Cognitive apprenticeship in health sciences education: a qualitative review.

Cognitive apprenticeship theory emphasizes the process of making expert thinking "visible" to students and fostering the cognitive and meta-cognitive processes required for expertise. The purpose of this review was to evaluate the use of cognitive apprenticeship theory with the primary aim of understanding how and to what extent the theory has been applied to the design, implementation, and analysis of education in the health sciences. The initial search yielded 149 articles, with 45 excluded because they contained the term "cognitive apprenticeship" only in reference list. The remaining 104 articles were categorized using a theory talk coding scheme. An in depth qualitative synthesis and review was conducted for the 26 articles falling into the major theory talk category. Application of cognitive apprenticeship theory tended to focus on the methods dimension (e.g., coaching, mentoring, scaffolding), with some consideration for the content and sociology dimensions. Cognitive apprenticeship was applied in various disciplines (e.g., nursing, medicine, veterinary) and educational settings (e.g., clinical, simulations, online). Health sciences education researchers often used cognitive apprenticeship to inform instructional design and instrument development. Major recommendations from the literature included consideration for contextual influences, providing faculty development, and expanding application of the theory to improve instructional design and student outcomes. This body of research provides critical insight into cognitive apprenticeship theory and extends our understanding of how to develop expert thinking in health sciences students. New research directions should apply the theory into additional aspects of health sciences educational research, such as classroom learning and interprofessional education.

Student experiences across multiple flipped courses in a single curriculum.

CONTEXT: The flipped classroom approach has garnered significant attention in health professions education, which has resulted in calls for curriculum-wide implementations of the model. However, research to support the development of evidence-based guidelines for large-scale flipped classroom implementations is lacking. OBJECTIVES: This study was designed to examine how students experience the flipped classroom model of learning in multiple courses within a single curriculum, as well as to identify specific elements of flipped learning that students perceive as beneficial or challenging. METHODS: A qualitative analysis of students' comments (n = 6010) from mid-course and end-of-course evaluations of 10 flipped courses (in 2012-2014) was conducted. Common and recurring themes were identified through systematic iterative coding and sorting using the constant comparison method. Multiple coders, agreement through consensus and member checking were utilised to ensure the trustworthiness of findings. RESULTS: Several themes emerged from the analysis: (i) the perceived advantages of flipped learning coupled with concerns about implementation; (ii) the benefits of pre-class learning and factors that negatively affect these benefits, such as quality and quantity of learning materials, as well as overall increase in workload, especially in the context of multiple concurrent flipped courses; (iii) the role of the instructor in the flipped learning environment, particularly in engaging students in active learning and ensuring instructional alignment, and (iv) the need for assessments that emphasise the application of knowledge and critical thinking skills. CONCLUSIONS: Analysis of data from 10 flipped courses provided insight into common patterns of student learning experiences specific to the flipped learning model within a single curriculum. The study points to the challenges associated with scaling the implementation of the flipped classroom across multiple courses. Several core elements critical to the effective design and implementation of the flipped classroom model are identified.

Prevalent but moderate variation across small geographic regions in patient nonadherence to evidence-based preventive therapies in older adults after acute myocardial infarction.

BACKGROUND: Patient long-term adherence to ß-blockers, HMG-CoA reductase inhibitors (statins), and angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) after acute myocardial infarction (AMI) is alarmingly low. It is unclear how prevalent patient adherence may be across small geographic areas and whether this geographic prevalence may vary. METHODS: This is a retrospective cohort study using Medicare service claims files from 2007 to 2009 with Medicare beneficiaries 65 years and above who were alive 30 days after the index AMI hospitalization between January 1, 2008 and December 31, 2008 (N=85,017). The adjusted proportions of patients adherent to ß-blockers, statins, and ACEIs/ARBs, respectively, in the 12 months after discharge across the 306 Hospital Referral Regions (HRRs) were measured and compared by control chart. The intracluster correlation coefficient (ICC) and the additional prediction power from this small-area variation on individual patient adherence were assessed. RESULTS: The adjusted proportion of patients adherent across HRRs ranged from 58% to 74% (median, 66%) for ß-blockers, from 57% to 67% (median, 63%) for ACEIs/ARBs, and from 58% to 73% (median, 66%) for statins. The ICC was 0.053 (95% CI, 0.043-0.064) for ß-blockers, 0.050 (95% CI, 0.039-0.061) for ACEIs/ARBs, and 0.041 (95% CI, 0.031-0.052) for statins. The adjusted proportion of patients adherent across HRRs increased the c-statistic by 0.01-0.02 (P < 0.0001). CONCLUSIONS: Nonadherence to evidence-based preventive therapies post-AMI among older adults was prevalent across small geographic regions. Moderate small-area variation in patient adherence exists.

Enhancing Quality in Psychiatry with Psychiatrists (EQUIPP)--results from a pilot study.

OBJECTIVES: To pilot a pharmacist-led, patient centered medication management program. DESIGN: Prospective, single arm trial. SETTING: Academic geriatric psychiatry outpatient clinic. PARTICIPANTS: Outpatients at least 65 years old, proxy available if demented, and on two or more psychiatric medications. INTERVENTION: A clinical pharmacist completed a baseline medication review and made evidence-based recommendations that were implemented by the pharmacist after discussion with the physician. The pharmacist made a minimum of monthly contact for 6 months to review medications and related issues. MEASUREMENTS: The primary outcome was the change in number of medication related problems over time (3 and 6 months) as defined by a predetermined classification system. RESULTS: The mean age of the 27 patients was 75 years, 10 of whom required a proxy to participate. On average, patients had nine chronic conditions and were taking 14 medications. The mean number (SD; range) of medication related problems at baseline was 4.1 (2.2; 0-8) and at 3 and 6 months were 3.6 (2.4, 0-9) and 3.4 (2.1; 0-8), respectively. Most follow-up problems were new (80% and 89% at 3 and 6 months, respectively). CONCLUSION: Using a pharmacist to deliver a medication management program was feasible and addressed existing problems. New problems, however, developed over a short interval (3-6 months), suggesting that ongoing intervention is required.

Patterns of medication adherence and health care utilization among patients with chronic disease who were enrolled in a pharmacy assistance program.

BACKGROUND: Poor medication adherence due to high drug costs is a barrier to optimal health outcomes among low-income uninsured patients with chronic conditions. Charitable pharmacy assistance programs provide medications to such patients, but little is known about the utilization patterns of program participants. METHODS: We used a retrospective cohort design to investigate 6-month outcomes for participants in the University of North Carolina (UNC) Health Care Pharmacy Assistance Program (PAP) who received medications indicated for hypertension, diabetes, and/or hyperlipidemia from 2009 through 2011. Logistic regression was used to analyze predictors of medication adherence and to evaluate the association between adherence and use of emergency and inpatient care. RESULTS: The 3 study cohorts included 866 patients receiving antihypertensive agents, 265 patients receiving oral glucose-lowering agents, and 455 patients receiving statins. When assessed 6 months after program enrollment, 52%, 45%, and 38% of patients in these 3 groups, respectively, were at least 80% adherent to treatment. Adherent patients in all cohorts had lower odds of requiring inpatient or emergency department care, but the decrease was only statistically significant among those taking antihypertensive agents (odds ratio for hospitalization = 0.58; 95% confidence interval, 0.39-0.87). LIMITATIONS: Selection bias and inability to capture utilization data from sources other than UNC Health Care may have biased results. CONCLUSION: Approximately 50% of PAP participants were adherent to chronic disease medications. Adherence to such therapies among patients who are receiving financial assistance with medications may reduce their need for costly health care services. Future research should assess the long-term ability of pharmacy assistance programs to promote medication adherence and should examine alternative strategies for improving adherence and health outcomes among low-income uninsured patients.

The University of North Carolina's Health Care Pharmacy Assistance Progam.

BACKGROUND: UNC Health Care has a Pharmacy Assistance Program (PAP) that provides financial assistance to uninsured patients in North Carolina who need prescription medications. Despite significant investment in the program, little is known about the patients accessing it or the specific health care services they use. Our objectives were to describe the PAP population, to examine their use of prescription medications and health services, and to characterize changes in prescription medication use and expenditures from 2009 through 2011. METHODS: We used a repeated cross-sectional study design, merging prescription claims with health records from Carolina Data Warehouse for Health, to measure use of prescription medications and use of inpatient, outpatient, and emergency department care by PAP participants. Prescription claims were grouped into therapeutic categories. We generated descriptive statistics for key variables to examine health service utilization from 2009 through 2011. RESULTS: From 2009 through 2011, PAP served 7,180 patients from 81 counties in North Carolina. PAP users received a mean of 23 prescriptions, at an average cost of $754 per recipient per year. An average of $2.93 million per year was spent on the program, with an 8% rise in spending from 2009 to 2011. Inpatient care and emergency department care were utilized by 30% and 31% of PAP users, respectively, and there was minimal change in these rates over 3 years. LIMITATIONS: Data were limited to medications dispensed through PAP and to health services provided by UNC Health Care. CONCLUSIONS: With the state's decision to not expand Medicaid, PAP will continue to be an important resource for North Carolina's low income citizens.

A renaissance in pharmacy education at the University of North Carolina at Chapel Hill.

The UNC Eshelman School of Pharmacy is transforming its doctor of pharmacy program to emphasize active engagement of students in the classroom, foster scientific inquiry and innovation, and immerse students in patient care early in their education. The admissions process is also being reengineered.

Completeness of prescription information in US commercial claims databases.

PURPOSE: Pharmacy commercial claims databases are widely used for pharmacoepidemiologic research. However, concerns have been raised that these databases may not fully capture claims for generic medications as a result of patients filling outside the context of their insurance. This has implications for many research activities and quality improvement programs. We sought to estimate the percentage of missing prescriptions in US commercial claims data using a novel design. METHODS: Using a large US commercial insurance database, we examined the completeness of warfarin prescription claims among patients with atrial fibrillation receiving regular medical follow-up and testing to manage warfarin dosing. We examined 14 different 6-month cross sections. Each cross section was treated independently to identify patients with at least two outpatient diagnoses of atrial fibrillation, two international normalized ratio tests, and one pharmacy claim. Trends in the percentage of patients with prescription claims for generic and branded warfarin were compared by year and 6-month periods using chi-square tests and generalized linear models adjusting for patient characteristics. RESULTS: Out of 111 170 patients, the percentage of patients with any warfarin drug decreased slightly from 91.7% (95% CI: 91.0, 92.4) in early 2003 to 87.1% (95% CI: 86.7-87.6) in late 2009 (χ(2) = 93.8, p < 0.0001). Over the same interval, the proportion of patients with generic warfarin exposure appearing increased significantly, whereas the proportion of patients with branded warfarin exposure decreased significantly. CONCLUSIONS: Our study supports the possibility that some prescriptions may not be captured in US commercial insurance databases.

Performance of Medometer visual tool for measuring medication adherence and comparison with other measures.

OBJECTIVES: To measure adherence in older adults with the use of a novel visual scale screening tool and to compare this adherence measurement with other adherence measures. DESIGN: Noncontrolled prospective intervention trial. SETTING: Geriatric psychiatry clinic in North Carolina between February 2008 and July 2009. PARTICIPANTS: 27 geriatric psychiatry clinic patients were identified as meeting eligibility criteria, and 26 of these participants completed the baseline and 3- and 6-month visits. INTERVENTION: Pharmacist-provided medication management program. MAIN OUTCOME MEASURES: A novel visual scale, the Medometer, assessed patient adherence to individual medications and aggregate medication regimen. The Medometer was compared with pharmacist subjective adherence assessment and the four-item Morisky scale. RESULTS: Aggregate regimen adherence based on the Morisky scale was 44%, 50%, and 38% at baseline, 3 months, and 6 months, respectively. Similarly it was 48%, 50%, and 46%, respectively, for the aggregate Medometer measurement. Measured individually by drug, average adherence at baseline, 3 months, and 6 months was 44%, 50%, and 35%, respectively, with the Medometer and 74%, 65%, and 50%, respectively, for the pharmacist's subjective assessment. Less stringent definitions for categorizing adherence identified a higher proportion of patients as adherent, with similar trends across measures. Individual medication and aggregate regimen adherence estimates provided face validity for the Medometer, with moderate agreement with other measures. CONCLUSION: The Medometer is a visual scale that can assess individual medication and overall medication regimen adherence. It performed well in this pilot study, but additional research is needed to assess the reliability and validity of this tool in larger, diverse populations and to test the effectiveness of this tool in guiding pharmacists' efforts to improve medication outcomes.

Racial disparities in the quality of medication use in older adults: baseline findings from a longitudinal study.

BACKGROUND: Medication-related problems are prevalent in older adults and adversely affect the quality of care. It has been suggested that racial differences exist in medication use. Most efforts to evaluate the quality of medication use target specific drugs or disease states, or a set of pre-defined quality indicators, rather than the patient. OBJECTIVE: We conducted a prospective cohort study to determine the prevalence and types of medication-related problems in older adults, examining the impact of race on quality medication use. METHODS: In-home interviews and medical record reviews of 200 (100 white, 100 black) older adults were conducted three times over 1 year. The quality of medication use was measured using a clinical pharmacist's assessment of quality and the Assessing Care of Vulnerable Elders quality indicators. We used logistic and negative binomial regression models to analyze the two primary endpoints of prevalence and number of medication-related problems. RESULTS: Mean age was 78.3 (whites) and 75.5 (blacks), with the majority being female. Although whites used more medications than blacks (11.6 versus 9.7; p < 0.01), blacks had more medication-related problems per person than whites (6.2 versus 4.9; p < 0.01). All patients had at least one medication-related problem; undertreatment, suboptimal drug, suboptimal dosing, and nonadherence were most prevalent. Blacks had significantly higher rates of nonadherence than whites (68% versus 42%; p < 0.01). CONCLUSION: Medication-related problems are prevalent in community-residing older adults. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in quality medication use.

Characteristics of High-Performing Interprofessional Health Care Teams Involving Student Pharmacists.

Objective. To identify key themes of interprofessional models of care that offer experiential education opportunities for pharmacy learners. Methods. Six pharmacists from four Area Health Education Centers in North Carolina participated in individual, 60-minute interviews. Using two pre-established frameworks, the data were analyzed qualitatively by two members of the research team to identify the characteristics of interdisciplinary care teams. Results. At the level of the organization or health care system, the theme of appropriate resources and procedures emerged. At the level of the team, the themes of appropriate resources and procedures, communication, appropriate skill mix, climate, quality and outcomes of care, and respecting and understanding roles emerged. At the level of the individual, the themes of communication, respecting and understanding roles, and individual characteristics emerged. Three themes identified in a previous study failed to emerge in the interviews: leadership and management; personal rewards, training and development; and clarity of vision. Conclusion. Although a growing body of evidence highlights the importance of designing practice models to achieve interdisciplinary care that is patient-centered and effective, capacity to support learners and effectively educate them in the principles and practices of team-based care is limited. This study provides critical insight into characterizations of interprofessional models that integrate pharmacy learners. Further research is needed to better understand the barriers to designing and implementing IPE in experiential settings.

Methodology of an ongoing, randomized controlled trial to prevent falls through enhanced pharmaceutical care.

BACKGROUND: Falls are the leading cause of both fatal and nonfatal injuries among adults aged > or =65 years in the United States. Past research suggests that individuals taking multiple medications are at increased risk of falls. Central nervous system-active drugs in particular have been associated with increased risk. OBJECTIVE: The goal of this research was to describe the design of a study evaluating the effectiveness of a community pharmacy-based falls prevention program. Also presented are the algorithms used to identify high-risk patients based on their prescription profile records and to deliver the experimental intervention. METHODS: The study is a randomized controlled trial. The target population was community-dwelling older adults (aged > or =65 years) at high risk for future falls because: (1) they had experienced > or =1 fall within the 12-month period preceding study enrollment; (2) they were currently using > or =4 chronic prescription medications; and (3) they were taking > or =1 of the high-risk medications targeted by the intervention. Participants were recruited using pharmacy prescription profile records. Individuals in the intervention group received a face-to-face medication consultation provided by a community pharmacy resident. Identification of drug therapy problems and therapeutic recommendations was guided by a series of algorithms developed for this study. All participants were followed up for 24 months. The primary study end points were: (1) time to first fall; and (2) proportion of participants who experienced > or =1 fall during the first year of follow-up. RESULTS: Participant enrollment began in September 2005 and was completed in August 2007. A total of 186 individuals were enrolled in the study (mean [SD] age, 74.8 [6.9] years; 132 women, 54 men), and 67 have completed the first year of follow-up. CONCLUSIONS: The study is using a rigorous randomized controlled research design, which will enhance the internal validity of its findings. Results of the study, which will be reported after the completion of follow-up data collection activities, will enable us to assess the effects of the intervention on both medication use and the incidence of falls. If the intervention is found to be effective, it will provide a resource for community pharmacists working with older adults at high risk of medication-related falls.

The quality of medication use in older adults: methods of a longitudinal study.

BACKGROUND: The quality of medication use in older adults is a recurring problem of substantial concern. Efforts to both measure and improve the quality of medication use often define quality too narrowly and fall short of addressing the complexity of an older adult's medication regimen. OBJECTIVES: In an effort to more comprehensively define the quality of medication use in older adults, we conducted a prospective cohort study to: (1) describe the quality of medication use in community-dwelling older adults at baseline, examining differences between whites and blacks; (2) examine the effect of race on medication-related problems; and (3) assess the change in quality medication use between whites and blacks over time. This paper presents the research design and methods of this longitudinal study. METHODS: We interviewed white and black community-dwelling older adults (aged > or =60 years) 3 times over 1 year (baseline, 6, and 12 months). We oversampled blacks so that we could estimate racial differences in the quality of medication use. We collected information on the quality of medication use, relying on a clinical pharmacist's assessment of quality and the Assessing Care of Vulnerable Elders quality indicators. We also collected data on demographic characteristics, health literacy, functional status, and participant-reported drug therapy concerns. RESULTS: Four hundred thirty-five older adults were assessed for inclusion; 200 older adults (100 white, 100 black) were enrolled in the study and completed a baseline visit. Of the 200, 92% completed the 6-month visit (n = 183) and 88% completed the 12-month visit (n = 176). We present baseline demographic characteristics for the 200 older adults enrolled in the study. CONCLUSION: This longitudinal study is an initial step toward developing more comprehensive, patient-centered measures and interventions to address the quality of medication use in older adults.

Identifying the Presence of Cognitive Apprenticeship in the Layered Learning Practice Model.

Objective. To identify the presence of cognitive apprenticeship themes in the layered learning practice model (LLPM). Methods. Attending pharmacists who had implemented an LLPM completed an individual 90-minute face-to-face semi-structured interview. Three researchers independently reviewed transcripts to identify cognitive apprenticeship themes according to the framework's dimensions and sub-dimensions. Results. Of 25 eligible attending pharmacists, 24 (96%) agreed to participate. All core dimensions of the cognitive apprenticeship framework emerged during the interviews; however, preceptors varied in how they used the framework in the training of pharmacy learners at different levels. This variability was especially apparent within the sub-dimensions of the content and method domains. Conclusion. This study demonstrates that all four cognitive apprenticeship principles are being used in the clinical environments operationalizing the LLPM. These findings suggest that cognitive apprenticeship is an applicable and relevant educational framework when engaging multiple learners in clinical education environments.

Geographic Information System mapping as a tool to assess nonresponse bias in survey research.

BACKGROUND: Surveys are a useful tool for assessing professional practice patterns, although declining response rates have caused concern over external validity. This is particularly relevant to Web-based surveys, where response rates traditionally have been lower than with paper mail surveys. In a 2005 survey of North Carolina community pharmacy managers using a Web-based data collection instrument, we achieved an overall response rate of 23%. OBJECTIVE: To explore nonresponse bias using accepted methods and to test whether Geographic Information System mapping is a useful tool for assessing response bias. METHODS: Cross-sectional survey of 1593 community pharmacy managers in North Carolina using a Web-based tool. Nonresponse bias was assessed quantitatively by comparing early responders with late responders (ie, wave analysis) and by comparing respondents with nonrespondents with regard to known pharmacy, pharmacist, and population characteristics. Significant variables from these analyses were then mapped using ArcGIS 9.1. RESULTS: Pharmacy type was identified as a predictor of response, with independent pharmacies less likely to respond than chain pharmacies (odds ratio 0.75; 95% confidence interval 0.59-0.95). This conclusion was consistent in the wave analysis and the analysis of known population characteristics. Other county-level variables such as the number of physicians per capita, income, and the percentage of residents eligible for Medicaid showed trends but were not statistically significant (P<.1). Geographic Information System mapping was able to descriptively illustrate nonresponse bias for pharmacy type but trends were more difficult to detect for statistically insignificant trends. CONCLUSION: The best way to avoid nonresponse bias is to improve response rates. When this is not possible, Geographic Information System mapping has some utility for assessing nonresponse bias, and for aggregating known population characteristics based on location. It is most useful in conjunction with other accepted techniques such as wave analysis and analysis of known population characteristics.

Exploring the Requisite Skills and Competencies of Pharmacists Needed for Success in an Evolving Health Care Environment.

Objective. To identify and describe the core competencies and skills considered essential for success of pharmacists in today's rapidly evolving health care environment. Methods. Six breakout groups of 15-20 preceptors, pharmacists, and partners engaged in a facilitated discussion about the qualities and characteristics relevant to the success of a pharmacy graduate. Data were analyzed using qualitative methods. Peer-debriefing, multiple coders, and member-checking were used to promote trustworthiness of findings. Results. Eight overarching themes were identified: critical thinking and problem solving; collaboration across networks and leading by influence; agility and adaptability; initiative and entrepreneurialism; effective oral and written communication; accessing and analyzing information; curiosity and imagination; and self-awareness. Conclusion. This study is an important step toward understanding how to best prepare pharmacy students for the emerging health care needs of society.

Improved Organizational Outcomes Associated With Incorporation of Early Clinical Experiences for Second-Year Student Pharmacists at an Academic Medical Center.

PURPOSE: To assess the feasibility of engaging second professional year student pharmacists in the medication reconciliation process on hospital and health system pharmacy practice outcomes. METHODS: Student pharmacists in their second professional year in the Doctor of Pharmacy degree program at our institution were randomly selected from volunteers to participate. Each participant completed training prior to completing three 5-hour evening shifts. Organizational metrics, student pharmacist perception regarding quality of interactions with health care professionals, and pharmacist perceptions were collected. RESULTS: A total of 83 medication histories were performed on complex medical patients (57.0 ± 19.2 years, 51% female, 65% Caucasian, 12 ± 6 medications); of those, 93% were completed within 24 hours of hospital admission. Second professional student pharmacists completed on average 1.9 ± 0.6 medication histories per shift (range 1-3). Student pharmacists identified 0.9 medication-related problems per patient in collaboration with a pharmacist preceptor. Student pharmacists believed the quality of their interactions with health care professionals in the Student Medication and Reconciliation Team (SMART) program was good or excellent. The program has been well received by clinical pharmacists involved in its design and implementation. CONCLUSION: This study provides evidence that second professional year student pharmacists can assist pharmacy departments in the care of medically complex patients upon hospital admission.

The layered learning practice model: Lessons learned from implementation.

PURPOSE: Pharmacists' views about the implementation, benefits, and attributes of a layered learning practice model (LLPM) were examined. METHODS: Eligible and willing attending pharmacists at the same institution that had implemented an LLPM completed an individual, 90-minute, face-to-face interview using a structured interview guide developed by the interdisciplinary study team. Interviews were digitally recorded and transcribed verbatim without personal identifiers. Three researchers independently reviewed preliminary findings to reach consensus on emerging themes. In cases where thematic coding diverged, the researchers discussed their analyses until consensus was reached. RESULTS: Of 25 eligible attending pharmacists, 24 (96%) agreed to participate. The sample was drawn from both acute and ambulatory care practice settings and all clinical specialty areas. Attending pharmacists described several experiences implementing the LLPM and perceived benefits of the model. Attending pharmacists identified seven key attributes for hospital and health-system pharmacy departments that are needed to design and implement effective LLPMs: shared leadership, a systematic approach, good communication, flexibility for attending pharmacists, adequate resources, commitment, and evaluation. Participants also highlighted several potential challenges and obstacles for organizations to consider before implementing an LLPM. CONCLUSION: According to attending pharmacists involved in an LLPM, successful implementation of an LLPM required shared leadership, a systematic approach, communication, flexibility, resources, commitment, and a process for evaluation.

A Study of Layered Learning in Oncology.

Objective. To explore use of pharmacy learners as a means to expand pharmacy services in a layered learning practice model (LLPM), to examine whether an LLPM environment precludes achievement of knowledge-based learning objectives, and to explore learner perception of the experience. Design. An acute care oncology pharmacy practice experience was redesigned to support the LLPM. Specifically, the redesign focused on micro discussion, standardized feedback (eg, rubrics), and cooperative learning to enhance educational gain through performing clinical activities. Assessment. Posttest scores evaluating knowledge-based learning objectives increased in mean percentage compared to pretest values. Learners viewed the newly designed practice experience positively with respect to perceived knowledge attainment, improved clinical time management skills, contributions to patient care, and development of clinical and self-management skills. A fifth theme among students, comfort with learning, was also noted. Conclusion. Layered learning in an oncology practice experience was well-received by pharmacy learners. Data suggest a practice experience in the LLPM environment does not preclude achieving knowledge-based learning objectives and supports further studies of the LLPM.

Outcomes from an outpatient smoking-cessation clinic.

STUDY OBJECTIVES: To determine the success of an outpatient smoking-cessation clinic by assessing smoking abstinence rates and factors associated with lower abstinence rates. We also sought to determine whether smoking abstinence rates differed among various smoking-cessation products. METHODS: Patients were referred by primary care providers to a pharmacist-managed smoking-cessation clinic. Patients received tailored behavioral counseling, educational materials, and drug therapy consisting of sustained-release (SR) bupropion; nicotine patch, inhaler, or nasal spray; or combination therapy. Patients were monitored by phone or clinic visit for 6 months, if possible. Outcomes assessed were abstinence (both point prevalence and continuous abstinence) and adverse effects. Patients lost to follow-up were assumed to be smoking. RESULTS: Over 2 years, 198 patients were enrolled in the program. At the initial visit, 35.4% received the patch, 32.8% bupropion SR, 18.2% a combination of patch plus inhaler, 9.6% inhaler alone, and fewer than 5% other therapies. At 6 weeks, a statistically significant difference was observed in continuous abstinence rates between the nicotine patch versus bupropion SR groups (22.9% vs 7.7%, p=0.02) and between the combination patch-inhaler versus bupropion SR groups (25% vs 7.7%, p=0.02). However, this difference was not significant beyond the 6-week visit. A trend toward higher abstinence rates was noted at 6 weeks in the nicotine patch-inhaler versus the other treatment groups, possibly suggesting the need for more intense treatment regimens with combination therapy. Point prevalence abstinence rates after 12 weeks were 18.6%, 15.4%, 22.2% and 21.1% respectively, for the patch, bupropion SR, patchinhaler, and inhaler alone treatment groups. The corresponding continuous abstinence rates were 10.0%, 3.1%, 11.1%, and 10.5%. CONCLUSION: Although statistically significant differences between products were noted at 6 weeks, no sustained difference in smoking abstinence rates was observed between products. At 6 months, point prevalence and continuous abstinence rates were small, but the decline in success noted over time and the limited overall success rates are consistent with rates for the United States. Our findings suggest that when smokers are assisted in quitting, initial contact as well as follow-up evaluation and monitoring must be intense and sustained to increase the likelihood of successful abstinence. Tobacco dependence is clearly a chronic condition warranting repeated treatment and monitoring until continuous abstinence is achieved.