Results

To develop the Senior Section, 5 pharmacy staff and 5 older adults were recruited into two separate stakeholder groups. The stakeholder groups met for 6 iterative participatory design sessions to clarify the problems from their own perspectives, to brainstorm strategies, and to prototype the intervention, which became the Senior Section. Each session was developed to include a variety of active participation activities, targeted for the perspectives of each stakeholder group. Utilizing participatory design provided a framework for incorporating feedback from each session in the preparation of the subsequent session. Participatory design was an effective and necessary approach to understand the needs of end-users so that the final intervention fit with the existing work system.

Following the participatory design, the Senior Section was beta tested in one pharmacy. Using Proctor’s implementation outcomes as the guiding framework, we sought formative evaluation from stakeholders. To ensure compatibility and practicability, stakeholders stressed the importance of the intervention having limited impact on routine processes and close proximity to the prescription department. The intervention was perceived as feasible – it minimally affected both workflow and overall OTC consult time. Prioritizing specific implementation outcomes during the design process allowed us to address these barriers early on and foster buy-in. This formative data collection allowed for rapid cycle improvement of the Senior Section.

Five Senior Section features facilitate older adults’ safe OTC medication selection: (1) dedicated, well-lit, section with a curated list of safe OTC medications for older adults, (2) proximity and sight line to the prescription department to facilitate pharmacist/patient engagement, (3) tools (e.g., countertop and lighted magnifying glass) for reading and reviewing OTC options, (4) strategically-placed signage to highlight potential risks and encourage seeking of pharmacist assistance, and (5) shelving height that placed OTC medications between shoulder and knee height to assist visual or physical impairment.

Our project required 72 older adult participants pre- and post-implementation in order to be powered for a 45% reduction in OTC medication misuse. The pharmacy organization partner filed for bankruptcy during our post-implementation data collection period. As a result, we were only able to recruit 15 older adult participants in the post-implementation period.

Patient characteristics (age, gender, race, education, number of prescribers, pharmacies, and medications, health status, and total health) revealed few notable differences in patient samples between pre- and post-implementation.  At pre-implementation, no patient had an educational level below high school, but one patient reported education up to eighth grade at post-implementation.  The number of medications that patients reported taking also was narrower at post-implementation (pre-implementation min/max: 1-33 vs. post-implementation min/max: 6-18), but this did not translate into any distinction between means.  In addition, over 60% of patients had a total health rating of very good/excellent prior to Senior Section implementation, while only a third of patients had the same rating at post-implementation.  Despite these slight differences, no patient characteristic varied significantly between pre-/post-implementation and were considered homogeneous.  Given these descriptive results, it is not surprising that the effect of patient characteristics (when added to the regression models as propensity scores had little if any adjusting effect on most misuse outcomes.

Even given the limited sample size, there were significant reductions in OTC medication misuse. Drug/Disease Misuse significantly lessened over time (z=-2.09, p=0.037). Drug/Label Misuse varied according to the sub-type, with reduced Daily-Dosage (z=-2.42, p=0.016) and Single-Dosage misuse (z=-5.82, p=0.001).

Importantly, the intervention fit with pharmacists’ workflow, did not add to pharmacist workload, and facilitated pharmacist-patient communication. The Senior Section improved the quality of pharmacist-older adult encounters.  After Senior Section implementation, pharmacy staff were more likely to initiate (and be involved in) patient encounters, address more topics or problems/symptoms, provide details about OTC products, discuss appropriateness of OTC use, and discuss medication classes highlighted in the Senior Section. Because of the proximity to the prescription department, pharmacy staff were less likely to need to leave the prescription department for extended periods and had fewer prolonged encounters. Pharmacy staff noted no barriers that would reduce Senior Section utilization.

Using data from a sample of older adult interviews (9 pre- and 3 post-implementation), we conducted a cognitive task analysis to compare the effect of Senior Section implementation on shoppers’ decision-making processes. Cognitive task analysis (specifically hierarchal task analysis, because it provides significant insight into a task being analyzed by describing the specific goals, subgoals, operations, and plans of that task) allows determination of whether the intervention improves decision-making (e.g. reduces the number of choices) and where it does not (e.g. information is still hard to process). Our hypothesis was that the intervention would influence older adult decisions and would predict medication choice appropriateness.

Analysis showed that decision-making did not differ between shoppers who use the Senior Section and those who use the normal OTC aisles to select a product. However, a closer examination of the way these two groups assess a product and consider alternatives provides unique insight about the Senior Section’s impact. As expected, decisions involved a multitude of factors, all of which are indicated in steps 5.1 to 5.10 above – some factors related to product safety (steps 5.4, 5.5, 5.7, 5.8, and 5.10), while others indicated shopper preferences (steps 5.1, 5.2, 5.3, 5.6 and 5.9).

After Senior Section implementation, the average number of factors that older adults used to make a decision reduced from 6.3 to 3.3, while two-thirds of shoppers considered the appropriateness of the OTC for their symptoms (step 5.8) (compared to 56% pre-implementation). When shopping from the Senior Section, older adults no longer considered the form of the medication (step 5.3), generic vs name brand (step 5.9), and ingredients (step 5.10), and were less likely to consider steps 5.1, 5.2, 5.4, 5.4, 5.5, and 5.7.