Tina Penick Brock

A medication self-management program to improve adherence to HIV therapy regimens.

This study examined whether a self-management intervention based on feedback of adherence performance and principles of social cognitive theory improves adherence to antiretroviral dosing schedules. Forty-three individuals with HIV/AIDS who were starting or switching to a new protease inhibitor regimen were randomly assigned to be in a medication self-management program or usual care control group. The self-management program included skills development exercises, three monthly visits for medication consultations, and monthly feedback of adherence performance using electronic monitors on medication bottles. Participants also completed a 40-item questionnaire that measured self-efficacy to take medications, on schedule, in a variety of situations. Logistic regression analysis indicated that individuals in the self-management group were significantly more likely to take 80% or more of their doses each week than individuals in the control group (n=29, OR=7.8, 95% CI=2.2-28.1). Self-management training with feedback of adherence performance is a potentially useful model for improving adherence to complex regimens in HIV/AIDS care.

Using digital videos displayed on personal digital assistants (PDAs) to enhance patient education in clinical settings.

OBJECTIVES To evaluate the effects of using an audiovisual animation (i.e., digital video) displayed on a personal digital assistant (PDA) for patient education in a clinical setting. METHODS Quasi-experimental study of a prospective technology intervention conducted in an outpatient infectious diseases clinic at an academic medical center. Subjects responded to questions immediately before, immediately after, and 4-6 weeks after watching a digital video on a PDA. Outcome measures include participant knowledge of disease, knowledge of medications, and knowledge of adherence behaviors; attitudes toward the video and PDA; self-reported adherence; and practicality of the intervention. RESULTS Fifty-one English-speaking adults who were initiating or taking medications for the treatment of HIV/AIDS participated in the study. At visit one, statistically significant improvements in knowledge of disease (p<0.005; paired t-test), knowledge of medications (p<0.005; paired t-test), and knowledge of adherence behaviors (p<0.05; ANOVA) were measured after participants watched the PDA-based video. At visit two (4-6 weeks later), statistically significant improvements in self-reported adherence to the medication regimens (p<0.005; paired t-test) were reported. Participants liked the PDA-based video and indicated that it was an appropriate medium for learning, regardless of their baseline literacy skills. The video education process was estimated to take 25 min of participant time and was viewed in both private and semi-private locations. CONCLUSIONS Technology-assisted education using a digital video delivered via PDA is a convenient and potentially powerful way to deliver health messages. The intervention was implemented efficiently with participants of a variety of ages and educational levels, and in a range of locations within clinical environments. Additional study of this methodology is warranted.

An Evaluation of Smoking Cessation-Related Activities by Pharmacists

OBJECTIVES To (1) describe the types of smoking cessation intervention activities performed by community pharmacists and (2) assess the perceived barriers to this type of intervention. DESIGN Confidential mail questionnaire. SETTING AND PARTICIPANTS 541 community pharmacists in North Carolina and 946 community pharmacists in Texas. RESULTS North Carolina and Texas differ with respect to the sale of cigarettes at the practice site, with North Carolina pharmacies being more likely to sell tobacco products. Overall, 555 (92.5%) respondents reported that they do not routinely ask new patients if they smoke or use tobacco products. Pharmacists described themselves as knowledgeable about smoking cessation therapies, and 42% of respondents had attended an educational program on smoking cessation. A total of 230 (39.5%) reported consistently counseling individual patients about smoking cessation treatment strategies on at least a weekly basis. Exploratory factor analysis identified four dimensions of barriers that inhibit pharmacists from engaging in smoking cessation-related activities: (1) pharmacist interpersonal characteristics, (2) practice site considerations, (3) patient characteristics, and (4) financial concerns. CONCLUSION Pharmacists have an opportunity to identify health risks and counsel patients about disease-preventing lifestyle changes. These findings suggest that although pharmacists believe they are qualified to perform smoking cessation interventions, they do not routinely identify smokers and they perceive several barriers to participating in such activities. Pharmacists should investigate increased involvement in smoking cessation activities for the benefit of their patients and for the potential professional and economic rewards.

Impact of Pharmacist-Led Community Bone Mineral Density Screenings

BACKGROUND: Osteoporosis-associated fractures burden both individuals and the overall healthcare system. Bone mineral density (BMD) screening remains the gold standard measure for identifying patients at risk. OBJECTIVE: To determine the impact of convenient, pharmacist-led BMD screening and counseling sessions on identification and education of patients at risk for or with osteoporosis. METHODS: Nonpregnant persons >18 years of age were eligible for enrollment in this descriptive study. At an urban retail pharmacy, participants underwent risk factor assessment, peripheral BMD scanning, and personalized counseling. At 3 and 6 months after screening, subjects were questioned by telephone regarding any subsequent primary care provider (PCP) interactions, as well as any behaviors initiated and/or medications modified. RESULTS: Of the 102 subjects screened, 22.6% and 11.7% were identified as being at medium risk (T score −1.0 to −2.5) and high risk (T score −2.5 or less) for osteoporosis, respectively. By 6 months, 42.5% of the participants reported increasing their dietary intake of calcium, 29.3% began or increased calcium supplements, and 54.9% positively modified smoking status, exercise level, alcohol consumption, or caffeine intake. Additionally, 24 of 52 subjects who had discussed their results with a PCP by 6 months also received a treatment recommendation. Eighty-nine participants reported the community location increased their likelihood of receiving a BMD scan. CONCLUSIONS: Overall, pharmacist-led BMD screenings that include individualized counseling sessions appear convenient, accessible, and beneficial for patients. With the establishment of clinical benefit of and positive reception to such screenings, pharmacists can now look toward securing consistent reimbursement for this vital pharmaceutical care service.

Needs-Based Education in the Context of Globalization

While opinion leaders in developed countries are calling for curricula to prepare students for specialized areas of pharmacy,1-4 developing countries are seeking patient-centered curricula and public health pharmacy to meet their changing health environments.5 In addition, there may be specific needs, especially in settings where tertiary pharmacy education has not been in place previously.6

Health Care Education Must Be More of a Team Sport

I am a member of a team, and I rely on the team, I defer to it and sacrifice for it, because the team, not the individual, is the ultimate champion. –Mia Hamm1 Much dialogue in pharmacy is associated with the things that serve to divide us worldwide. Academics discuss the differences in our disciplines (eg, biomedical sciences, clinical sciences, social/behavioral sciences). Practitioners discuss the differences in our practice sites (eg, community, health system, industry). Accreditors discuss the differences in our degree programs (eg, BPharm, MPharm, PharmD). Professional bodies discuss different perceptions of requirements for entry-level patient care (eg, licensure/registration, residency, board certification). Policy-makers discuss differences in the scope of the work we do (eg, advanced practice pharmacist/APP, clinical pharmacist practitioner/CPP, pharmacist/clinician/PhC). For a relatively small profession, we spend a great deal of time differentiating ourselves from one another in ways that don’t provide optimal role modeling for our students and are likely confusing to those outside of pharmacy. The “insider-outsider” patterns we use to classify the world are inherited from our culture as a sociological phenomenon described in The Silo Effect: The Peril of Expertise and the Promise of Breaking Down Barriers.2 Author Gillian Tett writes that because these divisive patterns exist at the borders of our consciousness, they seem “natural” and we rarely even notice them. This may also suggest that our educational systems unintentionally reinforce such patterns. And just as these intraprofessional silos have contributed to tunnel vision, they also have led to normalization of interprofessional tribalism, which is complicated by the increasing use of technologies in health and education. Indeed, for a nightmare-inducing example of this, read “The Overdose” section in The Digital Doctor: Hope, Hype, Harm at the Dawn of Medicine’s Computer Age, where a text message from a pharmacist in a disconnected system is described as “a lit match dropped onto the dry forest floor.”3 Moreover, relationships matter. To help break this silo mentality, the International Pharmaceutical Federation (FIP) published a report on interprofessional education (IPE), the intent of which was to focus on values and approaches that could not only unite us within our profession but also connect us to those in other professions.4 Indeed, all health professionals have a sustained, compelling need to work together in collaborative teams for the benefit of patients. Operationalizing this is one of the most important problems educators will face in the next decade. Training health professionals to work together is not a new concept. In 1972, the Institute of Medicine (IOM) issued a report called Educating for the Health Team based on the first time that leaders of the five major health professions had come together at a national meeting to examine what was then called interdisciplinary education and practice.5 This report was followed by a steady stream of supporting work from IOM, Pew Health Commission, Institute for Healthcare Improvement, Josiah Macy, Jr. Foundation, Robert Wood Johnson Foundation, World Health Organization, The Lancet Commission, and others.4 Despite the window of opportunity afforded by the major changes in curricular format for pharmacy in key countries in the last two decades (eg, entry-level PharmD in US), many of the recommendations from the 1972 IOM report are still aspirational today. Although some advances have been made (eg, we now have a national clearinghouse), many would argue that there is still a significant gap between where we are today and the high functioning teams required for consistently delivering comprehensive, effective, and compassionate care. This highlights an important perspective. Pharmacy appears to be entering another period of major curricular change, with programs that last made broad updates during their transition to the entry-level PharmD degree. This means we have another chance to prioritize IPE. Because of new guidance (eg, Accreditation Council for Pharmacy Education (ACPE) Standards 2016, Center for the Advancement of Pharmacy Education (CAPE) 2013 Outcomes, General Pharmaceutical Council Standards 2011) and new professional and accreditation collaborations (eg, Interprofessional Education Collaborative, Health Professions Accreditors Collaborative), we now have a stronger foundation on which to build this priority. The truth is that most of the “add-on” time in our curricular and cocurricular space is full. Further, our learners are savvy enough to see that when IPE activities are inserted into nooks and crannies, they don’t translate as “real” curriculum. To make interprofessional instruction convincing will mean profound changes in the classroom and clinical and organizational arenas. We must be willing to build the IPE skeleton first, and this may mean sacrificing some good things for the chance to build some great things. And although evidence regarding the impact of IPE on patient outcomes is still emerging, we have an ethical responsibility to contribute to this. It’s time to play smarter. To be sure, the challenges of logistics, funding, cultures, and general reluctance for change are no less complicated today than they were in 1972. Perhaps these challenges can never truly be overcome, and yet creative educational leaders must find effective ways to work around them. In the US education system, proximity to other health professions students for authentic, patient-facing collaboration is a problem—yet innovations from new and flexible programs without colocation are becoming more visible.6 As the FIP report shows, there are promising innovations from programs all over the world.4 While much of the published IPE literature comes from Australia, Canada, the United Kingdom, and the United States, there has been progress in IPE throughout all of the WHO regions. In fact, in countries such as Lebanon, Namibia, and the Philippines, programs are taking bold approaches to IPE. In some cases, these activities have become so interwoven in the pharmacy curricula, they no longer have to be labeled as separate curricular entities. There is much we can learn from these collaborations. To be able to contribute responsibly and accountably to team-based care, we not only need to model a different pharmacist practitioner, but we may also need to recruit a different kind of pharmacy student and develop a different kind of instructor. Schools are beginning to report including teamwork assessments as part of multiple mini-interview models,8 but we could find no published reports of admissions that include an interprofessional assessment. Students who come into pharmacy based on their individual performance must be intentionally taught to value team performance. And this team training must spiral through the curriculum to include classroom, experiential, and cocurricular activities. Some have suggested that because most faculty members came up in a system that emphasized personal autonomy and independence, we are part of both the problem and the solution.7 We must identify and encourage IPE innovators and early adopters in our programs. Endowed chairs, seed grants for IPE, and support to complete formal IPE teaching programs are a start. To encourage wider adoption of IPE, we will need to change the faculty incentive structure to prioritize collaboration, perhaps recognizing an IPE “extra credit” to motivate students and recognizing the importance of IPE in the faculty promotion and tenure process. Finally, to advance this conversation we need to move beyond the days of participating primarily in single profession gatherings. Even more ironic than a lecture on active learning is a pharmacist telling other pharmacists how much other team members value their contributions. Although combined meetings such as Collaborating Across Borders and All Together Better Health have grown in popularity, and the IPEC sessions are almost always oversubscribed, it’s going to take rethinking the efficacy of single profession organizations—in the educator, practitioner, and student arenas—if we are to prioritize collaboration. A compelling piece in the Journal of Interprofessional Education and Practice suggests that it is indeed time for an interprofessional professional society.9 What an unselfish and flexible proposition!

A Nontraditional Faculty Development Initiative Using a Social Media Platform

Objective. To assess the outcomes from an 11-year nontraditional professional development activity implemented by female faculty members at several colleges and schools of pharmacy. Design. Within the context of an online fantasy football league, faculty members practiced community-based faculty development strategies, including peer mentoring, skills development, constructive feedback and other supportive behaviors. Assessment. Data were extracted from curriculum vitae to characterize the academic progress of participants and to quantify scholarly work collaborations among league members. Analyses were limited to members who had participated in the league for 10 or more consecutive years. Seventy-one collaborative scholarly works occurred among team managers, including presentation of 20 posters and 2 oral presentations at national or international meetings, publication of 29 peer-reviewed articles and 15 book chapters, and funding of 5 research projects. Conclusion. Social media platforms can foster nontraditional faculty development and mentoring by enhancing connectivity between pharmacy educators who share similar interests.

Barriers to medication taking among Kuwaiti patients with type 2 diabetes: A qualitative study

Background Nonadherence to medications among Kuwaitis with type 2 diabetes mellitus (T2DM) is believed to be a major barrier to appropriate management of the disease. Published studies of barriers to medication adherence in T2DM suggest a Western bias, which may not adequately describe the Kuwaiti experience. Aim The purpose of this study was to explore barriers to medication adherence among Kuwaiti adults with T2DM. Methods Semi-structured interviews were conducted with 20 Kuwaiti patients with type 2 diabetes. The interviews were digitally recorded, transcribed, and analyzed using thematic analysis. Results Barriers to medication adherence were identified. Emerging themes were: 1) lack of education/awareness about diabetes/medications, 2) beliefs about medicines/diabetes, 3) spirituality and God-centered locus of control, 4) attitudes toward diabetes 5) perceptions of self-expertise with the disease and body awareness, 6) social stigma, 7) perceptions of social support, 8) impact of illness on patient’s life, 9) perceptions of health care providers’ attitudes toward patients, and 10) health system-related factors, such as access difficulties and inequalities of medication supply and services. Conclusion Personal, sociocultural, religious, health care provider, and health care system-related factors may impede medication adherence among Kuwaitis with type 2 diabetes. Interventions to improve care and therapeutic outcomes in this particular population must recognize and attempt to resolve these factors.

Accuracy of Float Testing for Metered-Dose Inhaler Canisters

OBJECTIVE To characterize and evaluate canister floating patterns of three commercially available metered-dose inhalers (MDIs) with varying amounts of medication remaining. DESIGN Four canisters each of three asthma medications were studied. MDIs were actuated every 30 seconds to 60 seconds, and canisters were weighed and floated at 100%, 75%, 66%, 50%, 33%, 25%, 10%, and 0% of remaining labeled actuations. Position of the canisters and percentage submersion in water were recorded. SETTING Controlled laboratory. RESULTS We observed differences among the products with regard to canister floating behavior at varying levels of fullness. All canisters were completely submerged with the nozzle up at two-thirds full and greater. The canisters remained nozzle-up and were submerged to varying levels at the half-full point. When observed at less than half full, canisters inverted and floated nozzle down. Positions of the canisters varied among products at less than half full. No canister was fully tilted when all labeled actuations were used. CONCLUSION Float characteristics are product-specific and a function of canister size, design, content, and method of testing. Clinicians and asthma educators should not advise patients to use a float test to assess the amount of medication remaining in an MDI. Recommendations from the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute suggest that the only reliable method for determining the number of doses remaining in a canister is to subtract the number of doses used from the number available.

Assessment of the readability and comprehensibility of a CFC-transition brochure

BACKGROUND In anticipation of public confusion about the availability of medications during the metered-dose inhaler CFC phaseout period, a multidisciplinary effort has resulted in the development of a brochure designed to educate patients and health care providers about the health consequences of ozone depletion and the transition to CFC-free inhaled products. This brochure is the subject of this assessment. OBJECTIVES The primary purpose of this study was to estimate the grade of reading difficulty of a brochure designed to educate patients about the change to CFC-free inhalation products. A secondary objective was to assess baseline knowledge of patients concerning CFC transition and their comprehension of this issue after reading the brochure. METHODS Standard readability formulae were used to assess the grade level of the CFC transition brochure. In addition, baseline knowledge of the CFC transition process and comprehensibility of the brochure were measured via a 2-page questionnaire. RESULTS The SMOG, Rix, and Flesch-Kincaid tests yielded readability at grade levels of 14, 10, and 10.4, respectively. The survey indicated that even after reading the brochure, many patients had concerns about the transition process. CONCLUSIONS These results suggest that the readability of the brochure entitled Your Metered-Dose Inhaler Will Be Changing... Here Are the Facts...may not be appropriate for a large segment of the population for whom it is intended. Further, the comprehensibility assessment suggests that many patients are either unaware of or unable to understand the impending changes to their inhaled therapies.