The Report of the 2021-2022 AACP Research and Graduate Affairs Committee.

EXECUTIVE SUMMARY. The work of the 2021-2022 AACP Research and Graduate Affairs Committee (RGAC) focused on barriers to graduate education and research-related careers in pharmacy education. AACP President Stuart Haines charged the RGAC with identifying the critical barriers that hinder current PharmD students/recent graduates as well as under-represented groups (e.g., Black and Latino) from pursuing advanced degrees and research-related career paths in the pharmaceutical, social & behavioral, and clinical sciences and recommending changes that might address these barriers - this may include recommendations to change the fundamental structure of graduate education.The committee began its work with a literature review to survey current perspectives on these barriers and assess the supporting evidence for effective solutions and programs, including their relevance to pharmacy education. Based on the review, the committee was able to identify numerous obstacles to entry into and progression through research training, for both underrepresented learners and student pharmacists. Obstacles are individual, e.g., lack of exposure to and self-efficacy in research, financial constraints, structural, e.g., lengthy training time, programmatic rigidity, and institutional, e.g., implicit and explicit bias. The committee found evidence of effective approaches and programs to address these barriers that could be applied in pharmacy schools. These approaches include improvements to existing practices in recruitment, admissions and hiring practices as well as creation of new programs and structural changes to existing programs to increase accessibility to learners. The committee also recognized a need for more research and development of additional approaches to address these barriers.The committee makes a series of recommendations that AACP develop resource guides and programs to address key issues in the recruitment and retention of underrepresented students and student pharmacists into graduate education and research careers, including as faculty. The committee also proposes new AACP policies to support innovative graduate programs and early, longitudinal engagement of learners from elementary school onward to increase access to graduate education and to support environments and cultures of commitment to accessibility, diversity, equity, inclusiveness, antiracism in pharmacy education.

Factors Influencing the Use of Second-Generation Antipsychotics in Children with Psychosis.

BACKGROUND: In 2011, the U.S. Department of Health and Human Services sent a letter to state Medicaid directors explaining the need for oversight of psychiatric prescriptions for children with mental health disorders. The National Committee for Quality Alliance proposed 3 quality measures for rating managed care organizations (MCOs) that involve use of second-generation or atypical antipsychotics in children. In order to ensure appropriate use and to effectively manage the use of second-generation antipsychotics in children, MCOs need to better understand the factors that influence medication treatment decisions for children. OBJECTIVES: To (a) determine how patient-level and physician-level factors influence decisions to prescribe second-generation antipsychotics to children (aged under 18 years) diagnosed with psychosis and (b) evaluate how the influence of these factors may differ between primary care providers and psychiatrists. METHODS: This study employed a cross-sectional survey of 193 primary care providers and psychiatrists. A web-based patient simulation survey using a fractional factorial design was administered via a commercial vendor. Respondents were presented with simulated patient profiles described by various levels of factors considered to be essential to decision making. Respondents were asked to make treatment recommendations for each profile evaluated. In addition to treatment recommendations, demographics and beliefs about products were measured. Modified Poisson regression accounting for multilevel data was used to identify the factors that significantly affect treatment recommendations. RESULTS: Psychiatrists were more likely to recommend second-generation antipsychotics than primary care practitioners (unadjusted RR = 1.36, 95% CI = 1.23-1.51). Social factors such as foster status or parental concern were not found to be significant predictors of prescribing second-generation antipsychotics. The percentage of a provider's patients using second-generation antipsychotics (RR = 1.002, 95% CI = 1.0002-1.003), patient age (aged 4 years: RR = 0.75, 95% CI = 0.68-0.84; aged 10 years: RR = 0.94, 95% CI = 0.91-0.99; reference group: aged 15 years), and patient disease severity (severe: RR = 1.11, 95% CI = 1.04-1.18; moderate: RR = 1.10, 95% CI = 1.05-1.17; reference group: mild) significantly predicted prescription behavior among primary care providers and psychiatrists. Primary care providers were about twice as likely to recommend antipsychotics if they believed the use of antipsychotics was a labeled indication (RR = 2.16, 95% CI = 1.56-2.98) or a medically accepted use (RR = 1.88, 95% CI = 1.33-2.67), when compared with physicians who believed there was no evidence available. This effect was not significant among psychiatrists. Primary care providers, but not psychiatrists, were also significantly influenced by patient white blood cell (WBC) count. Patients with healthy WBC counts were 1.11 times as likely (95% CI = 1.05-1.17) to receive antipsychotics from primary care providers compared with those with low WBC count. Patient body mass index (BMI) was not found to significantly influence prescribing behavior. Nearly 50% of patients did not receive recommendations for psychosocial care. Primary care providers recommended antipsychotic polypharmacy in 23% of the patient profiles, while psychiatrists did so in 42% of the profiles. CONCLUSIONS: This study provides valuable insight into physician-prescribing practices for antipsychotics. The lack of significance of foster status and parental concern, after controlling for other factors, shows that physicians base their decisions on clinical factors more than social factors. Results for patient BMI and frequency of recommendations of polypharmacy are concerning. The general lack of awareness of evidence supporting use of antipsychotics is also highly concerning. The effects of patient BMI, beliefs about evidence supporting use, and prescribing practices with regard to psychosocial care and antipsychotic polypharmacy provide actionable results for managed care programs looking to improve their quality metrics. The results of this study further demonstrate the need for the immediate implementation of the various proposed quality metrics in this area and for new practice guidelines to raise the current standard of care. DISCLOSURES: No outside funding supported this research. Bentley reports the receipt of grants from PQA and the NACDS Foundation. Patel is employed by Medical Marketing Economics. The authors report no other conflicting interests, potential or otherwise. Study concept and design were contributed by Ramachandran, Banahan, West-Strum, and Bentley. Ramachandran, Banahan, and Patel collected data; data interpretation was performed primarily by Ramachandran, Banahan, and Patel, along with Bentley and West-Strum. The manuscript was primarily written by Ramachandran, along with Banahan and Bentley, and revised by Banahan, Bentley, West-Strum, and Patel.

Measuring pharmacy performance in the area of medication adherence: addressing the issue of risk adjustment.

BACKGROUND: Pharmacies and pharmacists play an important role in the health care system, improving health outcomes and enhancing quality through better pharmaceutical care. Yet, little information is available to accurately evaluate pharmacy store quality and thereby encourage quality improvement at the pharmacy store level. OBJECTIVES: To (a) assess pharmacy performance in the area of medication adherence and (b) examine the impact of risk adjustment of performance scores on pharmacy rankings. METHODS: We used proportion of days covered (PDC) to compute pharmacy performance scores using the 2007 Mississippi Medicare administrative claims dataset. We calculated unadjusted and adjusted quality scores for 685 pharmacies serving 137,497 eligible Medicare beneficiaries. Risk-adjusted quality scores were computed using a hierarchical logistic regression model (Method 1) and the shrinkage estimators of the model (Method 2). Patient demographics, income subsidy status, and comorbidity burden were used as variables for risk adjustment.  RESULTS: Unadjusted scores showed low levels of agreement (Cohen's kappa less than 0.45) with risk-adjusted scores in identifying statistical outliers based on 95% CIs. Unadjusted scores also failed to identify 39%-43% of the top 20% and bottom 20% of pharmacies and displayed moderate agreement (0.4 less than kappa less than 0.5) with risk-adjusted scores. Pharmacy classifications based on risk-adjusted scores obtained from different statistical methods showed high levels of agreement (0.79 less than kappa less than 0.98).  CONCLUSIONS: In the risk-adjustment methods presented here, we account for many patient characteristics previously reported to be associated with medication adherence and available in our dataset. Risk-adjusted scores produced more robust indicators of pharmacy quality than unadjusted scores. Depending on the availability of important variables in the source data, the use of risk-adjusted quality indicators may lead to better evaluation of pharmacy quality and should be considered when providing public reports on pharmacy quality.