Publications

OBJECTIVES: To describe the prevalence and incidence of opioid and nonsteroidal anti-inflammatory drug (NSAID) use before and since the start of the Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) and to assess rates of adverse events (AEs).

STUDY DESIGN: Historical cohort study.

METHODS: The OSI began in August 2012 and was fully implemented by the end of fiscal year (FY) 2013. The study timeframe was categorized into baseline (FY 2011-2012), transition (FY 2013), and postimplementation (FY 2014-2015) phases. Prevalence and incidence rates were calculated for opioid and NSAID users by quarter between FY 2011 and FY 2015. For AEs among new users of an NSAID or opioid, Cox proportional hazards models with inverse probability weighting were used to adjust for potential confounding.

RESULTS: There were 3,315,846 regular users of VHA care with at least 1 opioid and/or NSAID outpatient prescription between FYs 2011 and 2015. The quarterly opioid prevalence rate was approximately 21% during the baseline and transition phases, then decreased to 17.3% in the postimplementation phase. NSAID prevalence remained constant at about 16%. Opioid incidence rates gradually decreased (2.7% to 2.2%) during the study, whereas NSAID incidence rates remained about 2.2%. After inverse probability weighting, patients receiving opioids had a greater risk of cardiovascular events (hazard ratio [HR], 1.41; 95% CI, 1.36-1.47), acute kidney injury (HR, 2.60; 95% CI, 2.51-2.68), gastrointestinal bleeding (HR, 1.68; 95% CI, 1.56-1.81), and all-cause mortality (HR, 3.73; 95% CI, 3.60-3.87) than NSAID users.

CONCLUSIONS: Opioid use declined following implementation of the OSI, whereas NSAID use remained constant. Rates of AEs were higher among opioid users, which provides additional rationale for efforts to use NSAIDs for pain management when appropriate.

RATIONALE AND OBJECTIVES: One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition.

RESULTS: We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together.

CONCLUSIONS: By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.

OBJECTIVES: To estimate the prevalence and consequences of receiving prescription opioids from both the Department of Veterans Affairs (VA) and Medicare Part D.

METHODS: Among US veterans enrolled in both VA and Part D filling 1 or more opioid prescriptions in 2012 (n = 539 473), we calculated 3 opioid safety measures using morphine milligram equivalents (MME): (1) proportion receiving greater than 100 MME for 1 or more days, (2) mean days receiving greater than 100 MME, and (3) proportion receiving greater than 120 MME for 90 consecutive days. We compared these measures by opioid source.

RESULTS: Overall, 135 643 (25.1%) veterans received opioids from VA only, 332 630 (61.7%) from Part D only, and 71 200 (13.2%) from both. The dual-use group was more likely than the VA-only group to receive greater than 100 MME for 1 or more days (34.3% vs 10.9%; adjusted risk ratio [ARR] = 3.0; 95% confidence interval [CI] = 2.9, 3.1), have more days with greater than 100 MME (42.5 vs 16.9 days; adjusted difference = 16.4 days; 95% CI = 15.7, 17.2), and to receive greater than 120 MME for 90 consecutive days (7.8% vs 3.1%; ARR = 2.2; 95% CI = 2.1, 2.3).

CONCLUSIONS: Among veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure.

BACKGROUND: Clinical Laboratory Improvement Amendments (CLIA)-waived tests allow for quick, accurate, and noninvasive laboratory testing. Community pharmacists utilize CLIA-waived tests to provide clinical services such as point-of-care (POC) testing to help manage chronic disease and acute illness.

OBJECTIVE: To identify key themes in the successful delivery of POC testing services by community pharmacists in Pennsylvania.

RESULTS: An initial search identified 51 Pennsylvania pharmacies with a CLIA waiver. Of these, five independent pharmacies met inclusion criteria, three of which completed interviews. The remaining 38 chain pharmacies were represented by three interviews. In total, five key themes were identified as essential to POC testing services: (1) utilize state resources and professional connections to navigate federal and state regulations, (2) establish relationships with physician partners (3) offer tests that are meaningful to patients and their physicians, (4) evaluate financial impact, workflow adaptations, and marketing approaches when implementing POC testing services, and (5) focus on individualized attention and convenience of community pharmacy-based POC testing to improve patient satisfaction.

CONCLUSION: Successful POC testing services in community pharmacy practice rely on utilizing resources, partnering with known physicians, selecting meaningful tests for patients, and analyzing finances, workflow, and marketing to provide individualized attention and convenient care.

The scope of community pharmacy practice has expanded beyond the provision of drug product to include the provision of patient care services. Likewise, the community pharmacist's approach to patient safety must also expand beyond prevention of errors during medication dispensing to include optimization of medications and prevention of adverse events throughout the entire medication use process. Connectivity to patient data and other health care providers has been a long-standing challenge in community pharmacy with implications for the delivery and safety of patient care. We describe three innovative advances in connectivity in community pharmacy practice that enhance patient safety in the provision of community pharmacist patient care services across the entire medication use process. Specifically, we discuss the growing use of immunization information systems, quality improvement platforms, and health information exchanges in community pharmacy practice and their implications for patient safety.

Entrustable professional activities (EPAs) are units of measure for a particular profession that describe the professional's unique abilities and work. EPAs can be used in two ways: as a link between individual competencies for mastery and overall professional responsibilities in practice; and as a mechanism for faculty to assess the student's progression using levels of decreasing supervision. Currently used in medical education, implementation and utilization of EPAs within pharmacy education has potential benefits and challenges. This article will describe, highlight benefits of, and share mitigation strategies for implementing EPAs within pharmacy education.

BACKGROUND: Although research conducted within the military has assessed the health and mental health problems of military personnel, little information exists about personnel who seek care outside the military. The purpose of this study is to clarify the personal characteristics, mental health diagnoses, and experiences of active duty U.S. military personnel who sought civilian sector services due to unmet needs for care.

MATERIALS AND METHODS: This prospective, multi-method study included 233 clients, based in the United States, Afghanistan, South Korea, and Germany, who obtained care between 2013 and 2016 from a nationwide network of volunteer civilian practitioners. A hotline organized by faith-based and peace organizations received calls from clients and referred them to the network when the clients described unmet needs for physical or mental health services. Intake and follow-up interviews at 2 wk and 2 mo after intake captured demographic characteristics, mental health diagnoses, and reasons for seeking civilian rather than military care. Non-parametric bootstrap regression analyses identified predictors of psychiatric disorders, suicidality, and absence without leave (AWOL). Qualitative analyses of clients' narratives clarified their experiences and reasons for seeking care. The research protocol has been reviewed and approved annually by the Institutional Review Board at the University of New Mexico.

RESULTS: Depression (72%), post-traumatic stress disorder (62%), alcohol use disorder (27%), and panic disorder (25%) were the most common diagnoses. Forty-eight percent of clients reported suicidal ideation. Twenty percent were absence without leave. Combat trauma predicted post-traumatic stress disorder (odds ratio [OR] = 8.84, 95% confidence interval [CI] 1.66, 47.12, p = 0.01) and absence without leave (OR = x3.85, 95% CI 1.14, 12.94, p = 0.03). Non-combat trauma predicted panic disorder (OR = 3.64, 95% CI 1.29, 10.23, p = 0.01). Geographical region was associated with generalized anxiety disorder (OR 0.70, 95% CI 0.49, 0.99, p = 0.05). Significant predictors were not found for major depression, alcohol use disorder, or suicidal ideation. Clients' narrative themes included fear of reprisal for seeking services, mistrust of command, insufficient and unresponsive services, cost as a barrier to care, deception in recruitment, voluntary enlistment remorse, guilt about actual or potential killing of combatants or non-combatant civilians, preexisting mental health disorders, family and household challenges that contributed to distress, and military sexual trauma.

CONCLUSIONS: Our work clarified substantial unmet needs for services among active duty military personnel, the limitations of programs based in the military sector, and the potential value of civilian sector services that are not linked to military goals. We and our institutional review board opted against using a control group that would create ethical problems stemming from the denial of needed services. For future research, an evaluative strategy that can assess the impact of civilian services and that reconciles ethical concerns with study design remains a challenge. Due to inherent contradictions in the roles of military professionals, especially the double agency that makes professionals responsible to both clients and the military command, the policy alternative of providing services for military personnel in the civilian sector warrants serious consideration, as do preventive strategies such as non-military alternatives to conflict resolution.

BACKGROUND: Rounding checklists are an increasingly common quality improvement tool in the intensive care unit (ICU). However, effectiveness studies have shown conflicting results. We sought to understand ICU providers' perceptions of checklists, as well as barriers and facilitators to effective utilisation of checklists during daily rounds.

OBJECTIVES: To understand how ICU providers perceive rounding checklists and develop a framework for more effective rounding checklist implementation.

METHODS: We performed a qualitative study in 32 ICUs within 14 hospitals in a large integrated health system in the USA. We used two complementary data collection methods: direct observation of daily rounds and semistructured interviews with ICU clinicians. Observations and interviews were thematically coded and primary themes were identified using a combined inductive and deductive approach.

RESULTS: We conducted 89 interviews and performed 114 hours of observation. Among study ICUs, 12 used checklists and 20 did not. Participants described the purpose of rounding checklists as a daily reminder for evidence-based practices, a tool for increasing shared understanding of patient care across care providers and a way to increase the efficiency of rounds. Checklists were perceived as not helpful when viewed as overstandardising care and when they are not relevant to a particular ICU's needs. Strategies to improve checklist implementation include attention to the brevity and relevance of the checklist to the particular ICU, consistent use over time, and integration with daily work flow.

CONCLUSION: Our results provide potential insights about why ICU rounding checklists frequently fail to improve outcomes and offer a framework for effective checklist implementation through greater feedback and accountability.

BACKGROUND: The Department of Veterans Affairs (VA) has implemented robust strategies to monitor prescription opioid dispensing, but these strategies have not accounted for opioids prescribed by non-VA providers. State-based prescription drug monitoring programs (PDMPs) are a potential tool to identify VA patients' receipt of opioids from non-VA prescribers, and recent legislation requires their use within VA.

OBJECTIVE: To evaluate VA physicians' perspectives and experiences regarding use of PDMPs to monitor Veterans' receipt of opioids from non-VA prescribers.

DESIGN: Qualitative study using semi-structured interviews.

PARTICIPANTS: Forty-two VA primary care physicians who prescribed opioids to 15 or more Veterans in 2015. We sampled physicians from two states with PDMPs (Massachusetts and Illinois) and one without prescriber access to a PDMP at the time of the interviews (Pennsylvania).

APPROACH: From February to August 2016, we conducted semi-structured telephone interviews that addressed the following topics regarding PDMPs: overall experiences, barriers to optimal use, and facilitators to improve use.

KEY RESULTS: VA physicians broadly supported use of PDMPs or desired access to one, while exhibiting varying patterns of PDMP use dictated by state laws and their clinical judgment. Physicians noted administrative burdens and incomplete or unavailable prescribing data as key barriers to PDMP use. To facilitate use, physicians endorsed (1) linking PDMPs with the VA electronic health record, (2) using templated notes to document PDMP use, and (3) delegating routine PDMP queries to ancillary staff.

CONCLUSIONS: Despite the time and administrative burdens associated with their use, VA physicians in our study broadly supported PDMPs. The application of our findings to ongoing PDMP implementation efforts may strengthen PDMP use both within and outside VA and improve the safe prescribing of opioids.