Team Communication on Tasks Performed in Blood Pressure Clinics in Community Pharmacies.

Background: To successfully deliver pharmacy services, pharmacists and technicians need to work as a team and have effective communication. Objectives: To measure the amount of communication between community pharmacists and their technicians during monthly blood pressure (BP) clinics. Methods: Cross-sectional survey method was used to assess the amount of communication pharmacists and technicians had on each task. Study participants were pharmacist-technician pairs (teams) from 10 intervention community pharmacies in the Team Education and Adherence Monitoring (TEAM) trial. Each team provided services designed to improve BP among hypertensive African American patients. Thirteen specific tasks were identified as essential in providing monthly BP clinics, and they were being performed by either the pharmacist or technician. At the end of the trial, each pharmacist and technician were asked to report his/her perception of discussion levels that occurred for each task. The level of team communication was summarized for each task (task-specific) and for each team (team-specific). Results: For task-specific communication, 3 teams had communication regarding pharmacist tasks and 5 teams engaged in communication for technician tasks. More communication was reported for newly developed technician tasks in the BP clinic. For team-specific communication, 2 teams reported no communication on any task, and another 2 teams reported having communication on all the tasks. Overall, pharmacy teams showed different levels of communication in this study. Conclusion: The amounts of communication between pharmacists and technicians were found to vary for different tasks and teams. This suggests that the nature of tasks and the unique dynamics existing in each pharmacy team could influence pharmacist-technician communication.

Type and Frequency of Opioid Pain Medications Returned for Disposal.

Prescription opioids have increasingly been involved in overdose deaths and treatment admissions. Disposal programs may play an important role in curbing this trend. The objectives of this study were to: (1) quantify the prescription opioids returned for disposal to a local take-back program, and (2) explore selected drug characteristics that may predict the quantity of unused opioids. Leftover prescription opioid medications returned for disposal to a community drug take-back event were quantified and analyzed according to controlled substances schedule, formulation, number of active ingredients, and directions for use. Days' supply of medication remaining, calculated using the number of dosage units remaining divided by the maximum number of dosage units per day allowed by the prescriber, was the primary outcome variable. Opioid prescriptions returned for disposal had greater than 60 % of the amount dispensed remaining unused. Short-acting C-II and C-III combination opioids accounted for greater than 80 % of the prescriptions returned. Day supply dispensed was the strongest predictor of day supply remaining, regardless of other drug characteristics. These findings indicate that disposal programs are effective at removing unused medication from patient homes. To reduce leftover medication, prescriber education programs should address the amount to be prescribed. Continual monitoring of quantities prescribed and returned for disposal may be useful in evaluating the effects of these programs on leftover medication. Further research on drug characteristics may inform prescribing practices and reduce leftover medication.

Improving refill adherence and hypertension control in black patients: Wisconsin TEAM trial.

OBJECTIVE: To assess the effectiveness and sustainability of a 6-month Team Education and Adherence Monitoring (TEAM) intervention for black patients with hypertension in community chain pharmacies. DESIGN: Cluster randomized trial. SETTING: 28 chain pharmacies (14 TEAM and 14 control) in five Wisconsin cities from December 2006 to February 2009. PARTICIPANTS: 576 black patients with hypertension. INTERVENTION: Trained pharmacist-technician teams implemented a 6-month intervention using scheduled visits, Brief Medication Questionnaires (BMQs), and novel toolkits for facilitating medication adherence and pharmacist feedback to patients and physicians. Control participants received patient information only. MAIN OUTCOME MEASURES: Refill adherence (≥80% days covered) and changes in systolic blood pressure (SBP), diastolic blood pressure, and blood pressure control using blinded assessments at 6 and 12 months. RESULTS: At baseline, all patients had blood pressure of 140/90 mm Hg or more. Of those eligible, 79% activated the intervention (mean 4.25 visits). Compared with control participants at 6 months, TEAM participants achieved greater improvements in refill adherence (60% vs. 34%, P < 0.001), SBP (-12.62 vs. -5.31 mm Hg, P < 0.001), and blood pressure control (50% vs. 36%, P = 0.01). Six months after intervention discontinuation, TEAM participants showed sustained improvements in refill adherence ( P < 0.001) and SBP ( P = 0.004), though the difference in blood pressure control was not significant ( P < 0.05) compared with control participants. Analysis of intervention fidelity showed that patients who received the full intervention during months 1 through 6 achieved significantly greater 6- and 12-month improvements in refill adherence and blood pressure control compared with control participants. CONCLUSION: A team-based intervention involving community chain pharmacists, pharmacy technicians, and novel toolkits led to significant and sustained improvements in refill adherence and SBP in black patients with hypertension.

Community pharmacy involvement in vaccine distribution and administration.

This study identified the type and number of doses of vaccine purchased, distributed, and administered in community pharmacies. Telephone interviews were conducted with 1704 community pharmacies in 17 states (response rate=69.1%). The 17-state population-level projections reveal that about 10% of hepatitis A, hepatitis B, meningococcal, MMR, and tetanus-containing vaccines for adults were administered in pharmacies and 90% were distributed to other sources for administration during July 2004-June 2005. Further, 24.1% of diphtheria-tetanus-pertussis for children (DTaP), 30.4% of influenza, 36.2% of pneumococcal polysaccharide, and 68.1% of travel vaccines in pharmacy inventory were administered in pharmacies, while the rest of vaccine doses were distributed to other immunizers.

Impact of perceived innovation characteristics on adoption of pharmacy-based in-house immunization services.

OBJECTIVES: An in-house immunization service in which staff pharmacists administer vaccines was conceptualized as an innovation. Prior to making adoption decisions, community pharmacies evaluated characteristics of in-house immunization services. This study examined the impact of three specific characteristics (perceived benefit, perceived compatibility and perceived complexity) of in-house immunization services on community pharmacies' adoption decisions. METHODS: A multi-stage mixed-mode survey design was used to collect data from key informants of community pharmacies in Washington State, USA. Key informants included pharmacy managers or pharmacists-on-duty who were able to answer questions related to immunization activities in their pharmacies. Perceived characteristics of in-house immunization services and pharmacy adoption decisions were measured in 2004 and in 2006-2007, respectively. KEY FINDINGS: Each perceived characteristic individually predicted adoption of in-house immunization services. When all three characteristics were included in logistic regression, perceived benefit was the only significant predictor of in-house immunization service adoption. CONCLUSIONS: Appropriate strategies, particularly promoting the benefit of in-house immunization services, should be implemented. The proposed model and findings may be applicable to other pharmacy-based innovative practices or other public health initiatives. We recommend that organizational leaders, researchers and practitioners consider the impact of perceived benefit and incorporate it when they design strategies to foster adoption of innovative practices. Doing this may increase the number of adopters and also increase diffusion rates for innovative services.

Pharmacy stages of involvement in pharmacy-based immunization services: results from a 17-state survey.

OBJECTIVES: To describe pharmacy stages of involvement in outsourced and inhouse immunization services and to explore the variability of stages of involvement across the sampled states. DESIGN: Cross-sectional study. SETTING: Community pharmacies in 17 states, between July 2005 and February 2006. PARTICIPANTS: Key informants of 2,558 community pharmacies. INTERVENTION: Computer-assisted telephone interviews regarding pharmacy involvement in immunization services. MAIN OUTCOME MEASURE: Pharmacies' stage of involvement in immunization services, based on the following categories: no interest; interested, no plan; planning; implemented; discontinued; and no response. RESULTS: Of 2,558 community pharmacies, 1,707 (69.1%) completed the interview. For outsourced immunization services, about one-half of participating pharmacies (50.6%) implemented and planned to implement the services while only 20.7% had no interest in offering the services. These percentages contrast sharply with inhouse immunization services: 24.7% of pharmacies in this category implemented and planned to implement the services and 38.1% indicated no interest in offering the services. Involvement in immunization services varied widely across the 17 states. For outsourced services, implementation ranged from 17.5% to 68.8% of pharmacies, while 13.5% to 39.3% had no interest in the services. For in-house services, implementation ranged from 0% to 42.1% of pharmacies; 19.6% to 49.5% had no interest. CONCLUSION: Understanding stages of pharmacy involvement in immunization services should allow design and implementation of more effective strategies for increasing involvement and decreasing abandonment of immunization practices.

Effects of repeated callbacks on response rate and nonresponse bias: results from a 17-state pharmacy survey.

BACKGROUND: Although surveys are the most common method of data collection in research in the social & behavioral pharmaceutical sciences, little evidence exists on pharmacists' and pharmacies' patterns of telephone survey participation and the impact of repeated callbacks on minimizing nonresponse bias. OBJECTIVES: To (1) describe final disposition of the survey sample, (2) describe the effect of repeated callbacks on response rate, and (3) examine whether hard-to-contact cases differ from those that are relatively easier to contact in terms of general pharmacy characteristics and characteristics specific to survey topics. METHODS: This study used a cross-sectional descriptive survey design that gathered information from key informants of 2558 community pharmacies in 17 states. Telephone interviews were conducted using a Computer Assisted Telephone Interview system. Final disposition of the sample units and the final response rate were reported. General pharmacy characteristics and characteristics specific to immunization delivery (ID) and emergency preparedness and response (EPR) activities were compared across different ease-of-contact levels. RESULTS: A total of 1707 pharmacies (66.7%) completed the interview; 757 (29.6%) were eligible cases that were not interviewed; 8 (0.3%) and 86 (3.4%) were cases of unknown eligibility and ineligibility, respectively. The final response rate was 69.1%. The number of calls to pharmacies was most productive on the first 9 calls and leveled off after the 14th call. When comparing characteristics among different ease-of-contact levels, 2 out of 3 characteristics related to ID activities were different. No differences were found in general pharmacy characteristics and characteristics specific to EPR activities, however. CONCLUSION: The greater number of callbacks resulted in higher response rates due to greater number of completed interviews. The increase in response rate did not rule out nonresponse bias, however. Hard-to-contact cases differed from relatively easier to contact cases in terms of characteristics related to the survey topic, but not general characteristics.

Evaluating telephone follow-up of a mail survey of community pharmacies.

BACKGROUND: Mail and telephone are commonly used modes of survey with pharmacists. Research conducted using general population surveys consistently describes mail surveys as being less expensive but yielding lower response rates than telephone surveys. However, findings obtained from the general population may not be generalizable to pharmacist surveys. OBJECTIVES: This study evaluates the effectiveness of telephone follow-up of mail survey nonrespondents by comparing the 2 survey modes on response rates, cooperation rates, cost per sample unit, and cost per usable response and evaluating potential nonresponse bias in the context of immunization activities. METHODS: A census mail survey of 1,143 Washington State community pharmacies and a follow-up telephone survey of 262 randomly selected mail survey nonrespondents were compared. Both surveys included the same 15 yes/no-type questions to ask respondents about their pharmacy's involvement in immunization activities. RESULTS: The mail survey yielded a response rate 1 of 26.7% and a cooperation rate 1 of 26.7%, compared with 83.6% and 87.8%, respectively, for the follow-up telephone survey. With respect to cost per sample unit, the mail survey was the least expensive option ($1.20). However, when comparing cost per usable response, the mail survey was the most expensive ($4.37), and the follow-up telephone survey without an advance notification was the least expensive ($1.99). Furthermore, results suggest the presence of nonresponse bias: compared with pharmacies participating in the follow-up telephone survey, pharmacies participating in the mail survey were more likely to be involved in in-house immunization services but less likely to be involved in outsourced services. CONCLUSIONS: The telephone survey achieved higher outcome rates with reduced cost per usable response. A telephone survey is a viable mode that holds promise in pharmacy practice research. Maximizing response rates and assessing potential nonresponse bias should be a standard practice among pharmacy practice researchers. More methodology research specific to pharmacist surveys is needed.

Pharmacy Service Orientation: a measure of organizational culture in pharmacy practice sites.

BACKGROUND: The importance of organizational culture in shaping everyday organizational life is well accepted, but little work has focused on organizational culture in pharmacy. Examining new pharmacists' experiences at various practice sites may help us to understand how these shape their professional ethos and practice habits. OBJECTIVES: (1) Present development and assessment of the Pharmacy Service Orientation (PSO) measure, a tool for assessing pharmacists' impressions of pharmacy practice sites. (2) Use data gathered from a sample of new pharmacists to explore potential predictors of PSO, including type of practice site, type of pharmacy work experience, and type of pharmacy degree. METHODS: Mail survey of randomly selected class of 1999 pharmacy graduates within 3 months of graduation (response rate: 259 of 1,850; 14%), each of whom reported on up to 6 different pharmacy practice sites for a total of 1,192 pharmacy observations. Pharmacy Service Orientation is scored on a 1-10 semantic differential scale and reliability was assessed using Cronbach's alpha. Predictors of PSO were explored using t test and ordinary least squares regression procedures. RESULTS: Reliability of the PSO across all observations was 0.86. When divided according to recency of experience and type of experience, reliabilities ranged from 0.78 to 0.87. Analysis of potential predictors of PSO showed that non-corporate-community sites had significantly greater pharmaceutical care-oriented cultures (mean PSOs of 7.42 and 5.13, respectively; P<.001). The same pattern was seen for academic and nonacademic worksites (mean PSOs of 7.46 and 6.01, respectively; P<.001). The pharmacist's pharmacy degree type was not predictive of PSO. Multivariate regression results showed that type of practice site and type of pharmacy work experience explained more than 25% of the observed variance in PSO. CONCLUSIONS: Pharmacy Service Orientation is a reliable measure. Statistically significant differences in PSO comparisons by degree and by experience type are explained by significant differences between the PSOs of corporate-community and non-corporate-community sites.

Expert and consumer evaluation of patient medication leaflets provided in U.S. pharmacies.

OBJECTIVE: Evaluate the distribution and quality of patient medication leaflets provided in U.S. pharmacies. DESIGN: Observational. SETTING: United States. PARTICIPANTS: 384 randomly selected community pharmacies in 44 states. INTERVENTIONS: Professional shoppers (acting as patients) presented four new prescriptions to study pharmacies. MAIN OUTCOME MEASURES: Medication leaflets obtained by shoppers were evaluated by expert and consumer raters using criteria specified in federal law mandating distribution of useful written information to 95% of individuals receiving new prescriptions by 2006. RESULTS: Leaflets were provided by pharmacies with 89% of 1,536 prescriptions presented by professional shoppers posing as patients. Leaflet quality varied: 95% of leaflets received high ratings on accuracy, but only 19% received high ratings on the specificity of directions. Fewer than 10% of all leaflets met quality criteria regarding contraindications, precautions, and how to avoid harm. One fourth of all leaflets had poor print size, according to the shoppers. CONCLUSION: Additional efforts are needed to meet federally mandated information distribution and quality goals by 2006.

Patient counseling provided in community pharmacies: effects of state regulation, pharmacist age, and busyness.

OBJECTIVE: To describe the nature and extent of patient counseling in community pharmacies and determine whether current counseling practices are influenced by pharmacist and pharmacy characteristics and variations in state regulation of patient counseling. DESIGN: Observational, cross-sectional study. SETTING: 306 community pharmacies in eight states. PARTICIPANTS: Trained shoppers (acting as patients). INTERVENTIONS: Three new prescriptions were presented in each pharmacy, and regression techniques were used to analyze the effects of pharmacist age, pharmacy type, and busyness; whether written information was provided; and "intensity" of a state's patient counseling regulation as measured by its scope, stringency, and duration. MAIN OUTCOME MEASURES: Whether any or all of these events occurred: pharmacist talked with shopper, oral drug information was given, oral risk information was given, and/or questions were asked to assess shopper understanding; number of informational items mentioned (range 0-7) was also recorded. RESULTS: About 63% of the shoppers were given oral drug information (mean = 2.3 items). Shoppers with a younger responsible pharmacist were more likely than other shoppers to receive risk information, a higher number of informational items, and assessment of understanding. While pharmacy type was unrelated to counseling, busyness reduced the odds of any pharmacist talk, oral information-giving, and assessment of understanding. Counseling practices varied significantly according to the intensity of a state's counseling regulation, with frequency of any information provision climbing from 40% to 94% as states' counseling regulations increased in intensity. More intensive regulations also increased the likelihood of any pharmacist talk, any provision of risk information, any assessment of shopper understanding, and amount of oral information given. CONCLUSION: Counseling varied significantly according to intensity of state regulation, pharmacy busyness, and age of responsible pharmacist. These results present important challenges to state boards of pharmacy, pharmacy associations, managers, and individual practitioners who are in a position to improve this important element of patient care.

Evaluation of written prescription information provided in community pharmacies: a study in eight states.

OBJECTIVES: To develop three tools for assessing the quality of written information provided with new prescriptions in community pharmacies and to identify pharmacy, pharmacist, and patient characteristics associated with the dissemination and quality of that information. DESIGN: Observational study. Regression techniques were used to analyze the influence of pharmacy, pharmacist, and shopper (acting as patient) characteristics on outcome measures. PARTICIPANTS: Trained shoppers (acting as patients) visited 306 randomly selected pharmacies in 8 states. Each shopper presented three prescriptions, answered questions according to a standard scenario, accepted the information offered, and paid for the prescriptions. MAIN OUTCOME MEASURES: Percentage of shoppers receiving any written information; quality of written information as judged by an expert panel using explicit criteria. RESULTS: Shoppers received an information leaflet with 87% of the 918 prescriptions dispensed. Although most leaflets provided unbiased information, leaflet length and quality of information varied greatly. A majority of leaflets did not include adequate information about contraindications, precautions, and how to avoid harm. Shoppers were more likely to receive leaflets in chain pharmacies and pharmacies with more staff. Information quality also was higher in chain pharmacies. Shopper and pharmacist demographic characteristics were unrelated to the level or quality of written information after controlling for other factors. CONCLUSION: The provision of patient leaflets is becoming a routine practice in the states studied. However, most leaflets do not meet quality criteria. It is important for pharmacists to become familiar with criteria for evaluating these leaflets and to take necessary action to improve their quality.

Effects of residents' depression, sleep, and demand for medication on benzodiazepine use in nursing homes.

OBJECTIVE: This study sought to identify risk factors associated with the prescription and use of benzodiazepines in nursing homes and to assess the prevalence and determinants of demand for benzodiazepines among nursing home residents. METHODS: Data were available for 2,060 residents who had participated in a previous study of use of medications in 18 randomly selected nursing homes in Wisconsin between 1986 and 1989. Data sources included nursing home and pharmacy records; nurses' assessments of residents' behavior, pain, sleep, and demand for medication; and researchers' observations of resident requests for medication. Measures of benzodiazepine use included benzodiazepine prescriptions, prevalence and extent of as-needed drug use, and chronic use as defined by Health Care Financing Administration guidelines. RESULTS: A quarter of the residents received prescriptions for benzodiazepines. Of these, 71 percent received prescriptions to aid sleep or to be taken at bedtime; 32 percent used benzodiazepines for a longer period than recommended; and 26 percent requested medication. Logistic regression analysis showed that residents with depression, pain, or sleep problems were more likely to have received benzodiazepines and to have requested medication. Chronic use was significantly higher among residents with depression, sleep problems, or multiple benzodiazepine regimens and among those who requested medication. Demand and sleep problems also were associated with higher rates of any as-needed use and with higher numbers of as-needed doses used. CONCLUSIONS: Efforts to improve benzodiazepine use in nursing homes must address the need for better assessment and management of depression, sleep, pain, and residents' demand for these medications.