A systematic review of the real-world effectiveness and economic and humanistic outcomes of selected oral antipsychotics among patients with schizophrenia in the United States: Updating the evidence and gaps

BACKGROUND

Schizophrenia is a chronic, relapsing, and burdensome psychiatric disorder affecting approximately 0.25%-0.6% of the US population. Oral antipsychotic treatment (OAT) remains the cornerstone for managing schizophrenia. However, nonadherence and high treatment failure lead to increased disease burden and medical spending. Cost-effective management of schizophrenia requires understanding the value of current therapies to facilitate better planning of management policies while addressing unmet needs.

OBJECTIVE

To review existing evidence and gaps regarding real-world effectiveness and economic and humanistic outcomes of OATs, including asenapine, brexpiprazole, cariprazine, iloperidone, lumateperone, lurasidone, olanzapine/samidorphan, paliperidone, and quetiapine.

METHODS

We conducted a literature search using PubMed, American Psychological Association PsycINFO (EBSCOhost), and the Cumulative Index of Nursing and Allied Health Literature from January 2010 to March 2022 as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. English-language articles describing adults with schizophrenia receiving at least 1 of the selected OATs and reporting real-world effectiveness, direct or indirect costs, humanistic outcomes, behavioral outcomes, adherence/persistence patterns, or product switching were identified.

RESULTS

We identified 25 studies from a total of 24,190 articles. Real-world effectiveness, cost, and adherence/persistence outcomes were reported for most OATs that were selected. Humanistic outcomes and product switching were reported only for lurasidone. Behavioral outcomes (eg, interpersonal relations and suicide ideation) were not reported for any OAT. The key economic outcomes across studies were incremental cost-effectiveness ratios, cost per quality-adjusted life-years, and health care costs. In studies that compared long-acting injectables (LAIs) with OATs, LAIs had a higher pharmacy and lower medical costs, while total health care cost was similar between LAIs and OATs. Indirect costs associated with presenteeism, absenteeism, or work productivity were not reported for any of the selected OATs. Overall, patients had poor adherence to OATs, ranging between 20% and 61% across studies. Product switching did not impact the all-cause health care costs before and after treatment.

CONCLUSIONS

Our findings showed considerable gaps exist for evidence on behavioral outcomes, humanistic outcomes, medication switching, and adherence/persistence across OATs. Our findings also suggest an unmet need regarding treatment nonadherence and lack of persistence among patients receiving OATs. We identified a need for research addressing OATs' behavioral and humanistic outcomes and evaluating the impact of product switching in adults with schizophrenia in the United States, which could assist clinicians in promoting patient-centered care and help payers understand the total value of new antipsychotic drugs.

Evaluation of a pharmacist-provider collaborative clinic for treatment of iron deficiency in patients with heart failure

PURPOSE

Intravenous iron therapy is recommended to improve symptoms and exercise tolerance in patients with heart failure (HF) with -reduced ejection fraction and iron deficiency (ID), but there are limited published data on the implementation of intravenous iron therapy in practice. A pharmacist-provider collaborative ID treatment clinic was established within an advanced HF and pulmonary hypertension service to optimize IV iron therapy. The objective was to evaluate the clinical impacts of the pharmacist-provider collaborative ID treatment clinic.

METHODS

A retrospective cohort study was performed to compare clinical outcomes among patients of the collaborative ID treatment clinic (the postimplementation group) and a cohort of patients who received usual care (the preimplementation group). The study included patients 18 years of age or older with diagnosed HF or pulmonary hypertension who met prespecified criteria for ID. The primary outcome was adherence to institutional intravenous iron therapy guidance. A key secondary outcome was ID treatment goal achievement.

RESULTS

A total of 42 patients in the preimplementation group and 81 in the postimplementation group were included in the study. The rate of adherence to the institutional guidance was significantly improved in the postimplementation group (93%) compared to the preimplementation group (40%). There was no significant difference in the ID therapeutic target achievement rate between the pre- and postimplementation groups (38% vs 48%).

CONCLUSION

Implementing a pharmacist-provider collaborative ID treatment clinic significantly increased the number of patients who adhered to intravenous iron therapy guidance compared to usual care.

The role of managed care professionals in the management of neovascular age-related macular degeneration and diabetic macular edema

Managed care professionals play a significant role in the management of neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) through formulary management and drug utilization strategies. These strategies are designed to improve access to affordable care and minimize medical costs to both patients and payers. Preserving vision in patients with nAMD and DME is key to improving clinical outcomes and reducing the risk of comorbid conditions, such as depression. With the approval of new intravitreal treatment options, managed care professionals must stay up to date with evidence-based guidelines as well as the addition of cost-effective treatments to drug formularies to better manage health care resources and improve patient outcomes.

Cost impact of different treatment regimens of brolucizumab in neovascular age-related macular degeneration: A budget impact analysis

BACKGROUND: Brolucizumab is a new anti-vascular endothelial growth factor (anti-VEGF) approved for treating neovascular age-related macular degeneration (nAMD). Multiple treatment regimens are available for treating nAMD. These regimens include manufacturer-recommended regimens, pro re nata (PRN) regimens, and treat-and-extend (T&E) regimens, which are based on clinical practice guidelines and data observed in the real-world clinical setting, classified as real-world evidence (RWE). Most budget impact models predict the financial consequences of adding a new drug to the formulary based on the manufacturer-recommended regimen. With different anti-VEGF treatment regimens being used in nAMD by ophthalmologists, it is OBJECTIVE: To estimate the budget impact of different treatment regimens of brolucizumab in nAMD from a US payer perspective. METHODS: A Microsoft Excel-based budget impact model was developed for different treatment regimens of brolucizumab over a 1-year time frame from a US payer perspective. A separate analysis was performed to estimate the budget impact from a US patient population perspective. Model inputs included drug costs, administration costs, physician visit costs, and disease monitoring costs. Outcomes in the budget impact model included the cost per member per month, annual health plan cost, and the US patient population-based annual cost. Based on the prevalence of nAMD in public and commercial health plans, a scenario analysis was conducted on the US population to account for the differences in the drug cost to the public and commercial payers. Further, 1-way sensitivity analyses were conducted to test model assumptions and uncertainty in model inputs. RESULTS: The addition of brolucizumab to the formulary increased the net budgetary impact under PRN and T&E regimens. The maximum increase in expenditure for a hypothetical health plan with 1 million enrollees was associated with the PRN regimen ($824,696), followed by the T&E regimen ($163,101). In contrast, using the manufacturer-recommended and RWE regimens led to an annual saving of $93,068 and $94,170 for the health plan, respectively. In the US patient population model, the introduction of brolucizumab resulted in savings in the manufacturer-recommended ($30.99 million) and RWE regimens ($31.35 million) but led to an increase in annual expenditures for the PRN ($274.58 million) and T&E ($54.30 million) regimens. CONCLUSIONS: Payers need to evaluate the cost impact of different treatment regimens of existing and new anti-VEGFs when making formulary decisions in nAMD management. DISCLOSURES: Mr Siddiqui, Ms Dhumal, Dr Patel, and Dr LeMasters have nothing to disclose. Dr Kamal has received research funding from Cerevel Therapeutics, served as a consultant to Pfizer/Cytel Inc, and received honoraria from Pharmacy Times Continuing Education. Dr Almony has served as a consultant to Cardinal Health and received honoraria from Pharmacy Times Continuing Education and Prime Education.

Adapting the layered learning model to a virtual international exchange program

INTRODUCTION

The layered learning model (LLM) is a well-established teaching approach designed for attending preceptors to train post-graduate learners and to precept students. The adaptation of a LLM to a virtual exchange program has not been previously described. The purpose of this study was to evaluate the effectiveness of the longitudinal virtual international exchange program in applying principles of the LLM to multiple levels of learners and instructors at West Virginia University (WVU) School of Pharmacy and Kitasato University (KU) School of Pharmacy.

METHODS

The online survey piloted the impact of applying the LLM to virtual international exchange sessions on improving participant knowledge in pharmacy practice, pharmacy education, cultural practices, and cultural awareness. The survey questions assessed the program's structure and effectiveness in achieving learning outcomes related to pharmacy residency topics and cultural competency using a five-point Likert scale.

RESULTS

Median scores of the effectiveness of the virtual international exchange program structure were high (≥ 4.0). Two questions evaluating the use of the LLM had median scores of 4.0. All nine residency-related questions were rated ≥3.0. The median scores for three questions evaluating small group discussions and the use of the LLM were rated significantly higher by WVU participants than KU participants. There were no significant differences in program structure and learning outcome ratings between participant groups (student vs. resident/fellow vs. preceptor/faculty).

CONCLUSIONS

Application of the LLM to the virtual international exchange program was positively received by participants, particularly by United States participants.

Length of Stay, Cost, and Outcomes related to Traumatic Subdural Hematoma in inpatient setting in the United States

OBJECTIVE

In the US, the prevalence of traumatic subdural hematoma (TSDH) continues to increase. Using a nationally representative sample of discharge records of patients with TSDH, the study objectives were to estimate trend in number of TSDH cases, surgical management, inpatient cost, length of stay (LOS), mortality rate, and complication rate; and to identify the association of sociodemographic, clinical and hospital characteristics with complications and mortality.

METHOD

We identified patients with a primary diagnosis of TSDH from the National Inpatient Sample (NIS) database from 2010 to 2017. Quarterly and monthly trends were estimated using interrupted time series design. Multivariate logistic regressions measured association between various factors and inpatient death and complications.

RESULTS

Number of cases, mean LOS, rate of complication increased. Proportion of patients undergoing surgery, mean inpatient cost, inpatient mortality decreased. Mean inpatient cost was $23,182.40 and LOS was 6.41 days. Odds of inpatient death and complications increased with injury severity score and comorbid conditions requiring use of anticoagulants. Odds of inpatient death were highest among those ≥85 years old and in south and northeast region.

CONCLUSION

Given the increase in prevalence of TSDH in USA, additional resources should be allocated toward improving patient outcomes and lowering healthcare costs.

Disposal practices for unused and expired medications: pilot data from three cities in three countries

Objective: To collect pilot data on medication disposal practices of unused and expired medications from three cities in three countries. Methods: A cross-sectional survey was conducted in Pittsburgh, United States (US); Turin, Italy; and Kobe, Japan. A convenience sampling was utilized through drug take-back programs in Pittsburgh, US; pharmacy customers in Turin, Italy; and pharmacy students and family members in Kobe, Japan. Descriptive analysis was conducted to assess medications disposal practices including attitudes and beliefs of respondents. Results: The sample included 342 respondents [99 (Pittsburgh, US); 168 (Turin, Italy); and 75 (Kobe, Japan)]. The mean unused and expired medications per patient for Pittsburgh, US was (1.60±2.30 and 0.51±1.54); Turin, Italy (1.69±1.86 and 0.49±1.22) and Kobe, Japan (6.69±8.78 and 0.84±2.26). The major reason for unused medications in Pittsburgh, US (31.3%) was "Medication was as needed"; in Turin, Italy (28.0%) "No longer suffer from the condition"; and in Kobe, Japan (54.7%) "No longer suffer from the condition". The most common reason for expired medications was "No longer suffer from the condition" (Pittsburgh, US 17.2%; Turin, Italy 15.5%; Kobe, Japan 12.0%). The disposal method in Pittsburgh, US was disposing in the toilet (35.4%); returned to the pharmacy in Turin, Italy (51.2%); and disposed the original container in the trash in Kobe, Japan (82.7%). Conclusions: There is a need for counseling protocols regarding proper disposal, which can lead to better adherence, reduction of prescription drug abuse, and less environmental hazards due to improper disposal of prescription medications.

Economic Impact of Ambulatory Clinical Pharmacists in an Advanced Heart Failure Clinic

BACKGROUND

Clinical pharmacists play pivotal roles in multidisciplinary heart failure (HF) teams through the management of HF pharmacotherapy, but no study has examined the economic impact of HF ambulatory clinical pharmacists in an advanced HF clinic.

OBJECTIVE

The objective of the study was to evaluate the economic impact of HF ambulatory clinical pharmacist interventions in an advanced HF clinic using a cost-benefit analysis.

METHODS

This prospective observational study detailed HF ambulatory clinical pharmacist interventions over 6 months in an advanced HF clinic in a single-center tertiary teaching hospital. The economic impact of the interventions was estimated based on the indirect cost savings with pharmacist interventions and direct cost savings recommendations. A cost-benefit analysis was performed to assess the cost of delivering the interventions compared with the benefits generated by clinical pharmacists. Results were reported as a benefit-cost ratio and net benefits.

RESULTS

HF ambulatory clinical pharmacists made a total of 2,361 provider-accepted interventions over 6 months. Overall, the 3 most common intervention types were medication reconciliation (28.7%), dose change (20.8%), and addition of medication (12.3%). Anticoagulation (21.2%) was the most common intervened class of medication, followed by sodium-glucose cotransporter-2 inhibitor (12.3%) and angiotensin receptor neprilysin inhibitor (9.2%). The total net benefits were $55,553.24 over 6 months and the benefit-cost ratio was 1.55.

CONCLUSION AND RELEVANCE

The addition of cardiology clinical pharmacists to an advanced HF clinic may be financially justified and cost-beneficial.

Description of pharmacists' reported interventions to prevent prescribing errors among in hospital inpatients: a cross sectional retrospective study

Background

Prescribing errors (PEs) are a common cause of morbidity and mortality, both in community practice and in hospitals. Pharmacists have an essential role in minimizing and preventing PEs, thus, there is a need to document the nature of pharmacists’ interventions to prevent PEs. The purpose of this study was to describe reported interventions conducted by pharmacists to prevent or minimize PEs in a tertiary care hospital.

Methods

A retrospective analysis of the electronic medical records data was conducted to identify pharmacists’ interventions related to reported PEs. The PE-related data was extracted for a period of six-month (April to September 2017) and comprised of patient demographics, medication-related information, and the different interventions conducted by the pharmacists. The study was carried in a tertiary care hospital in Riyadh region. The study was ethically reviewed and approved by the hospital IRB committee. Descriptive analyses were appropriately conducted using the IBM SPSS Statistics.

Results

A total of 2,564 pharmacists’ interventions related to PEs were recorded. These interventions were reported in 1,565 patients. Wrong dose (54.3 %) and unauthorized prescription (21.9 %) were the most commonly encountered PEs. Anti-infectives for systemic use (49.2 %) and alimentary tract and metabolism medications (18.2 %) were the most common classes involved with PEs. The most commonly reported pharmacists’ interventions were dose adjustments (44.0 %), restricted medication approvals (21.9 %), and therapeutic duplications (11 %).

Conclusions

In this study, PEs occurred commonly and pharmacists’ interventions were critical in preventing possible medication related harm to patients. Care coordination and prioritizing patient safety through quality improvement initiatives at all levels of the health care system can play a key role in this quality improvement drive. Future studies should evaluate the impact of pharmacists’ interventions on patient outcomes.

Adherence to cystic fibrosis transmembrane conductance regulator (CFTR) modulators: analysis of a national specialty pharmacy database

BACKGROUND

There have been significant advances in Cystic Fibrosis (CF) treatment, with the introduction of Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators. Adherence is an important goal for CF management, as nonadherence is linked to poor health outcomes.

OBJECTIVE

To calculate the medication adherence in patients taking CFTR modulators using a national specialty pharmacy database.

METHODS

This retrospective observational cohort study utilized de-identified specialty pharmacy data from September 2017 to August 2018 to assess medication adherence for three CFTR modulators: ivacaftor, lumacaftor/ivacaftor, and tezacaftor/ivacaftor & ivacaftor. The primary outcome was proportion of days covered (PDC) for each medication, with mean PDC values compared across age groups and insurance characteristics. All analyses were performed using the SAS 9.4 University Edition (SAS Institute, Cary, NC).

RESULTS

A total of 2,548 patients were analyzed, including 1,289 (50.59%) patients on lumacaftor/ivacaftor, 784 (30.77%) on ivacaftor, and 475 (18.64%) on tezacaftor/ivacaftor & ivacaftor. The mean PDC value for all CFTR modulators was above 0.80. Tezacaftor/ivacaftor & ivacaftor had the highest overall PDC of 0.92, while PDC values for both lumacaftor/ivacaftor and ivacaftor were 0.84. Children/adolescents on lumacaftor/ivacaftor (p = 0.0001) and tezacaftor/ivacaftor & ivacaftor (p = 0.001) had significantly higher mean PDC values compared to adults but not for ivacaftor (p = 0.3744). No statistical differences were seen in PDC across insurance characteristics.

CONCLUSION

To the best of our knowledge, this is the first study to assess the adherence of three CFTR modulators using a large nationwide specialty database. With high acquisition costs of CFTR modulator therapies, there is a need to improve rates of adherence in patients with CF.

Pharmacist Views Regarding the Prescription Opioid Epidemic

Community pharmacists have significant opportunity to contribute to prevention and treatment of opioid use disorders, but barriers to implementation still exist. Understanding their viewpoints is critical to designing future interventions. To qualitatively explore experiences and beliefs of community pharmacists regarding the misuse of prescription opioids in the United States. The study was part of a larger project that utilized a survey questionnaire to evaluate the relationships between knowledge, attitudes, and practices of community pharmacists in substance use disorders. The survey included an open-ended item on pharmacist views regarding the prescription opioid epidemic. The responses were used for inductive content analysis. Axial coding of themes was conducted to analyze underlying relationships: associations, consequences, intervening relationships, and action strategies regarding a central phenomenon. A model describing pharmacist experiences in the opioid epidemic was conceptualized. The open-ended question resulted in 50 (37.3%) usable responses. Final abstraction resulted in six themes including (1) overprescribing opioids: inappropriate prescribing as a contributor to the epidemic, (2) policy and practice recommendations: potential action strategies against the epidemic, (3) poor prescriber-pharmacist relationship: barrier to addressing the epidemic, (4) negative attitudes: intervening condition affecting roles of the pharmacist, (5) personal experience: facilitator to improve pharmacist roles and (6) decreased access to opioids: consequence of strict prescribing laws. The study identified themes that described pharmacist views, attitudes, barriers, and experiences related to their perceived role in prevention and treatment of opioid use disorders. Future research should consider the implications of the barriers and facilitators identified.

The relationship between knowledge, attitudes, and practices of community pharmacists regarding persons with substance use disorders

Background: Community pharmacists can play a meaningful role in identification and treatment of substance use disorders (SUD). However, inadequate disease knowledge and negative attitudes are known barriers. The relationship between knowledge, attitudes, and practice of pharmacists regarding persons with SUD has not been evaluated comprehensively in the United States. The objective of the study was to assess knowledge of community pharmacists regarding medications for SUD and evaluate their attitudes, levels of stigma, and clinical practices in SUD. Methods: A questionnaire was developed to assess practices, knowledge, screening services, and attitudes toward harm reduction strategies and treatment. A standardized measure of stigma was included along with demographics. A cross-sectional electronic survey was conducted in Pennsylvania, Ohio, and West Virginia among a non-probability sample of community pharmacists working for a retail pharmacy chain (n = 910) and a local alumni network (n = 50). Scores were calculated for each factor and descriptive analyses, mean differences (t-tests and ANOVA), correlations with demographics and practice characteristics were performed. Linear and ordinal regressions were utilized to predict knowledge, practice, screening, and stigma scores. Results: A total of 134 responses (response rate 13.9%) were collected. On average, the pharmacists were 38 years old, had worked for 15 years, primarily full-time with practice locations in suburban settings. Only 53% reported they received SUD education in pharmacy school. Pharmacists received a mean score of 5.5 and 3.5 out of eight and seven on knowledge and practice scales, respectively. Pharmacists overall had slightly stigmatizing and negative attitudes, with higher stigma significantly related to performing lesser services and considering screenings as important. Number of years worked significantly predicted knowledge and screening. Conclusion: Relationships between knowledge, attitudes, and practices indicate a need for experiential education that includes psychosocial aspects of care with increased opportunities for practice.

HTA Metro Map: a patient centred model for optimizing the decision making process

Health Technology Assessment (HTA) is a systematic evaluation of a health technology, designed to appraise the direct or intended effects and indirect or unintended consequences of the technology with an overall goal of supporting informed decision making regarding the use of these health technologies in the healthcare system.

In this paper, we present fundamental HTA concepts and provide a conceptual framework that embraces the processes and outcomes required for integrated healthcare decision-making. The “HTA Metro Map” was designed to guide the user through the different areas on: where to use, what and whom to involve within the decision process. The map reflects the complexity and inter-connectedness of the different kind of healthcare services that need to work together to be able to efficiently deliver coordinated decisions at local, regional, national, and international levels. This tool may also serve as base for facilitating developments and improvements of the HTA structure worldwide.

The paper discusses the main features of the “HTA Metro Map” while reinforcing the key concepts underlying HTA‘s integrated approach. The first view of the map provides the several layers of complexity seen in HTA and the various lines within the map represent the main actors involved in the assessment processes. The map connections and crossings symbolize the interprofessional and interpersonal collaborations while the stations denote the knowledge, skills, experiences, and attitudes of each professionals as they interact within this framework. Every line represents a HTA stakeholder and the circular line in the centre represents the patient at the centre of the system. The zones, from social to community and hospital level, represent the need for integration from the perspective of health systems. The HTA Metro Map also has different dimensions depicted by the level of profoundness. Finally, the concepts of different healthcare stakeholder perspectives are introduced both in visual and temporal terms.

The “HTA Metro Map” is designed as a flexible model for easy adaptability and in accurately capturing the complexity inherent in any healthcare system. It is hoped that the map will assist different stakeholders to build network capacity, pool existing resources, and develop a more holistic vision that will result in a sustainable, efficient and collaborative decision-making process.

Oral antidiabetic medication adherence and glycaemic control among patients with type 2 diabetes mellitus: a cross-sectional retrospective study in a tertiary hospital in Saudi Arabia

OBJECTIVES

The purpose of this study is to measure the adherence rates of oral antidiabetic drugs (OADs) in patients with type 2 diabetes mellitus (T2DM) and assess the relationship of glycaemic control and adherence to OADs after controlling for other associated factors.

DESIGN

Cross-sectional retrospective study.

SETTING

Large tertiary hospital in the central region of Saudi Arabia.

PARTICIPANTS

5457patients aged 18 years and older diagnosed with T2DM during the period from 1 January 2016 to 31 December 2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

The modified medication possession ratio (mMPR) was calculated as a proxy measure for adherence of OADs. The factors associated with OADs non-adherence and medication oversupply were assessed using multinomial logistic regression models. The secondary outcomes were to measure the association between OADs adherence and glycaemic control.

RESULTS

Majority of patients with T2DM were females (n=3400, 62.3%). The average glycated haemoglobin was 8.2±1.67. Among the study population, 48.6% had good adherence (mMPR >0.8) and 8.6% had a medication oversupply (mMPR >1.2). Good adherence was highest among those using repaglinide (71.0%) followed by pioglitazone (65.0%) and sitagliptin (59.0%). In the multivariate analysis, women with T2DM were more likely to have poor adherence (adjusted OR (AOR)=0.76, 95% CI=0.67, 0.86) compared with men. Also, medication oversupply was more likely among patients with hyperpolypharmacy (AOR=1.88, 95% CI=1.36, 2.63), comorbid osteoarthritis (AOR=1.72, 95% CI=1.20, 02.45) and non-Saudi patients (AOR=1.53, 95% CI=1.16, 2.01). However, no association was found between glycaemic control and adherence to OADs.

CONCLUSION

The study findings support the growing concern of non-adherence to OADs among patients with T2DM in Saudi Arabia. Decision makers have to invest in behavioural interventions that will boost medication adherence rates. This is particularly important in patients with polypharmacy and high burden of comorbid conditions.

Factors that facilitate reporting of adverse drug reactions by pharmacists in Saudi Arabia

Objectives: Adverse drug reactions (ADRs) are a pervasive global problem, and its management is integral to patient safety and healthcare quality. Pharmacists play a pivotal role in monitoring and reporting ADRs, which has a direct impact on patient care. The aim of this study was to identify potential factors that facilitate pharmacists in community and hospital settings to report ADRs. Methods: A cross-sectional, online survey using a validated questionnaire was administered to pharmacists working in community and hospital pharmacies in Saudi Arabia. Results: 1,717 community and 153 hospital pharmacists participated in this study. Only 10.2% and 26.8% of community and hospital pharmacists, respectively, admitted ever reporting an ADR. The most reported factors that may facilitate ADRs reporting have included ongoing improvements in therapeutic knowledge about ADRs, attending educational programs with continuous medical education credits, the seriousness of the experienced ADRs and accessibility to patients' medical profile. The impact of peers by seeing colleagues reporting ADRs and ADRs due to herbal or traditional medicine were the least important factors reported by pharmacists. Conclusion: The study identified factors that can effectively address the under-reporting of ADRs by pharmacists. A multi-stakeholder, multi-pronged approach of ADR reporting is needed to develop greater awareness of this issue among pharmacists.

The relationship between a cirrhosis-specific comorbidity scoring system and healthcare utilization patterns

BACKGROUND AND AIM

Patients with liver cirrhosis are impacted by comorbidities that affect healthcare utilization and survival. The study objective was to assess the relationship between a cirrhosis-specific comorbidity scoring system (CirCom) and healthcare utilization among patients with cirrhosis.

METHODS

A retrospective cohort analysis was conducted using electronic medical records from a large academic-based healthcare network. Patients aged 18-90 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for cirrhosis (571.2/571.5) between 2009 and 2014, and at least 180 pre-index and 365 days of post-index electronic medical record data were included. Patients were assigned CirCom scores based on comorbidities observed at/before index cirrhosis diagnosis. All-cause/cirrhosis-specific outpatient/hospital utilization was assessed post-index diagnosis across 1 year. Predictors of utilization (age, sex, race, body mass index, etiology, Model for End-stage Liver Disease, and CirCom) were assessed using negative binomial and Poisson regression with robust standard errors.

RESULTS

A total of 957 patients were included. Healthcare utilization according to CirCom demonstrated a positive linear relationship for both all-cause outpatient/hospital utilization, but no relationship was evident for cirrhosis-specific utilization. Increased CirCom was associated with an increased risk of all-cause utilization for both outpatient (relative risk [RR]: 1.75; 95% confidence interval [CI]: 1.47-2.07) and hospital (RR: 1.71; 95% CI: 1.38-2.12) utilization. However, CirCom showed a statistically non-significant association for cirrhosis-specific outpatient (RR: 1.08; 95% CI: 0.91-1.29) and cirrhosis-specific hospital (RR: 0.87, 95% CI: 0.67-1.13) utilization.

CONCLUSIONS

CirCom failed to predict cirrhosis-specific healthcare utilization but did positively predict all-cause utilization for both outpatient and hospital services and therefore may be useful in risk assessment and management of cirrhosis.

The Effects of the Opioid Epidemic on Prescribing Practices in Long-Term Care Residents

OBJECTIVE: Evaluate opioid prescribing practices for older adults since the opioid crisis in the United States.<br/> DESIGN: Interrupted time-series analysis on retrospective observational cohort study.<br/> SETTING: 176-bed skilled-nursing facility (SNF).<br/> PARTICIPANTS: Patients admitted to a long-term care facility with pain-related diagnoses between October 1, 2015, and March 31, 2017, were included. Residents discharged prior to 14 days were excluded. Of 392 residents, 258 met inclusion criteria with 313 admissions.<br/> MAIN OUTCOME MEASURE: Changes in opioid prescribing frequency between two periods: Q1 to Q3 (Spring 2016) and Q4 to Q6 for pre- and postgovernment countermeasure, respectively.<br/> RESULTS: Opioid prescriptions for patients with pain-related diagnoses decreased during period one at -0.10% per quarter (95% confidence interval [CI] -0.85-0.85; P = 0.99), with the rate of decline increasing at -3.8% per quarter from period 1 and 2 (95% CI -0.23-0.15; P = 0.64). Opioid prescribing from top International Classification of Diseases, Ninth Revision category, "Injury and Poisoning" decreased in prescribing frequency by -3.0% per quarter from Q1 to Q6 (95% CI -0.16-0.10; P = 0.54). Appropriateness of pain-control was obtained from the Minimum Data Set version 3.0 "Percent of Residents Who Self-Report Moderate to Severe Pain (Short Stay)" measure; these results showed a significant increase in inadequacy of pain relief by 0.28% per quarter (95% CI 0.12-0.44; P = 0.009).<br/> CONCLUSION: Residents who self-report moderate- to severe pain have significantly increased since October 2015. Opioid prescriptions may have decreased for elderly patients in SNFs since Spring 2016. Further investigation with a larger population and wider time frame is warranted to further evaluate significance.

Variation in prostate surgery costs and outcomes in the USA: robot-assisted versus open radical prostatectomy

AIM

To compare perioperative complications, inpatient cost and length of stay between robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP) using National Inpatient Sample data from 2010 to 2015.

PATIENTS & METHODS

A total of 69,009 records with RARP or ORP were analyzed using multivariate logistic regression and generalized linear models.

RESULTS

The RARP had superior perioperative outcomes at a higher cost (adjusted mean difference = 2956; 95% CI: $2822-$3090) and shorter length of stay (mean difference = 0.85; 95% CI: 0.81-0.89) compared with ORP. Mean cost of RARP was lowest in urban teaching, private invest-own, high volume and northeast region hospitals and highest for black men.

CONCLUSION

Compared with ORP, RARP had significantly better perioperative outcomes at a higher cost.

Adherence to Statin Therapy and Attainment of LDL Cholesterol Goal Among Patients with Type 2 Diabetes and Dyslipidemia

BACKGROUND

Statins are widely utilized antidyslipidemics with a proven track record of safety and efficacy. However, the efficacy of these therapeutic agents hinges on patients' adherence to their prescribed statins.

OBJECTIVE

The primary objectives of this study were to examine the relationship between adherence to prescribed statins and its impact on the low-density lipoprotein (LDL) level, and to explore the factors that influence patient adherence to statins among patients with diabetes and dyslipidemia.

METHODS

This was a retrospective, cross-sectional study using the electronic health records data of adults (≥18 years) with type 2 diabetes and dyslipidemia visiting outpatient clinics at a university-affiliated tertiary care center. Adherence to statin therapy was estimated using the proportion of days covered (PDC). Patients with diabetes were considered adherent to statins if they had a PDC of ≥80%. Treatment success was considered if the LDL level of < 2.6 mmol/L.

RESULTS

Out of 10,226 of patients with diabetes, 1532 met the inclusion criteria and were included in the study. Seventy-nine percent of the patients with diabetes were on atorvastatin and 21% were on simvastatin. The vast majority of the patients with diabetes (77%) were considered adherent and about 42% achieved LDL-cholesterol goal < 2.6 mmol/L. No association between adherence to statin therapy and LDL goal attainment was observed. Women had lower odds of being adherent to statin therapy (AOR=0.66, 95% CI: 0.49-0.87) compared to men. Further, young adults (18-44 years) had lower odds of being adherent to statin therapy (AOR=0.58, 95% CI: 0.32-0.97) compared to older adults (age>65 years).

CONCLUSION

The findings of this study highlight the need to examine the impact of adherence to statins on healthcare services utilization due to different complications of uncontrolled dyslipidemia.

Cost-Effectiveness and Budget Impact of Lumacaftor/Ivacaftor in the Treatment of Cystic Fibrosis

BACKGROUND

Cystic fibrosis (CF) is a chronic, progressive, genetic disease affecting more than 30,000 people in the United States and 70,000 people globally. The goals of treatment are to slow disease progression, reduce pulmonary exacerbations, relieve chronic symptoms, and improve the patient's quality of life. Lumacaftor/ivacaftor is a new therapy for CF that has demonstrated good clinical outcomes, including improved absolute percentage predicted forced expiratory volume in 1 second (FEV₁%). However, given the high cost of therapy, there is a need to evaluate the overall value of lumacaftor/ivacaftor in CF management.

OBJECTIVES

To (a) conduct a cost-effectiveness analysis (CEA) of lumacaftor/ivacaftor to understand the overall effectiveness of the drug compared with its costs and (b) conduct a budget impact analysis (BIA) to understand the potential financial effect of introducing a new drug in a health plan.

METHODS

Two static decision models were developed using Microsoft Excel to evaluate the cost-effectiveness and budget impact of lumacaftor/ivacaftor over a 1-year time frame from a payer perspective. Model inputs included drug costs (wholesale acquisition costs), drug monitoring schedules (package inserts), drug monitoring costs (Centers for Medicare & Medicaid physician fee schedule and published literature), FEV₁% predicted and pulmonary exacerbation values (clinical trials), and cost to treat pulmonary exacerbations (published literature). The outcomes in the CEA included total cost of therapy; average cost-effectiveness ratio (ACER), defined as cost per FEV₁% predicted; and incremental cost-effectiveness ratio (ICER), defined as the difference in the ratio of cost per FEV₁% predicted of lumacaftor/ivacaftor and placebo. Outcomes in the BIA included total budget impact; cost per member per month (PMPM), defined as total budget impact per hypothetical plan population; and cost per treated member per month (PTMPM), defined as total budget impact per target CF population. All costs were adjusted to 2016 dollars, and one-way sensitivity analyses were conducted to test the model robustness given uncertainty in model inputs and study assumptions.

RESULTS

The annual cost of therapy per patient for lumacaftor/ivacaftor was $379,780. The ACER for lumacaftor/ivacaftor was $151,912, while the ICER for lumacaftor/ivacaftor compared with placebo was $95,016 per FEV₁% predicted. The annual total budget impact due to the inclusion of lumacaftor/ivacaftor on the health plan formulary was $266,046. The PMPM cost was $0.02 and the PTMPM cost was $6.21.

CONCLUSIONS

In patients with CF, lumacaftor/ivacaftor has demonstrated better clinical effectiveness compared with placebo alongside an increased drug acquisition cost. However, the therapy may be a viable alternative to existing standard therapy over a short time horizon. Health care payers, both private and public, need to evaluate the cost-effectiveness and the financial effect when considering expansion of new drug coverage in CF management.

DISCLOSURES

No outside funding supported this study. Covvey and Kamal have received research funding from Novartis Pharmaceuticals. Covvey, Giannetti, and Kamal have received research funding from the College of Psychiatric and Neurologic Pharmacists. Kamal serves as a consultant to the Lynx Group (Cranbury, NJ) and Manticore Consulting Group (Scottsdale, AZ). Mukherjee has nothing to disclose. A related poster abstract was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting; March 27-30, 2017; Denver, CO.

Primary care physician perspectives on barriers and facilitators to self-management of type 2 diabetes

Objectives

To assess physician perspectives on perceived barriers and facilitators to type 2 diabetes self-management (DSM) in a primary care setting.

Methods

The study utilized survey methodology to measure perspectives of primary care physicians on DSM and the challenges they face in managing patients with poor glycaemic stability. Demographic and practice site-related information of the physicians were also collected.

Key findings

Of the 21 physicians who responded (53.8% response rate), 71.2% were aged 50 years or older, 54.2% had ≥25 years of clinical experience, and 50% practiced in an urban setting. The physicians examined 5–60 patients with type 2 diabetes per week (mean = 20), and over 75% of them spent &lt;20 min on face-to-face visits. Approximately, 95% of physicians considered self-care activities such as regular moderate exercise, following a recommended diet, regular blood glucose testing, proper insulin administration and adherence to oral medication as extremely important. Practice-related aspects such as patient–physician communication, patient health literacy and patient follow-up were unanimously considered extremely important, and performance on these measures was rated positively. Interestingly, 66% of physicians felt responsible to some extent for their patient's failure to reach type 2 DSM goals. Physician perceived barriers that contributed to clinical inertia included cost of medications, lack of patient motivation and knowledge, non-compliance with diet and medications, polypharmacy and lack of time and social support.

Conclusions

The study results underscore the importance of DSM in the overall management of type 2 diabetes. Addressing the challenges faced by physicians may result in better self-management and improved clinical outcomes in type 2 diabetes population.

Evaluation of Primary Care Physician Chronic Pain Management Practice Patterns

BACKGROUND

The management of chronic pain is complex and often involves the integration of multiple clinical, humanistic, and economic factors. Primary care physicians (PCPs) are often at the forefront of managing chronic pain and often initiate pharmacological pain management therapy. To date little is known surrounding the pain management practices of PCPs.

OBJECTIVE

The purpose of this study is to assess the knowledge and practice of PCPs in management of chronic pain.

STUDY DESIGN

A survey.

SETTING

Western region of Pennsylvania, US.

METHODS

A cross-sectional questionnaire survey evaluated PCPs pain management treatment practices including assessment of chronic pain, procedural activities surrounding therapy, decision-making input, and knowledge for therapeutic pain management including the 5 main classes of medications. The questionnaire was developed based on a review of the literature including published chronic pain guidelines. The questionnaire was mailed to a convenience sample of 300 PCPs practicing in Western Pennsylvania. The study was approved by the University Institutional Review Board.

RESULTS

The survey had a response rate of 16%. The respondents on average treated 30 chronic pain patients per month predominately in a community setting. The most common conditions treated included osteoarthritis, back and neuropathic pain. Although the major reported source of education was published literature, only 67% respondents referred to pain management guidelines. Multiple knowledge and practice gaps were identified surrounding pharmacological treatment, medication management including compliance practices, and pain assessment.

LIMITATIONS

Although low, the response rate is comparable to response rates for other chronic pain management topics including anticoagulation and prescription patterns for chronic pain physicians. Also, greater than 50% of the respondents were from private practice, therefore, the results may not pertain to other practice settings including academic and hospital-based practices.

CONCLUSIONS

The survey provided significant insight into PCP practices and highlights areas for future educational efforts. Further opioid prescribing education would be beneficial especially regarding the utilization of opioid risk assessment tools, the selection of opioids, and opioid end organ effects. Furthermore, patient education on the realities of chronic pain management and the importance of nonpharmacological treatment are needed in order to reduce the challenges faced by PCPs surrounding chronic pain management.

KEY WORDS

Chronic pain, primary care physician, pain management, survey questionnaire.

Hospitalization costs of cystic fibrosis in the United States: a retrospective analysis

OBJECTIVE

To determine patient, hospital, and clinical characteristics associated with the length of stay (LOS), total hospital charges, and total hospital costs in cystic fibrosis (CF).

METHODS

Hospital discharge records with primary and secondary diagnoses of CF were identified from the 2012 Kids' Inpatient Database (KID) consisting of inpatient records of ages 0-20 years; and 2012 National Inpatient Sample (NIS) consisting of inpatient records of ages 21 and above. Both the databases are part of the Healthcare Cost and Utilization Project (HCUP). Patient demographics, hospital characteristics, clinical characteristics, and outcome measures from KID and NIS were utilized in the analyses. Univariate and multivariate statistical analyses were conducted using IBM SPSS Statistics 24.0.

RESULTS

A total of 3142 and 10,258 CF-related hospital discharges were identified from 2012 KID and 2012 NIS databases, respectively. Among children, the mean (SD) LOS was 9.79 (10.51) days with a mean hospital costs of $26,249.23 (40,592.81). Adults had a mean LOS of 8.54 (8.42) days with a mean hospital costs of $21,600.91 (31,997.52). Number of procedures and total comorbidities were identified as the most important predictors of LOS, total hospital charges, and total hospital costs in both datasets.

CONCLUSIONS

Hospitalizations contribute significantly to the economic burden of CF. As inpatient costs in CF vary by patient, clinical, and hospital characteristics, healthcare decision makers need to utilize a targeted approach in different age groups to reduce hospital admission rates and the overall economic burden of CF.

Community pharmacists and mental illness: a survey of service provision, stigma, attitudes and beliefs

Background Half of Americans experience mental illness during their lifetime. Significant opportunity exists for community pharmacists to deliver services to these patients; however, personal and practice-related barriers may prevent full engagement. Objective To assess the demographics, practice characteristics, service provision, stigma, attitudes and beliefs of a national sample of community pharmacists towards individuals with mental illness. Setting National random sample of 3008 community pharmacists in the USA. Method 101-item cross-sectional mailed survey questionnaire on: (1) demographics, (2) knowledge and practice characteristics, (3) provision of clinical pharmacy services, and (4) comparative opinions. Main outcome measure Scaled measures of service provision (comfort, confidence, willingness and interest) and comparative opinions (stigma, attitudes and beliefs) of mental illness, four linear regression models to predict service provision. Results A total of 239 responses were received (response rate 7.95%). Across pharmacy services, ratings for willingness/interest were higher than those for comfort/confidence. Pharmacists who reported providing medication therapy management (MTM) services for patients reported higher comfort (18.36 vs. 17.46, p < 0.05), confidence (17.73 vs. 16.01, p < 0.05), willingness (20.0 vs. 18.62, p < 0.05) and interest (19.13 vs. 17.66, p < 0.05). Pharmacists with personal experience with mental illness also resulted in higher scores across all four domains of service provision, lower levels of stigma (18.28 vs. 20.76, p < 0.05) and more positive attitudes (52.24 vs. 50.53, p < 0.01). Regression analyses demonstrated increased frequency of MTM service delivery and more positive attitudes as significantly predictive across all four models for comfort, confidence, willingness and interest. Increased delivery of pharmacy services was significantly associated with both willingness and interest to provide mental illness-specific services. Conclusion Despite willingness/interest to provide services to patients with mental illness, decreased levels of comfort/confidence remain service-related barriers for community pharmacists.

Barriers and facilitators to diabetes self-management in a primary care setting - Patient perspectives

BACKGROUND

Diabetes self-management (DSM) is a key element in the overall management of type-2 diabetes (T2DM). Identifying barriers and facilitators to DSM and addressing them is a critical step in achieving improved health outcomes in this population.

OBJECTIVE

To assess patient reported barriers and facilitators to self-management of T2DM in a primary care setting.

METHODS

This cross sectional study combined patient survey data with electronic medical record (EMR) data. Patients (age≥18 years) with a recorded diagnosis of T2DM (ICD-9 code: 250. xx) and having ≥2 physician visits were identified from a physician group's EMR database. Patients were grouped based on their A1C levels: <7, 7-9, and >9. Information on demographics, knowledge of diabetes, attitudes, health beliefs, and level of self-management was collected through survey administration. Survey responses were linked to the EMR data, and additional patient information was extracted.

RESULTS

A total of 2100 surveys were administered (700 in each A1C category) of which 210 responses were received (10% response rate). Mean age was 63.7 years ( ±11.79), 108 (51.4%) were males, and 197 (93.8%) were Caucasian. Age (X² = 15.73, p < 0.01), insurance status (X² = 12.03, p < 0.05), referral to an endocrinologist (X² = 6.17, p < 0.05), level of self-management (X² = 12.01, p < 0.05) and willingness to use insulin (X² = 9.8, p < 0.01) were associated with glycemic variability. Level of self-management (X² = 33.04, p < 0.01) and referral to an endocrinologist (X² = 11.11, p < 0.01) were associated with readiness to change DSM behavior. Better self-management, older age, lower willingness to use insulin, and 'less than graduate level' education were significant predictors of glycemic stability.

CONCLUSIONS

Self-management behavior of patients with T2DM is strongly associated with glycemic stability. Interventions directed towards improving self-management in this population may result in improved clinical outcomes.

Impact of atrial fibrillation on inpatient cost for ischemic stroke in the USA

Background

Atrial fibrillation is a significant risk factor for ischemic stroke and increases cost of treatment.

Aims

To estimate the incremental inpatient cost and length of stay due to atrial fibrillation among adults hospitalized with a primary diagnosis of ischemic stroke after controlling for sociodemographic, clinical, and hospital characteristics in a nationally representative discharge record of US population.

Methods

Hospital discharge records with a primary diagnosis of ischemic stroke were identified from the National Inpatient Sample data for the years 2010–2013. Generalized linear model with log link and least-square means were utilized to estimate the incremental inpatient cost and length of stay in ischemic stroke due to atrial fibrillation after controlling for sociodemographic, clinical, and hospital characteristics.

Results

Among 434,544 hospital discharge records with a primary diagnosis of ischemic stroke, 90,190 (20.76%) discharge records had a secondary diagnosis of atrial fibrillation. The average inpatient cost for all discharge records with a primary diagnosis of ischemic stroke was (mean = $13,072, median = $9270.87) significantly (p < 0.0001) higher compared to all discharge records without ischemic stroke (mean = $12,543.07, median = $7517.13). The mean length of stay for all records was 4.55 days (95% CI = 4.53–4.56). Among those identified with ischemic stroke, adjusted mean inpatient cost was higher by $2829 (95% CI = $2708–$2949) and mean length of stay was greater by 0.85 (95% CI = 0.81–0.89) for those with atrial fibrillation compared to those without.

Conclusions

The presence of atrial fibrillation was associated with increased inpatient cost and length of stay among patients diagnosed with ischemic stroke. Increased inpatient cost and length of stay call for a more comprehensive patient care approach including targeted interventions among adults diagnosed with ischemic stroke and atrial fibrillation, which could potentially reduce the overall cost in this population.

Cost-Effectiveness of Peginterferon Beta-1a and Alemtuzumab in Relapsing-Remitting Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system, affecting 2.5 million people globally and 400,000 people in the United States. While no cure exists for MS, the goal is to manage the disease using disease-modifying therapies (DMTs), which have been shown to slow disease progression and prevent relapses. Relapsing-remitting MS (RRMS) is the most common form of MS at the time of diagnosis. Peginterferon beta-1a (PEG) and alemtuzumab (ALT) were recently approved and have demonstrated good clinical outcomes, including reduced relapse rates in clinical trials. High costs associated with these DMTs necessitates cost-effectiveness analyses to understand their overall value in RRMS management.

OBJECTIVES

To assess the cost-effectiveness of (a) Model 1: PEG relative to intramuscular interferon beta-1a (IM IFN), subcutaneous interferon beta-1b (SC IFN), glatiramer acetate 20 mg per mL (GA), fingolimod (FIN), natalizumab (NAT), and dimethyl fumarate (DMF), and (b) Model 2: ALT relative to subcutaneous interferon beta-1a 44 μg (IFN beta-1a 44 μg). Both analyses were conducted from a U.S. third-party payer perspective.

METHODS

Two static decision models were used to compare the cost-effectiveness of PEG and ALT over a 1-year and a 2-year time horizon, respectively. Model inputs were drug acquisition costs (wholesale acquisition cost from RED BOOK); drug administration and monitoring costs (package inserts and Centers for Medicare & Medicaid Services 2015 Physician Fee Schedule); relapse rates and relapse rate reduction (clinical trials); and cost of managing relapses (published literature). All costs were adjusted to 2015 U.S. dollars using the medical care component of the Consumer Price Index. Outcomes measured were total cost of therapy per patient, cost per relapse avoided, and incremental cost-effectiveness ratios (ICERs) calculated as cost per relapse avoided. Sensitivity analysis was conducted to test model robustness given the uncertainty of model inputs and study assumptions.

RESULTS

Model 1 results showed that PEG dominated IM IFN and GA, compared with SC IFN; PEG had an ICER of $1,978,000 per relapse avoided. Compared with FIN, NAT, and DMF, PEG was less expensive and less effective. Model 2 showed that ALT had an ICER of $25,276 per relapse avoided relative to IFN beta-1a 44 μg.

CONCLUSIONS

In patients with RRMS, PEG is a viable alternative when compared with the DMTs in our model. Deciding whether to choose PEG over other DMTs would depend on multiple factors. On the other hand, ALT had an ICER of $25,276 cost per relapse avoided relative to IFN beta-1a 44 μg. The study results will assist payers in evaluating different medication choices for effective therapy.

DISCLOSURES

No outside funding supported this study. Kamal has received research funding from Novartis Pharmaceuticals and the College of Psychiatric and Neurologic Pharmacists and also serves as a consultant for the Lynx Group. Dashputre and Pawar report no conflicts of interest. Study concept and design were primarily contributed by Dashputre, along with Kamal and Pawar. Dashputre took the lead in data collection, along with Kamal, and data analysis was performed by Dashputre, Kamal, and Pawar. The manuscript was written and revised primarily by Dashputre, along with Kamal and Pawar.

Sociodemographic Determinants of Out-of-Pocket Expenditures for Patients Using Prescription Drugs for Rheumatoid Arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disease that has a substantial economic impact on patients. Patients with RA are at an increased risk for disability and for loss of income. The inclusion of biologic drugs in RA therapy has increased the cost of treatment. Little is known about the relationship between sociodemographic characteristics and the out-of-pocket (OOP) expenditures for prescription drugs for patients with RA, including biologics, disease-modifying antirheumatic drugs (DMARDs), nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and analgesics.

OBJECTIVES

To explore the relationship between sociodemographic characteristics, personal characteristics, and OOP expenditures associated with RA prescription medications. A secondary objective was to measure the average OOP expenditures for different therapeutic classes of RA medications, including biologics, DMARDs, NSAIDs, corticosteroids, and analgesics.

METHODS

In this retrospective analysis of Medical Expenditure Panel Survey (MEPS) data from 2009 to 2012, we identified a patient sample of 1090 adults with RA, which represented approximately 9.71 million patients in the MEPS database. The total OOP expenditure was calculated based on the OOP expenditure for each prescription drug corresponding to an individual. Patient variables included age, race, sex, insurance status, number of comorbid conditions, region, area of living, annual family income, and marital status. Logistic regression and generalized linear models were used for analysis. The mean OOP expenditure for therapeutic classes was estimated using nonparametric percentiles from 1000 cluster bootstrap estimates.

RESULTS

Overall, the mean annual OOP expenditure was $273.99 (95% confidence interval [CI], $197.07-$364.75). The OOP expenditures were lower for privately insured (0.31; 95% CI, 0.21-0.45) patients and publicly insured (0.18; 95% CI, 0.12-0.27) patients versus uninsured patients, and for poor (0.60; 95% CI, 0.43-0.84) and low-income (0.69; 95% CI, 0.49-0.97) patients versus high-income patients. The mean annual OOP expenditure decreased with age (0.98; 95% CI, 0.97-0.99), was lower (0.73; 95% CI, 0.58-0.92) for male patients than for female patients, and increased with the presence of comorbidities (1.16; 95% CI, 1.07-1.25). The average annual OOP expenditure was highest for biologics ($2556.73), followed by DMARDs ($89.37). The average annual OOP expenditures were $27.97, $52.36, and $72.51 for corticosteroids, NSAIDs, and narcotic analgesics, respectively.

CONCLUSIONS

Age, sex, race, income level, insurance status, and comorbidity status significantly affected patient OOP expenditure. Higher OOP expenditures among the uninsured, female patients, patients with low income levels, and patients with several comorbidities could adversely affect RA therapy. The use of expensive biologics needs to be monitored to reduce prescription-related cost-sharing among patients with RA.

A Systematic Review of the Effect of Cancer Treatment on Work Productivity of Patients and Caregivers

BACKGROUND

Cancer is a leading cause of death with substantial financial costs. While significant data exist on the economic burden of care, less is known about the indirect costs of treatment and, specifically, the effect on work productivity of patients and their caregivers. To examine the full effect of cancer and the potential value of new therapies, all aspects of care, including indirect costs and patient-reported outcomes, should be evaluated.

OBJECTIVE

To perform a systematic review of the literature examining the effect of cancer treatment on work productivity in patients and their caregivers.

METHODS

Articles, abstracts, and bibliographies were searched in MEDLINE, Cochrane, Scopus, CINAHL, and conference lists from the American Society of Clinical Oncology, International Society for Pharmacoeconomics and Outcomes Research, and Academy of Managed Care Pharmacy up to January 2016. The PRISMA guidelines were used. Controlled search terminology included individual pharmacologic therapies for cancer and terms related to patient and caregiver work productivity. Citations were included if they evaluated the effect of cancer treatment on work productivity, used and described productivity assessments and instruments, and were written in English. Studies that reported only clinical outcomes or assessed only nonpharmacological treatments were excluded. Identified studies were screened and extracted for study inclusion by 2 independent reviewers, with adjudication by 2 secondary reviewers during the final eligibility phase.

RESULTS

Of 978 potential citations, 62 articles or abstracts were included. Forty-six studies (74.2%) evaluated patient-related productivity; 10 studies (16.1%) focused on caregivers, and 6 studies (9.7%) were a combination. Sixteen countries contributed literature, including 26 studies (41.2%) conducted in the United States. The most commonly studied cancer was breast cancer (53.2%). Nearly 22% of the studies were conducted on multiple types of cancer. The significant diversity of study methodologies and measurements rendered a single unifying conclusion difficult. A variety of metrics were used to quantify productivity (hours lost, return to work, change of status, and activity impairment). The Work Productivity and Activity Impairment questionnaire was the most commonly used standardized tool (n = 9; 14.5%). Factors found to be associated with impairment in productivity included disease- and treatment-related effects, such as disease progression and severity, cognitive and neurological impairments, poor physical and psychological status, receipt of chemotherapy, and time and expenses required to receive therapy.

CONCLUSIONS

This review highlights the considerable variety of studies that have assessed work productivity for cancer treatment and the multifaceted reasons affecting patients and caregivers. With increasing emphasis being given to understanding the value that patients assign to various aspects of cancer treatment, more streamlined information on productivity may be important to patients as they play a greater role in selecting treatment goals through shared decision making with their providers.

DISCLOSURES

This study was funded by Novartis Pharmaceuticals, which provided the concept, general oversight, and research collaboration on the project. Covvey and Kamal received research funding from Novartis Pharmaceuticals and the College of Psychiatric and Neurologic Pharmacists. Zacker is employed by, and owns stock in, Novartis Pharmaceuticals. A related poster abstract was presented at the Academy of Managed Care Pharmacy April 2016 Annual Meeting and published as Kamal KM, Covvey JR, Dashputre A, Ghosh S, Zacker C. A conceptual framework for valuebased oncology treatment: a societal perspective. J Manag Care Spec Pharm. 2016;22(4 Suppl A):S28. A publication-only abstract was presented at the American Society of Clinical Oncology 2016 Annual Meeting and published as Covvey JR, Kamal KM, Dashputre A, Ghosh S, Zacker C. The impact of cancer treatment on work productivity of patients and caregivers: a systematic review of the evidence. J Clin Oncol. 2016;34(Suppl):e18249. Study concept and design were contributed by Zacker, Kamal, and Covvey. Dashputre and Ghosh took the lead in data collection, along with Kamal and Covvey, and data interpretation was performed primarily by Shah and Bhosle, along with Ghosh, Dashputre, Covvey, and Kamal. The manuscript was written by Kamal, Covvey, Shah, and Bhosle and revised primarily by Zacker, along with Shah, Bhosle, Kamal, and Covvey.

Retrospective Analysis of the Medication Utilization and Clinical Outcomes of Patients Treated with Various Regimens for Hepatitis C Infection

BACKGROUND

The hepatitis C virus (HCV) is the most common chronic blood-borne infection and the leading cause of liver transplantation in the United States. There are approximately 3.2 million people currently infected with HCV in the United States. In late 2013, the introduction of sofosbuvir and simeprevir represented a critical advancement in the treatment of HCV by improving sustained virologic response (SVR) rates.

PURPOSE

The purpose of this study was to evaluate medication utilization and clinical outcomes of patients with HCV who were treated with any Food and Drug Administration-approved combination of ribavirin, peginterferon products, simeprevir, and sofosbuvir.

METHODS

Prescription records and clinical assessment forms of patients who started HCV therapy and were eligible for SVR between January 1, 2014, and December 31, 2014, were retrospectively reviewed. Data collection included patient demographics, genotype, SVR, patient-reported adverse events, discontinuations, and adherence markers.

RESULTS

A total of 367 eligible patients were identified who had initiated treatment during the study period. Genotype 1 was the most common genotype, and an overall SVR rate of 86.9% was observed. Results were similar to those seen in phase III clinical trials. In addition, adverse events of these medications were more tolerable, and discontinuation rates were lower than with previous therapies.

Burden of stroke in Italy: an economic model highlights savings arising from reduced disability following thrombolysis

BACKGROUND

The consequences of stroke must be assessed not only in terms of incidence and mortality rates, but also in terms of disability, which may persist long after the acute phase. Thrombolysis, if timely administered, can effectively reduce post-stroke disability.

AIMS

The economic model presented herein aims to evaluate, in eligible patients, the effects of alteplase on post-stroke disability and related costs over three-years.

METHODS

The economic analysis was developed on the basis of four key components: clinical outcomes from international trials, economic consequences extracted from cost of illness studies, regulatory data from national and international agencies, and national epidemiological data. A population-level model estimated the difference in disability costs between patients treated with standard care versus those receiving thrombolytic therapy within 4×5 h of acute ischemic stroke. The analysis covered 36 months from discharge.

RESULTS

Reduced costs related to post-stroke disability were observed in treated patients compared with those receiving standard care (control). The overall savings were €2330×15 per average patient: €1445×81 during the first 18 months, €362×25 between 18 and 24 months, and €522×09 in the 24-36 months period. The overall savings on 3174 Italian treated patients in 2013 were €7 395 907 over three-years.

CONCLUSION

Our study reveals that performing thrombolytic therapy in eligible patients improves economic outcomes compared with patients receiving standard care. This model is useful for decision makers, both within and outside of the Italian national context, as a tool to assess the cost-effectiveness of thrombolysis in both short- and long-term period.

Adherence With Therapeutic Regimens

There is an extensive literature regarding nonadherence with both therapeutic regimens and medication. This literature includes reviews of empirical research regarding the factors associated with nonadherence. Health care system, provider, and patient factors as well as the nature of the illness and therapeutic regimen all effect adherence rates. Different behavioral models for adherence counseling such as the Health Belief Model, the Theory of Reasoned Action, the Medication Interest Model, and Motivational Interviewing have also been reported in the research literature. This article will discuss the development of a brief model for patient counseling with specific techniques illustrated for pharmacists based on empirical findings that have demonstrated effectiveness in the adherence research literature. In addition, the article will address the measurement of the economic impact of medication nonadherence and propose a framework for assessing the cost-effectiveness of pharmacist counseling to increase adherence. The problem of nonadherence has significant effects upon health care expenditures through increase in physician’s visits, emergency department incidents, rehospitalizations, and nursing home readmissions. Thus, the overall goal is to assist the pharmacist in developing a brief adherence counseling program in community pharmacy and evaluating the economic feasibility of the intervention demonstrating the value-added proposition of pharmacist intervention.

Factors associated with therapeutic goal attainment in patients with concomitant hypertension and dyslipidemia

BACKGROUND

Hypertension and dyslipidemia are the most prevalent cardiovascular risk factors, with approximately 30 million patients in the United States having these concomitant conditions. Further, the presence of high body mass index (BMI) has a negative effect on the achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) targets.

OBJECTIVE

This study evaluates the demographic, diagnostic, and medication-related factors associated with BP and LDL-C goal attainment in patients with concomitant hypertension and dyslipidemia stratified by BMI.

METHODS

This retrospective study utilized the GE Centricity Electronic Medical Records database (2004-2011) of a primary care physician group. Patients aged ≥ 18 years with concomitant hypertension and dyslipidemia were included. The attainment of BP and LDL-C targets were assessed based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines. Patients were classified into 3 cohorts based on their BMI: normal weight (≤ 24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥ 30.0 kg/m2). Multivariate logistic regression analysis was conducted to identify the predictors of goal attainment.

RESULTS

A total of 9086 patients with concomitant hypertension and dyslipidemia were identified, of which 7723, 6724, and 5824 patients did not attain BP, LDL-C, and dual BP and LDL-C goals, respectively. Age was a significant predictor of BP and LDL-C goal attainment in those who were of normal weight or overweight, and obese women had a decreased likelihood of achieving these goals (P < 0.05). Failure to attain BP and LDL-C goals was more likely in patients with diabetes across all BMI groups (P < 0.001). Further, patients with stage 1 hypertension and higher baseline total cholesterol levels were less successful in attaining BP and LDL-C goals, respectively (P < 0.001).

CONCLUSIONS

These variations in therapeutic goal attainment in patients with concomitant hypertension and dyslipidemia across different BMI groups suggest that future research is needed to determine the underlying reasons for these disparities.

Variations in blood pressure and lipid goal attainment in primary care

BACKGROUND

Hypertension and dyslipidemia are the most prevalent cardiovascular risk factors. Blood pressure (BP) and lipid levels are modifiable and yet most patients fail to achieve their recommended target goals. The objective of this review was to examine the variations in achievement of optimal BP and lipid levels in individuals with cardiovascular risk factors or cardiovascular disease at a primary care level.

SCOPE

A comprehensive literature review and evaluation was conducted from January 2000 to June 2012 using electronic databases. The search was limited to studies reported in English language, published between January 2000 to June 2012 and those conducted in the US adult population (≥18 years). The inclusion of articles was limited to populations with cardiovascular risk factors or any cardiovascular disease.

FINDINGS

The review identified a total of 32 studies that assessed variations in attainment of BP or lipid goals. The demographic factors (age, sex, and race) and clinical factors (obesity, presence of diabetes, and history of cardiovascular conditions) were most commonly evaluated by the studies. However, modifiable factors such as diet, physical exercise, adherence to medication, or smoking habit were least commonly evaluated by the studies documented in this review.

CONCLUSION

The studies, conducted in a range of settings, reflect disparities in attainment of recommended BP or lipid goals. Given such disparities, future research is required to better understand the complexity of different factors underlying the failure of patients to achieve BP and lipid goals. This can help to identify appropriate treatment strategies or interventions that can address patient-specific needs at a primary care level.

Characteristics of Social and Administrative Sciences graduate programs and strategies for student recruitment and future faculty development in the United States

BACKGROUND

The rising demand of faculty in Social and Administrative Sciences (SAS) in pharmacy in the United States heightens the need to increase the number of Doctor of Philosophy (PhD) graduates in SAS who choose to pursue an academic career.

OBJECTIVES

To describe the characteristics of SAS graduate programs and graduate students and identify strategies for student recruitment and future faculty development.

METHODS

An Internet survey (phase I) with key informants (graduate program officers/department chairs) and semistructured telephone interviews (phase II) with phase I respondents were used. Items solicited data on recruitment strategies, number of students, stipends, support, and other relevant issues pertaining to graduate program administration. Descriptive statistics were tabulated.

RESULTS

Of the 40 SAS graduate programs identified and contacted, 24 completed the Internet survey (response rate [RR]=60.0%) and, of these, 16 completed the telephone interview (RR=66.7%). At the time of the survey, the median number of graduate students with a U.S.-based PharmD degree was 3. An average annual stipend for graduate assistants was $20,825. The average time to PhD degree completion was 4.57 years, and approximately 31% of PhD graduates entered academia. Various strategies for recruitment and future faculty development were identified and documented.

CONCLUSIONS

Findings allow SAS graduate programs to benchmark against other institutions with respect to their own achievement/strategies to remain competitive in student recruitment and development. Additional research is needed to determine the success of various recruitment strategies and identify potential new ones.

The impact of elective active-learning courses in pregnancy/lactation and pediatric pharmacotherapy

OBJECTIVE

To implement and evaluate the impact of 2 elective courses, Pregnancy & Lactation and Pediatrics on student acquisition of knowledge and development of lifelong learning skills related to these special populations.

DESIGN

Two 3-credit elective courses were implemented using various student-driven learning techniques, such as case-based exercises, group presentations, pro-con debates, and pharmacist "grab bag" questions. Strong emphasis was placed on medication literature retrieval and analysis, and a wiki was used to create an electronic resource for longitudinal use.

ASSESSMENT

Pre- and post-course tests showed significant improvement in knowledge related to pregnancy, lactation, and pediatrics. Pre- and post-course confidence and ratings on satisfaction survey tools also revealed significant improvement in several domains relating to lifelong-learning skills, knowledge related to medication use within these special populations, use of technology to enhance learning, and overall course design.

CONCLUSION

The combination of student-directed learning techniques used in 2 pediatric-concentration courses is an effective teaching model.

A systematic review of quality of life instruments in long-term breast cancer survivors

BACKGROUND

Breast cancer is the most common cancer in women, representing 16% of all female cancers. According to the American Cancer Society, long-term cancer survival is defined as more than five years of survivorship since diagnosis, with approximately 2.5 million breast cancer survivors (BCS) in 2006. The long-term effects from breast cancer and its treatment have been shown to have positive and negative effects on both recovery and survivors' quality of life (QoL). The purpose of the study was to identify QoL instruments that have been validated in long-term BCS and to review the studies that have used the QoL instruments in this population.

METHODS

A systematic literature search was conducted from January 1990 to October 2010 using electronic databases. Instruments validated and used in BCS were included in the review. In addition, QoL studies in long-term BCS using the validated instruments were reviewed. The search was limited to studies in English language. Studies of BCS of less than five years after initial diagnosis, any clinical or review studies were excluded.

RESULTS

The review identified a total of 12 instruments (10 disease-specific, 2 condition-specific) validated in long-term BCS. According to the QoL framework proposed by Ferrell and colleagues, three instruments (Quality of Life-Cancer Survivors, Quality of Life in Adult Cancer Survivors Scale, and Quality of Life Index-Cancer Version) evaluated all four domains (physical, psychological, social, and spiritual) of QoL. A review of the psychometric evaluation showed that Quality of Life in Adult Cancer Survivors Scale has acceptable reliability, validity, and responsiveness in long-term BCS compared to other disease-specific instruments. The review also yielded 19 studies that used these QoL instruments. The study results indicated that age-group, ethnicity, and type of treatment influenced different aspects of QoL.

CONCLUSIONS

There is a significant impact of breast cancer on QoL in long-term BCS. The review can help researchers and clinicians select the most appropriate instruments to assess the changes in QoL in BCS.

Research funding expectations as a function of faculty teaching/administrative workload

BACKGROUND

Persistent faculty shortages at US pharmacy schools make faculty recruitment and retention a perennial priority. The literature indicates that a key retention issue is whether the faculty member's scholarship is compromised because of a heavy teaching or service workload.

OBJECTIVE

Assess US pharmacy faculty perceptions concerning their views of appropriate expectations of research grant support given their teaching/administrative workloads.

METHODS

Data and opinions were collected using a multiple-choice, cross-sectional survey instrument (SurveyMonkey®; Menlo Park, CA), e-mailed to 1047 faculty members, randomly selected from all Accreditation Council of Pharmacy Education (ACPE)-accredited US pharmacy schools. Statistical analyses were performed using SPSS® (Chicago, IL) for Windows, Version 17.0.

RESULTS

Of the researcher respondents, a majority felt that the amount of teaching expected was too much to be a competitive researcher. Teaching commitment was found more likely to increase than decrease after achieving tenure. Reported new faculty start-up funding was well below that typically found at nonpharmacy research schools.

CONCLUSIONS

This information is anticipated to help pharmacy faculty members gauge their workload and productivity relative to a national peer group, and to help pharmacy schools improve in faculty recruitment and retention. The survey findings may assist pharmacy schools in clarifying reasonable teaching and funding expectations for pre- and post-tenure faculty, which in turn may help attract more pharmaceutical scientists to academic pharmacy positions.

Evaluating the cost-effectiveness of tiotropium versus salmeterol in the treatment of chronic obstructive pulmonary disease

OBJECTIVE

To assess the cost-effectiveness of 3 treatments (tiotropium, salmeterol, and no treatment) in patients with moderate chronic obstructive pulmonary disease (COPD).

METHODS

A Markov model with a time horizon of 1 year was developed. A hypothetical cohort of 100,000 subjects with moderate COPD with mean age of 65 years, smoking history of 50 pack-years, and disease duration of 9.5 years were included in the model. The efficacy and withdrawal data were taken from published randomized clinical trials. The effectiveness measure was exacerbations avoided per patient per year. Incremental cost-effectiveness ratio (ICER) was calculated as additional cost per patient to prevent 1 exacerbation, compared with the next most expensive option. A payer's perspective was used and only direct costs were included in the study. Sensitivity analyses were conducted to test the robustness of the baseline estimates and study assumptions.

RESULTS

The mean annual costs for the no treatment, salmeterol, and tiotropium groups were $392.1, $1268.7, and $1408.6, respectively. The ICER of tiotropium compared with no treatment was $1817.36 per exacerbation avoided, while the ICER of salmeterol compared with no treatment was $2454.48 per exacerbation avoided. Thus, in patients with moderate COPD, tiotropium is more cost-effective than salmeterol and no treatment.