School of Pharmacy UNIVERSITY OF WISCONSIN - MADISON SRC Research Projects The SRC’s research helps policy makers, the profession, and citizens to improve the health of our population and health care system, particularly as it relates to pharmacy. SRC investigators study the organization, delivery, financing, quality, patient perspective, and outcomes of pharmacy within the broader health care system. Since the SRC’s inception, grants for this work have generated over $10 million in external research funding beyond the original start-up gift. Researchers have conducted descriptive and intervention studies funded by federal, state, international and private agencies. Enhancing Physician Referral and Recommendation of Pharmacist Provided MTM Services 2010-2011 Michelle A. Chui, PharmD, PhD, Principal Investigator Awarded by: Community Pharmacy Foundation Patient uptake and physician awareness of programs implementing pharmacist provided MTM services have not been optimal. This has limited physician referral and acceptance of pharmacist-provided recommendations, one of the identified challenges of further implementation of these programs. The objective of this project is to facilitate a structured communication between local pharmacists and physicians for purposes of enhancing and encouraging physician referral and recommendation acceptance of pharmacist services. To accomplish the project aims, efforts will focus on: Exploring facilitators and barriers (actual and perceived) of collaboration and develop strategies to overcome them Identify priorities for practice agendas to improve the health of Wisconsin citizens Discover projects where physicians and pharmacists already have problem-solved and addressed potential challenges and barriers Our plan is to partner with the Wisconsin Medical Society (WMS), who will identify physicians interested in collaborating with pharmacists. Pharmacists in the same zip codes and providing MTM services will be paired with them and asked to participate in structured interviews to determine common language, values and goals related to MTM services. The interviews will be content analyzed so that the information may be synthesized into marketing tools that will help build awareness of MTM programs, lead to physician referrals, and increase acceptance of pharmacist-provided drug therapy recommendations. We hope that this project will set a foundation for a two-pronged approach to patient care with physicians, in addition to pharmacists, recommending patient centered services. Exploring Pharmacist to Pharmacist Communication During Patient and Prescription Handoffs 2009-2010 Michelle A. Chui, PharmD, PhD, Principal Investigator Awarded by: UW-Madison Graduate School The goals of this project are to explore how patient and prescription information is conveyed between pharmacists and how they perceive how responsibility of a patient or prescription is handed off from one pharmacist to another. Transcribed interviews with pharmacists were analyzed. Pharmacists, similarly to other health care professionals, do hand off prescription information and responsibility to their colleagues, however, the process was unstandardized and problematic. Pharmacists indicated that problems occurred when there was incomplete or confusing information, when there was no feedback loop back to the originating handoff pharmacist, and because it contributed to workflow distractions. Pharmacists tend to focus on prescriptions as the handoff unit (rather than the patient), since each prescription may have its own problems, many of which may be non-clinical in nature. Implications/Conclusions: This project was the first study to address handoff communication, a previously unexplored gap in the community pharmacy. It revealed the importance of studying this process and how it may be associated with medication safety. Future research needs to address multiple facets of the handoff process and pharmacist-pharmacist communication in the community pharmacy including factors that contribute to, and outcomes of poor handoffs, so that interventions can be developed to improve this process in community pharmacies. Pharmacy Quality Alliance – Wisconsin Pharmacy Quality Collaborative Demonstration Project (Phase I) 2008-present Dave Mott, PhD, Principal Investigator Awarded by: Pharmacy Society of WI, Pharmacy Quality Alliance Background: The implementation of Medicare Part D has made the Centers for Medicaid and Medicare Services (CMS) one of the largest payers for prescription drugs in the world. This role prompted CMS to support the formation of the Pharmacy Quality Alliance (PQA), a multi-stakeholder organization working to establish viable approaches for measuring and reporting pharmacy performance. The evolution of systems to report pharmacy quality is likely to quicken with the development of reliable pharmacy performance measures and establishment of mechanisms for collecting and reporting pharmacy performance. After initial work to develop a set of pharmacy quality measures, an important step in PQA’s mission of improving the quality of medication use through a collaborative process was supporting five Phase 1 Demonstration Projects. Wisconsin served as one of the five projects. This project involved SRC collaboration with the Pharmacy Society of Wisconsin (PSW) and the UW Center for Health Systems and Analysis (CHSRA). SRC coordinated pharmacist education, assisted with development of the QI report, and developing the content for a pharmacist website. The website included pharmacist education resources, a link to the PQA program, a section on defining quality indicators, a section about the reports, a FAQ section, and a performance report for each specific pharmacy. SRC also coordinated and received pharmacist feedback about the website and reports. Performance scores were calculated for all Wisconsin pharmacies serving Medicaid. A sample of participating pharmacists and payers were invited to provide feedback. Results of the demonstration projects suggest that there is room for improvement in performance scores (as shown by the considerable variability in scores across pharmacies and projects). Additionally, future work will address pharmacists’ impact on patient adherence, opportunities for pharmacists to work with patients and physicians to assure that their patients are receiving drug therapy that is consistent with accepted guidelines, and the need for development of a system that supports pharmacists in addressing their performance. A second project under this initiative addresses pharmacists lack confidence in their ability to provide MTM services. An MTM self-efficacy scale instrument was developed and evaluated in conjunction with the Wisconsin Pharmacy Quality Collaborative (WPQC) MTM program. Barriers to Medical Care and Medication Adherence in Persons with Alzheimer’s Disease and Related Disorders 2009-2010 Joshua Thorpe, PhD, Principal Investigator Awarded by: Wisconsin Comprehensive Memory Program The specific aims of this research are: (1) to gather preliminary data on medication adherence levels in persons with ADRD via caregiver report; (2) to obtain information about caregiver’s perceived barriers to outpatient care access in persons with ADRD and examine the relationship between access barriers and medication adherence; and (3) to test the feasibility of recruiting and retaining a sample of informal caregivers. Suboptimal Medication Use in Persons with Dementia and Their Informal Caregivers 2008-2011 Joshua Thorpe, PhD, Principal Investigator Awarded by: NIH, National Institute on Aging Study period: 2008 to 2011 The specific study aims are to: (1) describe the rate and identify determinants of inappropriate medication use in community-dwelling adults with dementia; (2) describe the rate and identify determinants of inappropriate medication use in informal caregivers of dementia patients; (3) determine if suboptimal medication use impacts patient health, caregiver physical and emotional health, and the timing of care-recipient institutionalization; and (4) examine the trajectories of inappropriate medication use over time in dementia patients and their caregivers. Medications Prescribed in Emergency Departments for Non-Traumatic Dental Conditions 2010-2011 Joshua Thorpe, PhD, Methodologist Consultant Awarded by: NIH, National Institute of Dental and Craniofacial Research (NIDCR) Disparities in Healthy Behaviors and Preventive Care in Adults with Elder Care Responsibilities 2010-2012 Joshua Thorpe, PhD, Principal Investigator Awarded by: NIH Loan Repayment Award for Health Disparities Research, National Center on Minority Health and Health Disparities (NCMHD) The Role of Pharmacist Evaluation in Activation of Adult Asthma Patients 2009-2010 Henry N. Young, PhD, Principal Investigator Awarded by: NIH, CTSA/MERC Optimal medication use is a vital strategy to improve patients’ control over asthma. Appropriate use of prescription medications prevent exacerbations and improve patients’ quality of life. Thirty to eighty percent of patients with asthma have problems adhering to prescribed treatment regimens. Nonadherence is associated with worse asthma control, poor quality of life, and increased health services utilization. Underserved, rural asthma patients may have additional barriers accessing pharmacist services that could improve their medication use and asthma control. Telepharmacy, or the provision of pharmaceutical care through the use of telecommunications and information technologies to patients at a distance, has shown promise in improving patients’ access to health care services. However, asthma-related pharmaceutical care programs have not been implemented through telepharmacy, nor have they targeted rural populations in a comprehensive manner. The goal of this study is to conduct a pilot test of a telepharmacy-based intervention to improve underserved, rural asthma patients’ use of prescribed medications and asthma management. In an effort to achieve this goal, we are conducting a randomized control trial to assess the feasibility, acceptability, and effectiveness of an asthma telepharmacy program. Thus far, we have recruited 98 patients from the Family Health Center of Marshfield Pharmacy to participate in this study. Forty-seven participants were randomly assigned to the intervention. The intervention consisted of three telephonic consultations with Marshfield Clinic pharmacists regarding asthma self-management and medication use over a three month period. Following a standardized protocol, pharmacists assessed and addressed patients’ barriers to managing their asthma and medication use. All of the intervention contacts have been completed. The control group received usual care, which consisted of the receipt of written medication use instructions through the mail with a prescription. We are currently in the follow-up/post-intervention survey phase of the study. We anticipate that all post-intervention surveys will be completed in November 2010. A Team Model of Hypertension Care in African Americans 2004–2010 Bonnie Svarstad, PhD, Principal Investigator Awarded by: National Heart Lung & Blood Institute, U.S. Department of Health and Human Services Objective: To determine whether blood pressure (BP) control can be improved in hypertensive African Americans through the use of pharmacist–technician teams and innovative tools (compared with usual care) and assess whether BP outcomes are associated with team “fidelity” to the study protocol. Methods: The Team Education and Adherence Monitoring (TEAM) trial is a randomized controlled trial testing organizational interventions for improving BP control in 28 corporately owned pharmacies. Pharmacies were randomized into 14 TEAM care sites (TC) and 14 usual care plus information sites (UC+). Intervention teams received training and innovative tools for monitoring and improving patient adherence and BP control. Blinded interviewers screened 1,250 African Americans, enrolled 576 African Americans, and used standard procedures to reassess BP. In this paper, we perform an “intent-to-treat” analysis and a “per protocol” analysis examining changes in systolic and diastolic BP (SBP, DBP) and BP control (BP <140/90 mm Hg) after 6 months. We use program records to quantify team fidelity to the monitoring protocol, with “high” team monitoring defined as completing at least 5 of 6 recommended patient consultations using certain monitoring tools over 6 months. Results: Patients had a mean age of 53 (range 19–87) and mean baseline SBP and DBP of 152.2 and 92.5 mm Hg. Interviewers reassessed 546 patients (95%) after 6 months. Compared with UC+ patients, TC patients experienced greater reductions in SBP (P < 0.004) and better BP control (P < 0.002) after 6 months. Of 276 TC patients, 55% received “low” team monitoring and 45% received “high” team monitoring. As predicted, team fidelity to the monitoring protocol was associated with greater reduction in SBP (P < 0.007) and BP control (P < 0.01). Conclusion: A team model using pharmacist–technician teams and innovative tools can be a powerful model for improving BP control among African Americans in corporately owned pharmacies. Older Adults & Drug Decisions: Collaboration & Outcomes 2002-2009 -Betty Chewning, PhD, Principal Investigator -Carolyn Bell, MD, and David Kreling, PhD, Co-Investigators -Betsy Sleath, PhD, University of North Carolina–Chapel Hill, Subcontract Principal Investigator Awarded by: National Institute on Aging, National Institutes of Health This was a two state randomized control trial of the impact of an intervention that identified pre-visit concerns of older adults with rheumatoid arthritis and then prompted both patients and physicians to address these concerns in the visit through a computer printout. Impact of the intervention on patient outcomes was evaluated longitudinally. The intervention significantly increased discussion of patient agendas and decreased reported patient pain 6 months later. Establishing a Center to Examine the Quality of Prescription Drug Use: A Pilot Study of Non-steroidal Anti-inflammatory Drugs (NSAIDs) 2005-2006 James M. Robinson, PhD, University of Wisconsin–Madison Center for Health Systems Research and Analysis, Principal Investigator David Kreling, PhD, Co-Investigator Awarded by: WEA Trust This pilot project sought to establish a research database of health insurance claim and coverage information to identify patterns and trends in prescription drug use and implications for subsequent health outcomes and service utilization. The project was undertaken in conjunction with the Center for Health Systems Research and Analysis (CHSRA). Specific objectives included conducting a descriptive study of the patterns of drug use, examining whether patterns of drug use conform to appropriate or preferred regimens for the therapeutic situation, and assessing whether other medical care use or outcomes differ when more appropriate or cost-effective drugs are used. A goal of this pilot project was to lay initial groundwork for a Center for Evidence-based Health Care Assessment and Quality that will enable better decisions about health care use that can save money on expenditures yet improve outcomes for patients. Student Outreach to Prevent and Reduce Smoking (STOPRS) 2004–2006 Betty Chewning, PhD, Principal Investigator David Kreling, PhD, and Beth Martin, RPh, MS, Co-Principal Investigators Awarded by: Ira and Ineva Reilly Baldwin Wisconsin Idea Endowment This research project trained students and pharmacists to market, offer and document their pharmacist-based smoking cessation programs. About 50 pharmacists and students were trained to offer smoking cessation programs in community pharmacies around the state. In addition, students were trained to offer smoking prevention education in middle schools. Over 300 middle school students received smoking prevention programming from School of Pharmacy professional students enrolled in this project. National Sample Survey of the Pharmacist Workforce to Determine Contemporary Demographic and Practice Characteristics: 2004 2004-2005 David Mott, PhD, David Kreling, PhD, Craig Pedersen, PhD, Jon C. Schommer, PhD, William Doucette, PhD, and Caroline Gaither, PhD, Principal Investigators Awarded by: Pharmacy Manpower Project, Inc. Developing and Validating a Measure of Patient Provider Concordance 2003-2004 Betty Chewning, PhD, Principal Investigator Awarded by: University of Wisconsin Graduate School This project involved development and validation of a measure and coding protocol for the interaction between a patient and health care provider. The goal is to measure the degree of concordance (agreement) sought and achieved with respect to medication regimens by the end of the encounter. Evaluation of Participation in the Wisconsin Medicaid Pharmaceutical Care Program 2003-2004 David Mott, PhD and David Kreling, PhD, Principal Investigator Awarded by: Community Pharmacy Foundation Pharmacy-Based Smoking Cessation Program for Young Adults 2001 Betty Chewning, PhD, Principal Investigator David Kreling, PhD, and Dale Wilson, MA, Co-Principal Investigators Awarded by: Tobacco Control Board, State of Wisconsin, Department of Health and Family Services The purpose of this pilot study was to design, implement and evaluate a pharmacy-based smoking cessation program for employees at their work site, drawing on the Transtheoretical Model. Pharmacists working in grocery stores offered tobacco cessation programs to 18-24 year old workers as a part of a major statewide initiative to decrease smoking among young adults. Updating the Prescription Drug Trends Chartbook 2001 David Kreling, PhD, and David Mott, PhD, Principal Investigators Awarded by: Henry J. Kaiser Family Foundation In this project, the original chartbook on trends in the pharmaceutical industry developed for the Kaiser Family Foundation was updated. Key charts were updated with more recent data, and new charts reflecting different analyses or aspects of trends were added. The update was intended to enhance understanding of trends and factors contributing to trends related to prescription drugs. The update also is published and distributed by the Kaiser Family Foundation (www.kff.org). Factors Associated with Academic Performance of School of Pharmacy Students 2001 David Mott, PhD, Principal Investigator Awarded by: Assessment Council, University of Wisconsin–Madison Prescription Drug Coverage for Older Americans: Prevalence, Type and Associated Drug Use 2001 Jon C. Schommer, PhD, and David Mott, PhD, Principal Investigators Awarded by: University of Minnesota Wisconsin Family Impact Seminars 2001 David Mott, PhD, and David Kreling, PhD, Speakers, Discussants, and Program Planning Committee Members These seminars were developed in partnership with the University of Wisconsin–Madison School of Human Ecology and the Center for Excellence in Family Studies. Collaborative funding was from the Helen Bader Foundation, Lynde and Harry Bradley Foundation, Sonderegger Research Center, and Elizabeth C. Davies. Family impact seminars were designed to bring a family focus to policy making. The series was established in 1993, and the State of Wisconsin became one of the first states to sponsor Family Impact Seminars, modeled after the seminar series for federal policy makers. Each seminar provided objective non-partisan research on current issues. Seminars included presentations, briefing reports, and follow-up activities that provide up-to-date, solution-oriented research on current issues to state policymakers, legislators and their aides, Governor’s office staff, legislative support bureau personnel, and state agency representatives. Seminar participants discussed policy options and identified common ground where it exists. The 15th seminar, “Rising Prescription Drug Costs: Reasons, Needs, and Policy Responses” (January 2001), featured David Mott; Bruce Stuart, PhD, from the Peter Lamy Center on Drug Therapy and Aging at the University of Maryland; and Tom Snedden, Director of the Pharmaceutical Assistance Contract for the Elderly in the Pennsylvania Department of Aging. The 16th seminar, “Designing a State Prescription Drug Benefit: Strategies to Control Costs” (March 2001), featured David Kreling; John Hansen, Assistant Director of Health Care Issues, U.S. General Accounting Office; and Stephen Schondelmeyer, PhD, Director of the PRIME Institute, University of Minnesota. Evaluation of Prescription Drug Information Materials–2001 2000-2001 Bonnie Svarstad, PhD, Principal Investigator Jeanine Mount, PhD, RPh, and Nathan Kanous, PharmD, Co-Investigators Awarded by: National Association of Boards of Pharmacy and the U.S. DHHS PHS Food and Drug Administration In this national study, the quality of written patient information provided with new prescriptions in community pharmacies was evaluated. Shoppers presented four prescriptions at a random sample of 400 pharmacies in 50 states during spring 2001. If pharmacy staff provided patient information leaflets, they were accepted and mailed to UW–Madison for evaluation using a national expert panel and consumer evaluators in different states. Findings were submitted to the FDA and public in spring 2002. Pharmacy Cost of Dispensing/Acquisition Cost Study 2000-2001 David Kreling, PhD, Principal Investigator Awarded by: State of Wisconsin, Department of Health and Family Services This study had two objectives: To estimate the cost of dispensing a prescription and assess prescription drug acquisition costs in community pharmacies that participate in the Wisconsin Medicaid program. For the cost of dispensing component, pharmacy managers and/or chain pharmacy executives at approximately 600 pharmacies were contacted to report financial and operational data for calculating the average cost of dispensing a prescription in their pharmacy(s). For the acquisition cost component of the study, a subset of pharmacies submitted one month’s prescription drug purchase invoices. Costs for selected target drugs (selected because they commonly are dispensed to Medicaid recipients) were compared with reference prices to determine the percentage of pharmacy acquisition costs relative to Average Wholesale Prices (AWPs). The costs determined in the two parts of the study were examined for differences across pharmacies associated with pharmacy characteristics (e.g., rural/urban, high/low volume, special services, etc.). National Sample Survey of the Pharmacist Workforce to Determine Contemporary Demographic and Practice Characteristics 2000 David Mott, PhD, William Doucette, PhD, Caroline Gaither, PhD, Craig Pedersen, PhD, Jon C. Schommer, PhD, Co-Principal Investigators Awarded by: Pharmacy Manpower Project, Inc. The overall objective of this study was to obtain reliable information on demographic and practice characteristics of the pharmacist workforce in the United States during 2000. The survey was designed to collect such information from a nationally representative sample of 5,000 pharmacists. Specific goals of the study included: 1) describe the pharmacist workforce in the United States in terms of demographic and practice characteristics, 2) examine factors influencing hours worked annually by pharmacists, 3) describe work patterns in terms of setting and hours worked, 4) examine job satisfaction, and 5) document job turnover intentions and pharmacist work histories. The Pharmacy Manpower Project was a consortium of national pharmacy organizations which included the APhA, AACP, NACDS, ASHP, NCPA, AMCP, ACA, ASCP, BHPr, NABP, NCSPAE, NPhA, NWDA, PhRMA, and PTCB. A National Survey of Elderly Drug Insurance and Drug Use 2000 David Mott, PhD and Jon C. Schommer, PhD, Co-Principal Investigators Awarded by: University of Minnesota The purpose of this study was to: 1) describe the presence and type of prescription drug coverage for older Americans (aged 65 and over), (2) describe the out-of-pocket payment level required by prescription drug plans used by older Americans, and (3) examine the association of prescription drug coverage type with the use of prescription drugs by older Americans. A randomly selected national sample of 1,300 community-dwelling older Americans were mailed a survey. Use of Over-the-Counter Drug Products: The Role of Prescription Drug Insurance and Time Costs 2000 David Mott, PhD, Principal Investigator Awarded by: University of Wisconsin Graduate School The purpose of this study was to evaluate empirically the association of insurance system variables, time variables and demographic variables with the use of over-the-counter drug products. A random sample of 4,000 Wisconsin residents between the ages of 25 and 64 were mailed surveys to evaluate use and cost of non-prescription drugs, risk they associated with using over-the-counter drugs, and the time costs of obtaining prescription and over-the-counter drugs. Chartbook on the Trends in the Pharmaceutical Industry 1999 David Kreling, PhD, Principal Investigator Joseph Wiederholt, PhD, and David Mott, PhD, Co-Principal Investigators Awarded by: Henry J. Kaiser Family Foundation A compilation of charts and supporting text was developed to inform policy makers about recent trends related to prescription drugs. Data from the literature and available sources were obtained to exhibit and examine trends and related factors influencing the trends. The chartbook included trends in expenditures, insurance coverage, prices, utilization, promotion, research and development, and characteristics of firms in the channel of distribution for pharmaceuticals (manufacturers, wholesalers, and retail pharmacies). The Kaiser Family Foundation published and distributed the chartbook. It is available at www.kff.org. Core Disease State Documents: Parkinson’s Disease and ALS 1999 David Kreling, PhD, Principal Investigator David Mott, PhD, Joseph Wiederholt, PhD, and Patrick D. Meek, PharmD, Co-Principal Investigators Awarded by: Eli Lilly and Company The purpose of this study was to review the literature and summarize available information about three aspects of Parkinson’s disease and ALS: 1) characteristics of each disease (etiology, clinical presentation, diagnosis, disease progression, incidence, care seeking behavior, current therapy, treatment guidelines); 2) humanistic measurements (quality of life and health status); and 3) economic measurements (patient costs and resource use). Wisconsin Pharmacist Salary Survey 1999 David Kreling, PhD, Principal Investigator David Mott, PhD, and Joseph Wiederholt, PhD, Co-Principal Investigators Awarded by: Pharmacy Society of Wisconsin Early Head Start Program Evaluation 1998-2003 Betty Chewning, PhD, Director of Evaluation Subcontract Awarded by: Administration for Children and Families, US Department of Health and Human Services This grant supports a subcontract to conduct the evaluation of an educational intervention for poor, young families to increase their self-efficacy and access to services, including needed pharmaceutical care services and medications. In this descriptive study of the health of families in poverty with children under 3 years of age, a subset of 80 families was followed for three years to document the influence of policy changes regarding HMO enrollment and Medicaid on their access to services, including pharmacy care. Consumer Attitudes and Behaviors Toward Pharmacist Services and Prescription Drug Plans 1998 Joseph Wiederholt, PhD, Principal Investigator David Kreling, PhD, Co-Principal Investigator Awarded by: Pharmacist Society of Wisconsin Two concurrent surveys of separate samples of consumers residing in Wisconsin were conducted. One survey focused on perceptions about pharmacies and pharmacy services, including patronage motives, importance of professional pharmacist services, and working and communicating with pharmacists. The second survey assessed prescription coverage and events/concerns about that coverage, perceptions about working with pharmacists, and attitudes about two sample expanded pharmacist medication services (e.g., usefulness, appropriate price, whether should be covered by insurance). Factors Associated with Generic Drug Use Behavior 1998 David Mott, PhD, Principal Investigator Awarded by: American Association of Colleges of Pharmacy The first aim of this project was to develop a comprehensive model of the characteristics—health system, physician, patient, insurance system, pharmacy and drug product—associated with generic drug use. The second goal was to use data at the pharmacy level to estimate empirically the effects of factors associated with generic drug use. A database of 7,500 prescription orders dispensed from community pharmacies was used for analysis. Springboard to Teaching Fellowship 1997 David Mott, PhD, Principal Investigator Awarded by: American Foundation for Pharmaceutical Education Patients with Epilepsy 1997 James McAuley, PhD, David Mott, PhD, and Jon C. Schommer, PhD, Principal Investigators Awarded by: Parke-Davis, Inc. Springboard to Teaching Fellowship 1996 David Mott, PhD, Principal Investigator Awarded by: American Foundation for Pharmaceutical Education The Influence of Patient Out-of-Pocket Payment for Prescription Drugs on Unit Costs of Prescribed Drugs: A Case Study in Ohio 1996 David Mott, PhD, Principal Investigator Awarded by: The Ohio State University Aazhiganan Project 1995-1998 Betty Chewning, PhD, Grant Author Awarded by: State of Wisconsin APPS Board to the Aazhiganan Coalition The Sonderegger Research Center was asked to help design and evaluate an education intervention to offer prevention services to adolescents considered at high risk for sexually transmitted disease and pregnancy. The project delivered the program to 150 adolescents through education and case management approaches. This grant augmented the activities of the National Institutes of Health grant already awarded to the Sonderegger Research Center in the same community. Assessment of the Impact of Pharmacy Benefit Managers 1995-1996 David Kreling, PhD, Co-Principal Investigator Helene Lipton, Co-Principal Investigator and Project Director, University of California, San Francisco Awarded by: Health Care Financing Administration, US Department of Health and Human Services This joint project submitted under the HCFA master contract held by the UW Center for Health Systems Research and Analysis (CHSRA) sought to assess the role of pharmacy benefits managers (PBMs) in providing pharmaceutical services and study their impact on quality, costs and other providers of pharmaceutical care. A comprehensive literature review provided background about and suggested a typology of PBMs. Phone interview and site visit surveys with Medicaid Directors, Managed Care Organization (MCO) executives, and PBM executives provided information for comparing costs and quality issues related to PBMs and the potential impact of PBMs on pharmacy systems (including pharmacists, patients, manufacturers, and Medicaid programs). Pharmaceutical Care Outcomes: The Role of the Patient 1993-1999 -Betty Chewning, PhD, Principal Investigator -Carolyn L. Bell, MD, Larry E. Boh, MS, Nancy S. Nowlin, MD, David Kreling, PhD, and Joseph Wiederholt, PhD, Co-Principal Investigators -Dale Wilson, MA, Co-Investigator Awarded by: Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research), US Department of Health and Human Services This descriptive study of patients with rheumatoid arthritis and osteoarthritis documented their medication decisions and outcomes. Over a three-year period, patients’ decisions to augment, substitute, adhere to, or discontinue medications were tracked with respect to both prescription and OTC drugs. Patients’ quality of life and functional health status as well as clinical measures of health status were examined in relation to their prescribed regimen variations and additional OTC drug use. The findings indicate that patients play an active role in their care, and their decisions have major implications for health outcomes. The findings also affirm the importance of acknowledging the complexity of patients’ medication and self-care regimens, the process and safety of patients’ decisions, their priorities for symptom management and economic pressures, and the need for effective partnerships with health care providers. Graduate Explorer Monograph Project 1993-1996 Joseph Wiederholt, PhD, Principal Investigator Awarded by: Glaxo A career guide was developed for pharmacy graduates entering a profession associated with Social Administrative Sciences rather than pharmacy practice. The Guide gives definitions of subdisciplines and the nature of careers available. Examples include pharmaceutical marketing, pharmacy law, and informatics. The guide was piloted-tested and evaluated in 12 Schools of Pharmacy. Methodology for Calculating the Savings Attributable to the Medicaid Drug Utilization Program 1993-1994 David Kreling, PhD, and Joseph Wiederholt, PhD, consultants to Shepard Patterson, Inc. Awarded by: Health Care Financing Administration, U.S. Department of Health and Human Services The product of this effort was a document, “Guidelines for Estimating the Impact of Medicaid DUR” for use by state Medicaid officials and others to evaluate DUR programs and interventions. As written, the guidelines are targeted toward state Medicaid staff and their advisors/consultants/contractors for their drug program DUR activities. Profs. Kreling and Wiederholt were part of a core team of five researchers (also including Ted Collins and David Zimmerman at the UW Center for Health Systems Research and Analysis, and Earlene Lipowski at the University of Florida School of Pharmacy) developing the guidelines with an advisory panel of experts nationwide. Rural Native Americans: A Minority Youth Intervention 1992-1999 Betty Chewning, PhD, Principal Investigator Pat Kokotailo, MD, and Dale Wilson, MA, Co-Investigators Awarded by: National Institute of Child Health and Human Development, US Department of Health and Human Services This collaboration with the Great Lakes Inter-Tribal Council worked to reduce adolescent pregnancy, the incidence of sexually transmitted disease, including HIV, and violence. Community and school-based interventions were targeted at adolescents in the community. The intervention used video, computer and class exercises to develop increased social skills for problem-solving, accessing support and services, and reducing health risk-taking behaviors. A longitudinal design of annual student surveys was used to examine the impact of different durations of exposure to the curriculum in Grades 6 through 9. Factors significantly associated with abstention from intercourse and/or consistent use of birth control included perceived lower risk behavior of friends, higher perceived parental support, higher perceived parental knowledge and monitoring of the adolescent’s activities and friends, a higher value on scholastic achievement, higher reported academic performance, and higher self-efficacy for safer sexual behaviors. Evaluation of the Wisconsin Pharmacy Self-Inspection Project 1992-1994 Joseph B. Wiederholt, PhD, Principal Investigator Jon C. Schommer PhD, and Thomas D. McGregor MBA, Co-Investigators Funding from: Wisconsin Department of Regulation and Licensing and an educational grant from Schering Pharmaceuticals To address the problems of understanding and interpreting pharmacy legal regulations (e.g., pharmacist consultation), the Wisconsin Pharmacy Examining Board (PEB) implemented a voluntary self-assessment program, the Wisconsin Pharmacy Self-Inspection Project. Of the 1,200 pharmacies (pharmacy managers) asked to participate, 80% did, and over 75% of the participants reported they had made changes in their practices to update practice procedures and improved compliance with regulations. Patient Gender and Psychotropic Prescribing 1992-1993 Betsy Sleath, PhD, Principal Investigator Bonnie Svarstad, PhD, Co-Investigator Awarded by: Agency for Health Care Policy Research, U.S. DHHS The study examined how patient gender differences in 508 audio-taped physician-patient interactions influenced the prescribing of psychotropic medications to male and female patients in 11 different primary care settings. Seventeen percent of the patients received at least one or more prescriptions for psychotropic medications. Logistic regression techniques were used to examine how: (1) patient gender, (2) patient somatic, emotional, and social problem expression, and (3) physician perceptions of patient emotional health and social problems influenced psychotropic prescribing. Male patients were almost twice as likely to receive a prescription. Patients who expressed more emotional complaints and patients physicians perceived as being in worse emotional health were significantly more likely to receive a prescription for psychotropic medication. Up-to-date Immunization Evaluation Project 1992-1993 Betty Chewning, PhD, Director, in collaboration with the Dane County Head Start Program Awarded by: U.S. Administration for Children and Families Madison’s most vulnerable population includes children under age two from the lowest income families. The Sonderegger Research Center was asked to collaborate with the Dane County Head Start Program and staff from the Madison Department of Public Health to design and evaluate an innovative program to increase immunizations to this difficult-to-reach group. This research led to a series of recommendations and a further grant submission in collaboration with the Dane County Head Start Program involving pharmacy students to help implement a comprehensive program to reach families most at risk. Background Paper — Alternative Payment Methods: Value and Payment of Pharmacy Services 1992 David Kreling, Co-Investigator with Michael T. Rupp, PhD, Associate Professor of Pharmacy Administration at Purdue University Awarded by: National Association of Chain Drug Stores A literature review of published and unpublished papers on the value of pharmacists’ cognitive services was written as background for a task force assembled by NACDS intended to examine the potential of alternate payment mechanisms that could be used to recognize and reward non-dispensing cognitive services by pharmacists. The literature search was supplemented with descriptions of research projects underway at universities relative to pharmacist cognitive service activities and provision thereof, with particular focus on those valuing the services (outcomes quantification). The studies and projects identified and reviewed support the notion that professional pharmacy services “add value to” patient care. The scope, magnitude, and cost of drug-related problems are compelling arguments that efforts to improve drug use are warranted. Although the “value” of pharmacists’ professional services has yet to be quantified fully, evidence in support of the positive impact that pharmacists’ efforts can have on patient health and economic outcomes is substantial. Analysis of Prescription Marketplace Parameters and Reimbursement 1991-1992 David Kreling, PhD, Principal Investigator Funded by: National Association of Chain Drug Stores Reimbursement amounts that would result from different approaches for determining third-party prescription payment were compared with marketplace parameters (usual and customary prices), and with each other to examine the effects of different methods or levels of reimbursement. Payment amounts under many potential scenarios were simulated for the market mix of prescriptions dispensed in community pharmacies that was represented by audit data on cash prescriptions dispensed in the pharmacies. Payment simulations included percentile caps on U&C prices and drug cost plus dispensing fee formulas, where drug cost estimates were based on varying discounts off of Average Wholesale Price (AWP) or varying percent mark-ups added to Wholesaler Acquisition Cost (WAC). To examine additional provisions typical in public (Medicaid) prescription drug programs, drug cost limits (FFP limits) and use of the lower of the calculated formula amount or U&C price (“lower of” clause) were added to the simulations. With a given payment level as a standard or basis, it generally was possible to match the overall outcome of that payment with alternate methods of determining payment amounts. Payment methods that combined FFP ingredient cost payment limit and “lower of” provisions yielded the most conservative payment levels. The Pharmaceutical Access and Prudent Purchasing Act of 1990: Estimating the Economic Impact on Institutional Pharmacy Providers 1990 David Kreling, PhD, Principal Investigator Funded by: American Society of Hospital Pharmacy The Pharmaceutical Access and Prudent Purchasing Act of 1990 included provisions whereby manufacturers of pharmaceuticals would be asked via a rebate mechanism to charge Medicaid programs no more than the lowest price charged to hospitals or other organizations serving the indigent. In this analysis we attempted to project, in the form of revenue shifts, the impact on hospitals that could occur by estimating potential pharmaceutical product price increases and subsequent costs of products purchased by institutional pharmacy providers as a result of the “best price” provision. The overall impact was estimated as increases in costs for hospital pharmaceutical purchases of approximately 4 to 7 percent. The estimates depended on the discount assumed that Medicaid would achieve from the “best price” provision, the mix of single-source and multiple-source pharmaceuticals used in the hospital, and whether the revenue compensation would occur as price increases on all products or single-source products only. The International Medication Compliance Project 1989-1991 Betty Chewning, PhD, Principal Investigator Bonnie Svarstad, PhD, and Larry E. Boh, MS, Co-Investigators Awarded by: APOTEKSBOLAGET, The National Corporation of Swedish Pharmacies Consumers of prescription medications often make one or more mistakes in taking their drugs: errors with respect to dosage, duration and/or early discontinuation of the medication prescribed. This joint Swedish and American project developed and evaluated an instrument to be used cross-nationally to measure patient drug errors. The instrument also measured factors to identify whether an individual was at risk of noncompliance. The instrument became the Brief Medication Questionnaire (BMQ). Investigators also tested the use of MEMS (a computerized medication vial cap that records each time the cap is opened) to validate the BMQ. Practice Economics in Community Pharmacies 1989 David Kreling, PhD, Principal Investigator Funded by: Wisconsin Independent Community Pharmacists Pharmacy providers participating in prescription drug plans of HMO and third-party insurers have been offered contracts with changes in payments for prescriptions dispensed to beneficiaries. Payments have been reduced in attempts to control costs for the drug component of coverage HMOs and insurers provide. Pharmacist costs of providing services were analyzed in relation to potential revenues from third-party reimbursements for a small, pilot sample of nine pharmacies. Cost of dispensing was estimated from data gathered from pharmacists via a brief self-report questionnaire. Revenues were estimated for 100 prescriptions [approximately 50 single source (brand) and 50 multi-source (generic) prescriptions] dispensed in the pharmacies. Existing and proposed reimbursement formulas were applied to the 100 prescriptions (drug cost plus fee formula) and the resulting gross margins were compared with the cost of dispensing for the pharmacies. Demonstration and Evaluation of a Computerized Contraceptive Counseling Aid for Adolescents 1988-1991 Betty Chewning, PhD, Principal Investigator Pat Mosena, PhD, Co-Principal Investigator for Chicago subcontract Awarded by: Office of Family Planning, US Department of Health and Human Services Patients’ drug compliance is a critical issue in the pharmacy field. This project examined the impact of a computerized education program on subsequent oral contraception compliance of family planning clinic patients. To assist individuals in selecting and using birth control, this research developed a computerized counseling aid, using input from national and local advisory committees. The computerized contraceptive decision aid was evaluated in terms of the patient knowledge, confidence, use and discontinuance of oral contraceptives. The target audience for this research consisted of women under age 20 who were making an initial visit to a Title X family planning clinic. A longitudinal study was conducted with 950 clients in inner-city Chicago and Madison. When clients were interviewed following their use of the computer program, none of the Madison, and only 2% of the Chicago clients reported they did not like using the computer. Sixty-seven percent of the Madison and 63% of the Chicago clients reported the program made them feel better about the method they chose. Immediately after the visit, and again one year later, there were significant gains in knowledge and confidence about oral contraceptives for the experimental group who had seen the computer program versus the control group who had not. Estimating the Costs of Inappropriate Psychotropic Medication Use Among Nursing Home Patients 1988 David Kreling, PhD, Principal Investigator Funded by: Graduate School, University of Wisconsin–Madison A method was developed to estimate direct costs of potentially inappropriate medication orders. Data from a previous qualitative study investigating the appropriateness of psychotropic drug orders among 760 nursing home residents in seven long-term care facilities in Wisconsin were used to exemplify the method. Direct costs were estimated by assigning the drug product cost for the number of units billed at Medicaid reimbursement rates and adding the Medicaid dispensing fee amounts. Overall, 80.7% of the dollars spent for psychotropic drug orders in this population of nursing home residents may have been wasted due to potentially inappropriate use. Antipsychotic orders with potential errors associated with them had both the highest estimated total monthly cost ($2,318) and mean monthly cost ($13.72). The type of potential error with the greatest estimated monthly cost was drugs with no indication (no corresponding diagnosis on the medical chart). Environmental Dimensions of Consumer Choice For the Purpose of Prescription Drugs 1986-1988 PhD dissertation by Earlene Lipowski Major professor Joseph B. Wiederholt, PhD Partially funded by: Sonderegger Research Center Some consumers select a pharmacy with little deliberation whereas others thoughtfully weigh multiple attributes. This study assessed the motivation and self-rated ability of consumers to select a pharmacy for the purchase of a prescription drug and examined the personal and environmental factors related to their motivation and ability. We surveyed 757 households in three communities with different pharmacy market environments and obtained responses from 461 (61%). Motivation varied with respondents’ perception of the business complexity of retail pharmacy, their familiarity with the prescription purchase task, income, product involvement, age and annual medical expenditures (R-square = 0.20). Predictors of perceived ability included familiarity with prescription purchase task and perception of interdependence among health professionals, the business complexity of retail pharmacy, conflict among health professionals, and diversity among pharmacies (R-square = 0.17). More reliable measures of consumer perceptions are needed, but market environment and individual characteristics appear to influence motivation and ability and thereby affect the choice process. Predicting Sleep Medication Use in Nursing Homes 1985-1988 Bonnie Svarstad, PhD, Principal Investigator Funded by: National Institute on Aging, NIH The purpose of this study was to examine the resident, nurse, and facility factors that affect the nature and quality of sleep medication use in nursing homes. Over 2,000 residents in 18 randomly selected skilled nursing facilities were studied using medical and pharmacy records, nurse surveys, and observational data. Findings showed that the quality of psychoactive drugs use was better in facilities with a resident-centered treatment culture and better nurse staffing. The study also found that resident depression, pain, and demand for medication played a significant role in whether or not the resident received benzodiazepine medications on a chronic basis. A follow-up study was done in the same facilities after implementation of stricter federal regulations. Results showed that antipsychotic drug use declined as a result of stricter regulations; however, stricter regulations had no effect on the prevalence or chronic use of benzodiazepines, antidepressants, or polymedicine. Aid for Contraceptive Decision Making 1985-1987 Betty Chewning, PhD, Principal Investigator Harold Erdman, PhD, Co-Investigator Awarded by: Office of Family Planning, US Department of Health and Human Services In this project investigators developed and pilot tested a computerized contraceptive counseling aid to be used in family planning clinics with adolescents. Antecedents and Sequella of Adolescent Sexual Risk-Taking 1985-1987 Betty Chewning, PhD, Principal Investigator Awarded by: Office of Adolescent Pregnancy Prevention, US Department of Health and Human Services This study involved analysis of a longitudinal data set to identify the relationship between key variables and sexual risk-taking of adolescents. The Potential Impact of Drug Reimbursement Policy Changes on Community Pharmacies in Wisconsin 1985-1986 David Kreling, PhD, Principal Investigator Funded by: Sonderegger Research Center This research analyzed how varying levels of reimbursement for prescription drug ingredient costs would affect community pharmacies economically. Specifically, the study evaluated whether drug cost reimbursement based on Average Wholesale Price (AWP) less 10.5% or wholesaler cost plus 5.01% would yield amounts above or below what pharmacists paid for products. Purchase costs for a large market basket of products were obtained from wholesalers serving community pharmacies throughout the state. Additional information about purchasing and pharmacy characteristics was obtained directly from pharmacists. In general, pharmacists were able to purchase drugs at the reimbursement amounts proposed. The “cost plus” reimbursement amounts tended to be more conservative, and variation between pharmacies was related to their purchase patterns, i.e. the wholesaler purchased from and percent of purchases from those wholesalers versus direct from manufacturers. The type of product involved (generic, brand, controlled substances, etc.) was also a factor.