Matthew J. Witry

Community pharmacists, medication monitoring, and the routine nature of refills: A qualitative study

OBJECTIVE To describe the attitudes, contextual factors, and behaviors associated with medication monitoring in the dispensing process by community pharmacists. DESIGN Descriptive qualitative research with semistructured interviews. SETTING Midwestern community pharmacies or telephone. PARTICIPANTS 12 licensed community pharmacists from chain, independent, and grocery pharmacies. INTERVENTION 45-minute, semistructured interviews were conducted to gather detailed live experiences and perspectives pertinent to the study objective. MAIN OUTCOME MEASURES Transcripts were coded descriptively and interpretively, originating with the input and monitoring process domains of the Health Collaboration Model. RESULTS A thematic dichotomy was interpreted in the analysis. All participants discussed both (1) the technical and routine nature of their work, and (2) the problem-solving and relational aspects of practice. More specifically, medication monitoring was constrained by busyness, lack of patient interest, and the routine nature of refills, although to varying extents. Some predominantly responded to unique circumstances such as patient question-asking, prior memory of a patient interaction or service utilization, or technical issues such as medication cost. Others added unprompted questions of varying specificity when handing off the prescription to understand patient medication experiences. Pharmacists felt challenged by nonadherence monitoring because workflows made this information difficult to access and late refills were prevalent. CONCLUSION Community pharmacies seeking to increase medication monitoring in the dispensing process may target the routine nature of refills and the availability of monitoring information.

A Leadership Elective Course Developed and Taught by Graduate Students

Objective. To develop and implement a flexible-credit elective course to empower student pharmacists to develop lifelong leadership skills and provide teaching practice opportunities for graduate students. Design. An elective course focusing on leadership development for second- and third-year doctor of pharmacy (PharmD) students was designed and taught by 4 graduate students under the mentorship of 2 faculty members. Student pharmacists could enroll in a 1-, 2-, or 3-credit-hour version of the course. Assessment. Attainment of course objectives was measured using student pharmacist reflection papers and continuing professional development portfolios. Additionally, self-assessments of graduate students and faculty members delivering the course were conducted. In their responses on course evaluations, student pharmacists indicated they found the course a valuable learning experience. Graduate students found course development to be challenging but useful in developing faculty skills. Conclusion. This flexible-credit elective course taught by graduate students was an innovative way to offer formal leadership instruction using limited college resources.

Factors influencing community pharmacists' likelihood to ask medication monitoring questions: A factorial survey.

BACKGROUND Community pharmacists are well positioned to identify and resolve medication related problems associated with chronic medication use during prescription dispensing, a process referred to as medication monitoring. Pharmacists need feedback about patient medication experiences to engage in effective monitoring, but the pharmacists decision making process for when to ask questions to solicit this information from patients has not been established. OBJECTIVES Identify significant factors contributing to a community pharmacists likelihood to ask medication monitoring questions at the time of refill. METHODS A factorial survey approach was used to test the effect of several pharmacist, patient, environment, drug, and past interaction factors (the domains of the Health Collaboration Model) on a pharmacists self-reported likelihood to ask non-adherence, side effect, and effectiveness monitoring questions for 5 randomly populated refill prescription dispensing vignettes. Surveys containing the vignettes, demographic items, and a new medication monitoring attitude measure were mailed to 599 community pharmacists. Hierarchical linear regression was used to test the independent effects of the vignette and pharmacist factors. RESULTS There were 254 (42.4%) returned and usable surveys. The hierarchical linear regression models showed that adherence questioning was driven more by the vignette characteristics whereas side effect and effectiveness questioning were more driven by the pharmacist. Overall, warfarin and hydrocodone were seen as more question-worthy than fluoxetine or metoprolol. The number of additional persons waiting in the pharmacy decreased, and more days late increased the likelihood of asking the three monitoring questions. An exception was hydrocodone where early fills prompted question asking. For side effect and effectiveness questioning, being short-staffed and the prescription previously being filled more times decreased question asking likelihood. DISCUSSION Factorial surveys are a useful approach to independently measuring the impact of respondent and contextual variables on pharmacist judgments. Reactions to the vignettes demonstrated that multiple factors go into a pharmacists mental model when deciding to ask a question at the time of refill. The lateness of a refill prescription was a significant cue to question asking. Pharmacies can ensure late refill information is reaching pharmacists as a means to increase in medication monitoring. Pharmacies also can design work environments and workflows conducive to question asking and prompt pharmacists to address potentially under-discussed medications.

A qualitative investigation of protégé expectations and proposition of an evaluation model for formal mentoring in pharmacy education

BACKGROUND Student pharmacist mentoring programs have gained attention from colleges of pharmacy as a way to enhance the student experience. However, no evaluative models have been proposed or theoretical explanations described for use in improving formal mentoring programs in pharmacy or for guiding the construction of a literature base. OBJECTIVES The objectives of this study were to investigate student expectations and preferences for formal mentoring programs and propose a model for evaluating formal mentoring programs in pharmacy education. METHODS Five, 60-minute focus groups were conducted in September 2009. Participants were PharmD candidates in their first 3 years of professional education. Discussion was facilitated using a question guide. Following transcription, an initial iteration of the model was used to code the data. A consensus-forming process was used to derive themes and identify representative quotes. Elaboration and specification of the final proposed model is presented. RESULTS In all, 28 students participated. Emergent constructs were identified from the data. Structures or inputs of the formal mentoring program included mentor and protégé characteristics and program structure. Mentoring processes included mentor functions, mentoring activities, and relationship development. Outcomes included both proximal outcomes in the form of mentor and protégé change, program satisfaction, and organizational learning; and distal outcomes comprised mentor, protégé, and organizational outcomes. CONCLUSIONS This formal mentoring evaluation model was useful in guiding analysis of protégé experiences and preferences for a college-sponsored program. The model can be used to guide college administrators and researchers on future theory-based inquiry into protégé; mentor; and organizational structures, processes, and outcomes for formal mentoring programs.

Assessing Opportunities for Student Pharmacist Leadership Development at Schools of Pharmacy in the United States

Objective. To summarize student pharmacist leadership development opportunities delivered by pharmacy programs, to describe selected opportunities, and to assess how these opportunities meet leadership development competencies. Methods. A multi-method study was conducted that comprised a systematic content analysis of pharmacy education journals, pharmacy program websites, and telephone interviews with key informants, which included open-ended questions and scaled responses. Results. Review of six articles, 37 American Association of Colleges of Pharmacy (AACP) Annual Meeting abstracts, and 138 websites resulted in the identification of 191 leadership development opportunities. These consisted of courses, projects/programs, and events/speaker series. Interviews with 12 key informants detailed unique events that developed leadership competencies. Formal assessments of student leadership development were limited and primarily focused on informal feedback and course evaluations. Conclusion. Most US pharmacy programs offer their students an array of opportunities to develop leadership abilities. Pharmacy programs should consider expanding opportunities beyond elective courses, learn from the successes of others to implement new leadership development opportunities, and bolster the assessment of student leadership competencies and outcomes.

Development of a medication monitoring attitude measure using a mixed methods item development process

Medication monitoring is important for safe and effective medication use; however, no attitudinal measure exists for a health care providers medication monitoring attitude. The objectives of this study were to (1) create a measure of a community pharmacist medication monitoring attitude; (2) test concurrent validity using a validated measure of medication monitoring behaviours; and (3) report community pharmacist attitudes towards medication monitoring.

Investigation of Simulated Pharmacist Decision Making Involving Prescriptions With a High Probability of Causing Patient Harm

Background: Medication errors pose a significant risk to patients, resulting in morbidity, mortality, and unnecessary health care utilization. Pharmacists, using their professional judgment, have an important role as a final check for identifying and resolving these problems. Little is known, however, about pharmacist perspectives and experiences with dispensing or withholding potentially dangerous prescriptions. Objectives: To (a) evaluate the extent to which pharmacists would not dispense a likely harmful prescription which has been confirmed by the prescriber and (b) assess pharmacist attitudes and experiences with dispensing likely harmful prescriptions. Methods: An anonymous, self-administered, 25-item survey was emailed to members of a state pharmacy association and a pharmacy college alumni list. A series of static prescription vignettes (1 reasonable and 4 likely dangerous doses) were presented and asked if they would fill each prescriber-confirmed prescription. Pharmacists also were asked a series of Likert-type, open-ended, multiple choice, and demographic items regarding their professional experiences and role perceptions. Results: There were 497 usable responses. Three of the 4 dangerous prescriptions were withheld by the majority of pharmacists (sumatriptan as the exception). No demographic variable was universally associated with filling dangerous vignette prescriptions; rather, there were vignette-specific differences. The majority of pharmacists reported refusing to fill a potentially harmful prescription during their career. Conclusions: There appears to be meaningful variation in how pharmacists react when presented with likely harmful prescriptions. More research is needed to better understand this role, its determinants, and the potential effects on patient safety.

evaluation of the pharmaceutical case management program implemented in a private sector health plan

OBJECTIVES To characterize the drug-related problems (DRPs) identified by pharmacists providing pharmaceutical case management (PCM), describe the effect of PCM on medication appropriateness, and compare the findings from this evaluation of private insurance beneficiaries with a previous evaluation of PCM provided to Iowa Medicaid beneficiaries. METHODS A pharmacy chart review was used to calculate medication appropriateness index (MAI) scores for patients before and after receiving PCM. Changes in MAI scores were calculated. DRPs identified by pharmacists during PCM services were characterized using online summaries submitted by pharmacists following each PCM encounter. RESULTS A total of 91 patients received 195 PCM services from 29 pharmacies (2.14 services/patient). On average, pharmacists providing PCM were able to identify 2.6 DRPs per patient. The most frequently identified problems were the need for additional therapy, adverse drug reactions, and inappropriate adherence. Compared with baseline, mean MAI scores did not improve significantly following PCM (1.53 vs. 1.24, P = 0.34). MAI scores for this group were significantly lower than in a previous study of Medicaid beneficiaries receiving PCM. CONCLUSION The lower number of medications and lower MAI scores for the private beneficiaries compared with Medicaid beneficiaries suggested that these two groups have different characteristics that could translate into different needs from medication therapy management services.

The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange

INTRODUCTION Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment. MATERIALS AND METHODS Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences. RESULTS Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD. CONCLUSIONS This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.

Analysis of a Community Pharmacy Intervention to Improve Low Adherence Rates to Oral Diabetes Medications

For patients with diabetes, suboptimal medication adherence contributes to disease progression, complications, and increased healthcare costs. Identification of, and intervention for patient-identified reasons for nonadherence are essential to improving medication adherence. This prospective, quality improvement study was conducted at an independent community pharmacy in the Mid-West United States. Patients with a proportion of days covered (PDC) for their oral antidiabetic medications of less than 80% were contacted by telephone and interviewed by a clinical pharmacist. The interviews and corresponding adherence interventions were guided by an abbreviated version of the Drug Adherence Work-Up (DRAW©) tool that focused on oral medications for diabetes. The change in PDC 120-days post-interview was assessed to determine the change in adherence rates. Patients receiving the pharmacist-delivered adherence intervention had significantly higher 120 day PDC values which are likely to indicate more regular medication-taking at home. Almost half of study patients signed up for medication synchronization and these patients trended toward higher PDC values, although the relative difference was not statistically significant from those receiving the intervention and not opting to have their medications synchronized.