Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling

How to engage healthcare providers in preventing medication waste through individualized prescribing and dispensing: A qualitative study

BACKGROUND

Medication waste is a threat to healthcare's sustainability. To prevent medication waste in patients' homes, medication quantities prescribed and dispensed to patients could be individualized. Perspectives of healthcare providers on engaging in this strategy however remain unclear.

OBJECTIVE(S)

To identify factors influencing healthcare providers in preventing medication waste through individualized prescribing and dispensing.

METHODS

Individual semi-structured interviews were conducted via conference calls with pharmacists and physicians prescribing and dispensing medication to outpatients of eleven Dutch hospitals. An interview guide based on the Theory of Planned Behaviour was developed. Questions related to participant's view on medication waste, current prescribing/dispensing behaviour and intention to personalising prescribing/dispensing quantities. Data was thematically analysed, following a deductive approach based on the Integrated Behavioural Model.

RESULTS

Nineteen out of 45 (42%) healthcare providers were interviewed, of whom eleven were pharmacists and eight physicians. Factors influencing individualized prescribing and dispensing by healthcare providers were identified and categorized in seven themes: (1) attitude: beliefs about consequences of waste, as well as perceived benefits and concerns of the intervention; (2) perceived norm: professional and social responsibilities; (3) personal agency: available resources; (4) knowledge and skills: intervention complexity; (5) salience of behaviour: perceived need from past experiences and evaluation of actions; (6) habit: prescribing and dispensing habits; and (7) situational factors: support for change, momentum for sustainable actions, need for guidance, triad collaboration and information provision.

CONCLUSIONS

Healthcare providers perceive a strong professional and social responsibility to prevent medication waste yet feel bound by limited resources available to engage in individualized prescribing and dispensing. Situational factors, including leadership, organizational awareness and strong collaborations, could help healthcare providers to engage in individualized prescribing and dispensing. Through the identified themes, this study offers directions for designing and implementing an individualized prescribing and dispensing program to prevent medication waste.

Association Between Cost-Saving Prescription Policy Changes and Adherence to Chronic Disease Medications: an Observational Study

BACKGROUND

Pharmacy benefit design is one tool for improving access and adherence to medications for the management of chronic disease.

OBJECTIVE

We assessed the effects of pharmacy benefit design programs, including a change in pharmacy benefit manager (PBM), institution of a prescription out-of-pocket maximum, and a mandated switch to 90 days' medication supply, on adherence to chronic disease medications over time.

DESIGN

We used a difference-in-differences design to assess changes in adherence to chronic disease medications after the transition to new prescription policies.

SUBJECTS

We utilized claims data from adults aged 18-64, on ≥ 1 medication for chronic disease, whose insurer instituted the prescription policies (intervention group) and a propensity score-matched comparison group from the same region.

MAIN MEASURES

The outcome of interest was adherence to chronic disease medications measured by proportion of days covered (PDC) using pharmacy claims.

KEY RESULTS

There were 13,798 individuals in each group after propensity score matching. Compared to the matched control group, adherence in the intervention group decreased in the first quarter of 2015 and then increased back to pre-intervention trends. Specifically, the change in adherence compared to the last quarter of 2014 in the intervention group versus controls was - 3.6 percentage points (pp) in 2015 Q1 (p < 0.001), 0.65 pp in Q2 (p = 0.024), 1.1 pp in Q3 (p < 0.001), and 1.4 pp in Q4 (p < 0.001).

CONCLUSIONS

In this cohort of commercially insured adults on medications for chronic disease, a change in PBM accompanied by a prescription out-of-pocket maximum and change to 90 days' supply was associated with short-term disruptions in adherence followed by return to pre-intervention trends. A small improvement in adherence over the year of follow-up may not be clinically significant. These findings have important implications for employers, insurers, or health systems wishing to utilize pharmacy benefit design to improve management of chronic disease.

The link between unemployment and opioid prescribing. An instrumental variable approach using evidence from England

BACKGROUND

Unemployment has been associated with chronic pain, which is often treated with prescription opioids. Opioid mortality has been included in the so-called category of 'deaths of despair' due to the role of lack of opportunity. While previous studies have found an association between unemployment and opioids, the relationship is endogenous and examining any effect is challenging.

OBJECTIVE

The objective of this paper is to study the association between unemployment and opioid prescribing in England.

DATA AND METHODS

We used data from the GP prescribing database in England for the period 2011-2017 and followed ordinary least squares (OLS) and Instrumental Variable econometric approaches, controlling for other confounders. We used the number of foreign direct investment projects and the number of registered companies as instruments for unemployment, taking population size into account.

RESULTS

The OLS model suggests that an increase in the unemployment rate by 1 percentage point is associated with 0.017 additional opioid defined daily doses per capita-a 0.9% increase compared with the mean of 1.745. According to the instrumental variable model, an increase in unemployment by 1 percentage point leads to an increase in the number of opioid doses prescribed per capita by between 0.315 and 0.437, which constitutes a 18-25% increase compared with the mean of 1.745.

CONCLUSIONS

Unemployment appears to have an impact on opioid prescribing volume in England. This reveals yet another negative effect of unemployment on health. Relevant labour market policies may play a protective role with regards to opioid use.

"Don't Let Medicines Go to Waste"-A Survey-Based Cross-Sectional Study of Pharmacists' Waste-Reducing Activities Across Gulf Cooperation Council Countries

Objectives

Medication waste has a negative environmental and economic impact. From avoiding unnecessary supply to recycling medicines that are no longer needed, pharmacists are placed in an advantageous position to minimise medication waste. Thus, the aim of this study was to detect waste-minimising activities undertaken by pharmacists to limit medication waste and to evaluate their importance for medication waste minimisation and feasibility for implementation.

Methods

A cross-sectional survey of 277 participants, conveniently selected from six Gulf countries. The eligibility criteria were pharmacists or pharmacy technicians, Arabic- or English-speaking individuals, aged ≥18 years, and living in the Gulf countries. An online self-administered survey was distributed during December 2019 and February 2020, via e-mail and social networks; it included the purpose of the study with a link to the webpage that hosted the questionnaire. Data were collected through the online survey site QuestionPro.com. All analyses were performed in SPSS Version 23 and Microsoft Excel.

Results

The majority of participants were female (175/277; 63%), hospital pharmacists (206/277; 74%), and had more than 10 years of work experience (100/277; 36%). This study indicates that most of the suggested activities (14/21) were implemented by the majority of pharmacists for minimising medication waste, except four activities in the dispensing stage and three activities in the leftover stage. Activities performed at the prescribing, dispensing and leftover stages were considered very important or important for reducing medication waste and very feasible or feasible for implementation in practice.

Conclusions

Many waste-minimising activities were undertaken by pharmacists in the prescribing, dispensing, and leftover stages. However, although waste-minimising activities were perceived as important for reducing waste and feasible for implementation in practice, not all activities were implemented in daily practice.

A Neurologist's Guide to REM Sleep Behavior Disorder

REM Sleep Behavior Disorder (RBD) is a chronic sleep condition characterized by dream enactment and loss of REM atonia. Individuals often present to clinic with complaints of injury to themselves or their bed-partner due to violent movements during sleep. RBD patients have a high risk of developing one of the neurodegenerative α-synucleinopathy diseases: over 70% will develop parkinsonism or dementia within 12 years of their diagnosis. RBD patients also exhibit accelerated disease progression and a more severe phenotype than α-synucleinopathy sufferers without RBD. The disease's low prevalence and the relatively limited awareness of the condition amongst medical professionals makes the diagnosis and treatment of RBD challenging. Uncertainty in patient management is further exacerbated by a lack of clinical guidelines for RBD patient care. There are no binary prognostic markers for RBD disease course and there are no clinical guidelines for neurodegeneration scaling or tracking in these patients. Both clinicians and patients are therefore forced to deal with uncertain outcomes. In this review, we summarize RBD pathology and differential diagnoses, diagnostic, and treatment guidelines as well as prognostic recommendations with a look to current research in the scientific field. We aim to raise awareness and develop a framework for best practice for RBD patient management.

Levothyroxine prescriptions trends may indicate a downtrend in prescribing

BACKGROUND

There has been a trend for increased prescribing of levothyroxine (LT4) in many countries, including the United States. Several different factors have been suggested to be the cause of this practice pattern. These factors include increased size of the United States population, more diagnosis of hypothyroidism, more treatment of minimally elevated thyroid-stimulating hormone (TSH) levels, more use of LT4 in older patients, and use of LT4 for treatment of euthyroid patients with non-thyroidal conditions.

METHODS

The electronic databases of the MedStar Health system operating in the Washington, DC and Maryland areas were interrogated to determine the number of patients who were being prescribed levothyroxine during the time period 2008-2016, the number of prescriptions supplied to these individuals, the associated diagnosis, and whether the prescriptions were new or existing prescriptions. Regression analyses were also performed to determine the prescribing trends during this time period.

RESULTS

Although the annual number of levothyroxine prescriptions increased during this time period, the percentage of patients in the database receiving levothyroxine for hypothyroidism initially increased and then decreased over time (2.5% to 3.2% to 2.5%). The percentage of prescriptions written for patients who did not appear to carry a diagnosis of hypothyroidism steadily declined (3.5% to 1.0%). Although the percentage of patients with existing prescriptions for hypothyroidism initially increased and then were maintained at steady levels (1.4% to 2.4% to 2.2%), a smaller percentage of patients with existing prescriptions were documented over time when there was no diagnosis of hypothyroidism (1.45% to 0.89%). The percentage of patients with new prescriptions declined over time for all groups. The number of annual 90-day period prescriptions increased over the time for patients with a diagnosis of hypothyroidism, but down-trended starting over the latter part of the time period for those patients without a diagnosis of hypothyroidism.

CONCLUSION

Taken together, these data suggest that there may be a stabilization, and even a down-trend in levothyroxine prescribing with the MedStar system. The decrease in levothyroxine prescribing appears to be accounted for by less use of levothyroxine without an established diagnosis of hypothyroidism, and less initiation of new prescriptions.

Duration of Insulin Supply in Type 1 Diabetes: Are 90 Days Better or Worse Than 30 Days?

OBJECTIVE

There have been few studies regarding the duration of insulin prescriptions and patient outcomes. This study evaluated whether A1C varied with the duration of insulin prescription in patients with type 1 diabetes.

METHODS

We conducted a longitudinal investigation (from 2001 to 2015) within a nationwide private health insurer. A cohort study was first used to compare A1C after 30-day only, 90-day only, and a combination (30-day and 90-day) of insulin prescriptions. Second, a self-controlled case series was used to compare A1C levels after 30-day versus 90-day prescriptions for the same person.

RESULTS

In the cohort study, there were 16,725 eligible patients. Mean A1C was 8.33% for patients with 30-day prescriptions compared to 7.69% for those with 90-day prescriptions and 8.05% for those who had a combination of 30- and 90-day prescriptions (P <0.001). Results were similar when stratified by age and sex. Mean A1C was 7.58% when all prescriptions were mailed versus 8.21% when they were not. In the self-controlled case series, there were 1,712 patients who switched between 30- and 90-day prescriptions. Mean A1C was 7.87% after 30-day prescriptions and 7.69% after 90-day prescriptions (P <0.001). Results were similar when stratified by sex. For this within-person comparison, the results remained significant for those ≥20 years of age (n = 1,536, P <0.001), but not for youth (n = 176, P = 0.972).

CONCLUSION

There was a statistically significant but clinically modest decrease in A1C with 90-day versus 30-day insulin prescriptions in adults. A mailed 90-day insulin prescription may be a reasonable choice for adults with type 1 diabetes.