Impact of the COVID-19 Pandemic on the Community Pharmacy Workforce.

This study sought to describe the impact of the COVID-19 pandemic on community pharmacy practice and its workforce. Interviews were conducted with 18 key informants from pharmacy associations and community pharmacists representing chain and independent pharmacy organizations across the United States from January to May 2022. Interview notes were analyzed using a rapid content analysis approach. Four themes resulted: (a) patient care at community pharmacies focused on fulfilling COVID-19 response needs; (b) pharmacists' history as immunizers and scope of practice expansions facilitated COVID-19 response efforts; (c) workforce supply shortages impeded COVID-19 response efforts and contributed to burnout; and (d) maintaining community pharmacy workforce's readiness will be critical to future emergency preparedness and response efforts. Formalizing scope of practice expansion policies and reimbursement pathways deployed during the COVID-19 pandemic could facilitate the community pharmacy workforce's ability to address ongoing public health needs and respond to future public health emergencies.

Interprofessional education and practice guide: interprofessional team writing to promote dissemination of interprofessional education scholarship and products.

Collaborations to develop, implement, evaluate, replicate, and write about interprofessional education (IPE) activities within and across institutions are wonderful opportunities to experience teamwork, team communication, ethics and values, and the roles and responsibilities of interprofessional team writing. Just as effective communication in interprofessional team-based care is essential for providing safe, high-quality health care, similar communication strategies are necessary to produce high-quality scholarship of IPE curricula and activities. Relationship and communication issues that affect health care teams' abilities to work together effectively (e.g., hierarchy, exclusion, assumptions, non-responsiveness, biases, stereotypes and poor hand-offs of information) can also occur in interprofessional team writing. Between 1970 and 2010, interprofessional practice research publications increased by 2293%. Although there has been tremendous growth in the IPE literature, especially of articles that require collaborative writing, there have not been any papers addressing the challenges of interprofessional team writing. As more teams collaborate to develop IPE, there is a need to establish principles and strategies for effective interprofessional team writing. In this education and practice guide, a cross-institutional team of faculty, staff, and graduate students who have collaborated on externally funded IPE grants, conferences, products, and workshops will share lessons learned for successfully collaborating in interprofessional team writing.

Interprofessional Error Disclosure Training for Medical, Nursing, Pharmacy, Dental, and Physician Assistant Students.

INTRODUCTION: Errors that harm patients often have many contributing factors and ideally should be disclosed by a team rather than an individual provider. However, most health professions students learn about errors and error disclosure in a single-profession class. METHODS: We developed a 2-hour small-group session in which our students practice discussing and disclosing a medical error that involves several professions, following a communication map. As they practice, students gain an understanding of the roles, skills, and perspectives of the other professions represented in the group. RESULTS: Over the last 5 years, student evaluations have been very positive. In 2016, our students strongly agreed that "The small group skills practice was a useful and interesting learning opportunity," "Learning with other professional students was valuable," and "Thinking about error disclosure from a team perspective was helpful." Student comments consistently indicated that they learned both about disclosing medical errors as well as other professionals' roles and perspectives. DISCUSSION: This activity has met both of our major goals. The first was to bring health professions students together to learn with, from, and about each other. The second was to practice a critical and challenging communication skill. This activity has been successfully implemented at other institutions, and can be adapted to fit other groups of students.

Medication adherence program: adherence challenges and interventions in type 2 diabetes.

OBJECTIVES: To describe medication adherence problems for adults with type 2 diabetes and to assess the nature and frequency of pharmacist activities in addressing them and proximate outcomes. DESIGN: Pre-post analysis. SETTING: Four community chain pharmacies located in Seattle, WA, from April 2008 to October 2009. PATIENTS: 120 patients (mean age >60 years) with type 2 diabetes taking oral diabetes medications and who were 6 or more days late for refills. INTERVENTION: Pharmacist telephone-initiated adherence support. MAIN OUTCOMES MEASURES: Nature and frequency of adherence-related problems and intervention activities and impact on reduction in refill gaps. RESULTS: The primary adherence challenge was difficulty taking medications (27.1%). Failure to remember doses and forgetting refills were reported by 24.6% and 26.3% of patients at baseline, respectively. Pharmacists provided support through some form of patient education (35.6% of encounters) or other adherence support (40.7%). Pharmacist time averaged slightly greater than 5 minutes per intervention and 12.6 ± 10.7 minutes (mean ± SD) over 12 months, with 3.4 ± 2.4 interventions per patient. Patient-specific education and adherence support by pharmacists and total intervention time were positively correlated, with a modest but significant reduction in refill gaps during 12 months of follow-up. CONCLUSION: Not remembering to refill medications was the most commonly reported problem. Patient encounters averaged 4 to 6 minutes for the first visit and 12 to 13 minutes over 12 months. Phone calls by pharmacists to adults who were late for oral diabetes medication refills were effective in identifying adherence-related problems and developing support strategies to promote medication self-management in busy urban community chain pharmacy settings.

MAP study: RCT of a medication adherence program for patients with type 2 diabetes.

OBJECTIVE: To evaluate the impact of a community pharmacy-based medication adherence detection and intervention protocol on medication adherence for patients with diabetes. DESIGN: Randomized controlled trial. SETTING: Four community chain pharmacies in the Seattle, WA, area from April 2008 to October 2009. PATIENTS: Patients with diabetes (n = 265) who were taking oral diabetes medications and late for refills by 6 days or more. INTERVENTION: Telephone-initiated adherence support by pharmacists following computer-generated missed refill alerts. Patients were randomized at the pharmacy level with pharmacists blinded to randomization. MAIN OUTCOMES MEASURES: Changes in medication adherence (i.e., days late at first refill, percent with a refill gap of 6 days or more at first refill, medication possession ratio [MPR] at 6 and 12 months) measured during three time periods. RESULTS: Baseline MPR (previous 12 months) of oral diabetes medications for study versus control participants was relatively high and similar (0.86 and 0.84, respectively). At 12 months, MPR was significantly improved for the study group ( P = 0.004) compared with the control group (difference between groups, P = 0.01). The intervention showed greater effect for patients with baseline MPR less than 80% (difference between groups, P = 0.02). The likelihood of MPR above 80% at the 12-month follow-up for any patient significantly favored the intervention group (odds ratio 4.77 [95% CI 2.00-11.40]). CONCLUSION: A brief missed refill intervention program involving urban community chain pharmacies was effective in achieving improved diabetes medication adherence, particularly among individuals with baseline MPR of 0.80 or less.

School of pharmacy-based medication therapy management program: development and initial experience.

OBJECTIVE: To describe a school of pharmacy-community pharmacy collaborative model for medication therapy management (MTM) service and training. SETTING: University of Washington (UW) School of Pharmacy (Seattle), from July to December 2008. PRACTICE DESCRIPTION: MTM services and training. PRACTICE INNOVATION: A campus-based MTM pharmacy was established for teaching, practice, and collaboration with community pharmacies to provide comprehensive medication reviews (CMRs) and MTM training. MAIN OUTCOME MEASURES: Number of collaborating pharmacies, number of patients contacted, number of CMRs conducted, and estimated cost avoidance (ECA). RESULTS: UW Pharmacy Cares was licensed as a Class A pharmacy (nondispensing) and signed "business associate" agreements with six community pharmacies. During July to December 2008, 10 faculty pharmacists completed training and 5 provided CMR services to 17 patients (5 telephonic and 12 face-to-face interviews). A total of 67 claims (17 CMRs and 50 CMR-generated claims) were submitted for reimbursement of $1,642 ($96.58/CMR case). Total ECA was $54,250, averaging $3,191.19 per patient. Seven student pharmacists gained CMR interview training. CONCLUSION: Interest in collaboration by community pharmacies was lower than expected; however, the campus-community practice model addressed unmet patient care needs, reduced outstanding MTM CMR case loads, increased ECA, and facilitated faculty development and training of student pharmacists.

Diabetes care practice patterns of recent pharmacy graduates.

PURPOSE: The objective of this project was to determine the amount and type of clinical skills and diabetes education provided by recent pharmacy school graduates. METHODS: Six hundred and one graduates were e-mailed a link to an online survey. Subjects were asked to report how frequently they either educate patients on diabetes self-care activities or perform diabetes-related patient care skills and to rate their ability to do so as poor, fair, good, or excellent. RESULTS: Data from 155 (25.8%) respondents were analyzed. The most commonly reported clinical activity was changing medication, followed by interpreting blood glucose patterns, medication management therapy, and interpreting laboratory results. Subjects reported educating patients more on the signs and symptoms of hypoglycemia, blood glucose monitoring, and diet information relative to other topics. The majority of subjects rated their skills as good or excellent. CONCLUSION: Pharmacists reported the most commonly performed diabetes-related clinical skill was changing medication and they most often educate patients about hypoglycemia and blood glucose monitoring. Subjects, who rated themselves poor/fair in these skills, preferred active learning strategies to enhance their ability.

Strengthening pharmaceutical care education in Ethiopia through instructional collaboration.

OBJECTIVE: To describe the development, implementation, and initial outcomes of a pharmaceutical care training-of-trainers course developed to assist Ethiopian pharmacy faculty members and graduate students in the development of curriculum and provision of pharmaceutical care services of relevance to this low-income country. DESIGN: In this collaboration, US and Ethiopian faculty members worked together in a week-long seminar and in hospital ward rounds to develop and offer a course to facilitate faculty members, curricular, and service development in pharmaceutical care in Ethiopia. ASSESSMENT: Assessments were conducted during the seminar, immediately post-seminar, at 3 months post-seminar, and at 1 year post-seminar. An examination was administered at the conclusion of the course to assess immediate learning outcomes for the graduate students. Post-course assessments of short-term (3-month) and longer-term (12-month) impact were conducted to identify pharmaceutical care services that had been implemented to assess knowledge and skill gained during the seminar. Correspondence between seminar participants and the US faculty members as well as graduate student thesis projects provided further evidence of changes at 3 and 12 months post-course. CONCLUSION: Pharmaceutical care training was developed for Ethiopian faculty members through a seminar and hospital ward rounds. Enhancements have been added to curricula for bachelor in pharmacy students and select pharmaceutical care services have been implemented through master's thesis projects.

The impact of diabetes concentration programs on pharmacy graduates' provision of diabetes care services.

OBJECTIVE: To determine practice outcomes associated with doctor of pharmacy (PharmD) graduates from 2 universities who completed a diabetes-concentration. METHODS: An online survey instrument was sent to 93 PharmD graduates who completed a concentration in diabetes and 94 control graduates to determine their knowledge of and skills in providing diabetes care and how frequently they provided diabetes care services. RESULTS: Ninety-seven graduates (52%) responded. Significantly more graduates with a diabetes concentration rated their ability to instruct patients on insulin administration, blood glucose monitoring, foot care, and insulin dose adjustment as good or excellent compared to a control group of graduates. Graduates with a diabetes concentration also rated their ability to perform blood glucose monitoring and foot examinations higher than graduates without a diabetes concentration (P < 0.05). CONCLUSION: Completing a diabetes concentration increased graduates' knowledge of diabetes and confidence in their ability to provide care but did not appear to alter their practice patterns significantly. Further study is needed to determine whether other barriers to pharmacists providing diabetes care exist in practice settings.

Interprofessional collaboration: three best practice models of interprofessional education.

Interprofessional education is a collaborative approach to develop healthcare students as future interprofessional team members and a recommendation suggested by the Institute of Medicine. Complex medical issues can be best addressed by interprofessional teams. Training future healthcare providers to work in such teams will help facilitate this model resulting in improved healthcare outcomes for patients. In this paper, three universities, the Rosalind Franklin University of Medicine and Science, the University of Florida and the University of Washington describe their training curricula models of collaborative and interprofessional education.The models represent a didactic program, a community-based experience and an interprofessional-simulation experience. The didactic program emphasizes interprofessional team building skills, knowledge of professions, patient centered care, service learning, the impact of culture on healthcare delivery and an interprofessional clinical component. The community-based experience demonstrates how interprofessional collaborations provide service to patients and how the environment and availability of resources impact one's health status. The interprofessional-simulation experience describes clinical team skills training in both formative and summative simulations used to develop skills in communication and leadership.One common theme leading to a successful experience among these three interprofessional models included helping students to understand their own professional identity while gaining an understanding of other professional's roles on the health care team. Commitment from departments and colleges, diverse calendar agreements, curricular mapping, mentor and faculty training, a sense of community, adequate physical space, technology, and community relationships were all identified as critical resources for a successful program. Summary recommendations for best practices included the need for administrative support, interprofessional programmatic infrastructure, committed faculty, and the recognition of student participation as key components to success for anyone developing an IPE centered program.

A web-based team-oriented medical error communication assessment tool: development, preliminary reliability, validity, and user ratings.

BACKGROUND: Multiple-choice exams are not well suited for assessing communication skills. Standardized patient assessments are costly and patient and peer assessments are often biased. Web-based assessment using video content offers the possibility of reliable, valid, and cost-efficient means for measuring complex communication skills, including interprofessional communication. DESCRIPTION: We report development of the Web-based Team-Oriented Medical Error Communication Assessment Tool, which uses videotaped cases for assessing skills in error disclosure and team communication. Steps in development included (a) defining communication behaviors, (b) creating scenarios, (c) developing scripts, (d) filming video with professional actors, and (e) writing assessment questions targeting team communication during planning and error disclosure. EVALUATION: Using valid data from 78 participants in the intervention group, coefficient alpha estimates of internal consistency were calculated based on the Likert-scale questions and ranged from α=.79 to α=.89 for each set of 7 Likert-type discussion/planning items and from α=.70 to α=.86 for each set of 8 Likert-type disclosure items. The preliminary test-retest Pearson correlation based on the scores of the intervention group was r=.59 for discussion/planning and r=.25 for error disclosure sections, respectively. Content validity was established through reliance on empirically driven published principles of effective disclosure as well as integration of expert views across all aspects of the development process. In addition, data from 122 medicine and surgical physicians and nurses showed high ratings for video quality (4.3 of 5.0), acting (4.3), and case content (4.5). CONCLUSIONS: Web assessment of communication skills appears promising. Physicians and nurses across specialties respond favorably to the tool.

Assessment of human patient simulation-based learning.

The most common types of assessment of human patient simulation are satisfaction and/or confidence surveys or tests of knowledge acquisition. There is an urgent need to develop valid, reliable assessment instruments related to simulation-based learning. Assessment practices for simulation-based activities in the pharmacy curricula are highlighted, with a focus on human patient simulation. Examples of simulation-based assessment activities are reviewed according to type of assessment or domain being assessed. Assessment strategies are suggested for faculty members and programs that use simulation-based learning.

Recent results of exenatide use as adjunctive therapy in the treatment of patients with type 2 diabetes.

Exenatide is a GLP-1 receptor agonist approved for use in type 2 diabetes mellitus. In clinical trials, significant reductions in serum glucose and weight were demonstrated for exenatide with primary glycemic effects of the twice daily formulation on prandial glucose control. In this paper, we review recent research with exenatide as adjunctive therapy in type 2 diabetes mellitus. In particular, studies demonstrate ongoing benefit on glycemic control and weight reduction with continued therapy up to 82 weeks duration and efficacy as adjunctive therapy for patients taking metformin, thiazolidinediones, and/or a sulfonylurea and as compared to sitagliptin and various insulin formulations. Compared to insulin, exenatide likely has greatest benefit for those patients who are overweight or who need improved prandial glucose control. The new long-acting release formulation of exenatide has demonstrated slightly improved efficacy compared to the twice daily formulation as well as a reduction in gastrointestinal side effects. Emerging research is further exploring novel benefits of exenatide as adjunctive DM therapy, effects on prandial glycemic control, markers of hepatic inflammation, alternative dosage forms including intra-nasal administration, and effects on beta cell function.

Barriers to medication adherence in poorly controlled diabetes mellitus.

PURPOSE: The purpose of this study is to characterize the adherence and medication management barriers for adults with poorly controlled type 2 diabetes mellitus (DM) (those with A1c 9% or above) and to identify specific adherence characteristics associated with poor diabetes control. METHODS: This was a cross-sectional analysis of baseline data from a randomized, controlled diabetes intervention conducted in University of Washington (UW) Medicine Clinics in the greater Seattle, Washington, area. The goal of the original study was to evaluate the effect of a pharmacist intervention on improving diabetes control over 12 months. Evaluation measures for medication adherence included self-reported adherence and medication management challenges using the Morisky question format and difficulty with taking medications for each diabetes medication based on the Brief Medication Questionnaire. Specific adherence characteristics associated with poor diabetes control (A1c >9%) were identified using multivariate regression analysis. RESULTS: Seventy-seven subjects (mean A1c, 10.4%; mean duration of DM, 7 years) were studied. The most common adherence challenges included paying for medications (34%), remembering doses (31%), reading prescription labels (21%), and obtaining refills (21%). Taking more than 2 doses of DM medication daily (beta = .78, SE = 0.32, P = .02) and difficulty reading the DM medication prescription label (beta = .76, SE = 0.37, P = .04) were significantly associated with higher hemoglobin A1c. Self-reported adherence was not related to A1c control. CONCLUSIONS: In this study, we identified 2 factors that were associated with poorer A1c control. These findings highlight the importance of identifying potential challenges to medication adherence for those with DM and providing support to minimize or resolve these barriers to control.

Looking to the future: focus on DPP-4 inhibitors for the treatment of type 2 diabetes and emerging therapies.

Strong evidence exists demonstrating the benefits of tight glycemic control in type 1 and type 2 diabetes mellitus patients, but glycemic goals are not adequately achieved for many patients. Advancement in the knowledge surrounding the physiology of endogenous glucoregulatory peptide hormones, such as glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1, has led to new therapeutic targets for the treatment of type 2 diabetes mellitus. Dipeptidyl peptidase-4 (DPP-4) inhibitors provide practitioners with a novel mechanism of action to use for combination therapies for the treatment of type 2 diabetes mellitus. This article, part 3 of a 3-part series, reviews the new class of medications known as DPP-4 inhibitors as well as discusses a future buccal insulin formulation, Oral-Lyn, on the horizon for the treatment of diabetes mellitus.

Medication taking and diabetes: a systematic review of the literature.

PURPOSE: The purpose of this systematic review is to evaluate the evidence of the challenges and barriers to medication taking (adherence) and to summarize the interventions that improve medication taking in type 1 and type 2 diabetes mellitus. METHODS: PubMed, the Cochrane Collaborative, and the Health and Psychosocial Instruments databases were used to obtain articles identified by using the MeSH headings of diabetes, medication, oral hypoglycemic agents, oral antihyperglycemic agents, oral antidiabetic agents, insulin, adherence, medication taking, compliance, fears, treatment, and electronic monitoring. Only articles published in English between 1990 and May 7, 2007, and including individuals of all ages with type 1 or type 2 diabetes mellitus were included. Retrospective and prospective studies reporting adherence to medications using self-report, pill counts, medication possession ratios, and electronic monitoring devices were included. Database analyses of prescription records from various organizations or countries were included only if adherence to pharmacologic therapy was stated. Surveys and questionnaires assessing medication taking were also included. The data from the selected literature was abstracted independently. The various studies were grouped together based on the type of study conducted. Studies were not included if a specific measure of adherence to medication was not used or stated. The studies are presented in 3 tables according to design. CONCLUSIONS: Several barriers to medication taking have been suggested for those with diabetes mellitus, although well-controlled trials to confirm and resolve these barriers are limited. Diabetes educators should be aware of the common barriers to medication taking (regimen complexity of more than 1 diabetes mellitus drug or more than 1 dose daily, depression, and remembering doses and refills) and provide screening and support to their patients to resolve barriers if they exist. Further studies are needed to test specific interventions to improve medication taking in diabetes.

Inhaled dry powder insulin for the treatment of diabetes mellitus.

BACKGROUND: Inhaled dry powder insulin (IDPI) is the first inhaled insulin approved for the treatment of type 1 and type 2 diabetes mellitus (DM). OBJECTIVE: This article reviews available information on IDPI, focusing on its clinical pharmacokinetics, comparative efficacy, tolerability, adverse events, dosage and administration, and cost. METHODS: MEDLINE (1966-July 2006) and Web of Science (1995-July 2006) were searched for original research and review articles published in English. The search terms used were inhaled insulin, inhaled human insulin, rDNA origin inhalation powder, inbaled dry powder insulin, and IDPI. All published comparative efficacy studies were included in the review, as well as selected information from the package insert for IDPI. RESULTS: IDPI is an inhaled dry powder form of regular human insulin (RHI) that is used as a premeal insulin to improve glycemic control by reducing postprandial glucose excursions. The literature search identified 5 efficacy trials comparing reductions in glycosylated hemoglobin (HbA(1c)) in a total of 582 patients with type 1 DM who received either premeal IDPI plus neutral protamine Hagedorn (NPH) or Ultralente insulin or injectable RHI plus NPH or Ultralente insulin. The search identified 5 comparative efficacy studies of IDPI monotherapy or the addition of IDPI to the current regimen in a total of 1413 patients with type 2 DM that was uncontrolled with diet and exercise, metformin, a sulfonylurea, metformin and a sulfonylurea, or a secretagogue plus an insulin sensitizer. The use of IDPI as a mealtime insulin in these studies was associated with absolute changes in HbA(1c) ranging from -0.6% to +0.1% in patients with type 1 DM and from -1.4% to -2.9% in patients with type 2 DM. HbA(1c) values <7% were achieved in 16.9% to 28.2% of patients with type 1 DM and 16.7% to 44.0% of patients with type 2 DM. The most common nonrespiratory adverse event noted during clinical trials of IDPI was hypoglycemia (type 1 DM: 8.6-9.3 episodes/subject-month; type 2 DM: 0.3-1.4 episodes/subject-month), and the most common adverse event involving the pulmonary system was cough (21.9%-29.5%). CONCLUSIONS: IDPI is the first available inhaled insulin. It provides an additional option for the achievement of HbA(1c) goals with a premeal insulin.

Update in the pharmacologic treatment of diabetes: focus on insulin detemir, insulin glulisine, and inhaled dry powdered insulin.

The prevalence of diabetes mellitus has increased to more than 20 million people in the United States, and current estimates indicate that one third of all Americans born in the year 2000 will develop diabetes mellitus in their lifetime. The need for diabetes therapies offering improved glucose control by mimicking normal physiological properties of glucose metabolism and improving on logistics such as ease of use, self-management, monitoring, and delivery is clear. This article, part 2 of a 3-part series, reviews newer injectable insulin preparations and examines the first-to-market orally inhaled dry powdered insulin (IDPI). The information provided is tailored to diabetes educators and includes mechanism of action, pharmacokinetics, drug interactions, clinical trials, dosage and administration guidelines, side effects, and educational pearls for each insulin discussed. A detailed patient case designed to acquaint the reader with these newer insulin products and provide an understanding of clinical issues to consider when providing diabetes education to patients is included.