Preliminary Investigation of Pharmacist-Delivered, Direct-to-Provider Interventions to Reduce Co-Prescribing of Opioids and Benzodiazepines among a Medicare Population.

Co-prescribing of opioids and benzodiazepines can lead to overdoses and mortality. This retrospective study analyzed prescription claims data collected in 2016. A national medication therapy management (MTM) program conducted prescriber-based outreach interventions for patients with concurrent opioid and benzodiazepine prescriptions. The pharmacist's direct-to-prescriber intervention was conducted following a targeted medication review. The pharmacist initiated interventions with the prescriber via facsimile to recommend discontinuation of concurrent use of these drugs. This study included 57,748 subjects who were predominantly female (67.83%) and aged ≥ 65 years (66.90%). Prescribers were most commonly located in the southern United States (46.88%). The top prescribed opioid medications were hydrocodone-acetaminophen (33.60%), tramadol (17.50%), and oxycodone-acetaminophen (15.66%). The top benzodiazepines prescribed concurrently with opioids were alprazolam (35.11%), clonazepam (21.16%), and lorazepam (20.09%). Based on the pharmacists' recommendations, 37,990 (65.79%) resulted in a medication discontinuation (benzodiazepines 40.23%; opioids 59.77%) by the provider. There were significant differences in the proportion of opioids discontinued by subject age (p < 0.001) and prescriber geographical region (p = 0.0148). The top medications discontinued by the prescriber were hydrocodone-acetaminophen (18.86%), alprazolam (14.19%), and tramadol HCl (13.51%). This study provides initial evidence for pharmacist-supported, direct-to-prescriber programs as an effective medication safety strategy.

Understanding reasons for nonadherence to medications in a medicare part d beneficiary sample.

BACKGROUND: Poor medication adherence is a predictor of poor health outcomes, especially in populations with chronic diseases. Although several self-reported measures of medication adherence exist, the scope of each is limited.  OBJECTIVE: To identify barriers to medication adherence in order to facilitate effective delivery of telephone-based medication therapy management (MTM) services to beneficiaries of contracted Medicare Part D plans. METHODS: This study used a cross-sectional telephone-based questionnaire designed to elicit reasons for low medication adherence. Patients were eligible to participate if they were identified as nonadherent for an antilipidemic, antihypertensive, or antidiabetic agent. Nonadherence was defined as less than 80% of proportion of days covered (PDC). The questionnaire included 17 items pertaining to medication use and 3 demographic items. Data were collected between September 2012 and February 2013. Data analyses included descriptive statistics and Rasch analyses. RESULTS: A total of 124 patients participated in the telephone survey. Of those completing the survey, the majority were patients (97.6%); only 3 surveys (2.4%) were completed by caregivers. The sample population had a mean age of 69.8 years (SD = 9.9), and more than half of participants (60.4%) were female. Nineteen percent of respondents received their medications by mail. Medication nonadherence generated alerts mostly associated with antilipidemic agents (n = 50, 40.3%), followed by antihypertensive drugs (n = 36, 29.0%), and antidiabetic medications (n = 23, 18.5%). The response categories for medication belief items were collapsed from 4 to 3 categories to achieve acceptable Rasch model fit (to fit the model and approximate interval level data). Ten percent of participants reported having medications prescribed either that they did not get or that they obtained but did not use. Almost 30% of patients reported having medications prescribed that they started using but stopped. However, only 4% of patients reporting adherence issues were related to the alert triggering for chronic medications; 96% of reports were linked to unrelated medications that did not generate an alert. The most common reason cited for medication nonadherence was experiencing side effects. CONCLUSIONS: Most participants reported positive beliefs about medications and did not report adherence issues related to those triggering alerts. MTM programs offer potential solutions to a number of barriers to medication adherence and a unique opportunity to raise awareness about the importance of medication adherence among members.

Evaluation of prescriber responses to pharmacist recommendations communicated by fax in a medication therapy management program (MTMP).

BACKGROUND: As defined by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, medication therapy management programs (MTMPs) must be designed to decrease adverse drug events and improve patient outcomes by promoting appropriate medication use. WellPoint Inc. contracted with the pharmacist-run University of Arizona College of Pharmacy Medication Management Center (UA MMC) to provide a pilot telephone-based MTMP to approximately 5,000 high-risk beneficiaries from among its nearly 2 million Medicare prescription drug plan (PDP) beneficiaries. Eligibility for the program was determined by a minimum of 2 of 6 chronic diseases (dyslipidemia, cardiovascular disease, depression, diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease; at least 1 of the latter 2 diseases must be present), at least 3 Part-D covered medications, and greater than $4,000 per year in predicted drug spending. In addition to these criteria, WellPoint Inc. used the Johns Hopkins adjusted clinical groups (ACG) predictive model to identify the high-risk beneficiaries to be enrolled in the program. Medication therapy reviews were conducted for these patients. If any medication-related problems (MRPs) were identified, the patient's prescribers were contacted via a fax communication with recommendation(s) to resolve these MRPs. The UA MMC fax interventions were categorized as cost saving, guideline adherence, or safety concerns. OBJECTIVES: To (a) determine prescriber responses to pharmacist-initiated recommendations in an MTMP for the 3 intervention categories, (b) compare prescriber responses between intervention categories, and (c) compare prescriber response by prescriber type (primary care physician [PCP] vs. specialist) within each intervention category. METHODS: A retrospective analysis of pharmacist-initiated interventions from August through December 2008 was performed using data collected from the UA MMC database. Data were collected on intervention category (cost saving, guideline adherence, or safety concerns), and responses of prescribers were recorded as either approval or decline (no response was considered decline). Prescriber specialty was identified from searching records of state medical boards. Logistic regression analyses with the robust variance option to adjust for correlation within prescribers were conducted to compare prescriber approval rates between and within intervention categories. Significance was assessed at alpha 0.05. RESULTS: Of 4,967 Medicare Part D beneficiaries determined to be MTMP-eligible, 4,277 beneficiaries (86.1%) were available for assessment (400 declined, 186 disenrolled, and 104 were deceased). Pharmacists initiated 1,548 valid medication recommendations (i.e., recommendations were excluded for deceased patients, incorrect prescribers, and where prescriber specialty was not identified). These recommendations for 1,174 beneficiaries (27.5% of those available) were faxed to prescribers requesting approval. Mean (SD) age for beneficiaries having recommendations was 72.9 (9.4) years, and the majority (57.6%) was female. By category of recommendation, 58.3% (n=902) were guideline adherence, 33.3% (n=515) were cost saving, and 8.5% (n=131) were safety concerns. Prescriber approval rates were 47.2% overall (n =731/1,548), 41.4% (n=373/902) for guideline adherence, 58.3% (n=300/515) for cost savings, and 44.3% (n=58/131) for safety concerns; 817 recommendations were not approved by prescribers (n= 255 [16.5%] denials and 562 no response [36.3%]). Prescriber approval was significantly higher for cost-saving interventions compared with guideline adherence interventions (odds ratio [OR]=1.98, 95% CI=1.56-2.51, P< 0.001) and compared with safety interventions (OR=1.76, 95% CI=1.19, 2.59, P=0.004); there was no significant difference in the prescriber approval rates for the interventions for safety versus guideline adherence. The overall approval rate was higher for PCPs (49.8%, n=525/1,054) versus specialists (41.7%, n=206/494; OR=1.39, 95% CI=1.08-1.78, P=0.011) and for the category for guideline adherence interventions (44.0% for PCPs vs. 35.9% for specialists; OR =1.40, 95% CI=1.01-1.95, P=0.044), but not for the other 2 intervention categories. CONCLUSIONS: Prescriber approval rates for pharmacist recommendations for drug therapy changes for MTMP beneficiaries were approximately 47% overall and higher for recommendations that involved cost savings compared with recommendations for safety concerns or guideline adherence. Compared with specialists, PCPs had higher approval rates for pharmacist recommendations overall and for the intervention category guideline adherence.

Improvisational exercises to improve pharmacy students' professional communication skills.

OBJECTIVE: To create and implement improvisational exercises to improve first-year pharmacy students' communication skills. DESIGN: Twelve 1-hour improvisational sessions were developed and added to an existing/established patient communication course to improve 3 basic skills: listening, observing and responding. Standardized patient examinations were used to evaluate student communication skills, and course evaluations and reflective journaling were used to evaluate students' perceptions of the improvisational exercises. ASSESSMENT: The improvisational exercises markedly improved the students' performance in several aspects of standardized patient examination. Additionally, course evaluations and student comments reflected their perception that the improvisational exercises significantly improved their communication skills. SUMMARY: Improvisational exercises are an effective way to teach communication skills to pharmacy students.

Research-related coursework and research experiences in doctor of pharmacy programs.

OBJECTIVES: To evaluate the research-related coursework and research experiences in doctor of pharmacy programs and compare the findings to those of 2 previous studies. METHODS: A questionnaire was mailed to 88 colleges and schools of pharmacy in the United States and Puerto Rico. The survey instrument sought information on formal research-related coursework; required and elective research experiences; and perceptions of student-conducted research. RESULTS: Seventy-nine colleges and schools completed the questionnaire for a response rate of 88%. Most colleges (>90%) required students to study/complete courses in biostatistics and drug information/literature evaluation; approximately half required research methods coursework. Twenty-five percent required some form of project and requirements were not influenced by class size. Students could often work in teams to complete projects. Respondents generally thought participation in research had some value for motivated students. CONCLUSIONS: This study demonstrates the variability in extent of research-related coursework and research experiences in PharmD programs across the country.