Exploring performance predictors among employees in a pharmacist-led medication management center.

OBJECTIVE: Health care companies are increasingly interested in developing and maintaining employee motivation. However, this can be challenging with different professions working together in delivering telephonic medication therapy management services. The purpose of the study is to assess employees' perceptions of performance metrics, strategies to achieve those metrics, motivational work factors, and barriers to achievement at a medication management center (MMC). DESIGN: Focus group using purposive sampling. SETTING: Six in-person focus groups were conducted with the MMC employees. PARTICIPANTS: Separate focus groups were conducted for pharmacists, student pharmacist interns, and pharmacy technicians. Each group consisted of approximately 5 participants, lasted roughly 1 hour, and was facilitated by trained qualitative researchers. OUTCOME MEASURES: The semistructured sessions involved participants responding to open-ended, predetermined questions introduced by a facilitator. The sessions were audio-recorded and transcribed for analysis. Two independent reviewers analyzed the transcripts; a third independent reviewer facilitated a consensus to resolve discrepancies. RESULTS: Thirty MMC employees, with an average age of 32.1 ± 10.5 years, participated; most of them (73.3%) were women and had worked at the MMC for an average of 2.8 ± 2.2 years. Six themes were identified: (1) awareness and understanding of performance measures; (2) perceptions of performance measures; (3) suggested changes to make the performance measures more reflective of their roles; (4) motivating factors to improve performance; (5) performance barriers; and (6) strategies to achieve performance goals. The intrinsic motivational factors included providing patient care, helping change patients' lives, and meeting work goals. The extrinsic motivational factors included remuneration, management, teamwork, work environment, and feedback. The performance barriers were unrealistic goals, lack of feedback, ineffective communication, and inconsistent operational procedures. CONCLUSIONS: These study findings contribute to a growing body of research surrounding employee motivation within organizations with diverse workforces. Future work is warranted to investigate employee motivation in similar pharmacy-related settings.

Greenhouse Gas Fluxes of Mangrove Soils and Adjacent Coastal Waters in an Urban, Subtropical Estuary.

Mangroves are known to sequester carbon at rates exceeding even those of other tropical forests; however, to understand carbon cycling in these systems, soil-atmosphere fluxes and gas exchanges in mangrove-adjacent shallow waters need to be quantified. Further, despite the ever-increasing impact of development on mangrove systems, there is even less data on how subtropical, greenhouse gas (GHG) fluxes are affected by urbanization. We quantified carbon dioxide (CO2) and methane (CH4) fluxes from mangrove soils and adjacent, coastal waters along a gradient of urbanization in the densely-populated, subtropical San Juan Bay Estuary (PR). Edaphic (salinity, pH, surface temperature) factors among sites significantly covaried with GHG fluxes. We found that mangrove systems in more highly-urbanized reaches of the estuary were characterized by relatively lower porewater salinities and substantially larger GHG emissions, particularly CH4, which has a high global warming potential. The magnitude of the CO2 emissions was similar in the mangrove soils and adjacent waters, but the CH4 emissions in the adjacent waters were an order of magnitude higher than in the soils and showed a marked response to urbanization. This study underscores the importance of considering GHG emissions of adjacent waters in carbon cycling dynamics in urbanized, tropical mangrove systems.

Participants' Utilitarian Choice Is Influenced by Gamble Presentation and Age.

No prior behavioral science research has delved into the impact of gamble presentation (horizontal or vertical) on individuals' utilitarian behavior, despite evidence suggesting that such choices can be influenced by comparing attributes like probability and money in gambles. This article addresses this gap by exploring the influence of gamble presentation on utilitarian behavior. A two-factor independent measures design was employed to explore the influence of the type of gamble presentation and age on participants' utilitarian decision-making preferences. The findings showed a reduced likelihood of participants choosing the non-utilitarian gamble with vertically presented gambles compared to horizontal ones. Consequently, participants' utilitarian behavior was influenced by between-gamble comparisons of available attributes, with utilitarian choices (e.g., choosing Gamble A) being more prevalent in vertical presentations due to a straightforward comparison on the probability attribute. Furthermore, the results also revealed that older participants take more time than their younger counterparts when making utilitarian errors. We attribute this to their abundant knowledge and experience. Future research should explore the comparative psychological processing used by participants in risky decision-making tasks.

Incidence and etiology of new liver lesions in pediatric patients previously treated for malignancy.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the time course, cause, and imaging characteristics of all new liver lesions in pediatric patients with a previously treated malignancy. MATERIALS AND METHODS: Our hospital cancer registry was used to identify patients between 1980 and 2005 who met the following criteria: solid tumor, survival > 2 years after diagnosis, no liver lesions at a posttreatment baseline, and cross-sectional imaging follow-up of > 2 years. Final dictated reports of all cross-sectional imaging examinations including the abdomen were reviewed for any mention of new liver lesions. Positive reports were followed by consensus review of the images and clinical data. Patients were divided into three groups: those with suspected or proven focal nodular hyperplasia (FNH), those with suspected or proven metastases, and those with other lesions. An exact Wilcoxon test was used to evaluate the differences between the groups. RESULTS: Of 967 patients who met the initial inclusion criteria, 273 had adequate follow-up to be included in the study. Forty-six patients (16.8%) developed new liver lesions during the study period, and 14 of those 46 were classified into the FNH group (30.4%) and seven were classified into the metastasis group (15.2%). A significant difference was found in the median time to the development of FNH versus metastasis and other lesions (FNH, 92.9 months; metastasis, 43.2 months; other lesions, 18.5 months; p < 0.0001). A significant difference was also seen in the median length of follow-up between the groups (FNH, 115.6 months; metastasis, 57 months; other lesions, 50.8 months; p = 0.002). The imaging features of the groups also differed. CONCLUSION: The most common liver lesion encountered in pediatric patients previously treated for malignancy was FNH, which occurred farther from the time of diagnosis and had different imaging characteristics from both metastases and other liver lesions.

Autonomous vehicles: How perspective-taking accessibility alters moral judgments and consumer purchasing behavior.

In preparation for unavoidable collisions, autonomous vehicle (AV) manufacturers could program their cars with utilitarian ethical algorithms that maximize the number of lives saved during a crash. However, recent research employing hypothetical AV crash scenarios reveals that people are not willing to purchase a utilitarian AV despite judging them to be morally appropriate (Bonnefon, Shariff, & Rahwan, 2016). This important result, indicating evidence for a social dilemma, has not yet been psychologically explored by behavioral scientists. In order to address the psychological underpinnings of this phenomenon, we developed and tested a novel theoretical proposal - perspective-taking accessibility (PT accessibility). Accordingly, we established that providing participants with access to both situational perspectives (AV buyers can be passengers or pedestrians) in crash scenarios, eliminated the behavioral inconsistency between their utilitarian judgments of moral appropriateness and non-utilitarian purchasing behavior. Moreover, our full PT accessibility induced respondents' utilitarian prosocial judgments and purchasing behavior (Experiments 1a and 1b) and consistent utilitarian preferences across judgment tasks (Experiment 2). Crucially, with full PT accessibility, participants' utilitarian purchasing behavior as well as their willingness to buy and ride utilitarian AVs were informed by their utilitarian moral judgments. Full PT accessibility provides the participants with even odds of being a pedestrian or passenger in crash scenarios, and thus impartiality. It could be argued that full PT accessibility is a new type of 'veil of ignorance', which is not based on purposely induced self-interest and uneven risk options (as in Huang, Greene, & Bazerman, 2019), but rather is based on even odds of being a passenger or pedestrian, and therefore with even 50/50 chance to die/live as passenger or pedestrian. Under these circumstances one can measure utilitarian preferences.

Moral Decision Making: From Bentham to Veil of Ignorance via Perspective Taking Accessibility.

Making morally sensitive decisions and evaluations pervade many human everyday activities. Philosophers, economists, psychologists and behavioural scientists researching such decision-making typically explore the principles, processes and predictors that constitute human moral decision-making. Crucially, very little research has explored the theoretical and methodological development (supported by empirical evidence) of utilitarian theories of moral decision-making. Accordingly, in this critical review article, we invite the reader on a moral journey from Jeremy Bentham's utilitarianism to the veil of ignorance reasoning, via a recent theoretical proposal emphasising utilitarian moral behaviour-perspective-taking accessibility (PT accessibility). PT accessibility research revealed that providing participants with access to all situational perspectives in moral scenarios, eliminates (previously reported in the literature) inconsistency between their moral judgements and choices. Moreover, in contrast to any previous theoretical and methodological accounts, moral scenarios/tasks with full PT accessibility provide the participants with unbiased even odds (neither risk averse nor risk seeking) and impartiality. We conclude that the proposed by Martin et al. PT Accessibility (a new type of veil of ignorance with even odds that do not trigger self-interest, risk related preferences or decision biases) is necessary in order to measure humans' prosocial utilitarian behaviour and promote its societal benefits.

Are Impulsive Decisions Always Irrational? An Experimental Investigation of Impulsive Decisions in the Domains of Gains and Losses.

Intertemporal choices are very prevalent in daily life, ranging from simple, mundane decisions to highly consequential decisions. In this context, thinking about the future and making sound decisions are crucial to promoting mental and physical health, as well as a financially sustainable lifestyle. In the present study, we set out to investigate some of the possible underlying mechanisms, such as cognitive factors and emotional states, that promote future-oriented decisions. In a cross-sectional experimental study, we used a gain and a loss version of an intertemporal monetary choices task. Our main behavioural result indicated that people are substantially more impulsive over smaller and sooner monetary losses compared to equivalent gains. In addition, for both decisional domains, significant individual difference predictors emerged, indicating that intertemporal choices are sensitive to the affective and cognitive parameters. By focusing on the cognitive and emotional individual factors that influence impulsive decisions, our study could constitute a building block for successful future intervention programs targeted at mental and physical health issues, including gambling behaviour.

Problem Gambling 'Fuelled on the Fly'.

Problem gambling is a gambling disorder often described as continued gambling in the face of increasing losses. In this article, we explored problem gambling behaviour and its psychological determinants. We considered the assumption of stability in risky preferences, anticipated by both normative and descriptive theories of decision making, as well as recent evidence that risk preferences are in fact 'constructed on the fly' during risk elicitation. Accordingly, we argue that problem gambling is a multifaceted disorder, which is 'fueled on the fly' by a wide range of contextual and non-contextual influences, including individual differences in personality traits, hormonal and emotional activations. We have proposed that the experience of gambling behaviour in itself is a dynamic experience of events in time series, where gamblers anchor on the most recent event-typically a small loss or rare win. This is a highly adaptive, but erroneous, decision-making mechanism, where anchoring on the most recent event alters the psychological representations of substantial and accumulated loss in the past to a representation of negligible loss. In other words, people feel better while they gamble. We conclude that problem gambling researchers and policy makers will need to employ multifaceted and holistic approaches to understand problem gambling.

Recent Nitrogen Storage and Accumulation Rates in Mangrove Soils Exceed Historic Rates in the Urbanized San Juan Bay Estuary (Puerto Rico, United States).

Tropical mangrove forests have been described as "coastal kidneys," promoting sediment deposition and filtering contaminants, including excess nutrients. Coastal areas throughout the world are experiencing increased human activities, resulting in altered geomorphology, hydrology, and nutrient inputs. To effectively manage and sustain coastal mangroves, it is important to understand nitrogen (N) storage and accumulation in systems where human activities are causing rapid changes in N inputs and cycling. We examined N storage and accumulation rates in recent (1970 - 2016) and historic (1930 - 1970) decades in the context of urbanization in the San Juan Bay Estuary (SJBE, Puerto Rico), using mangrove soil cores that were radiometrically dated. Local anthropogenic stressors can alter N storage rates in peri-urban mangrove systems either directly by increasing N soil fertility or indirectly by altering hydrology (e.g., dredging, filling, and canalization). Nitrogen accumulation rates were greater in recent decades than historic decades at Piñones Forest and Martin Peña East. Martin Peña East was characterized by high urbanization, and Piñones, by the least urbanization in the SJBE. The mangrove forest at Martin Peña East fringed a poorly drained canal and often received raw sewage inputs, with N accumulation rates ranging from 17.7 to 37.9 g -2 y-1 in recent decades. The Piñones Forest was isolated and had low flushing, possibly exacerbated by river damming, with N accumulation rates ranging from 18.6 to 24.2 g -2 y-1 in recent decades. Nearly all (96.3%) of the estuary-wide mangrove N (9.4 Mg ha-1) was stored in the soils with 7.1 Mg ha-1 sequestered during 1970-2017 (0-18 cm) and 2.3 Mg ha-1 during 1930-1970 (19-28 cm). Estuary-wide mangrove soil N accumulation rates were over twice as great in recent decades (0.18 ± 0.002 Mg ha-1y-1) than historically (0.08 ± 0.001 Mg ha-1y-1). Nitrogen accumulation rates in SJBE mangrove soils in recent times were twofold larger than the rate of human-consumed food N that is exported as wastewater (0.08 Mg ha-1 y-1), suggesting the potential for mangroves to sequester human-derived N. Conservation and effective management of mangrove forests and their surrounding watersheds in the Anthropocene are important for maintaining water quality in coastal communities throughout tropical regions.

Recent Carbon Storage and Burial Exceed Historic Rates in the San Juan Bay Estuary Peri-Urban Mangrove Forests (Puerto Rico, United States).

Mangroves sequester significant quantities of organic carbon (C) because of high rates of burial in the soil and storage in biomass. We estimated mangrove forest C storage and accumulation rates in aboveground and belowground components among five sites along an urbanization gradient in the San Juan Bay Estuary, Puerto Rico. Sites included the highly urbanized and clogged Caño Martin Peña in the western half of the estuary, a series of lagoons in the center of the estuary, and a tropical forest reserve (Piñones) in the easternmost part. Radiometrically dated cores were used to determine sediment accretion and soil C storage and burial rates. Measurements of tree dendrometers coupled with allometric equations were used to estimate aboveground biomass. Estuary-wide mangrove forest C storage and accumulation rates were estimated using interpolation methods and coastal vegetation cover data. In recent decades (1970-2016), the highly urbanized Martin Peña East (MPE) site with low flushing had the highest C storage and burial rates among sites. The MPE soil carbon burial rate was over twice as great as global estimates. Mangrove forest C burial rates in recent decades were significantly greater than historic decades (1930-1970) at Cañno Martin Peña and Piñones. Although MPE and Piñones had similarly low flushing, the landscape settings (clogged canal vs forest reserve) and urbanization (high vs low) were different. Apparently, not only urbanization, but site-specific flushing patterns, landscape setting, and soil fertility affected soil C storage and burial rates. There was no difference in C burial rates between historic and recent decades at the San José and La Torrecilla lagoons. Mangrove forests had soil C burial rates ranging from 88 g m-2 y-1 at the San José lagoon to 469 g m-2 y-1 at the MPE in recent decades. Watershed anthropogenic CO2 emissions (1.56 million Mg C y-1) far exceeded the annual mangrove forest C storage rates (aboveground biomass plus soils: 17,713 Mg C y-1). A combination of maintaining healthy mangrove forests and reducing anthropogenic emissions might be necessary to mitigate greenhouse gas emissions in urban, tropical areas.

Preference reversals during risk elicitation.

Understanding human behavior from the perspective of normative and descriptive theories depends on human agents having stable and coherent decision-making preferences. Both utility theory (expected rational behavior; von Neumann & Morgenstern, 1947) and prospect theory, with its certainty equivalent (CE) method (expected irrational behavior; Tversky & Kahneman, 1992), assume stable behavioral patterns of risk preferences. In contrast, our research pursues the opposite proposal: Human preferences (rational or irrational) are not stable; variations in the decision context during risk elicitation determine people's preferences even when the utilities of choice options are available. Accordingly, we found evidence that decision makers reverse their risk preferences between CE tasks with logarithmically spaced certainty (unequal number of risk-averse and risk-seeking sure options) and linearly spaced certainty (equal number of risk-averse and risk-seeking sure options). The results revealed that the effect of probability range (low and high) on preferences, predicted by prospect theory, is an artifact of the logarithmically spaced sure options. When the sure options were linearly spaced, the probability range no longer influenced risk preferences, indicating a preference reversal between decision tasks. Our findings highlight a need to investigate how the predictions of descriptive decision-making theories are shaped by their risk elicitation methods. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Dietitians vary by counseling status in bean promotion with type 2 diabetes clients: A pilot study.

Beans are noted for their beneficial effects on blood glucose for persons with type 2 diabetes mellitus (T2DM). However, little is known about dietitian attitudes and perceptions, self-efficacy, or counseling practices about beans in T2DM management. Through an online survey, the attitudes and perceptions dietitians have toward the role of beans in managing T2DM were examined. The practice intentions for advising T2DM clients about beans, perceived self-efficacy for counseling on general nutrition topics and specifically on beans, were evaluated. While the target population was dietitians, all persons on the Arizona Dietetic Association and the Arizona School Nutrition Association listservs received a direct email invitation for an online survey on foods and chronic disease. There was no mention of beans or pulses to reduce bias toward bean advocates. Of the 302 dietitian respondents, over 66% counseled clients with T2DM. Fewer clinical counseling dietitians recommended beans to control blood glucose (p = .041) or to increase fiber (p < .05), and more of them promoted beans as being the same as other carbohydrates (p = .002). Higher mean self-efficacy scores for general nutrition counseling were observed for T2DM counseling RDs (p < .001). Counseling dietitians in nonclinical settings had the highest bean self-efficacy score (p < .001). Findings suggest clinical counseling dietitians are aware of bean health benefits, but do not consistently suggest beans to improve nutrition for those with T2DM in contrast to dietitians who counsel in other settings.

Unexpected nitrogen sources in a tropical urban estuary.

Tropical urban estuaries are severely understudied. Little is known about the basic biogeochemical cycles and dominant ecosystem processes in these waterbodies, which are often low-lying and heavily modified. The San Juan Bay Estuary (SJBE) in San Juan, Puerto Rico is an example of such a system. Over the past 80 years, a portion of the estuary has filled in, changing the hydrodynamics and negatively affecting water quality. Here we sought to document these changes using ecological and biogeochemical measurements of surface sediments and bivalves. Measurements of sediment physical characteristics, organic matter content, and stable isotope ratios (δ13C, δ15N, δ34S) illustrated the effects of the closure of the Caño Martín Peña (CMP) on the hydrology and water quality of the enclosed and semienclosed parts of the estuary. The nitrogen stable isotope (δ15N) values were lowest in the CMP, the stretch of the SJBE that is characterized by waters with low dissolved oxygen and high fecal coliform concentrations. Despite this, the results of this study indicate that nitrogen (N) contributions from N-fixing, sulfate-reducing microbes may meet or even exceed contributions from urban runoff and sewage. While the importance of sulfate reducers in contributing N to mangrove ecosystems is well documented, this is the first indication that such processes could be dominant in an intensely urban system. It also underscores just how little we know about tropical coastal ecosystems in densely populated areas throughout the globe.

Long-term nutrient addition increases respiration and nitrous oxide emissions in a New England salt marsh.

Salt marshes may act either as greenhouse gas (GHG) sources or sinks depending on hydrological conditions, vegetation communities, and nutrient availability. In recent decades, eutrophication has emerged as a major driver of change in salt marsh ecosystems. An ongoing fertilization experiment at the Great Sippewissett Marsh (Cape Cod, USA) allows for observation of the results of over four decades of nutrient addition. Here, nutrient enrichment stimulated changes to vegetation communities that, over time, have resulted in increased elevation of the marsh platform. In this study, we measured fluxes of carbon dioxide (CO 2), methane (CH 4) and nitrous oxide (N2O) in dominant vegetation zones along elevation gradients of chronically fertilized (1,572 kg N ha-1 year-1) and unfertilized (12 kg N ha-1 year-1) experimental plots at Great Sippewissett Marsh. Flux measurements were performed using darkened chambers to focus on community respiration and excluded photosynthetic CO 2 uptake. We hypothesized that N-replete conditions in fertilized plots would result in larger N2O emissions relative to control plots and that higher elevations caused by nutrient enrichment would support increased CO 2 and N2O and decreased CH 4 emissions due to the potential for more oxygen diffusion into sediment. Patterns of GHG emission supported our hypotheses. Fertilized plots were substantially larger sources of N2O and had higher community respiration rates relative to control plots, due to large emissions of these GHGs at higher elevations. While CH 4 emissions displayed a negative relationship with elevation, they were generally small across elevation gradients and nutrient enrichment treatments. Our results demonstrate that at decadal scales, vegetation community shifts and associated elevation changes driven by chronic eutrophication affect GHG emission from salt marshes. Results demonstrate the necessity of long-term fertilization experiments to understand impacts of eutrophication on ecosystem function and have implications for how chronic eutrophication may impact the role that salt marshes play in sequestering C and N.

Evaluation of an Academic-Community Partnership to Implement MTM Services in Rural Communities to Improve Pharmaceutical Care for Patients with Diabetes and/or Hypertension.

BACKGROUND: Although the current methods of medication therapy management (MTM) delivery have demonstrably improved therapeutic, safety, economic, and humanistic health outcomes, patient- and prescriber-level barriers persist, limiting its reach and effectiveness. OBJECTIVE: To assess telephonic- and community-based clinical pharmacy services in improving health indicators for rural, underserved patients. METHODS: In 2014, an established MTM provider created a novel, collaborative pilot program with independent retail and community health center pharmacies to provide comprehensive, telephonic MTM services to rural Arizonans. This pilot program used a combined telephonic- and community-based pharmacist approach in the provision of MTM services for rural, underserved Arizona populations. Adults with diabetes mellitus and/or hypertension, seen by a prescriber or who filled prescriptions at a contracted, rural facility in 2014, were eligible to participate. Initial MTM telephonic consultations were conducted, and recommendations were communicated to patients' prescribers and/or pharmacists. Patients received a follow-up telephone call at standard intervals, depending on risk severity. RESULTS: A total of 517 patients participated, and 237 medication-related and 1,102 health promotion interventions were completed. Positive trends were observed in fasting blood glucose, postprandial glucose, and diastolic blood pressure. Broad variation in prescriber acceptance of pharmacist recommendations was observed (27%-60%). CONCLUSIONS: Study results provide initial evidence to support the efficacy of collaborative efforts in the provision of MTM services for improving health indicators and safety measures while potentially reducing health care disparities. While the results are encouraging, future research is warranted in more diverse populations and settings. DISCLOSURES: This work was supported in part by funding from the Centers for Disease Control and Prevention via a multiyear, interagency grant from the Arizona Department of Health Services. The findings and conclusions presented in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention nor the Arizona Department of Health Services. Study concept and design were contributed by M. Johnson, Jastrzab, Hall-Lipsy, Martin, and Warholak. M. Johnson took the lead in data collection, along with K. Johnson, Martin, Jastrzab, and Hall-Lipsy. Data interpretation was performed by Jastrzab, Warholak, and Taylor. The manuscript was written by K. Johnson, M. Johnson, and Jastrzab, along with the other authors, and revised by M. Johnson, Tate, and Taylor, along with Jastrzab, K. Johnson, and Hall-Lipsy. The data from this manuscript were previously presented in poster and podium format by Jastrzab and Johnson at the American Public Health Annual Meeting; Chicago, Illinois; October 31-November 4, 2015.

Integrating Innovative Telehealth Solutions into an Interprofessional Team-Delivered Chronic Care Management Pilot Program.

BACKGROUND: Pharmacist-delivered medication therapy management (MTM) services can improve patient outcomes, yet little is known about outpatient, interprofessional telepharmacy programs. OBJECTIVE: To evaluate an outpatient, interprofessional telehealth chronic care management (CCM) pilot program. METHODS: This 6-month program integrated family medicine providers, a university-based medication management telepharmacist, and an interprofessional care coordinator using telehealth solutions for CCM and pharmacy education services. A physician referred patients at risk for medicine-related problems to the telepharmacist. Eligible patients had 3 or more chronic conditions or took at least 5 medications, were aged 18 years and older, and had at least 1 appointment with their primary care provider during the program. The care coordinator met patients in person to facilitate these virtual clinic processes. The telepharmacist conducted a comprehensive medication review (CMR) via video-conferencing technology, providing CCM based on primary diagnosis, current medications and allergies, laboratory results, and previous chart notes. The consultation was documented in the electronic health record (EHR) for provider review and modification in real time. RESULTS: 69 patients received telepharmacy consultations and on-site registered nurse support during the program. Most patients were female (56.5%), aged 51-70 years (60.1%), Caucasian (72.4%), and non-Hispanic/Latino (71.0%). Patients had 1-9 chronic conditions, such as hypertension (82.6%), diabetes (56.5%), hyperlipidemia (31.9%), depression (30.4%), and osteoporosis (29.0%). Most patients (94.2%) took at least 5 chronic disease medications, such as statins (11.2%), nonsteroidal anti-inflammatory drugs (8.4%), selective serotonin reuptake inhibitors (6.5%), beta blockers (6.5%), and calcium channel blockers (5.6%). The telepharmacist completed 200 interventions for safety (49.0%), vaccines (24.5%), care gaps per national consensus guidelines (13.5%), adherence (10.0%), and cost savings (3.0%). Patients' providers accepted one third (n = 75, 37.5%) of the telepharmacist recommendations (e.g., monitoring and medication changes). CONCLUSIONS: This telehealth program constituted an added service for patients while simultaneously filling a gap in on-site pharmacist counseling services. Integrating the telepharmacist and registered nurse was crucial to clinical service provision. The results are encouraging; however, more research must examine the effectiveness of telehealth services in reaching underserved populations, improving patient care, and decreasing health care costs. DISCLOSURES: External funding from SinfonîaRx was used to help conduct this project. Boesen is employed by SinfonîaRx. At the time this project was conducted, Martin was employed at the University of Arizona Medication Management Center but is now employed by SinfonîaRx. The other authors have no disclosures to report. This original research was presented as a poster at the Academy of Managed Care Pharmacy Nexus 2015; October 26-29, 2015; in Orlando, FL.

Discontinuities in soil strength contribute to destabilization of nutrient-enriched creeks.

In a whole-ecosystem, nutrient addition experiment in the Plum Island Sound Estuary (Massachusetts), we tested the effects of nitrogen enrichment on the carbon and nitrogen contents, respiration, and strength of marsh soils. We measured soil shear strength within and across vegetation zones. We found significantly higher soil percent organic matter, carbon, and nitrogen in the long-term enriched marshes and higher soil respiration rates with longer duration of enrichment. The soil strength was similar in magnitude across depths and vegetation zones in the reference creeks, but showed signs of significant nutrient-mediated alteration in enriched creeks where shear strength at rooting depths of the low marsh-high marsh interface zone was significantly lower than at the sub-rooting depths or in the creek bank vegetation zone. To more closely examine the soil strength of the rooting (10-30 cm) and sub-rooting (40-60 cm) depths in the interface and creek bank vegetation zones, we calculated a vertical shear strength differential between these depths. We found significantly lower differentials in shear strength (rooting depth < sub-rooting depths) in the enriched creeks and in the interface zones. The discontinuities in the vertical and horizontal shear strength across the enriched marshes may contribute to observed fracturing and slumping occurring in the marsh systems. Tide gauge data also showed a pattern of rapid sea level rise for the period of the study, and changes in plant distribution patterns were indicative of increased flooding. Longer exposure times to nutrient-enriched waters and increased hydraulic energy associated with sea level rise may exacerbate creek bank sloughing. Additional research is needed, however, to better understand the interactions of nutrient enrichment and sea level rise on soil shear strength and stability of tidal salt marshes.

What Patients Know About Services to Help Manage Chronic Diseases and Medications: Findings from Focus Groups on Medication Therapy Management.

BACKGROUND: Managing and treating patients with multiple chronic conditions presents challenges on many levels. Pharmacist-delivered medication therapy management (MTM) services, mandated as part of the Medicare Part D drug benefit, are designed to help patients manage their chronic conditions and medications. OBJECTIVE: To identify factors that influence patient understanding and use of MTM services and potential strategies to educate individuals about MTM. METHODS: Participants who had at least 2 chronic conditions, were taking 2 or more prescription medications, and were aged 18 years or older were recruited from community-based settings to participate in focus groups. The focus groups aimed to identify participants' perceptions and use of MTM services, barriers and facilitators to utilization, and medication problems. Participants were asked to complete a 14-item health care questionnaire and view a brief, 3-minute video introducing the topic of MTM before the group discussion. The health care questionnaire data were analyzed in Microsoft Excel. The focus group responses were transcribed and entered into the computer program ATLAS.ti for thematic analysis. Two independent reviewers qualitatively coded the discussion question responses; a third reviewer investigated discrepancies and facilitated consensus among the reviewers. RESULTS: Participants (N = 27) were mostly female (70.4%), college educated (62.9%), and had Medicare insurance (81.5%). Seven themes were identified: (1) new proposed names for MTM, (2) mechanisms to gain interest in and to promote the value of MTM, (3) familiarity with MTM, (4) pharmacists' training and expertise in MTM, (5) experience with MTM, (6) reasons for nonparticipation in MTM, and (7) preferred method to learn about MTM. Participants did not understand the term "medication therapy management" and felt the interpretation of "therapy"' differed between health care professionals and the public. Some participants used MTM services to learn about appropriate use of their medications, while others were unsure about their eligibility, associated costs, and how to access the services. Participants had limited pharmaceutical knowledge but felt pharmacist-provided MTM services were helpful. Participants were unfamiliar with pharmacists' skills and training. Participants' experiences with MTM services ranged from disregarding the invitation to participate to having pharmacists identify drug-drug interactions. Reasons for nonparticipation in MTM services included being unaware of their eligibility, failing to read excessive information from insurance companies, and being uncertain of the identity of the telephone caller. Preferred methods for learning more about MTM services included the Internet, e-mail, information availability at physician's office, and television advertisements. CONCLUSIONS: These results suggest that the lay public remains largely unaware of MTM services and that the term "MTM" is not well understood. Clearly, tailored public health campaigns and patient engagement strategies are needed to promote MTM in chronic disease management, pharmacists as respected providers, and the importance of the prescriber-MTM pharmacist collaborative relationship in managing medications for patients with multiple chronic conditions. DISCLOSURES: Grant funding from SinfoniaRx to Taylor, Axon, Campbell, Fair, and Warholak was used to help conduct this project. Boesen is employed by SinfoniaRx. The other authors have nothing to disclose. This original research was presented as a poster at the Academy of Managed Care Pharmacy 27th Annual Meeting and Expo; April 7-10, 2015; San Diego, CA.

Changing trends in human immunodeficiency virus and acquired immunodeficiency syndrome in the population aged 50 and older.

OBJECTIVES: To alert persons in the public and private healthcare professions to the increasing trends in higher proportions of persons aged 50 and older who are newly diagnosed with human immunodeficiency virus (HIV) and who are living with HIV and acquired immunodeficiency syndrome (AIDS). DESIGN: Data from the period 1992 through 2004 from the HIV/AIDS Reporting System (HARS) were analyzed. SETTING: New Jersey is the eleventh-most-populous state, with the highest density of persons per square mile. It also has the fifth-highest number of AIDS cases. PARTICIPANTS: All persons residing in New Jersey and reported to HARS with HIV infection or who are considered to have AIDS. MEASUREMENTS: Trends in persons aged 50 and older were compared with those in the population younger than 50 during 1992 through 2004 for the numbers of persons living with HIV/AIDS and the number of persons newly diagnosed with HIV infection. RESULTS: The proportion of all persons aged 50 and older living with HIV/AIDS in 2004 was significantly greater than the comparable proportion of persons in 1992. Proportionally, more persons were newly diagnosed with HIV who were aged 50 and older according to sex and for each of the three major race or ethnicity groups (white non-Hispanic, black non-Hispanic, and Hispanic) than were persons younger than 50. Each of these increases was statistically significant. CONCLUSION: HIV/AIDS social marketing campaigns should include images and issues related to older persons in educational and prevention efforts. New methods that reach older populations should be considered. Physicians and other healthcare providers should be made aware of their role in prevention and education about HIV. Testing of older populations with risk factors should be encouraged.

Positive Medication Changes Resulting from Comprehensive and Noncomprehensive Medication Reviews in a Medicare Part D Population.

BACKGROUND: Health care organizations face the challenge of reducing costs while improving health outcomes. Currently, more than 39 million seniors are enrolled in a Medicare Part D prescription benefit plan, many of whom also qualify for medication therapy management (MTM) services. MTM programs provide valuable services designed to prevent or resolve medication-related problems (MRPs). Two core components of all MTM programs include comprehensive medication reviews (CMRs) with followup interventions and focused non-CMR interventions. Currently, there is limited research comparing the rate of MRPs resolved by CMR and non-CMR interventions. OBJECTIVE: To determine whether CMRs versus non-CMR interventions resulted in more pharmacist-initiated intervention recommendations and positive medication changes. METHODS: This retrospective, cross-sectional quality improvement project evaluated outcomes for individuals who received interventions following a CMR compared with those who received non-CMR interventions as part of a comprehensive MTM program. For this project, eligible individuals qualified for an MTM program. A positive medication change was defined as the addition of an appropriate medication or the removal of an inappropriate medication within 120 days of a pharmacist recommendation. Differences between the groups were calculated using the Wilcoxon rank sum test. RESULTS: During the 2-year period (2012 and 2013), 788,756 beneficiaries were enrolled in the MTM program and evaluated for potential MRPs. In both years, pharmacists recommended more medication changes per member for those receiving a CMR (0.81 in 2012 and 0.82 in 2013) compared with the non-CMR group (0.68 in 2012 and 0.61 in 2013; P value < 0.001 for both years). However, recommendations made via non-CMR interventions (representing the vast majority of all medication reviews) were more likely to result in a positive medication change (OR = 1.24, 95% CI = 1.21-1.28 for 2012; OR = 1.26, 95% CI = 1.22-1.30 for 2013). CONCLUSIONS: These quality improvement project results suggest that Medicare Part D beneficiaries participating in a university-based MTM program who received non-CMR interventions had a higher likelihood of having positive medication changes than those receiving CMRs. These results are enlightening and may provide initial evidence to support inclusion of a non-CMR performance metric for the Centers for Medicare & Medicaid Service's star ratings for MTM programs. DISCLOSURES: No outside funding supported this study. The University of Arizona Medication Management Center (UAMMC)/SinfoniaRx provides grant funding to the University of Arizona for research. Augustine reports support from the UAMMC and ownership of Pfizer stock and was a graduate student at the University of Arizona College of Pharmacy at the time of this study. The authors report no other potential conflicts of interest. Buhl and Augustine contributed study concept and design, collected the data, and wrote the manuscript. Data interpretation was performed by all the authors. Taylor, Warholak, Augustine, and Martin revised the manuscript.