Article

The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for Asthma

Authors:
  • American Health Care
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Abstract

To assess clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program for 207 adult patients with asthma over 5 years. Quasi-experimental, longitudinal pre-post study. 12 pharmacy locations in Asheville, N.C. PATIENTS/OTHER PARTICIPANTS: Patients with asthma covered by two self-insured health plans; professional educator at Mission Hospitals; 18 certificate-trained community and hospital pharmacists. Education by a certified asthma educator; regular long-term follow-up by pharmacists (reimbursed for MTM by health plans) using scheduled consultations, monitoring, and recommendations to physicians. Changes in forced expiratory volume in 1 second (FEV1), asthma severity, symptom frequency, the degree to which asthma affected people's lives, presence of an asthma action plan, asthma-related emergency department/hospital events, and changes in asthma-related costs over time. All objective and subjective measures of asthma control improved and were sustained for as long as 5 years. FEV1 and severity classification improved significantly. The proportion of patients with asthma action plans increased from 63% to 99%. Patients with emergency department visits decreased from 9.9% to 1.3%, and hospitalizations from 4.0% to 1.9%. Spending on asthma medications increased; however, asthma-related medical claims decreased and total asthma-related costs were significantly lower than the projections based on the study population's historical trends. Direct cost savings averaged 725 dollars/patient/year, and indirect cost savings were estimated to be 1230 dollars/patient/year. Indirect costs due to missed/nonproductive workdays decreased from 10.8 days/year to 2.6 days/year. Patients were six times less likely to have an emergency department/hospitalization event after program interventions. Patients with asthma who received education and long-term medication therapy management services achieved and maintained significant improvements and had significantly decreased overall asthma-related costs despite increased medication costs that resulted from increased use.

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... and an indirect cost saving of $1,230/pt./Y of these interventions. 45 Finally, a study in Australia concluded annual savings per patient Australian $132.84, but p-values were not mentioned. 46 Evidence base through meta-analysis ...
... For instance, all studies with collaboration-scores 10/10 (indicator of highest form collaboration) has significantly improved all outcomes (clinical, humanistic, and economical) in the intervention group. 15,43,45,47,49,50 On the contrary, the studies with a Collaboration scale score ≤5 have shown multiple outcomes with no significant statistical difference in the intervention group as compared to the control group. 42,[51][52][53] In his doctoral thesis, Amirthalingam 54 pointed out that collaboration between CP-GP rather than solo CPs' interventions could produce more promising results in clinical and humanistic outcomes in chronic diseases like hypertension. ...
... 46,56 • Data of (n=2) were not convertible to x ̅ and SD, hence, could not be pooled. 45 x ̅ and SD were given in (n=2). 51,52 However, 51 could not be combined being the only RCT. ...
Article
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Objective: This systematic review aims to investigate the impact of collaborative practice between community pharmacist (CP) and general practitioner (GP) in asthma management. Methods: A systematic search was performed across 10 databases (PubMed, Medline/Ovid, CINAHL, Scopus, Web of Science, Cochrane central register of controlled trials, PsycARTICLES®, Science Direct, Education Resource Information Centre, PRO-Quest), and grey literature using selected MeSH and key words, such as "community pharmacist", "general practitioner", and "medicine use review". The risk of bias of the included studies was assessed by Cochrane risk of bias tool. All studies reporting any of the clinical, humanistic, and economical outcomes using collaborative practice between CPs and GPs in management of asthma, such as CPs conducting medications reviews, patient referrals or providing education and counseling, were included. Results: A total of 23 studies (six RCTs, four C-RCT, three controlled interventions, seven pre-post, and three case control) were included. In total, 11/14 outcomes were concluded in favor of CP-GP collaborative interventions with different magnitude of effect size. Outcomes, such as asthma severity, asthma control, asthma symptoms, PEFR, SABA usage, hospital visit, adherence , and quality of life (QoL) (Asthma Quality-of-Life Questionnaire [AQLQ]; Living with Asthma Questionnaire [LWAQ]) demonstrated a small effect size (d≥0.2), while inhalation technique, ED visit, and asthma knowledge witnessed medium effect sizes (ES) (d≥0.5). In addition to that, inhalation technique yielded large ES (d≥0.8) in RCTs subgroup analysis. However, three outcomes, FEV, corticosteroids usage, and preventer-to-reliever ratio, did not hold significant ES (d<0.2) and, thus, remain inconclusive. The collaboration was shown to be value for money in the economic studies in narrative synthesis, however, the limited number of studies hinder pooling of data in meta-analysis. Conclusion: The findings from this review established a comprehensive evidence base in support of the positive impact of collaborative practice between CP and GP in the management of asthma.
... The consultation process is time consuming, and its integration to ongoing care depends on available resources. It appears that despite many published studies evaluating this process, the benefits of pharmaceutical consultation have yet to be definitively proven [7][8][9][10][11][12][13][14][15][16]. The lack of clarity is related to the great variability in the implementation of the pharmaceutical consultation service. ...
... It is also linked to methodological limitations in most of the studies. Follow-up was usually short (only several months), and most studies were conducted in unique settings, focused on disease management of a specified disease and with limited outcome evaluation [8][9][10][11]. The outcome measures mostly included changes in the number of medications and adherence, usually without evaluating adherence to guidelines, impact on morbidity, and healthcare resource utilization [12][13][14]. ...
... In the intervention group, significantly more chronic medications were stopped, and new ones were added. These findings are in concordance with several previous studies [8,10]. ...
Article
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Background: Pharmacist medication review has been implemented in many health organizations throughout the world in an attempt to alleviate the underlying risk of polypharmacy in elderly patients. These consultations are often frequent and prolonged, and are thus associated with increased costs. To date, data regarding the most effective way to utilize pharmacist consultations for the improvement of health status is scant. Aim: To evaluate the effectiveness of a single pharmacist consultation on changes in chronic medication regimes and on selected outcomes of diabetes 1-year after the consultation. Methods: A case-control study included an intervention group of 740 patients who had pharmacist consultations and a reference group of 1476 matched patients who did not have a pharmacist consultation. 1-year outcome measures were compared including changes in medications, improved safety, and objective variables such as Hba1c, blood pressure, and lipid profile. Results: In the pharmacist consultation group, there were significantly more treatment changes ([mean 1.5 vs. 0.7, p < 0.001 medications were stopped], and [mean 1.3 vs. 0.4, p < 0.05 medications were started]). Patient safety improved with a general reduction in opiates and benzodiazepines ([50.0% vs. 31.6%, p < 0.05 opioids were stopped] and [58.8% vs 43.8%, p < 0.001 benzodiazepines were stopped]). Sulfonylurea treatment reduced (10.7% vs. 3.6%, p < 0.05 patients who stopped Sulfonylurea) and Glucagon-like peptide-1 receptor agonists (GLP-1) increased (16.4% vs. 11.2%, p < 0.001 patients who started GLP-1). Additionally, HbA1c levels showed a small decrease in the pharmacist consultation group ([- 0.18 ± 1.11] vs. [- 0.051 ± 0.80], p = 0.0058) but no significant differences were found regarding blood pressure or lipids profile. Conclusion: A single pharmacist consultation beneficially impacted specific clinical and patient safety outcomes. Pharmacist consultations may thus help resolve polypharmacy complexities in primary care.
... In addition to pharmacists' ability to improve clinical outcomes for patients through disease management or other advanced clinical roles, pharmacists have contained or reduced health care costs, whether associated with reduced adverse clinical events (hospitalizations, emergency room visits, etc.), 115,116 reduced outpatient visits, cost savings to a health care institution or health insurance plan, 93,95,112,[116][117][118][119][120][121][122][123] direct cost savings to the patient, 124,125 or less missed/non-productive workdays. 112,115 Bond and Raehl have shown on a macro-level that advanced patient care services delivered by pharmacists reduce drug-related morbidity and mortality, and lower the overall cost of care. ...
... In addition to pharmacists' ability to improve clinical outcomes for patients through disease management or other advanced clinical roles, pharmacists have contained or reduced health care costs, whether associated with reduced adverse clinical events (hospitalizations, emergency room visits, etc.), 115,116 reduced outpatient visits, cost savings to a health care institution or health insurance plan, 93,95,112,[116][117][118][119][120][121][122][123] direct cost savings to the patient, 124,125 or less missed/non-productive workdays. 112,115 Bond and Raehl have shown on a macro-level that advanced patient care services delivered by pharmacists reduce drug-related morbidity and mortality, and lower the overall cost of care. 126 Utilizing pharmacists as drug therapy experts will maximize resources, contain or reduce costs and improve care. ...
...  Direct medical costs decreased by $1,200 per patient per year and an estimated annual increase in productivity of $18,000 due to reduction of sick time were reported. 115 Even after paying the pharmacists to provide these services, net costs were lower. 112 Schumock et al. 123,128 and Perez et al. 129 conducted multiple ACCP-funded studies across two decades that evaluated the economic value of clinical pharmacy services. ...
... 3,4 The general consensus in the research community and with policymakers is that MTM outcomes have been beneficial but with wide variations of results. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] These outcomes have included clinical (e.g., resolution of medication-related problems and hospital readmissions); economic (e.g., return on investment [ROI]); and humanistic (e.g., patients' satisfaction with the service), but some of these outcomes were proxy or surrogate measures, such as high blood pressure reduction. MTM, originally mandated for Medicare beneficiaries, has since been adopted or recommended by third-party payers that include Medicaid and commercial plans. ...
... 5 MTM services can be delivered face-to-face, by telephone, or by mailings; in different settings (e.g., community pharmacies, outpatient settings, MTM vendors, pharmacy benefit managers, and health plans); and by different health care providers (mainly pharmacists but could include nurses and case managers), which potentially explains the differences in outcomes and scope of practice. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] The type and intensity of MTM services delivered have evolved with time from just patient education to more streamlined and robust interventions, necessitating ongoing evaluation of the effect on clinical and economic outcomes. There are also minimum requirements for eligibility in the Medicare program and no mandated requirements for the other non-Medicare health plans, such as commercial plans and Medicaid. ...
Article
BACKGROUND: Although medication therapy management (MTM) has specific eligibility criteria and is mandated for specific Medicare Part D enrollees, some health plans have expanded MTM eligibility beyond the minimum criteria to include other Medicare Part D enrollees, Medicaid, and commercial health plan patients. Differences exist in the mode of delivery, location of services, type of personnel involved in managing the service, and the subsequent outcomes. The type and intensity of MTM services delivered have evolved with time to more streamlined and robust interventions, necessitating ongoing evaluation of the effect on clinical and economic outcomes. OBJECTIVE: To assess the effect of changes to an existing MTM program on cost of care, utilization, and medication adherence. METHODS: UPMC Health Plan made changes to an existing MTM program by expanding eligibility (customized by the type of health plan), intervention types, pharmacist involvement, and patient followup contacts. After matching our intervention cohort (identified January 2017-June 2018) with the pre-2016 MTM historical controls (patients identified January 2014-June 2015 who would have been eligible if we used the intervention cohort eligibility criteria), we estimated that the effect of the program changes with a difference-in-difference model (preintervention [2014-2016] and postintervention [2017-2019]). Outcomes of interest included cost (total cost of care including medical, pharmacy, and unplanned care [i.e., unscheduled health care use such as emergency department visits] in 2017 U.S. dollars); utilization; medication adherence (proportion of days covered); and return on investment (ROI). Target population included continuously enrolled patients aged ≥ 21 years in the commercial, Medicare, and Medicaid health plans. RESULTS: Total propensity score-matched members was 10,747, 55% of which were in the historic control group. The average (SD) ages after matching the groups were similar (historical control group: 57.08 years [14.23], intervention group: 56.79 years [14.21]) and the majority was female (57%). Comorbidities identified most for patients included hypertension (77%), dyslipidemia (70%), and diabetes (52%). Forty-one percent were in the commercial, 37% in the Medicaid, and 23% in the Medicare health plans. Proportion of care activities undertaken in the intervention period compared with the control period were significantly different: "sent letter to physician" (67% vs. 87%), "sent letter to member" (15% vs. 0%), "pharmacist phone call to physician" (15% vs. 0.1%), and "pharmacist phone call to member" (13% vs. 7%). There were statistically significant reductions in unplanned care across all health plans especially in the Medicare population, in total cost of care, and increases in medication adherence in 4 therapeutic classes: anticoagulants (OR = 1.25, P = 0.005), cardiac medications (OR = 1.20, P < 0.001), statins (OR = 1.21, P < 0.001), and antidepressants (OR = 1.15, P < 0.001). There was a positive ROI of $18.50 per dollar spent, which equated to a cumulative net savings of $11 million over 24 months. CONCLUSIONS: In a large health plan, expanding MTM eligibility, intensifying patient follow-up contact and pharmacist involvement, and improving provider awareness had favorable clinical and economic benefits. DISCLOSURES: There was no funding for this project except employees' time. All authors are employees of UPMC and have no conflicts of interest to report.
... One of the most touted studies in pharmacy-patient history is the Asheville Project along with the Patient Self-Management Program for Diabetes and the Diabetes Ten City Challenge [22][23][24][25]. These were the efforts by selfinsured employers, to better manage the health of their employee population with chronic diseases such as diabetes, hypertension and high cholesterol [25]. ...
... The patient populations were enrolled in collaborative care programs with a community pharmacist on each care team. The outcomes were substantial savings, improved population health and improved prevention measures [22][23][24][25]. Despite the aforementioned articles underlining the value of pharmacists in population health, there are still weaknesses and threats (e.g., reimbursement challenges, outdated statutes, competency knowledge gaps between healthcare professions, limited access to Electronic Health Records (EHRs) and other health technologies) that create barriers for pharmacists to smoothly integrate in holistic and coordinated patient care. ...
Article
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The annual amount spent on healthcare per capita is higher and expected to grow in the U.S. compared to healthier level 4 countries (e.g., United Kingdom, Canada, Germany, Australia, Japan, Sweden, Netherlands), while health outcomes continue to be suboptimal [123]. Therefore, healthcare is slowly shifting from a fee-for-service to value-based care, which addresses social determinants of health, promotes outcome-based contracting and employs more Population Health Management (PHM) activities. The root cause for this shift has been the increase in patients' out-of-pocket costs and the pervasiveness of poorer outcomes. PHM has been defined by many as a mindset and activities that support the Triple Aim Initiative (i.e., improving population health, experience of care, reducing costs) [4]. This article outlines the value of pharmacists on health outcomes in the U.S., Germany, and Scotland and innovative PHM approaches through pharmacist collaborative networks, polypharmacy management and pharmacists' integration in care models [15].
... Although well positioned to fill gaps in health care, pharmacists have long been underused (1,2). This is especially relevant in chronic disease management despite evidence that demonstrates pharmacists' success in improving outcomes through collaborative care and medication therapy management (MTM) (1)(2)(3)(4)(5)(6). MTM involves a multifaceted approach of reviewing medications, identifying and remedying medication-related problems, providing dis-The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. ...
... MTM involves a multifaceted approach of reviewing medications, identifying and remedying medication-related problems, providing dis-The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. ease state management and self-management education, addressing medication adherence issues, and considering preventive health strategies to optimize medication-related health (3,4,7,8). An MTM service includes a comprehensive medication review to ensure that the patient's medication-related needs have been met and all of their medications are appropriate, effective, safe, and convenient. ...
Article
Full-text available
Introduction: Pharmacists are underused in the care of chronic disease. The primary objectives of this project were to 1) describe the factors that influence initiation of and sustainability for pharmacist-provided medication therapy management (MTM) in federally qualified health centers (FQHCs), with secondary objectives to report the number of patients receiving MTM by a pharmacist who achieve 2) hemoglobin A1c (HbA1c) control (≤9%) and 3) blood pressure control (<140/90 mm Hg). Methods: We evaluated MTM provided by pharmacists in 10 FQHCs in Ohio through qualitative thematic analysis of semi-structured interviews with pharmacists and FQHC leadership and aggregate reporting of clinical markers. Results: Facilitators of MTM included relationship building with clinicians, staff, and patients; regular verbal or electronic communication with care team members; and alignment with quality goals. Common MTM model elements included MTM provided distinct from dispensing medications, clinician referrals, and electronic health record access. Financial compensation strategies were inadequate and varied; they included 340B revenue, incident-to billing, grants, and shared positions with academic institutions. Of 1,692 enrolled patients, 60% (n = 693 of 1,153) achieved HbA1c ≤9%, and 79% (n = 758 of 959) achieved blood pressure <140/90 mm Hg. Conclusion: Through this statewide collaborative, access for patients in FQHCs to MTM by pharmacists increased. The factors we identified that facilitate MTM practice models can be used to enhance the models to achieve clinical goals. Collaboration among clinic staff and community partners can improve models of care and improve chronic disease outcomes.
... adherence, clinical goals, health-related costs and health-related quality of life. 1,[7][8][9][10][11][12][13] In Denmark, the current medication review service is based on data and experience from several programmes: The Therapeutic Outcome Monitoring Program, Safe and Effective Use of Medicines and the Pharmaceutical Care Model. 8,12,[14][15][16][17] A recent medication review study from Denmark included 951 home-dwelling elderly people (>65 years of age) using five or more medications. ...
... We wanted to investigate the effect of medication reviews delivered to specific subgroups of patients to identify whether the criteria for including patients for medication reviews could be optimised. 1,[7][8][9][10][11][12][13][14][15][16] We were particularly interested in studies reporting a positive economic outcome, such as a reduction in contacts ...
Article
Full-text available
Background: A medication review is a possibility to assess and optimise a patient’s medicine. A model that includes a medication review and a follow-up seem to provide the best results. However, it is not known whether specific subgroups of patients benefit more from a medication review than others. Objective: This literature review summarises the evidence that is available on which patient subgroups exist positive outcomes from a medication review carried out in a primary care setting. Methods: We performed a PICO analysis to identify keywords for setting, medication review and effect. We then conducted a search using the PubMed database (2004 to 2019) to identify studies relevant for our investigation. A screening process was carried out based on either title or abstract, and any study that matched the aim and inclusion criteria was included. All matching studies were obtained and read, and were included if they met predefined criteria such as study design, medication review and primary care. The studies were divided into subgroups. First, each subgroup was divided according to the studies’ own definition. Secondly, each subgroup was allocated as either risk patients if the subgroup described a specific patient subgroup or risk medication, if the subgroup was defined as using a specific type of medication. This was done after discussion in the author group. Results: 28 studies from a total of 935 studies were included. Identified studies were divided into either risk patients; frail, recently discharged or multimorbid patients, or risk medication; heart medication, antithrombotic medication, blood pressure lowering medication, antidiabetic medication, anti-Parkinson medication or medication increasing the risk of falls. The subgroups identified from a medication review in primary care were defined as being frail, recently discharged from hospital or multimorbid (risk patients), or defined as patients using anticoagulant or blood pressure lowering medication (risk medication). Most of the medication reviews in the studies that showed an economic effect included at least one follow-up and were delivered by a pharmacist. Conclusions: The literature review demonstrates that medication reviews delivered by pharmacists to specific subgroups of patients are a way of optimising the economic effect of medication reviews in primary care. This is obtained by reducing health-related costs or the number of contacts with primary or secondary health care services.
... The difference in the number of pharmacy and primary care physician encounters was larger in rural areas (median [IQR], 14 [10-17] vs 5 [2-11]; P < .001) than in metropolitan areas (median [IQR], 13 [8-17] vs 8 [ [4][5][6][7][8][9][10][11][12][13][14]; P < .001). In all 50 states and in all but 9 counties, the number of community pharmacy visits was larger than the number of encounters with primary care physicians. ...
... 2 Pharmacists have also shown positive effects on patient and medication outcomes when contributing to the management of chronic diseases, including diabetes (type 1 and type 2), hypertension, hyperlipidemia, asthma, and depression. [3][4][5][6][7] To understand the potential for pharmacist-delivered preventive services and chronic care management, it is important to quantify how many times patients are likely to encounter community pharmacists and how this frequency compares with the number of patient encounters with primary care physicians. Previously, Tsuyuki et al 8 performed a nonsystematic review and found that patients encountered pharmacists between 1.5 and 10 times more frequently than they encountered primary care physicians. ...
Article
Full-text available
Importance The shift toward value-based care has placed emphasis on preventive care and chronic disease management services delivered by multidisciplinary health care teams. Community pharmacists are particularly well positioned to deliver these services due to their accessibility. Objective To compare the number of patient visits to community pharmacies and the number of encounters with primary care physicians among Medicare beneficiaries who actively access health care services. Design, Setting, and Participants This cross-sectional study analyzed a 5% random sample of 2016 Medicare beneficiaries from January 1, 2016, to December 31, 2016 (N = 2 794 078). Data were analyzed from October 23, 2019, to December 20, 2019. Medicare Part D beneficiaries who were continuously enrolled and had at least 1 pharmacy claim and 1 encounter with a primary care physician were included in the final analysis (n = 681 456). Those excluded from the study were patients who were not continuously enrolled in Part D until death, those with Part B skilled nursing claims, and those with Part D mail-order pharmacy claims. Exposures We conducted analyses for the overall sample and for subgroups defined by demographics, region of residence, and clinical characteristics. Main Outcomes and Measures Outcomes included the number of visits to community pharmacies and encounters with primary care physicians. Unique visits to the community pharmacy were defined using a 13-day window between individual prescription drug claims. Kruskal-Wallis tests were used to compare the medians for the 2 outcomes. Results A total of 681 456 patients (mean [SD] age, 72.0 [12.5] years; 418 685 [61.4%] women and 262 771 [38.6%] men) were included in the analysis; 82.2% were white, 9.6% were black, 2.4% were Hispanic, and 5.7% were other races/ethnicities. Visits to the community pharmacy outnumbered encounters with primary care physicians (median [interquartile range (IQR)], 13 [9-17] vs 7 [4-14]; P < .001). The number of pharmacy visits was significantly larger than the number of primary care physician encounters for all subgroups evaluated except for those with acute myocardial infarction (median [IQR], 15 [12-19] vs 14 [7-26]; P = .60 using a 13-day window). The difference in the number of pharmacy and primary care physician encounters was larger in rural areas (median [IQR], 14 [10-17] vs 5 [2-11]; P < .001) than in metropolitan areas (median [IQR], 13 [8-17] vs 8 [4-14]; P < .001). In all 50 states and in all but 9 counties, the number of community pharmacy visits was larger than the number of encounters with primary care physicians. Conclusions and Relevance This cross-sectional study suggests that community pharmacists are accessible health care professionals with frequent opportunities to interact with community-dwelling patients. Primary care physicians should work collaboratively with community pharmacists, who can assist in the delivery of preventive care and chronic disease management.
... Pharmacists were able to identify many of these MRPs. The most common were (1) the requirement for a less expensive medication (33.3-85%) [15,18,20], (2) the need for additional medications (22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39).8%) [8,[22][23][24], (3) low medication dose (19.9-26.1%) ...
... In one study, patients saved an average of USD 628/year on cardiovascular-and cerebrovascularrelated medical health plan expenditures [24]. In another report, asthma patients, directly and indirectly, saved averages of USD 725/year and USD 1230/year, respectively [28]. In another study, the mean cost saving of 600 pharmacists' recommendations in regard to adjusting medications dosage and discounting unneeded medications was USD 420,155 [29]. ...
Article
Full-text available
Abstract: Medication therapy management (MTM) is provided by pharmacists and other healthcare providers, improves patient health status, and increases the collaboration of MTM providers with others. However, little is known about pharmacists’ intention to provide MTM services in Saudi Arabia. This study aimed to predict the pharmacists’ willingness in this nation to commit to providing MTM services there. This study used a cross-sectional questionnaire based on the theory of planned behaviour (TPB). The survey was distributed to 149 pharmacists working in hospital and community pharmacies. It included items measuring pharmacist attitudes, intentions, subjective norms, perceived behavioural control, knowledge about the provision of MTM services, and other sociodemographic and pharmacy practice-related items. The pharmacists had a positive attitude towards MTM services (mean = 6.15 ± 1.12) and strong intention (mean = 6.09 ± 1.15), highly perceived social pressure to provide those services (mean = 5.42 ± 1.03), strongly perceived control over providing those services (mean = 4.98 ± 1.05), and had good MTM knowledge (mean = 5.03 ± 1.00). Pharmacists who completed a pharmacy residency programme and had good knowledge of MTM services and a positive attitude towards them usually strongly intended to provide MTM services. Thus, encouraging pharmacists to complete pharmacy residency programmes and educating them about the importance and provision of MTM services will enhance their motivation to provide them.
... The risk factors for each recognized phenotype of asthma include genetic, environmental and host factors. The risks factors for insistent asthma at different ages, precisely the antenatal period, infancy, childhood and adulthood [4]. ...
Article
Asthma is the episodic and most chronic disease that exists worldwide. Factors that trigger asthma are allergens, pollens, cigarette smoke, dust, mites, and animal dander, cockroaches and food. A increased knowledge of asthma, its causes and prevention influence the researchers to find out new and improved medication therapies for future to serve asthma patients is a great opportunity for ambulatory care pharmacists. A questionnaire based, cross-sectional study was planned for this research. Questionnaires were standardized based on common research or they can be customized to meet the specific data gathering need. The study was conducted at five different hospitals of Lahore, Children hospital Lahore, Jinnah hospital Lahore, General hospital Lahore, Social security hospital Lahore and Chaudhary Muhammad Akram teaching and research hospital Lahore. The results indicated that 85% of population is suffering from asthma. 91.5% of population is any taking medication for asthma. Most recently used medication for asthma are inhalers i.e. 80% and inhaled corticosteroids i.e. 82%.Patients are taking medication therapies for asthma but most commonly used are inhalers and steroids. Education provided by pharmacist about asthma was an integral part of health maintenance services its management to control or prevent further attacks because of his knowledge in pathophysiology pharmacology and medication techniques of asthma. Pharmacist driven medication therapy management services were economically stabilized.
... Medication therapy management (MTM) service is defined as a service or group of services that optimize therapeutic outcomes for individual patients [1,2]. It requires the collaboration between patient, pharmacist, physician and other healthcare providers to control patient's condition, prevent drug related problems and ensure safe and effective use of medicines to reach patient's therapy outcomes [3,4]. ...
Article
Full-text available
Background: Medication therapy management (MTM) service provides set of clinical activities to optimize therapeutic outcomes for patients. It requires the collaboration between patient, pharmacist and other healthcare providers to ensure safe and effective use of medicines. The objective of the current study was to assess Hospital Pulau Pinang pharmacists’ knowledge, attitude and practice on MTM service. Methods: A self-administrated validated survey was carried out among all pharmacists working at Hospital Pulau Pinang. Results: A total of 93 pharmacists out of 130 (71.5%) were included in the study (61.3% between the age of 20–30 years old, 74.2% female, 68.8% Chinese, 88.2% holding bachelor’s degree and 48.4% working in medication therapy adherence clinic and outpatient pharmacy). Majority of pharmacists had a high level of knowledge and positive attitudes regarding MTM service. All pharmacists agreed that MTM service could improve the quality of health services and most pharmacists were interested in providing MTM service (92.5%). Moreover, 95.7% were interested in acquiring more information about MTM service. About the barriers that might affect MTM service implementation, the most common barriers identified by pharmacists were lack of training (88.2%), need of high budget to implement MTM service (51.6%) and lack of time (46.2%). Conclusions: Overall, the research findings provide some insights about the Hospital Pulau Pinang pharmacists’ knowledge, attitude and practice regarding MTM service. Majority of pharmacists agreed and showed their interest towards the implementation of MTM service.
... [25][26][27][28] Primary care practices are using a variety of payment methods to integrate pharmacists. [3][4][5][6][7]28 Replicable, scalable, and sustainable models for pharmacist integration into primary care are needed. The present study sought to learn from pharmacist leaders in organizations where sustainable pharmacist integration in primary care is a reality. ...
Article
Objectives: To (1) identify strategies for financial justification of pharmacists integrated into team-based primary care, (2) describe the payment models currently used for integration of pharmacists into team-based primary care, and (3) elicit key factors facilitating sustainable pharmacist-provided patient care services in the primary care setting. Design: Qualitative analysis using semistructured interviews. Setting: Nonacademic outpatient primary care physician practices throughout the United States from January to April 2014. Participants: Pharmacists responsible for leadership of clinical pharmacists in primary care practices whose positions are supported through nondispensing patient care services. Main outcome measures: Current payment model, infrastructure, documentation strategies, and methods of quality assessment. Results: Twelve interviews were conducted. Practices included a combination of single- and mixed-payer models in integrated and nonintegrated health systems. Various billing strategies were used, particularly in nonintegrated models, to sustain pharmacists in primary care practices utilizing both fee-for-service (FFS) and value-based incentives payments. Five main themes were elicited: (1) Pharmacists are integrated and valuable members of health care teams; (2) pharmacists are documenting in an accessible electronic health record; (3) data tracking is a facilitator for justifying and adapting practice; (4) systematized processes for pharmacist integration exist in each practice; and (5) pharmacists' responsibilities on the team have grown and evolved over time. Conclusion: Pharmacists' contributions to improving patients' medication-related care are the same regardless of payment model. Financially sustainable integration of pharmacists on the team involves using a combination of FFS and value-based incentive payments, consistent documentation, meaningful collection of pharmacists' contributions to improve the quality of care, and a firm understanding of the practice's needs and financial structure. These themes can be used as a guide for pharmacists as they establish themselves in an FFS environment and adapt to a future in value-based care.
... 9 In 2006, The Asheville Project followed adult patients with asthma over a 5 year period. 10 As a result of their interventions, pharmacists were able to drive down asthma-related ER visits (9.9%-1.3%) and hospitalizations (4.0%-1.9%), in addition to generating cost savings for patients through patient education and long-term MTM services. ...
Article
Background Collaborative drug therapy management (CDTM) rules were implemented in 2012 in Missouri, but community pharmacists are not working with physicians to implement services. Purpose This study aims to uncover barriers to CDTM adoption by Missouri community pharmacists. Methods A nine question, cross-sectional survey was mailed to a sample of 500 community pharmacists and 500 outpatient physicians in Missouri. Surveys were designed to assess knowledge, attitudes, and beliefs regarding CDTM. Discussion A total of 103 community pharmacists (21.7%) and 23 outpatient physicians (4.7%) completed the survey. Pharmacists identified concern about operational barriers like time (93.2%), and reimbursement for services (80.6%). Physicians indicated concern with clinical risks, including potential disconnect between providers (70%) and inadequate pharmacist training (63.6%). Conclusions Demonstration of clinical abilities and development of working relationships with physicians is important for the implementation of CDTM. Development of standardized reimbursement models and workflow models should be further evaluated.
... The review looked at the following countries: Australia, 15 16 Belgium, 17 Canada, 18 Denmark, 19 Finland, 20 21 Germany, 22 23 Malta, 24 New Zealand, 25 Spain, 26 UK 27 28 and USA. 29 The review included randomised and non-randomised studies and allowed identification of the strengths and limitations of each study. Eighteen key points were identified during the review and informed the development of the pharmacist-led intervention, which was informed and retrospectively mapped to the Medical Research Council (MRC) framework 30 for complex intervention. ...
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Introduction A key priority in asthma management is achieving control. The Asthma Control Test (ACT) is a validated tool showing a numerical indicator which has the potential to provide a target to drive management. A novel pharmacist-led intervention recently evaluated and introduced in the Italian setting with a cluster randomised controlled trial (C-RCT) showed effectiveness and cost-effectiveness. This paper evaluates whether the intervention is successful in securing the minimally important difference (MID) in the ACT score and provides better health outcomes and economic savings. Methods Clinical data were sourced from 816 adult patients with asthma participating in the C-RCT. The success of the intervention was measured looking at the proportion of patients reaching MID in the ACT score. Different levels of asthma control were grouped according to international guidelines and graded using the traffic light rating system. Asthma control levels were linked to economic (National Health Service (NHS) costs) and quality-adjusted life years outcomes using published data. Results The median ACT score was 19 (partially controlled) at baseline, and 20 and 21 (controlled) at 3-month and 6-month-follow up, respectively (p<0.01). The percentage of patients reaching MID at 3 and 6 months was 15.8% (129) and 19.9% (162), respectively. The overall annual NHS cost savings per 1000 patients attached to the shift towards the MID target were equal to €346 012 at 3 months and increased to €425 483 at 6 months. Health utility gains were equal to 35.42 and 45.12 years in full health gained, respectively. Discussion The pharmacist-led intervention secured the MID in the ACT score and provided better outcomes for both patients and providers.
... The SafeMed model differs from earlier care transition models [26][27][28] by focusing explicitly on the highest utilizers of inpatient and emergency services rather than all hospitalized patients and emphasizing intensive patient engagement and proven medication therapy management approaches. 22,[29][30][31] We examined quality, outcomes, and medical expenditures from 2013 to 2015 to assess whether intensive interdisciplinary transitional care for high-need, high-cost patients can help health systems simultaneously improve quality and outcomes while reducing costs. ...
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Background Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies. Objective To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs. Design Quasi-experimental study. Patients Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls. Interventions The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days. Main Measures Primary difference‐in‐differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30‐day readmissions, and hospital days), and medical expenditures. Key Results Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (− 0.40; 95% confidence interval (CI), − 0.73 to − 0.06), 31% fewer 30-day readmissions (− 0.34; 95% CI, − 0.61 to − 0.07), and reduced medical expenditures ($− 8690; 95% CI, $− 14,441 to $− 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, − 39.1% to 72.9%). Conclusions Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.
... • primarily professional training 216,217 • primarily organisational change 8,271,273 • primarily patient education 213,[265][266][267][268]276 • a whole systems approach with components operating explicitly at patient, professional and organisational levels. 264 ...
Book
SIGN 158 British Guideline on the Management of Asthma. A National Clinical Guideline BTS/ SIGN Full text is available here: https://www.sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma.html
... There have been several examples of direct contracts between pharmacy networks and payer systems that have shown significant effect economically and on patient health outcomes, suggesting this is a viable role for pharmacists to play. [16][17][18][19] One element that was mentioned but was not quantified because of its overall complexity is pharmacy's role in affecting Medicare Part D star ratings. There are a number of factors included in third-party star ratings that pharmacists can positively affect (examples listed in Table 1) to improve a thirdparty plan's overall ranking and help attract new members to the plan. ...
Article
Background: This study summarizes the potential financial impact of a 3-year collaboration focused on delivering disease management services through pharmacies in 12 rural Colorado communities. Objectives: To (a) identify components within the disease management program that would be billable and generate revenue to each pharmacy and (b) estimate the revenue amount that could be generated based on these services across the 3-year project. Methods: Reimbursable services included diabetes self-management education; medication therapy management services, including the comprehensive medication review; and improvements in Medicare star ratings through pharmacy interventions. Results: An estimated total of $117,800 could have been generated by services provided to patients across the 12 pharmacy sites. After subtracting the estimated cost of labor for a pharmacist to provide these services, an estimated net profit of $60,023 resulted over 3 years. Star rating impacts were discussed but were not able to be included as specific revenue based on the complex contracting between pharmacies and third-party insurers. Conclusions: Based on these estimates, delivery of chronic disease management could represent a financially feasible option for community pharmacists. Some credentialing and changes to the mode of delivery would be required to meet billing requirements. Further research is needed to better estimate the cost savings resulting from these services to possibly expand pharmacists' reimbursement opportunities. Disclosures: This publication was supported by Cooperative Agreement Number DP004796-05, funded by the Centers for Disease Control and Prevention. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. None of the authors have any conflicts of interest to disclose regarding this work.
... 27 As one example, the reimbursement model for the Asheville projects involved a per capita payment to pharmacies and associated patient financial incentives. 31,33 The impact of retail clinics on the transformation of health care has been described elsewhere. 34 The parallels between retail clinics and community pharmacy are striking, including both opportunities and associated challenges. ...
Article
Federal legislation has yet to be implemented designating pharmacists as health care providers. Progress has taken place at the state level, with California and Washington among the first states to successfully pass such legislation. Although the designation of pharmacists as providers has now been realized in these states, it should be recognized that the road to provider status has required decades of legislative efforts and advocacy. Similarities, as well as differences, are evidenced with the two states' efforts to expand pharmacy scope of practice. Although the goal of provider status has been accomplished in California and Washington, the lack of shared patient health care records among pharmacies and other segments of the health care delivery system, and a robust business model, are barriers to full implementation of pharmacist provider services.
... Various approaches are needed to optimize therapeutic treatments among asthma patients. Several studies in developed countries, such as the United States [10,11] and Australia [12][13][14], have showed that better health outcomes for asthma patients resulted from the following factors: adequate knowledge among asthma patients, regular monitoring of therapy, and high level of understanding among both health care professionals and patients regarding the disease management behavior. In Indonesia, asthma is one of the top 10 causes of morbidity and death, together with chronic bronchitis and emphysema [15]. ...
... Pharmacists and/or pharmacydispensing workers remain some of the most accessible healthcare professionals. They are an important way of providing medicines, counseling, knowledge, and advice on the safe and effective use of drugs [10][11][12]. A study has demonstrated the positive benefits for patients of pharmacist AED therapy management, including a significant improvement in adherence through therapeutic patient education. ...
Article
Epilepsy is the most common neurological disorder encountered in primary care in Southeast Asia. People with epilepsy require long-term therapy management. Nonadherence to antiepileptic drugs (AEDs) has been identified as a major factor in suboptimal control of epilepsy. Pharmacies offer patients a first-line point of contact with the healthcare system. Many pharmacies operate with limited or nonqualified human resources that can lead to insufficient knowledge, inappropriate supply of medicines, and insufficient counseling. Objective The aim of this study was to evaluate the qualification and knowledge concerning epilepsy and AEDs among pharmacy-dispensing workers who sell drugs to people with epilepsy. Method A cross-sectional qualitative study was conducted in public and private pharmacies, in both urban and rural areas of Cambodia and Lao People's Democratic Republic (Lao PDR). The knowledge was collected through a questionnaire. Results A total of 180 respondents from 123 outlets in the two countries were included in this study. A proportion of 40.8% (31) of respondents in Cambodia and 38.5% (40) in Lao PDR were pharmacists, followed by sellers who did not received any healthcare training with a proportion of 18.4% (14) in Cambodia compared to 20.2% (21) in Lao PDR. Head trauma was cited as the main cause of epilepsy by 72.4% (55) in Cambodia and 27.2% (28) in Lao PDR (p < 0.001). Epilepsy was considered as a contagious disease by 6.6% (5) of respondents in Cambodia compared to 18.4% (19) in Lao PDR (p = 0.03). Eighty-seven percent (66) of respondents in Cambodia knew at least one long-term AED versus 67.3% (70) in Lao PDR (p = 0.003). Phenobarbital was mentioned in more than 90.0% of cases in both countries. In overall, 15.4% (21) thought that if seizures are controlled for some months, people with epilepsy could stop taking their AEDs. Only one respondent from Lao PDR was aware of drug–drug interaction between AEDs and oral contraception. Conclusion An educational intervention should be implemented to improve the knowledge of epilepsy and AEDs for pharmacy-dispensing workers. This could include advice for all pharmacy-dispensing workers in order to improve AED management and follow-up of therapeutic adherence.
... An adequate pharmaceutical service provided by the pharmacist is a vital component of the health care delivery system. Moreover, studies have reported that the implementation of PC in hospital and community settings improves patients' health outcomes, reduces hospital stay, improves medication adherence, and reduces health care costs [4][5][6][7][8][9]. ...
Article
Full-text available
Objective. To assess knowledge and attitudes toward pharmaceutical care service among hospital and community pharmacists working in Harar and Dire Dawa town, Eastern Ethiopia. Method. A descriptive cross-sectional study was conducted among pharmacists working in hospital and community pharmacies, 2018. A total of 43 health settings (6 hospital and 37 community pharmacies) were involved in this study. All pharmacists who met the inclusion criteria were selected using a purposive sampling technique to take part in the study. The pretested structured self-administered questionnaires were used to collect data. The collected data was coded, entered, and analyzed using Statistical Package for Social Sciences (SPSS) version 21.0. The findings were presented by frequencies and percentages, and summary measures were displayed using tables. Chi-Square test and Fisher’s exact test were performed to determine the association between sociodemographic characteristics and the level of knowledge and attitude about pharmaceutical care. The study protocol was approved by the Harar Health Sciences College Research Ethics Review Committee. Results. A total of seventy-eight pharmacists were included in the study with a response rate of 97.5%. The mean age (±Standard Deviation (SD)) of the study participants was 32.47 ± 7.42 years, and the majority (88.3%) of the respondents were males. 56.4% of the respondents were working in the hospitals while 43.6% were working in community pharmacy. Overall, 85.9% of the respondents had good knowledge of pharmaceutical care. The types of training curriculum of the participants showed an association with the attitude of pharmacists ( value = 0.022). Similarly, pharmacists’ knowledge was associated with their practice setting ( value = 0.008). Conclusion. The majority of pharmacists are knowledgeable about PC. However, nearly half of the pharmacists had an unfavorable attitude toward pharmaceutical care. Harari Regional and Dire Dawa City Health Bureaus should organize and provide in-service training on pharmaceutical care to pharmacists working in community and hospital pharmacies. Furthermore, the bureaus should advocate pharmaceutical care as one area in a continuous professional development program. 1. Introduction Over the past four decades, there has been a trend for pharmacy practice to move away from its original focus on medicine supply to a more inclusive focus on patient care. The role of the pharmacist has evolved from that of a compounder and supplier of pharmaceutical products to that of a provider of services and information and, ultimately, that of a provider of patient care. This new approach has been known as pharmaceutical care (PC) [1]. PC is a multifactorial and structured process that is defined per International Pharmaceutical Federation (FIP) as “the responsible provision of pharmacotherapy to achieve definite outcomes that improve or maintain a patient’s quality of life” [2]. By taking direct responsibility for individual patient’s medicine-related needs, pharmacists can make a unique contribution to the outcome of medical therapy and their patients’ quality of life [1]. In this regard, the philosophy of PC focuses on the responsibility of the pharmacist to meet all of the patient’s drug-related needs and assist the patients in achieving their goal through collaboration with other health professionals [3]. An adequate pharmaceutical service provided by the pharmacist is a vital component of the health care delivery system. Moreover, studies have reported that the implementation of PC in hospital and community settings improves patients’ health outcomes, reduces hospital stay, improves medication adherence, and reduces health care costs [4–9]. In response, several professional pharmacy organizations have adopted the philosophy of PC and it was initiated in various countries to shift the demands of the pharmacy profession toward patient care [10]. In this line in Ethiopia, various efforts have been made to introduce PC in the health care system, including development and implementation of a 5-year patient-oriented Bachelor of Pharmacy (B.Pharm) curriculum in public universities since 2008 and initiating the clinical pharmacy and pharmacy practice programs at postgraduate levels [11, 12]. In addition to this, the Federal Ministry of Health (FMOH) included clinical pharmacy services in the pharmacy section of the Ethiopian Hospital Reform Implementation Guidelines (EHRIG) in 2010 [13]. Furthermore, clinical pharmacy service has been incorporated in the health facilities minimum regulatory standards by Ethiopian Standards Authority (ESA)/Ethiopian Food, Medicines and Health Care Administration and Control Authority (FMHACA) in 2012 [14]. It has been known that pharmacists’ knowledge, attitudes, skill, commitments, and ethics are the foundations to provide PC to patients [3, 15]. However, several barriers have hampered the implementation of PC practice universally, including the insufficient time to provide PC, lack of pharmacists’ self-confidence, inadequate clinical knowledge, and communication skills of pharmacists. Moreover, the unfavorable attitudes of pharmacists themselves toward performing PC have served as barriers to providing PC [16–18]. In this regard, because the Ethiopian pharmacy sector is experiencing PC as a new initiative, it is imperative to assess factors influencing the implementation of PC. However, as far as the knowledge of authors concerned, there is no published study about PC in the study area. Thus, this study aimed at assessing knowledge and attitudes toward PC service among hospital and community pharmacists working in Harar and Dire Dawa town, Eastern Ethiopia. 2. Material and Methods 2.1. Study Area and Period This study was conducted among pharmacists working in community and hospital pharmacies in Harar and Dire Dawa towns, from May to June 2018. Harar and Dire Dawa towns are located in the Eastern part of Ethiopia, at a distance of 525 km and 515 km from Addis Ababa, the capital city of Ethiopia, respectively. During the study period, there were 6 hospital pharmacies (2 were private and 4 were governmental) and 16 community pharmacies in the Harar town. In these pharmacies, a total of 34 (13 community and 21 hospital) pharmacists were working and registered by the Harari regional health bureau. Similarly, there were 7 hospital pharmacies (5 were private and 2 were governmental) and 21 community pharmacies in Dire Dawa town. A total of 46 (21 community and 25 hospital) pharmacists were working in these pharmacies and registered by the Dire Dawa counsel health bureau. 2.2. Study Design and Study Population A descriptive cross-sectional study was conducted among the community and hospital pharmacists working in Harar and Dire Dawa towns. All pharmacists of Harar and Dire Dawa towns were the source populations. All pharmacists working in community and hospital pharmacies of Harar and Dire Dawa towns during the study period were the study populations. Pharmacists working in a public hospital or community pharmacy and who were willing to give their informed consent were included in the study. Pharmacists who were in annual leave and sick leave were excluded from the study. 2.3. Sample Size and Sampling Technique The sample for this study was all pharmacists working in community and hospital-based pharmacies of Harar and Dire Dawa towns during the study period. The list of all pharmacists was obtained from Harari Regional and Dire Dawa City Health Bureaus. Then, the list was checked to evaluate the fulfillment of the inclusion criteria. Finally, all pharmacists who met the inclusion criteria were selected using a purposive sampling technique to take part in the study. 2.4. Data Collection Instrument and Technique Data was collected using a structured self-administered questionnaire which is developed after reviewing related studies from the literature [19–22]. A self-administered questionnaire was used to obtain information on sociodemographic variables, knowledge, and attitude of study participants toward PC. The questionnaire was structured into three sections: the first section was designed to collect demographic information such as the age of respondents, gender, qualification, and years of experience. The second section consisted of 10 questions to ascertain the knowledge of pharmacists about pharmaceutical care. These questions were designed using a 3-point response format consisting of “Yes,” “No,” and “I do not know.” The third section encompassed 10 statements to assess the attitude of pharmacists toward pharmaceutical care. It is a 5-Likert-type scale (agree strongly “5”, agree slightly “4”, neutral “3”, disagree lightly “2”, and disagree strongly “1” with a total score range from 10 to 50). These statements measure three constructs: professional requirement (statements 2, 3, and 8), professional duty (statements 1, 6, 7, and 9), and professional effect (statements 4, 5, and 10). An attempt was made to balance negatively and positively worded questions to minimize mechanical responses. Therefore, five of the ten items were negatively worded [4, 6, 7, 9, 10] and the remaining five were positively worded. The five negatively worded statements were reverse-scored during the analysis so that the more positive attitudes toward PC would be reflected by higher scores. The self-administered questionnaire was distributed by four trained and experienced pharmacies. A standardized working process was carried out by these pharmacies who distributed the questionnaire: (1) a brief self-introduction, (2) systemic explanation of the overall nature and processes of the study as indicated on the cover page of the questionnaire as participant information sheet, (3) declaration of anonymous nature of the study, and (4) confirmation of respondents’ participation and taking their voluntary consent. Whenever respondents made queries about the study, the data collectors would provide more specific information. All of the questionnaires were distributed directly to the respondents at their working place and collected during the next day’s visit. 2.5. Data Quality Control The quality of data was ensured using various strategies like pretesting the questionnaire, training of the data collectors and supervisors, supervision, and checking the questionnaire. The data collectors and supervisors were trained on the data collection technique for two days prior to data collection processes. After the questionnaire was developed, the content, clarity, validity, reliability, and format were evaluated using a pretest involving a convenience sample of 10 pharmacists working in private hospitals of Harar (Yimag and General Hospitals) and Dire Dawa town (Delt, Art, Bilal, and Yemaryam Work hospitals). In the pretest, pharmacists were asked to provide feedback on the design of the questionnaire, its relevance, and the flow of individual questions between sections. Comments were also obtained from three senior academic pharmacists from Haramaya University and Harar Health Science College. The pretest was also served as a practice session for the data collectors to be well acquainted with the data collection instrument. Then, the internal consistency (reliability) of the items was tested by determining Cronbach’s alpha Coefficient (minimum 0.5, ideally between 0.7 and 0.8), inspecting partial alphas of each item (>0.3), and determining the item to total correlation. After this checking, the finalized questionnaire was employed, in order to collect data from the major sample. All the collected data were checked for completeness, accuracy, and consistency by the principal investigators and the supervisors on a daily base. 2.6. Data Processing and Analysis The collected data were coded, entered, and analyzed using Statistical Package for Social Sciences (SPSS) version 21.0. Descriptive statistics was used to summarize the data and organize them into sociodemographics characteristics, knowledge, and attitudes of the participants according to the sections of the questionnaires. Then, the findings were presented by frequencies and percentages, and summary measures were displayed using tables. For knowledge questions, score 1 was assigned to the correct answers and zero was assigned to wrong answers. For attitude questions, a Likert-type summation of scores was employed. First, negatively worded questions were reversed so as to align all the scores in one direction. For the knowledge and attitude items, means and median were used to determine the overall response of the respondents, respectively. Moreover, the Chi-Square test and Fisher’s exact test were performed to determine the association between sociodemographic characteristics and the level of knowledge and attitude about PC. The five factors included were gender, age, years of experience, practice setting, and training curriculum. The factors indicated statistically significant differences at the level. 2.7. Ethical Consideration The study protocol was approved by the Harar Health Sciences College Research Ethics Review Committee. A formal permission letter was obtained from Harar Health Sciences College and submitted to community and hospital pharmacy managers, and the purpose of the research and how its premise is selected were also communicated. Before the data collection, written consent was obtained from each participant by informing them of the purpose of the study. 2.8. Operational Definitions 2.8.1. Knowledge We used a ten-item composite score of the knowledge to measure the knowledge level of respondents regarding definition, philosophy of practice, practitioners’ responsibility, goals and objectives, and roles and activities of practitioners of PC. The cumulative mean score of knowledge of participants about PC was estimated using the mean score. Based on this, those who had scored less than the mean were considered to have “poor knowledge” and those who had scored greater than or equal to the mean value were considered as having “good knowledge.” 2.8.2. Attitude To assess the respondents’ attitudes toward PC, a five-point Likert scale (rating from 1 = strongly disagree to 5 = strongly agree) was utilized to measure the extent to which the respondents agreed with 10 statements related to PC. The total of each respondent score was made to range between 10 and 50. A score of median value and above was considered as a “favorable attitude” whereas those scores below median value were thought of as having an “unfavorable attitude.” 3. Results 3.1. Sociodemographic Characteristics of Study Participants In the present study, a total of 80 questionnaires were distributed and 78 were found complete with a response rate of 97.5%. The mean age (±Standard Deviation (SD)) of the study participants was 32.47 ± 7.42 years and the majority (88.3%) of the respondents were males. Regarding training, less than half (44.9%) were trained with a clinically oriented curriculum or have got in-service training in clinical pharmacy. The respondents had an average (±SD) of 5.79 ± 5.34 years of experience. Concerning practice setting, 56.4% of the respondents were working in the hospitals while 43.6% were working in community pharmacies (Table 1). Variables Frequency (%) Age ≥30 35 44.9 <30 43 55.1 Gender Male 65 88.3 Female 13 16.7 Religion Christian 52 66.7 Muslim 26 33.3 Current marital status Single 48 61.5 Married 30 38.5 Ethnicity Amhara 36 46.2 Oromo 33 42.3 Harari 5 6.4 Others# 4 5.1 Training status B.Pharm with old curriculum 43 55.1 B.Pharm with new clinical oriented curriculum and others 35 44.9 Year of experience (in years) <5 49 62.8 6–10 18 23.1 ≥10 11 14.1 Practice setting Community pharmacy 34 43.6 Hospital pharmacy 44 56.4 #Guragae (2) and Somali (2). Including B.Pharm with old curriculum plus 1 month in-service and MSc in clinical pharmacy.
... 11 Many studies have determined that involvement of pharmacists towards PC services improves patients' health outcomes through the identification and prevention of TRPs in several diseases [12][13][14][15][16][17][18][19] and reduces health costs. [20][21][22][23] However, several barriers have impeded the implementation of PC practice worldwide. These include lack of pharmacists` time, poor clinical knowledge and communication skills, insufficient pharmacists' self-confidence in addition to the negative attitudes of pharmacists themselves toward performing PC. [24][25][26][27][28][29] International pharmacy bodies like The Accreditation Council for Pharmacy Education (ACPE) 30 and The Centre for the Advancement of Pharmacy Education (CAPE) 31 require trainee (and practicing) pharmacists to possess an appropriate awareness and competencies within a patient-centred model of practice to enable evidence-based decision-making. ...
Article
Full-text available
Objective: To investigate the effectiveness of an online tutorial and its impact on improving knowledge and skills of pharmacy students in the clinical problem-solving process that is necessary to implement pharmaceutical care. Methods: This is a prospective interventional study conducted during the COVID-19 pandemic restrictions using four novel templates. The first two levels of Kirkpatrick's Model (Reaction and Learning) were used. Results: 129 participants completed all of the online training parts. The findings indicated a significant improvement in the students' knowledge and skills. The participants achieved higher score following the tutorial than the baseline, with a statistically significant difference (p < 0.001). There was a significant improvement in the number of detected treatment-related problems. The majority of students were satisfied with the overall training process and stated a high evaluation score out of 10 (mean = 7.93 ± 1.42, median = 8.00). Conclusion: The educational intervention achieved a substantial positive impact on decision-making skills of participating students and was considered effective in helping them attain basic skills such as teamwork, peer assessment, communication and critical evaluation. Healthcare providers must work together to ensure accurate medication use during care transitions. Pharmacists, as medication experts, play an important role in the implementation process. Pharmacy educators must prepare pharmacy student to use pharmaceutical care in their future practice.
... The implication of this is that as the practitioners gain higher knowledge on MTM, and provide MTTM services, their attitude towards it also improves. This is in contrast to a study of pharmacist's attitude towards Pharmaceutical Care, where the attitude ratings were inversely proportional to the level of professional experience, with pharmacists having less experience showing better attitude towards pharmaceutical care [3,[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36]. ...
... 37 MTM programs have been used to improve health outcomes and overall costs for chronic diseases such as hypertension, diabetes, and asthma; to improve ART adherence; and to decrease the use of contraindicated regimens in HIV care. [38][39][40][41] To conduct MTM most effectively for ART adherence, pharmacists can collaborate with primary medical care providers to share patient clinical information (eg, HIV viral load and drug resistance test results, CD4 counts, failed drug regimens) with the patient's consent and as allowed by laws that protect the sharing of private medical and personal information. Because HIV viral suppression depends on additional factors other than adherence (eg, drug resistance, individual treatment history, concomitant medications), sharing clinical information allows pharmacists to effectively evaluate the patient's therapy and recommend appropriate treatment interventions. ...
Article
In 2019, President Trump announced a new initiative, Ending the HIV Epidemic: A Plan for America (EHE). EHE will use 3 key strategies—diagnose, treat, and prevent—to reduce new HIV infections at least 90% by 2030, as well as new laboratory methods and epidemiological techniques to respond quickly to potential outbreaks. Partnerships are an important component in the initiative’s success. Pharmacists and pharmacies can play important roles in EHE, including dispensing antiretroviral therapy and providing HIV screening, adherence counseling, medication therapy management, preexposure prophylaxis, and nonprescription syringe sales. The objective of this report is to discuss potential roles that pharmacists and pharmacies can play under the key strategies of EHE.
... These patients may benefit from programs that utilize a combination of education and inhaler coaching from an asthma educator and regular, long-term follow up with pharmacists; an intervention that demonstrated reduced emergency department utilization, hospitalization, and direct cost savings. 26 Additionally, a pharmacist-led intervention dedicated to improving asthma medication use was associated with reductions in exacerbations, improved asthma symptom control and quality of life, and improved adherence to prescribed treatment. 27 While surrogate markers for disease severity such as number of controller medication classes and albuterol fills were consistently associated with medication adherence in 2019 and 2020, corticosteroids were not. ...
Article
Background Data regarding medication adherence in older adults with asthma before and during the COVID-19 pandemic is lacking. Objective To evaluate medication adherence and determine factors associated with adherence in Medicare enrolled older adults with asthma before and during the COVID-19 pandemic. Methods This was a retrospective cohort analysis of Medicare enrolled patients with asthma. Medication adherence was measured using proportion of days covered (PDC) rates for dates January-July 2019 and January-July 2020. Patients <65 years of age, with chronic obstructive pulmonary disease, or cystic fibrosis were excluded. Paired t-tests assessed change in adherence between 2019 and 2020. Logistic regression evaluated association of age, sex, depression, moderate/severe asthma, use of a 90-days’ supply, having ≥3 albuterol fills, and number of medications, medication-related problems, prescribers, pharmacies, controller medication classes, and systemic corticosteroid fills with high adherence (PDC ≥80%). Results Mean adherence to asthma controller medications ranged from 75-90%, in 2019. Adherence significantly decreased (p<0.001) to 51-70% for all controller medications, except theophylline in 2020. Similar results were observed among patients with moderate/severe asthma. In 2019 and 2020, number of controller medications, ≥3 albuterol fills, and having a 90 days’ supply were associated with high adherence (p<0.001). Conclusion Adherence to asthma controller medications significantly decreased during the COVID-19 pandemic among Medicare enrolled patients with asthma. Patients with markers for more severe asthma, overuse of albuterol, and a 90-day supply of controller medications were more likely to have high adherence. These findings can be used to identify opportunities to improve adherence and prescribing among adult patients with asthma.
... Pharmacists accessed patients' health records from primary care physicians and communicated information back to physicians. The pharmaceutical care services provided in the Asheville Project resulted in improved patient outcomes, lower healthcare costs, fewer sick days, and increased satisfaction with pharmacists' services [30][31][32]. ...
Chapter
Pharmaceutical care in the US and Canada is regulated at the level of the state/province generating differences in the practice of pharmacy across the countries. Pharmacist counseling and utilization review are generally required to be offered at dispensing in community pharmacies. There is a trend toward the development of pharmaceutical care services provided at the community pharmacy, the integration of the pharmacist in the healthcare team, and the implementation of collaborative agreements expanding the role of the pharmacist in patient care. This chapter is divided into two sections, one for the United States of America, and one for Canada. In 2015, there were 65,280 US community pharmacies [1], representing one pharmacy per 4915 people. US community pharmacies dispensed a total of 4065 million prescriptions with an average of 12.6 prescriptions per inhabitant and a total cost of $379,247 million in the same year [2]. Community pharmacy expenditures represented over 10% of US healthcare expenditures [3]. Public programs including Medicare and Medicaid and other federal and state programs covered over 50% of the pharmaceutical expenditures in the country. In 2015, community pharmacies dispensed 83.3% of the prescriptions and accounted for 68% of the pharmacy expenditures, while mail-order pharmacies dispended 16.7% of the prescriptions and accounted for 31.9% of the expenditures. Pharmacy chains represented 41.2%
... MTM services make use of the pharmacist's skill set in assessing the safety and efficacy of a patient's medication regimen, while leveraging pharmacist accessibility to communitydwelling patients. Many examples exist that indicate the positive impact MTM services can have on economic and clinically important outcomes [32][33][34]. Other examples of utilizing a pharmacist's unique skills and accessibility include pharmacist-administered medications [35], tobacco cessation programs [36], wellness coaching [37], and travel health services [38,39]. ...
Article
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In the United States, pharmacists’ scope of practice continues to expand, with increasing opportunities for pharmacists in all practice settings to enhance health in society. In ambulatory care, pharmacists remain integral members on the healthcare team and have demonstrated positive impacts on patient care. Sharing similar characteristics as pharmacists in the community setting, a deeper look into common elements of a successful ambulatory care practice that can be applied in the community pharmacy setting is warranted. Key success factors identified from ambulatory care include (1) maximizing a pharmacist’s unique knowledge base and skill set, (2) forming collaborations with physicians and other providers, (3) demonstrating outcomes and value, and (4) maintaining sustainability. Opportunities exist for pharmacists in the community setting to utilize these success factors when developing, implementing, and/or expanding direct patient care services that improve accessibility to quality care and population health.
... 19 Another prominent example was the Hickory Project which report on the sustainability of such outcomes over three years from 2007 to 2009 to confirm the advantages of involvement of CPs in the management of chronic diseases. [20][21][22] Similarly, Diabetes Ten City Challenge, a project which was delivered through CPs in 10 USA cities, reported significant improvement in diabetic patients' outcomes. 23 A recent report to US Surgeon-General, ″Improving patient and health system outcomes through advanced pharmacy practice″, summarised evidence-based conclusion about the significant impact CPs' valuable contributions had made in MTM, adherence support and educational interventions to manage chronic diseases. ...
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Medicine use review is a tool to improve medication adherence and safety. Current narrative review was planned to explore global policies and practices of medicine use review by community pharmacists in chronic diseases and its impact and way forward for low-and middle-income countries. Key words, such as ″medicine use review″, ″medication therapy management″ and ″community pharmacy″ were used for search on PubMed and CINAHL databases for articles published from 2004 to 2019. Medicine use review has opened an avenue of ongoing collaboration between community pharmacists and general practitioners. High-income countries have witnessed a gradual yet cautious adoption of these services through effective policy shift. In terms of practices and impact, the situation in high-income countries was promising where on an average ″type-II″ medicine use review was widely in practice and had improved clinical, humanistic and economic outcomes in chronic disease. However, in low-and middle-income countries, a paucity of effective policies was noted. Nevertheless, an emergent recognition of the potential of community pharmacists to contribute to the management of chronic diseases was evident.
... [2] Asthma is a typical example of a chronic disease state in which community pharmacists have been actively engaging in a range of disease and patient-centred management services for adults, resulting in improved asthma outcomes and reductions in healthcare costs. These services range from patient education and counselling, [3][4][5] medication management and review, [6][7][8][9] disease monitoring, [3,10,11] health promotion, [12] self-management education, [13][14][15] pharmaceutical care [16][17][18][19][20] and disease-state management. [11,[21][22][23][24] Community pharmacy provides a strategic venue for the provision of ongoing asthma care services. ...
Article
Objectives Few studies have explored pharmacists' perceptions of their potential role in asthma management. This study aimed to investigate community pharmacists' perceptions of their role in the provision of asthma care, to compare the perceptions of metropolitan and regional pharmacists with regards to their role, to identify barriers to the provision of asthma management services and to explore their level of inter‐professional contact. Methods A 29‐item questionnaire was mailed to a convenience sample of community pharmacists. Items included pharmacists' perceptions of their role in asthma management, barriers to pharmacy asthma services and inter‐professional contact. The setting was community pharmacies in metropolitan and rural New South Wales, Australia. Key findings Seventy‐five pharmacists (63% male, 69% in metropolitan pharmacies) returned completed questionnaires (response rate 89%). Pharmacists perceived their role in asthma management along three major dimensions: ‘patient self‐management’, ‘medication use’ and ‘asthma control’. Regional pharmacists described a broader role than metropolitan pharmacists. Most participants perceived time and patient‐related factors to be the main barriers to optimal asthma care with pharmacist's lack of confidence and skills in various aspects of asthma care less important barriers. Almost 70% indicated that they would like more inter‐professional contact regarding the care of patients with asthma. Conclusions Community pharmacists perceived a three‐dimensional role in asthma care with regional pharmacists more likely to embrace a broader role in asthma management compared to metropolitan pharmacists. Pharmacists identified time and patient‐related factors as the major barriers to the provision of asthma services. Future research should explore barriers and facilitators to expansion of the pharmacist's role in asthma management in a holistic way.
... 19 Another prominent example was the Hickory Project which report on the sustainability of such outcomes over three years from 2007 to 2009 to confirm the advantages of involvement of CPs in the management of chronic diseases. [20][21][22] Similarly, Diabetes Ten City Challenge, a project which was delivered through CPs in 10 USA cities, reported significant improvement in diabetic patients' outcomes. 23 A recent report to US Surgeon-General, ″Improving patient and health system outcomes through advanced pharmacy practice″, summarised evidence-based conclusion about the significant impact CPs' valuable contributions had made in MTM, adherence support and educational interventions to manage chronic diseases. ...
Article
Full-text available
Medicine use review is a tool to improve medication adherence and safety. The current narrative review was planned to explore global policies and practices of medicine use review by community pharmacists in chronic diseases, its impact and way forward for low-and middle-income countries. Key words, such as ″medicine use review″, ″medication therapy management″ and ″community pharmacy″ were used for search on PubMed and CINAHL databases for articles published from 2004 to 2019. Medicine use review has opened an avenue of ongoing collaboration between community pharmacists and general practitioners. High-income countries have witnessed a gradual yet cautious adoption of these services through effective policy shift. In terms of practices and impact, the situation in high-income countries was promising where on an average ″type-II″ medicine use review was widely in practice and had improved
... Pharmacists are well-positioned to provide cost-effective care and effect medication adherence that has a direct impact on patient outcomes. As an example, the Asheville Project, a quasi-experimental, longitudinal pre-post cohort study launched in 1997 in 12 community pharmacies in Asheville, North Carolina led to improved adherence, reduced adverse events, and ultimately decreased overall healthcare costs) [14,15]. ...
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This article describes the history and evolution of pharmacist-physician collaborative practice agreements (CPAs) in the United States with future directions to support pharmacists’ provider status as the profession continues to evolve from product-oriented to patient-centered care and population health. The pharmacy profession has a long history of dispensing and compounding, with the addition of clinical roles in the late 20th century. These clinical roles have continued to expand into diverse arenas such as communicable and non-communicable diseases, antimicrobial stewardship, emergency preparedness and response, public health education and health promotion, and critical and emergency care. Pharmacists continue to serve as integral members of interprofessional and interdisciplinary healthcare teams. In this context, CPAs allow pharmacists to expand their roles in patient care and may be considered as a step towards securing provider status. Moving beyond CPAs to a provider status would enable pharmacists to be reimbursed for cognitive services and promote integrated public health delivery models. Access paper at: https://www.mdpi.com/2226-4787/9/1/57/htm
... The role of the pharmacist has traditionally centered on the provision of pharmacotherapeutic counselling, the evaluation of treatments and the prevention of adverse effects. 1,2 However, given increasing demands on primary and emergency services and an aging population together with the higher prevalence of chronic diseases, the pharmacist's position has had to change towards a patient-centered model. Community pharmacists are particularly well positioned to provide these "pharmaceutical services" 3,4 which include both the management of medicines and clinical attention. ...
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Purpose: The aim of this study was to evaluate the provision of a professional pharmaceutical patient-centered model in a weight management program and optimization of the medication in a Spanish community pharmacy. Patients and methods: This was a single-group intervention study with a mean follow-up period of 8.2 months (sd 2.3). Patients ≥18 years old seeking to lose weight or improve eating habits were recruited. On the first visit, the pharmacist collected patients' sociodemographic and anthropometric variables, dietary history and lifestyle habits, biochemical measurements and other clinical and therapeutic data. The intervention was based on the Spanish Society of Community Pharmacy recommendations for diet and exercise and for pharmacotherapy management. The follow-up included a two-month visit and a final visit. Results: A total of 330 patients were included (80% women; mean age 51.3 years old (sd 15.3)). A statistically significant reduction in anthropometric measurements (weight, BMI, and waist circumference) and a statistically significant increase in the number of patients with normal cholesterol and LDL-cholesterol (p<0.001) were observed at two-month visit compared with first visit (p<0.001). The number of patients with normal triglyceride levels at final visit compared with first visit also increased significantly (p=0.04). A total of 186 (56.4%) patients had drug-related problems at first visit and 31 (9.4%) patients at two-month visit. Conclusion: The implementation of a patient-centered weight management model had a positive impact on the improvement of anthropometric, clinical and therapeutic parameters.
... Several RCTs and systematic reviews have reported the clinical, economic and humanistic outcomes of PPSs in community pharmacy [30][31][32][33][34][35][36][37][38][39][40][41], although further research may be needed to determine whether these services can improve health-related quality of life and reduce healthcare costs [42]. Most of the studies reported in the literature have used an explanatory RCT design, which result in low external validity with consequent limitations associated with the generalisation of results [43][44][45][46]. ...
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Background Implementation of Professional Pharmacy Services (PPSs) requires a demonstration of the service’s impact (efficacy) and its effectiveness. Several systematic reviews and randomised controlled trials (RCT) have shown the efficacy of PPSs in patient’s outcomes in community pharmacy. There is, however, a need to determine the level of evidence on the effectiveness of PPSs in daily practice by means of pragmatic trials. To identify and analyse pragmatic RCTs that measure the effectiveness of PPSs in clinical, economic and humanistic outcomes in the community pharmacy setting. Methods A systematic search was undertaken in MEDLINE, EMBASE, the Cochrane Library and SCIELO. The search was performed on January 31, 2020. Papers were assessed against the following inclusion criteria (1) The intervention could be defined as a PPS; (2) Undertaken in a community pharmacy setting; (3) Was an original paper; (4) Reported quantitative measures of at least one health outcome indicator (ECHO model); (5) The design was considered as a pragmatic RCT, that is, it fulfilled 3 predefined attributes. External validity was analyzed with PRECIS- 2 tool. Results The search strategy retrieved 1,587 papers. A total of 12 pragmatic RCTs assessing 5 different types of PPSs were included. Nine out of the 12 papers showed positive statistically significant differences in one or more of the primary outcomes (clinical, economic or humanistic) that could be associated with the following PPS: Smoking cessation, Dispensing/Adherence service, Independent prescribing and MTM. No paper reported on cost-effectiveness outcomes. Conclusions There is limited available evidence on the effectiveness of community-based PPS. Pragmatic RCTs to evaluate clinical, humanistic and economic outcomes of PPS are needed.
Article
Purpose:: To evaluate the difference in the number of drug therapy interventions between patients seen by pharmacists and patients seen by nonpharmacist providers during Medicare Annual Wellness Visits (AWVs). Methods:: Pharmacists completed the medication history portion of AWVs at a primary care, interdisciplinary clinic in Central Texas. Drug therapy problems were collected and compared to those identified by physicians conducting AWVs. Drug therapy problems were grouped into 4 categories: indication, effectiveness, safety, and adherence. Each category was divided into subcategories to further specify the problem. Results:: Fifty patients received an AWV in each group. Pharmacists identified more drug therapy problems in all 4 categories as compared to physicians (100 vs 20 interventions, respectively) and significant differences were detected in most subcategories: indication without medication ( P = .005), suboptimal regimen ( P = .0034), drug-drug interaction ( P = .0267), warning/precaution requiring additional monitoring ( P = .0267), nonadherence ( P = .0058), and patient lack of understanding medication therapy ( P = .005). Conclusion:: Pharmacist involvement in AWVs helped identify drug therapy problems.
Article
Objective: Asthma is one of the major causes of hospital readmissions in the South Bronx. The goal of this study was to assess the impact of asthma education provided by registered pharmacists with asthma educator certification (AE-C), on medication adherence and hospitalizations/Emergency Department (ED) visits. Methods: This was a retrospective chart review of patients seen in the pulmonary clinic from October 2014 to August 2015 for asthma education by AE-C pharmacists. Medical records were reviewed over an 18-month period – 9 months before and after the initial asthma education session. Data obtained included adherence to asthma controller inhalers based on pharmacy refill claims, asthma control using asthma control test (ACT) scores and asthma-related hospitalizations or ED visits within 30 days of asthma education. Pre-education data served as the pre-intervention group data and post-education data served as the post-intervention group data, allowing each patient to serve as their own control. Results: We found a statistically significant improvement in average medication adherence, i.e. asthma controller inhaler fills at pharmacy (46.3% vs 67.9%, p-value < 0.001) and asthma control (15.71% vs 56.38%, p-value < 0.001) between the pre-intervention and the post-intervention groups. Additionally, a lower hospitalization/ED utilization rate (31.2% vs 6.38%, p-value < 0.001) was observed in the post-intervention group within 30 days of education. Conclusion: Asthma education provided by AE-C pharmacists had a positive impact on asthma care in our inner-city community. Improving medication adherence and asthma control as well as decreasing hospital utilization could potentially decrease health care costs in addition to improving quality of life.
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Aim This study aimed to assess the consistency and replicability of these process measures during provision of the Italian Medicines Use Review (I-MUR). Background Medication review is a common intervention provided by community pharmacists in many countries, but with little evidence of consistency and replicability. The I-MUR utilised a standardised question template in two separate large-scale studies. The template facilitated pharmacists in recording medicines and problems reported by patients, the pharmaceutical care issues (PCIs) they found and actions they took to improve medicines use. Methods Community pharmacists from four cities and across 15 regions were involved in the two studies. Patients included were adults with asthma. Medicines use, adherence, asthma problems, PCIs and actions taken by pharmacists were compared across studies to assess consistency and replicability of I-MUR. Findings The total number of pharmacists and patients completing the studies was 275 and 1711, respectively. No statistically significant differences were found between the studies in the following domains: patients’ demographic, patients’ perceived problems, adherence, asthma medicines used and healthy living advice provided by pharmacists. The proportion of patients in which pharmacists identified PCIs was similar across both studies. There were differences only in the incidence of non-steroidal anti-inflammatory drug use, the frequency of potential drug-disease interactions and in the types of advice given to patients and GPs. Conclusions The use of a standardised template for the I-MUR may have contributed to a degree of consistency in the issues found, which suggests this intervention could have good replicability.
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Background Pharmaceutical care in outpatient settings is a type of health service that has been shown to contribute to decreasing drug-related morbidity and mortality rates. However, every process of implementing a new service brings about changes and transformations in the work routine, thus posing challenges. Objectives This systematic review aims to identify barriers to and facilitators for the implementation of pharmaceutical care in outpatient settings by applying the CFIR method, a framework based on the theory of health services, used to analyze and synthesize research data, which can direct strategies for the service to work as planned. Methods A systematic review was conducted exploring the barriers to and facilitators for the implementation of pharmaceutical care in outpatient settings. The MEDLINE, EMBASE, CINAHL, COCHRANE, and LILACS databases were consulted. Results Eight studies were included: five qualitative ones, two mixed-method ones, and a quantitative one. The most frequent CFIR constructs identified were Patient Needs and Resources (n = 30, 10.75%), Knowledge and Beliefs about the Intervention (n = 31, 11.11%), Networks and Communications (n = 34, 12.19%), and Available Resources (n = 56, 20.07%). The most cited barriers were: insufficient human resources, patients' unawareness of the existence of the pharmaceutical care service, and pharmacists’ resistance to changes. Facilitators included: the opportune presentation of the service to the healthcare team; the use of electronic devices for specific guidance; and the assessment of patient satisfaction. Conclusions This systematic review allowed detecting key guidelines to improve the implementation process, including (1) defining an implementation method and exploring it extensively during the pre-implementation phase, (2) ensuring human and financial resources, (3) determining how the new service will interact with other existing services. More research is needed to understand how these factors can affect the implementation of clinical services.
Article
Objective: This systematic review aimed to evaluate the cost-effectiveness of medication adherence-improving interventions in patients with asthma. Data source: Search engines including PubMed, Scopus and EBSCOhost were used to locate relevant studies from the inception of the databases to 19 October 2018. Drummond’s checklist was used to appraise the quality of the economic evaluation. Study selection: Economic studies evaluating the cost-effectiveness of medication adherence enhancing interventions for asthmatic patients were selected. Relevant information including study characteristics, quality assessment, health outcomes and costs of intervention were narratively summarized. The primary outcome of interest was cost-effectiveness (CE) values and the secondary outcomes were costs, medication adherence and clinical consequences. Results: Twenty studies including 11 randomized controlled trials, 6 comparative studies and 3 modeled studies using Markov models were included in the review. Among these, 15 studies evaluated an educational intervention with 13 showing cost-effectiveness in improving health outcomes. The CE of an internet-based intervention showed similar results between groups, while 3 studies of simplified drug regimens and adding a technology-based training program achieved the desirable cost-effectiveness outcome. Conclusion: Overall, our results would support that all of the identified medication adherence-enhancing interventions were cost-effective considering the increased adherence rate, improved clinical effectiveness and the reduced costs of asthma care. However, it was not possible to identify the most cost-effective intervention. More economic studies with sound methodological conduct will be needed to provide stronger evidence in deciding the best approach to improve medication adherence.
Article
Background: Pharmacists can play an important role in providing medication therapy management (MTM) services, which focus on appropriate medication use. This pilot study aimed to describe pharmacists' MTM service provision, results/outcomes of pharmacists' recommendations and resolution/acceptance rate among patients with high-risk asthma and/or chronic obstructive pulmonary disease (COPD). Methods: This was a prospective descriptive study of MTM services provided by community pharmacists to Texas Medicaid patients (5-63 years) with "high risk" asthma or COPD. Patients received in-person and telephone consultations that included medication review, asthma control test assessment, and education on adherence and proper medication/device use. Data extracted from MTM software was used to describe: reasons for MTM services, type of pharmacists' interventions, outcomes of pharmacists' recommendations and acceptance rate. Results: Twenty-eight pharmacists provided 139 MTM interventions with 63 patients (2.2 interventions per patient). The most frequent intervention reason was complex drug therapy (53.2%), underuse of medication (8.6%), need for drug therapy (8.6%), new or changed prescription therapy (6.5%), and administration technique (5.0%). The resolution rate was 77.7%. Patient and prescriber, respectively, refused recommendation in 12% and 6% of the interventions. Outcomes included comprehensive medication review (46.7%), improved adherence (6.5%), therapeutic success (6.5%), improved administration technique (5.0%), and initiation of new therapy (5.0%). Conclusion: Through the provision of MTM, pharmacists were able to identify and intervene with medication-related problems. These interventions are instrumental in helping patients better manage their asthma/COPD. The high resolution rate was encouraging. Larger scale studies are needed to assess clinical and economic outcomes.
Article
Objectives: To determine the impact of a pharmacist home-based and telephonic medication therapy management (MTM) program for African American children enrolled in a state Medicaid plan with asthma exacerbations. Caregivers' knowledge of asthma is described. Design: This study was a quasi-experimental, pre-post prospective study with 2 phases: a pre-phase followed by a 12-month intervention post-phase in which each patient served as their own control. Pharmacists were sent to the patients' homes to provide MTM at weeks 1, 24, and 48 while pharmacy students provided telephonic outreach at weeks 4, 8, 12, and 36. Setting: A local Medicaid managed care organization. Participants: Pediatric African American patients (4-17 years old) with uncontrolled asthma. Main outcome measures: Outcomes included emergency department (ED) visits, change in pharmacist assessment of asthma control, change in asthma knowledge test, change in Asthma Control Test, and change in medication adherence score. Results: Overall, 366 pediatric patients (4-17 years old) were enrolled in this program over a 1-year period. Among the patients who were enrolled in the program, there were 122 asthma-related ED visits in the year preceding enrollment compared to 57 ED visits after their first home-based visit (P < 0.001). Although only 102 patients completed the study, more patients were assessed by the pharmacists as having well-controlled asthma at the final visit (76.8%) than at baseline (58.7%). Based on the Asthma Control Test, more patients reported uncontrolled asthma at baseline (47.5%) than at the final visit (39%). There was a statistically significant increase in the Asthma Knowledge Test (P < 0.05) and the Medication Adherence Assessment (P = 0.035) among patients compared with baseline. Conclusion: Rates of asthma exacerbations requiring an ED visit were substantially lower in the year after the initial pharmacist visit compared with the year preceding enrollment in the medication therapy management program.
Article
Introduction The objective of this study was to assess the impact of a mental health educational intervention on pharmacy students' confidence and comfortability when engaging in depression counseling. Methods Third-year pharmacy students completed two 15-item rating scales addressing confidence and comfortability about depression. The intervention was 2.5 hours long and included a depression overview, consumer educator presentation, motivational interviewing, and case studies. Surveys were administered at baseline, immediately after the intervention, and three months post intervention. Data were analyzed using paired t-tests and repeated measures analyses. Results Of the 23 students who participated in the intervention, 12 (52.2%) completed the three-month follow-up. Confidence increased significantly (p < 0.05) from 3.5 ± 0.5 to 4.1 ± 0.4 immediately post intervention and was sustained at three months post (3.9 ± 0.5). Similarly, comfortability increased significantly (p < 0.05) from 3.6 ± 0.4 to 4.1 ± 0.5 immediately post and was sustained at three months post (4.1 ± 0.6). Cronbach's alphas ranged from 0.90 to 0.96. Conclusion Pharmacy students' depression counseling confidence and comfortability improved and was sustained after a 2.5-hour intervention with motivational interviewing, consumer education, and case studies.
Article
Objective: Examine the factors that influence a patient's likelihood of participating in clinical pharmacy services so that pharmacists can use this knowledge to effectively expand clinical services. Methods: An online survey was distributed to U.S. citizens 55 years of age or older through a market research company. The survey assessed pharmacy and medication use, general health, interest in clinical pharmacy services, and general demographics. The specific clinical services examined included medication therapy management (MTM) and a collaborative practice agreement (CPA). Logistic regression and best-worst scaling were used to predict the likelihood of participating and determine the motivating factors to participate in clinical pharmacy services, respectively. Results: Two hundred eight (58.45%) respondents reported being likely to participate in MTM services, and 108 (50.6%) reported being likely to participate in the services offered by a pharmacist with a CPA, if offered. The motivations to participate in MTM were driven by pharmacist management of medication interactions and adverse effects (best-worst scores 0.62 and 0.51, respectively). The primary motivator to participate in a CPA was improved physician-pharmacist coordination (best-worst score 0.80). Those with a personal pharmacist were more likely to participate in MTM (odds ratio [OR] 2.43 [95% CI 1.41-4.22], P = 0.002) and a pharmacist CPA (2.08 [1.26-3.44], P = 0.004). Previous experience with MTM increased the likelihood of participating again in MTM (5.98 [95% CI 2.50-14.35], P < 0.001). Patient satisfaction with the pharmacy increased the likelihood of participating in a pharmacist CPA (1.47 [95% CI 1.01-2.13], P = 0.04). Conclusion: Patients are interested in clinical pharmacy services for the purposes of medication interaction management, adverse effect management, and improved physician-pharmacist coordination. The factors that influenced the likelihood of participating included having a personal pharmacist, previous experience with MTM, and pharmacy satisfaction. These results suggest a potential impact of the patient-pharmacist relationship on patient participation in clinical services.
Article
Objective To evaluate the impact of a community pharmacist–driven health coaching program on clinical outcomes from baseline to 1 year. Setting Independent community pharmacy in western North Carolina. Practice description Sona Pharmacy + Clinic is an independent community pharmacy offering enhanced clinical services such as medication synchronization, adherence packaging, and free delivery. Sona Benefits offers pharmacy benefit manager (PBM) services to self-funded plans in western North Carolina. Practice innovation Sona Health Management Program is a disease management program offered to Sona Benefits PBM clients; the services began in October 2016. Evaluation : Change in clinical outcome measures (total number of medications, blood pressure, hemoglobin A1c, weight, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], triglycerides [TG], patient health questionnaire [PHQ-9] scores, and asthma control test [ACT] scores) were assessed for members who participated in the program for a minimum of 12 months for at least 2 of the following conditions: hypertension, hyperlipidemia, diabetes, depression, and asthma. Results Health coaching was provided to 42 members (mean age of 55.9 years and 2.7 qualifying disease states). The mean number of medications per patient significantly decreased from 7.2 to 6.2 (P = 0.02). Systolic and diastolic blood pressures were significantly reduced from 130.8 mm Hg to 125.7 mm Hg (P = 0.04) and 76.9 mm Hg to 73.7 mm Hg (P = 0.04), respectively. Other clinical outcome measures evaluated, such as hemoglobin A1c, weight, LDL-C, HDL-C, TG, and PHQ-9 and ACT scores, were improved but did not reach significance. Conclusion These results suggest that community pharmacists can have a positive impact on patients with multiple chronic conditions through health coaching services. This project suggests a potential model of pharmacist health coaching through pharmacist-run PBM services.
Article
Background With expansion of more advanced clinical roles for pharmacists we need to be mindful that the extent to which clinical pharmacy services are implemented varies from one country to another. To date no comprehensive assessment of number and types of services provided by either community or hospital pharmacies in Austria exists. Objective To analyse and describe the number and types of clinical pharmacy services provided in both community and hospital pharmacies, as well as the level of clinical pharmacy education of pharmacists across Austria. Setting Austrian community and hospital pharmacies. Method An electronic questionnaire to determine number and types of clinical pharmacy services provided was send to all chief pharmacists at all community (n = 1365) and hospital pharmacies (n = 40) across Austria. Besides current and future services provision, education and training provision were also assessed. Main outcome measure Extent of and attitude towards CPS in Austria. Results Response rates to the surveys were 19.1% (n = 261/1365) in community and 92.5% (n = 37/40) in hospital pharmacies. 59.0% and 89.2% of community and hospital pharmacies, respectively, indicated that the provision of clinical pharmacy services in Austria has increased substantially over the past 10 years. Fifty-one percent of community pharmacies reported to provide a medication review service, while 97.3% of hospitals provide a range of services. Only 18.0% of community pharmacies offer services other than medication review services at dispensing. Binary regressions show that provision of already established medication management is a predictor for the willingness of community pharmacists to extend the range of CPS (p < 0.01), while completed training in the area of clinical pharmacy is not (p > 0.05). More hospital than community pharmacists have postgraduate education in clinical pharmacy (17.4% vs 6.5%). A desire to complete postgraduate education was shown by 28.3% of community and 14.7% of hospital pharmacists. Lack of time, inadequate remuneration, lack of resources and poor relationship between pharmacists and physicians were highlighted as barriers. Conclusion Both community and hospital pharmacists show strong willingness to expand their service provision and will need continued support, such as improved legislative structures, more supportive resources and practice focused training opportunities, to further these services.
Article
Numerous studies have demonstrated positive therapeutic and economic outcomes associated with pharmacist-provided care. However, public policy on provider status with subsequent payment for non-dispensing services has been slow to reflect an expanded pharmacist role. It is important for the public to understand the value of a pharmacist outside of the drug distribution system. Pharmacists and other health care and public health practitioners must share this information to further knowledge and affect policies and systems that can most effectively include pharmacists fully in the health care system. The purpose of this commentary is to provide advocates for improved patient health with a resource for promoting increased access to pharmacist care. The primary objectives are (1) to summarize key economic outcomes associated with pharmacist-provided care on the basis of the existing body of literature, and (2) to provide advocates with strategies to communicate the economic value of pharmacists to the health care system and society. The 3 main areas identified in which the pharmacist has economic impact are decreased total health expenditures, decreased unnecessary care, and decreased societal costs. Evidence supports the economic value of the pharmacist; however, public opinion and political movements supporting patients’ access to pharmacist-provided care are variable. Strategies to advocate and effect change include advocating to elected leaders for policy change and advocating to other health professionals, patients, and community members to better their understanding of the positive economic value of pharmacist-provided care. Through prioritizing community outreach and legislator education, pharmacist advocates can leverage 3 key areas in which pharmacists have economic value to advance policy and increase patients’ access to care.
Article
Health disparities between rural and urban areas are widening at a time when urban health care systems are increasingly buying rural hospitals to gain market share. New payment models, shifting from fee-for-service to value-based care, are gaining traction, creating incentives for health care systems to manage the social risk factors that increase health care utilization and costs. Health system consolidation and value-based care are increasingly linking the success of urban health care systems to rural communities. Yet, despite the natural ecosystem rural communities provide for interprofessional learning and collaborative practice, many academic health centers (AHCs) have not invested in building team-based models of practice in rural areas. With responsibility for training the future health workforce and major investments in research infrastructure and educational capacity, AHCs are uniquely positioned to develop interprofessional practice and training opportunities in rural areas and evaluate the cost savings and quality outcomes associated with team-based care models. To accomplish this work, AHCs will need to develop academic-community partnerships that include networks of providers and practices, non-AHC educational organizations, and community-based agencies. In this commentary, the authors highlight 3 examples of academic-community partnerships that developed and implemented interprofessional practice and education models and were designed around specific patient populations with measurable outcomes: North Carolina's Asheville Project, the Boise Interprofessional Academic Patient Aligned Care (iAPACT) model, and the Interprofessional Care Access Network (I-CAN) framework. These innovative models demonstrate the importance of academic-community partnerships to build teams that address social needs, improve health outcomes, and lower costs. They also highlight the need for more rigorous reporting on the components of the academic-community partnerships involved, the different types of health workers deployed, and the design of the interprofessional training and practice models implemented.
Article
Objective: To determine how implementing a systematic medication therapy management (MTM) process impacted MTM completion rates. Methods: This process improvement pilot included 4 grocery store-based community pharmacy sites. Site staff were trained on a systematic process to integrate OutcomesMTM opportunities into pharmacy workflow. Technicians prepared MTM paperwork, including a standardized comprehensive medication review (CMR) worksheet, which pharmacists used to deliver the service at the counsel window. The primary outcome was the change in CMR completion rate from pre- to post implementation, with each site serving as its own control. Secondary outcomes were change in targeted intervention program (TIP) completion rate and survey results assessing barriers and feasibility. Results: The mean CMR completion rate improved from 2.7% ± 5.4% to 23.2% ± 7.7% ( P < .10). The mean TIP completion rate improved from 3.4% ± 4.2% to 24.9% ± 19.2% ( P < 0.10) pre- to post-implementation. Survey results indicated that pharmacists were satisfied with this; the most significant barriers were time spent contacting prescribers, documentation, and claim submission. Conclusion: Implementing this systematic approach to providing MTM into the pharmacy workflow may lead to an improvement in CMR completion rate. However, the sample size is small, and the results and process may not be generalizable to other sites.
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To review treatment prescribed to asthmatic children in Great Britain during the 12 months after publication of the first guidelines and to assess effectiveness of prophylactic treatment. Review of prescribing information from January 1990 to June 1991 in a representative sample of general practices in Great Britain with a Compufile/AAH Meditel computer. 17,846 children with asthma aged 4-17 years. Numbers of children prescribed different asthma treatments; estimated use of inhaled beta agonists in those receiving prophylactic treatment. From January to December 1990, 9,362 (52.5%) children were prescribed preventive treatments. 16,211 (90.8%) children were prescribed bronchodilators of some kind. 3,055 (17.1%) were prescribed sodium cromoglycate, and the proportion decreased significantly during the study (from 19.5% (95% confidence interval 18.6% to 20.4%) to 17.2% (16.4% to 18.1%), P < 0.001, in children aged 4-11 years and from 14.9% (14.0% to 15.9%) to 11.3% (10.4% to 12.2%), P < 0.001, in those aged 12-17 during January-July 1991). 6,952 (39.0%) were prescribed inhaled steroids, and the proportion increased during the study (from 35.1% (34.0% to 36.2%) to 44.1% (43.0% to 45.2%), P < 0.001, in children aged 4-11 years and from 38.7% (37.4% to 40.0%) to 44.1% (42.7% to 45.5%), P < 0.001, in those aged 12-17 during January-July 1991). Only 1,358 of the 9,362 children (14.5%) received sufficient repeat prescriptions to suggest that they might be taking the prophylactic treatment regularly. Among these children short acting inhaled beta agonists were being used on average four to eight times a day. These results are useful baseline data for audit of the impact of published clinical guidelines, particularly in terms of reducing the need for short acting inhaled beta agonists with prophylactic treatment.
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We hypothesized that a pharmacist-provided comprehensive education program in conjunction with care provided by a pulmonologist would lead to improved economic, clinical, and humanistic outcomes in adults with asthma, compared with similar patients receiving care from a pulmonologist alone. The experimental group reported receiving more information about asthma self-management (p=0.001), were more likely to monitor peak flow readings (p=0.004), and had increased satisfaction with care, and perceived higher quality of care. Both groups had less lost productivity, fewer emergency department visits, fewer hospitalizations, and fewer physician visits, as well as improvement in symptoms scores within 45 days. Both groups improved in all functional status domains except the mental component score of the SF-12. Our results show a positive impact on outcomes in adults with asthma who received pharmaceutical care.
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To assess factors associated with participation in pharmaceutical care and the benefits of participation--in terms of amount of information about medications, administration of medications, and awareness of side effects. Quasi-experimental design, with a control group. Medication Survey, administered 6 months after pharmaceutical care intervention to participants, refusers, and controls. Logistic regression analyses. Three staff clinic pharmacies and three contract clinic pharmacies affiliated with a health maintenance organization (HMO). Patients with chronic health conditions (asthma, chronic obstructive pulmonary disease, or heart disease) enrolled at six intervention sites, identified through the HMO's electronic pharmacy database. Control sample with the same chronic health conditions, without access to pharmaceutical care (n = 210 participants, 162 refusers, and 368 controls; overall adjusted response rate = 72%). Pharmaceutical care, in the form of a comprehensive drug therapy management program. Predictors of participation, amount of information about medications, use of reminder methods, and awareness of side effects. The following variables were significantly associated with the probability of participating in pharmaceutical care (P < .05): number of medications, employment, income, health status, education, and living situation. Participants were more likely than controls to say they received "a lot of information" from their pharmacist about all aspects of medications (odds ratio [OR], 1.75 to 2.68). Participants were more likely to report leaving their medication container in a visible place and using two or more reminder methods (OR, 1.87 to 1.48). There were no significant differences in the probability of missing doses. Participants were more likely to report experiencing "symptoms or problems" associated with prescription medications (OR, 1.81). Pharmaceutical care appears to increase the information given to patients about medications, promote more effective self-administration of medications by encouraging patients to use systematic reminders, and increase awareness of medication side effects.
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To assess short-term clinical, economic, and humanistic outcomes of pharmaceutical care services (PCS) for patients with diabetes in community pharmacies. Intention-to-treat, pre-post cohort-with-comparison group study. Twelve community pharmacies in Asheville, N.C. Eighty-five patients with diabetes who were employees, dependents, or retirees from two self-insured employers; community pharmacists who completed a diabetes certificate program and received reimbursement for PCS. Patients scheduled consultations with pharmacists over 7 to 9 months. Pharmacists provided education, self-monitored blood glucose (SMBG) meter training, clinical assessment, patient monitoring, follow-up, and referral. Group 1 patients began receiving PCS in March 1997, and group 2 patients began in March 1999. Change from baseline in the two employer groups in glycosylated hemoglobin (A1c) values, serum lipid concentrations, health-related quality of life (HRQOL), satisfaction with pharmacy services, and health care utilization and costs. Patients used SMBG meters at home, stored all readings, and brought their meters with them to 87% of the 317 PCS visits (3.7 visits per patient). Patients' A1c concentrations were significantly reduced, and their satisfaction with pharmacy services improved significantly. Patients experienced no change in HRQOL. From the payers' perspective, there was a significant dollars 52 per patient per month increase in diabetes costs for both groups, with PCS fees and diabetes prescriptions accounting for most of the increase. In contrast, both groups experienced a nonsignificant but economically important 29% decrease in nondiabetes costs and a 16% decrease in all-diagnosis costs. A clear temporal relationship was found between PCS and improved A1c, improved patient satisfaction with pharmacy services, and decreased all-diagnosis costs. Findings from this study demonstrate that pharmacists provided effective cognitive services and refute the idea that pharmacists must be certified diabetes educators to help patients with diabetes improve clinical outcomes.
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To determine whether a letter-based intervention program submitted to prescribers and pharmacists would improve drug therapy in users of high-dose beta(2)-agonists (HDBs). Retrospective drug utilization review. The intervention group consisted of 135 asthmatic patients (identified through ICD-9-CM codes) in the Connecticut Medicaid Program who submitted >1 claim per month for short-acting beta(2)-agonists (over a 6-mo period). Patient-specific intervention packets were mailed to the patients' prescribers and pharmacists, and their use of long-term control agents and healthcare utilization was evaluated over 6 months. These variables were compared with a comparison group (n = 510) of asthmatics drawn from the same Medicaid program who were not considered to be high-dose users of short-acting beta(2)-agonists at baseline. Prior to the intervention, the intervention group used fewer long-term asthma control agents as compared with the comparison group (58% vs. 96%; p < 0.001); there was no significant difference after the intervention program (65% vs. 71%; p = 0.169). The acquisition of spacers was greater in the intervention group than in the control group after the intervention (7% vs. 2%; p = 0.007). At the end of the 6-month intervention period, 46% of patients in the intervention group were no longer HDB users (p < 0.001). The higher frequency of prescriber office visits in the intervention group than the comparison group before the intervention (0.46 +/- 0.82 vs. 0.25 +/- 0.66; p < 0.001) was not evident after the intervention program (0.24 +/- 0.63 vs. 0.18 +/- 0.60; p = 0.283). This intervention program had modest impact on improving the use of long-term control agents and reducing prescriber office visits.
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No randomised studies have addressed whether self-management for asthma can be successfully delivered by community pharmacists. Most randomised trials of asthma self-management have recruited participants from secondary care; there is uncertainty regarding its effectiveness in primary care. A randomised controlled study was undertaken to determine whether a community pharmacist could improve asthma control using self-management advice for individuals recruited during attendance at a community pharmacy. Twenty four adults attending a community pharmacy in Tower Hamlets, east London for routine asthma medication were randomised into two groups: the intervention group received self-management advice from the pharmacist with weekly telephone follow up for 3 months and the control group received no input from the pharmacist. Participants self-completed the North of England asthma symptom scale at baseline and 3 months later. The groups were well matched at baseline for demographic characteristics and mean (SD) symptom scores (26.3 (4.8) and 27.8 (3.7) in the intervention and control groups, respectively). Symptom scores improved in the intervention group and marginally worsened in the control group to 20.3 (4.2) and 28.1 (3.5), respectively (p<0.001; difference adjusted for baseline scores=7.0 (95% CI 4.4 to 9.5). A self-management programme delivered by a community pharmacist can improve asthma control in individuals recruited at a community pharmacy. Further studies should attempt to confirm these findings using larger samples and a wider range of outcome measures.
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The prevalence and impact of adult asthma are substantial, and poor self-management practices, especially failures to adhere to treatment regimens, appear to be a significant problem. Desirable characteristics of an intervention program to improve self-management were identified through needs assessment and review of existing patient education resources. A comprehensive program was developed that integrated a workbook with one-to-one counseling and adherence-enhancing strategies. A longitudinal 1-year study compared patients receiving this self-management program with "usual care" patients receiving standard asthma pamphlets. Patients were randomly assigned to conditions. Baseline score and asthma severity were statistically controlled. Self-management patients had substantially better adherence than usual care patients, as well as improved functional status, at follow-up. Hospital and emergency department visits decreased in both groups but did not differ between groups.(Arch Intern Med. 1990;150:1664-1668)
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Background: Noncompliance with medications is one of the most serious problems facing health care today. However, methods to measure compliance have many limitations. Methods: To measure specific drug compliance and dosing frequency of two asthma medications, we used medical records data and pharmacy claims data from 276 patients who had concurrent prescriptions for inhaled anti-inflammatory agents and oral theophylline. Patients were randomly selected from the pharmacy claims data files of a health maintenance organization. The patients' medical records were reviewed, and records that did not contain clear documentation of the medication, dose, and dosing frequency were excluded. Data from the remaining 119 medical records were compared with data from pharmacy claims to calculate compliance rates for each medication. Results: Our calculations showed that patients were significantly more compliant with prescribed theophylline medication than with two inhaled anti-inflammatory medications (P=.0001). No significant differences in compliance were found relative to prescribed dosing frequency (twice daily or less compared with three times daily or more) for either medication (P=.6517). Conclusions: Comparison of medical record data with pharmacy claims data is an effective indirect measure of patients' compliance with prescribed oral theophylline and inhaled anti-inflammatory agents. Additional interventions must be pursued for patients with asthma regarding adherence to regimens for their prescribed inhaled anti-inflammatory agents.(Arch Intern Med. 1994;154:1349-1352)
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Many patients entering a long-term clinical study ate unable to remain active in the trial (taking medication as prescribed and attending clinic as scheduled) for up to 6 years. We studied a group of 622 patients entering an antiepileptic drug study with maximum possible follow-up period of 6 years. A centralized case validation system was used in this VA Epilepsy Cooperative Study to note problems in patients entering the study. The categories established for pre-entry case status were associated with events occurring during the course of the study that led to noncompletion of the study. The data were reviewed to determine whether pre-entry status can be used to suggest the likelihood that an individual patient will remain in the study to completion or become a non-drug-related loss. Over one-half of all losses were related to failure to return to clinic. Medical problems (18%), medication noncompliance (14%), and psychiatric problems (12%) accounted for the remainder of losses. Pre-entry issues often were the same reason for early loss. However, many patients with problems known at entry were maintained in the study when targeted for extra support, We found some groups of patients had considerably more early terminations whereas others had less loss to the trial than we predicted originally. Thus, case categorization at entry can be used to estimate the likelihood of early termination from a clinical trial.
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A multidisciplinary program for managing asthma in a pediatric population is discussed. A coordinated, multidisciplinary program for managing asthma in children was initiated in November 1997 at a U.S. Army medical center. The program, designed to improve care and decrease hospitalizations for asthma, was pharmacist managed and pulmonologist directed and was implemented by pediatricians. Patient education was provided by a pediatric clinical pharmacist or a nurse case manager; providers also received intensive education. Follow-up occurred at predetermined intervals and included asthma education, discussion of expectations and goals, analysis of metered-dose-inhaler and spacer technique, and assessment of compliance. Between November 1997 and January 1999, 210 inpatients were screened for asthma. One hundred seven were believed to have asthma and received inpatient asthma counseling and teaching. Of these 107 patients, 79 were enrolled in the program and monitored in the ambulatory care setting. Seventy-one (90%) of the 79 program enrollees were not rehospitalized during the ensuing two years. The number of children admitted to the hospital for asthma decreased from 147 in 1997 (a rate of 3.2 per 1000 population) to 93 in 1998 (2.1 per 1000) and to 87 in 1999 (1.9 per 1000). A multidisciplinary approach to the management of children with asthma may reduce hospitalizations of such patients.
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To improve asthma disease management, the National Asthma Education Program (NAEP) Expert Panel published Guidelines for the Diagnosis and Management of Asthma in 1991. To compare the current status of asthma disease management among patients in a large health maintenance organization with the NAEP guidelines and to identify the factors that may be associated with medical care (eg, emergency department visits and hospital admissions) and adherence to the guidelines. Analyses of 1996 survey data from 5580 members with asthma (age range, 14 to 65 years) covered by a major health maintenance organization in California (Health Net). In general, adherence to NAEP guidelines was poor. Seventy-two percent of respondents with severe asthma reported having a steroid inhaler, and of those, only 54% used it daily. Only 26% of respondents reported having a peak flowmeter, and of those, only 16% used it daily. Age (older), duration of asthma (longer), increasing current severity of disease, and treatment by an asthma specialist correlated with daily use of inhaled steroids. Ethnicity (African American and Hispanic) correlated negatively with inhaled steroid use but positively with emergency department visits and hospital admissions for asthma. Increasing age and treatment by an asthma specialist were also identified as common factors significantly related to the daily use of a peak flowmeter and, interestingly, to overuse of beta2-agonist metered-dose inhalers. Although the NAEP guidelines were published 7 years ago, compliance with the guidelines was low. It was especially poor for use of preventive medication and routine peak-flow measurement. Furthermore, the results showed that asthma specialists provided more thorough care than did primary care physicians in treating patients with asthma. Combining the results of the regression analyses revealed that some of the variation in rates of emergency department visits and hospitalizations among some subpopulations can be explained by the underuse of preventive medication. This study serves the goal of documenting the quality of care and services currently provided to patients with asthma through a large health maintenance organization and provides baseline information that can be used to design and assess effective population-based asthma disease management intervention programs.
Article
The prevalence and impact of adult asthma are substantial, and poor self-management practices, especially failures to adhere to treatment regimens, appear to be a significant problem. Desirable characteristics of an intervention program to improve self-management were identified through needs assessment and review of existing patient education resources. A comprehensive program was developed that integrated a workbook with one-to-one counseling and adherence-enhancing strategies. A longitudinal 1-year study compared patients receiving this self-management program with "usual care" patients receiving standard asthma pamphlets. Patients were randomly assigned to conditions. Baseline score and asthma severity were statistically controlled. Self-management patients had substantially better adherence than usual care patients, as well as improved functional status, at follow-up. Hospital and emergency department visits decreased in both groups but did not differ between groups.
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The parents of 128 children with asthma were interviewed about their knowledge of asthma medications. Simple understanding of the modes of action of these drugs was present in only 42.2% (for beta 2-agonists), 12.1% (methylxanthines), 11.7% (cromoglycate), 0% (inhaled corticosteroids), and 3.6% (oral corticosteroids) of parents. Simple understanding of when to use these drugs was present in 13.4% (beta 2-agonists), 4% (methylxanthines), 50% (cromoglycate), 47.1% (inhaled corticosteroids), and 0% (oral corticosteroids). Some understanding of the side effects was observed in 51.6% (beta 2-agonists), 40.4% (methylxanthines), 10% (cromoglycate), 5.9% (inhaled corticosteroids), and 25% (oral corticosteroids). Poor parental knowledge about the pharmacology of asthma was underlined by the inclusion of antibiotics, antihistamines, and decongestants as medications used in asthma. This study also uncovered the continuing misuse of compound methylxanthine preparations and non-selective sympathomimetics in a small percentage of patients.
Article
We investigated a cluster of five deaths of adolescents from asthma in St. Louis during a 3-month period in 1987. Although the cluster represented a statistically significant increase in the number of asthma deaths in this age group over that observed in previous years, no common exposure to environmental, infectious, or therapeutic agents could be identified. The patterns of hospital admissions for asthma and emergency room visits at the two pediatric hospitals in the community did not suggest an increase in the frequency or severity of asthma during this time. Despite the lack of evidence for common exposure, the decedents shared many personal and medical characteristics. All decedents were black patients and were of lower socioeconomic status. All were adolescents and were responsible for regulating their own medication schedules. Lack of appreciation of the severity of their asthma by medical personnel and the patients' families was evident. For example, two patients with severe asthma had not been prescribed inhaled corticosteroids. In addition, the four decedents tested had markedly subtherapeutic or zero serum theophylline levels measured at the time of the fatal episode, even though appropriate amounts of theophylline had been prescribed. Their theophylline levels were substantially lower than levels in patients of the same age observed at the emergency room or hospitalized for asthma during the same time period. Continued efforts to educate adolescent patients, their families, and medical care providers about the treatment of asthma are warranted.
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To determine whether the number of emergency department (ED) visits for acute asthma exacerbations could be decreased by providing patients with a comprehensive program of asthma management delivered by a pharmacist and a physician. Patients were selected from the ED and asked to attend a special asthma clinic that provided education about asthma and proper use of asthma medications, regular telephone contact between the pharmacist and patient, and an open-door clinic policy. A university-affiliated urban teaching hospital. The study population consisted of 25 asthmatic patients who were at least 18 years of age and who were seen in the ED a minimum of 3 times in a 12-month period. The number of visits to the ED for acute exacerbations of asthma was measured. Patients served as their own controls. The number of ED visits for asthma during the 6-month study period was compared with two 6-month periods prior to the study period for each patient. The total number of ED visits for the 25 enrolled patients six months prior to their enrollment into the study was 92; the number of ED visits during the same months of the study in the prior year was 47. During the study period, there were only 6 ED visits for asthma exacerbations. The comprehensive asthma management program reduced the number of ED visits for acute exacerbations of asthma.
Article
Noncompliance with medications is one of the most serious problems facing health care today. However, methods to measure compliance have many limitations. To measure specific drug compliance and dosing frequency of two asthma medications, we used medical records data and pharmacy claims data from 276 patients who had concurrent prescriptions for inhaled anti-inflammatory agents and oral theophylline. Patients were randomly selected from the pharmacy claims data files of a health maintenance organization. The patients' medical records were reviewed, and records that did not contain clear documentation of the medication, dose, and dosing frequency were excluded. Data from the remaining 119 medical records were compared with data from pharmacy claims to calculate compliance rates for each medication. Our calculations showed that patients were significantly more compliant with prescribed theophylline medication than with two inhaled anti-inflammatory medications (P = .0001). No significant differences in compliance were found relative to prescribed dosing frequency (twice daily or less compared with three times daily or more) for either medication (P = .6517). Comparison of medical record data with pharmacy claims data is an effective indirect measure of patients' compliance with prescribed oral theophylline and inhaled anti-inflammatory agents. Additional interventions must be pursued for patients with asthma regarding adherence to regimens for their prescribed inhaled anti-inflammatory agents.
Article
Poor adherence to recommended regimens is a substantial problem in the clinical management of adults with asthma and other chronic diseases. Research on adherence assessment is complicated by methodological difficulties including limitations associated with the use of self-report measures. In this study, psychometric techniques were used to analyze two self-report scales for assessing adherence to recommended medication and inhaler use regimens in adults with asthma. Results indicated that the two scales had standard deviations large enough to detect variation adherence, had adequate reliability, and reflected the impact of an intervention designed to improve adherence. The results supported the usefulness of these scales for research on adherence. Additional analyses indicated that the two scales could be combined if the research goal required an overall measure of adherence.
Article
The failure of patients to adhere to physician-prescribed regimens, either pharmacologic or behavioral, has been well documented in medical literature. Poor adherence to asthma medication regimens has been repeatedly demonstrated in both children and adults, with rates of nonadherence commonly reported from 30 to 70%. Medication regimens for asthma care are particularly vulnerable to adherence problems because of their duration, the use of multiple medications, and the periods of symptom remission. The clinical effects of this nonadherence by asthmatic patients can include treatment failure, unnecessary and dangerous intensification of therapy, and costly diagnostic procedures, complications, and hospitalizations. Although the measurement of adherence is an important component of both medical and behavioral interventions to control asthma, relatively little research has directly addressed the reliability and validity of the measures most widely used to assess asthma medication compliance. This review will discuss methods and issues in the measurement of adherence in general, and where available, measures that have been specifically used in evaluating adherence to asthma medication. Common measures used to assess compliance with asthma medications include direct measures, which confirm the use of medication by assaying it in blood, urine, or saliva, or which confirm the to use a medication, such as observed skill in using a metered dose inhaler. Indirect measures infer use with varying degrees of reliability, by use of clinical judgment, self-report/asthma diaries, medication measurement, and electronic medication monitors. The uses and limitations of these measures will be discussed.
Article
This study evaluated the economic impact of patient-focused pharmacist intervention in the community retail setting in patients with hypertension, diabetes, asthma, and/or hypercholesterolemia. Specially trained pharmacists intervened by providing targeted patient education, performing systematic patient monitoring, offering feedback and behavior modification, and communicating regularly with patients' physicians to enable early intervention for drug-related problems. We evaluated prescription drug costs and total medical costs by comparing claims data from 188 patients enrolled in the program at three intervention pharmacies with data from 401 control patients at five nonparticipating pharmacies from the same retail chain. For all disease states, the average cost per prescription was significantly higher in the group receiving intervention than in the control group. Differences in total monthly prescription costs were significant only for patients with asthma, with higher monthly costs in the group receiving intervention. Substantial savings were demonstrated across all cost analyses for total monthly medical costs. Savings ranged from a conservative estimate of $143.95 per patient per month to $293.39 per patient per month when accounting for the possible influence of age, comorbid conditions, and disease severity. Our data indicate that pharmacist intervention in this community pharmacy-based disease management model substantially reduced monthly health care costs in patients with hypertension, hypercholesterolemia, diabetes, and asthma.
Article
The costs and benefits of a planned patient education programme for patients with asthma were evaluated in a controlled trial. The patient education group received a planned patient education programme, performed by a physician, a pharmacist and a nurse over a 6-month period. Changes in the use of resources, productive output and in health status were measured for the patient education group and the control group. The total cost for planning, implementation and evaluation of the programme was £14 074. The patient education group increased its contacts to general practitioners and the extra costs totalled £252. The increased costs of drugs used by the patient education group in the 6-month period was £2313 compared with costs in the control group. The number of days lost through sickness decreased in the patient education group, corresponding to a £4528 saving of otherwise lost earnings. The quality of life increased in the patient education group by 3.2 points on the Psychosomatic Discomfort Scale (2.9%). Health status increased by 38.9%. The study shows that the patient education programme has a positive clinical effect on the patient’s quality of life and health status. The economic consequences of the implementation programme depend on the specific setup of the local healthcare system, where the programme is applied.
Article
To determine whether patients targeted to receive intervention from an asthma management program reported receiving more services and had greater perceived benefit and satisfaction with those services compared with asthma patients not targeted by the program. Mailed survey. Community pharmacy. 471 community-based patients receiving asthma medications from 44 intervention pharmacies and 1,164 patients from 46 usual care (control) pharmacies. Five-point agreement scale measuring asthma services received, perceived value of the services, and satisfaction. Usable surveys were received from 39.0% of intervention patients and 42.4% of controls. There were no statistically significant differences between groups in the frequency of provision of listed services. Approximately 60% of respondents from both groups received written materials on asthma medications and 54% received inhaler counseling; both were rated high for perceived benefit. Fewer than 20% reported being counseled about asthma triggers. Fewer than 5% reported pharmacists talking to physicians on their behalf. General satisfaction with pharmacy services was high (78.2% agree or strongly agree), but not statistically different between groups. More than 65% believed that pharmacists spend enough time counseling patients. Several comments indicated that patients did not expect or ask for information because they were unaware that services were available and/or they had already been counseled by their physician. Responses to the statement "my asthma is better controlled because of help given to me by the pharmacist" were equivocal and not different between groups. Overall, there were few differences between groups. General satisfaction with pharmacy services is high, but patients' perceived benefit and satisfaction with cognitive services is lower. Increased public awareness of pharmacists' capabilities and a more proactive approach to providing cognitive services is needed.
Article
This study aimed to establish whether the outpatient management of patients presenting with an asthma exacerbation to the emergency department (ED) was in compliance with the 1992 guidelines of the "International Consensus Report on the Diagnosis and Management of Asthma." Prospective, observational study using a researcher-administered questionnaire. University tertiary referral ED. Convenience sample of asthmatics (aged 18 to 54 years) presenting for asthma treatment between July 1, 1997, and June 30, 1998. Eighty-five asthmatic patients were enrolled. Of these, 34 patients (40%) smoked, 53 patients (62%) were undertreated with medication when compared to the consensus guidelines, and 74 patients (87%) had no written "plan of action." During an asthma attack, 9 patients (11%) did not use a bronchodilator as first-line action and 76 patients (89%) did not commence or increase the use of an inhaled steroid. Forty-nine patients (58%) did not know that bronchospasm occurred in asthma, and 53 patients (62%) did not know that bronchial swelling occurred. Twenty-six patients (31%) thought short-acting bronchodilator drugs were asthma preventers. Sixty-two patients (73%) could not adequately define peak expiratory flow (PF), 41 patients (48%) did not own a PF meter, and only 8 patients (9%) determined their PF daily. Fifty-three patients (62%) were reviewed by a physician once a year or less, and 18 patients (21%) noted family and friends as their only source of asthma education. The outpatient management of most asthma patients presenting to the ED did not comply with the consensus guidelines, and asthma knowledge was poor.
Article
The cost-effectiveness of a community pharmacy based programme for therapeutic outcomes monitoring of asthma patients' drug therapy is evaluated. Five hundred asthma patients, aged 16-60 and treated in primary care, with moderate to severe asthma, 31 community pharmacies and 139 general practitioners participated in the study. The total programme costs, costs of drugs, health care resource costs and indirect costs were evaluated together with the effects of the programme on: asthma symptoms status, days of sickness, quality of life, satisfaction with health care, peak-flow (PEF), inhalation technique and knowledge. The evaluation of the programme shows it to be cost-effective with cost-effectiveness ratios between 0.18 and 0.56. The pay off time for the programme is 23 months (range 9-64 months in the sensitivity analysis). It is concluded that the community pharmacist can contribute to identify and solve drug-related problems in a cost-effective way with positive impact on asthma patients health, clinical and psycho-social outcomes, even though the program is time consuming and intensive.