Clinical impact of a community pharmacy-based health and wellness introductory pharmacy practice experience.

OBJECTIVE: To assess the clinical impact of an intensive community pharmacy-based Health and Wellness Introductory Pharmacy Practice Experience (IPPE) completed by second-year (P2) student pharmacists. DESIGN: The Health and Wellness IPPE was a 1-week rotation developed to provide P2 student pharmacists with opportunities to provide clinical services to patients within the community pharmacy setting. Student pharmacists administered immunizations, performed blood pressure screenings and blood glucose measurements, and provided education to patients under the guidance of licensed pharmacist preceptors. SETTING AND PARTICIPANTS: Second-year student pharmacists completing a required Health and Wellness IPPE rotation in the community pharmacy setting. OUTCOMES MEASURED: Student pharmacist interventions were assessed to determine the course's clinical impact, and preceptors were surveyed regarding the feasibility of student pharmacists performing clinical services at their training sites. RESULTS: A total of 147 student pharmacists completed the IPPE at 89 community pharmacy training sites and administered 9392 injections, 90% of which were influenza vaccinations. Student pharmacists performed 3458 patient health assessments, including measuring patients' blood pressure and blood glucose and reviewing patient education materials. Most preceptors indicated that core activities were feasible during the experience. CONCLUSION: This study found that implementing a concentrated IPPE focused on immunizations and health screenings allowed student pharmacists to enhance their clinical skills and fulfill a large public health need, improving patient outcomes. Future studies should explore utilizing student pharmacists in community pharmacy settings to expand clinical services offered beyond these 2 services, such as diabetes risk tests, influenza point-of-care testing, and smoking cessation counseling.

A Dietary Intervention High in Green Leafy Vegetables Reduces Oxidative DNA Damage in Adults at Increased Risk of Colorectal Cancer: Biological Outcomes of the Randomized Controlled Meat and Three Greens (M3G) Feasibility Trial.

Green leafy vegetables (GLV) may reduce the risk of red meat (RM)-induced colonic DNA damage and colorectal cancer (CRC). We previously reported the primary outcomes (feasibility) of a 12-week randomized controlled crossover trial in adults with habitual high RM and low GLV intake with body mass index (BMI) > 30 kg/m2 (NCT03582306). Herein, our objective was to report a priori secondary outcomes. Participants were recruited and enrolled in 2018, stratified by gender, and randomized to two arms: immediate intervention group (IG, n = 26) or delayed intervention group (DG, n = 24). During the 4 week intervention period, participants were provided with frozen GLV and counseled to consume 1 cooked cup equivalent daily. Participants consumed their normal diet for the remaining 8 weeks. At each of four study visits, anthropometrics, stool, and blood were taken. Overall, plasma Vitamin K1 (0.50 ± 1.18 ng/mL, p < 0.001) increased, while circulating 8OHdG (-8.52 ± 19.05 ng/mL, p < 0.001), fecal 8OHdG (-6.78 ± 34.86 ng/mL, p < 0.001), and TNFα (-16.95 ± 60.82 pg/mL, p < 0.001) decreased during the GLV intervention compared to control periods. Alpha diversity of fecal microbiota and relative abundance of major taxa did not differ systematically across study periods. Further investigation of the effects of increased GLV intake on CRC risk is warranted.

Primary Outcomes of a Randomized Controlled Crossover Trial to Explore the Effects of a High Chlorophyll Dietary Intervention to Reduce Colon Cancer Risk in Adults: The Meat and Three Greens (M3G) Feasibility Trial.

Preclinical and observational research suggests green leafy vegetables (GLVs) may reduce the risk of red meat (RM)-induced colonic DNA damage and colon cancer (CC). We sought to determine the feasibility of a high GLV dietary intervention in adults with an increased risk of CC (NCT03582306) via a 12-week randomized controlled crossover trial. Participants were randomized to immediate or delayed (post-4-week washout) intervention groups. During the 4-week intervention period, participants were given frozen GLVs and counseled to consume one cooked cup equivalent daily. The primary outcomes were: accrual-recruiting 50 adults in 9 months; retention-retaining 80% of participants at completion; and adherence-meeting GLV intake goals on 90% of days. Adherence data were collected twice weekly and 24-h dietary recalls at each time point provided nutrient and food group measures. The Food Acceptability Questionnaire (FAQ) was completed to determine acceptability. On each of the four study visits, anthropometrics, stool, saliva, and blood were obtained. Fifty adults were recruited in 44 days. Participants were 48 ± 13 years of age, 62% female, and 80% Caucasian, with an average BMI at screening of 35.9 ± 5.1. Forty-eight (96%) participants were retained and completed the study. During the intervention phase, participants consumed GLVs on 88.8% of days; the adherence goal of one cup was met on 73.2% of days. Dietary recall-derived Vitamin K and GLVs significantly increased for all participants during the intervention periods. Overall satisfaction did not differ between intervention and control periods (p = 0.214). This feasibility trial achieved accrual, retention and acceptability goals, but fell slightly short of the benchmark for adherence. The analysis of biological specimens will determine the effects of GLVs on gut microbiota, oxidative DNA damage, and inflammatory cytokines.

Pilot Study to Test the Effectiveness of Different Financial Incentives to Improve Medication Adherence.

BACKGROUND: Medication nonadherence affects health care costs, morbidity, and mortality. Concepts from behavioral economics can guide the development of interventions to improve medication adherence. OBJECTIVE: To measure the relative effectiveness of 2 behavioral economic-based incentive structures to improve medication adherence. METHODS: This randomized controlled trial compared adherence among participants taking antihypertensive or antihyperlipidemic medications randomized to usual care (UC), guaranteed pay-out (GPO) incentives, or lottery incentives. Daily adherence was measured over a 90-day period using electronic caps (Medication Event Monitoring System [MEMS]). The GPO group received $30 up-front in a virtual account, with $0.50 deducted for each missed dose. Lottery group participants were eligible for a weekly $50 drawing, but only if they had taken their medication as prescribed all week. An electronic survey assessed self-reported adherence. Statistical analysis included descriptive statistics, paired t tests, ANOVA, and Pearson's correlations. RESULTS: In all, 36 participants were randomized (UC, n = 11; GPO, n = 14; lottery, n = 11). Mean percentage (±SD) of days adherent during the incentive period was highest in the lottery group (96% ± 5%), followed by the GPO group (94% ± 9%) and the UC group (94% ± 9%). There were no statistically significant differences among groups (P > 0.05). MEMS-measured adherence was not significantly correlated with a patient's self-reported adherence (P > 0.05) at baseline but was correlated at 90-day follow-up (P < 0.001). CONCLUSIONS: Although no statistically significant differences in adherence were demonstrated in this small sample of highly adherent participants, larger studies in a more diverse population or with other medications might show otherwise.

Incidence of Intravenous Medication Errors in a Chinese Hospital.

OBJECTIVES: The purpose of this study was to explore intravenous (IV) medication errors in a Chinese hospital. The specific objectives were to 1) explore and measure the frequency of IV medication errors by direct observation and identify clues to their causes in Chinese hospital inpatient wards and 2) identify the clinical importance of the errors and find the potential risks in the preparation and administration processes of IV medications. METHODS: A prospective study was conducted by using the direct observational method to describe IV medication errors on two general surgery patient wards in a large teaching hospital in Beijing, China. A trained observer accompanied nurses during IV preparation rounds to detect medication errors. The difference in mean error rates between total parenteral nutrition (TPN) and non-TPN medications was tested by using the Mann-Whitney U test. RESULTS: A final total of 589 ordered IV doses plus 4 unordered IV doses as prepared and administered to the patients was observed from August 3, 2010, to August 13, 2010. The overall error rate detected on the study ward was 12.8%. The most frequent errors by category were wrong dose (5.4%), wrong time (3.7%), omission (2.7%), unordered dose (0.7%), and extra dose (0.3%). Excluding wrong time errors, the error rate was 9.1%. Non-TPN medications had significantly higher error rates than did TPN medications including wrong time errors (P = 0.0162). CONCLUSIONS: A typical inpatient in a Chinese hospital was subject to about one IV error every day. Pharmacists had a very limited role in ensuring the accuracy of IV medication preparation and administration processes.

Adoption of a biometric screening service in community pharmacies: a qualitative study.

OBJECTIVE: To explore differences in perceived attributes of biometric screening services and organization characteristics among community pharmacies that adopt, outsource, or do not adopt biometric screening services that assess patients' blood pressure, blood glucose, serum cholesterol, and body mass index. DESIGN: Qualitative, comparative analysis. SETTING: Independently owned community pharmacies in Alabama. PARTICIPANTS: 25 key informants from community pharmacies were classified as adopters, outsourced adopters, and nonadopters of biometric screening services. Pharmacies using in-house staff to conduct screenings are referred to as adopters; those using external staff are referred to as outsourced adopters. MAIN OUTCOME MEASURES: Perceived attributes of the screening service and organizational characteristics identified through emergent theme analysis based on the Diffusion of Innovations Model and Model of Innovation Assimilation. RESULTS: The screening service was perceived differently by adopters, outsourced adopters, and nonadopters. Adopters saw the opportunity to increase revenue and expand the role of the pharmacist in health care by offering the service. Adopters also perceived the service to be compatible with their pharmacy layout and organizational identity; simple to implement; modifiable in terms of experimentation with models of service delivery; and visible by external constituencies (which positively affects pharmacy image). In contrast, nonadopters felt the amount of time, investment, and lack of potential patients associated with the service influenced their decision not to adopt it. Adopters and nonadopters differed in regard to their innovativeness in patient care services, their connectedness in professional networks, and how they make sense of and deal with the uncertainty of new programs. Outsourced adopters were similar to adopters but were more cautious in their decision making. CONCLUSION: Perceived attributes of the screening service and organizational characteristics differed among adopters, outsourced adopters, and nonadopters.

Evaluation of medication therapy management services for patients with cardiovascular disease in a self-insured employer health plan.

BACKGROUND: Cardiovascular disease (CVD) is a major cause of mortality in the United States, representing the highest total expenditures among major diseases. To improve CVD-associated outcomes, medication therapy management (MTM) services have been included in essential health benefit packages offered by various health plans. Nevertheless, the impact of such MTM services on outcomes is still unclear, especially from the perspective of the self-insured employer.  OBJECTIVES: To (a) compare economic outcomes between patients who received and those who did not receive MTM services from the self-insured employer's perspective and (b) compare clinical outcomes before and after receiving MTM services.  METHODS: This study consisted of 2 pre- and post-retrospective designs: (1) a cohort study with comparison groups and (2) a cohort study within group comparison. Patients were beneficiaries aged 19 years or older who were diagnosed with CVD conditions according to ICD-9-CM codes and continuously enrolled in a public university-sponsored insurance plan between 2008-2010. Patients were divided into MTM and non-MTM groups. The first MTM encounter was assigned as the index date for the MTM group. Match-paired patients who did not receive MTM services were randomly assigned the index date based on age category, gender, and comorbidity. Measures for pharmacy, medical, and total expenditures were obtained from medical and pharmacy claims. Paired t-tests and independent t-tests using data generated from 1000 bootstraps compared mean cost difference within and between groups. The return on investment (ROI) was calculated by dividing the average net benefit from MTM services by the average cost of MTM services. Clinical parameters, including blood pressure (BP) and body mass index (BMI), were retrieved from electronic medical records from a pharmacist-provided clinic where MTM services took place. Paired-t tests were used to compare the mean difference between baseline and endpoint values. Further, this study examined changes in the proportion of patients who achieved an individualized treatment goal for BP and BMI. The study also quantified the improvement in disease stages after the index date using the McNemar's test. Statistical analyses were performed by using SAS software version 9.2 with statistical significance level of 0.05.   RESULTS: A total of 63 patients and 62 match-paired patients were included in the MTM group and the non-MTM group, respectively. The mean cost (SD) per patient in the MTM group during the 6 months post-index period for CVD-related pharmacy, all-cause medical, and total expenditures was lower than the 6 months pre-index period by $22.0 (19.1), $79.2 (99.6), and $75.1 (136.2), respectively. In contrast, the mean cost (SD) for the non-MTM group increased during the 6 months post-index date by $10.7 (24.2), $246.4 (248.4), and $289.0 (269.5) for pharmacy, medical, and total expenditure, respectively. When comparing the 2 groups, the MTM group had statistically significantly lower costs per patient for pharmacy expenditures (difference of -31.9 ± 25.1, P less than 0.0001), medical expenditures (difference of -$325.6 ± 271.2, P less than 0.0001), and total direct expenditures (difference of -$359.3 ± 219.2, P less than 0.0001). Given the net benefit of MTM services ($359.3) and the average cost of MTM service ($134.6), the ROI was $1.67 per $1 in MTM cost. Regarding clinical outcomes, while no statistically significant differences were observed in clinical outcomes, MTM services demonstrated clinical benefits. At the post-index period, the percentage of patients who had achieved their goals increased from 55% to 70% for BP and from 13.0% to 21.7% for normal BMI compared with the pre-index period. In terms of the extent of improvement in disease stages, clinical improvements in the stages of hypertension (χ2 =12.77, P less than 0.05) as well as BMI (χ2 =6.39, P less than 0.05) at the endpoint were observed.  CONCLUSIONS: Cardiovascular-related pharmacy, all-cause medical, and total expenditures were statistically lower among beneficiaries who received MTM services compared with those who did not. In addition, MTM services had a positive ROI and demonstrated clinical significances by the increasing number of patients who achieved treatment goals and improved disease stages for hypertension and BMI.