Xm(2) Scores for Estimating Total Exposure to Multimodal Strategies Identified by Pharmacists for Managing Pain: Validity Testing and Clinical Relevance

Objective. To assess the validity of an exposure score obtained from the Xm(2) tool for all pharmacological and nonpharmacological strategies used by individuals to manage chronic pain. Methods. Using data from individuals with chronic pain, eXposure multimodal (Xm(2)) scores were calculated by assigning one point for every 100 mg of morphine equivalent used (opioid medications); 25% of the maximum recommended exposure used (nonopioid medications); and any use of another strategy then summed. Content, criterion, construct, and convergent validity were assessed. Results. The sample of 149 individuals used a mean of 12.6 (SD = 4.6) strategies to manage pain and had a mean Xm(2) score of 16.8 (SD = 9.1). Content validity was established by demonstrating that the pain management strategies identified were also reported in the literature. Criterion validity was established by the positive association of exposure scores with the following: interference with work (odds ratio (OR) = 2.23, 95% confidence interval (CI) = 1.14-4.36), daily activities (OR = 2.10, CI = 1.07-4.13), relationships (OR = 1.98, CI = 1.01-3.88), and leisure activities (OR = 2.31, CI = 1.18-4.50); workdays missed (OR = 5.10, CI = 1.92-13.58); emergency department visits (OR = 3.40, CI = 1.17-9.91); hospitalizations (OR = 4.18, CI = 0.86-20.37); and by a negative association with satisfaction (OR = 0.40, CI = 0.18-0.88). Construct validity was established by the positive association of exposure with baseline pain intensity (p < 0.01) and odds of experiencing an adverse event (OR = 2.31, CI = 1.18-4.52). Convergent validity was established through correlations of pain intensity from the Xm(2) score and existing quantitative analgesic questionnaire (QAQ) score. Discussion. Xm(2) scores represent a valid estimate of total exposure to multimodal strategies used and provide clinically relevant information for deciding what strategies to use at what level.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Junior doctors’ communication with hospital pharmacists about prescribing: findings from a qualitative interview study

Objectives To explore factors affecting communication between Foundation Year (FY) 1 doctors and hospital pharmacists about prescribing from the junior doctors’ perspective. Methods Trained interviewers (n=4) conducted semistructured interviews with FY1 doctors who were purposively sampled from three hospitals in England. FY1 doctors were asked about their experiences of communication with hospital pharmacists about their prescribing; instances where they disagreed with or did not implement a hospital pharmacist’s recommendation; and their preferences for communicating with hospital pharmacists about prescribing. Interviews were audiorecorded, transcribed verbatim and analysed thematically. Results A total of 27 FY1 doctors were interviewed. Findings were categorised into four main themes: (1) nature and context of communication; (2) FY1 doctors’ perceptions of communication with hospital pharmacists; (3) factors influencing FY1 doctors’ decision whether to act on pharmacists’ prescribing recommendations; and (4) suggestions to improve communication with pharmacists. FY1 doctors and hospital pharmacists generally communicated well. FY1 doctors appreciated and frequently acted on pharmacists’ advice yet there was deference to senior medical staff when advice differed. Joint ward rounds, pharmacist-led teaching sessions and a standardised approach to communication were all suggested as ways to improve communication and may increase the likelihood of pharmacists’ recommendations being acted on. Conclusions FY1 doctors and hospital pharmacists communicated frequently about medication prescribing. Issues occurred when there were differences in professional judgement between senior medical staff and pharmacists but these were usually resolved satisfactorily for the FY1 doctor. Further interventions to improve communication and safe prescribing could involve a multidisciplinary and systems approach

Development and Validation of a Tool to Calculate an Exposure Score for All Pain Self-Management Strategies Used By Individuals with Chronic Pain

Objectives: To develop a tool to calculate the exposure scores for all pain self-management strategies used by individuals with chronic pain, and to test the validity of the tool by assessing associations between exposure and pain outcomes using regression. Methods: Survey data of pharmacists’ pain self-management strategies were used to calculate the exposure score. One point was assigned for every: 100mg of morphine used (opioid medications); 25% of the maximum recommended dose used (non-opioid medications); and any use of another strategy. Points were summed to calculate each individual’s exposure. Regressions assessed associations between exposure and pain outcomes. Results: Data for 149 individuals with chronic pain were included in the study. Individuals with chronic pain used a mean of 12.7 (SD=4.7) strategies to manage their pain, and had a mean exposure score of 16.8 (SD=9.1). Exposure score was positively associated in the multivariate models with the self-reported pain outcomes: adverse events experienced due to pain; workdays lost in the last six months due to pain; and pain interference on relationships (p<0.05). Conclusions: This validity study showed positive associations between the exposure score calculated by our tool, and adverse events experienced due to pain, workdays lost in the last six months due to pain, and pain interference with relationships. The personalized exposure profile produced by the tool may assist patients and providers when determining the most appropriate pain self-management strategies to use.Release after 14-Dec-201

Differences in Healthcare Expenditure, Health-Related Quality of Life, Perceived Quality, Medication Access, and Provider Respect Between Opioid and Non-Opioid Users Among a National Sample of Community-Based Older United States Adults with Pain, 2015

Introduction: Increasing numbers of older adults, coupled with increasing use of opioids and opioid-related deaths, presents considerable healthcare challenges in the United States (US). This study compared the healthcare expenditure, health-related quality of life (HRQoL), perceived healthcare quality, access to medications, and perceived respect shown by provider between older US adults (≥50 years) with pain who use opioid medications and those who do not use opioid medications. Methods: This study employed a retrospective, cross-sectional database design using Medical Expenditure Panel Survey (MEPS) data from 2015. Eligible participants were those alive for the calendar year, aged 50 years or older, and reported having chronic pain in the past four weeks. The key independent variable was opioid use status (opioid users were defined as those who had a Multum Lexicon therapeutic class code of 60 or 191; the remainder was deemed non-opioid users). Hierarchical linear regression models were constructed to assess healthcare expenditures (inpatient, outpatient, office-based, emergency room, prescription medications, other, and total), HRQoL (short form 12 version 2 physical component summary [SF-12v2-PCS], short form 12 version 2 mental component summary [SF-12v2-MCS], and Kessler 6 [K6] scores), and perceived quality between opioid users and non-opioid users, adjusting for appropriate covariates. Hierarchical logistic regression models were constructed to assess access to medications (unable to receive prescription medications, delayed receiving prescription medications) and perceived respect shown by provider between opioid users and non-opioid users, adjusting for appropriate covariates. National estimates were obtained by adjusting for the complex survey design of MEPS. An alpha level of 0.05 was set a priori for all analyses. All analyses were conducted using SAS version 9.4. This study was deemed exempt from the human subject protection program. Results: The study cohort consisted of 4,759 subjects - 1,525 opioid users and 3,234 non-opioid users. The weighted total number of non-institutionalized adults alive aged 50 or older with pain in the US in the year 2015 was 50,898,592 - 16,757,516 (32.9%) were opioid users and 34,141,076 (67.1%) were non-opioid users. Opioid use was associated with all personal characteristics (p0.05). Conclusions: This study estimated that the number of older US adults (≥50 years) with pain in 2015 was approximately 51 million, and that the estimated prevalence of opioid use among older US adults (≥50 years) with pain in 2015 was approximately 17 million. Opioid use was associated with all personal characteristics, except gender and race. Adjusted healthcare expenditures were greater among opioid users compared to non-opioid users for all categories of expenditure, except inpatient expenditures. Adjusted perceived healthcare quality measures and perceived respect shown by healthcare provider measures were greater among opioid users compared to non-opioid users. Adjusted health-related quality of life measures and access to prescription medication measures were not associated with opioid use status. Future research is warranted to investigate reasons why some of these findings exist, and to explore these variables in greater depth, over longer periods of time, and in additional populations

Student pharmacists' experiences of teamwork in a quality improvement course

Student pharmacists need to work in teams in the educational and practice settings, but there is limited information on their teamwork experiences in the published literature. The study objective was to assess second-year (P2) student pharmacists' teamwork experiences in an experiential quality improvement (QI) course. A retrospective pre-post survey was conducted with P2 students to assess teamwork experience attitudes. Students reported their agreement with 17 statements about teamwork, first after the project was planned and again after the project was complete. A Kuder-Richardson 20 score was calculated to assess internal consistency. Differences between pre- and post- groups for each teamwork item were assessed using McNemar's test. An alpha level of 0.05 was used, and a Bonferroni correction was applied for multiple comparisons. Sixty P2 students (50%) responded to the survey. After the project was complete, the majority indicated agreement with good teamwork qualities and disagreement with poor teamwork qualities for most items. More than 60% of respondents indicated they would like to do collaborative work again while 20% of respondents indicated imbalances in member contributions caused conflict within the team. The majority of student pharmacists in this investigation had positive experiences working in teams, but new important findings from this study indicate that further work is needed to prevent imbalances in team-member contributions and to encourage students to work on future collaborative projects in some cases.12 month embargo; published online: 23 November 2018This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

How do pharmacists use and recommend vitamins, minerals, herbals and other dietary supplements?

Background Use of complementary and alternative medicine (CAM), including vitamins, minerals, herbals, and other dietary supplements, is widespread in the United States (ranging from 24% in Hispanics to 50% in American Indians). Pharmacists are an accessible source for healthcare information, but little is known about their use of CAM products and to whom they would recommend these products. Methods A cross-sectional survey was sent via email to pharmacists licensed in one state in the United States in 2015. The survey included items about their use of 10 vitamins and minerals, and 21 herbal or other dietary supplements, as well as reasons for use, conditions used to treat, if they would recommend the product to patients, family, or friends, their perception of CAM safety and effectiveness, and four demographic questions. Descriptive statistics were used to summarize the data, and a chi-square test was used to determine differences between pharmacists' use of vitamins/minerals and herbals/other dietary supplements. The a priori alpha level was 0.05. Results A total of 639 pharmacists completed the survey. Female pharmacists used vitamins/minerals (p = 0.031) and herbals/others (p = 0.039) more than male pharmacists. Older pharmacists used herbals/others more than younger pharmacists (p < 0.001). Fifty-nine percent thought the dietary supplements in the survey were safe while 32% reported they were effective. Seventy-eight percent of respondents reported use of any vitamin or mineral product versus 42% who reported use of any herbal or other dietary supplement. Commonly used products included: multivitamins (91%), vitamin C (71%), fish oil (65%), probiotics (53%), and fiber (53%). The most commonly reported reason for use was general health and wellness (17-90%). Pharmacists most commonly recommend fiber/psyllium (94%) and calcium (90%) to patients, family, and friends. Conclusions Pharmacists in this survey selectively used vitamins, minerals, herbals and other dietary supplements, and recommended some of the more commonly used products to patients, family and friends. This is valuable information given that pharmacists are frontline healthcare professionals who may be asked to provide advice about these products.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Validation Assessment of a Pain Interference Questionnaire among Student Pharmacists

Validation studies of pain interference instruments used among student pharmacists are rare yet essential for understanding their appropriate use and interpretation in pharmacy education and practice. This study conducted validation and reliability assessments of a five-item Pain Interference Scale previously administered to student pharmacists. Construct validity was assessed using Rasch analysis. Unidimensionality was measured using: point-biserial measure correlations; percent of raw variance explained by items; difference between expected; variance modeled by items; and Rasch model fit. To assess scale functioning, response frequency distribution, observed average and sample expected logit distribution, Andrich logit distribution, item separation, and item reliability were assessed. Visual examination of the Item-Person Map determined content validity. Items explained 64.2% of data raw variance. The difference between raw variance modeled and observed was 0.6. Point-biserial measure correlations were >0.77. Item mean-square infits were 0.7–1.3 while outfit measures were 0.72–1.16. There were >10 responses per response category, response frequency and Andrich thresholds progressively advanced, and observed average and sample expected logits advanced monotonically, Andrich logits = −2.33–1.69, item separation = 2.61, and item reliability = 0.87. Item probability curves indicated response categories were minimally yet adequately distinct. Cronbach’s alpha = 0.93. The Item-Person Map had a ceiling effect indicating content gaps. In conclusion, the pain interference instrument has acceptable construct validity yet contains content gaps. Additional difficult items should be added to the instrument to better capture pain interference among student pharmacists

Initial assessment of an interprofessional team-delivered telehealth program for patients with epilepsy

Introduction: Epilepsy affects 3.5 million people in the United States (US). Rural-dwelling individuals have less access to healthcare and consequently poorer health outcomes. This study describes the outcomes of an interprofessional telehealth program for rural-dwelling individuals with epilepsy in one US state. Methods: An academic medication therapy management pharmacist provided clinical services to rural-dwelling individuals with epilepsy between November 2015 and June 2018, using video-conferencing technology and follow-up telephonic consultation. Data collected included: demographics, prescribed seizure medications, comorbidities, drug-drug and drug-disease interactions, adverse drug reactions, therapeutic duplications, doserelated safety concerns, adherence concerns, and recommendations to resolve identified issues. Data were summarized using appropriate descriptive statistics. Results: A total of 168 patients (51% male, mean age 28 +/- 15 years), participated in this pilot study. Most participants (94%) were prescribed at least one seizure medication including: benzodiazepines (n = 89), Iamotrigine (n = 58), and levetiracetam (n = 56). The majority (55%) had at least one comorbidity including: mood disorders (n = 49) and psychiatric disorders (n = 26). Common medications with reported precautions for people with a seizure history were: selective serotonin reuptake inhibitors (n = 18), second-generation atypical antipsychotics (n = 17) and benzodiazepines (n = 16). Participants had at least one: drug-disease interaction (33%), drug-drug interaction (54%), adverse drug reaction (37%), therapeutic duplication (13%); dose-related safety concerns (35%); and medication utilization concerns (13%). Discussion: This pharmacist-delivered pilot program was effective in: reaching underserved patients with epilepsy, identifying and recommending resolutions to medication-related problems, and demonstrating the value of pharmacists in an interprofessional team. Further work is warranted to identify telehealth strategies to reduce medication associated problems.SinfoniaRx12 month embargo; published online: 31 October 2019This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Prevalence, patterns and predictors of depression treatment among community-dwelling older adults with stroke in the United States: a cross sectional study

Background: Depression is one of the most common psychiatric conditions among stroke survivors and is associated with several negative health outcomes. However, little is known about the depression treatment patterns among stroke survivors. The objective of this study was to examine national-level prevalence, patterns and predictors of depression treatment among community-dwelling stroke survivors. Methods: This study adopted a retrospective, cross sectional study design using multiple years of Medical Expenditure Panel Survey (MEPS) (2002-2012) data. The study population consisted of older adults (age >= 50 years) who (i) were stroke survivors (ICD-9-CM codes of 430-438), (ii) did not die during the calendar year, and (iii) had co occurring depression (ICD-9-CM code of 296.xx, or 311.xx). Depression treatment, identified by antidepressant medication and/or psychotherapy use, was the dependent variable of this study. Multinomial logistic regression analysis was conducted to examine the association of individual level factors with depression treatment among stroke survivors with co occurring depression. Results: The final study sample consisted 370 (unweighted) community-dwelling older adults with self-reported stroke and depression. The prevalence of co-occurring depression among stroke survivors was 22.03% [95% Confidence Interval (Cl) 19.7-24.4%]. An overwhelming majority (87.6%) of stroke survivors with co occurring depression reported some form of depression treatment. Antidepressants only and combination therapy was reported by 74.8% (95% Cl, 71.6-78.0%] and 12.8% (95% CI, 10.5-15.1%) by stroke survivors with co-occurring depression respectively. Approximately, 61% of stroke survivors with co occurring depression reported using SSRIs, followed by SNRIs (15.2%), miscellaneous antidepressants (12.1%), TCAs (9.8%), phenylpiperazine antidepressants (5.2%), and tetracyclic antidepressants (4%). Sertraline (15.8, 95% Cl, 12.7-19.0%) had the highest reported use among individual antidepressants. Conclusions: Vast majority (nearly 90%) of the study sample received some form of depression treatment and several individual level factors (such as age, education) were associated with the report of depression treatment use. Future longitudinal studies are warranted to assess the comparative treatment benefits of antidepressants, psychotherapy and their combination. Healthcare providers should carefully assess the risks and benefits of antidepressant (such as SSRIs or TCAs) use in this vulnerable population prior to their use.Open access journal.This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Improving rating scales: Applying Rasch analysis to student pharmacists' attitudes towards herbal medications

Background: This study analyzed the psychometric properties of a cross-sectional survey of student pharmacists' attitudes regarding herbal medications using a polytomous Rasch model. Seven items assessed students' attitudes towards herbal medications using a 6-point agreement scale (0 to 5). Student responses were reviewed to identify outliers and aberrant response patterns, assess scale fit, and perform item analysis. Scale performance was assessed to determine if response categories were independent and equally represented. Items were reviewed for model fit and construct validity with significant item gaps identified using a z-test. Impact: A total of 324 students completed the survey. The initial 6-point scale was analyzed. Student responses with outfit mean-square (MNSQ) values > 5 were removed, yet the scale did not have appropriate functionality. The categories were merged to form a 4-point scale with no improvement. Therefore, two different 3-point scale options were analyzed: response categories of 0, 1 to 3, and 4 to 5; and response categories of 0, 1 to 4, and 5. With ten students removed, both 3-point scales mat the requirements for functionality and all items exhibited good fit with MNSQ values between 0.6 and 1.4, person-separation value of 1.29, and person-reliability value of 0.62. Recommendations: Both 3-point scales ma the requirements for Rasch analysis. The most optimal scale was the 0, 1 to 4, and 5 option. Discussion: This study provides findings from the survey validity assessment alongside the survey results, which is useful for readers to have confidence in the quality of the study findings.12 month embargo; available online 27 March 2019This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]