Optimizing HIV PrEP Persistence: Does Your Pharmacy Matter?

Persistence to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is integral to preventing new HIV infections. Previous studies have shown real-world PrEP persistence is low and insight is needed into PrEP delivery strategies that improve persistence. This single-center, retrospective, cohort study measured persistence in patients filling PrEP through an integrated health-system specialty pharmacy (HSSP) compared to those filling at external pharmacies. The Kaplan-Meier estimates for persistence probability at 6, 12, and 18 months were 0.87 (95% CI 0.79-0.95), 0.75 (95% CI 0.66-0.86), and 0.64 (95% CI 0.53-0.76) for the HSSP cohort compared to 0.65 (95% CI 0.51-0.83), 0.41 (95% CI 0.28-0.62), and 0.32 (95% CI 0.2-0.53), respectively, for the non-HSSP cohort (log-rank p < 0.001, [Formula: see text] = 11.2). Cox PH modeling showed that patients using a non-HSSP were 2.7 times more likely to be non-persistent than HSSP patients (HR 2.7, 95% CI 1.6-4.7, p < 0.001, [Formula: see text] = 12.61), demonstrating patients were better maintained on PrEP therapy when their prescriptions were filled with the HSSP.

Patient-Tailored Interventions to Improve Specialty Medication Adherence: Results from a Prospective Randomized Controlled Trial

BACKGROUND

Specialty medication nonadherence results in poor clinical outcomes and increased costs. This study evaluated the impact of patient-tailored interventions on specialty medication adherence.

METHODS

A pragmatic, randomized controlled trial was conducted at a single-center health-system specialty pharmacy from May 2019 to August 2021. Participants included recently nonadherent patients prescribed self-administered specialty medications from multiple specialty clinics. Eligible patients were stratified by historical clinic rates of nonadherence and randomized 1:1 to usual care or intervention arms. Intervention patients received patient-tailored interventions and 8 months of follow-up. A Wilcoxon test was used to analyze the difference in 6-, 8-, and 12-month post-enrollment adherence, calculated using proportion of days covered, between the intervention and usual care arms.

RESULTS

Four hundred and thirty eight patients were randomized. Baseline characteristics were similar between groups: mostly women (68%), white (82%), with a median age of 54 years (interquartile range, 40, 64). The most common reasons for nonadherence in the intervention arm were memory (37%) and unreachability (28%). There was a significant difference in median proportion of days covered between patients in the usual care and intervention arms at 8-months (0.88 vs 0.94, P < .001), 6-months (0.90 vs 0.95, P = .003), and 12-months post-enrollment (0.87 vs 0.93, P < .001).

CONCLUSIONS

Patient-tailored interventions resulted in significant specialty medication adherence improvement compared with standard of care. Specialty pharmacies should consider targeting nonadherent patients for adherence interventions.

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.

Development of an integrated rheumatoid arthritis simulation that reinforces specialty pharmacy and managed care concepts

BACKGROUND AND PURPOSE

As pharmacy services expand, it is critical for schools/colleges of pharmacy to prepare learners to provide patient care in a variety of settings and to subsequently assess skills that are necessary for clinical practice. The objectives of this study were to (1) develop and implement a simulation that required students to integrate knowledge from multiple courses and disciplines, (2) assess students' performance and perceptions of the activity, and (3) measure student confidence related to managed care, specialty pharmacy, and clinical and foundational concepts prior to and after the simulation.

EDUCATIONAL ACTIVITY AND SETTING

Faculty developed an integrated simulation that required students to provide information for prior authorization of a new medication, counsel a patient on rheumatoid arthritis and the medication, and address patient questions about insurance formularies, cost, and prior authorization processes. Students completed pre- and post-surveys to determine changes in knowledge and perceptions of the simulation. Exam questions that corresponded to simulation concepts were also analyzed.

FINDINGS

Analysis of pre-post surveys indicated that students' self-perceived knowledge and confidence significantly improved in all areas (P < .001 and P < .05, respectively). Student perceptions of the simulation were positive, with comments referencing the activity's realism. Correct answers on knowledge-based questions related to simulation concepts were selected by at least 90% of students on course examinations.

SUMMARY

This integrated simulation was effective at increasing self-perceived student knowledge and confidence on concepts from all disciplines, and it can easily be replicated and adapted at other pharmacy institutions.

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.

Addressing the Challenges of Novel Oncology and Hematology Treatments Across Sites of Care: Specialty Pharmacy Solutions

BACKGROUND

The number of Food and Drug Administration (FDA) approvals for anticancer therapies has significantly increased in recent years, but these novel therapies are costly and present challenges to patients and providers. Many institutions have implemented health systems specialty pharmacies (HSSPs) to help patients and providers navigate financial and logistical barriers to treatment with oral anticancer therapies. Patients on oral anticancer therapy are often treated across multiple sites of care which can complicate the inpatient specialty medication initiation process. Health systems often limit inclusion of oral anticancer therapies for inpatient administration due to costs, however several new therapies necessitate admission for treatment initiation. Health systems are then faced with the challenge of starting costly oral anticancer therapy inpatient and ensuring continued access to therapy upon discharge. We describe the integrated HSSP multidisciplinary approach to this MUP including providers, inpatient and outpatient pharmacists, specialty and inpatient pharmacies, institutional procurement team, and the institutional pharmacy and therapeutics (P&T) committee to streamline this process.The HSSP multidisciplinary processes addresses a growing need for cancer patients to receive timely and affordable treatments across different sites of care. The healthcare team and P&T committee ensure the patient receives the most appropriate therapy while being conscious of health-system costs. The HSSP and procurement team ensure the patient can obtain and afford the medication. The implemented processes allows for direct communication and collaboration between different sites of care and this collaborative approach leads to optimal patient care.

Primary medication nonadherence calculation method specifications impact resulting rates

BACKGROUND

Previous literature has illustrated a wide range of primary medication nonadherence (PMN) rates due to inconsistent calculation methods and parameters, but the impact of parameter specifications on PMN rates has not been assessed.

OBJECTIVES

The objective of this study was to evaluate the impact of lookback window (LBW), duplicate window (DW), and fill window (FW) specifications on PMN rates in patients prescribed specialty self-administered oncology medications.

METHODS

This was a single-center, retrospective cohort analysis. Patients receiving a new electronic specialty oncology prescription January-December 2018 were included; excluded if re-routed to an external pharmacy within 2 days, fell within a DW, or cancelled within a FW. Twenty-four methods were used to calculate PMN based on combinations of the following parameters: (i) absence of prior specialty self-administered oncology medication fill within LBW (90, 180 days); (ii) absence of a duplicate prescription within DW (2, 7, 30 days); and (iii) sold status within FW (14, 30, 60, 90 days). For each method, PMN was calculated as the number of unsold prescriptions within the FW divided by all eligible prescriptions.

RESULTS

We evaluated 4,482 prescriptions, resulting in PMN ranging from 16% to 23%. Patients were commonly male (53%) and white (83%), with a median age of 64 years (interquartile range, IQR, 54, 72). Increasing the LBW from 90 to 180 days resulted in exclusion of 72 (2%) prescriptions and minimally impacted PMN rates. Most duplicate prescriptions (87%) occurred within two days of original prescription and PMN rates were minimally affected by DW. Most fulfilled prescriptions were filled within FW 30 days, 98% with a method of LBW 180, DW 2, and FW 30. Adjusting the FW consistently impacted PMN rates.

CONCLUSIONS

Because various PMN definitions can significantly impact results, a thorough explanation of all parameter specifications should be reported in research using PMN.

Implementing a specialty pharmacy course within a professional pharmacy curriculum

BACKGROUND AND PURPOSE

Specialty pharmacy is an important area of pharmacy practice where patients who are prescribed a growing number of specialty drugs receive specialized care, including: benefits investigation, financial support, side effect management, and adherence assessment. As these specialty medications continue to emerge, it is important for pharmacy students to have knowledge of this specialized practice and awareness of the opportunities that exist in this area. The objective is to describe the development of a specialty pharmacy elective course to meet this educational need.

EDUCATIONAL ACTIVITY AND SETTING

A one-credit specialty pharmacy elective course was created for second and third-year pharmacy students. Content experts with a variety of clinical and administrative specialty pharmacy expertise led student lectures and topic discussions. Students were assessed for baseline specialty pharmacy knowledge, knowledge at the completion of the course, and satisfaction with the course.

FINDINGS

Student knowledge of specialty pharmacy practice increased 27.7% when comparing baseline to post-course test scores. Students evaluated the new course positively with recommendations that the course could benefit by being expanded by an additional credit.

SUMMARY

The development of a specialty pharmacy elective course within a college of pharmacy curriculum improved student knowledge of specialty pharmacy practice and was well-received by students who enrolled in the course. Given the complexity and growing importance of specialty pharmacy in practice, this type of course should be considered by other colleges of pharmacy.

Intensive Pharmacy Care Improves Outcomes of Hepatitis C Treatment in a Vulnerable Patient Population at a Safety-Net Hospital

BACKGROUND

Treatment of hepatitis C virus (HCV) with direct-acting antiviral (DAA) regimens has resulted in high rates of sustained virologic response (SVR). Treatment of vulnerable populations may be improved by incorporating an on-site intensive specialty pharmacy (ON-ISP).

AIMS

To describe outcomes of HCV treatment at a safety-net hospital and proportion of subjects achieving SVR for those using the ON-ISP compared to an off-site pharmacy (OFF-SP).

METHODS

A retrospective cohort study of 219 subjects treated for HCV with DAA at Boston Medical Center was conducted. Subject characteristics, virologic response, and pharmacy services used were recorded. We used multivariable logistic regression to test the association between ON-ISP and SVR after adjusting for covariates.

RESULTS

SVR occurred in 71% of subjects by intention-to-treat (73% among ON-ISP users vs 57% among OFF-SP users) and 95% completing treatment per-protocol (96% among ON-ISP users vs 87% among OFF-SP users). Adjustment for age, sex, ethnicity, insurance, fibrosis, prior treatment, and MELD revealed an increased likelihood of SVR among users of ON-ISP: OR 6.0 (95% CI 1.18-31.0). No significant difference in treatment delay or adverse events was seen among users of either pharmacy type.

CONCLUSIONS

HCV treatment with DAA was well tolerated, but the rate of SVR was low (71%) compared to trials. This was due to loss to follow-up, as the per-protocol rate of SVR was much higher (95%). Use of ON-ISP was associated with an increase in SVR and may be valuable for improving care for vulnerable populations.

Titration of pulmonary arterial hypertension therapeutics: Experience-based recommendations

The availability of new medications has improved exercise capacity, enhanced quality of life, and extended time to clinical worsening in patients with pulmonary arterial hypertension (PAH). For many of these medications, careful individualized dose titration is required to maximize therapeutic effectiveness while minimizing side effects. In addition, specific routes of administration, including intravenous (IV), subcutaneous (SC), and inhaled administration may present additional challenges for patients and healthcare providers. These challenges include the possibility of catheter-related infections (IV), infusion site pain (SC), and adherence to frequent dosing schedules (inhaled). Temporary discontinuations may require re-titration and, in some cases, may even be life threatening. Here, based on our clinical experience, we provide our recommendations for dose titration schemes for PAH medications that require individualized dosing in adult patients, including agents acting on the endothelin-1 pathway (bosentan and ambrisentan), the prostacyclin pathway (epoprostenol, treprostinil, and selexipag), and the nitric oxide pathway (tadalafil and the soluble guanylate cyclase stimulator riociguat). A case study that illustrates the application of best practices for PAH medication dose titration in a real-world setting is presented. Good two-way communication between specialty pharmacies and other healthcare providers promotes optimal medication usage and patient health. Experience has shown that slow, cautious up-titration is generally associated with better long-term outcomes. In all cases, patient education, frequent monitoring and careful management of side effects, and treatment adherence are critical.

Impact of pharmacy channel on adherence to oral oncolytics

BACKGROUND

Oral chemotherapy is increasingly prescribed to treat cancer. Despite its benefits, concerns have been raised regarding adherence to therapy. The study objective was to compare and measure adherence, persistence, and abandonment in patients filling prescriptions in traditional retail (TR) versus specialty pharmacy (SP) channels.

METHODS

Using a retrospective cohort design, we selected newly treated patients aged ≥18 years with a prescription for erlotinib, capecitabine, or imatinib during 2007-2011 from a Medco population of both United States commercial and Medicare health plans. Patients were classified according to pharmacy channel providing the medication. Abandonment was defined as a reversal following initial approval of the index prescription claim with no additional paid claims for agent within 90 days of reversal. Patients were considered adherent if the proportion of days covered between the date of the first and last oral prescription was ≥80%.

RESULTS

In our retrospective cohort, 11,972 filled their prescriptions within the SP channel, and 30,394 filled their prescriptions within the TR channels, respectively. The SP channel had the highest proportion of adherent patients compared with TR (71.6% vs. 56.4%, P < .001). Abandonment of the initial prescription was low with overall rates of only 1.7%. In multivariate models controlling for demographic characteristics, index oncolytic, days of supply, and copay, SP channel (relative to TR) was significantly associated with lower rates of abandonment and increased adherence.

CONCLUSIONS

Pharmacy channel may be influential on abandonment and adherence. Lower rates of abandonment and higher rates of adherence were observed among SP patients versus TR.