Pharmacists Perceptions of Providing Colorectal Cancer Screening in Community-Based Practice.

BACKGROUND: Colorectal cancer (CRC) is the third most common diagnosed cancer in the United States. Kentucky pharmacists can be instrumental in the CRC early detection process through board authorized protocols (BAP): a regulatory approach managed by the Kentucky Board of Pharmacy that allows pharmacists to increase access to care while saving lives through early detection screening. Determining the barriers and successes of implementing CRC screening can improve access to education and care for patients. OBJECTIVE(S): This study aims to evaluate community pharmacists' perceptions of implementing a colorectal screening for patients via protocol and identify pharmacists' confidence and potential barriers such as cost, staff support, and patient need for colorectal screening in community pharmacy settings. METHODS: A survey was sent electronically to a convenience sample of pharmacists throughout Kentucky. The survey collected demographics, opinions regarding implementation of the colorectal cancer screening protocol, pharmacists' perceptions of knowledge, as well as the barriers and benefits associated with implementation of CRC services. RESULTS: 207 responses were received and of those 151 were from community-based pharmacists. 34% of pharmacists agreed or strongly agreed to offer CRC screening. Overwhelmingly, 81.3% of pharmacists reported need for additional training. There were no statistically significant differences in support among demographic factors; practice setting (p-value = 0.937), gender (p-value = 0.973), age (p-value = 0.568), years practicing (p-value = 0.870). In addition, the most common barriers reported were lack of reimbursement (97%), lack of willingness for patients to pay (98%), and time or workflow issues (97%). Most pharmacists stated that lack of trust in pharmacists was not a barrier (87%). CONCLUSIONS: Overall, 34% of pharmacists either agreed or strongly agreed to offer colorectal cancer screening via the board-approved protocol. However, overwhelmingly the pharmacists believe that there is a need for additional training and opportunities for additional training on board authorized protocols have increased drastically in Kentucky. Barriers such as lack of reimbursement, willingness to pay, and time or workflow issues are barriers that need to be overcome before implementation. Finding solutions to these barriers will increase pharmacist's support.

Acceptability of patient-centered, multi-disciplinary medication therapy management recommendations: results from the INCREASE randomized study.

BACKGROUND: Polypharmacy and inappropriate medications may be a modifiable risk factor for Alzheimer's Disease and Related Dementias (ADRD). Medication therapy management (MTM) interventions may mitigate medication-induced cognitive dysfunction and delay onset of symptomatic impairment. The objective of the current study is to describe an MTM protocol for a patient-centered team intervention (pharmacist and non-pharmacist clinician) in a randomized controlled trial (RCT) directed at delaying the symptomatic onset of ADRD. METHODS: Community dwelling adults 65 + years, non-demented, using ≥ 1 potentially inappropriate medications (PIM) were enrolled in an RCT to evaluate the effect of an MTM intervention on improving medication appropriateness and cognition (NCT02849639). The MTM intervention involved a three-step process: (1) pharmacist identified potential medication-related problems (MRPs) and made initial recommendations for prescribed and over-the-counter medications, vitamins, and supplements; (2) study team reviewed all initial recommendations together with the participants, allowing for revisions prior to the finalized recommendations; (3) participant responses to final recommendations were recorded. Here, we describe initial recommendations, changes during team engagement, and participant responses to final recommendations. RESULTS: Among the 90 participants, a mean 6.7 ± 3.6 MRPs per participant were reported. Of the 259 initial MTM recommendations made for the treatment group participants (N = 46), 40% percent underwent revisions in the second step. Participants reported willingness to adopt 46% of final recommendations and expressed need for additional primary care input in response to 38% of final recommendations. Willingness to adopt final recommendations was highest when therapeutic switches were offered and/or with anticholinergic medications. CONCLUSION: The evaluation of modifications to MTM recommendations demonstrated that pharmacists' initial MTM recommendations often changed following the participation in the multidisciplinary decision-making process that incorporated patient preferences. The team was encouraged to see a correlation between engaging patients and a positive overall response towards participant acceptance of final MTM recommendations. TRIAL REGISTRATION: Study registration number: clinicaltrial.gov NCT02849639 registered on 29/07/2016.

Case Report: The Complexities of Managing Medications and the Importance of Deprescribing Anticholinergics in Older Adults.

Potentially inappropriate anticholinergic medications (including over-the-counter products), polypharmacy, and the existence of communication barriers among members of the interprofessional team frequently contribute to clinical complexity in older adults. We present the case of a frail 86-year old female from the perspective of a community pharmacist managing outpatient medications and transitions of care. CD's past medical history is significant for dementia, multiple falls, recurrent urinary tract infections, depression, cardiac arrhythmia, macular degeneration, chronic pain, depression, and cerebrovascular disease.

One-Year Evaluation of a Targeted Medication Therapy Management Intervention for Older Adults.

BACKGROUND: Older adults are especially susceptible to adverse effects of inappropriate medication therapy, and anticholinergic medications are common culprits for cognitive dysfunction due to their action on the central nervous system. Medication therapy management (MTM) interventions can aid in deprescribing and reducing inappropriate medication use in older adults. However, there is sparse literature on the long-term sustainability of these interventions. OBJECTIVES: To (a) investigate whether the deprescribing of anticholinergic medications during an 8-week randomized controlled trial (RCT) of a targeted MTM intervention is sustained at 1-year postintervention follow-up and (b) compare anticholinergic utilization trends in the study population with a large sample of similar individuals not exposed to the intervention. METHODS: Participants in the targeted MTM (tMTM) RCT had normal cognition or mild cognitive impairment and were recruited from enrollees in a longitudinal study at the University of Kentucky Alzheimer's Disease Center (ADC) and thus have pertinent medical information gathered approximately annually. In this posttrial observational follow-up, sustainability of the anticholinergic deprescribing intervention was assessed in participants in the RCT, and anticholinergic medication use trends were described from the RCT baseline (which occurred immediately following an ADC visit) to the next annual visit in all participants. Mean change in anticholinergic burden from RCT baseline to the next annual visit was estimated using analysis of covariance, and participants were compared with 2 external samples. Anticholinergic burden was measured using the Anticholinergic Drug Scale (ADS). The odds of decreasing baseline anticholinergic burden and number of total and strong anticholinergic medications at the follow-up study time point was assessed using logistic regression. RESULTS: Of the deprescribing changes made during the initial RCT, 50% were sustained after 1 year. Participants in the tMTM trial reported decreases in the use of anticholinergic antihistamines and bladder agents (-6.5 and -4.4%, respectively), but there was no change in the use of anticholinergic agents targeted at the central nervous system. While the anticholinergic burden of RCT participants decreased over 1 year (adjusted mean ADS change [95% CI] = -0.33 [-0.72, 0.07]), it was not different than the change observed in 2 external samples at the trial center (-0.20 [-0.42, 0.02]) and nationally (-0.33 [-0.39, -0.26]). There were no statistically significant differences between trial participants and external samples in the odds of decreasing anticholinergic burden nor in decreasing the number of total, or strongly anticholinergic, medications at the 1-year follow-up. CONCLUSIONS: This study demonstrates that the sustainability of deprescribing is limited to the period of intervention, rather than affording lasting effects even over periods as short as 1 year, which was demonstrated not only in the small group of RCT participants but also by comparison with external groups. Future work should extend the duration of intervention and follow-up periods for MTM interventions to allow further insights regarding the sustainability of deprescribing efforts in older adults. DISCLOSURES: The original trial was supported by a pilot study award from the University of Kentucky Center for Clinical and Translational Sciences (UL1TR000117). Additional support for this study was provided by the National Institutes of Health/National Institute on Aging (R01 AG054130). Jicha reports contract research for Esai, Biohaven, Alltech, Suven, Novartis, and Lilly. The other authors have nothing to disclose.

INtervention for Cognitive Reserve Enhancement in delaying the onset of Alzheimer's Symptomatic Expression (INCREASE), a randomized controlled trial: rationale, study design, and protocol.

BACKGROUND: The course of Alzheimer's disease (AD) includes a 10-20-year preclinical period with progressive accumulation of amyloid ß (Aß) plaques and neurofibrillary tangles in the absence of symptomatic cognitive or functional decline. The duration of this preclinical stage in part depends on the rate of pathologic progression, which is offset by compensatory mechanisms, referred to as cognitive reserve (CR). Comorbid medical conditions, psychosocial stressors, and inappropriate medication use may lower CR, hastening the onset of symptomatic AD. Here, we describe a randomized controlled trial (RCT) designed to test the efficacy of a medication therapy management (MTM) intervention to reduce inappropriate medication use, bolster cognitive reserve, and ultimately delay symptomatic AD. METHODS/DESIGN: Our study aims to enroll 90 non-demented community-dwelling adults ≥ 65 years of age. Participants will undergo positron emission tomography (PET) scans, measuring Aß levels using standardized uptake value ratios (SUVr). Participants will be randomly assigned to MTM intervention or control, stratified by Aß levels, and followed for 12 months via in-person and telephone visits. Outcomes of interest include: (1) medication appropriateness (measured with the Medication Appropriateness Index (MAI)); (2) scores from Trail Making Test B (TMTB), Montreal Cognitive Assessment (MoCA), and California Verbal Learning Test (CVLT); (3) perceived health status (measured with the SF-36). We will also evaluate pre- to post-intervention change in: (1) use of inappropriate medications as measured by MAI; 2) CR Change Score (CRCS), defined as the difference in scopolamine-challenged vs unchallenged cognitive scores at baseline and follow-up. Baseline Aß SUVr will be used to examine the relative impact of preclinical AD (pAD) pathology on CRCS, as well as the interplay of amyloid burden with inappropriate medication use. DISCUSSION: This manuscript describes the protocol of INCREASE ("INtervention for Cognitive Reserve Enhancement in delaying the onset of Alzheimer's Symptomatic Expression"): a randomized controlled trial that investigates the impact of deprescribing inappropriate medications and optimizing medication regimens on potentially delaying the onset of symptomatic AD and AD-related dementias. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02849639. Registered on 29 July 2016.

Patient awareness, willingness, and barriers to point-of-care hepatitis C screening in community pharmacy.

OBJECTIVES: To determine patients' awareness of the screening recommendations for hepatitis C virus (HCV) in "Baby Boomers," to assess patients' willingness to receive a point-of-care HCV screening test in the pharmacy, and to determine patients' barriers to receiving a point-of-care HCV screening test in a community pharmacy. METHODS: An anonymous 12-question survey was developed. Five shareholder pharmacies of American Pharmacy Services Corporation (APSC) volunteered to participate. Surveys were mailed to participating pharmacies with instructions to distribute to patients born in 1945 to 1965 at the pharmacy point-of-sale. Data were collected over a 12-week period from October 2016 to January 2017. Completed surveys were collected by participating pharmacies and mailed to the primary investigator. Data were analyzed with the use of descriptive statistics. RESULTS: Ninety-five eligible surveys were returned and analyzed. A majority of respondents were female (63.00%) and held a bachelor degree or higher (63.16%); 38.95% of patients were aware of HCV age-based risk factors and screening recommendations. Only 9.80% of patients were aware of the fingerstick point-of-care testing (POCT) option for HCV. Nearly three-fourths (71.70%) were willing to receive POCT at a community pharmacy. A majority of patients (65.52%) were unwilling to pay an amount that would cover the cost of testing. Descriptive statistics, including a Pearson chi-square test, were used to analyze the data. Significant differences in the distribution of the percentages of people willing to receive testing and to pay for testing were found among levels of annual household income. CONCLUSION: A majority of patients are willing to receive POCT at a community pharmacy. Patients were unwilling to pay for testing, however, so pharmacies looking to offer point-of-care HCV screening would need to secure further financial resources, such as insurance reimbursement or grant funding, for this service to be financially feasible.

Quality of Life and Medication Adherence of Independently Living Older Adults Enrolled in a Pharmacist-Based Medication Management Program.

This study sought to understand the medication adherence and quality of life (QOL) of recipients of a pharmacist-based medication management program among independently living older adults. Using a cross-sectional, quasi-experimental study design, we compared older adults enrolled in the program to older adults not enrolled in the program. Data were collected via face-to-face interviews in independent-living facilities and in participants' homes. Independently living older adults who were enrolled in the medication management program (n = 38) were compared to older adults not enrolled in the program (control group (n = 41)). All participants were asked to complete questionnaires on health-related quality of life (QOL, using the SF-36) and medication adherence (using the four-item Morisky scale). The medication management program recipients reported significantly more prescribed medications (p < 0.0001) and were more likely to report living alone (p = 0.01) than the control group. The medication management program recipients had a significantly lower SF-36 physical functioning score (p = 0.03) compared to the control group, although other SF-36 domains and self-reported medication adherence were similar between the groups. Despite taking more medications and more commonly living alone, independent living older adults enrolled in a pharmacist-based medication management program had similar QOL and self-reported medication adherence when compared to older adults not enrolled in the program. This study provides initial evidence for the characteristics of older adults receiving a pharmacist-based medication management program, which may contribute to prolonged independent living and positive health outcomes.

Optimizing medication appropriateness in older adults: a randomized clinical interventional trial to decrease anticholinergic burden.

BACKGROUND: The complexity of medication therapy in older adults with multiple comorbidities often leads to inappropriate prescribing. Drugs with anticholinergic properties are of particular interest because many are not recognized for this property; their use may lead to increased anticholinergic burden resulting in significant health risks, as well as negatively impacting cognition. Medication therapy management (MTM) interventions showed promise in addressing inappropriate medication use, but the effectiveness of targeted multidisciplinary team interventions addressing anticholinergic medications in older populations is yet to be determined. METHODS: We conducted an 8-week, parallel-arm, randomized trial to evaluate whether a targeted patient-centered pharmacist-physician team MTM intervention ("targeted MTM intervention") reduced the use of inappropriate anticholinergic medications in older patients enrolled in a longitudinal cohort at University of Kentucky's Alzheimer's Disease Center. Study outcomes included changes in the medication appropriateness index (MAI) targeting anticholinergic medications and in the anticholinergic drug scale (ADS) score from baseline to the end of study. RESULTS: Between October 1, 2014 and September 30, 2015 we enrolled and randomized 50 participants taking at least one medication with anticholinergic properties. Of these, 35 (70%) were women, 45 (90%) were white, and 33 (66%) were cognitively intact (clinical dementia rating [CDR] = 0); mean age was 77.7 ± 6.6 years. At baseline, the mean MAI was 12.6 ± 6.3; 25 (50%) of the participants used two or more anticholinergics, and the mean ADS score was 2.8 ± 1.6. After randomization, although no statistically significant difference was noted between groups, we identified a potentially meaningful imbalance as the intervention group had more participants with intact cognition, and thus included CDR in all of the analyses. The targeted MTM intervention resulted in statistically significant CDR adjusted differences between groups with regard to improved MAI (change score of 3.6 (1.1) for the MTM group as compared with 1.0 (0.9) for the control group, p = 0.04) and ADS (change score of 1.0 (0.3) for the MTM group as compared with 0.2 (0.3) for the control group, p = 0.03). CONCLUSIONS: Our targeted MTM intervention resulted in improvement in anticholinergic medication appropriateness and reduced the use of inappropriate anticholinergic medications in older patients. Our results show promise in an area of great importance to ensure optimum outcomes for medications used in older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT02172612 . Registered 20 June 2014.