Objective. To describe the redesign of a large self-care course previously delivered in a traditional lecture format to a small-group case-based course.Design. Prereadings and study guides were used ...to facilitate students' independent learning prior to class. Large lecture classes were replaced with smaller group-based learning classes. This change in delivery format allowed students to spend the majority of class time conducting small-group learning activities, such as case studies to promote communication, problem solving, and interpersonal skills.Assessment. Changes in course delivery were assessed over a 2-year period by comparing students' grades and satisfaction ratings on course evaluations. A comparison of course evaluations between the class formats revealed that students were provided more opportunities to develop verbal communication skills and tackle and resolve unfamiliar problems in the revised course. The activities resulted in better overall course grades.Conclusions. Redesigning to a small-group discussion format for a self-care course can be accomplished by increasing student accountability for acquiring factual content outside the classroom. Compared with student experiences in the previous large lecture-based class, students in the smaller-class format reported a preference for working in teams and achieved significantly better academic grades with the new course format.
Naloxone prescribing to older adults in primary care Luther, Caroline D.; Hughes, Tamera D.; Ferreri, Stefanie P.
Journal of the American Geriatrics Society (JAGS),
December 2021, 2021-12-00, 20211201, Letnik:
69, Številka:
12
Journal Article
Recenzirano
While opioid prescribing has declined in the last 10 years, prescription fill rates remain high in older adults.6 Despite sustained prescription opioid exposure and overdose risk status, this ...population has not been integrated into naloxone prescribing protocols in outpatient clinics.4 In the absence of protocols targeted to older adults, it is important to understand the decision-making process of providers in prescribing naloxone to older adults.
Racial disparities in drug overdose exist, with black, indigenous, and Hispanic individuals experiencing higher rates of opioid overdose deaths. Opioid use disorder prevention services, such as ...opioid deprescribing and naloxone dispensing, have been identified as ways to prevent opioid overdose. Pharmacists can help use these strategies, but racial disparities in use exist.
This study aimed to evaluate North Carolina (NC) pharmacist knowledge, attitudes, and practices (KAP) of opioid management practices, including opioid deprescribing and naloxone dispensing, across different racial and ethnic groups.
This was a prospective, cross-sectional study conducted through a Web-based KAP survey distributed via e-mail to all NC pharmacists using a modified Dillman's method. Descriptive statistics were used to analyze demographics and pharmacist KAP data. Attitudes data were further analyzed using one-way analysis of variance tests and Tukey's post hoc analyses.
After applying exclusion criteria, 527 participants were eligible for analysis; 254 of these individuals completed the entire survey. The survey response rate was 15.3% and respondents were mostly female (59.1%) and white (86.6%). Approximately half of pharmacists knew the correct opioid morphine milliequivalent cutoffs considered to be high risk (47.7%) and not to be exceeded (51.9%). When asked about chronic opioid statistics within the United States, respondents overestimated that 23.70% of patients on chronic opioid therapy receive naloxone (SD = 18.93%). Pharmacists believed that black patients were more likely to adhere to an opioid taper than any other race or ethnicity and Hispanic patients were more likely to adhere to naloxone treatment than any other race or ethnicity. Finally, 91% of pharmacists knew what an opioid taper was, but 77% of pharmacists had never designed one.
Gaps in knowledge may contribute to further disparities in opioid management. Pharmacists' attitudes may contribute to biases in opioid management practices and practices related to opioid deprescribing may limit the pharmacists' current role. More education is needed so pharmacists can play an increased role in opioid management across all patient populations.
We characterized real-world prescribing patterns of opioids and benzodiazepines (BZDs) for older adults to explore potential disparities by race and sex and to characterize patterns of ...co-prescribing.
A retrospective evaluation was conducted using electronic health data for adults ≥65 years old who presented to one of 15 primary care practices between 2019 and 2020 (n = 25,141). Chronic opioid and BZD users had ≥4 prescriptions in the year prior, with at least one in the last 90 or 180 days, respectively. We compared demographic characteristics between all older adults versus chronic opioid and BZD users. We used logistic regression to identify characteristics (age, sex, race, Medicaid use, fall history) associated with opioid and BZD co-prescribing.
We identified 833 (3.3%) chronic opioid and 959 chronic BZD users (3.8%) among all older adults seen in these practices. Chronic opioid users were less likely to be Black (12.7% vs. 14.3%) or other non-White race (1.4% vs. 4.3%), but more likely to be women (66.8% vs. 61.3%). A similar trend was observed for BZD users, with less prescribing among Black (5.4% vs. 14.3%) and other races (2.2% vs. 4.3%) older adults and greater prescribing among women (73.6% vs. 61.3%). Co-prescribing was observed among 15% of opioid users and 13% of BZD users. Co-prescribing was largely driven by the presence of relevant co-morbid conditions including chronic pain, anxiety, and insomnia rather than demographic characteristics.
We observed notable disparities in opioid and BZD prescribing by sex and race among older adults in primary care. Future research should explore if such patterns reflect appropriate prescribing or are due to disparities in prescribing driven by biases related to perceived risks for misuse.
Opioids remain commonly prescribed in older adults, despite the known association with falls and fall-related injuries. This retrospective cohort study sought to determine the association of opioid ...use and falls in older adult opioid users. Using a one-year lookback period in electronic health records, daily morphine milligram equivalents (MMEs) were calculated using prescription orders. Fall history was based on patient self-reporting. A receiver operating characteristic (ROC) curve was used to identify the threshold of average daily MMEs at which the likelihood of falls was increased. Older opioid users were most often women and White, with 30% having fallen in the prior year. In ROC analyses (n = 590), the threshold where fall risk increased was 37 MMEs (
= 0.07). Older adults prescribed more than 37 MMEs daily may be at increased fall risk and should be targeted for deprescribing interventions. Additionally, analysis on patient characteristics and covariates suggest that sex, age, COPD, sleep apnea, cancer, and psychiatric conditions may indicate an increased risk of falls in older adults taking chronic opioids (
< 0.05). Multifactorial interventions may be needed to modify fall risk beyond medication use alone.
OBJECTIVES
To evaluate the effects of a community pharmacy‐based fall prevention intervention (STEADI‐Rx) on the risk of falling and use of medications associated with an increased risk of falling.
...DESIGN
Randomized controlled trial.
SETTING
A total of 65 community pharmacies in North Carolina (NC).
PARTICIPANTS
Adults (age ≥65 years) using either four or more chronic medications or one or more medications associated with an increased risk of falling (n = 10,565).
INTERVENTION
Pharmacy staff screened patients for fall risk using questions from the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) algorithm. Patients who screened positive were eligible to receive a pharmacist‐conducted medication review, with recommendations sent to patients' healthcare providers following the review.
MEASUREMENTS
At intervention pharmacies, pharmacy staff used standardized forms to record participant responses to screening questions and information concerning the medication reviews. For participants with continuous Medicare Part D/NC Medicaid coverage (n = 3,212), the Drug Burden Index (DBI) was used to assess exposure to high‐risk medications, and insurance claims records for emergency department visits and hospitalizations were used to assess falls.
RESULTS
Among intervention group participants (n = 4,719), 73% (n = 3,437) were screened for fall risk. Among those who screened positive (n = 1,901), 72% (n = 1,373) received a medication review; and 27% (n = 521) had at least one medication‐related recommendation communicated to their healthcare provider(s) following the review. A total of 716 specific medication recommendations were made. DBI scores decreased from the pre‐ to postintervention period in both the control and the intervention group. However, the amount of change over time did not differ between these two groups (P = .66). Risk of falling did not change between the pre‐ to postintervention period or differ between groups (P = .58).
CONCLUSION
We successfully implemented STEADI‐Rx in the community pharmacy setting. However, we found no differences in fall risk or the use of medications associated with increased risk of falling between the intervention and control groups. J Am Geriatr Soc 68:1778‐1786, 2020.
Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and ...monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina.
We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs.
This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings.
Clinicaltrials.gov NCT04272671 . Registered on February 17, 2020.
As pharmacy practice shifts its focus toward population health care needs that serve public health, there is a need to understand community-based pharmacies' contributions to the reduction in health ...disparities. A scoping review was conducted to identify what community-based pharmacies in the United States are doing to target racial and ethnic disparities in community-based pharmacies. Forty-two articles revealed that community-based pharmacy services addressed racial and ethnic inequities in a variety of ways, including the types of interventions employed, as well as the ethnicities and conditions of the sample populations. Future work should focus on ensuring interventions are carried out throughout pharmacy practice and accessible to all racial and ethnic minoritized populations.
While medication synchronization programs are becoming a staple in community pharmacies, a standard process needs to be identified to provide consistent positive outcomes. Many studies demonstrate ...how medication synchronization affects individual level patients but have not examined how medication synchronization affects the pharmacy's performance. Because community pharmacies are calibrated based on performance to adherence measures for all patients, it is important to understand whether resource-intensive interventions, such as medication synchronization, lead to improved performance.
The aims of this study were to 1) examine pharmacy characteristics associated with medication synchronization adoption and 2) examine whether medication synchronization is associated with pharmacy-level performance on select medication adherence and utilization measures.
This study used a cross-sectional design. Community pharmacies participating in the North Carolina Community Pharmacy Enhanced Services Network (NC CPESN℠) program were included in this study. Pharmacy performance was measured as summary score of pharmacy's performance on seven risk-adjusted measures which were used to measure pharmacy's performance in the program. Adoption of medication synchronization was measured as a binary variable capturing whether the pharmacy offered med sync at the time the survey was administered.
Surveys were received from 160 out of 268 participating pharmacies (59.7% response rate) with a total of 155 pharmacies being included in the analytic sample. Pharmacies that adopted medication synchronization were more likely to have a clinical pharmacist on staff (c = 5.4, p = 0.019). Holding all else constant, medication synchronization adoption was not significantly associated with total medication adherence performance (p = 0.371).
Medication synchronization has proven successful in improving individual patient level adherence but may not change a pharmacy's overall performance in adherence for all patients. Further research is needed to examine how effective implementation might contribute to whether a medication synchronization program leads to meaningful gains in adherence for all patients.
Community pharmacy participation in performance-based payment models has increased in recent years. Despite this, there has been neither much research done to evaluate the effect of these models on ...health care quality and spending nor is there extensive literature on the design of these models.
To (a) describe the types of measures used in performance-based pharmacy payment models (PBPPMs); (b) describe the financial impact of PBPPMs on pharmacies; (3) explore pharmacy owners' perceptions of PBPPMs; and (4) describe any practice changes made in response to PBPPMs.
This is a cross-sectional study that surveyed independent community pharmacy owners between November 2019 and January 2020. The survey included 45 items split into 5 sections that covered respondent characteristics and the 4 domain objectives. Descriptive statistics were used for quantitative responses, and free-text responses were assessed for themes.
Of the 68 individuals who responded to the survey, 42 were community pharmacy owners who met the study eligibility criteria, and 30 responded to most survey items. Owners expressed frustration at the design of PBPPMs, with 90% stating that they did not feel that the actions necessary to meet or exceed performance standards were within their control, and 90% also reported a loss of revenue because of these models. In addition, large numbers of respondents felt that they did not have enough information on how performance measures were computed (76.7%) or how cut-points were determined (86.7%). Despite negative feelings, most owners reported implementing changes in service offerings as a result of these models.
PBPPMs appear to be commonplace and put substantial financial burden on community pharmacies. Study results suggest that greater education by payers could improve pharmacist engagement, as could involvement of pharmacies in the design and maintenance of PBPPMs.
This work was supported by a grant from the American Association of Colleges of Pharmacy, which was not involved in the collection, analysis, and interpretation of data; writing of the report; or the decision to submit this article for publication. Urick reports consulting fees from Pharmacy Quality Solutions. The other authors declare no conflicts of interest with respect to the research, authorship, and/or publication of this article.
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