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1.  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
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
14.  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
15.  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
16.  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
17.  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
18.  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
19.  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
20.  Effects of mental demands during dispensing on perceived medication safety and employee well being: A study of workload in pediatric hospital pharmacies 
Background
Pharmacy workload is a modifiable work system factor believed to affect both medication safety outcomes and employee outcomes such as job satisfaction.
Objectives
This study sought to measure the effect of workload on safety and employee outcomes in two pediatric hospitals and to do so using a novel approach to pharmacy workload measurement.
Methods
Rather than measuring prescription volume or other similar indicators, this study measured the type and intensity of mental demands experienced during the medication dispensing tasks. The effects of external (interruptions, divided attention, rushing) and internal (concentration, effort) task demands on perceived medication error likelihood, adverse drug event likelihood, job dissatisfaction, and burnout were statistically estimated using multiple linear and logistic regression.
Results
Pharmacists and pharmacy technicians reported high levels of external and internal mental demands during dispensing. The study supported the hypothesis that external demands (interruptions, divided attention, rushing) negatively impacted medication safety and employee well being outcomes. However, as hypothesized, increasing levels of internal demands (concentration and effort) were not associated with greater perceived likelihood of error, adverse drug events, or burnout, and even had a positive effect on job satisfaction.
Conclusion
Replicating a prior study in nursing, this study shows that new conceptualizations and measures of workload can generate important new findings about both detrimental and beneficial effects of workload on patient safety and employee well being. This study discusses what those findings imply for policy, management, and design concerning automation, cognition, and staffing.
doi:10.1016/j.sapharm.2009.10.001
PMCID: PMC3052977  PMID: 21111387
Workload; mental demands; medication error; safety; employee well being; human factors
21.  Use of Complementary and Alternative Medicine (CAM) for Treatment among African-Americans: A Multivariate Analysis 
Background
Complementary and alternative medicine (CAM) use is substantial among African-Americans; however, research on characteristics of African-Americans who use of CAM to treat specific conditions is scarce.
Objective
To determine what predisposing, enabling, need, and disease state factors are related to CAM use for treatment among a nationally representative sample of African-Americans.
Methods
A cross-sectional study design was employed using the 2002 National Health Interview Survey (NHIS). A nationwide representative sample of adult (≥ 18 years) African-Americans who used CAM in the past 12 months (n= 16,113,651 weighted; n=2,952 unweighted) were included. The Andersen Healthcare Utilization Model served the framework with CAM use for treatment as the main outcome measure. Independent variables included: predisposing (e.g., age, gender, education), enabling (e.g., income, employment, access to care); need (e.g., health status, physician visits, prescription medication use); and disease state (i.e., most prevalent conditions among African-Americans) factors. Multivariate logistic regression was used to address the study objective.
Results
Approximately one in five (20.2%) CAM past 12 month users used CAM to treat a specific condition. Ten of the 15 CAM modalities were used primarily for treatment by African-Americans. CAM for treatment was significantly (p<0.05) associated with the following factors: graduate education, smaller family size, higher income, region (northeast, midwest, west more likely than south), depression/anxiety, more physician visits, less likely to engage in preventive care, more frequent exercise behavior, more activities of daily living (ADL) limitations, and neck pain.
Conclusions
Twenty percent of African-Americans who used CAM in the past year were treating a specific condition. Alternative medical systems, manipulative and body-based therapies, as well as folk medicine, prayer, biofeedback, and energy/Reiki were used most often. Health care professionals should routinely ask patients about CAM use, but when encountering African-Americans, there may be a number of factors that may serve as cues for further inquiry.
doi:10.1016/j.sapharm.2009.08.001
PMCID: PMC2933406  PMID: 20813333
African-American; Andersen Healthcare Utilization Model; CAM; CAM for treatment complementary/alternative medicine
22.  Development of a Scale to Measure Pharmacists’ Self-Efficacy in Performing Medication Therapy Management Services 
Background
Measuring community pharmacists’ self-efficacy in performing medication therapy management (MTM) services can be useful for tailoring interventions and predicting participation.
Objective
To identify relevant survey constructs related to the Wisconsin Pharmacy Quality Collaborative (WPQC) MTM program and to evaluate scale validity.
Methods
The 31-item MTM Self-efficacy Scale was developed using previous research, identifying critical program components, and beta-testing. After administration to pharmacists in the 53 WPQC pilot sites, summary statistics and exploratory factor analysis (EFA) were conducted. Parallel analysis was used to determine the optimal number of factors. Internal consistency reliabilities were calculated.
Results
Baseline participation rate was 94% (N=76). The 11-point scale (0–10) item means ranged from 2.83±3.05 to 7.82±2.19. Parallel analysis produced a 3-factor solution, accounting for 56% of the variance. Low factor loadings or unacceptably high cross-loadings resulted in 17 item deletions. The final EFA on the remaining 14 items retained the original 3-factor solution and increased the proportion of explained variance (72%). The factors relate to MTM tasks (alpha = 0.92), personal interactions (alpha = 0.86), and goal setting (alpha = 0.84). Overall Cronbach’s alpha = 0.90.
Conclusion
Constructs for measuring self-efficacy were identified that may aid in future research predicting whether pharmacists engage in and persist in providing MTM services.
doi:10.1016/j.sapharm.2010.05.001
PMCID: PMC2904078  PMID: 20511114
Self-efficacy; Medication therapy management; Community pharmacy; Scale validation; Research methods
23.  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
24.  Roles and Responsibilities of Pharmacists with Respect to Natural Health Products: Key Informant Interviews 
Background
Although many pharmacies sell natural health products (NHPs), there is no clear definition as to the roles and responsibilities (if any) of pharmacists with respect to these products.
Objective
The purpose of this study was to explore pharmacy and stakeholder leaders’ perceptions of pharmacists’ professional NHP roles and responsibilities.
Methods
Semi-structured key informant interviews were conducted with pharmacy leaders (n= 17) and stakeholder (n=18) leaders representing consumers, complementary and alternative medicine practitioners, conventional healthcare practitioners, and industry across Canada.
Results
Overwhelmingly all participants believed a main NHP responsibility for pharmacists was safety monitoring. One challenge identified in the interviews was pharmacists’ general lack of NHP knowledge. Stakeholder leaders did not expect pharmacists to be experts on NHPs, rather that pharmacists should have a basic level of knowledge about NHPs. Many pharmacy leaders appeared to be unfamiliar with current pharmacy policies and guidelines concerning NHPs.
Conclusion
Participants described pharmacists’ professional roles and responsibilities for NHPs as similar to those for over-the-counter drugs. More awareness of existing NHP-related pharmacy policies is needed. Pharmacy owners/managers should provide additional training to ensure front-line pharmacists have appropriate knowledge of NHPs sold in the pharmacy.
doi:10.1016/j.sapharm.2009.02.004
PMCID: PMC2923149  PMID: 20188329 CAMSID: cams1316
natural health products; pharmacists; professional roles and responsibilities
25.  Pre-Dialysis Chronic Kidney Disease: Evaluation of Quality of Life in Clinic Patients Receiving Comprehensive Anemia Care 
Background
Anemia is common in chronic kidney disease (CKD), and suboptimal management of anemia can lead to serious health complications and poor quality of life.
Objectives
1) To describe health-related and overall quality of life among patients entering a clinic focused on anemia management; 2) to compare their baseline quality of life with other relevant populations; 3) to explore predictors of quality of life prior to anemia management; and 4) to explore changes in quality of life over 1 year for patients managed in the clinic.
Methods
The Kidney Disease Quality of Life questionnaire – short form (KDQOL™-SF) was used to measure kidney disease specific and overall quality of life in a cohort of pre-dialysis CKD patients (n=79) enrolled in the clinic from January 2003 to September 2004. Baseline measures were compared to previously published measurements. The influence of demographic and clinical characteristics on baseline quality of life was explored. Changes in quality of life were evaluated over time.
Results
Patients with CKD entering the clinic had lower overall quality of life compared with estimates from the general US population (physical composite 35.7 vs. 48.4 and mental composite 46.0 vs. 50.2, respectively). Clinic patients had better kidney disease specific scores than patients with end stage kidney disease. General quality of life scores were similar regardless of kidney disease severity, with the exception of physical functioning which was lowest for patients with end-stage disease. Hemoglobin was the only factor predictive of quality of life. Over time, quality of life improved among patients managed in the CKD clinic, with statistically significant improvements in sleep (change of 6.2 ± 15.2; p < 0.05) and social function (change of 11.6 ± 27.7; p < 0.05).
Conclusions
Patients with anemia of chronic kidney disease reported reduced quality of life compared to populations without kidney disease, but better quality of life compared to populations with end stage kidney disease on dialysis. Quality of life generally improved among patients managed in the multidisciplinary anemia clinic.
doi:10.1016/j.sapharm.2008.06.004
PMCID: PMC2722114  PMID: 19524862
Quality of life; chronic kidney disease; anemia; SF-36; KDQOL; multidisciplinary

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