Managing medications for patients with cancer and chronic conditions: It's time for collaboration between primary care and oncology pharmacists.

OBJECTIVE: To provide a rationale for a collaborative care model involving oncology and primary care pharmacists to improve the coordination of care of medications for cancer patients with multiple chronic conditions. DATA SOURCES: A review of selected literature and the authors' own research was used. Studies illustrating the gaps in care for medications and pharmacists' roles in oncology and primary care settings from PubMed were reviewed. DATA SUMMARY: There has been a substantial increase in the development and utilization of oral anticancer agents (OAAs). Although OAAs offer convenience and flexibility, they also introduce challenges related to medication adherence, monitoring, and managing side effects. Up to 17.5% of patients experience moderate to severe symptoms from OAAs and about 30% report less than excellent medication adherence. Further, studies showed that 30% to 53% of adult cancer patients have at least one chronic condition that complicates their treatment plan due to the need for medications, increasing the risk of drug interactions, side effects, and non-adherence. The Primary Care Oncology Model (PCOM) incorporates both primary care and oncology pharmacists with comprehensive medication review and patient-reported outcome measure, respectively, to enhance medication appropriateness and effectiveness, and improve overall patient experience. CONCLUSION: Implementing PCOM may improve the medication management of patients taking OAAs for active cancer treatment and chronic medications for their multiple chronic conditions. This collaborative approach can transform patient care by leveraging the expertise of both primary care and oncology pharmacists.

Impact of initiating oral anticancer agents for leukemia on adherence to medications for multiple chronic conditions.

INTRODUCTION: Increased use of oral anticancer agents (OAAs) has empowered adults with chronic lymphocytic leukemia (CLL) and chronic myelogenous leukemia (CML) to manage their therapy, but this shift may complicate medication use, particularly among adults with multiple chronic conditions (MCC). METHODS: This retrospective cohort study used 2013-2018 commercial and Medicare claims data to assess medication use in adults with CML or CLL. To be included, patients must have been at least 18 years old, diagnosed with and had 2+ claims for an OAA indicated for either CML or CLL, continuously enrolled 12 months before and after OAA initiation, and treated for (2+ fills) at least two select chronic conditions. Proportion of days covered (PDC) determined medication adherence and was compared for 12 months before and after OAA initiation by Wilcoxon signed-rank tests, McNemar's tests, and difference-in-differences models. RESULTS: Among CLL patients, mean OAA adherence in the first year of therapy was 79.8% (SD: 21.1) and 74.7% (SD: 24.9) for commercial and Medicare patients, respectively; mean adherence for CML patients was 84.5% (SD: 15.8) and 80.1% (SD: 20.1) for commercial and Medicare patients, respectively. Adherence and the proportion adherent (PDC ≥ 80%) to comorbid therapies was generally unchanged following OAA initiation. Consistently unremarkable changes in MCC adherence were observed in 12-month difference-in-differences models, but significant decline was observed in MCC adherence after 6 months of OAA use. CONCLUSIONS: OAA initiation among adults with CML or CLL was not associated with significant, initial changes to adherence to medications for chronic diseases.

Age-related differences in risks and outcomes of 30-day readmission in adults with sickle cell disease.

BACKGROUND: Literature on 30-day readmission in adults with sickle cell disease (SCD) is limited. This study examined the overall and age-stratified rates, risk factors, and healthcare resource utilization associated with 30-day readmission in this population. METHODS: Using the Nationwide Readmissions Database, a retrospective cohort study was conducted to identify adult patients (aged ≥ 18) with SCD in 2016. Patients were stratified by age and followed for 30 days to assess readmission following an index discharge. The primary outcome was 30-day unplanned all-cause readmission. Secondary outcomes included index hospitalization costs and readmission outcomes (e.g., time to readmission, readmission costs, and readmission lengths of stay). Separate generalized linear mixed models estimated the adjusted odds ratios (aORs) for associations of readmission with patient and hospital characteristics, overall and by age. RESULTS: Of 15,167 adults with SCD, 2,863 (18.9%) experienced readmission. Both the rates and odds of readmission decreased with increasing age. The SCD complications vaso-occlusive crisis and end-stage renal disease (ESRD) were significantly associated with increased likelihood of readmission (p < 0.05). Age-stratified analyses demonstrated that diagnosis of depression significantly increased risk of readmission among patients aged 18-to-29 years (aOR = 1.537, 95%CI: 1.215-1.945) but not among patients of other ages. All secondary outcomes significantly differed by age (p < 0.05). CONCLUSION: This study demonstrates that patients with SCD are at very high risk of 30-day readmission and that younger adults and those with vaso-occlusive crisis and ESRD are among those at highest risk. Multifaceted, age-specific interventions targeting individuals with SCD on disease management are needed to prevent readmissions.

Exploring the Membership Pharmacy Model: Initial impact and feasibility.

BACKGROUND: There is a need to shift pharmacy payment models, given the expanding role of the community pharmacist in improving patient outcomes, misaligned incentives of the existing reimbursement model, and deleterious effects of a lack of transparency on prescription costs. OBJECTIVES: The primary objective of this paper was to develop a payment strategy for a Membership Pharmacy Model within an independent community pharmacy setting. A secondary objective of this paper is to explore the early impact of a novel value-based pharmacy payment model on patients, pharmacies, and self-insured employers. PRACTICE DESCRIPTION: Good Shepherd Pharmacy, a nonprofit Membership Pharmacy founded in Memphis, TN, in 2015. PRACTICE INNOVATION: We discuss a novel, value-based payment model for community pharmacy, which involves a partnership between pharmacy and employer, without the use of a pharmacy benefit manager, using a recurring (i.e., membership pharmacy) business revenue model. EVALUATION METHODS: The pilot program was assessed using the RE-AIM framework. RESULTS: The pilot enrolled 34 patients for whom 1399 prescriptions were filled spanning 13 quarterly refill cycles from January 2019-March 2022. After the intervention, proportion of days covered for diabetes and cholesterol medications both increased: 96.7% and 100% (P < 0.05); 90.3% and 98.1% (P > 0.05). Financial savings for the employer group were realized across both fee charges and prescription medication costs. The net savings provided to the employer was $67,843, a 35% reduction in topline pharmacy spending. Revenue for the pharmacy was realized exclusively through synchronization fees of $30 per fill. Synchronization fees for the entire study totaled $41,970, and the average revenue per quarterly batch refill was $3228. CONCLUSION: The Membership Pharmacy Model represents a potentially viable alternative to traditional fee-for-service, buy-and-bill pharmacy payment models through its use of medication pricing based on actual acquisition costs, lean pharmacy operations, and value-based reimbursement methods.

Laxative Use and Risk of Dyskalemia in Patients with Advanced CKD Transitioning to Dialysis.

BACKGROUND: Patients with advanced CKD experience increased intestinal potassium excretion. This compensatory mechanism may be enhanced by laxative use; however, little is known about the association of laxative use with risk of dyskalemia in advanced CKD. METHODS: Our study population encompassed 36,116 United States veterans transitioning to ESKD from 2007 to 2015 with greater than or equal to one plasma potassium measurement during the last 1-year period before ESKD transition. Using generalized estimating equations with adjustment for potential confounders, we examined the association of time-varying laxative use with risk of dyskalemia (i.e., hypokalemia [potassium <3.5 mEq/L] or hyperkalemia [>5.5 mEq/L]) versus normokalemia (3.5-5.5 mEq/L) over the 1-year pre-ESKD period. To avoid potential overestimation of dyskalemia risk, potassium measurements within 7 days following a dyskalemia event were disregarded in the analyses. RESULTS: Over the last 1-year pre-ESKD period, there were 319,219 repeated potassium measurements in the cohort. Of these, 12,787 (4.0%) represented hypokalemia, and 15,842 (5.0%) represented hyperkalemia; the time-averaged potassium measurement was 4.5 mEq/L. After multivariable adjustment, time-varying laxative use (compared with nonuse) was significantly associated with lower risk of hyperkalemia (adjusted odds ratio [aOR], 0.79; 95% confidence interval [95% CI], 0.76 to 0.84) but was not associated with risk of hypokalemia (aOR, 1.01; 95% CI, 0.95 to 1.07). The results were robust to several sensitivity analyses. CONCLUSIONS: Laxative use was independently associated with lower risk of hyperkalemia during the last 1-year pre-ESKD period. Our findings support a putative role of constipation in potassium disarrays and also support (with a careful consideration for the risk-benefit profiles) the therapeutic potential of laxatives in hyperkalemia management in advanced CKD.

The Optimizing Care Model: Final findings of a novel community pharmacy practice model to enhance patient care delivery using technician product verification.

BACKGROUND: The community pharmacy represents a convenient health care access point for patients and is increasingly used to deliver direct patient care services; however, several barriers exist that hinder widespread patient service implementation and scalability. Such barriers include scope of practice restrictions, a dearth of sustainable payment models, lack of pharmacist capacity given other responsibilities, and workflow models developed for dispensing medications rather than clinical care. In an effort to overcome the lack of pharmacist time and capacity, further task delegation to pharmacy technicians has been suggested. OBJECTIVES: The primary objective of this study was to present the final outcomes of the Optimizing Care Model's impact. The model's impact on pharmacist patient care, workday composition, and rates of product selection errors not identified during final product verification are reported. METHODS: The Optimizing Care Model is an innovative approach to community pharmacy practice aiming to foster a new patient-centered care delivery model that expands clinical service delivery and fosters collaboration across health care settings through task delegation, primarily through technician product verification (TPV). To investigate the impact of its sustained implementation, a quasi-experimental, 1-group pretest-posttest design was used. Outcomes assessed included medication errors, clinical activities, and workday composition. RESULTS: Six chain and 3 independent pharmacies completed the final, continuation phase of the study. Overall pharmacist time spent delivering patient care services increased significantly upon implementation of the Optimizing Care Model (21% vs. 43%; P < 0.05), whereas pharmacist time spent performing dispensing-related activities decreased significantly (67% vs. 37%; P < 0.05). Total undetected error rates were significantly less in the Optimizing Care Model phase compared with the traditional model (0.05% vs. 0.01%; P < 0.001). CONCLUSION: This study presented the final results of a 2-year assessment of the Optimizing Care Model. Results reaffirmed initial published findings that the model and its use of TPV increase the array and frequency of direct patient care services rendered while resulting in lower undetected error rates. Final project results of the Optimizing Care Model demonstrate increased clinical service delivery versus the traditional model, while also improving patient safety with lower rates of undetected dispensing errors within the Optimizing Care Model. The Optimizing Care Model continues to show promise as a future practice model for community pharmacies.

A social media microinfluencer intervention to reduce coronavirus disease 2019 vaccine hesitancy in underserved Tennessee communities: A protocol paper.

BACKGROUND: Central to effective public health policy and practice is the trust between the population served and the governmental body leading health efforts, but that trust has eroded in the years preceding the pandemic. Vaccine hesitancy among adults is also a growing concern across the United States. Recent data suggest that the trustworthiness of information about the coronavirus 2019 (COVID-19) vaccine was a larger concern than the vaccine's adverse effects or risks. OBJECTIVE: This study aims to describe the methods used to create a public health microinfluencer social media vaccine confidence campaign for the COVID-19 vaccine in underserved Tennessee communities. A secondary objective is to describe how the Social-Ecological Model (SEM) and Social Cognitive Theory may address vaccine hesitancy using community pharmacies. METHODS: In late 2020, 50 independent community pharmacies in underserved communities across Tennessee were involved in a public health project with the State of Tennessee Department of Health and the University of Tennessee Health Science Center College of Pharmacy. The project involved a 3-pronged, pharmacy-based COVID-19 vaccination outreach project, including (1) social media messaging (i.e., microinfluencer approach), (2) community partner collaboration, and (3) in-pharmacy promotion. Quantitative and qualitative data will assess the quality and effectiveness of the program. Social media outcomes will also be assessed to measure the impact of the microinfluencer social media training. RESULTS: Project implementation is planned for 6 months (January 2021 to June 2021) after an initial month of planning by the research team (December 2020) and preceding several months of assessment (July 2021 and beyond). CONCLUSIONS: Novel, theory-based approaches will be necessary to improve vaccine confidence. One approach to promoting public health, derived from the SEM, may be to use trusted microinfluencers on social media platforms, such as local community pharmacists and community leaders.

Association of Dyskalemias with Ischemic Stroke in Advanced Chronic Kidney Disease Patients Transitioning to Dialysis.

INTRODUCTION: Hypo- and hyperkalemia are associated with a higher risk of ischemic stroke. However, this association has not been examined in an advanced chronic kidney disease (CKD) population. METHODS: From among 102,477 US veterans transitioning to dialysis between 2007 and 2015, 21,357 patients with 2 pre-dialysis outpatient estimated glomerular filtration rates <30 mL/min/1.73 m2 90-365 days apart and at least 1 potassium (K) each in the baseline and follow-up period were identified. We separately examined the association of both baseline time-averaged K (chronic exposure) and time-updated K (acute exposure) treated as categorized (hypokalemia [K <3.5 mEq/L] and hyperkalemia [K >5.5 mEq/L] vs. referent [3.5-5.5 mEq/L]) and continuous exposure with time to the first ischemic stroke event prior to dialysis initiation using multivariable-adjusted Cox regression models. RESULTS: A total of 2,638 (12.4%) ischemic stroke events (crude event rate 41.9 per 1,000 patient years; 95% confidence interval [CI] 40.4-43.6) over a median (Q1-Q3) follow-up time of 2.56 (1.59-3.89) years were observed. The baseline time-averaged K category of hypokalemia (adjusted hazard ratio [aHR], 95% CI: 1.35, 1.01-1.81) was marginally associated with a significantly higher risk of ischemic stroke. However, time-updated hyperkalemia was associated with a significantly lower risk of ischemic stroke (aHR, 95% CI: 0.82, 0.68-0.98). The exposure-outcome relationship remained consistent when using continuous K levels for both the exposures. DISCUSSION/CONCLUSION: In patients with advanced CKD, hypokalemia (chronic exposure) was associated with a higher risk of ischemic stroke, whereas hyperkalemia (acute exposure) was associated with a lower risk of ischemic stroke. Further studies in this population are needed to explore the mechanisms underlying these associations.

Laxative use in patients with advanced chronic kidney disease transitioning to dialysis.

BACKGROUND: Constipation is highly prevalent in patients with chronic kidney disease (CKD), particularly among those with end-stage renal disease (ESRD), partly due to their dietary restrictions, comorbidities and medications. Laxatives are typically used for constipation management; however, little is known about laxative use and its associated factors in patients with advanced CKD transitioning to ESRD. METHODS: In a retrospective cohort of 102 477 US veterans transitioning to dialysis between October 2007 and March 2015, we examined the proportion of patients who filled a prescription for any type of laxative within each 6-month period over 36 months pre- and post-transition to ESRD. Factors associated with laxative use during the last 1-year pre-ESRD period were identified by multivariable logistic regression. RESULTS: The proportion of patients prescribed laxatives increased as patients progressed to ESRD, peaking at 37.1% in the 6 months immediately following ESRD transition, then remaining fairly stable throughout the post-ESRD transition period. Among laxative users, stool softeners were the most commonly prescribed (∼30%), followed by hyperosmotics (∼20%), stimulants (∼10%), bulk formers (∼3%), chloride channel activator (<1%) and several combinations of these. The use of anticoagulants, oral iron supplements, non-opioid analgesics, antihistamines and opioid analgesics were among the factors independently associated with pre-ESRD laxative use. CONCLUSION: The use of laxatives increased considerably as patients neared transition to ESRD, likely mirroring the increasing burden of drug-induced constipation during the ESRD transition period. Findings may provide novel insight into better management strategies to alleviate constipation symptoms and reduce medication requirements in patients with advanced CKD.

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

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

Laxative Use and Change in Estimated Glomerular Filtration Rate in Patients With Advanced Chronic Kidney Disease.

OBJECTIVES: Constipation is highly prevalent in advanced chronic kidney disease (CKD), due in part to dietary (e.g., fiber) restrictions, and is often managed by laxatives; however, the effect of laxative use on kidney function in advanced CKD remains unclear. We aimed to examine the association of laxative use with longitudinal change in estimated glomerular filtration rate (eGFR) in patients with advanced CKD. DESIGN AND METHODS: In a retrospective cohort of 43,622 US veterans transitioning to end-stage renal disease (ESRD) from 2007 to 2015, we estimated changes in eGFR (slope) by linear mixed-effects models using ≥2 available outpatient eGFR measurements during the 2-year period before transition to ESRD. The association of laxative use with change in eGFR was examined by testing the interaction of time-varying laxative use with time for eGFR slope in the mixed-effects models with adjustment for fixed and time-varying confounders. RESULTS: Laxatives were prescribed in 49.8% of patients during the last 2-year pre-ESRD period. In the crude model, time-varying laxative use was modestly associated with more progressive eGFR decline compared with non-use of laxatives (median [interquartile interval] -7.1 [-11.9, -4.3] vs. -6.8 [-11.6, -4.0] mL/min/1.73 m2/year, P < .001). After multivariable adjustment, a faster eGFR decline associated with laxative use (vs. non-use of laxatives) remained statistically significant, although the between-group difference in eGFR slope was minimal (median [interquartile interval] -8.8 [-12.9, -5.9] vs. -8.6 [-12.6, -5.6] mL/min/1.73 m2/year, P < .001). The significant association was no longer evident across different types of laxatives (i.e., stool softeners, stimulants, or hyperosmotics). CONCLUSIONS: There was a clinically negligible association of laxative use with change in eGFR during the last 2-year pre-ESRD period, suggesting the renal safety profile of laxatives in advanced CKD patients.

Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review.

BACKGROUND: Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities. OBJECTIVE: This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities. METHODS: A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study. RESULTS: PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information. CONCLUSIONS: Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.

Facilitating pneumococcal vaccination among high-risk adults: Impact of an assertive communication training program for community pharmacists.

BACKGROUND: Community pharmacies are vital access points to provide a range of vaccines to adults, including pneumococcal vaccines; however, despite a growth in the number of vaccines given at these sites, the most recent rates of adults being immunized against pneumococcal disease remain below the goals set by Health People 2020. Low patient awareness is a leading reason for suboptimal vaccination rates, suggesting that a need exists to improve provider communication in recommending pneumococcal vaccination in high-risk adults. OBJECTIVES: To evaluate the impact of a communication training program to improve pharmacist promotion of the pneumococcal vaccine among high-risk adults in Tennessee. METHODS: A multiphase training program was initiated in partnership with 2 regions of a nationwide community pharmacy chain (n = 100) focusing on improving evidence-based, presumptive recommendations related to pneumococcal vaccination. All locations were randomized to one of 3 arms on the basis of training intensity: (1) no training; (2) online training only; and (3) online and in-person simulation training. The program focused on improving evidence-based, pharmacist vaccine recommendations using health behavior theories, sales techniques, and improvisation provided through online and in-person simulation training. Changes in vaccinations (compared with the same 6-month period in the previous year) and provider self-efficacy were evaluated by Mann-Whitney U tests, chi-square tests, and general linear models. RESULTS: Completing the full training program led to nominal changes in pharmacist self-efficacy across the 6 items measured (P > 0.05). Overall counts of all pneumococcal vaccines were lower (-11.3%) across all stores in the period after training; however, a small increase (2.1%) was observed in the stores that underwent the full training, versus changes of -22.0% (P = 0.084) and -9.4% (P = 0.199) in control and online-only training comparisons, respectively. CONCLUSIONS: Pharmacists' vaccine-related self-efficacy may be improved through an evidence-based communication training program, but a more holistic focus on all recommended adult vaccines may be necessary to realize meaningful improvements.

An Exploratory Study of Pharmacist Perceptions of Opioid Interventions for Acute Pain.

Background: As the last health care provider encountered before an opioid is dispensed, pharmacists have a vital role in reducing unnecessary opioid exposure while facilitating access to non-opioid alternatives. Objective: To characterize pharmacist perceptions in providing interventions for patients with an opioid prescription for acute pain. Methods: This cross-sectional survey was administered over 3 months to pharmacy preceptors affiliated with the University of Tennessee Health Science Center College of Pharmacy. The electronic survey utilized 7 demographical and baseline questions, 1 open-ended question, and 5 Likert-type scales to assess the following domains: responsibility in making decisions, willingness to provide information, comfort in speaking to patients, willingness to use a standing order, and importance of following up with patients. Results: Of the 380 participants invited to participate, 126 responded to at least one question and 90 completed all survey questions. Most participants were PharmD graduates practicing in hospital and community settings. Participants felt that opioids are frequently overprescribed and pharmacist interventions are often necessary. Most participants reported that pharmacists and physicians share similar responsibilities in making opioid-related decisions. Participants were willing to provide information about opioid alternatives but were only somewhat comfortable speaking to patients. Responses to the open-ended question revealed the following themes: Significance of educating the patient; Importance of alternatives to opioid medications; Impacts of pharmacist interventions; and Need for enhanced collaboration with physicians. Conclusions: Pharmacists face complex issues with limited clinical guidance when providing opioid-related interventions. Future research is needed to develop evidence-based clinical support tools and collaborative practice models.

Cost-Utility Analysis of Glaucoma Medication Adherence.

PURPOSE: The majority of patients with glaucoma do not take their medications as prescribed. Estimates of the cost-utility value of adherence to prescribed glaucoma medication are vital to implement potentially effective interventions. DESIGN: Cost-utility analysis using Monte Carlo microsimulations incorporating a series of Markov cycles (10 000 iterations per strategy). PARTICIPANTS: Patients with glaucoma aged ≥40 years with a full lifetime horizon (up to 60 years). METHODS: The analysis estimated glaucomatous progression on the basis of data from the United Kingdom Glaucoma Treatment Study. Participants with glaucoma entered the model at age 40 years with a mean deviation in the better-seeing eye of -1.4±-1.9 decibels (dB) and -4.3±-3.4 dB in the worse-seeing eye. Participants whose glaucoma worsened each year accumulate -0.8 dB loss compared with -0.1 dB loss for those who remained stable. Data from the Glaucoma Laser Trial and the Tube versus Trabeculectomy Studies were used to assign probabilities of worsening disease among treated patients. Claims data estimating rates of glaucoma medication adherence over 4 years were used to assign probability of adherence. Those with poor adherence were modeled as having outcomes similar to the placebo arm of the clinical trials. As patients' mean deviation deteriorated, they transitioned between health states from mild (≥-6 dB), to moderate (<-6 to ≥-12 dB), to severe glaucoma (<-12 to ≥23 dB), to unilateral (<-20 dB) and bilateral blindness. At each health state, patients incurred the costs of treatment and established health utilities; ultimately, societal costs of low vision and blindness were included. MAIN OUTCOME MEASURES: Cost and quality-adjusted life year (QALY) of glaucoma medication adherence. RESULTS: Beginning at an initial glaucoma diagnosis at age 40 years, patients proceeded to single-eye blindness as early as 19 years among those who were nonadherent and 23 years for those remaining adherent. Total healthcare costs for adherent patients averaged $62 782 (standard deviation [SD], 34 107), and those for nonadherent patients averaged $52 722 (SD, 38 868). Nonadherent patients had a mean loss of 0.34 QALYs, resulting in a cost-effectiveness ratio of $29 600 per QALY gained. CONCLUSION: At a conservative willingness to pay of $50 000/QALY, there is room to expand services to improve patient adherence.

Racial and Regional Disparities in Outcomes Among Veterans Initially Adherent to Oral Antidiabetic Therapies: an Observational Cohort Study.

BACKGROUND: Adherence to prescribed medications is connected with, but is not a guarantee of, improved disease management and health outcomes. It remains unclear whether underlying health disparities exist among patients adherent to therapy and whether differences in outcomes vary by race and residential areas of the country. OBJECTIVE: To determine the extent of racial and regional variation in outcomes within 5 years of oral antidiabetic drug initiation among veterans adherent to therapy. DESIGN: Retrospective cohort study of 83,265 US Veterans Health Administration data, 2002-2014 PATIENTS: US veterans with uncomplicated diabetes and taking oral antidiabetic agents MAIN MEASURES: Veterans initially adherent to oral antidiabetic therapy were followed for up to 5 years, and comparisons focused on differences between non-Hispanic White and non-Hispanic Black veterans across geographic region and residential type (urban or rural). Outcomes included composite cardiovascular events, composite cerebrovascular events, or all-cause mortality using Poisson and adjusted Cox proportional hazards models. KEY RESULTS: Cardiovascular event and all-cause mortality rates differed by race and region, while urban/rural differences were evident for cerebrovascular events and all-cause mortality. For non-Hispanic Blacks, the mortality rate was half that compared to non-Hispanic Whites (6.5 [95% CI 5.8-7.2] versus 13.3 [95% CI 12.9-13.8], p < 0.0001). Compared to the Northeast, all other regions had higher adjusted hazards for cardiovascular or cerebrovascular events (with a single exception), but no regional differences in all-cause mortality were observed. Models with interactions demonstrated that racial differences in cardiovascular events and all-cause mortality were isolated to the Midwest (HR 1.99 [95% CI 1.301-3.06; HR 1.64 [95% CI 1.210-2.215]) and South (HR 1.69 [85% CI 1.347-2.131]; HR 1.27 [95% CI 1.095-1.470]). CONCLUSIONS: Despite adherence to therapy, differences in outcomes are likely among veterans with diabetes based on race and geography. Localized analyses may uncover specific social determinants contributing to differences in outcomes.

Impact of oral oncolytic initiation on medication adherence for pre-existing comorbid chronic conditions.

PURPOSE: Oral oncolytics have improved survival in hematological cancers like chronic myeloid leukemia, chronic lymphocytic leukemia/small lymphocytic lymphoma, and multiple myeloma; however, it is unclear of the extent to which initiating these treatments might impact adherence to oral therapies for pre-existing comorbid chronic conditions. METHODS: Adults diagnosed with and prescribed oral oncolytics for chronic myeloid leukemia, chronic lymphocytic leukemia/small lymphocytic lymphoma, or multiple myeloma between 2013 and 2016 and with continuous eligibility six months before and after oral oncolytic initiation were identified from the Truven Health MarketScan databases. Among those identified, patients with pre-existing diabetes, hypertension, and/or hyperlipidemia with ≥1 fill for oral comorbid therapies were selected. Adherence to oral oncolytics and comorbid therapies was measured using the proportion of days covered metric. Wilcoxon signed-rank tests assessed changes in adherence for comorbid therapies after initiation of an oral oncolytic. Unadjusted difference-in-difference models assessed the impact of adherence to oral oncolytics on changes in adherence to comorbid therapies. RESULTS: Significant reductions in adherence after oncolytic initiation were observed across the comorbid therapies and were highest for patients taking lipid-lower agents (10.7-15.6%). Unadjusted difference-in-difference models revealed consistent and significantly lower reductions in adherence for those taking antihypertensives (chronic myeloid leukemia: p = 0.03; chronic lymphocytic leukemia/small lymphocytic lymphoma: p = 0.007; multiple myeloma: p = 0.09) and adherent to oral oncolytics. CONCLUSION: Initiation of oral oncolytics may negatively impact adherence to oral therapies for chronic comorbid conditions, necessitating the need for medication management strategies to help patients adhere to their entire medication regimen.

Community pharmacist workflow and medication therapy management delegation: An assessment of preferences and barriers.

OBJECTIVES: The role of community pharmacists continues to evolve to meet the changing medication-related needs of patients in the United States, requiring a fundamental shift in the pharmacist's workflow and tasks including medication dispensing and medication therapy management (MTM). To compare community pharmacists' current and idealized time allocation. Barriers to, and potential facilitators of, typical and specific pharmacist functions are also reported, with an emphasis on MTM practices. A secondary objective included interpreting how pharmacists perceived the value of social determinants of health to the MTM process. METHODS: Community pharmacists practicing in Tennessee were surveyed online with 3 distinct foci: time allocation and delegation, MTM barriers, and the perceived value of health-related and social data to the MTM process. For the first 2 sections, the respondents provided responses in 2 different scenarios: (1) current workflow and (2) an idealized workflow. Paired Wilcoxon signed-rank and chi-square tests compared the responses to workday items, and Spearman correlations assessed the relationships between preferences and perceived barriers. RESULTS: The pharmacists reported spending the largest share of time verifying product (32.8% [SD 19.28]), and most indicated that they spent no time in either point-of-care testing (POCT) or physical patient assessment. In an ideal work environment, more patient-focused roles would be preferred (e.g., health screening, POCT, MTM, and vaccinations), with more than 80% indicating that they would delegate register activities, data entry, and product verification to technicians. In performing MTM, the pharmacists indicated that they would prefer delegating more data collection and patient management activities to technicians to reserve time for patient assessment and care plan creation. Key barriers to MTM included a lack of time, staff support, and patients' willingness to participate. CONCLUSION: Ideally, pharmacists would prefer to do no prescription filling or selling or register activities. Facilitating community pharmacy practice evolution will require focusing on building teams around support personnel.

Exploring the early phase of implementation of a vaccine-based clinical decision support system in the community pharmacy.

OBJECTIVE: To explore the implementation strategy of a recombinant zoster vaccine (RZV) clinical decision support (CDS) intervention in community pharmacy workflow to increase second-dose vaccination rates. SETTING: The level of analysis was the unit (e.g., pharmacy). The participants were selected from across approximately 2200 pharmacies in 37 states on the basis of criteria believed to affect implementation success (e.g., size, location) using a sampling matrix. PRACTICE DESCRIPTION: Large supermarket pharmacy chain. PRACTICE INNOVATION: Vaccine-based CDS intervention in community pharmacy workflow. EVALUATION: A mixed-methods contextual inquiry approach explored the implementation of a new RZV CDS workflow intervention. Data collection involved key informant, semistructured interviews and an electronic, Web-based survey. The survey was based on a validated instrument and was made available to all pharmacists nationwide within the study organization to assess views of the implementation's appropriateness, acceptability, and feasibility during early implementation. Afterward, a series of semistructured, in-depth interviews were conducted until a point of saturation was reached. The interview guide was based on selected constructs of the Consolidated Framework for Implementation Research. RESULTS: A total of 1128 survey responses were collected. Survey respondents agreed or strongly agreed that the implementation was acceptable (78.34%), appropriate (79.92%), and feasible (80.53%). Twelve pharmacist participants were interviewed via telephone. Five themes emerged from the interviews, revealing facilitators and barriers that affected implementation of the intervention: intervention characteristics, outer setting, inner setting, characteristics of individuals, and process. CONCLUSION: The implementation of the RZV CDS "nudge" intervention was welcomed, suitable, and operable in the community pharmacy setting to meet the needs of the organization, employees, and patients. The contextual factors identified during the implementation process of this CDS intervention in a community pharmacy setting may be used in scaling this and future CDS interventions for public health initiatives aimed at pharmacists in this setting.

Glycemic Status and Mortality in Chronic Kidney Disease According to Transition Versus Nontransition to Dialysis.

OBJECTIVE: The impact of glycemic control in diabetic patients with chronic kidney disease (CKD) who may or may not transition to dialysis remains uncertain, given recent interest in the conservative management of advanced CKD without dialysis therapy, which may benefit from alternative glycemic control strategies. DESIGN AND METHODS: Among a national cohort of US Veterans, we examined the association of glycemic status, defined by averaged random blood glucose and hemoglobin A1c (HbA1c), with mortality after transitioning to dialysis over 2007-2011 (Transition Cohort) compared with patients in a one-to-one matched cohort of CKD patients with diabetes who did not transition to dialysis (Nontransition Cohort). RESULTS: Among 17,121 patients in the Transition Cohort, averaged random glucose ≥200 mg/dL was associated with higher mortality in expanded case-mix analyses (reference: 100-<120 mg/dL): adjusted hazard ratio (95% confidence interval) 1.26 (1.13-1.40). In the transition cohort, HbA1c 8-<10% and ≥10% were associated with higher mortality (reference: 6-<8%): adjusted hazard ratios (95% confidence interval) 1.21 (1.11-1.33) and 1.43 (1.21-1.69), respectively. Among 8,711 patients in the Nontransition Cohort, averaged random glucose <100 mg/dl and ≥160 mg/dl were associated with higher death risk, whereas HbA1c was not associated with mortality. CONCLUSION: In diabetic CKD patients transitioning to dialysis, higher averaged random glucose and HbA1c were associated with early dialysis mortality, whereas in matched CKD patients who did not transition, both lower and higher glucose levels were associated with higher mortality. These data suggest the need for different glycemic strategies based on whether there are plans to transition to dialysis versus pursue conservative management among diabetic patients with CKD.