Applying RE-AIM to examine the impact of an implementation facilitation package to scale up a program for Veterans with chronic obstructive pulmonary disease.

BACKGROUND: US Veterans are four times more likely to be diagnosed with chronic obstructive pulmonary disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans' Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of five implementation strategies was designed and implemented. METHODS: This evaluation utilized a mixed-methods approach to assess the impact of the Academy's implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians' perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted 8 to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items. RESULTS: Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy session attendance (90%) and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians' significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation. CONCLUSIONS: This evaluation found that the use of implementation facilitation paired with additional strategies enhanced the capacity of clinicians to implement COPD CARE. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

Sociotechnical Work System Approach to Occupational Fatigue.

INTRODUCTION TO THE PROBLEM: Occupational fatigue is a characteristic of excessive workload and depicts the limited capacity to complete demands. The impact of occupational fatigue has been studied outside of health care in fields such as transportation and heavy industry. Research in health care professionals such as physicians, medical residents, and nurses has demonstrated the potential for occupational fatigue to affect patient, employee, and organizational outcomes. A conceptual framework of occupational fatigue that is informed by a sociotechnical systems approach is needed to (1) describe the multidimensional facets of occupational fatigue, (2) explore individual and work system factors that may affect occupational fatigue, and (3) anticipate downstream implications of occupational fatigue on employee well-being, patient safety, and organizational outcomes. CONCEPTUAL FRAMEWORK OF OCCUPATIONAL FATIGUE: The health care professional occupational fatigue conceptual framework is outlined following the Systems Engineering Initiative for Patient Safety (SEIPS) model and adapted from the Conceptual Model of Occupational Fatigue in Nursing. Future research may apply this conceptual framework to health care professionals as a tool to describe occupational fatigue, identify the causes, and generate solutions. Interventions to mitigate and resolve occupational fatigue must address the entire sociotechnical system, not just individual or employee changes.

Applying RE-AIM to examine the impact of an implementation facilitation package to scale up a program for Veterans with Chronic Obstructive Pulmonary Disease.

Background: U.S. Veterans are four-times more likely to be diagnosed with Chronic Obstructive Pulmonary Disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans' Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of four implementation strategies was designed and implemented. Methods: This evaluation utilized a mixed-methods approach to assess the impact of the Academy's implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians' perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted eight to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items. Results: Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy completion (97%), session attendance (90%), and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians' significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation. Conclusions: This evaluation found that the use of implementation facilitation paired with additional strategies seemed to demonstrate positive implementation outcomes across all RE-AIM domains and identified areas for potential improvement. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

Instrument development to determine student self-efficacy to present a patient to a pharmacy preceptor (4P).

INTRODUCTION: Effective patient assessment is often supported through simulated experiences where students identify potential drug-related problems (DRPs) through evaluation of the patient's electronic health record and verbally present their assessment and proposed resolutions for DRPs. This research aimed to initiate validation of a Patient Presentation to a Pharmacy Preceptor (4P) tool using exploratory factor analysis (EFA) to examine underlying constructs, refine items, and improve tool conciseness. The 4P tool was designed to assess student self-efficacy to identify, assess, resolve, and verbally present DRPs to a pharmacy preceptor. METHODS: The 4P instrument was administered to third-year doctor of pharmacy students in a performance-based skills laboratory course. EFA was conducted on student confidence data to examine underlying 4P constructs and improve survey conciseness. Laboratory faculty evaluated EFA results and came to consensus on factor extraction, item reduction and revision, and a finalized version of the 4P tool. RESULTS: Faculty interpretation of EFA results suggested elimination of two constructs resulting in a four-factor solution. Item evaluation further led to renaming the four constructs based on underlying factor themes. Out of the original 34-item tool, 13 items were eliminated, eight items were revised, and 1 new item was generated to retain relevant concepts. The refined 4P instrument contained four factors and 22 items. CONCLUSIONS: Use of EFA was useful to determine core 4P tool constructs and improved tool conciseness. This final four-factor model including 22 items will be used for a future confirmatory factor analysis.

Characteristics of initiators of budesonide/glycopyrrolate/formoterol for treatment of chronic obstructive pulmonary disease (COPD) in the United States: the AURA study.

INTRODUCTION: A twice-daily single inhaler triple therapy consisting of budesonide/glycopyrrolate/formoterol fumarate (BGF) was approved by the US Food and Drug Administration (FDA) in July 2020 as a maintenance treatment for patients with chronic obstructive pulmonary disease (COPD). The objective of this AURA study is to describe patient characteristics, exacerbation and treatment history, and healthcare resource utilization (HCRU) before BGF initiation to better inform treatment decisions for prescribers. METHODS: This retrospective cohort study leveraged data of all payer types from IQVIA's Longitudinal Prescription Data (LRx) linked to Medical Data (Dx). Patients with COPD who had ⩾1 LRx claim for BGF between 1 October 2020 and 30 September 2021 were included. The date of first BGF claim was the index date. Patient demographic and clinical characteristics, history of COPD exacerbation or related event, treatment history, and HCRU were assessed during the 12 months before index (baseline). RESULTS: We identified 30,339 patients with COPD initiating BGF (mean age: 68.2 years; 57.1% female; 67.6% Medicare). Unspecified COPD (J44.9; 74.0%) was the most commonly coded COPD phenotype. The most prevalent respiratory conditions/symptoms were dyspnea (50.8%), lower respiratory tract infection (25.3%), and sleep apnea (19.0%). Uncomplicated hypertension (58.8%), dyslipidemia (43.9%), cardiovascular disease (41.4%), and heart failure (19.9%) were the most prevalent nonrespiratory conditions. During the 12-month baseline, 57.9% of patients had evidence of a COPD exacerbation or related event, and 14.9% had ⩾1 COPD-related emergency department (ED) visit; 21.0% of patients had evidence of prior triple therapy use, while 54.3% had ⩾1 oral corticosteroid (OCS) fill. Among OCS users, 29.9% had cumulative exposures >1000 mg [median [Q1-Q3] exposure: 520 (260-1183) mg]. CONCLUSION: This real-world data analysis indicates that BGF is being initiated in patients with COPD experiencing symptoms and exacerbations despite current therapy, and among patients who have various chronic comorbidities, most often cardiopulmonary-related.

Development of a scale to determine student self-efficacy in performing key pharmacists' patient care skills.

BACKGROUND: The Pharmacists' Patient Care Process (PPCP) was developed to describe a consistent process in which pharmacists in any setting provide patient care. Faculty at a midwestern university developed and refined an assessment tool which provides an indirect approach to measure student confidence in performing skills essential to the PPCP. The objective of this paper is to conduct a stepwise factor analysis to refine the PPCP survey. METHODS: Assessing appropriateness of survey response data led to an exploratory factor analysis (EFA) on student confidence data to refine the survey instrument and examine the underlying constructs that influence student responses. Post EFA, the results were presented to the research team that collaboratively reached consensus on inclusion or exclusion of items. RESULTS: EFA factor loadings identified a 4-factor solution suggesting elimination of 30 items from the original 53 item survey. Team discussions led to eliminating 29 items, combining two items and generation of 5 new items in order to retain important concepts. The outcome was a well-conceptualized and refined 29 item-survey model assessing 4 constructs. CONCLUSION: To potentially improve patient outcomes, it is imperative to utilize comprehensive yet concise survey instruments, like the PPCP Skills Self-Efficacy Survey, to prepare students to translate PPCP skills to practice.

Impact of a novel project management course sequence on innovative thinking in pharmacy students.

BACKGROUND: As healthcare continues to become more complex, pharmacist innovators have worked to advance the profession and expand the role of the pharmacist on the healthcare team. Accreditation standards for schools of pharmacy recognize the importance of developing future pharmacist innovators capable of making positive change in the profession, but there are limited resources available on how to best instill innovative thinking in student pharmacists. EDUCATIONAL ACTIVITY: A two-semester elective course sequence was created for third-year doctor of pharmacy students requiring completion of a longitudinal quality improvement project at a partnering health system. Students collaborated with key stakeholders to design a project plan and charter, identify deliverables, and deliver project results. Innovative thinking was assessed using a mixed methods approach including questionnaires with forced choice and open response items, focus group data, and semi-structured interviews. Each questionnaire item mapped specifically to an element of a validated model for employee innovation. From the beginning to the end of the course sequence, there were significant improvements in student-perceived project management self-efficacy and innovative thinking. CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY: Student learning outcomes and the course structure mapped closely with a validated model of innovative behavior, demonstrating the effectiveness of utilizing project management to instill innovative thinking in student pharmacists. These findings support the concept that innovative thinking can be taught in pharmacy didactic curricula by situating students in the environment of real-world pharmacy practice.

Application of the replicating effective programs framework to design a COPD training program.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally and a common cause of hospital readmissions in the United States. While best practices exist in COPD management, incorporation of such approaches into routine clinical care remains a challenge. OBJECTIVES: This evaluation applied principles from the field of dissemination and implementation (D&I) science to design a training package integrating best practice for COPD management. The D&I field promotes evidence-based implementation strategies, frameworks, and assessment approaches that can be considered by clinicians to promote adoption of best practices. METHODS: This prospective mixed-methods evaluation applied a D&I science model to develop, implement, and evaluate an interprofessional training program for COPD management originally piloted in 2016. The authors provide a contextual example of how a guiding D&I framework, replicating effective programs, was applied to design and implement a Web-based training program for clinicians preparing to implement the COPD service. A questionnaire and profession-specific focus group sessions were conducted to evaluate trainee confidence and enactment of critical service components. RESULTS: A total of 41 of the 50 interprofessional trainees responded to the pre- and postquestionnaire including primary care clinical pharmacists (n = 15), primary care registered nurses (n = 9), triage registered nurses (n = 12), and respiratory therapists (n = 5). Statistically significant improvements in trainee confidence and enactment were observed in 31 of the 40 total survey items (77%). Pooled focus group data provided attestation that the training enhanced practitioners' confidence in their role within the service. Opportunities for further improvement were also identified, such as incorporating a video modeling clinic example and accompanying written materials. CONCLUSION: This evaluation provides a case-study example of how D&I science can be used to design, implement, and evaluate a training package for trainees to spread a promising best practice. Clinicians can consider similar applications of D&I science to enhance training and spread novel services across health systems.

Let External Stakeholders Be Your Guide to Curricular Revision.

Schools and colleges of pharmacy undertake curriculum revisions for a variety of reasons ranging from the reactionary (eg, responding to changes in practice patterns, accreditation standards) to the proactive (eg, striving for innovation and excellence). Continuous quality improvement processes and published curriculum models, both described in this commentary, should be used to guide revision processes. Equally important is engaging the expertise of external stakeholders. While there may be challenges to incorporating external stakeholders in a curriculum revision process, their perspectives and knowledge can contribute to a more robust result, often in unexpectedly positive ways. Logic modeling is one mechanism to structure this approach, maximize the utility of external stakeholders, and strengthen the overall curriculum revision process. Regardless of the size of the revision, a good rule of thumb is to engage external stakeholders at the outset and to let their expertise be your guide.

Reducing COPD Readmission Rates: Using a COPD Care Service During Care Transitions.

A chronic obstructive pulmonary disease care service improves timely access to follow-up care and patient education at the time of transition from hospital to home.