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1.  Evaluation of Pharmacist Provided Medication Therapy Management Services in an Oncology Ambulatory Setting at a Comprehensive Cancer Center 
Journal of the American Pharmacists Association : JAPhA  2012;52(2):10.1331/JAPhA.2012.11171.
In 2005 a definition for medication therapy management services (MTM) was developed by eleven pharmacy organizations. That year the American Medical Association introduced three temporary Current Procedural Terminology (CPT) codes for MTM. In 2008 these codes were made permanent making billing for outpatient MTM services possible. In 2010 our institution implemented a MTM program to augment services already provided. Clinical pharmacy specialists documented within the electronic medical record (EMR) upon completion of service and submitted a charge for MTM. The primary objective was to determine the effect of formal MTM services on pharmacist workload. Secondary objectives included describing the population receiving MTM, describing services provided, and determining the reimbursement rate for billed MTM services.
Data Sources
MTM CPT code claims, EMR, pharmacist MTM log
Study Selection
Not applicable
Data Synthesis
A retrospective review of all MTM charges from 1/1/2010-3/31/2010 was performed. Data collected included: location of MTM visit, age, gender, insurance, primary malignancy, comorbidities, home medications, time completing and documenting MTM visit, and rate of reimbursement.
In the three month period 239 MTM visits were completed. It took pharmacists a median of 20 minutes (range: 15–127 minutes) of face-to-face time and 18 minutes (range: 5–90 minutes) for documentation per visit. To date no claims for MTM have been rejected and reimbursement rates range from 47–79% depending on the insurance provider.
MTM in the ambulatory clinic is feasible despite the increase in pharmacist work load from documenting and billing. Increased visibility of clinical pharmacy services justify the extra time required for formal MTM.
PMCID: PMC3868215  PMID: 22370379
Medication therapy management; clinical pharmacy; reimbursement; ambulatory clinic; CPT codes
2.  Potential Health Implications of Racial and Ethnic Disparities in Meeting MTM Eligibility Criteria 
Research in social & administrative pharmacy : RSAP  2013;10(1):10.1016/j.sapharm.2013.03.007.
Previous studies have found that racial and ethnic minorities would be less likely to meet the Medicare eligibility criteria for medication therapy management (MTM) services than their non-Hispanic White counterparts.
To examine whether racial and ethnic disparities in health status, health services utilization and costs, and medication utilization patterns among MTM-ineligible individuals differed from MTM-eligible individuals.
This study analyzed Medicare beneficiaries in 2004–2005 Medicare Current Beneficiary Survey. Various multivariate regressions were employed depending on the nature of dependent variables. Interaction terms between the dummy variables for Blacks (and Hispanics) and MTM eligibility were included to test whether disparity patterns varied between MTM-ineligible and MTM-eligible individuals. Main and sensitivity analyses were conducted for MTM eligibility thresholds for 2006 and 2010.
Based on the main analysis for 2006 MTM eligibility criteria, the proportions for self-reported good health status for Whites and Blacks were 82.82% vs. 70.75%, respectively (difference=12.07%; P< .001), among MTM-ineligible population; and 56.98% vs. 52.14%, respectively (difference=4.84%; P= .31), among MTM-eligible population. The difference between these differences was 7.23% (P< .001). In the adjusted logistic regression, the interaction effect for Blacks and MTM eligibility had an OR of 1.57 (95% Confidence Interval, or CI=0.98–2.52) on multiplicative term and difference in odds of 2.38 (95% CI=1.54–3.22) on additive term. Analyses for disparities between Whites and Hispanics found similar disparity patterns. All analyses for 2006 and 2010 eligibility criteria generally reported similar patterns. Analyses of other measures did not find greater racial or ethnic disparities among the MTM-ineligible than MTM-eligible individuals.
Disparities in MTM eligibility may aggravate existing racial and ethnic disparities in health outcomes. However, disparities in MTM eligibility may not aggravate existing disparities in health services utilization and costs and medication utilization patterns. Future studies should examine the effects of Medicare Part D on these disparities.
PMCID: PMC3858402  PMID: 23759673
Health disparities; race; ethnicity; medication therapy management services; eligibility criteria
3.  Development and validation of a scale to measure patients’ trust in pharmacists in Singapore 
To develop and validate a scale to measure patients’ trust in pharmacists for use as an outcomes predictor in pharmacoeconomic and pharmaceutical care studies.
Literature review, study team discussion and focus group discussions were conducted to generate items of a candidate version to be pilot-tested for content validity. An amended candidate version was then tested among eligible Singaporeans across different ethnic and age groups. Score distributions were assessed for discriminatory power and item analyses for finalizing items. Exploratory factor analysis was used to identify dimensionality and homogeneous items. Cronbach’s alpha was measured for internal consistency and Pearson’s correlation coefficients for convergent validity.
Eighteen items were generated with good variability (SD > 1.0) and symmetry (means ranged from −1 to 1) for score distribution. After minor changes to improve content clarity, the amended questionnaire was self-administered among 1196 respondents [mean (SD) age: 38.6 (14.9) years, 51.6% female, 87% >6 years of education]. Six items were dropped due to inadequate item-total correlation coefficients, leaving 12-item scale for factor analysis. Three factors (“benevolence”, “technical competence” and “global trust”) were identified, accounting for 55% of the total variance. Cronbach’s alpha was 0.83, indicating high internal consistency. Convergent validity was demonstrated by statistically significant positive correlations between trust and patients’ satisfaction with pharmacists’ service (r = 0.54), returning for care (r = 0.30) and preference of medical decision-making pattern (r = 0.16).
The 12-item trust in pharmacists scale demonstrated high reliability and convergent validity. Further studies among other populations are suggested to confirm the robustness and even improve the current scale.
PMCID: PMC2778414  PMID: 19936139
trust; pharmacist; scale; factor analysis; patient relationship
4.  An Advanced Pharmacy Practice Experience in a Student-Staffed Medication Therapy Management Call Center 
Objective. To describe the implementation of an advanced pharmacy practice experience (APPE) in medication therapy management (MTM) designed to contribute to student pharmacists’ confidence and abilities in providing MTM.
Design. Sixty-four student pharmacists provided MTM services during an APPE in a communication and care center.
Assessment. Students conducted 1,495 comprehensive medication reviews (CMRs) identifying 6,056 medication-related problems. Ninety-eight percent of the students who completed a survey instrument (52 of 53) following the APPE expressed that they had the necessary knowledge and skills to provide MTM services. Most respondents felt that pharmacist participation in providing Medicare MTM could move the profession of pharmacy forward and that pharmacists will have some role in deciding the specific provisions of the Medicare MTM program (92% and 91%, respectively).
Conclusion. Students completing the MTM APPE received patient-centered experiences that supplemented their confidence, knowledge, and skill in providing MTM services in the future.
PMCID: PMC3425925  PMID: 22919086
medication therapy management; advanced pharmacy practice experience; student pharmacists; patient-centered care
5.  Contingent Valuation and Pharmacists' Acceptable Levels of Compensation for Medication Therapy Management Services 
Research in social & administrative pharmacy : RSAP  2012;10.1016/j.sapharm.2012.02.001.
Pharmacists' acceptable level of compensation for medication therapy management (MTM) services needs to be determined using various economic evaluation techniques.
Using contingent valuation method, determine pharmacists' acceptable levels of compensation for MTM services.
A mailing survey was used to elicit Tennessee (US) pharmacists' acceptable levels of compensation for a 30-minute MTM session for a new patient with 2 medical conditions, 8 medications, and an annual drug cost of $2,000. Three versions of a series of double-bounded, closed-ended, binary discrete choice questions were asked of pharmacists for their willingness-to-accept (WTA) for an original monetary value ($30, $60, or $90) and then follow-up higher or lower value depending on their responses to the original value. A Kaplan-Meier approach was taken to analyze pharmacists' WTA, and Cox's proportional hazards model was used to examine the effects of pharmacist characteristics on their WTA.
Three hundred and forty-eight pharmacists responded to the survey. Pharmacists' WTA for the given MTM session had a mean of $63.31 and median of $60. The proportions of pharmacists willing to accept $30, $60, and $90 for the given MTM session were 30.61%, 85.19%, and 91.01%, respectively. Pharmacists' characteristics had statistically significant association with their WTA rates.
Pharmacists' WTA for the given MTM session is higher than current Medicare MTM programs' compensation levels of $15 to $50 and patients' willingness-to-pay of less than $40. Besides advocating for higher MTM compensation levels by third-party payers, pharmacists also may need to charge patients to reach sufficient compensation levels for MTM services.
PMCID: PMC3445666  PMID: 22436583
Medication therapy management services; contingent valuation; pharmacists; compensation; willingness to accept
6.  Medication therapy management clinic: perception of healthcare professionals in a University medical center setting 
Pharmacy Practice  2013;11(3):173-177.
To determine the overall perception and utilization of the pharmacist managed medication therapy management (MTM) clinic services, by healthcare professionals in a large, urban, university medical care setting.
This was a cross-sectional, anonymous survey sent to 195 healthcare professionals, including physicians, nurses, and pharmacists at The University of Illinois Outpatient Care Center to determine their perception and utilization of the MTM clinic. The survey consisted of 12 questions and was delivered through a secure online application.
Sixty-two healthcare professionals (32%) completed the survey. 82% were familiar with the MTM clinic, and 63% had referred patients to the clinic. Medication adherence and disease state management was the most common reason for referral. Lack of knowledge on the appropriate referral procedure was the prominent reason for not referring patients to the MTM clinic. Of the providers that were aware of MTM services, 44% rated care as ‘excellent’, 44% as ‘good’, 5% as ‘fair’, and 0% stated ‘poor’. Strengths of MTM clinic identified by healthcare providers included in-depth education to patients, close follow-up, and detailed medication reconciliation provided by MTM clinic pharmacists. Of those familiar with MTM clinic, recommendations included; increase marketing efforts to raise awareness of the MTM clinic service, create collaborative practice agreements between MTM pharmacists and physicians, and ensure that progress notes are more concise.
In a large, urban, academic institution MTM clinic is perceived as a valuable resource to optimize patient care by providing patients with in-depth education as it relates to their prescribed medications and disease states. These identified benefits of MTM clinic lead to frequent patient referrals specifically for aid with medication adherence and disease state management.
PMCID: PMC3809139  PMID: 24223083
Medication Therapy Management; Professional Practice; Academic Medical Centers; Personal Satisfaction; Attitude of Health Personnel; Pharmacists; United States
7.  Medication Therapy Management Training Using Case Studies and the MirixaPro Platform 
To implement and assess a medication therapy management (MTM) training program for pharmacy students using the MirixaPro (Mirixa Corporation, Reston, VA) platform and case studies.
Students received lectures introducing MTM and were given a demonstration of the MirixaPro platform. They were divided into teams and assigned cases and times to interview patients portrayed by faculty members. Using the MirixaPro system, students performed 2 comprehensive medication reviews during the semester, recording the patient's current medications, indications, side effects, allergies, health conditions, and laboratory test recommendations and developed a personal medication record and medication action plan.
Based on a rubric with a rating scale of 0-10, campus and distance pathway students received mean scores ranging from 6.3-7.4 for their performance on the second MTM exercise, an increase of 47%-54% over the first MTM exercise. In qualitative assessments, the majority of students believed that their confidence in providing MTM was enhanced by the activity, while faculty members recognized the advantage of using MirixaPro, which allowed students to experience what is required in processing a pharmacist led, billable MTM encounter.
Use of the MirixaPro system and patient cases provides students with a “hands-on” experience that may encourage them to promote MTM during their APPEs and provide MTM services as practicing pharmacists.
PMCID: PMC3109803  PMID: 21655403
medication therapy management (MTM); Web-based technology; active learning; patient simulation; case-based learning
8.  An Online Virtual-Patient Program to Teach Pharmacists and Pharmacy Students How to Provide Diabetes-Specific Medication Therapy Management 
Objective. To develop, implement, and assess the effectiveness of an online medication therapy management (MTM) program to train pharmacists and pharmacy students in providing MTM services for patients with diabetes and to increase their intent to perform these services.
Design. An online program was created using an Internet-based learning platform to simulate 4 MTM meetings between a pharmacist and a virtual patient diagnosed with diabetes.
Assessment. Eighty students and 42 pharmacists completed the program. After completing the program, scores on post-intervention assessments showed significant improvement in 2 areas: control over performing MTM, and knowledge of how to perform MTM. Students had a significantly less-positive attitude about MTM and a decline in their perception of the social expectation that MTM is part of the practice of pharmacy, while pharmacists’ attitudes did not change significantly in these areas.
Conclusion. This online program using a virtual patient improved both participants’ belief that they have control over performing MTM, and their knowledge of how to perform MTM for diabetic patients, which may increase the likelihood that pharmacists and pharmacy students will perform MTM in the future.
PMCID: PMC3448469  PMID: 23049103
medication therapy management; diabetes; pharmacist; virtual patient; simulation; pharmacy student
9.  Assessing Medicare Beneficiary Eligibility for Medication Therapy Management Programs Using PINNACLE, a National Cardiovascular Data Registry 
American Health & Drug Benefits  2013;6(7):367-374.
Medication therapy management (MTM) is a mandated component of the 2003 Medicare Modernization Act for Part D prescription drug plans and Medicare Advantage plans, authorizing the pharmacist or other qualified provider to identify, resolve, and prevent medication-related problems for patients with chronic diseases. MTM programs have been shown to improve medication adherence and reduce medication errors while reducing overall costs in patients with cardiovascular (CV) disease; however, MTM has been greatly underutilized for patients with chronic diseases.
To identify the proportion of Medicare beneficiaries who are eligible for, and who could potentially benefit from, participating in MTM among patients enrolled in the National Cardiovascular Data Registry's PINNACLE Registry.
Patient MTM eligibility is based on the presence of multiple chronic diseases and meeting a minimum annual insurance medication costs. We used patient data from 462 academic and private cardiology practices in the United States who participated in the PINNACLE Registry between May 1, 2008, and September 30, 2010, to determine Medicare beneficiaries' eligibility to participate in an MTM program for patients meeting the MTM criteria of (1) a number of chronic diseases (in this case, the number of CV conditions) and (2) an estimated minimum annual medication expenses, using a weighted average cost calculated based on the average wholesale price of the most often prescribed medications, by class, as extracted from the HealthCore Integrated Research Database and weighted according to prescribing frequency within a class.
Among the Medicare beneficiaries in the PINNACLE Registry, 93,089 (58%) had ≥3 chronic CV conditions, and the median annual estimated medication expenditure per patient enrolled in the PINNACLE Registry was $1329. Of the total of 93,089 Medicare beneficiaries, 21.4% were eligible for MTM, based on the 2010 minimum eligibility criterion of an annual insurer medication expenditure of $3000 or more. These costs ranged from $366 for low-cost generics to $3958 for the highest-cost drug in a class. In addition, based on the 2010 minimum eligibility rule, the proportion of patients eligible for MTM ranged from 7.9% for those eligible for MTM for low-cost generics to 64% of patients eligible for MTM for the highest-cost medication in a class.
These data serve to raise awareness regarding patients' potential eligibility to receive the benefits of MTM programs. Providers caring for patients with multiple CV conditions, including specialists such as cardiologists, should explain to eligible patients about MTM programs and encourage these patients to take advantage of such programs.
PMCID: PMC4031728  PMID: 24991369
10.  Development and Validation of the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) for Primary Care Patients with Type 2 Diabetes 
PLoS ONE  2013;8(11):e78933.
To develop and evaluate the psychometric properties of a Chinese questionnaire which assesses the barriers and enablers to commencing insulin in primary care patients with poorly controlled Type 2 diabetes.
Research Design and Method
Questionnaire items were identified using literature review. Content validation was performed and items were further refined using an expert panel. Following translation, back translation and cognitive debriefing, the translated Chinese questionnaire was piloted on target patients. Exploratory factor analysis and item-scale correlations were performed to test the construct validity of the subscales and items. Internal reliability was tested by Cronbach’s alpha.
Twenty-seven identified items underwent content validation, translation and cognitive debriefing. The translated questionnaire was piloted on 303 insulin naïve (never taken insulin) Type 2 diabetes patients recruited from 10 government-funded primary care clinics across Hong Kong. Sufficient variability in the dataset for factor analysis was confirmed by Bartlett’s Test of Sphericity (P<0.001). Using exploratory factor analysis with varimax rotation, 10 factors were generated onto which 26 items loaded with loading scores > 0.4 and Eigenvalues >1. Total variance for the 10 factors was 66.22%. Kaiser-Meyer-Olkin measure was 0.725. Cronbach’s alpha coefficients for the first four factors were ≥0.6 identifying four sub-scales to which 13 items correlated. Remaining sub-scales and items with poor internal reliability were deleted. The final 13-item instrument had a four scale structure addressing: ‘Self-image and stigmatization’; ‘Factors promoting self-efficacy; ‘Fear of pain or needles’; and ‘Time and family support’.
The Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) appears to be a reliable and valid measure for assessing barriers to starting insulin. This short instrument is easy to administer and may be used by healthcare providers and researchers as an assessment tool for Chinese diabetic primary care patients, including the elderly, who are unwilling to start insulin.
PMCID: PMC3827341  PMID: 24236071
11.  The chronic kidney disease self-efficacy (CKD-SE) instrument: development and psychometric evaluation 
Nephrology Dialysis Transplantation  2012;27(10):3828-3834.
While the new disease-specific self-efficacy scale for early CKD appears to be a promising new tool (…), additional evaluation is needed to further refine it.
Self-management has been associated with positive health outcomes among adults with chronic kidney disease (CKD). Perceived disease-related self-efficacy (DSE) is considered a critical component in the successful self-management of chronic disease. A valid and reliable instrument for measuring CKD patients' self-efficacy is needed. This study aims to develop and test a new instrument to measure the DSE of patients with early stage CKD.
A total of 594 Taiwanese patients with early stage CKD recruited from two medical centers and one regional hospital in southern Taiwan completed the questionnaire. The CKD self-efficacy (CKD-SE) was evaluated using exploratory factor analyses (EFA) and measures of reliability.
EFA identified four distinct factors with loadings ranging from 0.557 to 0.970: autonomy, self-integration, problem solving and seeking social support, accounting for 64.348% of the total variance. Cronbach's alpha coefficients for the subscales ranged from 0.843 to 0.901.
This promising 25-item CKD-SE instrument can be used for the early identification of patients with low DSE, thus allowing the development of interventions to help these patients attain an appropriate level of DSE.
PMCID: PMC3808692  PMID: 22344776
chronic kidney disease; exploratory factor analysis; instrument development; self-efficacy; self-management
12.  Validation of an HIV-related stigma scale among health care providers in a resource-poor Ethiopian setting 
Stigma and discrimination (SAD) against people living with human immunodeficiency virus (HIV) are barriers affecting effective responses to HIV. Understanding the causes and extent of SAD requires the use of a psychometrically reliable and valid scale. The objective of this study was to validate an HIV-related stigma scale among health care providers in a resource-poor setting.
A cross-sectional validation study was conducted in 18 health care institutions in southwest Ethiopia, from March 14, 2011 to April 14, 2011. A total of 255 health care providers responded to questionnaires asking about sociodemographic characteristics, HIV knowledge, perceived institutional support (PIS) and HIV-related SAD. Exploratory factor analysis (EFA) with principal component extraction and varimax with Kaiser normalization rotation were employed to develop scales for SAD. Eigenvalues greater than 1 were used as a criterion of extraction. Items with item-factor loadings less than 0.4 and items loading onto more than one factor were dropped. The convergent validity of the scales was tested by assessing the association with HIV knowledge, PIS, training on topics related to SAD, educational status, HIV case load, presence of an antiretroviral therapy (ART) service in the health care facility, and perceived religiosity.
Seven factors emerged from the four dimensions of SAD during the EFA. The factor loadings of the items ranged from 0.58 to 0.93. Cronbach’s alphas of the scales ranged from 0.80 to 0.95. An in-depth knowledge of HIV, perceptions of institutional support, attendance of training on topics related to SAD, degree or higher education levels, high HIV case loads, the availability of ART in the health care facility and claiming oneself as nonreligious were all negatively associated with SAD as measured by the seven newly identified latent factors.
The findings in this study demonstrate that the HIV-related stigma scale is valid and reliable when used in resource-poor settings. Considering the local situation, health care managers and researchers may use this scale to measure and characterize HIV-related SAD among health care providers. Tailoring for local regions may require further development of the tool.
PMCID: PMC3333803  PMID: 22536080
stigma; discrimination; health care providers; HIV
13.  Assessing self-management in patients with diabetes mellitus type 2 in Germany: validation of a German version of the Summary of Diabetes Self-Care Activities measure (SDSCA-G) 
One of the most widely used self-reporting tools assessing diabetes self-management in English is the Summary of Diabetes Self-Care Activities (SDSCA) measure. To date there is no psychometric validated instrument in German to assess self-management in patients with diabetes mellitus. Therefore, this study aimed to translate the SDSCA into German and examine its psychometric properties.
The English version of the SDSCA was translated into German following the guidelines for cultural adaptation. The German version of the SDSCA (SDSCA-G) was administered to a random sample of 315 patients with diabetes mellitus type 2. Reliability was analyzed using Cronbach’s alpha coefficient and item characteristics were assessed. Exploratory and confirmatory factor analysis (EFA and CFA) were carried out to explore the construct validity. A multivariable linear regression model was used to identify the influence of predictor variables on the SDSCA-G sum score.
The Cronbach’s alpha for the SDSCA-G (all items) was α = 0.618 and an acceptable correlation between the SDSCA-G and Self-management Diabetes Mellitus-Questionnaire (SDQ) (ρ = 0.664) was identified. The EFA suggested a four factor construct as did the postulated model. The CFA showed the goodness of fit of the SDSCA-G. However, item 4 was found to be problematic regarding the analysis of psychometric properties. The omission of item 4 yielded an increase in Cronbach’s alpha (α = 0.631) and improvements of the factor structure and model fit. No statistically significant influences of predictor variables on the SDSCA-G sum score were observed.
The revised German version of the SDSCA (SDSCA-G) is a reliable and valid tool assessing self-management in adults with type 2 diabetes in Germany.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-014-0185-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4297436  PMID: 25519204
Diabetes mellitus type 2; Self-management; Self-care; Outcome measurement; German; Validation
14.  Simulated Medication Therapy Management Activities in a Pharmacotherapy Laboratory Course 
Objective. To measure the impact of medication therapy management (MTM) learning activities on students’ confidence and intention to provide MTM using the Theory of Planned Behavior.
Design. An MTM curriculum combining lecture instruction and active-learning strategies was incorporated into a required pharmacotherapy laboratory course.
Assessment. A validated survey instrument was developed to evaluate student confidence and intent to engage in MTM services using the domains comprising the Theory of Planned Behavior. Confidence scores improved significantly from baseline for all items (p < 0.00), including identification of billable services, documentation, and electronic billing. Mean scores improved significantly for all Theory of Planned Behavior items within the constructs of perceived behavioral control and subjective norms (p < 0.05). At baseline, 42% of students agreed or strongly agreed that they had knowledge and skills to provide MTM. This percentage increased to 82% following completion of the laboratory activities.
Conclusion. Implementation of simulated MTM activities in a pharmacotherapy laboratory significantly increased knowledge scores, confidence measures, and scores on Theory of Planned Behavior constructs related to perceived behavioral control and subjective norms. Despite these improvements, intention to engage in future MTM services remained unchanged.
PMCID: PMC3142971  PMID: 21829269
medication therapy management; active learning; theory of planned behavior; laboratory course; student confidence; intention
15.  Medication Therapy Management Services Provided by Student Pharmacists 
Objectives. To evaluate the impact of student pharmacists delivering medication therapy management (MTM) services during an elective advanced pharmacy practice experience (APPE).
Methods. Student pharmacists provided MTM services at community pharmacy APPE sites, documented their recommendations, and then made follow-up telephone calls to patients to determine the impact of the MTM provided. Students were surveyed about the MTM experience.
Results. Forty-seven students provided MTM services to 509 patients over 2 years and identified 704 drug-related problems (average of 1.4 problems per patient). About 53% of patients relayed the recommendations to their physician and 205 (75%) physicians accepted the recommendations. Eighty-eight percent of patients reported feeling better about their medications after receiving MTM services. A majority of the students perceived their provision of MTM services as valuable to their patients.
Conclusions. Providing MTM services to patients in a pharmacy practice setting allowed student pharmacists to apply skills learned in the doctor of pharmacy (PharmD) curriculum.
PMCID: PMC3327249  PMID: 22544968
medication therapy management; experiential education; doctor of pharmacy program; advanced pharmacy practice experience; community pharmacy
16.  Validation of the condom use self-efficacy scale in Ethiopia 
The measurement of condom use self-efficacy requires contextually suitable, valid and reliable instruments due to variability of the scale across nations with different cultural and ethnic backgrounds. This study aims to construct a condom use self-efficacy scale suitable to Ethiopia (CUSES-E), based on the original scale developed by Brafford and Beck.
A cross-sectional study was conducted on a random sample of 492 students at Hawassa University. A self-administered questionnaire containing 28 items from the original scale was used to collect the data. Principal Component Analysis (PCA) with Varimax rotation was used to extract factor structures. Cronbach’s alpha and item-total correlations were used to determine the internal consistency of the scale. The convergent and discriminant validity of the scale was verified using a correlation matrix.
The PCA extracted three factors containing a total of 9-items. The extracted factors were labeled Assertiveness, Fear for partner rejection and Intoxicant Control, with internal consistency coefficients (Cronbach’s alpha) of 0.86, 0.86 and 0.92, respectively. Altogether, the factors explained 77.8% of variance in the items. An evaluation of CUSES-E showed a significantly higher self-efficacy score among students who ever used condoms; P < 0.001. The correlation matrix revealed that all of the convergent correlations were higher than the discriminant ones, providing evidence in support of both types of validity. In the split sample validation, the communalities, factor loadings and factor structure were the same on the analysis on each half and the full data set, suggesting that the new scale is generalizable and replicable.
This study of CUSES using an Ethiopian population found a different dimension to emerge, suggesting that the scale should be validated to local contexts before application. The CUSES-E is valid, reliable and replicable. Therefore, health cadres and researchers in Ethiopia can apply this scale to promote condom utilization to Ethiopian school youths. However, future research to develop a suitable scale (highly valid and reliable) in concordance with the local vernacular using a prior qualitative study is needed.
PMCID: PMC3644237  PMID: 23617404
Validation; CUSES-E; Hawassa University
17.  Psychometric Properties of a Symptom Management Self-Efficacy Scale for Women Living with HIV/AIDS 
Many people with HIV/AIDS find it difficult to manage the symptoms of the disease, but by adopting effective symptom management behavior, they increase the potential of alleviating the burden of those symptoms. Self-efficacy is a recognized mediator of successful behavior change and is utilized by many researchers and clinicians when developing symptom management interventions. Despite this, an instrument measuring the self-efficacy of symptom management behavior specifically for people living with HIV/AIDS has not yet been made available.
To introduce and test the psychometric properties of the HIV Symptom Management Self-Efficacy for Women Scale (HSM-SEWS) for women with HIV/AIDS. This scale, a new 9-item measurement instrument, was modified from the Chronic Disease Self-Efficacy Scale.
In this study, psychometric testing focused on the reliability and validity of the HSM-SEWS instrument. Reliability was assessed using Cronbach’s alpha. Exploratory factor analysis with oblique promax rotation was used to examine validity and test hypothetical associations.
Eighty-nine HIV-positive women were recruited and asked to complete the scale every four weeks for a total of 16 weeks. Factor analysis supported a one-factor solution explaining 93% of the variance among items. Internal consistency of the nine items was found to range from 0.83–0.93, with an overall Cronbach’s alpha of 0.92.
Psychometric analyses suggest that the HIV Symptom Management Self-Efficacy for Women Scale is a reliable and valid instrument that measures the self-efficacy of symptom management behavior in women with HIV/AIDS and can be used during interventions and in research targeting this area of health care research.
PMCID: PMC3062714  PMID: 21145198
Self-efficacy; symptom management; psychometric; women; HIV/AIDS
18.  Development and psychometric properties of a scale for measuring internal participation from a patient and health care professional perspective 
Effective patient-centred health care requires internal participation, which is defined as interprofessional patient-centred teamwork. Many scales are designed for measuring teamwork from the perspective of one type of health care professional (e.g. physician or nurse), rather than for the use for all health care professionals as well as patients. Hence, this paper’s purpose is to develop a scale for measuring internal participation from all relevant perspectives and to check its psychometric properties.
In a multicentre cross-sectional study, a 6-item Internal Participation Scale (IPS) was developed and administered to 661 health care professionals (staff) and 1419 patients in 15 rehabilitation clinics to test item characteristics, acceptance, reliability (internal consistency) and construct validity. Additionally, we performed an exploratory factor analysis (EFA) to determine the factorial structure and explained variance. Confirmatory factor analysis (CFA) was used to verify the theoretically assumed one-dimensional factorial structure.
A total of 275 health care professionals and 662 patients participated, and the complete data sets of 272 staff members and 536 patients were included in the final analysis. The discrimination index was above .4 for all items in both samples. Internal consistency was very good, with Cronbach’s alpha equalling .87 for the staff and .88 for the patient sample. EFA supported a one-dimensional structure of the instrument (explained variance: 61.1% (staff) and 62.3% (patients)). CFA verified the factorial structure, with the factor loadings exceeding .4 for five of six items in both samples. Global goodness-of-fit indices indicated a good model fit, with a Tucker-Lewis index (TLI) of .974 (staff) and .976 (patients) and a comparative fit index (CFI) of .988 (staff) and .989 (patients). The root mean square error of approximation (RMSEA) amounted to .068 for the patient sample and .069 for the staff sample. There is evidence of construct validity for both populations.
The analysis of the scale’s psychometric properties resulted in good values. The scale is a promising instrument to assess internal participation from the perspective of both patients and staff. Further research should investigate the scale’s psychometric properties in other interprofessional health care settings to examine its generalizability as well as its sensitivity to change.
PMCID: PMC3850532  PMID: 24083632
Internal participation; Interprofessional collaboration; Team; Psychometrics; Scale development; Healthcare; Germany
19.  Cultural adaptation of the Condom Use Self Efficacy Scale (CUSES) in Ghana 
BMC Public Health  2010;10:227.
Accurate assessment of self-reports of sexual behaviours is vital to the evaluation of HIV prevention and family planning interventions. This investigation was to determine the cross-cultural suitability of the Condom Use Self Efficacy Scale (CUSES) originally developed for American adolescents and young adults by examining the structure and psychometric properties.
A self-administered cross-sectional survey of a convenient sample of 511 participants from a private university in Ghana with mean age 21.59 years.
A Principal Component Analysis with varimax rotation identified a 14 item scale with four reliable factors labelled Appropriation (Cronbach alpha = .85), Assertive (Cronbach alpha = .90), Pleasure and Intoxicant (Cronbach alpha = .83), and STDs (Cronbach alpha = .81) that altogether explained 73.72% of the total variance. The scale correlated well with a measure of condom use at past sexual encounter (r = .73), indicating evidence of construct and discriminatory validity. The factor loadings were similar to the original CUSES scale but not identical suggesting relevant cultural variations.
The 14 item scale (CUSES-G) is a reliable and valid instrument for assessing condom use self efficacy. It is culturally appropriate for use among Ghanaian youth to gauge actual condom use and to evaluate interventions meant to increase condom use. Finally, the study cautioned researchers against the use of the original CUSES without validation in African settings and contexts.
PMCID: PMC2874779  PMID: 20433724
20.  Effects of Medicare Part D on Disparity Implications of Medication Therapy Management Eligibility Criteria 
American Health & Drug Benefits  2014;7(6):346-358.
Previous studies have shown that there were greater racial and ethnic disparities among individuals who were ineligible for medication therapy management (MTM) services than among MTM-eligible individuals before the implementation of Medicare Part D in 2006.
To determine whether the implementation of Medicare Part D in 2006 correlates to changes in racial and ethnic disparities among MTM-ineligible and MTM-eligible beneficiaries.
Data from the Medicare Current Beneficiary Survey were analyzed in this retrospective observational analysis. To examine potential racial and ethnic disparities, non-Hispanic whites were compared with non-Hispanic blacks and Hispanics. Three aspects of disparities were analyzed, including health status, health services utilization and costs, and medication utilization patterns. A generalized difference-in-differences analysis was used to examine the changes in difference in disparities between MTM-ineligible and MTM-eligible individuals from 2004–2005 to 2007–2008 relative to changes from 2001–2002 and 2004–2005. Various multivariate regressions were used based on the types of dependent variables. A main analysis and several sensitivity analyses were conducted to represent the ranges of MTM eligibility thresholds used by Medicare Part D plans in 2010.
The main analysis showed that Part D implementation was not associated with reductions in greater racial and ethnic disparities among MTM-ineligible than MTM-eligible Medicare beneficiaries. The main analysis suggests that after Part D implementation, Medicare MTM eligibility criteria may not consistently improve the existing racial and ethnic disparities in health status, health services utilization and costs, and medication utilization. By contrast, several sensitivity analyses showed that Part D implementation did correlate with a significant reduction in greater racial disparities among the MTM-ineligible group than the MTM-eligible group in activities of daily living and in instrumental activities of daily living. Part D implementation may be also associated with a reduction in greater ethnic disparities among the MTM-ineligible group than the MTM-eligible groups in the costs of physician visits.
Part D implementation was not associated with consistent reductions in the disparity implications of the Medicare MTM eligibility criteria. The main analysis showed that Part D implementation was not associated with a reduction in disparities associated with MTM eligibility, although several sensitivity analyses did show reductions in disparities in specific aspects. Future research should explore alternative Medicare MTM eligibility criteria to eliminate racial and ethnic disparities among the Medicare population.
PMCID: PMC4280526  PMID: 25558303
21.  Measuring teamwork and conflict among Emergency Medical Technician personnel 
We sought to develop a reliable and valid tool for measuring teamwork among Emergency Medical Technician (EMT) partnerships.
We adapted existing scales and developed new items to measure components of teamwork. After recruiting a convenience sample of 39 agencies, we tested a 122-item draft survey tool. We performed a series of Exploratory Factor Analyses (EFA) and Confirmatory Factor Analysis (CFA) to test reliability and construct validity, describing variation in domain and global scores using descriptive statistics.
We received 687 completed surveys. The EFA analyses identified a 9-factor solution. We labeled these factors [1] Team Orientation, [2] Team Structure & Leadership, [3] Partner Communication, Team Support, & Monitoring, [4] Partner Trust and Shared Mental Models, [5] Partner Adaptability & Back-Up Behavior, [6] Process Conflict, [7] Strong Task Conflict, [8] Mild Task Conflict, and [9] Interpersonal Conflict. We tested a short form (30-item SF) and long form (45-item LF) version. The CFA analyses determined that both the SF and LF versions possess positive psychometric properties of reliability and construct validity. The EMT-TEAMWORK-SF has positive internal consistency properties with a mean Cronbach’s alpha coefficient ≥0.70 across all 9-factors (mean=0.84; min=0.78, max=0.94). The mean Cronbach’s alpha coefficient for the EMT-TEAMWORK-LF version was 0.87 (min=0.79, max=0.94). There was wide variation in weighted scores across all 9 factors and the global score for the SF and LF versions. Mean scores were lowest for the Team Orientation factor (48.1, SD 21.5 SF; 49.3 SD 19.8 LF) and highest (more positive) for the Interpersonal Conflict factor (87.7 SD 18.1 for both SF and LF).
We developed a reliable and valid survey to evaluate teamwork between EMT partners.
PMCID: PMC3233978  PMID: 22128909
22.  Reliability and validity of the Chinese version of reporting of clinical adverse events scale (C-RoCAES) 
Background: Adverse event is a crucial issue affecting patient’s safety of healthcare services. To assess nurses’ attitude of reporting adverse events is important to establish a safe environment for patients. However, no relevant instrument has been validated and used in China. This study was to examine validity and reliability of Chinese version of Reporting of Clinical adverse Event Scale (C-RoCAES). Material and methods: Chinese version of 25-item RoCAES was used in a sample of 1557 nurses. Confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were selected for construct validity test. Internal consistency was also examined. Results: After CFA and EFA, two items were removed and two items loaded on different factors in our sample. Five factors were generated, including perceived blame, perceived criteria for identifying events that should be reported, perceptions of colleagues’ expectations, perceived benefits of reporting and perceived clarity of reporting procedures. Cronbach’s alpha for the total scale and subscales ranged from 0.70 to 0.85. Conclusion: C-RoCAES is applicable to healthcare services of China. The instrument provide information for the providers of healthcare services to develop staff education regarding patient safety, and also help them to evaluate strategies of preventing adverse events in clinical practice in China.
PMCID: PMC4238501  PMID: 25419395
Reporting of clinical adverse events scale (RoCAES); confirmatory factor analysis; exploratory factor analysis
23.  Evaluating Pennsylvania Pharmacists’ Provision of Community-based Patient Care Services to Develop a Statewide Practice Network 
Innovations in pharmacy  2011;2(4):61-.
To identify and describe Pennsylvania pharmacists who currently provide or are interested in providing community-based patient care services and are interested in joining a statewide practice network.
Cross-sectional survey.
February to June 2009 in Pennsylvania.
1700 pharmacists.
Mailed and electronic survey.
Main outcome measures
Number and geographic location of pharmacists providing or interested in providing community-based patient care in Pennsylvania. Description of patient care documentation methods; physical space; services provided; perceived barriers to providing patient care; training needs; and interest in joining a statewide practice network.
The final analysis included data from 1700 pharmacists. Approximately one-third of pharmacists (n=554) were providing patient care services to community-based patients. Most were routinely documenting (67.5%) and many had a semi-private or private space to provide care. MTM and immunizations were the most common services provided. Respondents reported the most significant barrier to providing MTM, diabetes education, and smoking cessation education was time constraints, whereas training was a barrier for immunization provision. Most pharmacists were not being compensated for patient care services. Of the 869 pharmacists interested in joining a statewide network, those providing care were more interested in joining than those who were not (70.8% vs. 43.8%, p < 0.001). Conclusion: Pennsylvania pharmacists are interested in providing community-based patient care services and joining a statewide practice network focused on providing community-based patient care services. This research serves as a foundation for building a pharmacist practice network in Pennsylvania.
PMCID: PMC4232935  PMID: 25405069
Medication Therapy Management (MTM); network; statewide survey; cognitive services; pharmacy services
24.  Medication adherence behaviors of Medicare beneficiaries 
Medication adherence is crucial for positive outcomes in the management of chronic conditions. Comprehensive medication consultation can improve medication adherence by addressing intentional and unintentional nonadherence. The Medicare Part D prescription drug benefit has eliminated some cost barriers. We sought to examine variables that impact self-reported medication adherence behaviors in an ambulatory Medicare-beneficiary population and to identify the factors that influence what information is provided during a pharmacist consultation.
Medicare beneficiaries who attended health fairs in northern California were offered medication therapy management (MTM) services during which demographic, social, and health information, and responses to survey questions regarding adherence were collected. Beneficiaries were also asked which critical elements of a consultation were typically provided by their community pharmacist. Survey responses were examined as a function of demographic, socioeconomic, and health-related factors.
Of the 586 beneficiaries who were provided MTM services, 575 (98%) completed the adherence questions. Of responders, 406 (70%) reported taking medications “all of the time”. Of the remaining 169 (30%), the following reasons for nonadherence were provided: 123 (73%) forgetfulness; 18 (11%) side effects; and 17 (10%) the medication was not needed. Lower adherence rates were associated with difficulty paying for medication, presence of a medication-related problem, and certain symptomatic chronic conditions. Of the 532 who completed survey questions regarding the content of a typical pharmacist consultation, the topics included: 378 (71%) medication name and indication; 361 (68%) administration instructions; 307 (58%) side effects; 257 (48%) missed-dose instructions; and 245 (46%) interactions. Subsidy recipients and non-English speakers were significantly less likely to be counseled on drug name, indication, and side effects. The presence of certain health conditions was also associated with missing consultation elements.
While Medicare beneficiaries are generally adherent to medication therapy, adherence barriers must be identified and addressed during comprehensive medication consultation.
PMCID: PMC4172241  PMID: 25258521
pharmacist consultation; adherence behaviors
25.  The Thai version of the PSS-10: An Investigation of its psychometric properties 
Among the stress instruments that measure the degree to which life events are perceived as stressful, the Perceived Stress Scale (PSS) is widely used. The goal of this study was to examine the psychometric properties of a Thai version of the PSS-10 (T-PSS-10) with a clinical and non-clinical sample. Internal consistency, test-retest reliability, concurrent validity, and the factorial structure of the scale were tested.
A total sample of 479 adult participants was recruited for the study: 368 medical students and 111 patients from two hospitals in Northern Thailand. The T-PSS-10 was used along with the Thai version of State Trait Anxiety Inventory (STAI), the Thai Version of the Rosenberg Self-Esteem Scale (RSES), and the Thai Depression Inventory (TDI).
Exploratory Factor Analysis (EFA) yielded 2 factors with eigenvalues of 5.05 and 1.60, accounting for 66 percent of variance. Factor 1 consisted of 6 items representing "stress"; whereas Factor 2 consisted of 4 items representing "control". The item loadings ranged from 0.547 to 0.881. Investigation of the fit indices associated with Maximum Likelihood (ML) estimation revealed that the two-factor solution was adequate [χ2 = 35.035 (df = 26, N = 368, p < 0.111)]; Goodness-of-Fit Index (GFI) = 0.981; Root Mean Square Residual (RMR) = 0.022; Standardized Root Mean square Residual (SRMR) = 0.037, Comparative Fit Index (CFI) = 0.989; Normed Fit Index (NFI) = 0.96, Non-Normed Fit Index (NNFI) = 0.981, Root Mean Square Error of Approximation (RMSEA) = 0.031. It was found that the T-PSS-10 had a significant positive correlation with the STAI (r = 0.60, p < 0.0001), and the TDI (r = 0.55, p < 0.0001); and was significantly negatively correlated with the RSES (r = -0.46, p < 0.0001, N = 368). The overall Cronbach's alpha was 0.85. The ICC was 0.82 (95% CI, 0.72 and 0.88) at 4 week-retest reliability.
The Thai version of the PSS-10 demonstrated excellent goodness-of-fit for the two factor solution model, as well as good reliability and validity for estimating the level of stress perception with a Thai population. Limitations of the study are discussed.
PMCID: PMC2905320  PMID: 20540784

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