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Donohue JM, Huskamp HA, Wilson IB, Weissman J. Whom do older adults trust most to provide information about prescription drugs? ACTA ACUST UNITED AC 2009; 7:105-16. [PMID: 19447363 DOI: 10.1016/j.amjopharm.2009.04.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cost-related nonadherence to medieations is common among older adults, yet physician-patient communication about medication cost concerns is infrequent. One factor affecting communication and adherence may be older adults' confidence in the information about prescription drugs provided by physicians and other sources. OBJECTIVES This study was conducted to identify which source older adults most trust to provide information on drugs and to examine the relationship between older patients' trust in physicians to provide price information and the occurrence of cost-related nonadherence. METHODS We conducted a cross-sectional national telephone survey of individuals aged > or =50 years who were taking at least 1 prescription medication. Respondents were asked how much they would trust various sources (physician, pharmacist, nurse, insurance plan, the Internet, consumer groups, friends and family) to provide helpful information on "the price of the prescription medicine compared to others like it" and on "how well the prescription medicine will work for you compared to other medicines like it." The response options were a lot, somewhat, and not at all. Other measures of interest were respondents' beliefs concerning physicians' ability to lower drug costs and patient activation. We also evaluated the potential association between trust in physicians to deliver drug price information and cost-related medication nonadherence. RESULTS Compared with the other sources of information studied, doctors and pharmacists were the sources that respondents were most likely to trust "a lot" to provide information on drug prices (55.6% and 61.7%, respectively) and to provide information on drug effectiveness (79.9% and 66.4%). Less than half (42.3%) of respondents who said that they trusted their doctor to provide drug price information "somewhat" or "not at all" agreed that there are ways doctors could lower drug costs (P = 0.01 vs those who trusted their doctor "a lot"). Adults aged > or =65 years were more likely than those aged 50 to 64 years to trust their doctors "a lot" to provide information on drug prices (odds ratio [OR] = 1.44; 95% CI, 1.08-1.92); the same was true of members of minority groups compared with white respondents (OR = 1.72; 95%) CT, 1.1 3-2.61 ). Among individuals with high drug spending, those who placed "a lot" of trust in their doctors to provide price information were less likely than those who trusted their doctor "somewhat" or "not at all" to have cost-related nonadhcrence (OR = 0.40; 95% CI, 0.20-0.78). CONCLUSIONS In this survey, older adults trusted physicians and pharmacists more than the other sources studied to provide information on prescription drugs. Trust in physicians to provide price information was an important moderator of the effect of high drug spending on cost-related nonadhcrence. Efforts to provide patients and their providers with comparative data on drug prices and effectiveness may reduce cost-related nonadhcrence.
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Affiliation(s)
- Julie M Donohue
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA.
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152
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Luz TCB, Loyola Filho AID, Lima-Costa MF. Estudo de base populacional da subutilização de medicamentos por motivos financeiros entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. CAD SAUDE PUBLICA 2009; 25:1578-86. [DOI: 10.1590/s0102-311x2009000700016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Accepted: 02/09/2009] [Indexed: 02/25/2023] Open
Abstract
O objetivo deste trabalho foi estimar a prevalência e avaliar os fatores associados à subutilização de medicamentos por motivos financeiros em amostra representativa de 1.134 idosos, residentes na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. A prevalência da subutilização foi de 12,9%, estando independentemente associada à renda pessoal mensal inferior a dois salários mínimos (RP = 0,57; IC95%: 0,34-0,97), à filiação a plano privado de saúde (RP = 0,68; IC95%: 0,46-0,99), à freqüência com que o profissional de saúde esclareceu sobre a saúde/tratamento (raramente/nunca, RP = 1,79; IC95%: 1,10-2,90), à auto-avaliação de saúde (razoável, RP = 1,66; IC95%: 0,95-2,90 e ruim/muito ruim, RP = 2,49; IC95%: 1,38-4,48) e ao número de condições crônicas (uma, RP = 2,51; IC95%: 0,99-6,35; duas, RP = 3,51; IC95%: 1,40-8,72 e três ou mais, RP = 4,52; IC95%: 1,79-11,41). Os resultados confirmam a importância dos aspectos sócio-econômicos para a subutilização, mas indicam que sua determinação também está ligada à qualidade da comunicação médico-paciente. Evidencia-se ainda uma situação de risco para idosos em piores condições de saúde.
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153
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Skarupski KA, de Leon CFM, Barnes LL, Evans DA. Medicare part D enrollment in a biracial community-based population of older adults. THE GERONTOLOGIST 2009; 49:828-38. [PMID: 19531806 DOI: 10.1093/geront/gnp055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The Medicare Prescription Drug Benefit (Part D) program debuted in January 2006. We ascertained the sociodemographic and health characteristics of Blacks and Whites who enrolled in the early stages of the program. DESIGN AND METHODS Data were collected between April 2006 and October 2007 from an ongoing population-based biracial study of older adults. RESULTS We interviewed 2,694 subjects, 1,784 Blacks and 910 Whites, of whom 40% and 35% reported to have enrolled in Medicare Part D, respectively. Among Blacks, those who enrolled were more likely to be female, unmarried, have less education and income, more medical conditions, greater physical disability, and poorer physical function than Blacks who did not enroll. Among Whites, enrollees were older, female, and had less education compared with White nonenrollees. In the multivariate analyses, older age, female, being married, lower income, worse physical function, and better cognitive function were associated with program enrollment. IMPLICATIONS These results indicate that the profiles of adults who initially enrolled in Medicare Part D differed somewhat by race. Program enrollment among Blacks was largely driven by financial need and poor health; however, among Whites, there was no such discernible pattern of enrollment. In addition, we observed a knowledge gap among Black nonenrollees who reported that they were unaware of and confused by the program and plans. The findings suggest that Medicare Part D may serve different needs in different subpopulations. The long-term impact of these differential program profiles on Black-White health disparities remains uncertain and requires continued monitoring.
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Affiliation(s)
- Kimberly A Skarupski
- Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, IL 60612-3227, USA.
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154
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Zivin K, Kabeto MU, Kales HC, Langa KM. The effect of depression and cognitive impairment on enrollment in Medicare Part D. J Am Geriatr Soc 2009; 57:1433-40. [PMID: 19515100 DOI: 10.1111/j.1532-5415.2009.02348.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine concerns that vulnerable populations, such as depressed or cognitively impaired beneficiaries would have challenges accessing Part D coverage. DESIGN Logistic regression analysis was used to assess whether elderly Medicare beneficiaries with depression or cognitive impairment differentially planned to and actually signed up for Part D. SETTING 2004 and 2006 data from the Health and Retirement Study (HRS) were used, including a subsample that completed the Prescription Drug Study (PDS) in 2005. PARTICIPANTS Nine thousand five hundred ninety-three HRS respondents and 3,567 PDS respondents. MEASUREMENTS The outcome variables of interest were planned and actual enrollment in Part D. The independent variables were depression and cognitive impairment status. The analyses were adjusted using clinical and demographic predictors including age, sex, race or ethnicity, educational attainment, net worth, marital status, health status, number of health conditions being treated with prescription medications, and presence of a caregiver. RESULTS Although having depression or cognitive impairment was associated with a higher likelihood of planning to and actually signing up for Part D in unadjusted analyses, in adjusted analyses, having depression or cognitive impairment was not significantly associated with whether Medicare beneficiaries planned to enroll in or actually enrolled in Part D. CONCLUSION Vulnerable Medicare beneficiaries with depression or cognitive impairment were able to access Part D benefits to the same extent as nonvulnerable beneficiaries. More research is needed to determine how well Part D meets the needs of these populations.
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Affiliation(s)
- Kara Zivin
- Serious Mental Illness Treatment Research and Evaluation Center, Department of Veterans Affairs, Ann Arbor, Michigan, USA.
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155
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Does synchronizing initiation of therapy affect adherence to concomitant use of antihypertensive and lipid-lowering therapy? Am J Ther 2009; 16:119-26. [PMID: 19114872 DOI: 10.1097/mjt.0b013e31816b69bc] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although efficacious medications are available to treat hypertension and dyslipidemia, treatment adherence is often poor. This retrospective study evaluated adherence in patients newly initiating antihypertensive (AH) and lipid-lowering (LL) therapies simultaneously versus within 180 days of one another. Data were analyzed for US managed care plan enrollees initiating AH before LL (cohort 1;n = 7099), LL before AH (cohort 2; n = 3229), or AH/LL simultaneously (cohort 3; n = 5072). A multivariate model evaluated potential predictors of adherence (medication possession ratio >or= 0.80 over a bimonthly period). Percentages of patients adherent to AH/LL at 2, 6, and 12 months were as follows: 59.4%, 32.7%, and 31.3% in cohort 1; 45.0%, 30.8%, and 31.0% in cohort 2; and 75.2%, 34.4%, and 34.0% in cohort 3, respectively. After adjustment for potential confounders, patients initiating AH before LL therapy, or LL before AH therapy, were less likely to be adherent than patients prescribed both agents simultaneously (odds ratios = 0.838 and 0.691, respectively; P , 0.0001). Synchronous initiation of AH and LL therapies is an important predictor of adherence.
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156
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Ryan R, Santesso N, Hill S, Kaufman C, Grimshaw J. Consumer-oriented interventions for evidence-based prescribing and medicine use: an overview of Cochrane reviews. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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157
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Kennedy J, Morgan S. Cost-related prescription nonadherence in the United States and Canada: a system-level comparison using the 2007 International Health Policy Survey in Seven Countries. Clin Ther 2009; 31:213-9. [PMID: 19243719 DOI: 10.1016/j.clinthera.2009.01.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prior research indicates that residents of the United States are nearly twice as likely as Canadian residents to report cost-related nonadherence (CRNA) (ie, being unable to fill > or =1 prescription due to cost). However, these kinds of national comparisons obscure important within-country differences in insurance coverage. OBJECTIVE This study was designed to compare rates of CRNA across major financing systems for prescription drugs in the United States and Canada. METHODS This study used the 2007 International Health Policy Survey in Seven Countries (supported by the US Commonwealth Fund) to estimate rates of CRNA in the following health systems: Canadian compulsory coverage (Quebec), Canadian senior and social assistance coverage (Ontario), Canadian income-based coverage (British Columbia, Manitoba, and Saskatchewan), Canadian mixed coverage (all other provinces), US private coverage (employer-based or individual insurance), US senior and social assistance coverage (Medicare and/or Medicaid), and US no coverage (uninsured). RESULTS Adults in the United States were far more likely than adults in Canada to report CRNA (23.1% vs 8.0%; chi(2) = 147.4; P < 0.001). Seniors (> or =65 years of age) were less likely than younger adults (<65 years) to report CRNA in both the United States (9.2% vs 25.8%; chi(2) = 64.3; P < 0.001) and Canada (4.6% vs 8.7%; chi(2) = 14.9; P < 0.001), presumably due to categorical eligibility for prescription drug insurance. Comparative analyses therefore focused on working-age adults (<65 years). Adults in Quebec (who have compulsory drug coverage) were only half as likely as those in Ontario to report CRNA (odds ratio [OR] = 0.5; 95% CI, 0.3-0.8). Uninsured adults in the United States were >7 times as likely to report CRNA (OR =7.2; 95% CI, 5.0-10.5), and adults with public insurance (OR = 2.2; 95% CI, 1.4-3.5) and private insurance (OR = 2.2; 95% CI, 1.6-3.0) were >2 times as likely to report CRNA. CONCLUSIONS After stratifying by age and simultaneously adjusting for sex, household income, and chronic illness, large differences in CRNA were found between and within countries. Even in a compulsory prescription insurance system like that in Quebec, 4.4% of working-age adults reported CRNA. However, these rates were low compared with CRNA rates for working-age adults in the United States who lack any health insurance (43.3%).
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Affiliation(s)
- Jae Kennedy
- Department of Health Policy and Administration, Washington State University, Spokane, Washington, USA.
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158
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Trompeter JM, Havrda DE. Impact of Obtaining Medications from Pharmaceutical Company Assistance Programs on Therapeutic Goals. Ann Pharmacother 2009; 43:469-77. [DOI: 10.1345/aph.1l420] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Limited data exist regarding whether improved access to medications for indigent persons through pharmaceutical company assistance programs (PCAPs) leads to attainment of therapeutic goals. Objective: To evaluate the impact of obtaining medications through PCAPs with pharmacist assistance versus prescription insurance on the likelihood of achieving therapeutic goals. Methods: A retrospective chart review was conducted in a private family practice clinic. Individuals prescribed one or more drugs for the treatment of hypertension, diabetes, or dyslipidemia and receiving medication through a PCAP or prescription insurance were included. Eligible records were reviewed for pertinent laboratory and medication information and to assess achievement of hypertension, diabetic, and dyslipidemia goals. Results: A total of 458 persons were eligible for inclusion: 250 with prescription insurance and 208 using a PCAP. The PCAP group was older, with more females and multiple disease states. There was no significant difference between the groups in reaching hypertension goals; the goals were not predicted by PCAP, presence of diabetes, or class of drug. More PCAP individuals (67.1%) achieved hemoglobin A1C values less than 7% compared with patients in the prescription insurance group (39.6%; p = 0.002). The PCAP group had lower low-density lipoprotein cholesterol (LDL-C) values (95.8 ± 28.0 mg/dL; mean ± SD) and higher high-density lipoprotein cholesterol (HDL-C) values (40.8 ± 12.1 mg/dL) compared with the prescription insurance group (111.8 ± 37.5 mg/dL; p < 0.001 and 33.7 ± 13.6 mg/dL; p = 0.011, respectively). Achieving LDL-C goals were significant only for a goal less than 130 mg/dL and less than 160 mg/dL (p = 0.007); diabetes patients were less likely to achieve LDL-C goals compared with those without diabetes in both groups. Enrollment in PCAP was a predictor in reaching diabetic and some dyslipidemia therapeutic goals. Conclusions: Individuals without prescription insurance and receiving pharmacist and PCAP assistance in obtaining medications were more likely to reach diabetic goals and have better cholesterol values compared with persons with prescription insurance. The presence of prescription insurance alone does not guarantee reaching therapeutic goals; pharmacist involvement with PCAP and obtaining drugs enhances the likelihood of persons achieving therapeutic goals.
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Affiliation(s)
- Jessica M Trompeter
- Department of Pharmacy Practice and Division of Physician Assistant Studies, Shenandoah University, Winchester, VA
| | - Dawn E Havrda
- Department of Pharmacy Practice, Shenandoah University
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159
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Cunningham PJ. High medical cost burdens, patient trust, and perceived quality of care. J Gen Intern Med 2009; 24:415-20. [PMID: 19101775 PMCID: PMC2642571 DOI: 10.1007/s11606-008-0879-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 08/18/2008] [Accepted: 11/07/2008] [Indexed: 01/26/2023]
Abstract
BACKGROUND The financial burden of medical care expenses is increasing for American families. However, the association between high medical cost burdens and patient trust in physicians is not known. OBJECTIVE To examine the association between high medical cost burdens and self-reported measures of patient trust and perceived quality of care. METHODS Cross-sectional household survey based on random-digit dialing and conducted largely by telephone, supplemented by in-person interviews of households with no telephones. The sample for this analysis includes 32,210 adults who reported having a physician as their regular source of care. Measures of patient trust include overall trust, confidence in being referred to a specialist, and belief that the physician uses more services than necessary. Perceived quality measures include thoroughness of exam, ability to listen, and ability to explain. RESULTS In adjusted analyses, persons with high medical cost burdens had greater odds of lacking trust in their physician to put their needs above all else (OR = 1.43, CI = 1.19, 1.73), not referring them to specialists (OR = 1.39, CI = 1.22, 1.58), and performing unnecessary tests (OR = 1.42, CI = 1.20, 1.62). Patients with high medical cost burdens also had more negative assessments of the thoroughness of care they receive from their physician (OR = 1.26, CI = 1.02, 1.56). The association of high medical cost burdens with patient trust and perceived quality of care was greatest for privately insured persons. CONCLUSION The rising cost of medical care threatens a vital aspect of the effective delivery of medical care-patient trust in their physician and continuity of care. Exposing patients to more of the costs could lead to greater skepticism and less trust of physicians' decision-making, thereby making health-care delivery less effective.
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Affiliation(s)
- Peter J Cunningham
- Center for Studying Health System Change, 600 Maryland Ave., S.W., Suite 550, Washington, DC 20024, USA.
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160
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Schneeweiss S, Patrick AR, Pedan A, Varasteh L, Levin R, Liu N, Shrank WH. The effect of Medicare Part D coverage on drug use and cost sharing among seniors without prior drug benefits. Health Aff (Millwood) 2009; 28:w305-16. [PMID: 19189990 DOI: 10.1377/hlthaff.28.2.w305] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study evaluates the effect of Medicare Part D among seniors who previously lacked drug coverage, using time-trend analyses of patient-level dispensing data from three pharmacy chains. Of 114,766 seniors without drug benefits, 55 percent initiated drug insurance under Part D. After the penalty-free Part D enrollment period, use of statins, clopidogrel, and proton pump inhibitors stabilized at levels ranging from 11 percent to 37 percent above the trend that would have been expected if Part D had not been implemented. Patients reaching the Part D coverage gap (12 percent) experienced a decrease in essential medication use ranging from 5.7 percentage points per month for warfarin to 6.3 percentage points for statins.
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Affiliation(s)
- Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital in Boston, Massachusetts, USA.
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161
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Resident physician and hospital pharmacist familiarity with patient discharge medication costs. ACTA ACUST UNITED AC 2009; 31:195-201. [DOI: 10.1007/s11096-009-9280-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 12/28/2008] [Indexed: 11/27/2022]
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162
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McHorney CA. The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease. Curr Med Res Opin 2009; 25:215-38. [PMID: 19210154 DOI: 10.1185/03007990802619425] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To conceptualize, develop, and provide preliminary psychometric evidence for the Adherence Estimator--a brief, three-item proximal screener for the likelihood of non-adherence to prescription medications (medication non-fulfillment and non-persistence) for chronic disease. RESEARCH DESIGN AND METHODS Qualitative focus groups with 140 healthcare consumers and two internet-based surveys of adults with chronic disease, comprising a total of 1772 respondents, who were self-reported medication adherers, non-persisters, and non-fulfillers. Psychometric tests were performed on over 150 items assessing 14 patient beliefs and skills hypothesized to be related to medication non-adherence along a proximal-distal continuum. Psychometric tests included, but were not limited to, known-groups discriminant validity at the scale and item level. The psychometric analyses sought to identify: (1) the specific multi-item scales that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters) and, (2) the single best item within each prioritized multi-item scale that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters). RESULTS The two rounds of psychometric testing identified and cross-validated three proximal drivers of self-reported adherence: perceived concerns about medications, perceived need for medications, and perceived affordability of medications. One item from each domain was selected to include in the Adherence Estimator using a synthesis of psychometric results gleaned from classical and modern psychometric test theory. By simple summation of the weights assigned to the category responses of the three items, a total score is obtained that is immediately interpretable and completely transparent. Patients can be placed into one of three segments based on the total score--low, medium, and high risk for non-adherence. Sensitivity was 88%--of the non-adherers, 88% would be accurately classified as medium or high risk by the Adherence Estimator. The three risk groups differed on theoretically-relevant variables external to the Adherence Estimator in ways consistent with the hypothesized proximal-distal continuum of adherence drivers. CONCLUSIONS The three-item Adherence Estimator measures three proximal beliefs related to intentional non-adherence (medication non-fulfillment and non-persistence). Preliminary evidence of the validity of the Adherence Evidence supports its intended use to segment patients on their propensity to adhere to a newly-prescribed prescription medication. The Adherence Estimator is readily scored and is easily interpretable. Due to its brevity and transparency, it should prove to be practical for use in everyday clinical practice and in disease management for adherence quality improvement. Study limitations related to sample representation and self reports of chronic disease and adherence behaviors were discussed.
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Affiliation(s)
- Colleen A McHorney
- US Outcomes Research, Merck & Co., Inc., West Point, PA 19486-0004, USA.
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163
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Curkendall S, Patel V, Gleeson M, Campbell RS, Zagari M, Dubois R. Compliance with biologic therapies for rheumatoid arthritis: do patient out-of-pocket payments matter? ACTA ACUST UNITED AC 2008; 59:1519-26. [PMID: 18821651 DOI: 10.1002/art.24114] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the impact of patient out-of-pocket (OOP) expenditures on adherence and persistence with biologics in patients with rheumatoid arthritis (RA). METHODS An inception cohort of RA patients with pharmacy claims for etanercept or adalimumab during 2002-2004 was selected from an insurance claims database of self-insured employer health plans (n=2,285) in the US. Adherence was defined as medication possession ratio (MPR): the proportion of the 365 followup days covered by days supply. Persistence was determined using a survival analysis of therapy discontinuation during followup. Patient OOP cost was measured as the patient's coinsurance and copayments per week of therapy, and as the proportion of the total medication charges paid by the patient. Multivariate linear regression models of MPR and proportional hazards models of persistence were used to estimate the impact of cost, adjusting for insurance type and demographic and clinical variables. RESULTS Mean +/- SD OOP expenditures averaged $7.84+/-$14.15 per week. Most patients (92%) paid less than $20 OOP for therapy/week. The mean +/- SD MPR was 0.52+/-0.31. Adherence significantly decreased with increased weekly OOP (coeff= -0.0035, P<0.0001) and with a higher proportion of therapy costs paid by patients (coeff= -0.8794, P<0.0001), translating into approximately 1 week of therapy lost per $5.50 increase in weekly OOP. Patients whose weekly cost exceeded $50 were more likely to discontinue than patients with lower costs (hazard ratio 1.58, P<0.001). CONCLUSION Most patients pay less than $20/week for biologics, but a small number have high OOP expenses, associated with lower medication compliance. The adverse impact of high OOP costs on adherence, persistence, and outcomes must be considered when making decisions about increasing copayments.
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Affiliation(s)
- S Curkendall
- Cerner LifeSciences, Beverly Hills, California, USA.
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164
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Donohue JM, Fischer MA, Huskamp HA, Weissman JS. Potential savings from an evidence-based consumer-oriented public education campaign on prescription drugs. Health Serv Res 2008; 43:1557-75. [PMID: 18479406 PMCID: PMC2653882 DOI: 10.1111/j.1475-6773.2008.00858.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To estimate potential savings associated with the Consumer Reports Best Buy Drugs program, a national educational program that provides consumers with price and effectiveness information on prescription drugs. DATA SOURCES National data on 2006 prescription sales and retail prices paid for angiotensin-converting enzyme inhibitors (ACEIs), β-blockers, calcium channel blockers, and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-coA) reductase inhibitors (statins). STUDY DESIGN We converted national data on aggregate unit sales of drugs in the four classes to defined daily doses (DDD) and estimated a range of potential savings from generic and therapeutic substitution. PRINCIPAL FINDINGS We estimated that $2.76 billion, or 7.83 percent of sales, could be saved if use of the drugs recommended by the educational program was increased. The recommended drugs' prices were 15-65 percent lower per DDD than their therapeutic alternatives. The majority (57.4 percent) of potential savings would be achieved through therapeutic substitution. CONCLUSIONS Substantial savings can be achieved through greater use of comparatively effective and lower cost drugs recommended by a national consumer education program. However, barriers to dissemination of consumer-oriented drug information must be addressed before savings can be realized.
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Affiliation(s)
- Julie M Donohue
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, Crabtree Hall A613, Pittsburgh, PA 15261, USA
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165
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Wilbur K. Hospital Pharmacist Familiarity with Patient Discharge Medication Costs. J Pharm Technol 2008. [DOI: 10.1177/875512250802400503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Drug therapy poses a financial burden for many individuals. Cost-related medication nonadherence is ultimately associated with increased healthcare resource utilization and poor patient outcomes. Physicians are often unaware of the costs associated with their prescribed therapy, but little is documented regarding familiarity of hospital pharmacists with out-of-pocket medication expenses borne by patients in the community setting. Objective: To evaluate how familiar hospital pharmacists are with prescribed medication costs for discharged patients. Methods: Hospital pharmacists within a specific healthcare organization were invited to participate in an online survey. Ten brief patient case scenarios and associated discharge therapeutic regimens were outlined and respondents were asked to identify the costs that discharged patients would incur when having the prescriptions filled. The total number and proportion of estimates either above or below the actual medication cost as determined from community pharmacies were calculated. Results: Thirty-one pharmacists completed the survey. For the therapeutic regimens described, 47% of medication costs were underestimated, 33% were overestimated, and 20% were correctly estimated (within 10% of the actual value). Incorrect estimates were evident across all therapeutic classes and medical indications presented in the survey. The greatest mean absolute cost differences were underestimation of a linezolid treatment course for skin and soft tissue infection ($384.18 below the mean absolute cost) and overestimation of monthly bisoprolol heart failure therapy ($22.42). Conclusions: Hospital pharmacists are often unfamiliar with what discharged patients must pay for drug therapy.
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Affiliation(s)
- Kerry Wilbur
- KERRY WILBUR BScPharm ACPR PharmD, Assistant Professor, College of Pharmacy, Qatar University, PO Box 2713, Doha, Qatar, fax 974/493-0449
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Cutler TW, Stebbins MR, Lai E, Smith AR, Lipton HL. Problem-based learning using the online Medicare Part D Plan Finder tool. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2008; 72:47. [PMID: 18698399 PMCID: PMC2508730 DOI: 10.5688/aj720347] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 12/21/2007] [Indexed: 05/22/2023]
Abstract
OBJECTIVES To implement didactic and problem-based learning curricular innovations aimed at increasing students' knowledge of Medicare Part D, improving their ability to apply the online Medicare Prescription Drug Plan Finder tool to a patient case, and improving their attitudes toward patient advocacy for Medicare beneficiaries. METHODS A survey instrument and a case-based online Medicare Prescription Drug Plan Finder tool exercise were administered to a single group (n = 120) of second-year pharmacy graduate students prior to and following completion of a course on health policy. Three domains (knowledge, skill mastery and attitudes) were measured before and after two 90-minute lectures on Medicare Part D. RESULTS The online Medicare Prescription Drug Plan Finder exercise and Medicare Part D didactic lectures had positive effects on students' knowledge of Part D, attitudes toward patient advocacy, and ability to accurately use the Medicare Prescription Drug Plan Finder tool. CONCLUSIONS The success of these didactic and problem-based curricular innovations in improving pharmacy students' knowledge, skills, and attitudes regarding Part D warrants further evaluation to determine their portability to clinical settings and other pharmacy schools.
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Affiliation(s)
- Timothy W Cutler
- School of Pharmacy, University of California-San Francisco, C-152 Box 0622, 521 Parnassus Avenue, San Francisco, CA 94143-0622, USA.
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167
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Tjia J, Briesacher BA, Soumerai SB, Pierre-Jacques M, Zhang F, Ross-Degnan D, Gurwitz JH. Medicare beneficiaries and free prescription drug samples: a national survey. J Gen Intern Med 2008; 23:709-14. [PMID: 18365289 PMCID: PMC2517874 DOI: 10.1007/s11606-008-0568-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Revised: 01/14/2008] [Accepted: 01/26/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND New policies regulating physician/pharmaceutical company relationships propose to eliminate access to free prescription drug samples. Little is known about the prevalence of patient activity in requesting or receiving free prescription drug samples, or the characteristics of patients who access drug samples. OBJECTIVE To determine the prevalence of free sample access and to examine demographic, clinical, and insurance characteristics of Medicare beneficiaries who access free samples. DESIGN Cross-sectional study. PARTICIPANTS A national sample of 13,847 Medicare beneficiaries participating in the fall 2004 Medicare Current Beneficiary Survey. MEASUREMENTS AND MAIN RESULTS Prevalence of free prescription drug sample access (self-reported request for or receipt of free drug samples) and the demographic, clinical, and insurance characteristics of Medicare beneficiaries who accessed drug samples. Overall, 48.3% (95% confidence of interval [CI]: 46.6%, 49.9%) of Medicare beneficiaries reported accessing free drug samples. Access was higher among beneficiaries reporting cost-related medication nonadherence compared to those without (77.7% (95% CI: 74.5%, 80.6%) vs 43.0% (95% CI: 41.4%, 44.7%)). Multivariable analysis revealed cost-related medication nonadherence (CRN) to have the strongest relationship with accessing drug samples (adjusted odds ratio [AOR] 4.43 [95% CI: 3.64, 5.39]). Compared to beneficiaries with generous drug benefits from Medicaid, beneficiaries who lacked prescription drug benefits were more likely to access drug samples (AOR 2.42 [95% CI: 2.06, 2.85]). Beneficiaries with drug coverage from employer-sponsored plans or partial coverage (Medicare HMO, self-purchased Medicare supplement, or state-sponsored low-income plans) were also more likely to access drug samples (AOR 2.02, 1.74, respectively). Having 2-3 or > or = 4 comorbidities (vs 0-1 comorbidities) also increased the likelihood of accessing drug samples (AOR 1.60 (95% CI: 1.44, 1.79) and 2.00 (95% CI: 1.74, 2.29). CONCLUSIONS Accessing free prescription drug samples is prevalent among many categories of beneficiaries, especially among individuals with cost-related medication nonadherence and poor health status. Policies restricting or prohibiting drug sample distribution may adversely impact access to medications among patients in high-risk groups.
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Affiliation(s)
- Jennifer Tjia
- Meyers Primary Care Institute, Fallon Clinic Foundation, Worcester, MA, USA.
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168
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Polli JE. In vitro studies are sometimes better than conventional human pharmacokinetic in vivo studies in assessing bioequivalence of immediate-release solid oral dosage forms. AAPS J 2008; 10:289-99. [PMID: 18500564 PMCID: PMC2751377 DOI: 10.1208/s12248-008-9027-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 03/12/2008] [Indexed: 11/30/2022] Open
Abstract
Human pharmacokinetic in vivo studies are often presumed to serve as the "gold standard" to assess product bioequivalence (BE) of immediate-release (IR) solid oral dosage forms. However, when this general assumption is re-visited, it appears that in vitro studies are sometimes better than in vivo studies in assessing BE of IR solid oral dosage forms. Reasons for in vitro studies to sometimes serve as the better method are that in vitro studies: (a) reduce costs, (b) more directly assess product performance, and (c) offer benefits in terms of ethical considerations. Reduced costs are achieved through avoiding in vivo studies where BE is self-evident, where biopharmaceutic data anticipates BE, and where in vivo BE study type II error is high. In vitro studies more directly assess product performance than do conventional human pharmacokinetic BE studies, since in vitro studies focus on comparative drug absorption from the two products, while in vivo BE testing can suffer from complications due to its indirect approach. Regarding ethical considerations, in vitro studies better embrace the principle "No unnecessary human testing should be performed" and can result in faster development. Situations when in vitro test should be viewed as preferred include Class I drugs with rapid dissolution, Class III drugs with very rapid dissolution, and highly variable drugs with rapid dissolution and that are not bio(equivalence)problem drugs. Sponsors of potential in vivo human pharmacokinetic BE testing should be required to justify why in vitro data is insufficient, similar to proposed animal testing requires justification to not employ an in vitro approach.
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Affiliation(s)
- James E Polli
- Univerisity of Maryland School of Pharmacy, Baltimore, MD, 21201, USA.
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169
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Kliethermes MA, Schullo-Feulner AM, Tilton J, Kim S, Pellegrino AN. Model for medication therapy management in a university clinic. Am J Health Syst Pharm 2008; 65:844-56. [PMID: 18436731 DOI: 10.2146/ajhp070338] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Experience with a referral-based medication therapy management (MTM) clinic in a university medical center is described. SUMMARY The MTM clinic's mission is to assist patients who take multiple medications due to multiple chronic conditions with the management of their drug therapy to improve or maintain their health and prevent or minimize drug-related problems. The clinical services provided at the clinic have evolved into a comprehensive program providing five distinct service areas: access, adherence, coordination of care, medication therapy review, and education. During initial visits, patient information is collected, patients are interviewed, medications are reconciled, and the pharmacist identifies and attempts to solve any immediate drug-related problems and concerns. Routine visits are scheduled monthly to coincide with a patient's medication refills. On a typical day, a minimum of two MTM pharmacists and one pharmacy technician staff the clinic. On two days of the week, three MTM pharmacists are available in the clinic. The clinic averages 9-13 scheduled patient visits per day. The MTM clinic functions as a subset of the outpatient pharmacy and is merged financially in the general operational budget of the ambulatory care pharmacy. This model of MTM patient care is intensive and comprehensive and is significantly different from the majority of MTM models currently provided by Medicare Part D plans. CONCLUSION A referral-based MTM clinic managed by pharmacists at a university medical center outpatient pharmacy provides care to patients with the goal of improving medication access, medication adherence, continuity of care, medication therapy management, and patient education.
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Affiliation(s)
- Mary Ann Kliethermes
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL 60515, USA.
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170
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Khan N, Kaestner R, Lin SJ. Effect of prescription drug coverage on health of the elderly. Health Serv Res 2008; 43:1576-97. [PMID: 18479405 DOI: 10.1111/j.1475-6773.2008.00859.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To estimate the effect of prescription drug insurance on health, as measured by self-reported poor health status, functional disability, and hospitalization among the elderly. DATA Analyses are based on a nationally representative sample of noninstitutionalized elderly (≥65 years of age) from the Medicare Current Beneficiary Survey (MCBS) for years 1992-2000. STUDY DESIGN Estimates are obtained using multivariable regression models that control for observed characteristics and unmeasured person-specific effects (i.e., fixed effects). PRINCIPAL FINDINGS In general, prescription drug insurance was not associated with significant changes in self-reported health, functional disability, and hospitalization. The lone exception was for prescription drug coverage obtained through a Medicare HMO. In this case, prescription drug insurance decreased functional disability slightly. Among those elderly with chronic illness and older (71 years or more) elderly, prescription drug insurance was associated with slightly improved functional disability. CONCLUSIONS Findings suggest that prescription drug coverage had little effect on health or hospitalization for the general population of elderly, but may have some health benefits for chronically ill or older elderly.
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Affiliation(s)
- Nasreen Khan
- College of Pharmacy, MSC09 53601 University of New Mexico, Albuquerque, NM 87131, USA
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171
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Cardarelli R, Weis S, Adams E, Radaford D, Vecino I, Munguia G, Johnson KL, Fulda KG. General health status and adherence to antiretroviral therapy. ACTA ACUST UNITED AC 2008; 7:123-9. [PMID: 18441253 DOI: 10.1177/1545109708318526] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Highly active antiretroviral therapy (HAART) adherence is crucial in lowering HIV/AIDS-related mortality. General health status is known to predict mortality, but no study has assessed its association with HAART adherence. A total of 103 whites, African Americans, and Hispanic/Latinos with HIV/AIDS underwent an interview using validated measures. Regression analyses assessed the relationship between general health status and HAART adherence while controlling for social support, sense of control, depression, stress, HIV stigma, substance abuse, and unfair treatment because of race. Those rating their general health as fair/poor were 4 times more likely to be nonadherent (odds ratio [OR], 4.34; 95% confidence interval [CI], 1.19-15.79). This association dramatically strengthened in the multivariate regression model (OR, 10.96; 95% CI, 1.46-82.36) after controlling for the covariates. CONCLUSION General health status was the strongest predictor of HAART nonadherence, and future research is needed to assess whether this 1-question general health measure can be clinically used to influence adherence.
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Affiliation(s)
- Roberto Cardarelli
- Primary Care Research Institute, University of North Texas Health Science Center, Fort Worth, USA.
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172
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Madden JM, Graves AJ, Zhang F, Adams AS, Briesacher BA, Ross-Degnan D, Gurwitz JH, Pierre-Jacques M, Safran DG, Adler GS, Soumerai SB. Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D. JAMA 2008; 299:1922-8. [PMID: 18430911 PMCID: PMC3781951 DOI: 10.1001/jama.299.16.1922] [Citation(s) in RCA: 198] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Cost-related medication nonadherence (CRN) has been a persistent problem for individuals who are elderly and disabled in the United States. The impact of Medicare prescription drug coverage (Part D) on CRN is unknown. OBJECTIVE To estimate changes in CRN and forgoing basic needs to pay for drugs following Part D implementation. DESIGN, SETTING, AND PARTICIPANTS In a population-level study design, changes in study outcomes between 2005 and 2006 before and after Medicare Part D implementation were compared with historical changes between 2004 and 2005. The community-dwelling sample of the nationally representative Medicare Current Beneficiary Survey (unweighted unique n = 24,234; response rate, 72.3%) was used, and logistic regression analyses were controlled for demographic characteristics, health status, and historical trends. MAIN OUTCOME MEASURES Self-reports of CRN (skipping or reducing doses, not obtaining prescriptions) and spending less on basic needs to afford medicines. RESULTS The unadjusted, weighted prevalence of CRN was 15.2% in 2004, 14.1% in 2005, and 11.5% after Part D implementation in 2006. The prevalence of spending less on basic needs was 10.6% in 2004, 11.1% in 2005, and 7.6% in 2006. Adjusted analyses comparing 2006 with 2005 and controlling for historical changes (2005 vs 2004) demonstrated significant decreases in the odds of CRN (ratio of odds ratios [ORs], 0.85; 95% confidence interval [CI], 0.74-0.98; P = .03) and spending less on basic needs (ratio of ORs, 0.59; 95% CI, 0.48-0.72; P < .001). No significant changes in CRN were observed among beneficiaries with fair to poor health (ratio of ORs, 1.00; 95% CI, 0.82-1.21; P = .97), despite high baseline CRN prevalence for this group (22.2% in 2005) and significant decreases among beneficiaries with good to excellent health (ratio of ORs, 0.77; 95% CI, 0.63-0.95; P = .02). However, significant reductions in spending less on basic needs were observed in both groups (fair to poor health: ratio of ORs, 0.60; 95% CI, 0.47-0.75; P < .001; and good to excellent health: ratio of ORs, 0.57; 95% CI, 0.44-0.75; P < .001). CONCLUSIONS In this survey population, there was evidence for a small but significant overall decrease in CRN and forgoing basic needs following Part D implementation. However, no net decrease in CRN after Part D was observed among the sickest beneficiaries, who continued to experience higher rates of CRN.
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Affiliation(s)
- Jeanne M Madden
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Ave, 6th Floor, Boston, Massachusetts 02215, USA.
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173
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174
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Simoni-Wastila L, Zuckerman IH, Shaffer T, Blanchette CM, Stuart B. Drug use patterns in severely mentally ill Medicare beneficiaries: impact of discontinuities in drug coverage. Health Serv Res 2008; 43:496-514. [PMID: 18370965 PMCID: PMC2442367 DOI: 10.1111/j.1475-6773.2007.00779.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the extent of drug coverage among severely mentally ill Medicare beneficiaries and to determine whether and to what extent discontinuities in prescription drug coverage influence the use of medications used to treat serious mental health conditions. DATA SOURCE 1997-2001 Medicare Current Beneficiary Surveys. STUDY DESIGN We use a zero-inflated negative binomial model to estimate: (1) the probability of not receiving any mental health drug and (2) the number of medications received, adjusting for age, race, income, census region, health status, and comorbidity. Severe mental illness is defined using inpatient and outpatient claims with ICD-9 codes of schizophrenia, other psychotic disorders, bipolar disorders, and major depression. Mental health medications include antidepressants, antipsychotics, mood stabilizers, anxiolytic/sedative-hypnotics, and stimulants. Prescription drug coverage is assessed as full coverage (0 percent discontinuities), no coverage (100 percent discontinuities), or as discontinuous coverage, measured as 1-25, 26-50, and 51-99 percent of time without coverage. DATA COLLECTION/EXTRACTION METHODS We constructed three 3-year longitudinal cohorts of severely mentally ill Medicare beneficiaries residing in the community (n=901). PRINCIPAL FINDINGS Severely mentally ill Medicare beneficiaries with drug coverage discontinuities are more likely than their continuously insured peers not to receive medications used to treat mental health disorders, with the most significant impact seen in the probability of receiving any psychiatric medications. Analysis of two therapeutic classes-antidepressants and antipsychotics-revealed varying impacts of drug gaps on both probability of any drug use, as well as number of medications received among users. CONCLUSIONS Severely mentally ill Medicare beneficiaries may be particularly vulnerable to the Medicare Part D drug benefit design and, as such, warrant close evaluation and monitoring to insure adequate access to and utilization of medications used to manage mental illness.
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Affiliation(s)
- Linda Simoni-Wastila
- Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore School of Pharmacy, 220 Arch Street, 12th Floor, Baltimore, MD 21201, USA
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175
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Demers V, Melo M, Jackevicius C, Cox J, Kalavrouziotis D, Rinfret S, Humphries KH, Johansen H, Tu JV, Pilote L. Comparison of provincial prescription drug plans and the impact on patients' annual drug expenditures. CMAJ 2008; 178:405-9. [PMID: 18268266 DOI: 10.1503/cmaj.070587] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Reimbursement for outpatient prescription drugs is not mandated by the Canada Health Act or any other federal legislation. Provincial governments independently establish reimbursement plans. We sought to describe variations in publicly funded provincial drug plans across Canada and to examine the impact of this variation on patients' annual expenditures. METHODS We collected information, accurate to December 2006, about publicly funded prescription drug plans from all 10 Canadian provinces. Using clinical scenarios, we calculated the impact of provincial cost-sharing strategies on individual annual drug expenditures for 3 categories of patients with different levels of income and 2 levels of annual prescription burden ($260 and $1000). RESULTS We found that eligibility criteria and cost-sharing details of the publicly funded prescription drug plans differed markedly across Canada, as did the personal financial burden due to prescription drug costs. Seniors pay 35% or less of their prescription costs in 2 provinces, but elsewhere they may pay as much as 100%. With few exceptions, nonseniors pay more than 35% of their prescription costs in every province. Most social assistance recipients pay 35% or less of their prescription costs in 5 provinces and pay no costs in the other 5. In an example of a patient with congestive heart failure, his out-of-pocket costs for a prescription burden of $1283 varied between $74 and $1332 across the provinces. INTERPRETATION Considerable interprovincial variation in publicly funded prescription drug plans results in substantial variation in annual expenditures by Canadians with identical prescription burdens. A revised pharmaceutical strategy might reduce these major inequities.
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Affiliation(s)
- Virginie Demers
- Division of General Internal Medicine, McGill University Health Centre, Montréal, Que
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176
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Tseng CW, Tierney EF, Gerzoff RB, Dudley RA, Waitzfelder B, Ackermann RT, Karter AJ, Piette J, Crosson JC, Ngo-Metzger Q, Chung R, Mangione CM. Race/ethnicity and economic differences in cost-related medication underuse among insured adults with diabetes: the Translating Research Into Action for Diabetes Study. Diabetes Care 2008; 31:261-6. [PMID: 18000177 DOI: 10.2337/dc07-1341] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine racial/ethnic and economic variation in cost-related medication underuse among insured adults with diabetes. RESEARCH DESIGN AND METHODS We surveyed 5,086 participants from the multicenter Translating Research Into Action for Diabetes Study. Respondents reported whether they used less medication because of cost in the past 12 months. We examined unadjusted and adjusted rates of cost-related medication underuse, using hierarchical regression, to determine whether race/ethnicity differences still existed after accounting for economic, health, and other demographic variables. RESULTS Participants were 48% white, 14% African American, 14% Latino, 15% Asian/Pacific Islander, and 8% other. Overall, 14% reported cost-related medication underuse. Unadjusted rates were highest for Latinos (23%) and African Americans (17%) compared with whites (13%), Asian/Pacific Islanders (11%), and others (15%). In multivariate analyses, race/ethnicity significantly predicted cost-related medication underuse (P = 0.048). However, adjusted rates were only slightly higher for Latinos (14%) than whites (10%) (P = 0.026) and were not significantly different for African Americans (11%), Asian/Pacific Islanders (7%), and others (11%). Income and out-of-pocket drug costs showed the greatest differences in adjusted rates of cost-related medication underuse (15 vs. 5% for participants with income <or=$25,000 vs. >$50,000 and 24 vs. 7% for participants with out-of-pocket costs >$150 per month vs. <or=$50 per month. CONCLUSIONS One in seven participants reported cost-related medication underuse. Rates were highest among African Americans and Latinos but were related to lower incomes and higher out-of-pocket drug costs in these groups. Interventions to decrease racial/ethnic disparities in cost-related medication underuse should focus on decreasing financial barriers to medications.
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Affiliation(s)
- Chien-Wen Tseng
- Pacific Health Research Institute, 846 S Hotel St., #303, Honolulu, HI 96813, USA.
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177
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O'Connor AB, Noyes K, Holloway RG. A cost-utility comparison of four first-line medications in painful diabetic neuropathy. PHARMACOECONOMICS 2008; 26:1045-1064. [PMID: 19014205 DOI: 10.2165/0019053-200826120-00007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Painful diabetic neuropathy is common and adversely affects patients' quality of life and function. Several treatment options exist, but their relative efficacy and value are unknown. OBJECTIVE To determine the relative efficacy, costs and cost effectiveness of the first-line treatment options for painful diabetic neuropathy. METHODS Published and unpublished clinical trial and cross-sectional data were incorporated into a decision analytic model to estimate the net health and cost consequences of treatment for painful diabetic peripheral neuropathy over 3-month (base case), 1-month and 6-month timeframes. Efficacy was measured in QALYs, and costs were measured in $US, year 2006 values, using a US third-party payer perspective. The patients included in the model were outpatients with moderate to severe pain associated with diabetic peripheral neuropathy and no contraindications to treatment with tricyclic antidepressants. Four medications were compared: desipramine 100 mg/day, gabapentin 2400 mg/day, pregabalin 300 mg/day and duloxetine 60 mg/day. RESULTS Desipramine and duloxetine were both more effective and less expensive than gabapentin and pregabalin in the base-case analysis and through a wide range of sensitivity analyses. Duloxetine offered borderline value compared with desipramine in the base case ($US47,700 per QALY), but not when incorporating baseline-observation-carried-forward analyses of the clinical trial data ($US867,000 per QALY). The results were also sensitive to the probability of obtaining pain relief with duloxetine. CONCLUSIONS Desipramine (100 mg/day) and duloxetine (60 mg/day) appear to be more cost effective than gabapentin or pregabalin for treating painful diabetic neuropathy. The estimated value of duloxetine relative to desipramine depends on the assumptions made in the statistical analyses of clinical trial data.
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Affiliation(s)
- Alec B O'Connor
- Department of Medicine, University of Rochester School of Medicine and Dentistry, University of Rochester, Rochester, New York 14642, USA.
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178
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Krumholz HM, Masoudi FA. The year in epidemiology, health services research, and outcomes research. J Am Coll Cardiol 2007; 50:2254-62. [PMID: 18061075 DOI: 10.1016/j.jacc.2007.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 08/27/2007] [Accepted: 08/27/2007] [Indexed: 12/31/2022]
Affiliation(s)
- Harlan M Krumholz
- Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, New Haven, Connecticut 06520-8088, USA.
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179
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Abstract
Many argue that high costs of pharmaceutical research and development leads to high drug-prices and that existing prices are necessary to fund future expenditures on research and development. However, high pharmaceutical-prices can limit patient access to life-saving therapeutics. This paper examines the impact of high prices on patients and the relation between prices and innovation, and finally, considers policies that may balance patients' access to medications and financial rewards to industry.
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Affiliation(s)
- Salomeh Keyhani
- Mount Sinai School of Medicine, Department of Health Policy, Box 1077, One Gustave L. Levy Place, NY 10029, New York, USA
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180
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Gellad WF, Haas JS, Safran DG. Race/ethnicity and nonadherence to prescription medications among seniors: results of a national study. J Gen Intern Med 2007; 22:1572-8. [PMID: 17882499 PMCID: PMC2219813 DOI: 10.1007/s11606-007-0385-z] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Revised: 08/20/2007] [Accepted: 09/07/2007] [Indexed: 12/29/2022]
Abstract
BACKGROUND Nonadherence to prescription drugs results in poorer control of chronic health conditions. Because of significant racial/ethnic disparities in the control of many chronic diseases, differences in the rates of and reasons for medication nonadherence should be studied. OBJECTIVES 1) To determine whether rates of and reasons for medication nonadherence vary by race/ethnicity among seniors; and 2) to evaluate whether any association between race/ethnicity and nonadherence is moderated by prescription coverage and income. DESIGN/SETTING Cross-sectional national survey, 2003. PATIENTS Medicare beneficiaries > or = 65 years of age, who reported their race/ethnicity as white, black, or Hispanic, and who reported taking at least 1 medication (n = 14,829). MAIN OUTCOME MEASURES Self-reported nonadherence (caused by cost, self-assessed need, or experiences/side effects) during the last 12 months. RESULTS Blacks and Hispanics were more likely than whites to report cost-related nonadherence (35.1%, 36.5%, and 26.7%, respectively, p < .001). There were no racial/ethnic differences in nonadherence caused by experiences or self-assessed need. In analyses controlling for age, gender, number of chronic conditions and medications, education, and presence and type of prescription drug coverage, blacks (odds ratio [OR] 1.38; 95% confidence interval [CI] 1.08-1.78) and Hispanics (1.35; 1.02-1.78) remained more likely to report cost-related nonadherence compared to whites. When income was added to the model, the relationship between cost-related nonadherence and race/ethnicity was no longer statistically significant (p = .12). CONCLUSIONS Racial/ethnic disparities in medication nonadherence exist among seniors, and are related to cost concerns, and not to differences in experiences or self-assessed need. Considering the importance of medication adherence in controlling chronic diseases, affordability of prescriptions should be explicitly addressed to reduce racial/ethnic disparities.
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Affiliation(s)
- Walid F. Gellad
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | - Jennifer S. Haas
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
- Division of General Medicine and Primary Care, Brigham andWomen’s Hospital, 1620 Tremont Street, Boston, MA 02120-1613 USA
| | - Dana Gelb Safran
- The Health Institute, Tufts-New England Medical Center and Department of Medicine, Tufts University School of Medicine, Boston, MA USA
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181
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Zarowitz BJ. Fixed-Dose Combinations for Improving Medication Adherence in Assisted Living Environments. Geriatr Nurs 2007; 28:341-5. [DOI: 10.1016/j.gerinurse.2007.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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182
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Frishman WH. Importance of medication adherence in cardiovascular disease and the value of once-daily treatment regimens. Cardiol Rev 2007; 15:257-63. [PMID: 17700384 DOI: 10.1097/crd.0b013e3180cabbe7] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An estimated 71 million individuals in the United States are currently diagnosed with cardiovascular disease (CVD). If untreated, CVD conditions such as systemic hypertension, coronary artery disease, and heart failure will have potentially serious and often fatal outcomes. Numerous clinical trials have established a variety of evidence-based medications that are efficacious in the treatment of CVD. These drugs will be ineffective, however, if patients have trouble adhering to their prescribed regimens. In patients with hypertension or heart failure, or in those who have suffered a myocardial infarction, poor adherence to therapies has been linked to a variety of problems, including poor blood pressure control, rehospitalization, and increased healthcare resource utilization. Both the asymptomatic nature of some forms of CVD and the high pill burden associated with certain therapies have been linked to poor adherence. Reducing pill burden through the use of once-daily formulations has proven valuable in improving adherence to evidence-based therapies. This review will discuss the impact of adherence to prescribed therapies for CVD, outline common barriers to adherence, and demonstrate the value of once-daily dosing regimens for improved patient adherence.
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Affiliation(s)
- William H Frishman
- Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York 10595, USA.
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183
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Abstract
BACKGROUND Clinical management of two key modifiable risk factors for cardiovascular disease (CVD), hypertension and dyslipidemia, has evolved considerably over the past 40 years, in terms of the focus of therapy, available pharmacologic agents, and therapeutic targets. MATERIALS AND METHODS A brief review of the epidemiology of hypertension and hyperlipidemia and of controlled clinical trials of pharmacologic therapy of these conditions in decreasing cardiovascular events is presented. RESULTS Risk factors for CVD generally do not occur in isolation, and the co-occurrence of hypertension and dyslipidemia, with or without other additional risk factors, greatly increases the risk of CVD. Clinical trials performed in the last 40 years have demonstrated the clinical benefit of treating hypertension and dyslipidemia. Recent trials have shown that intensive, early management of these risk factors provide the greatest clinical benefits. Emerging evidence suggests that lipid management provides clinical benefit in patients at high risk of CVD, regardless of their baseline cholesterol levels, and that lipid-lowering with statin therapy provides additional benefits over antihypertensive therapy alone in high-risk patients with hypertension. It has become evident that the most effective means of reducing CVD risk is the simultaneous management of all modifiable risk factors. Treatment of an individual risk factor can reduce CVD events by approximately 30%, whereas treatment of multiple risk factors can reduce the risk of CVD by more than 50%. However, a large number of patients are not treated or receive suboptimal treatment. CONCLUSIONS Overwhelming controlled clinical trial evidence supports the clinical benefit of treating hypertension and hypercholesterolemia. Fixed-dose combination medications for hypertension, and integrative combination therapies containing antihypertensive and lipid-lowering medications in a single pill contribute to better risk factor management with the potential for greater adherence and improved clinical outcomes.
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Affiliation(s)
- John B Kostis
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, Clinical Academic Building, Suite 5200, 125 Paterson Street, New Brunswick, NJ 08903-0019, USA.
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184
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Briesacher BA, Gurwitz JH, Soumerai SB. Patients at-risk for cost-related medication nonadherence: a review of the literature. J Gen Intern Med 2007; 22:864-71. [PMID: 17410403 PMCID: PMC2219866 DOI: 10.1007/s11606-007-0180-x] [Citation(s) in RCA: 258] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 01/05/2007] [Accepted: 03/06/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs. DESIGN We conducted searches of four databases (MEDLINE, CINAHL, Sciences Citations Index Expanded, and EconLit) from 2001 to 2006 for English-language original studies. Articles were selected if the study included an explicit measure of CRN and reported results on covarying characteristics. MAIN RESULTS We found 19 studies with empirical support for concluding that certain patients may be susceptible to CRN: research has established consistent links between medication nonadherence due to costs and financial burden, but also to symptoms of depression and heavy disease burden. Only a handful of studies with limited statistical methods provided evidence on whether patients understand the health risks of CRN or to what extent clinicians influence patients to keep taking medications when faced with cost pressures. No relationship emerged between CRN and polypharmacy. CONCLUSION Efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage. Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare's new drug benefit.
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Affiliation(s)
- Becky A Briesacher
- Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Biotech Four, Suite 315, 377 Plantation Street, Worcester, MA 01605, USA.
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185
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Abstract
Non-adherence with medical regimens in heart failure is a significant challenge and serves as a major reason that favorable outcomes associated with various therapies evaluated in clinical trials have not translated to the so-called real-world setting. Non-adherence has complex influences and is clearly associated with poorer outcomes. The approaches that are used or have been proposed to improve drug-taking behavior, such as in-hospital initiation of therapy, simplification of dosing regimens through adoption of combination and long-acting formulations, and improvements in provider-patient communication, are reviewed.
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Affiliation(s)
- Paul J Hauptman
- Division of Cardiology, Saint Louis University School of Medicine, St. Louis, Missouri, USA.
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186
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Abstract
PURPOSE OF REVIEW Pharmacoeconomic evaluations are increasingly important in all aspects of medicine. In rheumatology, such studies have become all the more relevant following the introduction of highly effective biologic agents. Brought to the clinic initially for the treatment of rheumatoid arthritis, biologic agents have found expanded indication in other rheumatic diseases. RECENT FINDINGS Building upon a long tradition in rheumatology, recent studies have updated and expanded upon the costs of various rheumatic diseases. These studies set the stage for determining the value of newer therapies. As a result of the chronic nature of rheumatic diseases, pharmacoeconomic evaluations must be carried out over sufficiently long time frames. Therefore, methodologic issues continue to be an area of ongoing discussion. Finally, ongoing studies have estimated the cost-effectiveness of novel rheumatologic therapies, in particular the inhibitors of tumor necrosis factor. These studies have shown that in several clinical circumstances, tumor necrosis factor inhibitors can indeed have an incremental cost-efficacy within the range of generally accepted medical interventions. While many of these studies focused on rheumatoid arthritis, there is growing interest in pharmacoeconomic evaluations in other rheumatic diseases. SUMMARY Pharmacoeconomic evaluations are crucial to the optimal use of new therapies in rheumatology.
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Affiliation(s)
- Arthur Kavanaugh
- Center for Innovative Therapy, Division of Rheumatology, Allergy, and Immunology, University of California San Diego, La Jolla, CA 92093-0943, USA.
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Aspinall S, Sevick MA, Donohue J, Maher R, Hanlon JT. Medication errors in older adults: A review of recent publications. ACTA ACUST UNITED AC 2007; 5:75-84. [PMID: 17608250 DOI: 10.1016/j.amjopharm.2007.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This paper reviews recent articles examining medication errors in the elderly. METHODS MEDLINE and International Pharmaceutical Abstracts were searched for articles published in 2006 using a combination of the terms medication errors, medication adherence, medication compliance, suboptimal prescribing, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Those studies that described new measures of medication errors or had a randomized controlled design, evaluated the impact of an intervention on > or =1 measure of medication errors, and involved the community-dwelling elderly were included in the review. RESULTS The search identified 5 studies and a new set of explicit criteria for prescribing problems in nursing homes from the Centers for Medicare and Medicaid Services (CMS). One of the studies found a new instrument, the Medication Management Instrument for Deficiencies in the Elderly, to be a reliable and valid measure of medication management in older adults. A study in the ambulatory elderly found that 13.0% reported cost-related medication nonadherence. A randomized controlled trial of a pharmacist intervention in elderly patients at high risk for coronary events found the intervention was associated with improvements in both medication adherence and systolic blood pressure control. The report from the CMS described new explicit criteria for unnecessary drug use in elderly patients in long-term care facilities, including drugs to avoid, drugs that should be limited in dose or duration, drugs to be monitored, and drug-drug interactions. A modified Delphi survey of an expert panel reached consensus on 28 drug-disease interactions in older adults. Finally, a randomized controlled trial of computerized feedback in a health maintenance organization found improvements in inappropriate prescribing of target drugs in older adults. CONCLUSION Data from recently published studies may provide guidance to practitioners and help direct future research.
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Affiliation(s)
- Sherrie Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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