Impact of Teaching Social Determinants of Health on PIF in the Health Professions.

OBJECTIVE: To address the lack of methods for assessing learning on social determinants of health, particularly from a health systems perspective. Using a conceptual framework of professional identity formation applied across 3 professions (athletic training, occupational therapy, and pharmacy), the study aimed to describe students' level of professional identity when applying knowledge of structural factors' impact on health. METHODS: This study was a deductive content analysis of students' written reflections. Identified themes explored how students explained sociopolitical influences on health as well as their assessed level of professional identity. RESULTS: Students were inclined to author narratives focused on the ways in which structural factors influence individual outcomes and aspects within the health care system. Most students were assessed to be at the initial levels of professional identity formation, but those with a comparatively higher level of professional identity expressed a commitment to professional behaviors that address social determinants of health. CONCLUSION: This analysis created a foundation for future pedagogical work in health care system-related structural learning outcomes within and between different health professions. Findings suggest that across professions, most first-year students demonstrated the ability to reconcile different perspectives and were in the early stages of aligning personal values with professional values. The use of reflection has the potential to assess professional identity formation among a range of health professional students.

An Ethical Analysis of Pharmacy Benefit Manager (PBM) Practices.

The high costs associated with pharmaceuticals and the accompanying stakeholders are being closely evaluated in the search for solutions. As a major stakeholder in the U.S. pharmaceutical market, the practices of pharmacy benefit manager (PBM) organizations have been under increased scrutiny. Examples of controversial practices have included incentives driving formulary status and prohibiting pharmacists from disclosing information on lower-cost prescription alternatives. Ethical investigations have been largely omitted within the debate on the responsibilities of these organizations in the health care system. Ethical analysis of organizational practices is justified based on the potential impact during health care delivery. The objective of this study was to analyze several specific PBM practices using multiple ethical decision-making models to determine their ethical nature. This study systematically applied multiple ethical decision-making models and codes of ethics to a variety of practices associated with PBM-related dilemmas encountered in the pharmaceutical environment. The assessed scenarios resulted in mixed outcomes. PBM practices were both ethical and unethical depending on the applied ethical model. Despite variation across applied models, some practices were predominately ethical or unethical. The point of sale rebates were consistently determined as ethical, whereas market consolidation, gag clauses, and fluctuation of pharmacy reimbursements were all predominantly determined as unethical. The application of using provider codes of ethics created additional comparison and also contained mixed findings. This study provided a unique assessment of PBM practices and provides context from a variety of ethical perspectives. To the knowledge of the authors, these perspectives have not been previously applied to PBM practices in the literature. The application of ethical decision-making models offers a unique context to current health care dilemmas. It is important to analyze health care dilemmas using ethics-based frameworks to contribute solutions addressing complexities and values of all stakeholders in the health care environment.

Health Informatics Competencies for Pharmacists in Training.

Objective. To gather feedback from focus groups regarding health informatics competencies that should be taught in a Doctor of Pharmacy (PharmD) curricula and to revise the competencies based on this feedback. Methods. The pharmacy informatics task force of the American Association of Colleges of Pharmacy (AACP) used 11 sources to create a list of pharmacy informatics competencies. Subsequently, faculty feedback about the competency list was obtained via two synchronous online focus groups in August 2015. The list was then revised based on the feedback. Results. Eight people (a department chair, six faculty members and a graduate student) participated in the focus groups (six were from private and two were from public institutions). Participants felt the list had too many competencies to be covered in a timely manner and some indicated that basic computer and Internet competencies should be considered pre-requisites. Participants also recommended that competencies be split by proposed curricular placement (eg, prerequisite, required, elective, didactic, experiential) for each objective. The competency list was revised in response to focus group feedback. Conclusion. The proposed curriculum aligns with the new Accreditation Council for Pharmacy Education (ACPE) standards requiring that professional pharmacy curricula cover multiple aspects of health informatics. The proposed competencies list can serve as a reference to assist in the development of the curriculum and ensure compliance with the new standards.

Impact of a mobile app on medication adherence and adherence-related beliefs in patients with type 2 diabetes.

OBJECTIVES: To assess the impact of a customizable medication management mobile app (Medsimple) on medication adherence and adherence-related beliefs in patients with type 2 diabetes. The app contains a medication database, list tracking, reminders, cost-saving information, and other features. A second objective was to determine differentiating factors associated with 6 months of use. DESIGN: A prospective, observational, single-cohort study using previously tested scales at 3 time points over 6 months. SETTINGS AND PARTICIPANTS: Participants included a convenience sample of community-dwelling adults with type 2 diabetes in the United States who used at least 2 prescriptions, had Internet access, and used e-mail and a mobile device for operating the study app. OUTCOME MEASURES: Participants who served as their own controls were assessed on psychosocial theory-based concepts of self-efficacy, locus of control, and outcome expectations in addition to self-reported adherence. Instrument reliability, repeated assessments, and differential dropout analyses were conducted. RESULTS: Repeated assessments of 51, 49, and 41 participants occurred at baseline and 90 and 180 days (6 months), respectively. Instrument measurement of concepts showed strong reliability, except in the locus of control subscales. Participants exhibited no significant change on the scales of self-reported adherence behaviors or adherence-related beliefs during the study. Results showed that the mobile app may have influenced specific adherence behaviors or beliefs, but significant differences on overall scales were not found. Differential dropout analyses comparing study finishers to dropouts revealed that 6-month use was associated with being younger, lower self-efficacy beliefs, lower internal locus of control beliefs, and lower adherence behaviors. CONCLUSION: Scales were reliable to measure concepts but the locus of control scale warrants further testing. The mobile app may not affect adherence and adherence-related beliefs in a 6-month period. Further testing is needed to determine benefit for patients with specific adherence behaviors or who hold certain beliefs.

Communication networks of medication management in an ambulatory care setting.

BACKGROUND: Systems approaches in healthcare address complexities of care related to medication safety. Adverse drug events can be prevented by communication between providers. Thus, methods that depict the structures and processes of communications are foundational for prevention efforts. Social network analysis is a methodology applied in healthcare settings to describe and quantify communication patterns. Knowledge of the structures and processes surrounding medication management communications will be useful to explain and intervene on related quality or safety outcomes. OBJECTIVES: The aim of this study was to use social network analysis as a tool to describe the communication structures and processes of medication management for patients on warfarin therapy in an ambulatory care setting. METHOD: A longitudinal, roster-based assessment was used for the social network analysis. Data were collected from electronic medical records and coded using a fixed-list format. Information was collected regarding who was involved as well as frequency and type of communications. The analysis followed 16 subjects at one internal medicine clinic over six months. RESULTS: Structurally, communications were unidirectional and most often connected actors from different groups. Most communications were directed from nursing staff to patients. Central actors were a pharmacist, several nursing staff and one prescriber. Difference in processes were identified by characterizing communications according to level of impact on patient safety. Moderate impact communications corresponded to focused connections between providers. Further, the pharmacist was measured as the most prominent gatekeeper in moderate impact communications compared to an advanced registered nurse practitioner for low impact communications. CONCLUSIONS: Medication management reflected a unidirectional and interdisciplinary communication structure that maintained process variation according to the potential impact on patient safety. The level of influence of the pharmacist as a connector in the network rose in conjunction with the level of potential impact the communication had on patient safety.

A drug procurement, storage and distribution model in public hospitals in a developing country.

BACKGROUND: There is growing interest in pharmaceutical supply chains and distribution of medications at national and international levels. Issues of access and efficiency have been called into question. However, evaluations of system outcomes are not possible unless there are contextual data to describe the systems in question. Available guidelines provided by international advisory bodies such as the World Health Organization and the International Pharmacy Federation may be useful for developing countries like Vietnam when seeking to describe the pharmaceutical system. OBJECTIVE: The purpose of this study was to describe a conceptual model for drug procurement, storage, and distribution in four government-owned hospitals in Vietnam. METHOD: This study was qualitative and used semi-structured interviews with key informants from within the Vietnamese pharmaceutical system. Translated transcriptions were used to conduct a content analysis of the data. RESULTS: A conceptual model for the Vietnamese pharmaceutical system was described using structural and functional components. This model showed that in Vietnam, governmental policy influences the structural framework of the system, but allows for flexibility at the functional level of practice. Further, this model can be strongly differentiated from the models described by international advisory bodies. This study demonstrates a method for health care systems to describe their own models of drug distribution to address quality assurance, systems design and benchmarking for quality improvement.

Pharmacy technicians' attitudes about their roles in Iowa public safety.

OBJECTIVES: To describe and apply a model for combining self-assessed frequency and criticality for pharmacy technicians' roles and to evaluate similarities and differences between attitudes toward public safety in various practice settings. DESIGN: Cross-sectional mail survey of randomly selected pharmacy technicians in one state. SETTING: Iowa in fall 2012. PARTICIPANTS: 1,000 registered technicians. INTERVENTION: Mail survey with option for online completion. MAIN OUTCOME MEASURES: Scored ratings related to perceptions of frequency and criticality of roles. Technicians rated role frequency on a scale from 1 (not responsible) to 6 (daily) and role criticality on a scale from 1 (no importance) to 4 (extremely important). A weighted relative importance score was ranked to show importance of the role considering frequency and criticality together. RESULTS: The response rate was 25.81%. Ratings for frequency were correlated to ratings for criticality for 22 of 23 roles. A Mann-Whitney U test found a difference between ambulatory technicians and hospital technicians. A visual matrix of a dual-scaled analysis showed both groups' role ratings to be positively linearly related. Hospital technicians showed wider discrimination in their ratings for some roles than for others. CONCLUSION: Perceived role frequency and criticality can be considered together to contextualize the practice environment. The data suggest a relationship between perceived frequency of role performed and perception of a role's criticality. The study found differences between how technicians from various practice settings perceive their roles.

Decision-making during initiation of medication therapy.

BACKGROUND: Individuals' frequent and consistent interaction with medications can serve as a unifying element to help coordinate individuals' health care services. Despite its potential to improve coordination of heath care, initiation of medication therapy from the perspective of individuals' experiences remains largely unexamined. OBJECTIVES: The objectives for this study were to describe the viewpoints of consumers, physicians, pharmacists, and social workers regarding initiation of medication therapy in terms of: (1) activation and engagement, (2) information processing, and (3) economic factors. METHODS: Data were collected via mailed survey methodology from random samples of 400 adults, 400 physicians, 400 pharmacists, and 400 social workers residing in Minnesota. Responses to open-ended questions were coded using content analysis and summarized with descriptive statistics. RESULTS: The findings showed that consumer views of (1) activation and engagement, (2) information processing, and (3) economic factors differed from the views of physicians, pharmacists, and social workers. Consumers typically view initiation of medication therapy within the context of their overall lives. Physicians view it as a biomedical puzzle in which diagnosis, drug product selection, and risk assessment are main concerns. Pharmacists view it as a health care systems puzzle in which insurance coverage, cost, and risk management are main concerns. Social workers view it as a social systems puzzle in which access to care, cost, and social support are main concerns. CONCLUSIONS: Initiation of medication therapy is a disjointed experience for many consumers. The best timing for providing information about prescription drugs to individuals depends largely on what kinds of thoughts and impressions they have about a new therapy at various stages of the medication use process. The findings from this study can be useful for (1) developing consumer-centered approaches for medication use and (2) coordinating health care through the integration of the medication experience using consumer viewpoints.

The social network paradigm and applications in pharmacy.

BACKGROUND: There have been calls for research to include contextual and macrolevel factors within explanatory models of human health. A network approach focuses on the influence of relationships to predict behavior. OBJECTIVES: The first objective was to describe the social network paradigm based in sociology that uses network principles and methods to visualize, quantify, and predict outcomes using the structure and function of relationships. The second objective was to discuss applications of this approach in the context of health to guide future research in pharmacy. METHODS: This was a descriptive overview of conceptual models, methods, measures, and analyses that are used in the social network paradigm. RESULTS: The social network paradigm contains conceptual models that rely on relational and structural assumptions to make predictions related to human behavior. Although there is not 1 dominate theory of social networks, several models hold across applications and are commonly used by scholars. The methodology emphasized considerations of network boundaries, sampling strategies, and the type of data collected. Specific variables used in social network analysis were defined and dichotomized into constructs of centrality and cohesion. Network analysis was described in terms of available computational programs, data management, and statistical testing. Related research in health care was applied and ideas for pharmacy were proposed using a social network-based theoretical model. CONCLUSIONS: There is growing momentum for health behaviorists to gain familiarity for studying the effect of social networks on behavior. Applications in pharmacy using social network models, methods, and analysis can be used as a stand-alone perspective or in conjunction with other theoretical perspectives in an effort to explain human health or organizational behavior in health care settings.

A comparison of drug formularies and the potential for cost-savings.

BACKGROUND: Brand-name drug costs have been escalating in the United States, and the reasons for this are not immediately clear. A lack of adequate and accurate information about drug effectiveness, safety, and cost has implications for drug utilization and cost. OBJECTIVE: To explore the extent to which health plan formularies were consistent with recommended drug listings and identify what would be the potential cost-savings on total drug expenditures if the utilization rate of the recommended therapies was increased. METHOD: This study compared publicly available recommended drug listings with the formularies of 8 major health plans in Minnesota. Data from 1 of the health plans underwent an in-depth case analysis to evaluate the potential impact on pharmaceutical expenditures, using increased utilization rate scenarios of the recommended drugs. RESULTS: Health plans were similar with respect to degree of coverage for the recommended drugs. However, the case analysis showed that by increasing the utilization rate of recommended drugs, a potential cost-savings of more than 50% could be realized for the evaluated health plan for some therapeutic categories. CONCLUSION: This study demonstrates an approach to assessing drug formularies using publicly available, recommended drug lists that incorporated evidence for effectiveness, safety, and cost. By using the application of this type of reliable information, formulary changes can be guided to incentivize value-based utilization for patient populations.

A thematic analysis for how patients, prescribers, experts, and patient advocates view the prescription choice process.

BACKGROUND: Typically, patients are unaware of the cost consequences regarding prescribing decisions during their clinical encounter and rarely talk with their physicians about costs of prescription drugs. Prescription medications that are deemed by patients to be too costly when the costs become known after purchase are discontinued or used at suboptimal doses compared to prescription medications that are deemed to be worth the cost. OBJECTIVES: To learn more about the prescription choice process from several viewpoints, the purpose of this study was to uncover and describe how patients, prescribers, experts, and patient advocates view the prescription choice process. METHODS: Data were collected via 9 focus group interviews held between April 24 and July 31, 2007 (3 with patients, 3 with prescribers, 2 with experts, and 1 with patient advocates). The interviews were audiotaped and transcribed. The resulting text was analyzed in a descriptive and interpretive manner. Theme extraction was based on convergence and external divergence; that is, identified themes were internally consistent but distinct from one and another. To ensure quality and credibility of analysis, multiple analysts and multiple methods were used to provide a quality check on selective perception and blind interpretive bias that could occur through a single person doing all of the analysis or through employment of a single method. RESULTS: The findings revealed 5 overall themes related to the prescription choice process: (1) information, (2) relationship, (3) patient variation, (4) practitioner variation, and (5) role expectations. The results showed that patients, prescribers, experts, and patient advocates viewed the themes within differing contexts. CONCLUSIONS: It appears that the prescription choice process entails an interplay among information, relationship, patient variation, practitioner variation, and role expectations, with each viewed within different contexts by individuals engaged in such decision making.