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1.  A Randomized, Controlled Pragmatic Trial of Telephonic Medication Therapy Management to Reduce Hospitalization in Home Health Patients 
Health services research  2014;49(5):1537-1554.
Objective
To evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing hospitalizations among home health patients.
Setting
Forty randomly selected, geographically diverse home health care centers in the United States.
Design
Two-stage, randomized, controlled trial with 60-day follow-up. All Medicare-insured home health care patients were eligible to participate. Twenty-eight consecutive patients within each care center were recruited and randomized to usual care or MTM intervention. The MTM intervention consisted of the following: (1) initial phone call by a pharmacy technician to verify active medications; (2) pharmacist-provided medication regimen review by telephone; and (3) follow-up pharmacist phone calls at day seven and as needed for 30 days. The primary outcome was 60-day all-cause hospitalization.
Data Collection
Data were collected from in-home nursing assessments using the OASIS-C. Multivariate logistic regression modeled the effect of the MTM intervention on the probability of hospitalization while adjusting for patients’ baseline risk of hospitalization, number of medications taken daily, and other OASIS-C data elements.
Principal Findings
A total of 895 patients (intervention n = 415, control n = 480) were block-randomized to the intervention or usual care. There was no significant difference in the 60-day probability of hospitalization between the MTM intervention and control groups (Adjusted OR: 1.26, 95 percent CI: 0.89–1.77, p = .19). For patients within the lowest baseline risk quartile (n = 232), the intervention group was three times more likely to remain out of the hospital at 60 days (Adjusted OR: 3.79, 95 percent CI: 1.35–10.57, p = .01) compared to the usual care group.
Conclusions
This MTM intervention may not be effective for all home health patients; however, for those patients with the lowest-risk profile, the MTM intervention prevented patients from being hospitalized at 60 days.
doi:10.1111/1475-6773.12176
PMCID: PMC4177456  PMID: 24712335
Clinical trial; medication therapy management; home health care; hospitalization; outcomes
2.  A Randomized, Controlled Pragmatic Trial of Telephonic Medication Therapy Management to Reduce Hospitalization in Home Health Patients 
Health Services Research  2014;49(5):1537-1554.
Objective
To evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing hospitalizations among home health patients.
Setting
Forty randomly selected, geographically diverse home health care centers in the United States.
Design
Two-stage, randomized, controlled trial with 60-day follow-up. All Medicare- insured home health care patients were eligible to participate. Twenty-eight consecutive patients within each care center were recruited and randomized to usual care or MTM intervention. The MTM intervention consisted of the following: (1) initial phone call by a pharmacy technician to verify active medications; (2) pharmacist-provided medication regimen review by telephone; and (3) follow-up pharmacist phone calls at day seven and as needed for 30 days. The primary outcome was 60-day all-cause hospitalization.
Data Collection
Data were collected from in-home nursing assessments using the OASIS-C. Multivariate logistic regression modeled the effect of the MTM intervention on the probability of hospitalization while adjusting for patients’ baseline risk of hospitalization, number of medications taken daily, and other OASIS-C data elements.
Principal Findings
A total of 895 patients (intervention n = 415, control n = 480) were block-randomized to the intervention or usual care. There was no significant difference in the 60-day probability of hospitalization between the MTM intervention and control groups (Adjusted OR: 1.26, 95 percent CI: 0.89–1.77, p = .19). For patients within the lowest baseline risk quartile (n = 232), the intervention group was three times more likely to remain out of the hospital at 60 days (Adjusted OR: 3.79, 95 percent CI: 1.35–10.57, p = .01) compared to the usual care group.
Conclusions
This MTM intervention may not be effective for all home health patients; however, for those patients with the lowest-risk profile, the MTM intervention prevented patients from being hospitalized at 60 days.
doi:10.1111/1475-6773.12176
PMCID: PMC4177456  PMID: 24712335
Clinical trial; medication therapy management; home health care; hospitalization; outcomes
3.  Hypertension treatment intensification among stroke survivors with uncontrolled blood pressure 
Background and Purpose
We examined blood pressure 1 year after stroke discharge and its association with treatment intensification.
Methods
We examined the systolic blood pressure (SBP) stratified by discharge SBP (<140; 141 to 160; or >160 mmHg) among a national cohort of Veterans discharged after acute ischemic stroke. Hypertension treatment opportunities were defined as outpatient SBP >160 mm Hg or repeated SBPs >140 mm Hg. Treatment intensification was defined as the proportion of treatment opportunities with antihypertensive changes (range 0 to 100%, where 100% indicates that each elevated SBP always resulted in medication change).
Results
Among 3153 ischemic stroke patients, 38% had at least one elevated outpatient SBP eligible for treatment intensification in the 1 year post stroke. Thirty percent of patients had a discharge SBP <140mmHg; and an average 1.93 treatment opportunities and treatment intensification occurred in 58% of eligible visits. Forty seven percent of patients discharged with SBP 141 to160 mmHg had an average of 2.1 opportunities for intensification and treatment intensification occurred in 60% of visits. Sixty three percent of the patients discharged with an SBP >160mmHg had an average of 2.4 intensification opportunities, and treatment intensification occurred in 65% of visits.
Conclusion
Patients with discharge SBP >160mmHg had numerous opportunities to improve hypertension control. Secondary stroke prevention efforts should focus on: initiation and review of antihypertensives prior to acute stroke discharge; management of antihypertensives and titration; and patient medication adherence counseling.
doi:10.1161/STROKEAHA.114.007566
PMCID: PMC4308422  PMID: 25550374
4.  Evaluation of Specialized Medication Packaging Combined With Medication Therapy Management 
Medical care  2012;50(6):485-493.
Background
This study evaluates the effect of a program combing specialized medication packaging and telephonic medication therapy management on medication adherence, health care utilization, and costs among Medicaid patients.
Research Design
A retrospective cohort design compared Medicaid participants who voluntarily enrolled in the program (n = 1007) compared with those who did not (n = 13,614). Main outcome measures were medication adherence at 12 months, hospital admissions and emergency department visits at 6 and 12 months, and total paid claim costs at 6 and 12 months. Multivariate regression models were used to adjust for the effect of age, sex, race, comorbidities, and 12-month preenrollment health care utilization.
Results
Measures of medication adherence were significantly improved in the program cohort compared with the usual care cohort. At 6 months, adjusted all-cause hospitalization was marginally less in the program cohort compared with the usual care cohort [odds ratio = 0.73, 95% confidence interval (CI), 0.54–1.0, P = 0.05]. No statistically significant differences were observed between the 2 cohorts for any of the other adjusted utilization endpoints at 6 or 12 months. Adjusted total cost at 6 and 12 months were higher in the program cohort (6-month cost ratio = 1.76, 95% CI, 1.65–1.89; 12-month cost ratio = 1.84, 95% CI, 1.72–1.97), primarily because of an increase in prescription costs. Emergency department visits and hospitalization costs did not differ between groups.
Conclusions
The program improved measures of medication adherence, but the effect on health care utilization and nonpharmacy costs at 6 and 12 months was not different from the usual care group. Reasons for these findings may reflect differences in the delivery of the specialized packaging and the medication therapy management program, health care behaviors in this Medicaid cohort, unadjusted confounding, or time required for the benefit of the intervention to manifest.
doi:10.1097/MLR.0b013e3182549d48
PMCID: PMC4126258  PMID: 22498687
adherence; Medicaid; outcomes; pharmacy service
5.  Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation 
Objective
To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors.
Materials and methods
We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug–allergy, drug–drug interaction, and drug–disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors.
Results
Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1–5) compared to original alerts: 4 (1–7); p=0.024).
Discussion
Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts.
Conclusions
This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes.
doi:10.1136/amiajnl-2013-002045
PMCID: PMC4173163  PMID: 24668841
6.  Predictors of Medication-Related Problems Among Medicaid Patients Participating in a Pharmacist-Provided Telephonic Medication Therapy Management Program 
Pharmacotherapy  2014;34(10):1022-1032.
Study Objective
To identify predictors of medication-related problems (MRPs) among Medicaid patients participating in a telephonic medication therapy management (MTM) program.
Design
Retrospective analysis of data from patients enrolled in a previously published study
Data Sources
Two Medicaid administrative claims file databases (for healthcare utilization and prescription dispensing information) and one pharmacy organization file for MTM program information.
Patients
Seven hundred twelve adult Medicaid patients who participated in a statewide pharmacist-provided telephone-based MTM program and who received an initial medication therapy review.
Measurements and Main Results
The primary dependent variable was the number of MRPs detected during the initial medication therapy review. Secondary dependent variables were the detection of one or more MRPs related to indication, effectiveness, safety, and adherence. Predictor variables were selected a priori that, from the literature and our own practice experiences, were hypothesized as being potentially associated with MRPs: demographics, comorbidities, medication use, and healthcare utilization. Bivariate analyses were performed, and multivariable models were constructed. All predictor variables with significant associations (defined a priori as p<0.1) with the median number of MRPs detected were then entered into a three-block multiple linear regression model. The overall model was significant (p<0.001, R2= 0.064). Significant predictors of any MRPs (p<0.05) were total number of medications, obesity, dyslipidemia, and one or more emergency department visits in the past 3 months. For indication-related MRPs, the model was significant (p<0.001, R2= 0.049), and predictors included female sex, obesity, dyslipidemia, and total number of medications (p<0.05). For effectiveness-related MRPs, the model was significant (p<0.001, R2= 0.054), and predictors included bone disease and dyslipidemia (p<0.05). For safety-related MRPs, the model was significant (p<0.001, R2= 0.046), and dyslipidemia was a predictor (p<0.05). No significant predictors of adherence-related MRPs were identified.
Conclusion
This analysis supports the relative importance of number of medications as a predictor of MRPs in the Medicaid population and identifies other predictors. However, given the models’ low R2 values, these findings indicate that other unknown factors are clearly important and that criteria commonly used for determining MTM eligibility may be inadequate in identifying appropriate patients for MTM in a Medicaid population.
doi:10.1002/phar.1462
PMCID: PMC4426336  PMID: 25051943
administration; outcomes; pharmacy practice
7.  Evaluation of an Online Tobacco Cessation Course for Health Professions Students 
Objective
To implement and evaluate the impact of a semester-long, online, 1-credit elective course designed to promote tobacco cessation counseling proficiency among health professions students.
Design
Online technology was used to create an elective course devoted to tobacco cessation, modeled closely after the Rx for Change curriculum. Students from pharmacy, nursing, and other health disciplines enrolled in the course.
Assessment
Students completed pretraining and posttraining survey instruments that assessed their self-reported skills and ability to counsel patients for tobacco cessation. Overall ability to counsel for tobacco cessation and each of the “5 A's” approach for comprehensive counseling (ask, advise, assess, assist, arrange) increased significantly from pretraining to posttraining (p < 0.001). Self-efficacy also increased from 2.2 to 4.1 (p < 0.001; on a 5-point scale).
Conclusion
This study demonstrated that an online tobacco cessation course improved student-reported ability and skills to counsel patients on tobacco cessation.
PMCID: PMC2856429  PMID: 20414451
tobacco cessation; Internet; online learning; distance education
8.  Recruitment of community pharmacies in a randomized trial to generate patient referrals to the tobacco quitline 
Background
Community pharmacies have the potential to reduce the prevalence of tobacco use, yet most pharmacies do not integrate cessation activities into routine practice. Acquiring participation of community pharmacies is difficult. Strategies detailing requirements by researchers to elicit such participation have not been established.
Objectives
The objective of this study was to describe the recruitment strategy and participant yield for a two-state, randomized trial evaluating two intervention approaches for increasing pharmacy-based referrals to tobacco quitlines.
Methods
Detailed study recruitment tracking forms were used to document all contact attempts between the study investigators and each potential study site. These data were analyzed to characterize the overall recruitment and consent process for community pharmacies and pharmacy personnel (pharmacists, technicians).
Results
Achieving the target sample size of 64 study sites required contacting a total of 150 pharmacies (84 independent and 66 chain). Excluding 22 ineligible pharmacies, participation rates were 49% (32 of 65) for independent pharmacies and 51% (32 of 63) for chain pharmacies (50% overall). Across the 64 participating pharmacies, a total of 124 pharmacists (of 171; 73%) and 127 pharmacy technicians (of 215; 59%) were enrolled in the study. Pharmacies that chose not to participate most often cited time constraints as the primary reason. Overall, combining both the recruitment and consent process, a median of 5 contacts were made with each participating pharmacy (range, 2–19; IQR, 4–7), and the median overall duration of time elapsed from initial contact to consent was 25 days (range, 3–122 days; IQR, 12–47 days).
Conclusions
Results from this study suggest that pharmacy personnel are willing to provide brief tobacco cessation interventions in a community pharmacy setting and are receptive to participation in multi-site clinical research trials. However, execution of a representative sampling and recruitment scheme for a multi-state study in this practice setting is a time and labor intensive process.
doi:10.1016/j.sapharm.2012.06.001
PMCID: PMC3554859  PMID: 22841641
Tobacco; tobacco cessation; smoking; smoking cessation; pharmacist; community pharmacy; quitline; brief intervention
9.  A Randomized Trial Evaluating Two Approaches for Promoting Pharmacy-Based Referrals to the Tobacco Quitline: Methods and Baseline Findings 
Background
Historically, community pharmacies have not integrated tobacco cessation activities into routine practice, instead unbundling them as unique services. This approach might have limited success and viability.
Objective
The objective of this report is to describe the methods and baseline findings for a two-state, randomized trial evaluating two intervention approaches for increasing pharmacy-based referrals to their state’s tobacco quitline.
Methods
Participating community pharmacies in Connecticut (n=32) and Washington (n=32) were randomized to receive either (a) on-site education with an academic detailer, describing methods for implementing brief interventions with patients and providing referrals to the tobacco quitline, or (b) quitline materials delivered by mail. Both interventions advocated for pharmacy personnel to ask about tobacco use, advise patients who smoke to quit, and refer patients to the tobacco quitline for additional assistance with quitting. Study outcome measures include the number of quitline registrants who are referred by pharmacies (before and during the intervention period), the number of quitline materials distributed to patients, and self-reported behavior of cessation counseling and quitline referrals, assessed using written surveys completed by pharmacy personnel (pharmacists, technicians).
Results
Pharmacists (n=124) and pharmacy technicians (n=127), representing 64 participating pharmacies with equal numbers of retail chain and independently-owned pharmacies, participated in the study. Most pharmacists (67%) and half of pharmacy technicians (50%) indicated that they were “not at all” familiar with the tobacco quitline. During the baseline (pre-intervention) monitoring period, the quitline registered 120 patients (18 in CT and 102 in WA) who reported that they heard about the quitline from a pharmacy.
Conclusion
Novel tobacco intervention approaches are needed to capitalize on the community pharmacy’s frequent interface with tobacco users, and these approaches need to be evaluated to estimate their effectiveness. Widespread implementation of brief, yet feasible, pharmacy-based tobacco cessation efforts that generate referrals to a tobacco quitline could have a substantial impact on the prevalence of tobacco use.
doi:10.1016/j.sapharm.2012.03.001
PMCID: PMC3428501  PMID: 22554394
Tobacco; tobacco cessation; smoking; smoking cessation; pharmacist; community pharmacy; quitline; brief intervention
10.  Exploring successful community pharmacist-physician collaborative working relationships using mixed methods 
Background
Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration.
Objective
To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration.
Methods
A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification.
Results
On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential.
Conclusions
The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.
doi:10.1016/j.sapharm.2009.11.008
PMCID: PMC3004536  PMID: 21111388
Pharmacists; Physicians; Collaborative working relationships; Pharmacist-physician collaborative index; Community
11.  A Human Factors Investigation of Medication Alerts: Barriers to Prescriber Decision-Making and Clinical Workflow 
Computerized medication alerts (e.g., drug-drug interaction alerts), which are intended to protect patient safety, should also be designed to support prescriber workflow. However, relatively few studies have examined the use of medication alerts during patient care processes. To assess barriers associated with the use of medication alerts, we directly observed medication prescribing during routine patient care. Prescribers (physicians, pharmacists, and nurse practitioners) were recruited from five outpatient primary care clinics at a major Midwestern Veterans Affairs Medical Center (VAMC). A total of 199 alerts were observed across 91 patients and 20 prescribers during normal patient care tasks. Through inductive qualitative analysis, we identified 15 barriers associated with medication alerts; herein, we describe five of the key barriers in detail. Results may be used to create alert redesigns, which have the potential to more fully support clinical workflow, prescriber decision-making, and patient safety.
PMCID: PMC2815493  PMID: 20351915
12.  Hypertension Outcomes Through Blood Pressure Monitoring and Evaluation by Pharmacists (HOME Study) 
Journal of General Internal Medicine  2005;20(12):1091-1096.
Objective
To evaluate the effectiveness of a community pharmacist–based home blood pressure (BP) monitoring program.
Design
Trial of a high-intensity (HI) versus low-intensity (LI) intervention randomized in 12 community pharmacies. The HI intervention comprised 4 face-to-face visits with a trained pharmacist. Pharmacists provided patient-specific education about hypertension. Following the first and third visits, patients were provided with a home BP monitoring device and instructed to measure their BP at least once daily for the next month. Home BP readings were used by the pharmacists to develop treatment recommendations for the patient's physician. Recommendations were discussed with the physician and, if approved, implemented by the pharmacist. In the LI intervention, pharmacists measured patients BP in the pharmacy and referred them to their physician for evaluation.
Participants
Patients with uncontrolled BP at baseline.
Measurements
The main outcomes were the differences in systolic and diastolic BP (SBP and DBP) from baseline to follow-up between the HI and LI patients.
Results
The study enrolled 125 patients, 64 in the HI and 61 in the LI group. From baseline, SBP declined 13.4 mmHg in the HI group and 9.0 mmHg in the LI group. At the final visit, the difference in SBP/DBP change between the HI and LI group was −4.5/−3.2 mmHg (P=.12 for SBP and P=.03 for DBP).
Conclusions
The HI intervention achieved a lower DBP and this model could be a strategy for patients with hypertension.
doi:10.1111/j.1525-1497.2005.0226.x
PMCID: PMC1490290  PMID: 16423096
hypertension; pharmaceutical care; community-based intervention

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