Informing collaborative relationships between community pharmacists and health care professionals in primary care practices.

BACKGROUND: Collaborative relationships between community pharmacists and health care professionals in primary care practices can assist with the provision of medication and disease management services in community pharmacy settings. OBJECTIVES: The objective was to describe the attitudes of providers working in primary care practices with on-site pharmacist collaborators to understand how to facilitate similar collaborations with pharmacists in community pharmacy settings. METHODS: This qualitative study was conducted among physicians, nurse practitioners, and nurses of 3 primary care practice sites in the Commonwealth of Pennsylvania. A demographic survey and a semistructured interview were conducted to elicit feedback on participant perceptions about building relationships with community pharmacists. Interviews were audio-recorded and transcribed. A qualitative analysis was performed to identify emerging themes using an inductive approach. Demographic data were summarized using descriptive statistics. This study was approved by the University's Institutional Review Board. RESULTS: Nineteen interviews were conducted. Fifty-eight percent of participants were physicians and 68% were female with a mean age of approximately 46 years. Five themes were identified: (1) Pharmacists were highly valued and were effective team members to promote coordination of medication-related care; (2) Direct access to pharmacists facilitates efficient communication and effective patient care; (3) Trust is the foundation of an effective collaboration between pharmacists and providers; (4) Pharmacists demonstrating responsibility for patients enables collaboration with providers who view themselves as stewards of patient care; and (5) Providers believe that community pharmacists' dispensing requirements may limit their ability to participate in patient care. CONCLUSIONS: The following strategies to establish relationships with primary care practices are suggested: pharmacists should initiate face-to-face relationships with providers in practices; communication and patient interventions should be conveyed directly to providers and be conducted by the same person; and pharmacists need to demonstrate their commitment to patient care by following up promptly on patient interventions.

Non-interventional cardiologists' perspectives on the role of pharmacogenomic testing in cardiovascular medicine.

AIM: To evaluate factors influencing cardiologists' perspectives about pharmacogenomic (PGx) testing in clinical practice. PATIENTS & METHODS: Semistructured interviews with practicing cardiologists were qualitatively analyzed to identify common themes. RESULTS: Five themes were identified among 16 cardiologists from four specialties (n = 5 general cardiology, n = 3 electrophysiology, n = 2 adult congenital and n = 6 heart failure/transplant): cardiologists' knowledge and needs, perceived clinical validity and utility of PGx testing, dissemination and management of PGx results, patient-related considerations and incidental findings. CONCLUSION: Lack of evidence was considered by many cardiologists to be a major barrier hindering the use of PGx testing. However, they would consider adopting PGx if they were provided additional education, ongoing support and evidence supporting the clinical utility of PGx testing in cardiovascular medicine.

Metabolic monitoring in children 5 years of age and younger prescribed second-generation antipsychotic medications.

INTRODUCTION: The objective of this article was to identify the rates of patients ≤5 years of age who received recommended monitoring before and after second-generation antipsychotic (SGA) initiation and had an SGA metabolic adverse effect (MAE). METHODS: This was a retrospective cohort analysis conducted at Kaiser Permanente Colorado, an integrated health care delivery system, between January 1, 2002, and June 30, 2011. Commercially insured patients ≤5 years of age newly initiated on an SGA were included. Patients were followed for up to 3 years. Metabolic monitoring included lipid profile, blood glucose, blood pressure, and weight measurements. Patient characteristics and outcomes were described using descriptive statistics. RESULTS: A total of 40 patients were included. Overall, 2 (5.0%) patients received all recommended baseline monitoring, and no (0.0%) patients received all recommended follow-up monitoring. Weight monitoring was completed most frequently with rates of completion of 57.5%, 95.0%, 85.0%, and 76.5% at baseline and years 1, 2, and 3, respectively. At least 1 MAE was identified in 14/40 (35.0%), 5/28 (17.9%), and 2/17 (11.8%) patients during years 1, 2, and 3, respectively. The most frequent MAE identified was weight gain. Among patients identified with at least 1 MAE, 4/14 (28.6%), 2/5 (40.0%), and 2/2 (100%) received a behavioral intervention during years 1, 2, and 3, respectively. DISCUSSION: Overall, baseline and follow-up metabolic monitoring were poor. Future studies should focus on examining barriers to monitoring in order to improve health care quality.

Patient Specific Factors Influencing Adherence to INR Monitoring.

OBJECTIVE: The specific reasons underlying nonadherence to monitoring the international normalized ratio (INR) from the patient's perspective have not been formally studied. Understanding why patients do or do not adhere has the potential to reveal useful targets for improving adherence to INR monitoring or alternative treatment strategies. The objective of this study was to gain further insight into INR monitoring nonadherence from the patient's perspective. METHODS: This qualitative study was conducted among members of Kaiser Permanente Colorado; patients were characterized as adherent or nonadherent and recruited from the Clinical Pharmacy Anticoagulation and Anemia Service to participate in an individual interview. Qualitative analysis was performed to identify emerging themes using an inductive approach. Demographic data were summarized using descriptive statistics. RESULTS: Patients were primarily white and employed with a mean age of 61.3 years. Perspectives and experiences were similar for all interviewed patients regardless of classification as adherent or nonadherent. The most common themes were the desire for INR monitoring to be inexpensive, convenient, and accessible; finding reassurance with INR monitoring; and a preference for interacting with the same group of prescribers, pharmacists, and phlebotomists. CONCLUSIONS: The following strategies to improve adherence to INR testing are suggested: (i) assign anticoagulation providers to work with the same patients consistently; (ii) provide formal INR reminders; (iii) avoid harsh language or lecturing patients following missed INR tests; (iv) reinforce the clinical and psychological utility of INR results; and (v) facilitate access to INR testing. Adopting these strategies into clinical practice can support the patient-clinician relationship and empower patients to be more engaged in their health care.

Interventions aimed at improving performance on medication adherence metrics.

BACKGROUND: medication adherence is one determining factor of treatment success. Poor medication adherence mitigates optimum clinical benefits and increases total health care costs. Current evidence suggests that for population-based adherence interventions to be effective, a multidisciplinary, multifactorial approach that can be tailored for each individual should be adopted. In the United States, national organizations such as the National Committee for Quality Assurance and the Centers for Medicare and Medicaid Services include medication adherence as a metric of health care system performance Aim of the COMMENTARY: This article provides an overview of efforts at Kaiser Permanente Colorado to impact medication adherence-related metrics. Described interventions are supported by electronic data gathering processes with an emphasis on the role of pharmacists.

Exploring the value of clinical pharmacy services for patients with diabetes in safety net settings.

BACKGROUND: The role of the pharmacist in safety net settings has not been well studied, specifically in meeting unmet needs of vulnerable patients with diabetes. OBJECTIVES: To identify unmet management and medication-related needs of patients with diabetes who are receiving care in two distinct underserved practices in Pittsburgh, PA. METHODS: Individual, semi-structured interviews with patients from a free clinic (FC) and a federally qualified community health center (FQHC) in Pittsburgh were conducted. Inclusion criteria included: adults at least 18 years old with uncontrolled diabetes (A1C > 7%) who received health care services from either the FC or the FQHC. Participants completed a short demographic survey and answered questions about their perceptions and attitudes in four thematic areas: (1) self-management of diabetes; (2) medication-related needs; (3) the role of the pharmacist in their care; and (4) how pharmacists can be better integrated in their diabetes management. Transcripts were analyzed using principles of Grounded Theory. RESULTS: Twenty-nine interviews were conducted: 15 participants were from the FC, and 14 were from the FQHC. Five main themes emerged from each site including: patients experience challenges managing their diabetes, patients identify the emotional struggle associated with living with diabetes, patients feel that they are "on their own" to care for their diabetes, patients desire a personal and caring relationship with their pharmacist, and patients value a pharmacist who is knowledgeable about diabetes care. CONCLUSIONS: These results will help provide guidance to pharmacists working in safety net settings who are interested in expanding clinical pharmacy services for patients with diabetes.

HIV medication therapy management services in community pharmacies.

OBJECTIVES: To present a rationale and a proposed structure to support pharmacist-delivered medication therapy management (MTM) for human immunodeficiency virus (HIV ) disease and to outline challenges to implementing and sustaining the service. DATA SOURCES: Professional literature. SUMMARY: Historically, the effect of pharmacy services for HIV-infected persons has been demonstrated in inpatient and clinic-based settings. Developing similar programs adapted for community pharmacists could be a model of care to improve patient adherence to antiretroviral therapy and retention in care. Initiation of antiretroviral therapy and regular monitoring of CD4+ cell count, HIV RNA viral load, adverse drug events, and adherence form the backbone of successful medical management of HIV infection. Support for these services can be provided to HIV-infected patients through pharmacist-managed HIV MTM programs in community pharmacy settings in collaboration with primary providers and other health care professionals. CONCLUSION: Community pharmacists can help meet the growing need for HIV care through provision of MTM services. Although resources have been developed, including the general MTM framework, challenges of adequate training, education, and support of community pharmacists need to be addressed in order for HIV MTM to be a successful model.