Thesis (MSc ( Med In Pharmacy)) -- University of Limpopo (Medunsa / Summary Summary Summary The words “researcher” and “pharmacist” are used interchangeably. In the last two decades, the role of the pharmacist has been expanding beyond product orientated functions, such as procurement, stock control and dispensing, towards patient centered functions, in which the pharmacist assumes responsibility for treatment outcomes as part of the health care team. This research aimed to assess the need for the provision of pharmaceutical care from the pharmacist to the surgical wards of Steve Biko Academic Hospital. The objectives of the study were to determine the role of the pharmacist in the general surgical wards, to assist in the design of an antimicrobial ward protocol for the surgical wards, to record and assess antimicrobial patterns in the surgical wards, to describe and categorize the interventions performed by a pharmacist during the provision of pharmaceutical care, to identify factors which limited the provision of pharmaceutical care and provide recommendations for future undertakings, to calculate the cost implications of pharmaceutical care interventions made, to assess the time spent on interventions performed by a pharmacist during the provision of pharmaceutical care and to determine if the medical staff members in the surgical unit feel there is a need for the pharmacist providing pharmaceutical services to the wards. The study was conducted in the surgical wards of Steve Biko Academic Hospital. The study design was a cross-sectional operational study in which 62 patients were recruited over the eight week period. A pilot study was conducted to validate the data collection instruments. The data was analyzed with the assistance of a statistician using various statistical methods for the different variables in the study. ix Of the 62 study patients, 33 were female and 29 were male. The female-to-male ratio of the study patients was thus 1:0.88. The average age of the patient population, was 52.5 ± 17.2 years, with a range of 15 to 88 years. The mean duration of stay for the study patients was 8.9 days, with a range 1 to 111 days. A total of 120 diagnoses were made for the 62 study patients. Conditions diagnosed most frequently included conditions affecting the gastro-intestinal tract (38 patients), conditions affecting the cardiovascular system (28 patients), conditions affecting the endocrine system (14 patients) and infections (12 patients). The five medicines used most frequently in terms of numbers of patients and duration of therapy were paracetamol (53 patients, 277 patient-days), morphine/papaverine/codeine (41 patients, 155 patient-days), enoxaparin sodium (24 patients, 113 patient-days), co-amoxiclav (21 patients, 101 patient-days) and metoclopramide (22 patients, 90 patient-days). A total 188 interventions were made and documented during the study period and 153 (81.4%) interventions were accepted. The number of interventions suggested ranged from 0 to 10, with an average of three interventions per patient and a median of one intervention per patient. The most frequent interventions were made due to system error or non-compliance (29.3% of all interventions), on patient or nursing staffs’ knowledge of the medication (18.6%), untreated medical conditions (11.2%), therapeutic duplications (9.0%) and on prescribed doses and dosing frequency (5.9%). The total time spent providing pharmaceutical care services within the surgical wards over the study period was 32 days (227.9 hours) with an average time of 7.1 hours per day. Of the total time in the ward, 48% was spent on providing pharmaceutical care to the patients, 26% to record and access the total antibiotic usage in the ward, 9% on administration and 6% on meetings. Other functions comprising of 3% and less of the time was information to patients, x communication with doctors, educational sessions with nursing staff, communication with the pharmacy and stock control procedures. Questionnaires were completed by the doctors and nursing staff before and after the study period to determine if they felt there was a need for a pharmacist in the surgical ward. The doctors felt that there was a need for a pharmacist in the ward in terms of providing information and assisting in the rational use of medication. All of the nursing staff felt that there was a need for a pharmacist to visit the surgical ward and specifically to assist with the legal aspects of the prescriptions and with the education of the nursing staff. The pharmacist played an important role in the design of an antimicrobial ward protocol and in order to do so the pharmacist recorded and assessed the antimicrobial prescribing patterns of the surgical wards. In conclusion, the pharmacist present in the ward functioned as a gateway between the nursing staff and the doctors. The interventions that require the most attention was made due to system error and non-compliance. Important interventions were made on the patients’ and nursing staffs’ knowledge of the prescribed medication. The pharmacist played an important role in the education of nursing staff to discuss relevant topics and problems often encountered. Educational sessions with the patients involved giving them advice on home medication and the medication prescribed to them to take home. The amount of patients seen per week increased with time and the average time spent per patient consultation decreased with time. This is a clear indication that the researcher gained confidence and became more familiar with the pharmaceutical care process as the time passed. From the questionnaires completed by the doctors and nursing staff it was clear that they felt that there was a need for a pharmacist in the ward in terms of xi providing information, assisting in the rational use of medication, to assist with the legal aspects of the prescriptions and with the education of the nursing staff.

Abstract Purpose: An evaluation of the oral chemotherapy patient education process at one ambulatory cancer center identified a deficit in documentation in the electronic medical record (EMR) of many recommendations from the American Society of Clinical Oncology (ASCO) and Oncology Nursing Society (ONS) chemotherapy administration and safety standards. Aims: The aim of this quality improvement project is to evaluate the effectiveness of the implementation of two newly developed templates into the EMR at one ambulatory cancer center. Process: The project will evaluate effectiveness by comparing the frequency in documentation of 16 key elements pre and post implementation of the two new EMR templates. These 16 elements are recommended by ASCO/ONS to be included in the documentation of a patient education for oral chemotherapy. This project has been approved by both the East Tennessee State University and Ballad Health IRBs. After EMR system access is granted, there will be two chart reviews of patients newly started on oral chemotherapy. The first review will be prior to template implementation, and the other post implementation. Both reviews will abstract the frequency in documentation of the 16 ASCO/ONS elements using a data abstraction tally tool created by the project investigator. Results: Preliminary evaluation is ongoing. Limitations: This project only includes one cancer center, and therefore includes a small sample size. Conclusion: It is projected that by incorporating these national safety standards into the EMR, this will increase compliance and sustainability in the utilization and documentation of national guideline recommendations. Keywords: Oral chemotherapy, adherence

Objectives: Managed care organizations reduce healthcare costs and may improve patient health outcomes by encouraging better control of prevalent chronic diseases. The purpose of this study was to determine whether changing from a fee-for-service program to a capitated managed care program improved medication adherence for Medicaid patients in Kentucky with hypertension, hypercholesterolemia, or type 2 diabetes. Methods: We conducted a quasi-experimental study of patients enrolled in Kentucky Medicaid to evaluate the impact of transitioning to capitated managed care in November 2011. Medication adherence was measured using the proportion of days covered (PDC) method. Multivariable analyses measured the adjusted differences in adherence as a result of the implementation of capitated managed care. Results: Adjusted analyses indicate an average decrease in PDC by about 17-22 days of therapy coverage in the post-policy time period. However, no significant difference in adherence rate changes between the treatment and control populations were observed. Conclusions: Results indicate clinically inconclusive evidence regarding the immediate effect of the implementation of Medicaid managed care in Kentucky on medication adherence rates in patients with prevalent chronic diseases. There is a need to address the decline in average adherence rates, and the efficacy of Medicaid managed care based on medication adherence.

A mixed methods approach was used for this study. The setting was a low-income, subsidized housing apartment building for community-dwelling older and younger disabled adults identified as a health care hot spot due to high rates of ambulance use. The study purpose was to identify reasons for ED use and problems during transition from ED to home, predictors of zip code 23220 (health care hot spot) in emergent and non-emergent ED visits, and predictors of total ED costs in community-dwelling older adults living in a health care hot spot. Semi-structured interviews with residents who used the ED, an existing database from an interprofessional care coordination and wellness program for residents, and community-dwelling older adults’ electronic medical record and billing data from 2010-2013 ED visits from an academic medical center were used. The Gelberg-Andersen Behavioral Model for Vulnerable Populations was utilized. A total of 14 interviews were conducted. Themes related to ED use included: high use of ambulance services, timely use of the ED or attempt at self-care, and lack of communication with a health care provider prior to ED visit. Themes related to care transitions were: delay in medication receipt after discharge, lack of a current medication list and personal health record, PCP follow-up instruction, and education on warning signs of a worsening condition. The interprofessional program’s care coordination activities were education, disease monitoring, referral for PCP visit, and discrepancy reconciliation. A total of 7,805 ED visits were included, of which 3,871 were non-emergent and 1,179 were emergent. Common primary ED visit diagnoses were chest pain and abdominal pain. White race, a Charlson Comorbidity Index score of 3, and a total disease count of 10 or more were significant predictors of zip code 23220 in non-emergent ED visits. White race was a significant predictor of zip code 23220 in emergent ED visits. Significant predictors of total ED costs were white or other race, arrival by ambulance, emergent visit type, and year of visit. Pain was a common reason for ED use. Care transition problems related to medication management and follow-up care indicate an area for targeted interventions after ED discharge.

Objective To describe common facilitators, challenges, and lessons learned in 5 schools and colleges of pharmacy in establishing community pharmacy research fellowships. Setting: Five schools and colleges of pharmacy in the United States. Practice description: Schools and colleges of pharmacy with existing community partnerships identified a need and ability to develop opportunities for pharmacists to engage in advanced research training. Practice innovation: Community pharmacy fellowships, each structured as 2 years long and in combination with graduate coursework, have been established at the University of Pittsburgh, Purdue University, East Tennessee State University, University of North Carolina at Chapel Hill, and The Ohio State University. Evaluation: Program directors from each of the 5 community pharmacy research fellowships identified common themes pertaining to program structure, outcomes, and lessons learned to assist others planning similar programs. Results: Common characteristics across the programs include length of training, prerequisites, graduate coursework, mentoring structure, and immersion into a pharmacist patient care practice. Common facilitators have been the existence of strong community pharmacy partnerships, creating a fellowship advisory team, and networking. A common challenge has been recruitment, with many programs experiencing at least one year without filling the fellowship position. All program graduates (n = 4) have been successful in securing pharmacy faculty positions. Conclusion: Five schools and colleges of pharmacy share similar experiences in implementing community pharmacy research fellowships. Early outcomes show promise for this training pathway in growing future pharmacist-scientists focused on community pharmacy practice.

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This thesis aimed to elucidate the demographic characteristics associated with elevated or reduced rates of pneumococcal conjugate 13 (PCV13) vaccination. A retrospective cohort study was performed using the Truven Health MarketScan® Database. Three cohorts were created corresponding to populations for which the CDC recommends PCV13 vaccination. Cohort 1: children < 36 months of age. Cohort 2: adults 19-64 years of age with high infection risk. Cohort 3: adults > 65 years of age. Odds of having a PCV13 claim were calculated for each cohort. For Cohort 1, 78% out of a total of 353,214 subjects had a sufficient number of PCV13 doses to meet CDC recommendations. For Cohort 2, 3.7% out of a total of 673,157 subjects had a PCV13 claim. For Cohort 3, 18% of 1,262,531 subjects had a PCV13 claim. Odds of vaccination were generally lower in younger subjects, those with fewer outpatient claims, and those with residence in the Northeast and South regions. In Cohort 2, odds were reduced in subjects with generalized malignancy. Gender and urban residence were poor predictors of vaccination status. By understanding the demographic factors associated with lower rates of vaccination, clinicians may more effectively direct their efforts to increase pneumococcal vaccination coverage.

Introduction: Cigarette smoking is associated with lung cancer, cardiovascular disease, and chronic respiratory conditions. It is responsible for high mortality and morbidity risk in the US population. Smokers find sudden quitting difficult and it is reported that a large number of unassisted quitting attempts are eventually unsuccessful. Electronic cigarette or e-cig is a novel battery-driven, nicotine delivery product, currently being used as a smoking cessation tool by current and former smokers. Since its resemblance to a conventional cigarette, and its non-combustible nature, e-cig use has risen exponentially in the last few years. To address such public health issues, the US FDA is working on formulating regulations to manufacture, market, and distribute e-cigs has called for research evidence on the long term use of e-cig use. Objective: The objective of this study was to develop and validate a Discrete Event Simulation model to simulate the electronic cigarette (e-cig) use behavior, and to estimate the long term e-cig use prevalence, in different groups of the US population. Methods: The model population was generated from analyzing the National Health Interview Survey data from 2011-2013. The population was categorized into current, recent former, late former and never smokers. Population birth rates and death rates were applied using the 2012 US Census Bureau data. Model parametrization, transition probabilities and e-cig related risks were obtained and applied using cross sectional survey and longitudinal e-cig studies done on US population. The model was run for the period of 15 years and e-cig use prevalence at the end of the simulation period was estimated. Each simulation was replicated 100 times using Monte Carlo simulation approach. Model validation was performed by the use of null and extreme input values (internal validation), examining programing codes (debugging), verification by tobacco science and system analysis experts (structural and technical validation), comparison of model’s first year results with CDC reports (external validation). Conclusion: Total projected e-cig prevalence in the US population at the end of simulation of period was found to be around 19%. The results showed a gradual reduction in the number of conventional cigarette smokers and an increase in the e-cig users over the simulation period. Highest e-cig users were old, male, white and had less than high school level education. Sensitivity analyses of various model parameters showed that the e-cig prevalence was most sensitive to the impact and timing of policy implementation. As a novel nicotine delivery system, e-cigs are rapidly gaining acceptance in the US and recent reports have shown an exponential rise in the popularity of e-cig among minors and young adults. Our research provides empirical evidence that can be used by the scientific community and regulatory bodies to formulate regulations for marketing and sales of e-cigs in various sections of the population, where the prevalence is expected to rise in future. Our study can also guide the policy makers to introduce relevant policies at specific time points when the e-cig use is expected to rise.

Objective: To compare community pharmacists' self-perceived communication confidence in prescription drug abuse and addiction (PDAA)-related scenarios to their self-confidence in other scenarios. Methods: An 18-item survey instrument adapted from the Self-Perceived Communication Competence instrument was administered to 2000 licensed Tennessee community pharmacists. Items elicited communication confidence across common community pharmacy scenarios. Analysis of communication self-confidence scores across context, receiver, audience, and demographic variables was conducted. Results: Mean self-confidence ratings ranged from 54.2 to 92.6 (0-100 scale). Self-perceived communication confidence varied across context, receiver, audience, personal and practice setting characteristics. Scenarios that involved PDAA communication with patients were scored significantly lower than non-PDAA patient scenarios (mean = 84.2 vs. 90.4, p Conclusion: Community pharmacists are less confident in their ability to communicate with patients about PDAA as compared to non-PDAA scenarios. Practice Implications: Engaging patients and prescribers in PDAA conversations is a critical component of preventing and treating PDAA. Research is warranted to further explore measures of situational communication self-confidence and interventions to optimize self-confidence beliefs across PDAA scenarios.

The United States is in the midst of an opioid epidemic. In addition to other system level interventions, almost all states have responded to the crisis by implementing prescription drug monitoring programs (PDMPs). PDMPs are state-level interventions that track the dispensing of Controlled Substances. Data generated at the time of medication dispensing is uploaded to a central data server that may be used to assist in identifying drug diversion, medication misuse, or potentially aberrant prescribing practices. Prior studies assessing the impact of PDMPs on trends in opioid-related morbidity have often failed to take into account the wide heterogeneity of program features and how the effectiveness of these features may be mitigated by insurance status. Previous research has also failed to differentiate the effects of these programs on prescription vs. illicit opioid-related morbidity. The studies in this dissertation attempt to address these gaps using epidemiological techniques to examine the associations between specific PDMP features and trends in prescription and illicit opioid-related poisonings in populations of different insurance beneficiaries. Results of these studies demonstrate that implementation of specific PDMP features is significantly associated with differential trends in prescription and illicit-opioid related poisonings and that the effectiveness of these features vary depending on the insurance status of the population studied. These results suggest that PDMPs offer a valuable tool in addressing the United States’ opioid epidemic, and may be used as empirical evidence to support PDMP best practices in the future.