Bringing Iowa TelePrEP to Scale: A Qualitative Evaluation.

INTRODUCTION: Regional partnerships between public health organizations and telehealth programs have the potential to expand access to HIV pre-exposure prophylaxis in rural and small urban areas. However, little is known about the best practices for such partnerships. Iowa TelePrEP, a regional public health‒partnered telehealth model created by the Iowa Department of Public Health and the University of Iowa, expanded statewide between 2017 and 2019. This qualitative evaluation assessed the barriers and facilitators to statewide expansion and the lessons learned. METHODS: Key informants from public health partners across Iowa participated in a focus group and interviews between May 2019 and November 2020. Public health partners included local health departments and disease intervention specialist/partner services programs. Qualitative data were transcribed and thematically coded. Program documents and routinely collected reporting data were reviewed to provide the context for qualitative findings. Data were analyzed in 2020. RESULTS: TelePrEP expanded in 4 phases through partnerships with 12 public health partners. Public health partners referred 708 clients with pre-exposure prophylaxis indications to telenavigation; of these, 258 were navigated to TelePrEP, and 167 initiated pre-exposure prophylaxis. The facilitators of expansion included early public health partner engagement, model acceptability and inclusion of a navigator, and adaptability to local public health partner settings. The barriers included the need to adapt communication and processes to varying public health partners, difficulty in engaging underserved populations, the COVID-19 pandemic, and perceived gaps in understanding client outcomes. CONCLUSIONS: Partnerships between regional telehealth programs and local health departments can expand to the state level and increase the capacity to implement pre-exposure prophylaxis in rural and small urban settings. Partnerships should consider how to balance program adaptability to local public health partners with standardization and scalability.

Mixed-Methods Evaluation of the Incorporation of Home Specimen Self-Collection Kits for Laboratory Testing in a Telehealth Program for HIV Pre-exposure Prophylaxis.

Home specimen self-collection kits with central laboratory testing may improve persistence with PrEP and enhance telehealth programs. We offered Iowa TelePrEP clients the choice of using a home kit or visiting a laboratory site for routine monitoring. Mixed-methods evaluation determined the proportion of clients who chose a kit, factors influencing choice, associations between kit use and completion of indicated laboratory monitoring, and user experience. About 46% (35/77) chose to use a kit. Compared to laboratory site use, kit use was associated with higher completion of extra-genital swabs (OR 6.33, 95% CI 1.20-33.51, for anorectal swabs), but lower completion of blood tests (OR 0.21, 95% CI 0.06-0.73 for creatinine). Factors influencing choice included self-efficacy to use kits, time/convenience, and privacy/confidentiality. Clients reported kit use was straight-forward but described challenges with finger prick blood collection. Telehealth PrEP programs should offer clients home kits and support clients with blood collection and kit completion.

RESUMEN: Los kits de pruebas caseras de auto-recolección junto con los ensayos de laboratorio central puedan mejorar la persistencia de PrEP y aumentar los programas de telesalud. Ofrecimos a los clientes de Iowa TelePrEP la opción de o utilizar un kit de pruebas caseras o visitar un sitio de laboratorio para seguimiento rutinario.La evaluación de métodos mixtos determinó la proporción de los clientes que eligieron un kit, los factores que influyen en la elección, las asociaciones entre el uso del kit y la realización del monitoreo de laboratorio indicado y la experiencia de los usuarios. Casi 46 % (35 de 77) eligió utilizar un kit. Comparado con el uso del sitio de laboratorio, el kit fue asociado con mayores tasas de terminación para los hisopos extragenitales (OR 6.33, 95% CI 1.20-33.51, para hisopos anorectales), pero menores tasas de terminación para los análisis de sangre (OR 0.21, 95% CI 0.06-0.73 para creatinina). Los factores que influyeron en la elección incluyeron la autoeficacia para usar los kits, el tiempo / la comodidad y la privacidad/ confidencialidad. Los clientes informaron que el uso del kit fue sencillo pero describieron desafíos con la recolección de sangre por un pinchazo. Los programas de PrEP de telesalud deben ofrecer a los clientes kits para el hogar y apoyarlos con la recolección de sangre y la terminación del kit.

A texting-based blood pressure surveillance intervention.

The authors examined whether using home BP measurements collected via a custom-built bi-directional-texting platform incorporated into patients' electronic medical records would lead to treatment calibration and improved BP management. Patients were randomized to either the intervention group and collected home measurements based on reminders and reported via bi-directional texting, or to the control group, with home BP measurement reporting via standard practice (eg, phone, electronic medical record portal) and instructed to return 7 morning and 7 evening BP measurements. Outcomes included number of BP measurements submitted, the number of medication changes, reduction in BP, and BP control. 72% of the intervention group submitted at least 14 readings, compared with 45% of the control group. BP control improved in both groups. However, the authors found no statistically significant difference in BP or the number of BP-medication changes at 1, 3, or 6 months compared with the control group.

Iowa TelePrEP: A Public-Health-Partnered Telehealth Model for Human Immunodeficiency Virus Preexposure Prophylaxis Delivery in a Rural State.

BACKGROUND: Access to human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) is often poor in small urban and rural areas because of stigma and long distances to providers. The Iowa Department of Public Health and The University of Iowa created a regional telehealth program to address these barriers ("Iowa TelePrEP"). We describe initial TelePrEP results and share lessons learned. METHODS: Iowa Department of Public Health personnel in sexually transmitted infection (STI) clinics, disease intervention specialist and partner services, and HIV testing programs referred clients to pharmacists at University of Iowa. Clients could also self-refer via a website. Pharmacists completed video visits with clients in the community on smartphones and other devices, arranged local laboratory studies, and mailed medications. We performed a retrospective record review to quantify rates of PrEP referral, initiation, retention, guideline-concordant laboratory monitoring, and STI identification and treatment. RESULTS: Between February 2017 and October 2018, TelePrEP received 186 referrals (37% from public health) and completed 127 (68%) initial video visits with clients. Median client age was 32; 91% were men who have sex with men. Most clients with video visits (91%) started PrEP. Retention in TelePrEP at 6 months was 61%, and 96% of indicated laboratory monitoring tests were completed. Screening identified 37 STIs (8 syphilis, 10 gonorrhea, 19 chlamydia). Disease intervention specialist and partner services linked all clients with STIs to local treatment within 14 days (80% in 3 days). CONCLUSIONS: Using widely available technology and infrastructure, public health departments and health care systems can collaborate to develop regional telehealth programs to deliver PrEP in small urban and rural settings.

Development and reliability testing of the clinical pharmacist recommendation taxonomy.

STUDY OBJECTIVE: To evaluate the reliability of a newly developed taxonomy--the Clinical Pharmacist Recommendation (CPR) taxonomy--to classify clinical pharmacy interventions. DESIGN: The CPR taxonomy was developed and refined in three phases. In each phase, reviewers independently reviewed recommendations made by a clinical pharmacist-physician team and categorized them into mutually exclusive categories: priority, problem, and response. Interrater reliability was assessed for all categories during each development phase. SETTING: Primary care clinics of a Veterans Affairs Medical Center. PATIENTS: Fifty-three patients enrolled in the Veterans Affairs Enhanced Pharmacy Outpatient Clinic (EPOC) trial. MEASUREMENTS AND MAIN RESULTS: Interrater reliability was assessed using the kappa statistic. A total of 423 recommendations were evaluated during the three testing phases. In the final testing phase, agreement was moderate for pharmacotherapy problem subcategories (kappa = 0.57), substantial for pharmacotherapy problem primary categories (kappa = 0.64), and almost perfect for response categories (kappa = 0.85). Taxonomy completion time/patient averaged 4.6 minutes (range 1-11 min). CONCLUSION: The CPR taxonomy provides a reliable method to systematically evaluate clinical pharmacy recommendations based on the therapeutic problem identified and specific action recommended to resolve the problem.

Clinical pharmacists and inpatient medical care: a systematic review.

BACKGROUND: The role of clinical pharmacists in the care of hospitalized patients has evolved over time, with increased emphasis on collaborative care and patient interaction. The purpose of this review was to evaluate the published literature on the effects of interventions by clinical pharmacists on processes and outcomes of care in hospitalized adults. METHODS: Peer-reviewed, English-language articles were identified from January 1, 1985, through April 30, 2005. Three independent assessors evaluated 343 citations. Inpatient pharmacist interventions were selected if they included a control group and objective patient-specific health outcomes; type of intervention, study design, and outcomes such as adverse drug events, medication appropriateness, and resource use were abstracted. RESULTS: Thirty-six studies met inclusion criteria, including 10 evaluating pharmacists' participation on rounds, 11 medication reconciliation studies, and 15 on drug-specific pharmacist services. Adverse drug events, adverse drug reactions, or medication errors were reduced in 7 of 12 trials that included these outcomes. Medication adherence, knowledge, and appropriateness improved in 7 of 11 studies, while there was shortened hospital length of stay in 9 of 17 trials. No intervention led to worse clinical outcomes and only 1 reported higher health care use. Improvements in both inpatient and outpatient outcome measurements were observed. CONCLUSIONS: The addition of clinical pharmacist services in the care of inpatients generally resulted in improved care, with no evidence of harm. Interacting with the health care team on patient rounds, interviewing patients, reconciling medications, and providing patient discharge counseling and follow-up all resulted in improved outcomes. Future studies should include multiple sites, larger sample sizes, reproducible interventions, and identification of patient-specific factors that lead to improved outcomes.

Assessing the accuracy of computerized medication histories.

OBJECTIVE: To determine the accuracy of computerized medication histories. STUDY DESIGN: Cross-sectional observational study. PATIENTS AND METHODS: The study sample included 493 Department of Veterans Affairs primary care patients aged 65 years or older who were receiving at least 5 prescriptions. A semistructured interview confirmed medication, allergy, and adverse drug reaction (ADR) histories. Accuracy of the computerized medication lists was assessed, including omissions (medications not on the computer record) and commissions (medications on the computer record that were no longer being taken). Allergy and ADR records also were assessed. RESULTS: Patients were taking a mean of 12.4 medications: 65% prescription, 23% over-the-counter products, and 12% vitamins/herbals. There was complete agreement between the computer medication list and what the patient was taking for only 5.3% of patients. There were 3.1 drug omissions per patient, and 25% of the total number of medications taken by patients were omitted from the electronic medical record. There were 1.3 commissions per patient, and the patients were not taking 12.6% of all active medications on the computer profile. In addition, 23.2% of allergies and 63.9% of ADRs were not in the computerized record. CONCLUSIONS: Very few computerized medication histories were accurate. Inaccurate medication information may compromise patient care and limit the utility of medication databases for research and for assessment of the quality of prescribing and disease management.