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Gang Fang,1 Stacy Cooper Bailey,2 Izabela E Annis,1 Michael K Paasche-Orlow,3 Michael S Wolf,2 Laurie T Martin,4 Michael Emch,5 M Alan Brookhart,6 Karen B Farris7 1Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; 2Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; 3Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; 4RAND Corporation, Arlington, VA, USA; 5Department of Geography and Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA; 6Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA; 7College of Pharmacy, The University of Michigan, Ann Arbor, MI, USACorrespondence: Gang FangDivision of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 2202, Kerr Hall, Chapel Hill, NC 27599-7573, USATel +1 919-966-7517Fax +1 919-966-8486Email gang_fang@unc.eduPurpose: Individual measures of health literacy are not feasible for administration on a large scale, yet estimates of community-level health literacy in the US recently became available. We sought to investigate whether community-level health literacy estimates are associated with the initiation of oral antihyperglycemic agents (OHA) and the use of standard preventive care services among older adults with newly diagnosed diabetes.Patients and methods: We conducted a retrospective cohort study of 169,758 patients, ≥65 years old with hypertension and newly diagnosed type 2 diabetes using 2007–2011 data from the Center for Medicare and Medicaid Services Chronic Conditions Warehouse. We examined the relationship between community-level health literacy estimates and initiation of OHA, receipt of flu shots, eye exams, Hemoglobin A1c tests, and lipid tests within 12 months post diabetes diagnosis.Results: Patients living in communities with above basic health literacy (vs. basic/below basic) were 15% more likely to initiate OHA (Hazard Ratio=1.15; 95% CI 1.12 to 1.18). After classifying the health literacy distribution as quintiles, the analysis revealed a dose–response relationship with OHA initiation that plateaued at the third and fourth quintiles and declined at the fifth quintile. Individuals residing in communities with higher health literacy were more likely to participate in preventive care services (relative risk ranged from 1.09 for lipid test [95% CI 1.07–1.11] to 1.43 for flu shot [95% CI 1.41–1.46]).Conclusion: Community-level health literacy estimates were associated with the initiation of OHA and uptake of standard preventive care services in older adults. Community-level health literacy may help to inform targeted diabetes education and support efforts.Keywords: health literacy, diabetes mellitus, adherence, preventive care

INTRODUCTION: The Medicare Part D medication therapy management (MTM) program positions pharmacists to optimize beneficiaries’ medications and improve care. Little is known regarding Part D MTM delivery by community pharmacists and other pharmacist provider types. OBJECTIVES: To (1) characterize Medicare Part D MTM delivery by community pharmacists, (2) compare MTM delivery by community pharmacists to other pharmacists, and (3) generate hypotheses for future research. METHODS: A descriptive cross-sectional study using merged data from a 20% random sample of Medicare beneficiary enrollment data with a 100% sample of recently available 2014 Part D MTM files was conducted. Andersen’s Behavioral Model was applied to describe MTM delivery across beneficiary characteristics. Descriptive and bivariate statistics were used to compare delivery of MTM between community and other pharmacist providers. RESULTS: Among beneficiaries sampled, community pharmacists provided comprehensive medication reviews (CMRs) to 22% (n=26,337) of beneficiaries receiving at least one CMR. Almost half (49.4%) were provided face-to-face. Across pharmacist cohorts, median days to CMR offer of post-MTM program enrollment were within the 60-day policy requirement. The community pharmacist cohort had fewer days from CMR offer to receipt (median 47 days). Community pharmacists provided more medication therapy problem (MTP) recommendations (mean [SD] of 1.8 [3.5]; p

58 Background: The oncology pharmacist role has evolved to address implications of newer cancer therapies by increased integration in direct patient care and management of cancer therapy side effects and adherence. Despite the ability of oncology pharmacists to provide high-value, high-quality care to patients with cancer, it remains difficult for community oncology practices to justify the cost of the pharmacist. The purpose of this study is to characterize a model, Pharmacists Optimizing Oncology Care Excellence in Michigan (POEM), that supports the integration of clinical oncology pharmacists into community practices via financial support to the practices, clinical support to the pharmacist team, and outcomes assessment. The results will provide insight into how pharmacists support patient care and how to substantiate a pharmacist in practices. Methods: This multicenter, retrospective analysis was conducted between October 2020 – March 2022. POEM pharmacists received support in the development of collaborative practice agreements, billing guidance, and ongoing oncology continuing education. Practices received support via a percentage of salary support for the pharmacist the first 3 years and value-based reimbursement for participation. A standardized method for collecting patient demographics, pharmacist encounter characteristics, and intervention information was created via RedCap. Patients receiving care by the pharmacist were provided a 4-item survey to rate their experience. Results: As of March 2022, POEM has 6 clinical oncology pharmacists representing 8 physician organizations, 24 oncology clinics, and 72 physicians. 1944 patients have been seen via 4296 encounters and 4380 interventions. 49% of patients were female, 93% white, and 74% > 60 years. The primary reasons for pharmacist care were treatment with oral anticancer agents (OAA) (52%), non-immunotherapy IV (22%), and immunotherapy (20%). Pharmacists recorded an average of 77 patient encounters/week over the last year and 108/week over the past quarter. 47% of these encounters were billed using care management codes. Additionally, pharmacists recorded an average of 82 interventions/week over the past year and 101/week over the last quarter. Interventions were Education and Referrals (49%), Medication Modification (24%), and Comprehensive Medication Review or Medication Reconciliation (20%). Patients were satisfied with the pharmacists’ care and felt it was important to meet with a pharmacist before beginning their cancer treatment. Conclusions: Early results indicate positive patient experiences from education sessions and medication interventions to improve patient symptoms. Future outcome analyses will quantify the return on investment of clinical pharmacist integration into oncology community practices by measuring pre- and post-intervention healthcare utilization and patient clinical outcomes.

OBJECTIVES: Race differences in contraceptive use and in geographic access to pharmacies are well established. We explore race differences in characteristics of nearby pharmacies that are likely to facilitate (or not) contraceptive purchase. STUDY DESIGN: We conducted analyses with two geocode-linked datasets: (1) the Relationship Dynamics and Social Life (RDSL) project, a study of a random sample of 1,003 women ages 18–19 living in a county in Michigan in 2008–09; and (2) the Community Pharmacy Survey, which collected data on 82 pharmacies in the county in which the RDSL study was conducted. RESULTS: Although young African-American women tend to live closer to pharmacies than their white counterparts (1.2 miles to the nearest pharmacy for African Americans vs. 2.1 miles for whites), those pharmacies tend to be independent pharmacies (43% vs. 12%) that are open fewer hours per week (64.6 vs. 77.8) and have fewer female pharmacists (17% vs. 50%), fewer patient brochures on contraception (2% vs. 5%), more difficult access to condoms (49% on the shelf vs. 85% behind glass, behind the counter, or not available), and fewer self-check-out options (3% vs. 9%). More African-American than white women live near African-American pharmacists (8% vs. 3%). These race differences are regardless of poverty, measured by the receipt of public assistance. CONCLUSIONS: Relative to white women, African-American women may face a “contraception desert,” wherein they live nearer to pharmacies, but those pharmacies have characteristics that may impede the purchase of contraception.

Purpose: ASCO has worked to facilitate the improvement in quality oncology care via the development of the Quality Oncology Practice Initiative (QOPI). The extent to which the ASCO QOPI identifies areas in which pharmacists may enhance care is not known. These findings are important, as pharmacists are an integral part of the care team, providing direct clinical care in addition to medication use guidelines and practice-based policies. In addition, high-performing practices may receive reimbursement from the Centers for Medicare and Medicaid Services. Methods: Three pharmacists reviewed 200 QOPI measures for potential pharmacist involvement. We used the Hematology/Oncology Pharmacy Association Scope of Practice document and a validated summary of services provided by board-certified oncology pharmacists to identify which practice domains and pharmacy services would best fit the care provided by the selected QOPI measures. Results: A total of 177 QOPI measures were analyzed. Potential areas of pharmacist impact were identified in 67 (38%) of the included metrics. Measures largely related to optimizing drug therapy through the development and implementation of pharmacy guidelines. Patient counseling and symptom management are services that best described the majority of QOPI measures deemed actionable by a pharmacist. We also found that several QOPI measures pharmacists can intervene upon overlap with metrics currently assessed for reimbursement via the Centers for Medicare and Medicaid Services Merit-Based Incentive Payment System. Conclusion: Oncology pharmacists are uniquely positioned to improve the quality of care provided to patients with cancer within the team-based setting.

PURPOSE Patient-reported outcome measures (PROMs) for symptom monitoring during cancer therapy have been shown to have a positive impact on outcomes. These findings have primarily been shown for patients receiving intravenous chemotherapy. In addition, there is known discordance between physician reporting of symptoms and patient self-report. This initiative sought to describe patient-reported symptom burden and medication adherence and to indicate the degree of PROM results being discussed with the provider as indicated by documentation in the medical record for patients taking oral oncolytic therapy. METHODS The Michigan Oncology Quality Consortium (MOQC) PROM, which included symptom ratings, medication adherence, and patient confidence in self-management, was completed during outpatient visits and compared with corresponding data documented in the electronic medical record (EMR). RESULTS There were 82 completed PROMs. Approximately half included at least one symptom rated as severe (46%). Sixty-five percent of reported severe symptoms were documented in the EMR. Patient-reported moderate-to-severe pain was most likely to be documented in the EMR (100%), whereas patient-reported moderate-to-severe depression and anxiety were least likely to be documented (21%). Of the total symptoms documented, grading of symptom severity matched that of the patients’ own report for 11% of severe symptoms. Adherence to oral oncolytics was excellent for 63% of patients, and patient adherence was documented in 7% of provider notes. CONCLUSION Patients frequently reported moderate-to-severe symptoms, and approximately 40% of patients reported nonadherence. Clinician report (documented in the EMR) of the patient symptom burden, symptom severity, and adherence to oral oncolytic therapy was not consistent with the patients’ self-report. Use of a PROM for patients taking oral oncolytics has the opportunity to improve symptom management and medication adherence.

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.

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).

The objective of this study was to determine if a Web application that promoted mindfulness of the progress of the chronic disease through self-monitoring improved quality of life in heart failure.This was a prospective single-center single-group study. Participants were instructed how to use the Web application and to perform self-monitoring daily for 12 weeks. A comprehensive physical exam, assessment of New York Heart Association (NYHA) class, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and an evaluation of self-management were performed in person at baseline and at 12 weeks.Participants consisted of older (mean, 59 years), predominantly female (63%) adults with NYHA class II or III symptoms. NYHA classification (preintervention versus postintervention, 2.5±0.13 versus 2.0±0.13; p=0.0032) and MLHFQ score (55.7±4.6 versus 42.6±5.1, respectively; p=0.0078) improved over 12 weeks of self-monitoring. A trend toward improvement was also demonstrated in weight (preintervention versus postintervention, 209±9.6 pounds versus 207±9.4 pounds; by paired t test, p=0.389), number of times exercised per week (1.29±0.5 versus 2.5±0.6, respectively; p=0.3), and walk distance (572±147 yards versus 845±187 yards, respectively; p=0.119). Jugular venous distention (preintervention versus postintervention, 8.1±0.6 cm versus 6.7±0.3 cm; p=0.083) and peripheral edema (29.2% versus 16.7%, respectively; p=0.375) decreased after 12 weeks of self-monitoring via the Web application.A Web application for self-monitoring heart failure over 12 weeks improved both NYHA classification and MLHFQ score. The trend in improved physical activity and physical exam support these outcomes. The number of patients reporting a sodium-restricted diet increased over the 12 weeks, which may have led to the positive findings.

Purpose The effect of hospital pharmacists’ enhanced communication with patients and community providers on the underutilization of key cardiovascular medications was studied. Methods Patients enrolled in the Iowa Continuity of Care study were eligible for inclusion in this study if they had a diagnosis of hypertension, hyperlipidemia, heart failure, coronary artery disease, or a combination of these diagnoses. Eligible patients also had to be admitted to the internal medicine, family medicine, cardiology, or orthopedics services and receive their usual medical care in the community and their prescriptions from a community pharmacy. Patients were randomized to receive minimal intervention, enhanced intervention, or usual care. For the minimal- and enhanced-intervention groups, pharmacy case managers (PCMs) performed comprehensive medication reconciliations and identified drug-related problems within 24 hours of admission. The PCMs made recommendations to the inpatient care team and to patients’ community physicians. For patients in the enhanced-intervention group, the PCM developed a discharge care plan containing the patient’s discharge medication list. PCMs made specific recommendations to optimize regimens that did not meet current guidelines or medications that were underutilized. Medication underutilization was assessed at admission, discharge, 30 days after discharge, and 90 days after discharge. Results A total of 732 patients were enrolled in this study. There were no significant differences among the three study groups. Overall, the rate of underutilization remained constant among all three groups, despite enhanced pharmacist involvement in both intervention groups. Conclusion Enhanced interventions by PCMs had no effect on the underutilization of key cardiovascular drugs during hospitalization or after hospital discharge.

Non-adherence/persistence to adjuvant endocrine therapy can negatively impact survival. Beliefs about medicines are known to affect adherence. This study aims to identify socio-demographic and clinical characteristics associated with medication beliefs among women taking aromatase inhibitors (AIs). Women completed an online survey on beliefs about AI therapy [Beliefs about Medicines Questionnaire (BMQ)], beliefs about breast cancer [Assessment of Survivor Concerns scale (ASC)], and depression [Personal Health Questionnaire depression scale (PHQ-8)]. Socio-demographic and clinical characteristics were collected. Bivariate analyses and linear regression models were performed to investigate relationships between variables. A total of 224 women reported currently taking AI therapy and were included in the analysis. Significantly higher concern beliefs were found among women who had at least mild depression, experienced side effects from AIs, and previously stopped therapy with another AI. Significant correlations were found between concern and necessity beliefs and cancer and health worry. Women age 70 and older displayed less fear of cancer recurrence and health worry, and a trend towards lower necessity and concern beliefs. No differences were found for other variables. In the regression model, greater necessity beliefs were found with increases in the number of current prescription medications (B = 1.06, 95% CI 0.31–1.81, p = 0.006) and shorter duration of current AI therapy (B = −0.65, 95% CI −1.23 to −0.07, p = 0.029), whereas greater concern beliefs were associated with higher depression scores (B = 1.19, 95% CI 0.35–2.03, p = 0.006). Medication necessity and concern beliefs were associated with a definable subset of patients who may be at higher risk for non-persistence.

Purpose The development of a patient-centered medical home (PCMH) health care model and the role of pharmacists in PCMHs at the University of Michigan are described. Summary In 2009, Blue Cross Blue Shield of Michigan (BCBSM) provided financial incentives to physician groups to implement PCMH principles. A partnership was formed among the department of pharmacy, college of pharmacy, and faculty group practice at the University of Michigan Health System (UMHS) to integrate clinical pharmacists into the PCMH model at eight general medicine practices. The rationale was that PCMH pharmacists could assist in managing chronic conditions by substituting or augmenting physician care, help achieve quality indicators, and increase revenue by billing for their services. At the University of Michigan, PCMH pharmacists currently provide direct patient care services at eight general medicine health centers for patients with diabetes, hypertension, hyperlipidemia, and polypharmacy, which are billable using T codes, which are payable to UMHS by most BCBSM plans. In the first year, the number of PCMH pharmacist half-day clinics varied from one to six per health center, and the mean number of patients per half-day clinic ranged from 2.2 to 6. Pharmacists in four PCMHs made more medication changes per visit than the other four, particularly for patients with diabetes. Conclusion At the University of Michigan, PCMH pharmacists currently provide direct patient care services at eight general medicine health centers for patients with diabetes, hypertension, hyperlipidemia, and polypharmacy via referral from physicians.

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.

Evaluation of: Cárdenas-Valladolid J, Martín-Madrazo C, Salinero-Fort MA et al.: Prevalence of adherence to treatment in homebound elderly people in primary healthcare: a descriptive, cross-sectional, multicentre study. Drugs Aging 27(8) 641–651 (2010). A descriptive cross-sectional study determined the prevalence of nonadherence in homebound elderly who were taking at least four or more drugs, and predicted nonadherence. A random sample of subjects and their caregivers was identified in Madrid, Spain. Trained nurses interviewed subjects and their caregiver, physicians and nurses. Data were collected on self-reported medication adherence, chronic comorbidities, visual and auditory perception, cognitive status, activities of daily living, knowledge of disease, caregiver burden, relationship between the caregiver and the patient, and previous caregiving experiences. Adherence was defined using the four items on Morisky’s self-reported scale and 65.7% were considered adherent. Caregiver burden, hearing impairment, and difficulty associated with activities of daily living were significant predictors of nonadherence.

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.

Background Unintended pregnancy is a major public health problem in the United States.Correct contraceptive use can reduce the rate of unintended pregnancy. Community pharmacies are well positioned to provide contraceptives and advice about contraception. Objectives To determine young women's perceptions and experiences with contraception supply in community pharmacies and to identify whether pharmacy characteristics predicted very positive experiences. Design This study comprised two cross-sectional surveys including an online women's pharmacy perceptions and experiences (PPE) survey and a faxed/observed survey of community pharmacies. Setting One county in Michigan Participants Young women and community pharmacies Main outcome measure The two surveys were merged to explore pharmacy characteristics that may impact women's perceptions and experiences with community pharmacies. Multiple logistic regression analysis was used to explore relationships between pharmacy characteristics and positive outcomes. Results The response rate for the PPE survey was 54% (n = 343/637). Data from all community pharmacies in the county was retrieved via fax (n = 41/94, 43.6%) or observation (n = 53/94, 56.4%). Women were included in this analysis if they indicated a regular pharmacy (one they go to most often) in the county of interest (n = 210). More than 50% of women (n = 125/210) visited a pharmacy more than once per month. Sixty percent of women were currently using something to prevent pregnancy (n = 124/210, 60.8%). Thirty-five percent of women had a positive experience (n = 73/210, 34.8%). In the multiple logistic regression, women who visited a chain pharmacy had almost 65% lower odds of an overall positive experience with their regular pharmacy compared with women who visited a grocery or mass merchandise pharmacy (odds ratio 0.35 [95% CI 0.16], P = 0.75). Conclusion Young women visit community pharmacies and use contraceptives frequently. Interventions need to be developed and implemented to improve young women's perceptions and experiences with contraception at community pharmacies.

Study Objective. To assess the effectiveness of a community pharmacist–delivered cardiovascular case-management program by comparing body mass index (weight), systolic and diastolic blood pressure, and full lipid profile at the beginning of the program with these outcome measures at the end of the program. Design. Retrospective data analysis using billing data submitted between July 1, 2001, and October 31, 2004, with a pre-post design in which subjects served as their own controls. Setting. Manufacturing workplace in rural Iowa. Participants. Fifty-six workers with risk factors for cardiovascular disease (mean age 40.67 yrs), 37 had diabetes mellitus and 19 did not. Intervention. During visits to the workers, pharmacists provided education about cardiovascular disease, identification of drug therapy problems, and importance of routine blood pressure, pulse, and weight measurements; they communicated with participants' physicians as needed. Measurements and Main Results. The number of pharmacist visits/participant ranged from 1–13 (mean ± SD 6.97 ± 3.05). Outcome measures were weight, systolic and diastolic blood pressures, full lipid profiles (in patients with diabetes), and percentage of patients achieving treatment goal by the end of the 3 years. Statistically significant differences between the first and last visits were achieved for both systolic (124.12 ± 11.07 and 120.36 ± 14.39 mm Hg, respectively, p=0.016) and diastolic (80.4 ± 9.01 and 77.43 ± 9.14 mm Hg, respectively, p=0.019) blood pressure. The 19 patients without diabetes showed a statistically significant improvement in diastolic blood pressure (p=0.039), but the 37 patients with diabetes did not show a significant difference. A nonsignificant increase was seen in the percentage of patients with diabetes achieving low-density lipoprotein cholesterol (LDL) level goal between the first and last visits (p=0.06). Conclusion. A cardiovascular case-management program delivered in the workplace to middle-aged working adults by community pharmacists improved blood pressure and reduced LDL levels. The program was not effective, however, in weight reduction.

Objective. We assessed which of a broad range of determinants of health are most strongly associated with health-related quality of life (HRQL) among people with type 2 diabetes. Methods. Our analysis included respondents from the Canadian Community Health Survey Cycle 1.1 (2000‐2001) who were aged 18 years and older and who were identified as having type 2 diabetes. We used regression analyses to assess the associations between the Health Utilities Index Mark 3 and determinants of health. Results. Comorbidities had the largest impact on HRQL, with stroke (‐0.11; 95% confidence interval [CI] = ‐0.17, −0.06) and depression (‐0.11; 95% CI = ‐0.15, −0.06) being associated with the largest deficits. Large differences in HRQL were observed for 2 markers of socioeconomic status: social assistance (‐0.07; 95% CI = ‐0.12, −0.03) and food insecurity (‐0.07; 95% CI = ‐0.10, −0.04). Stress, physical activity, and sense of belonging also were important determinants. Overall, 36% of the variance in the Health Utilities Index Mark 3 was explained. Conclusion. Social and environmental factors are important, but comorbidities have the largest impact on HRQL among people with type 2 diabetes. (Am J Public Health. 2006;96:1649‐1655. doi:10.2105/AJPH.2005.067728)

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.

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.

(2004). Primary health care teams: team members' perceptions of the collaborative process. Journal of Interprofessional Care: Vol. 18, No. 1, pp. 75-78.

Who is responsible for medication administration at school? To answer this question, a descriptive, self-administered survey was mailed to a random sample of 850 school principals in Iowa. The eight-page, 57-item, anonymous survey was mailed first class, and a follow-up reminder post card was mailed two weeks later. Descriptive analyses were conducted, with type of respondent (principal versus school nurse), grade level, and size of school examined to explore differences. A 46.6% response rate was obtained; 97% of respondents indicated their schools had written guidelines for medication administration. Principals (41%) and school nurses (34%) reported that they have the ultimate legal responsibility for medication administration. Policies for medication administration on field trips were available in schools of 73.6% of respondents. High schools were more likely to allow self-medication than other grade levels. "Missed dose" was the most common medication error. The main reasons contributing to medication administration errors included poor communication among school, family, and healthcare providers, and the increased number of students on medication. It remains unclear who holds ultimate responsibility for medication administration in schools. Written policies typically exist for medication administration at school, but not field trips. Communicating medication changes to schools, and ensuring medications are available at school, likely can reduce medication administration errors.

Study Objective. To examine community pharmacy practice with regard to providing smoking-cessation counseling. Design. Mailed survey. Setting. Iowa community pharmacies. Participants. A stratified random sample of pharmacists statewide. Measurements and Main Results. Descriptive statistics were computed for all study variables. Fisher exact test or χ2 analysis was performed on selected variables to determine the relationship of each item with pharmacists routinely offering smokers suggestions for quitting. Responses from 129 (38.2%) of 338 pharmacists indicated that although most felt it is important to offer smoking-cessation counseling, about half actually offer this service. Most pharmacists indicated they are prepared to provide counseling, but fewer than 25% had received formal training or were aware of national clinical practice guidelines. Those who had received specific training (p=0.020) or recently attended an educational program (p=0.014) on smoking cessation were more likely to counsel smokers. Primary barriers to providing counseling were lack of time, inability to identify smokers, low patient demand, and lack of reimbursement. Conclusion. Our findings suggest that opportunities exist for improving pharmacist education and reducing practice barriers in order to bridge the gap between pharmacists’ knowledge and attitudes related to smokingcessation counseling and their provision of patient counseling in community pharmacy practice.

Background: The concept of customer engagement and devotion has been applied in various service businesses to keep the customers with business However, a limited number of studies were performed to examine the context of customer engagement and devotion in pharmacy business which focus on the impact of customer perceptions about pharmacists, perceived quality of pharmacy structure, medication price strategy on pharmacy engagement and pharmacy customer devotion in a pharmacy providing pharmaceutical care to the customers. Objective: This study aimed to assess a conceptual model depicting the relationships among customer perceptions about pharmacists, pharmacy quality structure, medication price, customer engagement, and customer devotion. And also aimed to assess and measure if there is a direct or indirect relationship between these factors. Methods: A quantitative study was conducted by using self-administered questionnaires. Two hundred and fifty three customers who regularly visited the pharmacy were randomly recruited from a purposively selected 30 community pharmacies in Bangkok. The survey was completed during February to April 2016. A structural equation model (SEM) was used to assess the direct and indirect relationships between constructs. Results: A total of 253/300 questionnaires were returned for analysis, and the response rate was 84%. Only perceptions about pharmacist in customers receiving professional pharmacy services was statically significant regarding relationship with pharmacy engagement (beta=0.45). Concurrently, the model from empirical data fit with the hypothetical model (p-value = 0.06, adjusted chi-square (CMIN/DF)=1.16, Goodness of Fit Index (GFI)=0.93, Comparatively Fit Index (CFI)=0.99, and Root Mean Square Error Approximation (RMSEA)=0.03). Conclusion: The study confirmed the indirect positive influence of customer perceptions about pharmacist on pharmacy customer devotion in providing pharmacy services via pharmacy engagement It was customer perceptions about pharmacist that influenced customer retention, positive word of mouth and constructive advice to pharmacies, not quality of pharmacy structure and medication price. To create a long term impact on community pharmacy business, pharmacist is the key success factor.

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.

Background Pharmacists in various settings have been effective in initiating diabetes treatment. Patients with diabetes require ongoing disease management, and community pharmacists are in a strategic position to provide such extended care. Little is known, however, about the effects of community pharmacist–provided interventions beyond the initial treatment period. Objective To evaluate the effect of community pharmacist–provided extended diabetes care service on primary clinical outcomes, including hemoglobin A1c (A1C), low-density lipoprotein cholesterol (LDL-C), and blood pressure, and on patients' reported self-care activities. Methods A randomized controlled trial was conducted in patients with diabetes. Participants had already completed at least 2 diabetes education sessions at a local diabetes education center. Nine specially trained pharmacists administered interventions during up to 4 quarterly visits per patient. Interventions included discussing medications, clinical goals, and self-care activities with patients and recommending medication changes to physicians when appropriate. The main outcome measures were 12-month changes in A1C, LDL-C, blood pressure, and self-report of self-care activities. Results Seventy-eight patients participated in the study (36 intervention, 42 control); 66 were included in the final analysis (31 intervention, 35 control). Compared with changes in the control group, patients who received interventions significantly increased the number of days per week that they engaged in a set of diet and diabetes self-care activities (1.25 and 0.73 more days/wk, respectively). The mean 12-month changes for A1C, LDL-C, and blood pressure were not significantly different between the 2 study groups. Conclusions Although pharmacist-provided interventions did not demonstrate statistically significant improvements in clinical outcomes over the study period, study results did show that pharmacists were effective at increasing the number of days that patients spent engaging in healthy diet and diabetes self-care activities. Addressing lifestyle and self-care behaviors can be a beneficial component of a pharmacist-provided extended diabetes care service.

Study Objectives. To evaluate trends in adverse symptoms as blood pressure becomes controlled, and to determine if these symptoms are influenced by social support and self-efficacy. Design. Secondary analysis from a randomized controlled study of physician-pharmacist collaboration to improve blood pressure control. Setting. Five university-affiliated primary care clinics. Patients. A total of 179 patients (aged 21–85 yrs) with uncontrolled primary hypertension who were taking no antihypertensive drugs or up to three antihypertensive drugs at baseline were randomized to the intervention group, in which pharmacists were involved in their care, or to the control group, who received usual care from their physicians. Of these patients, 160 completed the study: 92 were in the intervention group, and 68 were in the control group. Intervention. In both groups, patient-reported symptoms suggestive of adverse drug reactions (ADRs) were recorded at each study visit with use of a structured ADR questionnaire. Social support and self-efficacy questionnaires were also administered at each study visit. Measurements and Main Results. Patients' ADR scores decreased significantly from baseline to the end of the study in both the control (from a mean of 26.5 to 18.4) and intervention (from 29.9 to 22.7) groups (p

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides a prescription drug benefit for Medicare-eligible seniors that includes access to medication therapy management services (MTMS) through pharmacists. We theorize that local community pharmacy market competition affects the decision of individual community pharmacies to provide MTMS. Our model suggests that MTMS services are more apt to be supplied in markets at the extremes of community pharmacy concentration (very low and very high). We found that local community pharmacy competition affected the service choices made by the pharmacy decision-makers willing to provide MTMS in a manner consistent with our theory. As a result, patient access to MTMS services depends on both (1) patient access to pharmacies willing to provide MTMS and (2) the level of local community pharmacy competition.

Despite clear evidence for the efficacy of lowering cholesterol levels, there is a deficiency in its real-world application. There is a need to explore alternative strategies to address this important public health problem. This study aimed to determine the effect of a program of community pharmacist intervention on the process of cholesterol risk management in patients at high risk for cardiovascular events.A randomized controlled trial conducted in 54 community pharmacies (1998-2000) included patients at high risk for cardiovascular events (with atherosclerotic disease or diabetes mellitus with another risk factor). Patients randomized to pharmacist intervention received education and a brochure on risk factors, point-of-care cholesterol measurement, referral to their physician, and regular follow-up for 16 weeks. Pharmacists faxed a simple form to the primary care physician identifying risk factors and any suggestions. Usual care patients received the same brochure and general advice only, with minimal follow-up. The primary end point was a composite of performance of a fasting cholesterol panel by the physician or addition or increase in dose of cholesterol-lowering medication.The external monitoring committee recommended early study termination owing to benefit. Of the 675 patients enrolled, approximately 40% were women, and the average age was 64 years. The primary end point was reached in 57% of intervention patients vs 31% in usual care (odds ratio, 3.0; 95% confidence interval, 2.2-4.1; P.001).A community-based intervention program improved the process of cholesterol management in high-risk patients. This program demonstrates the value of community pharmacists working in collaboration with patients and physicians.

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.