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Whitmire N, Schlueter M, Kirkpatrick M. Advanced Therapies for Inflammatory Bowel Disease: Navigating Payor and Financial Challenges. Curr Gastroenterol Rep 2024; 26:68-76. [PMID: 38243152 PMCID: PMC10937800 DOI: 10.1007/s11894-024-00916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 01/21/2024]
Abstract
PURPOSE OF REVIEW In the United Sates the cost of managing Crohn's disease and ulcerative colitis, the two most common inflammatory bowel diseases, is a major factor that can alter the course of treatment. The increasing use of advanced therapies such as biologics and oral small molecules is a driver of these costs. Many IBD providers find navigating the payor and non-insurance cost assistance processes to be a significant challenge in care management. We aim to clarify these processes and provide an outline for success. RECENT FINDINGS Insurance companies use various processes to manage medication costs and while they may not ultimately be cost-effective, the processes have continued and are increasingly complex. This complexity has led to measurable delays in care and negative outcomes. With a deeper understanding of payor and non-insurance cost-assistance processes we have developed a workflow for navigating the use of advanced therapies in the treatment of IBD.
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Affiliation(s)
- Natalie Whitmire
- Division of Gastroenterology, UC San Diego Health, 9350 Campus Pt Dr Ste 2B, La Jolla, CA, 92037, USA.
| | - Michelle Schlueter
- Division of Gastroenterology, UC San Diego Health, 9350 Campus Pt Dr Ste 2B, La Jolla, CA, 92037, USA
| | - Melissa Kirkpatrick
- Division of Gastroenterology, UC San Diego Health, 9350 Campus Pt Dr Ste 2B, La Jolla, CA, 92037, USA
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Abstract
Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system that causes significant disability and healthcare burden. The treatment of MS has evolved over the past three decades with development of new, high efficacy disease modifying therapies targeting various mechanisms including immune modulation, immune cell suppression or depletion and enhanced immune cell sequestration. Emerging therapies include CNS-penetrant Bruton's tyrosine kinase inhibitors and autologous hematopoietic stem cell transplantation as well as therapies aimed at remyelination or neuroprotection. Therapy development for progressive MS has been more challenging with limited efficacy of current approved agents for inactive disease and older patients with MS. The aim of this review is to provide a broad overview of the current therapeutic landscape for MS.
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Affiliation(s)
- Jennifer H. Yang
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
- *Correspondence: Jennifer H. Yang
| | - Torge Rempe
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Natalie Whitmire
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Anastasie Dunn-Pirio
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Jennifer S. Graves
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
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Battat R, Hemperly A, Truong S, Whitmire N, Boland BS, Dulai PS, Holmer AK, Nguyen NH, Singh S, Vande Casteele N, Sandborn WJ. Baseline Clearance of Infliximab Is Associated With Requirement for Colectomy in Patients With Acute Severe Ulcerative Colitis. Clin Gastroenterol Hepatol 2021; 19:511-518.e6. [PMID: 32348905 PMCID: PMC7606215 DOI: 10.1016/j.cgh.2020.03.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/06/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hospitalized patients with acute severe ulcerative colitis (ASUC) often require surgery. Although the tumor necrosis factor antagonist infliximab is an effective salvage therapy to prevent colectomy in patients with ASUC, optimal dosing is unclear. Calculated infliximab clearance has been associated with important outcomes in patients with ulcerative colitis, but its utility in patients with ASUC has not been established. We assessed the relationship between calculated the baseline infliximab clearance before infliximab salvage therapy and the requirement for colectomy in patients hospitalized for ASUC. METHODS We obtained data from hospitalized patients with ASUC who initiated infliximab therapy. We then calculated the baseline infliximab drug clearance in these patients based on an existing formula. The primary aim was to compare clearance between patients who required colectomy 6 months later and patients who did not require colectomy. Receiver operating characteristic curve analyses evaluated clearance thresholds for colectomy. Multivariable logistic regression analysis evaluated factors associated with colectomy. RESULTS In 39 patients with ASUC, the median baseline calculated clearance was higher in patients requiring colectomy at 6 months than in patients without colectomy (0.733 vs 0.569 L/d; P = .005). An infliximab clearance threshold of 0.627 L/d identified patients who required colectomy with 80.0% sensitivity and 82.8% specificity (area under the curve, 0.80). A higher proportion of patients with infliximab clearance of 0.627 L/d or more underwent colectomy within 6 months (61.5%) than patients with lower infliximab clearance values (7.7%) (P = .001). Multivariable analysis identified baseline infliximab clearance as the only factor associated with colectomy. The infliximab dose in the hospital was higher in patients who required colectomy. Results were similar at 30 days and 1 year. CONCLUSIONS In patients hospitalized with ASUC, higher values of calculated infliximab clearance before infliximab administration is associated with higher rates of colectomy. Although patients who required colectomies received higher doses, data on infliximab concentrations are lacking. Infliximab pharmacokinetic models are needed for patients with ASUC to allow comparative trials on clearance-based vs standard dosing.
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Affiliation(s)
- Robert Battat
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California; Jill Roberts Center for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Amy Hemperly
- Division of Gastroenterology, Department of Pediatrics, Rady Children's Hospital University of California, San Diego, La Jolla, California
| | - Stephanie Truong
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Natalie Whitmire
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Parambir S Dulai
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Ariela K Holmer
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Nghia H Nguyen
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Niels Vande Casteele
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California.
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Sorensen A, Grotts JF, Tseng CH, Moreno G, Maranon R, Whitmire N, Viramontes O, Atkins S, Sefilyan E, Simmons JW, Mangione CM. A Collaboration Among Primary Care-Based Clinical Pharmacists and Community-Based Health Coaches. J Am Geriatr Soc 2020; 69:68-76. [PMID: 33026662 DOI: 10.1111/jgs.16839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Medication discrepancies and adverse drug events are common following hospital discharge. This study evaluates whether a collaboration between community-based health coaches and primary care-based pharmacists was associated with a reduction in inpatient utilization following hospitalization. DESIGN Retrospective cohort study using propensity score matching. SETTING Urban academic medical center and surrounding community. PARTICIPANTS Intervention patients (n = 494) were adults aged 65 and older admitted to the University of California, Los Angeles (UCLA) Ronald Reagan Medical Center during the study period and who met study inclusion criteria. A matched-control group was composed of patients with similar demographic and clinical characteristics who were admitted to the study site during the study period but who received usual care (n = 2,470). A greedy algorithm approach was used to conduct the propensity score match. INTERVENTION Following acute hospitalization, a health coach conducted a home visit and transmitted all medication-related information to a pharmacist based in a primary care practice. The pharmacist compared this information with the patient's electronic medical record medication list and consulted with the patient's primary care provider to optimize medication management. MEASUREMENTS Thirty-day readmissions (primary outcome), 60- and 90-day readmissions, and 30-day emergency department (ED) visits (secondary outcomes) to UCLA Health. RESULTS Among 494 patients who received the intervention, 307 (62.1%) were female with a mean age of 83.0 years (interquartile range [IQR] = 76-90 years). Among 2,470 matched-control patients, 1,541 (62.4%) were female with a mean age of 82.7 years (IQR = 74.9-89.5 years). For the propensity score match, standardized mean differences were below .1 for 23 of 25 variables, indicating good balance. Patients who received this intervention had a significantly lower predicted probability of being readmitted within 30 days compared with matched-control patients (10.6%; 95% confidence interval [CI] = 7.9-13.2) vs 21.4%; 95% CI = 19.8-23.0; P value < .001). CONCLUSION A home visit conducted by a health coach combined with a medication review by a primary care-based pharmacist may prevent subsequent inpatient utilization.
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Affiliation(s)
- Andrea Sorensen
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Jonathan F Grotts
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Gerardo Moreno
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Richard Maranon
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Natalie Whitmire
- Department of Pharmacy, UC San Diego Health, San Diego, California, USA
| | - Omar Viramontes
- Department of General Internal Medicine at UCSF, San Francisco, California, USA
| | - Sandy Atkins
- Partners in Care Foundation, Burbank, California, USA
| | | | | | - Carol M Mangione
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA.,Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Yang E, Panaccione N, Whitmire N, Dulai PS, Vande Casteele N, Singh S, Boland BS, Collins A, Sandborn WJ, Panaccione R, Battat R. Letter: combination of biologics in inflammatory bowel diseases. Authors' reply. Aliment Pharmacol Ther 2020; 52:568-569. [PMID: 32656846 DOI: 10.1111/apt.15919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Edward Yang
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA
| | | | - Natalie Whitmire
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA
| | - Parambir S Dulai
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA
| | - Niels Vande Casteele
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA
| | - Angelina Collins
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA
| | - Remo Panaccione
- Division of Gastroenterology, Department of Medicine, University of Calgary Inflammatory Bowel Disease Center, Calgary, AB, Canada
| | - Robert Battat
- Division of Gastroenterology, Department of Medicine, UCSD Inflammatory Bowel Disease Center, La Jolla, CA, USA.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, Jill Roberts Center for Inflammatory Bowel Disease, New York, NY, USA
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Yang E, Panaccione N, Whitmire N, Dulai PS, Vande Casteele N, Singh S, Boland BS, Collins A, Sandborn WJ, Panaccione R, Battat R. Efficacy and safety of simultaneous treatment with two biologic medications in refractory Crohn's disease. Aliment Pharmacol Ther 2020; 51:1031-1038. [PMID: 32329532 PMCID: PMC8032452 DOI: 10.1111/apt.15719] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 02/09/2020] [Accepted: 03/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biologic therapies in patients with Crohn's disease often yield low clinical and endoscopic remission rates. After multiple failed therapies, combining two biologic therapies is possibly the sole medical alternative to recurrent surgery. However, data on this approach are limited. AIMS To assess the efficacy and safety of concomitant use of two biologic therapies in the largest cohort to date of refractory Crohn's disease patients. METHODS Data were extracted from Crohn's disease patients started on dual biologic therapy at two referral centres. Biologics utilised include infliximab, adalimumab, vedolizumab, ustekinumab, certolizumab and golimumab. The primary outcome was endoscopic improvement (>50% reduction in Simplified Endoscopic Score-Crohn's disease [SES-CD] or explicitly stated). Endoscopic remission (SES-CD < 3 or stated), clinical response (Crohn's disease-patient-reported outcome-2 score [PRO2] reduced by 8), clinical remission (PRO2 < 8), and C-reactive protein (CRP) were also assessed. RESULTS A total of 22 patients with 24 therapeutic trials of dual biologic therapy were identified. The majority of patients had prior surgical resections (91%), stricturing (59%) or penetrating (36%) phenotype, and perianal fistulas (50%). Median number of prior failed biologics was 4. Endoscopic improvement occurred in 43% of trials and 26% achieved endoscopic remission. Fifty per cent had clinical response and 41% achieved clinical remission. There were significant post-treatment reductions in median SES-CD (14.0 [12.0-17.5] to 6.0 [2.5-8.0], P = 0.0005], PRO-2 (24.1 [20.3-27.0] to 13.4 [4.6-21.8], P = 0.002] and CRP (17.0 [11.0-24.0] to 9.0 [4.0-14.0], P = 0.02). Presence of perianal fistulas decreased from 50% to 33%. Adverse events occurred in 13% of trials. CONCLUSION Dual biologic therapy was associated with clinical, biomarker and endoscopic improvements in selected patients with refractory Crohn's disease who failed multiple biologics. Further studies are needed to validate this approach.
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Affiliation(s)
- Edward Yang
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Nicola Panaccione
- Faculty of Health Science, Western University, 1151 Richmond Street, London, Ontario, Canada
| | - Natalie Whitmire
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Parambir S. Dulai
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Niels Vande Casteele
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Siddharth Singh
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Brigid S. Boland
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Angelina Collins
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - William J. Sandborn
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Remo Panaccione
- University of Calgary Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 3280 Hospital Drive NW, Calgary, Alberta
| | - Robert Battat
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093,Weill Cornell Jill Roberts Center for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, Department of Medicine, 1283 York Avenue, 9th Floor, New York, New York 10065
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Moreno G, Lonowski S, Fu J, Chon JS, Whitmire N, Vasquez C, Skootsky SA, Bell DS, Maranon R, Mangione CM. Physician experiences with clinical pharmacists in primary care teams. J Am Pharm Assoc (2003) 2017; 57:686-691. [DOI: 10.1016/j.japh.2017.06.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 11/27/2022]
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Kostas T, Zimmerman K, Salow M, Simone M, Whitmire N, Rudolph JL, McMahon GT. Improving medication management competency of clinical trainees in geriatrics. J Am Geriatr Soc 2014; 62:1568-74. [PMID: 25040361 DOI: 10.1111/jgs.12933] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The authors hypothesized that an interprofessional workshop would improve geriatrics trainees' medication management. The workshop was based on a needs assessment and comprised an interactive session with pharmacists on managing medications in elderly adults. Participants were trainees in their geriatrics rotation at a tertiary care medical center. Trainees completed a medication appropriateness survey for three patients, one of which was their own. After the workshop, trainees reviewed medications of the three patients. Trainees completed online surveys after their rotation and 3 months later. Of 95 trainees rotating through geriatrics, 76 (80%) attended the workshop and completed the worksheet. Trainees' scores on reviewing medication lists improved significantly, from 6.7±2.3 to 7.7±2.0 out of 11 for standardized patient 1 (P<.001) and from 5.7±1.8 to 6.4±1.5 out of 11 for standardized patient 2 (P=.009). Trainees' scores on their own patients' lists also improved significantly, from 5.6±1.5 to 6.6±1.5 out of 10 (P<.001). After the workshop, 95% (71/75) planned to change the medication regimen of the patient they presented, and 93% (68/73) planned to change other patients' medications based on information learned during the workshop. Three months later, 35% (12/34) had made changes to the regimen of the patient they discussed during the workshop, and 71% (15/21) had made changes to other patients' regimens. Seventy-eight percent (18/23) rated the workshop as the top nonclinical experience of their geriatrics rotation. In conclusion, this interprofessional medication management workshop improved trainees' ability to perform medication reviews accurately and led to change in self-reported prescribing behavior.
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Affiliation(s)
- Tia Kostas
- Brigham and Women's Hospital, Boston, Massachusetts; Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Whitmire N, Mohr JP, Brass LM. False-positive carotid compression with transcranial Doppler examination. J Ultrasound Med 1995; 14:703-705. [PMID: 7500440 DOI: 10.7863/jum.1995.14.9.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- N Whitmire
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut 06510, USA
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