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Supplemental digital content is available in the text., Objectives We sought to identify potential patient safety practices to reduce high-risk opioid prescribing. Methods We conducted a systematic review of the literature to identify opioid stewardship (OS) strategies implemented in primary care and other settings. Included studies evaluated an OS strategy or a multicomponent OS initiative to address potential harms of opioids and used experimental or quasi-experimental designs. Results We identified 14 studies and 1 systematic review that met inclusion criteria. Most studies examined multicomponent OS interventions, which often consisted of guideline-recommended clinical interventions or care processes (e.g., use urine drug screening, check Prescription Drug Monitoring Program), as well as implementation strategies (e.g., dashboards, audit and feedback). Most studies examined the effect of OS interventions on reducing the potential risks of opioids with judicious prescribing and guideline-concordant care (e.g., reduce inappropriate high opioid dosages, avoid co-prescribing opioids and benzodiazepines, use urine drug screening, treatment agreements). Conclusions The strength of the evidence is low to moderate that OS efforts decrease numbers of opioid prescriptions, proportion of patients on long-term opioids, or days’ supply. The strength of the evidence for OS initiatives producing significant reductions in opioid dosages was moderate. Future research is needed on the effectiveness of OS interventions, particularly studies with experimental designs and in diverse settings within the health care system. more...

Informed consent is a process of communication between clinician and patient that results in the patient's decision about whether to undergo a specific intervention. However, patients often do not understand the risks, benefits, and alternatives, even after signing a consent form.Mixed-methods pilot test of two Agency for Healthcare Research and Quality (AHRQ) informed consent training modules implemented in four hospitals. Methods included staff and patient surveys, interviews, site visits, and pre- and posttests of the modules.A low proportion of clinicians reported using teach-back (40.0%) or high-quality decision aids (55.0%). Patients reported limited use of best practices, including being asked to teach-back (58.4%), having other options described (54.9%), viewing decision aids (37.4%), and finding the form very easy to understand (66.8%). Content of the training modules aligned well with identified deficiencies. Barriers to completing the modules included staff turnover, competing demands, and lack of accountability. Facilitators included committed champions with available time, motivation, and release time for staff to take modules. Knowledge increased for leaders (p 0.05) and staff (p 0.001) who completed the training modules. Hospitals reported the effects of piloting the modules included fostering dialogue and identifying opportunities for improvements, identifying and rectifying policy ambiguity and noncompliance, reinforcing the use of interpreter services, and using modules' strategies and tools to improve informed consent.Many opportunities exist for hospitals to improve their informed consent practices. AHRQ's two training modules, have face validity, addressed demonstrated deficiencies in hospitals' informed consent policies and processes, and stimulated improvement activity in motivated hospitals. more...

Background Community pharmacies are an increasingly important health care setting with opportunities for improving quality and safety, yet little is understood about determinants of implementation in this setting. Objective This paper presents an implementation framework for pharmacy based on the Consolidated Framework for Implementation Research (CFIR). Methods This study employed a critical review of 45 articles on professional services provided in community pharmacies, including medication therapy management (MTM), immunizations, and rapid HIV testing. Results The relevant domains and associated constructs for pharmacy services were as follows. Intervention Characteristics ultimately depend on the specific service; of particular note for pharmacy are relative advantage and complexity. The former because implementation of services can pose a cost-benefit challenge where dispensing is the primary role and the latter because of the greater challenge implementing multi-faceted services like MTM compared to a discrete service like immunizations. "In terms of Outer Setting , pharmacies are affected by patient needs and acceptance, and external policies and incentives such as reimbursement and regulations. For Inner Setting , structural characteristics like pharmacy type, size and staff were important as was pharmacists' perception of their role and available resources to provide the service. Key Characteristics of Individuals include training, preparedness, and self-efficacy of the pharmacist for providing a new service. Few studies revealed relevant Process constructs, but if they did it was primarily related to engaging (e.g., champions). Conclusions As pharmacists' roles in health care are continuing to expand, a framework to inform implementation research in community pharmacy (and other) settings is crucially needed. more...

Objectives To develop and validate a theoretical logic model for comprehensive medication management (CMM) services. Methods The components of a logic model were constructed after a literature review and interviews with 4 CMM professionals. To validate the logic model, a panel of 17 CMM experts participated in three online Delphi method rounds to achieve consensus on the model. The consensus between the experts on each component of the logic model was evaluated using the Content Validity Index and Inter-rater Agreement in each of the rounds. Key findings A logic model for CMM services containing 51 items was constructed and validated. Both the items of each component of the model and the linkage between the main components were agreed upon among the experts. Conclusions A logic model for CMM services was developed and validated. It is an innovative tool that, if used as a theoretical framework for the implementation of CMM, can ensure greater reproducibility of CMM services in different scenarios of practice and levels of care. more...

Interprofessional team-based care is increasingly regarded as an important feature of delivery systems redesigned to provide more efficient and higher quality care, including primary care. Measurement of the functioning of such teams might enable improvement of team effectiveness and could facilitate research on team-based primary care. Our aims were to develop a conceptual framework of high-functioning primary care teams to identify and review instruments that measure the constructs identified in the framework, and to create a searchable, web-based atlas of such instruments (available at: http://primarycaremeasures.ahrq.gov/team-based-care/ ). Our conceptual framework was developed from existing frameworks, the teamwork literature, and expert input. The framework is based on an Input-Mediator-Output model and includes 12 constructs to which we mapped both instruments as a whole, and individual instrument items. Instruments were also reviewed for relevance to measuring team-based care, and characterized. Instruments were identified from peer-reviewed and grey literature, measure databases, and expert input. From nearly 200 instruments initially identified, we found 48 to be relevant to measuring team-based primary care. The majority of instruments were surveys (n = 44), and the remainder (n = 4) were observational checklists. Most instruments had been developed/tested in healthcare settings (n = 30) and addressed multiple constructs, most commonly communication (n = 42), heedful interrelating (n = 42), respectful interactions (n = 40), and shared explicit goals (n = 37). The majority of instruments had some reliability testing (n = 39) and over half included validity testing (n = 29). Currently available instruments offer promise to researchers and practitioners to assess teams' performance, but additional work is needed to adapt these instruments for primary care settings. more...

Primary care is foundational to the US health care system and key to improving health, reducing cost, and improving patient experience.[1][1] Yet, primary care has been struggling with increasing demands and expectations, diminishing economic margins, and a challenging work environment.[2][2],[3][3 more...

The medication experience is an individual&rsquo, s subjective experience of taking a medication in daily life and can be at the root of drug therapy problems. It is recommended that the patient-centered approach to comprehensive medication management (CMM) starts with an understanding of the patient&rsquo, s medication experience. This study aims to develop a medication experience documentation tool for use in CMM services, and to understand the usefulness and challenges of using the tool in practice. The tool was developed based on previous research on patients&rsquo, medication experiences. It was tested in two rounds by ten CMM pharmacists utilizing the tool as they provided care to patients. Focus groups were conducted to revise the tool after each round and to understand pharmacists&rsquo, experiences. The tool was tested for 15 weeks in 407 patient encounters. There was at least one medication experience documented in the electronic medical record 62% of the time. Pharmacists found the tool helpful in raising awareness of the medication experience and motivational interviewing strategies, planning for follow-up visits, as a teaching tool, and making pharmacists realize the fluidity of the medication experience. The tool offered pharmacists a better way to recognize and address medication experiences affecting medication taking behaviors. more...

There is growing appreciation in the health care field for the role of self-management support (SMS) as a strategy to help patients change behavior, reach health goals, improve health outcomes, and decrease the burden of chronic illness. To help primary care teams, including nurse practitioners, implement effective SMS strategies in practice, the Agency for Healthcare Research and Quality developed a multi-media library of action-oriented SMS resources and 3 companion videos. This article discusses the current state of SMS, describes the library and videos, the process by which they were developed, and what the resources can offer clinical teams. more...

Background Pharmacies are key sources of medication information for patients, yet few effectively serve patients with low health literacy. The Agency for Healthcare Research and Quality (AHRQ) supported the development of four health literacy tools for pharmacists to address this problem, and to help assess and improve pharmacies' health literacy practices. Objectives This study aimed to understand the facilitators and barriers to the adoption and implementation of AHRQ's health literacy tools, particularly a tool to assess a pharmacy's health literacy practices. Methods We conducted a comparative, multiple-case study of eight pharmacies, guided by an adaptation of Rogers's Diffusion of Innovations model. Data were collected and triangulated through interviews, site visit observations, and the review of documents, and analyzed on the factors affecting pharmacies' adoption decisions and implementation of the tools. Results Factors important to pharmacies' decision to adopt the health literacy tools included awareness of health literacy; a culture of innovation; a change champion; the relative advantage and compatibility of the tools; and an invitation to utilize and receive support to use the tools. The barriers included a lack of leadership support, limited staff time, and a perception of the tools as complex with limited value. For implementation, the primary facilitators were buy-in from leadership, qualified staff, college-affiliated change champions, the adaptability and organization of the tool, and support. Barriers to implementation were limited leadership buy-in, prioritization of other activities, lack of qualified staff, and tool complexity. Conclusions If pharmacists are provided tools that could ultimately improve their health literacy practices and patient-centered services; and the tools have a clear relative advantage, are simple as well adaptable, and the pharmacists are supported in their efforts - either by colleagues or by collaborating with colleges of pharmacy–then there could be important progress toward achieving the goals of the National Action Plan for Health Literacy. more...

Objective Medication errors in hospitals are common, expensive, and sometimes harmful to patients. This study's objective was to derive a nationally representative estimate of medication error reduction in hospitals attributable to electronic prescribing through computerized provider order entry (CPOE) systems. Materials and methods We conducted a systematic literature review and applied random-effects meta-analytic techniques to derive a summary estimate of the effect of CPOE on medication errors. This pooled estimate was combined with data from the 2006 American Society of Health-System Pharmacists Annual Survey, the 2007 American Hospital Association Annual Survey, and the latter's 2008 Electronic Health Record Adoption Database supplement to estimate the percentage and absolute reduction in medication errors attributable to CPOE. Results Processing a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48% (95% CI 41% to 55%). Given this effect size, and the degree of CPOE adoption and use in hospitals in 2008, we estimate a 12.5% reduction in medication errors, or ∼17.4 million medication errors averted in the USA in 1 year. Discussion Our findings suggest that CPOE can substantially reduce the frequency of medication errors in inpatient acute-care settings; however, it is unclear whether this translates into reduced harm for patients. Conclusions Despite CPOE systems’ effectiveness at preventing medication errors, adoption and use in US hospitals remain modest. Current policies to increase CPOE adoption and use will likely prevent millions of additional medication errors each year. Further research is needed to better characterize links to patient harm. more...

A1 Introduction to the 8th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health David Chambers1, Lisa Simpson2 1Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, 20850, USA; 2AcademyHealth, Washington, DC, 20036, USA For the second year in a row, we are pleased to be able to share the proceedings of the Annual Conference on the Science of Dissemination and Implementation in Health, a large meeting reflecting the expanding and evolving research field that seeks to optimize the use of evidence, interventions, and tools from health research within the myriad of settings where people receive health care, make health-related decisions, and increase knowledge of influences on the health of the population. We once again benefitted from a strong partnership, co-led by AcademyHealth and the National Institutes of Health (NIH), with co-sponsorship from the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), the US Department of Veterans Affairs (VA), and the WT Grant Foundation. In addition, we benefitted from the collaboration of staff from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). NIH and AcademyHealth again co-led the program planning committee, which focused on the development of the plenary sessions, and convened a scientific advisory panel to suggest speakers and advise on the overall conference development. The planning committee identified four key areas around which to focus the plenary panels and keynote address. Dr. America Bracho, M.D., M.P.H., Executive Director of Latino Health Access in Orange County, California, spoke about the opportunities for implementation science to inform efforts to improve community health and engage underserved populations. The three plenary panels each focused on a significant future direction for dissemination and implementation (D & I) research: the interface between D&I science and population health, emerging opportunities for global implementation science, and the challenges around implementation of precision medicine. The plenary sessions were complemented by facilitated lunchtime discussions on the same three topics, which offered participants an opportunity to identify key research questions for each and brainstorm next steps. Synopses of the lunchtime discussions are included in this supplement. Given the overwhelming success of the 2014 conference and the large number of abstracts received in 2014 (660), the program planning committee identified eight program tracks for abstract submitters to respond to, and through which the concurrent sessions of the conference would be organized. These tracks—Behavioral Health, Big Data and Technology for Dissemination and Implementation Research, Clinical Care Settings, Global Dissemination and Implementation, Promoting Health Equity and Eliminating Disparities, Health Policy Dissemination and Implementation, Prevention and Public Health, and Models, Measures and Methods— were designed to enable conference participants to follow a consistent theme across the multiple sessions of the conference and form the structure of this supplement. The call for abstracts, including individual paper presentations, individual posters and panel presentations, resulted in 515 submissions, spread across the eight thematic tracks. Over one hundred reviewers devoted their time to ensuring a comprehensive and expert review, and reviews were conducted within each track and coordinated by the track leads. For the final program, 64 oral presentations, 12 panels, and 263 posters were presented over the two-day meeting. Slides for the oral presentations and panels (with the agreement of the authors) were posted on the conference website (http://diconference.academyhealth.org/archives/2015archives) and all abstracts were included on the conference webapp (https://academyhealth.confex.com/academyhealth/2015di/meetingapp.cgi). This supplement has compiled the abstracts for presented papers, panel sessions, and lunchtime discussions from the 8th Annual Meeting on the Science of Dissemination and Implementation in Health: Optimizing Personal and Population Health. We are pleased to have the abstracts from the conference together in one volume once again, and look forward to the 9th Annual meeting, scheduled for December in Washington, D.C. more...

Objective To describe medication therapy management (MTM) pharmacists’ encounters with patients’ medication experiences, to examine the utility of the medication experience in practice, and to explore the value of the medication experience in patient education and counseling on medications. Methods A focus group of 10 MTM pharmacists, and 1 pharmacist's 9-month practice diary were analyzed to reveal patients’ medication experiences and the utility and value of the medication experience in practice. Results MTM pharmacists commonly encountered patients’ medication experiences in their practices. The medication experience was often at the root of drug therapy problems (DTPs) the practitioners identified. The pharmacists identified several examples of drug therapy problems with an associated medication experience at the root. The medication experience was a meaningful construct to guide patient education and counseling on new chronic medications to ultimately prevent DTPs, and valuable for tailoring patient education and counseling on medications to resolve DTPs. Conclusion Our study provides preliminary evidence of the value of the medication experience for patient education and counseling on chronic medications in practice. Practice implications The medication experience is a valuable tool for practitioners to understand patients’ needs, identify and resolve DTPs, and tailor patient education and counseling for chronic medications. more...

Despite the rapid growth of retail clinics (RCs), literature is limited in terms of how these facilities offer preventive services, particularly vaccination services. The purpose of this study was to obtain an in-depth understanding of the RC business model pertaining to vaccine offerings, profitability, and decision making. From March to June 2009, we conducted 15 interviews with key individuals from three types of organizations: 12 representatives of RC corporations, 2 representatives of retail hosts (i.e., stores in which the RCs are located), and 1 representative of an industry association. We analyzed interview transcripts qualitatively. Our results indicate that consumer demand and profitability were the main drivers in offering vaccinations. RCs in this sample primarily offered vaccinations to adults and adolescents, and they were not well integrated with local public health and immunization registries. Our findings demonstrate the potential for stronger linkages with public health in these settings. The findings also may help inform future research to increase patient access to vaccination services at RCs. more...

Background: Although hundreds of quality indicators (QIs) have been developed for various chronic conditions, QIs specific to multiple sclerosis (MS) care have only recently been developed. We sought to examine the extent to which the self-reported care of individuals with MS meets four recently developed MS QIs related to treatment of depression, spasticity, and fatigue and timely initiation of disease-modifying agents (DMAs) for relapsing MS. Methods: Using the Sonya Slifka Study data, we examined the proportion of the MS population meeting four QIs (based on patient-reported data) in a sample of individuals with MS in 2007–2009. For the three diagnoses, meeting the QI was defined as receiving appropriate medication or seeing a provider for treatment of the diagnosis; for timely initiation, it was defined as receiving a DMA within 3 months of a relapsing MS diagnosis. We also examined differences in characteristics between respondents who met the QI versus those who did not. Results: Approximately two-thirds of people with MS in this sample, per the predefined criteria, met the QIs for treatment of depression, management of spasticity, and DMA initiation within 3 months of a relapsing diagnosis, and approximately one-fifth met the QI for management of fatigue. There were some significant differences in characteristics between respondents who met the QIs and those who did not. Conclusions: This study examined a subset of MS QIs based on patient-reported data. Additional data sources are needed to fully assess compliance with MS QIs. more...

Objective: To understand and describe the meaning of medications for patients. Methods: A metasynthesis of three different, yet complementary qualitative research studies, was conducted by two researchers. The first study was a phenomenological study of patients’ medication experiences that used unstructured interviews. The second study was an ethnographic study of pharmaceutical care practice, which included participant observation, in-depth interviews and focus groups with patients of pharmaceutical care. The third was a phenomenological study of the chronic illness experience of medically uninsured individuals in the United States and included an explicit aim to understand the medication experience within that context. The two researchers who conducted these three qualitative studies that examined the medication experience performed the meta-synthesis. The process began with the researchers reviewing the themes of the medication experience for each study. The researchers then aggregated the themes to identify the overlapping and similar themes of the medication experience and which themes are sub-themes within another theme versus a unique theme of the medication experience. The researchers then used the analytic technique, “free imaginative variation” to determine the essential, structural themes of the medication experience. Results: The meaning of medications for patients was captured as four themes of the medication experience: a meaningful encounter; bodily effects; unremitting nature; and exerting control. The medication experience is an individual’s subjective experience of taking a medication in his daily life. It begins as an encounter with a medication. It is an encounter that is given meaning before it occurs. The experience may include positive or negative bodily effects. The unremitting nature of a chronic medication often causes an individual to question the need for the medication. Subsequently, the individual may exert control by altering the way he takes the medication and often in part because of the gained expertise with the medication in his own body. Conclusion: The medication experience is a practice concept that serves to understand patients’ experiences and to understand an individual patient’s medication experience and medication-taking behaviors in order to meet his or her medication-related needs. more...

Objectives To describe the features of medication therapy management (MTM) programs, including eligibility criteria, enrollment, services, and reimbursement, and to describe the criteria used to evaluate MTM programs and assess the evidence of relevance to Medicare. Design Descriptive, exploratory, nonexperimental study. Setting United States between July 2007 and June 2008. Participants 60 key informants from 46 different organizations and case studies with 28 representatives from four MTM programs. Intervention Literature review, key informant interviews, and evaluation of case studies. Main outcome measures MTM program features and evidence of effectiveness. Results MTM programs used a variety of practice models. Medicare MTM programs used different eligibility criteria than MTM programs sponsored by Medicaid or other payers. MTM programs that required patients to opt-in had less success in enrolling participants than those using opt-out. Most MTM programs conducted annual medication reviews. Most non-Medicare MTM programs provided face-to-face interventions, whereas Medicare MTM programs relied more on telephone or mail; no research tested the effectiveness of different modes. Almost all MTM programs used pharmacists to provide services. Little research on Medicare MTM programs was available. Costs were commonly measured in the MTM literature, although results were inconsistent. A few studies demonstrated significant improvements in intermediate outcomes (e.g., low-density lipoprotein cholesterol), while less studies demonstrated an impact on serious sequelae (e.g., emergency department visits). Conclusion Medicare MTM programs were still evolving when this study was conducted, and we found limited evidence to determine which beneficiaries would benefit most from MTM, which features achieved the desired outcomes, and which outcomes should be measured to compare MTM program performance. more...

Objective To present the benefits of openness for achieving patient centeredness by pharmacists, provide patient narratives from two qualitative research studies that demonstrated how patients have experienced pharmacists' traditional approach, and describe a tool with six component strategies for pharmacists to use in direct patient care. Design (1) Ethnographic study and (2) hermeneutic phenomenological study. Setting (1) Pharmaceutical care practices and (2) university. Participants (1) Patients, practitioners, and student pharmacists, and (2) university faculty and staff taking long-term medications for chronic diseases. Interventions (1) Participant observation, in-depth interviews, focus groups, and analysis of documents, and (2) unstructured, in-depth interviews. Main Outcome Measures (1) Observations and participant comments and (2) patient comments. Results Pharmacists' primary reliance on pharmacology and pharmacotherapy—without consideration of the patient as an individual—can devalue patients' personal understanding of their own situation and negatively affect care. This "natural attitude" of pharmacists, created through their preparation and education, involves their understanding of medications, focus on the product, use of counseling as the major approach with patients, and emphasis on medication adherence as a goal. Pharmacists as professionals must recognize how their natural attitude negatively affects care and work to become more patient-centered practitioners by the development of skills such as openness. Pharmacists can achieve openness by applying six strategies with patients (listen, acknowledge, wonder) and themselves and professional colleagues (recognize, question, reflect). Conclusion Patients want to be heard and seen as individuals with unique experiences and responses to medications. If pharmacists are intent on working with patients to ensure that their medication-related needs are met, they should grasp what it means to be patient-centered, and the six strategies for achieving openness should be applied in the daily practice of pharmacy. more...

Methods A meta-synthesis of qualitative findings from implementation evaluations and experiences of adult PCMH transformation in pilots/demonstrations, including national, multi-state and single state demonstrations. The majority of practices represented family or internal medicine with an average of 14.1 practices per demonstration (range: 1-36). Most were mixed-methods evaluations and included: site visits, observations, interviews, and focus groups. The mean number of interview respondents was 64.5. more...