activity and a healthy diet was channeled through several media, eg, 165 spots on radio, billboards in 250 public places, flyers in 360 public transport vehicles, and a dozen articles in several newspapers. A telephone survey in a representative sample of the population of the canton was performed after the campaign to evaluate the program. RESULTS: A total of 4222 participants (0.76% of all persons aged ≥18 years) underwent the screening program (median age: 53 years, 63% females). Among participants not treated for diabetes, 3.7% had RBG ≥ 7.8 mmol/L and 1.8% had both RBG ≥ 7.0 mmol/L and A1c ≥ 6.5. Untreated blood pressure ≥140/90 mmHg and/or untreated cholesterol ≥5.2 mmol/L were found in 50.5% of participants. One or several treated or untreated modifiable risk factors were found in 78% of participants. The telephone survey showed that 53% of all adults in the canton were sensitized by the campaign. Excluding fees paid by the participants, the program incurred a cost of CHF 330,600. CONCLUSION: A community-based screening program had low efficiency for detecting new cases of diabetes, but it identified large numbers of persons with elevated other cardiovascular risk factors. Our findings suggest the convenience of A1c for mass screening of diabetes, the usefulness of extending diabetes screening to other cardiovascular risk factors, and the importance of a robust background communication campaign.