Review of community pharmacy services: what is being performed, and where are the opportunities for improvement?

OBJECTIVE: The aim of this review was to assess pharmacist and pharmacy services being provided and identify opportunities to improve patient satisfaction. METHODS: Studies published between January 2006 and July 2016 examining patient satisfaction with pharmacy and pharmacist services, which were written in English, were identified in PubMed. Studies were excluded if they only looked at pharmacy student-provided services. KEY FINDINGS: A total of 50 studies were ultimately included in the review. Of these studies, 28 examined services traditionally provided by community pharmacists such as dispensing and counseling, while 16 examined a new in-person service being offered by a pharmacy, and the remaining six involved a new technology-assisted service. While study findings were generally positive for patient satisfaction of pharmacy services, several opportunities were identified for pharmacies to improve. CONCLUSION: Overall, patient satisfaction is high across pharmacy services; however, this satisfaction is related to prior patient exposure to services and their level of expectation. Pharmacists have multiple opportunities to improve the services they provide, and there are additional services pharmacists may consider offering to expand their role within the health care system

A nationwide survey of pharmacy students’ knowledge and perceptions regarding medical cannabis

Objective The primary objective of this study was to compare knowledge and perceptions of medical cannabis (MC) between pharmacy students who attended schools where MC was legal and illegal. Design A nationwide anonymous survey regarding MC was distributed to pharmacy students. The survey consisted of the following sections: (1) demographics and personal factors, (2) knowledge assessment of indications and adverse effects of MC, and (3) perceptions assessment. Setting and participants Equal numbers of pharmacy schools were selected and sent surveys based on geographical regions, private versus public universities, and the state’s legal status of MC for first through fourth-year pharmacy students to complete. Outcome measures Student knowledge of MC indications and adverse effects were treated as quizzes. Median percentage correct and whether students passed the quizzes (≥ 70%) were evaluated based on the state’s legal status. Students’ perceptions were similarly compared. Results A total of 629 students accessed the survey. Most students who completed the survey attended pharmacy schools where MC was illegal (55%), were female (68%), and had personally tried cannabis (53%). Overall, 91% of students believed that MC should be legalized nationally. A low number of students correctly identify approved indications with 14.8% of students in states with MC legalization scoring greater than 70% compared with 15.9% of students in states without MC legalization (P = 0.748). Similar findings were seen in the side effects quiz with only 6.1% of students in states with legal MC scoring greater than 70% compared with 7.4% of students where MC is illegal (P = 0.569) There were minimal differences in students’ perceptions of MC based on the states’ legal status. Conclusion Our study continues to highlight that pharmacy students lack knowledge and preparation to counsel and educate on MC. With increasing state legalizations, pharmacy schools need to address this knowledge gap to ensure optimal patient care

Structural Equation Model of Disability in Low Back Pain

Study Design—The effects of participant characteristics along with descriptions of pain, and psychological involvement, such as fear avoidance, were assessed using structural equation modeling to identify relationships between these factors and disability as a result of low back pain. Objective—The aim of this study was to evaluate the relationship between factors related to pain description, participants’ characteristics, psychological involvement and disability through structural equation modeling. Summary of Background Data—Low back pain is a complex multifactorial condition that can lead to disability. Understanding which factors contribute to disability and how those factors interact is important for predicting and minimizing disability in patients with low back pain. Methods—We analyzed data from 156 participants (63% female) with low back pain. A stepwise structural equation model was built with patient characteristics, pain intensity, depression, anxiety and fear avoidance to predict disability in low back pain. Results—Participants were 23–84 (49.7±15.1) years of age and experienced 0.03–300 months duration (25.5±36.4) of current low back pain. The final model explained 62% of the variance in disability and included female gender, full-time employment, depression, and fear avoidance beliefs as significant predictors. Full-time employment was the only significant predictor that reduced disability; all other significant predictors increased disability in the model. Conclusions—Understanding the relationship between these predictors and disability provides a foundation for predicting and managing disability for individual patients who suffer from low back pain

Impact of community pharmacist intervention on concurrent benzodiazepine and opioid prescribing patterns

Objectives (1) To evaluate the number of opioid/benzodiazepine (BZD) prescription changes resulting from pharmacist communication to prescriber(s); (2) to determine the number of patients on concurrent opioid/BZD therapy from single versus multiple prescribers; (3) to compare the number of opioid/BZD prescription changes resulting from communication when a single versus multiple prescribers was involved in a patient’s care; and (4) to compare the number of opioid/BZD prescription changes resulting from communication via fax versus the Kansas Health Information Network (KHIN) direct messaging feature. Methods Prospective study conducted at 13 community pharmacies, including patients 18 years of age or older simultaneously filling opioid and BZD prescriptions within 90 days before October 2017. Prescribers received faxed or KHIN communication proposing evidence-based prescription changes to opioid/BZD agents. Prescription changes were evaluated weekly for 3 months after the initial intervention. Descriptive statistics assessed demographics and the number and types of prescription changes. Spearman rho correlations compared prescription changes and number of prescriptions to number of prescribers; a priori alpha was set at 0.05. Results A total of 137 prescribers and 121 patients were included. Ninety-nine prescribers were contacted via fax and 38 via KHIN. After 4 weeks, 34 recommendations were received: 20 responses (59%) indicated rejection of recommendations, 5 (15%) approved BZD taper/discontinuation, 3 (9%) deferred changes until a patient visit, 2 (6%) approved opioid taper/discontinuation, 2 (6%) prescribed naloxone, and 2 (6%) withdrew from the patient’s care. Three months after communication, 35 prescription changes were noted: 22 (63%) opioid/BZD agent tapers/discontinuation, 14 (26%) opioid/BZD dose increases, and 2 (6%) naloxone prescriptions. There was positive correlation between the number of tapered/discontinued agents and the number of prescribers involved in a patient’s care (P = 0.046). Conclusion A faxed pharmacist intervention may help to reduce opioid/BZD coprescribing, especially when multiple providers are involved in a patient’s care

Reducing prescribing errors through creatinine clearance alert redesign

Background Literature has shown that computerized creatinine clearance alerts reduce errors during prescribing, and applying human factors principles may further reduce errors. Our objective was to apply human factors principles to creatinine clearance alert design and assess whether the redesigned alerts increase usability and reduce prescribing errors compared with the original alerts. Methods Twenty Veterans Affairs (VA) outpatient providers (14 physicians, 2 nurse practitioners, and 4 clinical pharmacists) completed 2 usability sessions in a counterbalanced study to evaluate original and redesigned alerts. Each session consisted of fictional patient scenarios with 3 medications that warranted prescribing changes because of renal impairment, each associated with creatinine clearance alerts. Quantitative and qualitative data were collected to assess alert usability and the occurrence of prescribing errors. Results There were 43% fewer prescribing errors with the redesigned alerts compared with the original alerts (P = .001). Compared with the original alerts, redesigned alerts significantly reduced prescribing errors for allopurinol and ibuprofen (85% vs 40% and 65% vs 25%, P = .012 and P = .008, respectively), but not for spironolactone (85% vs 65%). Nine providers (45%) voiced confusion about why the alert was appearing when they encountered the original alert design. When laboratory links were presented on the redesigned alert, laboratory information was accessed 3.5 times more frequently. Conclusions Although prescribing errors were high with both alert designs, the redesigned alerts significantly improved prescribing outcomes. This investigation provides some of the first evidence on how alerts may be designed to support safer prescribing for patients with renal impairment

Consumer perception, knowledge, and uses of cannabidiol

Introduction The legalization of cannabidiol (CBD) across the United States, in varying degrees, has made CBD easily accessible to consumers for complementary and medical purposes. However, there is a paucity of scientific evidence on the benefits and risks of commercially available CBD. In the literature, 2 studies have gathered consumer perceptions and attitudes on cannabis products, specifically CBD, using survey-based questionnaires. This study aimed to build on the aforementioned studies in obtaining consumer perception and knowledge of CBD products using a national survey-based questionnaire. Methods Respondents were recruited through an anonymous, nationwide, online survey administered through Qualtrics in the United States from March 28 to April 30, 2021. The survey consisted of demographics, perceived efficacy and safety of CBD, and resources to obtain CBD information. The survey responses were reported using descriptive statistics along with median and interquartile range for the Likert portion. Results A total of 1158 respondents accessed the survey. The median age was 43 and 50% of respondents were female. The uses for CBD included neurological disorders, pulmonary conditions, gastrointestinal disorders, and chronic pain. The most commonly reported safety concern related to taking CBD was anxiety. Participants agreed that CBD is safe when used responsibly for medical use, and social media was the main source used to obtain information about CBD. Discussion Respondents who used CBD for a condition thought it was helpful; however, most of the adverse effects were rated as moderate to severe, requiring medical attention from a health care professional, hospital, or emergency room visit

Comparison of inpatient psychiatric medication management in gender diverse youth with cisgender peers

Introduction The primary objective was to determine if gender diverse (GD) youth receive different psychotropic prescribing compared with cisgender (CG) peers with the same diagnosis. Secondary objectives include evaluation of readmission rates and the effect of gender-affirming hormone therapy (GAHT) on psychiatric outcomes in transgender (TG) patients. Methods A total of 255 GD youth patients were retrospectively matched to CG controls based on age, primary discharge diagnosis, and year of admission. Data collection included psychotropic medications at admission and discharge, baseline demographics, time to readmission, and total number of readmissions within 6 months. Use of GAHT was also documented. Wilcoxon signed rank test was used for continuous and χ2 for nominal data with an a priori α of 0.05. Results MDD was the primary discharge diagnosis in 74% of patients. GD youth were more likely to present on antidepressants (P = .031) and antipsychotics (P = .007), and to be discharged with antipsychotics (P = .003). They were additionally more likely to be readmitted within 30 days of discharge (P = .032). TG youth on GAHT (13%) had fewer readmissions (P = .046) than those not on GAHT, but there were no differences in psychotropic prescribing. Discussion Higher antipsychotic and antidepressant prescribing were seen in the GD population despite the same mental health diagnosis. Despite higher prescribing in the GD population, patients presented for readmission within 30 days more frequently, which may represent a need for more rigorous transitions-of-care practices in this population

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation

OBJECTIVE: To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. MATERIALS AND METHODS: We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. RESULTS: Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). DISCUSSION: Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. CONCLUSIONS: This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes

CpG-creating mutations are costly in many human viruses.

Mutations can occur throughout the virus genome and may be beneficial, neutral or deleterious. We are interested in mutations that yield a C next to a G, producing CpG sites. CpG sites are rare in eukaryotic and viral genomes. For the eukaryotes, it is thought that CpG sites are rare because they are prone to mutation when methylated. In viruses, we know less about why CpG sites are rare. A previous study in HIV suggested that CpG-creating transition mutations are more costly than similar non-CpG-creating mutations. To determine if this is the case in other viruses, we analyzed the allele frequencies of CpG-creating and non-CpG-creating mutations across various strains, subtypes, and genes of viruses using existing data obtained from Genbank, HIV Databases, and Virus Pathogen Resource. Our results suggest that CpG sites are indeed costly for most viruses. By understanding the cost of CpG sites, we can obtain further insights into the evolution and adaptation of viruses