Engaging Student Pharmacists in Social Determinants of Health and Health Equity Through Photovoice.

OBJECTIVE: This study aimed to evaluate the impact of an interactive photovoice activity on the perceptions of social determinants of health (SDOH) and health equity among first professional year student pharmacists. METHODS: This study used a mixed-methods exploratory approach at 4 institutions. All students completed a standardized intervention using a prerecorded lecture, active learning using photovoice, and an in-depth debriefing session. The photovoice responses and reflections were analyzed through a deductive approach using content analysis with the applied frameworks of Rolfe's reflection model and the social-ecological model. A presurvey/postsurvey assessed the students' perceptions of SDOH and health equity. Paired sample t tests were conducted to assess the prechange and postchange. RESULTS: A total of 349 students participated; most students reflected at the "what" level (97.7%), whereas 65% reached the "now what" level. Students identified more SDOH factors at the institutional/community level (75.9%) than at the individual/interpersonal level (59.4%) or the society/policy level (28.0%); 191 (55%) students had matchable survey data. A statistically significant improvement was found in the comprehension of health equity concepts (4 items), perceptions of health disparities and system response (4 items), awareness of structural factors impacting equity (3 items), and readiness for inclusivity behavior (3 items). CONCLUSION: A structured teaching and learning activity allowed deeper reflections among student pharmacists. Student perception of the basic terminologies and the impact of beliefs on health care improved after the photovoice assignment. Although students became aware of the SDOH, they had difficulty identifying the structural or upstream factors when addressing SDOH.

Characteristics of Successful International Pharmacy Partnerships.

Recommendations for global pharmacy collaborations are predominately derived from US institutions. This study utilized semi-structured interviews of global collaborators to assess important partnership components. Interviewees stated personal connections and understanding of each other's programs/systems were key components. Additionally, collaborators indicate that mutual benefits between partners can exist without the requirement for bidirectional exchange of learning experiences, and request and value partners and learners who are culturally aware, global citizens. This structured interview approach provided key insight into how to develop mutually beneficial, sustainable partnerships and provides additional confirmation that the five pillars of global engagement align with an international audience.

Students' knowledge and perceptions of social determinants of health utilizing interactive computer simulation-based learning.

INTRODUCTION: The purpose of this study was to assess if using computer simulations as a supplemental tool for teaching social determinants of health (SDoH) would impact first-year pharmacy students' knowledge and perceptions of SDoH. METHODS: A brief lecture and online poverty game were followed by completion of two, in-class, computer-simulated SDoH clinical scenarios and corresponding case discussion. Students completed a pre- and post-quiz and perception survey with two open-ended questions. Qualitative analysis of the open-ended questions and quantitative analyses of the poverty game choices, quiz, and perception survey were conducted. RESULTS: In total, 132 students were enrolled in this study. Thematic analysis of the open-ended question asking students what they learned included empathy (42%), general SDoH knowledge (30%), culture/religion (18%), and economic impact (15%). Student perceptions for all teaching modalities had a mean score of 4. Mean quiz scores on the pre- and post-class quizzes were 2.31 (SD 0.93) and 2.51 (SD 0.89), respectively. CONCLUSIONS: Computer simulations can be utilized as a supplemental tool to teach and apply clinical patient cases focused on SDoH. Strategically threading SDoH throughout the pharmacy curriculum is recommended to further develop SDoH knowledge and clinical skills.

Implementation and Assessment of a Heart Failure Virtual Patient Simulation in a Required Pharmacotherapy Course.

Objective. To assess second year Doctor of Pharmacy students' academic performance in and perceptions of a heart failure (HF) virtual patient simulation used in a required pharmacotherapy course.Methods. A heart failure virtual patient simulation was created to augment heart failure pharmacotherapy course material at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences in the fall of 2019. This was a retrospective, pre-post observational cohort study. The primary objective was to compare student performance on heart failure pharmacotherapy examination questions in a cohort of students who completed a virtual patient simulation in 2019 compared to a control cohort who completed a paper-based case activity in 2018. Student perceptions of the simulation experience were assessed via electronic survey.Results. Students completed either the virtual patient simulation (n=122) or a paper-based case activity (n=123). Overall, the proportion of correctly answered heart failure pharmacotherapy examination questions was 83.3% in the virtual simulation group compared to 79.2% in the paper-based case group. Survey results indicated that students would prefer that the virtual patient simulation be incorporated in the pharmacotherapy curriculum.Conclusion. Use of a heart failure virtual patient simulation was associated with improved examination performance and was well received by students.

Accessibility of postgraduate training program information to graduates from US doctor of pharmacy programs holding F-1 visas.

PURPOSE: To evaluate information provided by residency and fellowship programs to graduates of Accreditation Council for Pharmacy Education-accredited doctor of pharmacy programs holding F-1 visas who are seeking postgraduate training opportunities. METHODS: A 2-phase review of all US-based postgraduate year 1 (PGY1) residency and fellowship programs was conducted. In phase 1, program eligibility criteria were reviewed from the residency and fellowship directories published by the American Society of Health-System Pharmacists (ASHP) and American College of Clinical Pharmacy (ACCP). In phase 2, the postgraduate programs' official websites were reviewed for additional information. Each program was evaluated to determine the eligibility of international students with F-1 visa or Optional Practical Training (OPT) status, visa sponsorship and work authorization opportunities, and citizenship requirements. Programs were classified as eligible or noneligible to international students or as not providing sufficient information. Descriptive statistics were used to summarize the data. RESULTS: A total of 1,455 ASHP PGY1 programs and 69 fellowship programs were included in our analysis. In phase 1, there were 3 eligible programs accepting applicants with F-1/OPT status and 377 noneligible programs. In phase 2, there were 10 eligible programs accepting applicants with F-1/OPT status or providing H-1B sponsorship and 410 noneligible programs. Over 70% of programs (phase 1, n = 1,075; phase 2, n = 1,035) were classified as providing no information. None of the fellowship programs were classified as eligible in our review. CONCLUSION: Most residency and fellowship programs did not provide clear eligibility criteria for students with F-1/OPT status. Only a few programs clearly stated that they would accept applicants with F-1/OPT status or provide visa sponsorship to graduates holding F-1 visas.

Assessment of a Scholars Program Designed to Enhance Pharmacy Students' Competitiveness for Postgraduate Residency Training.

Objective. To assess pharmacy residency match/placement rates and student perceptions of a program designed to enhance Doctor of Pharmacy (PharmD) student competitiveness for postgraduate residency positions. Methods. The Scholars Program was developed to provide advanced training to select PharmD students who had an interest in postgraduate residency training and was completed during the third and fourth professional years. The program consisted of mentoring; elective coursework encompassing clinical practice, teaching, and leadership; modified experiential education; journal club meetings; teaching assistant duties; conducting research and/or scholarship; and delivering professional presentations. Residency match/placement rates of students who had completed the program were compared to national data and to students in the school who were not enrolled in the program. Perceptions of the program were assessed using an online survey. Results. Sixty-four students enrolled in and completed the Scholars Program from 2013 to 2019. Of these, 58 (91%) pursued postgraduate residency training. Students enrolled in the program had a higher combined phase 1/phase 2 match rate (91.4% vs 67.4%) than students in other PharmD programs across the United States. Similarly, students enrolled in the Scholars Program had a higher combined phase 1/phase 2 match rate (91.4% vs 62.9%) and overall residency placement rate (96.6% vs 67.0%) compared to students in the school who were not enrolled in the program. More than 85% of students enrolled in the Scholars Program who pursued residency training agreed that the program prepared them for and helped them attain a postgraduate residency. Conclusion. Pharmacy students enrolled in the Scholars Program experienced high residency match/placement rates and viewed the program as valuable preparation for postgraduate training.

A Multimodal Approach to Teaching Cultural Competency in the Doctor of Pharmacy Curriculum.

Objective. To assess first-year pharmacy students' grades and preferred teaching styles within a multimodal teaching approach for developing cultural competency during a required Pharmaceutical Care I course. Methods. A lecture, two active-learning exercises (global bead and trading places), and an in-class quiz were used to teach students about cultural competency in preparation for a practicum. A four-hour practicum consisting of videos, structured discussion, counseling, and a survey were used in this multimodal approach. Student quiz and practicum grades and survey results were analyzed. Reflection responses were collected. Results. Students scored an average of 86.1% on the in-class quiz and 92.6% on the practicum. Average rankings on the Trading Places exercise demonstrated a change in students' individual biases. Students perceived the practicum, lecture, and Worlds Apart videos to be the most useful elements of the cultural competency curriculum. Conclusion. The practicum and lecture were the teaching methods most preferred by students for conveying cultural competency; however, students agreed that all of the teaching methods used helped them to achieve the desired learning objectives. Students' grades improved from the quiz to the practicum, which may indicate enhanced cultural knowledge via a multimodal teaching approach.

Development of a medication health literacy program for refugees.

OBJECTIVES: To develop a community-based educational workshop to improve medication health literacy in refugees. SETTING: Workshops were provided in community locations including a local resettlement agency and English as a Second Language facility. PRACTICE DESCRIPTION: Pharmacy faculty mentored small group student workshop presentations to recently arrived refugees regarding medication health literacy topics. PRACTICE INNOVATION: A program was developed to use translated materials, interpreters, hands-on materials, and evaluations to teach refugees about medication-related issues. A needs assessment was conducted with a local refugee resettlement agency to determine topics. EVALUATION: Evaluations were administered after the workshop to ensure understanding of the workshop material. Verbal feedback and faculty oversight during interactions between pharmacy students and refugees in addition to evaluation responses were used for quality improvement. RESULTS: Workshop materials have been translated into 11 of the most common languages for our local refugee population. Twelve workshops were administered during the past year and a half, educating 282 refugees from 33 countries. There was an average of 78% correct responses on postevaluation questions assessing refugees' understanding of workshop concepts. Verbal feedback from the refugees supported an increase in knowledge regarding how to open a medication bottle, how to read medication labels, and how to dose liquid medications. CONCLUSION: Implementation of this health literacy program allowed us to address medication-related concerns with refugees. Working within the community setting provided a learning environment in which the refugees trusted the workers and were comfortable asking questions. Small group settings and evaluation allowed us to review concepts until proficiency was achieved.

Comparison of prescribing patterns between United States and Dominican Republic prescribers on short-term medical mission trips.

Background: Short-term medical missions (STMMs) have increased and are viewed as a way to extend care in low- and middle-income countries (LMICs). Although benefits may exist, visiting teams may lack insight into using medications safely and effectively. The primary objective was to assess prescribing differences between US-based and Dominican Republic (DR) healthcare providers on STMMs in the DR. Methods: A retrospective database review between January 2013 and 2015 was conducted. Data from US and DR groups were compared for differences in diagnoses, medication classes prescribed and prescriptions per patient. Results: The mean number of medical conditions diagnosed per patient in the DR (n=423) and US groups (n=1585) were 1.4±0.9 and 1.0±0.8, respectively. The diagnosis of infectious diseases was the same as non-communicable diseases. The DR group prescribed more medications at each patient encounter (mean 2.6 vs 2.2, respectively; p<0.001). The US group prescribed more antibiotics for respiratory infections (US 46.2% vs DR 25.0%; p=0.0001), used more metronidazole than albendazole alone for parasite infections (p=0.0022) and used more oral fluconazole for vaginal candidiasis (p<0.0001) and tinea infections (US 44.6%, DR 14.3%, respectively; p=0.0020). Conclusions: Although some significant prescribing differences exist between US and DR providers, many similarities were present. Visiting providers should understand the medication use system and disease burden before providing care in an LMIC.

Global Health Education in Doctor of Pharmacy Programs in the United States.

Objective. To determine the extent and manner in which global health education is taught at US PharmD programs. Methods. A pre-tested 40-question electronic survey instrument was developed and sent to each of the 127 accredited or candidate-status US doctor of pharmacy (PharmD) programs. Results. Twenty-eight public and 27 private PharmD programs responded to the survey (43.3%). Twenty-five (45.5%) programs had integrated global health topics into their required didactic curriculum, and 30 of 52 programs (57.7%) offered at least one standalone global health elective course. Of the 52 programs that provided details regarding experiential education, 41 (78.8%) offered introductory and/or advanced pharmacy practice experiences (IPPEs and/or APPEs) in global health, and 34 (65.4%) programs offered medical mission trips. Conclusion. Doctor of pharmacy programs participating in global health education most commonly educate students on global health through experiential learning, while inclusion of required and elective coursework in global health was less common. To adequately prepare students for an increasingly global society, US PharmD programs should consider expanding global health education.

Introduction and Assessment of a Blended-Learning Model to Teach Patient Assessment in a Doctor of Pharmacy Program.

Objective. To integrate a blended-learning model into a two-course patient assessment sequence in a doctor of pharmacy (PharmD) program and to assess the academic performance and perceptions of enrolled students. Design. A blended-learning model consisting of a flipped classroom format was integrated into a patient assessment (PA) course sequence. Course grades of students in the blended-learning (intervention) and traditional-classroom (control) groups were compared. A survey was administered to assess student perceptions. Assessment. The mean numeric grades of students in the intervention group were higher than those of students in the traditional group (PA1 course: 92.2±3.1 vs 90.0±4.3; and PA2 course: 90.3±4.9 vs 85.8±4.2). Eighty-six percent of the students in the intervention group agreed that the instructional methodologies used in this course facilitated understanding of the material. Conclusion. The blended-learning model was associated with improved academic performance and was well-received by students.

Azithromycin-Induced, Biopsy-Proven Acute Interstitial Nephritis in an Adult Successfully Treated with Low-Dose Corticosteroids.

Acute interstitial nephritis (AIN) is a form of acute kidney injury (AKI) characterized by a rapid deterioration of renal function, inflammatory infiltration of interstitial tissues, and renal edema. Drug-induced AIN is the most common etiology of AIN, but AIN can also have infectious, autoimmune, or idiopathic causes. ß-Lactam antibacterials, nonsteroidal antiinflammatory drugs, and proton pump inhibitors are recognized as leading causes of AIN; however, many other drugs have been identified as causes. We describe the case of a 59-year-old white male who developed AIN that required hemodialysis following azithromycin treatment. He presented to the hospital with complaints of nausea, vomiting, malaise, and fever over the past 3 days, along with no urine output in the preceding 24 hours. Two weeks earlier, he had completed a 5-day course of azithromycin 500 mg on day 1 followed by 250 mg/day on days 2-5 (total dose 1.5 g) for an upper respiratory tract infection. On admission, the patient's serum creatinine (S(cr)) concentration was 7.4 mg/dl (baseline = 1.3 mg/dl). He reported a similar episode of kidney failure 2 years earlier after taking azithromycin; however, at that time it was believed the AKI was likely due to benazepril use in the setting of acute infection, and a kidney biopsy was not performed. His S(cr) concentration peaked at 11.4 mg/dl, and three sessions of hemodialysis were required. A kidney biopsy was performed that revealed AIN. Low-dose prednisone 0.3 mg/kg (30 mg)/day, tapered over the next 3 months, was administered, and his renal function improved to near baseline prior to discharge; 6 months later, his Scr concentration was 1.4 mg/dl. Despite lower than recommended dosing, this patient responded well to prednisone and did not experience long-term sequelae from renal injury. Use of the Naranjo Adverse Drug Reaction Probability Scale indicated a definite relationship (score of 10) between azithromycin exposure and the manifestation of AIN. To our knowledge, this is the first report of azithromycin-induced acute interstitial nephritis with near-complete resolution of renal injury in an adult. This case report illustrates the importance of rapid recognition of drug-induced renal injuries and discontinuation of the offending agent. Select use of corticosteroids may improve both time to and extent of renal function recovery.

Long-acting reversible contraception: a review in special populations.

Almost half of the pregnancies in the United States are unintended. Currently available contraceptive methods are highly efficacious, but the most commonly used methods rely on patients for appropriate use. There has been a push to advocate for long-acting reversible contraceptives (LARCs) as first-line methods because they are placed by medical professionals and are the most effective form of reversible contraception available. There are four LARCs currently available in the United States: the Copper T intrauterine device, two forms of the levonorgestrel intrauterine system, and the etonogestrel subdermal implant. Once inserted, they can be left in place for 3-10 years, depending on the device. Some of these devices have been available for a number of years, but their use is limited in the United States due to controversies and misconceptions. A MEDLINE search from 1990-2012 was conducted to identify articles describing the use of LARCs in populations with limited data, including postpartum women, adolescents and nulliparous women, and women with sexually transmitted infections, including human immunodeficiency virus (HIV). Health care provider safety concerns surrounding intrauterine device (IUD) expulsions and infection are issues for use in adolescents and nulliparous women. Concern regarding IUD expulsion in the postpartum population questions the benefit of immediate versus delayed insertion, and the progestin effect in the levonorgestrel IUD and etonogestrel implant is of theoretic concern for breastfeeding women. In women with HIV, concerns have been raised about increased viral shedding with the IUD and drug interactions with the progestin methods. Many misconceptions surrounding LARCs are unfounded, but individual risk factors may leave LARC users at risk of unintended pregnancy if not addressed properly.

The rebirth of progesterone in the prevention of preterm labor.

OBJECTIVE: To evaluate data since 2003 on the efficacy and safety of progesterone supplementation in the prevention of preterm labor. DATA SOURCES: A MEDLINE and Ovid database search (January 2003-September 2012) was performed using the search terms preterm, progesterone, and 17α-hydroxyprogesterone caproate. All relevant abstracts were reviewed. STUDY SELECTION: For efficacy and safety data, the search was limited to randomized, double-blind, placebo-controlled trials with the primary outcome of preterm delivery, fetal loss, or neonatal morbidity or mortality. Quality of the studies was assessed using the CONSORT (Consolidated Standards of Reporting Trials) guidelines for reporting parallel-group randomized trials. Eleven articles were selected for review. DATA SYNTHESIS: Preterm birth, prior to 37 weeks' gestation, remains the leading cause of neonatal morbidity and mortality in the US due to lack of treatment options. Recently, the use of progesterone to prevent preterm labor, deemed decades ago to be ineffective, has been reexamined. Progesterone formulations and dosage regimens varied greatly between studies. In patients with prior preterm birth or shortened cervix shown on transvaginal ultrasound, progesterone appears efficacious in reducing the rate of preterm birth. However, this benefit was not demonstrated in multiple-gestation pregnancies. Overall, progesterone was well tolerated and appeared safe for mother and fetus. More studies are needed to confirm the dosage regimen and population that will benefit most from progesterone. CONCLUSIONS: Progesterone appears to be safe and efficacious in reducing the risk of preterm birth in a select group of high-risk women with prior spontaneous preterm births and those with an ultrasound-confirmed short cervix. Women with multiple gestations do not benefit from progesterone supplementation.

Impact of electronic device use in class on pharmacy students' academic performance.

OBJECTIVES: To evaluate and assess the impact of pharmacy students' electronic device (e-device) use during a lecture-based pharmacotherapeutics sequence. METHODS: A validated survey instrument to assess e-device use was e-mailed to 238 second- (P2) and third-year (P3) pharmacy students. Grades were reviewed retrospectively and correlated with e-device use to determine its impact on academic performance. RESULTS: Of 140 responding students (59% response rate), 106 reported using e-devices during class for course-related (91.5%) and non-course-related (81.1%) activities. When P2 and P3 students were combined, e-device use was not associated with academic performance (p = 0.70). Academic performance was not impacted among P3 students (p = 0.86), but P2 students performed better academically if they refrained from using e-devices during class (mean grade = 88.5% vs. 83.3%; p=0.019). CONCLUSIONS: The impact of e-device use on overall academic performance was negligible. Use of e-devices by students enrolled in their first pharmacotherapeutics course may negatively impact academics.

Future of personalized pharmacotherapy in chronic heart failure patients.

There is a significant amount of diversity among heart failure (HF) patients. Contemporary HF regimens often do not take into consideration many of the factors that might influence an individual's response to treatment. Clinical recommendations based on trial data derived from mainly younger Caucasian male study populations have, in most cases, been applied equally to women and African-Americans. Subgroup analyses of randomized HF trials and results of retrospective cohort studies have been used for customizing HF regimens in women and African-Americans. Pharmacogenetics is an emerging strategy for personalizing HF therapy. Genetic biomarkers may play an important role in predicting a patient's response to treatment and in predicting those at risk of toxicity. HF pharmacotherapy has improved over the last two decades; however, substantial work remains in order to personalize HF management and maximize the benefit of pharmacologic interventions, while limiting adverse events.