Intersection and Considerations for Patient-Centered Care, Patient Experience, and Medication Experience in Pharmacogenomics.

As healthcare continues to embrace the concept of person- and patient-centered care, pharmacogenomics, patient experience, and medication experience will continue to play an increasingly important role in care delivery. This review highlights the intersection between these concepts and provides considerations for patient-centered medication and pharmacogenomic experiences. Elements at the patient, provider, and system level can be considered in the discussion, supporting the use of pharmacogenomics, with components of the patient and medication experience contributing to the mitigation of barriers surrounding patient use and the valuation of pharmacogenomic testing.

Preparing for the spread of patient-reported outcome (PRO) data collection from primary care to community pharmacy: a mixed-methods study.

BACKGROUND: Medication non-adherence is a significant public health problem. Patient-reported outcomes (PROs) offer a rich data source to facilitate resolution of medication non-adherence. PatientToc™ is an electronic PRO data collection software originally implemented at primary care practices in California, United States (US). Currently, the use of standardized PRO data collection systems in US community pharmacies is limited. Thus, we are conducting a two-phase evaluation of the spread and scale of PatientToc™ to US Midwestern community pharmacies. This report focuses on the first phase of the evaluation. The objective of this phase was to prepare for implementation of PatientToc™ in community pharmacies by conducting a pre-implementation developmental formative evaluation to (1) identify potential barriers, facilitators, and actionable recommendations to PatientToc™ implementation and (2) create a draft implementation toolkit. METHODS: Data collection consisted of demographics, observations, audio-recorded contextual inquiries, and semi-structured interviews with staff (e.g., primary care providers, pharmacists, pharmacy technicians) and patients during 1-day site visits to a purposive sample of (1) primary care practices currently using PatientToc™ and (2) community pharmacies in Indiana, Wisconsin, and Minnesota interested in the future use of PatientToc™. Post-visit site observation debriefs were also audio-recorded. Verbatim transcripts of all recordings were coded using deductive/inductive approaches and intra-/inter-site summaries were produced identifying potential barriers, facilitators, and actionable recommendations mapped to the Consolidated Framework for Implementation Research constructs. A stakeholder advisory panel engaged in an Evidence-Based Quality Improvement (EBQI) implementation process. This included "member checking" and prioritizing findings, and feedback on the adapted PatientToc™ application, implementation strategies, and accompanying toolkit for community pharmacy implementation. RESULTS: Two primary care practices, nine pharmacies, and 89 individuals participated. Eight major themes (four barriers and four facilitators) and 14 recommendations were identified. Throughout the four EBQI sessions, the panel (1) confirmed findings; (2) designated high priority recommendations: (a) explain PatientToc™ and its benefits clearly and simply to patients, (b) ensure patients can complete questionnaires within 10 min, and (c) provide hands-on training/resources for pharmacy teams; and (3) provided feedback on the adapted PatientToc™ application and finalized toolkit items for initial community pharmacy implementation. CONCLUSIONS: Adoption of electronically captured PROs in community pharmacies is warranted. The implementation strategies systematically developed in this study can serve as a model for implementation of technology-driven health information patient care services, in the understudied context of community pharmacies.

Patient-Centered Care preferences & expectations in outpatient pharmacist practice: A three archetype heuristic.

BACKGROUND: Patient-Centered Care (PCC) resides in the center of the Joint Commission of Pharmacy Practitioners' "Pharmacists' Patient Care Process" (PPCP) and is essential to successful management of chronic disease. However, the widely recognized importance and relevance of PCC contrasts with the limited number of studies in the pharmacist literature investigating patient preferences and expectations that inform PCC. Filling this gap is vital for improving pharmacist PCC at the micro-level (i.e., within and adjacent to patient-pharmacist encounters), meso-level (i.e., healthcare systems), and macro-level (i.e., legislation, payment, workforce dynamics). OBJECTIVE: The study's objective was to describe, interpret, and compare patient preferences and expectations of Patient-Centeredness in pharmacist outpatient care. METHODS: This mixed methods study used semi-structured, in-depth phone interviews among a purposive national sample of US adult patients with multiple chronic conditions and the experienced outpatient pharmacists caring for them. Interviews aimed to elicit conceptual definitions and concrete experiences of Patient-Centeredness in pharmacist care, were analyzed following Bengtsson's Content Analysis procedures, and assessed for reliability using Perrault and Leigh's Reliability Index. Data trustworthiness was interpreted using processes outlined by Guba & Krefting. RESULTS: Data analysis revealed a three-archetype heuristic of preferences and expectations for pharmacist care: 'Partner,' 'Client,' and 'Customer.' Each respective archetype is described and distinguished from the others across five common factors: Nature of the Relationship & Locus of Control; Care Customization; Encounter Duration & Care Longevity; Intent of Communication; and Source of Value. Exemplar excerpts from study participants also illuminate the meaning and distinctiveness of each respective archetype across the five factors. CONCLUSIONS: Findings suggest a novel approach for exploring pharmacist PCC quality, design, evaluation, and value-based payment at the micro-, meso-, and macro-levels of care. Future research should include operational field testing to investigate the model's validity, applicability, and consistency in pharmacist PCC.

An evaluation of the spread and scale of PatientToc™ from primary care to community pharmacy practice for the collection of patient-reported outcomes: A study protocol.

BACKGROUND: Medication non-adherence is a problem of critical importance, affecting approximately 50% of all persons taking at least one regularly scheduled prescription medication and costing the United States more than $100 billion annually. Traditional data sources for identifying and resolving medication non-adherence in community pharmacies include prescription fill histories. However, medication possession does not necessarily mean patients are taking their medications as prescribed. Patient-reported outcomes (PROs), measuring adherence challenges pertaining to both remembering and intention to take medication, offer a rich data source for pharmacists and prescribers to use to resolve medication non-adherence. PatientToc™ is a PROs collection software developed to facilitate collection of PROs data from low-literacy and non-English speaking patients in Los Angeles. OBJECTIVES: This study will evaluate the spread and scale of PatientToc™ from primary care to community pharmacies for the collection and use of PROs data pertaining to medication adherence. METHODS: The following implementation and evaluation steps will be conducted: 1) a pre-implementation developmental formative evaluation to determine community pharmacy workflow and current practices for identifying and resolving medication non-adherence, potential barriers and facilitators to PatientToc™ implementation, and to create a draft implementation toolkit, 2) two plan-do-study-act cycles to refine an implementation toolkit for spreading and scaling implementation of PatientToc™ in community pharmacies, and 3) a comprehensive, theory-driven evaluation of the quality of care, implementation, and patient health outcomes of spreading and scaling PatientToc™ to community pharmacies. EXPECTED IMPACT: This research will inform long-term collection and use of PROs data pertaining to medication adherence in community pharmacies.

"We get double slammed!": Healthcare experiences of perceived discrimination among low-income African-American women.

BACKGROUND: On account of their racial/ethnic minority status, class, and gender, African-American women of low socioeconomic status are among the least privileged, underserved, and most marginalized groups in the United States. Generally, African Americans continue to experience poorer health outcomes, in which disparities have been attributed to socioeconomic inequities and structural racism. This objective of this study was to explore the lived experiences of low-income African-American women in interacting with the healthcare system and healthcare providers. METHODS: Twenty-two in-depth one-on-one interviews were conducted with low-income African-American women. The audio-recorded interviews were transcribed verbatim. An inductive content analysis was performed, using an analytical software, Dedoose® to enabled hierarchical coding. Codes were grouped into categories which were further analyzed for similarities that led to the emergence of themes. RESULTS: A key finding was the experience of discriminatory treatment. The three themes that emerged relevant to this category were (1) perceived discrimination based on race/ethnicity, (2) perceived discrimination based on socioeconomic status, and (3) stereotypical assumptions such as drug-seeking and having sexually transmitted diseases. CONCLUSION AND RECOMMENDATIONS: Low-income African-American women experience less than satisfactory patient care, where participants attribute to their experience of being stereotyped and their perception of discrimination in the healthcare system and from providers. Patients' experiences within the healthcare system have implications for their healthcare-seeking behaviors and treatment outcomes. Healthcare personnel and providers need to be more aware of the potential for implicit bias toward this population. Healthcare workforce training on culturally responsive patient care approaches and more community engagement will help providers better understand the context of patients from this population and more effectively meet their healthcare needs.

The Medication Experience: A Concept Analysis.

This is a concept analysis of the medication experience with a focus on how it applies to the pharmaceutical care practice framework used by pharmacist practitioners. The medication experience is a vital component of pharmaceutical care practice and of patient-centered care. Although the experience of taking medication has been studied across disciplines for decades, a concept analysis of the medication experience is lacking. Rodgers' evolutionary concept analysis method was utilized. Ovid Medline, CINAHL, PsycINFO, Sociological Abstracts and Google Scholar databases, references and hand searches were used to compile an international dataset of 66 papers published from 1982 to 2020. As a result of the available literature, the medication experience is defined as one of ambivalence and vulnerability in which the patient is actively engaged in an ongoing process or negotiation, which is pragmatic to the ways in which they live and experience life, contextualized and nuanced within the social construction of their individual realities. The concept of medication experience is an important addition to the scientific literature. The definition of medication experience from the perspective of the patient will help to better explain the concept for future research and theory development to move the discipline of pharmaceutical care practice forward.

Pharmacist and student pharmacist views of professional and personal well-being and resilience.

OBJECTIVES: To describe the views of pharmacists and student pharmacists regarding (1) aspects of life and experiences that provide professional and personal satisfaction and fulfillment, (2) causes of stress, and (3) needs related to maintaining satisfaction and fulfillment. DESIGN: A generic qualitative research design was used for collecting data from 380 pharmacists and 332 student pharmacists who wrote responses to an online survey hosted by the American Pharmacists Association (APhA) from November 17 to December 2, 2018, using standard data collection procedures applied by that organization. APhA uses its member and affiliate data files as its sampling frame and limits the number of contacts per year for each person in those files. De-identified responses from those who volunteered to write comments were sent to the research team for analysis. A conventional content analysis approach was applied for analysis of the text. Analysts convened to discuss emergent themes and develop operational descriptions. Key segments of text that best represented each theme were identified. Personal presuppositions were disclosed and were useful for developing group consensus for theme identification and description. Rigor was supported through assessment of credibility, confirmability, intercoder checking, transferability, inductive thematic saturation, and authenticity. SETTING AND PARTICIPANTS: Participants are in the design since data already collected. OUTCOME MEASURES: Not applicable. RESULTS: Findings showed that pharmacists and student pharmacists are able to recognize and pursue achievement, recognition, responsibility, advancement, relationship, esteem, self-actualization, meaning, and accomplishment in both their professional and personal lives. However, external factors such as "workism" and individual factors such as "moral distress" were identified as areas of improvement that are needed for well-being and resilience. CONCLUSION: Pharmacists' basic human needs are being met, but to improve well-being and resilience for pharmacists in both their professional and personal lives, there is a need for addressing both the external factors and individual factors that they encounter.

Pharmacodynamic characterization of gemcitabine cytotoxicity in an in vitro cell culture bioreactor system.

PURPOSE: Gemcitabine, a pyrimidine nucleoside, is approved for the treatment of non-small cell lung cancer, pancreatic carcinoma, and breast cancer. Chemotherapy regimens are determined experimentally with static tissue culture systems, animal models, and in Phase I clinical trials. The aim of this study was to assess for gemcitabine-induced cell death following infusion of drug under clinically-relevant conditions of infusion rate and drug exposure in an in vitro bioreactor system. METHODS: To estimate an appropriate harvest time for cells from the bioreactor after drug treatment, we estimated the temporal relationship between gemcitabine treatment for 1 h and cell death at a later time point with monolayer growth assays (i.e., static culture). Afterward, 5.3 mg gemcitabine was infused over 0.5 h in the bioreactor, followed by mono-exponential decay, simulating patient concentration-time profiles (n = 4). Controls were run with drug-free media (n = 4). Cells were harvested from the bioreactor at a later time point and assessed for cell death by flow cytometry. RESULTS: According to monolayer growth assay results, cytotoxicity became more apparent with increasing time. The E Max for cells 48 h after treatment was 50% and after 144 h, 93% (P = 0.022; t test), while flow cytometry showed complete DNA degradation by 120 h. Gemcitabine was infused in the bioreactor. The gemcitabine area under the concentration-time curve (AUC) was 56.4 microM h and the maximum concentration was 87.5 +/- 2.65 microM. Flow cytometry results were as follows: the G1 fraction decreased from 65.1 +/- 4.91 to 28.6 +/- 12% (P = 0.005) and subG1 increased from 14.1 +/- 5.28 to 42.6 +/- 9.78% (P = 0.004) relative to control. An increase in apoptotic cells was observed by TUNEL assay. CONCLUSIONS: The in vitro bioreactor system will be expanded to test additional cell lines, and will serve as a useful model system for assessing the role of drug pharmacokinetics in delivery of optimized anticancer treatment.