51
|
Skoy E, Eukel H, Werremeyer A, Strand M, Frenzel O, Steig J. Implementation of a statewide program within community pharmacies to prevent opioid misuse and accidental overdose. J Am Pharm Assoc (2003) 2020; 60:117-121. [DOI: 10.1016/j.japh.2019.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 01/24/2023]
|
52
|
Stone RH, Rafie S, Griffin B, Shealy K, Stein AB. Pharmacist self-perception of readiness to prescribe hormonal contraception and additional training needs. CURRENTS IN PHARMACY TEACHING & LEARNING 2020; 12:27-34. [PMID: 31843161 DOI: 10.1016/j.cptl.2019.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/29/2019] [Accepted: 10/15/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Our objectives were to describe pharmacist perceptions of training and preparation to prescribe hormonal contraception (HC), identify training gaps, and elicit preferred training methods. METHODS In this cross-sectional survey, pharmacists in the United States (US) completed an online 29-item survey. Descriptive statistics were used to analyze responses. RESULTS Of 823 participating pharmacists, 58% felt they received adequate training to prescribe HC. Prescribing any medications within the last five years or completion of residency training were significantly associated with more participants feeling adequately trained. Of those who indicated HC was not covered in their pharmacy school curriculum, most (78%) felt they were either not adequately trained or unsure. Only 36% were aware of the Centers for Disease Control and Prevention US Medical Eligibility Criteria for Contraceptive Use (CDC MEC). Residency-trained pharmacists were statistically more likely to have used the CDC MEC and feel comfortable prescribing for adolescents. Most participants desired more training about switching between products (80%) and patient specific product selection (72%). Preferred methods for additional training were basic (<four hours) live trainings, on-demand webinars, and online self-study programs. CONCLUSIONS As pharmacist scope of practice expands to include prescribing HC, many opportunities remain to ensure pharmacists feel adequately trained to provide this service. Pharmacy educators and training programs should incorporate the findings of this study into their curricula, experiential opportunities, and continuing education offerings. Additional studies are needed on the effectiveness of various training formats and programs.
Collapse
Affiliation(s)
- Rebecca H Stone
- Department of Clinical and Administrative Pharmacy, University of Georgia, College of Pharmacy, United States.
| | - Sally Rafie
- UC San Diego Health, 200 W. Arbor Dr. #8765, San Diego, CA 92103, United States.
| | - Brooke Griffin
- Midwestern University, Chicago College of Pharmacy, United States; Mt Sinai Medical Group, United States.
| | - Kayce Shealy
- Presbyterian College, School of Pharmacy, Clinton, SC, United States.
| | | |
Collapse
|
53
|
Luli AJ, Bounthavong M, Watanabe JH. Pharmacists on the front-line of solving a public health crisis: Increasing access to medications for opioid use disorder. J Am Pharm Assoc (2003) 2019; 60:297-303. [PMID: 31889651 DOI: 10.1016/j.japh.2019.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To demonstrate the advantages of pharmacist involvement to increase the accessibility of medication treatment for opioid use disorder (OUD). SUMMARY OUD continues to be a mounting public health crisis in the United States. Medications for OUD treatment have been reported to be safe and effective. Yet, underutilization and poor accessibility remain critical challenges. As the most accessible health care provider, pharmacists have the capability to help overcome these barriers and positively affect patient care. Preliminary strategies have been documented in the United States and abroad that can serve as a blueprint for expanded pharmacist involvement. CONCLUSION Pharmacists must expand efforts to increase patient accessibility to medications for OUD and become a key part of the solution to this epidemic.
Collapse
|
54
|
Evaluation of a pharmacist-led naloxone coprescribing program in primary care. J Am Pharm Assoc (2003) 2019; 59:867-871. [DOI: 10.1016/j.japh.2019.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/18/2019] [Accepted: 07/21/2019] [Indexed: 01/23/2023]
|
55
|
Kurian S, Baloy B, Baird J, Burstein D, Xuan Z, Bratberg J, Tapper A, Walley A, Green TC. Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians. J Am Pharm Assoc (2003) 2019; 59:824-831. [PMID: 31582224 DOI: 10.1016/j.japh.2019.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/19/2019] [Accepted: 08/23/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVES There is limited research on the attitudes of pharmacy technicians toward pharmacy naloxone provision, despite their widespread role in the pharmacy. We examined attitudes and perceptions of pharmacy technicians in the provision of naloxone in a sample of Massachusetts pharmacies. DESIGN Thirty-nine community retail pharmacies from 1 U.S. chain were purposely sampled in 13 municipalities across Massachusetts. Pharmacies were divided into high-risk municipalities (HRMs) versus low-risk municipalities (LRMs) based on the state average opioid-related death rate from 2011 to 2015. SETTING AND PARTICIPANTS A pharmacy technician working in each pharmacy was administered an in-person survey. Survey topics included technician beliefs about current naloxone provision practices; patient groups at greater risk of overdose; whether individuals filling prescriptions would benefit from naloxone; and whether individuals purchasing syringes would benefit from naloxone. OUTCOME MEASURES Closed-ended responses were analyzed by Mann-Whitney U, Fisher exact, and chi-square tests. Open-ended responses were summarized for themes and then contrasted by municipality risk status. RESULTS Technician participation was 100% (n = 39). Technicians in both groups believed they could identify patient groups at risk of overdose in their practice, but HRM technicians recognized the need for naloxone for more of their at-risk patients (81% in HRM vs. 33% in LRM believed > 25% of patients need naloxone, P < 0.01). A willingness to provide naloxone was high (> 89%) in both groups. Open-ended responses revealed commonalities between groups, including the belief that patients need lower-cost naloxone, and a lack of patient and technician awareness that naloxone could prevent overdose in individuals at risk through use of prescription opioids not just through use of illicit drugs. CONCLUSION Pharmacy technicians would benefit from overdose prevention training and are well positioned to recognize overdose risk and offer preventive interventions, such as naloxone. Among technicians, there is a high willingness to be involved in implementing broader naloxone access in pharmacies.
Collapse
|
56
|
Jimenez DE, Singer MR, Adesman A. Availability of Naloxone in Pharmacies and Knowledge of Pharmacy Staff Regarding Dispensing Naloxone to Younger Adolescents. J Adolesc Health 2019; 65:698-701. [PMID: 31540779 DOI: 10.1016/j.jadohealth.2019.07.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/12/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE This study assessed the immediate availability of naloxone in pharmacies and the knowledge of pharmacy staff regarding naloxone dispensing protocols, especially as it relates to younger adolescents. METHODS The primary sample included pharmacies in the 10 states with the highest number of opioid-related overdose deaths in 2016; in addition, pharmacies in the 2 states with the highest prevalence of opioid-related overdose deaths in 2016 were also contacted. Researchers simulated a routine conversation between pharmacy staff and a potential customer about the immediate availability of and requirements to purchase naloxone. RESULTS The primary sample included 120 pharmacies (82.5% chain pharmacies; 50.8% rural). The majority (80.3%) had at least one form of naloxone in stock. Pharmacy staff were knowledgeable about prescription and third-party purchasing requirements. However, almost half incorrectly responded that there was a minimum age requirement to purchase naloxone. CONCLUSION This study reveals barriers to obtaining naloxone, including a lack of immediate in-store availability and a common misperception that naloxone cannot be dispensed to minors.
Collapse
Affiliation(s)
- David E Jimenez
- Division of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, New York
| | - Miriam R Singer
- Division of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, New York
| | - Andrew Adesman
- Division of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, New York; Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
| |
Collapse
|
57
|
Hill LG, Reveles KR, Evoy KE. State-Level Approaches to Expanding Pharmacists' Authority to Dispense Naloxone May Affect Accessibility. JAMA Intern Med 2019; 179:1442-1443. [PMID: 31589259 DOI: 10.1001/jamainternmed.2019.3653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Lucas G Hill
- College of Pharmacy, The University of Texas at Austin
| | | | - Kirk E Evoy
- College of Pharmacy, The University of Texas at Austin
| |
Collapse
|
58
|
Bach P, Hartung D. Leveraging the role of community pharmacists in the prevention, surveillance, and treatment of opioid use disorders. Addict Sci Clin Pract 2019; 14:30. [PMID: 31474225 PMCID: PMC6717996 DOI: 10.1186/s13722-019-0158-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 08/06/2019] [Indexed: 12/15/2022] Open
Abstract
The global rise in opioid-related harms has impacted the United States severely. Current efforts to manage the opioid crisis have prompted a re-evaluation of many of the existing roles in the healthcare system, in order to maximize their individual effects on reducing opioid-associated morbidity and preventing overdose deaths. As one of the most accessible healthcare professionals in the US, pharmacists are well-positioned to participate in such activities. Historically, US pharmacists have had a limited role in the surveillance and treatment of substance use disorders. This narrative review explores the literature describing novel programs designed to capitalize on the role of the community pharmacist in helping to reduce opioid-related harms, as well as evaluations of existing practices already in place in the US and elsewhere around the world. Specific approaches examined include strategies to facilitate pharmacist monitoring for problematic opioid use, to increase pharmacy-based harm reduction efforts (including naloxone distribution and needle exchange programs), and to involve community pharmacists in the dispensation of opioid agonist therapy (OAT). Each of these activities present a potential means to further engage pharmacists in the identification and treatment of opioid use disorders (OUDs). Through a careful examination of these approaches, we hope that new strategies can be adopted to leverage the unique role of the community pharmacist to help reduce opioid-related harms in the US.
Collapse
Affiliation(s)
- Paxton Bach
- British Columbia Centre on Substance Use, University of British Columbia, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
| | - Daniel Hartung
- College of Pharmacy, Oregon State University/Oregon Health and Science University, Robertson Collaborative Life Science Building, 2730 SW Moody Ave, CL5CP, Portland, OR, 97201-5042, USA
| |
Collapse
|
59
|
Hill LG, Evoy KE, Reveles KR. Pharmacists are missing an opportunity to save lives and advance the profession by embracing opioid harm reduction. J Am Pharm Assoc (2003) 2019; 59:779-782. [PMID: 31402146 DOI: 10.1016/j.japh.2019.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/17/2019] [Accepted: 06/24/2019] [Indexed: 02/06/2023]
Abstract
More than 70,000 Americans died as a result of a drug overdose in 2017, and a substantial majority of those deaths involved an opioid. Supply-reduction interventions, such as prescription monitoring programs, tamper-resistant formulations, and prescribing limits have failed to reverse rising rates of opioid-related morbidity and mortality. Instead, they may be contributing to this trend by forcing people with opioid use disorder to an increasingly potent illicit market with scant resources for sterile injection. Pharmacists are recognized by governmental authorities, public health experts, and other health professionals as key partners in opioid harm reduction. This is reflected by the proliferation of state laws supporting pharmacy-based access to naloxone, an opioid antagonist that can rapidly reverse the effects of an opioid overdose. Expanded authority to distribute naloxone without an outside prescription, coupled with the provision of sterile syringes and evidence-based medications for opioid use disorder, represents a powerful opportunity for pharmacists to save lives while advancing the role of the profession. However, numerous studies have documented a lack of readiness among pharmacists to dispense naloxone and little willingness to provide sterile syringes. As a profession, it is imperative that we ensure all pharmacists receive adequate education regarding opioid harm reduction interventions and ongoing support to implement these interventions within their practices.
Collapse
|
60
|
Applying Contemporary Management Principles to Implementing and Evaluating Value-Added Pharmacist Services. PHARMACY 2019; 7:pharmacy7030099. [PMID: 31330816 PMCID: PMC6789523 DOI: 10.3390/pharmacy7030099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 07/13/2019] [Accepted: 07/18/2019] [Indexed: 12/11/2022] Open
Abstract
Value-added pharmacy services encompass traditional and emerging services provided by pharmacists to individual and entire populations of persons increasingly under the auspices of a public health mandate. The success of value-added pharmacy services is enhanced when they are carried out and assessed using appropriate theory-based paradigms. Many of the more important management theories for pharmacy services consider the “servicescape” of these services recognizing the uniqueness of each patient and service encounter that vary based upon health needs and myriad other factors. In addition, implementation science principles help ensure the financial viability and sustainability of these services. This commentary reviews some of the foundational management theories and provides a number of examples of these theories that have been applied successfully resulting in a greater prevalence and scope of value-added services being offered.
Collapse
|
61
|
Moving pharmacy forward: Student pharmacists “embrace and advocate change in the profession”. J Am Pharm Assoc (2003) 2019. [DOI: 10.1016/j.japh.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
62
|
Guadamuz JS, Alexander GC, Chaudhri T, Trotzky-Sirr R, Qato DM. Availability and Cost of Naloxone Nasal Spray at Pharmacies in Philadelphia, Pennsylvania, 2017. JAMA Netw Open 2019; 2:e195388. [PMID: 31173125 PMCID: PMC6563583 DOI: 10.1001/jamanetworkopen.2019.5388] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
IMPORTANCE Despite the increasingly important role of pharmacies in the implementation of naloxone access laws, there is limited information on the impact of such laws at the local level. OBJECTIVE To evaluate the availability (with or without a prescription) and cost of naloxone nasal spray at pharmacies in Philadelphia, Pennsylvania, following a statewide standing order enacted in Pennsylvania in August 2015 to allow pharmacies to dispense naloxone without a prescription. DESIGN, SETTING, AND PARTICIPANTS A survey study was conducted by telephone of all pharmacies in Philadelphia between February and August 2017. Pharmacies were geocoded and linked with the American Community Survey (2011-2015) to obtain information on the demographic characteristics of census tracts and the Medical Examiner's Office of the Philadelphia Department of Public Health to derive information on the number of opioid overdose deaths per 100 000 people for each planning district. Data were analyzed from March 2018 to February 2019. MAIN OUTCOMES AND MEASURES Availability and out-of-pocket cost of naloxone nasal spray (with or without a prescription) at Philadelphia pharmacies overall and by pharmacy and neighborhood characteristics. RESULTS Of 454 eligible pharmacies, 418 were surveyed (92.1% response rate). One in 3 pharmacies (34.2%) had naloxone nasal spray in stock; of these, 61.5% indicated it was available without a prescription. There were significant differences in the availability of naloxone by pharmacy type and neighborhood characteristics. Naloxone was both more likely to be in stock (45.9% vs 27.8%; difference, 18.0%; 95% CI, 8.3%-27.8%; P < .001) and available without a prescription (80.6% vs 42.2%; difference, 38.4%; 95% CI, 23.0%-53.8%; P < .001) in chain stores than in independent stores. Naloxone was also less likely to be available in planning districts with very elevated rates of opioid overdose death (≥50 per 100 000 people) compared with those with lower rates (31.1% vs 38.5%). The median (interquartile range) out-of-pocket cost among pharmacies offering naloxone without a prescription was $145 ($119-$150); costs were greatest in independent pharmacies and planning districts with elevated rates of opioid overdose death. CONCLUSIONS AND RELEVANCE Despite the implementation of a statewide standing order in Pennsylvania more than 3 years prior to this study, only one-third of Philadelphia pharmacies carried naloxone nasal spray and many also required a physician's prescription. Efforts to strengthen the implementation of naloxone access laws and better ensure naloxone supply at local pharmacies are warranted, especially in localities with the highest rates of overdose death.
Collapse
Affiliation(s)
- Jenny S. Guadamuz
- Institute of Minority Health Research, College of Medicine, University of Illinois at Chicago
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Center for Drug Safety and Effectiveness, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Tanya Chaudhri
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago
| | - Rebecca Trotzky-Sirr
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Dima M. Qato
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago
| |
Collapse
|
63
|
Beliefs Associated with Pharmacy-Based Naloxone: a Qualitative Study of Pharmacy-Based Naloxone Purchasers and People at Risk for Opioid Overdose. J Urban Health 2019; 96:367-378. [PMID: 30747371 PMCID: PMC6565759 DOI: 10.1007/s11524-019-00349-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Drug overdose is the leading cause of unintentional death in the USA and the majority of deaths involve an opioid. Pharmacies are playing an increasingly important role in getting naloxone-the antidote to an opioid overdose-into the community. The aim of the current study was to understand, from the perspective of those who had obtained naloxone at the pharmacy, whose drug using status and pain patient status was not known until the interviews were conducted, as well as those who had not obtained naloxone at the pharmacy but were at risk for overdose, factors that impact the likelihood of obtaining pharmacy-based naloxone (PBN). Fifty-two participants from two New England states were interviewed between August 2016 and April 2017. We used a phenomenological approach to investigate participants' beliefs about pharmacy-based naloxone. The social contextual model was chosen to structure the collection and analysis of the qualitative data as it takes into account individual, interpersonal, organizational (pharmacy), community, and societal influences on a specific health behavior. Of the 52 people interviewed, 24 participants had obtained naloxone from the pharmacy in the past year, of which 4% (n = 1) self-disclosed during the interview current illicit drug use and 29% (n = 7) mentioned using prescribed opioid pain medication. Of the 28 people who had not obtained naloxone from the pharmacy, 46% (n = 13) had obtained an over the counter syringe from a pharmacy in the past month and had used an opioid in the past month, and 54% (n = 15) had used a prescribed opioid pain medication in the past month but did not report a syringe purchase. Several main themes emerged from the interview data. Individual-level themes were as follows: helplessness and fear, naloxone as empowerment to help, and past experiences at the pharmacy. Interpersonal-level themes were as follows: concern for family and friends, and sources of harm reduction information. Themes associated with pharmacy-level influence were as follows: perceived stigma from pharmacists, confusion at the pharmacy counter, and receptivity to pharmacists' offer of naloxone; community-level themes were as follows: community caretaking and need for education and training. Finally, themes at the societal-level of influence were as follows: generational crisis, and frustration at lack of response to opioid crisis. Overall our findings reveal factors at multiple levels which may play a role in likelihood of obtaining naloxone at the pharmacy. These factors can be used to inform interventions seeking to increase provision of pharmacy-based naloxone.
Collapse
|
64
|
Naloxone Deserts in NJ Cities: Sociodemographic Factors Which May Impact Retail Pharmacy Naloxone Availability. J Med Toxicol 2019; 15:108-111. [PMID: 30805884 DOI: 10.1007/s13181-019-00700-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Retail pharmacies in NJ are permitted to dispense naloxone without a prescription. However, not all pharmacies have participated in this effort, and it is not clear what factors may impact its availability. We sought to determine the naloxone availability of select NJ cities and what sociodemographic factors are associated with its availability. We compared naloxone availability in retail pharmacies to median household income, population, and the prevalence of opioid-related hospital visits (ORHV). METHODS All retail pharmacies in ten New Jersey cities were surveyed by phone in February-July 2017. The standardized survey instrument asked scripted questions to each pharmacist concerning the stocking of naloxone for dispensing. Median household income data and population data for each city were obtained from census.gov . Opioid-related hospital visits were obtained through the NJ SHAD database and the prevalence of ORHV was calculated. Naloxone availability was compared to median household income, population, and ORHV using Spearman's rho and Pearson's correlation. RESULTS Naloxone availability in the 90 retail pharmacies we surveyed was 31% and ranged from 15.38 to 66.67% by city. An increase in median household income indicated more pharmacy naloxone availability. An increase in population indicated less pharmacy naloxone availability. While no significant relationship existed between ORHV and pharmacy naloxone availability, we did identify individual cities with severe opioid-related public health concerns with limited naloxone access. CONCLUSIONS Naloxone deserts exist in select high-risk New Jersey cities, and pharmacy naloxone availability may be positively related to median household income and negatively related to population.
Collapse
|
65
|
Affiliation(s)
- Michael A Steinman
- Division of Geriatrics, University of California San Francisco, California
- San Francisco VA Health Care System, San Francisco, California
| | | |
Collapse
|