Incorporating a learning unit on vaccine hesitancy into a first-year doctor of pharmacy immunization course.

INTRODUCTION: Vaccine hesitancy is a growing threat to public health. The objective of this research was to investigate the effect of incorporating a learning unit on addressing vaccine hesitancy into a doctor of pharmacy immunization delivery course. METHODS: The learning unit, implemented fall 2019 at the University of Rhode Island, involved two interactive lectures and an at-home assignment. A family medicine physician spoke about her experiences with vaccine-hesitant families, and students viewed video scenarios depicting a pharmacist talking with vaccine-hesitant patients followed by an in-class discussion. Data was collected using pre- and post-surveys and a one-year follow-up survey. RESULTS: Out of 125 students enrolled in the course, 121 completed the pre-survey, 113 the post-survey, and 120 the follow-up survey. For pre-/post-survey comparison questions, statistically significant improvements were seen in 9 of 13 items. The follow-up survey showed 83.4% of students had applied knowledge and 85.7% had applied skills gained from the learning unit. CONCLUSION: Incorporating a learning unit on addressing vaccine hesitancy into a pharmacy immunization class resulted in improvements in student self-reported knowledge and comfort in talking with patients who are vaccine hesitant. Long-term use of self-reported knowledge and skills gained was seen one-year post-implementation.

Pharmacist-led telehealth disease management program for patients with diabetes and depression.

INTRODUCTION: The aim of this study was to determine whether a pharmacist-led telehealth disease management program is superior to usual care of nurse-led telehealth in improving diabetes medication adherence, haemoglobin A1C (A1C), and depression scores in patients with concomitant diabetes and depression. METHODS: Patients with diabetes and depression were randomized to pharmacist-led or nurse-led telehealth. Veterans with type 1 or type 2 diabetes, an A1C ≥ 7.5%, diagnosis of depression, and access to a landline phone were invited to participate. Patients were randomized to usual care of nurse-led telehealth or pharmacist-led telehealth. Patients were shown how to use the telehealth equipment by the nurse or pharmacist. In the pharmacist-led group, the patients received an in-depth medication review in addition to the instruction on the telehealth equipment. RESULTS: After six months, the pharmacist-led telehealth arm showed significant improvements for cardiovascular medication adherence (14.0; 95% confidence interval (CI) 0.4 to 27.6), antidepressant medication adherence (26.0; 95% CI 0.9 to 51.2), and overall medication adherence combined (13.9; 95% CI 6.6 to 21.2) from baseline to six-month follow-up. There was a significant difference in A1C between each group at the six-month follow-up in the nurse-led telehealth group (6.9 ± 0.9) as compared to the pharmacist-led telehealth group (8.8 ± 2.0). There was no significance in the change in patient health questionnaire-9 (PHQ-9) and Center for Epidemiologic Studies Depression Scale (CES-D) from baseline to follow-up in both groups. DISCUSSION: Pharmacist-led telehealth was efficacious in improving medication adherence for cardiovascular, antidepressants, and overall medications over a six-month period as compared to nurse-led telehealth. There was no significant improvement in overall depression scores.

The Effect of a Student Pharmacist Directed Health-Education Program for Elementary-School Children.

OBJECTIVE: The primary objective of this study was to measure the effect of an annual student pharmacist led elementary-school health education program by assessing children's comprehension of educational sessions. Secondary objectives were to evaluate student pharmacists' knowledge of health-related topics and practice skills. METHODS: Student pharmacists led interactive learning sessions for elementary school students on nutrition, physical activity, summer safety, hygiene, medication safety, and tobacco prevention. Pre- and post-intervention surveys were administered to measure change in knowledge of health promotion and healthy lifestyles. Student pharmacists also completed pre- and post-health education intervention surveys to measure change in self-perception of knowledge, confidence, and practice application of health-related topics and practice skills. RESULTS: Three-hundred and four elementary school children participated in the study with significant knowledge improvements observed in medication safety and tobacco prevention. Twenty-five student pharmacists completed surveys, resulting in a collective self-improvement in each area measured. CONCLUSION: Interactive educational sessions led by student pharmacists have a positive impact on elementary school children's knowledge. Student pharmacists also demonstrated professional growth through increased knowledge, confidence, and communication skills in interacting with pediatric populations. PRACTICE IMPLICATION: A co-curricular educational activity allowed student pharmacists to promote health and wellness to elementary students, a Healthy People 2020 goal, while also providing an opportunity to develop professional skills for future practice with pediatric patients.

Costs and effectiveness of pharmacist-led group medical visits for type-2 diabetes: A multi-center randomized controlled trial.

OBJECTIVES: The effectiveness and costs associated with addition of pharmacist-led group medical visits to standard care for patients with Type-2 Diabetes Mellitus (T2DM) is unknown. METHODS: Randomized-controlled-trial in three US Veteran Health Administration (VHA) Hospitals, where 250 patients with T2DM, HbA1c >7% and either hypertension, active smoking or hyperlipidemia were randomized to either (1) addition of pharmacist-led group-medical-visits or (2) standard care alone for 13 months. Group (4-6 patients) visits consisted of 2-hour, education and comprehensive medication management sessions once weekly for 4 weeks, followed by quarterly visits. Change from baseline in cardiovascular risk estimated by the UKPDS-risk-score, health-related quality-of-life (SF36v) and institutional healthcare costs were compared between study arms. RESULTS: After 13 months, both groups had similar and significant improvements from baseline in UKPDS-risk-score (-0.02 ±0.09 and -0.04 ±0.09, group visit and standard care respectively, adjusted p<0.05 for both); however, there was no significant difference between the study arms (adjusted p = 0.45). There were no significant differences on improvement from baseline in A1c, systolic-blood-pressure, and LDL as well as health-related quality-of-life measures between the study arms. Compared to 13 months prior, the increase in per-person outpatient expenditure from baseline was significantly lower in the group visit versus the standard care arm, both during the study intervention period and at 13-months after study interventions. The overall VHA healthcare costs/person were comparable between the study arms during the study period (p = 0.15); then decreased by 6% for the group visit but increased by 13% for the standard care arm 13 months post-study (p<0.01). CONCLUSIONS: Addition of pharmacist-led group medical visits in T2DM achieved similar improvements from baseline in cardiovascular risk factors than usual care, but with reduction in the healthcare costs in the group visit arm 13 months after completion compared to the steady rise in cost for the usual care arm. TRIAL REGISTRATION: NCT00554671 ClinicalTrials.gov.

A Description of Patient and Provider Experience and Clinical Outcomes After Heart Failure Shared Medical Appointment.

BACKGROUND: Shared medical appointments (SMAs) are clinical visits in which several patients meet with 1 or more providers at the same time. OBJECTIVE: To describe the outcomes of an interdisciplinary SMA for veterans recently discharged for heart failure (HF). METHODS: A retrospective chart review for patients' readmission rates, survival, medication adherence, and medication-related problems. For qualitative outcomes, we performed semistructured interviews on 12 patients who had undergone HF SMAs and their respective caregivers focusing on care satisfaction, HF knowledge, disease self-care, medication reconciliation, and peer support. RESULTS: The cohort comprised 70 patients-49% had left ventricular function <40% and 50% were prescribed >10 medications. Medication-related problems occurred in 60% of patients. Interviews revealed overall satisfaction with HF-SMA, but patients felt overwhelmed with HF instructions, perceived lack of peer support and self-efficacy, and feelings of hopelessness related to HF. CONCLUSION: Shared medical appointments are well-perceived. Medication problems and need for medication management are prevalent along with patient's lack of self-efficacy in HF care. Multiple HF-SMA visits may be needed to reinforce concepts, reduce confusion, and garner peer support.

Availability and Accuracy of Information Regarding Nonprescription Emergency Contraception.

BACKGROUND: Although access to emergency contraception (EC) has increased with nonprescription status and approval of Plan B One-Step without age restrictions, barriers may still remain in patient education. This study assesses product availability and accuracy of information for EC among community pharmacies in Rhode Island, comparing changes from 2009 to 2012. METHODS: Two female investigators posing as patients seeking EC followed a standardized script over telephone conversations. Investigators assessed EC availability, product use information, and cost at all community (retail) pharmacies in Rhode Island. Data were reported as group results with no identifiers. Chi-square and Fisher exact tests were used to analyze results. RESULTS: During spring of 2009 and 2012, 165 and 171 pharmacies were telephoned, respectively. Approximately 90% of pharmacies stocked EC both years. In all, 62% versus 28% (P < .001) indicated EC should be taken as soon as possible; 82.5% versus 87.7% (P = .220) provided correct administration information; 67% versus 84% (P < .001) warned about adverse effects; and 67% versus 53% (P = .123) provided the correct minimum age for purchase. CONCLUSIONS: Access to nonprescription EC in Rhode Island is very good. Sites not stocking EC should reassess plans for patients to obtain medication. There is need for reeducation on EC labeling to improve counseling provided over the telephone.

Promoting Safe Use of Medications: Providing Medication Education to Seniors Receiving Meals on Wheels.

STUDY OBJECTIVES: To assess whether pharmacist-provided medication education and counseling to Meals on Wheels (MOW) participants decreases medication-related preventable harm and improves adherence. DESIGN: Prospective, quasi-experiment. SETTING: Ambulatory congregrate dining centers. PATIENTS: Persons 60 years of age and older participating in MOW receiving prescription, nonprescription, or complementary products were eligible. In total, 42 patients consented. Five patients did not complete the first visit, and 13 patients did not complete the six-month follow-up visit. INTERVENTIONS: Pharmacists provided comprehensive medication education about prescription, nonprescription, and complementary products at baseline. Additional resources to enhance adherence and avoid medication-related preventable harm were provided and discussed. MAIN OUTCOME MEASURES: Medication-related preventable harm and medication adherence were assessed before pharmacist intervention and six months after intervention. Adherence was assessed and compared with baseline using the Morisky scale and pill counts. RESULTS: Women constituted the majority of participants (94.4%) with an average age of 74.5 ± 8.2 years. Mean difference in Morisky score from baseline to six months was 0.28 (-0.11 to 0.56). After adjustment for age and living situation, the change in Morisky score was associated with a 14% improvement in adherence. Mean differences in drug-drug and drug-supplement interactions, and medication-related harm were not significantly reduced from baseline to study end. CONCLUSION: Pharmacist intervention with MOW participants appeared to improve medication adherence rates but had limited effect on medication-related preventable harm. No findings reached statistical significance as the sample size was inadequate. Larger studies are needed to confirm these findings.

Benefits of a primary care clinic co-located and integrated in a mental health setting for veterans with serious mental illness.

INTRODUCTION: Efficacy trials have shown that primary care co-located in the mental health setting improves the receipt of high-quality medical care among people with serious mental illness. We tested whether implementation of such a program affected health service use and cardiovascular risk factor control among veterans with serious mental illness who had previously demonstrated limited primary care engagement. METHODS: We performed a cohort study of veterans enrolled in a co-located, integrated primary care clinic in the mental health outpatient unit through targeted chart review. Two successive 6-month periods in the year before and in the year following enrollment in the co-located primary care clinic were examined for primary care and emergency department use and for goal attainment of blood pressure, fasting blood lipids, body mass index (BMI), and, among patients with diabetes, hemoglobin A1c (HbA1c). We used repeated-measures logistic regression to analyze goal attainment and repeated measures Poisson regression to analyze service use. RESULTS: Compared with the period before enrollment, the 97 veterans enrolled in the clinic had significantly more primary care visits during 6 months and significantly improved goal attainment for blood pressure, low-density lipoprotein cholesterol, triglycerides, and BMI. Changes with regard to goal attainment for high-density lipoprotein cholesterol and HbA1c were not significant. CONCLUSION: Enrollment in a co-located, integrated clinic was associated with increased primary care use and improved attainment of some cardiovascular risk goals among veterans with serious mental illness. Such a clinic can be implemented effectively in the mental health setting.

Pharmacist-led shared medical appointments for multiple cardiovascular risk reduction in patients with type 2 diabetes.

PURPOSE: To assess whether VA MEDIC-E (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH] Extended for 6 months), a pharmacist-led shared medical appointments program, could improve attainment of target goals for hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to standard primary care after 6 months of intervention. METHODS: A randomized, controlled trial of VA MEDIC-E (n = 50) versus standard primary care (n = 49) in veterans with type 2 diabetes, hemoglobin A1c (A1C) > 7%, blood pressure (BP) > 130/80 mmHg, and low density lipoprotein cholesterol (LDL-C) > 100mg/dl (2.59 mmol/l) in the previous 6 months was conducted. The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions. Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist. Evaluation measures included lab values of A1C, LDL cholesterol, BP, and goal attainment of these values, and diabetes self-care behavior questionnaires at 6 months. RESULTS: The randomization groups were similar at baseline in all cardiovascular risk factors except for LDL, which was significantly lower in the MEDIC-E arm. At 6 months, significant improvements from baseline were found in the intervention arm for exercise, foot care, and goal attainment of A1C, LDL-C, and BP but not in the control arm. CONCLUSIONS: The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk.

Pharmacist-led group medical appointments for the management of type 2 diabetes with comorbid depression in older adults.

BACKGROUND: Depression is associated with poor glycemic control, increased number of microvascular and macrovascular complications, functional impairment, mortality, and 4.5 times higher total health care costs in patients with diabetes. Shared medical appointments (SMAs) may be an effective method to attain national guideline recommendations for glycemic control in diabetes for patients with depression through peer support, counseling, problem solving, and improved access to care. OBJECTIVE: To test the efficacy as assessed by attainment of a hemoglobin A(1c) (A1C) <7% of pharmacist-led group SMA visits, Veterans Affairs Multidisciplinary Education in Diabetes and Intervention for Cardiac Risk Reduction in Depression (VA-MEDIC-D), in patients with type 2 diabetes mellitus. METHODS: This was a randomized controlled trial of VA-MEDIC-D added to standard care versus standard care alone in depressed patients with diabetes with A1C >6.5%. VA-MEDIC-D consisted of 4 once-weekly, 2-hour sessions followed by 5 monthly 90-minute group sessions. Each SMA session consisted of multidisciplinary education and pharmacist-led behavioral and pharmacologic interventions for diabetes, lipids, smoking, and blood pressure. No pharmacologic interventions for depression were provided. The change in the proportion of participants who achieved an A1C <7% at 6 months was compared. RESULTS: Compared to standard care (n = 44), a lower proportion of patients in VA-MEDIC-D (n = 44) had systolic blood pressure (SBP) <130 mm Hg at baseline, but were similar in other cardiovascular risk factors and psychiatric comorbidity. The change in the proportion of participants achieving an A1C <7% was greater in the VA-MEDIC-D arm than in the standard care arm (29.6% vs 11.9%), with odds ratio 3.6 (95% CI 1.1 to 12.3). VA-MEDIC-D participants also achieved significant reductions in SBP, low-density lipoprotein cholesterol, and non-high-density lipoprotein (HDL) cholesterol from baseline, whereas significant reductions were attained only in non-HDL cholesterol with standard care. There was no significant change in depressive symptoms for either arm. CONCLUSIONS: Pharmacist-led group SMA visits are efficacious in attainment of glycemic control in patients with diabetes and depression without change in depression symptoms.

Maintenance of risk factor control in diabetic patients with and without mental health conditions after discharge from a cardiovascular risk reduction clinic.

BACKGROUND: Diabetes and hypertension can be challenging to manage in patients with mental health conditions. While the effectiveness of a cardiovascular risk reduction clinic (CRRC) has been shown not to differ between those with and without mental health conditions, it is unknown whether patients with mental health conditions would differ in durability of success following discharge from the CRRC. OBJECTIVE: To determine the effect of mental health conditions on the maintenance of glycemic control and blood pressure control in patients with diabetes following successful completion of a CRRC program. METHODS: Patients were discharged from the CRRC when therapeutic goals of hemoglobin A(1c) (A1C) <7% and blood pressure <130/80 mm Hg were achieved. We performed a retrospective chart review of a cohort of 231 patients by quarterly intervals for A1C and systolic blood pressure (SBP), providing up to 3 years of data following discharge from the CRRC. We assessed the time to failure to maintain goal A1C and SBP following CRRC discharge for patients with diagnosed mental health conditions versus patients without mental health conditions. RESULTS: For patients with and without mental health conditions, 50% of those who had been discharged from the CRRC with an SBP goal of <130 mm Hg failed to maintain SBP by 1 quarter. The hazard ratio for failure to maintain SBP, with those without mental health conditions as the reference group, was 0.96 (95% CI 0.68 to 1.35). Overall, for patients with an A1C goal of <7%, the combined median time to failure was 3 quarters. Among patients without mental health conditions, 25% failed in 3 quarters, and of those with mental health conditions, 25% failed in 4 quarters (HR 0.91; 95% CI 0.50 to 1.66). CONCLUSIONS: There was no significant difference between diabetic patients with and without mental health conditions in maintenance of A1C and SBP after discharge from a CRRC. This provides further evidence that a CRRC is a viable approach to cardiovascular risk reduction in individuals with mental health conditions.

Pharmacist-led group medical appointment model in type 2 diabetes.

PURPOSE: The purpose of this study was to assess whether the VA-MEDIC (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction), a pharmacist-led group medical visit program, could improve achievement of target goals in hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to usual care. METHODS: This was a randomized controlled trial of VA-MEDIC intervention in addition to usual care versus usual care alone in diabetic patients to reduce cardiac risk factors. VA-MEDIC consisted of a 40- to 60-minute educational component by nurse, nutritionist, physical therapist, or pharmacist followed by pharmacist-led behavioral and pharmacological interventions over 4 weekly sessions. Measures The attainment of target goals in hemoglobin A1C (A1C), blood pressure, fasting lipids, and tobacco use recommended by the American Diabetes Association. RESULTS: Of 118 participants, 109 completed the study. VA-MEDIC (n = 58) participants were younger and had greater tobacco use at baseline than usual care but were similar in other cardiovascular risk factors. After 4 months, a greater proportion of VA-MEDIC participants versus controls achieved an A1C of less than 7% and a systolic blood pressure less than 130 mm Hg. No significant change was found in lipid control or tobacco use between the 2 study arms. CONCLUSION: Pharmacist-led group medical visits are feasible and efficacious for improving cardiac risk factors.

Maintenance of cardiovascular risk goals in veterans with diabetes after discharge from a cardiovascular risk reduction clinic.

The authors evaluated maintenance of achieved cardiovascular risk control after discharge from a pharmacist-coordinated cardiovascular risk reduction clinic. Using data from 2001 to 2004 divided by financial quarters (ie, 3-month periods), the authors performed survival analysis of diabetic patients who had attained at least one cardiovascular risk goal in the clinic. Mean times to failure were 7.1 +/- 0.21 quarters for hemoglobin A1c, 7.6 +/- 0.29 quarters for low-density lipoprotein cholesterol (LDL-C), and 2.5 +/- 0.24 quarters for systolic blood pressure (SBP). Body mass index predicted glycemic control failure (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.01-1.15; P = .02), insulin use predicted LDL-C control failure (HR, 3.08; 95% CI, 1.15-8.22; P = .03), and baseline SBP predicted SBP control failure (HR, 1.02; 95% CI, 1.01-1.03; P = .0003). The authors found good durability of effect for most cardiovascular risk targets. Worse control at entry predicted failure after successful attainment of a cardiovascular goal. More sustained attention or booster interventions for patients with worse control at entry may be necessary.

Effectiveness of a multifactorial cardiovascular risk reduction clinic for diabetes patients with depression.

INTRODUCTION: Depression may attenuate the effects of diabetes interventions. Our ongoing Cardiovascular Risk Reduction Clinic simultaneously addresses hyperglycemia, hypertension, smoking, and hyperlipidemia. We examined the relationship between depression diagnosis and responsiveness to the Cardiovascular Risk Reduction Clinic. METHODS: We studied Cardiovascular Risk Reduction Clinic participants with diabetes who had a depression diagnosis and those with no mental health diagnosis. Our outcome measure was change in 20-year cardiovascular mortality risk according to the United Kingdom Prospective Diabetes Study (UKPDS) score. RESULTS: Of 231 participants, 36 (15.6%) had a depression diagnosis. Participants with a depression diagnosis had a higher baseline UKPDS score (56.8 [SD 21.3]) than participants with no mental health diagnosis (49.5 [SD 18.7], P = .04). After Cardiovascular Risk Reduction Clinic participation, mean UKPDS scores did not differ significantly (37.8 [SD 15.9] for no mental health diagnosis and 39.4 [SD 18.6] for depression diagnosis). Mean UKPDS score reduction was 11.6 [SD 15.6] for no mental health diagnosis compared with 18.4 [SD 15.9] for depression diagnosis (P = .03). Multivariable linear regression that controlled for baseline creatinine, number of Cardiovascular Risk Reduction Clinic visits, sex, and history of congestive heart failure showed significantly greater improvement in UKPDS score among participants with a depression diagnosis (beta = 6.0, P = .04) and those with more Cardiovascular Risk Reduction Clinic visits (beta = 2.1, P < .001). CONCLUSION: The Cardiovascular Risk Reduction Clinic program reduced cardiovascular disease risk among patients with diabetes and a diagnosis of depression. Further work should examine how depressive symptom burden and treatment modify the effect of this collaborative multifactorial program and should attempt to determine the durability of the effect.

Efficacy of a pharmacist-led cardiovascular risk reduction clinic for diabetic patients with and without mental health conditions.

Coexisting mental health conditions (MHCs) attenuate treatment effects in diabetes. A retrospective analysis was performed of a pharmacist-led cardiovascular risk reduction clinic (CRRC) targeting hypertension, diabetes, hyperlipidemia, and tobacco use in patients with at least one CRRC visit between January 2001 and January 2002. The United Kingdom Prospective Diabetes Study (UKPDS) risk change (after/before CRRC) for those with and without MHCs was compared. Of the 297 with diabetes and complete UKPDS data, 40.7% had at least 1 MHC (22.3% had a severe MHC). Patients with MHCs had a similar number of CRRC visits (4.7+/-2.6 vs 4.4+/-2.6) but had a lower baseline UKPDS score (0.31+/-0.18 vs 0.40+/-0.20; P=.001) compared with non-MHC patients. The risk change after CRRC was similar for those with and without MHCs (0.10+/-0.13 vs 0.10+/-0.14; P=.82), but patients with MHCs had a longer CRRC enrollment (245+/-152 vs 205+/-161 days; P<.03). The efficacy of the CRRC model to reduce cardiovascular risk is not attenuated by a concomitant MHC.