Using a pharmacist–community health worker collaboration to address medication adherence barriers

ObjectivePharmacists are positioned to evaluate and educate patients regarding medication adherence; however, opportunities exist to leverage a collaborative approach in eliciting barriers encountered by patients, especially in minority groups. Community health workers (CHWs) are individuals from the communities who form relationships with patients and help increase their access to health care resources. This study aimed to evaluate the effectiveness of a collaboration between CHWs and pharmacists in identifying and addressing medication adherence barriers faced by hypertensive patients.MethodsAfter receiving training in medication therapy management support, CHWs from the South East American Indian Council collaborated with students and pharmacists from the Center for Quality Medication Management at the University of Florida to identify and address medication adherence barriers encountered by hypertensive patients who were mainly Native American or black. The CHWs documented information from the patient interviews during the initial and follow-up visits. The team collaborated to identify intervention opportunities on the basis of the adherence barriers identified. Follow-up visits were conducted to measure progress.ResultsThirty-three hypertensive patients with or without diabetes were included in the study. The pharmacists, in partnership with the CHWs, offered 149 interventions related to medication adherence barriers. The most commonly identified barriers included forgetfulness, adverse effects, and knowledge concerns. By the final visits, 75.6% of the barriers related to antihypertensive medications and 63.9% of the barriers related to antidiabetic medications were resolved. In addition, a paired t test indicated a significant difference in the mean blood pressure values (P = 0.006 for systolic and P = 0.008 for diastolic) recorded at the initial (mean = 136/85.7 mm Hg) and final (mean = 130.1/81.2 mm Hg) visits.ConclusionThe findings of this pilot project support the collaboration between pharmacists and CHWs to help improve medication adherence and patient outcomes. Additional research is recommended to validate these study findings.     

Community health worker perspectives of an academic community medication therapy management collaboration

ObjectiveTo qualitatively assess community health workers’ (CHWs’) perceptions of the challenges and benefits associated with participating in a collaborative, interprofessional medication therapy management (MTM) program for rural, underserved, predominantly Latinx, patients with diabetes and hypertension.MethodsNine CHWs participated in a 1-hour, semistructured focus group that explored their experiences while assisting in the delivery of MTM services through an academic community partnership between an MTM provider and participating rural clinics. Audio recordings of the focus group were transcribed and thematically analyzed by 2 independent reviewers.ResultsAll program-involved CHWs participated in the focus group. Qualitative analysis identified 2 overarching themes: (1) opportunities and (2) challenges. Opportunities were further subcategorized as benefits to (1) CHWs, (2) patients, or (3) academic community MTM research. The CHWs perceived that they served as a liaison among the medical provider (prescriber), patient, and MTM pharmacist. Benefits to the patients focused on the integration of CHWs as essential to patient recruitment, especially for those who were reluctant to participate or receive a phone call from a stranger. The major challenges identified were (1) interruptions in workflow and (2) communication between CHWs and the health care practitioners (physicians, nurse practitioners, pharmacists). Specifically, the CHWs universally agreed that they needed more time after receiving patient report, scheduling a visit with the patient, and communicating with the patient’s health care provider to better understand the individual’s circumstances and needs.ConclusionThis study identified perceived opportunities and challenges faced by CHWs and chronically ill, rural Latinx patients in the acceptance of MTM program. These findings may be useful for all interprofessional health care team members to better understand and appreciate the role of CHWs, while simultaneously enhancing and improving respective medication adherence efforts, and to improve collaborative, academic community programs in the future.     

Economic,clinical, and humanistic outcomes (ECHOs) of pharmaceutical care services for minority patients: A literature review

BackgroundThe U.S. population of racial/ethnic minorities continues to increase; however, health disparities and poor health outcomes among many of them continue to be a major public health problem confronting the U.S. health care system.ObjectivesThe objective of this review was to summarize published pharmaceutical care services literature reporting economic, clinical, and/or humanistic outcomes (ECHOs) among racial/ethnic minorities. Studies that reported differences by race/ethnicity and studies where most participants were from multiracial/ethnic minorities were included.MethodsPubMed and International Pharmaceutical Abstracts databases were searched for articles that reported the effects of pharmaceutical care on ECHOs among racial/ethnic minorities published between January 1980 and November 2010. The literature review was focused on racial groups that included black/African-American, Native American, Indian American Asian, Alaska Native, Native Hawaiian, and Pacific Islander patients, and ethnic group that was non-white Hispanic/Latino patients.ResultsThere were 24 articles that studied the impact of pharmaceutical care on ECHOs by race/ethnicity or where most participants were from multiracial/ethnic minorities. Twenty-three studies reported that pharmaceutical care has a positive impact on health outcomes of the studied populations. About half of the studies meeting inclusion criteria evaluated only 1 type of patient outcome, primarily clinical outcomes. Education/consultation and medication/therapy management were the most commonly evaluated types of pharmaceutical care services throughout the studied groups. Comprehensive disease management was evaluated mainly in multiracial/ethnic populations and blacks/African-Americans. Few studies adopted randomized controlled designs, which make it difficult to attribute changes in patient outcomes to the provision of pharmaceutical care. Nine studies that involved cooperation between pharmacists and other medical professionals reflect an increased tendency for interprofessional collaboration in the current health care system.ConclusionThis review shows that there is a positive relationship between pharmaceutical care and ECHOs in patients from racial/ethnic minority groups. However, more studies are needed to document the effects of pharmaceutical care on reducing racial/ethnic health disparities and to determine which interventions are most effective among certain groups with health disparities.     

A review of published studies of patients’ illness perceptions and medication adherence: Lessons learned and future directions

BackgroundPatients who seek medical care and who are prescribed medication may choose to either accept or not accept the prescriber’s recommendations to use the prescribed medication. The Common Sense Model (CSM) is one behavioral model that can help researchers and practitioners to identify patients’ illness perceptions that drive their decisions.ObjectiveThis article reviews published research that evaluated the impact of illness representations (as defined in CSM) with medication adherence.MethodsA narrative review of published research in illness representation and medication adherence was conducted. Articles were searched using MEDLINE, PreMEDLINE, evidence-based medicine reviews, and the International Pharmaceutical Abstracts databases and using the search terms medication adherence, compliance, illness perception, self-regulation theory, and common-sense model.ResultsEleven published studies were identified that compared illness representation (or illness perception) and medication adherence. Each illness representation factor, with the exception of illness coherence, directly or indirectly impacted medication adherence. Illness identity, where symptoms are used to label a health condition, can impact medication adherence, even with asymptomatic conditions such as hypertension. Patient age, disease condition, and culture may impact patient response to illness perceptions. Recommendations for future research are to (1) use longitudinal studies to evaluate the cause-effect relationships between illness perceptions and medication adherence, (2) study patients’ early experiences with their illness, (3) recruit patients who are nonadherent, (4) use clinical outcome measures in addition to the self-report medication adherence measures, and (5) include patient age and culture in the model.ConclusionsAlthough the CSM is a well-known patient behavior model, its use to explain medication adherence has been limited to cross-sectional studies across various health conditions. Further research is needed to elucidate the relationships between illness perceptions and patient medication adherence, which can help practitioners to better engage and communicate with patients.     

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.     

Consumer,physician, and payer perspectives on primary care medication management services with a shared resource pharmacists network

BackgroundHealth care reform initiatives are examining new care delivery models and payment reform alternatives such as medical homes, health homes, community-based care transitions teams, medical neighborhoods and accountable care organizations (ACOs). Of particular interest is the extent to which pharmacists are integrated in team-based health care reform initiatives and the related perspectives of consumers, physicians, and payers.ObjectivesTo assess the current knowledge of consumers and physicians about pharmacist training/expertise and capacity to provide primary care medication management services in a shared resource network; determine factors that will facilitate/limit consumer interest in having pharmacists as a member of a community-based “health care team;” determine factors that will facilitate/limit physician utilization of pharmacists for medication management services; and determine factors that will facilitate/limit payer reimbursement models for medication management services using a shared resource pharmacist network model.MethodsThis project used qualitative research methods to assess the perceptions of consumers, primary care physicians, and payers on pharmacist-provided medication management services using a shared resource network of pharmacists. Focus groups were conducted with primary care physicians and consumers, while semi-structured discussions were conducted with a public and private payer.ResultsMost consumers viewed pharmacists in traditional dispensing roles and were unaware of the direct patient care responsibilities of pharmacists as part of community-based health teams. Physicians noted several chronic disease states where clinically-trained pharmacists could collaborate as health care team members yet had uncertainties about integrating pharmacists into their practice workflow and payment sources for pharmacist services. Payers were interested in having credentialed pharmacists provide medication management services if the services improved quality of patient care and/or prevented adverse drug events, and the services were cost neutral (at a minimum).ConclusionsIt was difficult for most consumers and physicians to envision pharmacists practicing in non-dispensing roles. The pharmacy profession must disseminate the existing body of evidence on pharmacists as care providers of medication management services and the related impact on clinical outcomes, patient safety, and cost savings to external audiences. Without such, new pharmacist practice models may have limited acceptance by consumers, primary care physicians, and payers.     

Using educational games to promote the seeking of a pharmacist and to teach key medication use messages: Results from an inner city health party

BackgroundLow health literacy affects 80–90 million Americans with low-income, minority populations being more vulnerable to this condition. One method of addressing limited literacy that may be particularly well accepted within vulnerable populations is the use of educational board games in order to emphasize seeking health information from reliable sources such as pharmacists.ObjectiveThe research objective was to determine if the use of educational board games could impact community pharmacy patron intentions to seek pharmacist advice in an urban, minority, economically-disadvantaged population.MethodsFour medication-related educational games were played at an urban community pharmacy under the leadership of pharmacy students in the setting of a health party. Game messages, design, and evaluation processes were uniquely guided by community members' input. A verbally administered questionnaire measured game impact via knowledge and perception questions with responses compared between a non-randomly allocated intervention group and a control group.ResultsNinety-nine adults were included in the intervention (or game) group and 94 adults were in the control group. Game participants were significantly more likely than the control group to indicate they would seek pharmacist medication advice in the future.ConclusionEducational board games played in the setting of a health party can be a fun and effective way to convey selected health messages within an urban, minority, economically disadvantaged population. Community input into game development and layering multiple strategies for overcoming health literacy barriers were essential components of this initiative.     

The effect of visual interventions on illness beliefs and medication adherence for chronic conditions: A scoping review of the literature and mapping to behaviour change techniques (BCTs)

BackgroundMaintaining health with chronic conditions often involves taking multiple medications; however, approximately 50% of patients with chronic conditions are non-adherent to medication. Patients’ illness beliefs inform health behaviour, including medication-taking. Research has shown that visuals accompanying health information increased patient comprehension and the accuracy of illness perceptions. To date, the influence of visuals on illness beliefs and medication adherence has not been comprehensively reviewed.ObjectivesThe review aimed to collate available literature on visualisation interventions for illness beliefs and medication adherence in chronic conditions and identify key intervention characteristics.MethodsA scoping review was conducted according to recommended guidelines and the PRISMA-ScR statement. Searches used keywords relating to ‘illness’, ‘visual’, ‘adherence’, ‘illness perception’, ‘intervention’, and ‘medication’. Six databases were searched from inception to 2019; reference-list searching provided additional articles. Articles were included if the study population had a chronic health condition, the intervention included a visual element, had a measure of illness beliefs or medication adherence. Data regarding intervention characteristics and outcomes were extracted. Behaviour change techniques (BCTs) were identified to provide further insight into intervention characteristics.ResultsInitially, 18,012 articles were identified. Screening led to 293 full-text articles, ultimately resulting in 45 studies for final analysis. Forty-four were quantitative studies, 1 was qualitative. Studies were grouped into those using visuals to conceptualise a condition, medication reminders and educational interventions. Almost two-thirds of visual interventions were effective post-intervention, 3 sustained post-1-year, although many studies only assessed impact immediately post-intervention. BCTs from ‘Natural consequences’, ‘Social support’ and ‘Feedback and monitoring’ categories were prevalent in effective interventions for both outcomes, particularly the ‘Salience of consequences’ BCT.ConclusionsThis comprehensive scoping review found that visual interventions can positively influence illness beliefs and medication adherence. These findings highlight the need to further evaluate the impact and sustainability of visual interventions.     

Characterizing medication management and the role of pharmacists in caring for people living with cystic fibrosis: A work system approach

BackgroundCystic fibrosis (CF) is an autosomal recessive genetic disease requiring complex, lifelong medication regimens. Given the importance of medication in CF treatment, pharmacists are vital CF care team members in the care of people living with CF (PwCF).ObjectivesThis study aimed to (1) define patients’ CF medication experiences and educational needs and (2) investigate the CF outpatient clinic and community pharmacist’s role in addressing patient challenges.MethodsA work system approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model was used to characterize knowledge and perception of CF medication regimens, educational modalities, and pharmacist interactions for PwCF. Semistructured interviews were conducted with adults living with CF at a CF center clinic. Data analyses identified relationships between the themes in the data and 4 SEIPS work system domains: tasks, tools and technology, person, and environment.ResultsThirty PwCF interviews highlighted 4 themes regarding health care experiences: (1) medication use experience, (2) medication education needs, (3) disease experience, and (4) pharmacist and pharmacy interactions. Patients reported complex medication regimens leading to challenges with medication adherence, although the benefit of treatment was recognized. Although a high level of disease-state knowledge was identified among the participants, PwCF desired to learn about CF medication benefits and adverse effects through credible sources using multiple modalities. Many reported a benefit of pharmacist involvement in their care.ConclusionPharmacists are well-positioned to support PwCF in adherence, medication regimen management, and medication education. Opportunities exist for growth in these supportive roles of a pharmacist in both community and outpatient clinic settings.     

Racial and ethnic disparities associated with the measure for drug-drug interactions among Medicare beneficiaries

BackgroundDrug-drug interactions (DDIs) cause many preventable hospitalizations and admissions. Efforts have been made to raise DDI awareness and reduce DDI occurrence; for example, Medicare Part D Star Ratings, a health plan quality assessment program, included a DDI measure. Previous research reported racial and ethnic disparities in health services utilization and that racial and ethnic minorities, compared with non-Hispanic whites (whites), may be less likely to be targeted for a similar measure, a Star Ratings adherence measure for diabetes medications.ObjectiveThis study aimed to investigate whether any racial and ethnic disparities are associated with the DDI measure in Part D Star Ratings among Medicare populations with diabetes, hypertension, and hyperlipidemia.MethodsThis cross-sectional study analyzed a 2017 Medicare Part D data sample, including 3,960,813 beneficiaries. Because the inclusion in the denominator of the Star Ratings DDI measure was determined by the use of a list of target medications, the likelihood of using a listed target medication was compared between racial and ethnic minorities and whites. Individuals with diabetes, hypertension, and hyperlipidemia were included in the analysis owing to the high prevalence of these conditions. Patient- and community-level characteristics were adjusted by logistic regression.ResultsOf the entire study sample, 26.2% used a target medication. Compared with whites, most racial and ethnic minorities were less likely to use a target medication. For example, among individuals with diabetes, blacks, Hispanics, Asians/Pacific Islanders, and others had, respectively, 14% (odds ratio 0.86 [95% CI 0.84–0.88]), 5% (0.95 [0.93–0.98]), 12% (0.88 [0.84–0.92]), and 10% (0.90 [0.87–0.93]) lower odds compared with whites. Findings were similar among hypertension and hyperlipidemia cohorts, except that Hispanics had similar odds of use as whites.ConclusionMost racial and ethnic minorities may have lower likelihood of being targeted for the DDI measure compared with whites. Future studies should examine whether these disparities affect health outcomes and devise new DDI measures for racial and ethnic minorities.     

A multi-theoretical approach to linking medication adherence levels and the comparison of outcomes

BackgroundThere has been relatively little theoretical research exploring the cognitive complexity of how patients decide the level to which they adhere to prescribed regimens.ObjectivesTo integrate various psychosocial theories into a conceptual framework to review how patients relate their medication use behavior to therapeutic outcomes and how such relationships affect subsequent medication use.MethodsKey psychosocial theories were reviewed involving health beliefs and medication adherence, individual control, and how individuals might compare outcomes with expectations and alternatives. These concepts were integrated into one larger multilevel explanatory model, the Dynamic Exchange Model for Medication Adherence Levels and Comparison of Outcomes (DEMMALCO), explaining how patients might attribute outcomes related to their medication use and choose future actions based on expectations and alternatives available. Key assumptions of the model were also identified.ResultsDEMMALCO indicates that patients make initial attributions of their control over their illness, which affects their subsequent adherence to their regimens. The model suggests that patients actively compare their treatment outcomes with their expectations about outcomes and the outcomes that are related to their best alternative. They are thought to reassess how their control in treatment was related to those outcomes and subsequently modify their adherence behavior based on the presence or absence of resources.ConclusionsStrengths and limitations of the model are noted. DEMMALCO may help inform researchers and clinicians on new ways to conceptualize, monitor, and change medication adherence behavior.     

The association of health literacy with illness perceptions,medication beliefs,and medication adherence among individuals with type 2 diabetes

Background

Beliefs in medications and illness perceptions is associated with medication adherence among individuals with diabetes and several adherence interventions focus on patients' beliefs in medicines and illnesses. Though health literacy is important in medication adherence, the relationship between health literacy and medication adherence remains inconclusive; thus raising the question as to whether health literacy has an amplifying or reducing effect on the relationship between beliefs and adherence.

Pharmacists improve diabetes outcomes: a randomized controlled trial

BackgroundThere is a growing shortage of primary care physicians. Pharmacists can fill the gap, and interdisciplinary teams are being evaluated as part of health care reform.ObjectiveThis study aimed to determine whether adding a pharmacist to an interprofessional health team will improve diabetes outcomes.MethodsIn this 2-phase pilot study, Medicaid-eligible patients with diabetes were randomized to receive standard of care (control arm) or standard of care plus the care of a pharmacist (intervention arm) for 12 months (phase 1). The primary outcome was change in glycated hemoglobin (A1C) from baseline. Secondary outcomes included identifying and correcting medication therapy problems (MTPs) for comorbid conditions, adherence to preventive care visits, health care utilization, self-rated health, and satisfaction surveys. After phase 1, patients in the control arm who did not achieve an A1C of < 8% were eligible to enroll into phase 2 where they received treatment with a pharmacist for 6 months.ResultsOf the 239 patients enrolled, 122 completed phase 1. At 12 months, intervention patients’ mean A1C was 1.85 percentage point (pp) below baseline versus 0.94 pp for control (between-group difference 0.91 pp; P = 0.0218). Most control patients (79%) who completed phase 1 and enrolled into phase 2 improved their A1C by more than 1 pp (P < 0.01). The pharmacists completed 806 patient visits and identified 2638 MTPs. Intervention patients were more adherent to preventive care visits with nutrition (P = 0.043), ophthalmology (P = 0.002), and dentistry (P = 0.007). For intervention patients, 78% rated their experience with the pharmacist as excellent whereas, for control patients, 37% rated their experience with their provider as excellent.ConclusionPharmacist comanagement of patients with diabetes can significantly improve glucose control and patient satisfaction. Creative payment models were used to include pharmacists in the interprofessional patient care team.     

Understanding the attitudes of hospital pharmacists to reporting medication incidents: A qualitative study

BackgroundThe attitudes of doctors, nurses, and midwives to reporting errors in health care have been extensively studied, but there is very limited literature considering pharmacists’ attitudes to medication error reporting schemes, in particular in hospitals.ObjectivesTo explore and understand the attitudes of hospital pharmacists to reporting medication incidents.MethodsFocus groups were conducted with a total of 17 hospital pharmacists from 4 purposively sampled hospitals in the North West of England. The recordings of the focus groups were transcribed verbatim and subject to thematic analysis using a framework analysis approach.ResultsPharmacists agreed that the high prevalence of medication errors, especially prescribing errors of omission, has led to an acceptance of not using hospital reporting systems. There were different personal thresholds for reporting medication errors but pharmacists agreed that the severity of any patient harm was the primary reporting driver. Hospital pharmacists had specific anxieties about the effects of reporting on interprofessional working relationships with doctors and nurses, but felt more confident to report if they had previously witnessed positive feedback and system change following an error. Existing reporting forms were considered too cumbersome and time consuming to complete, as pharmacists felt the need to find and record every possible detail.ConclusionsHospital pharmacists understood the importance of reporting medication incidents, but because of the high number of errors they encounter do not report them as often as may be expected. The decision to report was a complex process that depended on the severity of patient harm, anxieties about harming interprofessional relationships, prior experience of the outcomes from reporting, and the perceived effort required to use reporting forms.     

台湾临床药师用药教育介绍

目的为加强临床药师患者用药教育,促进临床合理用药提供参考。方法介绍台湾医院的·临床药师对患者开展用药教育的模式与特色。结果台湾临床药师的工作细致深入,用药教育的形式多样化,且后续工作周到完善。结论与台湾地区相比,大陆的临床药师在人员配备、培养模式以及信息化程度方面存在较大的差距,用药教育的开展也非常有限。可借鉴台湾用药教育的模式,逐渐提升临床药师在治疗团队中的地位和作用。