Barriers and facilitators associated with implementing interventions to support oral anticancer agent adherence in academic and community cancer center settings.

PURPOSE: The goal of this study is to determine barriers and facilitators to the implementation of medication adherence interventions to support cancer patients taking novel, targeted oral anticancer agents (OAAs). METHODS: We conducted qualitative interviews using a semi-structured guide from the Consolidated Framework for Implementation Research (CFIR). We used purposive sampling to identify clinicians (physicians, pharmacists, nurse practitioners, nurses) and administrators (leadership from medicine, pharmacy, and nursing) who delivered care and/or oversee care delivery for patients with chronic leukemia prescribed an OAA. RESULTS: A total of 19 individuals participated in an interview (12 clinicians and 7 administrators), with 10 primarily employed by an academic cancer center; 5 employed by the community cancer center; and 4 employed by the integrated health-system specialty pharmacy. Barriers identified included low awareness of adherence interventions, difficulty in adherence measurement, complexity of designing and implementing a structured adherence intervention, and competing priorities. Facilitators identified included support of hospital administrators, value for pharmacists, and willingness to embrace change. Participants also made recommendations moving forward including standardizing workflow, designating champions, iterating implementation strategies, and improving communication between clinicians and with patients. CONCLUSION: Individual and system level factors were identified as determinants of implementation effectiveness of medication adherence interventions. A multidisciplinary advisory panel will be assembled to design comprehensive and actionable strategies to refine and implement a structured intervention to improve medication adherence in cancer patients.

Facilitating pneumococcal vaccination among high-risk adults: Impact of an assertive communication training program for community pharmacists.

BACKGROUND: Community pharmacies are vital access points to provide a range of vaccines to adults, including pneumococcal vaccines; however, despite a growth in the number of vaccines given at these sites, the most recent rates of adults being immunized against pneumococcal disease remain below the goals set by Health People 2020. Low patient awareness is a leading reason for suboptimal vaccination rates, suggesting that a need exists to improve provider communication in recommending pneumococcal vaccination in high-risk adults. OBJECTIVES: To evaluate the impact of a communication training program to improve pharmacist promotion of the pneumococcal vaccine among high-risk adults in Tennessee. METHODS: A multiphase training program was initiated in partnership with 2 regions of a nationwide community pharmacy chain (n = 100) focusing on improving evidence-based, presumptive recommendations related to pneumococcal vaccination. All locations were randomized to one of 3 arms on the basis of training intensity: (1) no training; (2) online training only; and (3) online and in-person simulation training. The program focused on improving evidence-based, pharmacist vaccine recommendations using health behavior theories, sales techniques, and improvisation provided through online and in-person simulation training. Changes in vaccinations (compared with the same 6-month period in the previous year) and provider self-efficacy were evaluated by Mann-Whitney U tests, chi-square tests, and general linear models. RESULTS: Completing the full training program led to nominal changes in pharmacist self-efficacy across the 6 items measured (P > 0.05). Overall counts of all pneumococcal vaccines were lower (-11.3%) across all stores in the period after training; however, a small increase (2.1%) was observed in the stores that underwent the full training, versus changes of -22.0% (P = 0.084) and -9.4% (P = 0.199) in control and online-only training comparisons, respectively. CONCLUSIONS: Pharmacists' vaccine-related self-efficacy may be improved through an evidence-based communication training program, but a more holistic focus on all recommended adult vaccines may be necessary to realize meaningful improvements.

Laxative use in patients with advanced chronic kidney disease transitioning to dialysis.

BACKGROUND: Constipation is highly prevalent in patients with chronic kidney disease (CKD), particularly among those with end-stage renal disease (ESRD), partly due to their dietary restrictions, comorbidities and medications. Laxatives are typically used for constipation management; however, little is known about laxative use and its associated factors in patients with advanced CKD transitioning to ESRD. METHODS: In a retrospective cohort of 102 477 US veterans transitioning to dialysis between October 2007 and March 2015, we examined the proportion of patients who filled a prescription for any type of laxative within each 6-month period over 36 months pre- and post-transition to ESRD. Factors associated with laxative use during the last 1-year pre-ESRD period were identified by multivariable logistic regression. RESULTS: The proportion of patients prescribed laxatives increased as patients progressed to ESRD, peaking at 37.1% in the 6 months immediately following ESRD transition, then remaining fairly stable throughout the post-ESRD transition period. Among laxative users, stool softeners were the most commonly prescribed (∼30%), followed by hyperosmotics (∼20%), stimulants (∼10%), bulk formers (∼3%), chloride channel activator (<1%) and several combinations of these. The use of anticoagulants, oral iron supplements, non-opioid analgesics, antihistamines and opioid analgesics were among the factors independently associated with pre-ESRD laxative use. CONCLUSION: The use of laxatives increased considerably as patients neared transition to ESRD, likely mirroring the increasing burden of drug-induced constipation during the ESRD transition period. Findings may provide novel insight into better management strategies to alleviate constipation symptoms and reduce medication requirements in patients with advanced CKD.

The need to prioritize "prioritization" in clinical pharmacy service practice and implementation.

Pharmacists are increasingly asked to incorporate new and greater amounts of clinical services into their traditional medication distribution responsibilities, but many barriers exist. Given the demanding pharmacy practice environment, improved time management may improve implementation rates. One area not previously explored within this area is the clinical skill of "prioritization" of medication related problems (MRPs). Prioritization is vital as the workload demand for pharmacist time exceeds time available; however, the underdeveloped skills of prioritizing is a concern in the field of pharmacy practice, as it also is across professions in healthcare. Previous research has suggested that pharmacists and student pharmacists inexperienced in implementing clinical services struggle knowing where to begin when providing direct patient care, given the complex patient care regimens, a complex pharmacy practice workload, and the numerous preventative care interventions possible for a given patient. This paper provides a review of theory and science of prioritization in patient care service delivery, including Multicriteria Decision Analysis (MCDA), Lean Six Sigma (LSS), and Jaen's Competing Demands framework. A case study is shared which emphasizes both the need for and potential impact of a renewed focus on workload management skills, such as prioritization.

Characteristics of Health-related Text Messages Preferred by Medically Underserved African-American Patients with Diabetes.

Introduction Text messaging (TM) is increasingly used by the U.S. medical practices and healthcare delivery systems, but little is known about preferences of medically underserved minority patients for TM supporting improved self-care decisions. We sought to determine the characteristics of text messages and TM programs preferred by African-American patients with diabetes in medically underserved areas. Methods This convergent mixed methods study employed a self-administered survey and focus group interviews. Quantitative and qualitative data were collected simultaneously, analyzed separately, and merged to provide a holistic view of the TM characteristics patients preferred. Participants (N = 36) were recruited from a medically underserved area in Memphis, Tennessee. Focus group data were uploaded into the NVivo qualitative data analysis software program, and main themes were identified. Standard frequencies were calculated for survey responses. Results Participants ranged in the age of 22-74 years (M = 54.1; SD = 14.6) were predominantly female (77.8%), African-Americans (88.9%), and had at least a high school education (91.7%). A majority used mobile phones for sending (69.4%) and receiving (72.2%) text messages. Participants wanted to receive daily (44.4%) or weekly (47.2%) text messages from their healthcare provider (61.1%), or a motivational message program (33.3%). They preferred actionable messages with a positive tone and wanted options to customize message type, content, and frequency according to their preferences, goals, and needs. Discussion Medically underserved African-American diabetes patients want customized text messages that are practical, actionable, encouraging, and from their doctor. Healthcare providers seeking to develop patient-centered TM programs for medically underserved minority patients should personalize and tailor messages according to patient preferences, health goals, and self-care needs.

Beyond the reminder: The next steps in pharmacist-driven, mHealth patient engagement.

OBJECTIVE: To describe opportunities for pharmacists to use mobile messaging and real-time monitoring to engage with patients taking long-term medications. SUMMARY: The proliferation of mobile phone use across the United States has been met with increased application of these devices by the medical community. However, beyond simple text messages and app-based functions, use of these devices by pharmacies and pharmacists has not been leveraged to improve patient outcomes, such as medication adherence. Resources now exist that can facilitate more advanced mobile communication between patients and pharmacists, which can be managed and informed by data available in most pharmacies. Such tailored messaging can be personalized further by being reactive to patient behavior using real-time medication use monitoring tools, facilitating low-cost, high-reach interventions for patients in need of ongoing guidance. CONCLUSION: Mechanisms now exist for pharmacies to engage patients more proactively with their prescribed therapy using mobile communication and devices. By facilitating such engagement, pharmacists can remain connected with patients throughout their care, better interpret their needs, navigate adherence-related issues, and more holistically counsel patients based on observed behaviors. Community pharmacy leadership should pursue the use of these advanced mobile messaging techniques as another tool in their arsenal to improve patient outcomes.

Impact of clinical pharmacists in outpatient oncology practices: A review.

PURPOSE: Published literature describing the effectiveness of outpatient oncology services delivered by clinical pharmacists is summarized. METHODS: Peer-reviewed articles on studies evaluating the provision of outpatient oncology services by licensed clinical pharmacists in the United States were identified and screened according to a study-specific protocol. Only research publications focused on the care of oncology patients and indicating the evaluation of measurable services and outcomes were selected for review. Data from eligible studies were extracted using a standardized tool, and agreement by a majority of the investigators was required for inclusion of articles in the final review. RESULTS: Eight publications were included in the review; nearly all were published since 2010. All of the included articles reported on results of observational studies in which data sourced from surveys, existing medical or prescription records, or medical cost information were analyzed to measure patient or provider satisfaction (or both) or patient-reported health outcomes. The evaluated evidence indicated that pharmacists were effective in identifying treatment issues and medication misuse, delivering satisfactory and valued services, and finding mechanisms to reduce medical costs or generate revenue to justify continuation or support expansion of clinical pharmacy services. Moreover, in two instances, pharmacists' services were associated with improvements in symptoms reported by oncology patients. CONCLUSION: Available evidence suggests that outpatient oncology practices may benefit from integrating pharmacists into care models in order to more effectively, efficiently, and holistically address the needs of patients with cancer.