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1.  Pharmacists’ Provision of Information to Spanish-speaking Patients: A Social Cognitive Approach 
Background
Hispanics with limited English proficiency face communication challenges that affect medication use and outcomes. Pharmacists are poised to help patients use medications safely and effectively, however scant research has explored factors that may impact pharmacists’ communication with Spanish-speaking patients (SSPs).
Objective
Guided by Social Cognitive Theory (SCT), the purpose of this study was to examine the relationships between pharmacy environmental factors, pharmacists’ cognition and pharmacists’ communication with SSPs.
Methods
A cross-sectional survey used a vignette to quantify the amount of information pharmacists would provide to a SSP. Pharmacy environmental factors (language-assistance resources, Spanish-speaking staff, and number of Spanish-speaking patients) and pharmacists’ cognition (self-efficacy beliefs and cultural sensitivity) that may influence communication also were assessed. The relationships between environmental factors, cognition and pharmacists’ communication with SSPs, including indirect relationships, were examined using composite indicator structural equation (CISE) modeling.
Results
Of the 183 respondents, the majority were white (91%) and male (63%) with a mean age of 47 years (SD=12.77). The CISE modeling revealed that the number of SSPs served by the pharmacy and the pharmacist's self-efficacy in communicating with SSPs were significantly directly associated with pharmacist's provision of information to SSPs. Two environmental factors (presence of interpreter services and Spanish-speaking staff) operated indirectly through self-efficacy to significantly impact the provision of information.
Conclusions
Study findings identify both environmental factors and cognition that could contribute to pharmacists’ communication behavior with SSPs. Thus, future interventions to improve pharmacists’ communication with SSPs may include training pharmacists to integrate interpretative services and Spanish-speaking staff into service delivery, as well as strengthening pharmacists’ self-efficacy beliefs.
doi:10.1016/j.sapharm.2012.02.003
PMCID: PMC4441301  PMID: 22554399
Pharmacists; Communication; Spanish-speaking patients
2.  Development and Evaluation of an Instrument to Measure Community Pharmacists' Self-Efficacy Beliefs about Communicating with Spanish-Speaking Patients 
Background
Hispanics are the largest growing population in the United States and their use of prescription medications can be influenced by the education and counseling they receive from pharmacists. However, little is known about pharmacists' communication with patients who speak Spanish or factors that can influence such communication.
Objectives
The objective of the study was to develop and validate an instrument to measure pharmacists' self-efficacy in communicating with Spanish-speaking patients.
Methods
An initial pool of 15 items developed from previous research and suggestions from communication experts and practicing pharmacists was subjected to cognitive interviewing. Nine retained items were administered to 1022 licensed pharmacists by mail survey. Summary statistics and exploratory factor analysis (EFA) were conducted. Retained factors were determined by the examination of eigenvalues and Scree test results. Cronbach's alpha coefficients were calculated to assess internal consistency.
Results
A total of 540 community pharmacists completed the survey. Item means ranged from 2.93(SD=1.47) to 1.58(SD=0.88) based on a 5-point scale (1-not at all confident to 5-extremely confident). EFA resulted in a 2-factor solution, accounting for 71% of the variance. The 2 factors consisted of Health and Drug Information (alpha = 0.92) and Opening the Encounter (alpha = 0.75). The alpha for the overall scale was 0.88.
Conclusions
We found evidence to support the reliability and validity of an instrument to measure pharmacists' self-efficacy beliefs about communicating with Spanish-speaking patients in community practice. Practitioners and researchers may use this instrument to inform pharmacy education, pharmacy practice improvement, and research efforts around communicating with Spanish-speaking clients.
doi:10.1016/j.sapharm.2010.08.003
PMCID: PMC4432470  PMID: 21272530
Self-efficacy; Pharmacists; Communication; Spanish-speaking patients
3.  Concordance between Observer Reports and Patient Survey Reports of Pharmacist Communication Behaviors 
Background
Findings from studies on pharmacist-patient communication differ on the extent of communication by pharmacists. This disagreement could be due to different methods of data collection, samples and concepts used to measure pharmacist-patient communication.
Objectives
This research compared findings from two widely used methods of data collection (survey and observation) to identify: 1) how much pharmacists communicate with patients, 2) agreement between observation and patient report data on pharmacist information giving and question asking and 3) how patient perceptions of question asking vary according to the structure of the question asked.
Methods
Results
While there was good agreement between the two measures regarding pharmacist information provision, this was less true of question asking. Certain types of questions showed greater concordance with the observed pharmacist questions. Patients were less likely to report having been asked a question when it took the form of a nonspecific closed ended questions, i.e., “Any questions?”
Conclusions
One of the most frequent questions pharmacists ask patients may not be either remembered or perceived by patients as a serious question, let alone an invitation to raise a concern. Second, during the selection of a specific method of data collection, researchers need to weigh specific strengths and weaknesses of the method of data collection and evaluate which concepts can be accurately measured by a specific method of data collection. Multi-method studies should be encouraged.
doi:10.1016/j.sapharm.2010.07.001
PMCID: PMC4349327  PMID: 21371946
Observation; Self-Report; Agreement; Pharmacist Patient Communication
4.  The Association of Subjective Workload Dimensions on Quality of Care and Pharmacist Quality of Work Life 
Background
Workload has been described both objectively (e.g., number of prescriptions dispensed per pharmacist) as well as subjectively (e.g., pharmacist’s perception of busyness). These approaches might be missing important characteristics of pharmacist workload that have not been previously identified and measured.
Objectives
To measure the association of community pharmacists’ workload perceptions at three levels (organization, job, and task) with job satisfaction, burnout, and perceived performance of two tasks in the medication dispensing process.
Methods
A secondary data analysis was performed using cross-sectional survey data collected from Wisconsin (US) community pharmacists. Organization–related workload was measured as staffing adequacy; job-related workload was measured as general and specific job demands; task-related workload was measured as internal and external mental demands. Pharmacists’ perceived task performance was assessed for patient profile review and patient consultation. The survey was administered to a random sample of 500 pharmacists who were asked to opt in if they were a community pharmacist. Descriptive statistics and correlations of study variables were determined. Two structural equation models were estimated to examine relationships between the study variables and perceived task performance.
Results
From the 224 eligible community pharmacists that agreed to participate, 165 (73.7%) usable surveys were completed and returned. Job satisfaction and job-related monitoring demands had direct positive associations with both dispensing tasks. External task demands were negatively related to perceived patient consultation performance. Indirect effects on both tasks were primarily mediated through job satisfaction, which was positively related to staffing adequacy and cognitive job demands and negatively related to volume job demands. External task demands had an additional indirect effect on perceived patient consultation performance, as it was associated with lower levels of job satisfaction and higher levels of burnout.
Implications/Conclusions
Allowing community pharmacists to concentrate on tasks and limiting interruptions while performing these tasks are important factors in improving quality of patient care and pharmacist work life. The results have implications for strategies to improve patient safety and pharmacist performance.
doi:10.1016/j.sapharm.2013.05.007
PMCID: PMC3805762  PMID: 23791360
Community Pharmacy; Workload; Medication Safety; Structural Equation Modeling
5.  Relationships between health literacy and heart failure knowledge, self-efficacy, and self-care adherence 
Background
It has been argued that only 12 percent of adults have the necessary health literacy to manage their health care effectively, which can lead to difficulties in self-care activities, such as medication adherence. Prior research suggests that health literacy may influence knowledge, self-efficacy and self-care, but this has not been fully examined.
Objective
To test a model to explain the relationships between health literacy, heart failure knowledge, self-efficacy, and self-care.
Methods
Prior to receiving clinic-based education, newly referred patients to 3 heart failure clinics completed assessments of health literacy, heart failure knowledge, self-efficacy, self-care, and demographics. Structural equation modeling was completed to examine the strength of the inter-variable relationships.
Results
Of 81 participants recruited, data from 63 patients were complete. Health literacy was independently associated with knowledge (p<0.001). Health literacy was not related to self-care. Self-efficacy was independently-associated with self-care adherence (p=0.016). No other relationships were statistically significant. The model had good fit (comparative fit index=1.000) and explained 33.6% of the variance in knowledge and 27.6% in self-care.
Conclusions
Health literacy influences knowledge about heart failure but not self-care adherence. Instead, self-efficacy influenced self-care adherence. Future research should incorporate additional factors that may better model the relationships between health literacy, knowledge, self-efficacy, and self-care.
doi:10.1016/j.sapharm.2013.07.001
PMCID: PMC3923851  PMID: 23953756
heart failure; health literacy; self-care; self-efficacy; heart failure knowledge
6.  Exploring safety systems for dispensing in community pharmacies: Focusing on how staff relate to organizational components☆ 
Background
Identifying risk is an important facet of a safety practice in an organization. To identify risk, all components within a system of operation should be considered. In clinical safety practice, a team of people, technologies, procedures and protocols, management structure and environment have been identified as key components in a system of operation.
Objectives
To explore risks in relation to prescription dispensing in community pharmacies by taking into account relationships between key components that relate to the dispensing process.
Methods
Fifteen community pharmacies in England with varied characteristics were identified, and data were collected using non-participant observations, shadowing and interviews. Approximately 360 hours of observations and 38 interviews were conducted by the team. Observation field notes from each pharmacy were written into case studies. Overall, 52,500 words from 15 case studies and interview transcripts were analyzed using thematic and line-by-line analyses. Validation techniques included multiple data collectors co-authoring each case study for consensus, review of case studies by members of the wider team including academic and practicing community pharmacists, and patient safety experts and two presentations (internally and externally) to review and discuss findings.
Results
Risks identified were related to relationships between people and other key components in dispensing. This included how different levels of staff communicated internally and externally, followed procedures, interacted with technical systems, worked with management, and engaged with the environment. In a dispensing journey, the following categories were identified which show how risks are inextricably linked through relationships between human components and other key components: 1) dispensing with divided attention; 2) dispensing under pressure; 3) dispensing in a restricted space or environment; and, 4) managing external influences.
Conclusions
To identify and evaluate risks effectively, an approach that includes understanding relationships between key components in dispensing is required. Since teams of people in community pharmacies are a key dispensing component, and therefore part of the operational process, it is important to note how they relate to other components in the environment within which they operate. Pharmacies can take the opportunity to reflect on the organization of their systems and review in particular how they can improve on the four key categories identified.
doi:10.1016/j.sapharm.2014.06.005
PMCID: PMC4330989  PMID: 25108523
Community pharmacy; Human factors; Patient safety; Clinical safety management
7.  Racial and ethnic disparities in influenza vaccinations among community pharmacy patients and non-community pharmacy respondents 
Research in social & administrative pharmacy : RSAP  2013;10(1):10.1016/j.sapharm.2013.04.011.
Background
Since 2009, pharmacists in all 50 states in the U.S. have been authorized to administer vaccinations.
Objectives
This study examined racial and ethnic disparities in the reported receipt of influenza vaccinations within the past year among noninstitutionalized community pharmacy patients and non-community pharmacy respondents.
Methods
The 2009 Medical Expenditure Panel Survey was analyzed. The sample consisted of respondents aged 50 years or older, as per the 2009 recommendations by the Advisory Committee on Immunization Practices. Bivariate and multivariate logistic regression analyses were conducted to examine the influenza vaccination rates and disparities in receiving influenza vaccinations within past year between non-Hispanic Whites (Whites), non-Hispanic Blacks (Blacks) and Hispanics. The influenza vaccination rates between community pharmacy patients and non-community pharmacy respondents were also examined.
Results
Bivariate analyses found that among the community pharmacy patients, a greater proportion of Whites reported receiving influenza vaccinations compared to Blacks (60.9% vs. 49.1%; P < 0.0001) and Hispanics (60.9% vs. 51.7%; P < 0.0001). Among non-community pharmacy respondents, differences also were observed in reported influenza vaccination rates among Whites compared to Blacks (41.0% vs. 24.3%; P < 0.0001) and Hispanics (41.0% vs. 26.0%; P < 0.0001). Adjusted logistic regression analyses found significant racial disparities between Blacks and Whites in receiving influenza vaccinations within the past year among both community pharmacy patients (odds ratio [OR]: 0.81; 95% CI: 0.69–0.95) and non-community pharmacy respondents (OR: 0.66; 95% CI: 0.46–0.94). Sociodemographic characteristics and health status accounted for the disparities between Hispanics and Whites. Overall, community pharmacy patients reported higher influenza vaccination rates compared to non-community pharmacy respondents (59.0% vs. 37.2%; P < 0.0001).
Conclusion
Although influenza vaccination rates were higher among community pharmacy patients, there were racial disparities in receiving influenza vaccinations among both community pharmacy patients and non-community pharmacy respondents. Increased emphasis on educational campaigns among pharmacists and their patients, especially minorities, may be needed.
doi:10.1016/j.sapharm.2013.04.011
PMCID: PMC3858597  PMID: 23706653
Racial ethnic disparities; Influenza vaccinations; Immunization; Community pharmacy; Pharmacists
8.  Exploring Information Chaos in Community Pharmacy Handoffs 
Research in social & administrative pharmacy : RSAP  2013;10(1):10.1016/j.sapharm.2013.04.009.
Background
A handoff is the process of conveying necessary information in order to transfer primary responsibility for providing safe and effective drug therapy to a patient from one community pharmacist to another, typically during a shift change. The handoff information conveyed in pharmacies has been shown to be unstructured and variable, leading to pharmacist stress and frustration, prescription delays, and medication errors.
Objective
The purpose of this study was to describe and categorize the information hazards present in handoffs in community pharmacies.
Methods
A qualitative research approach was used to elicit the subjective experiences of community pharmacists. Community pharmacists who float or work in busy community pharmacies were recruited and participated in a face to face semi-structured interview. Using a systematic content data analysis, the study identified five categories of information hazards that can lead to information chaos, a framework grounded in human factors and ergonomics.
Results
Information hazards including erroneous information and information overload, underload, scatter, and conflict, are experienced routinely by community pharmacists during handoff communication and can result in information chaos. The consequences of information chaos include increased mental workload, which can precipitate problematic prescriptions “falling between the cracks”. This can ultimately impact patient care and pharmacist quality of working life.
Conclusions
The results suggest that handoffs in community pharmacies result in information hazards. These information hazards can distract pharmacists from their primary work of assessing prescriptions and educating their patients. Further research on how handoffs are conducted can produce information on how hazards in the system can be eliminated.
doi:10.1016/j.sapharm.2013.04.009
PMCID: PMC3766497  PMID: 23665076
handoffs; community pharmacy; human factors; medication safety
9.  Predictors of $4 Generic Prescription Drug Discount Programs use in the Low-income Population 
Research in social & administrative pharmacy : RSAP  2013;10(1):10.1016/j.sapharm.2013.04.001.
Background
Generic drug discount programs (GDDPs) are an option to provide affordable prescription medication to low-income individuals. However, the factors that influence the use of GDDPs in low-income population are unknown.
Objectives
To evaluate factors associated with utilization of generic a drug discount program in a low-income population.
Methods
A survey was administered to adult participants at health centers and community based organizations in Houston, Texas, USA (n=525). Exploratory factor analysis was conducted to determine the construct validity of the survey instrument and to assess distinct factors associated with GDDP utilization. Descriptive statistics were used to summarize the distribution of patient socio-demographic characteristics and questionnaire responses. Multivariate logistic regression was used to compute adjusted odds ratios and to examine the strength of association with GDDP utilization after adjusting for participant socio-demographic features that were statistically significant at a priori level of p<0.05.
Results
In this study, 72% of respondents were aware of the GDDP, and 61% had utilized the GDDP. Participants were 4 times likely to use a GDDP when their physician (AOR: 4.0, 95% CI: 2.6 – 6.4, P < 0.001) or pharmacist (AOR: 4.0, 95% CI: 2.6 – 6.3, P < 0.001) talked to them about it. Participants indicated that the most important barriers to utilization of GDDPs were lack of awareness (44%), and lack of recommendation by a physician (19%).
Conclusions
Increased patient awareness and physician recommendation may increase the use of GDDPs, which may lead to improved compliance with medications, better health outcomes and reduced health care costs.
doi:10.1016/j.sapharm.2013.04.001
PMCID: PMC3830679  PMID: 23684716
10.  How do Community Pharmacies Recover from E-prescription Errors? 
Background
The use of e-prescribing is increasing annually, with over 788 million e-prescriptions received in US pharmacies in 2012. Approximately 9% of e-prescriptions have medication errors.
Objective
To describe the process used by community pharmacy staff to detect, explain, and correct e-prescription errors.
Methods
The error recovery conceptual framework was employed for data collection and analysis. 13 pharmacists and 14 technicians from five community pharmacies in Wisconsin participated in the study. A combination of data collection methods were utilized, including direct observations, interviews, and focus groups. The transcription and content analysis of recordings were guided by the three-step error recovery model.
Results
Most of the e-prescription errors were detected during the entering of information into the pharmacy system. These errors were detected by both pharmacists and technicians using a variety of strategies which included: (1) performing double checks of e-prescription information; (2) printing the e-prescription to paper and confirming the information on the computer screen with information from the paper printout; and (3) using colored pens to highlight important information. Strategies used for explaining errors included: (1) careful review of patient’ medication history; (2) pharmacist consultation with patients; (3) consultation with another pharmacy team member; and (4) use of online resources. In order to correct e-prescription errors, participants made educated guesses of the prescriber’s intent or contacted the prescriber via telephone or fax. When e-prescription errors were encountered in the community pharmacies, the primary goal of participants was to get the order right for patients by verifying the prescriber’s intent.
Conclusion
Pharmacists and technicians play an important role in preventing e-prescription errors through the detection of errors and the verification of prescribers’ intent. Future studies are needed to examine factors that facilitate or hinder recovery from e-prescription errors.
doi:10.1016/j.sapharm.2013.11.009
PMCID: PMC4045654  PMID: 24373898
Electronic prescribing; E-prescribing; Medication Errors; Error Recovery; Community Pharmacy
11.  Addressing medication nonadherence by mobile phone: Development and delivery of tailored messages 
Background:
Medication nonadherence remains a significant public health problem, and efforts to improve adherence have shown only limited impact. The tailoring of messages has become a popular method of developing communication to influence specific health-related behaviors but the development and impact of tailored text messages on medication use is poorly understood.
Objectives:
The aim of this paper is to describe an approach to developing theory-based tailored messages for delivery via mobile phone to improve medication adherence among patients with diabetes.
Methods:
Kreuter’s five-step tailoring process was followed to create tailored messages for mobile phone delivery. Two focus group sessions, using input from 11 people, and expert review of message content were used to adapt the survey instrument on which the messages were tailored and edit the developed messages for the target population.
Results and conclusions:
Following established tailoring methods a library of 168 theory-driven and 128 medication-specific tailored messages were developed and formatted for automated delivery to mobile phones. Concepts from the Health Belief Model and Self-Determination Theory were used to craft the messages and an algorithm was applied to determine the order and timing of messages with the aim of progressively influencing disease and treatment-related beliefs driving adherence to diabetes medication. The process described may be applied to future investigations aiming to improve medication adherence in patients with diabetes and the effectiveness of the current messages will be tested in a planned analysis.
doi:10.1016/j.sapharm.2014.01.002
PMCID: PMC4182163  PMID: 24603134
Tailoring; Adherence; Mobile health; Text messaging; Behavioral theory
12.  Historical Trend of Disparity Implications of Medicare MTM Eligibility Criteria 
Research in social & administrative pharmacy : RSAP  2012;9(6):10.1016/j.sapharm.2012.09.003.
Background
Non-Hispanic Blacks (Blacks) and Hispanics have a lower likelihood of being eligible for medication therapy management (MTM) services than do non-Hispanic Whites (Whites) based on Medicare MTM eligibility criteria.
Objective
To determine whether MTM eligibility criteria would perform differently over time, this study examined the trend of MTM disparities from 1996–1997 to 2007–2008.
Methods
The study populations were Medicare beneficiaries from the Medical Expenditure Panel Survey. Proportions and the odds of MTM eligibility were compared between Whites and ethnic minorities. The trend of disparities was examined by including in logistic regression models interaction terms between dummy variables for the minority groups and 2007–2008. MTM eligibility thresholds for 2008 and 2010–2011 were analyzed. Main and sensitivity analyses were conducted to represent the entire range of the eligibility criteria.
Results
This study found no statistical significant racial or ethnic disparities associated with the MTM eligibility criteria for 2008 among the Medicare population during 1996–1997. However, racial disparities associated with 2010–2011 MTM eligibility criteria were significant according to multivariate analyses among the Medicare population during 1996–1997. During 2007–2008, both racial and ethnic disparities associated with both 2008 MTM eligibility criteria and 2010–2011 eligibility criteria were generally significant. Disparity patterns did not exhibit a statistically significant change from 1996–1997 to 2007–2008.
Conclusion
Racial and ethnic disparities in meeting MTM eligibility criteria may not decrease over time unless MTM eligibility criteria are changed.
doi:10.1016/j.sapharm.2012.09.003
PMCID: PMC3549304  PMID: 23062785
Health disparities; race; ethnicity; medication therapy management services; eligibility criteria; historical trend
13.  Prevalence and Correlates of Self-Reported Medication Non-Adherence among Older Adults with Coronary Heart Disease, Diabetes Mellitus, and/or Hypertension 
Research in social & administrative pharmacy : RSAP  2013;9(6):10.1016/j.sapharm.2012.12.002.
Background
Information about the about the prevalence and correlates of self-reported medication nonadherence using multiple measures in older adults with chronic cardiovascular conditions is needed.
Objective
To examine the prevalence and correlates of self-reported medication nonadherence among community-dwelling elders with chronic cardiovascular conditions.
Methods
Participants (n=897) included members from the Health, Aging and Body Composition study with coronary heart disease, diabetes mellitus, and/or hypertension at year 10. Self-reported nonadherence was measured by the 4-item Morisky Medication Adherence Scale (MMAS-4) and 2-item cost-related nonadherence (CRN-2) scale at year 11. Factors (demographic, health status, and access to care) were examined for association with the MMAS-4 and then for association with the CRN-2 scale.
Results
Nonadherence per the MMAS-4 and CRN-2 scale was reported by 40.7% and 7.7% of participants, respectively, with little overlap (3.7%). Multivariable logistic regression analyses found that black race was significantly associated with nonadherence per the MMAS-4 (p=0.002) and the CRN-2 scale (p=0.005). Other correlates of nonadherence per the MMAS-4 (with independent associations) included having cancer (p=0.04), a history of falls (p=0.02), sleep disturbances (p=0.04) and having a hospitalization in the previous 6 months (p=0.005). Conversely, being unmarried (p=0.049), having worse self-reported health (p=0.04) and needs being poorly met by income (p=0.02) showed significant independent associations with nonadherence per the CRN-2 scale.
Conclusions
Self-reported medication nonadherence was common in older adults with chronic cardiovascular conditions and only one factor – race – was associated with both types. The research implication of this finding is that it highlights the need to measure both types of self-reported nonadherence in older adults. Moreover, the administration of these quick measures in the clinical setting should help identify specific actions such as patient education or greater use of generic medications or pill boxes that may address barriers to medication nonadherence.
doi:10.1016/j.sapharm.2012.12.002
PMCID: PMC3620923  PMID: 23291338
medication adherence; chronic disease; aged
14.  Using theory to predict implementation of a physician–pharmacist collaborative intervention within a practice-based research network 
Research in social & administrative pharmacy : RSAP  2013;9(6):10.1016/j.sapharm.2013.01.003.
Background
Studies have demonstrated that physician/pharmacist collaboration can improve management of chronic conditions.
Objective
The purpose of this study was to determine whether a correlation exists between existing clinical pharmacy services within a practice-based research network (PBRN) and provider attitudes and beliefs regarding implementing a new pharmacy intervention based on the Theory of Planned Behavior (TPB).
Methods
A validated survey was completed by one clinical pharmacist from each office. This instrument evaluated the current clinical pharmacy services provided in the medical office. TPB instruments were developed that measured beliefs concerning implementation of a clinical pharmacy intervention for either blood pressure or asthma. The pharmacy services and TPB surveys were then administered to physicians and pharmacists in 32 primary care offices throughout the United States.
Results
Physicians returned 321 (35.9%) surveys, while pharmacists returned 40 (75.5%). The Cronbach’s alpha coefficients generally ranged from 0.65 to 0.98. TPB subscale scores were lower in offices rated with lower pharmacy service scores, but these differences were not statistically significant. There was no correlation between clinical pharmacy service score and providers’ TPB subscale scores. In both the hypertension and asthma groups, pharmacists scores were significantly higher than physicians’ scores on the attitudes subscale in the multivariate analysis (P < 0.001 and P < 0.05, respectively).
Conclusions
Pharmacists consistently scored higher than physicians on the TPB, indicating that they felt the hypertension or asthma intervention would be more straightforward for them to implement than did physicians. There was no significant correlation between clinical pharmacy service scores and attitudes toward implementing a future physician/pharmacist collaborative intervention using the TPB. Future studies should investigate the ability of the TPB instrument to predict implementation of a similar intervention in offices of physicians never exposed to clinical pharmacy services.
doi:10.1016/j.sapharm.2013.01.003
PMCID: PMC3830625  PMID: 23506651
Physician–pharmacist collaboration; Team-based care; Theory; Theory of planned behavior; Hypertension; Asthma
15.  Review of Geographic Variation and Geographic Information Systems (GIS) Applications in Prescription Drug Use Research 
Background
While understanding geography’s role in healthcare has been an area of research for over 40 years, the application of geography-based analyses to prescription medication use is limited. The body of literature was reviewed to assess the current state of such studies to demonstrate the scale and scope of projects in order to highlight potential research opportunities.
Objective
To review systematically how researchers have applied geography-based analyses to medication use data.
Methods
Empiric, English language research articles were identified through PubMed and bibliographies. Original research articles were independently reviewed as to the medications or classes studied, data sources, measures of medication exposure, geographic units of analysis, geospatial measures, and statistical approaches.
Results
From 145 publications matching key search terms, forty publications met the inclusion criteria. Cardiovascular and psychotropic classes accounted for the largest proportion of studies. Prescription drug claims were the primary source, and medication exposure was frequently captured as period prevalence. Medication exposure was documented across a variety of geopolitical units such as countries, provinces, regions, states, and postal codes. Most results were descriptive and formal statistical modeling capitalizing on geospatial techniques was rare.
Conclusion
Despite the extensive research on small area variation analysis in healthcare, there are a limited number of studies that have examined geographic variation in medication use. Clearly, there is opportunity to collaborate with geographers and GIS professionals to harness the power of GIS technologies and to strengthen future medication studies by applying more robust geospatial statistical methods.
doi:10.1016/j.sapharm.2012.11.006
PMCID: PMC4160030  PMID: 23333430
GIS; geographic variation; geospatial; small area variation analyses; medication use
16.  Effects of Medicare Part D on Drug Affordability and Utilization: Are Seniors with Prior High Out-of-Pocket Drug Spending Affected More? 
Background
Medicare Part D was expected to have differential impacts on patient drug expenditures and utilization based on beneficiaries’ levels of pre-Part D patient drug spending, but it is unknown whether these projections have borne out
Objectives
We sought to evaluate whether and how the policy effect of Medicare Part D on drug expenditures and utilization was modified by levels of pre-Part D drug spending.
Methods
A quasi-experimental, pretest-posttest, nonequivalent control group design was used. Data were obtained from a regional supermarket chain for all prescriptions dispensed between January 1, 2005 and December 31, 2007 (n =1,230,612) to patients age 60 and older as of January 1, 2005 (n = 51,305) to construct 12-month pre-Part D and post-Part D periods. The treatment group was defined as individuals who were eligible via age, for Part D coverage on January 1, 2006 (ages 65+). The control group included individuals aged 60 through 62 on January 1, 2006. Annual medication utilization was measured as the total number of pill-days acquired. Annual drug expenditures were measured as total expenditures, patient out-of-pocket expenditures, and the proportion of total expenditures paid out of pocket by the patient.
Results
Part D resulted in significantly greater reductions in absolute and relative out-of-pocket spending for individuals in the highest pre-Part D drug spending group relative to the moderate and low pre-Part D drug spending groups.
Conclusions
Our findings suggest that, as expected, Part D facilitated access to medications for patients who previously experienced the greatest costs without adversely increasing use and costs among those with the lowest prior cost.
doi:10.1016/j.sapharm.2010.02.004
PMCID: PMC4087326  PMID: 20511108
Medicare Part D; Utilization; Out-of-pocket Spending; Access
17.  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
18.  A qualitative analysis of perceptions and barriers to therapeutic lifestyle changes among homeless hypertensive patients 
Background
Homeless individuals have higher rates of hypertension when compared to the general population. Therapeutic lifestyle changes (TLCs) have the potential to decrease the morbidity and mortality associated with hypertension, yet TLCs can be difficult for homeless persons to implement due to competing priorities.
Objectives
To identify: 1) Patients' knowledge and perceptions of hypertension and TLCs; and 2) Barriers to implementation of TLCs.
Methods
This qualitative study was conducted with patients from an urban healthcare clinic within a homeless center. Patients ≥ 18 years old with a diagnosis of hypertension were eligible. Three focus groups were conducted at which time saturation was deemed to have been reached. Focus group sessions were audio recorded and transcribed for data analysis. A systematic, inductive analysis was conducted to identify emerging themes.
Results
A total of 14 individuals participated in one of three focus groups. The majority were female (n = 8) and African-American (n = 13). Most participants were housed in a shelter (n=8). Others were staying with family or friends (n=3), living on the street (n=2), or had transitioned to housing (n=1). Participants had a mixed understanding of hypertension and how TLCs impacted hypertension. They were most familiar with dietary and smoking recommendations and less familiar with exercise, alcohol, and caffeine TLCs. Participants viewed TLCs as being restrictive, particularly with regards to diet. Family and friends were viewed as helpful in encouraging some lifestyle changes such as healthy eating, but less helpful in having a positive influence on quitting smoking. Participants indicated that they often have difficulty implementing lifestyle changes because of limited meal choices, poor access to exercise equipment, and being uninformed about recommendations.
Conclusions
Despite the benefits of TLCs, homeless individuals experience unique challenges to implementing TLCs. Future research should focus on developing and testing interventions that facilitate TLCs among homeless persons. The findings from this study should assist healthcare practitioners, including pharmacists, with providing appropriate and effective education.
doi:10.1016/j.sapharm.2012.05.007
PMCID: PMC3519971  PMID: 22835705
homeless; hypertension; perceptions; barriers; lifestyle
19.  Medication Adherence Challenges among Patients Experiencing Homelessness in a Behavioral Health Clinic 
Research in social & administrative pharmacy : RSAP  2012;S1551-7411(12)00349-X 10.1016/j.sapharm.2012.11.004.
Background
Behavioral health medication nonadherence is associated with poor health outcomes and increased healthcare costs. Little is known about reasons for nonadherence with behavioral health medications among homeless people.
Objectives
To identify reasons for medication nonadherence including the sociodemographic, health-related factors, and behavioral health conditions associated with medication nonadherence among behavioral health patients served by a Health Care for the Homeless center (HCH) in Virginia.
Methods
The study sample was selected from an existing database that included sociodemographic, health-related information, and medication-related problems identified during a pharmacist-provided medication review conducted during October 2008–September 2009. Patients experiencing or at risk of homelessness who were ≥ 18 years old with at least one behavioral health condition who had a medication review were eligible for the study. A qualitative content analysis of the pharmacist documentation describing the patient’s reason(s) for medication nonadherence was conducted. The Behavioral Model for Vulnerable Populations was the theoretical framework. The outcome variable was self-reported medication nonadherence. Descriptive and multivariate (logistic regression) statistics were used.
Results
A total of 426 individuals met study criteria. The mean age was 44.7 ± 10.2 years. Most patients were African-American (60.5%) and female (51.6%). The content analysis identified patient-related factors (74.8%), therapy-related factors (11.8%), and social or economic factors (8.8%) as the most common reasons for patients’ medication nonadherence. Patients with post-traumatic stress disorder (PTSD) (adjusted odds ratio: 0.4; 95% CI: 0.19–0.87) were less likely to have a medication adherence problem identified during the medication review.
Conclusions
The content analysis identified patient-related factors as the most common reason for nonadherence with behavioral health medications. In the quantitative analysis, patients with a PTSD diagnosis were less likely to have nonadherence identified which may be related to their reluctance to self-report nonadherence and their diagnosis, which warrants further study.
doi:10.1016/j.sapharm.2012.11.004
PMCID: PMC3733792  PMID: 23218849
Medication nonadherence; homeless; behavioral health
20.  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
21.  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.
Background
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.
Objectives
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1016/j.sapharm.2013.03.007
PMCID: PMC3858402  PMID: 23759673
Health disparities; race; ethnicity; medication therapy management services; eligibility criteria
22.  E-Prescribing: A Focused Review and New Approach to Addressing Safety in Pharmacies and Primary Care 
Research in social & administrative pharmacy : RSAP  2012;9(6):10.1016/j.sapharm.2012.09.004.
Summary
E-prescribing, the health information technology (HIT) that enables prescribers to electronically transmit prescriptions to community pharmacies has been touted as a solution for improving patient safety and overall quality of care. However, the impact of HIT, such as e-prescribing on medication errors in acute care settings has been widely studied and show that if poorly designed or implemented, HIT can pose a risk to patient safety by introducing a source of medication errors. Unlike acute care settings, safety issues related to e-prescribing in primary care settings (where e-prescriptions are generated and transmitted) and pharmacies (where e-prescriptions are received) have not received as much attention in the literature. This paper provides a focused review of patient safety issues related to using e-prescribing systems in primary care and pharmacies. In addition, the paper proposes using human factors engineering concepts to study e-prescribing safety in pharmacies and primary care settings to identify safety problems and recommendations for improvement.
doi:10.1016/j.sapharm.2012.09.004
PMCID: PMC3709012  PMID: 23062769
23.  Pharmacy workers’ perceptions and acceptance of bar coded medication technology in a pediatric hospital 
Background
The safety benefits of bar-coded medication dispensing and administration technology (BCMA) depend on its intended users favorably perceiving, accepting, and ultimately using the technology.
Objectives
(1) To describe pharmacy workers’ perceptions and acceptance of a recently implemented BCMA system and (2) to model the relationship between perceptions and acceptance of BCMA.
Methods
Pharmacists and pharmacy technicians at a Midwest US pediatric hospital were surveyed following the hospital’s implementation of a BCMA system. Twenty-nine pharmacists and ten technicians’ self-reported perceptions and acceptance of the BCMA system were analyzed, supplemented by qualitative observational and free-response survey data. Perception-acceptance associations were analyzed using structural models.
Results
The BCMA system’s perceived ease of use was rated low by pharmacists and moderate by pharmacy technicians. Both pharmacists and technicians perceived that the BCMA system was not useful for improving either personal job performance or patient care. Pharmacy workers perceived that individuals important to them encouraged BMCA use. Pharmacy workers generally intended to use BCMA but reported low satisfaction with the system. Perceptions explained 72% of the variance in intention to use BCMA and 79% of variance in satisfaction with BCMA.
Conclusions
To promote their acceptance and use, BCMA and other technologies must be better designed and integrated into the clinical work system. Key steps to achieving better design and integration include measuring clinicians’ acceptance and elucidating perceptions and other factors that shape acceptance.
doi:10.1016/j.sapharm.2012.01.004
PMCID: PMC3390462  PMID: 22417887
bar coded medication dispensing and administration systems; BCMA; technology acceptance; pediatric hospital
24.  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.
Background
Pharmacists' acceptable level of compensation for medication therapy management (MTM) services needs to be determined using various economic evaluation techniques.
Objectives
Using contingent valuation method, determine pharmacists' acceptable levels of compensation for MTM services.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1016/j.sapharm.2012.02.001
PMCID: PMC3445666  PMID: 22436583
Medication therapy management services; contingent valuation; pharmacists; compensation; willingness to accept
25.  A qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach 
Background
Although lack of time, trained personnel, and reimbursement have been identified as barriers to pharmacists providing cognitive pharmaceutical services (CPS) in community pharmacies, the underlying contributing factors of these barriers have not been explored. One approach to better understand barriers and facilitators to providing CPS is to use a work system approach to examine different components of a work system and how the components may impact care processes.
Objectives
The goals of this study were to identify and describe pharmacy work system characteristics that pharmacists identified and changed to provide CPS in a demonstration program.
Methods
A qualitative approach was used for data collection. A purposive sample of 8 pharmacists at 6 community pharmacies participating in a demonstration program was selected to be interviewed. Each semistructured interview was audio recorded and transcribed, and the text was analyzed in a descriptive and interpretive manner by 3 analysts. Themes were identified in the text and aligned with 1 of 5 components of the Systems Engineering Initiative for Patient Safety (SEIPS) work system model (organization, tasks, tools/technology, people, and environment).
Results
A total of 21 themes were identified from the interviews, and 7 themes were identified across all 6 interviews. The organization component of the SEIPS model contained the most (n = 10) themes. Numerous factors within a pharmacy work system appear important to enable pharmacists to provide CPS. Leadership and foresight by the organization to implement processes (communication, coordination, planning, etc.) to facilitate providing CPS was a key finding across the interviews. Expanding technician responsibilities was reported to be essential for successfully implementing CPS.
Conclusions
To be successful in providing CPS, pharmacists must be cognizant of the different components of the pharmacy work system and how these components influence providing CPS.
doi:10.1016/j.sapharm.2011.06.001
PMCID: PMC3351586  PMID: 21824822
Medication therapy management; Community pharmacy; Human factors; Work systems

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