Understanding the problem of digital medication inventory visibility in health systems

PURPOSE

This project describes and quantifies the perceived degree of digital visibility to medication inventory throughout 6 large health systems.

METHODS

In this project, 6 large health systems evaluated their physical medication inventory for digital visibility, or the degree to which physical medication inventory information is viewable in electronic systems, during a 2-year period (2019-2020). Inventory reports included medication items with either a National Drug Code (NDC) or a unique institutional identifier. Physical inventory reports contained the medication item name and a corresponding NDC or identifier, the quantity on hand, and the physical locations and the storage environments of the inventory items at the time of the audit. Investigators independently reviewed physical inventory reports and categorized medication line items by degree of digital visibility: (1) no digital visibility, (2) partial digital visibility without accurate quantities, (3) partial digital visibility with accurate quantities, or (4) full digital visibility. Data were anonymized, aggregated, and analyzed to characterize the degree of digital visibility across the health systems and to identify locations and storage environments where the greatest improvement is needed.

RESULTS

Overall, less than 1% of medication inventory was judged to have full digital visibility. The majority of the evaluated inventory items were categorized as having partial digital visibility, with or without accurate quantities. Analysis by both units of inventory and inventory valuation indicated that only 30% to 35% of inventory had full digital visibility or partial digital visibility with accurate quantities.

CONCLUSION

Most of the medication inventory within 6 large academic centers is either not digitally visible or partially digitally visible but without accurate quantities. Full digital visibility of inventory is rare. Better digital visibility can minimize disruption from recalls and decrease waste. Technology vendors and health systems must collaborate to develop improved automation and systems to make medications on hand more digitally visible.

Pharmacist Biosimilar Survey Reveals Knowledge Gaps

BACKGROUND

Biosimilars are of increasing significance to pharmacy practice, with the potential to improve patient access to biologic therapies and help reduce overall health care costs.

OBJECTIVES

This web-based survey assessed pharmacists' understanding of biosimilars, including interchangeability.

METHODS

WebMD LLC fielded a survey including true or false and Likert-type questions to the Medscape pharmacist and certified pharmacy technician (CPT) panel in March 2021. Those practicing in community, home care or infusion, hospital or health system, managed care, outpatient, or specialty pharmacy settings and currently providing prescription services, or formulary or benefit management related to biologic products were included, to a quota of 500 responses. Results were analyzed descriptively.

RESULTS

Data are reported for 507 of 992 respondents (265 did not meet eligibility criteria, 220 responded after the survey closed), including 498 pharmacists and 9 CPTs. These respondents worked in a community setting (66%), outpatient or ambulatory or other setting (16%), hospital or health system setting (14%), or managed care (5%). Overall, 87% and 91% of respondents knew that the biosimilar had equivalent efficacy and safety, respectively, to its reference product. Only 20% understood that a pharmacist can substitute a Food and Drug Administration-approved interchangeable without approval of the prescriber. However, 53% responded that they felt it was appropriate for a pharmacist to dispense an interchangeable in place of its reference product without authorization from the prescriber if consistent with state law; a numerically smaller proportion of community pharmacists understood this concept than the other groups (50% vs. 54%-61%). Only 11% of respondents knew that no biosimilars were designated as interchangeable at the time of the survey, with a numerically greater proportion of managed care pharmacists showing awareness than other groups. Slightly more than 50% of respondents felt that they were moderately or very comfortable in responding to patients' biosimilar questions.

CONCLUSION

Gaps remain in pharmacists' understanding and comfort with key concepts about biosimilar products, including interchangeability, suggesting the need for further education.

Factors associated with naloxone availability and dispensing through Michigan's pharmacy standing order

Background: Pharmacy standing order policies allow pharmacists to dispense naloxone, thereby increasing access to naloxone. Objectives: To describe pharmacy standing order participation and associations of pharmacy and community characteristics that predict naloxone availability and dispensing across eight counties in Michigan. Methods: We conducted a telephone survey of 662 standing order pharmacies with a response rate of 81% (n = 539). Pharmacies were linked with census tract-level demographics, overdose fatality rates, and dispensing data. County maps were created to visualize pharmacy locations relative to fatality rates. Regression models analyzed associations between pharmacy type, neighborhood characteristics, fatality rates, and these outcomes: naloxone availability, having ever dispensed naloxone, and counts of naloxone dispensed. Results: The prevalence of standing order pharmacies was 54% (n = 662/1231). Maps revealed areas with higher fatality rates had fewer pharmacies participating in the standing order or lacked any pharmacy access. Among standing order pharmacies surveyed, 85% (n = 458/539) had naloxone available and 82% had ever dispensed (n = 333/406). The mean out-of-pocket cost of Narcan_® was $127.77 (SD: 23.93). National chains were more likely than regional chains to stock naloxone (AOR = 3.75, 95%CI = 1.77, 7.93) and to have ever dispensed naloxone (AOR 3.02, 95%CI = 1.21,7.57). Higher volume of naloxone dispensed was associated in neighborhoods with greater proportions of public health insurance (IRR = 1.38, 95%CI = 1.21, 1.58) and populations under 44 years old (IRR = 1.24, 95%CI = 1.04, 1.48). There was no association with neighborhood overdose fatality rates or race in regression models. Conclusion: As deaths from the opioid epidemic continue to escalate, efforts to expand naloxone access through greater standing order pharmacy participation are warranted.

The global landscape on interchangeability of biosimilars

INTRODUCTION

Biosimilars hold the potential to be an integral healthcare component that can significantly improve affordability and thereby accessibility of the otherwise expensive biotherapeutic products. Regulators, payors, and policymakers, each have a major role to play in successful adoption of biosimilars. One of the issues that has been a point of frequent discussion is that of interchangeability of biosimilars.

AREAS COVERED

This article aims to review the position that the major regulatory bodies have taken on interchangeability of biosimilars. Key issues that remain are also discussed. Adalimumab and etanercept have been chosen as real-world case studies to demonstrate interchangeability considerations. The need for gaining global harmonization on interchangeability is highlighted.

EXPERT OPINION

A global harmonization on the interchangeability can likely accelerate biosimilar adoption and result in better accessibility to biologics. Experience gained with real-world studies supports switching to biosimilars from originators however post-marketing pharmacovigilance should be in place to assess the risk-benefit profile of biosimilars in the long run.

An analysis of hospital pharmacy practice in Namibia, based on FIP's Basel Statements

BACKGROUND

Sub-Saharan Africa, a region faced with a double challenge of infectious and non-communicable diseases requires strengthening of hospital pharmacy practice to improve treatment outcomes and patient safety.

OBJECTIVES

The objectives of this study were to assess the current state of pharmacy practice in hospitals in Namibia and to identify opportunities for expanding pharmacists' role in addressing public health challenges and improving medicines use outcomes.

METHODS

A survey utilized FIP's self-assessment tool to evaluate current hospital pharmacy practice in Namibia against best practices articulated in the Basel Statements. The study was conducted among hospital pharmacists across Namibia. Quantitative and qualitative data were analysed using descriptive statistics and thematic analysis.

KEY FINDINGS

The study was conducted in 24 hospital pharmacies across Namibia, the majority of which were public facilities (67%). Overall, current hospital pharmacy practice activities are focused on medicine procurement, preparation and distribution. The main barriers to optimal hospital pharmacy services are associated with limited human resources and collaboration across healthcare providers, as well as policy gaps.

CONCLUSIONS

There is a strong desire among hospital pharmacists to expand their contributions to improving medicines outcomes and solving public health problems. Namibia's pharmacy educational system is a strength and should be utilized to continue advancing hospital pharmacy practice and medicines use. Therapeutics committees are usually part of each hospital's structure and can be very effective for hospital-based policy change. The opportunity exists to optimize pharmacists' contributions by utilizing the local therapeutics committees in combination with the educational system to advance hospital pharmacy practice in Namibia.

Considerations related to comparative clinical studies for biosimilars

Introduction: Biosimilar medicines have transformed the healthcare landscape by providing improved access to life-saving medicines at a lower cost. Biosimilars are a distinct category of biologic therapeutics that enter the market after patent expiration of a reference molecule. Regulatory bodies worldwide have developed guidance to expedite the approval and entry of these drugs to the market. Biosimilar approval is based on a totality of the evidence approach, demonstrating similarity between the biosimilar and the originator in terms of physicochemical properties, quality characteristics, biological activity, safety, and efficacy.Areas covered: This article provides an overview of the biosimilar regulatory guidelines and discusses the importance and considerations of comparative clinical studies that are performed during biosimilar development. Two review assessment reports, one each from the EMA and the FDA, are presented.Expert opinion: The discussed case studies illustrate the importance of pharmacokinetic and pharmacodynamic studies in the regulatory approval of biosimilars. It is crucial for biosimilar developers to judiciously determine clinical parameters including biomarkers, endpoints, and acceptance criteria before executing clinical studies.

Evaluating a handheld decision support device in pediatric intensive care settings

OBJECTIVE

To evaluate end-user acceptance and the effect of a commercial handheld decision support device in pediatric intensive care settings. The technology, pac2, was designed to assist nurses in calculating medication dose volumes and infusion rates at the bedside.

MATERIALS AND METHODS

The devices, manufactured by InformMed Inc., were deployed in the pediatric and neonatal intensive care units in 2 health systems. This mixed methods study assessed end-user acceptance, as well as pac2's effect on the cognitive load associated with bedside dose calculations and the rate of administration errors. Towards this end, data were collected in both pre- and postimplementation phases, including through ethnographic observations, semistructured interviews, and surveys.

RESULTS

Although participants desired a handheld decision support tool such as pac2, their use of pac2 was limited. The nature of the critical care environment, nurses' risk perceptions, and the usability of the technology emerged as major barriers to use. Data did not reveal significant differences in cognitive load or administration errors after pac2 was deployed.

DISCUSSION AND CONCLUSION

Despite its potential for reducing adverse medication events, the commercial standalone device evaluated in the study was not used by the nursing participants and thus had very limited effect. Our results have implications for the development and deployment of similar mobile decision support technologies. For example, they suggest that integrating the technology into hospitals' existing IT infrastructure and employing targeted implementation strategies may facilitate nurse acceptance. Ultimately, the usability of the design will be essential to reaping any potential benefits.

Implementing a specialty pharmacy course within a professional pharmacy curriculum

BACKGROUND AND PURPOSE

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

EDUCATIONAL ACTIVITY AND SETTING

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

FINDINGS

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

SUMMARY

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

Board of Pharmacy Practices Related to Medication Errors and Their Potential Impact on Patient Safety

State boards of pharmacy are generally responsible for the governance of the practice of pharmacy. While the regulatory process and methods for accomplishing this task may vary by state, all boards of pharmacy must address medication errors committed by pharmacists. The National Association of Boards of Pharmacy (NABP) has recommended that state boards of pharmacy implement best practices and enforcement actions that are aimed to promote patient safety and reduce medication errors. The current study was designed to identify and compare current corrective action practices among boards of pharmacy in response to medication errors. An electronic survey regarding board policies and anticipated board actions in response to hypothetical medication error scenarios was sent to boards of pharmacy for completion. Approximately 45% of pharmacy boards responded. Survey responses demonstrated that corrective actions and consequences were levied against pharmacists inconsistently among state boards. Corrective action plans and process improvement components were lacking in a majority of state board of pharmacy practices. Medication safety education for pharmacists and for members on boards of pharmacy was insufficient in many states. Responses to hypothetical error scenarios indicated that most board actions are educational and punitive in nature, rather than focusing on systems improvement.

Biologics, Pharmacovigilance, and Patient Safety: It's All in the Name

The most appropriate naming convention for biologics and biosimilars has been an area of significant debate. The ultimate decision will have an impact on patient safety, pharmacovigilance program effectiveness, and, potentially, the overall adoption of biosimilars in the United States. This article reviews some of the advantages and disadvantages of various naming approaches. For clarity in communication, optimal pharmacovigilance, and patient safety, it is recommended that biosimilars be named with a common USAN (United States Adopted Name) with the reference product, along with a suffix that is memorable, such as one associated with the original manufacturer of the product. This approach supports the FDA's mission of protecting patient safety and public health, while minimizing the possibility of inadvertent switching of products and facilitating effective pharmacovigilance.

DISCLOSURES

No funding supported the writing of this article. Stevenson reports consulting fees from Amgen, Inc., AbbVie, and Pfizer and is employed by Visante. Green is employed by and owns stock in Amgen, Inc. Article concept was contributed primarily by Stevenson, along with Green. The manuscript was written and revised primarily by Stevenson, along with Green. Both authors contributed equally to data interpretation.

Oseltamivir for pandemic influenza preparation: Maximizing the use of an existing stockpile

With the threat of significant morbidity and mortality following an influenza pandemic, stockpiling of antiviral agents such as oseltamivir is recommended. Shelf-life extension was explored to maximize use of an existing stockpile. This analysis demonstrated that oseltamivir retains potency defined by United States Pharmacopeia acceptance criteria beyond the labeled expiration date.

Biosimilars: Practical Considerations for Pharmacists

Objective: To review the scientific and regulatory aspects of biosimilar development and practical considerations for the use of biosimilars that are relevant to pharmacists. Data Sources: Literature searches of PubMed and congress abstracts for publications pertaining to biosimilars were conducted from January 2016 to January 2017. Individual drug company web pages and governmental, regulatory, and other agency websites were also reviewed. Study Selection/Data Extraction: Published articles, regulatory guidelines, and other sources covering biologic/biosimilar development and approval, reporting results of biosimilar studies or survey research, and/or identifying biosimilars in development or approved for use in Europe or the United States were reviewed and included. Data Synthesis: Biologic therapies have revolutionized the treatment of serious diseases, including hematological or autoimmune disorders and cancers. A biosimilar is highly similar to a licensed biologic (ie, reference or originator) and has no clinically meaningful differences in safety, purity, and potency. Unlike small-molecule drugs, biologics are large, complex proteins that cannot be exactly replicated, so the concept of a generic equivalent cannot be applied to biologics. Regulatory agencies have provided a framework for biosimilar approval, but there are many practical considerations for pharmacists, including interchangeability, substitution, naming, indication extrapolation, product labeling, therapeutic drug monitoring, manufacturer attributes, logistics of product use, and reimbursement. Conclusions: Pharmacists will play a key role in managing the introduction of biosimilars into health care systems. Understanding the principles of biosimilar development and evolving regulatory guidelines relevant to their use will allow pharmacists to make informed decisions regarding formulary inclusion and educate patients and other health care providers about biosimilars.

Revision of the International Pharmaceutical Federation's Basel Statements on the future of hospital pharmacy: From Basel to Bangkok

PURPOSE

The processes used to revise the 2008 Basel Statements on the future of hospital pharmacy are summarized, and the revised statements are presented.

METHODS

The process for revising the Basel Statements followed an approach similar to that used during their initial development. The Hospital Pharmacy Section (HPS) of the International Pharmaceutical Federation (FIP) revised the 2008 FIP Basel Statements in four phases, including a survey of hospital pharmacists worldwide, an internal review, online forums, and a face-to-face "World Café" workshop in Bangkok, Thailand.

RESULTS

The global survey on the initial Basel Statements included input from 334 respondents from 62 countries. The majority of respondents agreed that most of the initial Basel Statements were acceptable as written and did not require revision. In total, 11 statements were judged by more than 10% of respondents as needing revision or deletion. The FIP HPS executive committee used the survey results to develop 69 initial revised draft statements. After an online discussion with the international hospital pharmacy community, including individuals from 28 countries representing all six World Health Organization regions, a final set of draft statements was prepared for the live discussion involving participants from 20 countries. The final 65 revised Basel Statements were voted on and accepted.

CONCLUSION

Systematic revision of the FIP Basel Statements resulted in an updated reflection of aspirational goals for the future of hospital pharmacy practice. While this revision reflects the development of new goals for hospital pharmacy practice, the core principles of the Basel Statements remain an essential foundation for the discipline.

Clinical data and regulatory issues of biosimilar products

Biologics are a fast-growing segment of pharmaceutical development. Many are effective in the treatment of illnesses such as cancers, rheumatoid arthritis, and multiple sclerosis. Biologics encompass a range of compounds, including recombinant hormones, growth factors, monoclonal antibodies, recombinant vaccines, and blood products. Many of these drugs are facing patent expiration, and pharmaceutical research is focusing on the development of generic substitutes, or "biosimilars." Because biologics generally exhibit high molecular complexity, the process of development and approval of biosimilars is complicated. Unlike standard small molecule generics where an identical drug copy is expected, variations in biosimilars may be inherent because the sponsor does not have knowledge of the originator's processes. Because of this intricacy, regulatory requirements are needed to ensure biosimilarity, comparability, and interchangeability with respect to efficacy and safety. Clinician awareness of the similarities and differences between original biopharmaceuticals and biosimilars, as well as their impact on efficacy and safety, is imperative.

Variability in compounding of oral liquids for pediatric patients: a patient safety concern

OBJECTIVE

To determine the degree in variation of oral liquid pediatric compounding practices in Michigan pharmacies.

DESIGN

Cross-sectional survey study.

SETTING

All types of inpatient and outpatient pharmacies across the state of Michigan, excluding nuclear pharmacies and long-term care facilities.

PARTICIPANTS

244 Michigan pharmacies.

INTERVENTION

An online survey tool was used to assess the current compounding practices of 147 oral liquid pediatric medications. The survey was e-mailed or faxed to hospitals, chain pharmacies, and independent pharmacies. Pharmacists were also mailed a follow-up postcard, and the Michigan Pharmacists Association publicized the project through its journal and annual meeting.

MAIN OUTCOME MEASURES

Pharmacy demographics; number of compounding pharmacies; number of medications compounded; awareness of compounding errors; results of compounding errors; and number of concentrations compounded per medication.

RESULTS

The majority of respondents were from outpatient pharmacies, but inpatient and other types of pharmacies were also represented. The majority of participating pharmacies compound fewer than five oral liquid medications per week. Awareness of errors was low overall, with no errors believed to result in permanent harm or death. The number of concentrations compounded per medication ranged from 1 to 9, with the majority of pharmacies compounding more than 3 concentrations per medication.

CONCLUSION

There is a considerable degree of variation in current oral pediatric liquid compounding practices in Michigan pharmacies. This variability poses a significant risk to patient safety.

A Call for Appropriate Evidence and Outcomes-Based Use and Measurement of Anticoagulation for Atrial Fibrillation: Moving the Population Towards Improved Health Via Multiple Stakeholders

A multidimensional approach involving consideration of available resources, individual patient characteristics, patient preferences, and cost of treatment is often required to optimize clinical decision making in the management of atrial fibrillation (AF). In order to bring together varying perspectives on effective tactics and to formulate innovative strategies to improve the management of AF, a think tank consortium of advisors was assembled from across the spectrum of health care stakeholders. Focus groups were conducted and facilitated by a moderator and a notetaker. Participants were asked to comment on preliminary data for the increased prevalence of AF, patterns of treatment, impact of adherence with anticoagulants on clinical and economic outcomes, and opportunities for optimizing treatment.Several recommendations to reach short- and long-term goals in improving AF management emerged from the focus group discussions. These recommendations specifically targeted 3 stakeholder groups--patients/caregivers, physicians, and payers--and addressed the need for better understanding of determinants of undertreatment and nonadherence for those on anticoagulation therapy. Recommendations included the use of real-world data studies to understand regional and demographic patterns of treatment and outcomes, the development of an enhanced national quality standard for anticoagulation, and engaging patients in shared decision making to optimize satisfaction with treatment. Actionable strategies were presented to address gaps related to anticoagulation management. Balancing new anticoagulants' higher prescription costs and safety concerns with their superior effectiveness and convenience of administration for at-risk individuals would require a concerted effort involving patients and their caregivers, physicians, and payers.

Building a business case for an outpatient pharmacy

To be successful, an outpatient prescription pharmacy service built and operated by a hospital should be run as a competitive business, not in the manner of an inpatient operation. The outpatient pharmacy should not be a siloed entity that operates separately from the inpatient pharmacy. A hospital may miss a significant margin opportunity if it runs the pharmacy strictly as a safety net for uninsured or underinsured patients.

Moving the Pharmacy Practice Model Initiative forward within a state affiliate

PURPOSE

Efforts to advance the ASHP Pharmacy Practice Model Initiative (PPMI) in the Michigan Society of Health-System Pharmacists (MSHP) are described.

SUMMARY

After the Pharmacy Practice Model Summit in November 2010, the board of directors of MSHP began to strategize ways to help health-system pharmacists in Michigan achieve the vision and concepts envisioned by the PPMI. The ultimate goal was to develop a process for acting on recommendations developed by the PPMI to advance the practice of health-system pharmacy in Michigan. A task force was formed and reviewed the 147 national recommendations from the ASHP Pharmacy Practice Model Summit and grouped them into related areas of focus. Six focus areas were identified: acute care, ambulatory care, education and training, organizational affairs and leadership, pharmacy technicians, and technology and information systems. A PPMI Michigan conference was arranged in which focus groups would assess these six areas. Each focus group was limited to six or seven participants, with a member of the task force serving as the facilitator for the group. Individual focus groups then formulated recommendations MSHP could develop into actionable strategies to address the key issues identified during the morning session. A total of 56 recommendations were submitted by the focus groups for consideration by all conference participants. Over 80% of the recommendations were deemed to be high impact/high feasibility.

CONCLUSION

A process for acting on recommendations of the ASHP PPMI to advance the practice of health-system pharmacy within the state of Michigan was developed.

Demonstrating the value of antimicrobial stewardship programs to hospital administrators

The movement away from fee-for-service models to those that emphasize quality of care and patient outcomes affords a unique opportunity for antimicrobial stewardship programs to expand their value for hospital administration. Antimicrobial stewardship participants must collaborate with administrators and key stakeholders to position themselves to improve economic, process, and outcomes measures. This will allow the establishment of antimicrobial stewardship programs as essential components of the present and future healthcare quality journey.

Formulary Selection Criteria for Biosimilars: Considerations for US Health-System Pharmacists

Pharmacists will play a key role in evaluating biosimilars for formulary inclusion in the United States. As defined by US law, a biosimilar is a biologic that is highly similar to its reference product, notwithstanding minor differences in clinically inactive components, and should not have clinically meaningful differences from its reference product in safety, purity, and potency. We review biosimilars and the current European Union and US regulatory pathways for biosimilars. Furthermore, we propose a checklist of considerations to ensure that US pharmacists thoroughly evaluate future biosimilars for formulary inclusion. Included in the checklist are considerations related to the availability of preapproval and postapproval safety and efficacy data; differences in product characteristics and immunogenicity between the biosimilar and reference product; manufacturer-related parameters that can affect a reliable supply of quality products; health-system and patient perspectives on product packaging, labeling, storage, and administration; costs and insurance coverage; patient education; interchangeability and differences in the range of indications; and evaluation of institutions' information technology systems.

Biosimilars: Implications for health-system pharmacists

PURPOSE

An update on scientific and regulatory challenges in the rapidly evolving field of biosimilar product development is presented.

SUMMARY

The U.S. market for biosimilar products (i.e., highly similar "follow-on" versions of approved biological drugs) is expected to expand with establishment of an expedited-approval pathway for biosimilars similar to that implemented in European Union countries eight years ago. In 2012, the Food and Drug Administration (FDA) published draft guidance clarifying the requirements of the biosimilars approval pathway; although no biosimilar has yet been approved via that pathway, FDA is engaged in ongoing meetings with a number of potential applicants. Due to molecular differences between innovator products and biosimilar versions, biosimilars are highly sensitive to manufacturing changes that can potentially have important safety and efficacy implications. Establishing the interchangeability of biosimilar and innovator drugs may be difficult at first, and it is possible that some biosimilars might not carry all the same indications for which the reference drug is approved. Pharmaceutical cost savings attained through the use of biosimilars are expected to average 20-30%. With several top-selling biologicals likely to lose patent exclusivity by 2020, health systems should prepare for the availability of new biosimilars by addressing formulary management and therapeutic interchange issues, pharmacovigilance and patient safety concerns, and related financial and operational issues.

CONCLUSION

Over the coming years, biosimilars will present opportunities for health care organizations to manage the growth of pharmaceutical expenditures. Pharmacists can play a key role in preparing health systems for projected rapid expansion in the use of biosimilars and associated medication-use policy challenges.

Profiles in Leadership: Donald E. Francke, MSc, DSc (Hon)

The Director's Forum series is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health systems. August 2013 marked the 50th anniversary of the publication of the Mirror to Hospital Pharmacy, the results of a federally funded comprehensive study of pharmacy services in the United States. The late Don E. Francke, MS, DSc, was the lead author of the Mirror and the principal investigator for the US Public Health Service grant W-45. To celebrate the anniversary of the Mirror, the Director's Forum is profiling the leadership styles of Drs. Latiolais and Francke. September's article highlighted Dr. Clifton J. Latiolais; this month's Director's Forum reviews Dr. Francke's biography and key career accomplishments, describes his leadership philosophy, and translates that philosophy to today's health care challenges. Don's influence on health system pharmacy serves as an example of effective leadership. This historical perspective provides directors of pharmacy a valuable leadership view as they develop strategies to enhance patient-centered pharmacy services.

Measuring Change in Health-System Pharmacy Over 50 Years: "Reflecting" on the Mirror, Part II

The Director's Forum guides pharmacy leaders in establishing patient-centered services in hospitals and health systems. 2013 marked the 50th anniversary of the publication of the Mirror to Hospital Pharmacy, which was a comprehensive study of hospital pharmacy services in the United States. This iconic textbook was co-authored by Donald Francke, Clifton J. Latiolais, Gloria N. Francke, and Norman Ho. The Mirror's results profiled hospital pharmacy of the 1950s; these results established goals for the profession in 6 paradigms: (1) professional philosophy and ethics; (2) scientific and technical expansion of health-system pharmacy; (3) development of administrative and managerial acumen; (4) increased practice competence; (5) wage and salary commensurate with professional responsibilities; and (6) health-system pharmacy as a vehicle for advancing the profession as a whole. This article critically reviews our progress on the last of 3 goals. An understanding of the profession's progress on these goals since the seminal work of the Mirror provides directors of pharmacy a platform from which to develop strategies to enhance patient-centered pharmacy services.

Clinical decision support for atypical orders: detection and warning of atypical medication orders submitted to a computerized provider order entry system

The specificity of medication-related alerts must be improved to overcome the pernicious effects of alert fatigue. A systematic comparison of new drug orders to historical orders could improve alert specificity and relevance. Using historical order data from a computerized provider order entry system, we alerted physicians to atypical orders during the prescribing of five medications: calcium, clopidogrel, heparin, magnesium, and potassium. The percentage of atypical orders placed for these five medications decreased during the 92 days the alerts were active when compared to the same period in the previous year (from 0.81% to 0.53%; p=0.015). Some atypical orders were appropriate. Fifty of the 68 atypical order alerts were over-ridden (74%). However, the over-ride rate is misleading because 28 of the atypical medication orders (41%) were changed. Atypical order alerts were relatively few, identified problems with frequencies as well as doses, and had a higher specificity than dose check alerts.

Evaluation of a transplantation specialty pharmacy program

PURPOSE

The value of a transplantation specialty pharmacy (TSP) program, including its impact on patient and health care provider satisfaction, selected clinical outcomes, and the institution's financial margin, was evaluated.

METHODS

Patient and health care provider surveys were distributed to evaluate satisfaction with the TSP program. Medication adherence (using continuous measures of medication adherence), hospital readmissions within 90 days of transplantation, and length of hospitalization were examined. Patients enrolled in the TSP program who received kidney transplants between July 1, 2009, and June 30, 2010, were included. Patients who received kidney transplants at the institution between July 1, 2007, and June 30, 2008, served as the control group.

RESULTS

Of the 838 patient surveys distributed, 290 (34.6%) were returned. Most patients (84%) reported being satisfied with the program, and 98% would recommend it to others. Ninety-six percent of providers believed the pharmacy improved continuity of care, and 91% reported spending less time on pharmacy-related problems after the program's initiation. Medication adherence appeared to be higher in patients enrolled in the TSP program compared with historical controls. Hospital readmissions and length of stay did not significantly differ between groups. The TSP program generated $7.5 million in revenue during its first fiscal year. Roughly $5.5 million was spent on incremental operating expenses, resulting in over $2 million in margin.

CONCLUSION

A TSP program provided a high level of satisfaction to patients and health care providers, may have influenced some clinical outcomes, and served as a source of positive margin for its institution.

Development and validation of a survey instrument for assessing prescribers' perception of computerized drug-drug interaction alerts

OBJECTIVE

To develop a theoretically informed and empirically validated survey instrument for assessing prescribers' perception of computerized drug-drug interaction (DDI) alerts.

MATERIALS AND METHODS

The survey is grounded in the unified theory of acceptance and use of technology and an adapted accident causation model. Development of the instrument was also informed by a review of the extant literature on prescribers' attitude toward computerized medication safety alerts and common prescriber-provided reasons for overriding. To refine and validate the survey, we conducted a two-stage empirical validation study consisting of a pretest with a panel of domain experts followed by a field test among all eligible prescribers at our institution.

RESULTS

The resulting survey instrument contains 28 questionnaire items assessing six theoretical dimensions: performance expectancy, effort expectancy, social influence, facilitating conditions, perceived fatigue, and perceived use behavior. Satisfactory results were obtained from the field validation; however, a few potential issues were also identified. We analyzed these issues accordingly and the results led to the final survey instrument as well as usage recommendations.

DISCUSSION

High override rates of computerized medication safety alerts have been a prevalent problem. They are usually caused by, or manifested in, issues of poor end user acceptance. However, standardized research tools for assessing and understanding end users' perception are currently lacking, which inhibits knowledge accumulation and consequently forgoes improvement opportunities. The survey instrument presented in this paper may help fill this methodological gap.

CONCLUSION

We developed and empirically validated a survey instrument that may be useful for future research on DDI alerts and other types of computerized medication safety alerts more generally.

A response duration schedule: effects of training, extinction, and deprivation

Rats were trained to hold down a lever for at least 40 consecutive seconds. When the lever had been held down for 40 sec, white noise came on. Releasing the bar in the presence of the noise turned off the noise and operated a feeder that delivered a pellet of food. At the end of training, frequency distributions of response durations peaked at 40 to 41 sec. If as in training, holding down the lever produced white noise at the end of 40 sec, and release of the lever terminated the noise and operated the feeder, but no food delivery occurred, duration distributions and several other measures were initially not very different from when food was delivered. However, if during extinction white noise was never produced by lever holding, and feeder operation did not occur upon lever release, most responses were shorter than 1 sec in duration, some were much longer than 41 sec, and duration distributions did not peak at 40 to 41 sec. When reinforcement was reinstated after extinction, performance quickly returned to pre-extinction measures. Further sessions at different levels of deprivation produced only temporary disruptions in performance.

Drug costs and utilization after implementation of a posaconazole prophylaxis protocol in adults with acute myelogenous leukemia

PURPOSE

Drug costs and utilization after implementation of a posaconazole prophylaxis protocol in adults with acute myelogenous leukemia (AML) were studied.

METHODS

Adult patients who initiated induction or reinduction chemotherapy for the treatment of AML between December 1, 2006, and March 31, 2008, at a tertiary care hospital were included in this retrospective cohort study. Patients were divided into two groups: preprotocol (treated before June 1, 2007) and postprotocol (treated on or after June 1, 2007). Medical charts, including pharmacy and laboratory data, were reviewed for all patients. Outcomes measured included antifungal and antibacterial drug costs and utilization and total pharmacy costs.

RESULTS

A total of 66 patients were evaluated (33 in each group). Baseline characteristics, except patient age, were similar between groups. Each group incurred similar costs and utilized resources for similar periods of time as evidenced by similar lengths of stay, duration of neutropenia, and mortality. Antibacterial costs, total pharmacy costs, and other utilization outcomes were also similar between the two groups. Alterations to antifungal management strategy occurred more often in the postprotocol group (33% versus 58%, p = 0.048).

CONCLUSION

Implementation of a posaconazole protocol did not significantly alter antifungal or antibacterial drug costs or utilization or total pharmacy costs. Prophylactic posaconazole was frequently changed to alternative antifungal therapy due to an adverse drug event, perceived lack of efficacy, avoidance of a drug interaction, or inability to tolerate oral intake.

A controlled trial of value-based insurance design - the MHealthy: Focus on Diabetes (FOD) trial

Background

Diabetes affects over 20 million Americans, resulting in substantial morbidity, mortality, and costs. While medications are the cornerstone of secondary prevention, many evidence-based therapies are underutilized, and patients often cite out-of-pocket costs as the reason. Value-based insurance design (VBID) is a 'clinically sensitive' refinement to benefit design which links patient cost-sharing to therapy value; the more clinically beneficial (and valuable) a therapy is for a patient, the lower that patient's cost-sharing should be. We describe the design and implementation of MHealthy: Focus on Diabetes (FOD), a prospective, controlled trial of targeted co-payment reductions for high value, underutilized therapies for individuals with diabetes.

Methods

The FOD trial includes 2,507 employees and dependents with diabetes insured by one large employer. Approximately 81% are enrolled in a single independent-practice association model health maintenance organization. The control group includes 8,637 patients with diabetes covered by other employers and enrolled in the same managed care organization. Both groups received written materials about the importance of adherence to secondary prevention therapies, while only the intervention group received targeted co-payment reductions for glycemic agents, antihypertensives, lipid-lowering agents, antidepressants, and diabetic eye exams. Primary outcomes include medication uptake and adherence. Secondary outcomes include health care utilization and expenditures. An interrupted time series, control group design will allow rigorous assessment of the intervention's impact, while controlling for unrelated temporal trends. Individual patient-level baseline data are presented.

Discussion

To our knowledge, this is the first prospective controlled trial of co-payment reductions targeted to high-value services for high-risk patients. It will provide important information on feasibility of implementation and effectiveness of VBID in a real-world setting. This program has the potential for broad dissemination to other employers and insurers wishing to improve the value of their health care spending.

Moving from A to Z: successful implementation of a statin switch program by a large physician group

OBJECTIVE

To describe the implementation and impact of a centralized statin switch program at a large academic medical center.

METHODS

Patients on atorvastatin were identified from electronic medical records and pharmacy claims data. Relevant information was sent to physicians for approval of the proposed switches. Approved patients were then contacted via phone and offered the opportunity to switch to simvastatin; those who switched received a new prescription for simvastatin. To assess the independent impact of the active switch process, conversion rates within a single insurance plan were compared for patients who participated in this program versus those who were contacted only by mail.

RESULTS

Physicians approved 3207 of the 3677 patients identified for this program. A total of 1710 approved patients accepted the switch, 704 declined, and 170 became ineligible. Information packets were mailed to 623 patients who could not be contacted. Within the single insurance plan, the generic dispensing rate for statins among the 1867 patients included in our program was significantly higher than that for the 2472 patients in the mail-only group (59.2% vs 35.8%, P <.001). Over 8 months, the direct cost of the program was $131,000 with projected annual cost savings of up to $1.14 million to payers and up to $250 for each patient who switched.

CONCLUSION

A proactive and voluntary statin switch program to promote the use of a lower cost generic alternative can be successfully implemented in a fee-for-service health system setting with benefits to patients, providers, and payers.

Enhanced photoemission spectroscopy for verification of high-risk i.v. medications

PURPOSE

The sensitivity and specificity of enhanced photoemission spectroscopy (EPS) for performing an automated final check of compounded i.v. admixtures at a pediatric hospital pharmacy were studied.

METHODS

A tabletop EPS device was used to test samples of seven high-risk drug-diluent combinations compounded in the pharmacy; the drugs were vancomycin, lorazepam, morphine, insulin, hydromorphone, gentamicin, and epinephrine. Ten sets of samples were prepared for each drug. Typically, a sample set consisted of dilutions ranging from 10-fold above to 10-fold below the targeted concentration. Testing was performed twice weekly between November 2005 and March 2006.

RESULTS

The EPS device detected errors departing from the targeted concentration by 20% or more with a sensitivity of at least 95%. Specificity in distinguishing among test medications at targeted concentrations was 100%. The percentage of passing samples with intermediate concentrations varied among the drugs.

CONCLUSION

A tabletop EPS device demonstrated acceptable sensitivity and specificity for validating the identity and concentrations of selected high-risk i.v. medications compounded for pediatric patients. The device may help prevent clinically important medication errors caused by inaccurate compounding.

Developing dashboards to measure and manage inpatient pharmacy costs

PURPOSE

A pharmacy dashboard was developed and implemented to identify trends in drug use; normalize data for patient volumes; allow the user to determine whether changes were due to cost increases, actual use changes, or both; permit evaluation of drug use within key diagnoses for individual services; and allow multiple formats and layers of analysis.

SUMMARY

At the University of Michigan, a drug cost and drug-use database had been developed, and an enterprise data warehouse had been implemented. The data warehouse served as the core data source for the pharmacy dashboard effort. The department of pharmacy services worked with the clinical information and decision support services (CIDSS) unit to develop and promote the use of the pharmacy dashboard. On the basis of the core data in the data warehouse, the dashboard was designed to harness these data for the useful and actionable presentation to service chiefs, individual house officers, and administration for a better understanding of drug costs and use within the institution. In addition to the drug cost and drug-use trend data, the dashboard included help features such as access to the Drugdex database for detailed clinical information about specific drugs, including indications, adverse effects, and drug interactions.

CONCLUSION

The cost reports that were developed through the collaboration between the CIDSS and the department of pharmacy services have permitted a more robust understanding of drug-use trends by a wider audience of physician leaders and clinical pharmacists at the institution. These data are critical in formulating strategies to control drug expenses by each service.

Pharmacist recognition of and adherence to medication-use policies and safety practices

PURPOSE

Pharmacist recognition of and adherence to medication-use policies and safety practices were assessed.

METHODS

Simulation testing was used to assess the performance of pharmacists in hypothetical scenarios simulating real-life situations. Fifty test case medication orders were developed, some requiring specific intervention and some requiring no special action. Orders were classified into four categories: those posing safety concerns n ( = 16), those with formulary and product standardization issues (n = 4), those with pharmacy and therapeutics (P&T) committee restrictions (n = 4), and those requiring no special action (n = 26). Potential barriers to compliance were identified by the project team and the orders categorized accordingly. The orders were processed by 25 pharmacists using a simulation testing procedure. Data were analyzed by pharmacists' demographics, order category, and perceived barriers to compliance.

RESULTS

Pharmacists were correctly able to recognize 77.3% of test orders: 67.3% with safety concerns, 98.9% with formulary issues, and 98.5% with restrictions. Appropriate action was taken with 74.2% of test orders: 64.5% of safety orders, 96.6% of formulary orders, and 92.4% of restriction orders. There was no correlation between pharmacists' performance and demographic characteristics. The two barriers to correct response identified most often were ambiguous responsibility and low perceived level of importance.

CONCLUSION

Pharmacists generally recognized and took appropriate action with simulated medication orders that contained problems related to formulary or P&T committee restrictions. They were less able to recognize and act appropriately on orders with safety-related problems. Ambiguous responsibility and low perceived importance were the most significant factors contributing to noncompliance with P&T committee policies and guidelines.

Impact of patient financial incentives on participation and outcomes in a statin pill-splitting program

OBJECTIVES

To examine willingness to participate in a pill-splitting program and the impact of pill splitting on patients' adherence and lipid control.

STUDY DESIGN

Nested randomized trial.

METHODS

A total of 200 patients who used statins and were candidates for a pill-splitting regimen were identified from a large university-based health plan. Sixty-three percent of study participants were female, 41% were nonwhite, and 94% had at least some college education. Patients were surveyed regarding their willingness to split pills, and 111 consented to participate in a 6-month trial in which half were randomized to receive a financial incentive to split pills: a 50% reduction in their per-refill copayment. Data on patients' statin refills and lipid control were obtained from billing and medical records.

RESULTS

Compared with patients unwilling to participate in the program, those agreeing to split pills were more likely to be female and white. After 6 months, most patients in the trial (89%) were willing to continue pill splitting for a 50% copayment reduction. Patients reported few problems with pill splitting and had no noticeable change in their adherence. The financial-incentive group and the control group did not differ significantly with respect to their low-density lipoprotein cholesterol levels after pill splitting: -2.0 mg/dL and -1.2 mg/dL, respectively.

CONCLUSIONS

Most patients indicated that at least a 50% copayment reduction would be required to enroll in a pill-splitting program after the study ended. However, in this relatively educated population, financial incentives did not influence patients' adherence, satisfaction, or health outcomes.