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El Asmar ML, Dharmayat KI, Vallejo-Vaz AJ, Irwin R, Mastellos N. Effect of computerised, knowledge-based, clinical decision support systems on patient-reported and clinical outcomes of patients with chronic disease managed in primary care settings: a systematic review. BMJ Open 2021; 11:e054659. [PMID: 34937723 PMCID: PMC8705223 DOI: 10.1136/bmjopen-2021-054659] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Chronic diseases are the leading cause of disability globally. Most chronic disease management occurs in primary care with outcomes varying across primary care providers. Computerised clinical decision support systems (CDSS) have been shown to positively affect clinician behaviour by improving adherence to clinical guidelines. This study provides a summary of the available evidence on the effect of CDSS embedded in electronic health records on patient-reported and clinical outcomes of adult patients with chronic disease managed in primary care. DESIGN AND ELIGIBILITY CRITERIA Systematic review, including randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, interrupted time series and controlled before-and-after studies, assessing the effect of CDSS (vs usual care) on patient-reported or clinical outcomes of adult patients with selected common chronic diseases (asthma, chronic obstructive pulmonary disease, heart failure, myocardial ischaemia, hypertension, diabetes mellitus, hyperlipidaemia, arthritis and osteoporosis) managed in primary care. DATA SOURCES Medline, Embase, CENTRAL, Scopus, Health Management Information Consortium and trial register clinicaltrials.gov were searched from inception to 24 June 2020. DATA EXTRACTION AND SYNTHESIS Screening, data extraction and quality assessment were performed by two reviewers independently. The Cochrane risk of bias tool was used for quality appraisal. RESULTS From 5430 articles, 8 studies met the inclusion criteria. Studies were heterogeneous in population characteristics, intervention components and outcome measurements and focused on diabetes, asthma, hyperlipidaemia and hypertension. Most outcomes were clinical with one study reporting on patient-reported outcomes. Quality of the evidence was impacted by methodological biases of studies. CONCLUSIONS There is inconclusive evidence in support of CDSS. A firm inference on the intervention effect was not possible due to methodological biases and study heterogeneity. Further research is needed to provide evidence on the intervention effect and the interplay between healthcare setting features, CDSS characteristics and implementation processes. PROSPERO REGISTRATION NUMBER CRD42020218184.
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Affiliation(s)
| | - Kanika I Dharmayat
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, UK
| | - Antonio J Vallejo-Vaz
- Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London. London, United Kingdom, London, UK
- Department of Medicine, Faculty of Medicine, University of Seville, Seville, Spain
- Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/Universidad de Sevilla/CSIC, Seville, Spain
| | - Ryan Irwin
- Department of Primary Care Clinical Sciences, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nikolaos Mastellos
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Cohen-Stavi CJ, Key C, Giveon S, Molcho T, Balicer RD, Shadmi E. Assessing guideline-concordant care for patients with multimorbidity treated in a care management setting. Fam Pract 2020; 37:479-485. [PMID: 32219299 DOI: 10.1093/fampra/cmaa024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Disease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated across multiple guidelines. OBJECTIVE Measure guideline-concordant care for patients with multimorbidity; assess in what types of care and by whom (clinician or patient) deviation from guidelines occurs and evaluate whether patient characteristics are associated with concordance. METHODS A retrospective cohort study of care received over 1 year, conducted across 11 primary care clinics within the context of multimorbidity-focused care management program. Patients were aged 45+ years with more than two common chronic conditions and were sampled based on either being new (≤6 months) or veteran to the program (≥1 year). MEASURES Three guideline concordance measures were calculated for each patient out of 44 potential guideline-recommended care processes for nine chronic conditions: overall score; referral score (proportion of guideline-recommended care referred) and patient-only score (proportion of referred care completed by patients). Guideline concordance was stratified by care type. RESULTS 4386 care processes evaluated among 204 patients, mean age = 72.3 years (standard deviation = 9.7). Overall, 79.2% of care was guideline concordant, 87.6% was referred according to guidelines and patients followed 91.4% of referred care. Guideline-concordant care varied across care types. Age, morbidity burden and whether patients were new or veteran to the program were associated with guideline concordance. CONCLUSIONS Patients with multimorbidity do not receive ~20% of guideline recommendations, mostly due to clinicians not referring care. Determining the types of care for which the greatest deviation from guidelines exists can inform the tailoring of care for multimorbidity patients.
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Affiliation(s)
- Chandra J Cohen-Stavi
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa
| | | | - Shmuel Giveon
- Community Medical Division, Clalit Health Services, Tel Aviv
| | | | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Epidemiology Department, Ben Gurion University of the Negev, Be'er Sheba, Israel
| | - Efrat Shadmi
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa
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Marx N, Rydén L, Brosius F, Ceriello A, Cheung M, Cosentino F, Green J, Kellerer M, Koob S, Kosiborod M, Nedungadi P, Rodbard HW, Vandvik PO, Standl E, Schnell O. Proceedings of the Guideline Workshop 2019: Strategies for the Optimization of Guideline Processes in Diabetes, Cardiovascular Diseases, and Kidney Diseases. Diabetes Technol Ther 2020; 22:546-552. [PMID: 32903066 DOI: 10.1089/dia.2020.0086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The Guideline Workshop 2019, held in October 2019 in Munich, Germany, had the purpose of facilitating discussion on strategies for optimization of guideline processes in diabetes among a group of representatives of renown national and international societies in the field of diabetes, cardiology, and nephrology. Results of this panel's discussions are presented in this article and comprise a variety of suggestions for improving the quality and usability of guidelines, as well as to accelerate the development and responsiveness of guidelines to newly published, relevant data from clinical trials such as cardiovascular outcome trials in diabetes mellitus. These include, but are not limited to, recommendations to optimize presentation of content in guidelines, use of the Grading of Recommendations Assessment, Development, and Evaluation approach to rating the quality of evidence to harmonize guidelines, and utilization of digital health technologies to accelerate, streamline, and optimize communication on relevant data and development of clinical guidelines and necessary updates, while reducing costs. Recognizing that achieving alignment in guideline development among various medical organizations will be a long-term process, representatives from cross-sectional medical organizations relevant to cardio/renal metabolic disease and experts in guideline methodology will work together in the future. Among other activities, it is planned to continue the activity and organize a Guideline Workshop in 2020.
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Affiliation(s)
- Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institute, Stockholm, Sweden
| | - Frank Brosius
- University of Arizona College of Medicine, Tucson, Arizona, USA
| | | | - Michael Cheung
- Kidney Disease: Improving Global Outcomes, Brussels, Belgium
| | | | - Jennifer Green
- Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Susan Koob
- PCNA National Office, Madison, Wisconsin, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | | | - Per Olav Vandvik
- Institute of Health and Society, University of Oslo, Oslo, Norway
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Marx N, Rydén L, Brosius F, Ceriello A, Cheung M, Cosentino F, Green J, Kellerer M, Koob S, Kosiborod M, Nedungadi P, Rodbard HW, Vandvik PO, Standl E, Schnell O. Proceedings of the Guideline Workshop 2019 - Strategies for the optimization of guideline processes in diabetes, cardiovascular diseases and kidney diseases. Diabetes Res Clin Pract 2020; 162:108092. [PMID: 32109519 DOI: 10.1016/j.diabres.2020.108092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 12/21/2022]
Abstract
The Guideline Workshop 2019, held in October 2019 in Munich, Germany, had the purpose of facilitating discussion on strategies for optimization of guideline processes in diabetes amongst a group of representatives of renown national and international societies in the field of diabetes, cardiology, and nephrology. Results of this panel's discussions are presented in this manuscript and comprise a variety of suggestions for improving the quality and usability of guidelines, as well as to accelerate the development and responsiveness of guidelines to newly published, relevant data from clinical trials such as cardiovascular outcome trials in diabetes mellitus. These include, but are not limited to, recommendations to optimize presentation of content in guidelines, use of the GRADE-approach to rating the quality of evidence to harmonize guidelines, and utilization of digital health technologies to accelerate, streamline, and optimize communication on relevant data and development of clinical guidelines and necessary updates, while reducing costs. Recognizing that achieving alignment in guideline development among various medical organizations will be a long-term process, representatives from cross-sectional medical organizations relevant to cardio-renal metabolic disease and experts in guideline methodology will work together in the future. Among other activities, it is planned to continue the activity and organize a Guideline Workshop in 2020.
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Affiliation(s)
- Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institute, Stockholm, Sweden.
| | - Frank Brosius
- University of Arizona College of Medicine, 1501 N. Campbell Ave, Tucson, AZ 85724-5022, USA.
| | - Antonio Ceriello
- IRCCS MultiMedica, Via Milanese 300, 20099 Sesto San Giovanni, MI, Italy.
| | - Michael Cheung
- KDIGO, Avenue Louise 65, Suite 11, 1050 Brussels, Belgium.
| | | | - Jennifer Green
- Duke University Medical Center, Duke Clinical Research Institute, 200 Morris St, DUMC Box 3850, Durham, NC 27715, USA.
| | - Monika Kellerer
- Marienhospital Stuttgart, Böheimstraße 37, 70199 Stuttgart, Germany.
| | - Susan Koob
- PCNA National Office, 613 Williamson Street, Suite 200, Madison, WI 53703, USA.
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 4401 Wornall Rd, Kansas City, MO 64111, USA; The George Institute for Global Health and University of New South Wales, Sydney, Australia.
| | - Prashant Nedungadi
- American Heart Association, 7272 Greenville Avenue, Dallas, TX 75082, USA.
| | - Helena W Rodbard
- Endocrine and Metabolic Consultants, 3200 Tower Oaks Blvd., Suite 250, Rockville, MD 20852, USA.
| | - Per Olav Vandvik
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Eberhard Standl
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, 85764 Neuherberg, Munich, Germany.
| | - Oliver Schnell
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, 85764 Neuherberg, Munich, Germany.
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Abstract
BACKGROUND There are numerous definitions of multimorbidity (MM). None systematically examines specific comorbidity combinations accounting for multiple testing when exploring large datasets. OBJECTIVES Develop and validate a list of all single, double, and triple comorbidity combinations, with each individual qualifying comorbidity set (QCS) more than doubling the odds of mortality versus its reference population. Patients with at least 1 QCS were defined as having MM. RESEARCH DESIGN Cohort-based study with a matching validation study. SUBJECTS All fee-for-service Medicare patients between age 65 and 85 without dementia or metastatic solid tumors undergoing general surgery in 2009-2010, and an additional 2011-2013 dataset. MEASURES 30-day all-location mortality. RESULTS There were 576 QCSs (2 singles, 63 doubles, and 511 triples), each set more than doubling the odds of dying. In 2011, 36% of eligible patients had MM. As a group, multimorbid patients (mortality rate=7.0%) had a mortality Mantel-Haenszel odds ratio=1.90 (1.77-2.04) versus a reference that included both multimorbid and nonmultimorbid patients (mortality rate=3.3%), and Mantel-Haenszel odds ratio=3.72 (3.51-3.94) versus only nonmultimorbid patients (mortality rate=1.6%). When matching 3151 pairs of multimorbid patients from low-volume hospitals to similar patients in high-volume hospitals, the mortality rates were 6.7% versus 5.2%, respectively (P=0.006). CONCLUSIONS A list of QCSs identified a third of older patients undergoing general surgery that had greatly elevated mortality. These sets can be used to identify vulnerable patients and the specific combinations of comorbidities that make them susceptible to poor outcomes.
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Huebsch JA, Kottke TE, McGinnis P, Nichols J, Parker ED, Tillema JO, Hanson AM. A qualitative study of processes used to implement evidence-based care in a primary care practice. Fam Pract 2015; 32:578-83. [PMID: 26089298 PMCID: PMC4592325 DOI: 10.1093/fampra/cmv045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Evidence-based guidelines for care of coronary heart disease patients are not fully implemented. Primary care practices provide most of the care for these patients. OBJECTIVE To learn how providers and staff in a busy primary care practice implement interventions to provide evidence-based care of coronary heart disease patients. METHODS We conducted a qualitative analysis of the responses to open-ended questions in nine electronically administered bimonthly surveys of key physicians, clinic staff and managers in the practice. RESULTS Ten to 16 (mean=12.3) personnel responded to each survey. Nearly 30% were physicians and 40.5% were clinic staff. Four major themes emerged from the qualitative analysis: (i) giving data about not-at-goal patients to providers for care plan development; (ii) developing team roles and defining tasks; (iii) providing patient care and implementing care plans and (iv) providing technology support to generate useful, accurate data. The frequency that the subthemes were mentioned varied from survey to survey, but their mention persisted over the entire time of all nine surveys. CONCLUSIONS Developing a system for implementing evidence-based care involves considerations of roles and teamwork, technology use to develop a patient registry and obtain needed clinical data, care processes for pre-visit planning, and between-visit care management. A registered nurse care manager is a central figure in implementing and sustaining the process. Implementing evidence-based guidelines is an ongoing process of revision, retraining and reinforcement.
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Affiliation(s)
| | - Thomas E Kottke
- HealthPartners Institute for Education and Research, Bloomington, MN and
| | | | | | - Emily D Parker
- HealthPartners Institute for Education and Research, Bloomington, MN and
| | - Juliana O Tillema
- HealthPartners Institute for Education and Research, Bloomington, MN and
| | - Ann M Hanson
- HealthPartners Institute for Education and Research, Bloomington, MN and
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7
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Adams AS, Banerjee S, Ku CJ. Medication adherence and racial differences in diabetes in the USA: an update. ACTA ACUST UNITED AC 2015. [DOI: 10.2217/dmt.14.55] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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8
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Aggarwal B, Liao M, Mosca L. Medication adherence is associated with having a caregiver among cardiac patients. Ann Behav Med 2014; 46:237-42. [PMID: 23536121 DOI: 10.1007/s12160-013-9492-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Medication non-adherence is a significant contributor to suboptimal control of blood pressure and lipids. PURPOSE This study determined if having a paid and/or family caregiver was associated with medication adherence in patients hospitalized for cardiovascular disease. METHODS Consecutive patients admitted to the cardiovascular service at a university medical center who completed a standardized questionnaire about medication adherence and caregiving (paid/professional or family member/friend) were included in this analysis (N = 1,432; 63 % white; 63%male). RESULTS Among cardiac patients, 39 % reported being prescribed ≥ 7 different medications, and one in four reported being non-adherent to their medication(s). Participants who reported having/planning to have a paid caregiver were 40 % less likely to be non-adherent to their medications compared to their counterparts. The association remained significant after adjustment for demographic confounders and comorbid conditions (OR = 0.49; 95 %CI = 0.29-0.82). CONCLUSION Cardiac patients with a paid caregiver were half as likely to be non-adherent to medications as those without caregivers.
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Affiliation(s)
- Brooke Aggarwal
- Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA
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Reich K, Mrowietz U, Karakasili E, Zschocke I. Development of an adherence-enhancing intervention in topical treatment termed the topical treatment optimization program (TTOP). Arch Dermatol Res 2014; 306:667-76. [PMID: 24895177 PMCID: PMC4139584 DOI: 10.1007/s00403-014-1475-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 05/13/2014] [Accepted: 05/19/2014] [Indexed: 11/26/2022]
Abstract
Psoriasis is a common, disabling, chronic, relapsing, inflammatory disorder of the skin with a worldwide prevalence of 2-3 % in which adherence to treatment is often poor. The majority of individuals have limited disease that is being treated with topical medication according to existing guidelines. Adherence rates are lower for topical compared with systemic treatment. Low medication adherence is a major problem for patients with chronic disorders as it results in suboptimal treatment outcomes, increased risk for development of concomitant diseases, inefficient use of health resources and considerable losses to society. However, to date no adherence-enhancing intervention has been developed for psoriasis patients under topical treatment. In this article, we report the development of the topical treatment optimization program (TTOP). The TTOP intervention aims to improve the information given to the patients and to result in an engaged patient-physician relationship. Application of the TTOP intervention in daily clinical practice may lead to a significant increase of adherence and the successful management of psoriasis and other chronic skin disorders.
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Affiliation(s)
- Kristian Reich
- Dermatologikum Hamburg, Stephansplatz 5, 20354 Hamburg, Germany
| | - Ulrich Mrowietz
- Department of Dermatology, Psoriasis-Center, University Medical Center Schleswig-Holstein, Schittenhelmstraße. 7, 24105 Kiel, Germany
| | | | - Ina Zschocke
- SCIderm GmbH, Drehbahn 1-3, 20354 Hamburg, Germany
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Nunlee M, Bones M. Addressing drug adherence using an operations management model. J Am Pharm Assoc (2003) 2014; 54:63-8. [PMID: 24407742 DOI: 10.1331/japha.2014.13150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To provide a model that enables health systems and pharmacy benefit managers to provide medications reliably and test for reliability and validity in the analysis of adherence to drug therapy of chronic disease. SUMMARY The quantifiable model described here can be used in conjunction with behavioral designs of drug adherence assessments. The model identifies variables that can be reproduced and expanded across the management of chronic diseases with drug therapy. By creating a reorder point system for reordering medications, the model uses a methodology commonly seen in operations research. The design includes a safety stock of medication and current supply of medication, which increases the likelihood that patients will have a continuous supply of medications, thereby positively affecting adherence by removing barriers. CONCLUSION This method identifies an adherence model that quantifies variables related to recommendations from health care providers; it can assist health care and service delivery systems in making decisions that influence adherence based on the expected order cycle days and the expected daily quantity of medication administered. This model addresses the possession of medication as a barrier to adherence.
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Taitel M, Fensterheim L, Kirkham H, Sekula R, Duncan I. Medication days' supply, adherence, wastage, and cost among chronic patients in Medicaid. MEDICARE & MEDICAID RESEARCH REVIEW 2012; 2:mmrr2012-002-03-a04. [PMID: 24800150 DOI: 10.5600/mmrr.002.03.a04] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND In an attempt to contain Medicaid pharmacy costs, nearly all states impose dispensing limits on medication days' supply. Although longer days' supply appears to increase the potential for medication wastage, previous studies suggest that it may also decrease pharmacy expenditures by reducing dispensing fees and drug ingredient costs. This study was conducted to determine whether 90-day refills at community pharmacies could improve adherence, minimize wastage, and control costs. METHODS This retrospective observational study used California Medicaid claims, from the Walgreens pharmacy chain dated January 2010, to identify 52,898 patients prescribed statin, antihypertensive, selective serotonin reuptake inhibitor (SSRI), or oral hypoglycemic medications. Adherence was measured by medication possession ratio (MPR) and persistency with a 30-day gap. Medication wastage was defined as a switch of drug or drug strength within the same therapeutic class that occurred before the expected refill date. RESULTS Adherence was 20% higher and persistency was 23% higher for the 90-day group than the 30-day group. This amounted to an average increase of 0.14 MPR and 44 days of continuous therapy. The two groups had comparable proportions of patients with wastage. After subtracting an average wastage cost of $7.34 per person per year (PPPY), all therapeutic classes had PPPY savings: statins ($7.70), antihypertensives ($10.80), SSRIs ($18.52), and oral hypoglycemics ($26.86). CONCLUSION Across four drug categories and compared to 30-day refills, patients with 90-day refills had greater medication adherence, greater persistency, nominal wastage, and greater savings.
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Adherence to uric acid treatment guidelines in a rheumatology clinic. Clin Rheumatol 2012; 31:1707-11. [PMID: 22948225 DOI: 10.1007/s10067-012-2081-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 08/05/2012] [Accepted: 08/24/2012] [Indexed: 10/27/2022]
Abstract
The aim of this study was to evaluate adherence to recommended serum uric acid levels in the rheumatology outpatients department of a university teaching hospital. We performed a retrospective study of all patients with a definitive diagnosis of gout attending our subspecialty gout clinic between 1 January 2010 and 31 December 2010. We evaluated adherence with two recently suggested uric acid thresholds, <300 μmol/L (<5 mg/dL) and <360 μmol/L (<6 mg/dL). Patient management was judged to adhere to the guidelines if either (1) the latest serum uric acid level was less than the specified guideline targets or (2) uric acid-lowering therapy was titrated upwards or the agent changed if the serum uric acid was above the guideline targets. One hundred two patients with a definitive diagnosis of gout attended the outpatients department between 1 January 2010 and 31 December 2010 and were included in the study. Median serum uric acid level was 331 μmol/L (IQR 276-456 μmol/L). Eighty-six patients (84 %) were treated with allopurinol, six patients (6 %) were treated with febuxostat (one of whom also received probenecid), and one with rasburicase. In 80 patients (78 %), the management adhered to a target guideline of <360 μmol/L (<6 mg/dL). In 66 patients (65 %), the management adhered to a target guideline of <300 μmol/L (<5 mg/dL). A treat-to-target approach has the potential to improve patient outcomes in the management of gouty arthritis. Our study shows encouraging results with the majority of patients on appropriate therapy and reaching recommended targets.
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Bell AM, Fonda SJ, Walker MS, Schmidt V, Vigersky RA. Mobile phone-based video messages for diabetes self-care support. J Diabetes Sci Technol 2012; 6:310-9. [PMID: 22538140 PMCID: PMC3380772 DOI: 10.1177/193229681200600214] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study examined whether mobile phone-based, one-way video messages about diabetes self-care improve hemoglobin A1c (A1C) and self-monitoring of blood glucose (SMBG). METHODS This was a 1-year prospective randomized trial with two groups. The active intervention lasted 6 months. The study enrolled 65 people with A1C >8.0% who were established (>6 months) patients in the endocrinology clinics of the Walter Reed Health Care System. Participants were randomized to receive "usual care" or self-care video messages from their diabetes nurse practitioner. Video messages were sent daily to cell phones of study participants. Hemoglobin A1c and SMBG data were collected at 0, 3, 6, 9, and 12 months. RESULTS Participants who received the messages had a larger rate of decline in A1C than people who received usual care (0.2% difference over 12 months, adjusting for covariates; p = .002 and p = .004 for the interaction between time and group and for the quadratic effect of time by group, respectively). Hemoglobin A1c decline was greatest among participants who received video messages and viewed >10 a month (0.6% difference over 12 months, adjusting for covariates; p < .001 for the interaction between time and group and the quadratic effect). Self-monitoring of blood glucose metrics were not related to the intervention. CONCLUSIONS A one-way intervention using mobile phone-based video messages about diabetes self-care can improve A1C. Engagement with the technology is an important predictor of its success. This intervention is simple to implement and sustain.
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Affiliation(s)
- Amanda M. Bell
- Department of Endocrinology and Metabolism, Walter Reed National Military Medical CenterBethesda, Maryland
| | - Stephanie J. Fonda
- Diabetes Institute, Walter Reed National Military Medical CenterBethesda, Maryland
| | - M. Susan Walker
- Department of Endocrinology and Metabolism, Walter Reed National Military Medical CenterBethesda, Maryland
- Diabetes Institute, Walter Reed National Military Medical CenterBethesda, Maryland
| | - Virginia Schmidt
- Department of Endocrinology and Metabolism, Walter Reed National Military Medical CenterBethesda, Maryland
- Diabetes Institute, Walter Reed National Military Medical CenterBethesda, Maryland
| | - Robert A. Vigersky
- Diabetes Institute, Walter Reed National Military Medical CenterBethesda, Maryland
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Pesa JA, Van Den Bos J, Gray T, Hartsig C, McQueen RB, Saseen JJ, Nair KV. An evaluation of the impact of patient cost sharing for antihypertensive medications on adherence, medication and health care utilization, and expenditures. Patient Prefer Adherence 2012; 6:63-72. [PMID: 22298945 PMCID: PMC3269319 DOI: 10.2147/ppa.s28396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To assess the impact of patient cost-sharing for antihypertensive medications on the proportion of days covered (PDC) by antihypertensive medications, medical utilization, and health care expenditures among commercially insured individuals assigned to different risk categories. METHODS Participants were identified from the Consolidated Health Cost Guidelines (CHCG) database (January 1, 2006-December 31, 2008) based on a diagnosis (index) claim for hypertension, continuous enrollment ≥12 months pre- and post-index, and no prior claims for antihypertensive medications. Participants were assigned to: low-risk group (no comorbidities), high-risk group (1+ selected comorbidities), or very high-risk group (prior hospitalization for 1+ selected comorbidities). The relationship between patient cost sharing and PDC by antihypertensive medications was assessed using standard linear regression models, controlling for risk group membership, and various demographic and clinical factors. The relationship between PDC and health care service utilization was subsequently examined using negative binomial regression models. RESULTS Of the 28,688 study patients, 66% were low risk. The multivariate regression model supported a relationship between patient cost sharing per 30-day fill and PDC in the following year. For every US$1.00 increase in cost sharing, PDC decreased by 1.1 days (P < 0.0001). Significant predictors of PDC included high risk, older age, gender, Charlson Comorbidity Index score, geography, and total post-index insurer- and patient-paid costs. An increase in PDC was associated with a decrease in all-cause and hypertension-related inpatient, outpatient, and emergency room visits and medical, pharmacy, and total costs. CONCLUSIONS The trend has been for managed care organizations and employers to require patients to bear a greater out-of-pocket burden for health care resources consumed. This study illustrates the potential adverse effects of higher patient cost sharing among patients with hypertension stratified by different risk levels. A decrease in PDC was predictive of higher resource utilization and health care costs, which should be of interest to payers and employers alike.
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Affiliation(s)
| | | | | | | | | | - Joseph J Saseen
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kavita V Nair
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Broder MS, Zazzali JL, Chang E, Yegin A. Concomitant asthma medication use by patients receiving omalizumab 2003-2008. J Asthma 2012; 48:1058-62. [PMID: 22091742 DOI: 10.3109/02770903.2011.631241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine patterns of omalizumab use in the first 5 years of its availability. METHODS Our study comprised a series of descriptive retrospective cohort analyses using healthcare claims data. The study population comprised patients of any age who had omalizumab claims in the 5 years after 1 July 2003, and we created five 1-year cohorts from this population. Each cohort included patients continuously enrolled for at least 12 months with ≥2 omalizumab claims during the year. Cohorts contained between 302 and 1382 unique omalizumab users, and over 99% of patients with an omalizumab claim had at least one asthma diagnosis. RESULTS In all years, the specialty most commonly seen in conjunction with the initial omalizumab prescription was allergy/immunology. In all years, omalizumab was used in conjunction with three or more additional classes of asthma medications at least 70% of the time and with five or more classes at least 33% of the time; the proportion of patients filling omalizumab prescriptions who had no other concomitant classes of asthma medications varied from 4% to 8%. The most common pattern of asthma medication treatment in all years was omalizumab with combination steroids/long-acting beta-agonist inhaler, a leukotriene receptor antagonist, a short-acting beta-agonist inhaler, and at least one course of oral corticosteroids. CONCLUSIONS In this study of a large sample of commercial health insurance claims covering the first 5 years after approval of omalizumab, we found that omalizumab was infrequently used as a single agent or without concomitant inhaled corticosteroids, and most omalizumab prescriptions came from specialist physicians.
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Affiliation(s)
- Michael S Broder
- Partnership for Health Analytic Research, Beverly Hills, CA, USA
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16
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Garfield RL, Damico A. Medicaid Expansion Under Health Reform May Increase Service Use And Improve Access for Low-Income Adults With Diabetes. Health Aff (Millwood) 2012; 31:159-67. [DOI: 10.1377/hlthaff.2011.0903] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Rachel L. Garfield
- Rachel L. Garfield ( ) is a senior researcher and associate director at the Kaiser Commission on Medicaid and the Uninsured, in Washington, D.C
| | - Anthony Damico
- Anthony Damico is a statistical analyst at the Kaiser Family Foundation in Washington, D.C
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17
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Abstract
BACKGROUND Performance measurement at the provider group level is increasingly advocated, but different methods for selecting patients when calculating provider group performance have received little evaluation. OBJECTIVE We compared 2 currently used methods according to characteristics of the patients selected and impact on performance estimates. RESEARCH DESIGN, SUBJECTS, AND MEASURES We analyzed Medicare claims data for fee-for-service beneficiaries with diabetes ever seen at an academic multispeciality physician group in 2003 to 2004. We examined sample size, sociodemographics, clinical characteristics, and receipt of recommended diabetes monitoring in 2004 for the groups of patients selected using 2 methods implemented in large-scale performance initiatives: the Plurality Provider Algorithm and the Diabetes Care Home method. We examined differences among discordantly assigned patients to determine evidence for differential selection regarding these measures. RESULTS Fewer patients were selected under the Diabetes Care Home method (n=3558) than the Plurality Provider Algorithm (n=4859). Compared with the Plurality Provider Algorithm, the Diabetes Care Home method preferentially selected patients who were female, not entitled because of disability, older, more likely to have hypertension, and less likely to have kidney disease and peripheral vascular disease, and had lower levels of predicted utilization. Diabetes performance was higher under Diabetes Care Home method, with 67% versus 58% receiving >1 A1c tests, 70% versus 65% receiving ≥1 low-density lipoprotein (LDL) test, and 38% versus 37% receiving an eye examination. CONCLUSIONS The method used to select patients when calculating provider group performance may affect patient case mix and estimated performance levels, and warrants careful consideration when comparing performance estimates.
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Strope SA, Elliott SP, Saigal CS, Smith A, Wilt TJ, Wei JT. Urologist compliance with AUA best practice guidelines for benign prostatic hyperplasia in Medicare population. Urology 2011; 78:3-9. [PMID: 21601254 PMCID: PMC3126893 DOI: 10.1016/j.urology.2010.12.087] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 12/13/2010] [Accepted: 12/13/2010] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To improve benign prostatic hyperplasia (BPH) care, the American Urological Association created the best practice guidelines for BPH management. We evaluated the trends in use of BPH-related evaluative tests and the extent to which urologists comply with the guidelines for these evaluative tests. METHODS From a 5% random sample of Medicare claims from 1999 to 2007, we created a cohort of 10,248 patients with new visits for BPH to 748 urologists. The trends in use of BPH-related testing were determined. After classifying urologists by compliance with the best practice guidelines, the models were fit to determine the differences in the use of BPH-related testing among urologists. Additional models were used to define the extent to which individual BPH-related tests influenced guideline compliance. RESULTS The use of most BPH testing increased with time (P<.001) except for prostate-specific antigen (declined; P<.001) and ultrasonography (P=.416). Northeastern and Midwestern urologists were more likely to be in the lowest compliance group compared with Southern and Western urologists (29%, 27%, 13%, and 19%, respectively; P=.01). The testing associated with high guideline compliance included urinalysis and prostate-specific antigen measurement (P<.01 for both). Prostate ultrasonography (P=.03), cystoscopy (P<.01), uroflow (P<.01), and postvoid residual urine volume determination (P=.02) were associated with low guideline compliance. Urodynamics, postvoid residual urine volume, cytology, serum creatinine, and upper tract imaging were not strongly associated with guideline compliance. CONCLUSIONS Despite the American Urological Association guidelines for BPH care, wide variations in the evaluation and treatment were seen. Improving guideline adherence and reducing variation could improve BPH care quality.
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Affiliation(s)
- Seth A Strope
- Division of Urology Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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