A Novel Simulation Program for Interprofessional Health Literacy Training.

Effective communication with patients and between members of the health care team are important strategies to enhance health care outcomes. Despite the prevalence of low health literacy and associated risks in the population, health professionals are often not trained adequately in health literacy communication practices. The purpose of this pilot program is to determine if offering learners an opportunity to practice health literacy communication techniques in a simulated patient care team can increase skills, attitudes, and confidence in this important area of patient care. We implemented a novel, team-based interprofessional Objective Structured Clinical Examination (iOSCE) focused on health literacy. Evaluation took place on three levels: student self-assessment of health literacy communication skills and beliefs about interprofessional teamwork, standardized patient assessment of skills during the clinical encounter, and observer assessment of interprofessional teamwork. Statistically significant gains were seen in students' health literacy communication confidence, as well as beliefs, attitudes and understanding of interprofessional teamwork. The aim of this article is to describe our pilot health literacy iOSCE findings. This pilot shows that an OSCE is an effective assessment tool for a mix of health professional learners at different levels to demonstrate health literacy practices in an interprofessional teamwork environment. [HLRP: Health Literacy Research and Practice. 2023;7(3):e139-e143.].

Developing Health Literacy Communication Practices for Medical Students.

Introduction: Health literacy and its associated communication practices are critical to patient-centered care and have been endorsed by various associations as important for health professional training. Unfortunately, there is little published literature on how to teach health literacy to medical students and health professionals. Methods: We developed a two-part curriculum during a required module for medical students including an introductory session in their first year and a skill-building workshop in their second year. In the workshop, students studied, observed, and practiced three health literacy communication techniques: teach-back, avoiding jargon, and effective questioning. Results: The workshop was implemented with approximately 100 second-year medical students as part of a course in their required curriculum. Results of a Wilcoxon rank sum test of pre/post survey responses showed a statistically significant move towards conviction of importance and confidence in ability to use three health literacy techniques. Discussion: A skills-based workshop on health literacy skills can improve medical students' conviction and confidence in using health literacy communication practices.

Pharmacist Intervention for Blood Pressure Control in Patients with Diabetes and/or Chronic Kidney Disease.

OBJECTIVES: The objectives of this study were to determine if hypertensive patients with comorbid diabetes mellitus (DM) and/or chronic kidney disease (CKD) receiving a pharmacist intervention had a greater reduction in mean blood pressure (BP) and improved BP control at 9 months compared with those receiving usual care; and compare Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guideline and 2014 guideline (JNC 8) BP control rates in patients with DM and/or CKD. METHODS: This cluster randomized trial included 32 medical offices in 15 states. Clinical pharmacists made treatment recommendations to physicians at intervention sites. This post hoc analysis evaluated mean BP and BP control rates in the intervention and control groups. MAIN RESULTS: The study included 335 patients (227 intervention, 108 control) when mean BP and control rates were evaluated by JNC 7 inclusion and control criteria. When JNC 8 inclusion and control criteria were applied, 241 patients (165 intervention, 76 control) remained and were included in the analysis. The pharmacist-intervention group had significantly greater mean systolic blood pressure reduction compared with usual care at 9 months (8.64 mm Hg; 95% confidence interval [CI] -12.8 to -4.49, p<0.001). The pharmacist-intervention group had significantly higher BP control at 9 months than usual care by either the JNC 7 or JNC 8 inclusion and control groups (adjusted odds ratio [OR] 1.97, 95% CI 1.01-3.86, p=0.0470 and OR 2.16, 95% CI 1.21-3.85, p=0.0102, respectively). PRINCIPAL CONCLUSIONS: This study demonstrated that a physician-pharmacist collaborative intervention was effective in reducing mean systolic BP and improving BP control in patients with uncontrolled hypertension with DM and/or CKD, regardless of which BP guidelines were used.

Advanced primary care in San Antonio: linking practice and community strategies to improve health.

Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels. Centered on patients' functional goals, promotores mobilize family and community resources and consider what community-level action will address the social determinants of health. On the clinical side, care teams implement population-based risk assessment and nurse care management with a focus on care transitions as well as other measures to meet the needs of patients with high morbidity and high use of health care. Population-based outcome metrics include reductions in hospitalizations, emergency department and urgent care visits, and the associated charges. Promotores also assess patients' progress along the trajectory of their selected functional goals.

Measuring diabetes care in the national interdisciplinary primary care practice-based research network (NIPC-PBRN).

STUDY OBJECTIVE: To assess diabetes care in a network of primary care practices that include pharmacist support by using a scoring system designed for the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program (DRP) measures. DESIGN: Retrospective medical record review. DATA SOURCE: Subset of the National Interdisciplinary Primary Care Practice-Based Research Network (NIPC-PBRN). PATIENTS: A total of 1309 adults who were seen at 17 practices for an outpatient diabetes mellitus visit between January 1 and June 30, 2008. MEASUREMENTS AND MAIN RESULTS: Patient demographic data and NCQA DRP process and outcome measures (hemoglobin A(1c) [A1C], blood pressure, and low-density lipoprotein cholesterol [LDL] level measurements; eye and foot examinations; nephropathy assessment; and smoking status and cessation advice or treatment) were recorded. Points for each measure were compiled, and practices achieving a sufficient score for NCQA recognition (≥ 75.0 points) were identified. Pharmacists were also surveyed regarding their services, participation in quality improvement initiatives, use of electronic medical records, and methods of data extraction. The relationships between DRP measures and quality improvement activities, pharmacist involvement in diabetes care, and use of electronic medical records were analyzed. The DRP outcome measures were satisfactory: mean ± SD A1C 7.6% ± 1.9%, LDL level 99.1 ± 35.1 mg/dl, and systolic and diastolic blood pressures 130.2 ± 18.1 and 74.4 ± 10.8 mm Hg, respectively. Five practices (29%) achieved a sufficient score for NCQA recognition. No significant relationships were noted between DRP measures and participation in quality improvement, type of clinical pharmacy services, or use of electronic medical records (p>0.05). In a regression analysis, only electronic medical record use was significantly related to DRP measures (p=0.02). CONCLUSION: Diabetes care in the NIPC-PBRN appears satisfactory, but improvements are necessary if NCQA recognition is the goal. Use of electronic medical records was associated with better DRP measures.

New quadrivalent HPV vaccine developments.

Human papillomavirus infection is the most prevalent sexually transmitted disease in the world and is responsible for cervical, vulvar, and vaginal cancers, as well as genital warts. A vaccine against HPV types 6, 11, 16, and 18 has been available since 2006 and has been approved for the prevention of cervical cancer, cervical precancers, and genital warts. Recently, the vaccine also received approval for the prevention of vulvar and vaginal cancers in women aged 9 to 26 years. Although Guillain-Barré syndrome and death have been reported in women who received the vaccine, an analysis of available data by the US Food and Drug Administration found no association between the vaccine and these adverse events. Since post-vaccination syncope is common among young women, providers should ensure that patients remain seated when vaccinated and under observation for at least 15 minutes following vaccination.

Human papillomavirus, cervical cancer, and the vaccines.

How are human papillomavirus (HPV), cervical cancer, and the recently developed HPV vaccines associated with each other? Human papillomavirus is a highly prevalent infection that is easily and unknowingly transmitted because of its asymptomatic nature and long incubation period. Infection requires skin-to-skin contact and is typically sexually transmitted. More than one-half of sexually active women acquire HPV, making it the most prevalent sexually transmitted disease. Cervical cancer ranks second in deaths from cancer among women in developing countries and kills nearly 4000 women in the United States annually. Several types of HPV have been strongly linked to causing cervical cancer and genital warts. Those causing cervical cancer are considered high-risk types and those causing genital warts are considered low-risk types. Until recently, prevention strategies included abstinence, condom usage, and early detection with a Papanicolaou test (Pap smear). New developments have led to 2 vaccines aimed at preventing the viral infection. One is a quadrivalent vaccine preventing infection from 4 HPV types (HPV types 6, 11, 16, and 18) (Gardasil). It is approved in the United States and Europe for the prevention of HPV-associated cervical cancers and genital warts in females between the ages of 9 and 26 years old. The second is a bivalent vaccine preventing infection from 2 high-risk oncogenic HPV types (HPV types 16 and 18) (Cervarix). It is currently under study and not yet available in the United States. Both vaccines have proven highly effective at preventing infection from their corresponding HPV types. Of importance, neither vaccine is to be used for treatment. Vaccination does not replace routine cervical cancer screening with Pap smears, as the vaccines do not protect against all HPV types.

Diabetic dyslipidemia: a practical guide to therapy.

Low-density lipoprotein (LDL) should be the primary target of lipid-lowering therapy for patients with diabetes. Because of their robust reduction of LDL, statins are considered the agents of choice for these patients. Triglyceride (TG) and high-density lipoprotein (HDL) levels are also important targets. Combination therapy with fibrates or niacin is common due to concurrent high TG and low HDL levels in these patients. Data supporting an LDL goal of <70 mg/dL for patients with diabetes are limited and contradictory at this time.

Formation of a primary care pharmacist practice-based research network.

PURPOSE: The results of a survey conducted to characterize participating practice sites, patient populations, and collaborative physician-pharmacist services provided through an emerging practice-based research network (PBRN) in the primary care setting are presented. METHODS: A targeted sample of faculty pharmacist investigators practicing in primary care settings were selected for participation in this PBRN based on several factors, including past research activities, their interest in soliciting additional clinics within their state to participate in a research network, the potential for regional collaboration, geographic location, and the patient population served. A baseline survey to characterize the PBRN was distributed to members of the PBRN in June 2006. Data were analyzed using descriptive statistics. RESULTS: A total of 81 pharmacists in 48 practice sites were recruited to join the PBRN. Most practice sites were located within family medicine residency programs, and the majority were affiliated with a community hospital or health system. Half of participating practices had 300-599 ambulatory care visits per week. Pharmacists in the PBRN spent their time performing direct patient management and had collaborative practice agreements with physicians. Patient revenue was used to cover pharmacist salaries in about one fifth of the practice sites. Pharmacists in the PBRN reported participation in diverse educational activities, such as point-of-care resident education and curbside consultation in the clinic hallways or their office. CONCLUSION: Eighty-one pharmacists from 48 primary care practice sites in 11 states were recruited to join a PBRN. These pharmacists provided descriptive data regarding their practice site, characteristics of patients served, and clinical services provided as a first step in collaborative research efforts.

Appropriate prescribing of medications: an eight-step approach.

A systematic approach advocated by the World Health Organization can help minimize poor-quality and erroneous prescribing. This six-step approach to prescribing suggests that the physician should (1) evaluate and dearly define the patient's problem; (2) specify the therapeutic objective; (3) select the appropriate drug therapy; (4) initiate therapy with appropriate details and consider nonpharmacologic therapies; (5) give information, instructions, and warnings; and (6) evaluate therapy regularly (e.g., monitor treatment results, consider discontinuation of the drug). The authors add two additional steps: (7) consider drug cost when prescribing; and (8) use computers and other tools to reduce prescribing errors. These eight steps, along with ongoing self-directed learning, compose a systematic approach to prescribing that is efficient and practical for the family physician. Using prescribing software and having access to electronic drug references on a desktop or handheld computer can also improve the legibility and accuracy of prescriptions and help physicians avoid errors.

Suboptimal medication use and mortality in an older adult community-based cohort: results from the Hispanic EPESE Study.

BACKGROUND: Numerous methods have been used to evaluate medication management quality in older adults; however, their predictive validities are unknown. Major medication quality indicators include polypharmacy, drug-drug interactions, and inappropriate medication use. To date, no study has attempted to evaluate the three approaches systematically or the effect of each approach on mortality in a Hispanic population. Our objective was to evaluate the relationship between polypharmacy, drug-drug interactions, and inappropriate medication use on the mortality of a community-based population of Mexican American older adults. METHODS: We used a life table survival analysis of a longitudinal survey of a representative sample of 3,050 older Mexican Americans of whom 1,823 were taking prescription and over-the-counter medications. RESULTS: After adjustment for relevant covariates, use of more than four different medications (polypharmacy) was independently associated with mortality. The presence of major drug interactions and the use of inappropriate medications were not significantly associated with mortality in our study sample. CONCLUSION: Polypharmacy (>4 medications) is significantly associated with mortality in Mexican American older adults. This community-based study is the first to demonstrate a direct association between polypharmacy and mortality in this population.

Correlates of medication knowledge and adherence: findings from the residency research network of South Texas.

BACKGROUND: Medication adherence is a complex phenomenon, influenced by a variety of factors. Most adherence research focuses on one medicine and does not represent the realities of clinical family medicine. This analysis examined factors associated with medication knowledge and adherence in family medicine patients with chronic conditions. METHODS: The Residency Research Network of South Texas (RRNeST) enrolled 150 patients with chronic disease who "sometimes have trouble taking medicines." Seventy-five percent were Latinos. This cross-sectional analysis used baseline survey data from an intervention study. Investigators correlated medication knowledge and adherence with known predictors--patient, health, medication, economic, and physician factors. New variables related to patients' motivation to change treatment behaviors ("importance" and "confidence") were also included. RESULTS: Linear regression analysis demonstrated that patient satisfaction, education level, and confidence were associated with better medication knowledge. Higher confidence, Spanish language, better functional and health status, and more prescription medicines were correlated with medication adherence. CONCLUSIONS: We recommend that family physicians enhance medication adherence by providing good information about treatment and counseling strategies to build patients' confidence. Our findings suggest that poor health status can be a barrier to, rather than a motivator for, treatment adherence.

Suggested guidelines for pharmacotherapy curricula in family medicine residency training: recommendations from the Society of Teachers of Family Medicine Group on Pharmacotherapy.

Rational drug use has increasingly received public policy attention in efforts to maintain quality health care at lower costs. Prescribing habits are developed during residency training, and education regarding rational drug use should be an integral part of the residency curricula. Considering that many medical errors in family medicine are related to incorrect medication management, there is need for a focused education in pharmacotherapy. This paper outlines suggested guidelines for pharmacotherapy curricula in family medicine residency training, as recommended by the Society of Teachers of Family Medicine Group on Pharmacotherapy. A pharmacotherapy curriculum should include common conditions managed in family medicine, as well as general principles of pharmacotherapy. This should allow for repeated exposure to core topics over a 3-year cycle and be delivered in various settings (didactic teaching, longitudinal active learning, point-of-care education, and rotations). The curriculum should apply and evaluate pharmacotherapy education according to the six core competencies of the Accreditation Council for Graduate Medical Education (ACGME). Although physician faculty can be responsible for pharmacotherapy education, a clinical pharmacist is uniquely qualified to provide this service. Overall, family medicine residents need comprehensive instruction in pharmacotherapy to develop rational prescribing habits. A structured pharmacotherapy curriculum may assist in achieving this goal and in meeting the ACGME core competencies for residency training.