Disease State Management Research Articles

Patient Perceptions of Pharmacist-Managed Clinics: A Qualitative Analysis

Background: Pharmacist-managed clinics have consistently demonstrated improvement in patient outcomes. Quantitative research offers the benefit of objective outcomes to track progress toward therapeutic goals at pharmacist-managed clinics. While quantitative studies are readily available in the literature, there is a paucity of qualitative studies to capture the patients' perspectives of pharmacy services. Objective: To assess through the use of qualitative research methods patient perceptions of pharmacist-managed services within ambulatory care clinics that operate under a collaborative practice agreement. Methods: A semi-structured interview questionnaire was developed, pilot tested, and revised using a focus group of clinical pharmacists. The questionnaire was used to conduct face-to-face patient interviews at 6 pharmacist-managed clinics in central Indiana. English-speaking patients with a minimum of 2 visits with the clinical pharmacist were included in this study. Pharmacist-managed clinics without established collaborative practice agreements were excluded. Patient interviews were conducted by a trained research assistant, audio-recorded, and transcribed verbatim. The interview transcripts were analyzed to identify cross-cutting themes without predetermined definitions via inductive qualitative analysis. Four study investigators independently identified themes using a sample of the transcripts. Additional themes were identified and defined in a series of independent reviews and investigator meetings using the remaining transcripts until theme saturation. All themes were assigned to segments of the interview transcripts according to the consensus definitions. Results: A total of 30 interviews were conducted across the clinics. Ten themes from the interview transcripts emerged, including disease state management expertise, patient alliance, practice novelty, accessibility, increased sense of patient well-being, and compassion. Conclusions: Patient perceptions from qualitative interviews revealed that pharmacists are viewed as medication experts who provide patient-centered care. This study highlights unique in-depth perspectives from the patient that further support maintenance and expansion of pharmacist-managed services.

Perceptions of Disease State Management Among Pakistani Hypertensive Patients: Findings from a Focus Group Discussion

Purpose: To explore the perceptions of disease state management among Pakistani hypertensive patients.Methods: A focus group discussion was conducted with 19 hypertensive patients in order to obtain an insight into their self-management practices. The study was conducted in Sandeman Provincial Hospital, Quetta, Pakistan.Results: Analysis of the focus group discussion yielded four major themes: (1) effect of hypertension on patients’ physical, mental and social states; (2) involvement in self-management; (3) factors contributing to self-management; and (4) perception of patients towards antihypertensive agents. A majority of the patients admitted that they were involved in self-management of hypertension but their management strategies were influenced by social sources - peer or family - with very little information received from health care professionals. Exercise of self-management was strongly linked to the philosophy of the patients regarding nature of drug, as well as comparative advantages and disadvantages. Patients also expressed reservations about continuous drug usage for the management of chronic illnesses.Conclusion: Patients suffering from chronic diseases such as hypertension tend to make individual and personal decisions about managing their illnesses. Patients seem to be more influenced by peers, family members and people with the disease condition, and thus try to manage their condition based on advice received from them. In addition, their philosophy of medication use and hypertension (being a chronic disease) prompts them to focus more on self-management practices.Keywords: Self-management, Focus group, Hypertension, Perception

Preliminary Results From a Multidisciplinary University-Based Disease State Management Program Focused on Hypertension, Hyperlipidemia, and Diabetes

Objective: To describe the implementation and evaluation of a pilot multidisciplinary disease state management (DSM) program for diabetes, hypertension, and hyperlipidemia at a private, self-insured university (over 900 covered lives). Methods: Enrollees met with a pharmacist, nurse, exercise physiologist, and students in these disciplines to improve clinical outcomes and fitness parameters. Clinical values, quality of life, patient knowledge of disease states, and patient satisfaction were assessed. Results: Of the 20 patients in the pilot program, 17 completed 1 nursing and 2 pharmacist visits; 8 completed exercise physiology visits. At baseline, elevated blood pressure readings were observed in 64.7% (11 of 17) of patients, 20% of those with diabetes (1 of 5) had an elevated hemoglobin A1c value (HbA1c), and 82.4% (14 of 17) had a cholesterol value that was not at goal. At least 1 medication-related problem was observed in 16 patients (94.1%). At 3 months, all patients with diabetes achieved HbA1c levels at or below 7%, 4 patients attained blood pressure control, and 1 achieved normal cholesterol readings. Patients characterized participation in the program as valuable and convenient. Conclusions: Patients involved in the multidisciplinary DSM showed improved clinical outcomes after 3 months. Ongoing analysis of patient outcomes will determine the long-term effectiveness of the DSM.

An innovative format of journal club among pharmacy practice residents

Introduction There have been reported and published formats of journal club in multiple health care disciplines, but there is a lack of descriptive information regarding journal club formats among pharmacy practice residents. During a pharmacy residency program, it is essential to evaluate the evidence and its implications in disease state management. Objective The main objective was to describe a novel format created for journal club presentations among affiliated pharmacy residents and provide preliminary feedback toward this format from two residency classes. Methods Journal club sessions have been organized into a first and second monthly discussion. During the first session, the disease state, guidelines, and an “In the News” are reviewed with two journal club articles, and a patient case in the second discussion. A standard debate is reserved for the last month discussion of the residency year. Results The survey results showed that the current format of journal club is well received and the residents find it beneficial to attend and participate in discussions. Conclusions Although our journal club sessions have only been implemented in a structured format for approximately two years, it has provided an opportunity and foundation for pharmacy residents to enhance critical thinking skills of medical and pharmacy literature, expand on breath and depth of knowledge, and develop oral communication skills by presenting drug and medical information to fellow health care providers.

Medication Therapy Management in the Primary Care Setting

Objectives: To evaluate the effect of medication therapy management on chronic disease management and generic drug prescribing in the clinic setting. Methods: Private insurer initiates Pay-for-Performance (PFP) project for clinic-based pharmacists in Iowa and South Dakota (n = 9 clinics) in 2009. Each pharmacist was assigned ∽300 patients with at least 1 of 4 disease states (diabetes mellitus, hyperlipidemia, hypertension, and asthma). Pharmacists were expected to complete 2 medication reviews for each patient. The primary outcome was frequency of patients achieving goal levels: diabetes: hemoglobin A1c (A1c) <8%, low-density lipoprotein (LDL) <130 mg/dL, and blood pressure (BP) <140/80 mm Hg; hypertension: BP <140/90 mm Hg; hyperlipidemia: LDL <130 mg/dL; and asthma: percentage of persistent asthmatics on controller medication. Generic prescribing rates were evaluated for antihypertensives, cholesterol-lowering agents, proton pump inhibitors, and antidepressants. Results: A total of 827 patients at 3 clinics were included in the analysis. For diabetes, 77.1% had A1c <8%, 83.2% had LDL <130 mg/dL, and 76.3% had BP <140/80 mm Hg. For hypertension, 86.2% had BP <140/90 mm Hg. For hyperlipidemia, 80.6% had LDL <130 mg/dL. For asthma, 100% were on controller medication. One medication review was completed on 88.8% of patients. Generic prescribing rates ranged from 65.8% to 79.4%. Implications/Adaptability: A high percentage of patients achieved goal levels at clinics with clinical pharmacist services. A multidisciplinary approach to patient care may improve disease state management and medication cost savings.

The Evolving Price of Perfection

The Evolving Price of Perfection

Perspectives of heart failure patients in Malaysia towards medications and disease state management: findings from a qualitative study

Aim This study aimed to explore the experiences of readmitted heart failure (HF) patients towards managing their medical problems and to identify factors influencing their adherence to medications.

Designing a Master of Public Health Degree Within a Department of Pharmacy Practice

The demand for public health services is being outpaced by a shrinking public health workforce. This creates a unique opportunity for pharmacists to become more engaged in public health activities, particularly in rural underserved areas. To meet the need for additional public health professionals, we designed a master of public health (MPH) program in a rural state under the leadership of a department of pharmacy practice. In addition to a core set of courses, the MPH program has public health specialty tracks (disease state management, emergency management, health promotion practice, infectious disease management, food safety, gerontology, and medical management and administration) that could be completed as a certificate program or used towards an MPH degree. The program allows students to complete the graduate degree with a minimum of prerequisite coursework. The MPH degree provides an opportunity for pharmacists and other health care professionals to gain an understanding of the interprofessional approach to solving public health problems and will enhance their role in public health and within their health care team.

Patients' willingness to pay for diabetes disease state management services in Australian community pharmacies

PurposeThe purpose of this paper is to determine whether and how much patients would be willing to pay for diabetes disease state management (DSM) services in community pharmacies, and also to determine the relationships between willingness to pay (WTP) and different clinical/socio/demographic characteristics of patients.Design/methodology/approachA sample of 130 diabetic patients recruited from 14 pharmacies across Sydney, Australia completed self‐administered questionnaires. SPSS 16.0 was used to assess WTP in four scenarios (50 and 100 percent improvement in diabetes control after a 30 minute initial and 30 minute follow‐up consultation, respectively). Descriptive and inferential statistical techniques (regression) were used to analyse data.FindingsPatients are willing to pay a median of AUS$30 for 50 percent improvement and AUS$40 for 100 percent improvement per 30 minute initial consultation, and AUS$20 for 50 percent improvement and AUS$30 for 100 percent improvement per 30 minute follow‐up consultation. Although results varied across scenarios, WTP generally increased when: patients' income is greater than AUS$150,000; frequency of patients' diabetes‐related hospitalizations is between 2 and 4; and patients' perceptions of pharmacists' ability are higher. The remainder of the variables tested are not significantly associated with WTP.Practical implicationsThe findings demonstrate that most patients are willing to pay for diabetes DSM services in community pharmacies, and there is a great opportunity for pharmacies to expand their clinical services in this area.Originality/valueThe key contribution to the literature is the data relating to the willingness of Australian diabetic patients to pay for pharmacy‐delivered disease management support, and how this varies across people with different clinical/socio/demographic characteristics.

Preventive Medicine: A Ready Solution for a Health Care System in Crisis

Preventive Medicine: A Ready Solution for a Health Care System in Crisis

Innovations in pharmacy through pharmacy practice: A call for papers

Type: Pharmacy Practice

Using Electronic Medical Records to Teach Patient-Centered Care

To develop, implement, and evaluate the use of electronic medical records (EMRs) in disease state management activities to teach pharmacy students patient-centered care skills. Faculty created 12 patient cases and an EMR for each simulated patient. Students used the information in the EMR to confirm the presence of a disease in their patient; to design and monitor an evidence-based patient-centered care plan, and document their assessment, medication, and monitoring recommendations; and to follow up in a SOAP (subjective, objective, assessment, plan) note format within the EMR. A precourse and postcourse survey instrument was administered to assess students' perceived gains in knowledge and attitudes regarding the use of EMRs for learning patient-centered care skills. A grading rubric was used to evaluate each SOAP note. Implementation of disease state management activities involving EMRs improved pharmacy students' patient care skills.

A cost-effectiveness analysis of a community pharmacist-initiated disease state management service for type 2 diabetes mellitus

AbstractObjectiveTo conduct an economic evaluation of a community pharmacy-delivered disease state management (DSM) service for type 2 diabetes mellitus.SettingThe study was a parallel groups design, with control and intervention groups matched on demographic and diabetes-related characteristics, and was conducted in New South Wales, Australia. Three different settings were included — rural and metropolitan community pharmacy settings and hospital diabetes clinics.MethodA cost-effectiveness analysis of the specialised service was conducted. The economic perspective adopted in the present analysis is that of the healthcare sector in general, taking into account the viewpoint of both the Commonwealth Government of Australia and the New South Wales State Government.Key findingsGlycosylated haemoglobin (HbA1c) levels decreased by 0.46% (P = 0.02) in the intervention group compared with a change of 0.03% (P = 0.81) in the control group after 9 months. To obtain the 0.43% (95% confidence interval (CI) 0.34-0.52) reduction in HbA1c achieved by the specialised service, the cost to the healthcare sector was $A383 (Australian dollars; 95% CI $A46.16–717.46) per patient per 9 months.ConclusionThis service has resulted in a significant reduction in HbA1c which should translate into improved health outcomes long term, since each 1% reduction in HbA1c has been associated with reductions in risk of 21% from any endpoint related to diabetes. Given the annual costs for the management of each patient with diabetes in Australia, the additional $A383 invested in the first 9 months of this service is likely to result in a saving to the healthcare system long term.

Exploring successful community pharmacist-physician collaborative working relationships using mixed methods

Background Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration. Objective To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration. Methods A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification. Results On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential. Conclusions The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.

A Method for Educating Patients and Documenting Smoking Status in an Electronic Medical Record

Published evidence demonstrates benefit from pharmacist smoking cessation interventions; however, there is limited research evaluating the impact of a template within an electronic medical record used at pharmacy disease state management visits. To determine the rates of smoking cessation and movement along the transtheoretical model of change after implementation of a template into existing pharmacy-related progress notes within the electronic medical record. Patients who were routinely followed by clinical pharmacists for anticoagulation and diabetes mellitus education at 3 clinics at the Medical University of South Carolina were included. At each visit, the pharmacist would document patient smoking information in a newly designed template within the existing progress note. In addition, pharmacists would educate patients on the benefits of smoking cessation and pharmacologic options that may be available to them. Data were collected between April 2007 and March 2008. Baseline demographic data and smoking cessation rates and products were compared using descriptive statistics. The McNemar chi(2) test was used to compare the groups of patients achieving smoking cessation pre- and postintervention. Of the 90 current smokers, 38 (42%) achieved smoking cessation postintervention. Movement along the transtheoretical model of change was also seen, with 52 (58%) patients progressing to at least the next stage. Thirty-four patients in the contemplation/preparation stage and 4 patients in the precontemplation stage moved to the action or maintenance stage by the end of the study period (p = 0.03). A variety of pharmacologic therapies were used in individuals who stopped smoking, although varenicline was most common. Thirty-nine percent of the patients used no medications to achieve cessation. Incorporating a smoking cessation template into existing progress notes and providing education during existing pharmacy referral visits is a simple and effective method to assist patients in achieving smoking cessation.

Pharmacy Characteristics Associated With the Provision of Drug Therapy Services in Nonmetropolitan Community Pharmacies

Higher prevalence of chronic diseases and reduced access to other health professionals in rural areas suggest that rural Medicare enrollees will benefit from pharmacist-provided drug therapy services (DTS). The purpose of this study was to describe non-metropolitan community pharmacy sites in Wisconsin, the provision of DTS at these sites, and to identify factors associated with provision of DTS. A cross-sectional, descriptive survey design was used to collect primary data in 2005. The manager/owner listed for each of the 279 non-metropolitan community pharmacy sites in Wisconsin was surveyed using an 8-page instrument. The 7 drug therapy services that key informants were asked to report on included 6 disease state management (DSM) programs and medication therapy management services (MTMS). Descriptive statistics were calculated for variables describing the pharmacy sites and how DTS were provided. Logistic regression was performed, with any drug therapy service provision as the dependent variable and 8 independent variables. The response rate to the survey was 44%. Overall, 31% of the respondent pharmacies offered MTMS and 31% offered DSM programs. Higher service orientation, location in a more rural area, and lower workload per pharmacist were significantly positively related to provision of any DTS. Conducted 4 months prior to the implementation of Medicare Part D, the results serve as a baseline against which the effects of Part D on MTMS provision may be evaluated. The negative association of pharmacist workload with pharmacy provision of DTS, coupled with the current pharmacist shortage, has important implications for patients' access to these services in rural areas.

Measuring patient satisfaction with diabetes disease state management services in community pharmacy

Background Disease state management (DSM) programs for chronic conditions such as type 2 diabetes delivered by community pharmacists are a developing trend in health care service delivery. Although patient satisfaction with DSM services is an important indicator of service quality from the consumers' perspective, to date there is no valid and reliable instrument to enable its measurement in the context of a community pharmacy delivered service. Objective To develop and validate an instrument to measure patient satisfaction with diabetes disease state management (DDSM) services delivered by community pharmacists. Methods The DDSM questionnaire (DDSM-Q) was developed on the basis of 14 in-depth, semi-structured interviews with consumers who had received diabetes care services in community pharmacy. Thirty-one questionnaire items were developed from the qualitative interview findings and also incorporated 16 modified items from an existing instrument, the Diabetes Measurement and Evaluation Tool. The DDSM-Q was sent to 160 participants of pharmacy diabetes care projects. Higher-order factor analysis was performed to extract factors of patient satisfaction. Results One hundred and fourteen questionnaires were returned, thus yielding a 71.3% response rate. Data from 108 out of 114 questionnaires were used to validate the DDSM-Q. Respondents had a mean age of 62 years and 61% were male. The 3 factors of patient satisfaction were interpreted as (1) satisfaction with the pharmacist's service (“Service”), (2) satisfaction with self-management (“Self-management”), and (3) satisfaction with knowledge and understanding of diabetes (“Knowledge”). The model fitted the data at moderate level (relative χ 2 = 1.58, n = 108, adjusted goodness-of-fit index = 0.77, comparative fit index = 0.89, root mean-square error of approximation = 0.07). The model was shown to have construct validity ( χ 167 2 = 235.62 , Bollen-Stine bootstrap P = .27). Reliabilities of the 3 factors were 0.92, 0.88, and 0.86, respectively. Conclusion The results support the validity and reliability of the DDSM-Q as an instrument to measure patient satisfaction with DDSM services in community pharmacy. Further research will be needed to validate the instrument in different populations.

Use of community pharmacy–provided diabetes services to aid physicians in the National Committee for Quality Assurance recognition program

Pay-for-performance (P4P) models are being adopted by many health care payers, including Medicare, for payment of physician services. To receive financial incentives in P4P programs, physicians are encouraged to attain recognition or credentialing from an agency, such as the National Committee for Quality Assurance (NCQA). To explore the potential roles of a community pharmacy-provided diabetes services in collaboration with physicians and to assist them in becoming acknowledged by the NCQA Diabetes Physician Recognition Program. KDI Health Solutions pharmacists have demonstrated success in the management of diabetes through the Asheville Project and the Diabetes Ten City Challenge. Continued pharmacists' efforts may focus on expanding current disease state management programs, community pharmacy diabetes education programs, and collaborative practices with physicians. Studies are currently being conducted to assess physician willingness to use pharmacists as part of the NCQA recognition process. Collaboration of physicians and pharmacists may improve diabetes standards of care and aid physicians in becoming NCQA-recognized providers. NCQA-recognized physicians can align themselves with current and future P4P programs.

Medication therapy management services in West Virginia: Pharmacists' perceptions of educational and training needs

Background The Medicare Modernization Act of 2003 recognizes the challenges associated with drug therapy in elderly patients with multiple chronic diseases, and requires the development of medication therapy management services (MTMS) for such beneficiaries. Objective To assess pharmacists' perception of educational and training needs necessary to implement MTMS in community pharmacies in West Virginia, USA. Methods Self-administered mail surveys with an explanatory cover letter were mailed to the designated pharmacist-in-charge (PIC) of each licensed community pharmacy (506) in West Virginia. Main outcome measures included pharmacists' comfort level, perceptions of value to patients, barriers to provision of services, and pharmacists' interest in receiving education and training related to MTMS. Results Of the 503 surveys that were deliverable, 203 (40.4%) usable responses were received. Fifty-five (27.1%) PICs reported that MTMS are currently being provided in their pharmacy. Respondents were likely to use services that aid in the development of MTMS and disease-state management, felt relatively comfortable in providing MTMS, and had a favorable view of the value of services to patients, but reported that lack of time tended to be a barrier. Conclusion PICs in West Virginia are interested in and open to their pharmacists receiving education and training for implementation of MTMS.

Medication Therapy Management Services

In the US, the Medicare Modernization Act of 2003 required that Medicare Part D insurers provide medication therapy management (MTM) services (MTMS) to selected beneficiaries, with the goals of providing education, improving adherence, or detecting adverse drug events and medication misuse. These broad goals and variety in MTM programmes available make assessment of these programmes difficult. The objectives of this article are to review the definitions of MTMS proposed by various stakeholders, and to summarize and evaluate the outcomes of MTMS consistent with those that may be offered in Medicare Part D or reimbursed by State Medicaid programmes. MTM programmes are approved by the Centers for Medicare and Medicaid Services (CMS). Pharmacy, medical and insurance organizations have provided guidelines and definitions for MTM programmes, distinguishing them from other types of community pharmacy activities. MTM has been distinguished from disease state management because of the focus on medications and multiple conditions. It differs from patient counselling because it is delivered independent of dispensing and involves collaboration with patients and providers. There is no consensus on the recommended mode of delivery (i.e. face-to-face or by telephone) for MTM. A MEDLINE search was conducted to identify articles published after 2000 using the search terms 'medication therapy management' and 'medication management'. Studies with outcomes evaluating community-based programmes consistent with MTMS, regardless of MTMS reimbursement source, were included in the review. Seven publications describing four MTMS were identified. For each of the identified articles, we describe the study design, service setting, inclusion criteria and outcomes. An additional three surveys describing multiple MTMS were identified and are summarized. Finally, ongoing efforts by CMS to evaluate the success of MTMS in the US are described. To date, there are limited outcomes available for MTMS. The wide variety of MTMS offered means that evaluations of individual programmes are necessary. Despite the potential benefits of MTMS, there are numerous challenges to providing MTMS, including reimbursement, justification of the service and stakeholder acceptance of the services. There remains a need for adequately funded, prospective, controlled studies of MTM programmes using strong designs to advance our knowledge of the effectiveness of various interventions and methods of delivery, and for naturalistic studies assessing the impact of CMS approved MTM programmes.