Despair and hope: Is the retail community pharmacy workforce in danger of becoming a monopsony labor market?

OBJECTIVE: Mergers of big chain retail community pharmacies can affect the competitiveness of the pharmacy workforce to negotiate better wages and work conditions. However, it is unclear whether these types of mergers are generalizable to the U.S. pharmacy workforce. We should observe this effect when comparing annual wage trends between retail community pharmacy workers and nonretail community pharmacy workers. In the absence of this effect, annual wage trends would be similar. To examine this theory, annual wage trends for community pharmacy workers were compared with hospital pharmacy workers between 2012 and 2022. DESIGN, SETTING AND PARTICIPANTS: A serial cross-sectional study was performed to compare the annual wages between retail community pharmacy workers and hospital pharmacy workers between 2012 and 2022 using data from the U.S. Bureau of Labor and Statistics (BLS). Pharmacy workforce was categorized as pharmacists, pharmacy technicians, and pharmacy aides (clerks) and grouped into retail or hospital pharmacy settings based on the North American Industry Classification System. Pharmacy workers' annual wages were based on the U.S. BLS Quarterly Census of Employment and Wages data. OUTCOME MEASURES: Annual wages. RESULTS: Between 2012 and 2022, statistically significant annual wage reduction was greater among pharmacists in the retail than pharmacists in the hospital setting by -$1974 (95% CI -$2921 to -$1026) per year. However, these trends were not statistically significant among pharmacy technicians and pharmacy aides. Pharmacy technicians in the retail and hospital settings had a 3.4% and 7.0% increase in average annual wages, respectively. Pharmacy aides in the retail and hospital settings had a 16.8% and 21.6% increase in average annual wages, respectively. CONCLUSION: Although pharmacists' annual wages decreased, it is unclear whether this was caused by the monopsony labor market. These findings suggest that there may be inefficiencies in the retail community pharmacy labor market, which may stimulate policies to improve pharmacy workforce conditions and patient safety.

Comparison between in-person, telehealth, and combination visits among veterans treated in a pharmacist-led diabetes management clinic.

BACKGROUND: The Veterans Affairs San Diego Healthcare System converted its pharmacist-run Diabetes Intense Medical Management Clinic to telehealth during the COVID-19 pandemic. Previous studies suggested that in-person DIMM visits improved glycemic control, medication adherence, and patient satisfaction. To explore if these benefits apply to telehealth, we compared glycemic control in veterans with post-COVID-19 telehealth DIMM visits and prepandemic in-person DIMM visits. OBJECTIVE: The primary study objective was to evaluate the mean hemoglobin (A1c) change from baseline in cohorts who received telehealth visits, traditional visits, or a combination of both after 12 months of intervention. Secondary objectives included evaluation of all-cause mortality and the average time to mortality (days). METHODS: A retrospective multiarm historical cohort control study was conducted to compare 12-month glycemic control among veterans with type 2 diabetes who initiated DIMM care via audio-only telehealth, in-person, or combination between August 2018 and November 2021. Primary endpoint was the 12-month change in A1c from baseline; secondary measures included all-cause mortality and the average time to mortality (days). RESULTS: A total of 44 veterans were included for analysis. At 12 months, the average decreases in A1c from baseline were -0.90% (95% CI: -2.82, 1.01), -1.73% (95% CI: -3.33, -0.14), and -1.42% (95% CI: -2.67, -0.18) for the In-Person, Telehealth, and Combination groups, respectively. No differences in quarterly HbA1c rate of change were reported across the groups. All-cause mortality was highest in the In-person group (15.4%) compared to the Telehealth (4.6%) and the Combination (0.0%) groups; however, these differences were not statistically significant. Lastly, there were no significant differences in average time to death between the groups. CONCLUSION: Telehealth may be an alternative method of access to pharmacist-led diabetes care that is slowly making its way into our healthcare systems as a permanent fixture.

Burnout assessment among pharmacist-academic detailers at the US Veterans Health Administration.

BACKGROUND: Burnout among clinical pharmacist practitioners has been well established, but not among those who perform academic detailing. OBJECTIVES: To measure burnout among clinical pharmacist practitioners who perform academic detailing (pharmacist-academic detailers) at the United States Veterans Health Administration and compare the findings using 2 validated burnout instruments for healthcare professionals. METHODS: A cross-sectional study design was performed to measure burnout in VHA pharmacist-academic detailers across all VA regions between April 2023 and May 2023. Burnout was measured using the Oldenburg Burnout Inventory (OLBI) and a validated single-item burnout measure (SIMB). OLBI has 2 domains (exhaustion and disengagement) and categorizes burnout into Low, Moderate, and High based on scores above or below 1 standard deviation (SD) of the mean. The validated SIMB categorized burnout as having a score of 3 or greater (range: 1-5). Interrater reliability testing between the OLBI and the SIMB at detecting burnout among pharmacist-academic detailers was performed using the kappa test. Correlation between the 2 burnout instruments was assessed using the Spearman rho test. RESULTS: A total of 50 pharmacist-academic detailers completed the burnout survey. A large proportion of respondents had Moderate levels of burnout for the total (72%) burnout score, disengagement (64%) domain, and exhaustion (74%) domain. In total, 86% of pharmacist-academic detailers reported having Moderate to High levels of burnout on the total OLBI score. On the SIMB, a total of 14 (28%) pharmacist-academic detailers reported having one or more symptoms of burnout. Interrater reliability was considered poor/slight agreement between the OLBI and SIMB. Correlation between the 2 burnout instruments was considered moderately correlated (rho = 0.67, P < 0.001). CONCLUSION: This study provides an empirical analysis of burnout among pharmacist-academic detailers; however, the ability to detect burnout among pharmacist-academic detailers may be impacted by the selection of burnout instrument used.

Piperacillin/tazobactam versus cefepime or carbapenems for cefoxitin-non-susceptible Enterobacter cloacae, Klebsiella aerogenes, Citrobacter freundii, Serratia marcescens and Morganella morganii bacteraemia in immunocompromised patients.

BACKGROUND: The role of piperacillin/tazobactam for treatment of serious infections due to AmpC-producing organisms remains debatable, particularly in immunocompromised patients. METHODS: This was a retrospective cohort study in immunocompromised patients that investigated the effect of definitive treatment with either piperacillin/tazobactam versus cefepime or carbapenems for bacteraemia caused by cefoxitin-non-susceptible Enterobacterales. The primary endpoint was a composite of clinical and microbiological failure. A logistic regression model was constructed to assess the impact of definitive treatment choice on the primary endpoint. RESULTS: A total of 81 immunocompromised patients with blood cultures positive for cefoxitin-non-susceptible Enterobacterales were included for analysis. There was more microbiological failure in the piperacillin/tazobactam arm compared with the cefepime/carbapenem arm (11.4% versus 0.0%, P = 0.019). Definitive treatment with cefepime or a carbapenem was associated with a decreased odds of clinical or microbiological failure (OR 0.303, 95% CI 0.093-0.991, P = 0.048) when controlling for baseline characteristics. CONCLUSIONS: In immunocompromised patients with bacteraemia due to cefoxitin-non-susceptible Enterobacterales, definitive treatment with piperacillin/tazobactam was associated with an increased risk of microbiological failure and higher odds of clinical or microbiological failure compared with cefepime or carbapenems.

Predicted Health Literacy Disparities Between Immigrant and US-Born Racial/Ethnic Minorities: a Nationwide Study.

BACKGROUND: Racial/ethnic minorities in the USA exhibit reduced health literacy (HL) proficiency, leading to increased health disparities. It is unclear how the effect of birth status (immigrant/US-born) affects HL proficiency among racial/ethnic minorities. OBJECTIVE: To identify the direct, indirect, and total effects of birth status on HL proficiency among a nationally representative population of racial/ethnic minority adults in the USA. DESIGN: A cross-sectional study of 2019 data from the Medial Expenditure Panel Survey. PARTICIPANTS: Participants aged 18 or older reporting as racial/ethnic minorities (Black, Asian, or Hispanic) with non-missing data. MAIN MEASURES: We predicted HL proficiency for each participant using a previously published model. Path analysis was used to estimate the direct, indirect, and total effects of birth status on HL proficiency, accounting for several other covariates. Prevalence ratios were estimated using adjusted Poisson regression to evaluate differences in the "Below Basic" HL category. KEY RESULTS: An estimated weighted 81,092,505 participants were included (57.5% US-born, 42.5% immigrant). More racial/ethnic minority immigrant participants fell into the lowest category of HL proficiency, "Below Basic" (14.3% vs 5.5%, p < 0.05). Results of the path analysis indicated a significant, negative direct effect of birth status on HL proficiency (standardized coefficient = - 0.24, SE = 0.01, 95%CI: - 0.26, - 0.23) in addition to an indirect effect mediated through insurance status, health-system resource use, and English proficiency. The total effect of birth status on HL proficiency was found to be - 0.29. The immigrant participant group had 81% higher prevalence of falling into the "Below Basic" HL category compared to US-born participants (prevalence ratio = 1.81, 95%CI: 1.52, 2.16). CONCLUSIONS: Immigrant status has a strong, negative, direct effect on HL proficiency among racial/ethnic minorities in the USA. This may be a result of barriers that prevent equitable access to resources that improve proper HL proficiency. US policymakers may consider several methods to reduce this disparity at the health-system-, provider-, and patient-levels.

Effectiveness of letermovir for cytomegalovirus prophylaxis in allogeneic hematopoietic stem cell transplant recipients: A global systematic review.

OBJECTIVE(S): Letermovir (LET), a novel antiviral, has largely supplanted more traditional preemptive therapy (PET) for cytomegalovirus (CMV) prophylaxis in allogeneic hematopoietic stem cell transplant (allo-HCT) patients. Use of LET demonstrated efficacy against placebo in phase III randomized controlled trials, but is considerably more expensive than PET. This review aimed to evaluate the real-world effectiveness of LET in preventing clinically significant CMV infection (csCMVi) for allo-HCT recipients and related outcomes. DESIGN: A systematic literature review was performed using an a priori protocol using PubMed, Scopus, and ClinicalTrials.gov from January 2010 to October 2021. SETTING AND PARTICIPANTS: Studies were included if they met the following criteria: LET compared with PET, CMV-related outcomes, patients aged 18 years or older, and English language-only articles. Descriptive statistics were used to summarize study characteristics and outcomes. OUTCOME MEASURES: CMV viremia, csCMVi, CMV end-organ disease, graft-versus-host-disease, all-cause mortality. RESULTS: A total of 233 abstracts were screened, with 30 included in this review. Randomized trials demonstrated efficacy of LET prophylaxis in preventing csCMVi. Observational studies demonstrated varying degrees of effectiveness of LET prophylaxis compared with use of PET alone. All studies with a comparator group resulted in lower rates of csCMVi for patients using LET. Included studies varied widely by CMV viral load threshold cutoff and CMV test units, limiting synthesis of results owing to high heterogeneity. CONCLUSION: LET reduces risk of csCMVi, but lack of standardized clinical definitions on how to evaluate csCMVi and related outcomes largely prevent synthesis of results. Clinicians must consider this limitation in the context of evaluating the effectiveness of LET to other antiviral therapies, especially for patients at risk of late-onset CMV. Future studies should focus on prospective data collection through registries and concordance of diagnostic definitions to mitigate study heterogeneity.

Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD): an Implementation Trial in Eight Veterans Health Administration Facilities.

BACKGROUND: Identifying effective strategies to improve access to medication treatments for opioid use disorder (MOUD) is imperative. Within the Veterans Health Administration (VHA), provision of MOUD varies significantly, requiring development and testing of implementation strategies that target facilities with low provision of MOUD. OBJECTIVE: Determine the effectiveness of external facilitation in increasing the provision of MOUD among VHA facilities with low baseline provision of MOUD compared to matched controls. DESIGN: Pre-post, block randomized study designed to compare facility-level outcomes in a stratified sample of eligible facilities. Four blocks (two intervention facilities in each) were defined by median splits of both the ratio of patients with OUD receiving MOUD and number of patients with OUD not currently receiving MOUD (i.e., number of actionable patients). Intervention facilities participated in a 12-month implementation intervention. PARTICIPANTS: VHA facilities in the lowest quartile of MOUD provision (35 facilities), eight of which were randomly assigned to participate in the intervention (two per block) with twenty-seven serving as matched controls by block. INTERVENTION: External facilitation included assessment of local barriers/facilitators, formation of a local implementation team, a site visit for action planning and training/education, cross-facility quarterly calls, monthly coaching calls, and consultation. MAIN MEASURES: Pre- to post-change in the facility-level ratio of patients with an OUD diagnosis receiving MOUD compared to control facilities. KEY RESULTS: Intervention facilities significantly increased the ratio of patients with OUD receiving MOUD from an average of 18% at baseline to 30% 1 year later, with an absolute difference of 12% (95% confidence interval [CI]: 6.6%, 17.0%). The difference in differences between intervention and control facilities was 3.0% (95% CI: - 0.2%. 6.7%). The impact of the intervention varied by block, with smaller, less complex facilities more likely to outperform matched controls. CONCLUSIONS: Intensive external facilitation improved the adoption of MOUD in most low-performing facilities and may enhance adoption beyond other interventions less tailored to individual facility contexts.

Risk factors and outcomes associated with persistent vancomycin resistant Enterococcal Bacteremia.

BACKGROUND: Prior studies have identified that vancomycin resistant enterococcus (VRE) bacteremia that persists for four days or more is an independent predictor of mortality. Despite this, there is no published data to identify those patients at highest risk of developing persistent VRE bacteremia. METHODS: This was a single center, retrospective, case-control study of adult patients with a VRE bloodstream infection (BSI). Case patients were those with persistent bacteremia (≥ 4 days despite VRE-directed therapy) and control patients were those with non-persistent bacteremia. Logistic regression was used to assess risk factors associated with persistent VRE BSIs. Secondary outcomes included in-hospital mortality, recurrent bacteremia, and breakthrough bacteremia. RESULTS: During the study period, 24/108 (22%) patients had persistently positive blood cultures. Risk factors for persistent bacteremia included severe neutropenia (OR 2.13), 4 out of 4 positive index blood cultures (OR 11.29) and lack of source control (OR 11.88). In an unadjusted analysis, no statistically significant differences in in-hospital mortality (58% versus 40%; p = 0.121), recurrent bacteremia (17% versus 6%; p = 0.090), or breakthrough bacteremia (13% versus 7%; p = 0.402) were observed between groups. CONCLUSION: Patients with severe neutropenia, 4 out of 4 positive index blood culture bottles, and lack of source control were more likely to develop persistent VRE bacteremia despite directed antibiotic treatment.

Risk of Negative Health Outcomes and High Costs for People With Diabetes and Unmet Psychological Needs in the United States.

Measuring the population-level relationship between compromised mental health and diabetes care remains an important goal for clinicians and health care decision-makers. We evaluated the impact of self-reported unmet psychological need on health care resource utilization and total health care expenditure in people with type 2 diabetes. Patients who reported unmet psychological needs were more likely than those who did not to incur a higher annual medical expenditure, have greater resource utilization, and have a higher risk of all-cause mortality.

Healthcare quality measures in implementation research: advantages, risks and lessons learned.

Implementation studies evaluate strategies to move evidence-based practices into routine clinical practice. Often, implementation scientists use healthcare quality measures to evaluate the integration of an evidence-based clinical practice into real-world healthcare settings. Healthcare quality measures have standardized definitions and are a method to operationalize and monitor guideline-congruent care. Implementation scientists can access existing data on healthcare quality measures through various sources (e.g. operations-calculated), or they can calculate the measures directly from healthcare claims and administrative data (i.e. researcher-calculated). Implementation scientists need a better understanding of the advantages and disadvantages of these methods of obtaining healthcare quality data for designing, planning and executing an implementation study. The purpose of this paper is to describe the advantages, risks and lessons learned when using operations- versus researcher-calculated healthcare quality measures in site selection, implementation monitoring and implementation outcome evaluation. A key lesson learned was that relying solely on operations-calculated healthcare quality measures during an implementation study poses risks to site selection, accurate feedback on implementation progress to stakeholders, and the integrity of study results. A possible solution is using operations-calculated quality measures for monitoring of evidence-based practice uptake and researcher-calculated measures for site section and outcomes evaluation. This approach provides researchers greater control over the data and consistency of the measurement from site selection to outcomes evaluation while still retaining measures that are familiar and understood by key stakeholders whom implementation scientists need to engage in practice change efforts.

Impact of Implementing an Academic Detailing Program on Opioid-Benzodiazepine Co-Prescribing Trends at the U.S. Department of Veterans Affairs.

OBJECTIVES: To assess the process and outcomes of academic detailing to enhance the Opioid Safety Initiative and the Psychotropic Drug Safety Initiative to reduce co-prescribing of opioid-benzodiazepine combinations in veterans. METHODS: A retrospective cohort design was conducted to evaluate the impact of implementing an academic detailing program on opioid-benzodiazepine co-prescribing between October 2014 through March 2019 at the U.S. Department of Veterans Affairs (VA). The primary outcome was the monthly prevalence of veterans (number per 1,000 population) who were co-prescribed opioid-benzodiazepine combination. Process measure was evaluated using implementation reach (proportion of providers who received academic detailing). Station-level analysis was performed using a linear fixed effects regression model to evaluate the rate of change in the prevalence of veterans co-prescribed opioid-benzodiazepine. RESULTS: Altogether 130 VA stations was included for analysis; 119 stations implemented opioid-related or benzodiazepine-related academic detailing, and 11 stations did not. Stations that had implemented academic detailing had a 33% greater monthly reduction on the opioid-benzodiazepine co-prescribing prevalence compared to stations that did not implement academic detailing (P = .036). In the linear fixed effects regression model, stations that were expected to have 100% of providers exposed to academic detailing were statistically associated with a greater decrease in the monthly prevalence of Veterans co-prescribed opioid-benzodiazepine by 4.9 veterans per 1,000 population (P < .001) compared to stations with 0% of providers exposed to academic detailing. CONCLUSIONS: Stations that implemented academic detailing and had a higher proportion of providers who were exposed to opioid- or benzodiazepine-related academic detailing had a significant decrease in the monthly prevalence of Veterans co-prescribed opioid-benzodiazepine combinations.

Impact of academic detailing on benzodiazepine use among veterans with posttraumatic stress disorder.

Background: Benzodiazepine use in the US Veterans Administration (VA) has been decreasing; however, a small number of veterans with posttraumatic stress disorder (PTSD) continue to receive benzodiazepine. Academic detailing, a targeted-educational outreach intervention, was implemented at VA to help reduce the disparity between existing and evidence-based practices, including the reduction in benzodiazepine use in veterans with PTSD. Since evidence to support the national implementation of academic detailing in this clinical scenario was scarce, we performed a quality improvement evaluation on academic detailing's impact on benzodiazepine use in veterans with PTSD. Methods: A retrospective cohort design was used to evaluate the impact of academic detailing on benzodiazepine prescribing in veterans with PTSD from January 1, 2016, to December 31, 2016. Providers exposed to academic detailing (AD-exposed) were compared with providers unexposed to academic detailing (AD-unexposed) using generalized estimating equations (GEEs) controlling for baseline covariates. Secondary aims evaluated academic detailing's impact on average lorazepam equivalent daily dose (LEDD), total LEDD, and benzodiazepine day supply. Results: Overall, there was a decrease in the prevalence in benzodiazepine use in veterans with PTSD from 115.5 to 103.3 per 1000 population (P < .001). However, the decrease was greater in AD-exposed providers (18.37%; P < .001) compared with AD-unexposed providers (8.74%; P < .001). In the GEE models, AD-exposed providers had greater reduction in the monthly prevalence of veterans with PTSD and a benzodiazepine prescription compared with AD-unexposed providers, by -1.30 veterans per 1000 population (95% confidence interval [CI]: -2.14, -0.46). Similar findings were reported for the benzodiazepine day supply; however, no significant differences were reported for total and average LEDD. Conclusions: Although benzodiazepine use has been decreasing in veterans with PTSD, opportunities to improve prescribing continue to exist at the VA. In this quality improvement evaluation, AD-exposed providers were associated with a greater reduction in the prevalence of veterans with PTSD and a benzodiazepine prescription compared with AD-unexposed providers.

Pharmacists on the front-line of solving a public health crisis: Increasing access to medications for opioid use disorder.

OBJECTIVE: To demonstrate the advantages of pharmacist involvement to increase the accessibility of medication treatment for opioid use disorder (OUD). SUMMARY: OUD continues to be a mounting public health crisis in the United States. Medications for OUD treatment have been reported to be safe and effective. Yet, underutilization and poor accessibility remain critical challenges. As the most accessible health care provider, pharmacists have the capability to help overcome these barriers and positively affect patient care. Preliminary strategies have been documented in the United States and abroad that can serve as a blueprint for expanded pharmacist involvement. CONCLUSION: Pharmacists must expand efforts to increase patient accessibility to medications for OUD and become a key part of the solution to this epidemic.

Comparison of naloxone prescribing patterns due to educational outreach conducted by full-time and part-time academic detailers at the U.S. Veterans Health Administration.

OBJECTIVE: To examine the impact of full-time equivalent employee (FTEE) allocation to academic detailers on naloxone prescribing at the U.S. Veterans Health Administration (VA). DESIGN: Longitudinal nonequivalent control group posttest-only design using a random effects model. SETTING AND PARTICIPANTS: Closed cohort of primary care providers exposed to academic detailing between September 1, 2016, and September 20, 2018, at VA. OUTCOME MEASURES: Previous analysis identified a cutoff of 0.40 FTEE was associated with a greater return on investment. We evaluated whether this level of FTEE allocation was associated with increases in naloxone prescribing rates and compared providers who had an interaction with an academic detailer allocated 0.4 FTEE or greater (high FTEE) to providers who interacted with an academic detailer allocated less than 0.4 FTEE (low FTEE). RESULTS: Among VA primary care providers who received academic detailing, 1770 (68%) had interactions with a high FTEE academic detailer. There were no differences in demographics between providers who interacted with high FTEE and low FTEE academic detailers except for the distribution of provider classes (P = 0.004) and geographic districts (P < 0.001). Providers who interacted with high FTEE academic detailers had a greater average monthly number of naloxone prescriptions prescribed compared with low FTEE academic detailers (0.60 vs. 0.53; P = 0.005). In the random effects model, there was a 65% greater increase in the average monthly number of naloxone prescriptions prescribed among providers who interacted with a high FTEE academic detailer compared with providers who interacted with low FTEE academic detailers (P = 0.027). We also observed a dose-dependent relationship between the number of naloxone prescribed and the amount of FTEE allocated. CONCLUSION: This observational study highlights the potential benefits (e.g., increased naloxone prescribing) of academic detailers having more FTEE allocated. Hence, implementation of academic detailing needs to consider the amount of dedicated time for academic detailers, given competing VA priorities.

Virtual academic detailing (e-Detailing): A vital tool during the COVID-19 pandemic.

As the coronavirus disease (COVID-19) pandemic continues its course in 2020, telehealth technology provides opportunities to connect patients and providers. Health policies have been amended to allow easy access to virtual health care, highlighting the field's dynamic ability to adapt to a public health crisis. Academic detailing, a peer-to-peer collaborative outreach designed to improve clinical decision-making, has traditionally relied on in-person encounters for effectiveness. A growth in the adoption of telehealth technology translates to increases in academic detailing reach for providers unable to meet with academic detailers in person. The U.S. Department of Veterans Affairs (VA) has used academic detailing to promote and reinforce evidence-based practices and has encouraged more virtual academic detailing (e-Detailing). Moreover, VA academic detailers are primarily clinical pharmacy specialists who provide clinical services and education and have made meaningful contributions to improving health care at VA. Amid the COVID-19 pandemic and physical isolation orders, VA academic detailers have continued to meet with providers to disseminate critical health care information in a timely fashion by using video-based telehealth. When working through the adoption of virtual technology for the delivery of medical care, providers may need time and nontraditional delivery of "evidence" before eliciting signals for change. Academic detailers are well suited for this role and can develop plans to help address provider discomfort surrounding the use of telehealth technology. By using e-Detailing as a method for both familiarizing and normalizing health professionals with video-based telehealth technology, pharmacists are uniquely poised to deliver consultation and direct-care services. Moreover, academic detailing pharmacists are ambassadors of change, serving an important role navigating the evolution of health care in response to emergent public health crises and helping define the norms of care delivery to follow.

Clinical dashboard development and use for academic detailing in the U.S. Department of Veterans Affairs.

OBJECTIVE: To describe the U.S. Department of Veterans Affairs (VA) Academic Detailing Service's (ADS) experience with the development and use of clinical dashboards across the VA's national clinical campaigns. We focused only on dashboards developed by the VA ADS national clinical program managers. SETTING: U.S. Department of Veterans Affairs Pharmacy Benefits Management National Academic Detailing Service. PRACTICE DESCRIPTION: Academic detailing is a multifaceted, educational outreach intervention that services providers through interactions with academic detailers (at the VA, these are specially trained clinical pharmacy specialists) using evidence-based research, educational brochures, and clinical dashboards to align prescribing behavior with best practices. The VA ADS developed clinical dashboards to benchmark and monitor academic detailing activities and performance and to identify opportunities for redistributing resources. We used the opioid crisis as an example to highlight key steps in the development of a clinical dashboard. EVALUATION: Testing is an important part of clinical dashboard development. Evaluations of the users perceptions contributed to lessons learned. RESULTS: Data validation, missing data, data availability, standardization, user engagement, and technical limitations were among several challenges the VA ADS encountered during dashboard development. Stakeholder engagement, communication, and flexibility with development time allowed us to develop efficient dashboards. CONCLUSIONS: Health care data and health analytics have transformed the type of clinical care that can be practiced by creating the ability to implement system-wide processes for both population management and quality improvement processes. End users of these VA ADS clinical dashboards can generate priority panel reports and data visualization of key performance indicators to identify areas for improvement or action.

Evaluating the Impact of a Clinical Decision Support Tool to Reduce Chronic Opioid Dose and Decrease Risk Classification in a Veteran Population.

BACKGROUND: Chronic opioid therapy-clinical reminder (COT-CR) is a decision support tool to prompt providers to carefully assess patients prescribed chronic opioids. This tool was developed to address inappropriate opioid prescribing. OBJECTIVE: To determine COT-CR's impact on reducing morphine equivalent monthly dose (MEMD) and risk index for overdose or serious prescription opioid-induced respiratory depression (RIOSORD) values in veterans receiving chronic opioids. METHODS: This retrospective cohort review matched patients with a complete COT-CR to patients with an incomplete COT-CR using propensity scores. In the primary aim, an interrupted time series design evaluated for changes in MEMD 12 months before and 6 months after the index date. The index date was the first pain or primary care provider visit post COT-CR installation. In the secondary aims, a retrospective cohort design was used to evaluate the changes in RIOSORD index score and risk class 6 months after the index date. RESULTS: After matching, 3801 patients were included in the complete and incomplete COT-CR groups, respectively. Greater average reduction in MEMD (-11.6 MEMD; 95% CI = -0.97 to -22.25 MEMD; P = 0.032) and RIOSORD index score (-0.53 RIOSORD index score; 95% CI = -1.00, -0.05 RIOSORD index score; P = 0.030) was observed in patients with a complete COT-CR compared to patients with an incomplete COT-CR. Differences in RIOSORD risk class were insignificant. CONCLUSION: Completing the COT-CR was associated with reduced MEMD and RIOSORD values. This suggests that active monitoring can change prescribing patterns, thereby, reducing the overall risk of opioid overdose in at-risk veterans.

Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation.

Objective: Academic detailing (AD) is a promising intervention to address the growing morbidity and mortality associated with opioids. While AD has been shown to be effective in improving provider prescribing practices across a range of conditions, it is unclear how best to implement AD. The present study was designed to identify key lessons for implementation based on a model AD program in the Veterans Health Administration (VA). Design: Qualitative process evaluation using semistructured interviews. Setting: Seven VA health care systems in the Sierra Pacific region. Subjects: Current and former academic detailers (N = 10) and VA providers with varying exposure to AD (high, low, or no; N = 20). Methods: Semistructured interviews were audio-recorded and transcribed. We used a team-based, mixed inductive and deductive approach guided by the Consolidated Framework for Implementation Research. Results: Key lessons identified by academic detailers and providers coalesced around key themes: 1) one-on-one sessions customized to the provider's patient population are most useful; 2) leadership plays a critical role in supporting providers' participation in AD programs; 3) tracking academic detailer and provider performance is important for improving performance for both groups; 4) academic detailers play a key role in motivating provider behavior change and thus training in Motivational Interviewing is highly valuable; and 5) academic detailers noted that networking is important for sharing implementation strategies and resources. Conclusions: Identifying and incorporating these key lessons into the implementation of complex interventions like AD are critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic.

Opioid overdose education and naloxone distribution: Development of the Veterans Health Administration's national program.

OBJECTIVES: To prevent opioid-related mortality, the Veterans Health Administration (VHA) developed a national Opioid Overdose Education and Naloxone Distribution (OEND) program. SETTING: VHA's OEND program sought national implementation of OEND across all medical facilities (n = 142). PRACTICE DESCRIPTION: This paper describes VHA's efforts to facilitate nationwide health care system-based OEND implementation, including the critical roles of VHA's national pharmacy services and academic detailing services. PRACTICE INNOVATION: VHA is the first large health care system in the United States to implement OEND nationwide. Launching the national program required VHA to translate a primarily community-based public health approach to OEND into a health care system-based approach that distributed naloxone to patients with opioid use disorders as well as to patients prescribed opioid analgesics. Key innovations included developing steps to implement OEND, pharmacy developing standard naloxone rescue kits, adding those kits to the VHA National Formulary, centralizing kit distribution, developing clinical guidance for issuing naloxone kits, and supporting OEND as a focal campaign of academic detailing. Other innovations included the development of patient and provider education resources (e.g., brochures, videos, accredited training) and implementation and evaluation resources (e.g., technical assistance, clinical decision support tools). EVALUATION: Clinical decision support tools that leverage VHA national data are available to clinical staff with appropriate permissions. These tools allow staff and leaders to evaluate OEND implementation and provide actionable next steps to help them identify patients who could benefit from OEND. RESULTS: Through fiscal year 2016, VHA dispensed 45,178 naloxone prescriptions written by 5693 prescribers to 39,328 patients who were primarily prescribed opioids or had opioid use disorder. As of February 2, 2016, there were 172 spontaneously reported opioid overdose reversals with the use of VHA naloxone prescriptions. CONCLUSION: VHA has successfully translated community-based OEND into health care system-based OEND targeting 2 patient populations. There is a tremendous amount that can be learned from VHA's experience implementing this novel health care innovation nationwide.

Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis.

OBJECTIVES: To evaluate the effects of the U.S. Veterans Health Administration (VA) National Academic Detailing Service alongside the Opioid Overdose Education and Naloxone Distribution (OEND) program on naloxone prescriptions prescribed from October 2014 to September 2016. METHODS: A retrospective, repeated measures cohort study was conducted to evaluate the effectiveness of a real-world application of academic detailing (AD) alongside OEND on providers' outpatient naloxone prescribing from October 2014 to September 2016. Outcome was the number of naloxone prescriptions prescribed per month per provider. During the study period, VA providers were aware of OEND, but may not have been exposed to academic detailing. Therefore, providers were categorized as exposed when the first OEND-specific academic detailing session was provided during the study period. Generalized estimating equations were used to estimate the association between exposure to academic detailing and monthly naloxone prescriptions prescribed while taking into account the correlation within each provider. Incident rate ratios with 95% CIs were reported. RESULTS: Seven hundred fifty (22.6%) of 3313 providers received at least 1 OEND-specific academic detailing visit. At 1 year, the average number of naloxone prescriptions per month was 3-times greater in AD-exposed providers compared with AD-unexposed providers (95% CI 2.0-5.3); and at 2 years, the average number of naloxone prescriptions was 7-times greater (95% CI 3.0-17.9). Moreover, the average difference in naloxone prescribing from baseline to 2 years was 7.1% greater in AD-exposed providers compared with AD-unexposed providers (95% CI 2.0%-12.5%). CONCLUSIONS: This preliminary analysis provides the first evidence that academic detailing influenced naloxone prescribing rates in a large, integrated health care system at 1 and 2 years. In addition, AD-exposed providers had a higher average difference in naloxone prescribing rate compared with AD-unexposed providers after 2 years of follow-up.