ICARE Trial Survey Post-Analysis Reid Ellingson, Courtney Fischels, Brenna Robinson, and Lexi Sieren Mentor: Korey Kennelty, PharmD, PhD

Funding & Disclosures Funding for the ICARE trial was provided by the National Heart, Lung, and Blood Institute R01 HL116311 We have no relevant financial or nonfinancial relationship that could contribute bias to the presentation

Outline Background ICARE Clinic Sites Objectives Methods Theory of Planned Behavior Example Survey Questions Results Discussion Conclusion Lessons Learned

Background Improved Cardiovascular Risk Reduction to Enhance Rural Primary Care (ICARE) was a prospective, cluster-randomized trial in 12 medical offices in Iowa This study provided “virtual” clinical pharmacy services to each of the private physicians within the ICARE study, determining whether there are different barriers or facilitators to such an intervention in small private providers offices that lack a clinical pharmacist Six rural primary care clinics were randomized to receive the remote, pharmacy service (i.e, intervention arm), and six rural primary care offices were randomized to maintain their usual care (i.e., control arm)

ICARE Clinic Sites Control Intervention Control sites: Akron, Clarion, Des Moines, Grinnell, Cedar Rapids, Davenport Intervention sites: Siouxland, Belmond, Knoxville, Newton, Riverside, Burlington

Background cont. One survey (pre and post intervention) was delivered to both the control and intervention arms of this study The survey measured the intent of physicians to include pharmacists into their daily workflow The pre- and post- surveys were then analyzed to see if the provider attitudes towards pharmacists and clinical pharmacy services had changed

Objective Determine the change in extent of physician-pharmacist collaboration from physician perceptions who practice in rural primary care clinics H1: Extent of physician-pharmacist collaboration from physician perceptions will be significantly greater in primary care clinics that received the intervention compared to the control group.

Methods Retrospective, longitudinal design with pre- and post- surveys to providers Survey utilized numerical, Likert scales Analyzed survey results with Wilcoxon signed-rank paired test Test used to compare matched samples of data Alternative to t-test when population is not normally distributed (small sample size) Ho: There is no difference H1: There is a difference (the median change was non-zero) Small sample size, not normal distribution data

Theory of Planned Behavior

Provider Survey Given a clinical scenario where patients A1c or blood pressure is not at goal even with multiple interventions and medication regimens attempted Asks about referring patients to physician/pharmacist collaborative model (PPCM) where pharmacist manages chronic disease states

Results - Provider Baseline Characteristics Baseline Characteristics (n=35) Value Mean age, years 48.4 years Male, % 39.3% Mean number of years practicing 16.4 years No academic affiliation, % 60.7%

Results - Survey results Intervention Group Control Group Pre-intervention Survey Average Score Post-intervention Survey Average Score 5 4 3 Positive sum: 93 Negative sum: -94 Test statistic: 93 Critical value: 60 Positive sum: 79 Negative sum: -36 Test statistic: 36 Critical value: 30 Ho= no difference between intervention and control group change If test statistic < critical value, then reject the null We do not have sufficient evidence to reject the null

Results - Question 15 What sources of information (or who) would you consult for clinical decision-making around the management of hypertension, diabetes, and hyperlipidemia? Free responses were sorted into categories Electronic Professional publications Medical professionals Own training/experience Other/misc.

Results - Intervention group

Results - Control group

Discussion Clinical inertia Guidelines vs. reimbursement Failure of healthcare providers to initiate or escalate therapy when indicated Follow up focus groups revealed that culture within each clinic impacted if providers would work with pharmacists and/or accept recommendations Guidelines vs. reimbursement BP and A1c goals may differ between guidelines and insurance reimbursement Incentives to escalate therapy may be influenced on reimbursement the clinic receives Survey scenario involved 8% A1c (close to reimbursement cutoff) Rural providers not familiar working with pharmacists At the end of study, many providers wanted the service to continue Established one contract with a facility

Recommendations 88.8% of recommendations were accepted

Conclusions Survey data did not reflect actual implementation of the service Majority of recommendations were accepted Rural providers were not familiar working with pharmacists in this capacity Continue interviews and focus groups with intervention sites regarding their intent to work with pharmacists Addressing barriers and facilitators in upcoming study (PI: Kennelty 1R01HL139918-01)

Lessons Learned Organizing and formatting data is difficult Survey question format - decision to refer to pharmacist is not clear Pre-testing surveys are critical with a variety of audiences Since we need matched pairs to analyze data, critical to follow up with providers to complete survey Team meetings are important throughout the study and for analyzing data Need structure and procedures

Questions