Karen B. Farris

A Cluster Randomized Trial to Evaluate Physician/Pharmacist Collaboration to Improve Blood Pressure Control

This was a prospective, cluster randomized controlled trial in patients with uncontrolled hypertension aged 21 to 85 years (mean, 61 years). Pharmacists made recommendations to physicians for patients in the intervention clinics (n=101) but not patients in the control clinics (n=78). The mean adjusted difference in systolic blood pressure (BP) between the control and intervention groups was 8.7 mm Hg (95% confidence interval [CI], 4.4–12.9), while the difference in diastolic BP was 5.4 mm Hg (CI, 2.8–8.0) at 9 months. The 24‐hour BP levels showed similar effects, with a mean systolic BP level that was 8.8 mm Hg lower (CI, 5.0–12.6) and a mean diastolic BP level that was 4.6 mm Hg (CI, 2.4–6.8) lower in the intervention group. BP was controlled in 89.1% of patients in the intervention group and 52.9% in the control group (adjusted odds ratio, 8.9; CI, 3.8–20.7; P<.001). Physician/pharmacist collaboration achieved significantly better mean BP values and overall BP control rates, primarily by intensification of medication therapy and improving patient adherence.

Pharmaceutical Care in Community Pharmacies: Practice and Research in the US

Objective: To describe the state of community pharmacy, including patient care services, in the US. Findings: Chain pharmacies, including traditional chains, mass merchandisers, and supermarkets, comprise more than 50% of community pharmacies in the US. Dispensing of drugs remains the primary focus, yet the incidence of patients being counseled on medications appears to be increasing. More than 25% of independent community pharmacy owners report providing some patient clinical care services, such as medication counseling and chronic disease management. Most insurance programs pay pharmacists only for dispensing services, yet there are a growing number of public and private initiatives that reimburse pharmacists for cognitive services. Clinical care opportunities exist in the new Medicare prescription drug benefit plan, as it requires medication therapy management services for specific enrollees. Discussion: The private market approach to healthcare delivery in the US, including pharmacy services, precludes national and statewide strategies to change the basic business model. To date, most pharmacies remain focused on dispensing prescriptions. With lower dispensing fees and higher operating costs, community pharmacies are focused on increasing productivity and efficiency through technology and technicians. Pharmacists remain challenged to establish the value of their nondispensing-related pharmaceutical care services in the private sector. As the cost of suboptimal drug therapy becomes more evident, medication therapy management may become a required pharmacy benefit in private drug insurance plans. Pharmacy school curricula, as well as national and state pharmacy associations, continually work to train and promote community pharmacists for these roles. Practice research is driven primarily by interested academics and, to a lesser degree, by pharmacy associations. Conclusions: Efficient dispensing of prescriptions is the primary focus of community pharmacies in the US. Some well designed practice-based research has been conducted, but there is no national research agenda or infrastructure. Reimbursement for cognitive services remains an infrequent, but growing, activity.

Understanding the determinants of health for people with type 2 diabetes.

OBJECTIVE We assessed which of a broad range of determinants of health are most strongly associated with health-related quality of life (HRQL) among people with type 2 diabetes. METHODS Our analysis included respondents from the Canadian Community Health Survey Cycle 1.1 (2000-2001) who were aged 18 years and older and who were identified as having type 2 diabetes. We used regression analyses to assess the associations between the Health Utilities Index Mark 3 and determinants of health. RESULTS Comorbidities had the largest impact on HRQL, with stroke (-0.11; 95% confidence interval [CI] = -0.17, -0.06) and depression (-0.11; 95% CI = -0.15, -0.06) being associated with the largest deficits. Large differences in HRQL were observed for 2 markers of socioeconomic status: social assistance (-0.07; 95% CI=-0.12, -0.03) and food insecurity (-0.07; 95% CI=-0.10, -0.04). Stress, physical activity, and sense of belonging also were important determinants. Overall, 36% of the variance in the Health Utilities Index Mark 3 was explained. CONCLUSION Social and environmental factors are important, but comorbidities have the largest impact on HRQL among people with type 2 diabetes.

From "retailers" to health care providers : Transforming the role of community pharmacists in chronic disease management

Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs-particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes.

Predictors of Older Adults’ Capacity for Medication Management in a Self-Medication Program A Retrospective Chart Review

Objectives: The aim of this project was to identify variables that predicted older adults’ ability to manage medications. Methods: The study used a retrospective cohort design and was set in a self-medication program within a rehabilitation hospital. A random sample of charts from 301 participants in the self-medication program was reviewed. Results: Logistic regression models accounted for 26.7% and 55.8% of the variance in the probability of making one or more self-medication errors during the initial and final weeks of the program, respectively. The importance of cognition in predicting medication management capacity was seen in bivariate and multivariate analyses and through a number of interactions with other predictors. Statistically significant predictors in one or both analyses included medication regimen complexity, Mini-Mental State Exam (MMSE) score, duration of institutionalization, depression, and interactions between (a) medication regimen complexity and MMSE score and (b) ability to cook and MMSE score. Discussion: The direct effects of cognition and medication regimen complexity were important predictors of medication management capacity.

Primary health care teams: team members' perceptions of the collaborative process

SHERRY L. DIELEMAN, KAREN B. FARRIS, DAVID FEENY, JEFFREY A. JOHNSON, ROSS T. TSUYUKI & SANDRA BRILLIANT Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada, College of Pharmacy, University of Iowa, Iowa, USA, Department of Public Health Sciences, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB Canada, 4 Institute of Health Economics, Edmonton, AB Canada and Division of Cardiology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB Canada

Unintentional non-adherence and belief in medicines in older adults

OBJECTIVE To determine whether beliefs in medicines are associated with forgetfulness and carelessness in taking medications. METHODS Using a survey research design, baseline data (N=1220) and follow-up data (N=1024) were collected through an Internet survey using a convenience sample from Medicare enrollees aged 65 and older and who were Internet users. Logistic regression models were used to determine if patients beliefs about the necessity of taking prescribed medications and their concern beliefs regarding the potential consequences of taking medications were significant in predicting forgetfulness and carelessness in taking medications. RESULTS Concern beliefs in medicines were a significant predictor of forgetfulness and carelessness in taking medications. CONCLUSION If all cases of forgetfulness and carelessness in taking medications are considered as unintentional non-adherence with no reference to the patients beliefs in medicines; using cue based interventions such as phone reminders or alarms are not likely to reduce non-adherence. There was a strong association between patient belief in medications and non-adherence in older adults who were Medicare enrollees. PRACTICAL IMPLICATIONS It is important that researchers consider the influence that patient medication beliefs have on patient adherence to develop better interventions to reduce non-adherence.

Multiple partners and partner choice as risk factors for sexually transmitted disease among female college students.

Multiple sexual partners and partner choice are believed to increase the risk of sexually transmitted disease (STD), but these behaviors had not previously been assessed outside of clinical populations. In this study, a cross-sectional survey among single, white, female students in their senior year of college was conducted to measure the association between behavioral risk factors and the acquisition of self-reported STDs during college. The usable response rate was 47.2% (n = 467). The combined prevalence of chlamydial infection, gonorrhea, genital herpes, human papillomavirus (HPV) infection, syphilis, and trichomoniasis during a 3.5-year period was 11.7%. There was a strong association between number of sexual partners and having an STD: those women with 5 or more sexual partners were 8 times more likely to report having an STD than those with only 1 partner, even after adjusting for age at first intercourse (odds ratio = 8.1; 95% confidence interval = 1.99, 32.64). The prevalence of a history of STDs increased with more causal partner choice and earlier age at first intercourse, but neither factor was independently associated with a history of STDs. Of the respondents, 23% always used condoms. Future research should focus on identifying ways of effectively changing high-risk sexual behavior.

Smoking-Cessation Services in Iowa Community Pharmacies

Study Objective. To examine community pharmacy practice with regard to providing smoking‐cessation counseling.

Assessing the Quality of Pharmaceutical Care II. Application of Concepts of Quality Assessment from Medical Care

Objective To present a framework that facilitates quality assessment of pharmaceutical care (PC) so that the profession and the public may identify pharmacists in ambulatory settings who provide quality care in all aspects of their practices. Data Sources A MEDLINE search augmented by a review of International Pharmacy Abstracts was used to identify pertinent quality assessment and pharmacy practice literature; indexing terms included quality assurance, healthcare, pharmacists, community pharmacy services, ambulatory, pharmacy, and process and outcome assessment. Study Selection All identified quality assessments of community pharmacy practice were considered. Studies that documented the effectiveness of specific pharmacist activities and patient satisfaction were also included. Data Extraction The literature was independently reviewed by the primary author. Data Synthesis The structure–process–outcome paradigm is presented as a framework for quality assessment of PC. Structure should be assessed at periodic intervals because it identifies the potential for the provision of quality care. Process, the care that pharmacists provide, must be documented and linked to outcomes before either structure or process can be used to make inferences about the quality of PC. Technical and interpersonal processes should be examined. Outcomes require an interdisciplinary approach that not only considers other medical care inputs but also recognizes the psychologic, economic, and social factors that affect health status and quality of life. Process and outcome must both be assessed to distinguish the contribution of pharmacists from that of other healthcare providers. Examples of criteria are provided and a model to integrate PC within the healthcare system is discussed. Conclusions It is pharmacists’ duty to ensure that patients receive an acceptable level of PC. The structure-process-outcome paradigm provides a framework to identify and link pharmacists’ processes with patients’ outcomes.