Validation of the Copenhagen Burnout Inventory in Pharmacists.

OBJECTIVES: This study aimed to 1) determine the validity of the Copenhagen Burnout Inventory (CBI) for use in the assessment of burnout in a sample of pharmacists using confirmatory factor analysis (CFA), and 2) use the CBI items and other measures of work-life to assess burnout in pharmacists employed in various types of practice. METHODS: A cross-sectional survey was administered to a sample of 2,582 pharmacists in a single Midwestern US state. The survey included the three subscales of the CBI, each of which measures personal, work-related, and patient-related dimensions of burnout. Other items included demographics, practice type, workload, and work-life balance. CFA was used to measure fit, and Cronbach's alpha was used to assess reliability. Correlation was used to assess criterion validity of the CBI. Logistic regression and bivariate analyses were used to assess pharmacist burnout based on demographics. RESULTS: Following the removal of 2 items from the measurement model, a 17-item 3-factor CBI was found to possess satisfactory psychometric properties for use in pharmacists. The CBI correlated with measures of work-life demonstrating criterion validity. A logistic regression showed that younger pharmacists and community pharmacists experience higher burnout than older pharmacists and clinical pharmacists. Community pharmacists also more often reported high workloads and poorer work-life integration. Both community and clinic pharmacists desired more time providing patient care services and less time dispensing. CONCLUSION: The CBI is a psychometrically reliable and valid instrument for assessing burnout in pharmacists. Younger pharmacists and community pharmacists warrant attention due to their higher degree of burnout.

Short-term medical service trips: what is the cost of patient care and student training?

BACKGROUND: Evaluations of the costs and effects of medical service trips (MSTs) are increasingly necessary. Estimates of costs can inform decision making to determine if participation is likely to be a wise use of resources. METHODS: This study estimates the costs and effects of a 1-week MST for 20 health professions students and seven providers to the Dominican Republic. Costs were defined as direct costs for students and providers and opportunity costs for providers. Effects were defined as the cost to treat one patient and the cost to train one student. Students were surveyed about their costs before and after the MST. Most provider costs were assumed to be the same as those of the students. RESULTS: The mean direct cost per student was US${\$}$1764 and US${\$}$2066 for providers. Total opportunity costs for seven providers was US${\$}$19 869. The total cost for the trip was US${\$}$69 612 to treat 464 patients. With and without provider opportunity costs, the cost to treat one patient was US${\$}$150 and US${\$}$107, and the cost to train one student was US${\$}$3481 and US${\$}$2487, respectively. CONCLUSIONS: Short-term MSTs may be more expensive than previously thought. The cost to treat one patient was similar to a medical office visit in the USA.

An evaluation of community pharmacies' actions under value-based payment.

OBJECTIVE: To determine actions taken by community pharmacies to be successful under a value-based pharmacy program (VBPP). METHOD: An exploratory sequential mixed methods approach was used to evaluate pharmacies participating in the VBPP, with qualitative data collected and analyzed in the first phase, followed by quantitative measurement through a 30-item survey instrument in the second phase. RESULTS: The qualitative data showed that participating pharmacies were more involved with adherence and cardiovascular and diabetes metrics than with other metrics. Depression metrics received the lowest overall involvement. For total cost of care, different approaches were used; 5 pharmacies used the dashboard to identify likely high-cost patients they could try to manage, and 4 pharmacies monitored adherence to avoid complications that could contribute to increased cost. For the survey response rate was 72.6% (n = 53). The mean perception of level of success was 53.06 ± 20.15 (mean ± SD). Activities with the highest priority were adherence (1.98 ± 0.97) and diabetes care (2.04 ± 0.83), and the activity with the lowest priority was depression care (3.60 ± 1.10). The most frequently mentioned challenge was time availability, and the most common improvement suggestion was better communication between the insurer and providers. CONCLUSION: In conclusion, this study found that community pharmacies were transforming their practices to be successful under a commercial value-based payment program. The pharmacies tended to build on care processes already established (e.g., medication adherence, patients with diabetes or cardiovascular conditions) and developed new processes to address emerging metrics and associated patient needs (e.g., collecting and documenting blood pressure and hemoglobin A1c levels). Future research is needed to identify best practices for patient care and pharmacy success under broad VBPPs such as the one studied here.

Advancing Community Pharmacy Practice - A Technician Product Verification Pilot to Optimize Care.

Elevating the technical role of pharmacy technicians to perform Technician Product Verification (TPV) is one strategy that has shown promise to optimize pharmacy practice models. This is done by better positioning pharmacists to provide clinical care, in line with their education and expertise. TPV permits a Validated Pharmacy Technician, as defined by the Wisconsin Pharmacy Examining Board, to verify the accuracy of a product filled by another technician. The pharmacist maintains responsibility for assessing the clinical appropriateness of the prescription, including drug utilization review, data entry, and patient counseling. During the study period, 12,891 pharmacist-verified prescriptions (baseline) and 27,447 Validated Pharmacy Technician-verified prescriptions were audited for accuracy. The aggregate verification error rate for pharmacist-verified prescriptions was 0.16% and 0.01% for Validated Pharmacy Technician-verified prescriptions. The mean error rate was significantly less for Validated Pharmacy Technician-verified prescriptions than for pharmacist-verified prescriptions (0.19 ± 0.174 % vs 0.03 ± 0.089 %, p=0.020) (Figure 3). This suggests TPV in the community pharmacy setting maintained patient safety. In this study, Validated Pharmacy Technicians were shown to be more accurate than pharmacists at performing product verification. The ability to delegate the product verification task holds the potential to free up pharmacist time for increased direct patient care. Increasing direct patient care by pharmacists in community pharmacies may have significant implications for improving patient outcomes and pharmacy quality.

Short-term Experiences in Global Health: What is the Cost of Cultural Competence?

Students in a wide variety of health professions are increasingly interested in volunteering on a short-term experience in global health (STEGH). The literature suggests that STEGHs pose a variety of potential risks and benefits, and may carry a significant cost to plan and provide. One potential mitigating factor for any risks and costs is that student participation on a STEGH may enhance their cultural competence. Since monies spent on STEGHs are fungible, and there may be other opportunities to improve students' cultural competence, the objectives of this study were to determine if participation on a STEGH increased students' cultural competence and if so, what the cost for any such increase was. In this study, 20 students who participated on a 1-week STEGH to the Dominican Republic completed the Inventory for Assessing the Process of Cultural Competence Among Health Care Professionals - Student Version (IAPCC-SV) before and after the STEGH. The costs for all students and 7 supervising health professionals to volunteer for the STEGH were calculated, and the size of any increase in cultural competence was determined. The cost was divided by the change in cultural competence to ascertain the cost of the change. Students showed a measureable increase on the IAPCC-SV overall and on the subscales of knowledge and skill. The cost of a 1% overall increase in students' cultural competence ranged from $287 to $401. These results may allow schools offering STEGHs to determine if their offerings are cost-effective or not.

Patient Experiences at Enhanced-Service Pharmacies in Iowa.

OBJECTIVES: As payment systems are evolving, the role of community pharmacists has expanded from simply dispensing prescriptions to actively providing care to patients. Little is known about patients' experiences with enhanced pharmacy services under the pay-forperformance model. In Iowa, Wellmark implemented its Value-Based Pharmacy Program (VBPP) where pharmacists receive capitation for performance on a set of quality measurements. Therefore, the objective of this study was to evaluate the quality of services and pharmacies from patients' perspective in VBPP. A structured interview guide developed from the service quality model was used for this study. METHODS: We conducted telephone interviews with patients from 6 community pharmacies participating in VBPP between December 2017 and January 2018. Patients who were aged between 21 and 90 years, had Wellmark prescription drug coverage, were currently on at least three medications with one or more of the medications for a chronic condition and had received enhanced pharmacy services were invited for the study. The semi-structured interview transcripts were coded and analyzed using an inductive approach of thematic analysis. RESULTS: Interviews were completed by 25 patients. Most of them were female and the average age was 59. More than half of the patients were taking at least five medications for chronic conditions. A majority of the patients received medication synchronization and immunization. A total of 13 themes across the service quality dimensions were identified. Patients thought their pharmacists were reliable, responsive, knowledgeable and trustworthy when they provided services. Pharmacy services were accessible and perceived as high quality. Privacy was not a big concern for most patients. Patients had a somewhat limited view regarding how pharmacists helped them maintain health. CONCLUSION: Patients' perceptions of enhanced pharmacy services and pharmacies were generally positive while their understanding of pharmacists' clinical role was limited.

Rural Physician-Pharmacist Collaborative Practice Agreements Managing Patients in Supportive Living and Assisted Living Memory Care Facilities.

SETTING: Supportive living and assisted living memory care facilities in a rural West-Central Illinois county. OBJECTIVES: 1) Evaluate the impact of active pharmacist participation on patient care for residents living in supportive and assisted living facilities, 2) demonstrate feasibility and financial sustainability of rural community pharmacists providing disease state management services, 3) create processes for best practice to expand the clinical role of the community pharmacist. DESIGN: Case study. INTERVENTIONS: Participating residents received disease state management services provided by a community pharmacist as outlined through collaborative practice agreements with local physicians. The disease states managed included hypertension, hyperlipidemia, diabetes mellitus, and warfarin anticoagulation therapy. The pharmacist completed an initial chart review, initial face-to-face visit, subsequent monthly chart reviews, and monthly face-to-face visits with each resident. RESULTS: During the 6-month period of community pharmacist management, 86 face-to-face visits were completed to deliver a median of 5 visits per resident. The pharmacist identified 23 drug therapy problems with recommended solutions communicated to the resident's primary care provider. Providers accepted 19 of these recommendations, reflecting an 82.6% acceptance rate. CONCLUSIONS: Community pharmacists can feasibly implement enhanced clinical services to assist with disease state management of supportive living and assisted living residents in collaboration with physicians. Pharmacists can provide clinical assessment, education and effective communication to optimize medication management and utilization.

The Iowa new practice model: Advancing technician roles to increase pharmacists' time to provide patient care services.

OBJECTIVES: Determine the effects of an 18-month pilot project using tech-check-tech in 7 community pharmacies on 1) rate of dispensing errors not identified during refill prescription final product verification; 2) pharmacist workday task composition; and 3) amount of patient care services provided and the reimbursement status of those services. DESIGN: Pretest-posttest quasi-experimental study where baseline and study periods were compared. SETTING AND PARTICIPANTS: Pharmacists and pharmacy technicians in 7 community pharmacies in Iowa. OUTCOME MEASURES: The outcome measures were 1) percentage of technician verified refill prescriptions where dispensing errors were not identified on final product verification; 2) percentage of time spent by pharmacists in dispensing, management, patient care, practice development, and other activities; 3) the number of pharmacist patient care services provided per pharmacist hours worked; and 4) percentage of time that technician product verification was used. RESULTS: There was no significant difference in overall errors (0.2729% vs. 0.5124%, P = 0.513), patient safety errors (0.0525% vs. 0.0651%, P = 0.837), or administrative errors (0.2204% vs. 0.4784%, P = 0.411). Pharmacist's time in dispensing significantly decreased (67.3% vs. 49.06%, P = 0.005), and time in direct patient care (19.96% vs. 34.72%, P = 0.003), increased significantly. Time in other activities did not significantly change. Reimbursable services per pharmacist hour (0.11 vs. 0.30, P = 0.129), did not significantly change. Non-reimbursable services increased significantly (2.77 vs. 4.80, P = 0.042). Total services significantly increased (2.88 vs. 5.16, P = 0.044). CONCLUSION: Pharmacy technician product verification of refill prescriptions preserved dispensing safety while significantly increasing the time spent in delivery of pharmacist provided patient care services. The total number of pharmacist services provided per hour also increased significantly, driven primarily by a significant increase in the number of non-reimbursed services. This was mostly likely due to the increased time available to provide patient care. Reimbursed services per hour did not increase significantly mostly likely due to lack of payers.

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.

Expanding the scope of medical mission volunteer groups to include a research component.

BACKGROUND: Serving on volunteer groups undertaking medical mission trips is a common activity for health care professionals and students. Although volunteers hope such work will assist underserved populations, medical mission groups have been criticized for not providing sustainable health services that focus on underlying health problems. As members of a volunteer medical mission group, we performed a bed net indicator study in rural Mali. We undertook this project to demonstrate that volunteers are capable of undertaking small-scale research, the results of which offer locally relevant results useful for disease prevention programs. The results of such projects are potentially sustainable beyond the duration of a mission trip. METHODS: Volunteers with Medicine for Mali interviewed 108 households in Nana Kenieba, Mali during a routine two-week medical mission trip. Interviewees were asked structured questions about family demographics, use of insecticide treated bed nets the previous evening, as well as about benefits of net use and knowledge of malaria. Survey results were analyzed using logistic regression. RESULTS: We found that 43.7% of households had any family member sleep under a bed net the previous evening. Eighty seven percent of households owned at least one ITN and the average household owned 1.95 nets. The regression model showed that paying for a net was significantly correlated with its use, while low perceived mosquito density, obtaining the net from the public sector and more than four years of education in the male head of the household were negatively correlated with net use. These results differ from national Malian data and peer-reviewed studies of bed net use. CONCLUSIONS: We completed a bed net study that provided results that were specific to our service area. Since these results were dissimilar to peer-reviewed literature and Malian national level data on bed net use, the results will be useful to develop locally specific teaching materials on malaria prevention. This preventive focus is potentially more sustainable than clinical services for malaria treatment. Although we were not able to demonstrate that our work is sustainable, our study shows that volunteer groups are capable of undertaking research that is relevant to their service area.

Pharmacists' and pharmacy students' ability to identify drug-related problems using TIMER (Tool to Improve Medications in the Elderly via Review).

OBJECTIVE: Determine the effectiveness of TIMER (Tool to Improve Medications in the Elderly via Review) in helping pharmacists and pharmacy students identify drug-related problems during patient medication reviews. METHODS: In a randomized, controlled study design, geriatric patient cases were sent to 136 pharmacists and 108 third-year pharmacy students who were asked to identify drug related-problems (DRPs) with and without using TIMER. RESULTS: Pharmacists identified more tool-related DRPs using TIMER (p = 0.027). Pharmacy students identified more tool-related DRPs using TIMER in the first case (p = 0.02), but not in the second. CONCLUSION: TIMER increased the number of DRPs identified by practicing pharmacists and pharmacy students during medication reviews of hypothetical patient cases.