Preemptive pharmacogenetic testing: exploring the knowledge and perspectives of US payers.

PURPOSE: Preemptive pharmacogenetic testing aims to optimize medication use by having genetic information at the point of prescribing. Payers' decisions influence implementation of this technology. We investigated US payers' knowledge, awareness, and perspectives on preemptive pharmacogenetic testing. METHODS: A qualitative study was conducted using semistructured interviews. Participants were screened for eligibility through an online survey. A blended inductive and deductive approach was used to analyze the transcripts. Two authors conducted an iterative reading process to code and categorize the data. RESULTS: Medical or pharmacy directors from 14 payer organizations covering 122 million US lives were interviewed. Three concept domains and ten dimensions were developed. Key findings include clinical utility concerns and limited exposure to preemptive germ-line testing, continued preference for outcomes from randomized controlled trials, interest in guideline development, importance of demonstrating an impact on clinical decision making, concerns of downstream costs and benefit predictability, and the impact of public stakeholders such as the Food and Drug Administration and Centers for Medicare and Medicaid Services. CONCLUSION: Both barriers and potential facilitators exist to developing cohesive reimbursement policy for pharmacogenetics, and there are unique challenges for the preemptive testing model. Prospective outcome studies, more precisely defining target populations, and predictive economic models are important considerations for future research.

Do community pharmacist performance evaluations capture the modern pharmacist's role? Mapping competencies assessed in Canadian community pharmacy performance evaluation templates against the General Level Framework.

OBJECTIVES: Feedback on community pharmacists' practice is limited after graduation and often comes in the form of annual performance evaluations by pharmacy managers based on company-provided templates. The objective of this study was to examine the relevance of these review processes to all aspects of community pharmacy practice. METHODS: Competencies evaluated in performance evaluation templates used by pharmacy organizations were mapped to the General Level Framework (GLF)-a tool developed to assess the competency of general-level pharmacy practitioners-and studied in hospital and community practice settings. The competencies were further assessed with consideration of their applicability to the current scope of practice of Canadian community pharmacy practice. RESULTS: Performance evaluation templates from 7 community pharmacy organizations in Canada were obtained and evaluated. Performance evaluations mapped most closely to the GLF tool related to personal competencies (e.g., organization, communication, and teamwork), with the lowest level of congruence observed among competencies specific to patient care activities. Few evaluations considered recent expansions of scope in place across various Canadian provinces, such as ordering and interpreting laboratory tests or pharmacist prescribing. CONCLUSION: Performance evaluation can be a valuable tool to improve quality of care and the professional development of pharmacists; however, these tools should be reexamined to ensure that feedback on the most valuable aspects of a pharmacist's professional practice is the focus. As pharmacy practice continues to evolve toward greater direct patient care activities, so too should our evaluation tools align with this increasingly recognized role.

Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community: The Alberta Clinical Trial in Optimizing Hypertension (RxACTION).

BACKGROUND: Hypertension control rates remain suboptimal. Pharmacists' scope of practice is evolving, and their position in the community may be ideal for improving hypertension care. We aimed to study the impact of pharmacist prescribing on blood pressure (BP) control in community-dwelling patients. METHODS AND RESULTS: We designed a patient-level, randomized, controlled trial, enrolling adults with above-target BP (as defined by Canadian guidelines) through community pharmacies, hospitals, or primary care teams in 23 communities in Alberta. Intervention group patients received an assessment of BP and cardiovascular risk, education on hypertension, prescribing of antihypertensive medications, laboratory monitoring, and monthly follow-up visits for 6 months (all by their pharmacist). Control group patients received a wallet card for BP recording, written hypertension information, and usual care from their pharmacist and physician. Primary outcome was the change in systolic BP at 6 months. A total of 248 patients (mean age, 64 years; 49% male) were enrolled. Baseline mean±SD systolic/diastolic BP was 150±14/84±11 mm Hg. The intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group, an adjusted difference of 6.6±1.9 mm Hg (P=0.0006). The adjusted odds of patients achieving BP targets was 2.32 (95% confidence interval, 1.17-4.15 in favor of the intervention). CONCLUSIONS: Pharmacist prescribing for patients with hypertension resulted in a clinically important and statistically significant reduction in BP. Policy makers should consider an expanded role for pharmacists, including prescribing, to address the burden of hypertension. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00878566.

Understanding pharmacist success in practice: A scoping review.

OBJECTIVES: The objective was to identify literature providing a description of characteristics contributing to pharmacists' individual level success in providing advanced patient care. DESIGN: An interpretive scoping review was conducted to synthesize knowledge and address the study objective. SETTING: Searches were undertaken in Ovid MEDLINE (1946-2015), EMBASE (1974-2015), and International Pharmaceutical Abstracts (1970-2015). PARTICIPANTS: Not applicable. MAIN OUTCOME MEASURES: Specific keywords used in the search included: motivation, attitude, career, clinical competence, certification, pursuit of an expanded scope of practice, pharmacist, and success. This was not intended to be an exhaustive list, and every effort was made to be inclusive as the search revealed additional words and phrases of interest. RESULTS: A total of 93 articles were initially identified, 10 articles met inclusion criteria and were retained for full-text analysis. Most of the included articles were published in the United States (70%). One-third of the articles conducted semi-structured interviews, one-third of the articles were editorials or commentaries, and the remaining articles collected data using surveys, knowledge assessments, and observation. Content analysis of the extracted definitions of success yielded 2 themes; "what successful pharmacists do" and "what successful pharmacists should be." CONCLUSION: Professional organizations representing pharmacy have made significant strides in advocating for pharmacists' provision of advanced patient care. If pharmacists are to successfully provide advanced patient care a more specific and practically-oriented understanding that accounts for individual and environmental factors of how to achieve individual-level success is needed.

Pay-for-performance remuneration for pharmacist prescribers' management of hypertension: A substudy of the RxACTION trial.

BACKGROUND: To be sustainable, pharmacists providing direct patient care must receive appropriate payment for these services. This prespecified substudy of the RxACTION trial (a randomized trial of pharmacist prescribing vs usual care in patients with above-target blood pressure [BP]) aimed to determine if BP reduction achieved differed between patients whose pharmacist was paid by pay-for-performance (P4P) vs fee-for-service (FFS). METHODS: Within RxACTION, patients with elevated BP assigned to the pharmacist prescribing group were further randomized to P4P or FFS payment for the pharmacist. In FFS, pharmacists received $150 for the initial visit and $75 for follow-up visits. P4P included FFS payments plus incentives of $125 and $250 for each patient who reached 50% and 100% of the BP target, respectively. The primary outcome was difference in change in systolic BP between P4P and FFS groups. RESULTS: A total of 89 patients were randomized to P4P and 92 to the FFS group. Patients' average (SD) age was 63.0 (13.2) years, 49% were male and 76% were on antihypertensive drug therapy at baseline, taking a median of 2 (interquartile range = 1) medications. Mean systolic BP reductions in the P4P and FFS groups were 19.7 (SD = 18.4) vs 17.0 (SD = 16.4) mmHg, respectively (p = 0.47 for the comparison of deltas and p = 0.29 after multivariate adjustment). CONCLUSIONS: This trial of pharmacist prescribing found substantial reductions in systolic BP among poorly controlled hypertensive individuals but with no appreciable difference when pharmacists were paid by P4P vs FFS.

A Qualitative Approach to Investigating Developmental Opportunities Among Leaders and Followers.

Objective. To understand and identify developmental opportunities by exploring students' evolving views of leadership, including the emergence of leadership and self-identification, among students considered to be leaders and those considered to be followers.Methods. An exploratory qualitative study using semi-structured interviews was conducted, investigating developmental differences among leaders and followers. Fourteen students/residents were selected to participate in interviews. Student responses were analyzed using qualitative thematic analysis.Results. In discissions, four themes surfaced: motivations for exploring and engaging in leadership, perceptions of ideal leaders and followers, the value of coalition building, and a leader's role in sustainability. Leader respondents indicated that a potential barrier to helping others develop was their difficulty in delegation. Further, stress on leaders may contribute to a self-serving perspective on their responsibilities to help others develop.Conclusion. In comparison to their leader counterparts, followers may require a more individualized approach to their development and may become more deeply attached to their responsibilities, giving them a greater desire to promote sustainability in an organization or endeavor. Schools of pharmacy should be poised to support faculty, advisors, mentors, and student leaders with the tools to identify and develop active followers who may not seek out traditional leadership experiences.

Pharmacists' self-perception of their professional role: insights into community pharmacy culture.

OBJECTIVE: To obtain an understanding of how community pharmacists self-describe their professional role, in order to begin understanding some of the assumptions underlying pharmacy culture. DESIGN: Cross-sectional qualitative study. SETTING: Edmonton, Canada, and surrounding area. PARTICIPANTS: 115 community pharmacists. INTERVENTION: Brief telephone interview. MAIN OUTCOMES MEASURE: Pharmacists' self-description/perception of their professional role and its relation to underlying assumptions of pharmacy culture. RESULTS: 100 pharmacists provided usable responses. The majority of pharmacists practiced in a community chain setting (76%) and within the city of Edmonton (81%). The median length of time in practice was 15 years. A total of 278 separate response items were obtained. Of these responses, 45% were categorized as product focused, 29% as patient centered, and 26% as ambiguous. The first response of 52 of the 100 pharmacists was a product-focused description of their role. Overall, in either their first or second response, 57% of the pharmacists used the term "dispensing" or dispensing-related terms to describe their professional role. CONCLUSION: The results of this study seem to suggest that community pharmacists who participated viewed themselves primarily as "dispensers of medication," not patient-centered practitioners. Sustainable pharmacy practice change will be possible only if the current culture aligns with change initiatives. Our findings may suggest that pharmacists' self-perception of what they do and, perhaps by extension, the culture of pharmacy itself, could be important barriers to implementing practice change initiatives. We need to better understand the culture of pharmacy to foster meaningful practice change.

Primary healthcare policy and vision for community pharmacy and pharmacists in the United States.

The United States (US) has a complex healthcare system with a mix of public, private, nonprofit, and for-profit insurers, healthcare institutions and organizations, and providers. Unlike other developed countries, there is not a single payer healthcare system or a national pharmaceutical benefits scheme/plan. Despite spending over USD 10,000 per capita in healthcare, the US is among the worst performers compared to other developed countries in outcomes including life expectancy at birth, infant mortality, safety during childbirth, and unmanaged chronic conditions (e.g., asthma, diabetes). Primary care is delivered by physicians and advanced practice providers (i.e., nurse practitioners and physician assistants) in a variety of settings including large health systems, federally qualified health centers or free clinics that provide care to the underserved, or specific facilities for veterans or American Indian and Alaska native peoples. Since 2010, primary care delivery has shifted toward providing patient-centered, coordinated, comprehensive care focused on providing proactive, rather than reactive, population health management, and on the quality, versus volume, of care. Community pharmacy comprises a mix of independently owned, chain, supermarket and mass merchant pharmacies. Community pharmacies provide services such as immunizations, medication therapy management, medication packaging, medication synchronization, point-of-care testing and, in specific states where legislation has been passed, hormonal contraception, opioid reversal agents, and smoking cessation services. There has been criticism regarding the lack of standard terminology for services such as medication synchronization and medication therapy management, their components and how they should be provided, which hampers comparability across studies. One of the main challenges for pharmacists in the US is the lack of provider status at the federal level. This means that pharmacists are not allowed to use existing fee-for-service health insurance billing codes to receive reimbursement for non-dispensing services. In addition, despite there being regulatory infrastructure in multiple states, the extent of service implementation is either low or unknown. Research found that pharmacists face numerous barriers when providing some of these services. State fragmentation and the lack of a single pharmacy organization and vision for the profession are additional challenges.

Influence of the Fear of Missing Out in Student Pharmacists' Decision to Pursue Residency Training.

Objective. To examine the influence of the fear of missing out (FOMO) on student pharmacists' postgraduate career decisions, specifically on whether to pursue a residency. Methods. A 14-item FOMO scale was designed to examine the influence of this factor on student pharmacists' residency decision. A survey was distributed to second-, third-, and fourth-year student pharmacists at four participating universities. Average FOMO scores were compared based on residency intentions. Logistic regression analysis was used to predict residency intentions based on students' average FOMO scores. Results. The survey response rate was 74%. Of the 833 respondents, 42% indicated an intention to pursue residency training. Students indicated the FOMO items were "slightly" true of them, as evidenced by the overall FOMO mean score of 2.0 on a 5-point scale. Comparison among classes revealed a higher mean FOMO score among students in the second year of the pharmacy curriculum than among students in the third and fourth years. Logistic regression analysis indicated that FOMO score can reliably distinguish between students with residency intentions and those without. Conclusion. This study supports the existence of FOMO in the decision to pursue a pharmacy residency, although more research and scale refinement is needed to better identify its impact.

The Professional Culture of Community Pharmacy and the Provision of MTM Services.

The integration of advanced pharmacy services into community pharmacy practice is not complete. According to implementation research understanding professional culture, as a part of context, may provide insights for accelerating this process. There are three objectives in this study. The first objective of this study was to validate an adapted version of an organizational culture measure in a sample of United States' (US) community pharmacists. The second objective was to examine potential relationships between the cultural factors identified using the validated instrument and a number of socialization and education variables. The third objective was to examine any relationships between the scores on the identified cultural factors and the provision of MTM services. This study was a cross-sectional online survey for community pharmacists in the southeastern US. The survey contained questions on socialization/education, respondents' self-reported provision of medication therapy management (MTM) services, and the organizational culture profile (OCP). Analyses included descriptive statistics, a principle components analysis (PCA), independent samples t-test, and multivariate ordinal regression. A total of 303 surveys were completed. The PCA revealed a six-factor structure: social responsibility, innovation, people orientation, competitiveness, attention to detail, and reward orientation. Further analysis revealed significant relationships between social responsibility and years in practice, and people orientation and attention to detail and pharmacists' training and practice setting. Significant positive relationships were observed between social responsibility, innovation, and competitiveness and the increased provision of MTM services. The significant relationships identified between the OCP factors and community pharmacist respondents' provision of MTM services provides an important starting point for developing interventions to improve the uptake of practice change opportunities.

Clinical outcomes and satisfaction with a pharmacist-managed travel clinic in Alberta, Canada.

BACKGROUND: In Alberta, Canada, authorized pharmacists may prescribe medications and vaccines and administer injections. Some have implemented travel clinics to meet the growing demand for pre-travel consultations. As a new service, the outcomes of independent pharmacist-performed pre-travel consultations is unknown. METHODS: Chart review and post-travel surveys were performed among a convenience sample of patients presenting to a pharmacist-managed travel clinic for consultation. Data collected included patients' travel plans, recommendations for vaccines and other prescription and non-prescription drugs and adherence to these recommendations, satisfaction with the service, and health issues experienced during travel. RESULTS: 103 patients participated in the study. The overwhelming majority (79%) of recommended vaccinations were administered in clinic. The post-travel questionnaire was completed by 76% of patients, with 94% of these reporting being satisfied or very satisfied with the care received. Health issues during travel were infrequent, with gastrointestinal illness most common. Of those patients who experienced any health issue during their trip, 93% felt adequately prepared to manage the condition. CONCLUSIONS: This study reports positive patient satisfaction and health status while travelling following a pharmacist-performed pre-travel consultation including authorization to prescribe and to administer vaccines. These results support the continued expansion of pharmacists' scope in this area.

Pharmacists' perceptions of pay for performance versus fee-for-service remuneration for the management of hypertension through pharmacist prescribing.

OBJECTIVES: As pharmacists expand their roles as patient care providers, remuneration must be offered for patient care activities apart from dispensing. Most jurisdictions paying for such services utilize the fee-for-service (FFS) model, while little is known about the role of pay for performance (P4P) within the pharmacy profession. This study aimed to elicit the experience of pharmacists practicing under both models within the Alberta Clinical Trial in Optimizing Hypertension (RxACTION) study in Alberta, Canada. METHODS: Pharmacist participants in RxACTION caring for at least one patient under FFS and under P4P were interviewed about their experiences until data saturation was reached. Interviews were conducted in June-July 2015, with responses audio recorded, transcribed and coded to identify key themes. KEY FINDINGS: Eight pharmacists were interviewed, with three key themes identified: a perceived comfort with the existing FFS model particularly due to its ease related to business planning, the transformative effect of the study on their practices and a preference for future models to consider a blend of both service count- and performance-driven metrics. The degree of influence pharmacists feel they can have on outcomes achieved by patients, the perceptions of patients and other healthcare professionals on outcome-based payment, and concerns with the impact of variable remuneration on the pharmacy business model are concerns raised with P4P in pharmacy practice. CONCLUSIONS: This study reveals a hesitation to radically transform payment for pharmacists' patient care services towards a P4P model. Efforts to implement P4P should therefore be gradual and accompanied with a robust evaluation plan.

A randomized controlled study of practice facilitation to improve the provision of medication management services in Alberta community pharmacies.

BACKGROUND: The provision of medication management (MM) services by community pharmacists has not been as widely implemented as expected. The Promoting Action on Research Implementation in Health Services framework proposes that in addition to evidence of benefit and a practice context conducive to change, health professionals benefit from facilitation to support their efforts. However, the impact of facilitation on patient care services in community pharmacy has not been studied. OBJECTIVE: The primary objective of this study was to explore the needs of community pharmacists in improving the provision of MM services to patients, and secondarily to use external facilitation to support pharmacies in increasing the number of MM services provided. METHODS: Ten community pharmacies in Alberta, Canada were randomized to external task-focused facilitation or usual practice. Facilitators interviewed staff of each intervention pharmacy to determine current workflow and barriers and facilitators to service provision, and collaborated to address these site-specific barriers over 6 months. RESULTS: Barriers identified by all intervention sites related to the impact of MM on dispensing, lengthy documentation, inefficient use of follow-up opportunities to address lower-priority concerns, and inconsistent patient identification. Strategies to address these barriers were generally well received by sites, which noted that facilitation improved staff communication and encouraged reflection on current practices; however, MM counts across both groups decreased over the intervention versus baseline. This decline was likely due to the unanticipated effect of the influenza vaccination season occurring concurrently with the intervention period. CONCLUSIONS: External facilitation appears to be a feasible and acceptable method to support community pharmacy provision of MM services. However, as the scope of pharmacists' practice increases, serious consideration of how, and when, these services can be consistently offered must be made. Relevant stakeholders should consider strategies to mitigate the barriers identified in this study when introducing new services or evaluating existing programs to ensure their uptake within existing workflow demands. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT02191111.

Why take the chance? A qualitative grounded theory study of nocturnal haemodialysis recipients who decline kidney transplantation.

OBJECTIVE: The objective of this study was to examine the factors that influence decision-making to forgo transplantation in favour of remaining on nocturnal haemodialysis (NHD). DESIGN: A grounded theory approach using in-depth telephone interviewing was used. SETTING: Participants were identified from 2 tertiary care renal programmes in Canada. PARTICIPANTS: The study participants were otherwise eligible patients with end-stage renal disease who have opted to remain off of the transplant list. A total of 7 eligible participants were interviewed. 5 were male. The mean age was 46 years. ANALYSIS: A constant comparative method of analysis was used to identify a core category and factors influencing the decision-making process. RESULTS: In this grounded theory study of people receiving NHD who refused kidney transplantation, the core category of 'why take a chance when things are going well?' was identified, along with 4 factors that influenced the decision including 'negative past experience', 'feeling well on NHD', 'gaining autonomy' and 'responsibility'. CONCLUSIONS: This study provides insight into patients' thought processes surrounding an important treatment decision. Such insights might help the renal team to better understand, and thereby respect, patient choice in a patient-centred care paradigm. Findings may also be useful in the development of education programmes addressing the specific concerns of this population of patients.

A cluster-randomized controlled knowledge translation feasibility study in Alberta community pharmacies using the PARiHS framework: study protocol.

BACKGROUND: Despite evidence of benefit for pharmacist involvement in chronic disease management, the provision of these services in community pharmacy has been suboptimal. The Promoting Action on Research Implementation in Health Services (PARiHS) framework suggests that for knowledge translation to be effective, there must be evidence of benefit, a context conducive to implementation, and facilitation to support uptake. We hypothesize that while the evidence and context components of this framework are satisfied, that uptake into practice has been insufficient because of a lack of facilitation. This protocol describes the rationale and methods of a feasibility study to test a facilitated pharmacy practice intervention based on the PARiHS framework, to assist community pharmacists in increasing the number of formal and documented medication management services completed for patients with diabetes, dyslipidemia, and hypertension. METHODS: A cluster-randomized before-after design will compare ten pharmacies from within a single organization, with the unit of randomization being the pharmacy. Pharmacies will be randomized to facilitated intervention based on the PARiHS framework or usual practice. The Alberta Context Tool will be used to establish the context of practice in each pharmacy. Pharmacies randomized to the intervention will receive task-focused facilitation from an external facilitator, with the goal of developing alternative team processes to allow the greater provision of medication management services for patients with diabetes, hypertension, and dyslipidemia. The primary outcome will be a process evaluation of the needs of community pharmacies to provide more clinical services, the acceptability and uptake of modifications made, and the willingness of pharmacies to participate. Secondary outcomes will include the change in the number of formal and documented medication management services in the aforementioned chronic conditions provided 6 months before, versus after, the intervention between the two groups, and identification of feasible quantitative outcomes for evaluating the effect of the intervention on patient care outcomes. RESULTS: To date, the study has identified and enrolled the ten pharmacies required and initiated the intervention process. CONCLUSION: This study will be the first to examine the role of facilitation in pharmacy practice, with the goal of scalable and sustainable practice change. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT02191111.

Are pharmacists ready for a greater role in travel health? An evaluation of the knowledge and confidence in providing travel health advice of pharmacists practicing in a community pharmacy chain in Alberta, Canada.

BACKGROUND: Patients often consult community pharmacists for medication needs related to travel, but little is known of pharmacists' knowledge and readiness to provide this care. The aim of this study was to evaluate pharmacists' knowledge in travel health, and to assess their confidence in providing travel-related advice to patients. METHODS: A web-based survey was developed and distributed to 84 pharmacists practicing in a mid-size pharmacy chain in Alberta, Canada. The survey included knowledge and confidence assessment components. To assess knowledge, pharmacists were provided two cases, along with multiple-choice questions examining pre-travel risk assessment, and advice on travel at altitude, vaccines, malaria, travelers' diarrhea, and other potential travel health risks. Confidence was assessed by asking respondents to report their level of confidence in answering each knowledge assessment question and providing travel advice overall, using a 5-point Likert scale. Respondents were also asked to indicate preferred means for receiving additional training in travel health. RESULTS: A total of 53 pharmacists responded to the survey, with a response rate of 63%. Most (61%) indicated that they had some level of training in travel health and 69% counseled on travel health more than once a month. Only one respondent correctly answered all six questions in the knowledge assessment section. The mean knowledge score (proportion of correct answers, unaided) for the group was 27%. However, the majority (66%) felt confident that they would know where to seek the information required to answer the questions. Overall confidence in this group of pharmacists was determined to be low, with only 21% of respondents reporting that they felt highly confident in providing travel health advice. CONCLUSIONS: Travel health is becoming an increasingly common topic of discussion between patients and pharmacists. This study suggests that pharmacists' baseline knowledge of travel health may be incomplete, affecting their confidence in providing this advice. Undergraduate and continuing education training programs must expand travel health curricula to meet this growing need.