The effects of vaccination forecasts and value-based payment on adult immunizations by community pharmacists.

BACKGROUND: The prevalence of vaccine-preventable diseases in adults remains a significant public health issue in the United States. The objectives of this demonstration project were to increase the number of influenza, pneumococcal, pertussis, and herpes zoster immunizations administered to adults by community pharmacists, evaluate the percentage of immunizations documented in the state immunization information system (IIS), and design and pilot a value-based payment model. METHODS: A one-year prospective, observational demonstration project was conducted in 70 community pharmacies in western Washington State from September 1, 2016 to August 31, 2017. An immunization interface was integrated into workflow at each pharmacy to enable "forecasting" of and proactive recommendation to patients about their vaccine needs and documentation of vaccines administered in the state IIS. Categorical value-based payment models were developed and implemented in a subgroup of 12 community pharmacies from March 1 to November 30, 2017. The change in the number of immunizations administered in comparison to the baseline period and the percentage of immunizations documented in the state IIS during the demonstration period were analyzed using descriptive statistics. RESULTS: There was a 15% total increase in the collective number of influenza, pneumococcal, pertussis, and herpes zoster vaccines administered in the demonstration year in the 70 pharmacies, due to increases in influenza and pertussis vaccinations. Eighty-three percent of the vaccines administered were documented in the state IIS. Pneumococcal, pertussis, and herpes zoster performance appeared to be unaffected by the value-based payment models while influenza performance improved across the 12 pilot pharmacies. CONCLUSIONS: This work demonstrated that community pharmacists contribute to improving adult immunizations through vaccine "forecasting" and proactive recommendation. Meaningful quality measures with both positive and negative incentives could further drive adoption of best immunization practices. Further implementation and outcomes research is needed to fully examine the impact and scalability of these strategies.

Comparison of two training methods in community pharmacy: Project VACCINATE.

OBJECTIVE: To compare the impact of a whole-staff training strategy with a train-the-trainer strategy on 1) the number of influenza, pneumococcal, herpes zoster, and pertussis vaccines administered by community pharmacists to adults; 2) staff confidence; and 3) fidelity to the intervention. SETTING: Eight Quality Food Centers (QFC) Pharmacies in Seattle, Washington. PRACTICE DESCRIPTION: QFC Pharmacy is a grocery store division of The Kroger Co. with 30 pharmacies located in Washington State. QFC provides all routine and travel vaccines to adolescents and adults and has a culture of improving vaccine access to its community. PRACTICE INNOVATION: Pharmacists and pharmacy technicians from 8 QFC pharmacies received training to enhance their immunization care for adults. The entire staff from 4 pharmacies received whole-staff training, and staff members from the other 4 pharmacies received a train-the-trainer approach. The whole-staff training group had all staff members attend a live, 2-hour training. The train-the-trainer group sent 1 pharmacist and 1 pharmacy technician champion to attend the live training and then return to their pharmacy to train the other staff members. EVALUATION: The number of immunizations administered, staff confidence, and self-reported fidelity to the intervention were measured before and after training. All data were analyzed using descriptive statistics. RESULTS: The number of total influenza, pneumococcal, herpes zoster, and pertussis vaccines administered increased 12.6% in the whole-staff training group and 15.2% in the train-the-trainer group. Both training strategies increased confidence in identifying patients eligible for vaccines, talking to patients about vaccine needs, and using the bidirectional immunization platform. Pharmacy staff members in both groups indicated fidelity to key steps in the intervention process. CONCLUSION: Both whole-staff training and train-the-trainer approaches were associated with an improvement in the number of vaccines administered, staff confidence, and fidelity to the intervention. Community pharmacy organizations could use either training strategy when implementing enhancements to an existing patient care service. The train-the-trainer strategy may be less resource intensive.

The relationship between neuropsychological assessment, numeracy, and functional status in older adults with type 1 diabetes.

While data are accumulating on the association between neuropsychological performance and real-world endpoints, less is known about the association with medical self-management skills. The self-management of type 1 diabetes (T1D) is often complex, and mismanagement can result in hypoglycaemia and hyperglycaemia and associated morbidity and mortality. The T1D Exchange conducted a case-control study evaluating factors associated with severe hypoglycaemia in older adults (≥ 60 years old) with longstanding T1D (≥ 20 years). A battery of neuropsychological and functional assessments was administered, including measures of diabetes-specific self-management skill (diabetes numeracy) and instrumental activities of daily living (IADL). After adjusting for confounding variables, diabetes numeracy was related to memory and complex speeded attention; while IADL were associated with simple processing speed, executive functioning, complex speeded attention and dominant hand dexterity. The severity of overall cognitive deficit was uniquely associated with both diabetes numeracy and IADL, when controlling for age, education, frailty and depression. This study demonstrates that the cognitive deficits in older adults with T1D have functional implications for both diabetes management and IADL. Further research is needed to determine specific interventions to maximise diabetes self-management in older adults with declining cognition.

Enhancing Access to Diabetes Self-management Education in Primary Care.

PURPOSE: The purpose of this continuous quality improvement project was to improve access to diabetes self-management education (DSME) and to evaluate the impact on glycemic and weight control by translating an academic medical center's DSME program, accredited per the Education Recognition Program (ERP) of the American Diabetes Association, into a program offered at primary care clinics (PCCs). METHODS: Certified diabetes educators from the medical center trained PCC registered dietitian nutritionists, registered nurses, and social workers to provide DSME in their community-based clinic. Main outcomes of this retrospective, pretest/posttest, observational project were to evaluate enrollment in DSME classes and change in A1C and weight as patients underwent a combined intervention of diabetes education classes with or without consultation and support from a PCC registered dietitian nutritionist or registered nurse. RESULTS: PCC DSME was associated with increased enrollment in DSME classes and a significant reduction of A1C and weight at 3 and 6 months post-DSME. Greatest A1C and weight reductions were observed in patients with newly diagnosed diabetes. Reductions were also seen in patients with diabetes duration ≥10 years, participants taking insulin, and those with depression. CONCLUSIONS: PCC DSME availability increased access to group diabetes education and resulted in reduced A1C and weight for participants. This model was successful in translating an established academic accredited DSME-ERP into a PCC. Results have implications for increasing access to diabetes education programs and improving diabetes control for patients not located near major hospital-based DSME programs.

Medication Adherence With Diabetes Medication: A Systematic Review of the Literature.

PURPOSE: The primary purpose of this systematic review is to synthesize the evidence regarding risk factors associated with nonadherence to prescribed glucose-lowering agents, the impact of nonadherence on glycemic control and the economics of diabetes care, and the interventions designed to improve adherence. METHODS: Medline, EMBASE, the Cochrane Collaborative, BIOSIS, and the Health and Psychosocial Instruments databases were searched for studies of medication adherence for the period from May 2007 to December 2014. Inclusion criteria were study design and primary outcome measuring or characterizing adherence. Published evidence was graded according to the American Association of Clinical Endocrinologists protocol for standardized production of clinical practice guidelines. RESULTS: One hundred ninety-six published articles were reviewed; 98 met inclusion criteria. Factors including age, race, health beliefs, medication cost, co-pays, Medicare Part D coverage gap, insulin use, health literacy, primary nonadherence, and early nonpersistence significantly affect adherence. Higher adherence was associated with improved glycemic control, fewer emergency department visits, decreased hospitalizations, and lower medical costs. Adherence was lower when medications were not tolerated or were taken more than twice daily, with concomitant depression, and with skepticism about the importance of medication. Intervention trials show the use of phone interventions, integrative health coaching, case managers, pharmacists, education, and point-of-care testing improve adherence. CONCLUSION: Medication adherence remains an important consideration in diabetes care. Health professionals working with individuals with diabetes (eg, diabetes educators) are in a key position to assess risks for nonadherence, to develop strategies to facilitate medication taking, and to provide ongoing support and assessment of adherence at each visit.

Implementing ward based clinical pharmacy services in an Ethiopian University Hospital.

BACKGROUND: Clinical pharmacy practice has developed internationally to expand the role of a pharmacist well beyond the traditional roles of compounding, dispensing and supplying drugs to roles more directly in caring for patients. Studies on the activities of the clinical pharmacist in an inpatient ward in resource constrained settings are scarce, however. OBJECTIVE: To assess ward based clinical pharmacy services in an internal medicine ward of Jimma University Specialized Hospital. METHODS: The study was carried out in the internal medicine ward from March to April, 2011 at Jimma University Specialized Hospital. The study design was a prospective observational study where pharmaceutical care services provided by clinical pharmacists for inpatients were documented over a period of two months. Interventions like optimization of rational drug use and physician acceptance of these recommendations were documented. Clinical significance of interventions was evaluated by an independent team (1 internist, 1 clinical pharmacologist) using a standardized method for categorizing drug related problems (DRPs). RESULTS: A total of 149 drug related interventions conducted for 48 patients were documented; among which 133(89.3%) were clinical pharmacists initiated interventions and 16(10.7%) interventions were initiated by other health care professionals. The most frequent DRPs underlying interventions were unnecessary drug therapy, 36(24.2%); needs additional drug therapy, 34(22.8%) and noncompliance, 29(19.5%). The most frequent intervention type was change of dosage/instruction for use, 23(15.4%). Acceptance rate by physicians was 68.4%. Among the interventions that were rated as clinically significant, 46(48.9%) and 25(26.6%) had major and moderate clinical importance respectively. CONCLUSIONS: Involving trained clinical pharmacists in the healthcare team leads to clinically relevant and well accepted optimization of medicine use in a resource limited settings. This approach can likely be generalized to other health care settings in the country to improve medication outcomes.

Implementing ward based clinical pharmacy services in an Ethiopian University Hospital / Implantación de servicios de farmacia clínica en los departamentos de un hospital universitario etíope

Background: Clinical pharmacy practice has developed internationally to expand the role of a pharmacist well beyond the traditional roles of compounding, dispensing and supplying drugs to roles more directly in caring for patients. Studies on the activities of the clinical pharmacist in an inpatient ward in resource constrained settings are scarce, however. Objective: To assess ward based clinical pharmacy services in an internal medicine ward of Jimma University Specialized Hospital. Methods: The study was carried out in the internal medicine ward from March to April, 2011 at Jimma niversity Specialized Hospital. The study design was a prospective observational study where pharmaceutical care services provided by clinical pharmacists for inpatients were documented over a period of two months. Interventions like optimization of rational drug use and physician acceptance of these recommendations were documented. Clinical significance of interventions was evaluated by an independent team (1 internist, 1 clinical pharmacologist) using a standardized method for categorizing drug related problems (DRPs). Results: A total of 149 drug related interventions conducted for 48 patients were documented; among which 133(89.3%) were clinical pharmacists initiated interventions and 16(10.7%) interventions were initiated by other health care professionals. The most frequent DRPs underlying interventions were unnecessary drug therapy, 36(24.2%); needs additional drug therapy, 34(22.8%) and noncompliance, 29(19.5%). The most frequent intervention type was change of dosage/instruction for use, 23(15.4%). Acceptance rate by physicians was 68.4%. Among the interventions that were rated as clinically significant, 46(48.9%) and 25(26.6%) had major and moderate clinical importance respectively. Conclusion: Involving trained clinical pharmacists in the healthcare team leads to clinically relevant and well accepted optimization of medicine use in a resource limited settings. This approach can likely be generalized to other health care settings in the country to improve medication outcomes (AU)

Antecedentes: El ejercicio de la farmacia clínica se ha desarrollado internacionalmente para expandir el papel del farmacéutico más allá de los papeles tradicionales de formulación, dispensación y distribución de medicamentos a papeles más directamente relacionados con los cuidados de los pacientes. Sin embargo, son escasos los estudios de las actividades del farmacéutico clínico en los departamentos en establecimientos de recursos escasos. Objetivo: Evaluar los servicios de farmacia clínica en un departamento de medicina interna del hospital universitario especializado de Jimma. Métodos: El estudio fue realizado en el departamento de medicina interna desde marzo a abril de 2011 en el hospital Universitario especializado de Jimma. El diseño del estudio fue observacional prospectivo donde se documentaron los servicios de atención farmacéutica proporcionados por un farmacéutico clínico a pacientes internados durante un periodo de dos meses. Se documentaron intervenciones como la optimización del uso racional y la aceptación de los médicos de estas recomendaciones. Un equipo independiente (1 internista y 1 farmacólogo clínico) evaluó la significación clínica de estas intervenciones usando un método estandarizado de clasificar los problemas relacionados con medicamentos (PRM). Resultados: Se realizó un otal de 149 intervenciones para 48 pacientes.; de ellos, 133 (83,9%) fueron intervenciones iniciadas por el farmacéutico clínico y 16 (10,7%) fueron iniciadas por otros profesionales de la salud. Los PRM más frecuentes subyacentes a cada intervención fueron medicación innecesaria 36 (24,2%); necesidad de medicación adicional 34 (22,8%); e incumplimiento 29 (19,5%). El tipo de intervención más frecuente fue el cambio de dosis/instrucciones de uso 23(15.4%). La tasa de aceptación por médicos fue del 68,4%. Entre las intervenciones que fueron calificadas de clínicamente significativas, 46 (48,9%) y 25 (26,6%) tuvieron grande y moderada importancia clínica, respectivamente. Conclusión: Envolver a un farmacéutico clínico en el equipo de salud lleva a la optimización clínicamente relevante y aceptada del uso de medicamentos en un establecimiento de recursos limitados. Este abordaje puede, probablemente, generalizarse a otros establecimientos en el país para mejorar los resultados de la medicación (AU)

Pharmacists' journey to clinical pharmacy practice in Ethiopia: Key informants' perspective.

OBJECTIVE: Clinical pharmacy practice has developed internationally to expand the role of a pharmacist well beyond the traditional roles of compounding and supplying drugs to roles more directly in caring for patients and providing medication consultation to staff. This area of practice is at the infant stage in Ethiopia. The aim of this study was to explore key informants' perspective in the implementation of clinical pharmacy practice in Jimma University Specialized Hospital, Ethiopia. METHOD: A qualitative study was conducted through in-depth interviews with the heads of departments (internal medicine, paediatrics, surgery, nurse, pharmacy, medical director, administration) and pharmacy student representatives. Qualitative data analysis was done after audiotapes were transcribed verbatim and notes were compiled. RESULTS: All of the respondents interviewed express diverse and conflicting perspectives on pharmacists' role, varying from a health-care professional to a business man. Despite this, the current pace of change worldwide takes the professions' mission to that of a provider of clinical pharmacy services. The data ascertained the change in pharmacy practice, and integrating clinical pharmacy services within the health-care system should be seen as a must. Pharmacists should delineate from a business perspective and focus on widening the scope of the profession of pharmacy and should come close to the patient to serve directly. CONCLUSIONS: Although the perception of people on traditional roles of pharmacists was weak, there were promising steps in developing clinical pharmacy practice within the health-care system. Moreover, the results of this study revealed a high demand for this service among health-care providers.

Prevalence and correlates of dietary supplement use in individuals with diabetes mellitus at an academic diabetes care clinic.

OBJECTIVES: This study sought to describe the prevalence of supplement use by those with diabetes mellitus receiving care at an academic outpatient diabetes care center and to identify any association of supplement use with glycemic control. METHODS: This study is based on a retrospective audit of provider-verified and patient-self-reported medication and supplement use by adults with diabetes at the University of Washington Diabetes Care Center during four 2-week periods from fall 2006 through summer 2007 (1 period per season). RESULTS: Verified medication and supplement histories for 459 adults demonstrated a per-person average use of 7 ± 4.1 prescription medicines and 0.4 ± 0.9 over-the-counter medicines daily, with 55% using some form of vitamin, mineral, or nonvitamin-nonmineral supplement on a daily basis. The rate of nonvitamin-nonmineral use was nearly twice that for type 2 diabetes mellitus as for type 1 diabetes mellitus (39.3% vs 20.3%), and A1c was lower in those using any supplement compared to those not using supplements. Vitamin use was associated with reduced A1c; however, this relationship did not hold at A1c < 7.0%. CONCLUSIONS: The findings highlight the prevalence of supplement use in diabetes mellitus and association of supplement use with improved glycemic control. Findings are limited by the retrospective design.

The relationship between anticholinergic medications and Mini-Cog scores in older adults receiving home health care.

OBJECTIVES: To describe anticholinergic use patterns in older adult home health recipients and examine their relationship to evidence of cognitive impairment. DESIGN: Retrospective study. SETTING: A home health care agency in Eastern Washington state. PARTICIPANTS: Potential study subjects were 174 recipients of home health services between March 1, 2006, and October 1, 2006, who were 60 years of age or older and had been screened for cognitive impairment by the Mini-Cog assessment test. A random sample of 65 out of 75 patients who scored in the impaired range on the Mini-Cog and a random sample of 65 out of 99 patients who scored in the unimpaired range were included in the study. MAIN OUTCOME MEASURE: prevalence of anticholinergic medication use. RESULTS: The majority of participants (80.0%) were using a medication with anticholinergic effects; however, more participants were using weak anticholinergics (66.1%) than potent agents (33.8%). After controlling for age, caregiver presence, and marital status, participants who scored as cognitively impaired on the Mini-Cog were less likely to be taking a medication with anticholinergic properties (odds ratio 0.34, 95% confidence interval 0.13-0.94). CONCLUSION: Although anticholinergic use was common in this older adult, home health population, the majority of participants were using medications with weak anticholinergic activity, as opposed to potent ones. Participants with cognitive impairment were less likely to be using any medication with anticholinergic properties.

Interprofessional initiatives at the University of Washington.

Pharmacists must collaborate with other health professionals to promote the optimal use of medications, relying on coordinated, interprofessional communication and care to do so. In 2003, the Institute of Medicine (IOM) recommended "all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics." At the University of Washington, the Center for Health Sciences Interprofessional Education (CHSIE) was established in 1997 to promote interprofessional curricular and clinical innovation in education, faculty development, and student activities, and to conduct evaluative research regarding the impact of interprofessional innovations. In this manuscript, we will describe the Center for Health Sciences Interprofessional Education, and highlight key projects that serve as examples of pharmacy involvement in interprofessional education, research, and service.

Geriatric pharmacy education: a strategic plan for the future.

The aging of the US population will have a major effect on the future practice of pharmacy. By 2030, 20% of Americans will be aged 65 years and older, an increase from 12.4% in 2000. A challenge to colleges and schools of pharmacy in the 21st century is to prepare students and practitioners to meet the growing pharmaceutical care needs of the older adult population and to meet these needs in a variety of care settings. This paper reviews the present state of geriatric pharmacy education and training, including strategies for ensuring that practicing pharmacists will have adequate knowledge, skills, attitudes, and values to provide this care. Secondly, this report provides strategic directions and recommendations for successfully implementing geriatrics curricula at an institutional level.

Quality of medication records and use of pharmacy resources in community residential care facilities.

BACKGROUND: In community residential care (CRC) facilities, medication administration is often performed by unlicensed personnel with minimal knowledge in medication use. Medication management is one of the top 3 quality-of-care issues facing these facilities. OBJECTIVE: To examine the type of medication assistance residents received, determine the proportion of facilities that used pharmacy resources, and examine the quality of facility medication records in CRC facilities (eg, adult family homes, adult residential care, assisted living facilities). METHODS: Baseline in-person interviews were conducted with 349 residents and 299 facility providers in the Puget Sound region of Washington. Information was also obtained from facility medication records at enrollment and state databases. A pharmacist determined quality of the records using a standardized form. RESULTS: The average resident was a 78-year-old white female taking 7 drugs. Medication records that were computer generated were significantly less likely to have misspelled names of drugs and errors in or absence of dose, directions for use, and route of administration. Overall, 26.3% of facilities reported that a consultant pharmacist reviewed residents' medication lists, 52.0% reported the use of preprinted lists, and 75.6% received prepackaged medications from the pharmacy. Adult family homes, the smallest facility type, were the least likely to use pharmacy-related services. CONCLUSIONS: The quality of handwritten medication records was a concern in CRC facilities. These facilities may benefit from services offered by pharmacies that may enhance medication management, many of which were underutilized.

Caring for poorly controlled diabetes mellitus: a randomized pharmacist intervention.

BACKGROUND: There is limited information from randomized controlled studies about the influence of pharmacist interventions on diabetes control. OBJECTIVE: To evaluate the effect of a pharmacist intervention on improving diabetes control; secondary endpoints were medication appropriateness and self-reported adherence. METHODS: A randomized, controlled, multi-clinic trial was conducted in the University of Washington Medicine Neighborhood Clinics. Seventy-seven subjects, > or =18 years old with a hemoglobin (Hb) A(1c) > or =9% at baseline and taking at least one oral diabetes medication, were randomized to receive a pharmacist intervention (n = 43) or usual care (n = 34) for 6 months followed by a 6-month usual-care observation period for both groups. Subjects met with a clinical pharmacist to establish and initiate a diabetes care plan followed by weekly visits or telephone calls to facilitate diabetes management and adherence. HbA(1c), medication appropriateness, and self-reported adherence were assessed at baseline, 6 months, and 12 months. RESULTS: The mean HbA(1c) did not differ between groups over the 12-month period (p = 0.61). A reduction in HbA(1c) was noted for both groups over time compared with baseline (p = 0.001); however, control subjects relied more heavily on provider visits. Medication appropriateness was not improved for diabetes medications (p = 0.65). Self-reported adherence was not significantly improved by the intervention. CONCLUSIONS: This pharmacist intervention did not significantly improve diabetes control, but did allow for similar HbA(1c) control with fewer physician visits. Medication appropriateness and self-reported adherence compared with usual care in individuals with poorly controlled diabetes were not changed.

Pharmacokinetics of estrogen and progesterone in chronic kidney disease.

Estradiol, estrone, and estrone sulfate are the primary circulating estrogens in women; the relative amounts depend on the menopausal status of the women. Administration of oral estradiol or conjugated equine estrogens (CEE) results in a high ratio of estrone to estradiol, whereas use of nonoral routes (dermal, vaginal, or parenteral) results in approximately equal plasma concentrations of estradiol and estrone. Although estradiol and estrone are predominately eliminated by metabolism, and little is excreted unchanged in the urine, evidence indicates that chronic kidney disease (CKD) alters the pharmacokinetics of estradiol. Free and total estradiol plasma concentrations are higher in women with end-stage renal disease (ESRD) after an oral estradiol dose, but no change occurs in estrone concentrations. Neither estradiol nor estrone is removed in the dialysate. These studies suggest that women with CKD should receive a least a 50% reduction in oral estradiol doses. No information is available on the pharmacokinetics of any of the progestins in CKD. In the future, knowledge of the concentration effect relationship for the treatment of symptoms of menopause, as well as prevention of osteoporosis, will benefit all postmenopausal women who choose to use hormone replacement therapy.