Application of intervention mapping to develop and evaluate a pharmaceutical discharge letter to improve information transfer between hospital and community pharmacists

BackgroundInsufficient information transfer is a major barrier in the transition from hospital to home. This study describes the systematic development and evaluation of an intervention to improve medication information transfer between hospital and community pharmacists.ObjectiveTo develop and evaluate an intervention to improve the medication information transfer between hospital and community pharmacists based on patients', community and hospital pharmacists’ needs.MethodsThe intervention development and evaluation was guided by the six-step Intervention Mapping (IM) approach: (1) needs assessment to identify determinants of the problem, with a scoping review and focus groups with patients and healthcare providers, (2) formulation of intervention objectives with an expert group, (3) inventory of communication models to design the intervention, (4) using literature review and qualitative research with pharmacists and patients to develop the intervention (5) pilot-testing of the intervention in two hospitals, and (6) a qualitative evaluation of the intervention as part of a multicenter before-after study with hospital and community pharmacists.ResultsBarriers in the information transfer are mainly time and content related. The intervention was designed to target a complete, accurate and timely medication information transfer between hospital and community pharmacists. A pharmaceutical discharge letter was developed to improve medication information transfer. Hospital and community pharmacists were positive about the usability, content, and comprehensiveness of the pharmaceutical discharge letter, which gave community pharmacists sufficient knowledge about in-hospital medication changes. However, hospital pharmacists reported that it was time-consuming to draft the discharge letter and not always feasible to send it on time.The intervention showed that pharmacists are positive about the usability, content and comprehensiveness.ConclusionThis study developed an intervention systematically to improve medication information transfer, consisting of a discharge letter to be used by hospital and community pharmacists supporting continuity of care.     

A successful intervention to improve medication adherence in Black patients with hypertension: Mediation analysis of 28-site TEAM trial

BackgroundWe previously reported the main effects and cost-effectiveness of a successful multifaceted Team Education and Adherence Monitoring (TEAM) intervention to improve refill adherence in Black patients with hypertension. It is important to identify the key mediators or intervention components that contributed to this intervention effect.ObjectivesThis study aimed to conduct a “mediation analysis” to determine which intervention components had the largest effect on refill adherence and assess patient satisfaction with pharmacy care.MethodsA cluster-randomized trial was conducted among 576 Black patients in 28 pharmacies (14 TEAM, 14 control). TEAM participants were invited to 6 visits with a pharmacist-technician team that monitored the patient’s blood pressure and used a 9-item Brief Medication Questionnaire, Brief Goal Check, and other novel tools to identify and reduce barriers to adherence in Black patients. Control participants received printed information only. Refill adherence was defined as >80% days covered (proportion of days covered) per refill records during months 7 to 12 (postintervention); potential mediators and patient satisfaction were assessed using a research questionnaire administered at month 6. A structural probit model examined 4 potential mediators that might explain intervention success.ResultsOf 4 potential mediators, the most important factors in explaining the improvement in refill adherence (postintervention) were greater pharmacist collaboration with patient in barrier reduction (68.5% of total indirect effect) and patient use of a pillbox (27.2% of total indirect effect). Pharmacist contact with physician and suggestion of a change in regimen did not have significant effects on adherence. TEAM participants were more likely than control participants to rate their pharmacist care as “very satisfactory” (80.2% vs. 44.2%, P < 0.001) and technician care as “very satisfactory” (81.2% vs. 47.4%, P < 0.001).ConclusionRefill adherence and satisfaction can be improved in Black patients with hypertension by implementing a collaborative TEAM model with novel tools that enable community pharmacists and technicians to help identify and reduce the core barriers to adherence. Our results can be used to individualize and improve patient care and adherence outcomes in this vulnerable population.     

A Theory of Planned Behavior informed factorial survey of New York community pharmacists to determine their intentions to monitor antihypertensive medication adherence among older adults

BackgroundOlder adults with uncontrolled hypertension can benefit from pharmacist-led interventions as they regularly access community pharmacies. However, several barriers to adherence interventions in a community pharmacy setting exist, and few studies have evaluated the feasibility of medication adherence monitoring within the community pharmacy workflow in the United States.ObjectivesTo undertake a factorial survey to determine medication adherence monitoring attitudes of pharmacists and the factors that facilitate or impede adherence counseling by pharmacists within a U.S. community pharmacy setting for antihypertensives in older adults.MethodsThe study was a Theory of Planned Behavior informed factorial survey of New York community pharmacists. The survey had (1) a factorial vignette, to determine how pharmacists make real-life decisions in response to complex situations; (2) questionnaires on medication monitoring attitudes, behavioral beliefs, normative beliefs, and perceived behavioral control regarding medication adherence monitoring, and (3) respondent and workplace characteristics. In response to vignettes, the adherence monitoring tasks were (1) examining patients dispensing records to assess adherence, (2) asking patients about their adherence behavior, and (3) exploring patient beliefs about their antihypertensives.ResultsFrom the 350 completed responses, more than the vignette characteristics, it was the pharmacist characteristics that explained the major variance in the 3 medication monitoring tasks. The respondents demonstrated modestly positive attitudes to medication monitoring, were less positive about their external perception of medication monitoring, and reported difficulty to perform the medication monitoring tasks. In factorial vignette analysis, these attitudes and beliefs significantly impacted adherence monitoring tasks as did situational factors such as time pressures, medication beliefs of patients, the relationship developed with patients, and staffing in the pharmacy, and respondent factors such as pharmacy type and location.ConclusionFuture community pharmacist-led adherence interventions should be designed to address pharmacist attitudes and beliefs and certain workplace characteristics to enable successful implementation.     

The development and evaluation of an extended adherence support programme by community pharmacists for elderly patients at home

Objective —To devise, implement and evaluate a medication adherence support service by community pharmacists for elderly patients living at home and at risk of non‐adherence. Method — Six community pharmacists identified patients who were 65 years of age and older, prescribed four or more regular medicines and living alone. A random sample of patients was visited at home and assessed for adherence‐related problems using a structured interview. The pharmacist then drew up an action plan in conjunction with the patient and general practitioner (GP), and returned for a second home visit, where the revised regime was delivered and explained. A self‐reported adherence questionnaire was also administered. After two months an independent researcher visited the patients at home to assess progress. Setting — Six community pharmacies in the city of Leeds, UK, and patients' homes. Key findings — A total of 143 patients were recruited and 441 medicine‐related problems were identified. Of these, 241 (55 per cent) required the provision of information and advice, 106 (24 per cent) required consultation with the GP and 86 (20 per cent) required changes in the presentation of the medicines. The median number of regular prescribed medicines fell from six to five (P<0.001). Overall, there was a reduction in the number of patients with one or more problems from 94 per cent to 58 per cent (P<0.001). The proportion of patients who reported non‐adherence fell from 38 per cent to 14 per cent (P<0.001). Conclusion — This study shows that community pharmacists can target patients at risk of medication non‐adherence and, using a structured approach, identify problems and implement solutions. The pharmacy patient medication record is an underutilised tool for identifying patients with adherence problems. The software needs enhancing to enable pharmacists to maximise their use of these records in adherence support. An adherence support programme needs to take more account of intentional non‐adherence and should be closely linked with the rest of the primary health care team.     

DOTx.MED: Pharmacist-delivered interventions to improve care for patients with diabetes

ObjectivesTo describe the development and implementation of the Discussions on Taking Medications (DOT_x.MED) Diabetes Pilot Program and to report the impact on adherence to diabetes therapy, improvement in communication of pharmacists, and satisfaction of patients, pharmacists, and health care providers.Participants10 community pharmacy residency sites across the United States enrolled 216 patients with diabetes to participate in the pilot project.InterventionPharmacists delivered behavioral interventions using motivational interviewing techniques and increased personal communication with patients during routine visits to the pharmacy during a 6-month period.ResultsDuring the initial 6-month pilot program, modest improvements in medication adherence were documented. Patients in the intervention group showed a 6.55% increase in proportion of days covered (PDC) compared with the previous 180 days preintervention and a 2.8% increase in PDC compared with the control group. Based on survey results, overall reports of satisfaction from patients, pharmacists, and health care providers were favorable.ConclusionAccess to educational programs, tools, and resources provided through the DOT_x.MED Diabetes Pilot Program improved pharmacist knowledge of diabetes care and increased the amount of time spent communicating with patients. The program demonstrated that small, focused interactions addressing issues of concern to patients can improve patient adherence to medication therapy.     

Assessing the impact of adding pharmacist management services to an existing discharge planning program on 30-day readmissions

BackgroundAlthough hospital readmission rates are declining nationally, avoidable readmissions remain a public health concern. Effective readmission interventions are multifaceted and include discharge planning and transition-of-care coordination. Clinical pharmacists are effective contributors to these processes, bringing expertise to discharge counseling, medication reconciliation, medication adherence, and postdischarge follow-up counseling.ObjectiveWe evaluated the impact of adding health plan clinical pharmacy management services to an existing discharge program on all-cause readmissions and postdischarge primary physician visits.MethodPharmacy management services by health plan clinical pharmacists of a large regional integrated delivery system were added to an existing optimal discharge planning (ODP) program. Criteria for eligibility for these pharmacists’ services included patients who prescribed a new maintenance medication after discharge, received a therapeutic substitution, had a previous discharge within 30 days, or were taking a high-risk medication. A retrospective, observational analysis of a subgroup of patients, who received the pharmacy management services as part of ODP, was performed using a difference-in-difference model, by comparing propensity-matched discharges from February 22, 2016, to January 31, 2017 (preprogram implementation) with discharges from February 22, 2017, to January 31, 2018 (implementation period), to estimate changes in 30-day readmission rates and postdischarge primary physician visits.ResultsA total of 111 of the propensity matched received the pharmacy management services; of these, 73% (ODP) versus 64% (non-ODP) were ≥58 years, 60% were females, and 62% (ODP) versus 52% (non-ODP) were Medicare beneficiaries. There was a 16.7% (P = 0.022) statistically significant reduction in combined inpatient and observation 30-day readmissions and a 19.7% increase in 5-day postdischarge follow-up physician visits (P = 0.037) for the subgroup who also received the pharmacy management services.ConclusionAddition of pharmacist management services to an existing hospital discharge program for select at-risk patients was associated with reduced inpatient and observation 30-day readmissions.     

Medication adherence program: Adherence challenges and interventions in type 2 diabetes

ObjectivesTo describe medication adherence problems for adults with type 2 diabetes and to assess the nature and frequency of pharmacist activities in addressing them and proximate outcomes.DesignPre–post analysis.SettingFour community chain pharmacies located in Seattle, WA, from April 2008 to October 2009.Patients120 patients (mean age >60 years) with type 2 diabetes taking oral diabetes medications and who were 6 or more days late for refills.InterventionPharmacist telephone-initiated adherence support.Main outcomes measuresNature and frequency of adherence-related problems and intervention activities and impact on reduction in refill gaps.ResultsThe primary adherence challenge was difficulty taking medications (27.1%). Failure to remember doses and forgetting refills were reported by 24.6% and 26.3% of patients at baseline, respectively. Pharmacists provided support through some form of patient education (35.6% of encounters) or other adherence support (40.7%). Pharmacist time averaged slightly greater than 5 minutes per intervention and 12.6 ±  minutes (mean ± SD) over 12 months, with 3.4 ±  interventions per patient. Patient-specific education and adherence support by pharmacists and total intervention time were positively correlated, with a modest but significant reduction in refill gaps during 12 months of follow-up.ConclusionNot remembering to refill medications was the most commonly reported problem. Patient encounters averaged 4 to 6 minutes for the first visit and 12 to 13 minutes over 12 months. Phone calls by pharmacists to adults who were late for oral diabetes medication refills were effective in identifying adherence-related problems and developing support strategies to promote medication self-management in busy urban community chain pharmacy settings.     

药物治疗管理模式在抗感染多学科诊疗中的应用探讨

目的：探索建立药师的抗感染多学科诊疗工作模式，为药师参与多学科协作提供参考。方法：参考美国"药物治疗管理"服务模式，从收集患者信息、药物治疗相关问题的评估、药物治疗行动计划的制定、干预和随访等5个核心要素，结合我院实际案例探讨标准化的药学服务流程的建立。结果：探索建立的工作流程提升了药师在多学科工作中的影响力，且为现阶段药师绩效考核制度的建立提供了依据。结论：药物治疗管理模式有助于药师参与抗感染多学科诊疗工作标准的建立，但还需要更多研究数据优化用药相关问题的制订标准。     

Opportunities and responsibilities for pharmacists to improve their effectiveness in addressing medication adherence through culturally sensitive collaborations with community health workers

ObjectivesDespite progress in addressing health disparities among vulnerable populations, minority populations are at risk for chronic health conditions associated with multiple determinants of health, which affects their health status and access to care. We offer a potential solution, which creates an unconventional medical team between a pharmacist and a community health worker (CHW). We explore weaknesses and challenges in our medication use system in the context of adherence as a drug therapy problem, the role of culture in shaping medication use, and finally offer a unique paradigm for a collaborative interprofessional team consisting of CHWs and pharmacists.SummaryMedication adherence is far from optimal, especially in minority ethnic populations. Members of an ethnic group may acquire beliefs about illness consistent with their culture’s shared customs. These findings intimate that ethnocultural minority groups may have their own remedies for illness that shape their decision to use medications as prescribed. An interprofessional team in which CHWs and pharmacists collaborate offers an opportunity to improve the effectiveness of pharmacists to address adherence-related problems, especially among minority populations in which culturally determined beliefs can shape medication use decisions.This approach holds promise because CHWs are usually embedded within the community in which their patients live, having experienced the same life experiences. These shared experiences may lead CHWs to uncover medication use practices that pharmacists are not able to discover on their own because the relationship with their patients is often not authentic, which, for many minority patients, can only be established through shared experiences.ConclusionThis paper argues that creating teams of CHWs and pharmacists will help address challenges in achieving health equity and health disparities among vulnerable populations in the medication use system.