Measuring changes in perception using the Student Perceptions of Physician-Pharmacist Interprofessional Clinical Education (SPICE) instrument.

BACKGROUND: The Student Perceptions of Physician-Pharmacist Interprofessional Clinical Education (SPICE) instrument contains 10 items, 3 factors (interprofessional teamwork and team-based practice, roles/responsibilities for collaborative practice, and patient outcomes from collaborative practice), and utilizes a five-point response scale (1 = strongly disagree, 5 = strongly agree). Given the SPICE instrument's demonstrated validity and reliability, the objective of this study was to evaluate whether it was capable of measuring changes in medical (MS) and pharmacy students' (PS) perceptions following an interprofessional education (IPE) experience. METHODS: In this prospective cohort study, MS and PS completed the SPICE instrument before and after participation in a predefined IPE experience. Descriptive statistics were used to characterize students and pre-post responses. Independent samples t tests and Fisher's Exact tests were used to assess group difference in demographic variables. Mann Whitney U tests were used to assess between-group differences in item scores. Wilcoxon Signed-Rank tests were used to evaluate post-participation changes in item scores. Spearman correlations were calculated to assess associations between ordinal demographic variables and item scores, and whether the number of clinic visits completed was associated with post-test responses. Paired samples t tests were used to calculate mean score changes for each of the factors. RESULTS: Thirty-four MS and 15 PS were enroled. Baseline differences included age (25.3. ± 1.3 MS vs. 28.7 ± 4.4 PS; p = 0.013), years full-time employment (0.71 ± 0.97 MS vs. 4.60 ± 4.55 PS; p < 0.001), and number of prior IPE rotations (1.41 ± 1.74 MS vs. 3.13 ± 2.1 PS; p < 0.001). Two items generated baseline differences; 1 persisted post-participation: whether MS/PS should be involved in teamwork (3.91 MS vs. 4.60 PS; p < 0.001). For all students, significant mean score increases were observed for role clarity ("my role" [3.72 vs. 4.11; p = 0.001] and "others' roles" [3.87 vs. 4.17; p = 0.001]), impact of teamwork on patient satisfaction (3.72 vs. 4.34; p < 0.001), and ideal curricular location for IPE (4.06 vs. 4.34; p = 0.002). Significant increases were observed for all three factors (teamwork, p = 0.003; roles/responsibilities and patient outcomes, p < 0.001). CONCLUSIONS: This study demonstrated the SPICE instrument's ability to measure changes in perception for medical and pharmacy students exposed to an IPE experience, both at the individual item level and at the factor level.

Malignant transformation of testicular teratoma to primitive neuroectodermal tumor.

Teratoma is a common germ cell tumor that affects young adult males. A small number of testicular teratomas have the potential for malignant transformation along endodermal, ectodermal, or mesodermal lines. The metastatic mixed germ cell tumor we reported consists of the primitive neuroectodermal tumor (PNET) with mature teratoma. PNET is a highly aggressive tumor with a poor prognosis given its poor response to standard platinum-based chemotherapy. The primary treatment for PNET is surgical resection. Malignant transformation of teratoma to PNET is a rare phenomenon. Only a few cases of malignant transformation of teratomas to PNET are reported in the literature. Here, we present a rare case of PNET arising in a malignant mixed germ cell tumor in a 23-year-old male who underwent adjuvant adriamycin, cyclophosphamide (VAC) alternating with ifosfamide and etoposide (IE) chemotherapy and retroperitoneal lymph node dissection.

Impact of a Pharmacist-Led Chronic Disease State Management Clinic on Patient Assessment of Chronic Illness Care.

Background: The Patient Assessment of Chronic Illness Care (PACIC) tool measures patient satisfaction with chronic disease care. Objective: A modified PACIC tool (PACIC-RxFM) was used to assess patient satisfaction in a pharmacist-led chronic disease state management clinic. The secondary outcome compared satisfaction with pharmacist-led and physician-led visits. Methods: This cross-sectional study surveyed individuals with ≥ 1 chronic disease who saw a pharmacist (pharmacotherapy) or primary care provider (usual care) in the Texas Tech Physicians Family Medicine Clinic. The PACIC-RxFM survey included 15 items rated on a five-point Likert scale (5 = "always satisfied"). Results: A total of 107 patients with no significant differences in demographics or complexity between groups were surveyed. All mean domain scores indicated a high level of satisfaction in the pharmacotherapy group with statements regarding perceptions of care organization and encouragement to go to group classes yielding statistically significantly higher scores than the usual care group. Conclusion: Patients are satisfied with both providers' and pharmacists' involvement in chronic illness care. This involvement leads to significant improvement in patient perception of care organization.

Impact of a Pharmacist-Driven Protocol to Improve Guideline-Concordant Prescribing of Diabetes Medications in Patients With Atherosclerotic Cardiovascular Disease: A Pilot Study.

PURPOSE: To determine whether a pharmacist-driven protocol improves guideline-concordant prescribing of diabetes medications in patients with atherosclerotic cardiovascular disease (ASCVD). METHODS: A retrospective pre- and post-intervention study was conducted at a university-based family medicine clinic. A pharmacist-driven protocol was implemented which involved the creation of an algorithm recommending specific diabetes medications in patients with ASCVD. An in-service presentation reviewing the algorithm and process for referral of eligible patients to an appointment with a clinical pharmacist was delivered to providers. Clinical pharmacist appointments focus was on improving diabetes management and initiating cardiovascular risk-reducing medications if appropriate. RESULTS: A total of 234 patients were screened, and 108 met inclusion criteria. Upon completion of patient outreach, 34% were scheduled with a pharmacist. Forty-three percent of patients (16 of 37) attended the appointment. Of those, 31% were initiated on an evidence-based regimen indicated for diabetes and ASCVD. In comparing pre- to post-implementation of the pharmacist-driven protocol, the rate of guideline-concordant prescribing increased by 48% (3.8% to 5.6%). CONCLUSION: Implementation of a pharmacist-driven protocol can increase guideline-concordant prescribing. However, further exploration of patient- and system-level barriers is necessary to implement such a program more broadly.

Use of the internet for health information among primary care patients in rural West Texas.

BACKGROUND: Little is known about how primary care patients in rural, remote or border areas use the internet for their health information. This study examined the factors related to internet use for medical information among primary care clinic patients in such areas of West Texas. METHODS: A convenience sample was drawn from nine clinics that serve low-income rural area populations. Surveys were distributed to the patients during a 6-week period in the winter of 2006. The analytical sample included 1890 participants. Logistic regressions were conducted. RESULTS: Of 1890 subjects, 699 (37%) reported having used the internet for medical information. Among those who reported using the internet for health information, respondents' primary usage pattern was to request more health information (29.9%), followed by the purchase of health supplies (13.4%). Most internet users (78.8%) agreed that the online medical/health information had improved their understanding of a specific condition, disease, or treatment. Almost 60% of the internet users thought the information was reliable. The correlates of internet use included health insurance, self-rated health, health confidence, and number of worried days as well as age, education level, ethnicity, and language. CONCLUSIONS: Our findings showed a much lower rate of internet use for medical/health information compared with a 2006 nationwide survey. This finding suggests that promoting health/medical information through websites or other on-line resources might not be the most effective way to reach a majority of patients in remote, rural or border areas.

Complementary and alternative medicine use among primary care patients in west Texas.

BACKGROUND: This study explored factors related to practitioner-based complementary and alternative medicine (CAM) usage among primary care clinic patients in rural West Texas areas, including physicians' awareness of their patients' CAM use. METHODS: A convenience sample was drawn from nine clinics that served low-income populations. Surveys were distributed to patients during a 6-week period in the winter of 2006. The analytical sample included 1731 participants. Logistic regressions were conducted to explore the factors related to CAM use. RESULTS: Of 1731 subjects, 52.0% (900) reported that they were currently using or had used CAM. The main types of CAM practitioners were chiropractor (42.7%) followed by massage therapist (33.3%) and herbalist (8.3%). Those who had discussed the use of alternative medicine with their physicians and those who had more days where they felt worried in the past 30 days were more likely to use CAM than their counterparts. Patients whose healthcare was covered by nonprivate insurance, those who rated their healthcare providers more highly, and those who agreed that their doctor visits were obtainable were less likely to use CAM. CONCLUSIONS: CAM use is clearly not uncommon among primary care patients in rural areas, with more than half of patients reporting some type of use. This study suggests that further research should elicit opinions on CAM among people who do not regularly access a conventional primary care provider, as well as assess the relationship between CAM and conventional medical treatment in terms of cost and health benefits.

Blood pressure targets: How low should you go (and for whom)?

The ACC/AHA's lower BP goals are supported by previously unavailable evidence, the strongest of which is for patients with CVD. But others can benefit, too.

Overall self-rated health: a new quality indicator for primary care.

RATIONALE, AIMS AND OBJECTIVES: Patient 'empowerment' gives patients choices about their own care and about the outcomes they would most prefer. Many patients can be presumed to regard overall self-rated health as an important outcome. Therefore, overall self-rated health can be considered a relevant and important outcome measure for a patient-centred medical clinic. The purpose of this study was to use this new outcome measure as a dependent variable and to test the hypothesis that patients who are confident about their ability to manage their health will have better health, in comparison to more dependent patients. METHODS: We conducted a randomized cross-sectional postal survey of 500 veteran patients from the Panhandle of Texas and the surrounding areas; and 302 participated in the study. Multiple logistic regression analysis was used to test the hypothesis that health confidence is positively related to self-rated health, controlling for obesity, cigarette smoking and participation in recreational activities. RESULTS: Veterans who strongly disagreed with the statement that they usually could overcome illnesses on their own were less likely to report good, very good or excellent self-rated health (adjusted odds ratio=0.25). CONCLUSIONS: Overall self-rated health as measured by a single question proved to be significantly related to behavioural risk factors in this sample of primary care patients, attesting to its validity as an outcome indicator. Furthermore, health confidence was associated with better health. Most primary providers believe that they can, through good communication and providing self-care tools, increase healthy behaviours in their patients. If we are indeed able to increase health confidence in our patients, this study would suggest that self-rated health would improve.

Overall self-rated health as an outcome indicator in primary care.

RATIONALE, AIMS AND OBJECTIVES: The ultimate goal of health care systems is to improve overall health from the patient's point of view. However, overall self-rated health is not routinely monitored as a performance indicator. The purpose of this study was to investigate the feasibility of using a measure normally employed in community health surveys as a quality indicator in primary care clinics. METHODS: In order to do so, we conducted a cross-sectional survey of community medicine patients treated in five clinics in Amarillo, Texas to test the theory that, in primary care patients, a single-item measure of self-rated health is significantly related to the usual risk factors found in community health surveys (environmental factors, demographic characteristics and health behaviours). RESULTS: Multiple logistic regression analysis revealed that age, race, frequent mental distress, current smoking and health confidence were independently related to the odds of reporting good health. CONCLUSION: Our results support using a single-item measure of self-rated health in primary care. Our data also suggest that encouragement of health confidence would appear to be in the best interests of patients.

Utilization and prescribing patterns of direct oral anticoagulants.

BACKGROUND: Scant literature exists evaluating utilization patterns for direct oral anticoagulants (DOACs). OBJECTIVES: The primary objective was to assess DOAC prescribing in patients with venous thromboembolism (VTE) and nonvalvular atrial fibrillation (NVAF) in outpatient clinics. Secondary objectives were to compare utilization between family medicine (FM) and internal medicine (IM) clinics, characterize potentially inappropriate use, and identify factors associated with adverse events (AEs). METHODS: This was a retrospective cohort study of adults with NVAF or VTE who received a DOAC at FM or IM clinics between 10/19/2010 and 10/23/2014. Descriptive statistics were utilized for the primary aim. Fisher's exact test was used to evaluate differences in prescribing using an adapted medication appropriateness index. Logistic regression evaluated factors associated with inappropriate use and AEs. RESULTS: One-hundred twenty patients were evaluated. At least 1 inappropriate criterion was met in 72 patients (60.0%). The most frequent inappropriate criteria were dosage (33.0%), duration of therapy (18.4%), and correct administration (18.0%). Apixaban was dosed inappropriately most frequently. There was no difference in dosing appropriateness between FM and IM clinics. The odds of inappropriate choice were lower with apixaban compared to other DOACs (odds ratio [OR]=0.088; 95% confidence interval [CI] 0.008-0.964; p=0.047). Twenty-seven patients (22.5%) experienced an AE while on a DOAC, and the odds of bleeding doubled with each inappropriate criterion met (OR=1.949; 95% CI 1.190-3.190; p=0.008). CONCLUSION: Potentially inappropriate prescribing of DOACs is frequent with the most common errors being dosing, administration, and duration of therapy. These results underscore the importance of prescriber education regarding the appropriate use and management of DOACs.

Impact of an Interprofessional Teaching Clinic on Preventive Care Services.

BACKGROUND AND OBJECTIVES: Recent legislative and regulatory initiatives have emphasized preventive medicine and team-based health care delivery and education. Influenced by these initiatives, the investigators created an interprofessional teaching clinic to provide preventive care services (PCS) structured around Medicare's Annual Wellness Visit (AWV). The primary objective of this pilot study was to determine if PCS status improved for participating patients. METHODS: AWV-naïve Medicare beneficiaries aged 66--74 years were recruited for the interprofessional teaching clinic, which involved physicians, pharmacists, and nurses. Patients were screened for 11 PCS variables, underwent medication review, and received recommendations to address identified PCS deficiencies prior to completing a satisfaction survey. Follow-up telephone visits were completed to determine recommendation outcomes and final PCS status for each variable. Descriptive statistics were used to characterize patients, the medication review, PCS status, and satisfaction scores. McNemar tests were used to assess the PCS status of patients before and after participation, and Fisher's Exact tests were used to compare baseline PCS status between the pilot cohort and a comparator group. RESULTS: Thirty-four patients were enrolled in the pilot intervention, and one patient was lost to follow-up. Ninety-one percent (10/11) of PCS variables improved following participation. Significant improvements were observed for pneumococcal vaccination, mammography screening, fecal occult blood testing, and bone mineral density scanning. Patient satisfaction was high (mean scores for all items ?4.7). CONCLUSIONS: This interprofessional teaching clinic provides a promising mechanism to improve patients' PCS status, medication utilization, and satisfaction while training students to function effectively as a team.

Self-esteem, stress and self-rated health in family planning clinic patients.

BACKGROUND: The independent effects of stress on the health of primary care patients might be different for different types of clinic populations. This study examines these relationships in a low-income female population of patients attending a family planning clinic. METHODS: This study investigated the relevance of different sources of personal stress and social support to self-rated health, adjusting for mental health, health behavior and demographic characteristics of subjects. Five hundred women who attended family planning clinics were surveyed and 345 completed the form for a response rate of 72 percent. RESULTS: Multiple logistic regression analysis revealed that liking oneself was related to good self-rated health (Odds ratio = 7.11), but stress or support from children, parents, friends, churches or spouses were not significant. White non-Hispanic and non-white non-Hispanic respondents had lower odds of reporting good self-rated health than Hispanic respondents (odds ratios were 2.87 and 2.81, respectively). Exercising five or more days per week also was related to good self-rated health. Smoking 20 or more cigarettes per day, and obese III were negatively related to good self-rated health (odds ratios were.19 and.22, respectively with corresponding p-values equal to.0043 and.0332). CONCLUSIONS: Among younger low-income women, addressing low self-esteem might improve health status.

Physician-pharmacist collaborative management of asthma in primary care.

OBJECTIVE: To determine if asthma control improves in patients who receive physician-pharmacist collaborative management (PPCM) during visits to primary care medical offices. DESIGN: Prospective pre-post study of patients who received the intervention in primary care offices for 9 months. The primary outcome was the sum of asthma-related emergency department (ED) visits and hospitalizations at 9 months before, 9 months during, and 9 months after the intervention. Events were analyzed using linear mixed-effects regression. Secondary analysis was conducted for patients with uncontrolled asthma (Asthma Control Test [ACT] less than 20). Additional secondary outcomes included the ACT, the Asthma Quality of Life Questionnaire by Marks (AQLQ-M) scores, and medication changes. INTERVENTION: Pharmacists provided patients with an asthma self-management plan and education and made pharmacotherapy recommendations to physicians when appropriate. RESULTS: Of 126 patients, the number of emergency department (ED) visits and/or hospitalizations decreased 30% during the intervention (p=0.052) and then returned to preenrollment levels after the intervention was discontinued (p=0.83). Secondary analysis of patients with uncontrolled asthma at baseline (ACT less than 20), showed 37 ED visits and hospitalizations before the intervention, 21 during the intervention, and 33 after the intervention was discontinued (p=0.019). ACT and AQLQ-M scores improved during the intervention (ACT mean absolute increase of 2.11, AQLQ-M mean absolute decrease of 4.86, p<0.0001) and sustained a stable effect after discontinuation of the intervention. Inhaled corticosteroid use increased during the intervention (p=0.024). CONCLUSIONS: The PPCM care model reduced asthma-related ED visits and hospitalizations and improved asthma control and quality of life. However, the primary outcome was not statistically significant for all patients. There was a significant reduction in ED visits and hospitalizations during the intervention for patients with uncontrolled asthma at baseline. Our findings support the need for further studies to investigate asthma outcomes achievable with the PPCM model.

Development and validation of the student perceptions of physician-pharmacist interprofessional clinical education (SPICE) instrument.

OBJECTIVES: To describe the development and validation of an instrument designed to assess student perceptions of physician-pharmacist interprofessional clinical education (SPICE). METHODS: Faculty members from pharmacy and medical schools developed items for the instrument, and 179 medical and pharmacy students completed the scale. Psychometric properties, including reliability and construct validity, were assessed using confirmatory factor analysis. RESULTS: The final instrument consisted of 10 items with 3 subscales measuring student perceptions of interprofessional teamwork and team-based practice, roles/responsibilities for collaborative practice, and patient outcomes from collaborative practice. Validity and reliability of the instrument were demonstrated. CONCLUSION: The SPICE instrument demonstrated promise as a valid and reliable measure of pharmacy and medical student perceptions of interprofessional clinical education. SPICE may serve as a useful instrument for educational researchers in assessing the impact of interprofessional educational experiences.

Institutional review board barriers and solutions encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now Study: a national multicenter practice-based implementation trial.

STUDY OBJECTIVE: To categorize institutional review board (IRB) challenges and solutions encountered in a multicenter practice-based research network (PBRN) study and to assess the impact of IRB requirements on the willingness of individual principal investigators (PIs) to participate in future PBRN studies. DESIGN: Descriptive analysis of IRB challenges and solutions encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now (CAPTION) trial, a multicenter prospective cluster-randomized study conducted by the National Interdisciplinary Primary Care PBRN, and a correlational analysis from a survey of individual site PIs. MEASUREMENTS AND MAIN RESULTS: IRB barriers encountered and solutions were categorized for study sites. A survey of study-site PIs was conducted with a correlational analysis assessing the impact of various IRB requirements and the willingness of individual PIs to participate in future PBRN studies; of 31 study sites participating in the CAPTION study, 28 study-site PIs were surveyed. IRBs posed a number of challenges including bias regarding the source of the application, issues regarding study design, study instruments, access to patient records, study procedures, Spanish-only speaking subjects, role of clinic physicians, interdepartmental concerns, and updates at continuing review. Responses from the PI survey (21 of 28 PIs surveyed [75% response rate]) indicated that the willingness of an individual to serve as a PI in the future was inversely related to the perceived difficulty of obtaining initial (rS  = -0.599, p=0.004) and continuing (rS  = -0.464, p=0.034) IRB approval. CONCLUSION: Significant time and resources were required to address various challenges associated with IRB approval, which had a negative impact on an individual PI's willingness to participate in future PBRN projects. A revision of current rules and regulations regarding the protection of human subjects for practice-based studies, improvement in IRB processes, and support from coordinating centers may decrease the burden associated with IRB approval and increase participation in practice-based research.

The detection of antibacterial actions of whole herb tinctures using luminescent Escherichia coli.

Two whole cell Escherichia coli luminescent biosensors were used to determine the antibacterial actions of 16 herbal tinctures. These bioassays can detect genotoxic (strain DPD2794) and general oxidative stress (DE135) events when challenged with antibacterial substances. Many of the herbal tinctures were active against these Gram-negative bacteria, affecting their metabolism without, in some cases, arresting cell growth or causing cell death. Antibacterial activity ranged from undetectable for Curcuma longa, Cinnamomum zeylanicum and Apium graveolens to highly effective against both E. coli strains in the case of Rosmarinus officinalis. Some of the results were unexpected. Althaea officinalis affected microbial metabolism in spite of the lack of literature precedent, and Cinnamomum zeylanicum did not appear to be antimicrobial, as claimed in some literature. It is concluded that studies using luminescent bacterial biosensors can provide important new insights into the potency and modes of the lethal and sub-lethal antibacterial action of whole herbs, and thereby provide crucial evidence for efficacy demanded by modern science and medicine.

How do family physicians provide anticipatory guidance during well-child visits?

INTRODUCTION: Anticipatory guidance is an important part of well-child care, yet little is known about the way family physicians provide this guidance. This study describes the methods that family physicians use to provide anticipatory guidance during well-child visits. METHODS: A questionnaire was mailed to 1000 family physicians. Respondents rated 6 anticipatory guidance methods on frequency of use. The questionnaire addressed method of documentation, use of forms or guidance prompts, visit frequency for total, well-child, and other pediatric visits, and demographic information; t tests and ANOVA were applied (P < .05 significant). RESULTS: There were 495 questionnaires returned for a response rate of 49.5%. Respondents were more likely to provide anticipatory guidance verbally than by handout (Likert scale where 1 = never and 9 = always, mean 7.8 vs 4.2, P < .0001). Physicians using well visit forms more commonly initiate guidance discussions (7.6 vs 6.8, P = .0002), address concerns (8.2 vs 7.5, P = .0001), and provide handouts (4.3 vs 3.3, P = .0002). Physicians in academic or multispecialty practices used handouts more often than private practitioners (5.0 vs 3.6, P = .0003, 5.1 vs 3.6, P = .0002, respectively) as did those with > or = 7 well-child visits per week compared with < 7 visits per week (4.8 vs 3.8, P = .0028). CONCLUSIONS: Family physicians primarily provide anticipatory guidance verbally. Use of well visit forms or other prompts are associated with better provision of anticipatory guidance.