Michelle A. Chui

Comparison of quality of life measures in heart failure

BackgroundAlthough numerous health-related quality-of-life instruments are available to measure patients’ quality of life, few studies have compared these measures directly to determine how they function in the same group of patients. ObjectiveThe purpose of this study was to empirically compare psychometric properties of the Chronic Heart Failure Questionnaire (CHQ), the Minnesota Living with Heart Failure Questionnaire (LHFQ), and the General Health Survey Short-form-12 (SF-12). SampleA convenience sample of 211 patients with heart failure completed baseline questionnaires; 165 patients completed the entire 26-week study. MethodsPatients completed telephone interviews at baseline and at 4, 8, and 26 weeks after baseline. To compare mode of administration, a subset of patients (n = 173) completed face-to-face and telephone interviews. ResultsPatients reported low-to-moderate health-related quality-of-life overall. Reliability of the three instruments was satisfactory. Responsiveness to changing condition, as evaluated by analysis of variance, receiver operating curve characteristics, and the minimal clinically important difference method, indicated that the CHQ and LHFQ were more responsive to changing conditions than the SF-12. No major differences were noted between the scores of the face-to-face interviews and the baseline telephone interviews. The LHFQ and SF-12 were easier and took less time to administer than the CHQ. ConclusionsWhile all three instruments were reliable and valid, the CHQ and LHFQ were more sensitive than the SF-12 in detecting clinically important changes over time.

A qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach

BACKGROUND Although lack of time, trained personnel, and reimbursement have been identified as barriers to pharmacists providing cognitive pharmaceutical services (CPS) in community pharmacies, the underlying contributing factors of these barriers have not been explored. One approach to better understand barriers and facilitators to providing CPS is to use a work system approach to examine different components of a work system and how the components may impact care processes. OBJECTIVES The goals of this study were to identify and describe pharmacy work system characteristics that pharmacists identified and changed to provide CPS in a demonstration program. METHODS A qualitative approach was used for data collection. A purposive sample of 8 pharmacists at 6 community pharmacies participating in a demonstration program was selected to be interviewed. Each semistructured interview was audio recorded and transcribed, and the text was analyzed in a descriptive and interpretive manner by 3 analysts. Themes were identified in the text and aligned with 1 of 5 components of the Systems Engineering Initiative for Patient Safety (SEIPS) work system model (organization, tasks, tools/technology, people, and environment). RESULTS A total of 21 themes were identified from the interviews, and 7 themes were identified across all 6 interviews. The organization component of the SEIPS model contained the most (n=10) themes. Numerous factors within a pharmacy work system appear important to enable pharmacists to provide CPS. Leadership and foresight by the organization to implement processes (communication, coordination, planning, etc.) to facilitate providing CPS was a key finding across the interviews. Expanding technician responsibilities was reported to be essential for successfully implementing CPS. CONCLUSIONS To be successful in providing CPS, pharmacists must be cognizant of the different components of the pharmacy work system and how these components influence providing CPS.

Association between adherence to diuretic therapy and health care utilization in patients with heart failure.

Study Objective. To determine the relationship between adherence to diuretic therapy and health care utilization.

E-prescribing errors in community pharmacies: Exploring consequences and contributing factors

OBJECTIVE To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors. METHODS Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10. RESULTS Pharmacy staff detected 75 e-prescription errors during the 45 h observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information. CONCLUSION Study findings suggest that a wide range of e-prescribing errors is encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies.

Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing

OBJECTIVE This paper explored pharmacy staff perceptions of the strengths and weaknesses of electronic prescribing (e-prescribing) design in retail pharmacies using the sociotechnical systems framework. This study examined how adoption of e-prescribing technology is affecting clinical practice and patient care. MATERIALS AND METHODS Direct observations and think aloud protocols were used to collect data from seven retail pharmacies. RESULTS Pharmacists and pharmacy technicians reported strengths of e-prescribing design that facilitated pharmacy work which included: legibility, ease of archiving, quick access to prescriptions and consistency in the format of electronic prescriptions (e-prescriptions). Design weaknesses and potential hazards to patient care associated with e-prescribing systems were due to differences between pharmacy and prescriber computer systems which resulted in the selection of wrong patient or drug (name, directions, dose, strength, formulation, package sizes). There were unique strengths and weaknesses in the design of e-prescriptions peculiar to the three pharmacy computer systems examined in this study. DISCUSSION Findings from this study can help inform policy on creating e-prescribing design standards for pharmacy. e-Prescribing system developers can use the results of this study to identify and apply the most usable features of the three main pharmacy computer systems to design systems that support dispensing efficiency and safety. CONCLUSIONS This is the first study to highlight design flaws with e-prescribing in retail pharmacies. The sociotechnical systems framework was useful in providing an indepth understanding of the pharmacist and pharmacy technicians interface with e-prescribing technology. This information can be used by policy makers to create e-prescribing standards for pharmacies.

IDENTIFYING PREDIABETES USING FASTING INSULIN LEVELS

OBJECTIVE To determine whether patients with prediabetes can be accurately and easily identified in clinical settings using a predictive clinical and laboratory model. METHODS This retrospective study examined demographic and laboratory data from patients who had undergone 2-hour glucose testing for suspected prediabetes or diabetes between 2000 and 2004. Patients who met the diagnostic criteria for diabetes mellitus were excluded. Prediabetes was defined as a fasting glucose concentration > or = 100 mg/dL and < or = 125 mg/dL or a 2-hour postprandial glucose concentration > or = 140 mg/dL and < 200 mg/dL. Multivariate logistic regression was conducted to identify calculated or measured clinical and laboratory attributes that predict the presence of prediabetes, including fasting insulin quartiles, homeostasis model assessment of insulin resistance (HOMA-IR), and quantitative insulin sensitivity check index. RESULTS Of 965 patients, 287 (29.7%) had prediabetes. The study population primarily consisted of white, obese, female patients. A multivariate model revealed that compared with the referent lowest quartile of fasting insulin (mu = 4.9 [+/-SD] +/-1.2 microIU/mL), subsequent insulin quartiles increased the likelihood of identifying prediabetes (quartile 2: mu = 8.0 +/-0.8 microIU/mL, odds ratio [OR] = 2.076, confidence interval [CI] = 1.241-3.273; quartile 3: mu = 12.2 +/-1.7 microIU/mL, OR = 3.151, CI = 1.981-5.015; quartile 4: mu = 25.9 +/-12.4 microIU/mL, OR = 5.035, CI = 3.122-8.122). Older age and increased diastolic blood pressure also contributed modestly to this model. Further analysis using the area under the curve revealed that at a fasting insulin level > 9.0 microIU/mL, prediabetes would be correctly identified in 80% of affected patients. A second model revealed that increased HOMA-IR index (OR = 1.303, CI = 1.205-1.410) and older age (OR = 1.037, CI = 1.024-1.05) predicted prediabetes. CONCLUSIONS The most robust model, which used fasting insulin levels, may provide the most utility as a clinical tool because the highest quartiles suggest significantly greater likelihood of identifying prediabetes.

E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care.

E-prescribing, the health information technology (HIT) that enables prescribers to electronically transmit prescriptions to community pharmacies, has been touted as a solution for improving patient safety and overall quality of care. However, the impact of HIT, such as e-prescribing on medication errors in acute care settings, has been widely studied and shows that if poorly designed or implemented, HIT can pose a risk to patient safety by introducing a source of medication errors. Unlike acute care settings, safety issues related to e-prescribing in primary care settings (where e-prescriptions are generated and transmitted) and pharmacies (where e-prescriptions are received) have not received as much attention in the literature. This paper provides a focused review of patient safety issues related to using e-prescribing systems in primary care and pharmacies. In addition, the paper proposes using human factors engineering concepts to study e-prescribing safety in pharmacies and primary care settings to identify safety problems and possible mechanisms for improvement.

Relationship between e-prescriptions and community pharmacy workflow

OBJECTIVES To understand how community pharmacists use electronic prescribing (e-prescribing) technology and to describe the workflow challenges pharmacy personnel encounter as a result of using e-prescribing technology. DESIGN Cross-sectional qualitative study. SETTING Seven community pharmacies in Wisconsin from December 2010 to March 2011. PARTICIPANTS 16 pharmacists and 14 pharmacy technicians (in three chain and four independent pharmacies). INTERVENTIONS Think-aloud protocols and pharmacy group interviews. MAIN OUTCOME MEASURES Pharmacy staff descriptions of their use of e-prescribing technology and challenges encountered in their daily workflow related to this technology. RESULTS Two contributing factors were perceived to influence e-prescribing workflow: issues stemming from prescribing or transmitting software and issues from within the pharmacy. Pharmacies experienced both delayed and inaccurate e-prescriptions from physician offices. An overwhelming number of e-prescriptions with inaccurate or unclear information resulted in serious time delays for patients as pharmacists contacted physicians to clarify wrong information. In addition, lack of formal training and the disconnect between pharmacy procedures for verifying prescription accuracy and presentation of e-prescription information on the computer screen influenced the speed of processing an e-prescription. CONCLUSION E-prescriptions processing can hinder pharmacy workflow. As the number of e-prescriptions transmitted to pharmacies increases because of legislative mandates, it is essential that the technology supporting e-prescriptions (both on the prescriber and pharmacy operating systems) be redesigned to facilitate pharmacy workflow processes and to prevent unintended increase in medication errors, user frustration, and stress.

e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach

Objective To characterise the safety hazards related to e-prescribing in community pharmacies. Methods The sociotechnical systems framework was used to investigate the e-prescribing technology interface in community pharmacies by taking into consideration the social, technical and environmental work elements of a users interaction with technology. This study focused specifically on aspects of the social subsystem. Study design and setting The study employed a cross-sectional qualitative design and was conducted in seven community pharmacies in Wisconsin. Direct observations, think aloud protocols and group interviews were conducted with 14 pharmacists and 16 technicians, and audio recorded. Recordings were transcribed and subjected to thematic content analysis guided by the sociotechnical systems’ theoretical framework. Results Three major themes that may increase the potential for medication errors with e-prescribing were identified and described. The three themes included: (1) increased cognitive burden on pharmacy staff, such as having to memorise parts of e-prescriptions or having to perform dosage calculations mentally; (2) interruptions during the e-prescription dispensing process; and (3) communication issues with prescribers, patients and among pharmacy staff. Pharmacy staff reported these consequences of e-prescribing increased the likelihood of medication errors. Conclusions This study is the first of its kind to identify patient safety risks related to e-prescribing in community pharmacies using a sociotechnical systems framework. The findings shed light on potential interventions that may enhance patient safety in pharmacies and facilitate improved e-prescribing use. Future studies should confirm patient safety hazards reported and identify ways to use e-prescribing effectively and safely in community pharmacies.

Facilitating collaboration between pharmacists and physicians using an iterative interview process

OBJECTIVE To elicit and describe mutually agreed upon common problems and subsequent solutions resulting from a facilitated face-to-face meeting between pharmacists and physicians. DESIGN Descriptive, exploratory, nonexperimental study. SETTING Wisconsin from October to December 2011. PARTICIPANTS Physicians and community pharmacists. INTERVENTION Face-to-face semistructured interviews with pharmacists and physicians from the same community, informed by previous individual interviews. MAIN OUTCOME MEASURES Methods to enhance collaboration and barriers to implementing collaboration between pharmacists and physicians. RESULTS Physicians and pharmacists generated ideas in which collaboration could improve patient care, including controlled substance monitoring, medication adherence, collaborative practice agreements for point-of-service issues, and a mechanism for urgent communication. Methods on how to collaborate on these issues also were discussed. CONCLUSION Bringing physicians and pharmacists together for a face-to-face interaction that was informed by information gained in previous individual interviews successfully stimulated conversation on ways in which each profession could help the other provide optimal patient care. This interaction appeared to dispel assumptions and build trust. The results of this project may provide pharmacists with the confidence to reach out to their physician colleagues.