David Rhys Axon

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• Axon, D. R. (2024). Description and Evaluation of a Pharmacy Graduate Health Services Research Methods Course. Pharmacy (Basel, Switzerland), 12(4).
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  The purpose of this paper is to provide a description and evaluation of a graduate-level Health Services Research Methods course offered at the University of Arizona R. Ken Coit College of Pharmacy. This three-credit, round-table discussion-style course introduces students to fundamental concepts in healthcare study design and teaches them how to design and critique example studies for a variety of commonly encountered study designs. The course is assessed through essay-style examinations, development of a research proposal, and low-stakes weekly assignments. Twenty-seven students have completed the course in the past five years. Feedback from student course surveys was almost unanimously positive, with few meaningful suggestions for improvement. The description and evaluation of a graduate-level Health Services Research Methods course at one institution indicates that students had a largely favorable experience with the course. Considerations for future revisions to the course are discussed alongside other lessons learned.
• Axon, D. R. (2024). Investigating the Variables Associated with Physical Exercise Status among United States Adults with Arthritis. Journal of clinical medicine, 13(15).
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  Arthritis is a chronic, debilitating condition affecting millions of United States (US) adults. Regular physical exercise is particularly important for adults with arthritis. This study aimed to investigate the characteristics associated with regular physical exercise in US adults with arthritis. This cross-sectional database study used 2021 Medical Expenditure Panel Survey data and included US adults (age ≥ 18) alive with arthritis. A multivariable logistic regression model was developed to test the association of the following variables with regular physical exercise (defined as moderate-vigorous intensity exercise for ≥30 min ≥5 times weekly; yes, no): age, sex, Hispanic, race, census region, marriage status, schooling, employment, health insurance, household income, mental health, general health, smoking status, chronic conditions, pain, and functional limitations. Overall, 5091 people (regular physical exercise = 2331, no regular physical exercise = 2760) were involved in this analysis. Most were female, non-Hispanic, white, married, had schooling beyond high school, were unemployed, had private health insurance, had mid-high household income, had good mental health, had good general health, were non-smokers, had two or more chronic conditions, had little/moderate pain, and did not have a functional limitation. In multivariable logistic regression analysis, male vs. female sex (odds ratio [OR] = 1.440, 95% confidence interval [CI] = 1.185-1.749), employed vs. unemployed (OR = 1.277, 95% CI = 1.005-1.624), good vs. poor general health (OR = 2.174, 95% CI = 1.673-2.824), little/moderate vs. quite a bit/extreme pain (OR = 1.418, 95% CI = 1.109-1.818), and no functional limitation (OR = 1.592, 95% CI = 1.282-1.980) were associated with higher odds of reporting regular physical exercise, while Midwest vs. West census region (OR = 0.698, 95% CI = 0.521-0.935) was associated with lower odds of reporting regular physical exercise. This study identified variables associated with regular physical exercise among US adults with arthritis. Further work is needed to develop interventions for characteristics that may help increase exercise and, subsequently, health outcomes in this population.
• Axon, D. R. (2024). Limited Physical Functioning in United States Adults with Arthritis: Findings from the 2021 Medical Expenditure Panel Survey. Diseases (Basel, Switzerland), 12(8).
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  There is little published research on limited physical functioning in United States (US) adults with arthritis. The objective of this cross-sectional 2021 Medical Expenditure Panel Survey (MEPS) database study was to investigate the variables associated with limited physical functioning in US adults with arthritis. Logistic regression tested the associations of predisposing, enabling, and need variables with the dependent variable (limited physical functioning). This study included 5102 US adults with arthritis, reflecting an estimated weighted population of 64,136,870 US adults with arthritis. In the final multivariable logistic regression model, age ≥ 70 and ages 60-69 (vs. 18-49 years), female (vs. male) sex, having quite a bit/extreme or moderate (vs. little) pain, and having 6+ or 4-5 (vs. 0-1) comorbid conditions were all associated with higher odds of the person stating they had limited physical functioning. Whereas high school or less (vs. more than high school), being employed (vs. unemployed), being married (vs. not married), having excellent/very good or good (vs. poor) general health, and exercise (vs. no exercise) were each associated with lower odds of the person reporting they had limited physical functioning. Future work may be considered to explore these variables in greater detail.
• Axon, D. R., & Aliu, O. (2024). Association between self-reported pain severity and characteristics of United States adults (age ≥50 years) who used opioids. Scandinavian journal of pain, 24(1).
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  The aim of this study was to assess the associations between the characteristics of United States (US) adults (≥50 years) who used opioids and self-reported pain severity using a nationally representative dataset.
• Axon, D. R., & Eckert, B. (2024). Association of Number of Comorbid Conditions and Pain among United States Adults. Diseases (Basel, Switzerland), 12(7).
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  Studies have explored the association of particular conditions, or combinations of conditions, and pain among specific populations. However, there is limited information regarding the association of the number of comorbid conditions, as well as other demographic, economic, health, and limitation variables, with pain among adults in the United States. This cross-sectional database study aimed to examine the relationships between number of comorbid conditions (including cancer, arthritis, joint pain, stroke, heart attack, angina, coronary heart disease, high cholesterol, high blood pressure, other heart diseases, diabetes, asthma, chronic bronchitis, and emphysema), demographic, economic, health, and limitation variables with pain among United States adults using 2021 Medical Expenditure Panel Survey data. A multivariable logistic model assessed the association between the number of comorbid conditions (≥6, 5, 4, 3, 2, 1, versus 0 conditions) and quite a bit/extreme (versus little/moderate) pain, adjusting for demographic, economic, health, and limitation variables. The study found that greater numbers of comorbid conditions were associated with higher odds of quite a bit or extreme pain. In addition, age, education, employment, income, overall health, regular physical activity, and three limitation variables were each associated with pain in the multivariable model. These findings offer insight into the association between number of comorbid conditions and other variables with pain and suggest areas where interventions may be helpful to help improve pain outcomes for United States adults.
• Axon, D. R., & Robinson, A. (2024). Student pharmacists' perceptions of a NAPLEX preparation module in the pharmacy curriculum at one United States college of pharmacy. Currents in pharmacy teaching & learning, 16(6), 476-483.
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  To investigate final-year student pharmacists' experiences of a new module for North American Pharmacist Licensure Examination® (NAPLEX®) preparation at one college of pharmacy in the United States.
• Axon, D. R., & Smith, J. (2024). Relationship between pain severity and self-perceived health among United States adults: a cross-sectional, retrospective database study. . Medicine, 103(50), e40949.
• Bingham, J. M., Maldonado, T., & Axon, D. R. (2024). A qualitative analysis of student pharmacists' perceptions working in community settings during the COVID-19 pandemic. Currents in pharmacy teaching & learning, 16(9), 102104.
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  Student pharmacists made a considerable contribution to healthcare provision and public health efforts during the COVID-19 pandemic. However, little is known about student pharmacists' experiences working in community pharmacy during the COVID-19 pandemic. This study aimed to describe the perceived impact of the COVID-19 pandemic on student pharmacists working in community-based pharmacy settings.
• Castora-Binkley, M., Selvarajah, S., Felix, M., Campbell, P. J., Black, H., Warholak, T., & Axon, D. R. (2024). Patient perceptions of their experience with comprehensive medication reviews: A framework for continued quality improvement. Journal of managed care & specialty pharmacy, 30(12), 1385-1394.
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  A comprehensive medication review (CMR) is an annual service offered to eligible Medicare Part D beneficiaries as a component of the Medication Therapy Management program. However, little is known about the most meaningful aspect of CMRs from the patient's perspective. This information is necessary to help improve the service.
• Cornelison, B., Aqel, O., & Axon, D. R. (2024). Characteristics associated with perceived level of confidence managing diabetes among United States adults with diabetes: A retrospective cross-sectional study. Journal of family medicine and primary care, 13(6), 2440-2448.
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  Identifying characteristics associated with patients' confidence managing diabetes may aid the primary care provider in offering diabetes self-management education and support to patients. This analysis assessed the relationship between demographic, health, economic, access to care, satisfaction with care, and healthcare utilization characteristics with patients' confidence managing diabetes.
• Maciulewicz, T. S., Axon, D. R., & Shirazi, F. M. (2024). Characterization of hypofibrinogenemia following rattlesnake envenomation treated with crotalidae immune F(ab') (equine) antivenom. Clinical toxicology (Philadelphia, Pa.), 62(11), 749-753.
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  Hemotoxicity is common following rattlesnake envenomation. Published experiences with equine-derived crotalidae immune F(ab') antivenom have characterized hemotoxicity as delayed, recurrent, or persistent. This study investigated recovery of hypofibrinogenemia following rattlesnake envenomation treated with equine-derived crotalidae immune F(ab') antivenom.
• Martinović, A., & Axon, D. R. (2024). Investigating the Relationship between Body Mass Index, Cholesterol, and Cancer in United States Adults: A Cross-Sectional Study. Diseases (Basel, Switzerland), 12(6).
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  The purpose of this cross-sectional study was to investigate the relationship between Body Mass Index (BMI), cholesterol, and cancer in United States (US) adults. Data were collected from the 2020 Medical Expenditure Panel Survey (MEPS). Eligible participants were US adults (≥18 years) with data on BMI, cholesterol, and cancer status, who were alive at the end of the data collection period. An adjusted logistic regression model assessed associations between eight possible combinations of BMI and cholesterol status (independent variable) with cancer diagnosis (dependent variable). Among 27,805 individuals in the 2020 MEPS data, 20,818 met the eligibility criteria (weighted N = 252,340,615). Of these 2668 (weighted N = 29,770,359) had cancer and 18,150 (weighted N = 222,570,256) did not have cancer. In the adjusted logistic regression model, underweight and normal weight individuals with high cholesterol were associated with higher odds of cancer (odds ratio, OR = 2.002, and 95% confidence interval, CI = 1.032-3.885, and OR = 1.326 and 95% CI = 1.047-1.681, respectively), while obese individuals with normal cholesterol were associated with lower odds of cancer (OR = 0.681; 95% CI = 0.543-0.853) compared to normal weight individuals with normal cholesterol. This study offers insights into specific groups of individuals who may be prioritized for cancer prevention. Further research is required to investigate these findings in additional subpopulations.
• Nakamura, H., Maciulewicz, T., Ramirez, J., Hughes, B., Axon, D. R., Shirazi, F., & Smelski, G. (2024). Twenty-five years of suspected rattlesnake encounters in Arizona. Clinical toxicology (Philadelphia, Pa.), 62(8), 526-532.
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  Rattlesnake ( spp spp.) bites in the southwestern United States are associated with significant morbidity. This study aims to describe 25 years of rattlesnake encounters reported to the Arizona Poison and Drug Information Center to identify vulnerable populations and circumstances where encounters occur to create public education to reduce future bites.
• Rupp, M. T., Warholak, T., Murcko, A. C., & Axon, D. R. (2024). Stakeholder views on requiring diagnosis or clinical indication on e-prescriptions. Journal of managed care & specialty pharmacy, 30(4), 305-312.
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  Medication safety organizations have been recommending the inclusion of diagnosis or clinical indication on prescription orders for decades. However, this information is typically not provided by prescribers and shared with pharmacists, despite the availability of data fields in the most commonly used standard for electronic prescriptions.
• Zaidi, S. H., & Axon, D. R. (2024). Assessing the Association of Healthcare Resource Utilization and Patient-Reported Outcomes on Shared Decision-Making among Multimorbid Individuals. Healthcare (Basel, Switzerland), 12(17).
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  Shared decision-making (SDM) is an essential component of patient-centered healthcare and disease management. However, the association of SDM with healthcare resource utilization and patient-reported outcomes among multimorbid individuals is not well understood. This study sought to evaluate the association of SDM with healthcare resource utilization and patient-reported outcomes among United States (US) adults with multimorbidity. Data were collected from the 2020 Medical Expenditure Panel Survey (MEPS) for this cross-sectional study. Eligible participants were US adults with two or more comorbidities. The predictor variable was SDM (optimal versus not optimal). The outcome variables were healthcare resource utilization and patient-reported outcomes. Logistic regression models, adjusted for demographic characteristics, assessed associations with SDM for each healthcare resource utilization and patient-reported outcome variable. The analysis maintained the complex survey data and was weighted to produce nationally representative estimates. Individuals who reported optimal SDM in adjusted analyses utilized more healthcare resources compared to those who reported not optimal SDM. Individuals with optimal SDM had more than one outpatient visit (odds ratio OR = 1.23, 95% CI = 1.03-1.47), emergency room visit (OR = 1.55, 95% CI = 1.17-2.06), and inpatient discharge (OR = 1.44, 95% CI = 1.05-1.96). Additionally, these individuals had higher odds of reporting limitations in their ability to work or engage in other activities due to their physical health in the past four weeks (OR = 1.27, 95% CI = 1.01-1.60). This study indicated evidence of increased healthcare resource utilization among patients who participate in SDM with their providers, which should be explored in future studies.
• Almatruk, Z., Axon, D. R., Almatruk, Z., & Axon, D. R. (2023). Factors associated with frequent physical activity among United States adults with asthma. The Journal of asthma : official journal of the Association for the Care of Asthma, 60(6), 1237-1245.
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  This study investigated factors associated with frequent moderate-to-vigorous intensity physical activity among United States (US) adults with asthma. This retrospective cross-sectional study included US adults (≥18 years) with asthma in the 2019 Medical Expenditure Panel Survey data. Logistic regression models that added sequential groups of variables were used to assess associations between predisposing (age, gender, race), enabling (marital status, poverty level, education level, insurance coverage, employment status), and need (smoking status, co-morbidities, mental health, physical health, functional limitations) factors and doing ≥30 min moderate-to-vigorous intensity physical activity ≥ five times per week. The alpha level was 0.05. The study included 2,410 individuals, of which 46.9% (95% confidence interval [CI] = 44.2-49.6) reported doing frequent moderate-to-vigorous intensity physical activity. In fully adjusted analyses, the following variables were associated with a greater odds of reporting frequent moderate-to-vigorous intensity physical activity: men vs. women (adjusted odds ratio [AOR] = 1.4, 95% CI = 1.1-1.7), white vs. other races (AOR = 1.3, 95% CI = 1.0-1.6), excellent/very good/good vs. fair/poor physical health (AOR = 2.3, 95% CI = 1.7-3.0), and functional limitations no vs. yes (AOR = 1.7, 95% CI = 1.3-2.2). The factors identified in this study (gender, race, health status, and limitation status) may be helpful to target interventions to raise awareness and increase physical activity among US adults with asthma. Studies that can demonstrate a temporal relationship are needed to further our understanding of this topic.
• Aqel, O., Agu, U., Almatruk, Z., Axon, D. R., Aqel, O., Agu, U., Almatruk, Z., & Axon, D. R. (2023). Association between pain burden and presence of any limitation among older adults (≥50 years of age) with pain who used opioids in the United States: Cross-sectional study using 2020 medical expenditure panel survey. Medicine, 102(33), e34863.
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  This study aimed to assess the association between pain burden and presence of any limitation among older adults (≥50 years of age) with pain who used opioids in the United States. This cross-sectional study used 2020 Medical Expenditure Panel Survey data and included all adults aged 50 or older, who were alive for the 2020 calendar year, used an opioid at least once in the calendar year, and reported having pain in the past 4 weeks. Unadjusted and adjusted logistic regression models were developed to assess the association between any limitation (AL) (yes or no), pain burden (extremely, quite a bit, moderately, or little bit) and the control variables among a nationally representative sample of United States adults. A total of 844 of the 27,805 participants included in the dataset were eligible for the study. Of these, 71.2% (95% confidence interval (CI) = 67.2, 75.1%) reported the presence of AL. The adjusted logistic regression analysis showed that having extreme, quite a bit, or moderate pain (vs little pain) was associated with 10.30 (95% CI = 3.87, 27.40), 5.07 (95% CI = 2.77, 9.30), and 2.49 (95% CI = 1.40, 4.45), respectively, times greater odds of having AL. Furthermore, being unemployed (vs employed; adjusted odds ratio (aOR) = 5.26, 95% CI = 2.94, 9.09%), unmarried (vs married; aOR = 1.92, 95% CI = 1.12, 3.33%), having poor overall health (vs good overall health; aOR = 2.08, 95% CI = 1.08, 4.17), and residing in the Midwest (vs West; aOR = 2.04, 95% CI = 1.10, 3.80) were associated with greater odds of having AL. Extreme, quite a bit, and moderate pain burden were significantly associated with greater odds of reporting AL compared to little pain burden. Developing effective pain management strategies that address not only pain relief but also functional improvement among this population is of importance. Future research could then be conducted to determine the most effective pain management strategies that will provide pain relief and improve their functional abilities.
• Aqel, O., Alqadheeb, B., Felix, M., Amundson, C., Bingham, J. M., Meyer, K., Warholak, T., Axon, D. R., Aqel, O., Alqadheeb, B., Felix, M., Amundson, C., Bingham, J. M., Meyer, K., Warholak, T., & Axon, D. R. (2023). Cultivating COVID-19 Vaccine Confidence in Pharmacy Professionals. Pharmacy (Basel, Switzerland), 11(2).
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  Pharmacists promote vaccinations and challenge misconceptions about vaccine hesitancy, yet pharmacists' knowledge of vaccine confidence has not been assessed. The objective of this study was to compare pharmacists' knowledge of coronavirus disease 2019 (COVID-19) vaccine confidence before and after a live continuing education (CE) session. This pretest-posttest study evaluated the differences before and after a live CE session on COVID-19 vaccine confidence provided to pharmacists at a nationwide health technology company. Participants' total pretest and posttest scores were compared using paired -tests, while pretest and posttest scores for each item were compared using chi-squared tests. A Bonferroni correction was applied, resulting in an alpha level of 0.005. A total of 279 pharmacists participated in this study. After the CE session, mean knowledge scores increased (5.2 ± 1.5 to 7.4 ± 1.35, < 0.0001). After the CE session, there was no significant increase in pharmacists' knowledge about the approach that is not recommended when discussing vaccination beliefs with a patient (71.3% to 77.4%, = 0.099), determinants of vaccine uptake (83.9% to 87.8%, = 0.182), and social determinants of health that can influence vaccination rates (93.6% to 96.4%, = 0.121). There was a significant change in pre- and posttest knowledge for the remaining seven items.
• Arku, D., Axon, D. R., Arku, D., & Axon, D. R. (2023). Pain Severity Is Associated with Self-Reported Functional Limitations: Findings from the 2018 Medical Expenditure Panel Survey (MEPS). Pain medicine (Malden, Mass.), 24(6), 720-722.
• Axon, D. R. (2023). Student Pharmacists' Perspectives Regarding a Virtually Delivered Research Proposal Course in the Doctor of Pharmacy Curriculum. Pharmacy (Basel, Switzerland), 11(1).
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  This study aimed to assess third-year student pharmacists' perspectives regarding a virtually delivered research proposal course. A 23-item questionnaire was distributed to third-year student pharmacists enrolled in a research proposal course over three weeks in April 2021. The questionnaire contained 15 Likert-scale items, seven descriptive items, and a free-text item for additional comments about the course. Items were summarized using descriptive statistics. Fifty-four student pharmacists (response rate = 40.9%) participated in the survey. The student pharmacists surveyed generally had a positive perception of the virtually delivered research proposal course with median scores ≥ 4 (indicating agreement) for the majority (13/15) of survey items. Students did not agree that there was no difference in their motivation to succeed in the virtual course versus an in-person course and did not agree that they were more likely to pursue a career that involves undertaking a research project. This study found that student pharmacists generally had a positive perception of a virtually delivered research proposal course. These findings offer some support for the provision of an online, virtually delivered research proposal course for student pharmacists. Further research with a larger sample of students from multiple pharmacy schools is needed to improve the generalizability of the results.
• Axon, D. R., & Agu, U. (2023). Correlation of Positive Psychological Health among US Adults (Aged ≥ 50 Years) with Pain and Documented Opioid Treatment. Behavioral sciences (Basel, Switzerland), 14(1).
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  In this study, we aimed to identify the factors correlated with positive psychological health among United States older adults (≥50 years) with pain and documented opioid treatment. This retrospective cross-sectional study utilized a nationally representative dataset (Medical Expenditure Panel Survey). A multivariable logistic regression model was developed to assess the correlation of positive psychological health in the eligible population. The logistic regression model showed having excellent/very good/good (versus fair/poor) perceived health (adjusted odds ratio [AOR] = 9.062; 95% confidence interval [CI] = 5.383, 15.254) had a statistically significant correlation with positive psychological health among the eligible population. This finding offers important insights for clinicians and policymakers to consider when formulating approaches to better manage the psychological health of United States older adults with pain and documented opioid treatment.
• Axon, D. R., Grieser, M., Axon, D. R., & Grieser, M. (2023). Characteristics Associated with Multimorbidity among Older United States Adult Opioid Users with Pain. Journal of clinical medicine, 12(20).
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  The objective of this study was to investigate the variables associated with multimorbidity status among older United States (US) adults with self-reported pain and opioid use. This study used a cross-sectional retrospective database design that included US adults aged ≥50 years with self-reported pain who used an opioid in 2019 in the Medical Expenditure Panel Survey data. Multivariable logistic regression models, weighted to produce nationally representative estimates, were used to determine variables significantly associated with multimorbidity status (≥2 versus
• Axon, D. R., Kim, A., Axon, D. R., & Kim, A. (2023). Relationship between Perceived Pain Interference and Poor Psychological Wellbeing among United States Adults. Behavioral sciences (Basel, Switzerland), 13(3).
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  The goal of this observational project was to investigate the association among perceived pain interference and poor psychological wellbeing in United States adults. Adults over 18 years of age in the 2019 Medical Expenditure Panel Survey were eligible for inclusion if they were alive for the calendar year and had data available for their pain status. Hierarchical logistical regression examined statistically significant associations among perceived pain interference and poor psychological wellbeing. Results showed that greater levels of perceived pain interference were significantly related with larger odds of reporting poor psychological wellbeing. Additionally, several other variables were related with larger or lower odds of reporting poor psychological wellbeing. These findings provide insight into the effect of perceived pain interference and other variables with poor psychological wellbeing, which may help recuperate the psychological wellbeing of US adults with pain.
• Axon, D. R., Le, D., Chien, J., Axon, D. R., Le, D., & Chien, J. (2023). A Pilot Mixed-Methods Study to Establish the Clinical Usefulness of a Chronic Pain Profile (CPP) for Pain Management. Journal of clinical medicine, 12(16).
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  The Chronic Pain Profile (CPP) was developed as a tool for patients to document types and levels of use for all pain management strategies used. This pilot mixed-methods (quantitative and qualitative methods) study aimed to assess the perceived clinical usefulness of the CPP and identify potential areas of difficulty using the CPP among a sample of pharmacists. Data were obtained from an online survey of pharmacists licensed to practice in Arizona. Quantitative analysis included assessing the clinical usefulness of the CPP using 10 numerical items (scores ≥50% = useful), 5 ordinal items (scores ≥ 4 out of 5 = useful), and 11 open-response items. Qualitative analysis was conducted by two independent researchers who coded the comments and identified key themes through consensus. Data were collected for 33 individuals. Mean usefulness scores ranged from 66.6 ± 22.4 to 80.9 ± 23.5, and three of the five ordinal items had a median score ≥ 4. Three key themes (and subthemes) were identified: favorable features of the CPP, which included promoting patient advocacy and saving time when accessing pain information; using the CPP, which included evaluating of the effectiveness and appropriateness of the pain management approach and identifying gaps in patient knowledge; and limitations of the CPP, which included absence of customization, interpretation issues, complexity and wording issues, and concerns of internal consistency and reliability. This pilot study provides initial evidence of the CPP's clinical usefulness that could ultimately be used to help manage pain and improve health outcomes. Further analyses are needed to assess the CPP's validity and explore its use in wider populations of patients with pain.
• Axon, D. R., Maldonado, T., Axon, D. R., & Maldonado, T. (2023). Association between Pain and Frequent Physical Exercise among Adults in the United States: A Cross-Sectional Database Study. Sports (Basel, Switzerland), 11(7).
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  Pain affects over 20% of United States adults, and less than 50% of United States adults participate in frequent physical exercise. This cross-sectional database study included 13,758 United States adults aged >18 years from the 2020 Medical Expenditure Panel Survey (MEPS) and analyzed the association between severity of pain (independent variable) and frequent physical exercise (dependent variable), adjusting for demographic, economic, limitation, and health variables using multivariable logistic regression. The study showed 50.3% of adults report frequently exercising. Only 37.1% of adults reported experiencing pain of any degree, with a majority of them experiencing little pain. In the adjusted model, extreme pain vs. none, quite a bit of pain vs. none, Hispanic vs. non-Hispanic ethnicity, having a functional limitation vs. no limitation, and being overweight/obese vs. not being obese/overweight were associated with lower odds of reporting doing frequent physical exercise. Meanwhile, being ≥65 or 40-64 vs. 18-39 years of age, male vs. female, white vs. not white race, private or public vs. no health coverage, and good vs. poor general health were associated with greater odds of reporting doing frequent physical exercise. These variables associated with frequent physical exercise should be considered in future work when designing health interventions.
• Axon, D. R., Maldonado, T., Axon, D. R., & Maldonado, T. (2023). Investigating the Association of Pain Intensity and Health Status among Older US Adults with Pain Who Used Opioids in 2020 Using the Medical Expenditure Panel Survey. Healthcare (Basel, Switzerland), 11(14).
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  The number of older United States (US) adults is increasing, yet extra life years are not always spent in good health. This study explored the relationship between pain intensity and health status among US adults aged ≥50 with pain who used an opioid in the 2020 Medical Expenditure Panel Survey using multivariable logistic regression adjusting for demographic, economic, and health variables. Most (60.2%) older US adult opioid users with pain reported having good health (versus 39.8% poor health). In the fully adjusted analysis, those with extreme pain (odds ratio (OR) = 0.19, 95% confidence interval (CI) = 0.10, 0.35) and quite a bit of pain (OR = 0.34, 95% CI = 0.19, 0.60) had lower odds of reporting good health compared to those with little pain. There was no statistical relationship between health status for moderate versus little pain. In addition, males (versus females; OR = 0.61, 95% CI = 0.40, 0.91), white race (versus not white; OR = 0.43, 95% CI = 0.22, 0.84), education ≤high school (versus >high school; OR = 0.61, 95% CI = 0.41, 0.92), and current smoker (versus non-smoker; OR = 0.55, 95% CI = 0.32, 0.93) were associated with lower odds of reporting good health. Being employed (versus unemployed; OR = 1.88, 95% CI = 1.06, 3.33), having
• Axon, D. R., Quigg, M. D., Axon, D. R., & Quigg, M. D. (2023). Characteristics Associated with Self-Reported Exercise among US Adults Age ≥50 Years with Self-Reported Pain in the Past Four Weeks Who Used an Opioid. Healthcare (Basel, Switzerland), 11(8).
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  The number of older adults in the United States is growing, alongside the number of older adults experiencing some sort of pain and using opioids. Exercise is an important pain management and pain prevention strategy. However, little is known about the factors associated with exercise among United States adults ≥50 years old with pain who use opioids. This retrospective cross-sectional database study aimed to identify characteristics associated with self-reported frequent exercise (moderate- to vigorous-intensity exercise ≥30 min five times a week) in United States adults ≥50 years old with pain in the past four weeks who had also used an opioid. The study used 2020 Medical Expenditure Panel Survey data and logistic regression models. Analyses maintained the structure of the complex survey data and were weighted to obtain nationally representative estimates. Significantly associated variables with frequent exercise in the fully adjusted analysis included being aged 60-69 (versus ≥80 years, adjusted odds ratio [AOR] = 2.3, 95% confidence interval [CI] = [1.1-5.1]), having excellent/very good/good (versus fair/poor) self-perceived health (AOR = 2.4, 95% CI = [1.3-4.2]), normal/underweight (versus obese (AOR = 2.1, 95% CI = [1.1-3.9])), overweight (versus obese (AOR = 1.7, 95% CI = [1.0-2.9])), and having little (versus extreme) pain (AOR = 2.4, 95% CI = [1.0-5.7]). A secondary finding was that 35.7% considered themselves frequent exercisers, while the remaining 64.3% did not consider themselves frequent exercisers. In future, these findings can be used to personalize pain management strategies and encourage greater levels of exercise among this population.
• Bingham, J. M., & Axon, D. R. (2023). Telehealth Integration into Pharmacy Practice Curricula: An Exploratory Survey of Faculty Perception. Pharmacy (Basel, Switzerland), 11(4).
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  (1) Background: The use of telehealth in the United States during the coronavirus disease 2019 pandemic was accelerated and there was a lack of telehealth training programs available to clinicians of all levels. At the onset of the pandemic, the American Association of Colleges of Pharmacy (AACP) had no educational outcomes or professional activity standards for the inclusion of telehealth in the didactic Doctor of Pharmacy curriculum. Yet, in November 2022, the AACP encouraged colleges of pharmacy to include digital health and telehealth. The purpose of this study was to assess faculty perceptions in preparation for a nation-wide survey regarding telehealth integration into pharmacy practice curricula. (2) Methods: An exploratory questionnaire was developed to describe faculty perceptions and opinions of telehealth integration into the pharmacy practice curriculum at a single college of pharmacy. The questionnaire was emailed to 76 faculty members over six weeks in Summer 2022. Data were summarized descriptively. (3) Results: A total of 18 faculty members completed the survey (24% response rate). The responding faculty were typically very aware (median = 4) of telehealth, its benefits, and barriers, and were very comfortable (median = 4) discussing telehealth communication, benefits of telehealth, and barriers of telehealth. Yet, they were less comfortable discussing telehealth applications (median = 2.5). The faculty had a positive perception of telehealth in general (mean = 8.1 ± 1.5), telehealth services (mean = 8.6 ± 1.6), and the incorporation of telehealth instruction into the pharmacy practice curriculum (mean = 7.7 ± 2.7). Most respondents (67%) could discuss telehealth in their course. Lack of time to teach (50%) was the most reported reason by those who did not have plans to incorporate telehealth instruction into their course. (5) Conclusions: This exploratory survey of faculty at one college of pharmacy indicated positive perceptions and opinions of telehealth integration into the Doctor of Pharmacy curriculum. Further efforts to incorporate telehealth into the curriculum at other pharmacy schools is warranted.
• Bingham, J. M., Grabenstein, J. D., Leal, S., Axon, D. R., Bingham, J. M., Grabenstein, J. D., Leal, S., & Axon, D. R. (2023). Pharmacy on the front lines: A century of pandemic response in America. Journal of the American Pharmacists Association : JAPhA, 63(6), 1689-1693.
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  The history of American pharmacy contributions to pandemic responses can be described for five pandemics: 1918 (influenza A/H1N1 virus), 1957-1958 (H2N2 virus), 1968 (H3N2 virus), 2009 (H1N1pdm09 virus), and 2019-2023 (syndrome coronavirus-2 virus). Using historical surveillance data and published literature, this article provides opportunities to reflect on how the pharmacy profession played a role in preparedness and response.
• Castora-Binkley, M., Hines, L., Vaffis, S., Dhatt, H., Anderson, E., Le, D., Black, H., Campbell, P. J., Kolobova, I., Nelson, M., Axon, D. R., & Warholak, T. (2023). It is time for a new comprehensive medication review quality measure. Journal of managed care & specialty pharmacy, 29(6), 680-684.
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  Medication therapy management (MTM) services include comprehensive medication reviews (CMRs), which have been completed with millions of patients since their inception in the United States. The current MTM quality measure focuses on whether CMRs were completed (ie, the CMR completion rate). However, this process measure does not assess quality of care, or patient-reported or other outcomes of CMRs, and, therefore, does not reward MTM providers for improving health outcomes. In this viewpoint article, we present 3 reasons that shape our argument for new MTM quality measures and offer recommendations on next steps to achieve this. Dr Vaffis is an employee of Clinical Outcomes Solutions and discloses this was work was completed previously during her employment at the University of Arizona. Dr Dhatt is an employee of Janssen and discloses this was work was completed previously during her employment at the University of Arizona. Dr Anderson is an employee of The Freedom Fund and discloses this was work was completed previously during her employment at the University of Arizona. Dr Black is an employee of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. Dr Campbell received funding from Pharmacy Quality Alliance, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, and SinfoniaRx and discloses this work was completed previously during his employment at the University of Arizona. Dr Kolobova is an employee of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. Dr Hines is an employee of Pharmacy Quality Alliance. Dr Castora-Binkley is an employee of Pharmacy Quality Alliance. Dr Nelson is an employee of Pharmacy Quality Alliance. Dr Axon received funding from Pharmacy Quality Alliance, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, and SinfoniaRx. Dr Warholak received funding from Pharmacy Quality Alliance, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, and SinfoniaRx and discloses this was work was completed previously during her employment at the University of Arizona.
• Cernasev, A., Barenie, R. E., Metzmeier, S., Axon, D. R., Springer, S. P., & Scott, D. (2023). Student Perspectives on the Pharmacist's Role in Deprescribing Opioids: A Qualitative Study. Pharmacy (Basel, Switzerland), 11(4).
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  Opioid over-prescribing has led to changes in prescribing habits and a reduction in the amount of opioid prescriptions per patient. Deprescribing has proved to be an effective way of decreasing the number of opioids patients are receiving, and pharmacists are in the optimal position to provide these services for their patients. However, student pharmacists require additional education and training to be able to understand their role in deprescribing opioids upon entering the profession.
• Dhatt, H., Vaffis, S., Le, D., Axon, D. R., Campbell, P. J., Black, H., Kolobova, I., Nelson, M. L., Warholak, T., Dhatt, H., Vaffis, S., Le, D., Axon, D. R., Campbell, P. J., Black, H., Kolobova, I., Nelson, M. L., & Warholak, T. (2023). Qualitative analysis of telephonic comprehensive medication review content and delivery. Journal of the American Pharmacists Association : JAPhA, 63(2), 555-565.
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  Comprehensive medication reviews (CMRs) are offered to eligible Medicare beneficiaries to improve patient medication knowledge, identify, and address medication concerns, and empower medication self-management. However, the specific content of real-world CMRs is unclear.
• Henry, K., Henry, K., Axon, D. R., & Axon, D. R. (2023). A Look into Pharmacy Practices among the Purépecha Indigenous Community. Pharmacy (Basel, Switzerland), 11(4).
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  This report describes the adoption and integration of Western medicine in Cherán K'eri after the social changes in the 1940s which led to the transition from healer to pharmacist. There are various health models that rely heavily on community pharmacies. The place used as the basis for this report was a clinic managed by a Purépecha-speaking physician and pharmacist that served primarily monolingual indigenous Purépecha patients, whose population was around 9550 according to the 2010 census. Twelve major differences were observed between community pharmacies in the United States and the community pharmacies of Cherán. It was also observed that the modern approach to the health of the indigenous population used a combination of Western medicine together with traditional methods and only resorted to short-term therapies with Western medicines lasting five days or less. A formulary from the clinic's community pharmacy compiled in 2022 listed the 38 most common medications. Medications used included anti-infectives ( = 3), central nervous system ( = 2), endocrine/hormonal ( = 3), gastrointestinal ( = 3), musculoskeletal ( = 17), respiratory or allergy ( = 6), and genitourinary ( = 2).
• Marupuru, S., Almatruk, Z., Slack, M. K., Axon, D. R., Marupuru, S., Almatruk, Z., Slack, M. K., & Axon, D. R. (2023). Use of Pharmacological and Non-Pharmacological Strategies by Community-Dwelling Adults to Manage Migraine: A Systematic Review. Clinics and practice, 13(3), 553-568.
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  Migraine is a prevalent disease associated with high levels of disability and is often underdiagnosed and undertreated. This systematic literature review aimed to identify the types of pharmacological and non-pharmacological strategies that community-dwelling adults report using to manage migraine. A systematic literature review of relevant databases, grey literature, websites, and journals was conducted from 1 January 1989 to 21 December 2021. Study selection, data extraction, and risk of bias assessment were completed independently by multiple reviewers. Data were extracted on migraine management strategies and categorized as opioid and non-opioid medications and medical, physical, psychological, or self-initiated strategies. A total of 20 studies were included. The sample sizes ranged from 138 to 46,941, with a mean age of 34.7 to 79.9 years. The data were typically collected using self-administered questionnaires (nine studies), interviews (five studies), online surveys (three studies), paper-based surveys (two studies), and a retrospective database (one study). Community-dwelling adults with migraine reported they primarily used medications, specifically triptans (range 9-73%) and non-steroidal anti-inflammatory drugs (NSAIDs) (range 13-85%) to manage migraine. Except for medical strategies, the use of other non-pharmacological strategies was low. Common non-pharmacological strategies included consulting physicians (range 14-79%) and heat or cold therapy (35%).
• Marupuru, S., Arku, D., Axon, D. R., Villa-Zapata, L., Yaghoubi, M., Slack, M. K., & Warholak, T. (2023). Cost-effectiveness analysis of nivolumab-chemotherapy as first-line therapy for locally advanced/metastatic gastric cancer: a United States payer perspective. Expert review of pharmacoeconomics & outcomes research, 23(7), 831-841.
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  Nivolumab, an immune checkpoint inhibitor, was approved by the United States (US) Food and Drug administration as a first-line systemic therapy for locally advanced/metastatic gastric cancer patients. The current study aimed to investigate the cost-effectiveness of nivolumab-chemotherapy combination versus chemotherapy alone as a first-line therapy from a US payer perspective.
• Scott, D., Cernasev, A., Barenie, R. E., Springer, S. P., Axon, D. R., Scott, D., Cernasev, A., Barenie, R. E., Springer, S. P., & Axon, D. R. (2023). Teaching Deprescribing and Combating Polypharmacy in the Pharmacy Curriculum: Educational Recommendations from Thematic Analysis of Focus Groups. Clinics and practice, 13(2), 442-453.
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  In the last two decades in the United States (US), the previous research has focused on medication optimization, including polypharmacy. Polypharmacy is associated with several negative outcomes, which may be resolved by deprescribing medications that are no longer necessary. Although deprescribing is a critical aspect of a pharmacist's role, some studies have demonstrated that student pharmacists are less familiar with their future role in deprescribing. Thus, this study aimed to explore student pharmacists' perceptions of deprescribing in the pharmacy curriculum. This qualitative study was conducted with student pharmacists enrolled in three Doctor of Pharmacy (Pharm.D.) programs in the US. The participants, all student pharmacists at the time of the study, were identified via an email requesting their voluntary participation in a focus group study. The focus groups were conducted via an online platform over three months in 2022, and recruitment continued until thematic saturation was obtained. Using thematic analysis, the corpus of the transcribed data was imported into Dedoose, a qualitative software that facilitated the analysis. Three themes emerged from the data: (1) the importance of deprescribing; (2) barriers to deprescribing; (3) education recommendations. The data highlight that the student pharmacists believe integrating deprescribing content into the clinical, didactic, and simulation education would help them overcome the identified obstacles. Colleges of pharmacy should consider emphasizing the importance of deprescribing in their curriculum, creating programs to assist future pharmacists in addressing the barriers to deprescribing, and adopting the suggested educational strategies to improve the deprescribing education that is offered.
• Vaffis, S., Vaffis, S., Dhatt, H., Dhatt, H., Anderson, E., Anderson, E., Le, D., Le, D., Campbell, P. J., Campbell, P. J., Nelson, M., Nelson, M., Black, H., Black, H., Kolobova, I., Kolobova, I., Axon, D. R., Axon, D. R., Warholak, T., & Warholak, T. (2023). A checklist for a consistent, comprehensive medication review. Journal of the American Pharmacists Association : JAPhA, 63(5), 1504-1507.e1.
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  Medicare Advantage Part D plans and stand-alone Part D prescription drug plans are required by the Centers for Medicare and Medicaid Services to have qualified providers, including pharmacists, and offer annual comprehensive medication reviews (CMRs) for eligible Medicare beneficiaries. Although guidance on the components of a CMR is available, providers have flexibility in how to deliver the CMR to patients and which content to cover. With the variety of patient needs, CMR content is not always consistently delivered in practice. Our research group performed an extensive evaluation to create and test an ideal CMR content coverage checklist for CMR provision.
• Vaffis, S., Whaley, S., Axon, D. R., Hall-Lipsy, E., Hincapie, A., Slack, M., & Warholak, T. (2023). Features of Cancer mHealth Apps and Evidence for Patient Preferences: Scoping Literature Review. JMIR cancer, 9, e37330.
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  Cancer is increasingly being treated as a chronic disease rather than an acute one-time illness. Additionally, oral anticancer therapies, as opposed to intravenous chemotherapy, are now available for an increasing number of cancer indications. Mobile health (mHealth) apps for use on mobile devices (eg, smartphones or tablets) are designed to help patients with medication adherence, symptom tracking, and disease management. Several previous literature reviews have been conducted regarding mHealth apps for cancer. However, these studies did not address patient preferences for the features of cancer mHealth apps.
• Alfayoumi, I., Aqel, O., & Axon, D. R. (2022). An Assessment of Student Pharmacists' Knowledge of Electronic Cigarettes or Vapes-A Cross Sectional Study at One College of Pharmacy. Pharmacy (Basel, Switzerland), 10(5).
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  This study assessed the knowledge of e-cigarettes/vapes among a sample of student pharmacists. A 22-item cross-sectional electronic questionnaire was administered to all third- and fourth-year student pharmacists enrolled at one college of pharmacy in the United States (N = 256). Data were collected over six weeks in March/April 2022. One point was assigned for each correct knowledge item; points were then summed to create a total knowledge score for each person. Differences in the proportion of students who correctly answered each knowledge item were compared between year groups using a chi-square test, while differences between year groups for total knowledge score were compared using a two-sample -test. The a priori alpha level was 0.05. Fifty students (third year = 30, fourth year = 20; female = 60%) completed the survey. Students' e-cigarettes/vapes knowledge varied depending on the item. There was no statistically significant difference between third- and fourth-year students for total mean knowledge scores (third year = 12.5 ± 3.3, fourth year = 11.2 ± 3.1, = 0.1780) or for each knowledge item, except for items 10 and 20. In conclusion, the findings from this survey of student pharmacists at one college of pharmacy in the United States indicate a need for more education around e-cigarettes/vapes for student pharmacists so that they are better able to counsel patients on their use.
• Anderson, E. J., Dhatt, H., Vaffis, S., Nelson, M. L., Warholak, T., Campbell, P. J., Black, H., Kolobova, I., & Axon, D. R. (2022). Key informant perspectives about telephonic comprehensive medication review services in the United States. Journal of the American Pharmacists Association : JAPhA, 62(3), 817-825.e1.
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  Comprehensive medication reviews (CMRs) are provided by providers such as pharmacists to eligible beneficiaries. Although CMRs have been shown to provide value to patients, little is known about the service uniformity, quality, and content of CMRs.
• Arku, D., Almatruk, Z., Warholak, T., & Axon, D. R. (2022). Evaluating the reliability and validity of a questionnaire used to measure experiences of teamwork among student pharmacists in a quality improvement course. Currents in pharmacy teaching & learning, 14(5), 552-560.
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  The psychometric properties of instruments used to capture student pharmacists' perspectives of teamwork have not been well assessed. This study measured the reliability and validity of an instrument designed to assess teamwork experiences among student pharmacists in a quality improvement (QI) class at one United States pharmacy school.
• Arku, D., Bingham, J., Turgeon, J., Michaud, V., Warholak, T., & Axon, D. R. (2022). Exploring the association of the COVID-19 pandemic on employee sleep quality at a healthcare technology and services organization. . COVID.
• Arku, D., Felix, M., Warholak, T., & Axon, D. R. (2022). Program of All-Inclusive Care for the Elderly (PACE) versus Other Programs: A Scoping Review of Health Outcomes. Geriatrics (Basel, Switzerland), 7(2).
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  The Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive health and social services to community-dwelling older United States (US) adults. However, little is known about how PACE outcomes compare to similar caregiving programs. This scoping review searched nine databases to identify studies that compared economic, clinical, or humanistic outcomes of PACE to other caregiving programs in the US. Two reviewers independently screened and extracted data from relevant articles and resolved discrepancies through consensus. From the 724 articles identified, six studies were included. Example study outcomes included: limitations and needs, survival and mortality, healthcare utilization, and economic outcomes. In conclusion, there are few published comparisons of PACE outcomes versus other caregiving programs for older US adults, and identified studies indicate mixed results. Further studies are needed to compare PACE outcomes to other programs so that policymakers are well informed to manage and optimize health outcomes for the growing US older adult population.
• Awad, N. B., & Axon, D. R. (2022). Characteristics Associated with Good Self-Perceived Mental Health among United States Adults with Arthritis. Behavioral sciences (Basel, Switzerland), 12(8).
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  Mental health disorders are prevalent among United States (US) adults with arthritis. Yet, little is known about characteristics associated with mental health among US adults with arthritis. This retrospective cross-sectional study used 2019 Medical Expenditures Panel Survey data to assess the association between multiple personal characteristics and mental health status among US adults with arthritis. Hierarchical logistic regression models modeled associations between personal characteristics and mental health status. Model 1 included predisposing factors, model 2 included predisposing and enabling factors, while model 3 included predisposing, enabling, and need factors. The a priori alpha level was 0.05. Analyses accounted for the complex survey design and were weighted to produce national estimates. Among 28,512 individuals, 4984 met the inclusion criteria. Of these, 4181 had good mental health (85.5%, 95% confidence interval (CI) = 84.3%, 86.7%). The following characteristics were associated with good mental health status in the final adjusted model: age 18-64 vs. ≥65 (adjusted odds ratio (AOR) = 0.29, 95% CI = 0.12, 0.71), Midwest vs. West census region (AOR = 5.17, 95% CI = 1.63, 16.46), no degree vs. higher than high school education (AOR = 0.34, 95% CI = 0.12, 0.92), and high school diploma vs. higher than high school education (AOR = 0.40, 95% CI = 0.18, 0.86). In conclusion, this study suggests such characteristics may be targeted to help improve mental health among this population. Additional efforts are needed to help satisfy the unmet need for mental healthcare among this population.
• Axon, D. R. (2022). Development and Implementation of a Healthcare Database Analysis Course for Graduate Students. Pharmacy (Basel, Switzerland), 10(5).
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  There emerged a need to develop and implement a new healthcare database analysis course for Health Economics and Outcomes Research (HEOR) graduate students, which would allow students to apply their biostatistics and study design skills to answer healthcare-related research questions using large datasets. This communication establishes the need for this course, describes how the course was conceptualized, provides an overview of the course content, course cohort, and course outcomes, and discusses lessons learned from this process. This course was developed to meet the need of HEOR graduates to perform real-world data studies. The course required students to conceptualize a study, apply their data analysis skills to analyze the data, and develop their scientific writing skills by preparing a conference abstract and research report that should be submitted for publication. Lessons learned include focusing more on developing advanced research methodologies and less time on preparing dissemination materials, which can instead be done in subsequent courses or for independent study credit.
• Axon, D. R., & Barrios, L. P. (2022). Investigating Prescription Medication Expenditures and Level of Perceived Health Status among Older Adults with Pain in the United States. Medicines (Basel, Switzerland), 9(3).
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  the objective of this retrospective, cross sectional study was to assess the relationship between different levels of perceived health status and prescription medication expenditures among United States adults aged ≥50 years with self-reported pain. using 2019 Medical Expenditure Panel Survey (MEPS) data, four levels of perceived health status were formed (excellent, very good, good, and fair/poor health). Differences between characteristics in the groups were compared using chi square tests. Adjusted linear regression models, using logged positive annual prescription medication expenditures, were constructed to assess differences in prescription medication expenditures between levels of perceived health. a total of 4826 individuals were included in the study. Adjusted linear regression analysis indicated those who reported excellent health had 65.8% lower annual prescription medication expenditures than those with fair/poor health. Those with very good health had 49.7% lower annual prescription medication expenditures than those with fair/poor health, while those with good health had 27.2% lower annual prescription medication expenditures than those with fair/poor health. better perceived health status was generally associated with relatively lower prescription medication expenditures. Further research is needed to investigate if this pattern is also observed for other categories of healthcare expenditures and in other populations.
• Axon, D. R., & Chien, J. (2022). Assessing healthcare expenditures of older United States adults with pain and poor versus good mental health status: a cross-sectional study. BMJ open, 12(1), e049727.
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  This study aimed to determine if differences exist in healthcare expenditures of older United States (US) adults with pain based on self-reported mental health status, which is important to know given the prevalence of pain and poor mental health in the USA.
• Axon, D. R., & Dawid, A. (2022). Student pharmacist characteristics and management of headache. Currents in pharmacy teaching & learning, 14(9), 1169-1176.
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  Headache is a prevalent, debilitating condition that affects 50% of adults globally. Little is known about headache among student pharmacists. This study describes the characteristics and management of headache among student pharmacists as well as implications for pharmacy education.
• Axon, D. R., & Whaley, M. (2022). Student Pharmacists' Perspectives of In-Person versus Virtual Research Poster Presentations. Pharmacy (Basel, Switzerland), 10(5).
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  This study assessed the preferences of fourth-year student pharmacists for an in-person versus virtual pharmacy research poster session. An electronic survey was administered to all fourth-year student pharmacists enrolled in a research project course in Fall 2021 ( = 132). Six items explored students' opinions towards research posters using a five-point agreement scale. Twelve items explored students' preferences for either research poster format. Students also indicated their overall preference for an in-person or virtual research poster session. Data were analyzed descriptively. A total of 63 fourth-year student pharmacists completed the questionnaire. The median agreement score was four out of five, indicating favorable attitudes towards the importance of research posters in pharmacy curriculum. Most students said they would enjoy research posters more, and would be more able to present at, participate in and ensure that all can participate in poster sessions if the poster sessions were virtual as opposed to in-person. Most (76.2%) students indicated a preference for virtual rather than in-person research poster sessions. In conclusion, the study results suggest that student pharmacists prefer virtual rather than in-person poster sessions. Further research is recommended to explore the comparative effectiveness of these poster formats to achieve learning outcomes in varying university pharmacy programs.
• Axon, D. R., Alamer, A., Almatruk, Z., & Fazel, M. T. (2022). Assessing student pharmacists' confidence and knowledge of basic diabetes self-management skills. Currents in pharmacy teaching & learning, 14(8), 982-989.
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  The significance of diabetes self-management and recent advances in diabetes medications call for healthcare professionals' preparedness in educating patients. This study assessed correlations between student pharmacists' confidence and knowledge of diabetes self-management skills.
• Axon, D. R., Cernasev, A., Desai, M., Connor, S. E., Jonkman, L. J., & Sekar, M. C. (2022). Evaluating Students' COVID-19 Knowledge, Attitudes and Practices (COVKAP) during the COVID-19 Pandemic. Pharmacy (Basel, Switzerland), 10(2).
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  The COVID-19 pandemic led to significant disruption in students' lives through lockdowns, restricted movement, remote instruction, and mixed information. Therefore, this study aimed to capture the knowledge, attitudes, and practices of student pharmacists during 2020-2021. A 43-item COVID-19 Knowledge, Attitudes, and Practices (COVKAP) survey previously developed was administered at four schools of pharmacy across the U.S. during Fall 2020 and Spring 2021. A total of 418 responses were analyzed from graduating classes of 2021-2024. There were no significant differences in correct COVID-19 knowledge responses across the four graduating years. Respondents' attitudes around COVID-19 were homogenous with the exception for their belief in their preparedness to administer COVID-19 vaccines. Respondents reported wearing masks daily (76.8%), infrequently visiting restaurants (82.1%), practicing social distancing daily (45.7%), and referring to medical journals for information (72%). In conclusion, during the pandemic, student pharmacists experienced significant changes in their academic lives. Their knowledge and subsequent attitudes and practices were consistent with the state of evidence during Fall 2020 and Spring 2021. Subsequently, as newer information has emerged, the authors suggest that the COVKAP survey may be modified and administered frequently to address student needs and concerns as the pandemic evolves.
• Axon, D. R., Chien, J., & Dinh, H. (2022). Comparison of Health Care Expenditures Among U.S. Older Adults With Pain Who Reported Frequent Exercise Versus Nonfrequent Exercise. Journal of aging and physical activity, 30(5), 824-832.
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  This cross-sectional study included a nationally representative sample of U.S. adults aged ≥50 years with self-reported pain in the past 4 weeks from the 2018 Medical Expenditure Panel Survey. Adjusted linear regression analyses accounted for the complex survey design and assessed differences in several types of annual health care expenditures between individuals who reported frequent exercise (≥30 min of moderate-vigorous intensity physical activity ≥5 times per week) and those who did not. Approximately 23,940,144 of 56,979,267 older U.S. adults with pain reported frequent exercise. In adjusted analyses, individuals who reported frequent exercise had 15% lower annual prescription medication expenditures compared with those who did not report frequent exercise (p = .007). There were no statistical differences between frequent exercise status for other health care expenditure types (p > .05). In conclusion, adjusted annual prescription medication expenditures were 15% lower among older U.S. adults with pain who reported frequent exercise versus those who did not.
• Axon, D. R., Jang, A., Son, L., & Pham, T. (2022). Determining the association of perceived health status among United States older adults with self-reported pain. Aging and Health Research.
• Axon, D. R., Johnson, M., Abeln, B., Forbes, S., Anderson, E. J., Taylor, A. M., Aseret-Manygoats, T., Warholak, T., & Hall-Lipsy, E. (2022). An Academic-Community Collaboration to Deliver Medication Therapy Management (MTM) Services to Patients Living in Rural Counties of a Southwestern State in the United States. Journal of pharmacy practice, 35(5), 691-700.
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  Patients living in rural communities often experience pronounced health disparities, have a higher prevalence of diabetes and hypertension, and poorer access to care compared to urban areas. To address these unmet healthcare service needs, an established, academic-based MTM provider created a novel, collaborative program to provide comprehensive, telephonic services to patients living in rural Arizona counties.
• Axon, D. R., Kloster, J., Eckert, B., Morales, S., Riggs, S., Kilungo, A., Ehiri, J., Grieser, M., Turner-Warren, T., Aseret-Manygoats, T., Bingham, J. M., Scovis, N., & Warholak, T. (2022). Evaluation of a Pharmacist-Led Telephonic Medication Therapy Management Program in Rural Arizona: Implications for Community Health Practice. Clinics and practice, 12(3), 243-252.
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  This study evaluated a pharmacist-led telephonic Medication Therapy Management (MTM) program for rural patients in Arizona with poor access to healthcare services. A pharmacist provided telephonic MTM services to eligible adult patients living in rural Arizona communities with a diagnosis of diabetes and/or hypertension. Data were collected and summarized descriptively for demographic and health conditions, clinical values, and medication-related problems (MRPs) at the initial consultation, and follow-up data collected at 1 and 3 months. A total of 33 patients had baseline and one-month follow-up data, while 15 patients also had three-month follow-up data. At the initial consultation, the following MRPs were identified: medication adherence issues, dose-related concerns, adverse drug events (ADE), high-risk medications, and therapeutic duplications. Recommendations were made for patients to have the influenza, herpes zoster, and pneumonia vaccines; and to initiate a statin, angiotensin converting enzyme inhibitor, angiotensin receptor blocker, beta-blocker, and/or rescue inhaler. In conclusion, this study demonstrated that while pharmacists can identify and make clinical recommendations to patients, the value of these interventions is not fully realized due to recommendations not being implemented and difficulties with patient follow-up, which may have been due to the COVID-19 pandemic. Additional efforts to address these shortcomings are therefore required.
• Axon, D. R., Pesqueira, T., Jarrell, B., & Dicochea, D. (2022). Correlation of self-reported pain severity and healthcare expenditures in older United States adults. Scandinavian journal of pain, 22(1), 133-141.
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  Healthcare expenditures of older United States (US) adults with different pain severity levels are important to investigate given the increasing prevalence of pain in this population. This study assessed the correlation of healthcare expenditures among older US adults with different pain severities, hypothesizing that expenditures would increase as pain severity increased.
• Axon, D. R., Slack, M., & Warholak, T. (2022). Identifying predictors of opioid use among older United States' adults with pain. Journal of opioid management, 18(2), 95-105.
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  To identify the strongest predictors of opioid use among older United States' (US) adults (≥50 years) with pain.
• Campbell, P. J., Axon, D. R., Anderson, E. J., Ekstrand, M. J., Brummel, A., & Warholak, T. (2022). Psychometric evaluation of a comprehensive medication management service experience instrument. Journal of the American Pharmacists Association : JAPhA, 62(1), 218-223.
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  The Health-Systems Alliance for Integrated Medication Management (HAIMM) instrument was developed to estimate patient experience following pharmacist-delivered comprehensive medication management (CMM).
• Chien, J., Axon, D. R., & Cooley, J. (2022). Student pharmacists' perceptions of their professional identity. Currents in pharmacy teaching & learning, 14(6), 712-719.
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  Professional identity describes the internal feeling of belonging to a community, such that someone "thinks, feels, and acts" like a member of a profession. Clear professional identity formation can improve the transition from school to work. However, there is limited knowledge about student pharmacists' perceptions of their professional identity. This research aimed to identify and compare student pharmacists' perceptions of their professional identity and to compare those perceptions across class cohorts.
• Chinthammit, C., Bhattacharjee, S., Lo-Ciganic, W. H., Axon, D. R., Slack, M., Bentley, J. P., & Warholak, T. L. (2022). Association of low-income subsidy, medicaid dual eligibility, and disability status with high-risk medication use among Medicare Part D beneficiaries. Research in social & administrative pharmacy : RSAP, 18(4), 2634-2642.
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  Low-income subsidy/dual eligibility (LIS/DE) status and disability status may be associated with high-risk medication (HRM) use but are not usually accounted for in medication-use quality measures.
• Choi, B. M., Obeng-Kusi, M., & Axon, D. R. (2022). Association between Patient-Provider Communication and Self-Perceived Mental Health in US Adults with Cancer: Real-World Evidence through Medical Expenditure Panel Survey. Diseases (Basel, Switzerland), 10(4).
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  Using real-world data, this retrospective cross-sectional study aimed to analyze the association between patient-physician communication and self-reported mental health from cancer patients using publicly available 2019 Medical Expenditure Panel Survey (MEPS) household component data. Four adjusted logistic regression models were conducted to analyze the association between patient-physician communication and self-perceived mental health among United States adult cancer patients, with each model assessing different aspects of patient-physician communication: being respected (respect), being listened to (listen), spending enough time (time), and being explained (explain). The main finding from this study was that only the time model showed a statistical significance, where patients who reported that their physician always spent enough time perceived their mental health as good. Other covariates that showed statistical significance with self-perceived mental health in cancer patients included age, income level, physical limitation, and limitation from pain. In conclusion, there were generally no statistically significant associations between patient-physician communication and mental health among cancer patients.
• Cornelison, B., Baldry, A., & Axon, D. R. (2022). Pharmacy Students' Experiences with an Interactive Video Platform to Develop Clinical Reasoning. Pharmacy (Basel, Switzerland), 10(4).
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  Activities used to evaluate clinical reasoning include the use of standardized patients, role play, and case studies. To provide a standardized student experience at a lower cost than a standardized patient, standardized patients were developed using an interactive video platform. The purpose of this article is to report pharmacy students' perceptions of the interactive video standardized patients used to practice applying clinical reasoning in a self-care therapeutics course. Students participated in the following five methods to assess clinical reasoning: case studies, interactive patient videos, role play, case creation, and Zoom polls. Four of the five methods (case studies, interactive patient videos, role play, and case creation) were used in small breakout groups consisting of two to three students. Upon completion of the small group work, Zoom polls assessed the clinical reasoning of the entire class. Students completed a survey that assessed their level of agreement with 17 statements about the course on a five-point Likert scale and 2 questions that asked the students to rank the activities based on their experiences. There were 127 students that took the self-care therapeutics course, and 112 completed the survey (88%). Overall, the students preferred the Zoom poll activity; however, of the four different methods utilized within the small breakout groups, the findings of our survey indicated that students preferred to receive fully written-out patient cases followed by the interactive patient videos. Additionally, the students thought that the written-out patient cases and interactive patient videos were most efficient for learning and recall. The interactive patient videos may be an alternative activity that allows students to demonstrate and assess their clinical reasoning for each patient case, in addition to seeing how this impacted their patient's outcome.
• Cornelison, B., Edwards, C., Axon, D. R., Gorman, L., Rudin-Rush, L., Johnson, B., & Alvarez, N. A. (2022). Assessing the Association of Hispanic Ethnicity and Other Personal Characteristics with Pharmacy School Admissions. Pharmacy (Basel, Switzerland), 10(4).
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  Access to healthcare services for underrepresented minority populations can be improved by having a diverse profession that reflects the diversity of the patient population being served. The criteria used for pharmacy school admissions may inhibit or strengthen the opportunities that URM students have to be accepted into the University of Arizona R. Ken Coit College of Pharmacy (COP) program. It is currently unclear how personal characteristics are associated with pharmacy school admissions at the COP. This study evaluates whether Hispanic ethnicity was associated with pharmacy school admission status, and secondarily, determines other characteristics associated with admissions. This retrospective database study used admissions data from 2005 to 2018. Completed applications were included in the analysis. The outcome variable was admitted versus not admitted to the pharmacy program. A multivariable logistic regression model was used to identify variables associated with admission status using an a priori alpha level of 0.05. A total of 2096 applicants were included in the analysis (mean age 25.1 ± 5.2 years, 59.9% female, 13.0% Hispanic). Hispanic ethnicity was not associated with admission status. Characteristics significantly associated with admission to pharmacy school were age, gender, high school attended, previous application to the college, and Pharmacy College Admission Test (PCAT) biology and chemistry scores. Although bias was not seen in the admissions process, this study highlights the need for intervention to ensure future cohorts better reflect the diversity of the region.
• Marupuru, S., Roether, A., Guimond, A. J., Stanley, C., Pesqueira, T., & Axon, D. R. (2022). A Systematic Review of Clinical Outcomes from Pharmacist Provided Medication Therapy Management (MTM) among Patients with Diabetes, Hypertension, or Dyslipidemia. Healthcare (Basel, Switzerland), 10(7).
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  This study aimed to compare the clinical outcomes of pharmacist-provided medication therapy management (MTM) services as compared to no MTM services (i.e., standard of care) on outpatient clinical outcomes for patients with diabetes, hypertension, or dyslipidemia. A systematic literature review of PubMed, EMBASE, Cochrane library, International Pharmaceutical Abstracts, PsycINFO, Scopus, CINAHL electronic databases, grey literature, websites, and journals, was conducted from 1 January 2005-20 July 2021. The search field contained a combination of keywords and MeSH terms such as: "medication therapy management", "pharmacist", "treatment outcomes". Studies published in United States, included adults ≥18 years old who received at least one pharmacist-provided MTM consultation and at least one group who received no MTM, and reported pre-specified clinical outcomes for diabetes mellitus, hypertension, or dyslipidemia were included. Of 849 studies identified, eight were included (cohort studies = 6, randomized controlled trials = 2). Clinical outcomes improved with MTM interventions, as evidenced by statistically significant changes in at least one of the three chronic conditions in most studies. Improvements were observed for diabetes outcomes ( = 4 studies), hypertension outcomes ( = 4 studies), and dyslipidemia outcomes ( = 3 studies). Overall, this study indicated that pharmacist delivered MTM services (versus no MTM services) can improve clinical outcomes for patients with diabetes, hypertension, and dyslipidemia.
• Obeng-Kusi, M., Choi, B. M., Axon, D. R., Cooley, J., & Warholak, T. (2022). Improving and validating a rating scale to assess student pharmacists' perception of professional identity. Journal of the American Pharmacists Association : JAPhA, 62(5), 1623-1630.e2.
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  There are limited data on the psychometric properties of instruments evaluating professional identity (PI) among student pharmacists.
• Obeng-Kusi, M., Vardy, J. L., Bell, M. L., Choi, B. M., & Axon, D. R. (2022). Comorbidities and perceived health status in persons with history of cancer in the USA. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 31(1), 16.
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  Comorbidities can further challenge prognosis and general wellbeing of cancer patients. This study aimed to assess the association between comorbidities and perceived health status (PHS) of US persons with cancer.
• Springer, S. P., Cernasev, A., Barenie, R. E., Axon, D. R., & Scott, D. (2022). "I Think Deprescribing as a Whole Is a Gap!": A Qualitative Study of Student Pharmacist Perceptions about Deprescribing. Geriatrics (Basel, Switzerland), 7(3).
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  Older adults often manage multiple medications simultaneously, contributing to significant pill burden. Pill burden is a major concern for both patients and providers alike, and student pharmacists may play a role in decreasing that burden. Few studies exist evaluating student pharmacists' roles in and perceptions of deprescribing in the healthcare team. Thus, the aim of this study was to explore student pharmacist perceptions regarding deprescribing in their pharmacy curricula.
• Whaley, M., & Axon, D. R. (2022). Factors associated with pneumococcal vaccine uptake among vulnerable older adults in the United States primary care setting. Vaccine, 40(47), 6756-6766.
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  Pneumococcal vaccine uptake targets set by Healthy People 2020 were not met by 2019 among vulnerable United States populations, yet research suggests progress can be made in primary care settings. This study assessed factors associated with having gotten a pneumococcal vaccine among vulnerable adults aged 50 and older. This study used the 2018 Medical Expenditure Panel Survey nationally representative dataset. Eligible individuals were aged 50-64 with an 'at risk' health condition or ≥65 years and had a primary care provider as their usual source of care (N = 3,760). Binary logistic regression was used to test factors (identified from literature) for a significant association with getting the pneumococcal vaccine. Factors with significant associations were entered into an adjusted multivariable logistic regression model to generate the odds of endorsing a factor given that the respondent got the vaccine. Collinearity among variables was examined with an unacceptable threshold of 0.8 correlation. A significance threshold of 0.05 was used. Those who got the pneumococcal vaccine had 16.7 (p 
• Axon, D. R., & Arku, D. (2021). Associations of multiple (≥5) chronic conditions among a nationally representative sample of older United States adults with self-reported pain. Scandinavian journal of pain, 21(4), 814-822.
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  The association between an individuals' demographic and health characteristics and the presence of multiple chronic conditions is not well known among older United States (US) adults. This study aimed to identify the prevalence and associations of having multiple chronic conditions among older US adults with self-reported pain.
• Axon, D. R., & Chien, J. (2021). Predictors of Mental Health Status among Older United States Adults with Pain. Behavioral sciences (Basel, Switzerland), 11(2).
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  Poor mental health is common among older adults with pain, resulting in high economic burden and impaired quality of life. This retrospective, cross-sectional database study aimed to identify characteristics associated with good mental health status among United States (US) adults aged ≥50 years with self-reported pain in the last four weeks using a weighted sample of 2017 Medical Expenditure Panel Survey data. Hierarchical multivariable logistic regression models were used to identify statistically significant predictors of good (versus poor) perceived mental health status. From a weighted population of 57,074,842 individuals, 85.5% (95% confidence interval (CI) = 84.4%, 86.7%) had good perceived mental health. Good mental health was associated most strongly with physical health status (adjusted odds ratio (AOR) = 9.216, 95% CI = 7.044, 12.058). Employed individuals were 1.7 times more likely to report good mental health versus unemployed (AOR = 1.715, 95% CI = 1.199, 2.452). Individuals who had completed less than high school education (AOR = 0.750, 95% CI = 0.569, 0.987) or who reported having a limitation (AOR = 0.513, 95% CI = 0.384, 0.684) were less likely to report good mental health. These key characteristics can be utilized to predict mental health status, which may be investigated to better manage concurrent pain and poor mental health.
• Axon, D. R., & Emami, N. (2021). Association of Self-Reported Frequent Exercise Among a Nationally Representative Sample of Older People in the United States With Self-Reported Pain. Journal of aging and physical activity, 1-8.
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  This retrospective, cross-sectional database study aimed to identify characteristics associated with self-reported frequent exercise (defined as moderate- to vigorous-intensity exercise for ≥30 min five times a week) in older U.S. (≥50 years) adults with pain in the past 4 weeks, using 2017 Medical Expenditure Panel Survey data and hierarchical logistic regression models. The variables significantly associated with frequent exercise included being male (adjusted odds ratio [AOR] = 1.507, 95% confidence interval [CI] [1.318, 1.724]); non-Hispanic (AOR = 1.282, 95% CI [1.021, 1.608]); employed (AOR = 1.274, 95% CI [1.040, 1.560]); having no chronic conditions versus ≥5 conditions (AOR = 1.576, 95% CI [1.094, 2.268]); having two chronic conditions versus ≥5 conditions (AOR = 1.547, 95% CI [1.226, 1.952]); having no limitation versus having a limitation (AOR = 1.209, 95% CI [1.015, 1.441]); having little/moderate versus quite/extreme pain (AOR = 1.358, 95% CI [1.137, 1.621]); having excellent/very good versus fair/poor physical health (AOR = 2.408, 95% CI [1.875, 3.093]); and having good versus fair/poor physical health (AOR = 1.337, 95% CI [1.087, 1.646]). These characteristics may be useful to create personalized pain management protocols that include exercise for older adults with pain.
• Axon, D. R., & Kamel, A. (2021). Patterns of Healthcare Expenditures among Older United States Adults with Pain and Different Perceived Health Status. Healthcare (Basel, Switzerland), 9(10).
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  The objective of this study was to assess the pattern of healthcare expenditures among United States (U.S.) adults aged ≥50 years with pain and annual total positive healthcare expenditures with different levels of perceived health. The study used the 2018 Medical Expenditure Panel Survey data. Unadjusted and adjusted linear regression models were used to compare logarithmically transformed total healthcare expenditures between those with excellent, very good, good, and fair/poor health. The a priori alpha value was 0.05. The study included 5123 U.S. adults aged ≥50 with self-reported pain (excellent = 8.9%, very good = 28.3%, good = 36.2%, fair/poor = 26.6%). In adjusted analyses, compared to fair/poor health, those with excellent health had the greatest adjusted reduction in expenditures (55% lower), followed by very good health (36.5% lower) and good health (24.9% lower). In conclusion, total positive healthcare expenditures were comparatively lower among those with better perceived health status for older (≥50 years) U.S. adults with pain that interfered with normal work in the past four weeks.
• Axon, D. R., & Le, D. (2021). Association of Self-Reported Functional Limitations among a National Community-Based Sample of Older United States Adults with Pain: A Cross-Sectional Study. Journal of clinical medicine, 10(9).
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  The characteristics of self-reported functional limitations among older United States (US) adults with pain are currently unknown. This cross-sectional study aimed to determine the characteristics associated with functional limitations among non-institutionalized older (≥50 years) US adults with pain using 2017 Medical Expenditure Panel Survey (MEPS) data. Eligible subjects were alive for the calendar year, aged ≥50 years, and experienced pain within the past four weeks. Hierarchical logistic regression models were utilized to determine significant characteristics associated with functional limitations (outcome variable; yes, no). Functional limitations included difficulty with bending, stooping, climbing stairs, grasping objects, lifting, reaching overhead, standing for long periods of time, or walking. Extrapolation of national data values was possible by adjusting for the complex MEPS design. We found approximately 22 million of the 57 million older US adults (≥50 years) who reported pain had a functional limitation in 2017. Characteristics associated with functional limitations included: gender, race, ethnicity, employment status, marital status, pain intensity, physical health, number of chronic conditions, and frequent exercise status. Knowledge of characteristics associated with functional limitations may provide an opportunity to identify and resolve gaps in patient care among this population.
• Axon, D. R., & Le, D. (2021). Predictors of pain severity among community-dwelling older adults with pain in the United States: Findings from a cross-sectional, retrospective study using 2017 Medical Expenditure Panel Survey. Medicine, 100(20), e26011.
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  The purpose of this study was to determine predictors of pain severity among older United States (US) adults with pain.This cross-sectional, retrospective study utilized 2017 Medical Expenditure Panel Survey data. Eligible participants were alive for the calendar year, aged ≥50 years, and reported pain in the past 4 weeks. Hierarchical logistic regression models, adjusting for the survey design, were used to identify significant predictors of pain severity (i.e., extreme/quite a bit or moderate/little pain).An estimated 14,250,534 adults aged ≥50 with pain reported extreme/quite a bit of pain. Many variables were associated with extreme/quite a bit of pain, including: age 50 to 64 vs ≥65 years (adjusted odds ratio [AOR] = 1.49, 95% confidence interval [95% CI] = 1.22-1.82); males vs females (AOR = 0.80, 95% CI = 0.67-0.95); white race vs others (AOR = 0.75, 95% CI = 0.61-0.92); married vs other marital status (AOR = 1.31, 95% CI = 1.08-1.57); income
• Axon, D. R., Marupuru, S., & Vaffis, S. (2021). Health Costs of Older Opioid Users with Pain and Comorbid Hypercholesterolemia or Hypertension in the United States. Diseases (Basel, Switzerland), 9(2).
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  This retrospective cross-sectional database study used 2018 Medical Expenditure Panel Survey data to quantify and assess differences in healthcare expenditures between opioid users and non-users among a non-institutionalized sample of older (≥50 years) United States adults with pain in the past four weeks and a diagnosis of comorbid hypercholesterolemia (pain-hypercholesterolemia group) or hypertension (pain-hypertension group). Hierarchical multivariable linear regression models were constructed by using logarithmically transformed positive cost data and adjusting for relevant factors to assess cost differences between groups. Percent difference between opioid users and non-users was calculated by using semi-logarithmic equations. Healthcare costs included inpatient, outpatient, office-based, emergency room, prescription medication, other, and total costs. In adjusted analyses, compared to non-users, opioid users in the pain-hypercholesterolemia and pain-hypertension groups respectively had 66% and 60% greater inpatient expenditure, 46% and 55% greater outpatient expenditure, 67% and 72% greater office-based expenditure, 50% and 60% greater prescription medication expenditure, 24% and 22% greater other healthcare expenditure, and 85% and 93% greater total healthcare expenditure. In conclusion, adjusted total healthcare expenditures were 85-93% greater among opioid users versus non-users in older United States adults with pain and comorbid hypercholesterolemia or hypertension. Future research is needed to identify opioid use predictors among these populations and reduce expenditures.
• Axon, D. R., Slack, M., Barraza, L., Lee, J. K., & Warholak, T. (2021). Nationally Representative Health Care Expenditures of Community-Based Older Adults with Pain in the United States Prescribed Opioids vs Those Not Prescribed Opioids. Pain medicine (Malden, Mass.), 22(2), 282-291.
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  To compare health care expenditures between older US adults (≥50 years) with pain who were prescribed opioid medications and those who were not.
• Bingham, J. M., Black, M., Anderson, E. J., Li, Y., Toselli, N., Fox, S., Martin, J. R., Axon, D. R., & Silva-Almodóvar, A. (2021). Impact of Telehealth Interventions on Medication Adherence for Patients With Type 2 Diabetes, Hypertension, and/or Dyslipidemia: A Systematic Review. The Annals of pharmacotherapy, 55(5), 637-649.
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  To describe telehealth interventions and determine their effect on medication adherence for patients with type 2 diabetes, hypertension, and/or dyslipidemia.
• Bingham, J. M., Stanislaw, J., Warholak, T., Scovis, N., Axon, D. R., Turgeon, J., & Marupuru, S. (2021). Assessment of Glycosylated Hemoglobin Outcomes Following an Enhanced Medication Therapy Management Service via Telehealth. International journal of environmental research and public health, 18(12).
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  (1) Background: Regular contact with a medication therapy management (MTM) pharmacist is shown to improve patients' understanding of their condition; however, continued demonstration of the value of a pharmacist delivered comprehensive medication review (CMR) using enhanced MTM services via telehealth is needed. The study aimed to describe a pilot program designed to improve type 2 diabetes mellitus (T2DM) management through enhanced condition specific MTM services. (2) Methods: This retrospective study included patients with T2DM aged 40-75 years who received a pharmacist-delivered CMR between January and December 2018. An evaluation of glycosylated hemoglobin (HbA1c) values 3 months pre- and post-CMR was performed. Wilcoxon signed-rank and chi-square tests were used. (3) Results: Of 444 eligible patients, a majority were female (58%) with a median age of 70 years. Median HbA1c values post-CMR were lower than pre-CMR (median 7.1% range 4.5-13.6; median 7.4% range 4.5-13.9, respectively; = 0.009). There were fewer participants with HbA1c >9% post-CMR ( = 66) than pre-CMR ( = 80; < 0.001) and more with HbA1C
• Campbell, P. J., Axon, D. R., Taylor, A. M., Smith, K., Pickering, M., Black, H., Warholak, T., & Chinthammit, C. (2021). Hypertension, cholesterol and diabetes medication adherence, health care utilization and expenditure in a Medicare Supplemental sample. Medicine, 100(35), e27143.
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  Limited evidence exists regarding the relationships between adherence, as defined in Pharmacy Quality Alliance (PQA) medication adherence measures, health care utilization, and economic outcomes. PQA adherence measures for hypertension, cholesterol, and diabetes are of particular interest given their use in Medicare Star Ratings to evaluate health plan performance.The objective of this study was to assess the relationship between adherence and utilization and cost among Medicare Supplemental beneficiaries included in the aforementioned PQA measures over a 1-year period.Retrospective cohort study.Three cohorts (hypertension, cholesterol, and diabetes) of eligible individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009-2015) were used to assess associations between adherence and health care expenditure and utilization for Medicare Supplemental beneficiaries.Generalized linear models with log link and negative binomial (utilization) or gamma (expenditure) distributions assessed relationships between adherence (≥80% proportion of days covered) and health care utilization and expenditure (in 2015 US dollars) while adjusting for confounding variables. Beta coefficients were used to compute cost ratios and rate ratios.Adherence for all 3 disease cohorts was associated with lower outpatient and inpatient visits. During the 1-year study period, adherence was associated with lower outpatient, inpatient, and total expenditures across the cohorts, ranging from 9% lower outpatient costs (diabetes cohort) to 41.9% lower inpatient costs (hypertension cohort). Savings of up to $324.53 per member per month in total expenditure were observed for the hypertension cohort.Our findings indicate adherence is associated with lower health care utilization and expenditures within 1 year.
• Chinthammit, C., Axon, D. R., Mollon, L., Taylor, A. M., Pickering, M., Black, H., Warholak, T., & Campbell, P. J. (2021). Evaluating the relationship between quality measure adherence definitions and economic outcomes in commercial health plans: a retrospective diabetes cohort study. Journal of managed care & specialty pharmacy, 27(1), 64-72.
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  Diabetes is a prevalent chronic condition in the United States that results in considerable morbidity and mortality, frequent use of the health care system, and high health care expenditures. Adherence to antidiabetic medications can help improve health outcomes and lower health care utilization and expenditures. The Pharmacy Quality Alliance (PQA) Proportion of Days Covered (PDC): Diabetes All Class medication adherence measure was developed and endorsed to improve adherence to noninsulin antidiabetic medications; however, it has not been assessed in a commercial population of diabetes patients over a 1-year time frame. To determine the association between adherence, as defined in the PQA medication adherence measures, and health care utilization and expenditure among commercially insured individuals using antidiabetic medications. This 1-year retrospective study evaluated a cohort of individuals from IBM MarketScan Research Databases (2009-2015) with noninsulin antidiabetic medications. Eligible study subjects included adults (aged ≥ 18 years at index date) with continuous enrollment in their health plans for 6 months before (i.e., baseline period) and 12 months after (i.e., study period) the index date and ≥ 2 prescriptions dispensed for any medication included in the PQA PDC Diabetes All Class medication adherence measure, with at least 150 days between the first and last fill during the study period. The index date was defined as the first fill for a medication included in the PQA PDC Diabetes All Class adherence measure after a 180-day baseline period. Generalized linear models with log link and gamma distribution (expenditure) or negative binomial distribution (utilization) assessed relationships between adherence (≥ 80% PDC) and health care utilization and expenditure while adjusting for potential confounders. Cost ratios (CR) and rate ratios (RR) were computed using beta coefficients. Cohort characteristics were compared using t-tests, Wilcoxon rank sum tests, or chi-square tests with an alpha level of 0.001 set a priori. A total of 1,576,112 individuals were eligible; of these, 1,028,176 (65.2%) were adherent. Significant differences in demographic characteristics were observed between adherent and nonadherent groups ( < 0.001). Multivariable analyses demonstrated that adherence was associated with the following: (a) 16.6% fewer inpatient (RR = 0.834, 95% CI = 0.819-0.850) and 3.6% more outpatient service visits (RR = 1.036, 95% CI = 1.032-1.039) and (b) 16.8% lower inpatient expenditures (CR = 0.833, 95% CI = 0.829-0.836); 2.6% lower outpatient expenditures (CR = 0.974, 95% CI = 0.970-0.978); 16.4% higher prescription drug expenditures (CR = 1.164, 95% CI = 1.159-1.169); and 4.2% lower total (CR = 0.958, 95% CI = 0.954-0.962) expenditures. Adherent subjects were associated with lower incremental per member per month expenditures for inpatient (-$31.74), outpatient (-$10.09), and total (-$30.82) expenditures, yet higher prescription drug expenditures ($25.60) compared with nonadherent subjects. Adherence to noninsulin antidiabetic medications was associated with more outpatient and fewer inpatient visits, as well as lower total expenditures compared with nonadherence. Funding was provided by grants from Pharmacy Quality Alliance, Merck & Co. (Kenilworth, NJ), and SinfoniaRx. In addition, Chinthammit reports personal fees from Eli Lilly and Company, outside the submitted work. Axon reports grants from the American Association of Colleges of Pharmacy and the Arizona Department of Health Services, outside the submitted work. Taylor reports grants from the Arizona Department of Health Services, outside the submitted work. Warholak reports grants from Novartis and the Arizona Department of Health Services, outside the submitted work. Chinthammit and Campbell disclose that this work was completed during their employment at the University of Arizona. This research was presented as a poster at the AMCP Annual Meeting 2019; March 25-28, 2019; San Diego, CA.
• Le, L. D., Paulk, I. R., Axon, D. R., & Bingham, J. M. (2021). Comprehensive Medication Review Completion in Medically Underserved Areas and Populations. Journal of health care for the poor and underserved, 32(3), 1301-1311.
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  Pharmacists provide comprehensive medication reviews (CMRs) to address provider shortages in medically underserved rural areas/populations (MUA/P). Currently, there are no studies regarding the proportions of CMRs completed directly with patients (here called, beneficiaries) from MUA/Ps themselves, or with others such as caregivers or primary care providers.
• Marupuru, S., & Axon, D. R. (2021). Association of Multimorbidity on Healthcare Expenditures Among Older United States Adults With Pain. Journal of aging and health, 33(9), 741-750.
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  This cross-sectional study compared the healthcare expenditures associated with multimorbidity (having ≥2 chronic conditions) versus no multimorbidity among older United States (US) adults (aged ≥ 50 years) with self-reported pain in the past 4 weeks. This research used data from the 2018 Medical Expenditure Panel Survey. Adjusted linear regression models evaluated group differences in various annual healthcare expenditures. Descriptive statistics indicated multimorbidity was associated with all personal characteristics ( < 0.05) except gender and smoking status ( > 0.05). Multimorbidity had 75.8% greater annual total health expenditures ( = 0.0083), 40.6% greater office-based expenditures ( = 0.0224), 100.6% greater prescription medication costs, ( = 0.0268), yet 47.3% lower inpatient expenditures ( = 0.0158), and 56.6% lower home healthcare expenditures ( < 0.0001) than no multimorbidity. This study found greater healthcare expenditures among older US adults with pain and multimorbidity, which captures the financial burden of comorbidity in this population.
• Stich, A., Cava, C., Cava, D., & Axon, D. R. (2021). Student Pharmacists' Perceptions of Amazon Pharmacy. Pharmacy (Basel, Switzerland), 9(4).
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  Amazon recently launched their online pharmacy in the United States (US). However, no studies have explored student pharmacists' perceptions of the potential impact of Amazon Pharmacy. This qualitative study used individual semi-structured interviews to examine third- and fourth-year student pharmacists' perceptions of how Amazon Pharmacy will affect economic, clinical, and humanistic outcomes; the pharmacy experience; and the job market. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed by two independent reviewers until saturation was reached, with differences resolved through discussion with a third researcher. Seventeen students participated in the study. Five themes were identified: perceived economic outcomes for patients, perceived clinical outcomes for patients, perceived humanistic outcomes for patients, perceived impact of the pharmacy experience for patients, and perceived influence of Amazon Pharmacy on the pharmacy market. The majority suggested Amazon Pharmacy would offer lower costs for patients (71%), improved medication adherence (76%), and improved quality of life (65%). There was a consensus that the Amazon Pharmacy experience would be different, with various opinions highlighting potential positive or negative aspects of the service. There were mixed opinions about job opportunities and impact on existing pharmacies. Future studies should evaluate economic, clinical, and humanistic outcomes for patients utilizing Amazon Pharmacy.
• Whaley, M., Awad, N. B., Warholak, T., & Axon, D. R. (2021). Validation Assessment of a Pain Interference Questionnaire among Student Pharmacists. Pharmacy (Basel, Switzerland), 9(4).
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  Validation studies of pain interference instruments used among student pharmacists are rare yet essential for understanding their appropriate use and interpretation in pharmacy education and practice. This study conducted validation and reliability assessments of a five-item Pain Interference Scale previously administered to student pharmacists. Construct validity was assessed using Rasch analysis. Unidimensionality was measured using: point-biserial measure correlations; percent of raw variance explained by items; difference between expected; variance modeled by items; and Rasch model fit. To assess scale functioning, response frequency distribution, observed average and sample expected logit distribution, Andrich logit distribution, item separation, and item reliability were assessed. Visual examination of the Item-Person Map determined content validity. Items explained 64.2% of data raw variance. The difference between raw variance modeled and observed was 0.6. Point-biserial measure correlations were >0.77. Item mean-square infits were 0.7-1.3 while outfit measures were 0.72-1.16. There were >10 responses per response category, response frequency and Andrich thresholds progressively advanced, and observed average and sample expected logits advanced monotonically, Andrich logits = -2.33-1.69, item separation = 2.61, and item reliability = 0.87. Item probability curves indicated response categories were minimally yet adequately distinct. Cronbach's alpha = 0.93. The Item-Person Map had a ceiling effect indicating content gaps. In conclusion, the pain interference instrument has acceptable construct validity yet contains content gaps. Additional difficult items should be added to the instrument to better capture pain interference among student pharmacists.
• Anderson, E. J., Axon, D. R., Taylor, A. M., Towers, V., Warholak, T., Johnson, M., Forbes, S., & Manygoats, T. (2020). Impact evaluation of a four-year academic-community partnership in provision of medication management and tertiary prevention services for rural patients with diabetes and/or hypertension. Preventive medicine reports, 17, 101038.
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  Medication therapy management (MTM) services, including targeted, pharmacist-delivered, tertiary prevention interventions, were provided to rural patients with chronic diseases via an academic-community partnership. The purpose of this investigation was to evaluate the overall program and pre/post patient outcomes from this four-year, multi-site collaboration. Five community health sites collaborated with a university-based MTM provider to deliver services in Arizona (2012-16). Eligible patients: were 18 or older (median 65 years); had a diagnosis of diabetes and/or hypertension; and resided in a rural community. Participants received an initial telephone consultation with the MTM pharmacist; follow-up consultations were conducted after 30 or 90 days for high- and low-risk patients, respectively. Community partner staff collected clinical data and addressed pharmacists' recommendations. Descriptive analysis and bivariate analyses of pre- and post-intervention results were conducted. Most (n = 410, 70%) of the 577 participants receiving an initial and follow-up consultation with the MTM pharmacist had both diabetes and hypertension. These individuals showed statistically significant improvements in fasting blood glucose (p 
• Axon, D. R., Aljadeed, R., Potisarach, P., Forbes, S., DiLeo, J., & Warholak, T. (2020). Pilot study of focus groups exploring student pharmacists' perceptions of a medication management center internship. Currents in pharmacy teaching & learning, 12(9), 1123-1128.
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  Student pharmacists are expected to participate in real-life, patient-centered experiences to help develop clinical knowledge and professional skills. This study explored student pharmacist intern perceptions of work experience at a medication management center (MMC). We also examined how working at the MMC helped fulfill curricular requirements, helped develop leadership skills, and provided professional development opportunities.
• Axon, D. R., Chinthammit, C., Tate, J., Taylor, A. M., Leal, S., Pickering, M., Black, H., Warholak, T., & Campbell, P. J. (2020). Current Procedural Terminology Codes for Medication Therapy Management in Administrative Data. Journal of managed care & specialty pharmacy, 26(10), 1297-1300.
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  Three pharmacist-specific Current Procedural Terminology (CPT) codes exist to facilitate medication therapy management (MTM) reimbursement (codes 99605, 99606, and 99607). However, no studies have used CPT codes in administrative claims databases to identify subjects who have received MTM services.
• Axon, D. R., Vaffis, S., & Marupuru, S. (2020). Identifying Predictive Characteristics of Opioid Medication Use among a Nationally Representative Sample of United States Older Adults with Pain and Comorbid Hypertension or Hypercholesterolemia. Healthcare (Basel, Switzerland), 8(3).
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  The prevalence of older adults with pain and comorbid cardiovascular conditions is increasing in the United States (U.S.). This retrospective, cross-sectional database study used 2017 Medical Expenditure Panel Survey data and hierarchical logistic regression models to identify predictive characteristics of opioid use among a nationally representative sample of older U.S. adults (aged ≥50 years) with pain in the past four weeks and comorbid hypertension (pain-hypertension group) or hypercholesterolemia (pain-hypercholesterolemia group). The pain-hypertension group included 2733 subjects ( = 803 opioid users) and the pain-hypercholesterolemia group included 2796 subjects ( = 795 opioid users). In both groups, predictors of opioid use included: White race versus others, Hispanic versus non-Hispanic ethnicity, 1 versus ≥5 chronic conditions, little/moderate versus quite a bit/extreme pain, good versus fair/poor perceived mental health, functional limitation versus no functional limitation, smoker versus non-smoker, and Northeast versus West census region. In addition, Midwest versus West census region was a predictor in the pain-hypertension group, and 4 versus ≥5 chronic conditions was a predictor in the pain-hypercholesterolemia group. In conclusion, several characteristics of older U.S. adults with pain and comorbid hypertension or hypercholesterolemia were predictive of opioid use. These characteristics could be addressed to optimize individuals' pain management and help address the opioid overdose epidemic.
• Axon, D. R., Vaffis, S., Chinthammit, C., Lott, B. E., Taylor, A. M., Pickering, M., Black, H., Warholak, T., & Campbell, P. J. (2020). Assessing the association between medication adherence, as defined in quality measures, and disease-state control, health care utilization, and costs in a retrospective database analysis of Medicare supplemental beneficiaries using statin medications. Journal of managed care & specialty pharmacy, 26(12), 1529-1537.
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  Adherence to medication, and related health and economic outcomes, is becoming increasingly important as populations age and as the number of Americans managing chronic conditions increases. The Pharmacy Quality Alliance (PQA) statin medication adherence measure is used in Medicare star ratings to evaluate health plan performance. Yet, limited evidence exists that investigates the association between statin medication adherence, as specified in the PQA adherence quality measure, and disease-state control, health care utilization, and costs. To determine the association between adherence (≥80% proportion of days covered) and disease-state control, health care utilization, and health care costs for Medicare supplemental beneficiaries using statin medications eligible for inclusion in the PQA statin adherence quality measure. This retrospective study used a cohort of eligible beneficiaries for inclusion in the PQA statin adherence measure with low-density lipoprotein (LDL) laboratory values from IBM MarketScan Medicare Supplemental Research Databases (2009-2015). A logistic regression model assessed the association between adherence and LDL control (controlled individuals had LDL levels ≤ 100 mg/dL). Health care utilization and costs during a 1-year period, from first statin medication claim, were compared between adherent and nonadherent groups using generalized linear models with log link and negative binomial distribution (utilization) or gamma distribution (costs), adjusting for covariates. Beta coefficients were used to compute cost ratios (CR) and rate ratios (RR). Cohort characteristics were assessed using t-tests, Wilcoxon rank sum tests, or chi-square tests. An a priori alpha level of 0.001 was used. The study cohort consisted of 77,174 beneficiaries, of whom 58,668 (76.0%) were classified as adherent to their statin medications. After controlling for other factors, odds of disease-state control were approximately 2 times higher among medication adherent beneficiaries compared with their nonadherent counterparts (OR = 2.192; 95% CI = 2.109-2.278). Multivariable analyses showed adherers experienced 4.7% fewer outpatient (RR = 0.953; 95% CI = 0.940-0.965) and 27.5% fewer inpatient (RR = 0.725; 95% CI = 0.687-0.766) visits; had 9.9% lower outpatient (CR = 0.901; 95% CI = 0.885-0.916) and 28.3% lower inpatient (CR = 0.717; 95% CI = 0.705-0.729) costs; 14.7% lower total costs (CR = 0.853; 95% CI =0.838-0.868); and 7.0% higher prescription drug costs (CR = 1.070; 95% CI = 1.052-1.089) than nonadherers. Adherence to statin medications was associated with a reduction in total costs of $157.32 per member per month. This retrospective database analysis demonstrated that statin adherence was associated with approximately twice the odds of having a controlled disease state compared with nonadherence in a large Medicare sample. Adherent beneficiaries had fewer outpatient and inpatient visits (lower utilization), lower outpatient and inpatient costs, and lower total costs, a calculated savings of $157.32 per member per month, despite having higher prescription drug costs. Finally, these results provide important new information by demonstrating that adherence (≥ 80%) is associated with lower health care costs in a short (1-year) time frame. Funding for this study was provided by Pharmacy Quality Alliance; Merck & Co. (Kenilworth, NJ); and SinfoniaRx. All authors except Pickering and Black were employed by the University of Arizona College of Pharmacy or the Mel & Enid Zuckerman College of Public Health at the time of this study. Pickering is employed by the Pharmacy Quality Alliance, and Black is employed by Merck & Co. Chinthammit also reports employment with Eli Lilly and Company, and Campbell reports employment with the Pharmacy Quality Alliance. Axon reports grants from Arizona Department of Health Services, unrelated to this work. Warholak reports grants from Novartis and the Arizona Department of Health Services, unrelated to this work. This research was presented as a poster at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Annual Meeting 2019, May 18-22, 2019, in New Orleans, LA.
• Bingham, J. M., Michaud, V., Turgeon, J., & Axon, D. R. (2020). Effectiveness of an Advanced Clinical Decision Support System on Clinical Decision-Making Skills in a Call Center Medication Therapy Management Pharmacy Setting: A Pilot Study. Pharmacy (Basel, Switzerland), 8(4).
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  (1) Background: There is limited evidence related to the efficacy of advanced clinical decision support systems (CDSS) on the quantity of high-quality clinical recommendations in a pharmacy-related medication therapy management (MTM) setting. The study aimed to assess the effect of an advanced CDSS on the quantity of relevant clinical pharmacist recommendations in a call center MTM setting. (2) Methods: This pre-test/post-test with comparator group study compared clinical skills assessment scores between certified MTM pharmacists in March 2020. A Wilcoxon Signed Rank test assessed the difference between pre- and post-test scores in both groups. (3) Results: Of 20 participants, the majority were less than 40 years old (85%) with a Doctor of Pharmacy degree (90%). Nine were female. Intervention group participants had less than three years of experience as a pharmacist. The control group had less than three years (40%) or seven to ten years (40%) of experience. There was a significant increase in intervention group scores between pre- (median = 3.0, IQR = 3.0) and post-test segments (median = 6.5, IQR = 4.0, = 0.02). There was no significant change between control group pre- and post-test segments ( = 0.48). (4) Conclusion: Pharmacist exposure to an advanced CDSS was associated with significantly increased quantity of relevant clinical recommendations in an MTM pharmacy setting.
• Bingham, J. M., Silva Almodovar, A., Taylor, A. M., Axon, D. R., Nahata, M. C., Leal, S., Warholak, T., & Scovis, N. (2020). A Research Partnership to Enhance Postgraduate Pharmacy Residency Training Outcomes. Pharmacy (Basel, Switzerland), 8(3).
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  Pharmacy residents must complete research as part of their program; however, challenges exist in providing experiences that result in successful research dissemination outcomes. A university-based research team, integrated into an ambulatory care pharmacy residency program aimed to improve presentation and publication rates of pharmacy resident research projects. Data on the number of postgraduate year-2 (PGY2) residents and their productivity were collected and summarized to assess progress. A total of 13 residents completed their residency over seven years. Each resident produced one regional presentation, and one national presentation beginning in year four. To date, three peer-reviewed papers have been published, with another one in-press. Responses from residents found lack of guidance, lack of data availability for projects and feedback fatigue were barriers to a positive research experience. To address these problems, a university-based research team was integrated to provide research mentor guided support, ensure study feasibility, and provide structured feedback. This program evaluation highlighted the integration of a PGY2 ambulatory care pharmacy residency with a designated, interprofessional university-based research team. Future work is warranted to reduce research-related barriers and formally evaluate resident post-program knowledge, skills, and subsequent dissemination rates.
• Bingham, J. M., Taylor, A. M., Boesen, K. P., & Axon, D. R. (2020). Preliminary Investigation of Pharmacist-Delivered, Direct-to-Provider Interventions to Reduce Co-Prescribing of Opioids and Benzodiazepines among a Medicare Population. Pharmacy (Basel, Switzerland), 8(1).
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  Co-prescribing of opioids and benzodiazepines can lead to overdoses and mortality. This retrospective study analyzed prescription claims data collected in 2016. A national medication therapy management (MTM) program conducted prescriber-based outreach interventions for patients with concurrent opioid and benzodiazepine prescriptions. The pharmacist's direct-to-prescriber intervention was conducted following a targeted medication review. The pharmacist initiated interventions with the prescriber via facsimile to recommend discontinuation of concurrent use of these drugs. This study included 57,748 subjects who were predominantly female (67.83%) and aged ≥ 65 years (66.90%). Prescribers were most commonly located in the southern United States (46.88%). The top prescribed opioid medications were hydrocodone-acetaminophen (33.60%), tramadol (17.50%), and oxycodone-acetaminophen (15.66%). The top benzodiazepines prescribed concurrently with opioids were alprazolam (35.11%), clonazepam (21.16%), and lorazepam (20.09%). Based on the pharmacists' recommendations, 37,990 (65.79%) resulted in a medication discontinuation (benzodiazepines 40.23%; opioids 59.77%) by the provider. There were significant differences in the proportion of opioids discontinued by subject age ( < 0.001) and prescriber geographical region ( = 0.0148). The top medications discontinued by the prescriber were hydrocodone-acetaminophen (18.86%), alprazolam (14.19%), and tramadol HCl (13.51%). This study provides initial evidence for pharmacist-supported, direct-to-prescriber programs as an effective medication safety strategy.
• Campbell, P. J., Axon, D. R., Taylor, A. M., Pickering, M., Black, H., Warholak, T., & Chinthammit, C. (2020). Associations of Renin-Angiotensin System Antagonist Medication Adherence and Economic Outcomes Among Commercially Insured US Adults: A Retrospective Cohort Study. Journal of the American Heart Association, 9(17), e016094.
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  Background Medication non-adherence can result in considerable morbidity, mortality, and costs. The Pharmacy Quality Alliance hypertension medication adherence measure is used by US healthcare payers and providers to assess renin-angiotensin system antagonist medication adherence. However, associations between renin-angiotensin system antagonist adherence as calculated in quality measures, and healthcare service use and expenditure in commercial populations over a 1-year timeframe has not been assessed. Methods and Results This retrospective cohort study used eligible commercially insured individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009-2015). Generalized linear models with log link and gamma distribution (expenditure) or negative binomial distribution (usage) assessed relationships between hypertension adherence (≥80% proportion of days covered) and healthcare use and expenditures (in 2015 US dollars) while adjusting for covariates (age, sex, geographic region; health plan; Deyo-Charlson Comorbidity Index, number of chronic medications, and treatment naivety). Beta coefficients were used to compute cost ratios and rate ratios. A total of 4 842 058 subjects were eligible; of those, 3 310 360 (68%) were adherent (adherent mean age 53.3±8.0 years, 55.9% men; non-adherent mean age 50.3±9.1 years, 53.1% men). Adherence was associated with fewer inpatient (rate ratios, 0.612; 95% CI, 0.607-0.617) and outpatient visits (rate ratios, 0.995; 95% CI, 0.994-0.997); and lower total costs (cost ratios, 0.876; 95% CI, 0.874-0.878) compared with non-adherence. Adherence was associated with lower average per member per month total costs ($97.98) compared with non-adherence. Conclusions Adherence to renin-angiotensin system antagonists was associated with fewer outpatient and inpatient visits, and lower total costs compared with non-adherence in a 1-year time frame.
• Chinthammit, C., Axon, D. R., Anderson, S., Lott, B., Taylor, A. M., Pickering, M., Black, H., Warholak, T., & Campbell, P. J. (2020). A retrospective cohort study evaluating the relationship between statin medication adherence and economic outcomes in commercial health plans. Journal of clinical lipidology.
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  Adherence to statin medications is suboptimal; however, the association of statin adherence, as defined in medication adherence quality measures, with healthcare service use and expenditure within one year has not been assessed in a commercially insured United States (US) population.
• Chinthammit, C., Bhattacharjee, S., Axon, D. R., Slack, M., Bentley, J. P., Warholak, T. L., Wilson, D. L., & Lo-Ciganic, W. H. (2020). Geographic Variation in the Prevalence of High-Risk Medication Use Among Medicare Part D Beneficiaries by Hospital Referral Region. Journal of managed care & specialty pharmacy, 26(10), 1309-1316.
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  Understanding geographic patterns of high-risk medication (HRM) prescribed and dispensed among older adults may help the Centers for Medicare & Medicaid Services and their partners develop and tailor prevention strategies.
• Guerra, B., Vaffis, S., Axon, D. R., Leal, S., Warholak, T., Taylor, A. M., & Scovis, N. (2020). Perceptions and experiences of promotoras and pharmacists in an academic-community partnership providing telephonic MTM services to a Spanish-speaking, rural population: a focus group study. Journal of managed care & specialty pharmacy, 26(11), 1390-1397.
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  The literature is limited concerning the collaboration between pharmacists and promotoras in the delivery of medication therapy management (MTM) services. Yet, this information could help address a practice gap while improving MTM collaborative care approaches. To identify the knowledge, attitudes, and barriers of clinical call center health professionals (pharmacists, nurses, pharmacy interns) and promotoras towards MTM collaborative care in implementing the Rural Arizona Medication Therapy Management (RAzMTM) program. A descriptive, qualitative study using semistructured focus groups was conducted with call center health professionals and promotoras who participated in the RAzMTM program to improve pharmaceutical care for patients with diabetes and/or hypertension in rural Arizona. Recruitment and consent letters, a demographic questionnaire, and a focus group guide were designed specifically for this project. Three facilitators participated in each focus group-one guided the discussion while the others took notes. Focus groups were audio recorded to verify all responses and transcribed verbatim with omission of participant identifiers. Thematic analysis was conducted by 2 independent researchers who reviewed the transcripts to identify codes, seek consensus, and agree on themes, with negotiation from a third independent researcher. Nine participants took part in 2 focus groups. Participants were predominantly female (89%), college graduates and/or had postgraduate/professional degrees (78%), and were Hispanic or Latino (89%). Five themes were identified: (1) roles and responsibilities of RAzMTM participants; (2) benefits unique to the RAzMTM program; (3) interprofessional experience of RAzMTM participants; (4) professional growth for RAzMTM participants; and (5) opportunities for future improvement. Perceptions of the participants in the RAzMTM program were consistent-experiences of health professionals and promotoras were positive; they recognized the benefit of each other's involvement in the program; and they learned how to work together to improve patient care. Future recommended program improvements include improving ease of scheduling (e.g., extending pharmacist availability to provide MTM services). These focus group results suggest that provision of telephonic MTM services, using an academic-community partnership, was positively received by participating pharmacists and promotoras. However, future work is needed for continued improvement of strategies to enhance interprofessional relationships in patient chronic disease management. This project was supported by the Grant or Cooperative Agreement Number DP004793, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. This work also was supported, in part, by SinfoniaRx. Axon, Taylor, and Warholak received funding from SinfoniaRx. Axon reports grants from Tabula Rasa Op-Co, Merck & Co, Pharmacy Quality Alliance, Arizona Department of Health, and American Association of Colleges of Pharmacy, outside the submitted work. Warholak and Taylor received funding from Arizona Department of Health Services as part of a contract, outside the submitted work. Vaffis reports funding from Merck and Pharmacy Quality Alliance. This study was presented as a poster at the American Society of Health-System Pharmacists Summer Meetings & Exhibition (June 10-12, 2019, Boston, MA) and as a podium presentation at the Arizona Pharmacy Association Southwestern States Residency Conference (June 14, 2019, Phoenix, AZ).
• Hall-Lipsy, E., Anderson, E. J., Taylor, A. M., Warholak, T., Axon, D. R., Faqeeri, Z., & Jastrzab, R. (2020). Community health worker perspectives of an academic community medication therapy management collaboration. Journal of the American Pharmacists Association : JAPhA, 60(3), 475-480.e1.
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  To qualitatively assess community health workers' (CHWs') perceptions of the challenges and benefits associated with participating in a collaborative, interprofessional medication therapy management (MTM) program for rural, underserved, predominantly Latinx, patients with diabetes and hypertension.
• Marupuru, S., Axon, D. R., Campbell, P., Chinthammit, C., Forbes, S., Martin, R., Taylor, A. M., & Warholak, T. L. (2020). Exploring performance predictors among employees in a pharmacist-led medication management center. Journal of the American Pharmacists Association : JAPhA, 60(6), 809-817.
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  Health care companies are increasingly interested in developing and maintaining employee motivation. However, this can be challenging with different professions working together in delivering telephonic medication therapy management services. The purpose of the study is to assess employees' perceptions of performance metrics, strategies to achieve those metrics, motivational work factors, and barriers to achievement at a medication management center (MMC).
• Axon, D. R., Augustine, J. M., Warholak, T., & Lee, J. K. (2019). Improving rating scales: Applying Rasch analysis to student pharmacists' attitudes towards herbal medications. Currents in pharmacy teaching & learning, 11(7), 658-663.
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  This study analyzed the psychometric properties of a cross-sectional survey of student pharmacists' attitudes regarding herbal medications using a polytomous Rasch model. Seven items assessed students' attitudes towards herbal medications using a 6-point agreement scale (0 to 5). Student responses were reviewed to identify outliers and aberrant response patterns, assess scale fit, and perform item analysis. Scale performance was assessed to determine if response categories were independent and equally represented. Items were reviewed for model fit and construct validity with significant item gaps identified using a z-test.
• Axon, D. R., Campbell, P., & Warholak, T. (2019). Student pharmacists' experiences of teamwork in a quality improvement course. Currents in pharmacy teaching & learning, 11(2), 139-144.
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  Student pharmacists need to work in teams in the educational and practice settings, but there is limited information on their teamwork experiences in the published literature. The study objective was to assess second-year (P2) student pharmacists' teamwork experiences in an experiential quality improvement (QI) course.
• Axon, D. R., Patel, M. J., Martin, J. R., & Slack, M. K. (2019). Use of multidomain management strategies by community dwelling adults with chronic pain: evidence from a systematic review. Scandinavian journal of pain, 19(1), 9-23.
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  Background and aims Multidomain strategies (i.e. two or more strategies) for managing chronic pain are recommended to avoid excessive use of opioids while producing the best outcomes possible. The aims of this systematic review were to: 1) determine if patient-reported pain management is consistent with the use of multidomain strategies; and 2) identify the role of opioids and non-steroidal anti-inflammatory drugs (NSAIDs) in patient-reported pain management. Methods Bibliographic databases, websites, and reference lists of included studies were searched to identify published articles reporting community-based surveys of pain self-management from January 1989 to June 2017 using controlled vocabulary (and synonyms): pain; self-care; self-management; self-treatment; and adult. Two independent reviewers screened studies and extracted data on subject demographics, pain characteristics, pain self-management strategies, and pain outcomes. Pain self-management strategies were organized according to our conceptual model. Included studies were assessed for risk of bias. Differences between the researchers were resolved by consensus. Results From the 3,235 unique records identified, 18 studies published between 2002 and 2017 from 10 countries were included. Twenty-two types of pharmacological strategies were identified (16 prescription, six non-prescription). NSAIDs (15 studies, range of use 10-72%) and opioids (12 studies, range of use 5-72%) were the most commonly reported prescription pharmacological strategies. Other prescription pharmacological strategies included analgesics, acetaminophen, anticonvulsants, antidepressants, anxiolytics, salicylates, β-blockers and calcium channel blockers, disease-modifying anti-rheumatic drugs and steroids, muscle relaxants, topical products, triptans, and others. Twenty-two types of non-pharmacological strategies were identified: four medical strategies (10 studies), 10 physical strategies (15 studies), four psychological strategies (12 studies), and four self-initiated strategies (15 studies). Medical strategies included consulting a medical practitioner, chiropractic, and surgery. Physical strategies included exercise, massage, hot and cold modalities, acupuncture, physical therapy, transcutaneous electrical nerve stimulation, activity modification or restriction, assistive devices, and altering body position/posture. Psychological strategies included relaxation, prayer or meditation, therapy, and rest/sleep. Self-initiated strategies included dietary or herbal supplements, dietary modifications, and complementary and alternative medicine. Overall, the number of strategies reported among the studies ranged from five to 28 (out of 44 identified strategies). Limited data on pain outcomes was reported in 15 studies, and included satisfaction with pain management strategies, pain interference on daily activities, adverse events, lost work or restricted activity days, emergency department visits, and disabilities. Conclusions A wide variety and large number of pharmacological and non-pharmacological strategies to manage chronic pain were reported, consistent with the use of multidomain strategies. High levels of use of both NSAIDs and opioids also were reported. Implications Comprehensive review and consultation with patients about their pain management strategies is likely needed for optimal outcomes. Additional research is needed to determine: how many, when, and why multidomain strategies are used; the relationship between opioid use, multidomain management strategies, and level of pain; how multidomain strategies relate to outcomes; and if adding strategies to a pain management plan increases the risk of adverse events or interactions, and increases an individuals pain management burden.
• Axon, D. R., Taylor, A. M., Vo, D., & Bingham, J. (2019). Initial assessment of an interprofessional team-delivered telehealth program for patients with epilepsy. Epilepsy research, 158, 106235.
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  Epilepsy affects 3.5 million people in the United States (US). Rural-dwelling individuals have less access to healthcare and consequently poorer health outcomes. This study describes the outcomes of an interprofessional telehealth program for rural-dwelling individuals with epilepsy in one US state.
• Campbell, A. M., Axon, D. R., Martin, J. R., Slack, M. K., Mollon, L., & Lee, J. K. (2019). Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis. BMC geriatrics, 19(1), 272.
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  Older surgical patients are at high risk of developing postoperative delirium. Non-pharmacological strategies are recommended for delirium prevention, but no pharmacological agents have compelling evidence to decrease the incidence of delirium. The purpose of this study was to assess whether perioperative melatonin decreases the incidence of delirium in older adults undergoing surgical procedures.
• Marupuru, S., Axon, D. R., & Slack, M. K. (2019). How do pharmacists use and recommend vitamins, minerals, herbals and other dietary supplements?. BMC complementary and alternative medicine, 19(1), 229.
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  Use of complementary and alternative medicine (CAM), including vitamins, minerals, herbals, and other dietary supplements, is widespread in the United States (ranging from 24% in Hispanics to 50% in American Indians). Pharmacists are an accessible source for healthcare information, but little is known about their use of CAM products and to whom they would recommend these products.
• Tetuan, C., Axon, D. R., Bingham, J., Boesen, K., Lipsy, R., Scovis, N., Taylor, A. M., Warholak, T., Lott, B. E., & Leal, S. (2019). Assessing the Effect of a Telepharmacist's Recommendations During an Integrated, Interprofessional Telehealth Appointment and Their Alignment with Quality Measures. Journal of managed care & specialty pharmacy, 25(12), 1334-1339.
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  A growing provider shortage contributes to the widening gap in significant disparities that rural communities face. To expand access to care for rural-dwelling patients with epilepsy, a national nonprofit organization initiated an integrated, interprofessional telehealth program.
• Almodovar, A. S., Axon, D. R., Coleman, A. M., Warholak, T., & Nahata, M. C. (2018). The Effect of Plan Type and Comprehensive Medication Reviews on High-Risk Medication Use. Journal of managed care & specialty pharmacy, 24(5), 416-422.
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  In 2007, the Centers for Medicare & Medicaid Services (CMS) instituted a star rating system using performance outcome measures to assess Medicare Advantage Prescription Drug (MAPD) and Prescription Drug Plan (PDP) providers.
• Axon, D. R., Bhattacharjee, S., Warholak, T. L., & Slack, M. K. (2018). Xm Scores for Estimating Total Exposure to Multimodal Strategies Identified by Pharmacists for Managing Pain: Validity Testing and Clinical Relevance. Pain research & management, 2018, 2530286.
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  To assess the validity of an exposure score obtained from the Xm tool for all pharmacological and nonpharmacological strategies used by individuals to manage chronic pain.
• Axon, D. R., Hernandez, C., Lee, J., & Slack, M. (2018). An Exploratory Study of Student Pharmacists' Self-Reported Pain, Management Strategies, Outcomes, and Implications for Pharmacy Education. Pharmacy (Basel, Switzerland), 6(1).
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  The objective of this study was to describe the prevalence, management strategies, and outcomes of pain experienced by student pharmacists, and to discuss implications for pharmacy education. A questionnaire administered to student pharmacists collected data about their experience, management strategies, and outcomes of pain. Data were analyzed using -tests, chi-square or Fisher's tests, and logistic regression. Of the 218 student pharmacists who completed the survey, 79% experienced pain in the past five years. Chronic pain impacted students' ability to work (15%) and attend school (9%). Respondents most commonly used prescription (38%) and over-the-counter (OTC, 78%) non-steroidal anti-inflammatory drugs (NSAIDs), and rest (69%) to manage pain. Men used more opioids, whereas women used more OTC NSAIDs ( < 0.05). Emergency department visits were associated with increased prescription drug use to manage pain. This study found that 15% of student pharmacists had chronic pain in the past five years, which was managed with medical and non-medical strategies.
• Axon, D. R., Lim, R. H., Lewis, P. J., Sandher, S., Thondee, J., Edwards, K., & Howard, R. L. (2018). Junior doctors' communication with hospital pharmacists about prescribing: findings from a qualitative interview study. European journal of hospital pharmacy : science and practice, 25(5), 257-261.
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  To explore factors affecting communication between Foundation Year (FY) 1 doctors and hospital pharmacists about prescribing from the junior doctors' perspective.
• Bhattacharjee, S., Al Yami, M., Kurdi, S., & Axon, D. R. (2018). Prevalence, patterns and predictors of depression treatment among community-dwelling older adults with stroke in the United States: a cross sectional study. BMC psychiatry, 18(1), 130.
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  Depression is one of the most common psychiatric conditions among stroke survivors and is associated with several negative health outcomes. However, little is known about the depression treatment patterns among stroke survivors. The objective of this study was to examine national-level prevalence, patterns and predictors of depression treatment among community-dwelling stroke survivors.
• Bhattacharjee, S., Axon, D. R., Goldstone, L., & Lee, J. K. (2018). Patterns and Predictors of Depression Treatment among Stroke Survivors with Depression in Ambulatory Settings in the United States. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association, 27(3), 563-567.
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  Despite the importance of treating depression, little is known regarding the current practice pattern of depression treatment among older adults with stroke and depression. We used national survey data from ambulatory settings to examine the depression treatment patterns and predictors among stroke survivors in the United States (US).
• Bingham, J., Axon, D. R., Scovis, N., & Taylor, A. M. (2018). Evaluating the Effectiveness of Clinical Pharmacy Consultations on Nutrition, Physical Activity, and Sleep in Improving Patient-Reported Psychiatric Outcomes for Individuals with Mental Illnesses. Pharmacy (Basel, Switzerland), 7(1).
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  One fifth of U.S. adults have a current mental illness. Nutrition, physical activity, and sleep are critical to physical health; any related deficiencies may worsen existing mental health conditions. Little is known about the impact of clinical pharmacist assessment and consultation in improving physical and mental health outcomes. The study objective was to determine whether patients' mental health status improved following clinical pharmacist consultation. This pilot study involved clinical pharmacist-delivered services at an integrated medical behavioral health clinic in June 2018. Inclusion criteria required adults aged 18 years older, an established mental health diagnosis, and taking ≥2 prescribed psychotropic medications. One pharmacist conducted telephonic, medical, and psychiatric health risk assessment and counseling to improve nutrition, physical activity, and sleep status, both initially and at two-week follow-up. The Duke Health Profile (Duke) physical, anxiety, depression, and anxiety-depression scores measured patients' pre/post changes. Participants ( = 20) experienced higher Duke physical scores ( = 0.007) and significantly lower anxiety ( = 0.025), depression ( = 0.001) and anxiety-depression scores ( = 0.005) at follow-up. This pilot study provides preliminary evidence for pharmacist-led, targeted, telephonic counseling in improving short-term physical and mental Duke health scores. Further research evaluating the impact of clinical pharmacists' role in improving physical and behavioral health outcomes is warranted.
• Campbell, P. J., Patel, M., Martin, J. R., Hincapie, A. L., Axon, D. R., Warholak, T. L., & Slack, M. (2018). Systematic review and meta-analysis of community pharmacy error rates in the USA: 1993-2015. BMJ open quality, 7(4), e000193.
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  While much is known about hospital pharmacy error rates in the USA, comparatively little is known about community pharmacy dispensing error rates.
• Silva Almodovar, A., Surve, S., Axon, D. R., Cooper, D., & Nahata, M. C. (2018). Self-Directed Engagement with a Mobile App (Sinasprite) and Its Effects on Confidence in Coping Skills, Depression, and Anxiety: Retrospective Longitudinal Study. JMIR mHealth and uHealth, 6(3), e64.
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  Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety.
• Taylor, A. M., Axon, D. R., Campbell, P., Fair, M. K., Nelson, M., Boesen, K., Martin, R., & Warholak, T. L. (2018). What Patients Know About Services to Help Manage Chronic Diseases and Medications: Findings from Focus Groups on Medication Therapy Management. Journal of managed care & specialty pharmacy, 24(9), 904-910.
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  Managing and treating patients with multiple chronic conditions presents challenges on many levels. Pharmacist-delivered medication therapy management (MTM) services, mandated as part of the Medicare Part D drug benefit, are designed to help patients manage their chronic conditions and medications.
• Taylor, A. M., Bingham, J., Schussel, K., Axon, D. R., Dickman, D. J., Boesen, K., Martin, R., & Warholak, T. L. (2018). Integrating Innovative Telehealth Solutions into an Interprofessional Team-Delivered Chronic Care Management Pilot Program. Journal of managed care & specialty pharmacy, 24(8), 813-818.
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  Pharmacist-delivered medication therapy management (MTM) services can improve patient outcomes, yet little is known about outpatient, interprofessional telepharmacy programs.
• Axon, D. R., & Slack, M. (2017). Response to Dietary Supplement Use, Knowledge, and Perceptions Among Student Pharmacists. American journal of pharmaceutical education, 81(10), 6854.
• Axon, D. R., Vanova, J., Edel, C., & Slack, M. (2017). Dietary Supplement Use, Knowledge, and Perceptions Among Student Pharmacists. American journal of pharmaceutical education, 81(5), 92.
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  To compare dietary supplement use between student pharmacists and the general population, and assess knowledge, attitudes toward use, and dietary supplement effectiveness; and to explore how student pharmacists view their education on dietary supplements. Paper questionnaires administered to student pharmacists collected data about their use, knowledge, and attitudes of dietary supplements. Use was compared to the 2007 National Health Interview survey findings. Of 179 students who responded, 52% had used at least one dietary supplement in their lifetime versus 25% in the general population. Students perceived supplement label information as unhelpful, research into supplements inadequate, and supplements non-essential to health. Students thought supplement knowledge was important but their education was inadequate. Dietary supplement use was higher in this sample of student pharmacists than the general population. Student pharmacists had limited knowledge and need more education on dietary supplements.