Factors impacting medication adherence in a birth cohort at higher risk for Hepatitis C infection.

Due to the high prevalence of Hepatitis C virus (HCV) infection among individuals born between 1945 and 1965, in 2012 the Centers for Disease Control and Prevention began recommending HCV screening for this birth cohort. As adherence to HCV treatment is essential for sustained virologic response, identifying factors influencing medication adherence is important. The validated Adherence to Refills and Medications Scale (ARMS) is used to study recent medication adherence in those with chronic disease. This cross-sectional pilot study assesses factors associated with reduced adherence, indicated by higher ARMS scores, among individuals in this birth cohort. To elucidate factors associated with medication adherence, measured by the ARMS score, among a birth cohort at higher risk for HCV to guide future treatment and improve adherence. Patients born between 1945 and 1965, accessing care at an academic family medicine clinic, were recruited between April and June 2019. Demographics, prior HCV diagnosis, HCV risk factors (prior imprisonment, tattoos, and intravenous drug use), depression assessment (Patient Health Questionnaire-9), adverse childhood experiences (ACEs), and ARMS scores were collected. Mean ARMS scores were compared using t tests and analysis of variance (α = 0.05), while multiple variable models were performed using linear regression. Women comprised 58% of participants (n = 76), 52% reported depression and 37% 4 or more ACEs. The mean ARMS score was 16.3 (SD = 3.43) and 10% reported prior diagnosis of HCV. In the final multiple variable model, ARMS scores were 2.3 points higher in those with mild depression (95% CI: 0.63, 4.04), 2.0 in those with at least 4 ACEs (95% CI: 0.55, 3.49), and 1.8 in those with tattoos (95% CI: 0.30, 3.28). ACEs and food insecurity were identified as confounding variables in those with moderate to severe depression. This study found medication adherence was related to depression, ACEs, tattoos, and food insecurity among patients in this birth cohort at higher risk for HCV.

Pharmacist-led educational and error notification interventions on prescribing errors in family medicine clinic.

OBJECTIVES: To determine the rate of prescribing errors in a family medicine clinic and the subsequent impact of pharmacist-led educational and error notification interventions on prescribing errors. DESIGN: Single site, pre-post study design. SETTING: An outpatient academic family medicine clinic serving pediatric and adult populations in Oklahoma from March 1, 2011, through April 30, 2012. PARTICIPANTS: 24 resident physicians who prescribed medications during routine outpatient visits. INTERVENTION: A prescribing educational program, audit and feedback methods, and weekly newsletter. MAIN OUTCOMES MEASURE: Percentage of prescription errors and physician error rate before and after intervention among pediatric and adult populations. RESULTS: During the two assessment periods, 24 resident physicians wrote 2,753 prescriptions for 394 pediatric and 899 adult patients. The overall percentage of prescription errors decreased from 18.6% during March 2011 to 14.5% during April 2012 (P = 0.004). Errors were more commonly seen with prescriptions written for pediatric patients (24.9%) than for adult patients (13.9%) (P = 0.001). Individual physician error rates ranged from 5% to 36% (mean ± SD 16.5% ± 8.1). Physicians committed significantly fewer prescribing errors during the postintervention assessment period (14.9%) than during the preintervention assessment period (20.9%) (P = 0.002). Controlling for time, pediatric prescription error rates among physicians who participated in the educational intervention were 36% lower than the error rates among physicians who did not participate (rate ratio 0.64 [95% CI 0.45, 0.91], P = 0.01). CONCLUSION: The pharmacist-led educational program was effective in reducing pediatric prescribing errors among resident physicians in a family medicine clinic.

What is the Role of the Pharmacist in Obesity Management?

Obesity rates have increased over the last two decades. Based on NHANES data, 68.8 % of US adults are classified as overweight or obese. Obesity increases the risk of diseases and can contribute to increased morbidity and mortality. This review examines studies published in which pharmacists have provided weight management services alone or in a team. The electronic databases OVID Medline, International Pharmaceutical Abstracts and EMBASE (1946-2014) were searched. Nine articles were identified in which pharmacists delivered a weight management service either alone or in a team, and eight studies collected outcomes. Six studies evaluated the participant's weight loss or satisfaction with the service, and two studies evaluated weight loss associated with a meal-replacement program. The outcomes from these studies are limited and while positive, have failed to provide significant evidence of the impact of pharmacists providing these services. More randomized, controlled trials are needed to document weight management services.

Assessing health literacy practices in a community pharmacy environment: experiences using the AHRQ Pharmacy Health Literacy Assessment Tool.

BACKGROUND: The Agency for Healthcare Research and Quality (AHRQ) developed the tool, "Is Our Pharmacy Meeting Patients' Needs? Pharmacy Health Literacy Assessment Tool" to evaluate health literacy preparedness of pharmacy environments from patient, staff, and environmental perspectives. The tool was designed at a clinic-based, outpatient pharmacy of a large, urban, public hospital. Despite the ready availability of this tool and the encouragement of AHRQ to adapt it to other environments, there is no published literature on the dissemination and translation of this tool in the community pharmacy environment. OBJECTIVES: The five objectives of this study were to: (1) pilot the AHRQ tool "Is Our Pharmacy Meeting Patients' Needs? Pharmacy Health Literacy Assessment Tool" in a community pharmacy environment; (2) evaluate and adapt the tool; (3) describe the use of health literacy practices from patient, staff, and independent auditor perspectives using the revised tool; (4) evaluate the effect of a low-intensity educational health literacy awareness program; and (5) identify opportunities to improve health literacy-sensitive practices in the community pharmacy environment. METHOD: The study employed a mixed method, posttest-only control group design using community pharmacies in the Tulsa, OK area. Participants included community pharmacists, staff, patients, and independent auditors. Select pharmacy staff members were invited to receive a health literacy training program delivered by a nationally-recognized health literacy expert to raise awareness of health literacy issues. Approximately eight months after the program, pharmacy staffs were surveyed using a written instrument, patients were interviewed by telephone, and the study investigators performed independent environmental audits in each of the selected pharmacies. Results from auditor evaluations, staff survey responses, and patient interviews were compared for similarities and differences to provide a multidimensional perspective about the use of health literacy-sensitive practices. RESULTS: After piloting and adapting the AHRQ tool for the community pharmacy environment, 60 patients completed telephone interviews, 31 staff members completed surveys, and four independent auditors completed environmental audits in six study pharmacies using the revised data collection instruments. The majority of patients and staff were in agreement that written materials were easy to read. However, the auditors did not report equally high agreement regarding the readability qualities of the written materials. While the majority of staff reported use of literacy-sensitive communication techniques with patients, only a minority of patients reported actual communication with the pharmacist and use of literacy-sensitive communication techniques. At trained pharmacies, a significantly larger proportion of patients reported that the pharmacist spent enough time answering their questions (100% vs. 87%, P = 0.038), but a smaller proportion reported the pharmacists reviewed important information from the written information provided (30% vs. 57%, P = 0.035). A significantly smaller proportion of pharmacy staff also reported using the repeat-back technique at the trained pharmacies (40% vs. 79%, P = 0.035). CONCLUSION: This project is the first to report piloting, revision, and implementation of the AHRQ Health Literacy Assessment Tool in a community pharmacy practice setting. In addition to adapting data collection instruments and implementation strategies, opportunities that target training to facilitate use of literacy-sensitive practices and active patient engagement with literacy-sensitive communication techniques were identified.

Patients' perceptions of a pharmacist-managed weight management clinic in a community setting.

BACKGROUND: There have been many studies demonstrating patients' willingness to pay for medication therapy management services provided by pharmacists. There are few studies, however, evaluating the possible provision of a weight management service in the community pharmacy setting. OBJECTIVES: The objectives were to (1) determine patients' knowledge of obesity and its resultant health risks, (2) determine patients' beliefs about obesity, (3) determine interest in pharmacist-delivered weight management services, and (4) identify factors associated with knowledge, beliefs, and interest in obesity and/or weight management services. METHODS: One thousand patients were selected from 5 community pharmacies under a single chain located within a large metropolitan area to receive a mail survey. Survey items assessed patients' knowledge of obesity and the health risks associated with it by using the Obesity Risks Knowledge Scale and the Obesity Beliefs Scale. Additional survey questions were added to measure patients' willingness to pay for a pharmacist-managed weight management clinic. Descriptive statistics and linear regression models were used in analysis of the data. RESULTS: Nearly two-thirds (62%) of respondents were classified as overweight or obese based on self-reported height and weight. Most of the respondents demonstrated an average level knowledge regarding the health risks associated with obesity. Attitudes toward obesity were commensurate with prevailing knowledge. Only a small proportion (13%) of respondents were willing to pay out of pocket for a pharmacist-delivered weight management service. Very little variance in knowledge, beliefs, or interest in pharmacist-delivered weight management services were identified. CONCLUSIONS: Despite the fact that patients are aware of the health risks associated with obesity and believe it is healthier to maintain ideal body weight, most are not doing so. Additionally, most patients are not willing to pay for pharmacist-delivered weight management services. The findings can begin to assist pharmacists in developing strategies for implementation of weight management services.

Cardiovascular disease and non-steroidal anti-inflammatory drug prescribing in the midst of evolving guidelines.

RATIONALE, AIMS AND OBJECTIVES: Responding to safety concerns, the American Heart Association (AHA) published guidelines for non-steroidal anti-inflammatory drug (NSAID) use in patients with pre-existing cardiovascular disease (CVD) during 2005 and revised them in 2007. In the revision, a stepped approach to pain management recommended non-selective NSAIDs over highly selective NSAIDs. This research evaluated NSAID prescribing during and after guideline dissemination. METHOD: A cross-sectional sample of 8666 adult, community-based practice visits with one NSAID prescription representing approximately 305 million visits from the National Ambulatory Medical Care Survey (NAMCS) from 2005 to 2010 was studied. Multivariable logistic regression controlling for patient, provider and visit characteristics assessed the associations between diagnosis of CVD and NSAID type prescribed during each calendar year. Visits were stratified by arthritis diagnosis to model short-term/intermittent and long-term NSAID use. RESULTS: Approximately one-third (36.8%) of visits involving a NSAID prescription included at least one of four diagnoses for CVD (i.e. hypertension, congestive heart failure, ischaemic heart disease or cerebrovascular disease). Visits involving a CVD diagnosis had increased odds of a prescription for celecoxib, a highly selective NSAIDs, overall [adjusted odds ratio (AOR) = 1.29, 95% confidence interval (CI): 1.06-1.57] and in the subgroup of visits without an arthritis diagnosis (AOR = 1.45, 95% CI: 1.11-1.89). Results were not statistically significant for visits with an arthritis diagnosis (AOR = 1.10, 95% CI: 0.47-2.57). When analysed by year, the relationship was statistically significant in 2005 and 2006, but not statistically significant in each subsequent year. CONCLUSION: National prescribing trends suggest partial implementation of AHA guidelines for NSAID prescribing in CVD from 2005 to 2010.

Evaluation of a diabetes management program using selected HEDIS measures.

OBJECTIVE: To evaluate the efficacy of a community-based, pharmacist-directed diabetes management program among managed care organization enrollees using National Committee for Quality Assurance (NCQA)-Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. DESIGN: Randomized controlled trial. SETTING: Regional community pharmacy chain in Tulsa, OK, from November 2005 to July 2007. PATIENTS: 52 participants with diabetes and hypertension who were enrolled in a managed care organization. INTERVENTION: Diabetes management versus standard care. MAIN OUTCOME MEASURES: Comprehensive diabetes care measures of glycosylated hemoglobin (A1C <7.0%), blood pressure (<130/80 mm Hg), and low-density lipoprotein (LDL) cholesterol (<100 mg/dL). A composite research outcome of success was created by determining whether a participant achieved two of the three HEDIS goals at the end of 9 months. RESULTS: 46.7% of intervention group participants achieved the A1C goal, while 9.1% of control group participants achieved the goal ( P < 0.002). More than one-half (53.3%) of intervention participants achieved the blood pressure goal compared with 22.7% of control participants ( P < 0.02). Among control group participants, 50% achieved the LDL cholesterol goal compared with 46.67% of intervention group participants. The odds of the intervention group attaining the composite goal were 5.87 times greater than the control group. CONCLUSION: A community pharmacy-based diabetes management program was effective in achieving A1C and blood pressure goals measured by NCQA-HEDIS performance standards. Program participants were statistically significantly more likely to achieve two of three HEDIS standards during a 9-month period.

Recurrent episodes of serotonin-reuptake inhibitor-mediated hyponatremia in an elderly patient.

OBJECTIVE: To report a case of recurrent episodes of serotonin-reuptake inhibitor-mediated hyponatremia in an elderly patient and compare it with other reports of similar occurrences. CASE SUMMARY: A 66-year-old white woman was diagnosed with drug-induced syndrome of inappropriate antidiuretic hormone (SIADH) attributed to selective serotonin-norepinephrine-reuptake inhibitor (SNRI) therapy. Duloxetine was initiated following failure of several other antidepressants. The patient was admitted with sudden onset altered mental status, memory loss, personality changes, and a serum-sodium level of 128 mEq/L (range 135-145 mEq/L), despite receiving sodium supplementation. The duloxetine dose was 60 mg daily. Three months later she presented to the emergency department with complaints of lethargy, muscle weakness, nausea, altered mental status, and a serum sodium level of 129 mEq/L. SIADH was diagnosed and attributed to duloxetine therapy. Duloxetine was titrated to 30 mg every other evening. She remained stable on the lower dose, fluid restriction, and sodium supplementation. Diuretic reinitiation and sodium supplementation discontinuation resulted in serum sodium of 123 mEq/L. This increased to low/normal (136 mEq/L) with duloxetine discontinuation. A rechallenge with escitalopram resulted in low serum-sodium levels. DISCUSSION: A PubMed search was done utilizing the terms duloxetine, elderly, hyponatremia, selective serotonin-reuptake inhibitor, SSRI, SNRI, syndrome of inappropriate antidiuretic hormone, SIADH, and selective serotonin-norepinephrine reuptake inhibitor to find similar reports. CONCLUSION: Clinicians evaluating older patients taking serotonin-reuptake inhibitors are encouraged to monitor serum sodium if the patient presents with vague, nonspecific symptoms commonly associated with older age or depression to rule-out SIADH.

Evaluation of a hypertension medication therapy management program in patients with diabetes.

OBJECTIVE: To evaluate the effect of a 9-month community pharmacy-based medication therapy management (MTM) program on quality of care in patients with diabetes and hypertension. DESIGN: Randomized controlled trial. SETTING: Tulsa, OK, between November 2005 and July 2007. PATIENTS: 52 patients with diabetes and hypertension who were enrolled in a managed care organization. INTERVENTION: During monthly visits, intervention group participants received MTM services for hypertension and diabetes management. MAIN OUTCOME MEASURES: Systolic blood pressure (SBP), percentage at goal blood pressure (<130/80 mm Hg), and antihypertensive medication adherence. RESULTS: The mean intervention group SBP decreased 17.32 mm Hg, whereas the mean control group SBP level increased 2.73 mm Hg (P = 0.003). The percentage of patients at goal blood pressure increased from 16.0% to 48.0% in the intervention group and decreased from 20.0% to 6.67% in the control group. Intervention group participants were 12.92 times more likely than control group participants to achieve goal blood pressure (P = 0.021). Although the mean adherence rate in the intervention group increased 7.0% while remaining fairly constant in the control group (-0.7%), this group difference was not statistically significant. CONCLUSION: A community pharmacy-based hypertension MTM program was effective in improving blood pressure control among managed care enrollees with diabetes and hypertension. Community pharmacists are strategically positioned to provide MTM services and effectively communicate with providers to improve quality of care for patients.