Association between medication supplies and healthcare costs in older adults from an urban healthcare system

Generic Drug Usage in Dentistry across Japan: Analysis Using a Japanese National Database

The aim of this study was to identify regional disparities in generic drug usage and to examine related factors. The database used for the analysis was the 2018 national health insurance claims data published on the Japanese Ministry of Health, Labour, and Welfare. The drugs that were targeted were a combination of brand-name and generic tetracycline ointments for periodontal treatment and lidocaine injection solution used for dental anesthesia. The usage of generic drugs was calculated and compared by prefecture based on the number of health insurance claims. The comparison of related factors was conducted using data from other national statistical survey. The results showed that the mean generic drug usage of tetracycline for periodontal treatment in all prefectures was 71.2 ± 8.1%, ranging from 45.8% to 85.3%. The mean generic lidocaine used for dental anesthesia was 47.6 ± 10.0%, ranging from 30.5% to 66.2%. The rank correlation coefficient between the two was 0.359 (p < 0.05), and the tendency of using both generic drugs was low in major metropolitan areas. Generic drug usage in Japan is low; thus, in order to reduce healthcare costs, generic drugs need to be actively used in dentistry.

Oral antidiabetic medication adherence and glycaemic control among patients with type 2 diabetes mellitus: a cross-sectional retrospective study in a tertiary hospital in Saudi Arabia

OBJECTIVES

The purpose of this study is to measure the adherence rates of oral antidiabetic drugs (OADs) in patients with type 2 diabetes mellitus (T2DM) and assess the relationship of glycaemic control and adherence to OADs after controlling for other associated factors.

DESIGN

Cross-sectional retrospective study.

SETTING

Large tertiary hospital in the central region of Saudi Arabia.

PARTICIPANTS

5457patients aged 18 years and older diagnosed with T2DM during the period from 1 January 2016 to 31 December 2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

The modified medication possession ratio (mMPR) was calculated as a proxy measure for adherence of OADs. The factors associated with OADs non-adherence and medication oversupply were assessed using multinomial logistic regression models. The secondary outcomes were to measure the association between OADs adherence and glycaemic control.

RESULTS

Majority of patients with T2DM were females (n=3400, 62.3%). The average glycated haemoglobin was 8.2±1.67. Among the study population, 48.6% had good adherence (mMPR >0.8) and 8.6% had a medication oversupply (mMPR >1.2). Good adherence was highest among those using repaglinide (71.0%) followed by pioglitazone (65.0%) and sitagliptin (59.0%). In the multivariate analysis, women with T2DM were more likely to have poor adherence (adjusted OR (AOR)=0.76, 95% CI=0.67, 0.86) compared with men. Also, medication oversupply was more likely among patients with hyperpolypharmacy (AOR=1.88, 95% CI=1.36, 2.63), comorbid osteoarthritis (AOR=1.72, 95% CI=1.20, 02.45) and non-Saudi patients (AOR=1.53, 95% CI=1.16, 2.01). However, no association was found between glycaemic control and adherence to OADs.

CONCLUSION

The study findings support the growing concern of non-adherence to OADs among patients with T2DM in Saudi Arabia. Decision makers have to invest in behavioural interventions that will boost medication adherence rates. This is particularly important in patients with polypharmacy and high burden of comorbid conditions.

Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia

OBJECTIVE

To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia.

DATA SOURCES/STUDY SETTING

National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension.

STUDY DESIGN

We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives.

DATA COLLECTION/EXTRACTION METHODS

Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply.

PRINCIPAL FINDINGS

Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes.

CONCLUSIONS

Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.

Adherence trajectories of buprenorphine therapy among pregnant women in a large state Medicaid program in the United States

PURPOSE

Little is known about the longitudinal patterns of buprenorphine adherence among pregnant women with opioid use disorder, especially when late initiation, nonadherence, or early discontinuation of buprenorphine during pregnancy may increase the risk of adverse outcomes. We aimed to identify distinct trajectories of buprenorphine use during pregnancy, and factors associated with these trajectories in Medicaid-enrolled pregnant women.

METHODS

A retrospective cohort study included 2361 Pennsylvania Medicaid enrollees aged 15 to 46 having buprenorphine therapy during pregnancy and a live birth between 2008 and 2015. We used group-based trajectory models to identify buprenorphine use patterns in the 40 weeks prior to delivery and 12 weeks postdelivery. Multivariable multinomial logistic regression models were used to identify factors associated with specific trajectories.

RESULTS

Six distinct trajectories were identified. Four groups initiated buprenorphine during the first trimester of the pregnancy (early initiators): 31.6% with persistently high adherence, 15.1% with moderate-to-high adherence, 10.5% with declining adherence, and 16.7% with early discontinuation. Two groups did not initiate buprenorphine until midsecond or third trimester (late initiators): 13.5% had moderate-to-high adherence and 12.6% had low-to-moderate adherence. Factors significantly associated with late initiation and discontinuation were younger age, non-white race, residents of rural counties, fewer outpatient visits, more frequent emergency department visits and hospitalizations, and lower buprenorphine daily dose.

CONCLUSIONS

Six buprenorphine treatment trajectories during pregnancy were identified in this population-based Medicaid cohort, with 25% of women initiating buprenorphine late during pregnancy. Understanding trajectories of buprenorphine use and factors associated with discontinuation/nonadherence may guide integration of behavioral treatment with obstetrical/gynecological care to improve buprenorphine treatment during pregnancy.

Eye Drop Dispenser Type and Medication Possession Ratio in Patients With Glaucoma: Single-Use Containers Versus Multiple-Use Bottles

PURPOSE

To determine whether the consumption of topical glaucoma medication is influenced by the type of eye drop dispenser.

DESIGN

Retrospective cohort study.

METHODS

We examined 366 patients with open-angle glaucoma or ocular hypertension who were bilaterally treated with 0.0015% tafluprost or 2% dorzolamide/0.5% timolol fixed combination (DTFC). The patients were grouped by the type of dispenser and content of eye drops used: (1) tafluprost in bottles (T-Bottle group); (2) tafluprost in unit-dose pipettes (T-Unit group); (3) DTFC in bottles (C-Bottle group); and (4) DTFC in unit-dose pipettes (C-Unit group). We evaluated the medication possession ratio (MPR) among groups, and factors associated with over-consumption (MPR > 1.2) or under-consumption (MPR < 0.8) in multinomial logistic regression.

RESULTS

The mean MPR was 1.49 (range, 0.69-2.91) in the T-Bottle group, 0.91 (range, 0.32-1.27) in the T-Unit group, 1.25 (range, 0.51-2.60) in the C-Bottle group, and 0.96 (range, 0.36-1.60) in the C-Unit group. The Bottle groups demonstrated higher mean values and wider ranges of MPR compared to the Unit groups. The MPR interval at which the largest number of patients were found was 1.0-1.4 in the Bottle groups and 0.8-1.2 in the Unit groups. Bottle-type dispenser (odds ratio [OR] 64.02), tafluprost medication (OR 2.84), and older age (OR 1.03) were associated with over-consumption, whereas no factor was correlated with under-consumption.

CONCLUSIONS

The type of eye drop dispenser affects the consumption of glaucoma medication. Physicians should consider the type of eye drop dispenser when assessing glaucoma medication adherence.

Evaluation of the chronic disease management program for appropriateness of medication adherence and persistence in hypertension and type-2 diabetes patients in Korea

The chronic disease management program (CDMP), a multilevel intervention including copayment reduction and physician incentives, was introduced in 2012 in Korea to improve blood pressure and glycemic control by strengthening the function of clinic as primary care institutions in managing hypertension and diabetes. This study, therefore, aimed to evaluate the effect of CDMP on the appropriateness of medication adherence and persistence in hypertension or type-2 diabetes patients.A pre-post retrospective study was conducted using claims cohort data from 2010 to 2013. Hypertension or type-2 diabetes patients were selected as the CDMP group, while dyslipidemia patients were the control group. Study groups were further categorized as clinic shifters or non-shifters on the basis of whether hospital use changed to clinic use during the study period. Pre-post changes in adherence and persistence were assessed. Adherence was measured by medication possession ratio (MPR) and categorized as under (<0.8), appropriate (0.8-1.1), and over-adherence (>1.1). Persistence was measured by 12-month cumulative persistence rate.The pre-post change was significantly improved for appropriate-adherence (hypertension, +6.0%p; diabetes, +6.1%p), 12-month cumulative persistence (hypertension, +6.5%p; diabetes, +10.8%p), and over-adherence (hypertension, -5.3%p; diabetes, -2.8%p) only among the shifters in the CDMP group. Among these, patients visiting the same, single clinic showed a significant increase in appropriate-adherence, whereas those who changed their clinics showed a nonsignificant increase. No significant improvement was verified among the non-shifters in the CDMP group.CDMP improved medication adherence and persistence by significantly increasing appropriate-adherence and 12-month cumulative persistence rate in hypertension and type-2 diabetes patients. Particularly, CDMP significantly improved over-adherence, which was associated with increasing healthcare costs and hospitalization risk.

Association between trajectories of buprenorphine treatment and emergency department and in-patient utilization

BACKGROUND AND AIMS

Uncertainty about optimal treatment duration for buprenorphine opioid agonist therapy may lead to substantial variation in provider and payer decision-making regarding treatment course. We aimed to identify distinct trajectories of buprenorphine use and examine outcomes associated with these trajectories to guide health system interventions regarding treatment length.

DESIGN

Retrospective cohort study.

SETTING

US Pennsylvania Medicaid.

PATIENTS

A total of 10 945 enrollees aged 18-64 years initiating buprenorphine treatment between 2007 and 2012.

MEASUREMENTS

Group-based trajectory models were used to identify trajectories based on monthly proportion of days covered with buprenorphine in the 12 months post-treatment initiation. We used separate multivariable Cox proportional hazard models to examine associations between trajectories and time to first all-cause hospitalization and emergency department (ED) visit within 12 months after the first-year treatment.

FINDINGS

Six trajectories [Bayesian information criterion (BIC) = -86 246.70] were identified: 24.9% discontinued buprenorphine < 3 months, 18.7% discontinued between 3 and 5 months, 12.4% discontinued between 5 and 8 months, 13.3% discontinued > 8 months, 9.5% refilled intermittently and 21.2% refilled persistently for 12 months. Persistent refill trajectories were associated with an 18% lower risk of all-cause hospitalizations [hazard ratio (HR) = 0.82, 95% confidence interval (CI) = 0.70-0.95] and 14% lower risk of ED visits (HR = 0.86, 95% CI = 0.78-0.95) in the subsequent year, compared with those discontinuing between 3 and 5 months.

CONCLUSIONS

Six distinct buprenorphine treatment trajectories were identified in this population-based low-income Medicaid cohort in Pennsylvania, USA. There appears to be an association between persistent use of buprenorphine for 12 months and lower risk of all-cause hospitalizations/emergency department visits.

Medicine possession ratio as proxy for adherence to antiepileptic drugs: prevalence, associations, and cost implications

OBJECTIVE

To determine the adherence status to antiepileptic drugs (AEDs) among epilepsy patients; to observe the association between adherence status and age, sex, active ingredient prescribed, treatment period, and number of comorbidities; and to determine the effect of nonadherence on direct medicine treatment cost of AEDs.

METHODS

A retrospective study analyzing medicine claims data obtained from a South African pharmaceutical benefit management company was performed. Patients of all ages (N=19,168), who received more than one prescription for an AED, were observed from 2008 to 2013. The modified medicine possession ratio (MPRm) was used as proxy to determine the adherence status to AED treatment. The MPRm was considered acceptable (adherent) if the calculated value was ≥80%, but ≤110%, whereas an MPRm of <80% (unacceptably low) or >110% (unacceptably high) was considered nonadherent. Direct medicine treatment cost was calculated by summing the medical scheme contribution and patient co-payment associated with each AED prescription.

RESULTS

Only 55% of AEDs prescribed to 19,168 patients during the study period had an acceptable MPRm. MPRm categories depended on the treatment period (P>0.0001; Cramer's V=0.208) but were independent of sex (P<0.182; Cramer's V=0.009). Age group (P<0.0001; Cramer's V=0.067), active ingredient (P<0.0001; Cramer's V=0.071), and number of comor-bidities (P<0.0001; Cramer's V=0.050) were statistically but not practically significantly associated with MPRm categories. AEDs with an unacceptably high MPRm contributed to 3.74% (US$736,376.23) of the total direct cost of all AEDs included in the study, whereas those with an unacceptably low MPRm amounted to US$3,227,894.85 (16.38%).

CONCLUSION

Nonadherence to antiepileptic treatment is a major problem, encompassing ~20% of cost in our study. Adherence, however, is likely to improve with the treatment period. Further research is needed to determine the factors influencing epileptic patients' prescription refill adherence.

Utilizing an integrated infrastructure for outcomes research: a systematic review

OBJECTIVE

To explore the ability of an integrated health information infrastructure to support outcomes research.

METHODS

A systematic review of articles published from 1983 to 2012 by Regenstrief Institute investigators using data from an integrated electronic health record infrastructure involving multiple provider organisations was performed. Articles were independently assessed and classified by study design, disease and other metadata including bibliometrics.

RESULTS

A total of 190 articles were identified. Diseases included cognitive, (16) cardiovascular, (16) infectious, (15) chronic illness (14) and cancer (12). Publications grew steadily (26 in the first decade vs. 100 in the last) as did the number of investigators (from 15 in 1983 to 62 in 2012). The proportion of articles involving non-Regenstrief authors also expanded from 54% in the first decade to 72% in the last decade. During this period, the infrastructure grew from a single health system into a health information exchange network covering more than 6 million patients. Analysis of journal and article metrics reveals high impact for clinical trials and comparative effectiveness research studies that utilised data available in the integrated infrastructure.

DISCUSSION

Integrated information infrastructures support growth in high quality observational studies and diverse collaboration consistent with the goals for the learning health system. More recent publications demonstrate growing external collaborations facilitated by greater access to the infrastructure and improved opportunities to study broader disease and health outcomes.

CONCLUSIONS

Integrated information infrastructures can stimulate learning from electronic data captured during routine clinical care but require time and collaboration to reach full potential.

Medication oversupply in patients with diabetes

BACKGROUND

Studies in integrated health systems suggest that patients often accumulate oversupplies of prescribed medications, which is associated with higher costs and hospitalization risk. However, predictors of oversupply are poorly understood, with no studies in Medicare Part D.

OBJECTIVE

The aim of this study was to describe prevalence and predictors of oversupply of antidiabetic, antihypertensive, and antihyperlipidemic medications in adults with diabetes managed by a large, multidisciplinary, academic physician group and enrolled in Medicare Part D or a local private health plan.

METHODS

This was a retrospective cohort study. Electronic health record data were linked to medical and pharmacy claims and enrollment data from Medicare and a local private payer for 2006-2008 to construct a patient-quarter dataset for patients managed by the physician group. Patients' quarterly refill adherence was calculated using ReComp, a continuous, multiple-interval measure of medication acquisition (CMA), and categorized as <0.80 = Undersupply, 0.80-1.20 = Appropriate Supply, >1.20 = Oversupply. We examined associations of baseline and time-varying predisposing, enabling, and medical need factors to quarterly supply using multinomial logistic regression.

RESULTS

The sample included 2519 adults with diabetes. Relative to patients with private insurance, higher odds of oversupply were observed in patients aged <65 in Medicare (OR = 3.36, 95% CI = 1.61-6.99), patients 65+ in Medicare (OR = 2.51, 95% CI = 1.37-4.60), patients <65 in Medicare/Medicaid (OR = 4.55, 95% CI = 2.33-8.92), and patients 65+ in Medicare/Medicaid (OR = 5.73, 95% CI = 2.89-11.33). Other factors associated with higher odds of oversupply included any 90-day refills during the quarter, psychotic disorder diagnosis, and moderate versus tight glycemic control.

CONCLUSIONS

Oversupply was less prevalent than in previous studies of integrated systems, but Medicare Part D enrollees had greater odds of oversupply than privately insured individuals. Future research should examine utilization management practices of Part D versus private health plans that may affect oversupply.

Understanding medication oversupply and its predictors in the outpatient departments in Thailand

BACKGROUND

Medication oversupply is an important problem in the healthcare systems. It causes unnecessary avoidable healthcare costs. Although some studies have determined the magnitude and financial loss due to medication oversupply in western countries, they may not be applicable to Asia-pacific countries. This study aims to determine the prevalence, financial loss, and patterns of medication oversupply and the factors associated with such oversupply in Thailand.

METHODS

A retrospective database analysis was used from 3 public hospitals. Patients visiting the outpatient department of the hospitals in 2010 and receiving at least 2 prescriptions within 6 months were included. The modified medication possession ratio (MPRm) was used to determine the medication supply. Patients having MPRm > 1.20 were defined as receiving a medication oversupply. The measures were prevalence of medication oversupply, the number of oversupplied medications, and financial loss (2012 dollars) due to medication oversupply. Hierarchical logistic regression was used to determine the factors associated with the prevalence of medication oversupply.

RESULTS

A total of 99,743 patients were included. Patients were on average 49.7 ± 21.2 years of age, and 42.8% were male. Most of them were adult (53.7%). Among those patients, 60.2% of the patients were under universal coverage schemes. Around 13.4% of all the patients received a medication oversupply, and the patients in regional hospitals had a higher prevalence of medication oversupply than patients in district hospitals (13.8% VS 8.2%). The patients under civil servant medical benefit schemes (CSMBS) (13.6%) had the most prevalence of medication oversupply. The total financial loss was $189,024 per year. The average financial loss was $1.9 ± 19.0 per patient/year. Patients under CSMBS experienced the highest average financial loss (2.6 ± 23.2 $/patient/year). Age, gender, health insurance schemes, and the number of medications that the patients received were the factors associated with medication oversupply.

CONCLUSIONS

Medication oversupply is an important problem for the health system. Patients receiving care from regional hospitals had a higher likelihood of medication oversupply. Policymakers may consider developing policies for preventing medication oversupply. The policy should be implemented in regional hospitals and especially in children or patients with poly-pharmacy.

Medication supply, healthcare outcomes and healthcare expenses: longitudinal analyses of patients with type 2 diabetes and hypertension

INTRODUCTION

Patients with chronic conditions largely depend on proper medications to maintain health. This study aims to examine, for patients with diabetes and hypertension, whether the appropriateness of the quantity of drug obtained is associated with favorable healthcare outcomes and lower expenses.

METHODS

This study utilized a longitudinal design with a seven-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. The patients under study were those aged 18 years or older and newly diagnosed with type 2 diabetes or hypertension in 2002. Generalized estimating equations were performed to examine the relationship between medication supply and health outcomes as well as expenses.

RESULTS

The results indicate that while compared with patients with an appropriate medication supply, patients with either an undersupply or an oversupply of medications tended to have poorer healthcare outcomes. The study also found that an excess supply of medications for patients with diabetes or hypertension resulted in higher total healthcare expenses.

CONCLUSION

Either an undersupply or an oversupply of medication was associated with unfavorable healthcare outcomes, and that medication oversupply was associated with the increased consumption of health resources. Our findings suggest that improving appropriate medication supply is beneficial for the healthcare system.

Long-term anticholinergic use and the aging brain

BACKGROUND

Older Americans are facing an epidemic of chronic diseases and are thus exposed to anticholinergics (ACs) that might negatively affect their risk of developing mild cognitive impairment (MCI) or dementia.

OBJECTIVE

To investigate the association between impairment in cognitive function and previous AC exposure.

DESIGN

A retrospective cohort study.

SETTING

Primary care clinics in Indianapolis, Indiana.

PARTICIPANTS

A total of 3690 older adults who have undergone cognitive assessment and had a 1-year medication-dispensing record.

OUTCOME

Cognitive function was measured in two sequential steps: a two-step screening process followed by a formal diagnostic process for participants with positive screening results.

EXPOSURE

Three patterns of AC exposure were defined by the duration of AC exposure, the number of AC medications dispensed at the same time, and the severity of AC effects as determined by the Anticholinergic Cognitive Burden list.

RESULTS

Compared with older adults with no AC exposure and after adjusting for age, race, gender, and underlying comorbidity, the odds ratio for having a diagnosis of MCI was 2.73 (95% confidence interval, 1.27-5.87) among older adults who were exposed to at least three possible ACs for at least 90 days; the odds ratio for having dementia was 0.43 (95% confidence interval, 0.10-1.81).

CONCLUSION

Exposure to medications with severe AC cognitive burden may be a risk factor for developing MCI.

Message from the Regional Director

With great pleasure, I warmly welcome you all to this regional meeting.

As we all are aware, approximately 200,000 lives were lost due to the Earthquake and Tsunami at the end oflast year. It was one of the worst catastrophes of our times.The tragic event affected nine countries and displaced an estimated 1.2 million people. This was in spite of prompt responses by the governments of affected countries and international organizations.

Evidence-Based Approach for Disaster Preparedness Authorities to Inform the Contents of Repositories for Prescription Medications for Chronic Disease Management and Control

Introduction:

Chronic diseases are major causes of death and disability and often require multiple prescribed medications for treatment and control. Public health emergencies (e.g., disasters due to natural hazards) that disrupt the availability or supply of these medications may exacerbate chronic disease or even cause death.

Problem:

A repository of chronic disease pharmaceuticals and medical supplies organized for rapid response in the event of a public health emergency is desirable. However, there is no science base for determining the contents of such a repository. This study provides the first step in an evidence-based approach to inform the planning, periodic review, and revision of repositories of chronic disease medications.

Methods:

Data from the 2004 National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to examine the prescription medication needs of persons presenting to US hospital emergency departments for chronic disease exacerbations. It was assumed that the typical distribution of cases for an emergency department will reflect the patient population treated in the days after a public health emergency. The estimated numbers of prescribed drugs for chronic conditions that represent the five leading causes of death, the five leading primary diagnoses for physician office visits, and the five leading causes of disease burden assessed by disability-adjusted life years are presented.

Results:

The 2004 NHAMCS collected data on 36,589 patient visits that were provided by 376 emergency departments. Overall, the five drug classes mentioned most frequently for emergency department visits during 2004 were narcotic analgesics (30.7 million), non-steroidal anti-inflammatory drugs (25.2 million), non-narcotic analgesics (15.2 million), sedatives and hypnotics (10.4 million), and cephalosporins (8.2 million). The drug classes mentioned most frequently for chronic conditions were: (1) for heart disease, antianginal agents/vasodilators (715,000); (2) for cancer, narcotic analgesics (53,000); (3) for stroke, non-narcotic analgesics (138,000); (4) for chronic obstructive pulmonary disease, anti-asthmatics/bronchodilators (3.2 million); and (5) for diabetes, hypoglycemic agents (261,000). Ten medication categories were common across four or more chronic conditions.

Conclusions:

Persons with chronic diseases have an urgent need for ongoing care and medical support after public health emergencies. These findings provide one evidence-based approach for informing public health preparedness in terms of planning for and review of the prescription medication needs of clinically vulnerable populations with prevalent chronic disease.

The effects of medication supply on hospitalizations and health-care costs in patients with chronic heart failure

OBJECTIVES

Use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers results in decreased morbidity among patients with chronic heart failure (CHF). Undersupply of medication could result in inadequate control of CHF, whereas oversupply of medication could increase health-care costs and risks of toxicities. This study aimed to determine the effects of medication supplies on health-care costs and hospitalizations in patients with CHF receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

METHODS

We retrospectively examined the electronic database in a hospital in Thailand. Patients who were diagnosed with CHF and who received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in the year 2003 were included. Medication supplies were assessed by using the medication possession ratio (MPR). The Cox proportional hazard model was used to determine the association of medication supply (appropriate supply: MPR 0.8-1.2, oversupply: MPR > 1.2, undersupply: MPR < 0.8) with CHF-related and all-cause hospitalizations. Health-care costs were compared by using multiple linear regressions. All analyses were adjusted for propensity score and other variables.

RESULTS

A total of 393 patients were included. Their mean age was 66 years, with 56% being females. Fifty-seven percent of the patients received an inappropriate -supply of medication. Undersupply of medication likely increased the risks of CHF-related hospitalization with an adjusted hazard ratio of 1.66 (95% confidence interval [CI] 0.80-3.46). The adjusted hazard ratio of undersupply and oversupply of medication for all-cause hospitalization was 1.13 (95% CI 0.74-1.73) and 3.19 (95%CI 0.66-15.47), respectively. The total health-care costs in the undersupply and oversupply groups were significantly greater than that in the appropriate-supply group: $49 (95% CI 32-66) and $103 (95% CI 32-173), respectively.

CONCLUSIONS

Inappropriate medication supplies could increase the risks of CHF-related and all-cause hospitalizations. Both undersupply and oversupply of medication had significantly higher health-care costs.

Estimation of financial burden due to oversupply of medications for chronic diseases

Given the potential of financial burden due to oversupply of medications for chronic diseases, this study aims to determine the prevalence of oversupply and to estimate the magnitude of financial loss in Thailand. Electronic patient database in a university-affiliated hospital in Thailand was used. Based on the utilization of top 5 high drug expenditure in 2005, the prevalence and the financial loss of oversupply (medication possession ratio [MPR] >1.00) were estimated. In total, 1893 patients were included in this study. The average age was 65.2 years and the majority were female (56%). The prevalence of oversupply ranged from 23.2% to 62.8%, whereas the annual financial loss ranged from US $4108 to US $10 517. The total amount of loss was US $32 903 or 3.77% of total medication costs. In summary, because of the high prevalence and associated high financial loss, oversupply of medication is a significant financial burden on hospitals and society.

Personalized medicine: the absence of 'model-changing' financial incentives

This perspective biases on the side that personalized medicine can contribute to a more efficient collective model; however, the hard economics need and deserve significantly more critical analysis and new data input than they are currently being given, to determine their role, or not, in driving change. Put simply, as with the birth of all new and promising developments in healthcare, myth, hope and trend-spotting are driving this market forward, rather than any hard evidence of a sustainable commercial business model for all stakeholders. While there are clear economic benefits to aspects of delivery along the way to personalized care, there may in fact be no compelling economic drivers for radical change for payers and the pharmaceutical industry. The best they can hope to achieve is that the balance sheet is, just that, in balance.

Factors associated with drug adherence and blood pressure control in patients with hypertension

STUDY OBJECTIVES

To determine characteristics associated with drug adherence and blood pressure control among patients with hypertension, and to assess agreement between self-reported and refill adherences.

DESIGN

Cross-sectional analysis of baseline data from an ongoing randomized controlled trial.

SETTING

Primary care center at an urban, county health system in Indianapolis, Indiana.

PATIENTS

Four hundred ninety-two participants with hypertension and taking at least one antihypertensive drug.

MEASUREMENTS AND MAIN RESULTS

Social and demographic factors, comorbidity, self-reported drug adherence, prescription refill adherence, and systolic and diastolic blood pressures were recorded at baseline. Participants were aged 57 +/- 11 (mean +/- SD) years, were predominantly women (73%) and African-American (68%), and took 2.4 +/- 1.1 antihypertensive drugs. Agreement between self-reported and refill adherences was poor to fair (kappa = 0.21). On multiple logistic regression analysis, increased age (p< or =0.002) and being married (p=0.03) were independent predictors of improved self-reported and refill adherence, whereas depressed patients had low self-reported adherence (p=0.005), and African-Americans had low refill adherence (p<0.001). Compared with nonadherent patients, adherent patients had lower systolic (-5.4 mm Hg by self-report and -5.0 mm Hg by refill) and diastolic (-2.7 mm Hg by self-report and -3.0 mm Hg by refill) blood pressures (p< or =0.02). Increased age was the only other variable strongly associated with systolic and diastolic blood pressure control in both measures of drug adherence (p< or =0.001). The association of depression, race, and sex with blood pressure control was model dependent.

CONCLUSION

Age, sex, race and depression are associated with antihypertensive drug adherence and blood pressure control. Self-reported and refill adherences appear to provide complementary information and are associated with reductions in systolic and diastolic blood pressure of similar magnitude.

Association of Refill Adherence and Health Care Use Among Adults with Hypertension in an Urban Health Care System

STUDY OBJECTIVES

To determine the rates of undersupply, appropriate supply, and oversupply of antihypertensive drugs, as measured by refill adherence, among patients with complicated and uncomplicated hypertension (i.e., patients who have and have not, respectively, experienced hypertension-related target organ damage), and to examine the association of refill adherence with hospitalization and health care costs among these patients.

DESIGN

Retrospective analysis of electronic medical records.

SETTING

An urban, public health care system.

PATIENTS

A total of 15,206 patients aged 18 years or older whose electronic medical records indicated a clinical diagnosis of hypertension based on the International Classification of Diseases, Ninth Revision, Clinical Modification codes, and who had received at least one prescription of an antihypertensive drug from 1995-2001.

MEASUREMENTS AND MAIN RESULTS

We used multivariable analyses to investigate the association of refill adherence with hospitalization and costs. On average, 53% of patients had appropriate supplies (80-120% of supplies needed), 7% had undersupplies, and 40% had oversupplies of drug annually. For patients with complicated hypertension, an undersupply of drug was associated with a 15% greater probability (p=0.009) and an oversupply with a 16% greater probability (p<0.0001) of hospitalization. Among those with uncomplicated hypertension, oversupply was associated with an 11% greater probability (p=0.0002) of hospitalization; undersupply was not associated with greater probability of hospitalization. Total health care costs were lower for patients with undersupplies and higher for those with oversupplies of drug.

CONCLUSION

Among adults in an urban health care system with complicated hypertension, both undersupply and oversupply of drug were associated with increased hospitalization rates. Monitoring refill adherence of patients, particularly those with low income, minority status, and complicated hypertension, may be useful for targeting patients with undersupplies of drug to encourage refill adherence and identifying patients with oversupplies, who are at high risk of hospitalization.

Practice and opinion towards disposal of unused medication in Kuwait

OBJECTIVES

The aim of this study was to measure the attitude and practice of Kuwaiti patients in Kuwait with regard to safe disposal of unwanted medicines.

SUBJECTS AND METHODS

Three-hundred patients or their family members waiting for prescriptions at public general hospitals in Kuwait completed a questionnaire soliciting their practice with regard to medication use and disposal, and their opinion of the best way to dispose of unwanted medicines.

RESULTS

Almost half of the respondents (45.4%) obtained medicines on prescription more than 3 times a year and almost all had unwanted medicines in the home. Reasons for possessing unused medication were mostly due to a change of medication by the doctor (48.9%), or self-discontinuation (25.8%). Their most common method of disposal was to throw unwanted medicines in the trash (76.5%) or flush them down the drain (11.2%). Half (54.0%) thought that a system of taking medicines to pharmacies for safe disposal would be favorable.

CONCLUSION

The study indicates that the need for an appropriate method for disposal of unwanted medication exists in Kuwait. Hence, guidelines on safe disposal of unwanted medicines are required and an organized method of collecting unused medication needs to be introduced.

Evaluating the effect on patient outcomes of appropriate and inappropriate use of beta-blockers as secondary prevention after myocardial infarction in a medicaid population

BACKGROUND

Acute myocardial infarction (AMI) is associated with high mortality in the United States. Beta-blockers have been shown to reduce mortality and reinfarction rates when used for long-term prevention after an AMI. However, this therapy is both underused and misused. The effect of this practice on outcomes needs to be investigated.

OBJECTIVE

This study was undertaken to evaluate the effect on patient outcomes (ie, fatality, health care utilization, and costs) of appropriate and inappropriate prescribing of beta-blocker therapy after AMI in a Medicaid population aged <65 years.

METHODS

Data for 1 year before and after AMI were extracted from West Virginia Medicaid claims from January 1, 1996, to June 30, 2001. Information was obtained regarding prescriptions for beta-blockers for these patients within 90 days after discharge. Patients were divided into 2 groups: those who were prescribed therapy appropriately and those who were prescribed therapy inappropriately (underuse or misuse). Fatality rates during 1 year after discharge were compared using chi-square analysis. The study used regression analysis to model health care utilization and costs as a function of appropriately/inappropriately prescribed groups.

RESULTS

Data were assessed for 488 eligible patients (mean [SD] age, 53.70 [8.14] years; 246 men [50.4%], 242 women [49.6%]). Overall, 309 patients (63.3%) had appropriate prescribing of beta-blockers; at the end of 1 year, these patients had a significantly lower all-cause death rate compared with those who were prescribed therapy inappropriately (P = 0.030). Although the cardiac death rate was slightly lower for the appropriate group, the difference was not statistically significant. The appropriately prescribed group had significantly higher health care utilization in the follow-up period (P < 0.050 for hospital visits, emergency department visits, and length of stay). These groups demonstrated differences in a few variables at baseline (age, presence of absolute contraindications, presence of hypertension, number of noncardiac admissions before AMI, and use of beta-blockers before AMI: all, P < 0.050), implying different severity levels. Patient health status at the time of the incident AMI had a confounding effect on health care utilization, and there were indications that the appropriate group had greater severity compared with the inappropriate group.

CONCLUSIONS

Appropriate prescribing of beta-blockers for secondary prevention after an AMI was associated with better survival in this population. However, the effects of inappropriate and appropriate beta-blocker prescribing on health care utilization need to be evaluated prospectively so that all severity indicators can be properly adjusted.

Teaching Older Adults to Self-Manage Medications: PREVENTING ADVERSE DRUG REACTIONS

Older adults use more prescription and OTC medications than any other age group. Because their medication regimens often are complicated by many medications and different doses, times, and administration methods, older adults are at high risk for medication mismanagement. The most common errors associated with medication mismanagement include mixing OTC and prescription medications, discontinuing prescriptions, taking wrong dosages, using incorrect techniques, and consuming inappropriate foods with specific medications. Both human and environmental factors contribute to medication mismanagement among older adults. Human factors include faulty communication between the health care provider and the patient; the patient's lack of knowledge; ADRs; alcohol-drug interactions; use of OTC medications and herbal products; cognitive, sensory, and motor impairments; and polypharmacy. Environmental factors include high cost of prescribed medications, improper medication storage, and absence of clearly marked expiration dates. Nurses need to take advantage of both formal and informal teaching opportunities in all settings to prepare a patient for medication self-management. Teaching should be individualized and based on a thorough assessment of the patient's abilities to administer medication safely and the specific medication regimen. By involving older adults as active partners in their health care, many errors and medication-related health problems can be prevented. New technologies and devices have the potential for improving the patient's self-management of medications. The role of nurses in educating older adults and their families about proper medication management is vital.

Health care and medication costs and use among older adults with heart failure

BACKGROUND

Heart failure disproportionately affects older adults for whom multiple medications are prescribed to prevent exacerbations and hospitalization. To target interventions effectively, it is important to understand the association of medication acquisition with health care utilization and costs.

METHODS

We used electronic medical records from an urban public health care system to identify patients aged >/=50 years who had a diagnosis of heart failure. We assessed the association between inappropriate or appropriate medication supplies and hospitalization and costs using multivariable analyses that adjusted for demographic characteristics, prior health care use, health status, and insurance status.

RESULTS

Total health care costs for treating 1554 patients with heart failure from 1996 to 2000 were 36.6 million dollars (in 2000 dollars). Less than a third of patients received appropriate medication supplies (between 90% and 110% of the supplies needed) annually. Compared with patients with appropriate supplies, the odds of hospitalization were greater among those with undersupplies (odds ratio [OR] = 3.1; 95% confidence interval [CI]: 2.3 to 4.2; P <0.0001) or oversupplies (OR = 2.0; 95% CI: 1.7 to 2.4; P <0.0001). Total costs were 25% higher for patients with undersupplies (95% CI: 8% to 46%; P = 0.004) and 18% higher for those with oversupplies (95% CI: 7% to 30%; P = 0.0009) than for those with appropriate supplies.

CONCLUSION

Among adults with heart failure, inappropriate medication supplies were associated with increased hospitalization and higher costs. Monitoring medication supplies from electronic medical records may be a useful component of programs aiming to improve care while managing costs.

Hispanic ethnicity, physician-patient communication, and antidepressant adherence

The purpose of the study was to examine how Hispanic ethnicity influenced physician-patient communication about antidepressants and antidepressant adherence using a data set of audiotapes and transcripts of 98 medical visits and medical and pharmacy records. The data were collected in 1995 at the University of New Mexico's general medicine and family practice clinics. Physicians were more likely to state antidepressant information to non-Hispanic white patients than to Hispanic patients. Physicians were more likely to state information to patients who were prescribed new antidepressants. Physicians asked approximately one of five patients on continued therapy how well their antidepressants were working and only one of 10 patients if they were experiencing any side effects. Non-Hispanic white patients were significantly more likely to state information about their antidepressants than Hispanic patients. Younger patients and patients who were prescribed new antidepressants were more likely to ask questions about antidepressants. Hispanic patients and patients who were prescribed new antidepressants were significantly less adherent to their antidepressant therapy during the one hundred day period after their audio-taped visits than non-Hispanic white patients and patients on continued therapy.