Objectives Geriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers. Design We used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group. Setting Interviews took place in a tertiary, 886-bed hospital located in Los Angeles, California. Participants Interview participants included physicians, pharmacists, pharmacist technicians, and nurses. Results We interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge. Conclusions While we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.

Background: Remote, centralized clinical pharmacist services provided by board-certified clinical pharmacists have been shown to effectively assist in chronic disease management. We assess the feasibility of implementing a pharmacist-led, remote, centralized pharmacy service to improve A1c levels in patient with diabetes in a rural clinic setting. Methods: This was a non-randomized pilot and feasibility study. Participants were enrolled in a pharmacist-led telehealth intervention service, with data prior to enrollment used as baseline data for control. To be included, patients needed to have A1c readings of greater than 7% to be considered uncontrolled. A1c changes were reported for two groups based on A1c ranges: between 7 and 10% and ≥ 10%. Clinical pharmacists and clinical pharmacy interns initiated contact with patients via telephone communication and managed the patients remotely. The following outcomes were evaluated: organization perceptions (patients, providers, and clinic staff), changes in A1c, medication discrepancies, impact of an internally operated Patient Assistance Program, and potential return on investment (ROI). Results: Fifty-two patients were initially identified and referred to the service with 43 patients consenting to participate in the intervention. Patient and provider survey responses were recorded. In the initial analysis occurring during the first 3 to 5 months of the program, there was considerable improvement in diabetes control as measured by A1c. For patients with uncontrolled diabetes with a baseline A1c > 7% but less than < 10% and ≥ 10%, the intervention resulted in an A1c decrease of 0.57% and 2.55%, respectively. Clinical pharmacists and clinical pharmacy interns identified at least one medication discrepancy in 44% of patients, with number of discrepancies ranging from 1 to 5 per patient. At the conclusion of the study window, 42 potentially billable encounters were documented, which would have generated a net profit of $1140 USD, had they been submitted for reimbursement. Given the potential revenue generation, the service theoretically yields a ROI of 1.4 to 1. Conclusions: Initial results suggest that a pharmacist-led telehealth intervention has potential to decrease A1c levels in patients with diabetes, assist in identification of medication discrepancies, provide a positive return on investment for rural clinics, and potentially increase reimbursement for providers and clinics tasked with managing patients with uncontrolled diabetes.

Objective. The objectives of this study were to 1) quantify students9 communication ability using standardized patient (SP) communication rubric scores, 2) describe and categorize SP comments of student empathy and 3) test the relationship between communication scores and empathy. Methods. A concurrent mixed methods research design was used to assess a graded Performance Based Assessment (PBA) of student pharmacists at a college of pharmacy in the Midwest US. PBA rubrics (n=218) completed by SPs contained 20 assessment items with space for open-ended feedback. Scoring categories for communication assessment included: Yes, Inconsistent, No, and N/A. Descriptive statistics were calculated for rubric scores. SP feedback was transformed into categorical data by categorizing assessments suggesting high empathy, mixed empathy, and low empathy encounters. Kruskal-Wallis ANOVA was used to test the relationship between empathy category and communication score. Results. SPs wrote comments on 141 of 218 rubrics (64.7%). The mean communication score was 38.96 ± 1.64 (Range of 31 to 40) out of a maximum 40 points. The totals for the low, mixed, and high empathy category transformations were 6 (4.3%), 95 (67.4%), and 40 (28.4%), respectively. The results of the Kruskal-Wallis ANOVA were statistically significant, suggesting that communication scores were different between empathy categories. Conclusion. There is a positive association between scores on communication rubrics and student empathy categorization, with students exhibiting different levels of clinical empathy. While the PBA of interest was not specifically focused on empathy, SPs frequently provided empathy feedback to students suggesting empathy was important to the encounter.