Incorporating Social Determinants of Health into Patient Care Workflows Within a Health System Specialty Pharmacy.

BACKGROUND: The influence of adverse factors on social determinants of health (SDOH) and their impact on patient outcomes is widely recognized. Pharmacists, as accessible healthcare professionals, can play a pivotal role in identifying and addressing SDOH concerns. Health system specialty pharmacies have consistently assisted patients in accessing expensive specialty medications and ensuring adherence to therapy. As such, they are uniquely positioned to address SDOH concerns of patients. OBJECTIVE: To assess the effectiveness of incorporating standardized SDOH screening and referral methods into the patient care workflows of a health-system specialty pharmacy. PRACTICE DESCRIPTION: The University of North Carolina Health Care (UNC Health) Specialty and Home Delivery Pharmacy is a health-system owned specialty pharmacy serving patients in North Carolina, South Carolina, and Virginia. It holds accreditations from the Utilization Review Accreditation Commission and Accreditation Commission for Health Care. PRACTICE INNOVATION: A standardized SDOH screening and referral method was integrated into patient care workflows of a health-system specialty pharmacy. If SDOH concerns were identified upon screening by a specialty pharmacist, patients were referred to an entity within the health system responsible for connecting patients to local community resources to address their SDOH concerns. EVALUATION METHODS: The types of SDOH concerns, frequency of SDOH referrals, referral turnaround time, outcomes of the referrals, and patient demographics were evaluated to determine the impact of this project. Descriptive statistics were used to analyze results. RESULTS: Sixty-nine patients were included (female: n=38, 55.1%; age (mean±SD: 48.9±16.3). Eighty-seven SDOH concerns were reported, 54 patients (78.3%) were connected to local resources upon referral, and the average turnaround time of referrals was 2.2 business days. CONCLUSION: The findings of this pilot study highlight the effectiveness of incorporating SDOH screening and referral methods into specialty pharmacy workflows. Specialty pharmacies can successfully identify and address non-medical factors impacting patients.

Barriers and facilitators associated with implementing interventions to support oral anticancer agent adherence in academic and community cancer center settings.

PURPOSE: The goal of this study is to determine barriers and facilitators to the implementation of medication adherence interventions to support cancer patients taking novel, targeted oral anticancer agents (OAAs). METHODS: We conducted qualitative interviews using a semi-structured guide from the Consolidated Framework for Implementation Research (CFIR). We used purposive sampling to identify clinicians (physicians, pharmacists, nurse practitioners, nurses) and administrators (leadership from medicine, pharmacy, and nursing) who delivered care and/or oversee care delivery for patients with chronic leukemia prescribed an OAA. RESULTS: A total of 19 individuals participated in an interview (12 clinicians and 7 administrators), with 10 primarily employed by an academic cancer center; 5 employed by the community cancer center; and 4 employed by the integrated health-system specialty pharmacy. Barriers identified included low awareness of adherence interventions, difficulty in adherence measurement, complexity of designing and implementing a structured adherence intervention, and competing priorities. Facilitators identified included support of hospital administrators, value for pharmacists, and willingness to embrace change. Participants also made recommendations moving forward including standardizing workflow, designating champions, iterating implementation strategies, and improving communication between clinicians and with patients. CONCLUSION: Individual and system level factors were identified as determinants of implementation effectiveness of medication adherence interventions. A multidisciplinary advisory panel will be assembled to design comprehensive and actionable strategies to refine and implement a structured intervention to improve medication adherence in cancer patients.

The effects of body proportions on thermoregulation: an experimental assessment of Allen's rule.

Numerous studies have discussed the influence of thermoregulation on hominin body shape concluding, in accordance with Allen's rule, that the presence of relatively short limbs on both extant as well as extinct hominin populations offers an advantage for survival in cold climates by reducing the limb's surface area to volume ratio. Moreover, it has been suggested that shortening the distal limb segment compared to the proximal limb segment may play a larger role in thermoregulation due to a greater relative surface area of the shank. If longer limbs result in greater heat dissipation, we should see higher resting metabolic rates (RMR) in longer-limbed individuals when temperature conditions fall, since the resting rate will need to replace the lost heat. We collected resting oxygen consumption on volunteer human subjects to assess the correlation between RMR and lower limb length in human subjects, as well as to reexamine the prediction that shortening the distal segment would have a larger effect on heat loss and, thus, RMR than the shortening of the proximal segment. Total lower limb length exhibits a statistically significant relationship with resting metabolic rate (p<0.001; R(2)=0.794). While this supports the hypothesis that as limb length increases, resting metabolic rate increases, it also appears that thigh length, rather than the length of the shank, drives this relationship. The results of the present study confirm the widely-held expectation of Allen's rule, that short limbs reduce the metabolic cost of maintaining body temperature, while long limbs result in greater heat dissipation regardless of the effect of mass. The present results suggest that the shorter limbs of Neandertals, despite being energetically disadvantageous while walking, would indeed have been advantageous for thermoregulation.

The effect of lower limb length on the energetic cost of locomotion: implications for fossil hominins.

The consequences of the relatively short lower limbs characteristic of AL 288-1 have been widely discussed, as have the causes and consequences of the short limbs of Neanderthals. Previous studies of the effect of limb length on the energetic cost of locomotion have reported no relationship; however, limb length could have accounted for as much as 19% of the variation in cost and gone undetected (Steudel and Beattie, 1995; Steudel, 1994, 1996). Kramer (1999) and Kramer and Eck (2000) have recently used a theoretical model to predict the effect of the shorter limbs of early hominids, concluding that the shorter limbs may actually have been energetically advantageous. Here, we took an experimental approach. Twenty-one human subjects, of varying limb lengths, walked on a treadmill at 2.6, 2.8, 3.0 and 3.2m.p.h., while their expired gases were analyzed. The subjects walked for 12 minutes at each speed and their rates of oxygen consumption (VO2) over four minutes were averaged to estimate VO2. We also measured each subject's height, weight and lower limb length. Lean body mass and % fat were determined using dual-energy x-ray absorptiometry. ANCOVA with total VO2 at either speed as the dependent variable and total lean mass, % fat and lower limb length as covariates resulted in all three covariates having a significant positive effect on VO2 at p<0.01. Subjects with relatively longer lower limbs had lower locomotor costs. Thus the short lower limbs characteristic of some hominid taxa would have resulted in more costly locomotion, barring some physiological anomaly. The magnitude of this effect is substantial; Neanderthals are estimated to have had locomotor costs 30% greater than those of contemporary anatomically modern humans. By contrast the increase in lower limb length seen in H. erectus would have mitigated the increase in locomotor costs produced by the increase in body size.