Publications

OBJECTIVE: To identify implementation strategies used by community pharmacists when initiating the National Diabetes Prevention Program (NDPP).

DESIGN: This study was a qualitative, mid-implementation study using a semi-structured interview guide.

SETTING AND PARTICIPANTS: Community pharmacies in Pennsylvania that received grant funding from the Pennsylvania Pharmacists Association to begin the NDPP.

OUTCOME MEASURES: A final list of implementation strategies from the Expert Recommendations for Implementing Change and corresponding action items for pharmacists to begin the NDPP in their community pharmacies.

RESULTS: Twenty strategies were used by community pharmacists when implementing the NDPP. These strategies were grouped into 3 implementation phases: (1) designing the program; (2) enrolling patients; and (3) keeping patients engaged. Strategies were further organized into 8 clusters based on strategy characteristics. Pharmacists commonly noted that making classes dynamic, keeping patients engaged through interactive activities, and encouraging patients to join classes with a companion were important when implementing the NDPP.

CONCLUSION: Pharmacists used an array of strategies to implement the NDPP. This comprehensive list of strategies and accompanying action items can be used by community pharmacists nationwide to facilitate the implementation of the NDPP.

Objective. To cross reference the core entrustable professional activities (EPAs) to a complete set of educational guidance documents for the Doctor of Pharmacy (PharmD) curriculum to create a map for pharmacy educators.Methods. The Mapping EPAs Task Force consisted of nine members who first worked independently and then together in small working groups to map five assigned educational guidance documents (eg, Center for the Advancement of Pharmacy Education [CAPE] Outcomes, Accreditation Council for Pharmacy Education [ACPE] Standards 1-4, and the Essential Elements for Core Advanced Pharmacy Practice Experiences [APPEs]) to the Core Entrustable Professional Activities for New Pharmacy Graduates. Four working groups completed the mapping process during phases 1 and 2, which was followed by an independent quality assurance review and consensus in phase 3.Results. All 15 core EPA statements were mapped to one or more of the educational documents. One item from the CAPE Outcomes could not be mapped to a core EPA statement. The first five EPA statements mapped directly to the five elements of the Pharmacists' Patient Care Process: collect, assess, plan, implement, and follow-up: monitor and evaluate.Conclusion. This comprehensive EPA map is the first curriculum crosswalk that encompasses a complete set of educational guidance documents including the Essential Elements for Core APPEs for the Doctor of Pharmacy curriculum. If adopted by the Academy, this curriculum crosswalk will provide pharmacy schools with a common interpretation of important educational guidance documents; serve as the foundation for curricular development, revision, and assessment; and ensure student pharmacists are prepared to enter the pharmacy profession.

OBJECTIVE: To design a value-based payment model to incentivize pharmacists for increased administration of influenza, herpes zoster, pertussis-containing, and pneumococcal vaccines to adults at community pharmacies.

DESIGN: A modified delphi technique was used to create a concept for a value-based payment model through consensus of expert opinion.

SETTING: and participants: Experts were recruited from a regional supermarket pharmacy, a self-insured employer, a managed care organization, and an academic institution to participate in 4 electronic surveys and 1 in-person meeting.

OUTCOME MEASURES: Consensus on model design by means of a modified delphi technique.

RESULTS: A panel of 11 experts participated in a series of electronic surveys and 1 in-person meeting. The final value-based payment model addressed how and when pharmacists would receive an incentive for meeting specific vaccination goals. The final value-based payment model also addressed the following concepts: estimated cost avoidance, vaccine effectiveness, and community protection. A 3-tiered incentive model was agreed on by the participants to tie increased vaccination rates with increased payment. Vaccination goals for each tier were defined as the percent increase in vaccination rates from the year immediately preceding. Incentives were defined as a percentage of estimated direct medical costs avoided to be shared between the payer and pharmacy.

CONCLUSION: A conceptual value-based payment model to incentivize pharmacists for increased delivery of adult vaccinations at community pharmacies was designed and agreed on by experts representing a regional supermarket pharmacy, a self-insured employer, a managed care organization, and an academic institution. Consensus was achieved by aligning the interests of both payers and pharmacies. The final model included 3 tiers of bundled incentives to reward percent increases in adult vaccination from historical baselines. This model may be used as an example for community pharmacies and health care payers to design future value-based immunization programs.

This study characterizes government, academia, and private funding for gene therapy trials in the United States by technology type and therapeutic and disease area.

OBJECTIVE: To develop and validate a machine-learning algorithm to improve prediction of incident OUD diagnosis among Medicare beneficiaries with ≥1 opioid prescriptions.

METHODS: This prognostic study included 361,527 fee-for-service Medicare beneficiaries, without cancer, filling ≥1 opioid prescriptions from 2011-2016. We randomly divided beneficiaries into training, testing, and validation samples. We measured 269 potential predictors including socio-demographics, health status, patterns of opioid use, and provider-level and regional-level factors in 3-month periods, starting from three months before initiating opioids until development of OUD, loss of follow-up or end of 2016. The primary outcome was a recorded OUD diagnosis or initiating methadone or buprenorphine for OUD as proxy of incident OUD. We applied elastic net, random forests, gradient boosting machine, and deep neural network to predict OUD in the subsequent three months. We assessed prediction performance using C-statistics and other metrics (e.g., number needed to evaluate to identify an individual with OUD [NNE]). Beneficiaries were stratified into subgroups by risk-score decile.

RESULTS: The training (n = 120,474), testing (n = 120,556), and validation (n = 120,497) samples had similar characteristics (age ≥65 years = 81.1%; female = 61.3%; white = 83.5%; with disability eligibility = 25.5%; 1.5% had incident OUD). In the validation sample, the four approaches had similar prediction performances (C-statistic ranged from 0.874 to 0.882); elastic net required the fewest predictors (n = 48). Using the elastic net algorithm, individuals in the top decile of risk (15.8% [n = 19,047] of validation cohort) had a positive predictive value of 0.96%, negative predictive value of 99.7%, and NNE of 104. Nearly 70% of individuals with incident OUD were in the top two deciles (n = 37,078), having highest incident OUD (36 to 301 per 10,000 beneficiaries). Individuals in the bottom eight deciles (n = 83,419) had minimal incident OUD (3 to 28 per 10,000).

CONCLUSIONS: Machine-learning algorithms improve risk prediction and risk stratification of incident OUD in Medicare beneficiaries.

Rationale: Patients receiving prolonged mechanical ventilation experience low survival rates and incur high healthcare costs. However, little is known about how to optimally organize and manage their care.Objectives: To identify a set of effective care practices for patients receiving prolonged mechanical ventilation.Methods: We performed a focused ethnographic evaluation at eight long-term acute care hospitals in the United States ranking in either the lowest or highest quartile of risk-adjusted mortality in at least four of the five years between 2007 and 2011.Measurements and Main Results: We conducted 329 hours of direct observation, 196 interviews, and 39 episodes of job shadowing. Data were analyzed using thematic content analysis and a positive-negative deviance approach. We found that high- and low-performing hospitals differed substantially in their approach to care. High-performing hospitals actively promoted interdisciplinary communication and coordination using a range of organizational practices, including factors related to leadership (e.g., leaders who communicate a culture of quality improvement), staffing (e.g., lower nurse-to-patient ratios and ready availability of psychologists and spiritual care providers), care protocols (e.g., specific yet flexible respiratory therapy-driven weaning protocols), team meetings (e.g., interdisciplinary meetings that include direct care providers), and the physical plant (e.g., large workstations that allow groups to interact). These practices were believed to facilitate care that is simultaneously goal directed and responsive to individual patient needs, leading to more successful liberation from mechanical ventilation and improved survival.Conclusions: High-performing long-term acute care hospitals employ several organizational practices that may be helpful in improving care for patients receiving prolonged mechanical ventilation.

BACKGROUND: After non-fatal opioid overdoses, opioid prescribing patterns are often unchanged and the use of medications for opioid use disorder (MOUDs) remains low. Whether such prescribing differs by race/ethnicity remains unknown.

OBJECTIVE: To assess the association of race/ethnicity with the prescribing of opioids and MOUDs after a non-fatal opioid overdose.

DESIGN: Retrospective cohort study.

PARTICIPANTS: Patients prescribed ≥ 1 opioid from July 1, 2010, to September 30, 2015, with a non-fatal opioid overdose in the Veterans Health Administration (VA).

MAIN MEASURES: Primary outcomes were the proportion of patients prescribed: (1) any opioid during the 30 days before and after overdose and (2) MOUDs within 30 days after overdose by race and ethnicity. We conducted difference-in-difference analyses using multivariable regression to assess whether the change in opioid prescribing from before to after overdose differed by race/ethnicity. We also used multivariable regression to test whether MOUD prescribing after overdose differed by race/ethnicity.

KEY RESULTS: Among 16,210 patients with a non-fatal opioid overdose (81.2% were white, 14.3% black, and 4.5% Hispanic), 10,745 (66.3%) patients received an opioid prescription (67.1% white, 61.7% black, and 65.9% Hispanic; p < 0.01) before overdose. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively, with no significant difference-in-difference in opioid prescribing by race/ethnicity (p = 0.23). After overdose, 526 (3.2%) patients received MOUDs (2.9% white, 4.6% black, and 5.5% Hispanic; p < 0.01). Blacks (adjusted OR (aOR) 1.6; 95% CI 1.2, 1.9) and Hispanics (aOR 1.8; 95% CI 1.2, 2.6) had significantly larger odds of receiving MOUDs than white patients.

CONCLUSIONS: In a national cohort of patients with non-fatal opioid overdose in VA, there were no racial/ethnic differences in changes in opioid prescribing after overdose. Although blacks and Hispanics were more likely than white patients to receive MOUDs in the 30 days after overdose, less than 4% of all groups received such therapy.

OBJECTIVES: Shared decision making is essential to deprescribing unnecessary or harmful medications in older adults, yet patients' and caregivers' perspectives on medication value and how this affects their willingness to discontinue a medication are poorly understood. We sought to identify the most significant factors that impact the perceived value of a medication from the perspective of patients and caregivers.

DESIGN: Qualitative study using focus groups conducted in September and October 2018.

SETTING: Participants from the Pepper Geriatric Research Registry (patients) and the Pitt+Me Registry (caregivers) maintained by the University of Pittsburgh.

PARTICIPANTS: Six focus groups of community-dwelling adults aged 65 years or older, or their caregivers, prescribed five or more medications in the preceding 12 months.

MEASUREMENTS: We sought to identify (1) general views on medication value and what makes medication worth taking; (2) how specific features such as cost or side effects impact perceived value; and (3) reactions to clinical scenarios related to deprescribing.

RESULTS: We identified four themes. Perceived effectiveness was the primary factor that caused participants to consider a medication to be of high value. Participants considered a medication to be of low value if it adversely affected quality of life. Participants also cited cost when determining value, especially if it resulted in material sacrifices. Participants valued medications prescribed by providers with whom they had good relationships rather than valuing level of training. When presented with clinical scenarios, participants ably weighed these factors when determining the value of a medication and indicated whether they would adhere to a deprescribing recommendation.

CONCLUSION: We identified that perceived effectiveness, adverse effects on quality of life, cost, and a strong relationship with the prescriber influenced patients' and caregivers' views on medication value. These findings will enable prescribers to engage older patients in shared decision making when deprescribing unnecessary medications and will allow health systems to incorporate patient-centered assessment of value into systems-based deprescribing interventions. J Am Geriatr Soc 68:746-753, 2020.

BACKGROUND: As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems.

METHODS: We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes.

RESULTS: Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently.

DISCUSSION: Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis.