Healthcare Resource Utilization in Medicare Beneficiaries Obtaining Medication Synchronization.

BACKGROUND: An appointment-based medication synchronization (ABMS) is a service which aligns patients' chronic medications to a predetermined routine pickup date and includes a comprehensive medication review or other clinical appointment at the pharmacy. We compared healthcare utilization outcomes (outpatient, inpatient, emergency department visits, and pharmacy utilization) of Medicare beneficiaries enrolled in a med-sync program to beneficiaries not enrolled in such a program. METHODS: This retrospective cohort study included Medicare beneficiaries obtaining medications from pharmacies providing ABMS. All Medicare inpatient, outpatient, emergency, and pharmacy claims data from 2014 to 2016 obtained from the Research Data Assistance Center (ResDAC). These pharmacy claims were used to create medication-synchronized (med-sync) (n=13,193) and non-med-sync (n=156,987) cohorts. All patients were followed longitudinally for 12 months before and after a 2015 index/enrollment date. Baseline characteristics were utilized to create a logistic regression model for propensity score matching. A 1:1 greedy nearest neighbor matching algorithm was adapted for sequentially matching both cohorts. Difference-in-differences (DID) was used to compare mean changes in healthcare utilization outcomes (outpatient, inpatient, emergency department visits, and pharmacy utilization) between cohorts. RESULTS: After matching, 13,193 beneficiaries in each cohort were used for analysis. DID for mean of healthcare utilizations were significantly lower in the med-sync cohort compared to the non-med-sync cohort for outpatient visits (DID:0.012, p=0.0073) and pharmacy utilization (DID:0.013, p<0.0001). There was no significant DID for inpatient and emergency department visits between cohorts. CONCLUSION: Outpatient and pharmacy utilization changes were significantly lower in the med-sync cohort compared to the non-med-sync cohort in the 12-months after enrollment. Lower pharmacy utilization could be due to reducing duplicate prescriptions during synchronized refills or optimization of therapy during medication reviews if patients are enrolled in ABM med-sync.

Disparities in Medicare beneficiaries' receiving medication synchronization.

BACKGROUND: Medication synchronization (med-sync) aligns patients' monthly or quarterly chronic medications to a predetermined single pickup date at a community pharmacy. The study objective was to examine med-sync enrollment disparities based on Medicare beneficiaries' predisposing, enabling, and need characteristics. METHODS: This was a retrospective cohort study using a Medicare dataset of beneficiaries receiving medications from pharmacies that self-identified as providing med-sync. Medicare beneficiaries who were continuously enrolled in fee-for-service medical and pharmacy benefits during the study period (2014-2016) were included. Study cohorts (med-sync and non-med-sync patients) were defined, and bivariate and multivariable logistic regression analyses were performed. Andersen's Health Services Utilization Model guided our inclusion of predisposing, enabling, and need characteristics to examine for association with med-sync enrollment. RESULTS: A total of 170,180 beneficiaries were included, of which 13,193 comprised the med-sync cohort and 156,987 comprised the non-med-sync cohort. Bivariate logistic regression analysis revealed statistically significant differences (P < 0.05) in cohorts based on age, geographic region, type of residence, number of unique chronic medications, comorbidities, outpatient visits, and inpatient hospitalizations. Beneficiaries had higher odds of being enrolled in med-sync with increasing age (adjusted odds ratio [AOR] 1.003 [95% CI 1.001-1.005]) and if they resided in the Northeast (AOR 1.094 [95% CI 1.018-1.175]), South (AOR 1.109 [95% CI 1.035-1.188]), and West (AOR 1.113 [95% CI 1.020-1.215]) than those in the Midwest. Beneficiaries residing in nonmetro areas had lower odds of enrollment (AOR 0.914 [95% CI 0.863-0.969]) than those in metro areas. Beneficiaries with previous fewer inpatient hospitalizations (AOR 0.945 [95% CI 0.914-0.977]) were more likely to be enrolled, and those with more outpatient visits (AOR 1.003 [95% CI 1.001-1.004]) were more likely to be enrolled. Those taking a higher number of oral chronic medications (AOR 1.005 [95% CI 1.002-1.008]) had greater odds of enrollment in med-sync. CONCLUSIONS: Med-sync program expansion opportunities exist to address potential enrollment disparities based on age, geographic region, metropolitan area, and prior health utilization. Further studies are needed to develop and examine strategies among pharmacies to improve med-sync enrollment outreach to these subgroups of patients.

Evaluation of quality measure attainment with pharmacist-delivered Medicare annual wellness visits.

BACKGROUND: Medicare is required to fully cover annual wellness visits (AWVs) to increase access to preventive care. As health care converts to pay for performance models, clinical quality measures have increasing importance. Few studies have investigated the effect of pharmacist-delivered AWVs on clinical quality measure attainment in a rural family medicine (FM) clinic setting. OBJECTIVES: The primary objective of this study was to evaluate attainment of clinical quality measures for pharmacist-delivered AWVs compared with physician-delivered AWVs (usual care). Secondary objectives included assessment of the number and type of drug therapy problems (DTPs) identified by pharmacists during AWVs. METHODS: This single-center retrospective cohort study was conducted within an FM clinic located in southwest Georgia. Two cohorts were created according to the provider of AWVs during 2017: pharmacist or physician-usual care. Data on quality measure eligibility, attainment, and DTPs (for the pharmacist group only) were collected through electronic chart review. Descriptive statistics were used to characterize variables, and chi-square (or Fisher exact where appropriate) tests to compare the proportion of clinical quality measures attained between groups. RESULTS: Among 334 delivered AWVs, pharmacists performed 68.6%. Approximately 62% of pharmacist and usual care visits were female with mean ages of 72 (SD +/- 9.1) and 62 (SD +/- 13.9) years, respectively. Pharmacist-delivered AWVs had statistically significant greater quality measure attainment in the following categories: advance care planning, osteoporosis cardiovascular screenings, and Tdap vaccinations compared with usual care (P < 0.05). Usual care had statistically significant greater quality measure attainment for diabetes screening. Seventy-five DTPs were identified in the pharmacist group, with the majority being related to adherence (39%). CONCLUSION: Pharmacist-delivered AWVs had greater quality measure attainment in several areas than usual care. Furthermore, increased quality measure attainment may assist in meeting benchmarks set by payers to ensure ongoing reimbursement of these services.

Impact of pharmacist prescribing through direct pharmacy access policies on access to hormonal contraception.

BACKGROUND/OBJECTIVE: This study assesses the impact of direct pharmacy access (DPA) policies that allow pharmacists to prescribe hormonal contraceptives on women's access by comparing access among 3 groups: (1) women in a state without DPA (Indiana), (2) women in a state with DPA, but not using DPA, and (3) women in a state with DPA and using DPA. METHODS: This cross-sectional survey, including a scale to measure access to contraceptives, perception items, and demographics, was distributed through Amazon Mechanical Turk (Amazon.com, Inc). Kruskal-Wallis tests and linear regression analysis were used. RESULTS: The sample size was 316. When controlling for education, income, and age, the women not using DPA (in Indiana and a DPA state, respectively) reported significantly higher levels of approachability (P < 0.001 and P < 0.001, respectively), acceptability (P < 0.001 and P < 0.001, respectively), availability and accommodation (P < 0.001 and P = 0.009, respectively), affordability (P < 0.001 and P < 0.001, respectively), and appropriateness (P < 0.001 and P < 0.001) access than the women using DPA. The women using DPA reported significantly lower levels of privacy access than those not using DPA in a DPA state (P = 0.004) when controlling for education, income, and age. However, 78.9% of women using DPA agreed DPA made obtaining contraceptives easier. Most of the women who had never used DPA were previously unaware of DPA (81.1% in DPA states and 86.2% in Indiana) but felt that it would improve access (82.8% and 80.0%, respectively). CONCLUSION: Understanding the effects of DPA policies on women's access to contraceptives can inform future policies and support implementation. Lower levels of access across all dimensions among those using DPA may be influenced by imperfect implementation and failure to legislatively enable the sustainability of this service rather than pharmacists' ability to improve women's access.

Deintensification or No Statin Treatment Is Associated With Higher Mortality in Patients With Ischemic Stroke or Transient Ischemic Attack.

Background and Purpose: Practice guidelines recommend that most patients receive moderate- or high-potency statins after ischemic stroke or transient ischemic attack (TIA) of atherosclerotic origin. We tested the association of different patterns of potency for prescribed statin therapy­assessed before admission and at hospital discharge for ischemic stroke or TIA­on mortality in a large, nationwide sample of US Veterans. Methods: The study population included patients with an ischemic stroke or TIA occurring during 2011 at any of the 134 Veterans Health Administration facilities. We used electronic outpatient pharmacy files to identify statin dose at hospital admission and within 7 days after hospital discharge. We categorized statin dosing as low, moderate, or high potency; moderate or high potency was considered at goal. We created 6 mutually exclusive groups to reflect patterns of statin potency from hospital admission to discharge: goal to goal, low to goal, goal to low or goal to none (deintensification), none to none, none to low, and low to low. We used logistic regression to compare 30-day and 1-year mortality across statin potency groups. Results: The population included 9380 predominately White (71.1%) men (96.3%) who were hospitalized for stroke or TIA. In this sample, 34.1% of patients (n=3194) were discharged off a statin medication. Deintensification occurred in 14.0% of patients (n=1312) and none to none in 20.5% (n=1924). Deintensification and none to none were associated with a higher odds of mortality as compared with goal to goal (adjusted odds ratio 1-year mortality: deintensification versus goal to goal, 1.26 [95% CI, 1.02­1.57]; none to none versus goal to goal, 1.59 [95% CI, 1.30­1.93]). Adjustments for differences in baseline characteristics using propensity weighted scores demonstrated similar results. Conclusions: Underutilization of statins, including no treatment or underdosing after stroke (deintensification), was observed in approximately one-third of veterans with ischemic stroke or TIA and was associated with higher mortality when compared with patients who were at goal for statin prescription dosing.

Care Coordination Strategies and Barriers during Medication Safety Incidents: a Qualitative, Cognitive Task Analysis.

BACKGROUND: Medication errors are prevalent in healthcare institutions worldwide, often arising from difficulties in care coordination among primary care providers, specialists, and pharmacists. Greater knowledge about care coordination surrounding medication safety incidents can inform efforts to improve patient safety. OBJECTIVES: To identify strategies that hospital and outpatient healthcare professionals (HCPs) use, and barriers encountered, when they coordinate care during a medication safety incident involving an adverse drug reaction, drug-drug interaction, or drug-renal concern. DESIGN: We asked HCPs to complete a form whenever they encountered these incidents and intervened to prevent or mitigate patient harm. We stratified incidents across HCP roles and incident categories to conduct follow-up cognitive task analysis interviews with HCPs. PARTICIPANTS: We invited all physicians and pharmacists working in inpatient or outpatient care at a tertiary Veterans Affairs Medical Center. We examined 24 incidents: 12 from physicians and 12 from pharmacists, with a total of 8 incidents per category. APPROACH: Interviews were transcribed and analyzed via a two-stage inductive, qualitative analysis. In stage 1, we analyzed each incident to identify decision requirements. In stage 2, we analyzed results across incidents to identify emergent themes. KEY RESULTS: Most incidents (19, 79%) were from outpatient care. HCPs relied on four main strategies to coordinate care: cognitive decentering; collaborative decision-making; back-up behaviors; and contingency planning. HCPs encountered four main barriers: role ambiguity and constraints, breakdowns (e.g., delays) in care, challenges related to the electronic health record, and factors that increased coordination complexity. Each strategy and barrier occurred across all incident categories and HCP groups. Pharmacists went to extra effort to ensure safety plans were implemented. CONCLUSIONS: Similar strategies and barriers were evident across HCP groups and incident types. Strategies for enhancing patient safety may be strengthened by deliberate organizational support. Some barriers could be addressed by improving work systems.

Impact of Electronic Medication Reminder Caps on Patient Adherence and Blood Pressure.

Background: Medication adherence is widely recognized as an essential component of chronic disease management, yet only 50% of patients take their medication as prescribed. Newer technologies have the potential to improve medication adherence. Objective: To conduct a pilot study estimating the impact of a pharmacy-dispensed electronic reminder cap (SMARxT cap), which also records cap openings, on medication adherence and blood pressure (BP). Methods: After a 30-day run-in period, 28 individuals were randomized to receive a SMARxT or placebo cap on each BP medication. The primary outcome was adherence measured via (1) the medication possession ratio, (2) number of cap openings, and (3) self-report. The secondary outcome was the average of 2 BP readings at 6 months. Mean changes from baseline to 6 months were compared between the 2 groups. Results: The medication possession ratio increased 2.7% in the SMARxT cap group and decreased 1.1% in the control group (P = .13), and cap openings increased 11.9% in the SMARxT cap group and 9.9% in the control group (P = .83). Self-reported adherence increased 1.1 points in the SMARxT cap group and 0.8 points in the control group (P = .64). Systolic BP decreased 8.2 mm Hg in the SMARxT cap group and 2.8 mm Hg in the placebo cap group (P = .35), and diastolic BP decreased to 6.2 mm Hg in the SMARxT cap group and was unchanged in the placebo cap group (P = .06). Conclusions: Use of SMARxT cap showed nonsignificant improvement in medication adherence and BP lowering. This technology has potential to characterize and improve medication-taking behavior.

Nationwide estimates of medication therapy management delivery under the Medicare prescription drug benefit.

OBJECTIVE: To describe the national delivery of medication therapy management (MTM) to Medicare beneficiaries in 2013 and 2014. METHODS: Descriptive cross-sectional study using the 100% sample of 2013 and 2014 Part D MTM data files. We quantified descriptive statistics (counts and percentages, in addition to means and standard deviations) to summarize the delivery of these services and compare delivery between 2013 and 2014. RESULTS: Medicare beneficiaries eligible for MTM increased from 4,281,733 in 2013 to 4,552,547 in 2014. Among eligible beneficiaries, the number and percentage who were offered a comprehensive medication review (CMR) increased from 3,473,004 (81.1%) to 4,394,822 (96.5%), and beneficiaries receiving a CMR increased from 526,203 (12.3%) to 767,286 (16.9%). In 2014, CMRs were most frequently delivered by telephone (83.2%) and provided by either a plan sponsor (29.0%) or an MTM vendor in-house pharmacist (35.0%). In 2014, pharmacists provided 93.5% of all CMRs, and other providers (e.g., nurses and physicians) provided 6.5% of CMRs. Few patients who received a CMR received more than 1 within the same year (2.2% in 2014). Medication therapy problem (MTP) resolution among patients receiving a CMR stayed roughly the same between 2013 and 2014 (19.2% vs. 18.7%, respectively; P < 0.001). Finally, most beneficiaries (96.9% in 2014) received a targeted medication review, regardless of whether a CMR was offered or provided. CONCLUSION: More than 4 million Medicare beneficiaries were enrolled in Part D MTM in both 2013 and 2014. However, less than 20% of eligible beneficiaries received a CMR during those years, and rates of MTP resolution were low. Future evaluation of Part D MTM delivery should examine changes in eligibility criteria and delivery over time to inform MTM policy and changes in practice.

Utilizing a user-centered approach to develop and assess pharmacogenomic clinical decision support for thiopurine methyltransferase.

BACKGROUND: A pharmacogenomic clinical decision support tool (PGx-CDS) for thiopurine medications can help physicians incorporate pharmacogenomic results into prescribing decisions by providing up-to-date, real-time decision support. However, the PGx-CDS user interface may introduce errors and promote alert fatigue. The objective of this study was to develop and evaluate a prototype of a PGx-CDS user interface for thiopurine medications with user-centered design methods. METHODS: This study had two phases: In phase I, we conducted qualitative interviews to assess providers' information needs. Interview transcripts were analyzed through a combination of inductive and deductive qualitative analysis to develop design requirements for a PGx-CDS user interface. Using these requirements, we developed a user interface prototype and evaluated its usability (phase II). RESULTS: In total, 14 providers participated: 10 were interviewed in phase I, and seven providers completed usability testing in phase II (3 providers participated in both phases). Most (90%) participants were interested in PGx-CDS systems to help improve medication efficacy and patient safety. Interviews yielded 11 themes sorted into two main categories: 1) health care providers' views on PGx-CDS and 2) important design features for PGx-CDS. We organized these findings into guidance for PGx-CDS content and display. Usability testing of the PGx-CDS prototype showed high provider satisfaction. CONCLUSION: This is one of the first studies to utilize a user-centered design approach to develop and assess a PGx-CDS interface prototype for Thiopurine Methyltransferase (TPMT). This study provides guidance for the development of a PGx-CDS, and particularly for biomarkers such as TPMT.

Usability evaluation of a medication reconciliation tool: Embedding safety probes to assess users' detection of medication discrepancies.

OBJECTIVE: An electronic medication reconciliation tool was previously developed by another research team to aid provider-patient communication for medication reconciliation. To evaluate the usability of this tool, we integrated artificial safety probes into standard usability methods. The objective of this article is to describe this method of using safety probes, which enabled us to evaluate how well the tool supports users' detection of medication discrepancies. MATERIALS AND METHODS: We completed a mixed-method usability evaluation in a simulated setting with 30 participants: 20 healthcare professionals (HCPs) and 10 patients. We used factual scenarios but embedded three artificial safety probes: (1) a missing medication (i.e., omission); (2) an extraneous medication (i.e., commission); and (3) an inaccurate dose (i.e., dose discrepancy). We measured users' detection of each probe to estimate the probability that a HCP or patient would detect these discrepancies. Additionally, we recorded participants' detection of naturally occurring discrepancies. RESULTS: Each safety probe was detected by ≤50% of HCPs. Patients' detection rates were generally higher. Estimates indicate that a HCP and patient, together, would detect 44.8% of these medication discrepancies. Additionally, HCPs and patients detected 25 and 45 naturally-occurring discrepancies, respectively. DISCUSSION: Overall, detection of medication discrepancies was low. Findings indicate that more advanced interface designs are warranted. Future research is needed on how technologies can be designed to better aid HCPs' and patients' detection of medication discrepancies. CONCLUSION: This is one of the first studies to evaluate the usability of a collaborative medication reconciliation tool and assess HCPs' and patients' detection of medication discrepancies. Results demonstrate that embedded safety probes can enhance standard usability methods by measuring additional, clinically-focused usability outcomes. The novel safety probes we used may serve as an initial, standard set for future medication reconciliation research. More prevalent use of safety probes could strengthen usability research for a variety of health information technologies.

Outcomes of a randomized trial evaluating two approaches for promoting pharmacy-based referrals to the tobacco quitline.

OBJECTIVES: To evaluate the long-term impact of 2 promising intervention approaches to engage pharmacy personnel (pharmacists, technicians) in referring patients who want to quit smoking to the tobacco quitline. DESIGN: Randomized trial. SETTING: Community pharmacies in Connecticut (n = 32) and Washington (n = 32). INTERVENTION: Two intervention approaches were evaluated: academic detailing (AD), which involved on-site training for pharmacy staff about the quitline, versus mailed quitline materials (MM). MAIN OUTCOME MEASURES: Changes in the overall percentage of quitline registrants who reported hearing about the quitline from any pharmacy during the 6-month baseline monitoring period versus the 12-month intervention period, and between-group comparisons of a) the number of quitline registrants who reported hearing about the quitline from one of the study pharmacies during the 12-month intervention period, and b) the number of quitline cards and brochures distributed to patients during the first 6 months of the intervention period. RESULTS: The percentage of quitline callers who reported having heard about the quitline from a pharmacy increased significantly, from 2.2% during the baseline monitoring period to 3.8% during the 12-month intervention (P < 0.0001). In addition, comparisons controlled for seasonal effects also revealed significant increases in referrals. Across all 64 pharmacies, 10,013 quitline cards and 4755 brochures were distributed. The number of quitline cards distributed and the number registrants who reported hearing about the quitline from a pharmacy did not differ by intervention approach (AD vs. MM), although AD pharmacies distributed more quitline brochures (P = 0.022). CONCLUSION: Brief cessation interventions are feasible in community pharmacies, and the 2 approaches evaluated for engaging pharmacy personnel were similarly effective and collectively led to meaningful increases in the number and proportion of all patients who called the quitline. Involvement of community pharmacy personnel in tobacco cessation presents a significant opportunity to promote quitline services by connecting patients with an effective publicly available resource.

Pharmaceutical Role Expansion and Developments in Pharmacist-Physician Communication.

Expanded clinical pharmacist professional roles in the team-based patient-centered medical home (PCMH) primary care environment require cooperative and collaborative relationships among pharmacists and primary care physicians (PCPs), but many PCPs have not previously worked in such a direct fashion with pharmacists. Additional roles, including formulary control, add further elements of complexity to the clinical pharmacist-PCP relationship that are not well described. Our objective was to characterize the nature of clinical pharmacist-PCP interprofessional collaboration across seven federally funded hospitals and associated primary care clinics, following pharmacist placement in primary care clinics and incorporation of expanded pharmacist roles. In-depth and semistructured interviews were conducted with 25 practicing clinical pharmacists and 17 PCPs. Qualitative thematic analysis revealed three major themes: (1) the complexities of electronic communication (particularly electronic nonformulary requests) as contributing to interprofessional tensions or misunderstandings for both groups, (2) the navigation of new roles and traditional hierarchy, with pharmacists using indirect communication to prevent PCP defensiveness to recommendations, and (3) a preference for onsite colocation for enhanced communication and professional relationships. Clinical pharmacists' indirect communication practices may hold important implications for patient safety in the context of medication use, and it is important to foster effective communication skills and an environment where all team members across hierarchies can feel comfortable speaking up to reduce error when problems are suspected. Also, the lack of institutional communication about managing drug formulary issues and related electronic nonformulary request processes was apparent in this study and merits further attention for both researchers and practitioners.

The Effectiveness of Pharmacist-Provided Telephonic Medication Therapy Management on Emergency Department Utilization in Home Health Patients.

BACKGROUND: Preventable emergency department (ED) use may be targeted with interventions for improving the medication use process, as medication misadventures and non-adherence frequently cause preventable ED utilization. One intervention that could prevent ED visits is Medication Therapy Management (MTM). OBJECTIVE: To evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing emergency department utilization within a Medicare insured home health population. METHODS: This was a secondary analysis of data from a cluster-randomized controlled trial examining re-hospitalizations among Medicare insured patients within forty randomly selected, geographically diverse, home-health centers. The intervention consisted of an initial telephonic medication reconciliation with a pharmacy technician, a telephonic pharmacist-provided medication review, and follow-up pharmacist phone calls. The primary outcome of this analysis was 60-day all-cause emergency department utilization. Patients' baseline risk of ED utilization was calculated, and patients were stratified into quartiles based on their risk of ED utilization. Adjusted odd ratios of ED utilization were calculated. RESULTS: Data from 656 patients (intervention n=297, usual care n=359) were available for this study. Overall, the MTM intervention was not associated with 60-day ED use, as 24.4% of intervention patients and 25.1% of usual care patients utilized the ED (Adjusted Odds Ratio=1.11; 95% CI: 0.79-1.57). However, there was lower ED utilization among patients in the lowest risk-quartile (Adjusted Odds Ratio=2.52; 95% CI: 1.15-5.49; p= 0.02). CONCLUSION: This pharmacist-delivered telephonic medication therapy management program did not decrease ED utilization overall in a Medicare insured home health population, but may further reduce the risk of ED utilization among patients who are at lower risk of utilization.

Hypertension treatment intensification among stroke survivors with uncontrolled blood pressure.

BACKGROUND AND PURPOSE: We examined blood pressure 1 year after stroke discharge and its association with treatment intensification. METHODS: We examined the systolic blood pressure (SBP) stratified by discharge SBP (≤140, 141-160, or >160 mm Hg) among a national cohort of Veterans discharged after acute ischemic stroke. Hypertension treatment opportunities were defined as outpatient SBP >160 mm Hg or repeated SBPs >140 mm Hg. Treatment intensification was defined as the proportion of treatment opportunities with antihypertensive changes (range, 0%-100%, where 100% indicates that each elevated SBP always resulted in medication change). RESULTS: Among 3153 patients with ischemic stroke, 38% had ≥1 elevated outpatient SBP eligible for treatment intensification in the 1 year after stroke. Thirty percent of patients had a discharge SBP ≤140 mm Hg, and an average 1.93 treatment opportunities and treatment intensification occurred in 58% of eligible visits. Forty-seven percent of patients discharged with SBP 141 to160 mm Hg had an average of 2.1 opportunities for intensification and treatment intensification occurred in 60% of visits. Sixty-three percent of the patients discharged with an SBP >160 mm Hg had an average of 2.4 intensification opportunities, and treatment intensification occurred in 65% of visits. CONCLUSIONS: Patients with discharge SBP >160 mm Hg had numerous opportunities to improve hypertension control. Secondary stroke prevention efforts should focus on initiation and review of antihypertensives before acute stroke discharge; management of antihypertensives and titration; and patient medication adherence counseling.

Design and Evaluation of an Electronic Override Mechanism for Medication Alerts to Facilitate Communication Between Prescribers and Pharmacists.

BACKGROUND: Computerized medication alerts can often be bypassed by entering an override rationale, but prescribers' override reasons are frequently ambiguous to pharmacists who review orders. OBJECTIVE: To develop and evaluate a new override mechanism for adverse reaction and drug-drug interaction alerts. We hypothesized that the new mechanism would improve usability for prescribers and increase the clinical appropriateness of override reasons. METHODS: A counterbalanced, crossover study was conducted with 20 prescribers in a simulated prescribing environment. We modified the override mechanism timing, navigation, and text entry. Instead of free-text entry, the new mechanism presented prescribers with a predefined set of override reasons. We assessed usability (learnability, perceived efficiency, and usability errors) and used a priori criteria to evaluate the clinical appropriateness of override reasons entered. RESULTS: Prescribers rated the new mechanism as more efficient (Wilcoxon signed-rank test, P = 0.032). When first using the new design, 5 prescribers had difficulty finding the new mechanism, and 3 interpreted the navigation to mean that the alert could not be overridden. The number of appropriate override reasons significantly increased with the new mechanism compared with the original mechanism (median change of 3.0; interquartile range = 3.0; P < 0.0001). CONCLUSIONS: When prescribers were given a menu-based choice for override reasons, clinical appropriateness of these reasons significantly improved. Further enhancements are necessary, but this study is an important first step toward a more standardized menu of override choices. Findings may be used to improve communication through e-prescribing systems between prescribers and pharmacists.

A Novel Design for Drug-Drug Interaction Alerts Improves Prescribing Efficiency.

BACKGROUND: Drug-drug interactions (DDIs) are common in clinical care and pose serious risks for patients. Electronic health records display DDI alerts that can influence prescribers, but the interface design of DDI alerts has largely been unstudied. In this study, the objective was to apply human factors engineering principles to alert design. It was hypothesized that redesigned DDI alerts would significantly improve prescribers' efficiency and reduce prescribing errors. METHODS: In a counterbalanced, crossover study with prescribers, two DDI alert designs were evaluated. Department of Veterans Affairs (VA) prescribers were video recorded as they completed fictitious patient scenarios, which included DDI alerts of varying severity. Efficiency was measured from time-stamped recordings. Prescribing errors were evaluated against predefined criteria. Efficiency and prescribing errors were analyzed with the Wilcoxon signed-rank test. Other usability data were collected on the adequacy of alert content, prescribers' use of the DDI monograph, and alert navigation. RESULTS: Twenty prescribers completed patient scenarios for both designs. Prescribers resolved redesigned alerts in about half the time (redesign: 52 seconds versus original design: 97 seconds; p<.001). Prescribing errors were not significantly different between the two designs. Usability results indicate that DDI alerts might be enhanced by facilitating easier access to laboratory data and dosing information and by allowing prescribers to cancel either interacting medication directly from the alert. Results also suggest that neither design provided adequate information for decision making via the primary interface. CONCLUSION: Applying human factors principles to DDI alerts improved overall efficiency. Aspects of DDI alert design that could be further enhanced prior to implementation were also identified.

Pharmacists' experiences with a telephonic medication therapy management program for home health care patients.

OBJECTIVE: This study was designed to better understand perceived barriers and facilitators to providing medication therapy management (MTM) services by pharmacists who recently provided telephonic MTM services to home health care patients. These services were provided as part of a randomized, controlled trial (RCT) to develop suggested quality improvement strategies for future service design. DESIGN: This was a qualitative study. A semi-structured individual interview format was used to elicit responses. SETTING: Interviews were conducted by phone with participants. PARTICIPANTS: All pharmacists who recently provided telephonic MTM services as a part of an RCT participated in this study. INTERVENTIONS: Pharmacists were asked questions regarding their perceptions of the services, training opportunities, patient perceptions of the services, interactions with physicians, and suggestions for improvement. General demographic information was collected for each pharmacist and summarized using descriptive statistics. Interview data were analyzed using inductive qualitative methods to reveal key themes related to facilitators and barriers of MTM services in home health care patients. MAIN OUTCOME MEASURES: The main outcome measures were major themes identified from pharmacist interviews pertaining to barriers, facilitators, and quality improvement strategies for telephonic MTM delivery. RESULTS: A total of four pharmacists (i.e., 100% of those who participated in the prior RCT) were interviewed. Several themes emerged from the analysis, including: communication and relationships, coordinating care and patient self-management, logistics, professional fulfillment, service delivery and content, and training opportunities. CONCLUSIONS: This study provides possible strategies to overcome barriers and facilitate service provision for future telephonic MTM services.

Lessons Learned from a Shared Curriculum on Tobacco Cessation Using a Mixed-Methods Approach.

Although the sharing of curricular content between health professional schools can reduce faculty burden, the literature provides little guidance to support these efforts. The objective of this investigation was to synthesize data from two prior studies to delineate recommendations guiding the future development of shared curricula in health professional education. Applying Rogers' Diffusion of Innovations Theory as a guiding framework, relevant data were extracted from a two-phase mixed-methods study evaluating the long-term impact of the shared Rx for Change: Clinician-Assisted Tobacco Cessation program. Phase 1, a qualitative study, involved telephone interviews with faculty participants of train-the-trainer workshops conducted between 2003 and 2005. These results informed the development of a phase 2 national survey, administered electronically as a long-term follow-up (13 to 15 years later) with train-the-trainer workshop participants. Results from the two studies were synthesized and summarized, producing seven key recommendations to guide development of shared curricula: (1) appeal to attendees, (2) relate content to clinical practice, (3) deliver live, in-person training, (4) develop high-quality materials, delivered by experts, (5) provide support, (6) meet accreditation standards, and (7) demonstrate effectiveness. Future program developers should consider these recommendations to enhance dissemination, adoption, and long-term sustainability of shared curricular content.

Cognitive task analysis of clinicians' drug-drug interaction management during patient care and implications for alert design.

BACKGROUND: Drug-drug interactions (DDIs) are common and can result in patient harm. Electronic health records warn clinicians about DDIs via alerts, but the clinical decision support they provide is inadequate. Little is known about clinicians' real-world DDI decision-making process to inform more effective alerts. OBJECTIVE: Apply cognitive task analysis techniques to determine informational cues used by clinicians to manage DDIs and identify opportunities to improve alerts. DESIGN: Clinicians submitted incident forms involving DDIs, which were eligible for inclusion if there was potential for serious patient harm. For selected incidents, we met with the clinician for a 60 min interview. Each interview transcript was analysed to identify decision requirements and delineate clinicians' decision-making process. We then performed an inductive, qualitative analysis across incidents. SETTING: Inpatient and outpatient care at a major, tertiary Veterans Affairs medical centre. PARTICIPANTS: Physicians, pharmacists and nurse practitioners. OUTCOMES: Themes to identify informational cues that clinicians used to manage DDIs. RESULTS: We conducted qualitative analyses of 20 incidents. Data informed a descriptive model of clinicians' decision-making process, consisting of four main steps: (1) detect a potential DDI; (2) DDI problem-solving, sensemaking and planning; (3) prescribing decision and (4) resolving actions. Within steps (1) and (2), we identified 19 information cues that clinicians used to manage DDIs for patients. These cues informed their subsequent decisions in steps (3) and (4). Our findings inform DDI alert recommendations to improve clinicians' decision-making efficiency, confidence and effectiveness. CONCLUSIONS: Our study provides three key contributions. Our study is the first to present an illustrative model of clinicians' real-world decision making for managing DDIs. Second, our findings add to scientific knowledge by identifying 19 cognitive cues that clinicians rely on for DDI management in clinical practice. Third, our results provide essential, foundational knowledge to inform more robust DDI clinical decision support in the future.

Evaluation of specialized medication packaging combined with medication therapy management: adherence, outcomes, and costs among Medicaid patients.

BACKGROUND: This study evaluates the effect of a program combing specialized medication packaging and telephonic medication therapy management on medication adherence, health care utilization, and costs among Medicaid patients. RESEARCH DESIGN: A retrospective cohort design compared Medicaid participants who voluntarily enrolled in the program (n = 1007) compared with those who did not (n = 13,614). Main outcome measures were medication adherence at 12 months, hospital admissions and emergency department visits at 6 and 12 months, and total paid claim costs at 6 and 12 months. Multivariate regression models were used to adjust for the effect of age, sex, race, comorbidities, and 12-month preenrollment health care utilization. RESULTS: Measures of medication adherence were significantly improved in the program cohort compared with the usual care cohort. At 6 months, adjusted all-cause hospitalization was marginally less in the program cohort compared with the usual care cohort [odds ratio = 0.73, 95% confidence interval (CI), 0.54-1.0, P = 0.05]. No statistically significant differences were observed between the 2 cohorts for any of the other adjusted utilization endpoints at 6 or 12 months. Adjusted total cost at 6 and 12 months were higher in the program cohort (6-month cost ratio = 1.76, 95% CI,1.65-1.89; 12-month cost ratio = 1.84, 95% CI,1.72-1.97), primarily because of an increase in prescription costs. Emergency department visits and hospitalization costs did not differ between groups. CONCLUSIONS: : The program improved measures of medication adherence, but the effect on health care utilization and nonpharmacy costs at 6 and 12 months was not different from the usual care group. Reasons for these findings may reflect differences in the delivery of the specialized packaging and the medication therapy management program, health care behaviors in this Medicaid cohort, unadjusted confounding, or time required for the benefit of the intervention to manifest.