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To address the Quintuple Aim of health care improvement, the profession of pharmacy is on the verge of a practice transformation that incorporates continuous learning from medication-related data into existing clinical and dispensing roles. The pharmacists’ patient care process (PPCP) enables a learning pharmacy practice through the systematic and standardized collection of real-world medication-related data from pharmacists’ patient care activities. A learning pharmacy practice continually generates data-powered discoveries as a byproduct of PPCP interactions. In turn, these discoveries improve our medication knowledge while upgrading our predictive powers, thus helping all people achieve optimal health outcomes. Establishing a practice management system connected to the PPCP means that data are generated from every PPCP interaction, combined with existing data, and analyzed by teams of pharmacists and data scientists. The resulting new knowledge is then incorporated into all future PPCP interactions in the form of predictions coupled to actionable advice. The primary purpose of a learning pharmacy practice is to combine the power of predictive modeling with evidence-based best practices to achieve and sustain population-level health improvements. This purpose is achieved by systematically optimizing individual medication use in an equitable manner on a global scale.

To describe the national delivery of medication therapy management (MTM) to Medicare beneficiaries in 2013 and 2014.Descriptive cross-sectional study using the 100% sample of 2013 and 2014 Part D MTM data files. We quantified descriptive statistics (counts and percentages, in addition to means and standard deviations) to summarize the delivery of these services and compare delivery between 2013 and 2014.Medicare beneficiaries eligible for MTM increased from 4,281,733 in 2013 to 4,552,547 in 2014. Among eligible beneficiaries, the number and percentage who were offered a comprehensive medication review (CMR) increased from 3,473,004 (81.1%) to 4,394,822 (96.5%), and beneficiaries receiving a CMR increased from 526,203 (12.3%) to 767,286 (16.9%). In 2014, CMRs were most frequently delivered by telephone (83.2%) and provided by either a plan sponsor (29.0%) or an MTM vendor in-house pharmacist (35.0%). In 2014, pharmacists provided 93.5% of all CMRs, and other providers (e.g., nurses and physicians) provided 6.5% of CMRs. Few patients who received a CMR received more than 1 within the same year (2.2% in 2014). Medication therapy problem (MTP) resolution among patients receiving a CMR stayed roughly the same between 2013 and 2014 (19.2% vs. 18.7%, respectively; P0.001). Finally, most beneficiaries (96.9% in 2014) received a targeted medication review, regardless of whether a CMR was offered or provided.More than 4 million Medicare beneficiaries were enrolled in Part D MTM in both 2013 and 2014. However, less than 20% of eligible beneficiaries received a CMR during those years, and rates of MTP resolution were low. Future evaluation of Part D MTM delivery should examine changes in eligibility criteria and delivery over time to inform MTM policy and changes in practice.

Objectives To propose a metric evaluating the quality of comprehensive medication reviews (CMRs), and to discuss the optimal setting for CMR delivery. Summary First, we provide a current assessment of the quality of CMRs performed in community, payer, and health system/clinic settings, with recommended opportunities for improvement. Thereafter, a companion metric for CMR quality is discussed, because this is critical to ensuring that patients are not just receiving CMR services, but that CMRs reflect evidence-based recommendations supporting optimal patient outcomes. Conclusion Based on the data currently available, accessibility to electronic medical records would enhance patient-specific recommendations to optimize CMR delivery and patient outcomes. Future studies may help to identify additional factors, such as pharmacist-physician collaboration in clinic and use of evidence-based recommendations, that can further enhance CMR quality.

Improvements in chronic myeloid leukemia (CML), chronic lymphocytic leukemia (CLL), and multiple myeloma (MM) treatment options have increased the 5-year survival rates for patients with these hematologic malignancies. In addition to cancer management, these patients may need help to manage multiple chronic conditions (MCC). The overall objective of this study is to examine the impact and implementation of a model that coordinates care between oncology and primary care pharmacists for people taking an oral anti-cancer agent (OAAs) and medications for comorbid chronic conditions. This is a multi-center, prospective, single-arm pilot study that will recruit up to 40 patients from Michigan Medicine and Vanderbilt University Medical Center (VUMC). Eligible participants will be 18 years of age or older, prescribed an OAA, have a diagnosis of either CML, CLL or MM, and be diagnosed with and taking medication for at least two specified chronic conditions. The Pharmacists Coordinated Care Oncology Model (PCOM) is a two-month intervention that builds upon current pharmacist clinical responsibilities. Generally, participants will complete a patient-reported outcome measure at 2 and 6 weeks post-OAA initiation that is sent to their oncology pharmacist, and they will also receive a comprehensive medication review at week 4 from a primary care pharmacist for their chronic medications. The pharmacists will communicate about the results via electronic medical record (EMR) and intervene if necessary. The primary endpoints are (1) dose-adjusted OAA proportion of days covered (PDC), and (2) PDC for chronic condition medications. PDCs will be determined via prescription records. The association of OAA and chronic medication PDCs will be quantified via correlation and chi-squared tests. The association between symptom experience and OAA adherence will be examined via correlation analyses. For implementation, characteristics of patient participants, feasibility, acceptability, adoption, fidelity, and trialability will be described. Data will be collected via EMR and pharmacist and patient interviews. Median/IQR for acceptability, adoption and fidelity will be reported, and patient interviews will be analyzed using a grounded theory approach and pharmacist interviews will be analyzed using thematic analyses.

Background Text messages can improve medication adherence and outcomes in several conditions. For this study, experts developed text messages addressing determinants of medication adherence: disease beliefs, medication necessity, medication concerns, and forgetfulness, as well as positive reinforcement messages for patients who were adherent. Objectives To validate expert-developed text messages to address medication non-adherence with a group of non-researchers. Methods A two-wave, card-sorting activity was conducted with students and staff at the University of Michigan. In the first wave, 40 participants grouped 32 messages addressing barriers for medication adherence (disease beliefs, medication necessity, medication concerns, and forgetfulness) according to their perceived relationship. Messages with poor grouping agreement were deleted or modified. In the second wave, positive reinforcement messages were developed and tested along with the previous categories (36 messages) by 37 participants. Similarity and cluster analyses were used to assess agreement between experts and participants. Results In the first card-sorting wave, participants grouped messages into between 2 and 13 separate categories. Similarity analysis showed four groupings of messages, however, some had an agreement below 50% and clusters appeared dispersed. In the second wave, and after messages being edited, participants grouped the messages into between 4 and 9 categories. Five groups (now including positive reinforcement messages) were identified with higher agreement in the similarity and cluster analyses. Conclusions The structure of expert-developed text messages to address medication adherence key barriers was confirmed. Messages will be used in future research to determine their impact on affecting medication adherence to anti-hypertensive medications using a reinforcement learning controlled text messaging service.

Purpose To assess longer-term patterns of glaucoma medication adherence and identify whether patterns established during the first year of medication use persist during 3 subsequent years of follow-up. Design Retrospective, longitudinal cohort analysis. Participants Beneficiaries aged ≥40 years who were enrolled in a United States (US)-managed care plan for ≥7 years between 2001 and 2012 and newly diagnosed and treated for open-angle glaucoma. Methods For each enrollee, we quantified medication adherence using the medication possession ratio. Group-based trajectory modeling (GBTM) was applied to identify patterns of adherence for 1 and 4 years of follow-up. The percent of beneficiaries who remained in the same trajectory group in the 1- and 4-year models was tabulated to evaluate group stability. Factors impacting adherence at 1 and 4 years were identified using regression analyses. Main Outcome Measures Patterns of glaucoma medication adherence. Results Of the 1234 eligible beneficiaries, GBTM identified 5 distinct glaucoma medication adherence patterns in both the 1-year and 4-year follow-up periods. These groups were as follows: (1) never adherent after their index prescription fill (7.5% and 15.6% of persons in the 1- and 4-year models, respectively); (2) persistently very poor adherence (14.9% and 23.4% of persons in the 1- and 4-year models, respectively); (3) declining adherence (9.5% and 9.1% of persons in the 1- and 4-year models, respectively); (4) persistently moderate adherence (48.1% and 37.0% of persons in the 1- and 4-year models, respectively); and (5) persistently good adherence (20.0% and 15.0% of persons in the 1- and 4-year models, respectively). More than 90% of beneficiaries in the 4 groups with the worst and best adherence patterns (groups 1, 2, 3, 5) maintained their patterns from their first year throughout their 4 years of follow-up. Those with persistently moderate adherence (group 4), the largest group, were most likely to change groups from 1 to 4 years of follow-up. Persons with the best adherence over 4 years were more likely to be white, to be older, to earn >$60 000/year, and to have more eye care visits ( P P = 0.03). Conclusions For most patients who were newly prescribed glaucoma medications, adherence patterns observed in the first year of treatment reflect adherence patterns over the subsequent 3 years. Investing resources in both identifying and helping patients with suboptimal adherence patterns over the first year may have a large impact on longer-term adherence.

Purpose To evaluate the frequency of 11 commonly cited barriers to optimal glaucoma medication adherence among glaucoma patients and to identify barriers contributing to poor adherence. Design Prospective, cross-sectional survey. Participants One hundred ninety adults with glaucoma taking 1 or more glaucoma medication who received care in glaucoma clinics in Ann Arbor, Michigan, and Baltimore, Maryland. Methods Participants completed a survey on demographic and disease characteristics, barriers to optimal glaucoma medication adherence, interest in an eye drop aid, and self-reported adherence (measured by the Morisky Adherence Scale). Descriptive statistics and logistic regression analyses were performed. Main Outcome Measures Frequency and number of barriers to adherence among both adherent and nonadherent patients. Odds ratios (ORs) with 95% confidence intervals (CIs) identifying barriers associated with poor adherence. Results Twenty-seven percent of the sample reported poor adherence. Sixty-one percent of all participants cited multiple barriers and 10% cited a single barrier as impediments to optimal adherence. Twenty-nine percent of subjects cited no barriers, although only 13% of patients who cited no barriers were nonadherent. Among nonadherent patients, 31% or more cited each of the 11 barriers as important. Logistic regression analysis, adjusted for age, revealed that the following barriers were associated with higher odds of nonadherence: decreased self-efficacy (OR, 4.7; 95% CI, 2.2–9.7; P ≤ 0.0001), difficulty instilling drops (OR, 2.3; 95% CI, 1.1–4.9; P = 0.03), forgetfulness (OR, 5.6; 95% CI, 2.6–12.1; P ≤ 0.0001), and difficulties with the medication schedule (OR, 2.9; 95% CI, 1.4–6.0; P = 0.006). For each additional barrier cited as important, there was a 10% increased odds of being nonadherent (OR, 1.1; 95% CI, 1.0–1.2; P = 0.01). Conclusions Each of the 11 barriers was important to at least 30% of surveyed patients with poor adherence, with most identifying multiple barriers to adherence. Low self-efficacy, forgetfulness, and difficulty with drop administration and the medication schedule were barriers associated with poor adherence. Interventions to improve medication adherence must address each patient's unique set of barriers.

The type 2 diabetes epidemic is a global health issue, and it is especially severe in the US Pacific. Although there are nutrition interventions in Hawaii and the Pacific, success is limited, in part, because of the lack of tailoring for the Pacific context. The Pacific context is inclusive of environment, political, and economic situation; historical (precontact, colonial, and post colonial) background; cultural practices; and spiritual orientation. This study used Grounded Theory and Community-Based Participatory Research processes to identify influences that hinder or facilitate adherence to nutrition recommendations. Data were gathered through key informant interviews (faith leaders and health care providers) and focus-group discussions (individual with diabetes and care takers). Results showed barriers to nutrition recommendations adherence that were similar to other minority populations in the United States, such as cost of healthy foods, taste preference, low availability of healthy food choices, lack of ideas for healthy meals/cooking, and lack of culturally appropriate options for dietary modification. It also elucidated behaviors that influence adherence to nutrition recommendations, such as preparing and consuming meals for and with extended family and church members; patient and group motivation; and access to healthy, affordable, and palatable foods. Participants expressed the need for interventions that are tailored to the local culture and context and a holistic view of health, with a focus on motivation (spiritual and emotional support). These findings could be used to develop culturally and contextually appropriate programs. For example, adapting motivational interviewing techniques and materials by adding family members to motivational interviewing sessions vs patients only, as Pacific Islanders have a collectivistic culture and family members play an important role in adherence; conducting motivational interviewing in the community in addition to the clinical setting; utilizing church leaders as motivational interviewing counselors in addition to health care providers; and changing motivational interviewing narratives and tools (eg, a confidence scale of 1 to 10 will be unfamiliar to many Pacific Islanders); therefore, counselors need to develop another method to indicate levels of confidence, such as the color of the lagoon/ocean that goes from turquoise (the color of shallow water) to navy blue (the color of deep water).

Introduction Heart failure (HF) is the most common hospital discharge diagnosis among older adults. As a result, the management of HF is moving toward a proactive real-time technological model of assisting patients with monitoring and self-management. Hypothesis Our hypothesis was that a patient-centered mobile application, ManageHF, would reduce Minnesota Living with Heart Failure Questionnaire (MLHFQ) at 6 and 12 weeks post-hospital discharge compared to usual care. Methods A single-center randomized controlled trial was performed. Patients were included if they were greater than 45 years of age, had a left ventricular ejection fraction (LVEF) 40% (with LA size >40 mm or BNP > 200 pg/ml or NT-proBNP > 800 pg/ml) and were currently admitted or recently discharged for acute on chronic decompensated HF. Patients were excluded for any of the following: unstable coronary syndromes within 8 weeks, primary valvular heart disease, constrictive pericardial disease, uncorrected thyroid disease, dialysis or creatinine >4.0 mg/dL, a hospice candidate, active cancer, pulmonary fibrosis, discharged to a setting other than home, or required a chronic inotrope. The intervention group used a mobile application, ManageHF, along with a Fitbit wearable and scale. The mobile application prompted active self-monitoring and provided a health status indicator to promote self-management. The control group received usual care. The primary outcome was the change in MLHFQ from baseline to 6 and 12 weeks using mixed models. Secondary outcomes were the Self-Care Heart Failure Index (SCHFI) questionnaire and HF admissions. Results Eighty-two patients were enrolled and completed all baseline assessments. Baseline characteristics were similar between groups with the exception of HF type. The intervention group had a reduced MLHFQ at 6 weeks (p=0.026) but not at 12 weeks (p=0.61) compared to control (Figure). There was no effect of the intervention on the SCHFI or any of its subcomponents at 6 or 12 weeks. The time to first HF admission was not statistically different between the two groups (HR 0.85, 95% CI 0.36-2.0, p=0.71). Median number of days the intervention group performed self-monitoring was 63 days. Conclusion ManageHF improved MLHFQ at 6 weeks, but did not sustain its effects at 12 weeks. No effect was seen on self-care measured by SCHFI. Further research is needed to enhance engagement in the app for a longer period of time and to determine if the app can reduce HF admissions in a larger study.

Objective To develop and conduct an initial field test of the Drug Adherence Work-up (DRAW) tool, which was developed to guide pharmacists when addressing nonadherence during medication therapy management (MTM) visits. Methods The field test was a prospective cohort study, in which seven trained pharmacists used DRAW to evaluate patients by asking about possible reasons for nonadherence during an MTM visit. Pharmacists were notified of potentially nonadherent patients identified through drug claims data analyzed by Outcomes Pharmaceutical Health Care. The pharmacists reported on use of DRAW in an MTM claim and provided opinions about DRAW via an online survey. Results According to the online survey, pharmacists reported that DRAW helped them to improve the focus of their MTM services and address more adherence problems than their usual approach. They thought the tool was easy to use and well organized. Some commented that DRAW could be a useful tool for teaching pharmacists. The most common reasons reported for nonadherence were the presence of adverse effects (59.1%) or forgetting to take the medication (54.5%). More than three-fourths of patients (77.3%) indicated more than one reason for nonadherence. Conclusion A brief, comprehensive tool to evaluate medication nonadherence, such as DRAW, may help pharmacists address various reasons for medication nonadherence. Often nonadherence is multifaceted, which makes an inclusive tool like DRAW a useful approach; however further research is needed.

Objective To describe the relationship between the availability and accessibility of contraceptives in Iowa pharmacies and the extent to which pharmacists act as an information source regarding contraceptives. Design Descriptive, exploratory, nonexperimental study. Setting Iowa in fall 2008. Participants 282 pharmacists at Iowa community pharmacies. Intervention Cross-sectional survey. Main outcome measures Contraceptive availability score, contraceptive accessibility score, and total access score. Regression analyses tested the relationships between the pharmacist information source score and the contraceptive availability, accessibility, and total access scores, controlling for geography, ownership, staff size, and average number of prescriptions per day. Results Significant positive relationships between the pharmacist information source score and product accessibility, product availability, and total access were observed. The relationship appeared to be driven primarily by product availability, and all were significantly influenced by pharmacy type. Significant negative relationships were found between product accessibility and independent/small chain pharmacies and mass merchandiser/grocery store pharmacies relative to large chain pharmacies. A significant negative relationship was found between independent/small chain pharmacies and the product availability score. Conclusion Significant relationships were found between pharmacists' ability to act as sources of information for contraceptive products and the availability, accessibility, and overall access to contraceptives in the pharmacy.

Objective To quantify and compare the determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications using a theoretical approach. Methods Study design was online cross sectional survey. A conceptual framework was developed using Andersen's Behavioral Model and Leventhal's Common Sense Model to understand the determinants of medication non-adherence. Regression analyses were used to test the models for predicting non-adherence. Results The models based on Andersen's Behavioral Model and Leventhal's Common Sense Model were significant. While predisposing factors such as treatment convenience and beliefs in medications were significant in cholesterol lowering medications, need factors such as illness perceptions and disease severity were significant in asthma maintenance medications. Among the enabling factors, self efficacy was a significant predictor in both cholesterol lowering and asthma maintenance medications. Conclusion Different determinants explained different types of non-adherence and suggest the need to consider different types of non-adherence for different medications as well as different determinants for each type of non-adherence. Practice implications Identifying determinants of different types of non-adherence can help health care professionals develop targeted interventions which can be more successful than the current model of single and generalized interventions to reduce non-adherence.

Objectives To examine how prescription drug access and use of prescription cost-saving measures changed after Medicare Part D was implemented and to determine their predictors in Medicare beneficiaries with different insurance types. Design Repeated cross-sectional study. Setting United States in 2005 and 2007. Patients Medicare beneficiaries aged 65 years or older (n = 1,220 in 2005 and n = 1,024 in 2007). Intervention Web-based surveys using nonprobability samples. Main outcome measures Access to prescription drugs and use of seven cost-saving measures. Results Significantly fewer participants stopped taking a prescription because of cost, applied to an assistance program, received free prescription samples, and had limited prescription access in 2007 compared with 2005. Use of cost-saving measures by Medicare Part D patients was more comparable with that by uninsured participants than patients with employer-based drug coverage. One-third of all participants and almost one-half of Medicare Part D participants had requested a less expensive prescription. Among those participants, 70% received a less expensive prescription and most thought it worked about the same as the more expensive prescription. Conclusion Prescription drug access and use of cost-saving measures improved somewhat following the implementation of Medicare Part D, but some access problems continued to exist for Part D participants. Requests for less expensive prescriptions were common and frequently resulted in satisfactory switches.

Background The process by which symptoms are identified and characterized is related to adverse drug event reporting. Patient and pharmacist symptom attribution may differ and be related to certain patient characteristics. Objectives (1) To compare attribution of symptoms to a cause for patients and pharmacists; (2) to quantify the association between patients' concern beliefs and patient-pharmacist agreement on patients' symptom attribution to medications; and (3) to identify any associations between patients' propensity to agree with pharmacists' assessments of symptom attribution with various clinical and/or sociodemographic characteristics. Methods An Internet survey of Medicare beneficiaries was administered by Harris Interactive ® . The survey elicited information on health symptoms that subjects experienced and to whom they reported these symptoms. If subjects did not experience symptoms and did not report them, the reasons for not reporting were elicited. A clinical expert panel reported ratings about respondents' (1) likelihood of the symptom experienced being attributed to a medication and (2) probability of the symptom being attributed to the reason the patient stated. Frequencies of unreported symptoms for each reason/category were examined. Chi-square and Fisher's exact test analyses examined the variations between patients' and pharmacists' ratings of symptom attribution to medications and associations between attribution and patient sociodemographic and clinical characteristics, such as the number of medications used. Independent sample t tests examined how attributions were related to concern beliefs. Results Most patients thought their symptom(s) were the result of their disease, something other than medications or age. There was no statistically significant difference between patients' and pharmacists' symptom attribution ( χ 2 = 1.376, P = .24). Individuals whose symptom attributions differed from pharmacists were likely to have stronger concern beliefs in medication ( t = −3.03, P Conclusions Patients' concern about their medications may be related to their symptom attributions. Older adults may not consider these concerns when asked about their symptom attributions.

Background: Adverse drug events (ADEs), which can be especially problematic in older adults, often can be prevented by detecting potential risk factors. Sociopsychological factors such as concerns and beliefs about medicines (patients' anxieties about the harmful effects of prescribed medications) may also be risk factors related to self-reported ADEs, even when considering clinical variables such as receiving an inappropriate medication. Objectives: This study was designed to quantify the use of inappropriate medications among older adult outpatients and to determine whether an association exists between the use of inappropriate medications, concerns and beliefs about medicines, and self-reported ADEs. Methods: This cross-sectional, Internet-based survey of Medicare beneficiaries was conducted in 2007. Harris Interactive®, a New York-based marketing research firm, invited participants from their online panel who were ≥65 years of age, residents of the United States, and enrolled in the Medicare health plan to participate in the survey. The updated Beers criteria and a modified version of the Assessing Care of Vulnerable Elders quality indicators were used to determine the appropriateness of medications. Respondents' concerns about their medicines were assessed using items from a validated scale such as “Having to take medicines worries me” and “I sometimes worry about the long-term effects of my medicines.” To establish self-reported ADEs, respondents were asked, “Did you see a doctor about any side effects, unwanted reactions, or other problems from medicines you were taking in the past year?” Results: Of the 1024 panelists who responded to the survey, 874 provided all of the information required for analysis. The respondents who were included in the analyses ranged in age from 65 to 94 years; 56.6% were female, 94.4% were white, and 20.3% self-reported an ADE. The frequency of patients receiving either an inappropriate medication or a medication that failed a quality indicator was 45.8%. Stronger concerns and beliefs about medicines (odds ratio [OR] = 1.57; 95% CI, 1.02–2.39; P = 0.04) and having more symptoms (OR = 2.26; 95% CI, 1.22–4.22; P = 0.01) were significantly related to self-reporting of ADEs, whereas receiving an inappropriate medication (OR = 1.03; 95% CI, 0.65–1.64) and the number of medications received (OR = 1.28; 95% CI, 0.52–3.13) were not. Conclusions: Stronger concerns and beliefs about medicines and having more symptoms were significantly related to self-reporting of ADEs. Receiving an inappropriate medication and the number of medicines received were not significantly related.

Background In the Theory of Planned Behavior, perceived behavioral control (PBC) has been directly measured in 3 different ways, ie, perceived difficulty, self-efficacy, and controllability. To better assess PBC, it is important to examine the relationship among these concepts. Objective This study explored the relationship of perceived difficulty and self-efficacy in the factor structure of PBC, and examined the impact of controllability on this relationship. The study context was osteoarthritis patients' drug information seeking from physicians and pharmacists for advertised antiarthritic prescription medications. Methods One thousand patients were randomly selected from 3000 nationwide osteoarthritis patients. A self-administered survey collected perceived difficulty (3 items), self-efficacy (3 items), and controllability (2 items) of drug information seeking from physicians and pharmacists. Exploratory factor analyses using principal axis factoring with oblique rotation were conducted for each information source for perceived difficulty and self-efficacy items by (1) the Kaiser criterion and the scree plots, and (2) extracting 2 factors. The 2-factor factor loadings were examined by the extent of controllability. For each information source, 2-factor principal factor analyses were performed for those who reported high control over the behavior and those who reported low control. Results The response rate was 61.9%. Perceived difficulty and self-efficacy loaded on the same factor when the Kaiser criterion and the scree plots were used. They loaded on separate factors when forced into the 2-factor structure. The 2-factor structure for the group with low control had more cross loadings than the 2-factor solution for the group reporting high control of information search. Conclusions Perceived difficulty and self-efficacy may represent 2 dimensions of an overall concept. Controllability impacts whether perceived difficulty and self-efficacy overlap or diverge, with higher controllability associated with distinct dimensions.

Objective To evaluate the expectations, experiences, and satisfaction with the Iowa Priority Prescription Savings (IPPS) program. Design Longitudinal descriptive study. Setting Iowa. Participants Randomly selected Iowa Medicare beneficiaries who selfenrolled in the IPPS prescription discount card program. Interventions Three self-administered surveys mailed in November 2002, June 2003, and September 2004, during the first, second, and third years of IPPS operation. Main Outcome Measures Expectations of drug discounts, amount of discounts received, awareness of the IPPS preferred drug list (PDL), and satisfaction with the program. Results Usable response rates for the three surveys were 43.5%, 31.0%, and 38.4%. About one fourth of members initially expected discounts of more than 20% on their prescription medications. After IPPS was implemented, many members were unaware of the discounts they were receiving, but the percentage of members reporting discounts of more than $20 per month increased from 7.4% in year 1 to 16.4% in year 3. More than one half of the members were unaware of which drugs were on the PDL in years 1 and 2, but this improved to 21% unawareness in year 3. Satisfaction with the program was low but improved over time. Members who received discounts, did not expect large discounts, or received a medication review were more satisfied with the program. Conclusion Some IPPS members had unrealistic expectations about the amount of discounts they would receive, and expectations of large discounts decreased satisfaction. Satisfaction and amount of discounts improved over time, and beneficiaries whose medications were reviewed, usually by a pharmacist, were more satisfied with the program. PDL awareness was a problem despite substantial educational efforts by IPPS, a finding that has implications for the recently implemented Medicare Part D drug benefit.

Objective To assess the cross-sectional construct validity of the Health Utilities Index mark 3 (HUI3) in type 2 diabetes using population health survey data. Study Design and Setting Data used were from 5,134 adult respondents of Cycle 1.1 (2000–2001) of the Canadian Community Health Survey (CCHS) with type 2 diabetes. Analyses of covariance models were used to assess differences in overall and single-attribute HUI3 scores between groups hypothesized a priori to differ in HRQL. The association between health-care resource use (i.e., hospitalizations and physician and emergency room visits) and overall HUI3 scores was assessed using logistic regression models. Results For overall HUI3 scores, clinically important and statistically significant differences were observed between all groups expected to differ in HRQL. Depression was the comorbidity associated with the largest deficit (−0.17; 95% confidence interval CI = −0.22, −0.12), followed by stroke (−0.15; 95% CI = −0.21, −0.10) and heart disease (−0.08; 95% CI = −0.11, −0.05). Insulin use and comorbidities were associated with clinically important deficits in pain. Overall HUI3 scores were significantly predictive of all three categories of health-care resource use. Conclusion Observed differences between groups contribute further evidence of the construct validity of the HUI3 in type 2 diabetes.

Objective: To determine whether the population demographics of the location of pharmacies were associated with tobacco sales in pharmacies, when controlling for pharmacy type. Design: Retrospective analysis. Setting: Iowa. Participants: All retailers in Iowa that obtained tobacco licenses and all pharmacies registered with the Iowa Board of Pharmacy in 2003. Main Outcome Measure and Interventions: Percentage of pharmacies selling tobacco (examined by pharmacy type using chi-square analysis); median income and distribution of race/ethnicity in the county for pharmacies that did or did not sell tobacco (t tests); predictors of whether a pharmacy sold tobacco (logistic regression using the independent variables county-level demographic variables and pharmacy characteristics). Results: County gender composition, race/ethnicity make-up, and income levels were different for tobacco-selling and -nonselling pharmacies. Logistic regression showed that whether a pharmacy sold tobacco was strongly dependent on the type of pharmacy; compared with independent pharmacies (of which only 5% sold tobacco products), chain pharmacies were 34 times more likely to sell tobacco products, mass merchandiser outlets were 47 times more likely to stock these goods, and grocery stores were 378 times more likely to do so. Pharmacies selling tobacco were more likely to be located in counties with significantly higher numbers of multiracial groups. Conclusion: The best predictor of whether an Iowa pharmacy sells tobacco products is type of pharmacy. In multivariable analyses, population demographics of the county in which pharmacies were located were generally not predictive of whether a pharmacy sold tobacco.

Dr Bajcar et al 1 present a general process-oriented, descriptive framework called Team Approach to Medication Management (TeAMM) for considering medication management. Medication management in this instance refers to the medication use processes of obtaining and using medications and not specifically to a pharmacy or pharmacist service. Team refers to all individuals, not just health care professionals, involved in medication use processes. The rationale for team care is generally 4-fold. First, different providers of care offer particular expertise and perspectives of patient care. Besides a different focus, patients may confide in one provider and not in another. This disparity is not attributable to deceit but to the health professionals’ verbal prompting in different areas of perceived importance. Second, team care facilitates the sharing of information about patients. In teams, different providers assess either all patients or selected patients by referral. Then, these assessments will be shared either verbally or in writing within the decision-making structure of the team. This information, particularly from varying perspectives, affords more informed decisions. Third, improvements in access to diagnostic and treatment services may be seen via substitution of physician care by freeing physician time. Substitution is also based upon the assumption that the work of professionals, ie, doctors and nurses, should be separate and different and is an explicit expression of trust and shared responsibility, not just shared tasks. Finally, including patients in teams

Background Concerns about direct-to-consumer advertisement's (DTCA's) information quality have raised interest in patients' drug information–seeking after DTCA exposure. Objective To identify predictors of patients' intentions and behaviors to seek drug information from physicians, pharmacists, and the Internet after DTCA exposure, using theories of planned behavior and self-efficacy. Methods One thousand patients were randomly selected from 3,000 nationwide osteoarthritic patients. A self-administered survey examined predictors of intention including measurements of attitude toward behavior, subjective norm, perceived difficulty, self-efficacy, controllability, self-identity, intention, exposure to ads, and control variables. After 6 weeks, another survey measured respondents' information-seeking behavior. For patients exposed to DTCA, 6 multiple regressions were performed for information-seeking intention and behavior for 3 information sources: physicians, pharmacists, and the Internet. Results The response rates were 61.9% and 80.1% for the first survey and the second survey, respectively. Four hundred and fifty-four participants reported exposure to DTCA about arthritis prescription medicines in the previous month. Over 41% of the variance in intention and over 18% of the variance in behavior were explained by the regression procedures. The consistent positive predictors of intention were attitude toward behavior, self-identity, attitude toward DTCAs of arthritis medication, and osteoarthritis pain; while the consistent positive predictors of behavior were intention and osteoarthritis pain. The strongest predictors of intention were self-identity for physicians, subjective norm for pharmacists, and attitude toward behavior for the Internet. Perceived difficulty and self-efficacy did not predict intention, and self-efficacy and controllability did not predict behavior. Conclusions DTCA-prompted drug information–seeking may be under patients' complete volitional control. To promote information searching, efforts could be made to affect factors predicting intention. Interventions could address patients' attitude toward behavior, the influence of their important others, and their role as information seeker, respectively, for information sources like the Internet, pharmacists, and physicians.

Objective The Short Form 12 (SF-12) is widely used in primary care settings. The RAND-12 Health Status Inventory (HSI) and the Health Utilities Index Mark 3 (HUI3) have not been as widely used in such settings. The objective of this study was to examine the construct validity of the RAND-12 and HUI3 in the context of high-risk primary care patients. Study design and setting The SF-12, HUI2, and HUI3 were administered to a cohort of high-risk primary care patients. RAND-12 summary scores for physical and mental health were generated. Single-attribute utility scores for each dimension of health status and overall health in HUI3 were computed. A priori hypotheses were specified. Results In general, the relationships among RAND-12 and HUI3 scores were consistent with construct validity. Twelve of 24 a priori predictions were confirmed. However, predictions about the correlations between the number of medical conditions and the number of medications and the measures of health-related quality of life were, in general, not confirmed. Conclusions The RAND-12 and HUI3 seem to be useful among primary care patients with diverse chronic conditions. Further investigation is warranted.

Objective To evaluate the knowledge and attitudes of pharmacy technicians before and after attending a continuing education program about smoking cessation. Design A pre/post survey of a single group. Setting Two statewide meetings of the Iowa Pharmacy Association. Participants Pharmacy technicians. Intervention One 2-hour continuing education (CE) course about smoking cessation for pharmacy technicians. Main Outcome Measures Changes in scores before and after the CE sessions among three domains (knowledge, efficacy, and outcome) of a validated survey instrument. Results Fifty-one technicians completed both the presession and postsession questionnaire. For the three survey domains, technicians’ knowledge ( P = .034), efficacy ( P P Conclusion Pharmacy technicians who attended a CE program on smoking cessation improved their knowledge, attitudes, and self-confidence in helping smokers quit. Additional research should be conducted to test the role of pharmacy technicians in smoking cessation promotion.

Objective To compare patients' adherence to therapy, expectations, satisfaction with pharmacy services, and health-related quality of life (HRQOL) after the provision of pharmaceutical care with those of patients who received traditional pharmacy care. Design Randomized controlled cluster design. Setting Sixteen community pharmacies in Alberta, Canada. Patients and Other Participants Ambulatory elderly (≥ 65 years of age) patients covered under Alberta Health & Wellness's senior drug benefit plan and who were concurrently using three or more medications according to pharmacy profiles. Intervention Pharmacies were randomly assigned to either treatment (intervention) or control (traditional pharmacy care) groups. Patients at treatment pharmacies were recruited into the study, and pharmacists provided comprehensive pharmaceutical care services. Pharmacists at control pharmacies continued to provide traditional pharmacy care. Main Outcome Measures Study participants' opinions, adherence to therapy, and scores on the Medical Outcomes Study 36-ltem Short Form Health Survey (SF-36). Results Compared with those of patients receiving traditional care, treatment patients' expectations that their pharmacist would perform activities congruent with pharmaceutical care changed over the study period. Treatment patients' satisfaction with the constructs "trust," "evaluation and goal setting," and "communicates with doctor" were also positively affected. HRQOL and patient adherence were not significantly affected by pharmaceutical care interventions. Conclusion Successful implementation of a pharmaceutical care practice model has the potential to increase patients' satisfaction with their pharmacists' activities and may increase patients' expectations that pharmacists will work on their behalf to assist them with their health care needs. If pharmaceutical care affects patients' HRQOL, instruments more specific than the SF-36 may be needed to detect the differences.

Objectives: To describe the processes of care used by community pharmacists participating in the Pharmaceutical Care Research and Education Project (PREP) in terms of drug-related problems (DRPs), pharmacists' recommendations, and status of DRPs at follow-up, and to determine characteristics associated with DRPs. Design Descriptive analysis of the treatment group from a larger randomized, controlled cluster design. Setting Five independent community pharmacies in Alberta. Participants One hundred fifty-nine patients who were covered under Alberta Health and Wellness's senior drug benefit plan (i.e., 65 years or older), were taking three or more medications concurrently according to pharmacy records, were able to complete telephone interviews as determined by pharmacists, maintained residence in Alberta for 12 of the 15 study months, agreed to receive their prescription medications only from the study pharmacy during the study period, and provided informed consent. Main Outcome Measures Frequency of DRPs, recommendations, status of DRPs, and analysis of clinical results as determined during pharmacists' follow-up care. Results: In telephone surveys, patients reported taking 4.7 prescription medications per day, but pharmacists documented 8.7 prescription medications per day in their records. Pharmacists documented 559 DRPs, a mean (± SD) of 3.9 ± 3.2 problems per patient. Approximately 39% of problems were actual DRPs, while 60% were potential DRPs. Medical conditions associated most frequently with a DRP involved the respiratory, cardiovascular, and musculoskeletal systems. The most common DRP categories were "patient requires drug therapy" or "patient requires influenza or pneumococcal vaccination." Pharmacists wrote 551 initial clinical notes using the subjective, objective, assessment, plan (SOAP) format, and they recorded 346 follow-up interventions, also using SOAP notes. Counseling, preventive consultations, and clinical monitoring represented 40% of their recommendations. In 80% of situations, the pharmacist made the recommendation directly to the patient. On follow-up, 40% of the 559 DRPs identified were resolved, controlled, or improved. Patients accepted 76% of pharmacists' recommendations, and physicians accepted 72% of pharmacists' suggested resolutions of DRPs. Pharmacists were more likely to follow up about actual DRPs, as compared with potential ones; overall, they followed up on 62% of identified DRPs. Conclusion Pharmacists identified more DRPs for study patients than previous community-based, observational studies have reported. Undertreatment appears to be a prevalent DRP. Community pharmacists' recommendations to prevent and resolve DRPs were made primarily to patients and were we" accepted. More follow-up was needed for a" DRPs. When follow-up occurred, the DRP results generally showed improvement.

Accreditation standards implemented in July 2007 require colleges and schools of pharmacy to train student pharmacists to provide public health services.1 Moreover, population-based public health curricula for all health care professionals is encouraged in the Clinical Prevention and Population Health Curriculum Framework developed by the Healthy People Curriculum Task Force in January 2008.2 Practicing pharmacists are also assuming traditional public health roles such as vaccination and screening. However, pharmacists’ public health activities are much more diverse than expected, and this issue of the Journal of the American Pharmacists Association (JAPhA) provides a sample of pharmacist-led public health initiatives. The public health agenda is dynamic and responds to changing population needs. Public health began at the turn of the 20th century, primarily to fight epidemics and prevent the spread of disease. Today, public health efforts still focus on responding to community health threats, although those threats are different today than at the turn of the 20th century.3 Public health has long been thought of as government programs and services for the disadvantaged, but it is more encompassing than this limited definition. The Institute of Medicine defines public health as “fulfilling society’s interest in assuring conditions in which people can be healthy.”4 This definition requires that pharmacists take a population-based focus to prevent disease and improve overall health with the goal of achieving long and productive lives. Healthy People 2020, which was being finalized at the time of this writing, identifies several health goals for the United States, such as attaining highquality, longer lives free of preventable health threats and conditions, achieving health equity, creating environments that promote good health, and promoting quality of life across all life stages.5 Healthy People 2020 explicitly recognizes that pharmacists have direct access to patients and play an important role in prevention and appropriate treatment. Pharmacists, who seek to ensure appropriate medication use, can assist in achieving these national health goals.

Objective: To describe the tools and processes used in the practice enhancement program (PEP) of the Pharmaceutical Care Research and Education Project to enable community pharmacists to acquire the necessary skills, knowledge, and attitudes to deliver comprehensive pharmaceutical care to elderly ambulatory patients. Setting: Independent community pharmacies in Alberta. Practice Description: The PEP was designed to allow self-directed learning in a problem-based environment. The intent was for pharmacists to apply the knowledge they gained to improve drug therapy outcomes. Practice Innovation: As a systematic approach to providing care, several tools were adapted to help pharmacists execute tasks required by the nine steps of the pharmaceutical care process proposed by Hepler and Strand. These tools and processes facilitated (1) self-directed learning about diseases and drugs, (2) acquisition of relevant patient data, (3) a consistent and stepwise approach to the identification and resolution of drug-related problems, (4) documentation of care provided, and (5) continuity of care. Results: To help pharmacists in the PEP acquire the necessary competency to provide pharmaceutical care, they were required to use the tools and processes described herein to work up and resolve patient problems. Initially, patient problems were presented as paper cases covering a range of acute and chronic problems, including topics applicable to geriatric patients. This was followed by a practicum phase wherein patient problems represented individuals from among their clientele. Conclusion: The tools and processes used in the project increased community pharmacists' competency for providing pharmaceutical care, by helping them develop the needed skills, knowledge, and attitudes.

Cigarette smoking, the leading known cause of preventable morbidity and mortality in the United States, is a contributory factor in the deaths of more than 400,000 adults annually.1 Tobacco cessation is associated with immediate and long-term health benefits.2 The U.S. Public Health Service published clinical guidelines in 2000 recommending that all health care providers offer tobacco cessation counseling to patients, noting that even brief interventions are effective.3 Community pharmacists are easily accessible and have brief, regular contacts with patients. Pharmacists believe tobacco cessation counseling is important, yet fewer than 30% always or frequently ask patients about tobacco use. Lack of time, inadequate training, and inability to identify smokers are among the barriers that deter pharmacists from discussing this topic with patients.4–6 Clinic and hospital-based pharmacists have been somewhat effective in helping patients with tobacco cessation.7–13 While evidence is limited, community pharmacy personnel may be effective in decreasing smoking cessation rates, given adequate training, motivation, support, and demand.14 However, no reported study has examined the implementation of brief counseling interventions in community pharmacies.

Professional and governmental organizations continue to acknowledge the profound impact of pharmacists on public health,1-5 and the academy is no exception. It has long recognized the importance of preparing pharmacy students to assume roles in public health. Topics related to public health have been a fundamental component of each iteration of the Center for the Advancement of Pharmaceutical Education (CAPE) Educational Outcomes.6-9 For example, in the 2013 Outcomes, 1.1 (Learner), 2.1 (Patient-centered Care), 2.3 (Health and Wellness), 2.4 (Population-based Care), 3.2 (Educator), 3.3 (Patient Advocacy), 3.5 (Cultural Sensitivity), 3.6 (Communication), 4.1 (Self-awareness) and 4.2 (Leadership), support the need to include public health concepts in the doctor of pharmacy curriculum.9 In addition, the American Association of Colleges of Pharmacy (AACP) is a member of the Healthy People Curriculum Task Force, convened by the Association for Prevention Teaching and Research, which developed a Clinical Prevention and Population Health Curriculum Framework.10 Moreover, many pharmacy faculty members are involved and interested in public health, as evidenced by the robust membership in the Public Health Special Interest Group (SIG) of AACP. The group is currently the sixth largest among AACP’s 21 SIGs. Eight active subcommittees comprise the SIG, with areas of focus that include tobacco control, emergency preparedness and response, caring for the underserved, and global public health pharmacy.11 In this theme issue of the Journal, we present five diverse examples of ways colleges and schools of pharmacy are engaging their students and faculty members in public health inside and outside of the classroom. We include four areas where pharmacists may contribute to public health activities and principles, but enumerable examples exist beyond these. Also contributing to the issue is Georges Benjamin, MD, executive director of the American Public Health Association (APHA), which has one of the most comprehensive policy statements outlining opportunities for pharmacists in public health.3 A Pharmacy Special Primary Interest Group also has been recently established within the organization.12,13 Importantly, Benjamin distinguishes between public health and population health, the latter a term also used in the CAPE 2013 Outcomes and Accreditation Council for Pharmacy Education (ACPE) 2016 Standards.9,14 Pharmacists may contribute to both, in that public health may be considered local activities of a public health department to improve health, and population health may be considered the activities (medical care or public health activities) focused to improve the health of populations. In two articles, pharmacy faculty members provide examples of efforts that consider emergency preparedness, an area that public health organizations such as the National Association of County and City Health Officials have highlighted as needing pharmacy involvement.15 This topic has been specified as a necessary entry-level competency for pharmacists.14 For example, it is critical that pharmacists consider how individuals obtain their medications during emergencies when pharmacies may be flooded or transportation limited. Ford and colleagues share the results of a comprehensive analysis of pharmacy legal documents from US states and commonwealth territories to estimate the degree of pharmaceutical emergency preparedness, and Hannings and colleagues provide a guide to designing, implementing, and assessing an introductory pharmacy practice experience focused on emergency preparedness. Based on their findings, the profession may need to focus explicitly on this important public health activity, particularly in areas with a high risk of devastating events such as earthquakes, tornados, and floods. The remaining three papers present the variety of activity in which pharmacists may participate in public health and generally represent the theme of caring for underserved or vulnerable populations. Potential roles for pharmacy students as tuberculosis screeners are explored by McKennon and Arnold, significant because it represents a novel screening certification specifically created for and delivered to pharmacy students. Clarke and colleagues present the effect of a poverty simulation exercise on pharmacy students’ attitudes toward poverty, an important consideration as pharmacy students must be familiar with social determinants of health.9 This type of activity is important for pharmacy students in terms of CAPE Outcomes such as 2.1 (Patient-centered Care), 2.3 (Health and Wellness), 2.4 (Population-based Care), 3.5 (Cultural Sensitivity), 3.6 (Communication) and 4.1 (Self-awareness).9 It can be easy to find oneself in a judging mode after several years of practice—activities such as this may ameliorate such attitudes. Finally, Karwa and colleagues detail the construct and impact of an international residency program in global health, which is increasingly becoming a national priority16,17 and is included in Healthy People 2020 as a new topic area.18 Access to medications and their best use is a critical need, and pharmacists can help in this regard. The academy must continue to ensure that students are well-equipped to assume roles in public health and population health management. The papers presented here provide specific examples that can be implemented. However, the topics are not exhaustive; there are many other ways and opportunities for schools of pharmacy to incorporate principles of public health in didactic and experiential curricula, co-curricular or extracurricular activities, and postgraduate training. For example, members of the Public Health SIG have assisted faculty members at schools of pharmacy to adopt official policies to reduce the health burden associated with tobacco.19 Recent SIG webinars have explored subjects such as expedited partner therapy, quality improvement, and interprofessional collaborations in public health.20 As faculty members continue to develop and revise programs, especially in light of the updated CAPE Outcomes and ACPE Standards, we hope that this theme issue calls attention to the importance of public health in pharmacy education and practice. We also hope that faculty members who do not yet participate in the AACP Public Health SIG but who provide instruction or have an interest in public health consider joining the group in order to facilitate a continued sharing of ideas and strategies to best prepare pharmacy students in these areas.

Objective. To describe student pharmacists’ Signature Themes from the Clifton StrengthsFinder across 5 Midwestern pharmacy institutions and to compare themes by gender, institution, and undergraduate population. Methods. Student pharmacists completed the StrengthsFinder 2.0 assessment and received their top 5 Signature Themes. Themes were organized and examined by domains (Executing, Influencing, Relationship Building, Strategic Thinking). The distribution of the themes was compared between student pharmacists and undergraduates and themes and domains were compared by institution and gender. Results. Although results varied by institution, the top 5 themes among the 1244 of 1250 students (99.5%) who completed the assessment were: Achiever, Harmony, Learner, Responsibility, and Empathy. Female student pharmacists had more themes in Executing and Relationship Building, while males had more themes in Influencing and Strategic Thinking. Pharmacy students exhibit more Executing domain talents and fewer Influencing domain talents compared with undergraduates. Conclusion. Signature Themes were consistent among student pharmacists across 5 Midwestern colleges of pharmacy.

were low for TH (4.4 0.9) and ACC (5.4 1.0) as compared to the pMDI (8.1 0.9) (p!0.001, Independent Sample T test). Beside type of inhaler, higher inhaler technique scores were significantly associated with more recent diagnosis of asthma, older patient age (above 31), and lower reliever use (p1⁄40.019, one way ANOVA). Results showed no significant association between inhaler technique and ACT scores (mean SD), which were very low for all inhaler groups, with no significant differences between them (TH: 13.1 3.9, ACC: 13.3 3.9 and pMDI: 12.8 4.2, pO0.05). Conclusion: Patients in Jordan are using the pMDI inhalers more correctly than the newer DPIs. Significant association between higher inhaler technique scores and lower reliever use was found, but no significant association with ACT scores was detected.

To describe the perceptions of student pharmacists, graduate students, and pharmacy residents regarding social situations involving students or residents and faculty members at public and private universities.Focus groups of student pharmacists, graduate students, and pharmacy residents were formed at 2 pharmacy schools. Given 3 scenarios, participants indicated if they thought any boundaries had been violated and why. Responses were grouped into similar categories and frequencies were determined.Compared with private university students or pharmacy residents, student pharmacists at a public university were more likely to think "friending" on Facebook violated a boundary. No participants considered reasonable consumption of alcohol in social settings a violation. "Tagging" faculty members in photos on Facebook was thought to be less problematic, but most participants stated they would be conscious of what they were posting.The social interactions between faculty members and students or residents, especially student pharmacists, should be kept professional. Students indicated that social networking may pose threats to maintaining professional boundaries.

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

To examine PharmD students' knowledge about Medicare Part D and their attitudes toward and intention to provide Medicare medication therapy management services (MTMS).Fourth-professional year students were given a self-administered survey instrument that assessed: (1) knowledge about Medicare Part D; (2) attitudes, perceived behavioral control, subjective norms, and intention to provide Medicare MTMS; and (3) demographic and experience information.Ninety-five students responded for a response rate of 94%. Students showed good basic knowledge about Medicare Part D, with a mean score of 94%. Almost 60% of students agreed that they intended to provide Medicare MTMS, but agreement dropped to 37% when they were asked if they were willing to take initiative to provide MTMS.The lack of willingness to take initiative to provide Medicare MTMS suggests that colleges and schools of pharmacy must strengthen efforts to encourage students to take on the role of service provider.