Scholarship & Research
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Item Development and implementation of a new referral process and dot phrase technology for a rural medication therapy management program to improve patient safety(Montana State University - Bozeman, College of Nursing, 2023) Scott, Jonathan Muir; Chairperson, Graduate Committee: Margaret HammerslaNo medication or procedure will cure dementia, and most patients will experience behavioral and psychiatric symptoms as the disease progresses. Medications to treat the symptoms of dementia are complex. Medication therapy management is a patient-centered collaborative agreement between provider and pharmacist that has shown positive outcomes in reducing adverse drug reactions. In January 2021, an outpatient clinic in Southwest Montana implemented the Rural Access to a Psychiatric Pharmacist for Seniors (RAPPS), an MTM pilot program to address the complex medication-related problems of elderly dementia. During the RAPPS process, an internal review identified two major concerns: (1) clinical information being communicated from provider to pharmacist needs to be more consistent and (2) the current system lacks a clearly defined referral process. This ongoing process improvement project used four Plan-Do-Study-Act cycles to develop, implement, and evaluate the dot phrase. A dot phrase is a section of text to be inserted into an electronic health record progress note. The dot phrase's utilization was analyzed at three different timepoints over the project's 6-week implantation period. A five-question visual analog scale provider-satisfaction survey was developed to be conducted at the fourth PDSA cycle. Preliminary data collected from the electronic health record from November 2022 to December 2022 found that 45% of providers' notes at the time of referral did not document a psychiatric diagnosis, and 81% of the notes did not confirm or deny outside psychiatric management. The primary, secondary, and tertiary SMART goals were not met. The QI project encountered many unforeseen problems throughout this study. The preliminary data collected in this project demonstrated that documentation deficits are occurring between providers and the clinical pharmacist. As more and more of our medical information becomes digital, health professionals will require additional training to become proficient in using these systems. IT systems are complex and challenging, so future quality improvement projects should have a dedicated IT specialist on their team. For collaborative agreement programs to succeed, clear communication between all stakeholders must be championed. Future research should examine technologies that encourage interprofessional communication within electronic referral systems.Item Deprescribing proton pump inhibitors, benzodiazepines, antipsychotics, and antihyperglycemic medications in a rural clinic in an elderly population(Montana State University - Bozeman, College of Nursing, 2021) Wurz, Lucas; Chairperson, Graduate Committee: Susan LuparellBackground: Polypharmacy affects many patients as they age and develop multiple health problems. The increased number of medications has been directly related to adverse drug events (ADEs) which include overdoses, falls, diarrhea, or insomnia. A panel of experts at the Bruyère Research Institute identified four classes of medications (proton pump inhibitors [PPIs], benzodiazepines receptor agonists [BZRAs], antipsychotics [ASs], and antihyperglycemics [AGs]), which are especially problematic in the elderly. They created four algorithms to help evaluate the necessity of these medications and offer suggestions for deprescribing them. Aim: The aim of this project was to decrease the unnecessary use of PPIs, BZRAs, ASs and AGs among the elderly by using the Bruyère algorithm and to increase provider deprescribing self-efficacy scores. Methods: This quality improvement project was conducted in a small rural community clinic in Northwest Montana. Two nurse practitioners (NPs) were involved. A survey was filled out by both the NPs at the beginning and the end of the project to assess their self-reported self- efficacy. A brief description of the Bruyère algorithm was provided to the NPs. This algorithm was then applied over a ten-week period to all patients over the age of 60 who had been previously prescribed the medications of interest. The rates of deprescribing as well as changes in provider self-efficacy scores (SES) were measured at the end of the project. Results: A total of 29 patients were encountered during the project. Ten of the patients were on a PPI and one was on a BZRA. None of the patients screened were on any of the other two classes of medications. At the end of the project, none of the targeted medications were discontinued, although PPI dosing was decreased from twice daily to daily in two patients. Overall, provider self-efficacy scores improved by 15% during the intervention period. Conclusions: The deprescribing algorithms likely improved provider self-efficacy scores and may reduce the medication burden faced by patients over the age of 60.Item Increasing medication HCAHPS scores using a standardized, simplified process to educate patients on commonly prescribed new medications(Montana State University - Bozeman, College of Nursing, 2021) Wurz, Stephen; Chairperson, Graduate Committee: Margaret HammerslaBackground: An estimated 40% to 50% of patients do not understand their medications leading to 125,000 preventable deaths annually and $100 billion in preventable healthcare costs. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is used to measure patients' perspectives of their care with two of the questions explicitly related to new medication and side effects education. HCAHPS scores drive reimbursement to hospitals. Care that the patient perceives as positive improves outcomes and increases healthcare value. Aim: The aim of this project was to increase patient knowledge of new medications, develop a tool to guide nurse medication education, and improve medication HCAHPS scores. Methods: This project implemented a simple medication education tool which listed 8 common classes of medications, their uses, and most common side effects. This was done to increase patient understanding of prescribed medications on a telemetry floor at a large central Montana hospital. The tool was developed using evidence-based research, RN's were educated on its use, and it was placed at the patient bedside as a resource for patient medication education. Results: A total of 87% of unit RN's were educated on the tool and its expected use. To check for tool at the patient bedside, 6 rooms out of a total of 33 were audited twice weekly for four weeks. Two PDSA Cycles were completed after low rates of tool at the bedside were discovered. Scores improved after each PDSA Cycle with a score of 100% obtained at the beginning of Week 4 of implementation. HCAHPS data was not available at the time of writing. Conclusions: The development of a new medication and side effects education tool was placed at the bedside and used as a guide to educate patients on their prescribed medications. This was done to increase patient comprehension and thereby satisfaction of medication understanding as an attempt to increase HCAHPS scores in the medication education category.Item Interactive policy effects of the 2010 Oxycontin reformulation(Montana State University - Bozeman, College of Agriculture, 2021) Baan, Joseph Bradford; Chairperson, Graduate Committee: Isaac SwensenIn this paper I estimate the additional effects counties with active Prescription Drug Monitoring Programs and Medical Marijuana Laws felt after the 2010 OxyContin reformulation compared to counties without these laws. I also estimate the effect of each additional Substance Abuse Treatment facility as well after the reformulation. I find that counties with PDMPs and MMLs see the morphine equivalent of a 6.557 and 4.681 grams decrease in the Oxycodone shipped to pharmacies for every 1000 people. Each additional SAT is associated with a 0.11 Morphine Grams Equivalent decrease. For reference 6.557 represents about 3% of the county average of MGE in Oxycodone.Item Pharmaceutical biomarkers to inform public and environmental health law and policy(Montana State University - Bozeman, College of Agriculture, 2020) Margetts, Miranda Lee; Chairperson, Graduate Committee: Robert K. D. Peterson and Deborah Keil (co-chair); Aparna Keshaviah, Cindy Hu, Victoria Troeger, Jordan Sykes, Nicholas Bishop, Tammy Jones-Lepp, Marisa Henry and Deborah E. Keil were co-authors of the article, 'Using wastewater-based epidemiology with local indicators of opioid and illicit drug use to overcome data gaps' submitted to the journal 'Journal of the American Medical Association' which is contained within this dissertation.; Terri Mavencamp, Jordan Sykes, Tammy Jones-Lepp, Nicholas Bishop, Victoria Troeger, Robert K. D. Peterson and Deborah E. Keil were co-authors of the article, 'The environmental impact of substance use in Montana's waterways: investigation of prescription, illicit, and recreational drug metabolite concentrations into receiving waters' which is contained within this dissertation.; Trent McCallson and Deborah E. Keil were co-authors of the article, 'Wastewater testing to support new environmental health compliance obligations in the healthcare industry' which is contained within this dissertation.The increasing awareness of the prevalence of prescription and illicit drug metabolites in wastewater is affecting changes to public and environmental health laws and policies. Drug takeback laws have been enacted to limit environmental pollution from drugs flushed into sewers; however, these laws only apply to legally prescribed drugs. Wastewater-based epidemiology, which relies on the measurement of drug concentrations in untreated wastewater, is also emerging as a complementary drug-use data tool to estimate drug consumption patterns by a community in near real-time. We sampled both the untreated influent and treated effluent at two locations in Montana over three months from April to June, 2019, to ascertain the concentrations of certain prescription and illicit drugs of abuse. The concentrations of drugs obtained from the untreated influent were used to inform a wastewater-based epidemiology study that compared drug-dose estimates from our wastewater samples against existing local drug-use sources (emergency medical services calls, drug seizures, and prescription dispense data). We also measured the treated effluent to determine the concentration at which drugs of abuse are persisting through the wastewater-treatment process and potentially affecting aquatic life exposed to those concentrations in receiving waters. We undertook a risk assessment whereby measured drug concentrations were assessed against corresponding ecotoxicology thresholds. Our results indicate that both codeine and morphine concentrations were above predicted no-effect concentrations. The overall results indicate that (1) wastewater-based epidemiology may be an effective tool to better describe substance abuse in communities and (2) drugs are persisting at levels above ecotoxicological thresholds from wastewater treatment plants into receiving waters. To our knowledge, these investigations are the first of their kind to have been conducted in Montana.Item Exercise as treatment for depression, dissemination of evidence-based practice to providers(Montana State University - Bozeman, College of Nursing, 2019) Dean, Amber Jewel; Chairperson, Graduate Committee: Tracy HellemStatement of the problem: Depression is the leading cause of disability worldwide with low remission rates. Exercise has been used as an evidence-based treatment option with positive results. This project assessed the usefulness of a pocket card to disseminate evidence-based research to medication providers while collecting additional information. Methods: 93 medication providers were identified in northwestern Montana counties at 14 outpatient clinics to disburse an informational packet to, including the pocket card. A letter directed providers to take an initial survey and a follow up survey. Results: The majority of participants (86%) found the pocket card to be a useful way in receiving information regarding exercise as treatment for depression. Conclusion: The pocket card was a useful way to disseminate evidence for exercise as treatment for depression to medication providers.Item Benzodiazepine prescription evaluation on inpatient psychiatry(Montana State University - Bozeman, College of Nursing, 2018) Loven, Jill Marie; Chairperson, Graduate Committee: Maria WinesSince the Food and Drug Administration announced on August 31, 2016 it was requiring boxed warnings regarding the risk of respiratory depression and death when benzodiazepines are combined with opioid, facilities face growing scrutiny of benzodiazepine utilization. Benzodiazepines are an effective treatment for acute anxiety and often administered to patients who require inpatient psychiatric treatment. Medication Utilization Evaluation (MUE) is a multidisciplinary quality improvement method that can evaluate safety and utilization of medications in a facility. This MUE pilot project identified 261 records of patients prescribed benzodiazepines in a facility from January 1, 2017-March 31, 2017. Results showed that 75% of the sample received appropriate orders for benzodiazepine. Potential factors to predict inappropriate orders were depression and alcohol withdrawal. More information is needed pertaining to the actual utilization of benzodiazepines on the inpatient unit.Item Bayesian measurement error modeling with application to the area under the curve summary measure(Montana State University - Bozeman, College of Letters & Science, 2016) Weeding, Jennifer Lee; Chairperson, Graduate Committee: Mark Greenwood; Mark C. Greenwood was a co-author of the article, 'An introduction to the area under the curve summary measure' submitted to the journal 'Journal of dairy science' which is contained within this thesis.; Mark C. Greenwood, Shannon J.J. Moreaux and Jyme L. Nichols were co-authors of the article, 'Bayesian estimation of variance for AUC studies' submitted to the journal 'PLoS ONE' which is contained within this thesis.; Mark C. Greenwood was a co-author of the article, 'A comparison of measurement error correction methods with and without known measurement errors' submitted to the journal 'Journal of statistical computation and simulation' which is contained within this thesis.; Mark C. Greenwood, Shannon J.J. Moreaux and Jyme L. Nichols were co-authors of the article, 'Impacts of measurement error in an area under the curve study' submitted to the journal 'Journal of animal science' which is contained within this thesis.; Mark C. Greenwood was a co-author of the article, 'A Bayesian measurement error correction model for errors in both explanatory and response variables' which is contained within this thesis.Measurement errors arise in a variety of circumstances and occur when a variable cannot be observed exactly, but instead is observed with error. For example, summary measures contain measurement error, as the true value of the variable is estimated from observed data that contain sampling variability. Measurement errors should be accounted for when they are present, as the impacts of ignoring measurement errors include bias in parameter estimates and a loss of power to detect effects. Measurement error models are used to account for measurement errors and correct parameter estimates for the bias induced from variables measured with error. To account for measurement errors when present, most correction methods require that the measurement error variance be known (or estimated). Common correction methods include the method of moments correction, the SIMEX correction, and Bayesian correction methods. The area under the curve (AUC) summary measure is commonly used in pharmaceutical studies to estimate the total concentration of a substance present in the blood over a given time interval. Other areas, such as Ecology, use the AUC to estimate the total count of a species present over a specified time interval. In situations where the AUC is estimated, a measure of the uncertainty associated with it is often desired. Due to the longitudinal nature of AUC data, the estimation of its variance is often not straightforward. In this research we develop a Bayesian method to estimate the variance of the AUC, where our focus is on accounting for the possible correlation structure between repeated observations on the same subject. This estimate can then be used in measurement error models to account for the measurement error induced from estimating the AUC. We study the performance of three measurement error correction methods in the simple linear regression setting, where measurement errors are present in the explanatory variable, the response variable, or both. We extend the Bayesian correction methods to account for uncorrelated and correlated measurement errors between variables. The methods were validated using both simulated and real data collected from an equine study of blood glucose measurements.Item Studies on the mechanism of action of chloramphenicol(Montana State University - Bozeman, College of Letters & Science, 1972) Morgan, Edward Joseph