Nathaniel M. Rickles

Pharmacist Telemonitoring of Antidepressant Use: Effects on Pharmacist-Patient Collaboration

OBJECTIVE To explore the impact of telephone-based education and monitoring by community pharmacists on multiple outcomes of pharmacist-patient collaboration. DESIGN A randomized, controlled, unblinded, mixed experimental design. SETTING Eight Wisconsin community pharmacies within a large managed care organization. PATIENTS A total of 63 patients presenting new antidepressant prescriptions to their community pharmacies. INTERVENTIONS Patients were randomized to receive either three monthly telephone calls from pharmacists providing pharmacist-guided education and monitoring (PGEM) or usual pharmacists care. Usual care is defined as that education and monitoring which pharmacists may typically provide patients at the study pharmacies. MAIN OUTCOME MEASURES Patients frequency of feedback with the pharmacist, antidepressant knowledge, antidepressant beliefs, antidepressant adherence at 3 and 6 months, improvement in depression symptoms, and orientation toward treatment progress. RESULTS Of the 60 patients who completed the study, 28 received PGEM and 32 received usual pharmacists care. Results showed that PGEM had a significant and positive effect on patient feedback, knowledge, medication beliefs, and perceptions of progress. There were no significant group differences in patient adherence or symptoms at 3 months; however, PGEM patients who completed the protocol missed fewer doses than did the usual care group at 6 months (P < or = .05). CONCLUSION Antidepressant telemonitoring by community pharmacists can significantly and positively affect patient feedback and collaboration with pharmacists. Longer-term studies with larger samples are needed to assess the generalizability of findings. Future research also needs to explore additional ways to improve clinical outcomes.

Reflection and Analysis of How Pharmacy Students Learn to Communicate About Medication Errors

Medication errors are a serious and costly problem. This study focuses on the socialization of pharmacy students regarding medication errors. The qualitative interview protocol contained 28 questions on topics such as communication-related medication errors and training on how to handle medication errors. In-depth interviews were conducted with 44 students enrolled in a 6-year entry-level pharmacy program. Five main themes emerged regarding medication errors and communication: (a) pressure to be perfect, (b) feeling comfortable talking about mistakes, (c) assuming and communicating responsibility for mistakes, (d) learning how processes can contribute to errors and their prevention, and (e) inadequate and inconsistent training on how to handle medication errors. Study results indicate that pharmacy students experience both incomplete and inconsistent socialization to the role of communication in medication errors and in their prevention.

Adherence: a review of education, research, practice, and policy in the United States

Objective To describe the education, research, practice, and policy related to pharmacist interventions to improve medication adherence in community settings in the United States. Methods Authors used MEDLINE and International Pharmaceutical Abstracts (since 1990) to identify community and ambulatory pharmacy intervention studies which aimed to improve medication adherence. The authors also searched the primary literature using Ovid to identify studies related to the pharmacy teaching of medication adherence. The bibliographies of relevant studies were reviewed in order to identify additional literature. We searched the tables of content of three US pharmacy education journals and reviewed the American Association of Colleges of Pharmacy website for materials on teaching adherence principles. Policies related to medication adherence were identified based on what was commonly known to the authors from professional experience, attendance at professional meetings, and pharmacy journals. Results Research and Practice: 29 studies were identified: 18 randomized controlled trials; 3 prospective cohort studies; 2 retrospective cohort studies; 5 case-controlled studies; and one other study. There was considerable variability in types of interventions and use of adherence measures. Many of the interventions were completed by pharmacists with advanced clinical backgrounds and not typical of pharmacists in community settings. The positive intervention effects had either decreased or not been sustained after interventions were removed. Although not formally assessed, in general, the average community pharmacy did not routinely assess and/or intervene on medication adherence. Education National pharmacy education groups support the need for pharmacists to learn and use adherence-related skills. Educational efforts involving adherence have focused on students’ awareness of adherence barriers and communication skills needed to engage patients in behavioral change. Policy Several changes in pharmacy practice and national legislation have provided pharmacists opportunities to intervene and monitor medication adherence. Some of these changes have involved the use of technologies and provision of specialized services to improve adherence. Conclusions Researchers and practitioners need to evaluate feasible and sustainable models for pharmacists in community settings to consistently and efficiently help patients better use their medications and improve their health outcomes.

Methodological issues in pharmacotherapy research in older adults.

BACKGROUND The shifting of demographics to an aging society with multiple chronic illnesses and increased heterogeneity has created an undeniable imperative regarding the knowledge about pharmacotherapy in older patients, especially because older adults have a higher rate of medication use compared with the general population. More research on pharmacotherapy in older adults is needed to maximize not only the appropriate use of medications but also the benefits of available treatments in this historically underrepresented group. Investigators face many challenges that may greatly affect the outcomes of research on pharmacotherapy in older adults. OBJECTIVE This commentary discusses the common challenges of research on pharmacotherapy in older adults and provides strategies to overcome such challenges. METHODS The following databases were searched for examples of concepts (dates: 1976-September 14, 2010; key terms: research [in the title], aged, elderly, older adult, and geriatric): PubMed, Cumulative Index to Nursing and Allied Health Literature Database (CINAHL), Family & Societal Studies Worldwide, Womens Studies International, Academic Search Premier, Health Source: Academic/Nursing Edition, ISI Web of Knowledge, International Pharmaceutical Abstracts, PsycInfo, and Social Work Abstracts. RESULTS There are several methodological challenges related to study design, including the measurement of outcomes and the analytical plan; study implementation, such as the recruitment of sites and individuals; the informed-consent process; retention; and other practical considerations. A crucial area to consider is the measurement of medication adherence, both as an independent factor and as a confounder. Many challenges of research in older patients reflect the complexities of the aging process, including psychosocial consequences, and the resultant effects on study participation and outcomes. CONCLUSION It is hoped that the recommendations provided will help researchers and clinicians overcome the methodological challenges of conducting research on pharmacotherapy in older adults, thereby fostering more studies that critically evaluate pharmacotherapy and medication-management services and maximizing treatment outcomes in older adults.

A multi-theoretical approach to linking medication adherence levels and the comparison of outcomes

BACKGROUND There has been relatively little theoretical research exploring the cognitive complexity of how patients decide the level to which they adhere to prescribed regimens. OBJECTIVES To integrate various psychosocial theories into a conceptual framework to review how patients relate their medication use behavior to therapeutic outcomes and how such relationships affect subsequent medication use. METHODS Key psychosocial theories were reviewed involving health beliefs and medication adherence, individual control, and how individuals might compare outcomes with expectations and alternatives. These concepts were integrated into one larger multilevel explanatory model, the Dynamic Exchange Model for Medication Adherence Levels and Comparison of Outcomes (DEMMALCO), explaining how patients might attribute outcomes related to their medication use and choose future actions based on expectations and alternatives available. Key assumptions of the model were also identified. RESULTS DEMMALCO indicates that patients make initial attributions of their control over their illness, which affects their subsequent adherence to their regimens. The model suggests that patients actively compare their treatment outcomes with their expectations about outcomes and the outcomes that are related to their best alternative. They are thought to reassess how their control in treatment was related to those outcomes and subsequently modify their adherence behavior based on the presence or absence of resources. CONCLUSIONS Strengths and limitations of the model are noted. DEMMALCO may help inform researchers and clinicians on new ways to conceptualize, monitor, and change medication adherence behavior.

Teaching Medication Adherence in US Colleges and Schools of Pharmacy

Objective. To determine and describe the nature and extent of medication adherence education in US colleges and schools of pharmacy. Methods. A mixed-methods research study was conducted that included a national survey of pharmacy faculty members, a national survey of pharmacy students, and phone interviews of 3 faculty members and 6 preceptors. Results. The majority of faculty members and students agreed that background concepts in medication adherence are well covered in pharmacy curricula. Approximately 40% to 65% of the students sampled were not familiar with several adherence interventions. The 6 preceptors who were interviewed felt they were not well-informed on adherence interventions, unclear on what students knew about adherence, and challenged to provide adherence-related activities for students during practice experiences because of practice time constraints. Conclusions. Intermediate and advanced concepts in medication adherence, such as conducting interventions, are not adequately covered in pharmacy curriculums; therefore stakeholders in pharmacy education must develop national standards and tools to ensure consistent and adequate medication adherence education.

Medication adherence communications in community pharmacies: A naturalistic investigation

OBJECTIVE To describe the extent of pharmacy detection and monitoring of medication non-adherence, and solutions offered to improve adherence. METHODS Participants were 60 residents of the Boston area who had a generic chronic medication with 30 day supplies from their usual pharmacy. Participants received a duplicate prescription which they filled at a different pharmacy. For 5 months, participants alternated between the two pharmacies, creating gaps in their refill records at both pharmacies but no gaps in their medication adherence. Participants followed a scripted protocol and after each pharmacy visit reported their own and the pharmacy staffs behavior. RESULTS Across 78 unique community pharmacies and 260 pharmacy visits, pharmacies were inconsistent and inadequate in asking if participants had questions, discussing the importance of adherence, providing adequate consultations with new medication, and detecting and intervening on non-adherence. Insurers rarely contacted the participants about adherence concerns. CONCLUSION There is a need for more structured intervention systems to ensure pharmacists are consistently and adequately educating patients and detecting/managing potential medication non-adherence. PRACTICE IMPLICATIONS The present study calls for more attention to building infrastructure in pharmacy practice that helps pharmacists more consistently identify, monitor, and intervene on medication adherence.

Pharmacy Student Attitudes and Willingness to Engage in Care with People Living with HIV/AIDS

Objective. To describe the extent to which pharmacy students hold negative attitudes toward people living with HIV/AIDS (PLWHA) and to determine whether background variables, student knowledge, and professional attitudes may affect willingness to care for PLWHA. Methods. An online survey tool was developed and administered to 150 pharmacy students in their third professional year. Descriptive and stepwise multivariate regressions were performed. Results. While descriptive results showed a majority of respondents had favorable professional attitudes towards caring for PLWHA, most pharmacy students expressed discomfort with specific attitudes about being in close physical contact and receiving selected services from PLWHA. Multivariate results revealed that: (1) being a minority predicted greater knowledge; (2) having received prior HIV instruction and greater HIV knowledge predicted more positive professional attitudes caring for PLWHA; (3) being more socially liberal, having more positive professional attitudes caring for PLWHA, and having greater empathy towards PLWHA predicted student willingness to provide services. Conclusion. Future educational interventions specifically targeted toward socially conservative whites may impact greater student willingness to care for PLWHA. Additional research should also explore the generalizability of the present findings and modeling to pharmacy students in other regions of the country.

Forming Strong Collaboration Among Academic Researchers, Pharmacies, and Integrated Delivery Systems

To the Editor. In 2012, the National Association of Chain Drugs Stores Foundation announced a grant opportunity for research investigating how community-based medication management services, specifically services integrated into patient-centered medical homes (PCMHs) or accountable care organizations (ACOs), affect patient health outcomes. While 61 applicants sent in a letter of intent (LOI) for this grant, only 44 then sent in a full grant proposal. While attrition generally occurs between the time that LOIs are submitted and full proposals are completed, this was surprising given that this is a timely and important topic for academic pharmacy researchers because of the current focus on delivery system reform. The intent of this discussion is to understand why some faculty investigators were successful in submitting proposals while others were not. A better understanding of the facilitators and barriers to the submission of full proposals will help the academic community identify ways to resolve the barriers and support the mechanisms that make completed proposals and subsequent scholarship more likely. To achieve this understanding, a brief survey was sent to 17 principal investigators who completed the LOI only and 44 principal investigators who completed a full grant proposal (FGP). We received 5 (29.4%) surveys from the LOI-only group and 19 (43%) surveys from the FGP group. The lack of response to our survey from the LOI-only group was likely because of a lack of continued interest in pursuing this grant opportunity. The request for proposals (RFPs) encouraged research teams to develop a broad array of partners to promote success and scalability of the evaluation. A commonality among those who completed a grant proposal was a prior existing relationship between the partners, including the academic institution, community pharmacies, PCMH/ACO, and others. Additionally, initiation of the grant proposal process among respondents in the FGP was facilitated by academic institutions (47%), the pharmacy (32%), and the PCMH/ACO and other organizations (21%). Slightly more than half of the FGP applicants indicated no relationship with an insurer existed prior to starting the proposal, and nearly all of these individuals submitted the proposal without such partners. The 5 respondents in the LOI-only group indicated: (1) the grant being initiated by the academic institution, (2) not having prior research experience with the pharmacy or ACO/PCMH, and (3) prior experience with community partners being limited to student experiential sites as opposed to past research or shared faculty. Most FGP respondents indicated that little to moderate efforts were involved in getting their partners to participate in the grant development. However, most LOI-only respondents indicated it took moderate to significant effort to get the ACO/PCMH partner to participate. FGP and LOI-only participants reported the 2 biggest barriers were time needed to develop the proposal and data accessibility and sharing between the partners. The LOI-only group identified the lack of financial support from the academic institution as a barrier to completing the proposal, while the FGP group did not. Finally, FGP respondents indicated that having ready access to partners and the university’s research infrastructure were important to their submission. Access to partners and institutional research support were key barriers to submission for the LOI-only group. The quality of an institution’s research infrastructure and the time available to faculty members to work on grants may be critical factors affecting how quickly research teams can address time-sensitive RFPs. The responses from both groups indicated that success was potentially driven by existing relationships and the support of an institution. The respondents did indicate that certain aspects of institutional support, such as a research office, were helpful in timely completion of an RFP. Institutions wanting to compete for grant proposals involving pharmacies and community partners should proactively develop relationships with partners early and not wait to enter into such relationships when funding opportunities become available. This analysis of grant proposal submissions is helpful in highlighting the research needs of academic-community pharmacy partnerships. We need to remove the identified barriers to ensure researchers, community pharmacists, and other partners can successfully participate in innovative research efforts. A larger, more formal analysis should be conducted to confirm findings and identify support systems to allow research groups with viable innovative ideas but weak research infrastructures and relationships to advance to stages of fundable research applications. One support system, the American Association of Colleges of Pharmacy, should continue to help faculty researchers at institutions with less-developed research infrastructures find internal institutional solutions and form partnerships with other pharmacy programs with stronger research infrastructures. Multi-institutional efforts that combine weak and strong research environments may help strengthen competitive ideas and provide funding to places previously without any support.

Management of Medicare Part D Prescription Drug Plans and Medication Adherence: A Conceptual Framework and Empirical Analysis.

Background: Although contractors that offer prescription drug plans through the Medicare Part D program are evaluated in part on enrollees’ medication adherence scores, little evidence addresses contractors’ ability to influence these scores. Objective: We used data from the Centers for Medicare and Medicaid Services and US Census to investigate contractors’ ability to influence their medication adherence scores. In accordance with a conceptual model, we hypothesized that contractors can directly and indirectly influence their medication adherence scores based on how effectively they manage prescription drug benefits for enrollees. We focused on 4 plan management variables: service reliability, stability/accuracy of drug prices, accessibility of prescription drugs, and availability of drug information. We examined indirect effects via enrollees’ satisfaction with the plan. Research Design: We conducted a cross-sectional study based on 2012 data for which the contractor was the unit of analysis. We conducted path regression models that accounted for plan type (ie, Medicare Advantage vs. stand alone) and enrollee characteristics. Results: Among contractors, enrollee satisfaction scores were positively and significantly associated with medication adherence scores. Two of the 4 plan management variables were observed to have both direct and indirect effects on medication adherence scores: accessibility of prescription drugs and service reliability. Conclusions: Our study indicates that Part D contractors do appear to have some level of influence over their medication adherence scores based on how effectively they manage prescription drug benefits for enrollees. Accessibility to prescriptions and better service delivery appear important in this regard and should be explored further in future research.