Issue 15, November/December 2011
To improve the quality of medication management and use across healthcare settings with the goal
of improving patients' health through a collaborative process to develop and implement
performance measures and recognize examples of exceptional pharmacy quality. |
In This Issue
Second Annual PQA Leadership Summit Discusses Newly Approved Strategic Plan
The PQA Leadership Summit is held annually to provide the staff input from key members and stakeholders on future directions for the organization. The 2011 Summit took place on November 17th in the Washington DC area and included nearly 50 attendees composed of members of the PQA Board of Directors, workgroup co-chairs, member organizations, PQA staff and selected speakers and guests. Laura Cranston, PQA Executive Director, started the day by discussing elements and objectives contained in the PQA strategic plan for 2012-2014. Read more
The PQA Quality Forum Lecture Series for December: Learn About the New
"Measure Applications Partnership" (MAP)
The Measure Applications Partnership (MAP) is a public-private partnership convened by the National Quality Forum. MAP was created for the explicit purpose of providing input to the Department of Health and Human Services (HHS) on the selection of performance measures for public reporting and performance-based payment programs. The MAP is guided by the priorities and goals of the National Quality Strategy. PQA is pleased that our current Chair, Judith Cahill, serves on the MAP Coordinating Committee and will be our presenter for the final Quality Forum Lecture on December 8th at 1 pm ET. Read more
Hot Off the Press: Rapid Reviews of Key Quality Publications
by David Nau, PhD, RPh, CPHQ, Senior Director, Research & Performance Measurement, PQA
Three recent articles shed more light on the issue of medication adherence. Researchers from Harvard, Aetna and CVS/Caremark published the initial results of the Post Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) Trial. The participants in this trial were patients who had medical and prescription benefit coverage through Aetna and who had been recently discharged from the hospital subsequent to a myocardial infarction. Read more
Save the Date for the PQA 7th Annual Meeting! June 13-15, 2012 in Washington, DC
Mark your calendar and don't miss this very informative and interactive meeting. Senior level executives from health plans, PBMs, community pharmacy, government agencies and pharmaceutical companies, to name a few, will be in attendance. New this year, the meeting will kick off on Wednesday with the Keynote Address at 5 PM, followed by a welcoming reception. Read more
Primary Medication Non-Adherence Measures
The National Association of Chain Drug Stores Foundation, with corporate sponsorship from Pfizer, provided a grant to the Pharmacy Quality Alliance to develop standardized measures for primary medication non-adherence (PMN). Primary medication non-adherence occurs when a patient receives a prescription for a medication but never obtains the prescription medication. PQA convened an expert panel to review the literature and build consensus on appropriate definitions and measures for PMN. Read more
PQA Measures Incorporated into Medicare Part D Star Ratings
The Centers for Medicare & Medicaid Services has created health care plan ratings that indicate the quality of Medicare plans using a scale of 1 to 5 stars. The stars are determined through numerous performance measures across several domains of performance. Read more
Beacon Communities: A Review of the October PQA Quality Forum Lecture Series
The October PQA Quality Forum Lecture Series provided an overview and numerous insights into the current initiatives focusing on the Beacon Communities. Information was presented by Craig Brammer, Deputy Director of the Beacon Community Program, at the Office of the National Coordinator (ONC). Read more
Mitch Betses Appointed to the PQA Board of Directors
The PQA Board of Directors recently appointed Mitch Betses, Vice President of Pharmacy Operations for CVS pharmacy, to the PQA Board for a four-year term. Mr. Betses manages the overall retail pharmacy agenda at CVS, including managing and improving day-to-day pharmacy operations for nearly 7,300 retail pharmacies, defining and delivering differentiated products and services for CVS Caremark patients, and overseeing clinical services, quality assurance, and patient safety improvement processes. Read more
Patient Medication Information (PMI): A Review of the November Quality Forum Lecture
The PQA was honored to have Bryon Pearsall, a health scientist policy analyst, and Murewa Oguntimein, a social science analyst, from the Office of Medical Policy in the Center for Evaluation and Research at the FDA, present an update on Patient Medication Information (PMI) at the November Quality Forum Lecture. The FDA has been working on a new framework for the development and distribution of PMI to be provided to patients who are prescribed drug products. Read more
PQA Welcomes New Members
Capital Health Plan
Harding University
Read more |
Second Annual PQA Leadership Summit Discusses Newly Approved Strategic Plan
The PQA Leadership Summit is held annually to provide the staff input from key members and stakeholders on future directions for the organization. The 2011 Summit took place on November 17th in the Washington DC area and included nearly 50 attendees composed of members of the PQA Board of Directors, workgroup co-chairs, member organizations, PQA staff and selected speakers and guests. Laura Cranston, PQA Executive Director, started the day by discussing elements and objectives contained in the PQA strategic plan for 2012-2014. The strategic plan was developed and refined over a 6-month process and approved by the Board during their 4th Quarter meeting. Cranston emphasized the tremendous growth and accomplishments of PQA during the organization's relatively short existence, including the expansion of staff and NQF acceptance of PQA endorsed measures and uptake of measures by numerous other organizations.
PQA continues to refine its focus. Cranston shared the new PQA mission statement created by the Board, which reflects this maturing perspective:
"To improve the quality of medication management and use across healthcare settings with the goal of improving patients' health
through a collaborative process to develop and implement performance
measures and recognize examples of exceptional pharmacy quality."
She emphasized the focus on patient outcomes and also that PQA now has the expertise to fully develop performance measures rather than just measure concepts.
Summit attendees were provided the new strategic plan and informed on the three key objectives, including (1) implementation of PQA measures, (2) measure development and maintenance and (3) optimizing the PQA infrastructure and engagement of member and non-member organizations. Much of the Summit discussions and activities focused on how PQA can best achieve these strategic goals.
Attendees attended two facilitated breakout sessions to generate and collect ideas focused on
"Linking PQA Efforts to Stakeholder Needs." The first session focused on measure implementation. This session included questions about how PQA can best drive uptake of measures by individual stakeholders and also align measure adoption across a wide array of stakeholders. One takeaway from this session was the need for developing a business case for measure adoption that demonstrates value across all stakeholders in the measure use process, including the plan, the provider (i.e., the pharmacist/pharmacy) and the payor (i.e., CMS). Increasing the evidence base for the measures was also noted as an important area for continued development by expanding and creating new PQA demonstration projects as well as collecting data from practice settings where measures have been implemented. In the second breakout session, the groups focused on measure development with particular emphasis on identifying and prioritizing areas where gaps exists for measures related to medication use. Examples of gap areas where identified by attendees include specialty pharmacy practice, mental health and oncology. This breakout session will be used to guide workgroup activities in 2012.
Comprised of volunteers from member organizations, the PQA workgroups are the backbone of PQA. The workgroups are created, modified and realigned annually to address needs in the healthcare environment related to measure development. The PQA Leadership Summit attendees where provided updates on the current status of the PQA workgroup efforts and opportunity to address questions to the workgroup leaders and representatives regarding areas for new measure development.
A highlight of the day was an update on the National Priorities Partnership by Karen Adams, Vice President of the National Quality Forum. Dr. Adams reviewed the National Quality Strategy and specifically illustrated the NPP's input on goals for each NQS priority area. Measure concepts for monitoring progress at the national level were included for each of the priority area. Dr. Adams informed attendees that many of these measure concepts already have available measures, but others do not. These identified measure gaps at the national level should be considered as opportunities for organizations such as PQA. Dr. Adams highlighted the measure gap areas that may offer the most opportunity for PQA to serve in a leadership role to align with and advance the National Quality Strategy. Dave Domann continued the discussion following Dr. Adam's presentation about prioritization of PQA measure development based on key components of the National Quality Strategy. Summit attendees suggested that PQA demonstrate how existing PQA measures align with current national priorities as well as focusing new measure development on measure gaps in the NQS. Back to Top |
The PQA Quality Forum Lecture Series for December: Learn About the New
"Measure Applications Partnership" (MAP)
The Measure Applications Partnership (MAP) is a public-private partnership convened by the National Quality Forum. MAP was created for the explicit purpose of providing input to the Department of Health and Human Services (HHS) on the selection of performance measures for public reporting and performance-based payment programs. The MAP is guided by the priorities and goals of the National Quality Strategy.
PQA is pleased that our current Chair, Judith Cahill, serves on the MAP Coordinating Committee and will be our presenter for the final Quality Forum Lecture on December 8th at 1 pm ET. The MAP works in a very transparent manner and Ms. Cahill will share the progress that has been made during 2011 and next steps for this important effort. The MAP operates through a two-tiered structure, the Coordinating Committee and the MAP Workgroups. There are four MAP Workgroups: Hospital, Clinician, Post-acute Care and Long Term Care, and the Dual-Eligible Beneficiaries Workgroup.
To join this PQA Quality Forum Lecture Series call,
click the link - REGISTER
NOTE: there is also a NQF sponsored MAP meeting scheduled for December 8th
that will include all four workgroups. For more information about this
web-based meeting, use the link - NQF MAP Meeting. Back to Top |
Hot Off the Press: Rapid Reviews of Key Quality Publications
by David Nau, PhD, RPh, CPHQ, Senior Director, Research & Performance Measurement, PQA
Three recent articles shed more light on the issue of medication adherence. The most clinically-significant study will be reviewed here, but readers are encouraged to review all three of the studies listed at the end of this article.
Researchers from Harvard, Aetna and CVS/Caremark published the initial results of the Post Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) Trial. The participants in this trial were patients who had medical and prescription benefit coverage through Aetna and who had been recently discharged from the hospital subsequent to a myocardial infarction. Patients who were 65 years or older were not included in this trial. Patients were assigned to either a control group (with usual pharmacy benefits) or an intervention group wherein they were provided with free (i.e., no cost sharing by patient) medications from the following categories: beta-blockers, renin-angiotensin
system inhibitors (ACEI/ARBs), statins. All patients in the study received mail and telephone information on the importance of taking their medications. Patients in the intervention group were allowed to receive free medications throughout the follow-up period, and the median duration of follow-up across all patients was 394 days.
Through rigorous multivariable analyses, the researchers found that the patients who received free medication had higher levels of medication adherence and lower total cardiovascular events. The total costs of care did not significantly differ between the groups. Notably, the adherence rates were far from optimal across both the intervention and usual-benefit groups. Across all patients enrolled in the study, only 12.1% of intervention patients maintained high levels of adherence (MPR>80%) throughout the follow-up period, while 8.9% of usual-benefit patients maintained high levels of adherence. Despite the statistically significant improvement in adherence by providing free medications, there is still a substantial opportunity for improvement in medication adherence rates for post-MI patients.
Why This Study is Relevant
Medication non-adherence is a significant problem for our healthcare system. Numerous studies have identified the low rates of adherence and persistence to medications amongst patients with chronic diseases such as diabetes, hypertension and COPD. Additional studies have revealed the significant correlation of non-adherence with hospitalization rates, cardiovascular event rates, and total healthcare spending.
The Centers of Medicare & Medicaid Services (CMS) recently began to evaluate medication adherence rates as part of the Medicare Plan Ratings for MA-PD and PDP plans. All Medicare Part D plans are now evaluated on whether their members on targeted chronic medications are maintaining high levels of adherence. When examined across a single plan year, the percentage of MA-PD patients who maintained a high level of adherence (PDC > 80%) with oral diabetes medications was 73.0% compared to 72.2% for ACEI/ARBs and 68.0% for statins. Adherence rates amongst PDP patients were slightly higher for each category.
We must continue the search for highly-effective, and easily scalable, methods to help our patients achieve high-levels of adherence with their chronic medications. Although we may achieve some improvement through reduced costs of medications, the removal of cost barriers clearly does not address the full spectrum of reasons for patients who discontinue their medications. We must look beyond copay waivers and reminder systems, and consider multi-faceted approaches to supporting medication adherence.
PQA has undertaken demonstration projects to test different methods for pharmacists to collaborate with health plans in supporting medication adherence for patients with diabetes and cardiovascular disease. We recently unveiled the preliminary results from our demonstration in Pennsylvania involving Highmark, Rite Aid, CECity, the University of Pittsburgh and RTI International. In this study, 120 Rite Aid stores were assigned to an intervention group and compared over a year to 120 Rite Aid
"control" stores. The Rite Aid intervention pharmacists were trained on motivational interviewing, redesigned their workflow to implement a brief screening of all patients on diabetes and cardiovascular medications, intervened on patients who expressed concerns about their medications, and tracked their improvement using a web-based performance report. The pharmacies in the intervention group saw significant improvements in medication adherence rates relative to the control group. More details on this study are available at: Pennsylvania Collaborative.
PQA hopes to engage more health plans and pharmacies in this collaborative, technology-enabled, model for improvement of adherence and safety. In the coming year, you will hear more about our E-QuIPP Initiative that is launching in two states in early 2012. Hopefully, we can expand the impact of pharmacists on medication adherence to provide better healthcare and better value for all involved.
Highlighted Article:
Choudhry NK, Avorn J, Glynn RJ, et al. Full Coverage for Preventive Medications after Myocardial Infarction. N Engl J Med 2011; 365:2088-2097.
Additional articles of interest:
Khandelwal N, Duncan I, Rubenstein E, et al. Medication Adherence for 90-day Quantities of Medication Dispensed through Retail and Mail Order Pharmacies. Am J Manag Care 2011;17:e427-e434.
Sherman BW, Sekili A, Prakash ST, Rausch CA. Physician-Specific Variation in Medication Adherence among Diabetes Patients. Am J Manag Care 2011;17:729-736. Back to Top |
Save the Date for the PQA 7th Annual Meeting! June 13-15, 2012 in Washington, DC
Mark your calendar and don't miss this very informative and interactive meeting. Senior level executives from health plans, PBMs, community pharmacy, government agencies and pharmaceutical companies, to name a few, will be in attendance. New this year, the meeting will kick off on Wednesday with the Keynote Address at 5 PM, followed by a welcoming reception. On Thursday, PQA will host the Quality Awards Program and will recognize health plans that have achieved excellence in medication quality and overall excellence in healthcare delivery to their patients based on the Star Ratings. Friday will feature Best Practices and Lessons Learned sessions.
There is no charge to attend the PQA Annual Meeting for PQA members. For non-members there is a $395 registration fee. The meeting is taking place at the Omni Shoreham in Washington, DC.
Back by Popular Demand...The Exhibit Area! Last year our exhibitor partners shared cutting edge technologies, both high tech and high touch, and demonstrated some of the latest advances in improving medication adherence and safety. The exhibit program is designed to give each exhibitor maximum visibility. Space is Limited! For more information contact Jackie Green at 703-927-1599 or jgreen@pqaalliance.org. Back to Top |
Primary Medication Non-Adherence Measures
The National Association of Chain Drug Stores Foundation, with corporate sponsorship from Pfizer, provided a grant to the Pharmacy Quality Alliance to develop standardized measures for primary medication non-adherence (PMN). Primary medication non-adherence occurs when a patient receives a prescription for a medication but never obtains the prescription medication.
PQA convened an expert panel to review the literature and build consensus on appropriate definitions and measures for PMN. The expert panel proposed definitions of PMN and prescription abandonment and a standardized measure of PMN. A call for public comments on these proposed definitions and measures was issued in September and many comments were received. After review of the public comments, the expert panel submits the following definitions and measure for use and testing:
Primary Medication Non-Adherence (PMN)
PMN occurs when a new medication is prescribed for a patient, but the patient does not obtain the medication, or appropriate alternative, within an acceptable period of time after it was prescribed.
The measurement of PMN can gauge the extent to which patients do not initiate newly prescribed therapy. The growth of e-prescribing allows for more efficient measurement of prescriptions that were written but that were never filled by a pharmacy. Thus, an accurate and efficient measure of PMN is now feasible by combining e-prescribing transaction data with prescription claims data.
Prescription Abandonment
Abandonment occurs whenever a prescription is filled by the pharmacy but not claimed by the patient.
This can occur upon filling the initial (new) prescription for a patient or when refilling a prescription. Because abandonment rates are not typically limited to new prescriptions and do not account for prescriptions that were written but never filled by the pharmacy, they are an imperfect proxy for PMN. Nonetheless, abandonment rates may be useful for pharmacy self-assessment to track the impact of operational changes on abandonment.
PMN Measure
Using Prescription Claims & e-prescribing Transactions
This rate is intended to measure the level of primary medication non-adherence across a population of patients for which prescription claims data is available in addition to e-prescribing data from the patients' physicians. It will focus only on e-prescriptions so that the rate can also be used for comparisons across prescription drug plans or comparisons across physicians or pharmacies within a prescription drug plan's network. Limiting the rate to ONLY e-prescriptions is important when using the rate for comparisons of providers or plans since different providers may have very different proportions of prescriptions that are transmitted via e-prescribing portals (i.e., we can compare
"apples to apples" by including only e-prescriptions).
Denominator: All e-prescriptions for newly initiated drug therapy during the measurement period.
Denominator Notes:
- Include ONLY prescriptions that were transmitted through an e-prescribing portal.
- Include ONLY drugs for chronic conditions that are to be taken on a regular schedule (i.e., not PRN). (Note: This list of specific products will be provided by PQA.)
- Exclude e-prescriptions if the patient has filled a prescription for the same drug within the prior 180 days.
"Same drug" means generic equivalent products.
Numerator: The e-prescribing transactions in the denominator for which there was no prescription claim that matched the patient and the prescribed drug (or appropriate alternative drug) with a date of service within 30 days of the e-prescribing transaction.
Numerator Notes:
- "Appropriate alternative" is defined as any product within the same drug class as the prescribed drug. For example, if the physician prescribed glyburide, we would define the alternative products as any sulfonylurea drug.
- If the patient had a "reversed" prescription claim for the target drug, and no subsequent
"paid" claim, the event would be considered primary non-adherence.
Back to Top |
PQA Measures Incorporated into Medicare Part D Star Ratings
The Centers for Medicare & Medicaid Services has created health care plan ratings that indicate the quality of Medicare plans using a scale of 1 to 5 stars. The stars are determined through numerous performance measures across several domains of performance. The four domains are:
- Drug Plan Customer Service
- Member Complaints, Problems Assessing Services, and Leaving the Plan
- Member Experience with Drug Plan
- Drug Pricing and Patient Safety
PQA quality measures of medication safety and adherence have been adopted by CMS and are in the domain of Drug Pricing and Patient Safety. The measures included are the High-risk Medications in the Elderly, Appropriate Treatment of Hypertension in Persons with Diabetes,
and Proportion of Days Covered for three medications categories
(ACEI/ARB, statins, and oral diabetes agents).
In 2012, CMS will start a three-year demonstration project for Medicare Advantage plans wherein CMS will award
"quality bonus payments" (QBPs) to plans based on the plan's star ratings. Plans must receive at least 3 stars to be eligible for QBPs.
For additional information about the top performing plans for 2012, weighting of the measures used to determine the star ratings, and management of the star rating system, click the provided links for the PQA Executive Update or the CMS Five-Star Quality Rating Program site.
Back to Top |
Beacon Communities: A Review of the October PQA Quality Forum Lecture Series
The October PQA Quality Forum Lecture Series provided an overview and numerous insights into the current initiatives focusing on the Beacon Communities. Information was presented by Craig Brammer, Deputy Director of the Beacon Community Program, at the Office of the National Coordinator (ONC).
Craig outlined the activities in place around the country by type of "core" interventions as well as the actual number of Beacon Communities involved in the various activities. These interventions included work in Transitions of Care, Care Management/PCMH, Clinical Decision Support (computerized), Physician Data Reporting and Performance Feedback, and Public Health Registry-Based Management.
Brammer's descriptions provided an impressive sense of the scope and number of patients and providers touched by interventions related to the various Beacon Community programs. In addition, Mr. Brammer added that
"the programs will be focusing on the improvement goals of quality, cost and population health as the three tenets of the program framework." Models that show improvements in hospital readmission rates and HbA1C values as well as those that demonstrate innovative care approaches that can be sustainable and replicable are overarching program goals.
The Beacon Program is also offering special assistance
and support in the health information technology (HIT) use. Mr. Brammer
cited information from an April 2011 article published in Health
Affairs, "An Early Status Report on the Beacon Communities' Plans
for Transformation Via Health Information Technology" for which he was co-author. The complete slide deck provides a high level of detail with specific examples from the Beacon Communities. This Beacon Community Lecture slide deck is available on the PQA website for review or to share with interested colleagues.Back to Top |
Mitch Betses Appointed to the PQA Board of Directors
The PQA Board of Directors recently appointed Mitch Betses, Vice President of Pharmacy Operations for CVS pharmacy, to the PQA Board for a four-year term. Mr. Betses manages the overall retail pharmacy agenda at CVS, including managing and improving day-to-day pharmacy operations for nearly 7,300 retail pharmacies, defining and delivering differentiated products and services for CVS Caremark patients, and overseeing clinical services, quality assurance, and patient safety improvement processes.
Over the course of Mitch's career, he has been a practicing pharmacist, overseen pharmacy operations as a field supervisor, and supported the pharmacy chain through various corporate roles. Mitch was one of the primary architects of the Patient Care Initiative at CVS, which sought to improve patient adherence to appropriate medications. He understands the importance of careful design, implementation, and continued use of standard metrics and reporting in the community pharmacy as a key success factor in the implementation of patient products and services.
PQA will officially welcome Mitch to the PQA board effective January, 2012. Laura Cranston, PQA Executive Director noted that
"We are confident that Mitch will join with the other Board members in
helping to shape a successful strategy for measuring and reporting
performance information, particularly as it relates to pharmacy care
across the community pharmacy sector." Back to Top |
Patient Medication Information (PMI): A Review of the November Quality Forum Lecture
The PQA was honored to have Bryon Pearsall, a health scientist policy analyst, and Murewa Oguntimein, a social science analyst, from the Office of Medical Policy in the Center for Evaluation and Research at the FDA, present an update on Patient Medication Information (PMI) at the November Quality Forum Lecture. The FDA has been working on a new framework for the development and distribution of PMI to be provided to patients who are prescribed drug products. Many stakeholders have provided feedback to the FDA in an effort to help ensure consumers receive clear, actionable information when they have a prescription filled. Stakeholder outreach has included public hearings, workshops and expert meetings over the last year.
Criteria for the new PMI dictate that information must be accurate, balanced, and delivered in a consistent and easily understood format. Under the current system, patients may receive several types of information, developed by different sources. This results in PMI that often is duplicative, incomplete, or difficult to read and understand. The FDA has determined that this system is not adequate to ensure patients receive the essential medication information needed to use a drug safely. The FDA sees merit in adopting the use of a single document standardized with respect to content and format. PMI is intended to replace patient package inserts, consumer medication information, and medication guides.
The Patient Medication Information would be created by the product manufacturer and available at a central repository. PMI would be distributed through healthcare providers and pharmacies. It also could be directly accessed by the consumer free of charge and used for home reference. The National Library of Medicine is projected to be the repository of the PMI and all medications will be required to have a formal PMI file in place.
The FDA is investigating the usefulness of the PMI content and the format. The study is expected to be complete in the spring of 2012. Phase I research includes qualitative interviews which are:
- One-on-one
- Face-to-face
- Conducted with members of the following groups:
- Low literacy and chronic illnesses
- Patient with Rheumatoid Arthritis or another approved indication
for the drug, Rheutopia®
- Any chronic illness
Phase II will follow with a quantitative experiment and will include:
- Random assignment to conditions
- Each person will see only one version of the PMI
- Administered via Internet
Next steps for the FDA will include continued meetings with stakeholders, testing of the single-document PMI prototype, reviewing the distribution pilot tests, standardization of the content and format and identifying mechanisms to ensure PMI distribution.
During the question and answer period, a question was asked about how PMI will impact Risk Evaluation and Mitigation Strategies (REMS) requirements. Bryon Pearsall noted that the intention of PMI is to replace the MedGuides portion of REMS. However, the REMS program will still be in place. Once PMI comes out, clarification will be made.
The target date for implementation of the new PMI is sometime in 2015. Back to Top |
PQA Welcomes New Members
Capital Health Plan...
Capital Health Plan, created in 1982, is a local non-profit HMO focused solely on serving the area surrounding Tallahassee and providing high quality, affordable health care coverage to its 118,000 members. Capital Health Plan is the highest-ranked Medicare and Commercial plan in Florida and the number 3 ranked commercial plan in the nation by the National Committee for Quality Assurance (NCQA) in
"NCQA's Health Insurance Plan Rankings 2011-2012". For more information, please visit www.chp.org.
Harding University...
Harding University is a private Christian institution of higher education committed to the tradition of the liberal arts and sciences. The College of Pharmacy offers a four-year program of study leading to the Doctor of Pharmacy (Pharm.D.) degree. The four-year program consists of three years comprised of a combination of didactic instruction and early pharmacy practice experiences followed by a fourth year comprised entirely of advanced pharmacy practice experiences. For more information, please visit www.harding.edu. Back to Top |
Copyright 2011, PQA, Inc.
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