The Tennessee Medicaid medication therapy management program: early stage contextual factors and implementation outcomes.

BACKGROUND: First investigated in the 1990s, medication therapy management (MTM) is an evidence-based practice offered by pharmacists to ensure a patient's medication regimen is individualized to include the safest and most effective medications. MTM has been shown to a) improve quality of patient care, b) reduces health care costs, and c) lead to fewer medication-related adverse effects. However, there has been limited testing of evidence-based, a-priori implementation strategies that support MTM implementation on a large scale. METHODS: The study has two objectives assessed at the organizational and individual level: 1) to determine the adoption, feasibility, acceptability and appropriateness of a multi-faceted implementation strategy to support the MTM pilot program in Tennessee; and 2) to report on the contextual factors associated with program implementation based on the Consolidated Framework for Implementation Research (CFIR). The overall design of the study was a hybrid type 2 effectiveness-implementation study reporting outcomes of Tennessee state Medicaid's (TennCare) MTM Pilot program. This paper presents early stage implementation outcomes (e.g., adoption, feasibility, acceptability, appropriateness) and explores implementation barriers and facilitators using the CFIR. The study was assessed at the (a) organizational and (b) individual level. A mixed-methods approach was used including surveys, claims data, and semi-structured interviews. Interview data underwent initial, rapid qualitative analysis to provide real time feedback to TennCare leadership on project barriers and facilitators. RESULTS: The total reach of the program from July 2018 through June 2020 was 2033 MTM sessions provided by 17 Medicaid credentialed pharmacists. Preliminary findings suggest participants agreed that MTM was acceptable (µ = 16.22, SD = 0.28), appropriate (µ = 15.33, SD = 0.03), and feasible (µ = 14.72, SD = 0.46). Each of the scales had an excellent level of internal (> 0.70) consistency (feasibility, α = 0.91; acceptability, α = 0.96; appropriateness, α = 0.98;). Eight program participants were interviewed and were mapped to the following CFIR constructs: Process, Characteristics of Individuals, Intervention Characteristics, and Inner Setting. Rapid data analysis of the contextual inquiry allowed TennCare to alter initial implementation strategies during project rollout. CONCLUSION: The early stage implementation of a multi-faceted implementation strategy to support delivery of Tennessee Medicaid's MTM program was found to be well accepted and appropriate across multiple stakeholders including providers, administrators, and pharmacists. However, as the early stage of implementation progressed, barriers related to relative priority, characteristics of the intervention (e.g., complexity), and workflow impeded adoption. Programmatic changes to the MTM Pilot based on early stage contextual analysis and implementation outcomes had a positive impact on adoption.

Developing an effective intervention for IDU women: a harm reduction approach to collaboration.

Harm reduction is fundamentally a movement intended to empower the patient and consumer of health services. This project applied harm reduction theory as a strategy to empower collaborating community partners and researchers to overcome their preconceptions about each other in order to create a successful HIV prevention intervention and evaluation study for injection drug using women. The Women's Options for Risk Reduction through Knowledge of Self (WORKS) intervention program offered a series of four HIV prevention workshops, in conjunction with sexually transmitted infection (STI) and HIV counseling and testing to female injection drug users (IDUs) or the partners of IDUs. This community collaboration was to integrate the strengths of researchers and service providers in a comprehensive approach to prevention evaluation. In this collaborative research context, capacity building meant developing the long-term goal, explicit commitment to and integration of evaluation into the overall operation of a HIV prevention service delivery organization. The WORKS Intervention collaboration's aim was to improve the capacity of community-based organizations (CBOs) to use research-based data on HIV risk taking behavior and prevention strategies to provide effective interventions and services and effectively evaluate their efforts. Barriers to successful planning, implementation, and evaluation are presented with the strategies used to overcome them. Intervention effectiveness results from the process evaluation are presented in the context of prevention and research capacity development in CBOs.

Global effects of xanthine oxidase stress on alveolar type II cells.

OBJECTIVE: To delineate biochemical details of graded xanthine oxidase stress toward cultured alveolar type II cells, particularly oxidant-mediated damage of type II cell nucleic acid, protein, and lipid, as an in vitro model of distant ischemia-reperfusion lung injury. DESIGN: In vitro injury model using native rat and immortalized mouse alveolar type II cells and exogenous xanthine oxidase. SETTING: Research laboratory. Measurement: Cultured type II cells were subjected to xanthine oxidase-derived reactive oxygen stress at variable concentrations and incubation times. Reduction of type II cell double-stranded DNA, inhibition of de novo phosphatidyl choline synthesis, enhancement of lipid peroxidation, and suppression of mitochondrial redox capacity were analyzed in relation to high-intensity (xanthine oxidase, 25 munits/mL) oxidant stress. Alterations in type II cell cellular glutathione-related antioxidant repertoire were assessed at both high-intensity and low-intensity (xanthine oxidase, 1 munits/mL) oxidant stress. MAIN RESULTS: High-intensity xanthine oxidase stress significantly increased type II cell DNA strand breakage, inhibited de novo phosphatidyl choline synthesis, diminished mitochondrial integrity, and enhanced lipid peroxidation in the absence of overt cytolysis. This injury was modulated with addition of exogenous glutathione peroxidase, or catalase/superoxide dismutase, but not glutathione or N-acetylcysteine. Although aspects of the glutathione antioxidant repertoire were similarly diminished with high-intensity xanthine oxidase stress, low-dose (long duration) xanthine oxidase stress augmented the activities of type II cell glutathione peroxidase and gamma-glutamyl transferase (the rate-limiting enzyme in glutathione synthesis). CONCLUSION: High-intensity xanthine oxidase stress (in vitro model of in vivo ischemia-reperfusion) may overwhelm type II cell antioxidant defenses and mediate oxidant injury to nucleic acid, protein, and lipid in the absence of cell lysis. Immortalized murine type II cells seem to appropriately model xanthine oxidase-mediated nucleic acid and protein injury of native rat type II cells. Exogenous glutathione peroxidase reduces oxidant injury in this in vitro model. Depending on magnitude (and possibly duration) of the xanthine oxidase stress, type II cell glutathione antioxidant elements may be diminished or enhanced.