AuthorHarrington, Amanda R.
MetadataShow full item record
PublisherThe University of Arizona.
RightsCopyright © is held by the author. Digital access to this material is made possible by the University Libraries, University of Arizona. Further transmission, reproduction or presentation (such as public display or performance) of protected items is prohibited except with permission of the author.
EmbargoRelease after 01-Jan-2020
AbstractBackground: Recently, health plans have initiated pay-for-performance (P4P) programs to incentivize pharmacies to focus on medication-related quality measures. Little research exists as to what attributes help a pharmacy to perform well in a P4P program. Objectives: This study aimed to: (1) propose a conceptual framework evolved from theories pertaining to economic, psychology, and organizational behavior disciplines that may contribute to a pharmacy's performance in a financial incentive program; (2) develop theoretically-derived questionnaires designed to elicit from pharmacists and pharmacy management pharmacy characteristics and pharmacy personnel factors thought to be associated with achieving quality measures specified for a pharmacy P4P program; (3) psychometrically assess these two newly developed questionnaires designed to collect information from community pharmacies eligible to participate in a pharmacy P4P program; (4) assess the magnitude of the relationship between pharmacy-related and construct redundancy of latent variables identified in objective 3; and (5) examine pharmacy factors' association with community pharmacies achieving quality measures in a pharmacy P4P program. Methods: Two survey instruments were created from a theoretically-derived conceptual framework to measure pertinent pharmacy characteristics and pharmacy personnel factors using a multi-step, mixed-methods process. Questionnaire development entailed semi-structured interviews, item generation, expert content validation, and cognitive debriefings. Developed questionnaires were evaluated in a non-experimental, cross-sectional survey of pharmacists and pharmacy management. Pharmacy personnel surveyed for this study were affiliated with pharmacies in Inland Empire Health Plan's (IEHP's) community pharmacy network. Using items measured in each questionnaire, specified groups of items were hypothesized to have a certain underlying latent variable. Latent variables hypothesized for items measured in the pharmacist questionnaire included: (1)"adherence management -services," (2)"adherence management-counseling," (3) "asthma management," (4) "pharmacist-prescriber relationship," (5) "chronic disease management," (6) "non-dispensing ability," and (7) "workload impact". For items measured in the pharmacy management questionnaire, eight latent variables were hypothesized: (1) "program understanding," (2) "program financial salience," (3) "program involvement," (4) "organization's adaptability," (5) "organization's innovativeness," (6) "organization's proactiveness," (7) "organization's risk-taking." and (8) "organization's focal emphasis." For hypothesized latent variables with four or more items, the value thresholds of three assessment indexes were employed as criteria to evaluate each measurement model's goodness-of-fit. Indexes included: (1) 2 test statistic (i.e.,>0.05), (2) root mean square error of approximation (RMSEA) (i.e., 0.05), and (3) comparative fit index (CFI) (i.e.,>0.95). The statistical significance of item factor loadings was assessed for latent variables with (1) four or more items deemed to have adequate model fit per index criteria and (2) only three items, for which goodness-of-fit may not be assessed. Structural modeling was used to explore associations between (1) pairs of latent variables with adequate model fit and/or statistically significant factor loadings; and (2) latent variables with medication-related quality measures. The strength of associations among latent variable pairs was measured with correlation coefficients. Latent variable pairs with significant correlations greater than 0.50 were evaluated for construct redundancy, for which a change in CFI was used as the comparison criteria to determine whether the latent variables are better represented as one (i.e., (CFI<-0.01) or two constructs (i.e., (CFI ≥ -0.01). Mediation-related quality measures specified as dependent variables in structural models included: diabetes medication adherence, hypertension medication adherence, hypercholesterolemia medication adherence, absence of controller therapy in patients with asthma, use of high-risk medications in elderly, and generic dispensing rate. Results: The empirically derived conceptual framework outlined four major domains proposed for consideration when evaluating pharmacy P4P programs: (1) incentive; (2) pharmacy; (3) other influencing factors; and (4) P4P program measures. From this framework, two questionnaires were developed with the aim of measuring pharmacists' and pharmacy management's pharmacy attitudes and perspectives of a community pharmacy P4P program. The pharmacist survey instrument consisted of five sections: (i) community pharmacy P4P program; (ii) pharmacy services; (iii) pharmacist workload; (iv) pharmacy practice site; and (v) pharmacist's background. The pharmacy management questionnaire consisted of four sections: (i) pharmacy P4P program; (ii) pharmacy organization's characteristics; (iii) pharmacy practice site; and (iv) respondent's background information. Among the 604 pharmacies invited to participate, pharmacists from 114 unique pharmacies (19%) and pharmacy management from 100 unique pharmacies (17%) participated in the survey. This study identified psychometrically validated measurement models for latent constructs with items measured in the pharmacist ("adherence management-counseling," "asthma management," "workload impact" ) and pharmacy management ("program involvement," "organization's innovativeness," "organization's proactiveness," "organization's risk-taking" ) questionnaires). With the exception of "program involvement," the latent constructs measured in the pharmacy management questionnaire were identified to be significantly correlated (𝛹>0.50, p<0.001) and more parsimoniously represented as one factor rather than two (∆CFI<-0.01). No significant associations were identified in exploratory analyses of validated measurement models from the pharmacist questionnaire with targeted medication-related quality measures in IEHP's community pharmacy P4P program. Conclusion: This study collected data for two questionnaires evaluating (1) pharmaceutical care services conceptualized to be associated with targeting medication-related quality measures and (2) pharmacy management's attitudes toward a pharmacy P4P program. Furthermore, psychometric assessment of each questionnaire supplied initial validity evidence for three constructs for the pharmacist questionnaire ("adherence management-counseling," "asthma management," and "workload impact" ) and four constructs for the pharmacy management questionnaire ("program involvement," "organization's innovativeness," "organization's proactiveness," and "organization's risk-taking" ). Subsequent validation of these latent constructs in larger sample sizes is required. Continued study of pharmacy factors and their association with medication-related quality measures is needed to improve our understanding of pharmacies' performance in financial incentive programs. As pharmacy organizations are increasingly integrated into more financial incentive programs aimed at targeting process- and outcomes-related quality measures, it is essential to be able to measure pharmacy and management factors in order to determine which factor(s) impact pharmacy performance.
Degree ProgramGraduate College