Participation in online continuing education.

OBJECTIVES: The ADAPT (ADapting pharmacists' skills and Approaches to maximize Patients' drug Therapy effectiveness) e-learning programme requires weekly participation in module activities and facilitated discussion to support skill uptake. In this study, we sought to describe the extent and pattern of, satisfaction with and factors affecting participation in the initial programme offering and reasons for withdrawal. METHODS: Mixed methods - convergent parallel approach. Participation was examined in qualitative data from discussion boards, assignments and action plans. Learner estimations of time commitment and action plan submission rates were calculated. Surveys (Likert scale and open-ended questions) included mid-point and final, exit and participation surveys. KEY FINDINGS: Eleven of 86 learners withdrew, most due to time constraints (eight completed an exit survey; seven said they would take ADAPT again). Thirty-five of 75 remaining learners completed a participation survey. Although 50-60% of the remaining 75 learners actively continued participating, only 15/35 respondents felt satisfied with their own participation. Learners spent 3-5 h/week (average) on module activities. Factors challenging participation included difficulty with technology, managing time and group work. Factors facilitating participation included willingness to learn (content of high interest) and supportive work environment. Being informed of programme time scheduling in advance was identified as a way to enhance participation. CONCLUSIONS: This study determined extent of learner participation in an online pharmacist continuing education programme and identified factors influencing participation. Interactions between learners and the online interface, content and with other learners are important considerations for designing online education programmes. Recommendations for programme changes were incorporated following this evaluation to facilitate participation.

Learning and networking: utilization of a primary care listserv by pharmacists.

BACKGROUND: Expanding into new types of practice, such as family health teams, presents challenges for practising pharmacists. The Primary Care Pharmacy Specialty Network (PC-PSN) was established in 2007 to support collaboration among pharmacists working in primary care. The PC-PSN offers to its members a listserv (also referred to as an electronic mailing list) jointly hosted by the Canadian Society of Hospital Pharmacists and the Canadian Pharmacists Association. OBJECTIVES: To characterize PC-PSN membership and participation in the listserv and to examine how the listserv is used by analyzing questions posted, concerns raised, and issues discussed. METHODS: Qualitative content analysis was used to examine 1 year of archived PC-PSN listserv posts from the year 2010. Two coders used NVivo software to classify the content of posts. Research team members reviewed and discussed the coding reports to confirm themes emerging from the data. RESULTS: Overall, 129 people (52.9% of the 244 listserv members registered at the end of the calendar year) posted to the listserv during the study period. These participants worked in various practice settings, with over half residing in Ontario (68/129 [52.7%]). A total of 623 posts were coded. Agreement between coders, for a sample of posts from 10 users, was acceptable (kappa = 0.78). The listserv was used to share information on a diverse set of topics, to support decision-making and acquire solutions for complex problems, and as a forum for mentorship. CONCLUSIONS: The qualitative content analysis of the PC-PSN listserv posts for the year 2010 showed that the listserv was a medium for information-sharing and for providing and receiving support, through mentorship from colleagues. Apparent learning needs included effective question-posing skills and application of evidence to individual patients.

CONTEXTE: Passer à de nouveaux types de pratiques, comme les groupes de médecine de famille, présente différents défis pour les pharmaciens en exercice. Le Réseau de spécialistes en pharmacie (RSP) en soins de santé primaires a été mis sur pied en 2007 dans le but de favoriser la collaboration entre pharmaciens œuvrant en soins de santé primaires. Le RSP en soins de santé primaires offre à ses membres un gestionnaire de liste de diffusion (listserv) sous l'égide conjoint de la Société canadienne des pharmaciens d'hôpitaux et de l'Association des pharmaciens du Canada. OBJECTIFS: Offrir un portrait des effectifs du RSP en soins de santé primaires et de la participation des membres au forum de discussion, et étudier comment le gestionnaire de liste de diffusion est utilisé à l'aide d'une analyse des questions publiées, des préoccupations soulevées et des problèmes abordés. MÉTHODES: Une analyse qualitative du contenu a servi à étudier l'ensemble des messages archivés dans le gestionnaire de liste de diffusion de l'année 2010. Deux codeurs ont utilisé le logiciel NVivo pour classer le contenu des messages publiés. Les résultats de l'encodage ont été examinés par les membres de l'équipe de recherche afin d'identifier les thèmes se dégageant des données. RÉSULTATS: Dans l'ensemble, 129 personnes (52,9 % des 244 membres inscrits au gestionnaire de liste de diffusion à la fin de l'année civile) ont publié des messages durant la période à l'étude. Les participants travaillaient dans différents milieux et plus de la moitié habitaient en Ontario (68/129 [52,7 %]). Au total, 623 messages ont été encodés et la concordance entre les résultats des deux codeurs était satisfaisante pour un échantillon de messages provenant de 10 usagers (indice kappa = 0,78). Le gestionnaire de liste de diffusion a servi à partager de l'information sur une gamme de sujets, à appuyer des prises de décision et à trouver des solutions à des problèmes complexes. Il a aussi servi de forum de mentorat. CONCLUSIONS: L'analyse qualitative du contenu des messages publiés en 2010 dans le gestionnaire de liste de diffusion par les membres du RSP en soins de santé primaires a montré que le gestionnaire est un média d'échange d'information et qu'il permet d'offrir et de recevoir du soutien grâce au mentorat entre collègues. Parmi les besoins identifiés, on compte la capacité à bien formuler des questions et l'application des données probantes pour le traitement individuel des patients. [Traduction par l'éditeur].

Curriculum to enhance pharmacotherapeutic knowledge in family medicine: interprofessional coteaching and web-based learning.

PROBLEM ADDRESSED: Prescribing is an essential skill for physicians. Despite the fact that prescribing habits are still developing in residency, formal pharmacotherapy curricula are not commonplace in postgraduate programs. OBJECTIVE OF PROGRAM: To teach first-year and second-year family medicine residents a systematic prescribing process using a medication prescribing framework, which could be replicated and distributed. PROGRAM DESCRIPTION: A hybrid model of Web-based (www.rationalprescribing.com) and in-class seminar learning was used. Web-based modules, consisting of foundational pharmacotherapeutic content, were each followed by an in-class session, which involved applying content to case studies. A physician and a pharmacist were coteachers and they used simulated cases to enhance application of pharmacotherapeutic content and modeled interprofessional collaboration. CONCLUSION: This systematic approach to prescribing was well received by family medicine residents. It might be important to introduce the process in the undergraduate curriculum-when learners are building their therapeutic foundational knowledge. Incorporating formal pharmacotherapeutic curriculum into residency teaching is challenging and requires further study to identify potential effects on prescribing habits.

Pharmacist's identity development within multidisciplinary primary health care teams in Ontario; qualitative results from the IMPACT project.

BACKGROUND: Multidisciplinary team development generates changes in roles, responsibilities, and identities of individual health care providers. The Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics (IMPACT) project introduced pharmacists into family practice teams across Ontario, Canada, to provide medication assessments, drug information, and academic detailing and to develop office system enhancements to improve drug therapy. OBJECTIVE: To analyze pharmacists' narrative accounts during early integration to study identity development within emerging team-based care. METHOD: Qualitative design using 63 pharmacist narrative reports of pharmacists' experiences over a 9-month integration period. Four independent researchers with varied professional backgrounds used immersion and crystallization to identify codes and iterative grounded theory to determine and debate process and content themes relevant to identity development. RESULTS: The pharmacists' narratives spoke of the daily experiences of integrating into a family practice setting: feeling valued and contributing concretely to patient care; feeling underutilized; feeling like a nuisance, or feeling as though working too slowly. Pharmacist mentors helped deal with uncertainty and complexity of care. Pharmacists perceived that complementary clinical contributions enhanced their status with physicians and motivated pharmacists to take on new responsibilities. Changes in perspective, clinic-relevant skill development, and a new sense of professionalism signaled an emerging pharmacist family practice identity. CONCLUSION: Pharmacists found that the integration into team-based primary health care provided both challenges and fresh opportunities. Pharmacists' professional identities evolved in relation to valued role models, emerging practice-level opportunities, and their patient-related contributions.

Integrating pharmacists into family practice teams: physicians' perspectives on collaborative care.

OBJECTIVE: To explore family physicians' perspectives on collaborative practice 12 months after pharmacists were integrated into their family practices. DESIGN: Qualitative design using focus groups followed by semistructured interviews. SETTING: Seven physician-led group family practices in urban, suburban, and semirural Ontario communities. PARTICIPANTS: Twelve purposively selected family physicians participating in the IMPACT (Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics) project. METHODS: We conducted 4 exploratory focus groups to gather information on collaborative practice issues in order to construct our interview guide. We later interviewed 12 physicians 1 year into the integration process. Focus groups and interviews were audiotaped and transcribed verbatim. Four researchers used immersion and crystallization techniques to identify codes for the data and thematic editing to distil participants' perspectives on physician-pharmacist collaborative practice. FINDINGS The focus groups revealed concerns relating to operational efficiencies, medicolegal implications, effects on patient-physician relationships, and work satisfaction. The follow-up semistructured interviews revealed ongoing operational challenges, but several issues had resolved and clinical and practice-level benefits surfaced. Clinical benefits included having colleagues to provide reliable drug information, gaining fresh perspectives, and having increased security in prescribing. Practice-level benefits included group education, liaison with community pharmacies, and an enhanced sense of team. Persistent operational challenges included finding time to learn about pharmacists' role and skills and insufficient space in practices to accommodate both professionals. CONCLUSION: Physicians' perspectives on collaborative practice 12 months after pharmacists were integrated into their family practices were positive overall. Some ongoing operational challenges remained. Several of the early concerns about collaborative practice had been resolved as physicians discovered the benefits of working with pharmacists, such as increased security in prescribing.

Reliability testing of a case-leveling framework for assigning level of difficulty of pharmacist's initial patient medication assessments.

OBJECTIVE: To develop and test the reliability of a case-leveling framework for assigning level of difficulty of the pharmacist's task for initial medication assessments conducted by pharmacists integrated into family physician offices. DESIGN: Descriptive study. SETTING: Seven family practice sites in Ontario from June 2004 to July 2006. PATIENTS: Patients referred by their family physician for pharmacist assessment. INTERVENTION: Individual medication assessments, monitoring, and follow-up by pharmacists. A case-leveling framework was developed with three levels of complexity (graded as I, II, or III) including specific descriptors and practice-based examples. Reliability was assessed between two standardized assessors and between one assessor and project pharmacists. Project pharmacist feedback was elicited through an e-mail survey. Reliability is reported using the kappa statistic. MAIN OUTCOME MEASURES: Reliability of a case-leveling framework and helpfulness of the framework as reported by pharmacists. RESULTS: 53 patient cases were evaluated for interrater reliability between standardized assessors. The mean (+/- SD) case level assigned was 1.8 +/- 0.68, and the kappa was 0.62 (95% CI 0.44-0.79), indicating a substantial strength of agreement between raters. For the second reliability test, 52 cases were rated, with a level of agreement between project pharmacists and the external assessor of 0.46 (95% CI 0.27-0.65), indicating moderate agreement. Feedback resulted in slight revisions to the original framework. CONCLUSION: The case-leveling framework was a reliable method and can be used to determine the level of difficulty of patient cases in primary care.

Teaching pharmacotherapeutics to family medicine residents: a curriculum.

PROBLEM BEING ADDRESSED: Medication prescribing is becoming increasingly complex, and the need for formal curricula in pharmacotherapeutics and medication prescribing in accredited family medicine residency programs has been advocated. OBJECTIVE OF PROGRAM: The main objective of the pharmacotherapeutic curriculum is to support the development of family medicine residents' pharmacotherapeutic knowledge and medication prescribing skills required for rational prescribing. PROGRAM DESCRIPTION: The curriculum has 4 main components: 1) a medication prescribing framework based on the main tasks and key decisions related to the prescribing of medications, 2) 12 pharmacotherapeutic topics identified in the needs assessment, 3) a 5-step process for session design used by the curriculum development team, and 4) a description of specific roles of facilitators involved in delivering the curriculum. Formative evaluation of the curriculum using resident focus groups has helped to inform the further development of its components. CONCLUSION: A formalized curriculum was created to build knowledge of pharmacotherapeutics and effective medication prescribing skills, which are necessary for the current complex environment of patient care and medication management.

Developing a tool to measure contributions to medication-related processes in family practice.

Successful team care requires a shared understanding of roles and expertise. This paper describes the development and preliminary exploration of the psychometric properties of a tool designed to measure contributions to family practice medication-related processes. Our team identified medication-related processes commonly occurring in family practice. We assessed clinical appropriateness using a sensibility questionnaire and pilot-tested with 11 pharmacists, nurses and physicians. We performed a simulated exercise to group the processes and assessed the internal consistency of the groupings using Cronbach's alpha coefficient. We examined test-retest reliability using intra-class coefficient (ICC). Following three revisions, the final Medication Use Processes Matrix (MUPM) included 22 medication-related processes and scale descriptors reflecting contribution to each process. Mean sensibility ratings were high for each component. We developed five theoretical groupings (diagnosis & prescribing, monitoring, administrative/documentation, education, medication review) and found their overall internal consistency was good (alpha > 0.80). The test-retest reliability was strong (ICC > 0.80). Preliminary validation showed significant differences in how health professionals view interprofessional contributions toward medication-related processes. Interprofessional care requires a negotiated understanding of processes and contributions. The MUPM provides an explicit description of medication-related processes in primary care, measures perceived contributions and emerges as a new tool to measure collaborative care in family practices.

Elevated creatine kinase and myalgia in a patient taking rosiglitazone.

OBJECTIVE: To report a case of rosiglitazone-associated elevation in creatine kinase (CK) and coexisting myalgias and review other cases identified in the literature. CASE SUMMARY: A 42-year-old man originally from Sri Lanka developed an elevated CK, with peak concentrations of 1671 U/L (normal <160) and myalgias following 5 months of therapy with rosiglitazone. Signs and symptoms recurred upon rechallenge 3 years later. Other potential medical and medication causes were ruled out. Independent assessment by 2 raters using the Naranjo probability scale suggested a probable relationship with rosiglitazone. DISCUSSION: Only 5 previous reports of elevated CK, myalgias, myopathy, or rhabdomolysis in patients taking rosiglitazone or other thiazolidinediones were identified in the literature. Potential risk factors identified from previously published reports included concomitant therapy with fibrates, excessive use of ethanol, and asymptomatic mild CK elevation prior to starting therapy. Based on this case report, it seems reasonable to monitor CK levels in patients on rosiglitazone who are experiencing muscle symptoms or who have a history of myopathy. CONCLUSIONS: Marked elevations of CK and muscle pain may be a possible adverse reaction of rosiglitazone therapy.

A systematic review of interventions to improve diabetes care in socially disadvantaged populations.

OBJECTIVE: To identify and synthesize evidence about the effectiveness of patient, provider, and health system interventions to improve diabetes care among socially disadvantaged populations. RESEARCH DESIGN AND METHODS: Studies that were included targeted interventions toward socially disadvantaged adults with type 1 or type 2 diabetes; were conducted in industrialized countries; were measured outcomes of self-management, provider management, or clinical outcomes; and were randomized controlled trials, controlled trials, or before-and-after studies with a contemporaneous control group. Seven databases were searched for articles published in any language between January 1986 and December 2004. Twenty-six intervention features were identified and analyzed in terms of their association with successful or unsuccessful interventions. RESULTS: Eleven of 17 studies that met inclusion criteria had positive results. Features that appeared to have the most consistent positive effects included cultural tailoring of the intervention, community educators or lay people leading the intervention, one-on-one interventions with individualized assessment and reassessment, incorporating treatment algorithms, focusing on behavior-related tasks, providing feedback, and high-intensity interventions (>10 contact times) delivered over a long duration (>or=6 months). Interventions that were consistently associated with the largest negative outcomes included those that used mainly didactic teaching or that focused only on diabetes knowledge. CONCLUSIONS: This systematic review provides evidence for the effectiveness of interventions to improve diabetes care among socially disadvantaged populations and identifies key intervention features that may predict success. These types of interventions would require additional resources for needs assessment, leader training, community and family outreach, and follow-up.

Collaborative medication management in a team-based primary care practice: an explanatory conceptual framework.

BACKGROUND: In ambulatory practice many different health care professionals are involved in the drug use process. The roles and functions of these individuals can be difficult to define, because of a lack of a common ground for discussion. Deliberating the topic is important for developing a team approach to medication management. OBJECTIVE: To describe a conceptual framework to create a platform that can be used by different health care providers to identify, define, and discuss roles and responsibilities in collaborative medication management. METHODS: Authors reviewed and reflected upon their experiences as practitioners in implementing a pharmaceutical care-based consulting practice within a family medicine practice setting. Key roles and responsibilities relative to collaborative management of medications were identified and described. RESULTS: A conceptual framework subsequently developed, the Team Approach to Medication Management, consists of 3 primary components referred to as medication-related practices (medication prescribing, medication taking, and medication dispensing). Each of these primary practices is supported by a team of health care professionals who have supportive roles and responsibilities. In the Team Approach to Medication Management framework, the patient's medication-taking practice holds a central and key position within a collaborative approach to medication management. CONCLUSIONS: The proposed Team Approach to Medication Management framework can be used to guide discussions and decisions among the different health care providers working in primary care to define both direct and indirect roles that health care practitioners and patients play in collaborative medication management.