Changing the Conversation: Empowering Community Pharmacists to Address Pneumococcal Vaccine Hesitancy.

BACKGROUND: Although pneumococcal vaccine is recommended for everyone 65 years of age and older, only 58% of Canadians in this age group have been vaccinated, well below the Public Health Agency of Canada's target of 80%. To improve uptake, a stepped-wedge cluster randomized trial testing the effectiveness of a community pharmacist intervention was developed. OBJECTIVE: This pre-specified sub-study aimed to uncover and quantify factors contributing to vaccine hesitancy by exploring the nature of patient-pharmacist conversations about pneumococcal vaccine. METHODS: Beginning each month (April to August 2023), participating pharmacies were randomly selected to receive an education package designed to enhance pharmacists' knowledge, skills, and abilities in promoting pneumococcal vaccination. Pharmacists provided usual care (control stage) until they received the educational package and transitioned to the intervention stage. Weekly scorecards tracked patient-pharmacist conversations about pneumococcal vaccination. Chi-squared tests compared time taken for each conversation and patient-reported reason(s) for refusal between control and intervention stages. RESULTS: Thirteen pharmacies from across Alberta were included in the analysis, reporting 656 patient-pharmacist conversations (control stage n=271, intervention stage n=385). Time taken for pneumococcal vaccine conversations decreased after pharmacies received the education package (65% of conversations resulting in vaccination took <20 minutes in the control stage, compared to 88% in the intervention stage (p=0.004)). The most common patient-reported reason for refusal, needing more time to think about the vaccine, remained similar between stages (p=0.23). However, during the intervention stage, fewer patients refused vaccination due to lack of time to receive it today (p=0.016) and perceived lack of benefit (p=0.035), but more patients refused vaccination due to cost barriers (p=0.026). CONCLUSION: The education provided in this study changed the reasons for refusing vaccines, suggesting the nature of patient-pharmacist conversations became more efficient and informed. Similar interventions could be adopted across Canada and the US to help combat vaccine hesitancy.

Thiazide Diuretic-Induced Change in Fasting Plasma Glucose: a Meta-analysis of Randomized Clinical Trials.

BACKGROUND: Prior meta-analyses measuring thiazide-induced glycemic change have demonstrated an increased risk of incident diabetes; however, this measure's definition has changed over time. AIM: To determine the magnitude of change in fasting plasma glucose (FPG) for thiazide diuretics. DATA SOURCES: A research librarian designed and conducted searches in Medline®, EMBASE, and EBM Reviews-Cochrane Central Register of Controlled Trials (inception through July 2018) and International Pharmaceutical Abstracts (inception to December 2014). STUDY SELECTION: Randomized, controlled trials comparing a thiazide or thiazide-like diuretic to any comparator reporting FPG were identified. Trials enrolling < 50 participants, those with a follow-up period of < 4 weeks, and conference abstracts were excluded. DATA EXTRACTION: Independent duplicate screening of citations and full-text articles, data extraction, and assessment of risk of bias was conducted. DATA SYNTHESIS: Ninety-five studies were included (N = 76,608 participants), with thiazides compared with placebo, beta-blockers, calcium channel blockers, renin-angiotensin-aldosterone-system inhibitors, potassium-sparing diuretic, and others alone or in combination. Thiazide diuretics marginally increased FPG (weighted mean difference 0.20 mmol/L (95% CI 0.15-0.25); I2 = 84%) (1 mmol/L = 18 mg/dL). Results did not change substantially when considering dose or duration, comparing thiazides with placebo or an active comparator, or using thiazides as monotherapy or combination therapy, even when combined with a potassium-correcting agent. CONCLUSION: Thiazide diuretics have a small and clinically unimportant impact on FPG.

Professional Fulfillment and Burnout in Fourth-Year Pharmacy Students and Risk Factors for the Future: A Mixed Methods Study.

OBJECTIVE: Many factors shape the professional identity of pharmacy students; however, little is known about the influence of well-being. Two aspects of well-being explored in this study include professional fulfillment and burnout. We describe the current levels of each among fourth-year pharmacy students, identify possible predictors, and uncover themes. METHODS: The Stanford Professional Fulfillment Index was used to measure professional fulfillment and burnout among students in the prior 2 weeks. Multivariable linear regressions were conducted to identify individual characteristics and activities as predictors of professional fulfillment and burnout. Upon completion of activities to foster personal wellness, student self-reflections were analyzed using thematic analysis to describe student-perceived barriers and facilitators of professional fulfillment and burnout. RESULTS: In total 54 students completed the Professional Fulfillment Index, wellness activities, and self-reflection. Having already completed the jurisprudence examination required for licensure and having a job upon graduation were statistically significantly associated with higher professional fulfillment scores. We identified that working in a non-pharmacy-related job, while completing practicums, was statistically significantly associated with higher work exhaustion scores. Themes uncovered from student self-reflections included a definition of wellness, how doing what you are supposed to be doing and working in a psychologically and physically safe environment contributes to professional fulfillment, and system-level factors leading to burnout. CONCLUSION: This study provides evidence of the importance of supporting pharmacy students in the completion of the steps to licensure, the value of exposure to a variety of pharmacist-related activities through experiential education, and well-being as foundational to professional identity.

Are Guideline-concordant Processes of Care Consistent Across the Rural-Urban Continuum? A Retrospective Cohort Study of Adults Newly Treated for Type 2 Diabetes.

OBJECTIVES: Our aim in this study was to identify the association between place of residence (metropolitan, urban, rural) and guideline-concordant processes of care in the first year of type 2 diabetes management. METHODS: We conducted a retrospective cohort study of new metformin users between April 2015 and March 2020 in Alberta, Canada. Outcomes were identified as guideline-concordant processes of care through the review of clinical practice guidelines and published literature. Using multivariable logistic regression, the following outcomes were examined by place of residence: dispensation of a statin, angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB), eye examination, glycated hemoglobin (A1C), cholesterol, and kidney function testing. RESULTS: Of 60,222 new metformin users, 67% resided in a metropolitan area, 10% in an urban area, and 23% in a rural area. After confounder adjustment, rural residents were less likely to have a statin dispensed (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.79 to 0.87) or undergo cholesterol testing (aOR 0.86, 95% CI 0.83 to 0.90) when compared with metropolitan residents. In contrast, rural residents were more likely to receive A1C and kidney function testing (aOR 1.14, 95% CI 1.08 to 1.21 and aOR 1.17, 95% CI 1.11 to 1.24, respectively). ACEi/ARB use and eye examinations were similar across place of residence. CONCLUSIONS: Processes of care varied by place of residence. Limited cholesterol management in rural areas is concerning because this may lead to increased cardiovascular outcomes.

Rurality is associated with lower likelihood of dipeptidyl peptidase 4 inhibitor use for treatment intensification.

Background: Antihyperglycemic drug utilization studies are conducted frequently and describe the uptake of new drug therapies across may jurisdictions. An increasingly important, yet often absent, aspect of these studies is the impact of rurality on drug utilization. Objectives: The objective of this study was to explore the association between place of residence (rural, urban, metropolitan) and the use of dipeptidyl peptidase 4 inhibitors (DPP-4i) for first treatment intensification of type 2 diabetes. Methods: A retrospective cohort study was conducted from April 1, 2008 to March 31, 2019 of new metformin users. A multivariable logistic regression analysis was performed to determine the association between place of residence (using postal codes) and likelihood of DPP-4i dispensing. Results: After adjusting for confounders, analysis revealed that rural-dwellers are less likely to have a DPP-4i dispensed, compared with metropolitan-dwellers (aOR:0.64; 95%CI:0.61-0.67) and over-time, the uptake in rural areas was slower. Conclusions: This study demonstrates that rurality can have an impact on drug therapy decisions at first treatment intensification, with respect to the utilization of new therapies.

Rural Residence Is Associated With a Delayed Trend Away From Sulfonylurea Use for Treatment Intensification of Type 2 Diabetes.

OBJECTIVE: To examine the intersection between location of residence along the rural-urban continuum (metropolitan, urban, and rural) and sulfonylurea dispensation records for the management of type 2 diabetes. RESEARCH DESIGN AND METHODS: This retrospective cohort study used administrative health records of adult new metformin users between April 2008 and March 2019 in Alberta, Canada. Multivariable logistic regression was performed to examine the association between sulfonylurea-based treatment intensification and location of residence. RESULTS: Treatment was intensified in 66,084 (38%) of 171,759 new metformin users after a mean of 1.5 years. At treatment intensification, mean age was 55 years, 62% of users were male, and 27% were rural residents. The most common antihyperglycemic drug, given to 30,297 people (46%) for treatment intensification, was a sulfonylurea. At the beginning of our observation period, the proportion of people dispensed a sulfonylurea at first treatment intensification was highest in rural (57%), compared with urban (54%) and metropolitan (52%) areas (P = 0.009). Although proportions decreased over time across the province, rural residents continued to constitute the highest proportion of sulfonylurea users (45%), compared with urban (35%) and metropolitan (37%) residents (P < 0.001), and the trend away from sulfonylurea use was delayed by ∼4 years for rural residents. Adjusting for potential sources of confounding, rural residence was associated with a significantly higher likelihood of using a sulfonylurea compared with metropolitan residence (adjusted odds ratio 1.34; 95% CI 1.29-1.39). CONCLUSIONS: Variation in sulfonylurea dispensation across the rural-urban continuum provides a basis for continued research in the differences in process of care by location.

The impact of the COVID-19 pandemic on pharmacy students' personal and professional learning.

INTRODUCTION: The COVID-19 pandemic impacted both healthcare delivery and the education of healthcare students, with a shift to remote delivery of coursework and assessment alongside the expansion of the scope of practice of Alberta pharmacists. The objective of this research was to understand how the learning of pharmacy students at the University of Alberta was impacted by the COVID-19 pandemic. METHODS: A cross-sectional survey was distributed to 397 pharmacy students in years one through three. Students responded to three short-answer reflection questions: (1) how has the COVID-19 pandemic situation affected your learning; (2) from a pharmacy and pharmacy school perspective, what have you learned since the COVID-19 pandemic began; and (3) from a personal perspective, what have you learned about yourself since the COVID-19 pandemic began? A thematic analysis was undertaken of students' responses to these reflection questions. RESULTS: A total of 53 students responded to the survey (response rate 13%). Two major themes were identified across all three reflection questions, with several subthemes: remote learning (learning environment, knowledge transfer, knowledge retention, assessment) and mental health (appreciation, stress, extroversion, motivation). Adaptability, routine, professional identity, and the role of the pharmacist were also identified as less prevalent themes. CONCLUSIONS: Pharmacy students' responses led to the identification of several themes related to their learning given the changes brought about by the COVID-19 pandemic. This increased understanding of student perceptions has the potential to improve the remote delivery of education, support increased university-wide mental health resourcing, and shape pharmacy curriculum development.

Intervenção fonoaudiológica junto a mães de crianças com múltiplas deficiências / Speech therapy intervention on mothers of children with multiple deficiencies

Este artigo apresenta algumas reflexões sobre experiências clínicas fonoaudiológicas vividas com crianças portadoras de múltiplas deficiências e suas mães. Trata-se de um trabalho clínico que enfatizou a presença dessas mães nos atendimentos, colocando em um primeiro plano a relação delas com seus filhos deficientes. Para embasá-lo teoricamente, foram adotadas algumas concepções winnicottianas sobre a constituição humana. A metodologia utilizada foi a clínico-qualitativa, sendo apresentadas quatro dinâmicas relacionais entre mãe e filho, as quais foram observadas com certa freqüência na clínica fonoaudiológica e que, uma vez compreendidas pelo terapeuta, podem auxiliar no sucesso do tratamento, já que permitem que cada díade seja acolhida de maneira singular. São elas: evidências no corpo dificultando o vínculo; cuidados excessivos ou insuficientes; negação do diagnóstico; problemas para alimentar o filho. Ao longo de um processo em que as dificuldades das mães eram acolhidas pelo terapeuta, alguns resultados foram sendo produzidos na evolução clínica da criança. Trata-se de uma intervenção fonoaudiológica que não se restringe às questões técnicas, como a adequação dos órgãos fonoarticulatórios, da alimentação ou do desenvolvimento de linguagem, mas abre campo para aspectos fundamentais do desenvolvimento psíquico da criança. O objetivo é contribuir para a constituição de referenciais, pelo fonoaudiólogo, para que esse profissional possa pensar em um trabalho com mães de deficientes que não seja apenas voltado para as orientações e para o ensino de procedimentos, mas baseado em intervenções que promovam o acolhimento dessas mães e facilitem o amadurecimento da criança com múltipla deficiência