Research Article
Physicians’ Preferences for Communication of Pharmacist-Provided Medication Therapy Management in Community Pharmacy
Journal of Pharmacy Practice 2017, Vol. 30(1) 17-24 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190015585764 journals.sagepub.com/home/jpp
Kendall D. Guthrie, PharmD1,2, Steven C. Stoner, PharmD, BCPP3, D. Matthew Hartwig, BS, RPh4, Justin R. May, PharmD5, Sara E. Nicolaus, PharmD6, Andrew M. Schramm, PharmD5, and Kristen L. DiDonato, PharmD, BCACP3,4
Abstract Objectives: (1) To identify physicians’ preferences in regard to pharmacist-provided medication therapy management (MTM) communication in the community pharmacy setting; (2) to identify physicians’ perceived barriers to communicating with a pharmacist regarding MTM; and (3) to determine whether Missouri physicians feel MTM is beneficial for their patients. Methods: A cross-sectional prospective survey study of 2021 family and general practice physicians registered with MO HealthNet, Missouri’s Medicaid program. Results: The majority (52.8%) of physicians preferred MTM data to be communicated via fax. Most physicians who provided care to patients in long-term care (LTC) facilities (81.0%) preferred to be contacted at their practice location as opposed to the LTC facility. The greatest barriers to communication were lack of time and inefficient communication practices. Improved/enhanced communication was the most common suggestion for improvement in the MTM process. Approximately 67% of respondents reported MTM as beneficial or somewhat beneficial for their patients. Conclusions: Survey respondents saw value in the MTM services offered by pharmacists. However, pharmacists should use the identified preferences and barriers to improve their currently utilized communication practices in hopes of increasing acceptance of recommendations. Ultimately, this may assist MTM providers in working collaboratively with patients’ physicians. Keywords medication therapy management, community pharmacy, communication, physician preferences, barriers
Introduction There are approximately 1.5 million preventable adverse events that occur each year in the United States, resulting in US$177 billion in injury and death.1,2 Among these adverse events, a high incidence of preventable adverse drug events in the ambulatory care setting has been well documented in the literature.3-5 Additionally, the World Health Organization estimates the adherence rate for chronic medications to be approximately 50% for developed countries.6 In the United States, this nonadherence is estimated to contribute to 33% to 69% of medication-related hospital admissions resulting in approximately US$100 billion.7 Community pharmacists have the opportunity to improve these patient outcomes by providing medication therapy management (MTM) services. MTM services have the potential to increase patient adherence to chronic medications and decrease preventable adverse drug events.8 These services are provided in an effort to improve the quality of chronic care management and reduce health care expenses by preventing medication-related adverse outcomes.8
As first described in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, MTM services are designed to promote enhanced patient understanding, increased patient adherence to medication regimens, and detection of adverse drug events and patterns of overuse and underuse of prescription medications.9 To help achieve these goals
1
Red Cross Pharmacy, Inc, Warrensburg, MO, USA Was PGY1 Community Practice Resident, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA at the time this study was conducted 3 School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA 4 Red Cross Pharmacy, Inc, Excelsior Springs, MO, USA 5 Red Cross Pharmacy, Inc, Marshall, MO, USA 6 Red Cross Pharmacy, Inc, Grain Valley, MO, USA 2
Corresponding Author: Kristen L. DiDonato, Health Sciences Building 3244, 2464 Charlotte Street, Kansas City, MO 64108, USA. Email: [email protected]
18 and standardize the MTM process, the American Pharmacists Association and the National Association of Chain Drug Stores Foundation established 5 core elements of an MTM service model which include medication therapy review (MTR), personal medication record (PMR), medication-related action plan (MAP), intervention and/or referral, and documentation and follow-up.10 The intervention component to the MTM service model is vital to the success of these encounters. For these encounters to be effective, open communication must exist between prescribers, pharmacists, and patients.11 Numerous studies have been conducted to assess physicians’ perceptions and attitudes toward pharmacist-provided MTM services.11-16,17 In several of these studies, physicians point out the importance of pharmacist–physician collaboration and communication.11,12,16 However, no study has specifically evaluated physicians’ preferences and barriers in regard to communication of pharmacist-provided MTM recommendations in the community pharmacy setting. Addressing this knowledge gap may assist MTM providers in working collaboratively with patients’ physicians to optimize medication regimens and improve health outcomes.
Objectives The study objectives were to identify physicians’ preferences in regard to pharmacist-provided MTM communication in the community pharmacy setting; to identify physicians’ perceived barriers to communicating with a pharmacist regarding MTM; and to determine whether Missouri physicians feel MTM is beneficial for their patients.
Methods Study Setting The study was conducted within a family-owned, community pharmacy chain that serves northwest and central Missouri towns. The pharmacy chain consists of 15 retail pharmacies, 3 long-term care (LTC) pharmacies, and 2 durable medical equipment companies. MTM services are provided at these pharmacy locations using 3 Web-based platforms: OutcomesMTM (Outcomes, Inc, West Des Moines, Iowa), MirixaPro (Mirixa Corp, Reston, Virginia), and Direct Care Pro (ACS Health Management Solutions, Inc, Dearborn, Michigan). The pharmacy chain is currently working to improve the MTM services offered by the company in hopes of having more impactful, effective patient encounters. To help accomplish this goal, the company would like to improve pharmacist–physician communication practices.
Study Design A cross-sectional, prospective study was conducted using anonymous mail-in surveys. Surveys were distributed on January 9, 2014, and collected until June 1, 2014. Included in each mailing was a 1-page introduction letter (Appendix A), a 1-page survey (Appendix B), and a yellow postage-paid return envelope.
Journal of Pharmacy Practice 30(1) Study subjects were selected utilizing the publicly available provider listing maintained by MO HealthNet, Missouri’s Medicaid program. This physician database is organized by practice specialty and includes the physicians’ practice addresses and phone numbers. Fax numbers and e-mail addresses are not included in the listing. This study targeted the 2021 family and general practice physicians registered with MO HealthNet. Following the initial mailing of surveys, an additional round of faxed survey reminders were sent to 206 physicians on the listing whose fax numbers were contained within the pharmacy’s dispensing software. Included with each faxed reminder was the 1-page introduction letter and 1-page survey originally distributed by mail, along with an individualized cover letter. Due to the anonymous nature of the study, there was no way to identify which physicians had previously responded to the survey. Of the original 110 Missouri counties that received mailed surveys, the second round of faxed surveys focused on 10 of those counties where the pharmacy’s stores are located. These faxed survey reminders were sent between March and May 2014. To maintain anonymity, identifying information (including practice names and fax numbers) was removed from the returned surveys prior to reaching study investigators. This study was granted exemption by the institution’s Institutional Review Board in November 2013.
Survey Design A nonvalidated survey instrument was developed to collect the data necessary to meet the stated objectives. All questions were either multiple-choice, yes/no, or short answer format. The first set of survey questions assessed the following demographic and practice characteristics: gender, age, years in practice, practice specialty, and physicians’ experience with MTM. Next were several questions assessing physicians’ preferences for communication of MTM recommendations. These questions addressed preferred contact method, time, and preferred location for LTC physicians. The next question evaluated the familiarity of physicians with the Centers for Medicare and Medicaid Services (CMS) requirement for targeted Medicare patients to receive an annual medication review, followed by a question pertaining to physicians’ perceived barriers to communicating with pharmacists about MTM recommendations. This question allowed participants to enter ‘‘other’’ answers in addition to the available answer choices provided. Physicians were also asked whether or not they feel that MTM is beneficial for their patients. The last question on the survey was an openended question allowing participants to provide any further suggestions to improve the MTM process. Survey questions were developed using the experience and feedback of 5 pharmacists within the organization who provide MTM services. These pharmacists participated in 3 rounds of survey review and feedback. The survey was limited to 1 page, with 13 questions, in hopes that participants would complete it in its entirety. The finalized introduction letter and survey were then pilot tested by a local practitioner to ensure clarity and relevance of questions.
Guthrie et al
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Data Collection and Analysis
Table 1. Demographic Information.a
Completion of the survey instrument served as consent to participate in the study. Participants were informed that information would be collected in an anonymous nature. One investigator coded and entered all data into the statistical software program to provide consistency. Responses to open-ended questions were categorized into themes by 3 of the study investigators, based on consensus. Data points were analyzed using the IBM Statistical Package for Social Science Version 21 for Windows (SPSS1, Chicago, Illinois) and expressed as frequencies.
Variable
Results Of the 2021 mailed surveys, 6 were returned as undeliverable, making the adjusted sample size 2015. A total of 123 responses were received, giving a response rate of 6.1%. The demographic characteristics of the respondents are described in Table 1. The majority of respondents were males between 50 and 69 years of age. Although the provider listing used to identify the target population was only supposed to include family and general practice physicians, several respondents stated they were a specialist. Of the 123 responding physicians, 62.6% were familiar with the CMS requirement for targeted Medicare patients to receive an annual medication review. With regard to physicians’ preferences for MTM communication (Table 2), the majority of responding physicians preferred MTM data to be communicated via fax. Most of the responding physicians had no preference on the time of day to be contacted, but the least preferred time of day was evening. Approximately one-half of the respondents also provided care to patients in LTC facilities. Of those LTC physicians, the majority preferred to be contacted at their practice locations (81.0%). In response to physicians’ perceived barriers to communicating with pharmacists about MTM recommendations (Table 3), 15 ‘‘other’’ answers were provided in addition to the available answer options. The barriers were grouped into 6 different themes: no barriers, inefficient communication practices, lack of understanding, pharmacist not qualified, incomplete data/ inaccuracies, and lack of time. Of these barriers, lack of time and inefficient communication practices were the greatest barriers identified. Approximately one-fourth of the physicians did not feel there were any barriers to communication. For lack of time, physicians felt they do not have enough time to look at and respond to all of the MTM recommendations on top of their regular daily duties. Physicians’ thoughts regarding inefficient communication practices focused both on the method of communication used and on the way pharmacists were conveying recommendations within these communications. Examples of these communication issues included pharmacists using an inefficient communication format and communication not being integrated into the electronic medical record (EMR). Lack of understanding refers to the physicians having a misunderstanding of what MTM is and why pharmacists are performing
Gender Male Female No response Age 20-29 30-39 40-49 50-59 60-69 70-79 Other No response Years in practice 0-5 6-10 11-15 16-20 21-25 >25 No response Practice specialtyb Family medicine General medicine Emergency medicine Internal medicine Endocrinology Addictionology Wound care Obstetrics and gynecology Dermatology Infectious disease Rheumatology Cardiology Gastroenterology Sports medicine No response Previous MTM contact Yes No Unsure No response
Response, n (%) 84 (68.3) 36 (29.3) 3 (2.4) 1 (0.8) 21 (17.1) 24 (19.5) 32 (26.0) 37 (30.1) 1 (0.8) 1 (0.8) 6 (4.9) 10 (8.1) 16 (13.1) 17 (13.8) 11 (8.9) 17 (13.8) 45 (36.6) 7 (5.7) 97 (78.9) 6 (4.9) 6 (4.9) 4 (3.3) 2 (1.6) 2 (1.6) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 2 (1.6) 60 (48.8) 59 (48.0) 2 (1.6) 2 (1.6)
Abbreviations: MTM, medication therapy management. a n ¼ 123. b Participants could select more than one answer to this question.
MTM encounters. For incomplete data/inaccuracies, some of the physicians felt pharmacists did not have enough information to make recommendations for patients. This includes more complex medical issues being present that are not apparent by looking at the medication list, pharmacists not reviewing the patient’s history prior to making a recommendation, and pharmacists not having access to medical records. A small percentage of physicians (4.9%) felt pharmacists were not qualified to be performing MTM encounters with patients. Forty unique responses were provided for the last openended question on the survey. Further suggestions to improve
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Journal of Pharmacy Practice 30(1)
Table 2. Physician Communication Preferences.a Variable Preferred contact methodb Fax Telephone Postal mail Email Prefer not to be contacted Electronic No response Preferred time of dayb No preference Morning Afternoon No preference-not evening Evening No response Provide care at LTC facility Yes No No response Preferred contact location for LTC physiciansc Practice location LTC facility Not applicable No response
Table 4. Further Suggestions to Improve MTM Communication.a,b Response, n (%) 65 (52.8) 16 (13.0) 16 (13.0) 13 (10.6) 13 (10.6) 7 (5.7) 4 (3.3) 61 (49.6) 26 (21.1) 11 (8.9) 5 (4.1) 4 (3.3) 16 (13.0) 58 (47.2) 62 (50.4) 3 (2.4) 47 (81.0) 9 (15.5) 1 (0.8) 1 (0.8)
Abbreviations: LTC, long-term care. a n ¼ 123. b Participants could select more than 1 answer to this question. c Based on the 58 physicians who provide care to patients in LTC facilities.
Table 3. Perceived Barriers to Communicating With Pharmacists Regarding MTM.a,b Variable Perceived barriers Lack of time No barriers Inefficient communication practices Lack of understanding No response Incomplete data/inaccuracies Pharmacist not qualified
Response, n (%) 64 (52.0) 30 (24.4) 28 (22.8) 14 (11.4) 9 (7.3) 8 (6.5) 6 (4.9)
Abbreviations: MTM, medication therapy management. a n ¼ 123. b Participants could select more than 1 answer to this question.
MTM communication (Table 4) included the following themes: improved/enhanced communication (19.5%), MTM process education/increased awareness (4.9%), enhanced qualifications (4.1%), reimbursement/expansion to other populations (2.4%), and dedicated time (2.4%). Improved/enhanced communication was the most common suggestion for improvement in the MTM process. This included integrating communication into the EMR, keeping communications brief, providing rationale behind recommendations, and filtering concerns to the most important issues. For MTM process
Variable Further suggestions Improved/enhanced communication MTM process education/increased awareness Enhanced qualifications Dedicated time Reimbursement/expansion to other populations No response
Response, n (%) 24 6 5 3 3 84
(19.5) (4.9) (4.1) (2.4) (2.4) (68.3)
Abbreviations: MTM, medication therapy management. a n ¼ 123. b Two participants offered 2 suggestions for this question.
education/increased awareness, several physicians felt they do not understand what MTM is and thought pharmacists should educate physicians regarding MTM processes. A small percentage of physicians (4.1%) felt that pharmacists needed enhanced qualifications and/or additional training to perform these services. For the dedicated time theme, a few physicians felt they did not have enough time in their day to respond to pharmacist inquiries and needed dedicated time in their day to work on MTM communications. Finally, 3 physicians felt this service should be offered and reimbursed for nonMedicare patients as well as for the Medicare patients currently being served. Despite the barriers and suggestions for improvement identified in the survey, approximately 66.7% of respondents reported MTM as beneficial or somewhat beneficial for their patients.
Discussion The results from this study indicate that the majority of physicians see value in the MTM services offered by pharmacists. This is in contrast to a previous study completed by Alkhateeb et al, which showed low physician support of pharmacistprovided MTM services. That study showed that only 36% of surveyed West Virginia physicians felt pharmacists should provide MTM services.15 Although our study did not specifically compare physicians’ opinions on which type of provider should conduct MTM services, participants did appear to see value in these MTM programs. This study also shows that pharmacists may have higher success rates when communicating MTM data via fax. This is comparable to the results of a study completed by McGrath et al. The qualitative study assessed physician perceptions of pharmacist-provided MTM through a focus group. In an exit survey given to study participants, physicians were asked how they would like to be contacted regarding specific patients seen by pharmacists. The survey showed that 18 (78%) of the 23 participants preferred faxed communications from pharmacists. In comparison, our study showed 52.8% of physicians preferred faxed MTM communications from pharmacists. In the McGrath article, participants were only given 4 options to choose from for preferred method of communication: telephone, fax, postal mail, or would not participate.16 Our study provided
Guthrie et al the additional option of e-mail, and several participants added electronic as their preferred method of communication in the ‘‘other’’ category. Even with these additional answer options, faxed communication was still the most preferred method of communication and could lead to a higher percentage of answered physician communications. The results of this study show that physicians have many barriers to communicating with pharmacists regarding MTM. In order to have successful patient encounters and improve patient outcomes, pharmacists should work to address these barriers to provide high-quality medication reviews and recommendations. Many of the barriers identified in our study were also identified in the McGrath study. Overlapping concerns with MTM were pharmacist qualifications, reimbursement, incomplete data, physician misunderstanding of MTM, and the importance of clear communication between the pharmacist and physician. Additional issues mentioned in the McGrath study that were not identified in our study were the need for physicians and pharmacists to think like-minded regarding patient care and the need for the pharmacists conducting these services to be within the physician’s office.16 Overall, the 2 studies appear to identify many of the same physician barriers to working with pharmacists. To address some of these barriers, each pharmacy conducting MTM encounters should assess the currently utilized methods of communication and make changes when necessary to ensure brevity and clarity. Some of the physicians surveyed in the study indicated that pharmacists are using inefficient communication formats, which could suggest lack of conciseness and/or lack of supporting details. While keeping communications brief, reasoning and rationale should be included on all recommendations.12,18 Before making recommendations to physicians, pharmacists should always research the patient’s medication regimen and history to ensure accurate and valuable recommendations are being made.12 Finally, pharmacists should make an effort to educate physicians about the MTM process and the benefits of the service to both patients and physicians.16 A common theme that was mentioned several times during this study was the need for pharmacists to have access to the patient’s medical record and/or EMR. Although only 7 participants chose electronic communication as their preferred method of communication, this was not a predetermined answer choice but was written by study participants in the ‘‘other’’ category. We may have seen an even higher percentage of physicians choose this option had it been listed as an answer choice. In a study conducted by Lauffenburger et al, primary care physicians participated in focus groups to determine their perspectives on working with a pharmacist to manage medications and key attributes/barriers to an effective MTM program. Similar to our study, the physicians in this study identified lack of access to the patient’s medical record as a potential barrier to successful MTM encounters.12 In the future, pharmacist access to medical records and the ability to communicate with physicians through these electronic records may lead to more successful pharmacist–physician communication.
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Limitations The major limitation in this study is the low survey response rate, which could contribute to nonresponse bias. However, low survey response rates are common in physician populations.19 Use of a respondent-friendly questionnaire, personalized mailings, repeat contact for physicians within our pharmacy database, and mailings with postage-paid return envelopes were used to try to limit nonresponse bias.19 It is possible that the survey responders would be more open to pharmacist-provided MTM and more likely to respond to pharmacist recommendations. This could have potentially biased our results making the physicians view MTM services more favorably. Because the physician listing only included Missouri physicians, lack of geographic diversity could limit generalizability to all physicians. In addition, due to the low response rate and anonymous nature of the survey, there is no way to tell whether the surveyed population is representative of all regions of the state. The physician database used to identify the target population had many limitations in itself. First, the database only included mailing addresses. No e-mail addresses or fax numbers were included in the database. Based on the results of this study, fax appears to be the preferred method of communication, so there may have been a higher response rate sending the surveys via this method. Due to the rising utilization of technology and the interest in electronic communication identified in the study, we may have had a higher response rate if the listing included provider e-mail addresses. Furthermore, we were unable to follow-up with the target population or send reminders without the added expense of an additional mailing. This restricted our follow-ups to the small number of physicians whose fax numbers were contained within our pharmacy database. Additionally, the database was only supposed to include family and general practice physicians. As shown in Table 1, many physicians responded stating they were specialists. In a study conducted by Perera et al, the authors found that the approval rate for faxed MTM recommendations was greater for primary care physicians than for specialist physicians.11 If many specialists were included in the listing, this could have contributed to a broader group of subjects than we intended to target and a less favorable outlook on MTM services. Furthermore, due to the brevity of the survey instrument and the vague nature of some of the collected answers, some questions remain unanswered. In regard to the comments about inefficient communication formats, it is unclear whether the physicians were referring to the length of communications, communication style, and/or level of detail provided within the documentation. In future studies, it would also be beneficial to see how many pharmacist-provided MTM recommendations physicians are receiving on average and for those physicians who were never contacted by a pharmacist regarding MTM recommendations, what they are basing their experiences on.
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Conclusion Through MTM services, pharmacists can make a significant impact on patient outcomes. Although many Missouri physicians are aware of MTM services and appear to see value in these MTM services offered by pharmacists, several barriers to successful pharmacist–physician communication were identified. To be more effective in the MTM process, each pharmacy conducting these encounters should use an efficient and concise communication format, research the patient’s
Journal of Pharmacy Practice 30(1) medication regimen and history, and provide reasoning behind recommendations. Additionally, to assist MTM providers in working collaboratively with patients’ physicians, pharmacists should make an effort to educate physicians about the MTM process and the benefits of the service. Increasing pharmacist–physician collaboration and physicians’ responsiveness to recommendations could ultimately lead to optimized medication regimens and improved health outcomes.
Appendix A. Cover letter for physician survey mailing
Guthrie et al
Appendix B. Survey instrument
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24 Acknowledgments We thank Ethan Osborn, PharmD; Clayton Thompson, PharmD; Nick Cook, PharmD; and Bit Vo, PharmD for their assistance with data collection.
Authors’ Note This study was presented previously at the American Pharmacists Association Annual Meeting, Orlando, Florida, March 29, 2014; at the University of Missouri-Kansas City Health Sciences Student Research Summit, Kansas City, Missouri, April 17, 2014; at the Midwest Pharmacy Residents Conference, Omaha, Nebraska, May 9, 2014; and at the Missouri Pharmacy Association and Illinois Pharmacy Association joint Annual Convention and Trade Show, St. Louis, Missouri, September 27, 2014.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The University of Missouri-Kansas City Community Residency Program at Red Cross Pharmacy is funded by a Community Pharmacy Residency Expansion Project (PREP) grant from the National Association of Chain Drug Stores Foundation.
References 1. Institute of Medicine. Preventing medication errors; 2006. Web site. https://www.iom.edu/~/media/Files/Report%20Files/2006/ Preve nting-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf. Accessed May 11, 2015. 2. Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc. 2001;41(2):192-199. 3. Sarkar U, Lopez A, Maselli JH, et al. Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res. 2011;46(5):1517-1533. 4. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564. 5. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-1016. 6. World Health Organization. Adherence to long-term therapies: evidence for action; 2003. Web site. http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf?ua¼1. Accessed May 11, 2015.
Journal of Pharmacy Practice 30(1) 7. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497. 8. Perlroth D, Marrufo G, Montesinos A, et al. Medication therapy management in chronically ill populations: final report; 2013. Web site. http://innovation.cms.gov/Files/reports/MTM_Final_ Report.pdf. Accessed May 11, 2015. 9. Centers for Medicare and Medicaid Services. Medicare program: Medicare prescription drug benefit; 2005. Web site. http://www. gpo.gov/fdsys/pkg/FR-2005-01-28/pdf/05-1321.pdf. Accessed May 11, 2015. 10. Burns A. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc. 2008;48(3):341-353. 11. Perera PN, Guy MC, Sweaney AM, et al. Evaluation of prescriber responses to pharmacist recommendations communicated by fax in a medication therapy management program (MTMP). J Manag Care Pharm. 2011;17(5):345-354. 12. Lauffenburger JC, Vu MB, Burkhart JI, et al. Design of a medication therapy management program for Medicare beneficiaries: qualitative findings from patients and physicians. Am J Geriatr Pharmacother. 2012;10(2):129-137. 13. Padiyara RS, Rabi SM. Physician perceptions of pharmacist provision of outpatient medication therapy management services. J Am Pharm Assoc. 2006;46(6):660-663. 14. Alkhateeb FM, Unni E, Latif D, et al. Physician attitudes toward collaborative agreements with pharmacists and their expectations of community pharmacists’ responsibilities in West Virginia. J Am Pharm Assoc. 2009;49(6):797-800. 15. Alkhateeb FM, Clauson KA, McCafferty R, et al. Physician attitudes toward pharmacist provision of medication therapy management services. Pharm World Sci. 2009;31(4):487-493. 16. McGrath SH, Snyder ME, Duen˜as GG, et al. Physician perceptions of pharmacist-provided medication therapy management: qualitative analysis. J Am Pharm Assoc. 2010;50(1):67-71. 17. Oladapo AO, Rascati KL. Review of survey articles regarding medication therapy management (MTM) services/programs in the United States. J Pharm Pract. 2012;25(4):457-470. 18. McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effective precepting. Am J Pharm Educ. 2006;70(3):58. 19. Field TS, Cadoret CA, Brown ML, et al. Surveying physicians, do components of the ‘‘Total Design Approach’’ to optimizing survey response rates apply to physicians? Med Care. 2002;40(7): 596-605.
Physicians’ Preferences for Communication of Pharmacist-Provided Medication Therapy Management in Community Pharmacy
Journal of Pharmacy Practice 2017, Vol. 30(1) 17-24 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190015585764 journals.sagepub.com/home/jpp
Kendall D. Guthrie, PharmD1,2, Steven C. Stoner, PharmD, BCPP3, D. Matthew Hartwig, BS, RPh4, Justin R. May, PharmD5, Sara E. Nicolaus, PharmD6, Andrew M. Schramm, PharmD5, and Kristen L. DiDonato, PharmD, BCACP3,4
Abstract Objectives: (1) To identify physicians’ preferences in regard to pharmacist-provided medication therapy management (MTM) communication in the community pharmacy setting; (2) to identify physicians’ perceived barriers to communicating with a pharmacist regarding MTM; and (3) to determine whether Missouri physicians feel MTM is beneficial for their patients. Methods: A cross-sectional prospective survey study of 2021 family and general practice physicians registered with MO HealthNet, Missouri’s Medicaid program. Results: The majority (52.8%) of physicians preferred MTM data to be communicated via fax. Most physicians who provided care to patients in long-term care (LTC) facilities (81.0%) preferred to be contacted at their practice location as opposed to the LTC facility. The greatest barriers to communication were lack of time and inefficient communication practices. Improved/enhanced communication was the most common suggestion for improvement in the MTM process. Approximately 67% of respondents reported MTM as beneficial or somewhat beneficial for their patients. Conclusions: Survey respondents saw value in the MTM services offered by pharmacists. However, pharmacists should use the identified preferences and barriers to improve their currently utilized communication practices in hopes of increasing acceptance of recommendations. Ultimately, this may assist MTM providers in working collaboratively with patients’ physicians. Keywords medication therapy management, community pharmacy, communication, physician preferences, barriers
Introduction There are approximately 1.5 million preventable adverse events that occur each year in the United States, resulting in US$177 billion in injury and death.1,2 Among these adverse events, a high incidence of preventable adverse drug events in the ambulatory care setting has been well documented in the literature.3-5 Additionally, the World Health Organization estimates the adherence rate for chronic medications to be approximately 50% for developed countries.6 In the United States, this nonadherence is estimated to contribute to 33% to 69% of medication-related hospital admissions resulting in approximately US$100 billion.7 Community pharmacists have the opportunity to improve these patient outcomes by providing medication therapy management (MTM) services. MTM services have the potential to increase patient adherence to chronic medications and decrease preventable adverse drug events.8 These services are provided in an effort to improve the quality of chronic care management and reduce health care expenses by preventing medication-related adverse outcomes.8
As first described in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, MTM services are designed to promote enhanced patient understanding, increased patient adherence to medication regimens, and detection of adverse drug events and patterns of overuse and underuse of prescription medications.9 To help achieve these goals
1
Red Cross Pharmacy, Inc, Warrensburg, MO, USA Was PGY1 Community Practice Resident, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA at the time this study was conducted 3 School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA 4 Red Cross Pharmacy, Inc, Excelsior Springs, MO, USA 5 Red Cross Pharmacy, Inc, Marshall, MO, USA 6 Red Cross Pharmacy, Inc, Grain Valley, MO, USA 2
Corresponding Author: Kristen L. DiDonato, Health Sciences Building 3244, 2464 Charlotte Street, Kansas City, MO 64108, USA. Email: [email protected]
18 and standardize the MTM process, the American Pharmacists Association and the National Association of Chain Drug Stores Foundation established 5 core elements of an MTM service model which include medication therapy review (MTR), personal medication record (PMR), medication-related action plan (MAP), intervention and/or referral, and documentation and follow-up.10 The intervention component to the MTM service model is vital to the success of these encounters. For these encounters to be effective, open communication must exist between prescribers, pharmacists, and patients.11 Numerous studies have been conducted to assess physicians’ perceptions and attitudes toward pharmacist-provided MTM services.11-16,17 In several of these studies, physicians point out the importance of pharmacist–physician collaboration and communication.11,12,16 However, no study has specifically evaluated physicians’ preferences and barriers in regard to communication of pharmacist-provided MTM recommendations in the community pharmacy setting. Addressing this knowledge gap may assist MTM providers in working collaboratively with patients’ physicians to optimize medication regimens and improve health outcomes.
Objectives The study objectives were to identify physicians’ preferences in regard to pharmacist-provided MTM communication in the community pharmacy setting; to identify physicians’ perceived barriers to communicating with a pharmacist regarding MTM; and to determine whether Missouri physicians feel MTM is beneficial for their patients.
Methods Study Setting The study was conducted within a family-owned, community pharmacy chain that serves northwest and central Missouri towns. The pharmacy chain consists of 15 retail pharmacies, 3 long-term care (LTC) pharmacies, and 2 durable medical equipment companies. MTM services are provided at these pharmacy locations using 3 Web-based platforms: OutcomesMTM (Outcomes, Inc, West Des Moines, Iowa), MirixaPro (Mirixa Corp, Reston, Virginia), and Direct Care Pro (ACS Health Management Solutions, Inc, Dearborn, Michigan). The pharmacy chain is currently working to improve the MTM services offered by the company in hopes of having more impactful, effective patient encounters. To help accomplish this goal, the company would like to improve pharmacist–physician communication practices.
Study Design A cross-sectional, prospective study was conducted using anonymous mail-in surveys. Surveys were distributed on January 9, 2014, and collected until June 1, 2014. Included in each mailing was a 1-page introduction letter (Appendix A), a 1-page survey (Appendix B), and a yellow postage-paid return envelope.
Journal of Pharmacy Practice 30(1) Study subjects were selected utilizing the publicly available provider listing maintained by MO HealthNet, Missouri’s Medicaid program. This physician database is organized by practice specialty and includes the physicians’ practice addresses and phone numbers. Fax numbers and e-mail addresses are not included in the listing. This study targeted the 2021 family and general practice physicians registered with MO HealthNet. Following the initial mailing of surveys, an additional round of faxed survey reminders were sent to 206 physicians on the listing whose fax numbers were contained within the pharmacy’s dispensing software. Included with each faxed reminder was the 1-page introduction letter and 1-page survey originally distributed by mail, along with an individualized cover letter. Due to the anonymous nature of the study, there was no way to identify which physicians had previously responded to the survey. Of the original 110 Missouri counties that received mailed surveys, the second round of faxed surveys focused on 10 of those counties where the pharmacy’s stores are located. These faxed survey reminders were sent between March and May 2014. To maintain anonymity, identifying information (including practice names and fax numbers) was removed from the returned surveys prior to reaching study investigators. This study was granted exemption by the institution’s Institutional Review Board in November 2013.
Survey Design A nonvalidated survey instrument was developed to collect the data necessary to meet the stated objectives. All questions were either multiple-choice, yes/no, or short answer format. The first set of survey questions assessed the following demographic and practice characteristics: gender, age, years in practice, practice specialty, and physicians’ experience with MTM. Next were several questions assessing physicians’ preferences for communication of MTM recommendations. These questions addressed preferred contact method, time, and preferred location for LTC physicians. The next question evaluated the familiarity of physicians with the Centers for Medicare and Medicaid Services (CMS) requirement for targeted Medicare patients to receive an annual medication review, followed by a question pertaining to physicians’ perceived barriers to communicating with pharmacists about MTM recommendations. This question allowed participants to enter ‘‘other’’ answers in addition to the available answer choices provided. Physicians were also asked whether or not they feel that MTM is beneficial for their patients. The last question on the survey was an openended question allowing participants to provide any further suggestions to improve the MTM process. Survey questions were developed using the experience and feedback of 5 pharmacists within the organization who provide MTM services. These pharmacists participated in 3 rounds of survey review and feedback. The survey was limited to 1 page, with 13 questions, in hopes that participants would complete it in its entirety. The finalized introduction letter and survey were then pilot tested by a local practitioner to ensure clarity and relevance of questions.
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Data Collection and Analysis
Table 1. Demographic Information.a
Completion of the survey instrument served as consent to participate in the study. Participants were informed that information would be collected in an anonymous nature. One investigator coded and entered all data into the statistical software program to provide consistency. Responses to open-ended questions were categorized into themes by 3 of the study investigators, based on consensus. Data points were analyzed using the IBM Statistical Package for Social Science Version 21 for Windows (SPSS1, Chicago, Illinois) and expressed as frequencies.
Variable
Results Of the 2021 mailed surveys, 6 were returned as undeliverable, making the adjusted sample size 2015. A total of 123 responses were received, giving a response rate of 6.1%. The demographic characteristics of the respondents are described in Table 1. The majority of respondents were males between 50 and 69 years of age. Although the provider listing used to identify the target population was only supposed to include family and general practice physicians, several respondents stated they were a specialist. Of the 123 responding physicians, 62.6% were familiar with the CMS requirement for targeted Medicare patients to receive an annual medication review. With regard to physicians’ preferences for MTM communication (Table 2), the majority of responding physicians preferred MTM data to be communicated via fax. Most of the responding physicians had no preference on the time of day to be contacted, but the least preferred time of day was evening. Approximately one-half of the respondents also provided care to patients in LTC facilities. Of those LTC physicians, the majority preferred to be contacted at their practice locations (81.0%). In response to physicians’ perceived barriers to communicating with pharmacists about MTM recommendations (Table 3), 15 ‘‘other’’ answers were provided in addition to the available answer options. The barriers were grouped into 6 different themes: no barriers, inefficient communication practices, lack of understanding, pharmacist not qualified, incomplete data/ inaccuracies, and lack of time. Of these barriers, lack of time and inefficient communication practices were the greatest barriers identified. Approximately one-fourth of the physicians did not feel there were any barriers to communication. For lack of time, physicians felt they do not have enough time to look at and respond to all of the MTM recommendations on top of their regular daily duties. Physicians’ thoughts regarding inefficient communication practices focused both on the method of communication used and on the way pharmacists were conveying recommendations within these communications. Examples of these communication issues included pharmacists using an inefficient communication format and communication not being integrated into the electronic medical record (EMR). Lack of understanding refers to the physicians having a misunderstanding of what MTM is and why pharmacists are performing
Gender Male Female No response Age 20-29 30-39 40-49 50-59 60-69 70-79 Other No response Years in practice 0-5 6-10 11-15 16-20 21-25 >25 No response Practice specialtyb Family medicine General medicine Emergency medicine Internal medicine Endocrinology Addictionology Wound care Obstetrics and gynecology Dermatology Infectious disease Rheumatology Cardiology Gastroenterology Sports medicine No response Previous MTM contact Yes No Unsure No response
Response, n (%) 84 (68.3) 36 (29.3) 3 (2.4) 1 (0.8) 21 (17.1) 24 (19.5) 32 (26.0) 37 (30.1) 1 (0.8) 1 (0.8) 6 (4.9) 10 (8.1) 16 (13.1) 17 (13.8) 11 (8.9) 17 (13.8) 45 (36.6) 7 (5.7) 97 (78.9) 6 (4.9) 6 (4.9) 4 (3.3) 2 (1.6) 2 (1.6) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 1 (0.8) 2 (1.6) 60 (48.8) 59 (48.0) 2 (1.6) 2 (1.6)
Abbreviations: MTM, medication therapy management. a n ¼ 123. b Participants could select more than one answer to this question.
MTM encounters. For incomplete data/inaccuracies, some of the physicians felt pharmacists did not have enough information to make recommendations for patients. This includes more complex medical issues being present that are not apparent by looking at the medication list, pharmacists not reviewing the patient’s history prior to making a recommendation, and pharmacists not having access to medical records. A small percentage of physicians (4.9%) felt pharmacists were not qualified to be performing MTM encounters with patients. Forty unique responses were provided for the last openended question on the survey. Further suggestions to improve
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Journal of Pharmacy Practice 30(1)
Table 2. Physician Communication Preferences.a Variable Preferred contact methodb Fax Telephone Postal mail Email Prefer not to be contacted Electronic No response Preferred time of dayb No preference Morning Afternoon No preference-not evening Evening No response Provide care at LTC facility Yes No No response Preferred contact location for LTC physiciansc Practice location LTC facility Not applicable No response
Table 4. Further Suggestions to Improve MTM Communication.a,b Response, n (%) 65 (52.8) 16 (13.0) 16 (13.0) 13 (10.6) 13 (10.6) 7 (5.7) 4 (3.3) 61 (49.6) 26 (21.1) 11 (8.9) 5 (4.1) 4 (3.3) 16 (13.0) 58 (47.2) 62 (50.4) 3 (2.4) 47 (81.0) 9 (15.5) 1 (0.8) 1 (0.8)
Abbreviations: LTC, long-term care. a n ¼ 123. b Participants could select more than 1 answer to this question. c Based on the 58 physicians who provide care to patients in LTC facilities.
Table 3. Perceived Barriers to Communicating With Pharmacists Regarding MTM.a,b Variable Perceived barriers Lack of time No barriers Inefficient communication practices Lack of understanding No response Incomplete data/inaccuracies Pharmacist not qualified
Response, n (%) 64 (52.0) 30 (24.4) 28 (22.8) 14 (11.4) 9 (7.3) 8 (6.5) 6 (4.9)
Abbreviations: MTM, medication therapy management. a n ¼ 123. b Participants could select more than 1 answer to this question.
MTM communication (Table 4) included the following themes: improved/enhanced communication (19.5%), MTM process education/increased awareness (4.9%), enhanced qualifications (4.1%), reimbursement/expansion to other populations (2.4%), and dedicated time (2.4%). Improved/enhanced communication was the most common suggestion for improvement in the MTM process. This included integrating communication into the EMR, keeping communications brief, providing rationale behind recommendations, and filtering concerns to the most important issues. For MTM process
Variable Further suggestions Improved/enhanced communication MTM process education/increased awareness Enhanced qualifications Dedicated time Reimbursement/expansion to other populations No response
Response, n (%) 24 6 5 3 3 84
(19.5) (4.9) (4.1) (2.4) (2.4) (68.3)
Abbreviations: MTM, medication therapy management. a n ¼ 123. b Two participants offered 2 suggestions for this question.
education/increased awareness, several physicians felt they do not understand what MTM is and thought pharmacists should educate physicians regarding MTM processes. A small percentage of physicians (4.1%) felt that pharmacists needed enhanced qualifications and/or additional training to perform these services. For the dedicated time theme, a few physicians felt they did not have enough time in their day to respond to pharmacist inquiries and needed dedicated time in their day to work on MTM communications. Finally, 3 physicians felt this service should be offered and reimbursed for nonMedicare patients as well as for the Medicare patients currently being served. Despite the barriers and suggestions for improvement identified in the survey, approximately 66.7% of respondents reported MTM as beneficial or somewhat beneficial for their patients.
Discussion The results from this study indicate that the majority of physicians see value in the MTM services offered by pharmacists. This is in contrast to a previous study completed by Alkhateeb et al, which showed low physician support of pharmacistprovided MTM services. That study showed that only 36% of surveyed West Virginia physicians felt pharmacists should provide MTM services.15 Although our study did not specifically compare physicians’ opinions on which type of provider should conduct MTM services, participants did appear to see value in these MTM programs. This study also shows that pharmacists may have higher success rates when communicating MTM data via fax. This is comparable to the results of a study completed by McGrath et al. The qualitative study assessed physician perceptions of pharmacist-provided MTM through a focus group. In an exit survey given to study participants, physicians were asked how they would like to be contacted regarding specific patients seen by pharmacists. The survey showed that 18 (78%) of the 23 participants preferred faxed communications from pharmacists. In comparison, our study showed 52.8% of physicians preferred faxed MTM communications from pharmacists. In the McGrath article, participants were only given 4 options to choose from for preferred method of communication: telephone, fax, postal mail, or would not participate.16 Our study provided
Guthrie et al the additional option of e-mail, and several participants added electronic as their preferred method of communication in the ‘‘other’’ category. Even with these additional answer options, faxed communication was still the most preferred method of communication and could lead to a higher percentage of answered physician communications. The results of this study show that physicians have many barriers to communicating with pharmacists regarding MTM. In order to have successful patient encounters and improve patient outcomes, pharmacists should work to address these barriers to provide high-quality medication reviews and recommendations. Many of the barriers identified in our study were also identified in the McGrath study. Overlapping concerns with MTM were pharmacist qualifications, reimbursement, incomplete data, physician misunderstanding of MTM, and the importance of clear communication between the pharmacist and physician. Additional issues mentioned in the McGrath study that were not identified in our study were the need for physicians and pharmacists to think like-minded regarding patient care and the need for the pharmacists conducting these services to be within the physician’s office.16 Overall, the 2 studies appear to identify many of the same physician barriers to working with pharmacists. To address some of these barriers, each pharmacy conducting MTM encounters should assess the currently utilized methods of communication and make changes when necessary to ensure brevity and clarity. Some of the physicians surveyed in the study indicated that pharmacists are using inefficient communication formats, which could suggest lack of conciseness and/or lack of supporting details. While keeping communications brief, reasoning and rationale should be included on all recommendations.12,18 Before making recommendations to physicians, pharmacists should always research the patient’s medication regimen and history to ensure accurate and valuable recommendations are being made.12 Finally, pharmacists should make an effort to educate physicians about the MTM process and the benefits of the service to both patients and physicians.16 A common theme that was mentioned several times during this study was the need for pharmacists to have access to the patient’s medical record and/or EMR. Although only 7 participants chose electronic communication as their preferred method of communication, this was not a predetermined answer choice but was written by study participants in the ‘‘other’’ category. We may have seen an even higher percentage of physicians choose this option had it been listed as an answer choice. In a study conducted by Lauffenburger et al, primary care physicians participated in focus groups to determine their perspectives on working with a pharmacist to manage medications and key attributes/barriers to an effective MTM program. Similar to our study, the physicians in this study identified lack of access to the patient’s medical record as a potential barrier to successful MTM encounters.12 In the future, pharmacist access to medical records and the ability to communicate with physicians through these electronic records may lead to more successful pharmacist–physician communication.
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Limitations The major limitation in this study is the low survey response rate, which could contribute to nonresponse bias. However, low survey response rates are common in physician populations.19 Use of a respondent-friendly questionnaire, personalized mailings, repeat contact for physicians within our pharmacy database, and mailings with postage-paid return envelopes were used to try to limit nonresponse bias.19 It is possible that the survey responders would be more open to pharmacist-provided MTM and more likely to respond to pharmacist recommendations. This could have potentially biased our results making the physicians view MTM services more favorably. Because the physician listing only included Missouri physicians, lack of geographic diversity could limit generalizability to all physicians. In addition, due to the low response rate and anonymous nature of the survey, there is no way to tell whether the surveyed population is representative of all regions of the state. The physician database used to identify the target population had many limitations in itself. First, the database only included mailing addresses. No e-mail addresses or fax numbers were included in the database. Based on the results of this study, fax appears to be the preferred method of communication, so there may have been a higher response rate sending the surveys via this method. Due to the rising utilization of technology and the interest in electronic communication identified in the study, we may have had a higher response rate if the listing included provider e-mail addresses. Furthermore, we were unable to follow-up with the target population or send reminders without the added expense of an additional mailing. This restricted our follow-ups to the small number of physicians whose fax numbers were contained within our pharmacy database. Additionally, the database was only supposed to include family and general practice physicians. As shown in Table 1, many physicians responded stating they were specialists. In a study conducted by Perera et al, the authors found that the approval rate for faxed MTM recommendations was greater for primary care physicians than for specialist physicians.11 If many specialists were included in the listing, this could have contributed to a broader group of subjects than we intended to target and a less favorable outlook on MTM services. Furthermore, due to the brevity of the survey instrument and the vague nature of some of the collected answers, some questions remain unanswered. In regard to the comments about inefficient communication formats, it is unclear whether the physicians were referring to the length of communications, communication style, and/or level of detail provided within the documentation. In future studies, it would also be beneficial to see how many pharmacist-provided MTM recommendations physicians are receiving on average and for those physicians who were never contacted by a pharmacist regarding MTM recommendations, what they are basing their experiences on.
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Conclusion Through MTM services, pharmacists can make a significant impact on patient outcomes. Although many Missouri physicians are aware of MTM services and appear to see value in these MTM services offered by pharmacists, several barriers to successful pharmacist–physician communication were identified. To be more effective in the MTM process, each pharmacy conducting these encounters should use an efficient and concise communication format, research the patient’s
Journal of Pharmacy Practice 30(1) medication regimen and history, and provide reasoning behind recommendations. Additionally, to assist MTM providers in working collaboratively with patients’ physicians, pharmacists should make an effort to educate physicians about the MTM process and the benefits of the service. Increasing pharmacist–physician collaboration and physicians’ responsiveness to recommendations could ultimately lead to optimized medication regimens and improved health outcomes.
Appendix A. Cover letter for physician survey mailing
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Appendix B. Survey instrument
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24 Acknowledgments We thank Ethan Osborn, PharmD; Clayton Thompson, PharmD; Nick Cook, PharmD; and Bit Vo, PharmD for their assistance with data collection.
Authors’ Note This study was presented previously at the American Pharmacists Association Annual Meeting, Orlando, Florida, March 29, 2014; at the University of Missouri-Kansas City Health Sciences Student Research Summit, Kansas City, Missouri, April 17, 2014; at the Midwest Pharmacy Residents Conference, Omaha, Nebraska, May 9, 2014; and at the Missouri Pharmacy Association and Illinois Pharmacy Association joint Annual Convention and Trade Show, St. Louis, Missouri, September 27, 2014.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The University of Missouri-Kansas City Community Residency Program at Red Cross Pharmacy is funded by a Community Pharmacy Residency Expansion Project (PREP) grant from the National Association of Chain Drug Stores Foundation.
References 1. Institute of Medicine. Preventing medication errors; 2006. Web site. https://www.iom.edu/~/media/Files/Report%20Files/2006/ Preve nting-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf. Accessed May 11, 2015. 2. Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc. 2001;41(2):192-199. 3. Sarkar U, Lopez A, Maselli JH, et al. Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res. 2011;46(5):1517-1533. 4. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564. 5. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-1016. 6. World Health Organization. Adherence to long-term therapies: evidence for action; 2003. Web site. http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf?ua¼1. Accessed May 11, 2015.
Journal of Pharmacy Practice 30(1) 7. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497. 8. Perlroth D, Marrufo G, Montesinos A, et al. Medication therapy management in chronically ill populations: final report; 2013. Web site. http://innovation.cms.gov/Files/reports/MTM_Final_ Report.pdf. Accessed May 11, 2015. 9. Centers for Medicare and Medicaid Services. Medicare program: Medicare prescription drug benefit; 2005. Web site. http://www. gpo.gov/fdsys/pkg/FR-2005-01-28/pdf/05-1321.pdf. Accessed May 11, 2015. 10. Burns A. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc. 2008;48(3):341-353. 11. Perera PN, Guy MC, Sweaney AM, et al. Evaluation of prescriber responses to pharmacist recommendations communicated by fax in a medication therapy management program (MTMP). J Manag Care Pharm. 2011;17(5):345-354. 12. Lauffenburger JC, Vu MB, Burkhart JI, et al. Design of a medication therapy management program for Medicare beneficiaries: qualitative findings from patients and physicians. Am J Geriatr Pharmacother. 2012;10(2):129-137. 13. Padiyara RS, Rabi SM. Physician perceptions of pharmacist provision of outpatient medication therapy management services. J Am Pharm Assoc. 2006;46(6):660-663. 14. Alkhateeb FM, Unni E, Latif D, et al. Physician attitudes toward collaborative agreements with pharmacists and their expectations of community pharmacists’ responsibilities in West Virginia. J Am Pharm Assoc. 2009;49(6):797-800. 15. Alkhateeb FM, Clauson KA, McCafferty R, et al. Physician attitudes toward pharmacist provision of medication therapy management services. Pharm World Sci. 2009;31(4):487-493. 16. McGrath SH, Snyder ME, Duen˜as GG, et al. Physician perceptions of pharmacist-provided medication therapy management: qualitative analysis. J Am Pharm Assoc. 2010;50(1):67-71. 17. Oladapo AO, Rascati KL. Review of survey articles regarding medication therapy management (MTM) services/programs in the United States. J Pharm Pract. 2012;25(4):457-470. 18. McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effective precepting. Am J Pharm Educ. 2006;70(3):58. 19. Field TS, Cadoret CA, Brown ML, et al. Surveying physicians, do components of the ‘‘Total Design Approach’’ to optimizing survey response rates apply to physicians? Med Care. 2002;40(7): 596-605.
