Assessment of a Community Pharmacist Remote Monitoring Service in Patients Using Continuous Glucose Monitors (CGMs).

BACKGROUND: Diabetes is the eighth leading cause of death and has a substantial impact on the United States (U.S.) health care system. Recent changes to major insurance formularies allow for increased access to continuous glucose monitors (CGM). Community pharmacists routinely assist and educate patients about diabetes care, including usage of CGM. OBJECTIVES: The purpose of this study was to evaluate the clinical impact of a community pharmacist remote CGM monitoring service on patients' glycemic metrics. Patient completion of comprehensive diabetes standards of care and pharmacist interventions and recommendations were assessed as secondary objectives. METHODS: This study was a prospective, feasibility study conducted at two pharmacies within one regional division of a large community pharmacy chain between November 2022 and June 2023. A pharmacist conducted patient enrollment visits and remotely monitored CGM glycemic metrics via cloud-based platforms per the study protocol. CGM glycemic metrics were evaluated for each patient three months pre- and post-study enrollment, including time above range (TAR), time in range (TIR), time below range (TBR), glucose management indicator (GMI), average glucose, CGM utilization rate, and glucose variability. Metrics were evaluated for statistical significance using the Wilcoxon signed-rank test and descriptive statistics. RESULTS: Pharmacists enrolled 36 patients in this study with 20 patients completing the full three-month study period per protocol. There was a statistically significant improvement in three of eight glycemic metrics (very high TAR, TIR, and average glucose). Specifically, TIR had the largest improvement from 61.8% pre-enrollment to 69.9% (p < 0.006) post-enrollment. All other pertinent glycemic metrics displayed improvements but were not statistically significant. CONCLUSION: The results demonstrate clinically and statistically significant improvements in several glycemic metrics for patients who participated in the community pharmacist-led remote CGM monitoring service, which may result in improved diabetes control and fewer long-term diabetes-related health complications.

Physician-approved protocols increase naloxone dispensing rates.

OBJECTIVE: To measure the impact of the implementation of a law that allows pharmacists to provide naloxone under a physician-approved protocol on naloxone dispensing rates in an all-payer population across the United States. METHODS: Prescription claims from a national grocery chain for 31 states and Area Heath Resource File were used for this retrospective study. The study sample included all patients who filled at least one naloxone prescription during the study period from July 16, 2014 to January 16, 2017. A stepwise autoregression was performed for 30 consecutive months to evaluate the change in naloxone prescription dispensing rate. The primary independent variable was "implementation of the physician-approved protocol." The primary outcome measure was the rate of naloxone prescriptions dispensed per month per state. Secondary outcome measures were naloxone dispensing rates by each payer. RESULTS: Number of patients who received naloxone prescriptions in the states with physician-approved protocol was 423% higher compared to states without the protocol. The overall model showed that the naloxone dispensing rate was 6 times higher in the states with a physician-approved protocol. In the payer-based models, comparing states with and without protocol, the dispensing rate was highest for Medicare (9.0 times) followed by Private (4.6 times), Medicaid (3.2 times), and Cash (3.1 times). The number of prescriptions dispensed in the low-employment states with the protocol was 17.59 times higher compared to states without the protocol. CONCLUSIONS: Implementation of physician-approved protocol was strongly associated with an increase in naloxone dispensing rates, especially in the low-employment states.

The evaluation of mandatory alerts on long-acting opioid prescriptions and the use of a community pharmacy naloxone protocol.

BACKGROUND: Opioid overdose deaths accounted for approximately 69.5% of the total drug overdoses in the United States in 2018. In the same year, the Centers for Disease Control and Prevention estimates that around 9 million opportunities to dispense naloxone to high-risk patients were missed. Community pharmacists are equipped to help all patients obtain naloxone to prevent opioid-related overdoses. OBJECTIVES: The purpose of this study was to determine the impact of mandatory alerts on the dispensing of naloxone by pharmacists using a physician-approved protocol. The primary objective of this study was to evaluate the change in the number of dispensed naloxone prescriptions via physician-approved protocol compared with the same time period in the previous year. The secondary objective was to evaluate the pharmacists' knowledge and confidence dispensing naloxone via physician-approved protocol. PRACTICE DESCRIPTION: A system-generated mandatory alert that prompted pharmacists to assess the need for naloxone and initiate and dispense as appropriate via a physician-approved protocol was implemented in 5 pharmacies of a large community pharmacy chain between June and July 2020. PRACTICE INNOVATION: A technology enhancement was designed that automatically created a mandatory alert in the pharmacy management system for all patients who were dispensed a long-acting opioid medication to prompt pharmacists to initiate and dispense naloxone as appropriate. EVALUATION METHODS: The impact of the mandatory alert was evaluated by assessing patients' medication fill history in the pharmacy management system to determine the change in naloxone prescriptions dispensed. RESULTS: During the intervention period, pharmacists initiated and dispensed 34 incremental naloxone prescriptions via a physician-approved protocol compared with the same time period in the previous year. CONCLUSION: The results illustrated that system-generated mandatory alerts prompting pharmacist intervention can effectively increase pharmacist utilization of a physician-approved protocol, resulting in increased naloxone prescriptions dispensed to high-risk patients.

Validation and threshold identification of a prescription drug monitoring program clinical opioid risk metric with the WHO alcohol, smoking, and substance involvement screening test.

BACKGROUND: Prescription drug monitoring programs (PDMPs) are critical for pharmacists to identify risky opioid medication use. We performed an independent evaluation of the PDMP-based Narcotic Score (NS) metric. METHODS: This study was a one-time, cross-sectional health assessment within 19 pharmacies from a national chain among adults picking-up opioid medications. The NS metric is a 3-digit composite indicator. The WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was the gold-standard to which the NS metric was compared. Machine learning determined optimal risk thresholds; Receiver Operating Characteristic curves and Spearman (P) and Kappa (K) coefficients analyzed concurrent validity. Regression analyses evaluated participant characteristics associated with misclassification. RESULTS: The NS metric showed fair concurrent validity (area under the curve≥0.70; K=0.35; P = 0.37, p < 0.001). The ASSIST and NS metric categorized 37% of participants as low-risk (i.e., not needing screening/intervention) and 32.3% as moderate/high-risk (i.e., needing screening/intervention). Further, 17.2% were categorized as low ASSIST risk but moderate/high NS metric risk, termed false positives. These reported disability (OR=3.12), poor general health (OR=0.66), and/or greater pain severity/interference (OR=1.12/1.09; all p < 0.05; i.e., needing unmanaged-pain screening/intervention). A total of 13.4% were categorized as moderate/high ASSIST risk but low NS metric risk, termed false negatives. These reported greater overdose history (OR=1.24) and/or substance use (OR=1.81-12.66; all p < 0.05). CONCLUSIONS: The NS metric could serve as a useful initial universal prescription opioid-risk screener given its: 1) low-burden (i.e., no direct assessment); 2) high accuracy (86.5%) of actionable data identifying low-risk patients and those needing opioid use/unmanaged pain screening/intervention; and 3) broad availability.

Impact of an adherence intervention program on patient adherence and star ratings measures in a large community pharmacy chain.

OBJECTIVE: This study aimed to determine the impact of an adherence intervention program on medication adherence rates and performance on the Centers for Medicare and Medicaid Services star ratings measures. SETTING: The study was conducted in a large community pharmacy chain comprising more than 2200 pharmacies and 7000 pharmacists across 36 states. PRACTICE DESCRIPTION: Pharmacists conducted adherence interventions with patients with a proportion of days covered (PDC) of less than 80% for hypertension, cholesterol, and diabetes star ratings medications. PRACTICE INNOVATION: A longitudinal, pharmacist-led adherence intervention program with automated follow-up interventions was implemented between June 2017 and December 2017. EVALUATION: The percentage of patients with a PDC of greater than or equal to 80% and performance on CMS star ratings measures were evaluated for Medicare Part D Prescription Drug Plan (PDP) and Medicare Advantage Prescription Drug (MAPD) Plan populations in 2017 compared with that of 2015 and 2016. Patient-level PDC change, pharmacist intervention completion, and pharmacist recommendation of additional pharmacy services were also measured. RESULTS: A total of 241,261 interventions were generated in the electronic dispensing systems. Pharmacists enrolled 60,232 patients and completed 75.4% of follow-up interventions, with an average of 1.3 follow-ups per patient. For the Medicare PDP population, improvement in the percentage of adherent patients ranged from 1.1% to 1.2% and 0.9% to 1.8% for 2015-2016 and 2016-2017, respectively, whereas improvement ranged from 2.1% to 2.5% and 2.0% to 3.0% for 2015-2016 and 2016-2017, respectively, for the MAPD Plan population. In 2016 and 2017, performance on cholesterol and diabetes measures achieved the 4-star cut point, and the hypertension measure achieved the 5-star cut point. CONCLUSION: This study demonstrated the successful implementation and pharmacist participation in an adherence intervention program in a large community pharmacy chain. Compared with the previous year, medication adherence improved for patients attributed to hypertension, cholesterol, and diabetes measures, and performance on CMS star rating measures was maintained, despite an increase in cut points.

Association Between a State Law Allowing Pharmacists to Dispense Naloxone Without a Prescription and Naloxone Dispensing Rates.

Importance: Between 2015 and 2017, Ohio had the second highest number of opioid-related deaths. In July 2015, the Ohio General Assembly approved a law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol. This change in the law allowed pharmacists to have more opportunity to participate in the management of patients who were addicted to opioids. Objective: To determine the association between the implementation of an Ohio law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol and naloxone dispensing rates. Design, Setting, and Participants: A segmented regression analysis of an interrupted time series was performed for 30 consecutive months to evaluate the change in the naloxone dispensing rate before and after the implementation of the state law. Ohio Medicaid naloxone claims and Kroger Pharmacy naloxone claims for all 88 counties in Ohio were examined. Any patient 18 years or older with at least 1 naloxone order dispensed through Ohio Medicaid or by a Kroger Pharmacy in Ohio during the study period of July 16, 2014, to January 15, 2017, was included in the study. Data were analyzed from April 23, 2018, to July 7, 2019. Exposures: The primary independent variable was implementation of an Ohio law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol, which took effect in July 2015. Main Outcomes and Measures: The primary outcome measure was the naloxone dispensing rate per month per county. Results: In the Ohio Medicaid population, the number of naloxone orders dispensed after the policy was implemented increased by 2328%, from 191 in the prepolicy period to 4637 in the postpolicy period. The rate of naloxone orders dispensed per month per county after the policy was implemented increased by 4% in the Ohio Medicaid population and 3% in the Kroger Pharmacy population compared with the prepolicy period. The rate of naloxone orders dispensed after the policy was implemented increased by 18% per month in low-employment counties compared with high-employment counties in the Ohio Medicaid population. Conclusions and Relevance: The implementation of a state law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol was associated with an increase in the number of naloxone orders dispensed in the Ohio Medicaid and Kroger Pharmacy populations. Moreover, a significant increase was observed in the naloxone dispensing rate among the Ohio Medicaid population in counties with low employment and high poverty.

Assessment of community pharmacists' confidence, foundational knowledge, and coordination of care activities in patients with cancer as a chronic condition.

OBJECTIVES: To develop and deliver a series of structured educational programs to community pharmacists to build on current foundational knowledge of cancer and cancer therapy. The specific objectives were to: 1) develop and provide an educational program focused on oncology pharmacy practice in the community; and 2) measure the program impact on participants' confidence, foundational knowledge, and coordination of cancer care activities. PRACTICE INNOVATION: A structured, in-person, 6-hour educational program tailored for community pharmacists was developed and delivered along with two 20-minute online webinar sessions. The topics identified for the webinars were based on solicited feedback from participants attending the live educational program. EVALUATION: A pre- and post-survey was used to evaluate the participant's assessment of the live educational program, and a retrospective survey was used to evaluate the education sessions. RESULTS: Twenty-one pharmacists attended the in-person session. Participants indicated that they were more confident and able to coordinate care after the educational intervention. There was a nonsignificant improvement in foundational knowledge. CONCLUSION: The educational sessions provided current relevant information for community pharmacists to build on knowledge of oncology pharmacy practice and resources. This increased the pharmacists' confidence to address needs and facilitate coordination of care for individuals with cancer. Delivery of education tailored to community pharmacy is important as the advancing cancer care model continues to adapt with new medications and innovations.

Improving care transitions through medication therapy management: A community partnership to reduce readmissions in multiple health-systems.

OBJECTIVES: The primary objective was to measure the impact of a pharmacist-provided medication therapy management program on 30-day postdischarge readmission rates. The secondary study objectives were to characterize the number and types of pharmacist interventions, to determine the impact of the intervention on primary and secondary medication nonadherence, and to measure patient satisfaction with the intervention. DESIGN: Randomized, clinical trial. SETTING: Six hospitals and a supermarket pharmacy chain with 60 pharmacies. PARTICIPANTS: Four hundred patients discharged from a participating hospital with acute myocardial infarction, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, or diabetes. MAIN OUTCOME MEASURES: Primary outcome measure was 30-day readmission rate. Secondary outcomes were pharmacist interventions, primary and secondary medication nonadherence, and patient satisfaction. RESULTS: Four hundred patients were enrolled. There was not a significant difference in 30-day readmission rates between intervention and control groups (11.3% vs. 10.7%; P = 0.49). A large portion of patients randomized to the intervention did not attend their appointment. In a per protocol (PP) analysis, which included the 62 intervention patients who attended their appointment and the 187 patients in the control group, there was a significant difference in 30-day readmission rates (1.6% vs. 10.7%; P = 0.02). In the PP analysis, controlling for baseline differences, patients in the intervention group were significantly less likely to experience a readmission (odds ratio, 0.126; 95% confidence interval, 0.016-0.968; P = 0.046). In the PP analysis, the percentage of prescriptions not picked up in the intervention group compared with the control group was reduced by 2.5%, (6.4% vs. 8.9%; P = 0.59). Pharmacists identified many interventions, averaging 6 per patient. CONCLUSION: This study successfully implemented a large-scale transition of care program between multiple health systems and community pharmacies that reduced hospital readmissions. Pharmacists identified many interventions for patients. The transmission of patient information from the inpatient setting to the community pharmacy is key to transitioning patients successfully.

Addressing primary nonadherence: A collaboration between a community pharmacy and a large pediatric clinic.

OBJECTIVES: To decrease nonadherence rates through the design and implementation of a collaborative prescription management program involving a community pharmacy and a large pediatric primary care center. PRACTICE INNOVATION: Kroger and Cincinnati Children's Pediatric Primary Care Center collaborated to identify and address patients' barriers to filling new prescriptions. After filling new medications for clinic patients, pharmacists telephoned patients to inform them that their prescription was ready and to reinforce the importance of initiating the therapy. Pharmacists followed up with families to address barriers when prescriptions remained at the pharmacy after 48 hours. Pharmacists communicated with prescribers if prescriptions were not filled, allowing the clinic staff to follow up. EVALUATION: The primary outcome of this prospective pilot study with a comparison group was primary nonadherence (PNA), defined as the proportion of patients who did not pick up prescriptions or a reasonable alternative within 30 days after the pharmacy received the prescription. Secondary outcomes were the impact on secondary nonadherence and identification of adherence barriers. RESULTS: Fifty-nine patients were enrolled from November 2016 to April 2017. Characteristics between the intervention group and a standard-care group were similar. The majority of prescribed medications were for acute conditions, the average patient age was 4.9 years, and 86% of patients were covered by Medicaid. Intervention patients had significantly less PNA compared with the standard-care group (14.0% vs. 53.3%, respectively; P < 0.001). Intervention patients had significantly greater secondary adherence rates compared with standard-care patients (38.8% vs. 7%; P < 0.001). Common barriers likely resulting in PNA included lack of time, lack of urgency, transportation challenges, and cost. CONCLUSION: Increased communication between the primary care provider and the community pharmacy, coupled with targeted patient-specific interventions before the initial fill of medications, resulted in significant reductions in PNA.

An appointment-based model to systematically assess and administer vaccinations.

OBJECTIVES: To incorporate the assessment of vaccination status and administration of vaccines in an appointment-based model (ABM) and measure the impact on vaccinations administered and patient and pharmacist satisfaction with the appointment-based model. PRACTICE DESCRIPTION: An ABM was implemented to systematically assess vaccination status and administer vaccines. Patients made an appointment to pick up synchronized prescriptions, and pharmacists assessed vaccination histories and administered vaccinations during the appointment. In addition, pharmacists could access the statewide immunization information system to objectively determine vaccination histories and document administered vaccines. SETTINGS AND PARTICIPANTS: This project was conducted at 24 Kroger Pharmacies in the Cincinnati-Dayton Area. Any patient filling more than 1 maintenance medication was eligible for the ABM program. Pharmacists were encouraged to target patients at high risk for medication problems and vaccine-preventable diseases, including patients 60 years of age or older with more than 5 medications and high-risk disease states such as diabetes, asthma, and chronic obstructive pulmonary disease. EVALUATION: Pharmacies were randomized, and an a priori analysis was conducted to ensure that the 24 intervention and 78 control stores were similar at baseline. Postimplementation data on the mean number of vaccines per store were compared between the intervention stores and the control stores from September 2014 through December 2015. Patient and pharmacist satisfaction with the ABM was assessed via surveys. RESULTS: The pharmacist vaccine assessment as part of the ABM program showed higher overall mean vaccinations per store compared with the control group during the project period (1810.71 ± 500.88 vs. 1455.09 ± 754.43; P = 0.01). Patients and pharmacists felt that the ABM program facilitated vaccine discussions. CONCLUSION: The ABM program with a focus on vaccinations allowed pharmacists to systematically assess patient vaccination histories and administer vaccines in the pharmacy. Patients and pharmacists appreciated the dedicated time to discuss vaccinations.

Poverty, Transportation Access, and Medication Nonadherence.

BACKGROUND AND OBJECTIVES: Variability in primary medication nonadherence (PMN), or failure to fill a new prescription, influences disparities and widens equity gaps. This study sought to evaluate PMN across 1 metropolitan area and assess relationships with underlying zip code-level measures. METHODS: This was a retrospective observational study using data extracted from 1 regional community pharmacy market-share leader (October 2016-April 2017). Data included patient age, sex, payer, medication type, and home zip code. This zip code was connected to US census measures enumerating poverty and vehicle access, which were treated as continuous variables and within quintiles. The prescription-level outcome was whether prescriptions were not filled within 30 days of reaching the pharmacy. The ecological-level outcome was PMN calculated for each zip code (numerator, unfilled prescriptions; denominator, received prescriptions). RESULTS: There were 213 719 prescriptions received by 54 included pharmacies; 12.2% were unfilled. Older children, boys, and those with public insurance were more likely to have prescriptions not filled. Prescriptions originating from the highest poverty quintile were significantly more likely to not be filled than those from the lowest poverty quintile (adjusted odds ratio 1.60; 95% confidence interval 1.52-1.69); a similar pattern was noted for vehicle access (adjusted odds ratio 1.77; 95% confidence interval 1.68-1.87). At the ecological level, there were significant, graded relationships between PMN rates and poverty and vehicle access (both P < .0001); these gradients extended across all medication classes. CONCLUSIONS: Poverty and vehicle access are related to significant differences in prescription- and ecological-level PMN across 1 metropolitan area. Pharmacists and pharmacies can be key partners in population health efforts.

Appointment-based models: A comparison of three model designs in a large chain community pharmacy setting.

OBJECTIVES: To compare the effects of 3 different appointment-based model (ABM) designs on medication adherence and medication use outcomes controlling for patient and pharmacy characteristics. METHODS: This study was a retrospective cohort analysis in a large grocery store chain from January 1, 2012, to October 31, 2015. A total of 500 comparison and 613 intervention patients in 3 different model designs were analyzed. The outcome measures were proportion of days covered for selected medication classes, number of fills, administered vaccinations, number of trips, statin use in persons with diabetes, use of high-risk medications in older adults, and medication therapy for persons with asthma. RESULTS: After adjusting for relevant covariates, the authors found that all of the ABM designs significantly increased the number of fills after enrollment. Model designs 1 and 3 also significantly reduced the number of trips after enrollment: 4.5 fewer trips (95% CI -5.3 to -3.8; P < 0.05) for model 1 and 1.9 fewer trips (95% CI -3 to -0.9; P < 0.05) for model 3. Models 1 and 3 increased the percentage of patients considered to be adherent for diabetes medications and increased the number of vaccinations patients received. Models 1 and 2 significantly increased the percentage of patients considered to be adherent for statins. No model design was significantly associated with statin use in diabetes, high-risk medication use in older adults, nor percentage of patients considered to be adherent for the hypertension measure. CONCLUSION: All of the ABM designs were effective at increasing the number of fills after enrollment. This paralleled an increase in percentage of patients considered to be adherent to diabetes and statin therapies after enrollment. Models that included face-to-face delivery of the appointment and telephonic synchronization, or face-to-face delivery for all components, increased the number of vaccinations that patients received after enrollment and significantly reduced the number of trips a patient made to the pharmacy.

Community pharmacist collaboration with a patient-centered medical home: Establishment of a patient-centered medical neighborhood and payment model.

OBJECTIVES: To determine the feasibility of a partnership between a community pharmacy and a patient-centered medical home (PCMH) by measuring the impact on office- and patient-level clinical outcomes. SETTING: Kroger Pharmacy and a PCMH practice in Cincinnati, OH. PRACTICE DESCRIPTION: The Kroger Co. is a large grocery store chain that operates 102 pharmacies in the Cincinnati-Dayton marketing area. The PCMH practice is an accredited PCMH office serving more than 9000 patients in the Cincinnati area. PRACTICE INNOVATION: In a medical neighborhood, a PCMH coordinates care with other local specialty practices or partners. A partnership between the community pharmacy chain and the PCMH was established to create a medical neighborhood. The pharmacist spent 2 half-days per week at the PCMH. The pharmacist provided initial medication therapy management appointments in the PCMH and offered follow-up services in the office, the pharmacy, or both, depending on patient preference. The pharmacy received a capitated payment per patient per month for a predetermined number of 1000 high-risk patients. MAIN OUTCOME MEASURES: Office-level changes in clinical outcomes such as A1C, blood pressure, and lipid measures were collected and compared with those of a similar control office. In addition, patient-level outcomes such as change in A1C, blood pressure, lipids, and weight were measured. RESULTS: One hundred five patients were seen by the pharmacist during the study period, with 1.5% of the total managed at the office. There was a statistically significant increase in influenza vaccinations received. On a patient level, A1C and systolic blood pressure significantly improved. CONCLUSION: This project represents an exciting opportunity for community pharmacists to expand their scope of services through direct partnership with PCMHs and maintain a sustainable reimbursement structure.

Pediatric asthma medication therapy management through community pharmacy and primary care collaboration.

OBJECTIVES: To design and implement a collaborative medication therapy management (MTM) program targeting pediatric patients with high-risk asthma in a community pharmacy. SETTING: Underserved inner city of Cincinnati, OH. PRACTICE DESCRIPTION: A large national grocery store chain pharmacy and an academic hospital developed a partnership aimed at improving asthma care for shared patients. An interdisciplinary project team was formed, including 2 clinical pharmacists, 1 pharmacy district clinical coordinator, 1 pharmacy division clinical coordinator, 1 associate professor at a college of pharmacy, 1 pharmacy resident, and 3 pediatric physicians. This pilot project involved 2 Kroger Pharmacy sites and Cincinnati Children's Hospital Medical Center's (CCHMC) 3 pediatric primary care centers. PRACTICE INNOVATION: Kroger and CCHMC staff identified shared high-risk asthma patients (those cared for at the included primary care centers who used Kroger for their medication fills) with the use of information from validated symptom assessments (Asthma Control Test), refill history, and recent health care utilization. Community pharmacists recruited jointly identified patients and provided a targeted MTM intervention. Education focused on asthma diagnosis, types of asthma medications, appropriate medication administration, and environmental triggers. Pharmacists suggested medication changes to prescribers via facsimile. Pharmacists followed up with patients in 30 days to assess asthma control, provide additional education, and propose further recommendations. EVALUATION: Outcomes evaluated included the average number of recommendations made to patients and prescribers and acceptance rates for each of those measures. RESULTS: Six patients completed the project. Pharmacists provided an average of 3.7 recommendations to each patient and 1.5 to prescribers for each patient; 77.3% and 100% recommendations were accepted, respectively. CONCLUSION: This pilot project describes the design and implementation of a pharmacist-physician collaborative program for high-risk pediatric asthma patients. The greatest outcome of this project was the formation of a collaborative team between pharmacists and physicians that continues to work together on additional family-centered initiatives.

Health Beliefs Describing Patients Enrolling in Community Pharmacy Disease Management Programs.

OBJECTIVES: The purpose of this study was to survey new enrollees in a community pharmacy, employer-based diabetes and hypertension coaching program to describe the characteristics, health beliefs, and cues to action of newly enrolled participants. METHODS: A 70-question, 5-point Likert-type survey was developed using constructs from the Health Belief Model (HBM), Theory of Planned Behavior (TPB), and Theory of Reasoned Action (TRA). New enrollees in the coaching programs completed the survey. Survey responses between controlled and uncontrolled patients and patient demographics were compared. RESULTS: Between November 2011 and November 2012, 154 patients completed the survey. Patients were fairly well controlled with a mean hemoglobin A1C of 7.3% and a mean blood pressure of 134/82 mm Hg. The strongest cue to action for enrollment was the financial incentives offered by the employer (mean: 3.33, median: 4). White patients were significantly more motivated by financial incentives. More patients indicated they had not enrolled previously in the program because they were unaware it was available (mean: 2.89, median 3.0) and these patients were more likely to have an uncontrolled condition (P ≤ 0.050). CONCLUSION: A top factor motivating patients to enroll in a disease management coaching program was the receipt of financial incentives. Significant differences in HBM, TPB, and TRA responses were seen for patients with different demographics.

TransitionRx: Impact of community pharmacy postdischarge medication therapy management on hospital readmission rate.

OBJECTIVES: To determine if a community pharmacy-based transition of care (TOC) program that included the full scope of medication therapy management (MTM) services (TransitionRx) decreased hospital readmissions, resolved medication-related problems, and increased patient satisfaction. DESIGN: Prospective, quasi-experimental study. SETTING: Nine Kroger Pharmacies located in Western Cincinnati. PATIENTS: Patients older than 18 years of age and discharged from two local hospitals with a diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or pneumonia. Patients were recruited from two local hospitals and referred to the community pharmacy for MTM services with the pharmacist within 1 week of discharge. MAIN OUTCOME MEASURES: Pharmacists reconciled the patients' medications, identified drug therapy problems, recommended changes to therapy, and provided self-management education. At 30 days after discharge, research personnel conducted telephone surveys, using a previously validated survey instrument, to assess hospital readmissions and patient satisfaction. Pharmacist interventions and medication-related problems were documented. RESULTS: A total of 90 patients completed the study. Of these, 20% of patients in the usual care group were admitted to the hospital within 30 days compared with 6.9% of patients in the intervention group (P = 0.019). In the 30 patients who received MTM services from the pharmacist, 210 interventions were made. The overall mean patient satisfaction with the TOC process was not significantly different between patients who were seen by the pharmacist and those who were not seen by the pharmacist. CONCLUSION: Community pharmacies successfully collaborated with hospitals to develop a referral process for TOC interventions. Patients who received MTM services from the pharmacist experienced significantly fewer readmissions than patients who received usual care.

Impact of the pay-for-performance-for-patients program for diabetes management.

OBJECTIVES: To determine whether patients with diabetes who used a financial rewards program in a grocery chain pharmacy had increased rates of self-reported healthy behaviors, to measure the impact of the program on glycosylated hemoglobin (A1C), and to measure the impact of the program on grocery store sales. METHODS: This prospective study took place at one location of a grocery chain pharmacy in Cincinnati, OH. Adult patients with diabetes on at least one diabetes medication were eligible to participate. Participants received a $5 incentive for each weeklong behavior log completed and reviewed with the pharmacist, who provided counseling on improving healthy behaviors. Change in self-reported healthy behaviors, A1C, grocery store expenditure, and program satisfaction were measured. RESULTS: During the 12-week study, 25 patients enrolled in the program. A total of 13 participants completed the poststudy survey and reported increased rates of self-monitoring of blood glucose and blood pressure and increased exercise frequency. Differences in A1C and grocery store expenditures were unable to be detected. Satisfaction with the pay-for-performance-for-patients (P4P4P) program was favorable (8.6 on a 10-point scale). CONCLUSION: Participants given small, frequent financial incentives had increased frequency of healthy behaviors and were satisfied with the P4P4P program.

Development, implementation, and evaluation of a pharmacist-conducted screening program for depression.

OBJECTIVE: To develop, implement, and evaluate a depression screening program performed by pharmacists in the community setting; to determine the ability of this screening to identify and refer patients with symptoms of depression; and to determine whether physician referral results in initiation or modification of treatment. DESIGN: Prospective study. SETTING: 32 locations of a large grocery chain pharmacy in the Cincinnati and Dayton, OH, area from February 8, 2010, to March 30, 2011. PATIENTS: 3,726 patients 18 years or older. INTERVENTION: Patients were screened for depression using the Patient Health Questionnaire (PHQ). Patients who screened positive on the two-item PHQ (PHQ-2) then were given the nine-item PHQ (PHQ-9). Patients who screened positive on the PHQ-9 were referred to their physician. Pharmacists followed up with these patients to determine the action that was taken following the screening. MAIN OUTCOME MEASURES: Number of patients with a positive PHQ-9, number of patients referred to their physician, and number of patients for whom treatment was initiated or modified as a result of screening. RESULTS: 3,726 patients were screened for depression by pharmacists during the study period. A total of 67 (1.8%) patients screened positive on the PHQ-2. Of the patients who completed the PHQ-9, approximately 25% met the criteria for consideration of diagnosis and were referred to their physician. Five patients presented with suicidal thoughts and were referred for urgent treatment. Approximately 60% of patients with a positive PHQ-9 had initiated or modified treatment at the time of follow-up. CONCLUSION: A screening program for depression was successfully developed and implemented in the community pharmacy setting. Using the PHQ, pharmacists were able to quickly identify undiagnosed patients with symptoms of depression. The majority of patients with a positive screening had initiated or modified treatment at the time of follow-up.

Pharmacist-managed chronic obstructive pulmonary disease screening in a community setting.

OBJECTIVES: To implement a spirometry-based chronic obstructive pulmonary disease (COPD) screening in a community pharmacy chain, determine whether pharmacists can accurately perform spirometry screenings and interpret results, and determine whether performing screenings improved enrollment in smoking cessation programs. DESIGN: Prospective study. SETTING: Kroger pharmacies in the Cincinnati-Dayton Kroger Marketing Area and off-site screening events in Cincinnati, OH, from March to December 2010. PATIENTS: Consenting individuals older than 35 years who met inclusion and exclusion criteria. INTERVENTION: Specially trained community pharmacists administered a validated COPD screening questionnaire and performed spirometry. The results were interpreted, given to the patient, and faxed to the primary care physician. Any patient who was currently smoking was offered smoking cessation counseling. MAIN OUTCOME MEASURES: Spirometry technical quality and interpretation accuracy, screening questionnaire scores in relationship to spirometry results, number of patients enrolled in smoking cessation programs. RESULTS: Of the 185 patients, 10 were excluded due to inability to perform spirometry. After review, 174 (99%) of the spirometries were judged acceptable and 157 (90%) demonstrated reproducible results. The mean (+/-SD) score on the COPD Population Screener questionnaire was 2.3 ± 1.6 (range 0-8). Airflow limitation (defined as forced expiratory volume in 1 second/forced vital capacity < lower limit of normal) was detected in 16 (9%) of the patients. Although 12 (75%) of these patients were former or current smokers, only 3 (19%) were at increased risk for COPD based on their screening questionnaire scores. Of the nine current smokers who participated in a follow-up interview, two had successfully abstained from smoking for 6 months after the screening and five others had made an attempt to quit. CONCLUSION: This study demonstrated that pharmacists are able to perform accurate and reproducible spirometry in a community pharmacy setting.

Pharmacist-initiated peripheral arterial disease screening program in a community pharmacy setting.

OBJECTIVES: To evaluate the feasibility of implementing a pharmacist-initiated peripheral arterial disease (PAD) screening program in the community setting and to determine the ability of this screening to increase the number of patients identified with PAD. DESIGN: Prospective study. SETTING: Three locations of a large pharmacy grocery chain in the Cincinnati and Dayton, OH, area, from February 3, 2009, to May 31, 2009. PATIENTS: 39 patients 50 years or older with a diagnosis of hypertension, dyslipidemia, and/or diabetes. INTERVENTION: PAD screening, including an assessment of PAD symptoms and an ankle-brachial index (ABI) calculation using a handheld Doppler. Patients who screened positive were provided with appropriate counseling on possible treatments, medications, and lifestyle modifications and referred to their primary care physician for further evaluation. MAIN OUTCOME MEASURES: Successful implementation of program, number of patients referred to their physician for follow-up, and number of patients with ABI scores indicating PAD. RESULTS: 17 of the 39 patients screened (44%) were referred to their physician for follow-up because they had ABI scores indicating PAD, symptoms indicating PAD, or noncompressible vessels. Using ABI scores, PAD was detected in nine patients (23.1%). Pharmacists implemented the program successfully. CONCLUSION: This study successfully demonstrated the feasibility of implementing a pharmacist-initiated PAD screening program in the community setting. The implementation of this screening program included the acquisition of affordable equipment, training of pharmacists, and access to the appropriate patient population. This study also was effective in increasing the recognition of PAD in patients screened in the community setting.