Patient Knowledge and Experiences With Antibiotic Use and Delayed Antibiotic Prescribing in the Outpatient Setting.

BACKGROUND: Most antibiotic prescriptions originate in the outpatient setting and an estimated 30% are unnecessary. Pharmacists are well positioned to positively impact antibiotic prescribing habits; the role of the community pharmacist in outpatient antibiotic stewardship programs is not well defined. OBJECTIVES: The objectives of this study were to (1) assess the knowledge of the general public regarding appropriate antibiotic use, and (2) assess the experiences of the general public regarding delayed antibiotic prescriptions. METHODS: A cross-sectional survey was administered at community pharmacies in Kansas from September 2018 to January 2019. Eligible individuals were older than 18 years and self-reported their ability to speak and read English. The 22-item survey collected demographics, knowledge regarding appropriate antibiotic use, and participant understanding and experiences of delayed antibiotic prescribing. Descriptive statistics assessed demographics and chi-square compared responses between demographics. RESULTS: Of 347 surveys completed, respondents were mainly Caucasian (91.6%), female (58.2%), and aged 60 years or older (59.1%). Those with high school education or below were more likely to believe antibiotics kill viruses (43.1% vs 20.9%, respectively; p < 0.01) and that antibiotics work on most coughs and colds (31.4% vs 16.2%, respectively; p = 0.01). Delayed antibiotic prescriptions were more frequently offered to those who had received an antibiotic prescription in the last year compared to those who had not (36.1% vs 15%, p < 0.001). CONCLUSION: Gaps in patient knowledge about appropriate antibiotic use and delayed prescribing present an opportunity for community pharmacists to educate patients and become involved in outpatient antibiotic stewardship.

Pharmacist impact on medication dosing and billable coding accuracy in outpatients with chronic kidney disease.

BACKGROUND: Ambulatory care pharmacists can enhance economic and clinical outcomes as part of interdisciplinary health care teams. Patients with chronic kidney disease (CKD) often have complex medication regimens, potentially resulting in dosing errors and drug interactions. OBJECTIVE: To demonstrate the impact that clinic-based pharmacists may have in populations comprising ambulatory patients with CKD. PRACTICE DESCRIPTION: Community-owned, not-for-profit health system with outpatient, primary, and specialty care clinics. PRACTICE INNOVATION: This quality-assurance, cohort, interventional study included patients aged at least 18 years with a CKD- or end-stage renal disease-associated diagnosis code seen by a clinic primary care provider at least once between January and June 2019. Primary outcomes included the number of medications requiring pharmacist intervention, pharmacist-initiated recommendations, and associated outcomes. EVALUATION METHODS: Patients were randomly assigned to 2 cohorts. Providers of patients in the proactive pharmacist intervention group were notified of pharmacist recommendations immediately after initial data collection. Providers of patients in the group undergoing usual care (control group) were notified of identified medication recommendations after a 3-month period of usual care. Demographics were assessed using descriptive statistics. Differences in CKD staging, number of recommendations made, and provider responses were assessed using the chi-square, Fisher exact, and Mann-Whitney U tests. RESULTS: A total of 182 patients were eligible for inclusion. In the intervention group, 22.1% of patients were identified as having inappropriately dosed medications versus 19.5% in the control group. In the intervention group, 46 of the 95 patients (48.4%) had an inaccurate CKD stage documented compared with 48 of the 87 patients (55.2%) in the control group (P = 0.772). The rate of pharmacist recommendation rejection substantially decreased between the intervention and control groups' provider responses (24% to 11.8%). CONCLUSION: Pharmacist-initiated recommendations resulted in the identification and resolution of medication-dosing errors and improved collaboration between providers and pharmacists.

Public awareness of Mental Health First Aid and perception of community pharmacists as Mental Health First Aid providers.

OBJECTIVES: The objectives of this study were to (1) identify the number of participants who screened positive for major depressive disorder, (2) assess the number of participants who have discussed or would like to discuss mental illness with a trained professional, (3) determine public awareness about Mental Health First Aid (MHFA), and (4) determine public perception regarding community pharmacists trained in MHFA. METHODS: A cross-sectional survey was administered at community pharmacies to participants aged 18 years and older who were able to speak and read in English. The 18-question survey was used to screen for major depressive disorder using the Patient Health Questionnaire-2 (PHQ-2) and to collect demographic information, mental health diagnoses, beliefs regarding current mental illness and treatment, desire and history of talking with a trained professional about mental illness, and MHFA awareness. In addition, data on comfortability talking to a pharmacist about mental illness was collected. Data were analyzed with an a priori α of 0.05. RESULTS: A total of 358 surveys were collected. Seven participants (2%) screened positive for depression using PHQ-2. One hundred eight participants (30.4%) reported a previous desire to speak to someone about mental illness; of these, only 41 (38.7%) and 63 patients (59.4%) reported speaking to a physician or therapist, respectively. Only 53 participants (15.4%) reported awareness of MHFA. Participants reported a higher level of comfortability (P < 0.01) speaking about mental illness with an MHFA-trained pharmacist. Similarly, participants more strongly agreed (P < 0.01) that pharmacists are qualified to discuss mental illness if trained in MHFA. Most participants believed pharmacists should be trained in MHFA (n = 260, 68.2%). CONCLUSION: Participants indicated comfortability discussing mental illness with community pharmacists trained in MHFA, revealing an opportunity for pharmacists to expand access to mental health services by being trained in MHFA and counseling about mental illness.

Impact of community pharmacist intervention on concurrent benzodiazepine and opioid prescribing patterns.

OBJECTIVES: (1) To evaluate the number of opioid/benzodiazepine (BZD) prescription changes resulting from pharmacist communication to prescriber(s); (2) to determine the number of patients on concurrent opioid/BZD therapy from single versus multiple prescribers; (3) to compare the number of opioid/BZD prescription changes resulting from communication when a single versus multiple prescribers was involved in a patient's care; and (4) to compare the number of opioid/BZD prescription changes resulting from communication via fax versus the Kansas Health Information Network (KHIN) direct messaging feature. METHODS: Prospective study conducted at 13 community pharmacies, including patients 18 years of age or older simultaneously filling opioid and BZD prescriptions within 90 days before October 2017. Prescribers received faxed or KHIN communication proposing evidence-based prescription changes to opioid/BZD agents. Prescription changes were evaluated weekly for 3 months after the initial intervention. Descriptive statistics assessed demographics and the number and types of prescription changes. Spearman rho correlations compared prescription changes and number of prescriptions to number of prescribers; a priori alpha was set at 0.05. RESULTS: A total of 137 prescribers and 121 patients were included. Ninety-nine prescribers were contacted via fax and 38 via KHIN. After 4 weeks, 34 recommendations were received: 20 responses (59%) indicated rejection of recommendations, 5 (15%) approved BZD taper/discontinuation, 3 (9%) deferred changes until a patient visit, 2 (6%) approved opioid taper/discontinuation, 2 (6%) prescribed naloxone, and 2 (6%) withdrew from the patient's care. Three months after communication, 35 prescription changes were noted: 22 (63%) opioid/BZD agent tapers/discontinuation, 14 (26%) opioid/BZD dose increases, and 2 (6%) naloxone prescriptions. There was positive correlation between the number of tapered/discontinued agents and the number of prescribers involved in a patient's care (P = 0.046). CONCLUSION: A faxed pharmacist intervention may help to reduce opioid/BZD coprescribing, especially when multiple providers are involved in a patient's care.

Assessing pet owner and veterinarian perceptions of need for veterinary compounding services in a community pharmacy setting.

BACKGROUND: Pets, pet owners (referred to as clients in veterinary medicine and throughout this article), veterinarians, and community pharmacies may all benefit from veterinary compounding services provided in community pharmacies, but the benefits of this service are not well-documented in the literature. OBJECTIVES: This study identified perceived benefits and barriers and evaluated the need for veterinary compounding services in community pharmacies; it also evaluated current business practices related to veterinary compounding services. METHODS: A cross-sectional survey was administered to three groups: 1) clients who filled a pet prescription at a study pharmacy, 2) clients who had not filled pet prescriptions, and 3) local veterinarians. Eligible participants were 18 or older; clients must have owned a pet in the past five years. The surveys collected demographic information and assessed benefits, barriers, need, and business practices regarding veterinary compounding services. Demographics were evaluated through descriptive statistics. Responses to Likert-scale items were compared between groups using the Mann-Whitney U test. Qualitative responses were assessed for emerging themes. RESULTS: One hundred eighteen clients and 15 veterinarians participated in the study. Seventy-two of 116 clients (62%) and eight of 10 veterinarians (80%) agreed that clients would benefit from veterinary compounds provided in community pharmacies. Only 40% of veterinarians agreed that community pharmacists have the knowledge to compound pet medications, compared to 67% of clients (P=0.010). Similarly, 47% of veterinarians agreed that community pharmacists have the skills to compound pet medications, compared to 72% of clients (P=0.016). Forty-eight of 118 clients (41%) would travel 10 miles or more out of their way for veterinary compounding services at community pharmacies. CONCLUSIONS: This study assessed client and veterinarian perceptions of veterinary compounding service benefits, barriers, and need in community pharmacies. Clients identified more opportunities for veterinary compounding services in community pharmacies when compared to veterinarians. Both groups identified a need for veterinary compounding services and agreed community pharmacies providing these services would benefit pets and clients.

Assessing pet owner and veterinarian perceptions of need for veterinary compounding services in a community pharmacy setting

Background: Pets, pet owners (referred to as clients in veterinary medicine and throughout this article), veterinarians, and community pharmacies may all benefit from veterinary compounding services provided in community pharmacies, but the benefits of this service are not well-documented in the literature. Objectives: This study identified perceived benefits and barriers and evaluated the need for veterinary compounding services in community pharmacies; it also evaluated current business practices related to veterinary compounding services. Methods: A cross-sectional survey was administered to three groups: 1) clients who filled a pet prescription at a study pharmacy, 2) clients who had not filled pet prescriptions, and 3) local veterinarians. Eligible participants were 18 or older; clients must have owned a pet in the past five years. The surveys collected demographic information and assessed benefits, barriers, need, and business practices regarding veterinary compounding services. Demographics were evaluated through descriptive statistics. Responses to Likert-scale items were compared between groups using the Mann-Whitney U test. Qualitative responses were assessed for emerging themes. Results: One hundred eighteen clients and 15 veterinarians participated in the study. Seventy-two of 116 clients (62%) and eight of 10 veterinarians (80%) agreed that clients would benefit from veterinary compounds provided in community pharmacies. Only 40% of veterinarians agreed that community pharmacists have the knowledge to compound pet medications, compared to 67% of clients (P=0.010). Similarly, 47% of veterinarians agreed that community pharmacists have the skills to compound pet medications, compared to 72% of clients (P=0.016). Forty-eight of 118 clients (41%) would travel 10 miles or more out of their way for veterinary compounding services at community pharmacies. Conclusions: This study assessed client and veterinarian perceptions of veterinary compounding service benefits, barriers, and need in community pharmacies. Clients identified more opportunities for veterinary compounding services in community pharmacies when compared to veterinarians. Both groups identified a need for veterinary compounding services and agreed community pharmacies providing these services would benefit pets and clients

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Integrating a health information exchange into a community pharmacy transitions of care service.

OBJECTIVE: To describe the incorporation of a state health information exchange (HIE) into a community pharmacy transitions of care (TOC) service and to assess its impact on 30-day readmission rates. SETTING: Three suburban community pharmacies in Olathe, Kansas. PRACTICE DESCRIPTION: Balls Food Stores is a grocery store chain which operates 21 supermarket community pharmacies in the Kansas City metropolitan area. PRACTICE INNOVATION: Balls Food Stores launched a pharmacist-led self-referral TOC study in which a state HIE was utilized to collect discharge information from patients' electronic medical records (EMRs) to facilitate TOC comprehensive medication reviews (CMRs). EVALUATION: Descriptive statistics were used to assess types and outcomes of identified drug therapy problems and the ability to access Kansas Health Information Network EMRs. A chi-square test was used to assess 30-day readmissions between patients who accepted and declined the service. RESULTS: Forty patients were identified for inclusion and 18 elected to participate in the service. The majority of participants were white females with a median age of 64.5 years. Out of 40 study patients, 85% had an EMR available; 12.5% of patients had a medication list included in their EMR hospitalization documentation. Participants who underwent the service had a statistically significantly lower rate of overall 30-day hospital readmission than those who declined (11.1% vs 36.4%, P = 0.032). Among the 18 TOC CMRs performed, 90 drug therapy problems were identified and 77 were resolved in collaboration with a patient, caregiver, or physician. CONCLUSION: Incorporation of a state HIE into a community pharmacist-led TOC service is a novel strategy for collecting patient data. During the study, no TOC participants were readmitted within 30 days. However, pharmacists found HIE data alone was insufficient to perform TOC CMRs for the majority of participants. In order to expand state HIE utilization, more health systems will need to upload a minimum standard data set to help facilitate care.

Evaluation of Pharmacist-Initiated Interventions on Vaccination Rates in Patients with Asthma or COPD.

To determine if pharmacy-initiated interventions improved the rate of influenza and pneumococcal vaccinations in adult patients with asthma and/or chronic obstructive pulmonary disease (COPD). Adult patients who filled prescriptions at one of three community pharmacies, who had a dispensing history indicative of an asthma and/or COPD diagnosis were randomized to receive a personal phone call or standardized mailed letter recommending influenza and pneumococcal vaccinations, or control with no vaccination information. The rate of influenza and pneumococcal vaccinations was measured for each group and measured using Chi square. Of 831 eligible participants, 210 patients completed the study, and self-reported a diagnosis of asthma and/or COPD. The influenza vaccine was administered to 56 (72.7%), 55 (87.3%), and 62 (88.6%) patients (p = 0.019); pneumococcal vaccine was administered to 46 (59.7%), 39 (61.9%), and 39 (55.7%) patients in the phone call, letter, and control groups, respectively. While the control group had significantly more influenza vaccinations, between the interventions the letter showed a higher rate of influenza vaccination over the phone call. Reviewing patients under age 65, the letter had a significantly higher rate of influenza vaccination than the phone call (p = 0.021). No significant improvement was found for the pneumococcal vaccination. Patients under age 65 who received a mailed letter had a significantly higher rate of influenza vaccination than those who received a phone call, and had a higher rate of pneumococcal vaccination. A standardized, mailed letter may help community pharmacists improve vaccination rates in patients with asthma and/or COPD.

Comprehensive medication review recipients' opinions, actions, and information recall.

OBJECTIVES: Assess patients' and caregivers' perceptions of comprehensive medication review (CMR) offers and when a CMR is needed, follow-up actions performed after the CMR, and recall of pharmacists' recommendations made during CMRs. METHODS: A 22-item cross-sectional survey with multiple response, 5-point Likert scale (1 = strongly disagree; 5 = strongly agree), yes/no, and free response prompts was administered to patients and caregivers who completed a CMR between October 1, 2014, and September 30, 2015. Surveys were administered to study participants by telephone or by mail if they were not reachable by telephone. RESULTS: Eighty of 141 surveys were completed (57%). Respondents were mostly white, female, and age 65 years or older, with an annual income less than $25,000. Respondents indicated that they were likely to accept CMR offers from pharmacists or pharmacy technicians they know (100% and 94%, respectively) and by telephone call (90%). Respondents strongly agreed that CMRs should be completed annually and when initiating medication for a new diagnosis (median = 5; interquartile range, 3-5). Most respondents received at least 1 recommendation (90%), recalled receiving their CMR summary (66%), and discussed their CMR with their prescribers (67%). Respondents who reported receiving a pharmacist recommendation during their CMR were more likely to strongly agree they should have an annual CMR (P = 0.009). Accurate recall of recommendations made during CMRs was 54%. General health and medication recommendations were significantly associated with respondents' recall of recommendations (P = 0.011 and P = 0.045, respectively). CONCLUSION: Patients and caregivers who received a CMR stated that they are likely to accept future CMR offers from a pharmacist or technician with whom they are familiar, and more patients and caregivers would accept offers by telephone than by other methods. In addition, a newly diagnosed condition presents an opportunity for strategic CMR appointment offers. Although pharmacists regularly made therapy interventions during CMRs, it is important to ensure that CMR recipients have clear instructions for follow-up with their prescribers.

Home-Based Comprehensive Medication Reviews: Pharmacist's Impact on Drug Therapy Problems in Geriatric Patients.

OBJECTIVE: To evaluate the effects of pharmacist-conducted, home-based comprehensive medication reviews (CMRs) on drug therapy problems (DTPs) in geriatric patients. DESIGN: Pre-/postintervention study. SETTING: Grocery store chain affiliated with three independent living facilities. PARTICIPANTS: Twenty-five older adults using pharmacy delivery services for at least three chronic medications. INTERVENTION: A pharmacist conducted a home-based CMR for each participant. DTPs were identified across 13 categories. Patients received a medication action plan post-CMR. A follow-up patient phone call was completed two weeks following the appointment. Patient profiles were reviewed for three months postintervention for changes in DTPs. MAIN OUTCOME MEASURES: Changes in DTPs per patient and changes in five Centers for Medicare & Medicaid Services triple-weighted Star Rating performance measures. RESULTS: The average DTPs identified per patient were reduced from 3.4 ± 2.06 to 1.48 ± 1.68 (P < 0.05) DTPs three months postintervention. The most common categories identified-nonadherence and incorrect administration/ technique-were significantly reduced (P = 0.012 and P = 0.010, respectively). One Star Rating performance measure significantly improved: 68% of patients taking hypertension medications were adherent at baseline and 91% were adherent three months post-CMR (P = 0.016). CONCLUSION: Pharmacist-provided, home-based CMRs reduced the average number of DTPs per patient. The most common categories of DTPs identified-nonadherence and incorrect administration/technique-were reduced postintervention.

Patient Satisfaction With Pharmacist-Led Chronic Disease State Management Programs.

PURPOSE: To assess patient satisfaction, perception of self-management, and perception of disease state knowledge with pharmacist-led diabetes and cardiovascular disease state management (DSM) programs. METHODS: A self-insured chain of grocery store pharmacies in the Kansas City metropolitan area administers pharmacist-led diabetes and cardiovascular DSM programs for eligible employees and dependents. A modified version of the Diabetes Disease State Management Questionnaire was used to assess patient satisfaction with the DSM programs. Demographic information was also collected. Survey items were based on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). Patients were eligible to complete the survey if he or she had been in at least 1 DSM program for 6 months. Data were assessed using descriptive statistics and analysis of variance. RESULTS: Across 20 pharmacies, 281 eligible participants were identified, and 46% (n = 128) completed a survey. Means for summed items relating to overall satisfaction (8 items), self-management (5 items), and knowledge (4 items) were 36.6/40 (standard deviation [SD] = 3.9), 20.9/25 (SD = 3.4), and 17.6/20 (SD = 2.1), respectively. Participant comments further indicated that the program and pharmacists are helpful and increase motivation and accountability. CONCLUSIONS: Positive patient responses to the program support use of pharmacist-led DSM programs.

Participant satisfaction with a community-based medication synchronization program.

OBJECTIVE: To assess participant satisfaction with a community pharmacy-based medication synchronization program. SETTING: A single location of a grocery store pharmacy chain in the Kansas City metropolitan area. PRACTICE DESCRIPTION: A medication synchronization program, Time My Meds (TMM), was implemented in 1 of 20 community pharmacies within the grocery store chain. PRACTICE INNOVATION: Current pharmacy patients taking three or more chronic medications were recruited to enroll in the medication synchronization program. After at least 3 months of enrollment in TMM, participants were invited to complete a paper survey to assess satisfaction with the program. EVALUATION: Data were collected on overall participant satisfaction with the TMM program. A 10-statement survey gathered demographic information and assessed participant satisfaction using a 5-point Likert scale (1, strongly disagree, to 5, strongly agree). RESULTS: Data collected from 48 surveys were analyzed. No statistical differences in participant satisfaction were found when considering age, education, income, number of medications at pick-up, or number of monthly trips to the pharmacy prior to program enrollment. Median scores for individual survey items were all 5 out of 5 (strongly agree) using a 5-point Likert scale. CONCLUSION: Participants were highly satisfied with the medication synchronization program. These results, if expanded to a wider population, might provide valuable information for continued justification and implementation of this type of service in community pharmacies.

Administration of antiretroviral medication via enteral tubes.

PURPOSE: Case reports and other published or manufacturer-provided data on the administration of antiretroviral agents through enteral feeding tubes are reviewed. SUMMARY: There is very limited published evidence to guide clinicians in the delivery of therapies for human immunodeficiency virus (HIV) infection by feeding tubes, especially crushed tablets and capsule contents. A search of the primary literature (through February 2012) identified a total of nine articles describing the delivery of highly active antiretroviral therapy (HAART) agents via gastrostomy (G), jejunostomy, and other feeding tubes; correspondence with pharmaceutical manufacturers yielded additional information. Most of the published evidence (from two prospective studies, one retrospective study, and six case reports) pertains to the treatment of HIV-infected children (33 of 40 cases). Although not a primary endpoint of any of the reviewed studies, viral suppression was documented in 29 of the 40 patients referenced in the reviewed articles. Manufacturer-provided information indicates that crushed darunavir tablets in suspension, as well as oral solutions of ritonavir and lopinavir-ritonavir, can be administered through G-tubes without significant loss of therapeutic efficacy. CONCLUSION: Data regarding enteral feeding tube administration are available for 63% of commercially available oral HAART agents and are primarily limited to case reports specific to the pediatric population.

Accuracy and precision of the Prodigy AutoCode blood glucose monitor.

OBJECTIVES: To assess the accuracy and precision of the Prodigy AutoCode blood glucose monitor. METHODS: This open-label, prospective equivalence study was conducted at Wilson Community Health Center in Wilson, North Carolina. Accuracy was assessed by comparing finger stick blood glucose values to venipuncture. Precision was assessed by comparing consecutive finger stick blood glucose values from 2 Prodigy AutoCode monitors. Data were analyzed using paired t tests, signed rank tests, regression, and mixed effect models. RESULTS: Fifty-three subjects completed the study. Meter 1 produced 14 (26%) and meter 2 produced 13 (25%) blood glucose readings outside the acceptable error margin of ±20% set by the International Organization for Standardization (ISO) and the Food and Drug Administration (FDA). Neither meter was accurate compared to venipuncture (P < .001 for both). Consecutive blood glucose results obtained from meters 1 and 2 were precise (meter 1 vs 2, P = .533). CONCLUSIONS: The Prodigy AutoCode demonstrated precision between two different monitors but was inaccurate compared to venipuncture. Less than the required 95% of blood glucose values from each monitor fell within the acceptable 20% error margin relative to venipuncture. All readings outside the acceptable error margin were overestimations, indicating potentially significant safety concerns including untreated or undertreated hypoglycemia.