Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999-2018.

BACKGROUND: Psychoactive drug combinations are increasingly contributing to overdose deaths among White and Black Americans. To understand the evolving nature of overdose crisis, inform policies, and develop tailored and equitable interventions, this study provides a comprehensive assessment of polysubstance mortality trends by race and sex during the opioid epidemic. METHODS: We used serial cross-sectional US mortality data for White and Black populations from 1999 through 2018 to calculate annual age-adjusted death rates (AADR) involving any opioid, opioid subtypes, benzodiazepines, cocaine, psychostimulants, or combinations of these drugs, stratified by race and sex. Trend changes in AADR were analyzed using joinpoint regression models and expressed as average annual percent change (AAPC) during each period of the three waves of the opioid epidemic: 1999-2010 (wave 1), 2010-2013 (wave 2), and 2013-2018 (wave 3). Prevalence measures assessed the percent co-involvement of an investigated drug in the overall death from another drug. RESULTS: Polysubstance mortality has shifted from a modest rise in death rates due to benzodiazepine-opioid overdoses among White persons (wave 1) to a substantial increase in death rates due to illicit drug combinations impacting both White and Black populations (wave 3). Concurrent cocaine-opioid use had the highest polysubstance mortality rates in 2018 among Black (5.28 per 100,000) and White (3.53 per 100,000) persons. The steepest increase in death rates during wave 3 was observed across all psychoactive drugs when combined with synthetic opioids in both racial groups. Since 2013, Black persons have died faster from cocaine-opioid and psychostimulant-opioid overdoses. Between 2013 and 2018, opioids were highly prevalent in cocaine-related deaths, increasing by 33% in White persons compared to 135% in Blacks. By 2018, opioids contributed to approximately half of psychostimulant and 85% of benzodiazepine fatal overdoses in both groups. The magnitude and type of drug combinations with the highest death rates differed by race and sex, with Black men exhibiting the highest overdose burden beginning in 2013. CONCLUSIONS: The current drug crisis should be considered in the context of polysubstance use. Effective measures and policies are needed to curb synthetic opioid-involved deaths and address disparate mortality rates in Black communities.

Assessing community pharmacy services in health professional shortage areas across Wisconsin.

BACKGROUND: Primary care health professional shortage areas (HPSAs) lack sufficient primary care providers to meet their health care needs, which contributes to worse health outcomes within underserved populations. Community pharmacies are commonly located in HPSAs and provide nondispensing services that can help address unmet health care needs. However, there is limited data on the nature, scope, and reimbursement for community pharmacy services. OBJECTIVES: Using survey data from the state of Wisconsin, this study compares the prevalence of and reimbursement for services provided by community pharmacies in primary care HPSAs and non-HPSAs and describes barriers to pharmacy service implementation. METHODS: A survey tool on pharmacy services, reimbursement, and barriers to service implementation was developed, pilot tested, and administered to every community pharmacy in Wisconsin. Data were collected via mail and online over two waves of survey administration from November 2021 to May 2022. Pearson's chi-squared and t tests were used to compare the prevalence of and reimbursement for services between HPSA and non-HPSA pharmacies. Content analysis was used to identify themes that described barriers to pharmacy service implementation. RESULTS: Responses were received from 287 of 774 eligible community pharmacies (37.1%). HPSA pharmacies were significantly more likely to be in rural areas. Regardless of pharmacy location, community pharmacies reported commonly providing a variety of services, but reimbursement for these services was considerably less frequent. The prevalence of reimbursement was <50% for two-thirds of services. Pharmacy staffing, time, and financial issues were the most commonly reported barriers to service implementation. CONCLUSIONS: Community pharmacies provide a diverse set of services to meet the health care needs of their patients, but often do so with inadequate staffing or reimbursement. Action is needed to support community pharmacies in meeting the health care needs of their communities and to ensure patient access to medications and pharmacy services.

Prompt access to outpatient care post-incarceration among adults with a history of substance use: Predisposing, enabling, and need-based factors.

INTRODUCTION: As expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage. METHODS: In this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18-64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release. RESULTS: The size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7-15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48-2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use. CONCLUSIONS: Conditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.

Community pharmacists and improving contraception access: Relationships between contraceptive counseling and dispensing contraceptives.

BACKGROUND: Experiences of contraceptive counseling and obtaining contraceptives vary for women of childbearing age based on education level, race, ethnicity, and health insurance. Community pharmacists are an important resource for improving access to contraceptive care in states with over-the-counter access to and pharmacist prescribing of contraceptives. OBJECTIVES: We first aimed to determine how patient education level, race, ethnicity, insurance, and patient-provider race concordance influenced the likelihood of receiving contraceptive counseling. The second aim was to determine how receiving contraceptive counseling influenced the likelihood of being dispensed contraceptives by a pharmacist. METHODS: Pearson chi-square tests and logistic regression were used to address study aims. RESULTS: Older women and those with Medicaid were less likely to receive contraceptive counseling. Race concordance had no influence on counseling. Counseling and education level were strong predictors of being dispensed contraceptives. Race, ethnicity, Medicaid, and marital status were negatively associated with being dispensed contraceptives. CONCLUSIONS: Inequities exist in access to contraceptive care for women of diverse backgrounds as well as those insured through Medicaid. State-level policy advancements and over the counter access to oral contraceptives may provide pharmacists a unique opportunity to provide contraceptive care for women without access to a primary care provider.

Relationships Between Chronic Illness, Body Mass Index, and Patient-Provider Communication.

Little is known about how higher-weight patients experience patient-provider communication, particularly among those with chronic illness. This study uses quantitative analytical methods and nationally representative data to determine how patient-provider communication is affected when patients have one or more chronic illnesses, as well as if patient BMI has a moderating effect on this association. Pearson correlation and multivariate logistic regression were both used to determine the significance of these associations. A significant, negative, relationship was found between overall patient-provider communication and patient chronic illness status, but no significant relationship was found between respondent BMI and patient-provider communication. There was no observable moderation effect of respondent BMI on the relationship between their number of chronic illnesses and the perceived quality of the patient-provider communication they experienced. From this study there is evidence that patients with multiple chronic illness experience worse communication with their health care providers which could be due to numerous types of bias. More research is needed to better understand if and how weight and other bias affects outcomes for chronically ill patients. Research implications include improving the comprehensiveness of nation-wide surveys that measure health care quality to include improved measures of perceived bias, including weight bias, and patient-provider communication, as these are complex, multi-factorial concepts.

Naloxone analogy and opioid overdose terminology preferences among rural caregivers: Differences by race.

BACKGROUND: Despite national and state policies aimed at increasing naloxone access via pharmacies, opioid overdose death rates rose during the COVID-19 pandemic, particularly among Blacks and American Indians (AIs) in rural areas. Caregivers, or third parties who can administer naloxone during an overdose event, are important individuals in the naloxone administration cascade, yet no studies have explored rural caregivers' opioid overdose terminology and naloxone analogy preferences or whether these preferences differ by race. OBJECTIVES: To identify rural caregivers' overdose terminology and naloxone analogy preferences and determine whether preferences differ by race. METHODS: A sample of 40 caregivers who lived with someone at high risk of overdose and used pharmacies in 4 largely rural states was recruited. Each caregiver completed a demographic survey and a 20- to 45-minute audio-recorded semi-structured interview that was transcribed, de-identified, and imported into a qualitative software package for thematic analysis by 2 independent coders using a codebook. Overdose terminology and naloxone analogy preferences were analyzed for differences by race. RESULTS: The sample was 57.5% white, 35% Black, and 7.5% AIs. Many participants (43%) preferred that pharmacists use the term "bad reaction" to refer to overdose events over the terms "accidental overdose" (37%) and "overdose" (20%). The majority of white and Black participants preferred "bad reaction" while AI participants preferred "accidental overdose." For naloxone analogies, "EpiPen" was most preferred (64%), regardless of race. "Fire extinguisher" (17%), "lifesaver" (9.5%), and other analogies (9.5%) were preferred by some white and Black participants but not AI participants. CONCLUSION: Our findings suggest that pharmacists should use the "bad reaction" term and "EpiPen" analogy when counseling rural caregivers about overdose and naloxone, respectively. Caregivers' preferences varied by race, suggesting that pharmacists may want to tailor the terminology and analogy they use when discussing naloxone with caregivers.

Characteristics of U.S. older adult medicare beneficiaries receiving the influenza vaccination at retail pharmacies.

Background: Pharmacy-provided influenza vaccination services have become more prevalent among the older adult population. However, little is known about the characteristics of older adults associated with receiving the influenza vaccination at retail pharmacies and how these associated characteristics have changed. Objective: To examine characteristics of older adults associated with use of retail pharmacy-provided influenza vaccination services and how the characteristics changed between 2009 and 2015. Methods: The study used a retrospective, cross-sectional design with data from the 2009 and 2015 Medicare Current Beneficiary Survey. Older adults aged 65 and older who completed a community questionnaire and received the influenza vaccination during the previous winter were identified. Andersen's Behavioral Model of Health Services Use was the conceptual framework for inclusion of the population characteristics. A multivariable log-binomial regression was performed to estimate the association between the population characteristics and use of pharmacy-provided vaccination service, and the relative change in associations between 2009 and 2015. Survey weights were applied in all analyses. Results: The results showed older adults who were non-Hispanic black (compared to non-Hispanic white), who did not have secondary private insurance (compared to those who had), who did not have physician office visit (compared to those who had) and who lived in non-metro area (compared to those who lived in metro area) had become more likely to use pharmacy-provided influenza vaccination services in 2015 than in 2009. Conclusions: Pharmacy-provided influenza vaccination services appear to reduce access barriers for racially and socioeconomically disadvantaged older adults. Findings could help inform not only the retail pharmacies that provide vaccination services to better outreach to potential target populations but also policy makers about the disadvantaged populations that would benefit from the vaccination services provided by retail pharmacies.

Cost-Effectiveness of a Hypothetical Gene Therapy for Alzheimer's Disease: A Markov Simulation Analysis.

Background: Alzheimer's disease is a prevalent neurodegenerative condition causing significant health and economic burden. With limited therapeutic options, clinical trials have been investigating Alzheimer's disease treatment using more novel approaches, including gene therapy. However, there is limited evidence on the cost-effectiveness of such treatments. Objectives: This research aims to explore the cost-effectiveness of a hypothetical gene therapy for patients with Alzheimer's disease at varying degrees of severity. Methods: A Markov model with a 20-year time horizon was constructed for simulated cohorts with mild cognitive impairment due to Alzheimer's disease, assigned to receive either standard of care or a one-time gene therapy administration. Varying costs of care due to disease severity and treatment efficacy were utilized to determine the effect of those variables at different willingness-to-pay thresholds. Results: Under the initial assumption that the hypothetical gene therapy grants a 30% risk reduction in disease progression and entry into institutional care, the maximum cost-effective price for gene therapy is $141,126 per treatment using the threshold of $150,000 per quality-adjusted life year (QALY). By increasing the treatment effectiveness to 50%, cost-effective price nearly doubled at each willingness-to-pay threshold (e.g., $260,902 at the $150,000/QALY threshold). Conclusion: Despite being cost-effective at a very high price, the hypothetical gene therapy for AD would still need to be priced considerably lower than other approved gene therapies on the market. Thus, a comprehensive pharmacoeconomic assessment remains critical in pricing innovative therapy and determining coverage for patients in need.

The Association of Caregiver Characteristics and Caregivers' Perceived Difficulty in Medication Management Tasks.

Background: Medication management tasks are commonly performed by family caregivers caring for patients with dementia, but caregivers also reported difficulties in performing these tasks. Objectives: Using the 2017 National Study of Caregiving (NSOC) and the 2017 National Health and Aging Trends Study (NHATS), this study examined the association between caregiver characteristics and caregiver difficulty in performing medication management tasks (e.g., ordering medications, keeping track of medications, giving shots). Methods: The main independent variable was the number of medication management tasks performed by the caregivers. The dependent variable was difficulty in performing medication management tasks. Other variables of interest included caregiver age, sex, education, co-residence with the care recipient, and use of support services. This study used the Pearlin's Stress and Coping Model to select other control variables from hundreds of variables contained in the NSOC. A lasso logistic regression model was used to account for the large amount of other control variables. Results: Caregiver difficulty was found mainly in keeping track of medications or giving shots (42.4%). More medication management tasks were significantly related to caregiver difficulty [OR=2.71; 95% CI (1.84 - 3.99)]. A significant association linking support service use with task difficulty was also observed [OR=1.82; 95% CI (1.06 - 3.13)], which warrants additional research. Conclusions: Caregiver difficulty was found mainly in keeping track of medications or giving shots. More medication management tasks were significantly related to caregiver difficulty. Since patients with dementia are often on multiple medications, it is crucial to ensure medication management is done correctly to avoid adverse health consequences.

Addressing the opioid epidemic through community pharmacy engagement: Study protocol for a randomized controlled trial.

BACKGROUND: Despite the authority to dispense naloxone, pharmacists have been reluctant to offer and dispense it, often due to discomfort communicating about the sensitive topic of opioid overdose. Because existing online naloxone trainings do not sufficiently address how to communicate effectively with patients about naloxone, Nalox-Comm, a training module designed to improve pharmacists' self-efficacy to engage in naloxone discussions, was developed. OBJECTIVE: To describe the study protocol to evaluate the effectiveness of the Nalox-Comm training module on naloxone dispensing rates. METHODS: A randomized controlled trial, which began in July 2021, is used to evaluate the pre-post Nalox-Comm training intervention. Sixty pharmacists are being recruited from 62 pharmacies part of a single grocery store chain in rural counties of the southeastern United States. After completing a baseline survey, pharmacists are observed by simulated patients (SPs) who rate the quality of their pre-training naloxone communication. Pharmacists are then invited to complete either a basic online naloxone training module (control group) or a newly developed Nalox-Comm training (experimental group), after which they complete a post-training survey and are observed a second time by SPs. Three months post-training, study participants complete a final follow-up survey. Naloxone dispensing records are obtained from each participating pharmacy to assess change in naloxone dispensing rates. CONCLUSION: Informed by rural pharmacist stakeholders, the Nalox-Comm training module addresses communication barriers specific to rural communities. Compared to those in the control group, we hypothesize that pharmacies in the experimental group will dispense more naloxone in the three months post-training intervention.

The importance of providing gender-affirming care in pharmacy practice.

Transgender and gender diverse (TGD) individuals face bias and discrimination across many health care settings including pharmacy. While there is evidence of successful interventions to increase provider awareness of the needs of TGD individuals in medicine, nursing, and social work, little work has been done by the pharmacy profession to recognize and meet the needs of this population. This commentary examines the gaps in pharmacy practice and pharmacy research with regards to the needs of TGD individuals and looks at allied health fields for potential solutions that can be adapted by the pharmacy profession. We first examine the social pressures that TGD individuals face in multiple social contexts and describe how bias and discrimination spill over into their interactions with providers and health care systems. Solutions for improving pharmacy practice research's ability to identify TGD individuals and their needs follows as a measure that will lead to solutions for improving pharmacy practice. A discussion of TGD individuals' responses to actual and perceived discrimination by pharmacists is discussed next, and why their avoidance of pharmacy care can be problematic to their health. The remainder of the paper focuses on how pharmacy education can train future pharmacists to provide inclusive care to TGD individuals, and how interprofessional education and continuing education can enhance future and practicing pharmacists' ability to provide high quality care to TGD individuals.

Utilization of preventive services by women enrolled in the Affordable Care Act's Health Insurance Marketplace.

The Health Insurance Marketplace has offered access to private health insurance coverage for over 10 million Americans, including previously uninsured women. Per Affordable Care Act requirements, Marketplace plans must cover preventive services without patient cost-sharing in the same way as in employer-sponsored insurance (ESI). However, no study has evaluated whether the utilization of preventive services is similar between Marketplace enrollees and ESI enrollees. Using the Medical Expenditure Panel Survey data for 2014-2016, we identified working-age women with Marketplace plans (n = 792, N = 2,567,292) and ESI (n = 13,100, N = 52,557,779). We compared the two groups' receipt rates of five evidence-based preventive services: blood pressure screening, influenza vaccine, Pap test, mammogram, and colorectal cancer screening. Unadjusted results showed marketplace enrolled women had significantly lower odds of influenza vaccination, Pap test, and mammogram. However, after controlling for other factors, Marketplace insurance was not associated with lower receipt rates of preventive services, except for influenza vaccination (Adjusted OR = 0.64; 95% CI = 0.50-0.82). Regardless of an individual's private insurance type, higher educational attainment and having a usual source of medical care showed the strongest association with the receipt of all investigated preventive services. With the increased role of the Marketplace as a safety net in the COVID-19 pandemic, more research and outreach efforts should be made to facilitate access to preventive services for its enrollees.

Five-year impact of Medicare Part D coverage gap reform on drug expenditures and utilization.

OBJECTIVE: To estimate the impact of the Medicare Part D coverage gap reform under the Affordable Care Act (ACA) on the utilization of and expenditures for prescription drugs within the first five years of the policy's implementation. DATA SOURCES: 2008-2015 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN: We used a difference-in-differences approach to estimate the year-by-year changes in prescription drug use and expenditures before (2006-2010) and after (2011-2015) the ACA's Part D coverage gap reform between Part D beneficiaries not receiving the Low-Income Subsidy (LIS) and those receiving the LIS. DATA COLLECTION: The study sample included Part D beneficiaries (a) aged 65 years or older; (b) not disabled or having end-stage renal disease; (c) continuously enrolled in a Part D plan (d) having at least one prescription fill in a given year. Survey-reported and administrative Part D events data in the MCBS were used for the analyses. PRINCIPAL FINDINGS: After the ACA reform, annual out-of-pocket drug spending significantly decreased by $88 (P < .01) among non-LIS beneficiaries compared to LIS beneficiaries, with growing decreases over time (average decreases of $41 in 2011, $49 in 2012, $105 in 2013, and $135 in 2015, P < .01 or <.05). Changes in out-of-pocket costs were largely driven by significant decreases among brand-name drugs (overall decrease of $106, P < .01). Despite significantly reduced out-of-pocket spending, there were no significant changes in the overall number of 30-day drug fills and total drug spending; however, changes in the use of brand-name and generic drugs were seen after the ACA (increase of 1.9 fills for brand-name drugs and decrease of 2.3 fills for generic drug in 2015, P < .05). CONCLUSIONS: The ACA coverage gap reform has helped to reduce the out-of-pocket drug cost burden for beneficiaries, although it had no noticeable impact on drug use or total drug spending.

Financial burden and medication adherence among near-poor older adults in a pharmaceutical assistance program.

BACKGROUND: With increasing drug prices in the past decade, affordability and medication adherence are a growing concern for near-poor older adults, especially for those who are not receiving Low-Income Subsidy in Medicare Part D. SeniorCare is a pharmaceutical assistance program in Wisconsin for near-poor older adults, providing comprehensive prescription coverage with flat copayments. OBJECTIVES: To evaluate five-year trends in financial hardship and medication adherence and to examine factors associated with these outcomes in SeniorCare members. METHODS: SeniorCare program enrollment and pharmacy claims data from 2014 to 2018 were used. The study population was near-poor older adults in SeniorCare with annual family income ≤200% of the federal poverty level. Financial burden was assessed using the proportion of total annual out-of-pocket costs to total annual income. Medication adherence was assessed by adapting the measures endorsed by the Pharmacy Quality Alliance and National Quality Forum. Descriptive statistics and independent t-tests were used to evaluate the trends, and multivariate logistic regressions were conducted to examine factors associated with financial burden and medication adherence. RESULTS: From 2014 to 2018, mean annual out-of-pocket costs per member declined by 3.7% (p < 0.001) for all drugs, while those for specialty drugs increased by 31.2% (p < 0.05). Around 3.3% spent more than 5% of their income for prescription drugs in 2014, which decreased to 2.4% in 2018 (p < 0.001). The proportions of adherent patients increased from 78.1% to 81.2% (p < 0.001) for diabetes medications (excluding insulins), from 77.3% to 79.5% (p < 0.001) for statins, and from 79.8% to 80.8% (p < 0.05) for RASA. Members subject to a $500 annual deductible were more likely to experience high financial burden (adjusted odds ratio (AOR) = 1.677, p < 0.001) and less likely to be adherent to diabetes medications (AOR = 0.484, p < 0.001). CONCLUSIONS: The near-poor older adults enrolled in Wisconsin SeniorCare program had low financial burden and good medication adherence within the program.

Impact of a novel project management course sequence on innovative thinking in pharmacy students.

BACKGROUND: As healthcare continues to become more complex, pharmacist innovators have worked to advance the profession and expand the role of the pharmacist on the healthcare team. Accreditation standards for schools of pharmacy recognize the importance of developing future pharmacist innovators capable of making positive change in the profession, but there are limited resources available on how to best instill innovative thinking in student pharmacists. EDUCATIONAL ACTIVITY: A two-semester elective course sequence was created for third-year doctor of pharmacy students requiring completion of a longitudinal quality improvement project at a partnering health system. Students collaborated with key stakeholders to design a project plan and charter, identify deliverables, and deliver project results. Innovative thinking was assessed using a mixed methods approach including questionnaires with forced choice and open response items, focus group data, and semi-structured interviews. Each questionnaire item mapped specifically to an element of a validated model for employee innovation. From the beginning to the end of the course sequence, there were significant improvements in student-perceived project management self-efficacy and innovative thinking. CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY: Student learning outcomes and the course structure mapped closely with a validated model of innovative behavior, demonstrating the effectiveness of utilizing project management to instill innovative thinking in student pharmacists. These findings support the concept that innovative thinking can be taught in pharmacy didactic curricula by situating students in the environment of real-world pharmacy practice.

Lessons learned recruiting a diverse sample of rural study participants during the COVID-19 pandemic.

Residents of rural areas have been a hard-to-reach population for researchers. Geographical isolation and lower population density in rural areas can make it particularly challenging to identify eligible individuals and recruit them for research studies. If the study is about a stigmatizing topic, such as opioid overdose, recruitment can be even more difficult due to confidentiality concerns and distrust of outside researchers. This paper shares lessons learned, both successes and failures, for recruiting a diverse sample of rural participants for a multi-state research study about naloxone, an opioid overdose reversal agent. In addition, because our recruitment spanned the period before and after the COVID-19 pandemic in the U.S., we share lessons learned regarding the transition to all remote recruitment and data collection. We utilized various recruitment strategies including rural community pharmacy referrals, community outreach, participant referrals, mass emails, and social media with varying degrees of success. Among these modalities, pharmacist referrals and community outreach produced the highest number of participants. The trust and rapport that pharmacists have with rural community members eased their concerns about working with unknown researchers from outside their communities and facilitated study team members' ability to contact those individuals. Even with the limited in-person options during the pandemic, we reached our recruitment targets by employing multiple recruitment strategies with digital flyers and emails. We also report on the importance of establishing trust and maintaining honest communication with potential participants as well as how to account for regional characteristics to identify the most effective recruitment methods for a particular rural area. Our suggested strategies and recommendations may benefit researchers who plan to recruit underrepresented minority groups in rural communities and other historically hard-to-reach populations for future studies.

High Out-of-pocket Health Care Cost Burden Among Medicare Beneficiaries With Diabetes, 1999-2017.

OBJECTIVE: We examined the magnitude of and trends in the burden of out-of-pocket (OOP) costs among Medicare beneficiaries age 65 years or older with diabetes overall, by income level, by race/ethnicity, and compared with beneficiaries without diabetes. RESEARCH DESIGN AND METHODS: Using data from the 1999-2017 Medicare Current Beneficiary Survey, we estimated average annual per capita OOP costs and percentage of beneficiaries experiencing high OOP burden, defined as OOP costs >10% or >20% of household income. We used joinpoint regression to examine the trends and generalized linear model and logistic regression for comparisons between beneficiaries with and without diabetes. Cost and income estimates were adjusted to 2017 USD. RESULTS: Total OOP costs were $3,609-$5,283, with significant increases until 2005 followed by a leveling off. The prevalence of high OOP burden was 57%-72% at the 10% income threshold and 29%-41% at the 20% threshold, with significant increasing trends until 2003 followed by decreases. Total OOP costs were the highest in the ≥75% income quartile, whereas prevalence of high OOP burden was highest in the <25% and 25-50% income quartiles. Non-Hispanic Whites had the highest OOP costs and prevalence of high OOP burden. Beneficiaries with diabetes had significantly higher OOP costs ($498, P < 0.01) and were more likely to have high OOP burden than those without diabetes (odds ratios 1.32 and 1.25 at >10% and >20% thresholds, respectively, P < 0.01). CONCLUSIONS: Over the past two decades, Medicare beneficiaries age 65 years or older with diabetes have faced substantial OOP burden, with large income-related disparities.

Influenza vaccination rates and location for receiving the influenza vaccination among older adult Medicare beneficiaries.

OBJECTIVES: The objectives of this study were to (1) assess the trends in older adult influenza vaccination rates and (2) locations at which U.S. older adults received influenza vaccinations for the 2008-2009 to 2017-2018 influenza seasons, and (3) compare the estimates of influenza vaccination rates and locations with the estimates from other sources reported previously. METHODS: Data from the 2009 to 2017 Medicare Current Beneficiary Survey (MCBS) were used in this analysis. The weighted sample included an average of approximately 37 million community-dwelling older Medicare beneficiaries who completed questionnaires per year. The estimates for older adult influenza vaccination rates and the locations that they used to receive the influenza vaccination were weighted and reported for the 2008-2009 to 2017-2018 influenza seasons. RESULTS: The self-reported older adult influenza vaccination rates between 2008-09 and 2017-2018 ranged from 69.6% (24.6 million) to 75.0% (31.3 million). Across the study period, the percentage of older adults receiving the influenza vaccination at a physician office and clinic declined by 10.4%. The decline was more than offset by an increase in older adult influenza vaccination receipt at a community pharmacy, which substantially increased from 16.6% (4.1 million) in 2008-2009 to 34.8% (10.9 million) in 2014-2015. When compared with the estimates from other sources, the absolute value of the MCBS estimates corresponds with National Health Interview Survey estimates. The older adult influenza vaccination rate increased slightly between the 2008-2009 and 2017-2018 influenza seasons but is still below the 90% benchmark. CONCLUSION: Community pharmacies-increasingly important access points for the influenza vaccination for older adults-likely contributed to the growth in the rate of older adults vaccinated with influenza vaccines.

Illustrating access to community pharmacies in Wisconsin.

OBJECTIVES: Community pharmacists also play a vital public health role in increasing access to health care services and information during times of public health crisis. To examine access to community pharmacies in Wisconsin and the relationship between pharmacy locations and primary care health professional shortage areas (HPSAs). METHODS: A list of licensed pharmacies in Wisconsin was screened to identify community pharmacies. Rural-urban commuting area codes were used to classify the rurality of pharmacy locations. Descriptive measures and pharmacy location maps were used to assess access to community pharmacies in the state as well as the relationship between pharmacy locations and primary care HPSAs. Spatial analysis was conducted to estimate the percentage of the population that lives within 10-, 20-, and 30-minute drive times of each community pharmacy. RESULTS: Of the 837 community pharmacies in Wisconsin, 73 (68.5%) were located in metropolitan areas, 95 (11.4%) in micropolitan areas, 112 (13.4%) in small towns, and 57 (6.8%) in rural areas. A total of 265 (31.7%) community pharmacies were located in a primary care HPSA. The drive-time analysis found that 99.7% of the population lives within 30 minutes of a pharmacy, 98.7% within 20 minutes of a pharmacy, and 89.3% within 10 minutes of a pharmacy. CONCLUSIONS: Nearly the entire Wisconsin population has convenient access to community pharmacies. Community pharmacies are ideally located in underserved areas with shortages of other health professionals, which may provide an opportunity for pharmacists to take on additional clinical roles to support health care providers and facilities in these areas.

Development and validation of a theory-based instrument to predict community pharmacists' intention to provide pharmaceutical care services.

BACKGROUND: Predicting pharmacists' intention to provide Pharmaceutical Care (PC) and identifying modifiable factors associated with their intention can aid in the design and tailoring of behavior-based interventions to promote the adoption of PC as a standard of pharmacy practice. There is a need for valid and reliable instruments that are theoretically grounded to measure these factors. OBJECTIVE: To develop and test the psychometric properties of the "Pharmaceutical Care Intention (PCI) scale" to identify socio-cognitive factors associated with community pharmacists' intention to provide PC services to patients with chronic conditions. METHODS: A self-administered questionnaire was developed in English and translated into Arabic, guided by constructs derived from a modified Theory of Planned Behavior (TPB) framework and a thorough review of the PC literature. The questionnaire was reviewed for face and content validity, pilot tested, and then administered to a sample of community pharmacists in Alexandria, Egypt. Exploratory factor analysis (EFA) was employed to identify and refine the underlying dimensional structure of the PCI scale and test for its convergent and discriminant validity. Reliability was assessed by computing Cronbach's α. RESULTS: Out of the 109 approached pharmacists, 97 usable responses were analyzed (response rate = 89%). EFA resulted in a 23-item, 6-factor solution explaining 52.14% of the variance in responses and providing evidence for convergent and discriminant validity. The resulting factors aligned with the modified TPB constructs: intention (α = 0.74), attitude (α = 0.89), subjective norm (α = 0.58), perceived behavioral control to identify (α = 0.66) and intervene (α = 0.82) to address drug-related problems, and perceived moral obligation (α = 0.72). Cronbach's α of the pooled items of the PCI scale was 0.77. CONCLUSION: The PCI scale is a parsimonious, theory-driven instrument with acceptable construct validity and reliability to examine factors associated with community pharmacists' intention to provide PC.