Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation

Objective

Academic detailing (AD) is a promising intervention to address the growing morbidity and mortality associated with opioids. While AD has been shown to be effective in improving provider prescribing practices across a range of conditions, it is unclear how best to implement AD. The present study was designed to identify key lessons for implementation based on a model AD program in the Veterans Health Administration (VA).

Design

Qualitative process evaluation using semistructured interviews.

Setting

Seven VA health care systems in the Sierra Pacific region.

Subjects

Current and former academic detailers (N = 10) and VA providers with varying exposure to AD (high, low, or no; N = 20).

Methods

Semistructured interviews were audio-recorded and transcribed. We used a team-based, mixed inductive and deductive approach guided by the Consolidated Framework for Implementation Research.

Results

Key lessons identified by academic detailers and providers coalesced around key themes: 1) one-on-one sessions customized to the provider's patient population are most useful; 2) leadership plays a critical role in supporting providers' participation in AD programs; 3) tracking academic detailer and provider performance is important for improving performance for both groups; 4) academic detailers play a key role in motivating provider behavior change and thus training in Motivational Interviewing is highly valuable; and 5) academic detailers noted that networking is important for sharing implementation strategies and resources.

Conclusions

Identifying and incorporating these key lessons into the implementation of complex interventions like AD are critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic.

Leveraging electronic medical record data for population health management in the Veterans Health Administration: Successes and lessons learned

PURPOSE

The process and operational elements to establish a population health program using electronic medical record data in a Veterans Health Administration region are described.

SUMMARY

Pharmacists are uniquely qualified to assume important roles in population health through the use of their clinical knowledge, assisted by electronic tools that consolidate and report patient-specific data for clinical care. Veterans Integrated Services Network (VISN) 21 has developed 300 dashboards and reports to improve the quality, safety, and value of healthcare to veterans. Within a group of specialty task forces, physicians, nurses, and pharmacists assist in the design and development of evidence-based tools to leverage timely electronic health information into metrics, benchmarks, and targets to assist with goal achievement. Examples of programs designed to improve care in 3 areas were selected for further description and review of outcomes. Population health improvement using Healthcare Effectiveness Data and Information Set and hepatitis C metrics were used to describe populations that may have an indication for evidence-based care but are not receiving it. Deprescribing efforts are described, as are medication safety monitoring efforts to prevent potential adverse events known to be associated with therapy.

CONCLUSION

Quality, safety, and value outcomes are the measures of success for population health programs in VISN 21. Data-rich project dashboards and reports are developed by pharmacist data analysts and implemented and used by teams of clinicians who provide continuous feedback and support to improve population health. The use of task forces, metrics, benchmarks, targets, and teams is instrumental in the successful application of these tools.

Determinants of Treatment Eligibility in Veterans With Hepatitis C Viral Infection

PURPOSES

The objective of this study was to determine the percentage of veterans with active hepatitis C virus (HCV) infection who were deemed to be candidates for treatment and to identify factors associated with treatment ineligibility.

METHODS

This was a multisite, retrospective cohort analysis of veterans with HCV infection within the Veteran Integrated Service Network 21. Patients evaluated between August and November 2015 who were viremic and not receiving HCV treatment were included in the analysis. Reasons for treatment exclusion were determined by an experienced clinician and recorded into a regional population management dashboard. Descriptive statistics were used to describe the population. The t test for normally distributed data, the Mann-Whitney rank sum test for data that failed normality testing, or the χ² test were used to examine differences between the treatment eligible and ineligible cohorts. Generalized linear mixed-effects models were conducted to estimate patient outcomes relevant to various disease states and characteristics while controlling for interfacility variability.

FINDINGS

The cohort included 1,003 veterans within 5 medical centers; 988 (98.5%) were male, and 625 (62%) had a fibrosis 4 score >3.25, indicating the presence of ALD. According to clinician classification, 478 (48%) were considered HCV treatment candidates, whereas 525 (52%) were determined to be treatment ineligible. The most common reasons documented by clinicians for treatment ineligibility included unstable or uncontrolled comorbidities (n = 118 [22.4%]), excessive alcohol use (n = 116 [22.1%]), and treatment refusal by the patient (n = 69 [13%]). On the basis of statistical modeling and reporting odds ratios (ORs) and 95% CIs, diagnoses of active alcohol use disorder (OR = 0.68; 95% CI, 0.47-0.98; P = 0.038), hepatocellular carcinoma (OR = 0.24; 95% CI, 0.13-0.47; P < 0.001), and palliative care status (OR = 0.21; 95% CI, 0.05-0.99; P = 0.049) were statistically associated with treatment ineligibility, whereas posttraumatic stress disorder (OR = 1.48; 95% CI, 1.01-2.18; P = 0.046) was associated with treatment eligibility. There were no statistically significant differences found for other psychiatric diagnoses or an encounter for homelessness.

IMPLICATIONS

Results of this study indicate that a high percentage of patients may not be considered treatment eligible at initial clinical review. Within this veteran population, the presence of uncontrolled comorbidities and excessive alcohol use were the most commonly reported reasons for treatment ineligibility. On the basis of this analysis, processes could be established to address modifiable barriers to treatment, thus expanding the number of individuals receiving potentially curative therapy for HCV infection.

Leadership Advice for the Front Lines: Interviews with Max Ray, Sara White, and Scott Knoer

Pharmacy is striving to evolve from a technical profession in which pharmacists prepare and dispense medications to one in which they take responsibility for the development and execution of each patient's pharmacotherapeutic plan. This is being guided by pharmacy leaders and professional organizations, but they are not able to make the changes necessary to achieve their vision alone. In order to effectively implement change, pharmacists need to own their vision of pharmacy practice. The authors spoke to a number of established leaders in the pharmacy profession about what the individual pharmacist could do to change the culture and environment at the local level. The leaders' advice proved remarkably consistent and could be summarized into three categories: vision, socialization (relationships and networks), and self-development. Excerpts from three of these interviews were compiled into one report to be used as a guide to help pharmacists implement changes needed to achieve the vision of pharmacy practice.

Prader-Willi syndrome phenocopy due to duplication of Xq21.1-q21.31, with array CGH of the critical region

We report on a 4-year-old male with an interstitial tandem duplication of Xq21.1-q21.31 who presented with clinical features of Prader-Willi syndrome (PWS). The duplication was maternally inherited. Abnormalities of the X chromosome have previously been reported in association with a PWS phenotype, but to date, specific duplications of Xq21.1-q21.31 have not. We refined the chromosomal breakpoints seen on initial G-banded karyotyping in our case with comparative genomic hybridization by microarray (array CGH). The duplication was between 11.1 and 14.4 Mb in length and overlaps with three loci to which mental retardation with PWS-like features have been previously mapped, showing the utility of array CGH in helping to identify candidate genes. We conclude that duplication of chromosomal region Xq21.1-q21.31 potentially results in a PWS-like phenotype. Reviewing the literature on similar duplications, we further conclude that distal Xq duplications can result in features typically seen in infants with PWS, while proximal duplications can result in features typically seen in older children and adults with PWS. Duplications of chromosome Xq should be considered in the differential diagnosis of PWS, especially in males.

Establishment and outcomes of a model primary care pharmacy service system

PURPOSE

The establishment and outcomes of a model primary care pharmacy service system are described.

SUMMARY

A primary care pharmacy practice model was established at a government health care facility in March 1996. The original objective was to establish a primary pharmacy practice model that would demonstrate improved patient outcomes and maximize the pharmacist's contributions to drug therapy. Since its inception, many improvements have been realized and supported by advanced computer and automated systems, expanded disease state management practices, and unique practitioner and administrative support. Many outcomes studies have been performed on the pharmacist-initiated and -managed clinics, leading to improved patient care and conveying the quality-conscious and cost-effective role pharmacists can play as independent practitioners in this environment. These activities demonstrate cutting-edge leadership in health-system pharmacy. Redesign has been used to improve consistent access to a medication expert and has significantly improved the quality of patient care while easing physicians' workload without increasing health care costs.

CONCLUSION

A system using pharmacists as independent practitioners to promote primary care has achieved high-quality and cost-effective patient care.

The changing role of pharmacy practice--a clinical perspective

Professor Carmichael and Dr. Cichowlas argue for the reexamination of the pharmacist's role in the current health care system. Reexamination is necessitated due to changing complexities of the health care system as evidenced by increased economic demands and pharmaceutical surpluses. The authors advocate for Collaborative Drug Therapy Management, in which physicians and pharmacists maximize patient care by pooling their areas of expertise together.

Effect of clinical pharmacy input on physician prescribing habits in the nursing home care unit

The goal of this study was to evaluate any changes in medication use in our 60-bed nursing home care unit as a result of eliminating clinical pharmacy services during a 2-week period. Information was obtained on patient medications and number of doses dispensed. All patients were found to have a 6% increase in average number of scheduled medications, a 3% increase in average total medications, and an increase in scheduled doses dispensed by 10% during the absence of clinical pharmacy services. These numbers declined by 16, 18, and 9%, respectively, 2 weeks after the return of clinical pharmacy services. When evaluating only those 37 patients present the entire 4 week period, average scheduled medications rose 5% and total medications rose 4% during the absence of clinical pharmacy services and declined 13 and 17%, respectively, upon return of services. Eleven patients showed an increase in total number of medications during the absence of clinical pharmacy services whereas 21 patients showed a decline in medications after the return of clinical pharmacy services (P less than 0.001). The authors conclude that clinical pharmacy services must be provided on a continuous basis to maintain good physician prescribing habits in the nursing home care unit.

Survey of ulcer-recurrence risk factors associated with long-term cimetidine prescribing

The appropriateness of long-term cimetidine prescribing was evaluated retrospectively in 243 outpatients. Criteria defining appropriate indications for the use of cimetidine for longer than eight weeks were established. Of the 243 patients surveyed, 115 (47 percent) were considered to be inappropriately receiving long-term cimetidine, either because they had never been objectively studied radiographically or endoscopically (23 percent) or had negative results before initiation of therapy (24 percent). Risk factors known to be associated with recurrent peptic ulcer disease were reviewed. Patients fulfilling criteria for appropriate long-term cimetidine usage had a greater prevalence of risk factors compared to the nonjustifiable group. Of particular interest, individuals considered appropriate for long-term therapy were very likely to have had a gastrointestinal bleeding episode prior to beginning therapy (52 percent for gastric ulcer, 8 percent for the nonjustifiable group). This increased prevalence of gastrointestinal hemorrhage may be due to the inherent nature of peptic ulcer disease or a result of physicians selecting affected individuals who may benefit from long-term treatment. Eliminating inappropriate usage of long-term cimetidine in conjunction with a thorough evaluation of risk factors for recurrent ulcer disease can be useful in selecting those individuals most likely to benefit from long-term cimetidine therapy.

Rational approach to long-term use of H2-antagonists

Although the approved indications for long-term histamine (H2) receptor-antagonists are limited to the management of hypersecretory states and prophylaxis against recurrent duodenal ulcer, these agents are often prescribed indiscriminately. Definitive guidelines concerning proper patient selection for prophylaxis against duodenal ulcer recurrence are lacking. Persons likely to benefit from maintenance therapy include those who smoke and those with a long duration of symptoms or prior history of an ulcer complication. Although not an approved indication, maintenance therapy to prevent recurrent gastric ulcer is appropriate for elderly persons receiving nonsteroidal anti-inflammatory drugs or in patients with poor cardiopulmonary status who may not tolerate surgery for an ulcer-related complication. The role of long-term H2-antagonist therapy in reflux esophagitis is not defined but may be appropriate in scleroderma and Barrett's esophagus. Finally, several miscellaneous conditions, including cystic fibrosis, Menetrier's disease, and pancreatic exocrine insufficiency, may benefit from long-term H2-antagonist therapy. Currently, clinical trials document the efficacy of maintenance therapy in duodenal ulcer for up to a three-year period; however, for gastric ulcer and chronic reflux esophagitis, the duration and benefit of long-term therapy is not established, and treatment regimens need to be individualized. Therapy may be required indefinitely in the miscellaneous states mentioned previously.

New perspectives on glaucoma screening

Glaucoma is defined as elevated intraocular pressure resulting in visual field defects. Elevated intraocular pressure without visual field defects is referred to as ocular hypertension. The prevalence of open-angle glaucoma in the population above the age of 40 years is less than one percent. Approximately one out of ten people with elevated ocular pressure has glaucoma. The concept of variable sensitivity explains why high ocular pressures do not always result in glaucoma. Glaucoma screening by tonometry can be justified only if used in conjunction with visual field testing.

Emergency-room services for a community health center

The development and maintenance of an organized system of emergency care in isolated ambulatory health-care centers are described. A system of three community health centers, staffed chiefly by midlevel practitioners (i.e., physician's associates and nurse practitioners), had a need to provide occasional emergency care to patients. Emergency care needed to be provided (for up to one hour) until an ambulance arrived to transport the patient to a hospital. A system of emergency care, consisting of treatment protocols, a drug manual, equipment and medications, and a program for periodic inservice education was developed by physicians, midlevel practitioners, and pharmacists. Weekly checks of the supplies and medications are conducted. Lists of supplies and medications stocked, and a sample drug monograph, are included in the paper. The program has resulted in more efficient emergency care, including less confusion in executing and documenting treatment.