International, multidisciplinary Delphi consensus recommendations on non-pharmacological interventions for fibromyalgia.

OBJECTIVES: To develop evidence-based expert recommendations for non-pharmacological treatments for pain, fatigue, sleep problems, and depression in fibromyalgia. METHODS: An international, multidisciplinary Delphi exercise was conducted. Authors of EULAR and the Canadian Fibromyalgia Guidelines Group, members of the American Pain Society and clinicians with expertise in fibromyalgia were invited. Participants were asked to select non-pharmacological interventions that could be offered for specific fibromyalgia symptoms and to classify them as either core or adjunctive treatments. An evidence summary was provided to aid the decision making. Items receiving >70% votes were accepted, those receiving <30% votes were rejected and those obtaining 30-70% votes were recirculated for up to two additional rounds. RESULTS: Seventeen experts participated (Europe (n = 10), North America (n = 6), and Israel (n = 1)) in the Delphi exercise and completed all three rounds. Aerobic exercise, education, sleep hygiene and cognitive behavioural therapy were recommended as core treatments for all symptoms. Mind-body exercises were recommended as core interventions for pain, fatigue and sleep problems. Mindfulness was voted core treatment for depression, and adjunctive treatment for other symptoms. Other interventions, namely music, relaxation, hot bath, and local heat were voted as adjunctive treatments, varying between symptoms. CONCLUSIONS: This study provided evidence-based expert consensus recommendations on non-pharmacological treatments for fibromyalgia that may be used to individualise treatments in clinical practice targeting the diverse symptoms associated with fibromyalgia.

An Academic-Community Collaboration to Deliver Medication Therapy Management (MTM) Services to Patients Living in Rural Counties of a Southwestern State in the United States.

BACKGROUND: Patients living in rural communities often experience pronounced health disparities, have a higher prevalence of diabetes and hypertension, and poorer access to care compared to urban areas. To address these unmet healthcare service needs, an established, academic-based MTM provider created a novel, collaborative program to provide comprehensive, telephonic services to patients living in rural Arizona counties. OBJECTIVE: This study assessed the program effectiveness and described differences in health process and outcome measures (e.g., clinical outcomes, gaps in care for prescribed medications, medication-related problems) between individuals residing in different rural-urban commuting area (RUCA) groups (urban, micropolitan, and small town) in rural Arizona counties. METHODS: Subjects eligible for inclusion were 18 years or older with diabetes and/or hypertension, living in rural Arizona counties. Data were collected on: demographic characteristics, medical conditions, clinical values, gaps in care, medication-related problems (MRPs), and health promotion guidance. Subjects were analyzed using 3 intra-county RUCA levels (i.e., urban, micropolitan, and small town). RESULTS: A total of 384 patients were included from: urban (36.7%), micropolitan (19.3%) and small town (44.0%) areas. Positive trends were observed for clinical values, gaps in care, and MRPs between initial and follow-up consultations. Urban dwellers had significantly lower average SBP values at follow-up than those from small towns (p < 0.05). A total of 192 MRPs were identified; 75.0% were resolved immediately or referred to providers and 16.7% were accepted by prescribers. CONCLUSION: This academic-community partnership highlights the benefits of innovative collaborative programs, such as this, for individuals living in underserved, rural areas.

Hypertension, cholesterol and diabetes medication adherence, health care utilization and expenditure in a Medicare Supplemental sample.

ABSTRACT: Limited evidence exists regarding the relationships between adherence, as defined in Pharmacy Quality Alliance (PQA) medication adherence measures, health care utilization, and economic outcomes. PQA adherence measures for hypertension, cholesterol, and diabetes are of particular interest given their use in Medicare Star Ratings to evaluate health plan performance.The objective of this study was to assess the relationship between adherence and utilization and cost among Medicare Supplemental beneficiaries included in the aforementioned PQA measures over a 1-year period.Retrospective cohort study.Three cohorts (hypertension, cholesterol, and diabetes) of eligible individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009-2015) were used to assess associations between adherence and health care expenditure and utilization for Medicare Supplemental beneficiaries.Generalized linear models with log link and negative binomial (utilization) or gamma (expenditure) distributions assessed relationships between adherence (≥80% proportion of days covered) and health care utilization and expenditure (in 2015 US dollars) while adjusting for confounding variables. Beta coefficients were used to compute cost ratios and rate ratios.Adherence for all 3 disease cohorts was associated with lower outpatient and inpatient visits. During the 1-year study period, adherence was associated with lower outpatient, inpatient, and total expenditures across the cohorts, ranging from 9% lower outpatient costs (diabetes cohort) to 41.9% lower inpatient costs (hypertension cohort). Savings of up to $324.53 per member per month in total expenditure were observed for the hypertension cohort.Our findings indicate adherence is associated with lower health care utilization and expenditures within 1 year.

Corrigendum to "Impact evaluation of a four-year academic-community partnership in provision of medication management and tertiary prevention services for rural patients with diabetes and/or hypertension" preventive medicine reports 17 (2020): 101,038.

[This corrects the article DOI: 10.1016/j.pmedr.2019.101038.].

Evaluating the relationship between quality measure adherence definitions and economic outcomes in commercial health plans: a retrospective diabetes cohort study.

BACKGROUND: Diabetes is a prevalent chronic condition in the United States that results in considerable morbidity and mortality, frequent use of the health care system, and high health care expenditures. Adherence to antidiabetic medications can help improve health outcomes and lower health care utilization and expenditures. The Pharmacy Quality Alliance (PQA) Proportion of Days Covered (PDC): Diabetes All Class medication adherence measure was developed and endorsed to improve adherence to noninsulin antidiabetic medications; however, it has not been assessed in a commercial population of diabetes patients over a 1-year time frame. OBJECTIVE: To determine the association between adherence, as defined in the PQA medication adherence measures, and health care utilization and expenditure among commercially insured individuals using antidiabetic medications. METHODS: This 1-year retrospective study evaluated a cohort of individuals from IBM MarketScan Research Databases (2009-2015) with noninsulin antidiabetic medications. Eligible study subjects included adults (aged ≥ 18 years at index date) with continuous enrollment in their health plans for 6 months before (i.e., baseline period) and 12 months after (i.e., study period) the index date and ≥ 2 prescriptions dispensed for any medication included in the PQA PDC Diabetes All Class medication adherence measure, with at least 150 days between the first and last fill during the study period. The index date was defined as the first fill for a medication included in the PQA PDC Diabetes All Class adherence measure after a 180-day baseline period. Generalized linear models with log link and gamma distribution (expenditure) or negative binomial distribution (utilization) assessed relationships between adherence (≥ 80% PDC) and health care utilization and expenditure while adjusting for potential confounders. Cost ratios (CR) and rate ratios (RR) were computed using beta coefficients. Cohort characteristics were compared using t-tests, Wilcoxon rank sum tests, or chi-square tests with an alpha level of 0.001 set a priori. RESULTS: A total of 1,576,112 individuals were eligible; of these, 1,028,176 (65.2%) were adherent. Significant differences in demographic characteristics were observed between adherent and nonadherent groups (P < 0.001). Multivariable analyses demonstrated that adherence was associated with the following: (a) 16.6% fewer inpatient (RR = 0.834, 95% CI = 0.819-0.850) and 3.6% more outpatient service visits (RR = 1.036, 95% CI = 1.032-1.039) and (b) 16.8% lower inpatient expenditures (CR = 0.833, 95% CI = 0.829-0.836); 2.6% lower outpatient expenditures (CR = 0.974, 95% CI = 0.970-0.978); 16.4% higher prescription drug expenditures (CR = 1.164, 95% CI = 1.159-1.169); and 4.2% lower total (CR = 0.958, 95% CI = 0.954-0.962) expenditures. Adherent subjects were associated with lower incremental per member per month expenditures for inpatient (-$31.74), outpatient (-$10.09), and total (-$30.82) expenditures, yet higher prescription drug expenditures ($25.60) compared with nonadherent subjects. CONCLUSIONS: Adherence to noninsulin antidiabetic medications was associated with more outpatient and fewer inpatient visits, as well as lower total expenditures compared with nonadherence. DISCLOSURES: Funding was provided by grants from Pharmacy Quality Alliance, Merck & Co. (Kenilworth, NJ), and SinfoniaRx. In addition, Chinthammit reports personal fees from Eli Lilly and Company, outside the submitted work. Axon reports grants from the American Association of Colleges of Pharmacy and the Arizona Department of Health Services, outside the submitted work. Taylor reports grants from the Arizona Department of Health Services, outside the submitted work. Warholak reports grants from Novartis and the Arizona Department of Health Services, outside the submitted work. Chinthammit and Campbell disclose that this work was completed during their employment at the University of Arizona. This research was presented as a poster at the AMCP Annual Meeting 2019; March 25-28, 2019; San Diego, CA.

Expanding pharmacists' roles: Pharmacists' perspectives on barriers and facilitators to collaborative practice.

OBJECTIVE: The pharmacy profession is shifting from transactional dispensing of medication to a more comprehensive, patient-centered model of care. Collaborative practice agreements (CPAs) extend the role of a pharmacist to initiate, monitor, modify, and discontinue drug therapies and provide other clinical services. Although collaborative practice has been shown to improve health system efficiency and patient outcomes, little is known about how pharmacists perceive CPAs. To explore pharmacists' perspectives of CPAs, including barriers and facilitators to CPA implementation. METHODS: Semistructured key informant interviews were used to elicit information from licensed pharmacists practicing in a variety of settings in Arizona. Thematic analysis was used to identify key qualitative themes. RESULTS: Seventeen interviews of pharmacists with (n = 11, 64.7%) and without (n = 6, 35.3%) CPAs were conducted in April-May 2019. The pharmacists saw their role in CPAs as supportive, filling a care gap for overburdened providers. A heightened sense of job satisfaction was reported owing to increased pharmacist autonomy, application of advanced knowledge and clinical skills, and ability to have a positive impact on patients' health. Challenges to the implementation of CPAs included liability and billing issues, logistic concerns, some experiences with provider hesitancy, and lack of information and resources to establish and maintain a CPA. The barriers could be overcome with conscious team-building efforts to establish trust and prove the worth of pharmacists in health care teams; strategic engagement of stakeholders in the development of CPAs, including billing and legal departments; and mentorship in the CPA creation process. CONCLUSIONS: The pharmacists in this study enjoyed practicing collaboratively and had overall positive perceptions of CPAs. As health worker shortages become more dire and pharmacy practice evolves to expand the role of pharmacists in providing direct patient care, CPAs will be an important tool for restructuring care tasks within health systems.

Assessing the association between medication adherence, as defined in quality measures, and disease-state control, health care utilization, and costs in a retrospective database analysis of Medicare supplemental beneficiaries using statin medications.

BACKGROUND: Adherence to medication, and related health and economic outcomes, is becoming increasingly important as populations age and as the number of Americans managing chronic conditions increases. The Pharmacy Quality Alliance (PQA) statin medication adherence measure is used in Medicare star ratings to evaluate health plan performance. Yet, limited evidence exists that investigates the association between statin medication adherence, as specified in the PQA adherence quality measure, and disease-state control, health care utilization, and costs. OBJECTIVE: To determine the association between adherence (≥80% proportion of days covered) and disease-state control, health care utilization, and health care costs for Medicare supplemental beneficiaries using statin medications eligible for inclusion in the PQA statin adherence quality measure. METHODS: This retrospective study used a cohort of eligible beneficiaries for inclusion in the PQA statin adherence measure with low-density lipoprotein (LDL) laboratory values from IBM MarketScan Medicare Supplemental Research Databases (2009-2015). A logistic regression model assessed the association between adherence and LDL control (controlled individuals had LDL levels ≤ 100 mg/dL). Health care utilization and costs during a 1-year period, from first statin medication claim, were compared between adherent and nonadherent groups using generalized linear models with log link and negative binomial distribution (utilization) or gamma distribution (costs), adjusting for covariates. Beta coefficients were used to compute cost ratios (CR) and rate ratios (RR). Cohort characteristics were assessed using t-tests, Wilcoxon rank sum tests, or chi-square tests. An a priori alpha level of 0.001 was used. RESULTS: The study cohort consisted of 77,174 beneficiaries, of whom 58,668 (76.0%) were classified as adherent to their statin medications. After controlling for other factors, odds of disease-state control were approximately 2 times higher among medication adherent beneficiaries compared with their nonadherent counterparts (OR = 2.192; 95% CI = 2.109-2.278). Multivariable analyses showed adherers experienced 4.7% fewer outpatient (RR = 0.953; 95% CI = 0.940-0.965) and 27.5% fewer inpatient (RR = 0.725; 95% CI = 0.687-0.766) visits; had 9.9% lower outpatient (CR = 0.901; 95% CI = 0.885-0.916) and 28.3% lower inpatient (CR = 0.717; 95% CI = 0.705-0.729) costs; 14.7% lower total costs (CR = 0.853; 95% CI =0.838-0.868); and 7.0% higher prescription drug costs (CR = 1.070; 95% CI = 1.052-1.089) than nonadherers. Adherence to statin medications was associated with a reduction in total costs of $157.32 per member per month. CONCLUSIONS: This retrospective database analysis demonstrated that statin adherence was associated with approximately twice the odds of having a controlled disease state compared with nonadherence in a large Medicare sample. Adherent beneficiaries had fewer outpatient and inpatient visits (lower utilization), lower outpatient and inpatient costs, and lower total costs, a calculated savings of $157.32 per member per month, despite having higher prescription drug costs. Finally, these results provide important new information by demonstrating that adherence (≥ 80%) is associated with lower health care costs in a short (1-year) time frame. DISCLOSURES: Funding for this study was provided by Pharmacy Quality Alliance; Merck & Co. (Kenilworth, NJ); and SinfoniaRx. All authors except Pickering and Black were employed by the University of Arizona College of Pharmacy or the Mel & Enid Zuckerman College of Public Health at the time of this study. Pickering is employed by the Pharmacy Quality Alliance, and Black is employed by Merck & Co. Chinthammit also reports employment with Eli Lilly and Company, and Campbell reports employment with the Pharmacy Quality Alliance. Axon reports grants from Arizona Department of Health Services, unrelated to this work. Warholak reports grants from Novartis and the Arizona Department of Health Services, unrelated to this work. This research was presented as a poster at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Annual Meeting 2019, May 18-22, 2019, in New Orleans, LA.

Perceptions and experiences of promotoras and pharmacists in an academic-community partnership providing telephonic MTM services to a Spanish-speaking, rural population: a focus group study.

BACKGROUND: The literature is limited concerning the collaboration between pharmacists and promotoras in the delivery of medication therapy management (MTM) services. Yet, this information could help address a practice gap while improving MTM collaborative care approaches. OBJECTIVE: To identify the knowledge, attitudes, and barriers of clinical call center health professionals (pharmacists, nurses, pharmacy interns) and promotoras towards MTM collaborative care in implementing the Rural Arizona Medication Therapy Management (RAzMTM) program. METHODS: A descriptive, qualitative study using semistructured focus groups was conducted with call center health professionals and promotoras who participated in the RAzMTM program to improve pharmaceutical care for patients with diabetes and/or hypertension in rural Arizona. Recruitment and consent letters, a demographic questionnaire, and a focus group guide were designed specifically for this project. Three facilitators participated in each focus group-one guided the discussion while the others took notes. Focus groups were audio recorded to verify all responses and transcribed verbatim with omission of participant identifiers. Thematic analysis was conducted by 2 independent researchers who reviewed the transcripts to identify codes, seek consensus, and agree on themes, with negotiation from a third independent researcher. RESULTS: Nine participants took part in 2 focus groups. Participants were predominantly female (89%), college graduates and/or had postgraduate/professional degrees (78%), and were Hispanic or Latino (89%). Five themes were identified: (1) roles and responsibilities of RAzMTM participants; (2) benefits unique to the RAzMTM program; (3) interprofessional experience of RAzMTM participants; (4) professional growth for RAzMTM participants; and (5) opportunities for future improvement. Perceptions of the participants in the RAzMTM program were consistent-experiences of health professionals and promotoras were positive; they recognized the benefit of each other's involvement in the program; and they learned how to work together to improve patient care. Future recommended program improvements include improving ease of scheduling (e.g., extending pharmacist availability to provide MTM services). CONCLUSIONS: These focus group results suggest that provision of telephonic MTM services, using an academic-community partnership, was positively received by participating pharmacists and promotoras. However, future work is needed for continued improvement of strategies to enhance interprofessional relationships in patient chronic disease management. DISCLOSURES: This project was supported by the Grant or Cooperative Agreement Number DP004793, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. This work also was supported, in part, by SinfoniaRx. Axon, Taylor, and Warholak received funding from SinfoniaRx. Axon reports grants from Tabula Rasa Op-Co, Merck & Co, Pharmacy Quality Alliance, Arizona Department of Health, and American Association of Colleges of Pharmacy, outside the submitted work. Warholak and Taylor received funding from Arizona Department of Health Services as part of a contract, outside the submitted work. Vaffis reports funding from Merck and Pharmacy Quality Alliance. This study was presented as a poster at the American Society of Health-System Pharmacists Summer Meetings & Exhibition (June 10-12, 2019, Boston, MA) and as a podium presentation at the Arizona Pharmacy Association Southwestern States Residency Conference (June 14, 2019, Phoenix, AZ).

A retrospective cohort study evaluating the relationship between statin medication adherence and economic outcomes in commercial health plans.

BACKGROUND: Adherence to statin medications is suboptimal; however, the association of statin adherence, as defined in medication adherence quality measures, with healthcare service use and expenditure within one year has not been assessed in a commercially insured United States (US) population. OBJECTIVE: To investigate the relationship between statin adherence, as specified in the Pharmacy Quality Alliance (PQA) statin medication adherence quality measure, and healthcare resource utilization and expenditures within commercial health plans over a one-year period. METHODS: This one-year retrospective analysis involved a cohort of individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009-2015). Generalized linear models with log link and negative binomial distribution (use) or gamma distribution (expenditures) were used to assess relationships between medication adherence (≥80% proportion of days covered) and healthcare use and expenditures (adjusted to 2015 US dollars) while adjusting for covariates. Beta coefficients were used to compute cost ratios (CR) and rate ratios (RR). An alpha level of 0.001 was set a priori. RESULTS: Of 4,450,308 eligible individuals, 2,757,288 (61.9%) were classified as adherent. Multivariable analyses indicated adherent individuals had more outpatient (RR = 1.009, 95% CI = 1.007, 1.010) and fewer inpatient visits (RR = 0.756, 95% CI = 0.749, 0.762); and lower outpatient (CR = 0.965, 95% CI = 0.963, 0.967), inpatient (CR = 0.780, 95% CI = 0.779, 0.782), and total expenditures (CR = 0.975, 95% CI = 0.973, 0.977). Adherence was associated with lower per member per month total healthcare expenditures ($18.91) vs nonadherence. CONCLUSION: Within one year, statin adherence was associated with more outpatient and fewer inpatient visits, lower outpatient and inpatient expenditures, and lower total expenditures than nonadherence, within a commercially-insured population.

Current Procedural Terminology Codes for Medication Therapy Management in Administrative Data.

BACKGROUND: Three pharmacist-specific Current Procedural Terminology (CPT) codes exist to facilitate medication therapy management (MTM) reimbursement (codes 99605, 99606, and 99607). However, no studies have used CPT codes in administrative claims databases to identify subjects who have received MTM services. OBJECTIVE: To assess the prevalence of MTM services provided, using CPT codes identified in an administrative dataset. METHODS: A retrospective cohort study was conducted using a subset of Medicare Part D individuals from the IBM MarketScan Medicare Supplemental Research Databases (2009-2015). Researchers identified beneficiaries who received MTM services using CPT codes 99605, 99606, and 99607. RESULTS: Of the 16,483,709 individuals in the dataset, only 3,291 had CPT codes indicating that they received MTM services, representing an overall prevalence of 0.020%. CONCLUSIONS: The use of CPT codes as an indicator of MTM service provision resulted in far lower MTM utilization rates than in published literature. Reliance on CPT codes to identify MTM services in administrative claims is not recommended, given that it limited the researchers' ability to properly identify patient receipt of such services. More accurate methodologies are warranted for identifying MTM use and its effects on patient outcomes. DISCLOSURES: This work was supported by Pharmacy Quality Alliance; Merck Sharp & Dohme, a subsidiary of Merck & Co. (Kenilworth, NJ); and SinfoniaRx. The funding sources had no role in study design, collection, analysis, and interpretation of data, writing the report, or decision to submit the article for publication. Tate, Chinthammit, and Campbell completed this work during their employment at the University of Arizona. Pickering was an employee of Pharmacy Quality Alliance at the time of this study. Black is employed by Merck. Axon reports grants from the Arizona Department of Health Services and the American Association of Colleges of Pharmacy; Campbell reports a grant from the Community Pharmacy Foundation; Chinthammit reports fees from Eli Lilly; Black has received a grant from Merck; Warholak reports grants from the Arizona Department of Health Services and Novartis, all unrelated to this study. Taylor reports grants from Tabula Rasa Op-Co, during the conduct of the study, and from the Arizona Department of Health Services, outside the conduct of this study. This research was accepted as a poster presentation at the International Society for Pharmacoeconomics and Outcomes Research Annual Meeting, May 16-20, 2020, in Orlando, FL, but was not presented due to the COVID-19 pandemic. An abstract was published in Value in Health, 2020;23(Suppl 1):S305.

Reprint of: The role of the pharmacist in mental health: An investigation of the impact of pharmacist-led interventions on psychotropic medication adherence in patients with diabetes.

OBJECTIVE: To evaluate the impact of targeted telepharmacist mental health adherence interventions for patients with type 2 diabetes. METHODS: This retrospective review involved the analysis of a telepharmacist-led mental health intervention. The subjects included: patients aged 18 years or more with type 2 diabetes, enrolled in an adherence service and who had been prescribed psychotropics. Psychotropic medication adherence was measured using the proportion of days covered (PDC) 6 months before and after the telepharmacist-led medication intervention. RESULTS: A total of 8167 patients (67% women), with a mean age of 63 ± 11 years, were included in the study. Most alerts for psychotropics were for selective serotonin reuptake inhibitors (SSRIs) (53%, n = 4334), selective norepinephrine reuptake inhibitors (SNRIs) (22%, n = 1775), second-generation antipsychotics (11%, n = 909), and bupropion (10%, n = 782). Alerts with the greatest volume of PDCs (above 85%) at postintervention follow up included SSRIs (51%, n = 2228), SNRIs (50%, n = 884), and second-generation antipsychotics (47%, n = 424). Before the alert, the mean PDC was 66% ± 12% across all medications studied. Post intervention, the mean PDC rose to 79% ± 19. A paired t-test revealed statistically significant improvement in adherence overall, with the greatest change observed in these alert groups: SSRIs (P < 0.001), alpha-2 antagonist (P < 0.001), SNRIs (P < 0.001), and bupropion (P < 0.001). CONCLUSION: This retrospective review showed that pharmacist-led targeted, adherence interventions greatly improved psychotropic medication adherence in adult patients with type 2 diabetes. Future work is warranted to investigate the impact on type 2 diabetes medication adherence and health markers (e.g., HbA1c values) in larger and more diverse populations of patients with comorbid type 2 diabetes and a mental health condition.

Associations of Renin-Angiotensin System Antagonist Medication Adherence and Economic Outcomes Among Commercially Insured US Adults: A Retrospective Cohort Study.

Background Medication non-adherence can result in considerable morbidity, mortality, and costs. The Pharmacy Quality Alliance hypertension medication adherence measure is used by US healthcare payers and providers to assess renin-angiotensin system antagonist medication adherence. However, associations between renin-angiotensin system antagonist adherence as calculated in quality measures, and healthcare service use and expenditure in commercial populations over a 1-year timeframe has not been assessed. Methods and Results This retrospective cohort study used eligible commercially insured individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009-2015). Generalized linear models with log link and gamma distribution (expenditure) or negative binomial distribution (usage) assessed relationships between hypertension adherence (≥80% proportion of days covered) and healthcare use and expenditures (in 2015 US dollars) while adjusting for covariates (age, sex, geographic region; health plan; Deyo-Charlson Comorbidity Index, number of chronic medications, and treatment naivety). Beta coefficients were used to compute cost ratios and rate ratios. A total of 4 842 058 subjects were eligible; of those, 3 310 360 (68%) were adherent (adherent mean age 53.3±8.0 years, 55.9% men; non-adherent mean age 50.3±9.1 years, 53.1% men). Adherence was associated with fewer inpatient (rate ratios, 0.612; 95% CI, 0.607-0.617) and outpatient visits (rate ratios, 0.995; 95% CI, 0.994-0.997); and lower total costs (cost ratios, 0.876; 95% CI, 0.874-0.878) compared with non-adherence. Adherence was associated with lower average per member per month total costs ($97.98) compared with non-adherence. Conclusions Adherence to renin-angiotensin system antagonists was associated with fewer outpatient and inpatient visits, and lower total costs compared with non-adherence in a 1-year time frame.

A Research Partnership to Enhance Postgraduate Pharmacy Residency Training Outcomes.

Pharmacy residents must complete research as part of their program; however, challenges exist in providing experiences that result in successful research dissemination outcomes. A university-based research team, integrated into an ambulatory care pharmacy residency program aimed to improve presentation and publication rates of pharmacy resident research projects. Data on the number of postgraduate year-2 (PGY2) residents and their productivity were collected and summarized to assess progress. A total of 13 residents completed their residency over seven years. Each resident produced one regional presentation, and one national presentation beginning in year four. To date, three peer-reviewed papers have been published, with another one in-press. Responses from residents found lack of guidance, lack of data availability for projects and feedback fatigue were barriers to a positive research experience. To address these problems, a university-based research team was integrated to provide research mentor guided support, ensure study feasibility, and provide structured feedback. This program evaluation highlighted the integration of a PGY2 ambulatory care pharmacy residency with a designated, interprofessional university-based research team. Future work is warranted to reduce research-related barriers and formally evaluate resident post-program knowledge, skills, and subsequent dissemination rates.

Exploring performance predictors among employees in a pharmacist-led medication management center.

OBJECTIVE: Health care companies are increasingly interested in developing and maintaining employee motivation. However, this can be challenging with different professions working together in delivering telephonic medication therapy management services. The purpose of the study is to assess employees' perceptions of performance metrics, strategies to achieve those metrics, motivational work factors, and barriers to achievement at a medication management center (MMC). DESIGN: Focus group using purposive sampling. SETTING: Six in-person focus groups were conducted with the MMC employees. PARTICIPANTS: Separate focus groups were conducted for pharmacists, student pharmacist interns, and pharmacy technicians. Each group consisted of approximately 5 participants, lasted roughly 1 hour, and was facilitated by trained qualitative researchers. OUTCOME MEASURES: The semistructured sessions involved participants responding to open-ended, predetermined questions introduced by a facilitator. The sessions were audio-recorded and transcribed for analysis. Two independent reviewers analyzed the transcripts; a third independent reviewer facilitated a consensus to resolve discrepancies. RESULTS: Thirty MMC employees, with an average age of 32.1 ± 10.5 years, participated; most of them (73.3%) were women and had worked at the MMC for an average of 2.8 ± 2.2 years. Six themes were identified: (1) awareness and understanding of performance measures; (2) perceptions of performance measures; (3) suggested changes to make the performance measures more reflective of their roles; (4) motivating factors to improve performance; (5) performance barriers; and (6) strategies to achieve performance goals. The intrinsic motivational factors included providing patient care, helping change patients' lives, and meeting work goals. The extrinsic motivational factors included remuneration, management, teamwork, work environment, and feedback. The performance barriers were unrealistic goals, lack of feedback, ineffective communication, and inconsistent operational procedures. CONCLUSIONS: These study findings contribute to a growing body of research surrounding employee motivation within organizations with diverse workforces. Future work is warranted to investigate employee motivation in similar pharmacy-related settings.

Pharmacists' perceptions of the pharmacists' patient care process and performance in a simulated patient interaction.

OBJECTIVES: To (1) evaluate the use of the pharmacists' patient care process (PPCP) by licensed pharmacists through a simulated patient activity and (2) describe pharmacists' awareness and perceptions of the PPCP in the state of Arizona. DESIGN: Interviews were conducted to elicit pharmacists' perceptions and awareness of the PPCP. A simulated patient activity involved a role-play pharmacist-patient interaction in a community pharmacy setting. The PPCP was employed as the evaluative framework to assess pharmacist behavior. SETTING AND PARTICIPANTS: Pharmacists licensed in the state of Arizona practicing in various pharmacy settings were recruited through e-mail list serves and snowball recruitment. Data were collected in person, by telephone, and via video chat. OUTCOME MEASURES: Emergent qualitative themes from interviews were used to describe pharmacists' awareness and perceptions of the PPCP. The presence or absence of PPCP elements were assessed during the simulations. RESULTS: A total of 17 pharmacists were interviewed; 16 participated in the simulated activity. Of these, 7 (41.2%) participants recalled specific details regarding the PPCP process. Participants felt that the PPCP accurately reflected their daily workflow. Accordingly, a mean of 15.8 of the 19 PPCP elements was observed in simulated pharmacist-patient interactions, still allowing room for improvement in pharmacist-led care planning. Participants indicated perceived value in a shared patient care process that facilitates collaboration with myriad health professionals and as an aid to leverage pharmacists' role on health care teams. CONCLUSION: In this study, pharmacists practicing in Arizona in various settings expressed an awareness of the PPCP, felt it accurately reflected the work they do, and expressed that the tool potentially added value to their work.

The role of the pharmacist in mental health: An investigation of the impact of pharmacist-led interventions on psychotropic medication adherence in patients with diabetes.

OBJECTIVE: To evaluate the impact of targeted telepharmacist mental health adherence interventions for patients with type 2 diabetes. METHODS: This retrospective review involved the analysis of a telepharmacist-led mental health intervention. The subjects included: patients aged 18 years or more with type 2 diabetes, enrolled in an adherence service and who had been prescribed psychotropics. Psychotropic medication adherence was measured using the proportion of days covered (PDC) 6 months before and after the telepharmacist-led medication intervention. RESULTS: A total of 8167 patients (67% women), with a mean age of 63 ± 11 years, were included in the study. Most alerts for psychotropics were for selective serotonin reuptake inhibitors (SSRIs) (53%, n = 4334), selective norepinephrine reuptake inhibitors (SNRIs) (22%, n = 1775), second-generation antipsychotics (11%, n = 909), and bupropion (10%, n = 782). Alerts with the greatest volume of PDCs (above 85%) at postintervention follow up included SSRIs (51%, n = 2228), SNRIs (50%, n = 884), and second-generation antipsychotics (47%, n = 424). Before the alert, the mean PDC was 66% ± 12% across all medications studied. Post intervention, the mean PDC rose to 79% ± 19. A paired t-test revealed statistically significant improvement in adherence overall, with the greatest change observed in these alert groups: SSRIs (P < 0.001), alpha-2 antagonist (P < 0.001), SNRIs (P < 0.001), and bupropion (P < 0.001). CONCLUSION: This retrospective review showed that pharmacist-led targeted, adherence interventions greatly improved psychotropic medication adherence in adult patients with type 2 diabetes. Future work is warranted to investigate the impact on type 2 diabetes medication adherence and health markers (e.g., HbA1c values) in larger and more diverse populations of patients with comorbid type 2 diabetes and a mental health condition.

Preliminary Investigation of Pharmacist-Delivered, Direct-to-Provider Interventions to Reduce Co-Prescribing of Opioids and Benzodiazepines among a Medicare Population.

Co-prescribing of opioids and benzodiazepines can lead to overdoses and mortality. This retrospective study analyzed prescription claims data collected in 2016. A national medication therapy management (MTM) program conducted prescriber-based outreach interventions for patients with concurrent opioid and benzodiazepine prescriptions. The pharmacist's direct-to-prescriber intervention was conducted following a targeted medication review. The pharmacist initiated interventions with the prescriber via facsimile to recommend discontinuation of concurrent use of these drugs. This study included 57,748 subjects who were predominantly female (67.83%) and aged ≥ 65 years (66.90%). Prescribers were most commonly located in the southern United States (46.88%). The top prescribed opioid medications were hydrocodone-acetaminophen (33.60%), tramadol (17.50%), and oxycodone-acetaminophen (15.66%). The top benzodiazepines prescribed concurrently with opioids were alprazolam (35.11%), clonazepam (21.16%), and lorazepam (20.09%). Based on the pharmacists' recommendations, 37,990 (65.79%) resulted in a medication discontinuation (benzodiazepines 40.23%; opioids 59.77%) by the provider. There were significant differences in the proportion of opioids discontinued by subject age (p < 0.001) and prescriber geographical region (p = 0.0148). The top medications discontinued by the prescriber were hydrocodone-acetaminophen (18.86%), alprazolam (14.19%), and tramadol HCl (13.51%). This study provides initial evidence for pharmacist-supported, direct-to-prescriber programs as an effective medication safety strategy.

Evaluating provider acceptance of pharmacist interventions in the Discharge Companion Program and its association with readmission reduction.

OBJECTIVE: To evaluate provider acceptance of pharmacist interventions within the Discharge Companion Program (DCP) and its association with hospital readmissions. METHODS: This retrospective record review included patients referred to the DCP between January and October 2018. DCP pharmacists' interventions were assessed for provider acceptance on follow-up consultation or readmission. A chi-square test assessed the association between provider acceptance, communication modality, and technology used. A logistic regression model assessed the association between readmission risk and variables of interest. An a priori alpha level of 0.05 was used. RESULTS: Of the 197 patients referred to the DCP, 102 met inclusion criteria. DCP pharmacists made a total of 271 interventions; 185 (68.7%) required provider action. The most common intervention type was medication addition or discontinuation (n = 74, 40%); the communication mode was between DCP nurses and primary care provider offices or skilled nursing facilities (n = 56, 54.9%); and the preferred technology was the telephone (n = 58, 56.9%). Provider acceptance rate was 30.8% (n = 57) of actionable interventions, although it was not significantly associated with 30-day readmission reductions (P = 0.833) and did not differ significantly when interventions were communicated to other health care professionals (P = 0.53). The specific intervention communication mode (i.e., telephone, facsimile, or both) of pharmacist interventions did not significantly affect provider acceptance (P = 0.133). The overall readmission rate was 22.5% (n = 23), and the only significant predictor of 30-day readmission was the number of comorbidities (odds ratio 1.28 [95% CI 1.03-1.58], P = 0.024). CONCLUSION: Provider acceptance of pharmacists' interventions did not significantly affect 30-day readmission rates, regardless of communication mode (telephone or facsimile) or technology used. However, the DCP successfully identified numerous medication-related problems. Further study is warranted regarding provider acceptance of pharmacist recommendations on 30-day readmission reduction.

Impact evaluation of a four-year academic-community partnership in provision of medication management and tertiary prevention services for rural patients with diabetes and/or hypertension.

Medication therapy management (MTM) services, including targeted, pharmacist-delivered, tertiary prevention interventions, were provided to rural patients with chronic diseases via an academic-community partnership. The purpose of this investigation was to evaluate the overall program and pre/post patient outcomes from this four-year, multi-site collaboration. Five community health sites collaborated with a university-based MTM provider to deliver services in Arizona (2012-16). Eligible patients: were 18 or older (median 65 years); had a diagnosis of diabetes and/or hypertension; and resided in a rural community. Participants received an initial telephone consultation with the MTM pharmacist; follow-up consultations were conducted after 30 or 90 days for high- and low-risk patients, respectively. Community partner staff collected clinical data and addressed pharmacists' recommendations. Descriptive analysis and bivariate analyses of pre- and post-intervention results were conducted. Most (n = 410, 70%) of the 577 participants receiving an initial and follow-up consultation with the MTM pharmacist had both diabetes and hypertension. These individuals showed statistically significant improvements in fasting blood glucose (p < 0.0001), hemoglobin A1C (p = 0.0082) and systolic blood pressure (p = 0.009) while those with only one condition did not demonstrate significant changes. While the pre/post changes in chronic disease control indicators were statistically significant, the clinical significance was low to moderate. Patients with both comorbid diabetes and hypertension experienced benefit from collaborative, targeted MTM pharmacist-delivered, tertiary prevention interventions in tandem with community-based pharmacy resources. This multi-site MTM program showed promise in increasing patients' use of these services, yet effective strategies are needed to expand recruitment of eligible patients in the future.