An Integrated Health-System Specialty Pharmacy Model for Coordinating Transitions of Care: Specialty Medication Challenges and Specialty Pharmacist Opportunities

Clinical Considerations for Healthcare Provider-Administered Lipid-Lowering Medications

Atherosclerotic cardiovascular disease (ASCVD), a leading cause of mortality and morbidity, is associated with a substantial healthcare and economic burden. Reduction of low-density lipoprotein cholesterol (LDL-C) to guideline-recommended goals is crucial in the prevention or management of ASCVD, particularly in those at high risk. Despite the availability of several effective lipid-lowering therapies (LLTs), up to 80% of patients with ASCVD do not reach evidence-based LDL-C goals. This nonattainment may be due to poor adherence to, and lack of timely utilization of, LLTs driven by a range of variables, including polypharmacy, side effects, clinical inertia, costs, and access issues. Inclisiran was approved by the US Food and Drug Administration in 2021 as a novel, twice-yearly, healthcare provider (HCP)-administered LLT. In-office administration allows HCPs more control of drug acquisition, administration, and reimbursement, and may allow for more timely care and increased patient monitoring. In the USA, in-office administered drugs are considered a Medical Benefit and can be acquired and reimbursed using the "buy-and-bill" process. Buy-and-bill is a standard system for medication administration already established in multiple therapeutic areas, including oncology, vaccines, and allergy/immunology. Initiating in-office administration will involve new considerations for clinicians in the cardiovascular specialty, such as the implementation of new infrastructure and processes; however, it could ultimately increase treatment adherence and improve cardiovascular outcomes for patients with ASCVD. This article discusses the potential implications of buy-and-bill for the cardiology specialty and provides a practical guide to implementing HCP-administered specialty drugs in US clinical practice.

Lessons Pharmacy Practice in India Should Adopt From Advanced Nations: A Review

In India, pharmacy practice is still at a developing stage with the majority of the graduates taking the industry pathway. Currently, there are only a few pharmacists who have been board-certified by the Board of Pharmacy Specialities (BPS), which is the most established pharmacist board certification program globally. Even though India is the largest global exporter of generic medications, pharmacy practice is yet to gain stronghold within its healthcare scenarios. In this article, we aim to examine the development of pharmacy practice from a global viewpoint and scale down to the recent modern practice, particularly in advanced nations. Furthermore, we assess the ways through which pharmacy practice can be enhanced in India. Notably, with several pharmacy practice graduates completing their studies in India yearly, pharmacy practice is projected to significantly grow in the coming years. Gaining a proper understanding of and embracing advanced clinical pharmacy practices will improve the domain of pharmacy practice among both junior and senior pharmacists. Moreover, enrolling in and receiving international accreditations such as the Board of Pharmacy Specializations (BPS) will validate the practice standards being offered in India as compared to other developed countries, i.e., the US. The main objective of this review is to assess various means through which pharmacy practice can be improved in India.

Incorporating social determinants of health into patient care workflows within a health-system specialty pharmacy

BACKGROUND

The influence of adverse factors on social determinants of health (SDOH) and their impact on patient outcomes is widely recognized. Pharmacists, as accessible healthcare professionals, can play a pivotal role in identifying and addressing SDOH concerns. Health-system specialty pharmacies have consistently assisted patients in accessing expensive specialty medications and ensuring adherence to therapy. As such, they are uniquely positioned to address SDOH concerns of patients.

OBJECTIVE

To assess the effectiveness of incorporating standardized SDOH screening and referral methods into the patient care workflows of a health-system specialty pharmacy.

PRACTICE DESCRIPTION

The University of North Carolina Health Care (UNC Health) Specialty and Home Delivery Pharmacy is a health-system owned specialty pharmacy serving patients in North Carolina, South Carolina, and Virginia. It holds accreditations from the Utilization Review Accreditation Commission and Accreditation Commission for Health Care.

PRACTICE INNOVATION

A standardized SDOH screening and referral method were integrated into patient care workflows of a health-system specialty pharmacy. If SDOH concerns were identified upon screening by a specialty pharmacist, patients were referred to an entity within the health-system responsible for connecting patients to local community resources to address their SDOH concerns.

EVALUATION METHODS

The types of SDOH concerns, frequency of SDOH referrals, referral turnaround time, outcomes of the referrals, and patient demographics were evaluated to determine the impact of this project. Descriptive statistics were used to analyze results.

RESULTS

Sixty-nine patients were included (female: n = 38, 55.1%; age (mean±SD: 48.9 ± 16.3). Eighty-seven SDOH concerns were reported, 54 patients (78.3%) were connected to local resources upon referral, and the average turnaround time of referrals was 2.2 business days.

CONCLUSION

The findings of this pilot study highlight the effectiveness of incorporating SDOH screening and referral methods into specialty pharmacy workflows. Specialty pharmacies can successfully identify and address nonmedical factors impacting patients.

Evaluation of the impact of a clinic infusion pharmacist on the retention of infusion therapy

PURPOSE

To evaluate the impact of an embedded clinic infusion pharmacist on the retention of outpatient infusion therapy.

METHODS

This was a single-center, pre-post, retrospective and prospective cohort study at a large quaternary care academic medical center. Outpatient infusion administrations were included in this study if they originated from a clinic with an embedded clinic infusion pharmacist and were targeted high-impact medications. The primary outcome was the impact of embedded clinic infusion pharmacists on the number of infusion administrations from before to after implementation. Secondary outcomes included the time from order entry to first infusion, return on investment (ROI), and level of utilization of various infusion centers. Outpatient infusion and injection administrations were divided into 2 cohorts: a preimplementation cohort administered from April 2021 to March 2022 and a postimplementation cohort administered from April 2022 to March 2023.

RESULTS

A total of 12,257 outpatient infusion administrations were included in the study from the inflammatory bowel disease, Vanderbilt Eye Institute, and neurology clinics. As the embedded infusion pharmacists began working within the respective clinics, a statistically significant increase could be seen in the overall administration of high-impact medications (from 5,683 infusions before implementation to 6,574 infusions after implementation; P < 0.001). The ROI for an embedded clinic infusion pharmacist's services was greater than 2,500%.

CONCLUSION

Retention of outpatient infusion therapy can be significantly increased with a positive ROI through allocation of pharmacist resources to areas initiating infusions. Health systems can utilize this model to improve patient access to infusion and injection therapies at entity-owned clinics.

Health-system specialty pharmacy: Overview of a hybrid clinical model

PURPOSE

The prevalence of specialty pharmacies has grown, especially within the hospital setting. These pharmacies have shown benefits in the areas of patient education and adherence, financial support, and patient and provider satisfaction. Currently, there are gaps in literature describing use of a hybrid clinical model in health-system specialty pharmacies.

SUMMARY

The UofL Health - UofL Hospital Specialty Pharmacy (UofL Health SP) is attached to a retail pharmacy in a larger health system. Pharmacists in the UofL Health SP utilize a hybrid clinical model in which they split their time between working in a specialty clinic and staffing in the specialty pharmacy. The specialty pharmacy and its oncology satellite pharmacy each have a primary staffing pharmacist, and 5 other pharmacists participate in this hybrid clinical model. In addition to the specialty pharmacists, pharmacy technicians and patient care advocates support the operations of the specialty pharmacy and ensure financial access to medications for patients.

CONCLUSION

With the hybrid clinical model at UofL Health SP, there is increased workflow efficiency and better communication between specialty clinics and the specialty pharmacy, which results in a streamlined patient experience. Additionally, there has been an increase in specialty pharmacy prescriptions dispensed in the specialty pharmacy since the implementation of this hybrid clinical model.

Comparison of time to treatment initiation of specialty medications between an integrated health system specialty pharmacy and external specialty pharmacies

BACKGROUND

Specialty medications are commonly dispensed through specialty pharmacies equipped to meet unique monitoring and dispensing requirements. Integrated health system specialty pharmacies (HSSPs) coordinate with health system providers to deliver specialty medications to patients and ameliorate barriers to care. However, payors may restrict specialty medication fills to specialty pharmacies external to the health system, potentially leading to delayed treatment.

OBJECTIVE

To compare time to treatment initiation among patients whose specialty medications were transferred to external pharmacies and patients whose medications were filled at an internal HSSP.

METHODS

This was a retrospective, propensity-matched cohort study examining time to treatment initiation in patients with a specialty medication referral to the University of Kentucky HealthCare Specialty Pharmacy between July 1, 2021, and July 1, 2022. Patients were classified into cohorts by receipt of dispensing services from the internal HSSP or an external specialty pharmacy. Data collected via chart review included insurance type, reason for prescription transfer, dates of service (including prescription order, transfer, and receipt of medication), and whether a prior authorization or clinical intervention was performed. Subgroup analyses were performed for patients requiring a prior authorization or clinical intervention. The Wilcoxon signed-rank test was used to assess for statistically significant differences in time to treatment initiation between cohorts.

RESULTS

A total of 560 patients with external transfers were identified for inclusion into the study, and after exclusion criteria were applied, 408 external transfer patients were propensity matched 1:1 to 408 patients with internal fills (total n = 816). Time to treatment initiation was significantly longer in the external transfer cohort as compared with the internal fill cohort, (18 days vs 12 days; P < 0.0001). The internal fill cohort had a greater mean days from provider order to the medication being ready to fill compared with the external transfer cohort (10 days vs 6 days; P < 0.0001). The internal fill cohort had fewer mean days from the medication being ready to fill to patient receipt of the medication as compared with the external transfer cohort (2 days vs 12 days; P < 0.0001). Similar findings were observed in the subgroup analyses.

CONCLUSIONS

Average time to treatment initiation was 6 days shorter for patients whose specialty medications were filled at this HSSP compared with externally transferred patients. Delays in therapy can cause a negative impact on patient care and disease state management, with increased concern for specialty populations. The results of this study highlight the need for continued discussion about policies that limit patient choice to in-network pharmacies.

Utilization, reimbursement, and price trends for Hepatitis C virus medications in the US Medicaid programs: 2001-2021

Background

Hepatitis C Virus (HCV) remains a challenging health problem worldwide, with increasing incidence despite being curable with Direct Acting Antiviral (DAA) agents.

Objective

This study aimed to describe the utilization, reimbursement, and price trends of HCV treatments and evaluate the influence of treatment guidelines and policies.

Methods

A retrospective, descriptive drug utilization study conducted using the outpatient pharmacy data extracted from the Centers for Medicaid and Medicare Services State Drug Utilization Data between 2001 and 2021. All HCV treatments approved in the US were included, conventional therapy (CT), and DAA agents. The annual secular trends were calculated for each medication's total number of prescriptions, reimbursements, and prices. The average reimbursement per prescription was calculated and utilized as a proxy of prices. The HCV treatment guideline and policies and legislation were evaluated overtime to measure the impact on the trends.

Results

Despite CT having a higher total utilization, DAA agents commanded significantly greater reimbursements, with 4.1 billion USD for CT and 19.45 billion USD for DAA agents. CT utilization increased rapidly and dominated the market until 2011, peaking at 379,696 prescriptions in 2003 but declining afterward. DAA agents' utilization increased rapidly in their first year: i.e., sofosbuvir reached 50,377 prescriptions with 1.3 billion USD in 2014, while ledipasvir/sofosbuvir reached 79,387 prescriptions with 2 billion USD in 2015. The average price per prescription was high for the DAA agents, like 24,992 USD for sofosbuvir and 22,787 USD for ledipasvir/sofosbuvir, compared to CT medications ribavirin, around 500 USD, and pegINF, around 3000 USD. The new DAA agents replaced CT, and initiating market competition among DAA agents.

Conclusion

The introduction of multiple DAA agents slightly changed their prescription prices but remained high during the study period. The recent increase in HCV incidence cases indicates accessibility issues for costly and effective DAA agents, with treatment guidelines and policies playing a critical role in shaping these trends.

Insurance Approval Delay of Biologic Therapy Dose Escalation Associated with Disease Activity in Patients with Inflammatory Bowel Disease

BACKGROUND

Dose escalation of self-injectable biologic therapy for inflammatory bowel diseases may be required to counteract loss of response and/or low drug levels. Payors often require completion of a prior authorization (PA), which is a complex approval pathway before providing coverage. If the initial PA request is denied, clinic staff must complete a time and resource-intensive process to obtain medication approval.

AIMS

This study measured time from decision to dose escalate to insurance approval and evaluated impact of approval time on disease activity.

METHODS

This was a single-center retrospective analysis of adult patients with IBD prescribed an escalated dose of biologic therapy at an academic center with an integrated specialty pharmacy team from January to December 2018. Outcomes included time to insurance approval and the association between approval time and follow-up C-reactive protein (CRP) and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) scores. Associations were tested using linear regression analyses.

RESULTS

220 patients were included, median age 39, 53% female, and 96% white. Overall median time from decision to dose escalate to insurance approval was 7 days [interquartile range (IQR) 1, 14]. Approval time was delayed when an appeal was required [median of 29 days (IQR 17, 43)]. Patients with a longer time to insurance approval were less likely to have CRP improvement (p = 0.019). Time to insurance approval did not significantly impact follow-up SIBDQ scores.

CONCLUSION

Patients who had a longer time to insurance approval were less likely to have improvement in CRP, highlighting the negative clinical impact of a complex dose escalation process.

Effect on medication adherence of applying a specialty pharmacy care model to nonspecialty medications: A quasi-experimental cohort study

PURPOSE

Medication nonadherence is a multifactorial healthcare problem that contributes to increased healthcare costs and morbidity. To improve medication adherence, specialty pharmacies offer services not typically provided by retail pharmacies such as benefits investigation, financial assistance, medication synchronization, and proactive refill reminders. This study assessed the impact of the specialty pharmacy care model on medication adherence for patients on nonspecialty medications.

METHODS

This study was a quasi-experimental cohort comparison of patients who were transferred from a health-system retail pharmacy to a health-system specialty pharmacy between April 1, 2020, and June 30, 2021. The primary endpoint in this study was the difference in mean medication adherence proportion of days covered (PDC) between the post-transfer and pretransfer periods. Secondary outcomes included the proportion of patients with PDC of greater than 80%, medication adherence by drug group, shipment volumes, number of medications per shipment, and the mean copay per medication.

RESULTS

In this study of 163 patients, use of a specialty pharmacy care model led to a significant increase of 7.0% in mean PDC, a significant increase in the percentage of patients with PDC of greater than 80%, a significant decrease in the number of shipments per 30 days per patient, a significant increase in the number of medications included per shipment, and a significant reduction in the mean copay per medication.

CONCLUSION

The findings in this study suggest that the application of the specialty pharmacy care model to nonspecialty pharmacy patients may improve medication adherence, decrease the number of shipments per patient sent from the pharmacy, and reduce patient copays.

2022 ASHP Survey of Health-System Specialty Pharmacy Practice: Clinical Services

PURPOSE

Results of the first ASHP national survey of clinical services provided by health-system specialty pharmacies (HSSPs) are presented.

METHODS

A survey questionnaire was developed by 26 HSSP contacts after reviewing available literature on the role and services of HSSPs. After pilot and cognitive testing resulting in a final questionnaire of 119 questions, a convenience sample of 441 leaders in HSSPs was contacted using email and invited to participate in the survey.

RESULTS

The survey response rate was 29%. Almost half of respondents (48%) had offered pharmacy services for 7 years or more, and most (60%) dispensed more than 15,000 prescriptions annually. Respondents most commonly (42%) reported a specialist model wherein staff are dedicated to specific specialty disease states. Over half of respondents reported providing several medication access, pretreatment assessment, and initial counseling services to patients referred to them, regardless of whether the HSSP was used for medication fulfillment. All HSSP activities were noted to be documented in the electronic health record and visible to providers frequently or always. Almost all respondents noted that HSSP pharmacists have a role in specialty medication selection. Disease-specific outcomes were tracked in 95% of responding HSSPs, with 67% reporting that outcomes were used to drive patient monitoring. HSSPs were often involved in continuity of care services such as transitions of care (reported by 89% of respondents), referral to other health-system services (53%), and addressing social determinants of health (60%). Most respondents (80%) reported providing clinical education to specialty clinic staff, including medicine learners (62%). Though only 12% of respondents had dedicated outcomes research staff, many reported annually publishing (47%) or presenting (61%) outcomes research.

CONCLUSION

HSSPs are a clinical and educational resource for specialty clinics and have developed robust patient care services that encompass the patient journey from before specialty medication selection through treatment monitoring and optimization.

Adherence and persistence to self-administered disease-modifying therapies in patients with multiple sclerosis: A multisite analysis

BACKGROUND

Though there are several disease-modifying therapy (DMT) options for patients with multiple sclerosis (MS), treatment outcomes rely on patient adherence and persistence. Previous studies have demonstrated suboptimal adherence rates and high rates of early treatment discontinuation. Health-system specialty pharmacies (HSPPs) are a growing practice model that have demonstrated adherence and persistence benefits through single site evaluations. Research is needed across multiple HSSPs to understand and validate the outcomes of this practice model.

METHODS

A multisite prospective cohort study was performed including patients with at least three fills of a DMT between January 2020 and June 2021 at an HSSP. Patients were excluded due to pregnancy or death. Enrollment occurred for 6 months followed by 12 months of follow-up. Adherence was measured using pharmacy claims to calculate proportion of days covered (PDC) during the follow-up period. Time to non-persistence was calculated as the time from an index DMT fill to the first date of a gap of >60 days between medication exhaust and fulfillment dates. Adherence and persistence calculations were assessed at the therapeutic class level (any self-administered DMT dispensed by the HSSPs). The Kaplan-Meier method was used to present the probability of being persistent, and Cox proportional hazards regression analysis was used to estimate hazard ratios of factors associated with non-persistence, which included age, sex, study site, insurance type, and whether the patient switched medication as potential factors.

RESULTS

The most common self-administered DMTs filled among 968 patients were glatiramer acetate (32%), fingolimod (18%), and dimethyl fumarate (18%). Most patients (96%) did not switch DMT during the study period. The median PDC was 0.97 (interquartile range 0.90-0.99), which was similar across all sites. Patients who had at least one DMT switch were 76% less likely to have a higher PDC than those who did not have any switch after adjusting for other covariates (Odds ratio: 0.24, 95% confidence interval [CI]: 0.14-0.40, p<0.001). Most patients (86%) were persistent to DMT over the 12-month study period. Among those non-persistent, median time to non-persistence was 231 (IQR 177-301) days. Patients who switched medications were 2.4 times more likely to be non-persistent (95% CI: 1.3 - 4.5, p = 0.005). The most common reasons for non-persistence were discontinuation/medication held for an extended period (30%), often due to patient or prescriber decision (75%).

CONCLUSION

High rates of DMT adherence and persistence were seen among patients serviced by HSSPs, indicating potential benefits of this model for patients with MS. Switching DMTs was associated with lower adherence and persistence and may be an opportunity for added care coordination or resources to optimize therapy transitions.

Specialty pharmacy: Incorporating workflow management and medication access into pharmacy lecture and laboratory courses

BACKGROUND AND PURPOSE

The purpose of this study was to implement and evaluate a specialty pharmacy workshop across pharmacy management and skills lab courses.

EDUCATIONAL ACTIVITY AND SETTING

A specialty pharmacy workshop was developed and implemented. The lecture cohort (fall 2019) consisted of a 90-min lecture in pharmacy management. The lecture/lab cohort (fall 2020) consisted of the lecture plus a 30-min pre-lab video assignment and a two-hour laboratory activity. At the completion of lab, students presented findings virtually to specialty pharmacists. Pre-surveys and post-surveys assessed knowledge (10 items), self-confidence (9 items), and attitudes (11 items).

FINDINGS

Of the 123 students enrolled in the course, 88 students (71.5%) completed pre- and post-surveys. On a 10-point scale, knowledge improved from 5.6 (SD = 1.5) to 6.5 (SD = 2.0) points in the lecture cohort and from 6.0 (SD = 1.6) to 7.3 (SD = 2.0) points in the lecture/lab cohort with a significance difference favoring the lecture/lab cohort. Perceived confidence improved for five out of nine items in the lecture cohort but improved significantly for all nine items in the lecture/lab cohort. Attitudes toward learning about specialty pharmacy were generally positive for both cohorts.

SUMMARY

The specialty pharmacy workshop exposed students to workflow management and medication access processes. Students perceived the workshop to be a relevant and meaningful, allowing them to feel confident in developing knowledge and understanding of specialty pharmacy topics. The workshop can be replicated at a larger scale with schools of pharmacy utilizing the integration between didactic and laboratory courses.

Specialty pharmacy turnaround time impediments, facilitators, and good practices

BACKGROUND: Patients receiving specialty medications have conditions that are often complex, high cost, and high need. Prompt treatment initiation is essential for the appropriate management of many conditions treated by specialty products. Improving the turnaround time (TAT) of specialty pharmacy prescriptions helps ensure patients receive the medication they need in the necessary time frame to optimize health outcomes. Despite a clinical justification for improved TAT, there is a gap in the literature describing what factors impact these times. OBJECTIVE: To determine factors that may influence specialty pharmacy TATs and to identify good practices that specialty pharmacies use to improve TAT. METHODS: This qualitative study used 4 focus groups with specialty pharmacy subject matter experts. Each focus group represented different specialty pharmacy types, including health system, payer-associated, retail chain, and independent specialty pharmacies. Attitudes, beliefs, and experiences regarding specialty pharmacy TAT were captured. Open-ended questions and prompts eliciting impediments, facilitators, and good practices associated with specialty pharmacy TAT were asked of participants. Data were analyzed thematically. RESULTS: Fifteen individuals participated across 4 focus groups: payer-associated (n = 4), independent (n = 3), health system (n = 5), and retail chain (n = 3) specialty pharmacies. Average TATs varied across specialty pharmacy type and by prescription type (clean vs intervention). Several interconnected themes were identified, including barriers with health benefits formulary management, prior authorization delays, differences in requirements between managed care organizations, and miscommunication with physicians, among others. Five subthemes were identified during the discussion of factors influencing TAT, including patient characteristics, pharmacy characteristics, provider characteristics, clinical situations, and health benefit design and formulary considerations. Pharmacy workflow improvements through technology integration are thought to improve TAT. In addition, participants noted facilitators including specialization among pharmacists and technicians in certain diseases, particularly hepatitis C and cancer. Some good practices included using patient financial advocates, technology integration, and a structured patient onboarding process, which were found to minimize delays caused by prior authorization, communication, and formularies. CONCLUSIONS: A multitude of factors impacting specialty pharmacy prescription TAT were identified. Multidisciplinary coordination between pharmacies, physicians, and managed care organizations is essential to ensure patients receive medications in the necessary time frame to optimize health outcomes. DISCLOSURES: This study was conducted with support from Pfizer.

Health-system specialty pharmacy role and outcomes: A review of current literature

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Specialty medications can have life-altering outcomes for patients with complex diseases. However, their benefit relies on appropriate treatment selection, patients' ability to afford and initiate treatment, and ongoing treatment optimization based on patient response to therapy. Mounting research demonstrates the benefits of the health-system specialty pharmacy (HSSP) in improving specialty medication access, affordability, and outcomes. The purpose of this rapid review is to describe the currently reported role and function of HSSP pharmacists and outcomes reported with use of the HSSP model, and to identify gaps in the literature where more information is needed to better understand the HSSP model and outcomes.

SUMMARY

Current literature describes the role of HSSP pharmacists in facilitating patient access, affordability, and initiation and maintenance of specialty medications. Though it is clear HSSP pharmacists are involved in treatment monitoring, often through utilizing the electronic health record, more information is needed to elucidate the frequency, method, and extent of monitoring. Despite several valuable continuity of care services reported to be provided by HSSPs, the breadth and degree of standardization of these services remains unclear. There is minimal literature describing HSSP education and research involvement. HSSPs have reported significant benefits of this patient care model, as demonstrated by higher adherence and persistence; better clinical outcomes; financial benefits to patients, payers and the health system; better quality of care; higher patient and provider satisfaction with services, and highly efficient specialty pharmacy services. More literature comparing clinical and diagnosis-related outcomes in HSSP versus non-HSSP patients is needed.

CONCLUSION

HSSPs provide comprehensive, patient-centered specialty medication management that result in improved care across the continuum of the specialty patient journey and act as a valuable resource for specialty clinics and patients beyond medication management. Future research should build on the current description of HSSP services, how services affect patient outcomes, and the impact HSSP network restrictions.

Pharmacist-managed multistep order transmittal for electronic specialty prescriptions reduces represcribing burden in ambulatory clinics: A retrospective cohort pilot study

BACKGROUND: Specialty medications pose unique prescribing challenges, including complexities with drug dosing and safety monitoring, need for prior authorization and patient financial assistance, use of payer-mandated specialty pharmacies, and special requirements for storage and handling. These challenges can lead to higher rates of represcribing for specialty clinic providers, who may be operating with inadequate information or limited resources. Multistep order transmittal (MSOT) is an electronic medical record (EMR) prescription work queue functionality used by a specialty pharmacy service to support select ambulatory clinics. OBJECTIVE: To explore the relationship between an MSOT specialty pharmacy support service and represcribing burden of specialty medications for providers in an ambulatory care setting. METHODS: A retrospective cohort pilot study was performed before and after MSOT implementation. Prescription data were queried from Sanford Health's EMR for patients who were electronically issued at least 1 prescription for an injectable biologic medication at a dermatology and rheumatology clinic. The pre-intervention group included index prescriptions prescribed between October 1, 2017, and June 20, 2018. The post-intervention group included index prescriptions prescribed between October 1, 2018, and June 20, 2019. Retrospective EMR review was completed to identify any prescriptions that were represcribed and the reason for represcribing. The primary outcome was the rate of represcribing. Secondary endpoints explored reason for represcribing, when it occurred. Nominal data were compared using Pearson's chi-square tests. Regressions were performed to account for potential confounders. RESULTS: The pre-intervention group included 880 index biologic prescriptions, and the post-intervention group included 941 index biologic prescriptions. The aggregate represcribing rate decreased from 12.73% in the pre-intervention group to 9.56% in the postintervention group (P = 0.03). Represcribing directly by providers as a result of needing to modify the destination pharmacy decreased significantly from 6.25% of the pre-intervention group to 0.64% of the post-intervention group (P < 0.01). However, represcribing due to patient preferences and prescribing errors increased significantly between the pre- and post-intervention groups, with patient preferences increasing from 0.91% to 2.55% (P = 0.01) and prescribing errors from 0.68% to 1.70% (P = 0.05), respectively. Represcribing due to provider preferences and payer restrictions remained similar between groups. CONCLUSIONS: Within 2 ambulatory care clinics in an integrated health care system, the use of pharmacist-managed MSOT reduced overall represcribing burden. The need to represcribe owing to wrong destination pharmacy was nearly eliminated, while appropriate represcribing to accommodate patient preferences and correct prescribing errors increased. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to disclose.

Association between health system specialty pharmacy use and health care costs among national sample of Medicare Advantage beneficiaries

BACKGROUND: Health care expenditures are growing rapidly. There is a growing body of literature showing that health system specialty pharmacy is associated with improvement in clinical outcomes; however, there is a lack of data on its effect on health care costs and utilization. OBJECTIVE: To perform exploratory research assessing the association between health system specialty pharmacy use and health care costs and utilization. METHODS: A retrospective cohort study was conducted examining medical and pharmacy claims from 2018 and 2019 of Medicare Advantage beneficiaries. Optum Advisory Service's proprietary deidentified Normative Health Information database was used, which includes claims, membership, and provider data for 12.6 million Medicare Advantage members. Members who filled a prescription at a health system specialty pharmacy and had a specialty provider participating in the health system specialty pharmacy care model in clinic were assigned to the intervention group. Members who did not use a health system specialty pharmacy but had the same provider (provider benchmark group) or different provider (network benchmark group) were considered as comparisons. The network benchmark group was further refined to match variation in health care cost due to geography. The primary outcome measure was total health care costs (across the medical and pharmacy benefit) on a per-patient per-month basis. Secondary outcomes were selected utilization drivers and cost subcomponents. Cost and utilization metrics were calculated on a risk-adjusted basis using Centers for Medicare & Medicaid Services Hierarchical Condition Categories (CMS-HCC) risk score methodology. Differences were assessed for categorical variables with chi-square tests, and 2-tailed t-tests were used for continuous variables. RESULTS: Of the analytic sample of 9,780 members used in this study, 208 (2.1%) used health system specialty pharmacy services. During the 2018 baseline period, total health care costs and utilization were similar after CMS-HCC risk score adjustment ($9,520 among health system specialty pharmacy users; $8,691 among the provider benchmark group; $9,510 among the network benchmark group) but lower in 2019 ($7,060, $7,683, and $8,152, respectively). The differences in 2019 were primarily driven by savings in pharmacy and free-standing physician-related costs. CONCLUSIONS: Use of a health system specialty pharmacy is associated with a lower health care cost. Further study is required to analyze how drug and disease-specific interactions influence total health care costs and utilization for health system specialty pharmacy populations. DISCLOSURES: This study was funded by Shields Health Solutions and completed with Optum Advisory Services, which provided all analysis and was the sole source of data. University of Massachusetts Medical School investigators were independent context experts, who volunteered their time for this study. Hellems is employed by Optum Advisory Services; Fasching and Smith are employed by Shields Health Solutions; and Soni and McManus are employed by the University of Massachusetts Medical School. Soni received support from the National Institute of General Medical Science (T32GM107000), National Center for Advancing Translational Sciences (TL1-TR001454), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (1F30HD091975-03). McManus's time was supported by R01HL126911, R01HL137734, R01HL137794, R01HL135219, R01HL136660, U54HL143541 from the National Heart, Lung and Blood Institute. McManus has received research support from Bristol Myers Squibb, Care Evolution, Samsung, Apple Computer, Pfizer, Biotronik, Boehringer Ingelheim, Philips Research Institute, Flexcon, Fitbit; has consulted for Bristol Myers Squibb, Pfizer, Philips, Samsung Electronics, Rose Consulting, Boston Biomedical Associates, and FlexCon; and is also a member of the Operations Committee and Steering Committee for the GUARD-AF Study (NCT04126486), sponsored by Bristol Meyers Squibb and Pfizer. The other authors have nothing additional to disclose. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Impact of Oncology Pharmacists on the Knowledge, Attitude, and Practices of Clinicians to Enhance Patient Engagement of Self-Administered Oral Oncolytics

Oncology clinical pharmacists are uniquely positioned to make interventions to impact the knowledge, attitudes, and practices of clinicians as well as patient activation and engagement. To accomplish this goal, pharmacists can target health system-related, provider-related, and patient-related factors to enhance patient-centered care and drive behavioral health changes. Interventions that pharmacists must tackle include educating team members and patients on the medication acquisition process, communicating urgency of treatment, optimizing workflows, facilitating guideline recommendations, preventing, and managing treatment toxicities, and promoting patient self-advocacy through education and shared decision-making. As crucial members of the healthcare team, oncology pharmacists can simplify highly complex treatment regimens to facilitate and optimize patients’ ownership of their care. This narrative review will focus on the example of venetoclax treatment in acute myeloid leukemia to demonstrate the impact that pharmacists provide that leads to behavioral change of patients and clinicians.

Re-Engineering Collaborative Practice in Primary Care: Integrating Community Pharmacy to the Clinic; Creating a Pharmacy Referral and Quality Circle

Pharmacy practice is part of a value chain made up of suppliers(S), inputs(I), processes(P), outputs(O), and customers(C). The interface between community pharmacies and clinic-based prescribers is complicated by challenges related to gaps in the design of the chain. The supplier-input-process-outcome-customer (SIPOC) model can be used to re-engineer the chain: integrating an intervening clinical pharmacist in the interface creates a structure for interprofessional collaboration and communication across the interface. This innovation has important implications for patient referral between clinic and pharmacy, and the future role and scope of all patient-facing pharmacists.

Development, implementation, and evaluation of a health outcomes and research program at an integrated health-system specialty pharmacy

PURPOSE

Health-system specialty pharmacies (HSSPs) provide high-quality, efficient, and collaborative care to patients receiving specialty therapy. Despite proven benefits of the integrated model, manufacturer and payer restrictions challenge the viability and utility of HSSPs. Vanderbilt Specialty Pharmacy developed a health outcomes and research program to measure and communicate the value of this model, drive improvement in patient care delivery, and advocate for recognition of HSSP pharmacists' role in patient care. The purpose of this descriptive report is to describe the development and results of this program.

SUMMARY

The health outcomes and research program began as an initiative for pharmacists to evaluate and convey the benefits they provide to patients, providers, and the health system. Early outcomes data proved useful in communicating the value of an integrated model to key stakeholders and highlighted the need to further develop research efforts. The department leadership invested resources to build a research program with dedicated personnel, engaged research experts to train pharmacists, and fostered internal and external collaborations to facilitate research efforts. As of March 2021, the health outcomes and research program team has published 33 peer-reviewed manuscripts, presented 88 posters and 7 podium presentations at national conferences, and received 4 monetary research awards. Further, the program team engages other HSSP teams to initiate and expand their own health outcomes research in an effort to empower all HSSPs in demonstrating their value.

CONCLUSIONS

The health outcomes and research program described has pioneered outcomes research among HSSPs nationwide and has proven valuable to specialty pharmacists, the health system, and key specialty pharmacy stakeholders.

Effect of clinical pharmacist interventions on cost in an integrated health system specialty pharmacy

BACKGROUND: Patients who are prescribed specialty medications require close monitoring, including assessment of laboratory parameters, toxicities, and adherence. Specialty pharmacies integrated within a health system are able to access records, assess therapy, and efficiently communicate with prescribers. OBJECTIVE: To analyze interventions made by clinical pharmacists within the Cleveland Clinic Specialty Pharmacy (CCSP) regarding cost avoidance for the health care system and improvements in patient safety. METHODS: This was a retrospective, observational study that analyzed pharmacist interventions regarding specialty hematology/oncology medications. Interventions were measured with pharmacist documentation within the electronic health record (EHR). The primary endpoint was the cost-avoidance effect of clinical pharmacist interventions resulting from pharmacist access to the EHR. Secondary endpoints included pharmacist interventions that led to additional ancillary or supportive care, time taken to perform interventions, total interventions according to new or refill status, and total interventions performed according to insurance subtype. RESULTS: 547 interventions were identified during the study period, with a total cost avoidance of $1,508,131. The intervention with the highest overall cost savings was discontinuation of therapy ($290,091). The highest cost savings, based on intervention type, was lack of follow-up ($30,892). The medication with the highest overall cost savings was abiraterone ($273,160). Gilteritinib was associated with the highest cost saving per intervention ($28,350). The indication with the highest overall cost savings was prostate cancer ($402,601), while cutaneous T-cell lymphoma had the highest cost savings per intervention ($25,424). CONCLUSIONS: CCSP pharmacist interventions led to significant overall cost savings to the health care system. Although not measured in this study, it is reasonable to expect that decreased medication use may also translate into less financial burden for patients, as well as for pharmacy benefit managers. Access to the EHR and integration within the health care system may have facilitated the cost savings. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to disclose.