Costs and health care resource utilization among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia. However, published studies of CLL have either only focused on costs among individuals diagnosed with CLL without a non-CLL comparator group or focused on costs associated with specific CLL treatments. An examination of utilization and costs across different care settings provides a holistic view of utilization associated with CLL.

OBJECTIVE

To quantify the health care costs and resource utilization types attributable to CLL among Medicare beneficiaries and identify predictors associated with each of the economic outcomes among beneficiaries diagnosed with CLL.

METHODS

This retrospective study used a random 20% sample of the Medicare Chronic Conditions Data Warehouse (CCW) database covering the 2017-2019 period. The study population consisted of individuals with and without CLL. The CLL cohort and non-CLL cohort were matched using a 1:5 hard match based on baseline categorical variables. We characterized economic outcomes over 360 days across cost categories and places of services. We estimated average marginal effects using multivariable generalized linear regression models of total costs and across type of services. Total cost was compared between CLL and non-CLL cohorts using the matched sample. We used generalized linear models appropriate for the count or binary outcome to identify factors associated with various categories of health care resource utilization, such as inpatient admissions, emergency department (ED) visits, and oncologist/hematologist visits.

RESULTS

A total of 2,736 beneficiaries in the CLL cohort and 13,571 beneficiaries in the non-CLL matched cohort were identified. Compared with the non-CLL cohort, the annual cost for the CLL cohort was higher (CLL vs non-CLL, mean [SD]: $22,781 [$37,592] vs $13,901 [$24,725]), mainly driven by health care provider costs ($6,535 vs $3,915) and Part D prescription drug costs ($5,916 vs $2,556). The main categories of health care resource utilization were physician evaluation/management visits, oncologist/hematologist visits, and laboratory services. Compared with beneficiaries aged 65-74 years, beneficiaries aged 85 years or older had lower use and cost in maintenance services (ie, oncologist visits, hospital outpatient costs, and prescription drug cost) but higher use and cost in acute services (ie, ED). Compared with residency in a metropolitan area, living in a nonmetropolitan area was associated with fewer physician visits but higher ED visits and hospitalizations.

CONCLUSIONS

The cooccurrence of lower utilization of routine care services, along with higher utilization of acute care services among some individuals, has implications for patient burden and warrants further study.

Disparity in treatment patterns among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia: an analysis of patient and contextual factors

This study characterizes the patterns and timing of CLL treatment and, to our knowledge, is the first to identify social vulnerability factors associated with CLL treatment receipt in the Medicare population. A total of 3508 Medicare beneficiaries diagnosed with CLL from 2017 to 2019 were identified. We reported the proportion of individuals who received CLL treatment and the time until the first CLL treatment receipt after the first observed claim with a CLL diagnosis. Logistic regression and time-to-event models provided adjusted odds ratios and hazard ratios associated with baseline individual-level and county-level factors. Sixteen percent of individuals received CLL treatment, and the median follow-up time was 540 d. The median time to receipt of CLL treatment was 61 d. Older age and residence in a county ranked high in social vulnerability (as defined by minority status and language) were negatively associated with treatment receipt and time to treatment receipt.

Assessing suboxone access in community pharmacies: Secret shopper model

Objective

To assess whether Maryland community pharmacies had Suboxone available for dispensing.

Methods

This cross-sectional study used a secret shopper model to contact public-facing community pharmacies in Maryland. The secret shopper, guided by a script, asked whether a prescription for Suboxone was available for the same or next day pick-up. A small convenience sample of pharmacies who did not have Suboxone available received an in-person visit to inquire about medication availability and dispensing barriers.

Results

After contacting 99% (n = 1046) of Maryland public-facing pharmacies, Suboxone was confirmed available for immediate pick-up in 31% (n = 326). The remaining did not have, would not disclose, or had limited access (existing patients or specific providers only). Significant differences in Suboxone availability were found for National Capital vs. Baltimore metro region and when pharmacist asked questions vs. no questions. Of the 11 pharmacy visits completed, 10 said they had Suboxone currently in stock, with one clarifying medication was for existing patients only.

Conclusion

About 69% of patients may face challenges when calling to find out whether they can obtain Suboxone in Maryland pharmacies. Better patient education and more thorough pharmacy-level investigation of system and workflow barriers could offer solutions.

Efficacy of a Flavored Lubricating Oral Spray on Medication Swallowing in Older Individuals

Background Difficulty swallowing occurs in up to 35% of patients 50 years of age or older and can contribute to medication nonadherence and other alterations. The use of a flavored lubricating spray, available over-the-counter and found to be helpful in children to swallow oral solid medications, is not well studied in older adults. Objective To evaluate the effect of a flavored lubricating spray on the ability to swallow oral solid medication in older people. Methods A randomized, open-label, crossover study included community-dwelling individuals 65 to 88 years of age who took at least one solid oral medication daily and were not diagnosed with dysphagia, Parkinson's disease, or esophageal tumor. Participants were randomized to the strawberry-flavored lubricating spray or usual care and then crossed over to the alternate option. The median rating for swallowing difficulty for their regular medications was compared using a Likert scale, from 1 (very difficult) to 5 (very easy). To provide a degree of standardization between participants, all participants were also instructed to swallow a vitamin C (1,000 mg) tablet both with and without the flavored spray and rate their difficulty swallowing the tablet using the same Likert scale. Results There were 39 (90.7%) participants who completed the study. The median rating for swallowing difficultly was 5 (very easy) with the spray vs. 4 (easy) with usual care (P < 0.0001). For the 66.7% who took the vitamin C tablets, the median rating for swallowing difficulty was 5 (very easy) with the spray vs. 3.5 (between neutral and easy) without (P < 0.0001). There were 94.8% of participants who found the spray easy/ very easy to use, and 89.7% reported it tasted okay to delicious. Conclusion The use of a flavored lubricating spray provided an effective and easy-to-use tool to make medication swallowing easier in community-dwelling older adults without a diagnosis associated with difficulty swallowing.

Evolution of the Comprehensive Medication Review Completion Rate for Medicare Part D Plans: What Do the Stars Tell Us?

Objective To describe changes in the Medicare Part D Comprehensive Medication Review (CMR) completion rate within the Centers for Medicare & Medicaid Services (CMS) Star Ratings program since its inception. Methods Publicly available information for Star Ratings years 2014 to 2021 was obtained from the CMS website and through indexed literature and internet searches. Data elements for the CMR completion measure were extracted for Medicare Advantage prescription drug plans (MA-PDs) and prescription drug plans (PDPs) and included the annual weighted value, cut-points for star rating, completion rates, and star achievement. Results In 2014 and 2015, the CMR completion rate was a display measure in the Star Ratings program with rates between 10 and 16%. This measure was added in 2016 with a weighted value of 1 that has remained the same. The cut-points when comparing 2016 with 2021 have increased from less than 13.6 to less than 48% for 1 star and 76 to 89% or more for 5 stars for MA-PDs and from less than 8.5 to less than 24% for 1 star and 36.7 to 61% or more for 5 stars for PDPs. From 2016 to 2021, the average Star Ratings for CMR completion increased from 2.3 to 3.7 for MA-PDs and 2.3 to 3.6 for PDPs. Conclusion Since the inception of the CMR completion rate as a quality measure, an increasing proportion of eligible beneficiaries has received a CMR with MA-PDs consistently providing this service to more beneficiaries than PDPs. The cut-points for star achievement have also risen, requiring higher CMR completion rates to achieve higher star ratings. Further evolution of the CMR quality measure is needed for improving medication management.

Initial non-adherence to antihypertensive medications in the United States: a systematic literature review

An important component of hypertension management is the initiation and continuation of antihypertensive medications. Non-adherence during the long-term use of antihypertensive medications is well studied. However, there is a paucity of research about the frequency and clinical consequences of failing to take the first dose of an antihypertensive, a treatment challenge known as initial medication non-adherence (IMN). This systematic literature review summarizes the published evidence from 2010 to 2019 on the prevalence, associated factors, consequences, and solutions for IMN to antihypertensive medications in the United States. Of the fifteen studies identified, nine studies reported the prevalence of IMN, two studies examined patient-reported reasons for IMN, and four studies evaluated interventions aimed to lower IMN. It is estimated that 5-34% of patients do not obtain their new antihypertensive medications. Factors and reasons cited include patient demographics, patient beliefs or perceptions about medications, cost or financial barriers, and clinical characteristics, such as a new hypertension diagnosis or higher co-morbid disease burden. The clinical, economic, and patient-reported outcomes of IMN are not well researched. In addition, interventions to address IMN have yielded inconsistent results. Significant opportunities exist for further research into this dimension of patient behavior to better understand and address IMN to new antihypertensive medications.

Implementation of academic detailing for pharmacists on opioid use disorder and harm reduction

BACKGROUND

The US is experiencing an opioid crisis, substantially worsened by the pandemic. Pharmacists play a critical role in expanding access to care through harm reduction efforts and medications to treat opioid use disorder (mOUD), yet lack necessary education and resources. Academic detailing is a one-on-one technique, which can effectively address educational gaps.

OBJECTIVE

The purpose was to assess needs and equip pharmacy staff to address the health of people with substance use disorders (SUD).

PRACTICE DESCRIPTION

Community pharmacists provide ongoing care for patients with SUD.

PRACTICE INNOVATION

Based on needs' assessment findings, an academic detailing program was designed to provide education and resources for community pharmacies. The project sought to assess current practice and needs and address pharmacists' skills in managing patients with opioid use disorder (OUD) and/or at risk for overdose (OD). Visits were scheduled in high-risk regions. Coaching and materials were provided.

EVALUATION METHODS

Detailers completed visits reports. Discrete variables were reported using descriptive statistics. Associations between discrete variables were detected with Chi-square or Fisher's exact test.

RESULTS

Detailers visited 136 pharmacies. Most stocked naloxone (86.8%), mOUD (94.9%) and would sell syringes (64%) per state law. Fifty-seven percent of pharmacies provided all of these services. However, additional education and resources were needed. Only 27.9% had naloxone signage and/or handouts; 22.1% had supplemental materials; and 25% had referral information. When asked to explain barriers, frequently cited themes included providing resources/help, financial issues, stigma, and transportation.

CONCLUSION

Pharmacists routinely care for patients at risk for OD and diagnosed with OUD. Academic detailing is a well-received strategy to disseminate education and materials, while gathering information about pharmacist needs and barriers. However, there remains room for expansion of services and opportunities for improved care. Further efforts should incorporate ongoing training and access to materials with visual cues, as well as referral and cost savings information.

Improving Medication Management by Understanding Patient and Caregiver Preferences for Medication Packaging

OBJECTIVE: To assess older adults' perceptions and preferences when comparing multi-medication packaging products.<br/> DESIGN: Qualitative study involving focus group interviews (FGIs) and key informant interviews (KIIs).<br/> SETTING: Interviews were conducted in multiple cities within the United States during June-July 2019.<br/> PATIENTS, PARTICIPANTS: FGI participants (N=36) included community dwelling adults, 65 years of age or older, who took 5+ chronic medications, or their caregivers. KII participants (N=15) included health care professionals caring for similar populations.<br/> INTERVENTIONS: Participants were given samples of blister packs and pouches and asked about medication management and appearance and usability of medication packaging. Interviews were audio-recorded with participants' consent, then transcribed and coded using Atlas. ti. Recurrent and emergent themes were identified, and selected quotes served as examples of identified themes.<br/> MAIN OUTCOME MEASURE: Participants' perceptions regarding medication packaging.<br/> RESULTS: Participants' preferences varied for different multi-medication packaging systems. Similarly, most FGI participants did not communicate a strong attitude for or against their existing management systems. However, many FGI participants perceived a need for larger font size than seen on the either of the multimedication packaging samples. KII participants also preferred a larger font size on both packagings. KII participants thought the blister packs offered better visual organization and enabled caregivers to quickly assess adherence. However, KII participants expressed concern about integrating as-needed and short-term use medications and noted difficulty opening both types of packages.<br/> CONCLUSION: Visual appearance is important to both patients and health care providers. Continued research in this area is vital for tailoring packaging types and technology to patients.

Improving Medication Management by Understanding Patient and Caregiver Preferences for Medication Packaging

OBJECTIVE: To assess older adults' perceptions and preferences when comparing multi-medication packaging products.<br/> DESIGN: Qualitative study involving focus group interviews (FGIs) and key informant interviews (KIIs).<br/> SETTING: Interviews were conducted in multiple cities within the United States during June-July 2019.<br/> PATIENTS, PARTICIPANTS: FGI participants (N=36) included community dwelling adults, 65 years of age or older, who took 5+ chronic medications, or their caregivers. KII participants (N=15) included health care professionals caring for similar populations.<br/> INTERVENTIONS: Participants were given samples of blister packs and pouches and asked about medication management and appearance and usability of medication packaging. Interviews were audio-recorded with participants' consent, then transcribed and coded using Atlas. ti. Recurrent and emergent themes were identified, and selected quotes served as examples of identified themes.<br/> MAIN OUTCOME MEASURE: Participants' perceptions regarding medication packaging.<br/> RESULTS: Participants' preferences varied for different multi-medication packaging systems. Similarly, most FGI participants did not communicate a strong attitude for or against their existing management systems. However, many FGI participants perceived a need for larger font size than seen on the either of the multimedication packaging samples. KII participants also preferred a larger font size on both packagings. KII participants thought the blister packs offered better visual organization and enabled caregivers to quickly assess adherence. However, KII participants expressed concern about integrating as-needed and short-term use medications and noted difficulty opening both types of packages.<br/> CONCLUSION: Visual appearance is important to both patients and health care providers. Continued research in this area is vital for tailoring packaging types and technology to patients.

Understanding the Socioeconomic and Geographical Characteristics of Beneficiaries Receiving a Comprehensive Medication Review

BACKGROUND

Medicare Part D sponsors are required to offer medication therapy management (MTM) programs to eligible beneficiaries. Recent studies have demonstrated that there have been racial/ethnic disparities in MTM eligibility criteria. For example, compared with non-Hispanic White beneficiaries, Hispanic and non-Hispanic Black beneficiaries are less likely to be eligible for MTM. However, there is limited evidence for socioeconomic and geographical characteristics of those who are eligible and receive MTM services.

OBJECTIVE

To describe the demographic, socioeconomic, and geographic characteristics of Medicare beneficiaries who received MTM services.

METHODS

As part of a previous study, a national survey evaluated a convenience sample of perspectives of Medicare beneficiaries on the MTM standardized format. The survey was distributed through Medicare Part D plans to beneficiaries receiving MTM services from 2017-2018. As part of the survey, respondents could provide their ZIP codes. Geographical variables, such as the National Center for Health Statistics (NCHS) urban-rural classification scheme and economic research service (ERS) county typology codes, were then applied to respondents' ZIP codes, allowing for the classification of counties or census tracts by urbanization and economic dependence measures. Descriptive statistics are reported for demographic, geographical, and socioeconomic information.

RESULTS

Of the 300 (of 434) respondents who provided their ZIP codes, 51.3% were aged 65-74 years; 50% were male; and 66.7% had at least a college education. There were 82.7% who self-identified as White, while only 8% self-identified as Hispanic or Black/African American. The majority of respondents (58.4%) lived in large metropolitan areas as defined by the NCHS urban-rural classification scheme. Respondents' counties were characterized by economic dependence with 14.0% of respondents living in federal/state government-dependent counties and 12.7% living in recreation-dependent counties.

CONCLUSIONS

The majority of respondents who provided their ZIP codes identified themselves as White and lived in large metropolitan areas. Respondents who identified themselves as Hispanic or Black/African American were not well represented. This study provides geographical and socioeconomic characteristics of Medicare beneficiaries who received MTM services and highlights racial/ethnic differences. Further work is needed to confirm geographical and socioeconomic disparities among beneficiaries who received MTM services.

DISCLOSURES

No outside funding supported this study. Pellegrin is a member of the AMCP MTM Advisory Group. The other authors have nothing to disclose.

Abstract P153: Initial Non-adherence To Antihypertensive Medications: A Systematic Literature Review

Introduction: An important component of hypertension management is the initiation and continuation of antihypertensive medications. Ongoing medication non-adherence is well studied. However, there is a paucity of research about the frequency and clinical consequences of failing to take the first dose of the prescribed medication, a treatment challenge known as initial medication non-adherence (IMN).

Objective: To summarize the published evidence on the prevalence, associated factors, consequences, and solutions for IMN to antihypertensive medications in the United States (US).

Methods: A systematic literature search was performed in Medline (PubMed) to capture publications on IMN from 2010-2019. To be included, studies must have reported results of IMN to antihypertensive medications. Studies that solely evaluated non-adult populations, employed weaker study designs (i.e., case reports/series), were not written in English, or were conducted outside of the US were excluded.

Results: The search identified 2289 unique articles from which 15 studies were included. Estimates of the prevalence of IMN to new antihypertensive medications ranged from 5-34% (331/6393 to 269/791) of patients, and 1-48% (7160/642,376 to 10,987*/23,033) of prescriptions (n=9 studies). Results varied due to differences in study populations, data sources and whether new was defined as no prior history of the specific medication, the class or any antihypertensive. Associated with IMN were new hypertension diagnosis, lower blood pressure values, higher medication cost, non-white non-Hispanic race/ethnicity, fewer healthcare visits after prescribing, and higher co-morbid disease burden (n=3 studies). Patient-reported reasons for IMN included cost and side effect concerns (n=2 studies). One of the four intervention studies found lower IMN with a live phone call from the pharmacy compared to usual care (-6.9%, [29,106/82,373 - 841/1993], p<0.0001). No studies examined the clinical, economic, or humanistic consequences of IMN.

Conclusion: Up to one-third of patients fail to obtain a newly prescribed antihypertensive medication. Future research is needed to document the clinical consequences and determine cost-effective approaches to address IMN.

*calculated

Beneficiary, Caregiver, and Case Manager Perspectives on the Medication Therapy Management Program Standardized Format

Plan sponsors of Medicare Part D must provide beneficiaries who receive a comprehensive medication review (CMR) with a written summary using the Medicare Part D Medication Therapy Management Standardized Format (SF). The SF is a means to advance consistency in the CMR program by providing a template of expected content. However, barriers remain with beneficiary use and integration into existing electronic health records. The current study assessed Medicare beneficiary, caregiver, and case manager perceptions of the SF through five focus group interviews with a total of 23 participants. Qualitative analysis found that beneficiaries and case managers preferred a consolidated SF document to share and update their entire health care team. Beneficiaries suggested adding information to the SF on dosage, timing, drug interactions, cost, and less expensive alternatives. Identifying elements of the SF that are perceived as useful to beneficiaries will allow for a more streamlined SF that may enhance interoperability among the health care team. [Journal of Gerontological Nursing, 45(4), 7-13.].

Evolution of the Medicare Part D Medication Therapy Management Program from Inception in 2006 to the Present

BACKGROUND

In 2006, the Centers for Medicare & Medicaid Services (CMS) implemented the newly established Medicare Part D program that required plan sponsors to offer a medication therapy management (MTM) program. The MTM program requirements have become more prescriptive over the past decade in the attempt to address low beneficiary enrollment rates, improve the quality of services provided, and address gaps in meeting the needs of enrollees.

OBJECTIVE

To describe changes to the requirements for the Medicare Part D MTM program since its inception in 2006 and the impact of these changes to inform future program enhancements.

METHODS

We obtained publicly available information extracted from the Medicare Part D MTM program fact sheets for the years 2008 through 2018, in addition to searching indexed literature through PubMed and additional literature through Internet searches. We then categorized the program's requirement changes annually, and described the Part D MTM program characteristics and reported statistics.

DISCUSSION

Significant changes to the Part D MTM program requirements occurred in 2010, 2013, and 2016 regarding eligibility criteria, MTM services, and reporting requirements. Thresholds to determine beneficiary eligibility have been lowered. Specific MTM services now include an annual comprehensive medication review, followed by a written summary using the Standardized Format. Quarterly targeted medication reviews are also required. Reporting requirements now include comprehensive medication review completion rates and the number of prescriber interventions, among others. Despite more prescriptive MTM program requirements, the low utilization of the MTM program continues.

CONCLUSION

Low beneficiary enrollment rates in the Medicare Part D MTM program led CMS to lower thresholds required for eligibility to expand the beneficiary pool. More prescriptive MTM service requirements enhanced service standardization. Despite these changes, MTM enrollment and comprehensive medication review rates remain low, likely, in part, from a lack of financial incentives. The Enhanced MTM program is a 5-year test model that is providing participating Part D plans regulatory flexibility and financial incentives to design their own MTM programs, to evaluate the impact of different program designs on beneficiary engagement and outcomes.

Online Provision of Part D Medication Therapy Management Program Information

BACKGROUND

Low rates of beneficiary participation in medication therapy management (MTM) programs may be partly due to lack of awareness and understanding of the MTM program. To address this, the Centers for Medicare & Medicaid Services (CMS) requires Medicare Part D sponsors to provide online information about their MTM programs. An early study conducted in 2014 found low compliance rates, with only 59.5% of a small convenience sample of Part D plan contract websites compliant with CMS requirements. The current study provides a more recent evaluation of compliance with website requirements using a random sample of Part D plan contracts.

OBJECTIVES

To (a) evaluate Part D sponsors' compliance with MTM program website elements that are required and suggested by CMS and (b) investigate the use of elements recommended by the National Institute on Aging (NIA) for websites for older adults.

METHODS

A random sample of 184 Part D plan contract MTM program websites was selected from a list of 624 approved Part D plan contracts for 2016. Duplicate and inaccessible websites were excluded. The remaining websites were reviewed to determine compliance with CMS-required, CMS-suggested, and NIA-recommended elements. Descriptive statistics were reported at the Part D contract level for compliance with individual elements, category elements (CMS-required, CMS-suggested, and NIA-recommended), and overall compliance. Overall compliance by category was also reported by Part D plan type.

RESULTS

Of the 184 MTM websites that were reviewed, 106 remained after excluding duplicate (n = 67) and inaccessible (n = 11) websites: 81 from Medicare Advantage prescription drug (MAPD) plans, 16 from prescription drug plans (PDPs), and 9 from Medicare-Medicaid plans (MMPs). Overall, 51% of Part D plan contract MTM websites were compliant with all of the 14 CMS-required elements. The only element in the CMS-suggested elements category, "accessibility by clicking through a maximum of two links," had a compliance rate of 79%. For the NIA-recommended elements category, 46% of the Part D plan contract MTM websites were compliant with the 4 elements.

CONCLUSIONS

Medicare Part D plan sponsors are providing information about their MTM programs on plan websites. However, only 51% of Part D plan websites are fully compliant with CMS guidance, providing all required elements.

DISCLOSURES

No outside funding supported this study. The authors have no financial or other relationships to disclose. The original research on a small and nonrandom sample of Part D plan contracts was presented during AMCP Nexus 2014; October 7-10, 2014; in Boston, MA. The results presented here are a larger and random sample of Part D plan contracts.

Findings from a National Survey of Medicare Beneficiary Perspectives on the Medicare Part D Medication Therapy Management Standardized Format

BACKGROUND

The Medication Therapy Management (MTM) Program Standardized Format (SF) is a written summary of a comprehensive medication review (CMR) that must be provided to Medicare Part D beneficiaries. Concerns have been raised regarding the number of pages of the SF, mailing costs, the static nature of the document, and the lack of integration into beneficiaries' electronic health records. To date, limited research exists on beneficiaries' perceptions of the SF.

OBJECTIVE

To evaluate the perspectives of beneficiaries regarding the utility of the SF to inform potential modifications for optimal use.

METHODS

An online survey, designed based on the standard approach to measuring patient satisfaction with health service attributes and previous qualitative research, was distributed through Medicare Part D plans to beneficiaries who had received a CMR in the past year. Survey distribution began July 1, 2018, and data collection ended on October 31, 2018. Descriptive statistics are reported for demographic information; health status; perceived value and helpfulness of the SF and its 3 components (cover letter, medication action plan [MAP], personal medication list [PML]); updates to the SF; alternate formatting; and integration of the SF into health records.

RESULTS

A total of 9,975 surveys were sent electronically by 4 Medicare Part D plans to beneficiaries who had received a CMR in the past year. Of the 434 unduplicated survey respondents (response rate of 4.3%), 58.5% were aged 65 to 84 years; 60% identified themselves as white; and 49.1% had at least a college education. The most commonly reported comorbidities were diabetes (50.5%) and high cholesterol (43.1%), with 10.7% of respondents rating their health as "very good" or "excellent" and 27.4% choosing "poor" or "fair." Beneficiaries rated how well the SF helped improve different aspects of their medication management (e.g., solving medication-related problems, keeping track of medications, correctly using medications, and understanding why medications are being taken), with 40.8%-44.9% choosing "very good" to "excellent" for each aspect. Helpful sections included "What we talked about" and "What I need to do"for the MAP, and medication name, strength, dosage form, and "How and why I use the medication" for the PML. Less helpful were the fill-in sections of the MAP, with 48.6% reporting that they did not write in any information. In contrast, 44.7% of the participants noted that they updated their PML. A wallet card version of the PML, if available, would be used by 54.6% of participants. About one third of Medicare beneficiaries shared the SF with their doctor, and 26% of the participants gave copies of their medication summary to their relatives.

CONCLUSIONS

Fewer than half of the respondents perceived the SF as very good or excellent in helping them to manage their medications. This national survey provides Medicare beneficiary-focused evidence that more work is needed to improve the usability and portability of the SF. This can be achieved by allowing flexibility in the design of the SF, while including essential elements.

DISCLOSURES

This study was funded by the Academy of Managed Care Pharmacy (AMCP), which provided a grant to the University of Maryland School of Pharmacy to conduct this study. Carden and Kumbera are AMCP employees. Brandt reports a grant from IMPAQ and consulting fees from Rand, outside of this study. Pellegrin is a member of the AMCP MTM Advisory Board. The other authors have nothing to disclose.

Impact of formulary restrictions on medication intensification in diabetes treatment

OBJECTIVES

To explore formulary restrictions on noninsulin antihyperglycemic drugs (NIADs) in Medicare Part D plans and to estimate the impact of formulary restrictions on use of NIADs among low-income subsidy (LIS) recipient enrollees with type 2 diabetes (T2D) undergoing treatment intensification.

STUDY DESIGN

Retrospective cohort study.

METHODS

A cohort of 2919 LIS enrollees with T2D receiving metformin monotherapy during the first quarter of 2012 who intensified treatment later in the year was tracked to assess selection of and days' supply with sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and other NIADs. We tested whether being enrolled in a Part D plan with significant formulary restrictions on sole-source brand name NIADs reduced the likelihood of receiving such agents and, if so, what the impact was on days of therapy with the second agent. A 2-part regression model was estimated with explanatory variables for plan-level restrictions and individual covariates.

RESULTS

We found that 63% of study subjects initiated a sulfonylurea, 25% a DPP-4 inhibitor, and 12% another NIAD. Greater restrictions on DPP-4 inhibitors as a class were associated with small reductions in initiation of DPP-4 inhibitors and a concomitant increase in use of sulfonylureas, but neither effect was statistically significant. For individual DPP-4 inhibitors, step therapy requirements on sitagliptin and formulary exclusion of saxagliptin resulted in significant reductions in uptake of the specific drugs but had no significant impact on total days' supply of antihyperglycemic therapy.

CONCLUSIONS

Part D formulary restrictions on sole-source brand name NIADs had little impact on patterns of treatment intensification for T2D among LIS recipients enrolled in Medicare Part D plans in 2012.

Clinical, economic, and humanistic burden of needlestick injuries in healthcare workers

Introduction

Needlestick injuries (NSIs) from a contaminated needle put healthcare workers (HCWs) at risk of becoming infected with a blood-borne virus and suffering serious short- and long-term medical consequences. Hypodermic injections using disposable syringes and needles are the most frequent cause of NSIs.

Objective

To perform a systematic literature review on NSI and active safety-engineered devices for hypodermic injection.

Methods

MEDLINE, EMBASE, and COCHRANE databases were searched for studies that evaluated the clinical, economic, or humanistic outcomes of NSI or active safety-engineered devices.

Results

NSIs have been reported by 14.9%–69.4% of HCWs with the wide range due to differences in countries, settings, and methodologies used to determine rates. Exposure to contaminated sharps is responsible for 37%–39% of the worldwide cases of hepatitis B and C infections in HCWs. HCWs may experience serious emotional effects and mental health disorders after a NSI, resulting in work loss and post-traumatic stress disorder. In 2015 International US$ (IntUS$), the average cost of a NSI was IntUS$747 (range IntUS$199–1,691). Hypodermic injections, the most frequent cause of NSI, are responsible for 32%–36% of NSIs. The use of safety devices that cover the needle-tip after hypodermic injection lowers the risk of NSI per HCW by 43.4%–100% compared to conventional devices. The economic value of converting to safety injective devices shows net savings, favorable budget impact, and overall cost-effectiveness.

Conclusion

The clinical, economic, and humanistic burden is substantial for HCWs who experience a NSI. Safety-engineered devices for hypodermic injection demonstrate value by reducing NSI risk, and the associated direct and indirect costs, psychological stress on HCWs, and occupational blood-borne viral infection risk.

Disease burden of systemic light-chain amyloidosis: a systematic literature review

INTRODUCTION

A systematic literature review on systemic light chain (AL) amyloidosis was conducted in order to understand the disease burden, and identify unmet medical needs and knowledge gaps.

METHODS

MEDLINE, Embase and Cochrane databases were searched for English language studies published in the last 10 years using search terms that focused on the clinical, economic, and patient-reported outcome (PRO) aspects of AL amyloidosis. There was a low yield of articles in the economic and PRO categories and additional searches were conducted in clinical conference proceedings, and using Google and Google Scholar. After review, there were 65 articles included for data extraction.

RESULTS

AL amyloidosis is a rare disorder without any FDA or EMA approved indications for drug therapy. Using off-label therapies, there is a high rate, 42-64%, of non-response or progression, and an associated high mortality. Toxicities during therapy are common with estimates of up to 30-40% of patients experiencing severity of grade 3 or higher. Patients with AL amyloidosis report severe psychological distress, anxiety and clinical depression.

CONCLUSIONS

There is a deficiency in the literature on the economic costs associated with AL amyloidosis, and information on costs has been derived from studies that examined multiple myeloma or other disease or treatment components common to AL amyloidosis.

Medication Management and e-Care Planning: What are the Opportunities for the Future?

Effective communication and coordination of care is a priority strategy to improve health care quality in the United States. To address this strategy, care coordinators are being integrated into clinical practice settings and tasked with developing patient-centered care plans. One component of the care plan is the development of a medication list. This care plan medication list facilitates many medication management functions performed by pharmacists, such as identifying and resolving medication-related problems. Health information technology enables access to data to assist developing the medication list for the care plan and also provides routes to communicate the care plan with other health care providers, patients, and caregivers. The current article reviews the current landscape for promoting effective medication-related communication and care plan information.

Navigating Medicare Part D Websites: Are the Part D Plans in Compliance?

Today, more than one half of older adults use the internet to obtain health-related information, and there is growing interest from governmental agencies in providing information online. The Centers for Medicare & Medicaid Services (CMS) provides guidance to Part D prescription drug plan sponsors about information to include on their websites. The current article examines compliance with the 2014 CMS guidance for Medication Therapy Management (MTM) program information on Part D plan sponsors' websites. There were 59.5% of plan sponsors that had a dedicated MTM program webpage, accessible within two clicks from the plan sponsor's home page and provided basic information, eligibility for MTM services, and access to a blank copy of a personalized medication list document. Although improvements in the provision of information about plan sponsors' MTM programs can be made, future work should evaluate the usability and effectiveness of the online MTM program information provided to Medicare beneficiaries. [Journal of Gerontological Nursing, 42(10), 9-14.].

Collaborative Employee Wellness: Living Healthy With Diabetes

Innovative approaches to managing an employee population with a high prevalence of type 2 diabetes mellitus can mitigate costs for employers by improving employees' health. This article describes such an approach at McCormick & Company, Inc., where participants had statistically significant improvements in weight, average plasma glucose concentration (also called glycated hemoglobin or A1c) and cholesterol. A simulation analysis applying the findings of the study population to Maryland employees with a baseline A1c of greater than 6.0% showed that participation in the program could improve glycemic control in these patients, reducing the A1 c by 0.24% on average, with associated cost savings for the employer.

Adherence to antiretroviral therapy in managed care members in the United States: a retrospective claims analysis

BACKGROUND

Antiretroviral therapy (ART) extends life for patients with human immunodeficiency virus (HIV) infection. However, HIV treatment is lifelong, and adherence presents a special challenge. Suboptimal adherence to ART may lead to disease progression and virologic failure. Earlier studies with combination ART demonstrated that as much as 90%-95% adherence was needed to prevent disease progression.

OBJECTIVE

To measure adherence to ART regimens in commercially insured patients with HIV infection and analyze the clinical and demographic factors associated with ≥ 90% adherence.

METHODS

This study used retrospective claims data from a Mid-Atlantic states MCO. Members 18 years and older with an HIV diagnosis identified by medical claims were included in the cohort, and pharmacy claims were retrieved for these members. An ART regimen was established for each patient within a 120-day period after the last physician's visit occurring between January 1, 2010, and August 31, 2010. For patients who received an ART regimen recommended by the U.S. Department of Health and Human Services (HHS) 2011 Antiretroviral Guidelines, adherence, as measured by medication possession ratio (MPR), was calculated based on pharmacy claims for 12 months after the end of the 120-day period. Logistic regression was used to examine the association between MPR ≥ 90% and age, sex, type of health plan, use of single-tablet regimens (STR), inpatient and outpatient utilization, and direct health care costs.

RESULTS

Of the 4,547 adults with HIV diagnosis, 3,528 (77.6%) had received at least 1 antiretroviral. An HHS-recommended ART regimen was identified in 2,377 patients with 1,136 (47.8%) receiving STR. Mean MPR for patients on an HHS-recommended ART regimen was 91.5% ± 14.0 with 73.1% of patients having achieved MPR ≥ 90%. In univariate analyses, sex, number of outpatient visits, cost of inpatient care, and use of STR were significantly associated with MPR ≥ 90%. In multivariate analysis, only male sex (P = 0.027) and the use of STR (P = 0.009) were positively associated with MPR ≥ 90%. Patients on STR were 1.3 times more likely to achieve at least 90% adherence.

CONCLUSIONS

Adherence is a challenge for patients with HIV, and more than a quarter of patients who were on an HHS-recommended ART regimen failed to achieve an accepted adherence MPR threshold of ≥ 90%. Use of STR was associated with an increased likelihood of achieving adherence of at least 90%. Interventions to improve ART adherence are needed, and STR may be an effective strategy as it decreases pill burden.

You wrote the prescription, but will it get filled?

PURPOSE

Despite numerous studies on adherence, there is little research on the first-fill rate of antihypertensive prescriptions. Our study took advantage of the recent increase in electronic prescribing (e-prescribing) and used data from e-prescribing physicians to determine the first-fill failure rate of antihypertensive prescriptions and to assess which factors predict first-fill failure.

METHODS

This retrospective study reviewed claims from a Mid-Atlantic managed care organization (MCO). We included adult members with continuous medical and pharmacy coverage who were prescribed an antihypertensive in 2008 by an e-prescribing physician. First-fill failure occurred when the patient did not obtain the antihypertensive medication due to either a denial by the MCO or reversal by the dispensing pharmacist. (Pharmacists reverse claims when a patient fails to pick up a medication.) Multivariate regression analysis determined the clinical and demographic factors associated with failure to fill.

RESULTS

The cohort consisted of 14,693 antihypertensive prescriptions, prescribed by 164 e-prescribing physicians for 7061 unique members. There were 2289 out of 14,693 prescriptions (15.6%) that went unfilled, affecting 24.3% of patients. Of the prescriptions not obtained, 1466 (64%) were denied by the MCO and 823 (36%) were reversed. Significant factors associated with first-fill failure were new diagnosis of hypertension, new antihypertensive agent, higher co-payment, and enrollment in a health maintenance organization or preferred provider organization.

CONCLUSIONS

Patients newly diagnosed with hypertension and those prescribed a new antihypertensive were at particularly high risk for not obtaining their medication. Because nearly a quarter of patients did not obtain their initial fill of an antihypertensive prescription, future research should determine efficient and cost-effective systems to address first-fill failure in primary care.

Failure to fill electronically prescribed antidepressant medications: a retrospective study

OBJECTIVE

Nonadherence to antidepressants has been reported to range widely from 10% to 60%. Most adherence studies focus on persistence of use and do not include prescriptions that are not picked up by the patient. The objectives of this study were to determine the rate of unfilled antidepressant prescriptions as well as to identify factors associated with failure to fill these prescriptions.

METHOD

This retrospective study used administrative and pharmacy data from a mid-Atlantic managed care organization serving 3.3 million medical members and 1.2 million pharmacy members. Electronic prescriptions for citalopram, duloxetine, sertraline, and venlafaxine sent to pharmacies from July 1, 2007, to June 30, 2009, were matched to pharmacy claims to determine the rate of unfilled antidepressant prescriptions. Patients were ≥18 years of age and had continuous pharmacy coverage from July 1, 2006, to July 31, 2009. Logistic regression was used to assess whether clinical and demographic factors were associated with unfilled electronic prescriptions.

RESULTS

There were 557 electronically prescribed antidepressants for 267 patients. The rate of unfilled electronic prescriptions was 13.1%, which affected 19.9% of patients. Electronic prescriptions for new users of the antidepressant were 5 times more likely to be unfilled (odds ratio [OR]=5.13; 95% CI, 2.66-9.91; P<.001) than those for previous users. Antidepressant prescriptions for patients aged 18-34 years were most likely to be unfilled (OR=3.72; 95% CI, 1.81-7.67; P<.001).

CONCLUSIONS

Nonadherence to antidepressants is a significant problem with one-fifth of patients never receiving their electronically prescribed antidepressant. Prescriptions for patients without a previous antidepressant claim and aged 18-34 years were least likely to be filled. Interventions targeting patients who fail to fill their antidepressant prescription are needed.

Managing dyslipidemia in primary care with restricted access to lipid-modifying therapy

BACKGROUND

Many patients with dyslipidemia do not achieve goal low-density lipoprotein cholesterol levels. The barriers to achieving goal include inadequate assessment of cardiovascular risk status, medication cost, formulary restrictions, patient lack of adherence, and inadequate counseling time. Removing barriers may improve goal attainment and reduce the risk for cardiovascular events.

OBJECTIVE

To identify opportunities to improve dyslipidemia management in primary care by examining low-density lipoprotein cholesterol goal attainment in patients with unrestricted or restricted access to lipid-modifying therapy.

METHOD

A total of 5936 adult patients from a primary care practice with a low-density lipoprotein measurement were categorized by coronary heart disease risk into 1 of 4 lipid-modifying therapy groups: unrestricted (fluvastatin, lovastatin, pravastatin, or simvastatin monotherapy); restricted (atorvastatin, rosuvastatin, or simvastatin/ezetimibe fixed-dose combination); other (lipid-modifying combination statin therapy or a nonstatin lipid-modifying therapy); and no lipid-modifying therapy. The primary outcome was low-density lipoprotein cholesterol goal attainment by lipid-modifying therapy group. Logistic regression identified associated demographic and clinical factors.

RESULTS

In this cohort, 78.1% of the patients achieved low-density lipoprotein cholesterol goal levels. Overall goal attainment rates were lower in the high and very high coronary heart disease risk categories, at 52.6% and 31.6%, respectively. For patients at elevated coronary heart disease risk (high or very high), the rates of low-density lipoprotein cholesterol goal attainment were 14 to 16 percentage points higher for patients receiving restricted lipid-modifying therapy compared with patients receiving unrestricted lipid-modifying therapy (high coronary heart disease risk: 68% vs 52%, respectively; very high coronary heart disease risk: 42% vs 28%, respectively). Increasing age, male sex, and use of restricted lipid-modifying therapy were significantly associated with improved low-density lipoprotein cholesterol goal attainment. Of the 1298 patients who were not at low-density lipoprotein cholesterol goal, 54.1% were not receiving any lipid-modifying therapy. For each coronary heart disease risk category, there was a significantly higher percent utilization of unrestricted lipid-modifying therapy compared with restricted lipid-modifying therapy (P <.001).

CONCLUSION

A significant number of patients at elevated risk for coronary heart disease remain untreated or have low-density lipoprotein cholesterol levels above target. Removing barriers to the use of restricted lipid-modifying agents in patients at risk for heart disease provides an opportunity to improve low-density lipoprotein cholesterol levels.

Potential value of electronic prescribing in health economic and outcomes research

Improving access and quality while reducing expenditures in the United States health system is expected to be a priority for many years. The use of health information technology (HIT), including electronic prescribing (eRx), is an important initiative in efforts aimed at improving safety and outcomes, increasing quality, and decreasing costs. Data from eRx has been used in studies that document reductions in medication errors, adverse drug events, and pharmacy order-processing time. Evaluating programs and initiatives intended to improve health care can be facilitated through the use of HIT and eRx. eRx data can be used to conduct research to answer questions about the outcomes of health care products, services, and new clinical initiatives with the goal of providing guidance for clinicians and policy makers. Given the recent explosive growth of eRx in the United States, the purpose of this manuscript is to assess the value and suggest enhanced uses and applications of eRx to facilitate the role of the practitioner in contributing to health economics and outcomes research.

Persistence with injectable antidiabetic agents in members with type 2 diabetes in a commercial managed care organization

OBJECTIVE

While many patients with type 2 diabetes require insulin to achieve glycemic goals, little is known about patients' persistence with insulin or other injectable antidiabetic therapies. The objective of this study was to evaluate persistence with injectable antidiabetic agents in patients with type 2 diabetes who were naïve to these treatments.

METHODS

The study cohort was obtained using administrative and pharmacy claims data from a commercial managed care organization of approximately 1.2 million members with pharmacy benefits. The inclusion criteria were members with type 2 diabetes who had at least one pharmacy claim for insulin glargine, insulin detemir, exenatide, or isophane insulin human (NPH insulin) from January 1, 2006 through June 30, 2006. The first claim for any of these injectable therapies was considered the index prescription. Members were excluded if they filled a prescription (a) for any injectable antidiabetic medication from July 2005 through December 2005; or (b) for short/rapid-acting or mixed insulins during 2006, either prior to the index date or within 30 days following the index date. The primary outcome was persistence with the index drug, defined as number of months between the initiation of therapy (i.e., index date) and either the end of therapy (date of last fill plus days supply) or study period of 12 months. The secondary outcome was the percentage of patients with claims for new antidiabetic agents added after index date. Multivariate regression with life data (survival analysis) was performed with number of months of persistence as the dependent variable.

RESULTS

The cohort consisted of 1769 members with a mean (SD) age of 53.2 (12.5) years and 47.4% were men. Mean (SD) months of persistence for members on insulin glargine, insulin detemir and exenatide were similar at 7.8 (4.1), 7.8 (4.4), and 7.6 (4.4), respectively. Members taking NPH insulin had statistically lower persistence at 5.6 (4.5) months (P < 0.001). Overall persistence was 28.7% for injectable antidiabetics at 1 year among treatment-naïve patients. In a multivariate regression model, patients who were younger (P = 0.025) and who initially received NPH insulin (P < 0.001) were less likely to persist. There was no association between persistence and sex, initial copayment, or number of oral antidiabetic medications at time of index prescription. Members in the exenatide and NPH insulin groups were less likely to receive new antidiabetic agents compared with the insulin glargine group (P < 0.001). Limitations include the use of pharmacy claims to proxy the type of diabetes and patients with gestational diabetes may have been included. Missing or inaccurate claims data, the use of samples and hospitalizations may have occurred and would result in an underestimation of persistence.

CONCLUSIONS

Persistence was low for injectable antidiabetics at 1 year among treatment-naïve patients. Patients who received insulin glargine, insulin detemir, or exenatide were more likely to persist than patients receiving NPH insulin. Older patients were more likely to persist, but sex, copayment and number of oral antidiabetic medications at initiation of the injectable antidiabetic were not associated with persistence.

Prescribing trends and drug budget impact of the ARBs in the UK

OBJECTIVES

Angiotensin II receptor blockers (ARBs) were introduced into the UK antihypertensive drug market at a premium price relative to other antihypertensives during a period of evolving evidence about hypertension treatment. This study aimed to determine the UK antihypertensive drug budget impact as the first ARB market launched in December 1994 and what proportion of the increase was directly attributable to ARBs.

METHODS

Prescriptions for oral antihypertensives were identified from The Health Improvement Network database. Drug prices were based on the Chemist & Druggist January 2005 pricelist estimating real expenditure growth. Expenditure increases were disaggregated into the number of patients receiving antihypertensive drug prescriptions, the number of antihypertensive prescriptions per patient treated, and the average drug expenditure per antihypertensive prescription.

RESULTS

The annual ARB prescription frequency increased from 0.04% in 1995 to 6.57% in 2004. Expenditure for antihypertensive drugs was estimated at pound465,862,416 in 1995 and pound1,458,268,104 in 2004 (2005 values), reflecting a 213% real rate of increase. Use of ARBs accounted for only 9.3% (range: 5.8%-12.5%) of the average drug expenditure. Treatment prevalence rose from 11.30% in 1995 to 16.90% in 2004, while the average number of antihypertensive drug prescriptions per patient increased from 9.34 to 13.46 per year. The average expenditure per antihypertensive drug prescription increased over time reflecting a product shift toward more expensive therapies.

CONCLUSIONS

ARBs accounted for only 9.3% of the 213% increase in antihypertensive drug expenditure after their introduction. A substantial portion of the impact reflected increases in treatment prevalence and in the number of prescriptions per patient.

Effect of medication burden on persistent use of lipid-lowering drugs among patients with hypertension

OBJECTIVE

To determine the effect of medication burden on persistent use of newly added lipid-lowering (LL) drugs among patients with hypertension.

STUDY DESIGN

This retrospective database study used medical and pharmacy claims from a mid-Atlantic managed care organization. The cohort was obtained from continuous member enrollment in pharmacy and medical benefits from January 1, 2003, to December 31, 2005.

METHODS

Prescription claims were obtained for 18 months following the date of the first filled LL prescription (ie, index date). Patients were stratified into patients who changed LL drug or strength (group 1) and patients who did not change LL drug or strength (group 2). The primary outcome measure was persistence to newly added LL therapy. Persistence was defined by the length of time a member remained on therapy following the index date. The secondary outcome measure was the medication possession ratio (MPR). The MPR was calculated as the ratio of the sum of the days' supply of prescription filled divided by the number of days filled, plus the days' supply for the final prescription fill. Associations between the daily medication burden, defined as the number of unique drug products, and the outcome measures were analyzed.

RESULTS

In the cohort of 3058 patients, the mean medication burden was 2.9 medications. Medication burden was positively associated with persistence and MPR through 18 months. Patients who had greater medication burden had longer persistence (P <.001). Likewise, patients who had greater medication burden had higher MPRs and were more likely to be considered adherent (MPR, >80%) (P < .001 for both).

CONCLUSIONS

Patients with higher medication burden had greater adherence to newly added LL therapy. Medication burden should not deter clinicians from adding LL therapy. Among patients with added LL therapy, more attention should focus on patients who have changes to their LL regimen compared with patients who continue on the same LL prescription.

Pharmacotherapy after myocardial infarction: disease management versus usual care

OBJECTIVE

To evaluate the effectiveness of a disease management (DM) program compared with usual care on utilization of and adherence to key evidence-based therapies (angiotensin-converting enzyme [ACE] inhibitors/angiotensin II receptor blockers [ARBs], beta-blockers, and statins) after hospital discharge for patients with myocardial infarction (MI) in a managed care organization.

STUDY DESIGN

Retrospective case-control cohort.

METHODS

Members were included if they were 18 years of age or older and had any medical claims for hospitalization for MI, defined as International Classification of Diseases, Ninth Revision, Clinical Modification, codes 410.xx, from January 1, 2002, to December 31, 2002. The index date was the first date of discharge for members with an MI diagnosis. Members were categorized into the active group (automatically enrolled in the DM program) or the control group (not enrolled in the program because their employer group did not purchase the benefit). Pharmacy claims were obtained for 12 months after the index date for ACE inhibitors, ARBs, beta-blockers, and statins.

RESULTS

The study cohort included 250 members in the active group and 137 members in the control group. There were no statistical differences in utilization or time to first prescription fill of ACE inhibitors, ARBs, beta-blockers, and statins between the DM and usual care groups. Adherence to each of these therapies, as measured by medication possession ratio, was not statistically different between the 2 groups.

CONCLUSION

Compared with usual care, participation in the DM program did not improve ACE inhibitor, ARB, statin, or beta-blocker utilization or adherence in members post-MI.

Use of secondary prevention drug therapy in patients with acute coronary syndrome after hospital discharge

BACKGROUND

Acute coronary syndrome includes life-threatening clinical conditions ranging from unstable angina to non-Q-wave myocardial infarction and Q-wave myocardial infarction that are a major cause of emergency medical care and hospitalization in the United States. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the management of patients with unstable angina and non-ST-segment elevation myocardial infarction (2002-2004) recommend (1) angiotensinconverting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) for ACE inhibitor intolerance, (2) beta-blockers, and (3) statins for long-term treatment of patients after an acute coronary event.

OBJECTIVE

To examine rates of use of 3 key evidence-based drug therapies (ACE inhibitors/ARBs, beta-blockers, and statins) after hospital discharge for patients with acute coronary syndromes (ACS).

METHODS

The study cohort was identified using medical claims from commercial health plans within a managed care organization located in the Mid-Atlantic states, with approximately 3.4 million members with medical benefits of whom 1.2 million members (35.3%) had pharmacy benefits. Members were included if they were (1) aged >or= 18 years, (2) continuously enrolled with the same commercial plan from January 1, 2003, through December 31, 2005, (3) had any medical claims for hospitalization for ACS defined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 410.xx (acute myocardial infarction) or 411.1 (intermediate coronary syndrome) during the sample identification period from July 1, 2003 through June 30, 2004, and (4) had no medical claims for ACS hospitalizations from January 1, 2003, through June 30, 2003, in any of 10 diagnosis fields on an inpatient hospital claim. Pharmacy claims for ACE inhibitors, ARBs, beta-blockers, and statins were obtained for 18 months following each index date, defined as the earliest ACS diagnosis date during the identification period. Utilization was defined as the member having at least 1 pharmacy claim within each class from index date to 3 months post-index date. Five time periods were examined to assess therapy: - 180 to 0 days (6 months prior), 0 to 90 days (3 months), 0 to 180 days (6 months), 0 to 365 days (12 months), and 0 to 548 days (18 months) following the index date. ACE inhibitors and ARBs were considered together (i.e., a patient had to have at least 1 pharmacy claim for an ACE inhibitor or an ARB). Logistic regression analyses were used to predict use of the 3 drug classes for patients with different clinical (diagnosis and prior use) and demographic (sex and age) characteristics.

RESULTS

The study cohort included 1,135 patients (0.27% of 424,526 continuously enrolled members) with ACS as defined by ICD-9-CM codes in medical claims from July 1, 2003, to June 30, 2004. Nearly 65% of the sample patients were men (n = 734 men and n = 401 women), with a mean (standard deviation [SD]) age of 63.8 (SD 13.1) years. Of the 1,135 members with ACS, 588 (51.8%) had at least 1 pharmacy claim for an ACE inhibitor or ARB, 725 (63.9%) for a beta-blocker, and 710 (62.6%) for a statin during the 3-month follow-up period; receipt of at least 1 prescription in all 3 classes was found in 339 (29.9%) of patients. Patients who were aged < 45 years, 65-79 years, and e 80 years were significantly less likely than patients aged 45-64 years to receive statins (P < 0.05). In addition, patients who were aged e 80 years were significantly less likely to receive ACE inhibitors/ARBs (P = 0.003), beta-blockers (P < 0.001), or all 3 classes (P = 0.002). Women were less likely than men to receive statins (P = 0.004) and all 3 drug classes (P = 0.012). Patients with intermediate coronary syndrome were significantly less likely than those with acute myocardial infarction to receive any of the study drugs (P < 0.001). Those patients who had used ACE inhibitors/ARBs, beta-blockers, statins, and all 3 drug classes during the 6 months prior to the index diagnosis of ACS were more likely than those without prior use (odds ratios of 12.2, 9.4, 8.3, and 4.9, respectively, P < 0.001) to have these medications continued after ACS diagnosis.

CONCLUSION

At 3 months following the index ACS hospitalization, the majority of the patients were not receiving the 3 guideline medication therapies. ACS patients with intermediate coronary syndrome and those aged 80 years or older were less likely to be receiving any of the 3 therapies, and women were less likely than men to receive statin therapy.

Pharmacy measures to improve medication use through health-literacy principles

More than 90 million Americans have trouble understanding basic health information. Patients with inadequate health literacy encounter problems when trying to understand information related to medication. Consequently, this population has a greater chance of not using pharmaceuticals properly, resulting in poor clinical outcomes. Health care professionals, particularly pharmacists, should improve communication efforts with low-health literacy patients to achieve optimal results. This review examines the relationship between health literacy and medication use with the goals of helping the reader understand how to improve medication adherence and decrease adverse events from improper medication use.

Physician conformity and patient adherence to ACE inhibitors and ARBs in patients with diabetes, with and without renal disease and hypertension, in a medicaid managed care organization

BACKGROUND

The American Diabetes Association (ADA) recommends using angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in patients with diabetes and comorbid hypertension or renal disease.

OBJECTIVE

To examine the use of ACE inhibitors and ARBs in members of a Medicaid managed care organization (MCO) with diabetes and a diagnosis of hypertension and/or kidney disease to determine to what extent (1) physicians are conforming to the recommended course of treatment according to ADA guidelines published in 2002 and still current and (2) patients are adhering to their prescribed therapy.

METHODS

Patients with diabetes were identified using medical claims from a Medicaid MCO in Maryland of approximately 118,000 members continuously enrolled during the study period. To be included in the cohort, members had to have at least 1 medical claim containing a diagnosis of diabetes mellitus from April 1, 2001, through March 31, 2002, using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 250.xx. Additional medical claims during the same time period for hypertension, ICD-9- CM code 401.xx, and renal disease, ICD-9-CM codes for nephropathy (582.81 or 582.9), proteinuria (791.0), or diabetic nephropathy (250.40 or 250.42 for type 2 diabetes only), were used to categorize the cohort into 4 subgroups: diabetes and renal disease with hypertension, diabetes and renal disease without hypertension, diabetes and hypertension without renal disease, and diabetes without renal disease and without hypertension. Pharmacy claims for ACE inhibitors and ARBs were obtained from July 1, 2001, through June 30, 2002, and utilization was defined as the patient having at least 1 pharmacy claim for an ACE inhibitor or an ARB. Patient adherence with ACE inhibitor or ARB therapy was measured using medication possession ratio (MPR) and median gap between prescription refills.

RESULTS

There were 1,698 patients, approximately 2.3% of the total continuously enrolled members, with 1 or more medical claims containing an ICD-9-CM code of 250.xx for diabetes mellitus. The average age was 48 13.2 years for the total sample, and nearly 70% of the patients were women (1,188 women and 510 men). Only 13% of the patients in the sample had medical claim evidence of any renal involvement, while 63% of the study patients had hypertension. A total of 915 patients (53.9%) had at least 1 pharmacy claim for an ACE inhibitor or an ARB, accounting for 7,934 unique pharmacy claims, an average of 8.7 pharmacy claims per patient. Patients with renal involvement and without hypertension (47%) were less likely to receive an ACE inhibitor or an ARB than patients with renal involvement and hypertension (85%) (P <0.001). Patients without renal involvement or hypertension (19%) were less likely to receive an ACE inhibitor or an ARB than patients with hypertension and no renal involvement (71%) (P <0.001). The MPR for all patients was 0.77 ( 0.26). MPR and median gap did not differ significantly by sex. However, we found a significant correlation between age and MPR (P <0.001). In this sample with an age range of 18 to 65 years, there was a positive relationship between patient age and adherence to ACE inhibitor or ARB therapy.

CONCLUSIONS

Physicians. conformity is high when they prescribe an ACE inhibitor or ARB for patients with diabetes and hypertension but is lower than expected for patients with diabetes and renal disease but without hypertension. Older patients in this analysis of persons aged 18 to 65 years adhered more to their ACE inhibitor or ARB therapy.

Statin use in American Indians and Alaska Natives with coronary artery disease

PURPOSE

The use and adherence to statin therapy in American Indians and Alaska Natives with coronary artery disease (CAD) were studied.

METHODS

A retrospective database analysis of the Phoenix Area of the Indian Health Service was conducted. For the cohort of patients with CAD, prescription data were obtained for all statins during calendar year 2003. Use was determined by the presence of at least one statin prescription, whereas adherence was assessed using the medication possession ratio (MPR), persistence, and median gap.

RESULTS

The study cohort was composed of 2095 adults (55.6% men) with at least one medical encounter for CAD during calendar year 2002. The mean +/- S.D. age of the cohort was 62.7 +/- 12.7 years. At least one prescription for any statin drug during 2003 was found for 865 (41.3%) patients. Those who received a statin were more likely to be male, be younger than 80 years, and have a greater number of medical visits. The mean MPR was 0.78 +/- 0.25, and nonadherence was found in approximately 40% of patients receiving statins. In the age category of 65-79 years, men were more adherent than women, and patients in this category were overall more adherent than younger patients.

CONCLUSION

The use of statins in a cohort of American Indians and Alaska Natives at high risk for cardiovascular events was approximately 40% with a 60% adherence rate. Age, sex, and number of medical visits were associated with statin use, and age and sex were associated with adherence.

Retrospective review of sex differences in the management of dyslipidemia in coronary heart disease: an analysis of patient data from a Maryland-based health maintenance organization

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death in men and women in the United States, with a higher mortality in women, despite a lower prevalence. Statins effectively treat dyslipidemia and reduce the risk of CHD mortality.

OBJECTIVE

The objective of this study was to evaluate the treatment of dyslipidemia in patients with CHD and determine if sex differences exist.

METHODS

This was a retrospective chart review performed within a multioffice staff model health maintenance organization of approximately 70,000 members. An administrative database, containing inpatient and out-patient medical claims, was used to identify patients with CHD based on diagnostic codes. Charts were randomly selected and the following information was obtained from chart review: age; sex; risk factors for CHD; diagnosis and/or prescription for depression; blood low-density lipoprotein cholesterol (LDL-C) level; and drug, dosage, and duration of prescribed lipid-lowering therapy. Exclusion criteria included missing charts and unavailable LDL-C values. LDL-C values were classified as at target if LDL-C<2.59 mmol/L (<100 mg/dL). Patients receiving statin monotherapy were categorized into 3 potency groups, based on efficacy to lower LDL-C values: high (atorvastatin 20-80 mg, lovastatin 80 mg), medium (atorvastatin 10 mg, pravastatin 40 mg, simvastatin 200 mg), and low (fluvastatin 10-40 mg, lovastatin 10-40 mg, pravastatin 10-20 mg, simvastatin 5-10 mg).

RESULTS

A total of 1487 adult patients (64.4% male with a mean (SD) age of 65.7 (11.8) years were identified, based on diagnostic codes for CHD. Three hundred twenty charts were selected for review. After exclusion, the final study cohort was 290 patients. The cohort was 66.2% male (192/290) with no significant difference in mean (SD) age between men (65.2 [9.2] years) and women (66.9 [10.5] years). Weight of women ranged from 85 to 305 lbs; 134 to 288 lbs for men. Among the study cohort, 46.2% (134/290) of the patients achieved the target LDL-C of <2.59 mmol/L (<100 mg/dL), with significantly more men (51.0% [98/192]) than women (36.7% [36/98]) reaching target (P=0.021). Lipid-lowering therapy was prescribed to 68.6% (199/290) of the patients, with no significant sex differences (men, 71.4% [137/192]; women, 63.3% [62/98]). Of the patients prescribed lipid-lowering therapy (primarily statins), 53.8% (107/199) achieved target LDL-C. There was no significant sex difference in the potency groups prescribed, and the rate of LDL-C target attainment was similar across potency groups. Overall, 70.3% of patients who did not receive lipid-lowering therapy had inadequately controlled LDL-C (women, 31/36 [86.1%]; men, 33/55 [60.0%] [P=0.008]).

CONCLUSIONS

The majority of CHD patients from a Maryland-based health maintenance organization had elevated LDL-C values, despite a lipid-lowering prescription rate of 68.6%. A significant gap in dyslipidemia treatment in these CHD patients remained, particularly for women.

The Changing Face of Dyslipidemia Therapies

To date, the major emphasis of dyslipidemia management has focused on the reduction of serum low-density lipoprotein cholesterol (LDL-C) levels, which several robust trials show significantly decreases the risk of coronory heart disease (CHD). To achieve goal LDL-C levels will require that some individuals take more than 1 cholesterol-lowering medication. In addition, many dyslipidemic patients also have concomitant risk factors for cardiovascular disease including hypertension, elevated plasma glucose, and high body mass index, requiring additional therapies. In addition to drugs that lower LDL-C, several agents under investigation are targeting other markers for decreasing the risk of atherosclerotic disease. Some of these agents target the reduction of C-reactive protein with a more potent statin, increased high-density lipoprotein cholesterol (HDL-C) with the cholesterol ester transfer protein inhibitor, inhibition of triglyceride or very-low-density lipoprotein cholesterol (VLDL-C) with the acyl coenzyme A: cholesterol acyltransferase inhibitor, reduction of VLDL-C with microsomal triglyceride transfer protein inhibitor, change in percentage coronary atheroma volume with HDL-C mimetics, and the reduction of bile acid transport and reabsorption with the ileal bile acid transport inhibitors. This review will provide an overview of the existing landscape for the medical treatment of dyslipidemia, including available therapies and future trends.

The impact of health literacy on cardiovascular disease

One's ability to read, listen, and comprehend health information is a vital element of maintaining and improving health. However, 90 million people in the United States exhibit less than adequate health literacy skills. Given that more than 70 million Americans suffer from cardiovascular diseases, it is certain that every physician's practice is affected by health literacy issues. Those with language and cultural issues tend to be the most affected. Yet numerous studies find physicians do a poor job of assessing their patients' health literacy skills. Patients are also unaware of the steps they should take, and how to take them, to improve their health and prevent complications. Numerous studies find, however, that outcomes can be improved with targeted patient education and improved physician communication skills that take into account patients' health literacy levels. Unfortunately, the health care system is only beginning to recognize this problem and take action to overcome its negative impact. By improving the communication process with patients, physicians may be able to improve cardiovascular outcomes.

Utilization and cost of sildenafil in a large managed care organization with a quantity limit on sildenafil

OBJECTIVE

Erectile dysfunction (ED) affects approximately 30 million men in the United States. The objectives of this study were to (1) assess the cost and utilization of sildenafil citrate (Viagra), an oral therapeutic agent for ED, in a large managed care organization (MCO) with a quantity limit of 6 units per 30-day supply and (2) describe the incidence of comorbid conditions and the severity of cardiovascular disease in adult male users of sildenafil.

METHODS

Pharmacy claims for sildenafil were identified from an administrative database of claims with dates of service in calendar year 2001 for male members aged 18 years or older. Medical claims for MCO members who had sildenafil claims were used to identify comorbid diseases and categorize patients by degree of cardiovascular risk. High risk was defined as having at least 1 medical claim with a diagnosis of diabetes mellitus, ischemic heart disease, abdominal aortic aneurysm, or peripheral arterial disease, and medium risk was defined as not having any diagnosis in the high-risk category but at least 1 cardiovascular risk factor that included smoking, hypertension, hypercholesterolemia, family history of premature coronary heart disease, or being aged 45 years or older.

RESULTS

There were 67,914 pharmacy claims for sildenafil during 2001 for 20,281 MCO members, an average of 3.3 pharmacy claims per patient. The prevalence of sildenafil use was 54.1 per 1,000 male MCO members aged 18 years or older. The total allowed charges for sildenafil pharmacy claims in 2001 were 3.56 million US dollars, of which patients paid 26.6% in average cost-share, and the net MCO cost per member per month (PMPM) was 0.18 US dollars. A total of 1,681 patients (8.3%) exceeded their quantity restrictions for sildenafil tablets in 2001, of which 1,362 (81.0%) paid cash and 319 (19.0%, or 1.6% of all sildenafil users) appealed and received approval from the MCO for additional sildenafil tablets beyond the restriction of 6 tablets per month. Medical claims were available for 15,644 sildenafil patients (77.1%), and 12,720 sildenafil users (81.3% of those with medical claims) were judged to be at high or medium cardiovascular risk.

CONCLUSIONS

A quantity limit of 6 tablets of sildenafil per 30-day period was associated with a drug cost to users and the MCO of 0.25 US dollars PMPM. Sildenafil users paid an average cost-share of 26.6%, resulting in a net drug cost of 0.18 US dollars PMPM to the MCO.

A retrospective review of the effect of COX-2 inhibitors on blood pressure change

The objective of this study was to compare the difference between celecoxib and rofecoxib on blood pressure change. A retrospective review of medical records where the mean blood pressure in a 90-day period before and after start of the cyclooxygenase (COX)-2 inhibitors, celecoxib, and rofecoxib was compared. Data were abstracted from 249 patient records, of which 109 were included. The mean systolic blood pressures at baseline were comparable at 134.14 mm Hg and 134.05 mm Hg for the celecoxib (n = 52) and rofecoxib groups (n = 57), respectively (P = NS). A nonsignificant decrease in systolic blood pressure was observed for the celecoxib group (-1.15 mm Hg), while a statistically significant increase in systolic blood pressure was seen in the rofecoxib group (4.76 mm Hg, P = 0.044). The mean diastolic blood pressures at baseline were not significantly different between the two groups, and changes in the postperiod were also not statistically different compared with baseline values. The average total daily dose of COX-2 inhibitor was 219.2 mg for celecoxib and 25.23 mg for rofecoxib. A post hoc analysis of patients aged 65 years and older showed that the mean systolic blood pressure in the rofecoxib group increased by 7.37 mm Hg (P = 0.016), while there was an insignificant decrease for the celecoxib group (-1.94 mm Hg). This study showed that there were no significant changes in blood pressure after celecoxib initiation. While in the rofecoxib group, there was a significant increase in systolic blood pressure with an even greater increase for patients aged 65 years and older.

Pharmacist's guide to pregnancy registry studies

OBJECTIVE

To introduce the concept and design characteristics of pregnancy registries and to discuss opportunities for pharmacist involvement.

DATA SOURCES

Previous and ongoing pregnancy registry studies that assess the safety of pharmaceutical agents in pregnant women were identified from the medical literature, Internet, abstracts from professional meetings, and personal communications.

DATA EXTRACTION

The development and use of the pregnancy registry study for evaluating drug safety is described. Then, to illustrate the application of scientific principles to this unique study design, examples are given from previous and ongoing pregnancy registry studies.

DATA SYNTHESIS

Pregnancy registry studies are increasingly used to assess the safety of drugs and other therapeutic agents during pregnancy. In a pregnancy registry, women who took the study drug while pregnant are identified soon after that exposure and followed until their pregnancy ends and its outcome is determined. Information is compiled from hundreds or thousands of pregnancies and used to make a safety assessment.

CONCLUSION

Pharmacists can explain pregnancy registries to pregnant women and encourage enrollment. Also, pharmacists can use information derived from these studies to help patients and health care providers manage inadvertent drug exposures and optimize pharmaceutical therapy during pregnancy.

Disease state management in diabetes care

Diabetes affects over 16 million Americans. Caring for patients with diabetes requires extensive health care resources. Managed care organizations must utilize resources cost-effectively to survive in the health care industry. A disease state management program for diabetes may enable the managed care organization to meet its goal of providing cost-effective quality health care while meeting regulatory standards. The National Committee for Quality Assurance (NCQA) which accredits managed care organizations and provides information on performance, grants accreditation status to managed care organizations and reports favorable comparisons with competing managed care organizations.

Therapeutic Advances in the Treatment of Cigarette Addiction

Smoking-related diseases are preventable. Along with behavioral counseling, nicotine replacement therapies improve the chance for a successful attempt at quitting. Many of these nicotine replacement products are available without a prescription. Pharmacists are in a unique position to help decrease the number of smokers by encouraging smokers to quit. Once a patient has made the decision to quit, the pharmacist should discuss the physical and psychological effects of nicotine addiction and withdrawal and provide counseling on behavioral modifications and nicotine replacement products. Pharmacists can offer smoking cessation programs in their practice and will be rewarded for cost-effective management of smoking cessation.