Association of Burnout With Primary Care Clinician Perception of Team-Based Scheduling Support.

INTRODUCTION: Primary care clinician burnout is pervasive and detrimental. How components of teamwork and clinic culture might contribute to burnout remains unsettled. OBJECTIVE: To examine associations between primary care clinician perceptions of specific components of teamwork and of organizational culture, and perceived stress and burnout. METHODS: Cross-sectional survey study of primary care clinicians from 5 county health system clinics. Measures: Perceptions of teamwork related to coordination of care, and clinic provision of chronic disease self-management support; values alignment and workplace equity; and demographics. DATA ANALYSIS: Descriptive statistics and Spearman's correlations to examine associations, controlling for clinic and examining response variability by clinic. RESULTS: Of 72 clinicians, 64% were female and 32% non-white. About 56% had worked at least 4 years and half worked 5 to 6 half days/week or more in their clinic. Clinicians who reported having someone on the clinician's care team routinely schedule follow-up appointments for patients with complex chronic illnesses reported lower stress and burnout. Those who perceived greater values alignment with their clinic and greater personal and employee equitable treatment had lower stress and burnout. CONCLUSIONS: Teamwork among clinicians and non-clinical staff, a component of teamwork that is not well-considered in current literature, could be an important piece of the puzzle to decrease the persistent and challenging issue of stress and burnout among primary care clinicians.

Primary Care Provider Demographics and Engagement in Interprofessional Collaboration.

INTRODUCTION: Interprofessional care contributes to all components of the quadruple aim. While previous research has identified many facilitators and barriers to the provision of interprofessional care, whether demographic differences might influence the extent to which providers collaborate interprofessionally remains unknown. METHODS: Using electronic health record data, we characterized the level of primary care providers' (PCPs') interprofessional collaboration based on the percent of their patients who had a visit with an interprofessional team member over a 14-month period. We then obtained demographic data, including gender, years in practice, and provider type, from the electronic health record and publicly available sources. Subsequently, we used linear regression to predict the PCPs' level of interprofessional collaboration based on demographic indicators. RESULTS: The median of each PCP's patients who had a visit with an interprofessional team member during the study period was 12.6%. After controlling for the average age of the PCP's patient panel, the PCP's years in practice, and the PCP's clinic, when compared with male PCPs, approximately 2% more of patients cared for by female PCPs had a visit with an interprofessional team member. CONCLUSION: Female providers are more likely to share their patients with an interprofessional team.

How Comprehensive Medication Management Contributes to Foundational Elements of Primary Care.

Pharmacists are more often being recognized as a critical component of the primary care team. Previous literature has not clearly made the connection to how pharmacists and comprehensive medication management (CMM) contribute to recognized foundational elements of primary care. In this reflection, we examine how the delivery of CMM both supports and aligns with Starfield's 4 Cs of Primary Care. We illustrate how the delivery of CMM supports first contact through increased provider access, continuity through empanelment, comprehensiveness by addressing unmet medication needs, and coordination through collaborating with the primary care team and broader team. The provision of CMM addresses critical unmet medication-related needs in primary care and is aligned with the foundational elements of primary care.

Primary Care Providers Believe That Comprehensive Medication Management Improves Their Work-Life.

PURPOSE: In primary care, clinical pharmacists often deliver a service called comprehensive medication management (CMM). While research has identified that CMM positively influences most aspects of the Quadruple Aim, it is unclear how CMM-both the service and the role of the pharmacist-may influence the primary care provider's (PCP) clinical work, professional satisfaction, and burnout (described here as PCP's work-life). We aimed to identify how PCPs perceive CMM impacts their work-life. METHODS: Sixteen PCPs were interviewed. Interview questions centered on how CMM affects their work-life. After interviews were transcribed, a codebook was developed by 2 researchers and from the codes, themes were identified. RESULTS: PCPs spoke of the pharmacist being an added skillset and resource and a collaborative partner in caring for patients. They also described 7 outcomes of having CMM available that contribute to their work-life. These outcomes were: decreased workload, satisfaction patients are receiving better care, reassurance, decreased mental exhaustion, enhanced professional learning, increased provider access, and achievement of quality measures. Lastly, the PCPs described barriers and areas of opportunity related to CMM. CONCLUSION: Our findings suggest PCPs believe CMM, in general, positively affects their work-life. CMM's impact on PCPs aligns with many previously identified drivers of burnout and engagement among providers. These results shed light on how CMM may foster achievement of the Quadruple Aim.

Team work and collaborative practice agreements among pharmacists and nurse practitioners.

OBJECTIVES: The authors share their knowledge about partnering and establishing collaborative practice agreements with nurse practitioners. State laws and regulations were reviewed that affect pharmacists' ability to fully partner with nurse practitioners. SUMMARY: Nurse practitioners' role in primary care is growing, and, in many states, nurse practitioners practice independently. Collaborative practice agreements (CPAs) enable pharmacists to work with prescribers more efficiently. Pharmacists' and nurse practitioners' scope-of-practice laws and regulations may prevent CPAs between pharmacists and nurse practitioners. State pharmacy practice acts were reviewed to demonstrate which states allow for partnership under a CPA. CONCLUSION: Pharmacists should consider opportunities to partner more closely with nurse practitioners to provide care, sometimes under a CPA. In states where laws or regulations prevent CPAs between pharmacists and nurse practitioners, pharmacists should advocate for policy change.

Experience with the script concordance test to develop clinical reasoning skills in pharmacy students.

BACKGROUND: The script concordance test (SCT) is used to assess clinical reasoning and was originally developed for medical learners. The Accreditation Council for Pharmacy Education (ACPE) endorses the need for pharmacy students to develop clinical reasoning skills, but there is little documentation of use of the SCT for pharmacy learners. EDUCATIONAL ACTIVITY: A script concordance test activity was designed for a diabetes and metabolic syndrome pharmacotherapy course. Twenty-five cases were created and evaluated by an expert panel of 20 practicing pharmacists. Ten cases were presented as a formative activity in class. The students, design team, teaching team, and expert panel evaluated the activity. CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY: The SCT was received positively from the students, design team, teaching team, and expert panel. The design team noted that case writing was different for this approach and that the inclusion of various perspectives from panelists was beneficial. Although the activity was formative in nature, the teaching team scored the students and this provided insight into areas where the students may struggle. SUMMARY: This report provides information on the formative use of the SCT in the classroom, as well as categories of items suitable for pharmacy. The SCT provides an approach to illustrate clinical reasoning and clinical decision making among content experts and can be used to stimulate clinical discussions among student learners and content experts. The SCT could help incorporate clinical reasoning skills in a pharmacy curriculum to meet ACPE standards.

Comprehensive medication management services: benefits for seniors with diabetes.

Authors from the University of Minnesota College of Pharmacy highlight the role that pharmacists can play in care optimization for seniors with chronic conditions.

A comparison of the risk of QT prolongation among SSRIs.

OBJECTIVE: To report QT prolongation potential in selective serotonin reuptake inhibitors (SSRIs) in order to advise clinicians on safe use of SSRIs other than citalopram in light of citalopram warnings. DATA SOURCES: Primary literature and case reports were identified through a systematic search. Data from drug manufacturers, package inserts, and the ArizonaCERT database were also utilized. STUDY SELECTION AND DATA EXTRACTION: English-language studies and case reports were included. DATA SYNTHESIS: Studies demonstrate possible dose-related clinically significant QT prolongation with escitalopram. Fluoxetine, fluvoxamine, and sertraline at traditional doses demonstrate a lack of clinically significant increases in QTc in the majority of studies. Further, paroxetine monotherapy shows a lack of clinically significant QTc prolongation in all studies. However, case reports or reporting tools still link these SSRIs with QTc prolongation. Fluoxetine, escitalopram, and sertraline used in post-acute coronary syndrome patients did not demonstrate risk of QTc prolongation. CONCLUSION: For clinicians who choose not to use citalopram due to recent Food and Drug Administration (FDA) recommendations, other antidepressants within this class may be considered. When citalopram is not utilized based on risk factors for TdP, use of escitalopram is not likely the safest alternative. Based on current literature, fluoxetine, fluvoxamine, and sertraline appear to have similar, low risk for QT prolongation, and paroxetine appears to have the lowest risk. However, there are significant limitations in interpreting the studies, including varying definitions of significant QT prolongation. Therefore, choice of an alternative SSRI should be based on individual risk factors for arrhythmias and other patient-specific factors.

Strong H...F hydrogen bonds as synthons in polymeric quantum magnets: structural, magnetic, and theoretical characterization of [Cu(HF2)(pyrazine)2]SbF6, [Cu2F(HF)(HF2)(pyrazine)4](SbF6)2, and [CuAg(H3F4)(pyrazine)5](SbF6)2.

Three Cu(2+)-containing coordination polymers were synthesized and characterized by experimental (X-ray diffraction, magnetic susceptibility, pulsed-field magnetization, heat capacity, and muon-spin relaxation) and electronic structure studies (quantum Monte Carlo simulations and density functional theory calculations). [Cu(HF(2))(pyz)(2)]SbF(6) (pyz = pyrazine) (1a), [Cu(2)F(HF)(HF(2))(pyz)(4)](SbF(6))(2) (1b), and [CuAg(H(3)F(4))(pyz)(5)](SbF(6))(2) (2) crystallize in either tetragonal or orthorhombic space groups; their structures consist of 2D square layers of [M(pyz)(2)](n+) that are linked in the third dimension by either HF(2)(-) (1a and 1b) or H(3)F(4)(-) (2). The resulting 3D frameworks contain charge-balancing SbF(6)(-) anions in every void. Compound 1b is a defective polymorph of 1a, with the difference being that 50% of the HF(2)(-) links are broken in the former, which leads to a cooperative Jahn-Teller distortion and d(x(2))(-y(2)) orbital ordering. Magnetic data for 1a and 1b reveal broad maxima in chi at 12.5 and 2.6 K and long-range magnetic order below 4.3 and 1.7 K, respectively, while 2 displays negligible spin interactions owing to long and disrupted superexchange pathways. The isothermal magnetization, M(B), for 1a and 1b measured at 0.5 K reveals contrasting behaviors: 1a exhibits a concave shape as B increases to a saturation field, B(c), of 37.6 T, whereas 1b presents an unusual two-step saturation in which M(B) is convex until it reaches a step near 10.8 T and then becomes concave until saturation is reached at 15.8 T. The step occurs at two-thirds of M(sat), suggesting the presence of a ferrimagnetic structure. Compound 2 shows unusual hysteresis in M(B) at low temperature, although chi vs T does not reveal the presence of a magnetic phase transition. Quantum Monte Carlo simulations based on an anisotropic cubic lattice were applied to the magnetic data of 1a to afford g = 2.14, J = -13.4 K (Cu-pyz-Cu), and J(perpendicular) = -0.20 K (Cu-F...H...F-Cu), while chi vs T for 1b could be well reproduced by a spin-1/2 Heisenberg uniform chain model for g = 2.127(1), J(1) = -3.81(1), and zJ(2) = -0.48(1) K, where J(1) and J(2) are the intra- and interchain exchange couplings, respectively, which considers the number of magnetic nearest-neighbors (z). The M(B) data for 1b could not be satisfactorily explained by the chain model, suggesting a more complex magnetic structure in the ordered state and the need for additional terms in the spin Hamiltonian. The observed variation in magnetic behaviors is driven by differences in the H...F hydrogen-bonding motifs.

KCd2[N(CN)2]5(H2O)4: an enmeshed honeycomb grid.

The title compound, poly[potassium [diaquapenta-micro(2)-dicyanamido-dicadmium(II)] dihydrate], {K[Cd(2)(C(2)N(3))(5)(H(2)O)(2)].2H(2)O}(n), contains two-dimensional anionic sheets of {[Cd(2){N(CN)(2)}(H(2)O)(2)](-)}(n) with a modified (6,3)-net (layer group cm2m, No. 35). Two sets of equivalent sheets interpenetrate orthogonally to form a tetragonal enmeshed grid.