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Mandhana DM, Jacome CS, Ballard DI, Tesfai Y, Johnson SB, Gionfriddo MR, Espinoza Suarez NR, Perneth SA, Su L, Montori VM. Developing and validating the Unhurried Conversations Assessment Tool (UCAT). Patient Educ Couns 2024; 123:108237. [PMID: 38461793 DOI: 10.1016/j.pec.2024.108237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/29/2024] [Accepted: 02/29/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE Given the importance of unhurried conversations for providing careful and kind care, we sought to create, test, and validate the Unhurried Conversations Assessment Tool (UCAT) for assessing the unhurriedness of patient-clinician consultations. METHODS In the first two phases, the unhurried conversation dimensions were identified and transformed into an assessment tool. In the third phase, two independent raters used UCAT to evaluate the unhurriedness of 100 randomly selected consultations from 184 videos recorded for a large research trial. UCAT's psychometric properties were evaluated using this data. RESULTS UCAT demonstrates content validity based on the literature and expert review. EFA and reliability analyses confirm its construct validity and internal consistency. The seven formative dimensions account for 89.93% of the variance in unhurriedness, each displaying excellent internal consistency (α > 0.90). Inter-rater agreement for the overall assessment item was fair (ICC = 0.59), with individual dimension ICCs ranging from 0.26 (poor) to 0.95 (excellent). CONCLUSION UCAT components comprehensively assess the unhurriedness of consultations. The tool exhibits content and construct validity and can be used reliably. PRACTICE IMPLICATIONS UCAT's design and psychometric properties make it a practical and efficient tool. Clinicians can use it for self-evaluations and training to foster unhurried conversations.
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Affiliation(s)
- Dron M Mandhana
- Department of Communication, Villanova University, Villanova, PA, USA; Knowledge & Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
| | - Cristian Soto Jacome
- Knowledge & Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Norwalk Hospital, Department of Internal Medicine, Nuvance Health, Norwalk, CT, USA
| | - Dawna I Ballard
- Knowledge & Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Department of Communication Studies, The University of Texas at Austin, Austin, TX, USA
| | - Yohanna Tesfai
- Department of Communication Studies, The University of Texas at Austin, Austin, TX, USA
| | - Sarah B Johnson
- Knowledge & Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
| | - Michael R Gionfriddo
- Division of Pharmaceutical, Administrative, and Social Sciences, School of Pharmacy, Duquesne University, Pittsburgh, PA, USA
| | - Nataly R Espinoza Suarez
- Knowledge & Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Centre for Sustainable Health Research, Integrated University Health and Social Services Center of Capitale-Nationale, Quebec City, QC, Canada; Faculty of Nursing, Laval University, Quebec City, QC, Canada
| | - Sandra Algarin Perneth
- Knowledge & Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Lillian Su
- Division of Cardiovascular Intensive Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Victor M Montori
- Knowledge & Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA.
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Lussier ME, Desai RJ, Wright EA, Gionfriddo MR. Impact of cost on prescribing diabetes medications for older adults with type 2 diabetes in the outpatient setting. Res Social Adm Pharm 2024:S1551-7411(24)00149-9. [PMID: 38697890 DOI: 10.1016/j.sapharm.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Newer diabetes medications have cardiorenal benefits beyond blood sugar lowering that make them a preferred treatment option in many patients. Despite this, studies have shown that prescribing of these medications remains suboptimal with medication costs being hypothesized as a reason for underutilization. OBJECTIVE To understand clinicians' decision-making processes for prescribing diabetes medications in older adults, focusing on higher cost medications. METHODS Observations of patient encounters and semi-structured interviews were conducted with clinicians from primary care, endocrinology, and geriatrics to elucidate themes into diabetes medication prescribing. A qualitative descriptive approach was used to analyze the data from interviews using an inductive coding scheme with themes derived from the data. RESULTS Twenty-one interviews were conducted. Five themes were identified: 1) out-of-pocket costs drive prescribing decisions 2) out-of-pocket costs can be variable due to changing insurance plans or changing coverage 3) clinicians have difficulty with determining patient-specific out-of-pocket costs 4) clinicians manage the tradeoffs existing between cost, efficacy, and safety and 5) clinicians can use cost-modifying strategies such as patient assistance. CONCLUSION Addressing the challenges that medication costs pose to prescribing evidence-based medications for type 2 diabetes is necessary to optimize diabetes care for older adults.
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Affiliation(s)
- Mia E Lussier
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA; Binghamton University, School of Pharmacy and Pharmaceutical Sciences, PO Box 6000, Binghamton, NY, 13902-6000, USA.
| | - Ravi J Desai
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA
| | - Eric A Wright
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA
| | - Michael R Gionfriddo
- Duquesne University, Division of Pharmaceutical, Administrative, and Social Sciences, 600 Forbes Avenue, Pittsburgh, PA, 15282, USA
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Gionfriddo MR, McClendon C, Nolfi DA, Kalarchian MA, Covvey JR. Back to the basics: Guidance for designing good literature searches. Res Social Adm Pharm 2024; 20:463-468. [PMID: 38272775 DOI: 10.1016/j.sapharm.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
The number of scientific publications is growing at an unprecedented rate. Failure to properly evaluate existing literature at the start of a project may result in a researcher wasting time and resources. As pharmacy researchers and scholars look to conceptualize new studies, it is imperative to begin with a high-quality literature review that reveals what is known and unknown about a given topic. The purpose of this commentary is to provide useful guidance on conducting rigorous searches of the literature that inform the design and execution of research. Guidance for less formal literature reviews can be adapted from best practices utilized within the formalized field of evidence synthesis. Additionally, researchers can draw on guidance from PRESS (Peer Review of Electronic Search Strategies) to engage in self-evaluation of their search strategies. Finally, developing an awareness of common pitfalls when designing literature searches can provide researchers with confidence that their research is designed to fill clearly articulated gaps in knowledge.
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Affiliation(s)
| | | | - David A Nolfi
- Duquesne University Gumberg Library, Pittsburgh, PA, USA
| | | | - Jordan R Covvey
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA.
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Lussier ME, Gionfriddo MR, Graham JH, Wright EA. Factors Affecting Prescribing of Type 2 Diabetes Medications in Older Adults within an Integrated Healthcare System. J Gen Intern Med 2024; 39:195-200. [PMID: 37783983 PMCID: PMC10853133 DOI: 10.1007/s11606-023-08435-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/15/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Despite type 2 diabetes guidelines recommending against the use of sulfonylureas in older adults and for the use of sodium-glucose cotransporter-2 inhibitors (SGLT2) and glucagon-like peptide-1 agonists (GLP1s) in patients with atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), and heart failure (HF), real-world guideline-concordant prescribing remains low. While some factors such as cost have been suggested, an in-depth analysis of the factors associated with guideline-concordant prescribing is warranted. OBJECTIVE To quantify the extent of guideline-concordant prescribing in an integrated health care delivery system and examine provider and patient level factors that influence guideline-concordant prescribing. DESIGN We performed a cross-sectional study. PARTICIPANTS Participants were included if they had a diagnosis of type 2 diabetes, were prescribed a second-line diabetes medication between January 1, 2018 and December 31, 2020 and were at least 65 years old at the time of this second-line prescription. MAIN MEASURES Our outcome of interest was guideline-concordant prescribing. The definition of guideline-concordant prescribing was based on American Diabetes Association and American Geriatric Society recommendations as well as expert consensus. Factors affecting guideline concordant prescribing included patient demographics and provider characteristics among others. KEY RESULTS We included 1,693 patients of which only 50% were prescribed guideline-concordant medications. In a subgroup of 843 patients with cardiorenal conditions, only 30% of prescriptions were guideline concordant. Prescribing of guideline-concordant prescriptions was more likely among pharmacists than physicians (RR 1.34, 95% CI 1.19-1.51, p<0.001) and in endocrinology practices compared to primary care practices (RR 1.41 95% CI 1.16-1.72, p=0.007). Additionally, guideline concordant prescribing increased over time (42% in 2018 vs 53% in 2019 vs 53% in 2020, p<0.001). CONCLUSIONS Guideline-concordant prescribing remains low in older adults, especially among those with cardiorenal conditions. Future studies should examine barriers to prescribing guideline-concordant medications and interventions to improve guideline-concordant prescribing.
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Affiliation(s)
- Mia E Lussier
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Danville, PA, USA.
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Johnson City, NY, USA.
| | - Michael R Gionfriddo
- Division of Pharmaceutical, Administrative, and Social Sciences, School of Pharmacy, Duquesne University, Pittsburgh, PA, USA
| | - Jove H Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Danville, PA, USA
| | - Eric A Wright
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Danville, PA, USA
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Richards M, Stewart-Lynch A, McConaha J, Gionfriddo MR. A Systematic Review of APPE Readiness Assessments Utilized by US Schools of Pharmacy. Am J Pharm Educ 2024; 88:100650. [PMID: 38215941 DOI: 10.1016/j.ajpe.2024.100650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVE The 2016 Accreditation Council for Pharmacy Education standard 25.8 requires schools of pharmacy to assess student readiness for Advanced Pharmacy Practice Experiences (APPEs). We performed a systematic review to identify how schools of pharmacy in the United States assess student readiness for APPE rotations in accordance with Accreditation Council for Pharmacy Education accreditation guidelines. FINDINGS From a search of 6 databases, we identified 1053 unique studies, of which 11 were eligible for inclusion in our review. The most commonly reported assessment method was the use of a capstone course; however, these courses varied significantly from school to school in duration, resources used, and content. Regardless of the specific approach used, first-time and overall pass rates were high. SUMMARY We found that while most studies reported using some type of capstone course for APPE readiness assessment, there was variability in how these courses were structured and the assessment methods used within the courses. The future 2025 standards may dictate a more uniform structure for readiness assessments; however, further research is needed to identify best practices regarding the assessment of APPE readiness.
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Affiliation(s)
- Macy Richards
- School of Pharmacy, Duquesne University, Pittsburgh, PA, USA
| | | | - Jamie McConaha
- School of Pharmacy, Duquesne University, Pittsburgh, PA, USA
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Covvey JR, McClendon C, Gionfriddo MR. Back to the basics: Guidance for formulating good research questions. Res Social Adm Pharm 2024; 20:66-69. [PMID: 37838572 DOI: 10.1016/j.sapharm.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/16/2023]
Abstract
Good science is driven by rigorous questions. Much like the foundation of a house, a research question must be carefully constructed to prevent downstream problems in project execution. And yet, pharmacy researchers and scholars across all career stages may find themselves struggling when developing research questions. The purpose of this commentary is to provide useful guidance on composing and evaluating rigorous research questions. A variety of frameworks, such as PICO (Patient/population; Intervention; Comparison; Outcome), are available to researchers and can assist them in ensuring that their research question has covered all relevant components. Additionally, the FINER (Feasible; Interesting; Novel; Ethical; and Relevant) criteria can help researchers with evaluating their research questions for practical considerations. Finally, building awareness of common pitfalls when composing research questions can aid researchers to avoid issues that they may not otherwise discover until their manuscript undergoes peer review.
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Affiliation(s)
- Jordan R Covvey
- Duquesne University School of Pharmacy, 600 Forbes Ave, Pittsburgh, PA, USA
| | - Chyna McClendon
- Duquesne University School of Pharmacy, 600 Forbes Ave, Pittsburgh, PA, USA
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Boehmer KR, Álvarez-Villalobos NA, Barakat S, de Leon-Gutierrez H, Ruiz-Hernandez FG, Elizondo-Omaña GG, Vaquera-Alfaro H, Ahn S, Spencer-Bonilla G, Gionfriddo MR, Millan-Alanis JM, Abdelrahim M, Prokop LJ, Murad MH, Wang Z. The impact of health and wellness coaching on patient-important outcomes in chronic illness care: A systematic review and meta-analysis. Patient Educ Couns 2023; 117:107975. [PMID: 37738790 PMCID: PMC10964774 DOI: 10.1016/j.pec.2023.107975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Health and Wellness Coaching (HWC) may be beneficial in chronic condition care. We sought to appraise its effectiveness on quality of life (QoL), self-efficacy (SE), depression, and anxiety. METHODS We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane CENTRAL for randomized trials published January 2005 - March 2023 that compared HWC to standard clinical care or another intervention without coaching. We examined QoL, SE, depression, or anxiety outcomes. Meta-analysis utilizing the random-effects model was used to estimate the pooled standardized mean difference (SMD). RESULTS Thirty included studies demonstrated that HWC improved QoL within 3 months (SMD 0.62 95 % CI 0.22-1.02, p = 0.002), SE within 1.5 months (SMD 0.38, 95 % CI 0.03-0.73, p = 0.03), and depression at 3, 6, and 12 months (SMD 0.67, 95 % CI 0.13-1.20, p = 0.01), (SMD 0.72, 95 % CI 0.19-1.24, p = 0.006), and (SMD 0.41, 95 % CI 0.09-0.73, p = 0.01) Certainty in the evidence for most outcomes was either very low or low primarily due to the high risk of bias, heterogeneity, and imprecision. CONCLUSION HWC improves QoL, SE, and depression across chronic illness populations. Future research needs to standardize intervention reporting and outcome collection. PRACTICE IMPLICATIONS Future HWC studies should standardize intervention components, reporting, and outcome measures, apply relevant chronic illness theories, and aim to follow participants for greater than one year.
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Affiliation(s)
- Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA.
| | - Neri A Álvarez-Villalobos
- Plataforma INVEST-KER Unit Mayo Clinic (KER Unit Mexico), School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo León, Mexico; School of Medicine and University Hospital "Dr. Jose E. Gonzalez", Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo León, Mexico.
| | - Suzette Barakat
- Community Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Humberto de Leon-Gutierrez
- School of Medicine and University Hospital "Dr. Jose E. Gonzalez", Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo León, Mexico.
| | - Fernando G Ruiz-Hernandez
- School of Medicine and University Hospital "Dr. Jose E. Gonzalez", Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo León, Mexico.
| | | | - Héctor Vaquera-Alfaro
- School of Medicine and University Hospital "Dr. Jose E. Gonzalez", Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo León, Mexico.
| | - Sangwoo Ahn
- University of Tennessee Knoxville, Knoxville, TN, USA.
| | | | - Michael R Gionfriddo
- Department of Pharmaceutical, Administrative and Social Sciences, School of Pharmacy, Duquesne University, Pittsburgh, PA, USA.
| | - Juan M Millan-Alanis
- Plataforma INVEST-KER Unit Mayo Clinic (KER Unit Mexico), School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo León, Mexico.
| | | | | | - M Hassan Murad
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Zhen Wang
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Gionfriddo MR, Owens KM, Leist SE, Schrum LT, Covvey JR. Attitudes, beliefs, knowledge, and practices for over-the-counter syringe sales in community pharmacies: A systematic review. J Am Pharm Assoc (2003) 2023; 63:1472-1489.e3. [PMID: 37429389 DOI: 10.1016/j.japh.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/02/2023] [Accepted: 07/06/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Community pharmacies are an important resource for people who inject drugs (PWID) to purchase over-the-counter (OTC) syringes. Access to sterile injection equipment can reduce the transmission of blood-borne illnesses. However, pharmacists and their staff ultimately use discretion over sales. OBJECTIVE To identify staff attitudes, beliefs, knowledge, and practices in the sale of OTC syringes in community pharmacies. METHODS This systematic review was reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and registered with PROSPERO (CRD42022363040). We systematically searched PubMed, Embase, and Scopus from inception to September 2022. The review included peer-reviewed empirical studies regarding OTC syringe sales among community pharmacy staff (pharmacists, interns, and technicians). We screened records and extracted data using a predefined data extraction form. Findings were narratively synthesized, and critical appraisal was conducted using the Mixed Methods Appraisal Tool. RESULTS A total of 1895 potentially relevant articles were identified, and 35 were included. Most studies (23; 63.9%) were cross-sectional descriptive designs. All studies included pharmacists, with seven (19.4%) also including technicians, two (5.6%) including interns, and four (11.1%) including other staff. Studies found relatively high support among respondents for harm reduction-related services within community pharmacies, but less common reports of staff engaging in said services themselves. When studies investigated the perceived positive or negative impacts of OTC syringe sales, prevention of blood-borne illness was widely understood as a benefit, while improper syringe disposal and safety of the pharmacy and its staff commonly reported as concerns. Stigmatizing attitudes/beliefs toward PWID were prevalent across studies. CONCLUSION Community pharmacy staff report knowledge regarding the benefits of OTC syringes, but personal attitudes/beliefs heavily influence decisions to engage in sales. Despite support for various syringe-related harm reduction activities, offerings of services were less likely due to concerns around PWID.
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Steele AJ, Berletic JD, Gionfriddo MR. Pharmacist-Driven Geriatric Medication Assessment at an Acute Care Teaching Hospital. Sr Care Pharm 2023; 38:179-184. [PMID: 37185144 DOI: 10.4140/tcp.n.2023.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Older patients are often prescribed many medications and are at higher risk for medication-related problems. Pharmacists can help to identify potentially inappropriate medication use that may precipitate adverse drug events resulting in mental status changes, falls, and hospitalization. A Pharmacist-Driven Geriatric Medication Assessment program was established by clinical pharmacists to evaluate medication use in older patients admitted to a pilot unit of an acute care hospital as part of an Age-Friendly Care initiative. This article describes the implementation of this program and the types of medication interventions pursued by the pharmacists. Pharmacist recommendation acceptance rate by the health care team was greater than 90% overall for medication reconciliation, potentially inappropriate medications, and other medication interventions.
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Affiliation(s)
- Abigail J Steele
- 1 UPMC Mercy, Department of Pharmaceutical Services, Pittsburgh, Pennsylvania
| | - Josef D Berletic
- 1 UPMC Mercy, Department of Pharmaceutical Services, Pittsburgh, Pennsylvania
| | - Michael R Gionfriddo
- 2 Duquesne University, School of Pharmacy, Graduate School of Pharmaceutical Sciences, Pittsburgh, Pennsylvania
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Kunneman M, Gravholt D, Hartasanchez SA, Gionfriddo MR, Paskins Z, Prokop LJ, Stiggelbout AM, Montori VM. Assessing collaborative efforts of making care fit for each patient - A systematic review. Health Expect 2023. [PMID: 36973176 DOI: 10.1111/hex.13759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/14/2022] [Accepted: 03/26/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION For too many people, their care plans are designed without fully accounting for who they are, the lives they live, what matters to them, or what they aspire to achieve. We aimed to summarize instruments capable of measuring dimensions of patient-clinician collaboration to make care fit. METHODS We systematically searched several databases (Medline, Embase, Cochrane, Scopus, and Web of Science) from inception to September 2021 for studies using quantitative measures to assess, evaluate or rate the work of making care fit by any participant in real-life clinical encounters. Eligibility was assessed in duplicate. After extracting all items from relevant instruments, we coded them deductively on dimensions relevant to making care fit (as presented in a recent Making Care Fit Manifesto), and inductively on main action described. RESULTS We included 189 papers, mostly from North America (N=83, 44%) and in the context of primary care (N=54, 29%). Half of the papers (N=88, 47%) were published in the last five years. We found 1243 relevant items to assess efforts of making care fit, included within 151 instruments. Most items related to the dimensions "Patient-clinician collaboration: content" (N=396, 32%) and "Patient-clinician collaboration: manner" (N=382, 31%), and the least related to "Ongoing and iterative process" (N=22, 2%) and in "Minimally disruptive of patient lives" (N=29, 2%). The items referred to 27 specific actions. Most items referred to "Informing" (N=308, 25%) and "Exploring" (N=93, 8%), the fewest items referred to "Following up", "Comforting", and "Praising" (each N=3, 0.2%). DISCUSSION Measures of the work that patients and clinicians do together to make care fit focus heavily on the content of their collaborations, particularly on exchanging information. Other dimensions and actions previously identified as crucial to making care fit are assessed infrequently or not at all. The breadth of extant measures of making care fit and the lack of appropriate measures of this key construct limit both the assessment and the successful implementation of efforts to improve patient care. PATIENT CONTRIBUTION Patients and caregivers from the 'Making care fit Collaborative' were involved in drafting the dimensions relevant to patient-clinician collaboration. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Marleen Kunneman
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | | | | | - Michael R Gionfriddo
- School of Pharmacy, Division of Pharmaceutical, Social and Administrative Sciences, Duquesne University, Pittsburgh, PA, USA
| | - Zoe Paskins
- School of Medicine, Keele University, Newcastle-under-Lyme, UK
- Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | | | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, the Netherlands
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
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Rightnour J, Baird J, Benjamin K, Qing M, Gionfriddo MR, McConaha J, Schoen R. Medication affordability discussions with older adults in primary care. Explor Res Clin Soc Pharm 2023; 9:100230. [PMID: 36876148 PMCID: PMC9976569 DOI: 10.1016/j.rcsop.2023.100230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/22/2023] [Accepted: 01/22/2023] [Indexed: 02/04/2023] Open
Abstract
Introduction Cost is a major barrier to medication accessibility. While a minority of adults experience problems affording their medications, older adults are particularly vulnerable due to increased polypharmacy and fixed incomes.Clinicians can help reduce cost-related non-adherence and improve medication affordability; however, opportunities to improve affordability are often missed due to failure of the patient or clinician to discuss the issue. Objective Identify the incidence and resolution of cost-related conversations between patients and clinicians during primary care visits. Methods We conducted this quality improvement project at a primary care office. Student pharmacists observed in-person encounters with patients ≥65 years of age and documented the incidence of cost-related conversations and who initiated the conversation. After the visit, they asked if the patient had affordability issues. Patients and clinicians were blinded to the study purpose and hypothesis. Results Students observed 79 primary care visits. Cost conversations (medication or non-medication related) occurred in 37% (29/79) of visits. Having concerns about affordability did not impact the likelihood of conversation about non-medication related healthcare costs (RR = 1.21 95% CI 0.35-4.19, p = 0.67) or medication related costs (RR = 0.86 95% CI 0.13-5.65, p = 1.0). Conclusion Our results indicated that cost conversations did not routinely occur at our site. Failure to discuss costs, especially for patients with underlying cost concerns, may lead to cost related non-adherence and worse outcomes.
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Affiliation(s)
- Josalynn Rightnour
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 321 Bayer Hall, Pittsburgh, PA 15219, United States
| | - Jennifer Baird
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 321 Bayer Hall, Pittsburgh, PA 15219, United States
| | - Kendall Benjamin
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 321 Bayer Hall, Pittsburgh, PA 15219, United States
| | - Megan Qing
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 321 Bayer Hall, Pittsburgh, PA 15219, United States
| | - Michael R Gionfriddo
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 321 Bayer Hall, Pittsburgh, PA 15219, United States
| | - Jamie McConaha
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 321 Bayer Hall, Pittsburgh, PA 15219, United States
| | - Rebecca Schoen
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 321 Bayer Hall, Pittsburgh, PA 15219, United States
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Hor SY, Dadich A, Gionfriddo MR, Noble C, Wyer M, Mesman J. Research as care: practice-based knowledge translation as transformative learning through video-reflexive ethnography. Health Sociol Rev 2023; 32:1-15. [PMID: 36647579 DOI: 10.1080/14461242.2022.2161406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/24/2022] [Indexed: 06/17/2023]
Abstract
Collaborative approaches to knowledge translation seek to make research useful and applicable, by centring the perspectives and concerns of healthcare actors (rather than researchers) in problem formulation and solving. Such research thus involves multiple actors, in interaction with pre-existing ecologies of knowledge and expertise. Although collaboration is emphasised, conflict, dissonance, and other tensions, may arise from the multiplicity of perspectives and power dynamics involved. Our article examines knowledge translation in this space, as both empirical focus and research methodology. Drawing from practice theory and critical pedagogy, we describe knowledge translation as a situated and social process of transformative learning, enabled by reflexive dialogue about practice, and supported by care. With examples from five studies across two countries, we show that practice-based knowledge translation can be mediated by researchers, using video-reflexive ethnography. We describe the importance (and features) of practices of care in these studies, that created psychological safety for transformative learning. We argue that attempts to transform and improve healthcare must account for sustained and reciprocal care, both for, and between, those made vulnerable in the process, and that knowledge translation can, and should, be a process of capacity strengthening, with care as a core principle and practice.
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Affiliation(s)
- Su-Yin Hor
- School of Public Health, Faculty of Health, University of Technology Sydney, Broadway, Australia
| | - Ann Dadich
- School of Business, Western Sydney University, Parramatta, Australia
| | | | - Christy Noble
- Academy for Medical Education, Medical School, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Mary Wyer
- Sydney Institute for Infectious Diseases, The University of Sydney, Westmead, Australia
| | - Jessica Mesman
- Department of Society Studies, Faculty of Arts and Social Sciences, Maastricht University, Maastricht, The Netherlands
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13
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Gionfriddo MR, Dadich A. 'The Obstacle is the Way': Methodological Challenges and Opportunities for Video-Reflexive Ethnography During COVID-19. Int J Qual Methods 2023; 22:16094069231165710. [PMID: 37041766 PMCID: PMC10079893 DOI: 10.1177/16094069231165710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
The COVID-19 pandemic greatly impacted research. In this article, we explore the opportunities and challenges presented by the pandemic to a group of researchers using video-reflexive ethnography (VRE) - a methodology used to understand practices, grounded in: exnovation, collaboration, reflexivity, and care. To understand how the pandemic impacted researchers using VRE, we facilitated two focus groups with 12 members of the International Association of Video-Reflexive Ethnographers. The findings suggest the pandemic exacerbated existing methodological challenges, yet also provided an opportunity reflect on our own practices as researchers, namely: accessing sites, building relationships, facilitating reflexive sessions, and cultivating care. Due to public health measures, some researchers used insiders to access sites. While these insiders shouldered additional burdens, this shift might have empowered participants, increased the salience of the project, and enabled access to rural sites. The inability to access sites and reliance on insiders also impeded researcher ability to build relationships with participants and generate the ethnographic insights often associated with prolonged engagement at a site. In reflexive sessions, researchers had to learn how to manage the technological, logistical, and methodological challenges associated with either themselves or participants being remote. Finally, participants noted that while the transition to more digital methodologies might have increased project reach, there needed to be a mindfulness around cultivating practices of care in the digital world to ensure psychological safety and protect participants data. These findings reflect the opportunities and challenges a group of researchers using VRE had during the pandemic and can be used to stimulate future methodologic discussions.
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Affiliation(s)
- Michael R Gionfriddo
- Division of Pharmaceutical, Administrative
and Social Sciences, School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Ann Dadich
- School of Business, Western Sydney
University, Parramatta, Australia
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14
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Abstract
PURPOSE OF REVIEW Guidelines provide recommendations for clinicians based on the best available evidence and informed by clinical expertise. These recommendations often fail to be utilized by clinicians hindering the translation of evidence into practice. The purpose of this review is to describe novel ways in which implementation science has been used to improve translation of guidelines into clinical practice in the field of lipidology. RECENT FINDINGS We searched PubMed for articles related to guideline implementation in lipidology published in 2021 and 2022. Identified articles were categorized into three domains: first, poor uptake of guideline recommendations in practice; second, implementation science as a solution to improve care; and third, examples of how implementation science can be incorporated into guidelines. SUMMARY The field of lipidology has identified that many guideline recommendations fail to be translated into practice and has started to utilize methods from implementation science to assess ways to shrink this gap. Future work should focus on deploying tools from implementation science to address current gaps in guideline development. Such as, developing a systematic approach to restructure guideline recommendations so they are implementable in practice and aid in clinicians' ability to easily translate them into practice.
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Affiliation(s)
- Laney K. Jones
- Genomic Medicine Institute Geisinger, Danville, Pennsylvania, USA
- Heart and Vascular Institute, Geisinger, Danville, Pennsylvania, USA
| | - Amy C. Sturm
- Genomic Medicine Institute Geisinger, Danville, Pennsylvania, USA
- Heart and Vascular Institute, Geisinger, Danville, Pennsylvania, USA
| | - Michael R. Gionfriddo
- Division of Pharmaceutical, Administrative and Social Sciences, School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania, USA
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15
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Hamner AN, Andrick B, Mathur A, Gionfriddo MR. Cancer Patients’ Experience with a
Pharmacist‐Led
Oral Chemotherapy Clinic: A Qualitative Descriptive Study. J Am Coll Clin Pharm 2022. [DOI: 10.1002/jac5.1741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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16
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Babidhan R, Lewis A, Atkins C, Jozefczyk NJ, Nemecek BD, Montepara CA, Gionfriddo MR, Zimmerman DE, Covvey JR, Guarascio AJ. Safety and efficacy of cefiderocol for off-label treatment indications: A systematic review. Pharmacotherapy 2022; 42:549-566. [PMID: 35611627 DOI: 10.1002/phar.2704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Cefiderocol is a siderophore cephalosporin recently approved by the United States Food and Drug Administration for the treatment of hospital- and ventilator-acquired bacterial pneumonia and complicated urinary tract infections. However, there is potential for cefiderocol utility for a variety of other infections. The purpose of this systematic review was to identify literature examining the safety and efficacy of cefiderocol for off-label indications. METHODS The PRISMA guidelines were utilized for reporting. Databases searched included PubMed, Scopus, and Embase, from inception to September 2021. Manuscripts describing cefiderocol off-label use in clinical settings were included. Exclusion criteria were studies focused on labeled indications, animal studies, pharmacodynamic/pharmacokinetic studies, in vitro or laboratory studies, and manuscripts in languages other than English or Arabic. Each stage of review utilized two independent investigators, with conflicts resolved and critical appraisal performed. Data regarding presentation, clinical course, and infection characteristics were extracted and descriptively analyzed. RESULTS The search identified a total of 985 records, narrowed to a final set of 27 studies. Among studies included were 18 (66.7%) case reports, 8 (29.6%) case series, and 1 (3.7%) phase 3 clinical trial. Cefiderocol was most frequently used off-label for bacteremia/sepsis with or without an identified source in 51 (67.1%) out of a total of 76 included patients. Among case series/reports with available data, 43 of 53 patients (81.1%) received combination antibiotic therapy. The most common pathogens identified included multi/extensively drug-resistant Pseudomonas aeruginosa and/or Acinetobacter baumannii. Various clinical end points were reported, while microbiological end points were reported in 18 (66.7%) studies. Cefiderocol-related side effects were uncommon and rarely use-limiting. CONCLUSIONS This systematic review depicts relative clinical effectiveness of off-label cefiderocol, most commonly for P. aeruginosa and A. baumannii infections as combination antibiotic therapy. Further study is needed to elucidate the safety and efficacy of cefiderocol across an expanded set of patients and indications.
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Affiliation(s)
- Riyan Babidhan
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Abigale Lewis
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Cailin Atkins
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | | | - Branden D Nemecek
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, Pennsylvania, USA
| | - Courtney A Montepara
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | | | - David E Zimmerman
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, Pennsylvania, USA
| | - Jordan R Covvey
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Anthony J Guarascio
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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17
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Ball NS, Knable BM, Relich TA, Smathers AN, Gionfriddo MR, Nemecek BD, Montepara CA, Guarascio AJ, Covvey JR, Zimmerman DE. Xylazine poisoning: a systematic review. Clin Toxicol (Phila) 2022; 60:892-901. [PMID: 35442125 DOI: 10.1080/15563650.2022.2063135] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Xylazine is an alpha-2-adrenergic agonist used for its sedative and analgesic properties in veterinary medicine. While not approved by the Food and Drug Administration for use in humans, anecdotal evidence suggests that exposures in humans is on the rise. We sought to systematically review and synthesize the evidence on xylazine exposure in humans focusing on the clinical presentation, management, and outcomes. METHODS We conducted a systematic review of the literature including PubMed, Embase, and Scopus from their inception to September 9, 2021. We searched abstracts from selected emergency medicine and toxicology conferences from 2011 through 2021. We included clinical reports of xylazine exposure in humans. We excluded animal studies, in vitro studies, laboratory studies, or articles in a language other than English. From each included article, we extracted subjective and objective data that focused on clinical presentation, management, and outcomes of patients exposed to xylazine. RESULTS We evaluated a total of 1409 records, rendering a final set of 17 articles and 2 abstracts meeting inclusion criteria. We identified a total of 98 patients amongst reports ranging from 1979 to 2020 and across nine countries. The most common types of xylazine exposures reported were unintentional exposure and intentional misuse/abuse. Common symptoms on presentation included hypotension, bradycardia, drowsiness, lethargy, while apnea with intubation and death were less frequently reported. CONCLUSION Human exposure to xylazine appears to be a rising concern within the prehospital and emergency medicine setting. Although a standardized treatment algorithm cannot be recommended at this time, further research is needed to improve the care of patients exposed to xylazine.
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Affiliation(s)
- Noah S Ball
- Duquesne University School of Pharmacy, Pittsburgh, PA
| | | | | | | | | | - Branden D Nemecek
- Duquesne University School of Pharmacy, Pittsburgh, PA.,UPMC Mercy Hospital, Pittsburgh, PA
| | - Courtney A Montepara
- Duquesne University School of Pharmacy, Pittsburgh, PA.,Allegheny General Hospital, Pittsburgh, PA
| | - Anthony J Guarascio
- Duquesne University School of Pharmacy, Pittsburgh, PA.,Allegheny General Hospital, Pittsburgh, PA
| | | | - David E Zimmerman
- Duquesne University School of Pharmacy, Pittsburgh, PA.,UPMC Mercy Hospital, Pittsburgh, PA
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18
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Baraldi JH, Picozzo SA, Arnold JC, Volarich K, Gionfriddo MR, Piper BJ. A cross-sectional examination of conflict-of-interest disclosures of physician-authors publishing in high-impact US medical journals. BMJ Open 2022; 12:e057598. [PMID: 35410932 PMCID: PMC9021780 DOI: 10.1136/bmjopen-2021-057598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/04/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To assess the accuracy of self-reported financial conflict-of-interest (COI) disclosures in the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA) within the requisite disclosure period prior to article submission. DESIGN Cross-sectional investigation. DATA SOURCES Original clinical-trial research articles published in NEJM (n=206) or JAMA (n=188) from 1 January 2017 to 31 December 2017; self-reported COI disclosure forms submitted to NEJM or JAMA with the authors' published articles; Open Payments website (from database inception; latest search: August 2019). MAIN OUTCOME MEASURES Financial data reported to Open Payments from 2014 to 2016 (a time period that included all subjects' requisite disclosure windows) were compared with self-reported disclosure forms submitted to the journals. Payments selected for analysis were defined by Open Payments as 'general payments.' Payment types were categorised as 'disclosed,' 'undisclosed,' 'indeterminate' or 'unrelated'. RESULTS Thirty-one articles from NEJM and 31 articles from JAMA met inclusion criteria. The physician-authors (n=118) received a combined total of US$7.48 million. Of the 106 authors (89.8%) who received payments, 86 (81.1%) received undisclosed payments. The top 23 most highly compensated received US$6.32 million, of which US$3.00 million (47.6%) was undisclosed. CONCLUSIONS High payment amounts, as well as high proportions of undisclosed financial compensation, regardless of amount received, comprised potential COIs for two influential US medical journals. Further research is needed to explain why such high proportions of general payments were undisclosed and whether journals that rely on self-reported COI disclosure need to reconsider their policies.
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Affiliation(s)
- James H Baraldi
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven A Picozzo
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Jacob C Arnold
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Kathryn Volarich
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | | | - Brian J Piper
- School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania, USA
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19
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Larson S, Nemoianu A, Lawrence DF, Troup MA, Gionfriddo MR, Pousti B, Sun H, Riaz F, Wagner ES, Chrones L, Touya M. Characterizing primary care for patients with major depressive disorder using electronic health records of a US-based healthcare provider. J Affect Disord 2022; 300:377-384. [PMID: 34953925 DOI: 10.1016/j.jad.2021.12.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 10/24/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) is predominantly managed in primary care. However, primary care providers (PCPs) may not consistently follow evidence-based treatment algorithms, leading to variable patient management that can impact outcomes. METHODS We retrospectively analyzed adult patients with MDD seen at Geisinger, an integrated health system. Utilizing electronic health record (EHR) data, we classified patients as having MDD based on International Classification of Disease (ICD)-9/10 codes or a Patient Health Questionnaire (PHQ)-9 score ≥5. Outcomes assessed included time to first visit with a PCP or behavioral health specialist following diagnosis, antidepressant medication switching, persistence, healthcare resource utilization (HRU), and treatment costs. RESULTS Among the 38,321 patients with MDD managed in primary care in this study, significant delays between diagnosis with antidepressant prescribing and follow-up PCP visits were observed. There was also considerable variation in care following diagnosis. Overall, 34.9% of patients with an ICD-9/10 diagnosis of MDD and 41.3% with a PHQ-9 score ≥15 switched antidepressants. An ICD-9/10 diagnosis, but not moderately severe to severe depression, was associated with higher costs and HRU. More than 75% of patients with MDD discontinued antidepressant medication within 6 months. LIMITATIONS The study population was comparable with other real-world studies of MDD, but study limitations include its retrospective nature and reliance on the accuracy of EHRs. CONCLUSIONS Management of patients with MDD in a primary care setting is variable. Addressing these gaps will have important implications for ensuring optimal patient management, which may reduce HRU and treatment medication costs, and improve treatment persistence.
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Affiliation(s)
- Sharon Larson
- Main Line Health Center for Population Research at the Lankenau Institute for Medical Research, Wynnewood, PA, and Thomas Jefferson University College of Population Health, Philadelphia, PA, United States.
| | | | - Debra F Lawrence
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, United States
| | | | | | - Bobak Pousti
- Geisinger Health System, Danville, PA, United States
| | - Haiyan Sun
- Geisinger Health System, Danville, PA, United States
| | - Faisal Riaz
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, United States
| | - Eric S Wagner
- Geisinger Health System, Danville, PA, United States
| | - Lambros Chrones
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, United States
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20
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Jones LK, Duboski V, Romagnoli KM, Flango A, Marks J, Graham J, Gionfriddo MR. Evaluation of an educational strategy to improve medication reconciliation in ambulatory care. J Am Pharm Assoc (2003) 2022; 62:1179-1188.e3. [DOI: 10.1016/j.japh.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
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21
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Gionfriddo MR, Duboski V, Middernacht A, Kern MS, Graham J, Wright EA. A mixed methods evaluation of medication reconciliation in the primary care setting. PLoS One 2021; 16:e0260882. [PMID: 34855888 PMCID: PMC8638945 DOI: 10.1371/journal.pone.0260882] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/18/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To understand the extent to which behaviors consistent with high quality medication reconciliation occurred in primary care settings and explore barriers to high quality medication reconciliation. DESIGN Fully mixed sequential equal status design including ethnographic observations, semi-structured interviews, and surveys. SETTING Primary care practices within an integrated healthcare delivery system in the United States. PARTICIPANTS We conducted 170 observations of patient encounters across 15 primary care clinics, 48 semi-structured interviews with staff, and 10 semi-structured interviews with patients. We also sent out surveys to 2,541 eligible staff with 616 responses (24% response rate) and to 5,132 eligible patients with 577 responses (11% response rate). RESULTS Inconsistency emerged as a major barrier to effective medication reconciliation. This inconsistency was present across a variety of factors such as the lack of standardized workflows for conducting medication reconciliation, a lack of knowledge about medication and the process of medication reconciliation, varying levels of importance ascribed to medication reconciliation, and inadequate integration of medication reconciliation into clinical workflows. Findings were generally consistent across all data collection methods. CONCLUSION We have identified several barriers which impact the process of medication reconciliation in primary care settings. Our key finding is that the process of medication reconciliation is plagued by inconsistencies which contribute to inaccurate medication lists. These inconsistencies can be broken down into several categories (standardization, knowledge, importance, and inadequate integration) which can be targets for future studies and interventions.
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Affiliation(s)
- Michael R. Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, United States of America
- * E-mail:
| | - Vanessa Duboski
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, United States of America
| | - Allison Middernacht
- Wilkes University School of Pharmacy, Wilkes-Barre, PA, United States of America
| | - Melissa S. Kern
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, United States of America
| | - Jove Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, United States of America
| | - Eric A. Wright
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, United States of America
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22
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Jones LK, Ladd IG, Gregor C, Evans MA, Graham J, Gionfriddo MR. Evaluating implementation outcomes (acceptability, adoption, and feasibility) of two initiatives to improve the medication prior authorization process. BMC Health Serv Res 2021; 21:1259. [PMID: 34801025 PMCID: PMC8606066 DOI: 10.1186/s12913-021-07287-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/12/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Processes such as prior authorization (PA) for medications, implemented by health insurance companies to ensure that safe, appropriate, cost-effective, and evidence-based care is provided to all members, have created inefficiencies within healthcare systems. Thus, healthcare systems have implemented supplemental processes to reduce burden and ensure efficiency, timeliness, and appropriate care. OBJECTIVE Evaluate implementation outcomes of two initiatives related to PA for medications: a common record that records all PA-related information that was integrated into the health record and an auto-routing of specialty prescriptions to a hospital-owned specialty pharmacy. METHODS We conducted semi-structured interviews with medical staff to understand their experience, acceptability, adoption, and feasibility of these initiatives guided by Proctor's Framework for Implementation Outcomes. Transcripts were analyzed using consensus coding. RESULTS Eleven medical staff participated in semi-structured interviews. The two initiatives were analyzed together because the findings were similar across both for our outcomes of acceptability, adoption, and feasibility. Participants found the implemented initiatives to be acceptable and beneficial but felt there were still challenges with the new workflow. The initiatives were fully adopted by only one clinic site within the healthcare system, but limitations arose when adopting to another site. Individuals felt the initiatives were feasible and improved workflow, communication, and transparency. However, participants described future adaptations that would help improve this process including improved standardization, automation, and transparency. CONCLUSION The acceptability, adoption, and feasibility of two initiatives to improve the PA process within the one clinical site were well received but issues of generalizability limited the initiatives adoption system wide.
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Affiliation(s)
- Laney K. Jones
- Geisinger Health System, 100 N Academy Avenue, Danville, PA 17822 USA
| | - Ilene G. Ladd
- Geisinger Health System, 100 N Academy Avenue, Danville, PA 17822 USA
| | - Christina Gregor
- Geisinger Health System, 100 N Academy Avenue, Danville, PA 17822 USA
| | - Michael A. Evans
- Geisinger Health System, 100 N Academy Avenue, Danville, PA 17822 USA
| | - Jove Graham
- Geisinger Health System, 100 N Academy Avenue, Danville, PA 17822 USA
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23
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Lussier ME, Learn LS, Aftewicz H, Webster L, Gazes S, Kern MS, Gionfriddo MR, Graham J, Longyhore DS, Wright EA. Implementation and evaluation of a centralized pharmacy telehealth center within an integrated health delivery system. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Mia E. Lussier
- Center for Pharmacy Innovation and Outcomes, Geisinger Danville Pennsylvania USA
- Enterprise Pharmacy, Geisinger Danville Pennsylvania USA
| | | | - Henry Aftewicz
- Enterprise Pharmacy, Geisinger Danville Pennsylvania USA
| | - Leeann Webster
- Enterprise Pharmacy, Geisinger Danville Pennsylvania USA
| | - Seth Gazes
- Enterprise Pharmacy, Geisinger Danville Pennsylvania USA
| | - Melissa S. Kern
- Center for Pharmacy Innovation and Outcomes, Geisinger Danville Pennsylvania USA
- Enterprise Pharmacy, Geisinger Danville Pennsylvania USA
| | - Michael R. Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger Danville Pennsylvania USA
- Enterprise Pharmacy, Geisinger Danville Pennsylvania USA
- Dusquene University, Division of Pharmaceutical Administrative and Social Sciences Pittsburgh Pennsylvania USA
| | - Jove Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger Danville Pennsylvania USA
- Enterprise Pharmacy, Geisinger Danville Pennsylvania USA
| | | | - Eric A. Wright
- Center for Pharmacy Innovation and Outcomes, Geisinger Danville Pennsylvania USA
- Enterprise Pharmacy, Geisinger Danville Pennsylvania USA
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24
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Hanlon P, Bryson I, Morrison H, Rafiq Q, Boehmer K, Gionfriddo MR, Gallacher K, May C, Montori V, Lewsey J, McAllister DA, Mair FS. Self-management interventions for Type 2 Diabetes: systematic review protocol focusing on patient workload and capacity support. Wellcome Open Res 2021; 6:257. [PMID: 35928807 PMCID: PMC9308000 DOI: 10.12688/wellcomeopenres.17238.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: People living with type 2 diabetes undertake a range of tasks to manage their condition, collectively referred to as self-management. Interventions designed to support self-management vary in their content, and efficacy. This systematic review will analyse self-management interventions for type 2 diabetes drawing on theoretical models of patient workload and capacity. Methods and analysis: Five electronic databases (Medline, Embase, CENTRAL, CINAHL and PsycINFO) will be searched from inception to 27th April 2021, supplemented by citation searching and hand-searching of reference lists. Two reviewers will independently review titles, abstracts and full texts. Inclusion criteria include Population: Adults with type 2 diabetes mellitus; Intervention: Randomised controlled trials of self-management support interventions; Comparison: Usual care; Outcomes: HbA1c (primary outcome) health-related quality of life (QOL), medication adherence, self-efficacy, treatment burden, healthcare utilization (e.g. number of appointment, hospital admissions), complications of type 2 diabetes (e.g. nephropathy, retinopathy, neuropathy, macrovascular disease) and mortality; Setting: Community. Study quality will be assessed using the Effective Practice and Organisation of Care (EPOC) risk of bias tool. Interventions will be classified according to the EPOC taxonomy and the PRISMS self-management taxonomy and grouped into similar interventions for analysis. Clinical and methodological heterogeneity will be assessed within subgroups, and random effects meta-analyses performed if appropriate. Otherwise, a narrative synthesis will be performed. Interventions will be graded on their likely impact on patient workload and support for patient capacity. The impact of these theoretical constructs on study outcomes will be explored using meta-regression. Conclusion This review will provide a broad overview of self-management interventions, analysed within the cumulative complexity model theoretical framework. Analyses will explore how the workload associated with self-management, and support for patient capacity, impact on outcomes of self-management interventions. Registration number: PROSPERO CRD42021236980.
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Affiliation(s)
- Peter Hanlon
- Institute for Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Iona Bryson
- Institute for Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Holly Morrison
- Institute for Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Qasim Rafiq
- Institute for Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Kasey Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, USA
| | | | - Katie Gallacher
- Institute for Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Carl May
- London School of Hygiene and Tropical Medicine, London, UK
| | - Victor Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, USA
| | - Jim Lewsey
- Institute for Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Frances S Mair
- Institute for Health and Wellbeing, University of Glasgow, Glasgow, UK
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Graybill M, Duboski V, Webster L, Kern M, Wright E, Graham J, Blanchard C, Gionfriddo MR. Medication therapy problems identified by pharmacists conducting telephonic comprehensive medication management within a team‐based
at‐home
care program. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Margo Graybill
- Philadelphia College of Pharmacy, University of the Sciences Philadelphia Pennsylvania USA
| | - Vanessa Duboski
- Center for Pharmacy Innovation and Outcomes Geisinger, Danville Pennsylvania USA
| | - Leeann Webster
- Department of Pharmacy Geisinger, Danville Pennsylvania USA
| | - Melissa Kern
- Center for Pharmacy Innovation and Outcomes Geisinger, Danville Pennsylvania USA
| | - Eric Wright
- Center for Pharmacy Innovation and Outcomes Geisinger, Danville Pennsylvania USA
| | - Jove Graham
- Center for Pharmacy Innovation and Outcomes Geisinger, Danville Pennsylvania USA
| | - Carrie Blanchard
- Center for Medication Optimization UNC Eshelman School of Pharmacy Chapel Hill North Carolina USA
| | - Michael R. Gionfriddo
- Center for Pharmacy Innovation and Outcomes Geisinger, Danville Pennsylvania USA
- Division of Pharmaceutical, Administrative and Social Sciences Duquesne University Pittsburgh PA
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Kheloussi S, Johns A, Parente V, McLay W, Gionfriddo MR. Cost and clinical impact of a nonmedical DPP-4 inhibitor switch in patients with diabetes. J Manag Care Spec Pharm 2021; 27:846-854. [PMID: 34185559 PMCID: PMC10390945 DOI: 10.18553/jmcp.2021.27.7.846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Nonmedical formulary switches (NMFS) routinely occur in managed health care plans and involve changing preferred medications for reasons outside of clinical considerations. The cost implications of NMFS are infrequently published and the clinical outcomes rarely assessed. OBJECTIVE: To assess the real-world clinical and cost implications of an NMFS involving sitagliptin and linagliptin. METHODS: An NMFS was made to the Geisinger Health Plan (GHP) commercial, health care reform, and Medicaid formularies on February 1, 2018, involving a change in preferred medication from sitagliptin to linagliptin. Claims data from GHP and clinical information from electronic health records of the Geisinger Health System were used to evaluate the cost and clinical impact of this change. Patients aged 18 years or older who were continuously enrolled in a GHP commercial, health care reform, or Medicaid plan throughout the entire study period and had at least 1 fill for sitagliptin during the preswitch phase were included in the study. We investigated the differences in various clinical and economic outcomes from pre- to postswitch among those who switched and remained adherent to the new preferred therapy throughout the 12-month postperiod ("linagliptin switch" group) and patients who did not ("other switch" group). Clinical outcomes included all-cause hospitalization, diabetes-related hospitalization, and glycosylated hemoglobin (HbA1c), while economic measures included changes in per member per month (PMPM) spending. The negative binomial regression model was used to estimate utilization counts. A generalized linear model with a log link and gamma distribution was used to analyze cost data. RESULTS: 1,203 patients met the inclusion criteria. Of these, 501 (41.6%) individuals switched to and remained at least 80% adherent to linagliptin in the postperiod, while 702 (58.4%) did not. No difference between groups was found when comparing the pre- to postswitch change in all-cause hospitalization (incidence rate ratio (IRR) = 1.46, 95% CI = 0.66-3.23, P = 0.3436) or diabetes-related hospitalization (IRR = 1.39, 95% CI = 0.62-3.10, P = 0.4203). Additionally, no difference was found between groups regarding the change in HbA1c 12-month postswitch compared with baseline (difference between groups = -0.10%, 95% CI = -0.39%-0.19%, P = 0.4962). Total PMPM spending was 43% higher in the other switch group compared with the linagliptin switch group (IRR = 1.43, 95% CI = 1.25-1.63, P < 0.0001). This trend was driven by 92% higher medical PMPM spending in the other switch group compared with the linagliptin switch group (IRR = 1.92, 95% CI = 1.58-2.33, P < 0.0001) but was offset by 12% lower pharmacy PMPM spending in the other switch group (IRR = 0.88, 95% CI = 0.82-0.95, P = 0.0009). CONCLUSIONS: An NMFS from sitagliptin to linagliptin resulted in overall health plan savings with no significant changes in health outcomes. DISCLOSURES: Funding for this study was provided by Geisinger Health System, which had no role in the study outside of a final review of the submitted manuscript. Johns and Gionfriddo are Geisinger employees. The authors report no financial conflicts of interest.
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Affiliation(s)
| | - Alicia Johns
- Geisinger Center for Health Research, Department of Population Health Sciences, Danville, PA
| | | | - William McLay
- Wilkes University, Nesbitt School of Pharmacy, Wilkes-Barre, PA
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Barrera FJ, Ponce OJ, Espinoza NR, Alvarez-Villalobos NA, Zuñiga-Hernández JA, Prokop LJ, Gionfriddo MR, Rodriguez-Gutierrez R, Brito JP. Interventions supporting cost conversations between patients and clinicians: A systematic review. Int J Clin Pract 2021; 75:e14037. [PMID: 33497499 DOI: 10.1111/ijcp.14037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 01/19/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND AIM Discussing cost during medical encounters may decrease the financial impact of medical care on patients and align their treatment plans with their financial capacities. We aimed to examine which interventions exist and quantify their effectiveness to support cost conversations. METHODS Several databases were queried (Embase; Ovid MEDLINE(R); Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily; the Cochrane databases; and Scopus) from their inception until January 31, 2020 using terms such as "clinician*", "patient*", "cost*", and "conversation*". Eligibility assessment, data extraction and risk of bias assessment were performed independently and in duplicate. We extracted study setting, design, intervention characteristics and outcomes related to patients, clinicians and quality metrics. RESULTS We identified four studies (1327 patients) meeting our inclusion criteria. All studies were non-randomised and conducted in the United States. Three were performed in a primary care setting and the fourth in an oncology. Two studies used decision aids that included cost information; one used a training session for health care staff about cost conversations, and the other directly delivered information regarding cost conversations to patients. All interventions increased cost-conversation frequency. There was no effect on out-of-pocket costs, satisfaction, medication adherence or understanding of costs of care. CONCLUSION The body of evidence is small and comprised of studies at high risk of bias. However, an increase in the frequency of cost conversations is consistent. Studies with higher quality are needed to ascertain the effects of these interventions on the acceptability, frequency and quality of cost conversations.
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Affiliation(s)
- Francisco J Barrera
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Oscar J Ponce
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
- Unidad de Conocimiento y Evidencia (CONEVID), Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Nataly R Espinoza
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
| | - Neri A Alvarez-Villalobos
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Jorge A Zuñiga-Hernández
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | | | | | - Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
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Jones LK, Tilberry S, Gregor C, Yaeger LH, Hu Y, Sturm AC, Seaton TL, Waltz TJ, Rahm AK, Goldberg A, Brownson RC, Gidding SS, Williams MS, Gionfriddo MR. Implementation strategies to improve statin utilization in individuals with hypercholesterolemia: a systematic review and meta-analysis. Implement Sci 2021; 16:40. [PMID: 33849601 PMCID: PMC8045284 DOI: 10.1186/s13012-021-01108-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Numerous implementation strategies to improve utilization of statins in patients with hypercholesterolemia have been utilized, with varying degrees of success. The aim of this systematic review is to determine the state of evidence of implementation strategies on the uptake of statins. METHODS AND RESULTS This systematic review identified and categorized implementation strategies, according to the Expert Recommendations for Implementing Change (ERIC) compilation, used in studies to improve statin use. We searched Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from inception to October 2018. All included studies were reported in English and had at least one strategy to promote statin uptake that could be categorized using the ERIC compilation. Data extraction was completed independently, in duplicate, and disagreements were resolved by consensus. We extracted LDL-C (concentration and target achievement), statin prescribing, and statin adherence (percentage and target achievement). A total of 258 strategies were used across 86 trials. The median number of strategies used was 3 (SD 2.2, range 1-13). Implementation strategy descriptions often did not include key defining characteristics: temporality was reported in 59%, dose in 52%, affected outcome in 9%, and justification in 6%. Thirty-one trials reported at least 1 of the 3 outcomes of interest: significantly reduced LDL-C (standardized mean difference [SMD] - 0.17, 95% CI - 0.27 to - 0.07, p = 0.0006; odds ratio [OR] 1.33, 95% CI 1.13 to 1.58, p = 0.0008), increased rates of statin prescribing (OR 2.21, 95% CI 1.60 to 3.06, p < 0.0001), and improved statin adherence (SMD 0.13, 95% CI 0.06 to 0.19; p = 0.0002; OR 1.30, 95% CI 1.04 to 1.63, p = 0.023). The number of implementation strategies used per study positively influenced the efficacy outcomes. CONCLUSION Although studies demonstrated improved statin prescribing, statin adherence, and reduced LDL-C, no single strategy or group of strategies consistently improved outcomes. TRIAL REGISTRATION PROSPERO CRD42018114952 .
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Affiliation(s)
- Laney K Jones
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA.
| | - Stephanie Tilberry
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Christina Gregor
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA
| | - Lauren H Yaeger
- Bernard Becker Medical Library, Washington University in St. Louis, St. Louis, MO, USA
| | - Yirui Hu
- Population Health Sciences, Geisinger, Danville, PA, USA
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Terry L Seaton
- University of Health Sciences and Pharmacy in St. Louis, St. Louis, MO, USA
- Population Health, Mercy Clinic-East Communities, St. Louis, MO, USA
| | | | - Alanna K Rahm
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Anne Goldberg
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Department of Surgery (Division of Public Health Sciences) and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Samuel S Gidding
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Marc S Williams
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
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Spencer-Bonilla G, Serrano V, Gao C, Sanchez M, Carroll K, Gionfriddo MR, Behnken EM, Hargraves I, Boehmer K, May C, Montori VM. Patient Work and Treatment Burden in Type 2 Diabetes: A Mixed-Methods Study. Mayo Clin Proc Innov Qual Outcomes 2021; 5:359-367. [PMID: 33997635 PMCID: PMC8105508 DOI: 10.1016/j.mayocpiqo.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective To use quantitative and qualitative methods to characterize the work patients with type 2 diabetes mellitus (T2DM) enact and explore the interactions between illness, treatment, and life. Patients and Methods In this mixed-methods, descriptive study, adult patients with T2DM seen at the outpatient diabetes clinic at Mayo Clinic in Rochester, Minnesota, from February 1, 2016, through March 31, 2017, were invited to participate. The study had 3 phases. In phase 1, the Patient Experience with Treatment and Self-management (PETS) scale was used to quantify treatment burden. In phase 2, a convenience sample of patients used a smartphone application to describe, in real time, time spent completing diabetes self-management tasks and to upload descriptive digital photographs. In phase 3, these data were explored in qualitative interviews that were analyed by 2 investigators using deductive analysis. Results Of 162 participants recruited, 160 returned the survey (phase 1); of the 50 participants who used the smartphone application (phase 2), we interviewed 17 (phase 3). The areas in which patients reported highest treatment burden were difficulty with negotiating health services (eg, coordinating medical appointments), medical expenses, and mental/physical exhaustion with self-care. Participants reported that medical appointments required about 2.5 hours per day, and completing administrative tasks related to health care required about 45 minutes. Time spent on health behaviors varied widely—from 2 to 60 minutes in a given 3-hour period. Patients’ experience of a task’s burden did not always correlate with the time spent on that task. Conclusion The most burdensome tasks to patients with T2DM included negotiating health care services, affording medications, and completing administrative tasks even though they were not the most time-consuming activities. To be minimally disruptive, diabetes care should minimize the delegation of administrative tasks to patients.
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Affiliation(s)
| | - Valentina Serrano
- Department of Nutrition, Diabetes and Metabolism, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Catherine Gao
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN.,Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN
| | - Manuel Sanchez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Katherine Carroll
- School of Sociology, College of Arts and Social Sciences, Australian National University, Canberra, Australia
| | | | - Emma M Behnken
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ian Hargraves
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kasey Boehmer
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Carl May
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
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Blanchard CM, Duboski V, Graham J, Webster L, Kern MS, Wright EA, Gionfriddo MR. A mixed methods evaluation of the implementation of pharmacy services within a team-based at-home care program. Res Social Adm Pharm 2021; 17:1978-1988. [PMID: 33745855 DOI: 10.1016/j.sapharm.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Sub-optimal medication use results in significant avoidable morbidity, mortality, and costs. Programs, such as comprehensive medication management (CMM), can help to optimize medication use, improve outcomes, and reduce costs. However, implementing programs like CMM can be challenging and differences in how CMM has been implemented may be responsible for observed heterogeneity in the outcomes associated with CMM. OBJECTIVE(S) Describe the implementation strategies utilized in implementing CMM telephonically within a team-based at-home care program and evaluate the implementation process. METHODS The implementation of CMM was facilitated using various implementation strategies including: develop educational material and conduct training, change record system, audit and feedback, learning collaborative, quality monitoring, readiness assessment, and implementation team formation. The impact of these strategies as well as pharmacist and team member perspectives on the implementation of CMM were examined using mixed methods and guided by Proctor's conceptual model for implementation. RESULTS The pharmacists felt that most of the implementation strategies used to facilitate consistent delivery of CMM were useful, but were unable to successfully implement all of them. Despite this, significant increases in fidelity to steps of the patient care process was achieved. The pharmacists felt that CMM was acceptable, appropriate for patient population, and feasible, but barriers (e.g., the telephonic and remote nature of the practice, the evolving nature of the program, and the difficulty in coordinating care between the patients primary care team and the care team affiliated with the program) affected the feasibility and organizational fit of CMM within this team-based, at-home care program. General pharmacy services, however, were seen as acceptable, appropriate, and feasible. CONCLUSION Deliberately designing and utilizing a variety of implementation strategies can facilitate the implementation of CMM and significantly increase fidelity to the patient care process. To improve feasibility and organizational fit of CMM, additional barriers and challenges need to be addressed.
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Affiliation(s)
- Carrie M Blanchard
- Center for Medication Optimization, Division of Practice Advancement and Clinical Education UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA.
| | - Vanessa Duboski
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA
| | - Jove Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA
| | | | - Melissa S Kern
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA
| | - Eric A Wright
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA
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Khan S, Gionfriddo MR, Cortes-Penfield N, Thunga G, Rashid M. The trade-off dilemma in pharmacotherapy of COVID-19: systematic review, meta-analysis, and implications. Expert Opin Pharmacother 2020; 21:1821-1849. [PMID: 32752970 DOI: 10.1080/14656566.2020.1792884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people worldwide and has contributed to over 650,000 deaths. This review synthesizes the literature on COVID-19 pharmacotherapy to inform practice and policymaking. AREAS COVERED The authors systematically review the published literature on COVID-19 therapeutics, grouping candidate treatments into repurposed, adjunct, and experimental agents. They conducted meta-analysis where appropriate and provide recommendations based on compilation from real-time/interim therapeutic guidelines. They then advise on how to navigate and advance the evidence in the current context of uncertainty and urgency and provide expert opinion on suggested framework. EXPERT OPINION Current evidence does not support a clear role for pharmacotherapy in COVID-19. While promising signals have been found through limited number of RCTs, these must be interpreted with caution. Without proper protection from bias and confounding we risk exposing patients to treatments where the potential for benefit is at best unclear, yet the potential for harm from adverse effects is high leading to a trade-off dilemma in decision making. Advancing the evidence requires a coordinated effort to design and conduct robust trials and to systematically synthesize and critically evaluate findings. Therapies should be reserved for use in clinical trials, emergency or compassionate access until we gain more confidence in the balance of benefit and harm.
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Affiliation(s)
- Sohil Khan
- School of Pharmacy and Pharmacology, Menzies Health Institute, Griffith University , Gold Coast, Australia.,Mater Research Institute - The University of Queensland , South Brisbane, Australia.,Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education , Manipal, India.,Prasanna School of Public Health, Manipal Academy of Higher Education , Manipal, India
| | - Michael R Gionfriddo
- Centre for Pharmacy Innovation and Outcomes, Geisinger, Forty Fort , Danville, Pennsylvania, USA
| | - Nicolas Cortes-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center , Omaha, Nebraska, USA
| | - Girish Thunga
- Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education , Manipal, India
| | - Muhammad Rashid
- Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education , Manipal, India
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Castillo-Gonzalez DA, Dorsey-Trevino EG, Gonzalez-Gonzalez JG, Garcia-Leal M, Bautista-Orduño KG, Raygoza K, Gionfriddo MR, Ospina NMS, Rodriguez-Gutierrez R. A deeper analysis in thyroid research: A meta-epidemiological study of the American Thyroid Association clinical guidelines. PLoS One 2020; 15:e0234297. [PMID: 32520949 PMCID: PMC7286515 DOI: 10.1371/journal.pone.0234297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 05/24/2020] [Indexed: 01/02/2023] Open
Abstract
Background The American Thyroid Association (ATA) uses the GRADE or the American College of Physicians (ACP) system to develop recommendations. Recommendations based on low-quality evidence should spur for the conduction of clinical studies, if feasible. The extent to which recommendations by the ATA based on low-quality of evidence are being actively researched remains unknown. Methods Clinical guidelines produced by the ATA using the GRADE or the ACP system to classify evidence were deemed eligible. Reviewers, in duplicate and independently, extracted therapeutic recommendations based on low-quality evidence, whereas recommendations with higher quality of evidence, aimed at diagnosis, or best practice statements were excluded. Eligible recommendations based on low-quality evidence were deconstructed to their components using the PICO format. We then searched on clinicaltrials.gov to identify ongoing research. Trials were deemed eligible if they addressed the PICO question with at least one of the intended outcomes. Results A total of 543 recommendations were retrieved, of which 305 (56%) were based on low-quality of evidence and only 90 were deemed eligible. Of these, we found that 33 (37%) recommendations were actively being researched in 53 clinical trials. Most of the trials were randomized and funded by non-profit organizations. Many clinical trials studied thyroid nodules and differentiated thyroid cancer (26/53; 49%), whereas few studied were aimed at anaplastic thyroid cancer (2/53; 4%). Conclusion One out of three of gaps in evidence, identified as low quality during the development of ATA guidelines, are currently actively researched. This finding calls for the need to develop a better research infrastructure and funding to support thyroid research.
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Affiliation(s)
- Dalia A. Castillo-Gonzalez
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, México
- Plataforma INVEST Medicina UANL–KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Edgar G. Dorsey-Trevino
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, México
- Plataforma INVEST Medicina UANL–KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Jose G. Gonzalez-Gonzalez
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, México
- Plataforma INVEST Medicina UANL–KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, México
- Research Unit, University Hospital “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Mariana Garcia-Leal
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Karen G. Bautista-Orduño
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, México
- Plataforma INVEST Medicina UANL–KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Karina Raygoza
- Plataforma INVEST Medicina UANL–KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Michael R. Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Forty Fort, PA, United States of America
| | - Naykky M. Singh Ospina
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, United States of America
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Rene Rodriguez-Gutierrez
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, México
- Plataforma INVEST Medicina UANL–KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, México
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, United States of America
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America
- * E-mail:
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Jones LK, Ladd IG, Gionfriddo MR, Gregor C, Evans MA, Graham J. Medications requiring prior authorization across health insurance plans. Am J Health Syst Pharm 2020; 77:644-648. [DOI: 10.1093/ajhp/zxaa031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AbstractObjectiveTo determine the amount of variation in numbers and types of medications requiring prior authorization (PA) by insurance plan and type.MethodsMost health insurance companies require PA for medications to ensure safe and effective use and contain costs. We generated 4 lists of medications that required PA during 2017 for commercial, marketplace, Medicaid, and Medicare plans. We aggregated medications according to the generic medication name equivalent using codes and medication names. We compared these medications to assess how many of the medications required PA by 1, 2, 3, or all 4 of the insurance plans. We counted all prescription orders written for a patient age 18 years or older with health plan insurance during 2017 for any of the medications that appeared on the health plan’s PA lists by querying the electronic health record.ResultsPA was required for 600 unique medications in 2017 across the 4 plans. Of 691,457 prescription orders written for 114,159 members, 31,631 (5%) were written for 1 of the 600 medications that required PA by at least 1 insurance plan. There were 12,540 medication orders (written for 6,642 members) that potentially required PA. The marketplace plan required PA for the greatest number of medications (440), followed by the Medicare (272), commercial (271), and Medicaid (72) plans. The most commonly prescribed classes of medications for which PA was required by at least 1 plan were antihyperlipidemics (22% of orders potentially requiring PA), narcotic analgesics (13%), hypnotics (12%), antidiabetic medications (9%), and antidepressants (9%). For only 25% of medications (151 of 600) was PA required by at least 3 plans, and for only 5% (32 of 600) was PA required by all 4 insurance types.ConclusionMedications requiring PA can differ within a single health insurance company, but this variation may be unavoidable due to external factors.
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Affiliation(s)
| | - Ilene G Ladd
- Genomic Medicine Institute, Geisinger, Danville, PA
| | | | - Christina Gregor
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | | | - Jove Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
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Jones LK, Ladd IG, Gregor C, Evans MA, Graham J, Gionfriddo MR. Understanding the medication prior-authorization process: A case study of patients and clinical staff from a large rural integrated health delivery system. Am J Health Syst Pharm 2020; 76:453-459. [PMID: 31361821 DOI: 10.1093/ajhp/zxy083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The barriers and solutions to the current prior-authorization (PA) process at an integrated health system were evaluated. METHODS Focus groups were conducted with patients at an integrated health system who also had insurance from an affiliated health plan and at least 1 denial for a medication in the past year. Semistructured interviews were conducted with medical staff (physicians, office staff, and PA experts). Both focus groups and interviews were audio-recorded and transcribed. Inductive analysis was used to code transcripts and develop themes. RESULTS Three focus groups were conducted with 13 patients, and 9 medical staff (3 staff physicians, 2 office staff, and 4 PA staff) who have interactions with the PA process interviewed. Several themes were identified including the complexity of the PA process, consequences experienced, and ineffective communication between key stakeholders. A cross-cutting theme was that stakeholders expressed feelings of frustration, anxiety, and anger throughout the PA process. All stakeholders offered insights on how the process could be improved to better facilitate their preferences, such as access to the list of medications that require PA and the need for a patient advocate. CONCLUSION Results of this study revealed that the PA process was frustrating, upsetting, and infuriating to patients and medical staff involved in the process. Three main themes identified included the complexity of the PA process, consequences experienced from the PA process, and ineffective communication between stakeholders.
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Affiliation(s)
- Laney K Jones
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Ilene G Ladd
- Genomic Medicine Institute, Geisinger, Danville, PA
| | - Christina Gregor
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | | | - Jove Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
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Horsley RD, Vogels ED, McField DAP, Parker DM, Medico C, Dove J, Fluck M, Gabrielsen JD, Gionfriddo MR, Petrick AT. Multimodal Postoperative Pain Control Is Effective and Reduces Opioid Use After Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2019; 29:394-400. [PMID: 30317488 DOI: 10.1007/s11695-018-3526-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Opioids have been the mainstay for postoperative pain relief for many decades. Recently, opioid-related adverse events and death have been linked to postoperative dependency. Multimodal approaches to postoperative pain control may be part of the solution to this health care crisis. The safety and effectiveness of multimodal pain control regimens after laparoscopic Roux-en-Y gastric bypass (LRYGB) has not been well studied. The primary aim of our study was to determine if an evidence-based, multimodal pain regimen during hospitalization could decrease the total oral morphine equivalent (TME) use after LRYGB. STUDY DESIGN We conducted a retrospective cohort study comparing outcomes prior to the implementation of a multimodal pain protocol (December 2010-December 2012) to those after implementation (April 2013-July 2015). The protocol utilized oral celecoxib and scheduled oral acetaminophen for pain control, with opioids used only as needed for breakthrough pain. Data was extracted from an electronic medical record and an institutionally maintained database of all patients undergoing bariatric surgery at a single center. RESULTS Compared to controls, the multimodal pain regimen significantly reduced TME used and maximum pain scores with no change in mean pain scores. Multimodal pain protocol patients had a shorter length of stay with no increase in bleeding complications or marginal ulcer rates. CONCLUSIONS An opioid-sparing multimodal pain regimen adequately controls pain while reducing TME use. The regimen appears to be safe and was associated with a reduced length of stay in patients undergoing LRYGB.
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Affiliation(s)
- Ryan D Horsley
- Division of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 North Academy Ave, Danville, PA, 17822, USA.
| | - Ellen D Vogels
- Division of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 North Academy Ave, Danville, PA, 17822, USA
| | - Daaron A P McField
- Division of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 North Academy Ave, Danville, PA, 17822, USA
| | - David M Parker
- Division of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 North Academy Ave, Danville, PA, 17822, USA
| | - Charles Medico
- Enterprise Pharmacy, Geisinger, 100 North Academy Ave, Danville, PA, 17822, USA
| | - James Dove
- Division of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 North Academy Ave, Danville, PA, 17822, USA
| | - Marcus Fluck
- Division of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 North Academy Ave, Danville, PA, 17822, USA
| | - Jon D Gabrielsen
- Division of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 North Academy Ave, Danville, PA, 17822, USA
| | - Michael R Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger, 190 Welles Street, Suite 128, Forty Fort, PA, USA
| | - Anthony T Petrick
- Division of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 North Academy Ave, Danville, PA, 17822, USA
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Storlie CB, Branda ME, Gionfriddo MR, Shah ND, Rank MA. Prediction of individual outcomes for asthma sufferers. Biostatistics 2019; 19:579-593. [PMID: 29121247 DOI: 10.1093/biostatistics/kxx055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 07/21/2017] [Indexed: 11/13/2022] Open
Abstract
We consider the problem of individual-specific medication level recommendation (initiation, removal, increase, or decrease) for asthma sufferers. Asthma is one of the most common chronic diseases in both adults and children, affecting 8% of the US population and costing $37-63 billion/year in the United States of America. Asthma is a complex disease, whose symptoms may wax and wane, making it difficult for clinicians to predict outcomes and prognosis. Improved ability to predict prognosis can inform decision making and may promote conversations between clinician and provider around optimizing medication therapy. Data from the US Medical Expenditure Panel Survey (MEPS) years 2000-2010 were used to fit a longitudinal model for a multivariate response of adverse events (Emergency Department or in-patient visits, excessive rescue inhaler use, and oral steroid use). To reduce bias in the estimation of medication effects, medication level was treated as a latent process which was restricted to be consistent with prescription refill data. This approach is demonstrated to be effective in the MEPS cohort via predictions on a validation hold out set and a synthetic data simulation study. This framework can be easily generalized to medication decisions for other conditions as well.
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Huang RC, Song XT, Zhang DF, Xu JY, Boehmer KR, Leppin AA, Gionfriddo MR, Ting HH, Montori VM. Preferences and attitudes of young Chinese clinicians about using a shared decision making tools for communicating cardiovascular risk. Chronic Dis Transl Med 2019; 5:105-112. [PMID: 31367699 PMCID: PMC6656904 DOI: 10.1016/j.cdtm.2019.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE This study assesses the attitudes and preferences of Chinese clinicians toward their involvement in shared decision making (SDM). METHODS From May 2014 to May 2015, 200 Chinese clinicians from two hospitals were enrolled to complete a survey on their attitude towards SDM. We conducted the survey via face-to-face interviews before and after an educational intervention on SDM among young Chinese clinicians. The clinicians were asked to give the extent of agreement to SDM. They also gave the extent of difficulty in using decision aids (DAs) during the SDM process. The variation in the range of responses to each question before and after the SDM intervention was recorded. The frequency of changed responses was analyzed by using JMP 6.0 software. Data were statistically analyzed using Chi-square and Mann-Whitney U tests, as appropriate to the data type. Multiple logistic regressions were used to test for those factors significantly and independently associated with preference for an approach for each scenario. RESULTS Of the 200 young Chinese clinicians sampled, 59.0% indicated a preference for SDM and a desire to participate in SDM before receiving education or seeing the DA, and this number increased to 69.0% after seeing the DA with the sample video of the SDM process on Statin Choice. However, 28.5% of the respondents still reported that, in their current practice, they make clinical decisions on behalf of their patients. The clinicians who denied a desire to use the DA stated that the main barriers to implement SDM or DA use in China are lack of time and knowledge of SDM. CONCLUSIONS Most young Chinese clinicians want to participate in SDM. However, they state the main barriers to perform SDM are lack of experience and time. The educational intervention about SDM that exposes clinicians to DAs was found to increase their receptivity.
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Affiliation(s)
- Rong-Chong Huang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Xian-Tao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Dong-Feng Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Jia-Ying Xu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Kasey R. Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN 55902, USA
| | - Aaron A. Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN 55902, USA
| | - Michael R. Gionfriddo
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN 55902, USA
- Mayo Graduate School, Mayo Clinic, Rochester, MN 55902, USA
| | - Henry H. Ting
- Division of Cardiology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN 55902, USA
- Division of Endocrinology, Mayo Clinic, Rochester, MN 55902, USA
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Jones LK, Greskovic G, Grassi DM, Graham J, Sun H, Gionfriddo MR, Murray MF, Manickam K, Nathanson DC, Wright EA, Evans MA. Medication therapy disease management: Geisinger's approach to population health management. Am J Health Syst Pharm 2019; 74:1422-1435. [PMID: 28887344 DOI: 10.2146/ajhp161061] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Pharmacists' involvement in a population health initiative focused on chronic disease management is described. SUMMARY Geisinger Health System has cultivated a culture of innovation in population health management, as highlighted by its ambulatory care pharmacy program, the Medication Therapy Disease Management (MTDM) program. Initiated in 1996, the MTDM program leverages pharmacists' pharmacotherapy expertise to optimize care and improve outcomes. MTDM program pharmacists are trained and credentialed to manage over 16 conditions, including atrial fibrillation (AF) and multiple sclerosis (MS). Over a 15-year period, Geisinger Health Plan (GHP)-insured patients with AF whose warfarin therapy was managed by the MTDM program had, on average, 18% fewer emergency department (ED) visits and 18% fewer hospitalizations per year than GHP enrollees with AF who did not receive MTDM services, with 23% lower annual total care costs. Over a 2-year period, GHP-insured patients with MS whose pharmacotherapy was managed by pharmacists averaged 28% fewer annual ED visits than non-pharmacist-managed patients; however, the mean annual total care cost was 21% higher among MTDM clinic patients. CONCLUSION The Geisinger MTDM program has evolved over 20 years from a single pharmacist-run anticoagulation clinic into a large program focused on managing the health of an ever-growing population. Initial challenges in integrating pharmacists into the Geisinger patient care framework as clinical experts were overcome by demonstrating the MTDM program's positive impact on patient outcomes.
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Affiliation(s)
- Laney K Jones
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | | | - Dante M Grassi
- Enterprise Pharmacy, Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Jove Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Haiyan Sun
- Biomedical and Translational Informatics, Geisinger, Danville, PA
| | | | | | | | | | - Eric A Wright
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
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Ponce OJ, Larrea-Mantilla L, Hemmingsen B, Serrano V, Rodriguez-Gutierrez R, Spencer-Bonilla G, Alvarez-Villalobos N, Benkhadra K, Haddad A, Gionfriddo MR, Prokop LJ, Brito JP, Murad MH. Lipid-Lowering Agents in Older Individuals: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. J Clin Endocrinol Metab 2019; 104:1585-1594. [PMID: 30903687 DOI: 10.1210/jc.2019-00195] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/25/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND The efficacy of lipid-lowering agents on patient-important outcomes in older individuals is unclear. METHODS We included randomized trials that enrolled individuals aged 65 years or older and that included at least 1 year of follow-up.Pairs of reviewers selected and appraised the trials. RESULTS We included 23 trials that enrolled 60,194 elderly patients. For primary prevention, statins reduced the risk of coronary artery disease [CAD; relative risk (RR): 0.79, 95% CI: 0.68 to 0.91] and myocardial infarction (MI; RR: 0.45, 95% CI: 0.31 to 0.66) but not all-cause or cardiovascular mortality or stroke. These effects were imprecise in patients with diabetes, but there was no significant interaction between diabetes status and the intervention effect. For secondary prevention, statins reduced all-cause mortality (RR: 0.80, 95% CI: 0.73 to 0.89), cardiovascular mortality (RR: 0.68, 95% CI: 0.58 to 0.79), CAD (RR: 0.68, 95% CI: 0.61 to 0.77), MI (RR: 0.68, 95% CI: 0.59 to 0.79), and revascularization (RR: 0.68, 95% CI: 0.61 to 0.77). Intensive (vs less-intensive) statin therapy reduced the risk of CAD and heart failure. Niacin did not reduce the risk of revascularization, and fibrates did not reduce the risk of stroke, cardiovascular mortality, or CAD. CONCLUSION High-certainty evidence supports statin use for secondary prevention in older individuals. Evidence for primary prevention is less certain. Data in older individuals with diabetes are limited; however, no empirical evidence has shown a significant difference based on diabetes status.
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Affiliation(s)
- Oscar J Ponce
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Unidad de Conocimiento y Evidencia (CONEVID), Universidad Peruana Cayetano Heredia, Lima, Peru
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Laura Larrea-Mantilla
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bianca Hemmingsen
- Department of Internal Medicine, Herlev University Hospital, Herlev, Denmark
| | - Valentina Serrano
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Nutrition, Diabetes and Metabolism, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Universidad Autonoma de Nuevo Leon, Hospital Universitario "Dr. José E. Gonzalez," Plataforma INVEST-KER Mexico, Monterrey, Nuevo León, México
| | - Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Neri Alvarez-Villalobos
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Universidad Autonoma de Nuevo Leon, Hospital Universitario "Dr. José E. Gonzalez," Plataforma INVEST-KER Mexico, Monterrey, Nuevo León, México
| | - Khaled Benkhadra
- Department of Internal Medicine, School of Medicine, Wayne State University, Detroit, Michigan
| | - Abdullah Haddad
- Department of Medicine, Saint Clair Memorial Hospital, Pittsburgh, Pennsylvania
| | | | - Larry J Prokop
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Barrionuevo P, Gionfriddo MR, Castaneda-Guarderas A, Zeballos-Palacios C, Bora P, Mohammed K, Benkhadra K, Sarigianni M, Murad MH. Women's Values and Preferences Regarding Osteoporosis Treatments: A Systematic Review. J Clin Endocrinol Metab 2019; 104:1631-1636. [PMID: 30907968 PMCID: PMC7296202 DOI: 10.1210/jc.2019-00193] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/25/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several treatments are available to reduce the risk of fragility fractures associated with osteoporosis. The choice of treatment requires knowledge of patients' values and preferences. The aim of the present study was to summarize what is known about the values and preferences relevant to the management of osteoporosis in women. METHODS We conducted a comprehensive search of several databases for studies reported in any language that had included women who had already started or were about to start any pharmacological therapy for osteoporosis. Pairs of reviewers independently selected the studies and extracted the data. The results were synthesized narratively. RESULTS We included 26 studies reporting on 15,348 women (mean age, 66 years). The women considered the effectiveness and adverse events equally, followed by the convenience of taking the drug and its effect on daily routine (less frequent dosing was preferred, the oral route was preferred, and the injectable route was preferred over oral if given less frequently). The treatment cost and duration were less important factors for decision making. Fear of breast cancer and fear of resuming uterine bleeding were common reasons for not choosing estrogen therapy. Calcium and vitamin D were viewed as safe and natural. Across the studies, the preferences were not affected by age, previous drug exposure, or employment status. CONCLUSIONS Women starting osteoporosis medications value effectiveness and side effects equally and prefer medications given less frequently. Injectable drugs appear acceptable if given less frequently. More research on patient values and preferences is needed to guide decision making in osteoporosis.
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Affiliation(s)
| | - Michael R Gionfriddo
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, Pennsylvania
| | | | | | - Pavithra Bora
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Memorial Hermann Rehabilitation and Research, Houston, Texas
| | - Khaled Mohammed
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Khalid Benkhadra
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Department of Internal Medicine, School of Medicine, Wayne State University, Detroit, Michigan
| | - Maria Sarigianni
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
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Murad MH, Larrea-Mantilla L, Haddad A, Spencer-Bonilla G, Serrano V, Rodriguez-Gutierrez R, Alvarez-Villalobos N, Benkhadra K, Gionfriddo MR, Prokop LJ, Brito JP, Ponce OJ. Antihypertensive Agents in Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. J Clin Endocrinol Metab 2019; 104:1575-1584. [PMID: 30903690 DOI: 10.1210/jc.2019-00197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/25/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND This systematic review summarizes the benefits of treating blood pressure (BP) in individuals 65 years and older. METHODS We included randomized trials that evaluated BP-lowering medications or BP targets in individuals 65 years and older. Trials were selected and appraised by pairs of independent reviewers. RESULTS We included 19 trials (42,134 patients). In individuals 65 years or older, antihypertensive therapy was associated with a reduction in all-cause mortality [relative risk: 0.88 (95% CI: 0.81 to 0.94); high certainty evidence; mean follow-up 31 months], cardiovascular mortality, myocardial infarction, heart failure, stroke, and chronic kidney disease. Individuals 75 years or older had a significant reduction in the risk of all-cause and cardiovascular mortality, stroke, and heart failure. Strict systolic BP targets (<120 mm Hg and <130 mm Hg) were associated with a significant reduction in the risk of all-cause and cardiovascular mortality and heart failure, whereas more liberal systolic targets (<150 mm Hg and <160 mm Hg) were associated with lower risk of heart failure and stroke. Older adults with type 2 diabetes mellitus (DM) had lower risk of chronic kidney disease without a significant reduction in other outcomes. However, there was no significant difference in estimates (i.e., interaction) between those with and without DM. CONCLUSIONS Individuals aged 65 years and older or 75 years and older who receive antihypertensive therapy have statistically significant reduction in the risk of all-cause and cardiovascular mortality, heart failure, and stroke. There was no statistically significant difference in estimates between those with and without DM.
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Affiliation(s)
| | | | - Abdullah Haddad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Section of Cardiology, Temple University-Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | | | - Valentina Serrano
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Department of Nutrition, Diabetes and Metabolism, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rene Rodriguez-Gutierrez
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Plataforma INVEST Medicina UANL-KER Unit (KER Unit México), Subdireccion de Investigacion, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, México
| | - Neri Alvarez-Villalobos
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Plataforma INVEST Medicina UANL-KER Unit (KER Unit México), Subdireccion de Investigacion, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, México
| | - Khaled Benkhadra
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Michael R Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Forty Fort, Pennsylvania
| | - Larry J Prokop
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Juan P Brito
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Oscar J Ponce
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Unidad de Conocimiento y Evidencia (CONEVID), Universidad Peruana Cayetano Heredia, Lima, Peru
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Zeballos-Palacios CL, Hargraves IG, Noseworthy PA, Branda ME, Kunneman M, Burnett B, Gionfriddo MR, McLeod CJ, Gorr H, Brito JP, Montori VM. Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice. Mayo Clin Proc 2019; 94:686-696. [PMID: 30642640 PMCID: PMC6450705 DOI: 10.1016/j.mayocp.2018.08.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/02/2018] [Accepted: 08/29/2018] [Indexed: 12/31/2022]
Abstract
Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, tools-sometimes called conversation aids or decision aids-are prepared by collating, curating, and presenting high-quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Herein, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.
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Affiliation(s)
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Peter A. Noseworthy
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | | | - Christopher J. McLeod
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Haeshik Gorr
- Department of Medicine, Hennepin Healthcare System, Minneapolis, MN, USA
| | - Juan Pablo Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
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Kunneman M, Gionfriddo MR, Toloza FJK, Gärtner FR, Spencer-Bonilla G, Hargraves IG, Erwin PJ, Montori VM. Humanistic communication in the evaluation of shared decision making: A systematic review. Patient Educ Couns 2019; 102:452-466. [PMID: 30458971 DOI: 10.1016/j.pec.2018.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 10/03/2018] [Accepted: 11/05/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess the extent to which evaluations of shared decision making (SDM) assess the extent and quality of humanistic communication (i.e., respect, compassion, empathy). METHODS We systematically searched Web of Science and Scopus for prospective studies published between 2012 and February 2018 that evaluated SDM in actual clinical decisions using validated SDM measures. Two reviewers working independently and in duplicate extracted all statements from eligible studies and all items from SDM measurement instruments that referred to humanistic patient-clinician communication. RESULTS Of the 154 eligible studies, 14 (9%) included ≥1 statements regarding humanistic communication, either in framing the study (N = 2), measuring impact (e.g., empathy, respect, interpersonal skills; N = 9), as patients'/clinicians' accounts of SDM (N = 2), in interpreting study results (N = 3), and in discussing implications of study findings (N = 3). Of the 192 items within the 11 SDM measurement instruments deployed in the included studies, 7 (3.6%) items assessed humanistic communication. CONCLUSION Assessments of the quality of SDM focus narrowly on SDM technique and rarely assess humanistic aspects of patient-clinician communication. PRACTICE IMPLICATIONS Considering SDM as merely a technique may reduce SDM's patient-centeredness and undermine its' contribution to patient care.
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Affiliation(s)
- Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.
| | - Michael R Gionfriddo
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Center for Pharmacy Innovation and Outcomes, Geisinger, Forty Fort, PA, USA.
| | - Freddy J K Toloza
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
| | - Fania R Gärtner
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.
| | - Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; University of Puerto Rico School of Medicine, San Juan, PR, USA.
| | - Ian G Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
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Singh Ospina N, Phillips KA, Rodriguez-Gutierrez R, Castaneda-Guarderas A, Gionfriddo MR, Branda ME, Montori VM. Eliciting the Patient's Agenda- Secondary Analysis of Recorded Clinical Encounters. J Gen Intern Med 2019; 34:36-40. [PMID: 29968051 PMCID: PMC6318197 DOI: 10.1007/s11606-018-4540-5] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/18/2018] [Accepted: 06/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Eliciting patient concerns and listening carefully to them contributes to patient-centered care. Yet, clinicians often fail to elicit the patient's agenda and, when they do, they interrupt the patient's discourse. OBJECTIVE We aimed to describe the extent to which patients' concerns are elicited across different clinical settings and how shared decision-making tools impact agenda elicitation. DESIGN AND PARTICIPANTS We performed a secondary analysis of a random sample of 112 clinical encounters recorded during trials testing the efficacy of shared decision-making tools. MAIN MEASURES Two reviewers, working independently, characterized the elicitation of the patient agenda and the time to interruption or to complete statement; we analyzed the distribution of agenda elicitation according to setting and use of shared decision-making tools. KEY RESULTS Clinicians elicited the patient's agenda in 40 of 112 (36%) encounters. Agendas were elicited more often in primary care (30/61 encounters, 49%) than in specialty care (10/51 encounters, 20%); p = .058. Shared decision-making tools did not affect the likelihood of eliciting the patient's agenda (34 vs. 37% in encounters with and without these tools; p = .09). In 27 of the 40 (67%) encounters in which clinicians elicited patient concerns, the clinician interrupted the patient after a median of 11 seconds (interquartile range 7-22; range 3 to 234 s). Uninterrupted patients took a median of 6 s (interquartile range 3-19; range 2 to 108 s) to state their concern. CONCLUSIONS Clinicians seldom elicit the patient's agenda; when they do, they interrupt patients sooner than previously reported. Physicians in specialty care elicited the patient's agenda less often compared to physicians in primary care. Failure to elicit the patient's agenda reduces the chance that clinicians will orient the priorities of a clinical encounter toward specific aspects that matter to each patient.
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Affiliation(s)
- Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, USA
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Rochester, MN, USA
| | | | - Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Rochester, MN, USA
- Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Universidad Autónoma de Nuevo Leon, Monterrey, Mexico
- Laboratorio Nacional para el Estudio y Aplicación de la Medicina Basada en Evidencia, Análisis Crítico de la Información Científica y Farmacoeconomía, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | | | - Megan E Branda
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Rochester, MN, USA.
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45
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Dobler CC, Sanchez M, Gionfriddo MR, Alvarez-Villalobos NA, Singh Ospina N, Spencer-Bonilla G, Thorsteinsdottir B, Benkhadra R, Erwin PJ, West CP, Brito JP, Murad MH, Montori VM. Impact of decision aids used during clinical encounters on clinician outcomes and consultation length: a systematic review. BMJ Qual Saf 2018; 28:499-510. [PMID: 30301874 DOI: 10.1136/bmjqs-2018-008022] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/21/2018] [Accepted: 09/03/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Clinicians' satisfaction with encounter decision aids is an important component in facilitating implementation of these tools. We aimed to determine the impact of decision aids supporting shared decision making (SDM) during the clinical encounter on clinician outcomes. METHODS We searched nine databases from inception to June 2017. Randomised clinical trials (RCTs) of decision aids used during clinical encounters with an unaided control group were eligible for inclusion. Due to heterogeneity among included studies, we used a narrative evidence synthesis approach. RESULTS Twenty-five papers met inclusion criteria including 22 RCTs and 3 qualitative or mixed-methods studies nested in an RCT, together representing 23 unique trials. These trials evaluated healthcare decisions for cardiovascular prevention and treatment (n=8), treatment of diabetes mellitus (n=3), treatment of osteoporosis (n=2), treatment of depression (n=2), antibiotics to treat acute respiratory infections (n=3), cancer prevention and treatment (n=4) and prenatal diagnosis (n=1). Clinician outcomes were measured in only a minority of studies. Clinicians' satisfaction with decision making was assessed in only 8 (and only 2 of them showed statistically significantly greater satisfaction with the decision aid); only three trials asked if clinicians would recommend the decision aid to colleagues and only five asked if clinicians would use decision aids in the future. Outpatient consultations were not prolonged when a decision aid was used in 9 out of 13 trials. The overall strength of the evidence was low, with the major risk of bias related to lack of blinding of participants and/or outcome assessors. CONCLUSION Decision aids can improve clinicians' satisfaction with medical decision making and provide helpful information without affecting length of consultation time. Most SDM trials, however, omit outcomes related to clinicians' perspective on the decision making process or the likelihood of using a decision aid in the future.
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Affiliation(s)
- Claudia Caroline Dobler
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA .,Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Manuel Sanchez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael R Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger, Forty Fort, Pennsylvania, USA
| | - Neri A Alvarez-Villalobos
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.,Facultad de Medicina y Hospital Universitario, Unidad de Investigación Clínica, Universidad Autonoma de Nuevo León, Monterrey, Mexico
| | - Naykky Singh Ospina
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.,Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Bjorg Thorsteinsdottir
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Primary Care Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Raed Benkhadra
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Colin P West
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammad Hassan Murad
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
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Gionfriddo MR. Balancing feasibility and comprehensiveness: examining medications for reducing emergency hospital admissions. BMC Med 2018; 16:169. [PMID: 30286748 PMCID: PMC6172808 DOI: 10.1186/s12916-018-1160-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 08/24/2018] [Indexed: 11/10/2022] Open
Abstract
Emergency hospital admissions are common, with several interventions having been developed to reduce their rates. Bobrovitz et al. summarized the available body of evidence regarding pharmacologic therapies aimed at reducing emergency hospital admissions, and identified 28 medications for which high- or moderate-quality evidence supports their use, 11 of which were identified as being supported by current guideline recommendations. Additionally, the authors identified 28 medications supported by low- or very low-quality evidence, which can serve as targets for future research. The article by Bobrovitz et al. presents a good summary of the evidence, albeit with limitations in the search strategy that cannot guarantee the review as comprehensive. Despite this, the review has important implications for policymakers, guideline panels, researchers, clinicians, and funders since the identified medications can either be targets for quality improvement initiatives or for future research. Bobrovitz et al.'s review highlights the challenge that systematic reviewers face when balancing feasibility and comprehensiveness.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1104-9.
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Affiliation(s)
- Michael R Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger Precision Health Center, Forty Fort, PA, USA.
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47
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Gionfriddo MR, Branda ME, Fernandez C, Leppin A, Yost KJ, Kimball B, Spencer-Bonilla G, Larrea L, Nowakowski KE, Montori VM, Tilburt J. Comparison of audio vs. audio + video for the rating of shared decision making in oncology using the observer OPTION 5 instrument: an exploratory analysis. BMC Health Serv Res 2018; 18:522. [PMID: 29973207 PMCID: PMC6033223 DOI: 10.1186/s12913-018-3329-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND How non-verbal data may influence observer-administered ratings of shared decision making is unknown. Our objective for this exploratory analysis was to determine the effect of mode of data collection (audio+video vs. audio only) on the scoring of the OPTION5 instrument, an observer rated measure of shared decision making. METHODS We analyzed recordings of 15 encounters between cancer patients and clinicians in which a clinical decision was made. Audio+video or audio only recordings of the encounters were randomly assigned to four trained raters, who reviewed them independently. We compared the adjusted mean scores of audio+video and audio only. RESULTS Forty-one unique decisions were identified within the 15 encounters. The mean OPTION5 score for audio+video was 17.5 (95% CI 13.5, 21.6) and for audio only was 21.8 (95% CI 17.2, 26.4) with a mean difference of 4.28 (95% CI = 0.36, 8.21; p = 0.032). CONCLUSION A rigorous and well established measure of shared decision making performs differently when the data source is audio only. Data source may influence rating of observer administered measures of shared decision making. This potential bias needs to be confirmed as video recording to examine communication behaviors becomes more common.
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Affiliation(s)
- Michael R Gionfriddo
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Present address - Center for Pharmacy Innovation and Outcomes, Geisinger, 190 Welles Street, Suite 128, Forty Fort, PA, USA.
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Cara Fernandez
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kathleen J Yost
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Brittany Kimball
- Mayo Clinic School of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR, 00936, USA
| | - Laura Larrea
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Katherine E Nowakowski
- Stritch School of Medicine, Loyola University, 2160 South First Avenue, Maywood, IL, 60153, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Jon Tilburt
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Biomedical Ethics Scholars Training Program, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Biomedical Ethics Research Program, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Complementary and Integrative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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48
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Jones LK, Kulchak Rahm A, Gionfriddo MR, Williams JL, Fan AL, Pulk RA, Wright EA, Williams MS. Developing Pharmacogenomic Reports: Insights from Patients and Clinicians. Clin Transl Sci 2018; 11:289-295. [PMID: 29316365 PMCID: PMC5944570 DOI: 10.1111/cts.12534] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/06/2017] [Indexed: 01/17/2023] Open
Abstract
Increasingly, for a variety of indications, patients have their genomes sequenced and actionable results returned. A subset of returned results is pharmacogenomic (PGx) variants involved in the metabolism or action of medications. Although the impact of these variants on health is well-documented, little research exists on how to communicate these findings to patients and clinicians. We conducted semistructured interviews with end users to understand how best to communicate PGx results. Overall, patients and clinicians had similar opinions regarding report content, delivery, and application. Unique concerns specific to each stakeholder group were also expressed. Patients wanted an easy-to-understand individualized report that clinicians utilized to guide their care. Clinicians wanted reports that were easy-to-use, actionable, and integrated into their workflow. Implementation of these reports in a clinical setting will allow for broader user feedback and iterative improvement.
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Affiliation(s)
| | | | | | | | - Audrey L. Fan
- GeisingerDanvillePennsylvaniaUSA
- Genome MedicalSan FranciscoCaliforniaUSA
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Jones LK, Pulk R, Gionfriddo MR, Evans MA, Parry D. Utilizing big data to provide better health at lower cost. Am J Health Syst Pharm 2018; 75:427-435. [DOI: 10.2146/ajhp170350] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Laney K. Jones
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Rebecca Pulk
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | | | | | - Dean Parry
- Care Support Services, Geisinger, Danville, PA
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50
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Gionfriddo MR, Pulk RA, Sahni DR, Vijayanagar SG, Chronowski JJ, Jones LK, Evans MA, Feldman SR, Pride H. ProvenCare-Psoriasis: A disease management model to optimize care. Dermatol Online J 2018; 24:13030/qt5xt2s05b. [PMID: 29634876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 06/08/2023] Open
Abstract
There are a variety of evidence-based treatments available for psoriasis. The transition of this evidence into practice is challenging. In this article, we describe the design of our disease management approach for Psoriasis (ProvenCare®) and present preliminary evidence of the effect of its implementation. In designing our approach, we identified three barriers to optimal care: 1) lack of a standardized and discrete disease activity measure within the electronic health record, 2) lack of a system-wide, standardized approach to care, and 3) non-uniform financial access to appropriate non-pharmacologic treatments. We implemented several solutions, which collectively form our approach. We standardized the documentation of clinical data such as body surface area (BSA), created a disease management algorithm for psoriasis, and aligned incentives to facilitate the implementation of the algorithm. This approach provides more coordinated, cost effective care for psoriasis, while being acceptable to key stakeholders. Future work will examine the effect of the implementation of our approach on important clinical and patient outcomes.
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Affiliation(s)
| | - Rebecca A Pulk
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | | | | | | | - Laney K Jones
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Michael A Evans
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC,
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC
| | - Howard Pride
- Department of Dermatology, Geisinger, Danville, PA
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