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

2. 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

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

4. 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)

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

6. 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

7. 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.

8. 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

9. Theory of Planned Behavior

10. 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

12. 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%

13. 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

14. 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.

15. Results - Intervention group

16. Results - Control group

17. 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

18. Recommendations
88.8% of recommendations were accepted

19. 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 1R01HL )

20. 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

21. Questions