Impact of cost on prescribing diabetes medications for older adults with type 2 diabetes in the outpatient setting.

BACKGROUND: Newer diabetes medications have cardiorenal benefits beyond blood sugar lowering that make them a preferred treatment option in many patients. Despite this, studies have shown that prescribing of these medications remains suboptimal with medication costs being hypothesized as a reason for underutilization. OBJECTIVE: To understand clinicians' decision-making processes for prescribing diabetes medications in older adults, focusing on higher cost medications. METHODS: Observations of patient encounters and semi-structured interviews were conducted with clinicians from primary care, endocrinology, and geriatrics to elucidate themes into diabetes medication prescribing. A qualitative descriptive approach was used to analyze the data from interviews using an inductive coding scheme with themes derived from the data. RESULTS: Twenty-one interviews were conducted. Five themes were identified: 1) out-of-pocket costs drive prescribing decisions 2) out-of-pocket costs can be variable due to changing insurance plans or changing coverage 3) clinicians have difficulty with determining patient-specific out-of-pocket costs 4) clinicians manage the tradeoffs existing between cost, efficacy, and safety and 5) clinicians can use cost-modifying strategies such as patient assistance. CONCLUSION: Addressing the challenges that medication costs pose to prescribing evidence-based medications for type 2 diabetes is necessary to optimize diabetes care for older adults.

Automated Test for Monthly Quality Assurance of Optical Surface Imaging Dynamic Localization Accuracy.

The American Association of Physicists in Medicine (AAPM) recently published the report of Task Group (TG) 302, which provides recommendations on acceptance, commissioning, and ongoing routine quality assurance (QA) for surface-guided radiation therapy (SGRT) systems. One of the recommended monthly QA tests is a dynamic localization accuracy test. This work aimed to develop an automated procedure for monthly SGRT dynamic localization QA. An anthropomorphic head phantom was rigidly attached to the 6-dof couch of a TrueBeam linac. TrueBeam Developer Mode was used to take an MV image of the phantom at the starting position, then automatically drive the couch through a series of translations and rotations, taking an MV image after each translation. The Identify SGRT system monitored the motion of the phantom surface from the starting position. Translations assessed on MV images were compared to translations reported in trajectory log files and Identify log files. Rotations were compared between trajectory log files and Identify log files. Three experiments were conducted. None of the translations or rotations from any experiment exceeded the tolerance values for stereotactic ablative body radiation therapy (SABR) recommended by AAPM TG-142. Maximum deviations from the expected translation values from MV imaging, trajectory log files, and Identify log files were -0.94mm, -0.11mm, and -0.78mm, respectively. Maximum deviations from the expected rotation values from trajectory log files and Identify log files were 0.01 and -0.2 degrees, respectively. The proposed method is a simple automated way to complete monthly dynamic localization QA of SGRT systems.

Dispensaries and Medical Marijuana Certifications and Indications: Unveiling the Geographic Connections in Pennsylvania, USA.

Introduction: Pennsylvania opened its first medical marijuana (MMJ) dispensary in 2018. Qualifying conditions include six conditions determined to have no or insufficient evidence to support or refute MMJ effectiveness. We conducted a study to describe MMJ dispensary access in Pennsylvania and to determine whether dispensary proximity was associated with MMJ certifications and community demographics. Methods: Using data from the Pennsylvania Department of Health, we geocoded MMJ dispensary locations and linked them to US Census Bureau data. We created dispensary access measures from the population-weighted centroid of Zip Code Tabulation Areas (ZCTAs): distance to nearest dispensary and density of dispensaries within a 15-min drive. We evaluated associations between dispensary access and the proportion of adults who received MMJ certification and the proportion of certifications for low evidence conditions (amyotrophic lateral sclerosis, epilepsy, glaucoma, Huntington's disease, opioid use disorder, and Parkinson's disease) using negative binomial modeling, adjusting for community features. To evaluate associations racial and ethnic composition of communities and distance to nearest dispensary, we used logistic regression to estimate the odds ratios (OR) and 95% confidence intervals (CI), adjusting for median income. Results: Distance and density of MMJ dispensaries were associated with the proportion of the ZCTA population certified and the proportion of certifications for insufficient evidence conditions. Compared to ZCTAs with no dispensary within 15 min, the proportion of adults certified increased by up to 31% and the proportion of certifications for insufficient evidence decreased by up to 22% for ZCTAs with two dispensaries. From 2018 to 2021, the odds of being within five miles of a dispensary was up to 20 times higher in ZCTAs with the highest proportions of individuals who were not White (2019: OR: 20.14, CI: 10.7-37.8) and more than double in ZCTAs with the highest proportion of Hispanic individuals (2018: OR: 2.81, CI: 1.51-5.24), compared to ZCTAs with the lowest proportions. Conclusions: Greater dispensary access was associated with the proportions of certified residents and certifications for low evidence conditions. Whether these patterns are due to differences in accessibility or demand is unknown. Associations between community demographics and dispensary proximity may indicate MMJ access differences.

Evaluation of pharmacist-led transition of care program in patients with acute coronary syndrome.

BACKGROUND: Guideline-directed medical therapies (GDMTs), initiated in-hospital and continued during the transition to outpatient care, are paramount to successful outcomes for patients with acute coronary syndrome (ACS). Incomplete discharge medication prescribing and delayed follow-up lead to worse cardiovascular outcomes. OBJECTIVES: We investigated a system of care using inpatient and outpatient clinical pharmacists to close GDMT gaps, ensure seamless transition to outpatient care, improve patient education, and optimize therapies. METHODS: We conducted a pre-post cohort analysis of patients with ACS pre- versus post-intervention to compare process metrics and key outcomes using electronic health record data. RESULTS: There were 181 and 135 patients in the pre- and post-intervention cohorts, respectively. Patients post-intervention were significantly more likely to have appropriately-timed follow-up visits scheduled with cardiology (79% vs. 51%, P < 0.0001) and primary care (57% vs. 43%, P = 0.01), to be discharged with prescriptions for P2Y12 inhibitors (87% vs. 64%, P < 0.0001), high dose statins (86% vs. 70%, P = 0.001), and beta blockers (87% vs. 76%, P = 0.01), and significantly less likely to have 30-day all-cause hospital readmissions (4% vs. 12%, P = 0.02) and emergency department (ED) visits (10% vs. 18%, P = 0.04). CONCLUSIONS: The integration of advanced practicing pharmacists into a cardiology team at transition and post-hospitalization resulted in improved rates of posthospital follow-up visits, optimization of GDMT medications, and significantly lower 30-day hospital readmission and ED utilization.

Factors Affecting Prescribing of Type 2 Diabetes Medications in Older Adults within an Integrated Healthcare System.

BACKGROUND: Despite type 2 diabetes guidelines recommending against the use of sulfonylureas in older adults and for the use of sodium-glucose cotransporter-2 inhibitors (SGLT2) and glucagon-like peptide-1 agonists (GLP1s) in patients with atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), and heart failure (HF), real-world guideline-concordant prescribing remains low. While some factors such as cost have been suggested, an in-depth analysis of the factors associated with guideline-concordant prescribing is warranted. OBJECTIVE: To quantify the extent of guideline-concordant prescribing in an integrated health care delivery system and examine provider and patient level factors that influence guideline-concordant prescribing. DESIGN: We performed a cross-sectional study. PARTICIPANTS: Participants were included if they had a diagnosis of type 2 diabetes, were prescribed a second-line diabetes medication between January 1, 2018 and December 31, 2020 and were at least 65 years old at the time of this second-line prescription. MAIN MEASURES: Our outcome of interest was guideline-concordant prescribing. The definition of guideline-concordant prescribing was based on American Diabetes Association and American Geriatric Society recommendations as well as expert consensus. Factors affecting guideline concordant prescribing included patient demographics and provider characteristics among others. KEY RESULTS: We included 1,693 patients of which only 50% were prescribed guideline-concordant medications. In a subgroup of 843 patients with cardiorenal conditions, only 30% of prescriptions were guideline concordant. Prescribing of guideline-concordant prescriptions was more likely among pharmacists than physicians (RR 1.34, 95% CI 1.19-1.51, p<0.001) and in endocrinology practices compared to primary care practices (RR 1.41 95% CI 1.16-1.72, p=0.007). Additionally, guideline concordant prescribing increased over time (42% in 2018 vs 53% in 2019 vs 53% in 2020, p<0.001). CONCLUSIONS: Guideline-concordant prescribing remains low in older adults, especially among those with cardiorenal conditions. Future studies should examine barriers to prescribing guideline-concordant medications and interventions to improve guideline-concordant prescribing.

Pre-emptive pharmacogenomics implementation among polypharmacy patients 65 years old and older: a clinical pilot.

Aim: Pre-emptive testing of pharmacogenomic (PGx) variations has potential to improve medication safety and effectiveness; however, testing is not routine. Given the newfound payor coverage of multigene testing and the potential value of testing within aging patients, it is imperative to test local PGx testing capabilities, report results to patients and providers, and determine the value of testing. Materials & methods: We designed a randomized clinical pilot of a pre-emptive PGx testing process using the electronic health record compared with usual care among an aging primary care population. Results & conclusion: The impact of the program on prescribing patterns, healthcare utilization and costs of care will be evaluated. We hypothesize that implementation of a pre-emptive multigene PGx panel is feasible among elderly, polypharmacy, primary care patients, measured by the number of enrolled patients with PGx results entered in the medical record. Health system wide PGx implementation, including capacity needed to integrate these valuable results, is also described.

The potential impact of clinical decision support on nonwaivered primary care clinicians' prescribing of buprenorphine.

Elimination of the X-waiver increased potential buprenorphine prescribers 13-fold, but growth in prescribing will likely be much lower. We explored self-assessments of nonwaivered primary care clinicians (PCCs) for factors affecting their likelihood to prescribe buprenorphine were the X-waiver eliminated (since realized January 2023) and the potential impacts of a clinical decision-support (CDS) tool for opioid use disorder (OUD). Cross-sectional survey data were obtained between January 2021 and March 2022 from 305 nonwaivered PCCs at 3 health systems. Factors explored were patient requests for buprenorphine, PCC access to an OUD-CDS, and PCC confidence and abilities for 5 OUD-care activities. Relationships were described using descriptive statistics and odds ratios. Only 26% of PCCs were more likely to prescribe buprenorphine upon patient request, whereas 63% were more likely to prescribe with the OUD-CDS. PCC confidence and abilities for some OUD-care activities were associated with increased prescribing likelihood from patient requests, but none were associated with the OUD-CDS. The OUD-CDS may increase buprenorphine prescribing for PCCs less likely to prescribe upon patient request. Future research is needed to develop interventions that increase PCC buprenorphine prescribing. Clinical trial registration: ClinicalTrials.gov. Identifier: NCT04198428. Clinical trial name: Clinical Decision Support for Opioid Use Disorders in Medical Settings (Compute 2.0).

Assessing Ability Recovery of the Sequential IRT Model With Unstructured Multiple-Attempt Data.

The unstructured multiple-attempt (MA) item response data in virtual learning environments (VLEs) are often from student-selected assessment data sets, which include missing data, single-attempt responses, multiple-attempt responses, and unknown growth ability across attempts, leading to a complex and complicated scenario for using this kind of data set as a whole in the practice of educational measurement. It is critical that methods be available for measuring ability from VLE data to improve VLE systems, monitor student progress in instructional settings, and conduct educational research. The purpose of this study is to explore the ability recovery of the multidimensional sequential 2-PL IRT model in unstructured MA data from VLEs. We conduct a simulation study to evaluate the effects of the magnitude of ability growth and the proportion of students who make two attempts, as well as the moderated effects of sample size, test length, and missingness, on the bias and root mean square error of ability estimates. Results show that the model poses promise for evaluating ability in unstructured VLE data, but that some data conditions can result in biased ability estimates.

Associations of Healthcare Utilization and Costs with Increasing Pain and Treatment Intensity Levels in Osteoarthritis Patients: An 18-Year Retrospective Study.

INTRODUCTION: Osteoarthritis (OA) is a complex disease, and prior studies have documented the health and economic burdens of patients with OA compared to those without OA. Our goal was to use two strategies to further stratify OA patients based on both pain and treatment intensity to examine healthcare utilization and costs using electronic records from 2001 to 2018 at a large integrated health system. METHODS: Adult patients with ≥1 pain numerical rating scale (NRS) and diagnosis of OA were included. Pain episodes of ≥90 days were defined as mild (0-3), moderate (4-6), or severe (7-10) based on initial NRS. Patients were initially classified as mild and moved to moderate-severe OA if any of eight treatment-based criteria were met. Outpatient visits (OP), emergency department visits (ED), inpatient days, and healthcare costs (both all-cause and OA-specific) were compared among pain levels and OA severity levels as frequencies and per-member-per-year rates, using generalized linear regression models adjusting for age, sex, and body mass index, with contrasts of p < 0.05 considered significant. RESULTS: We identified 127,656 patients, 92,576 with pain scores. Moderate and severe pain were associated with significantly higher rates of OA-related utilization and costs, and all-cause ED visits and pharmacy costs. Moderate-severe OA patients had significantly higher OA-related utilization and costs, and all-cause OP, ED and pharmacy costs. CONCLUSIONS: Pain and treatment intensity were both strongly associated with OA-related utilization but not consistently with all-cause utilization. Our results provide promising evidence of better criteria and approaches for predicting disease burden and costs in the future.

Evaluation of a Web-Based Medication Reconciliation Application Within a Primary Care Setting: Cluster-Randomized Controlled Trial.

BACKGROUND: Despite routine review of medication lists during patient encounters, patients' medication lists are often incomplete and not reflective of actual medication use. Contributing to this situation is the challenge of reconciling medication information from existing health records, along with external locations (eg, pharmacies, other provider/hospital records, and care facilities) and patient-reported use. Advances in the interoperability and digital collection of information provides a foundation for integration of these once disparate information sources. OBJECTIVE: We aim to evaluate the effectiveness of and satisfaction with an electronic health record (EHR)-integrated web-based medication reconciliation application, MedTrue (MT). METHODS: We conducted a cluster-randomized controlled trial of MT in 6 primary care clinics within an integrated health care delivery system. Our primary outcome was medication list accuracy, as determined by a pharmacist-collected best-possible medication history (BPMH). Patient and staff perspectives were evaluated through surveys and semistructured interviews. RESULTS: Overall, 224 patients were recruited and underwent a BPMH with the pharmacist (n=118 [52.7%] usual care [UC], n=106 [47.3%] MT). For our primary outcome of medication list accuracy, 8 (7.5%) patients in the MT arm and 9 (7.6%) in the UC arm had 0 discrepancies (odds ratio=1.01, 95% CI 0.38-2.72, P=.98). The most common discrepancy identified was patients reporting no longer taking a medication (UC mean 2.48 vs MT mean 2.58, P=.21). Patients found MT easy to use and on average would highly recommend MT (average net promoter score=8/10). Staff found MT beneficial but difficult to implement. CONCLUSIONS: The use of a web-based application integrated into the EHR which combines EHR, patient-reported data, and pharmacy-dispensed data did not improve medication list accuracy among a population of primary care patients compared to UC but was well received by patients. Future studies should address the limitations of the current application and assess whether improved implementation strategies would impact the effectiveness of the application.

A mixed methods evaluation of medication reconciliation in the primary care setting.

OBJECTIVES: To understand the extent to which behaviors consistent with high quality medication reconciliation occurred in primary care settings and explore barriers to high quality medication reconciliation. DESIGN: Fully mixed sequential equal status design including ethnographic observations, semi-structured interviews, and surveys. SETTING: Primary care practices within an integrated healthcare delivery system in the United States. PARTICIPANTS: We conducted 170 observations of patient encounters across 15 primary care clinics, 48 semi-structured interviews with staff, and 10 semi-structured interviews with patients. We also sent out surveys to 2,541 eligible staff with 616 responses (24% response rate) and to 5,132 eligible patients with 577 responses (11% response rate). RESULTS: Inconsistency emerged as a major barrier to effective medication reconciliation. This inconsistency was present across a variety of factors such as the lack of standardized workflows for conducting medication reconciliation, a lack of knowledge about medication and the process of medication reconciliation, varying levels of importance ascribed to medication reconciliation, and inadequate integration of medication reconciliation into clinical workflows. Findings were generally consistent across all data collection methods. CONCLUSION: We have identified several barriers which impact the process of medication reconciliation in primary care settings. Our key finding is that the process of medication reconciliation is plagued by inconsistencies which contribute to inaccurate medication lists. These inconsistencies can be broken down into several categories (standardization, knowledge, importance, and inadequate integration) which can be targets for future studies and interventions.

Informing collaborative relationships between community pharmacists and health care professionals in primary care practices.

BACKGROUND: Collaborative relationships between community pharmacists and health care professionals in primary care practices can assist with the provision of medication and disease management services in community pharmacy settings. OBJECTIVES: The objective was to describe the attitudes of providers working in primary care practices with on-site pharmacist collaborators to understand how to facilitate similar collaborations with pharmacists in community pharmacy settings. METHODS: This qualitative study was conducted among physicians, nurse practitioners, and nurses of 3 primary care practice sites in the Commonwealth of Pennsylvania. A demographic survey and a semistructured interview were conducted to elicit feedback on participant perceptions about building relationships with community pharmacists. Interviews were audio-recorded and transcribed. A qualitative analysis was performed to identify emerging themes using an inductive approach. Demographic data were summarized using descriptive statistics. This study was approved by the University's Institutional Review Board. RESULTS: Nineteen interviews were conducted. Fifty-eight percent of participants were physicians and 68% were female with a mean age of approximately 46 years. Five themes were identified: (1) Pharmacists were highly valued and were effective team members to promote coordination of medication-related care; (2) Direct access to pharmacists facilitates efficient communication and effective patient care; (3) Trust is the foundation of an effective collaboration between pharmacists and providers; (4) Pharmacists demonstrating responsibility for patients enables collaboration with providers who view themselves as stewards of patient care; and (5) Providers believe that community pharmacists' dispensing requirements may limit their ability to participate in patient care. CONCLUSIONS: The following strategies to establish relationships with primary care practices are suggested: pharmacists should initiate face-to-face relationships with providers in practices; communication and patient interventions should be conveyed directly to providers and be conducted by the same person; and pharmacists need to demonstrate their commitment to patient care by following up promptly on patient interventions.

A mixed methods evaluation of the implementation of pharmacy services within a team-based at-home care program.

BACKGROUND: Sub-optimal medication use results in significant avoidable morbidity, mortality, and costs. Programs, such as comprehensive medication management (CMM), can help to optimize medication use, improve outcomes, and reduce costs. However, implementing programs like CMM can be challenging and differences in how CMM has been implemented may be responsible for observed heterogeneity in the outcomes associated with CMM. OBJECTIVE(S): Describe the implementation strategies utilized in implementing CMM telephonically within a team-based at-home care program and evaluate the implementation process. METHODS: The implementation of CMM was facilitated using various implementation strategies including: develop educational material and conduct training, change record system, audit and feedback, learning collaborative, quality monitoring, readiness assessment, and implementation team formation. The impact of these strategies as well as pharmacist and team member perspectives on the implementation of CMM were examined using mixed methods and guided by Proctor's conceptual model for implementation. RESULTS: The pharmacists felt that most of the implementation strategies used to facilitate consistent delivery of CMM were useful, but were unable to successfully implement all of them. Despite this, significant increases in fidelity to steps of the patient care process was achieved. The pharmacists felt that CMM was acceptable, appropriate for patient population, and feasible, but barriers (e.g., the telephonic and remote nature of the practice, the evolving nature of the program, and the difficulty in coordinating care between the patients primary care team and the care team affiliated with the program) affected the feasibility and organizational fit of CMM within this team-based, at-home care program. General pharmacy services, however, were seen as acceptable, appropriate, and feasible. CONCLUSION: Deliberately designing and utilizing a variety of implementation strategies can facilitate the implementation of CMM and significantly increase fidelity to the patient care process. To improve feasibility and organizational fit of CMM, additional barriers and challenges need to be addressed.

The impact of community pharmacist involvement on transitions of care: A systematic review and meta-analysis.

OBJECTIVES: To evaluate the impact of community pharmacist involvement on transitions of care, specifically on 30-day hospital readmissions. DATA SOURCES: We searched the following databases from inception to August 2018: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, ProQuest Health and Medical Collection, ProQuest Nursing and Allied Health Database, and Web of Science. We also searched clinical trials registries and personal files to identify additional studies. STUDY SELECTION: Studies were eligible if the intervention included community pharmacists and patients were being discharged from the hospital to home. We included reports of randomized controlled trials, nonrandomized controlled trials, controlled before-and-after studies, and interrupted time series published in English. DATA EXTRACTION: We extracted intervention characteristics from each study and 30-day readmissions when present. RESULTS: From 744 abstracts that met our inclusion criteria, we included 39 articles describing 36 unique studies, 10 which contributed to the primary outcome of 30-day readmissions. Overall, community pharmacist involvement in transitions of care was associated with a non-statistically significant 28% reduction in 30-day readmissions (relative risk [RR], 0.72; 95% CI 0.50-1.02; I2 = 82%). When using per protocol data, community pharmacist involvement in transitions of care was associated with a statistically significant 40% reduction in 30-day readmissions (RR, 0.60; 95% CI 0.41-0.88; I2 = 77%). Studies with more active involvement of community pharmacists had a greater effect on 30-day readmissions (RR, 0.55; 95% CI 0.32-0.95; I2 = 88%) than those with less active involvement did (RR, 1.02; 95% CI 0.80-1.31; I2 = 0%). CONCLUSION: Our review shows that community pharmacists can have a beneficial effect on patients' transitions of care; however, the body of evidence is limited by the heterogeneity and imprecision. Future studies should test interventions in which community pharmacists play an integral part and ensure that interventions are completed with fidelity.

Community Pharmacists' Perceptions of Care Following the Implementation of a Transitions-of-Care Program.

BACKGROUND: Pharmacist-led collaborative interventions can support improved medication use and adherence during transitions of care (TOC). Community pharmacists are not always actively connected with other health-care team professionals, however, and their confidence in having necessary information may vary. OBJECTIVE: To assess community pharmacists' perceptions of information, care provided, and communication, before and after a postdischarge intervention designed to increase communication between inpatient and community pharmacists. METHODS: A survey assessing 4 domains related to pharmacists' perceptions of information and care of hospital discharge patients was developed and distributed to 106 community pharmacists before and after a TOC interventional study. RESULTS: Based on 151 responses (77 baseline, 74 followup) from 84 participants, community pharmacists have high confidence in their ability to counsel and feel that they are an important part of the healthcare team. They are less confident that they have adequate information about patients and report gaps in having adequate support and resources to provide care. When a TOC intervention was implemented, there was significant improvement in community pharmacists' feeling of having adequate information about the patients. CONCLUSION: Not having adequate information regarding patients discharged from the hospital is an area of concern for community pharmacists and a modifiable opportunity to improve TOCs.

Associations of Opioid Prescriptions with Death and Hospitalization across the Spectrum of Estimated GFR.

BACKGROUND AND OBJECTIVES: Most opioids undergo kidney excretion. The goal of this study was to evaluate opioid-associated risks of death and hospitalization across the range of eGFR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The study population included adult primary care patients in Geisinger Health (Danville, PA) between 2008 and 2017. People receiving their first opioid prescription were propensity matched to people receiving NSAIDS (and, in sensitivity analysis, gabapentinoids) and the risk of death and hospitalization were compared, classifying opioid medication exposure as time-varying daily oral morphine milligram equivalents (MMEs) across time-varying eGFR. RESULTS: The propensity-matched cohort included 46,246 patients prescribed either opioids or NSAIDs between 2008 and 2017 (mean [SD] age, 54 [16] years; 56% female; 3% of black race). Prescriptions for 1-59 and ≥60 MMEs were associated with higher risk of death (HR, 1.70; 95% CI, 1.41 to 2.05 for 1-59 MMEs; HR, 2.25; 95% CI, 1.82 to 2.79 for ≥60 MMEs) and hospitalization (HR, 1.38; 95% CI, 1.30 to 1.46 for 1-59 MMEs; HR, 1.68; 95% CI, 1.56 to 1.81 for ≥60 MMEs) compared with NSAID prescriptions, when evaluated at eGFR 80 ml/min per 1.73 m2. The relative risk of death associated with ≥60 MMEs was higher at lower GFR (e.g., eGFR, 40 ml/min per 1.73 m2; HR, 3.94; 95% CI, 2.70 to 5.75; P for interaction, 0.01). When gabapentinoids were used as the comparison medication, only ≥60 MMEs were significantly associated with higher risk of death (HR, 2.72; 95% CI, 1.71 to 4.34), although both 1-59 and ≥60 MMEs were associated with risk of hospitalization (HR, 1.22; 95% CI, 1.04 to 1.43 for 1-59 MMEs; HR, 1.54; 95% CI, 1.28 to 1.86 for ≥60 MMEs). CONCLUSIONS: The receipt of prescription opioids was associated with a higher risk of death and hospitalization compared with other pain medications, particularly with higher doses and at lower eGFR.

Reductions in 30-day readmission, mortality, and costs with inpatient-to-community pharmacist follow-up.

OBJECTIVES: To determine the impact of pharmacist-provided continuous care and electronic communication on readmissions among a group of high-risk patients. DESIGN: Pragmatic interventional study with 5:1 matched control. SETTING AND PARTICIPANTS: Patients discharged from any of 4 hospitals with chronic obstructive pulmonary disease, pneumonia, heart failure, acute myocardial infarction, or diabetes within Pennsylvania. Patients in the intervention group received consultative services from inpatient pharmacists before discharge and inpatient-to-community pharmacist communication of hospitalization information facilitated with the use of a secure messaging system. After discharge, patients received up to 5 in-person or telephonic medication management consultations with their community pharmacists. MAIN OUTCOME MEASURES: The principal end point was 30-day readmission. Secondary end points included time to event (readmission, emergency department [ED] visit, death, or composite of hospitalization, ED, or death) over 90 days after discharge. Financial feasibility and sustainability were also assessed with the use of a return-on-investment (ROI) model based on information within the subset of patients with health plan coverage. RESULTS: Among patients who received inpatient intervention plus consultation with community pharmacists compared with matched control patients, we observed a lower 30-day readmission rate (9% vs. 15%, respectively; P = 0.02), 30-day all-cause mortality (2% vs. 5%; P = 0.04), and composite 30-day end point of readmission, ED visit, or death (22% vs. 28%; P = 0.09). Differences between the groups diminished and no longer maintained statistical significance at 90 days. An estimated average ROI of 8.1 was also observed among the subset with health plan information (worst base case range 1.9-16.3). CONCLUSION: Connecting community pharmacists to inpatient pharmacists during the transitional hospital-to-home time frame is feasible and resulted in lower 30-day readmissions and significant ROI, that is, significant impact on health care utilization and total health care costs. Results of this study have broad implications for improving the care of high-risk patients moving from hospital to home, most notably in the engagement of community pharmacists after discharge to assure medication use and follow-up to reduce readmissions and total costs of care.

Impact of a pharmacist-led diabetes management on outcomes, utilization, and cost.

PURPOSE: Pharmacist-led medication therapy disease management (MTDM) has shown improvement in clinical outcomes in patients with certain chronic diseases. However, only limited data demonstrating the impact on health care utilization and cost of care are available. This study seeks to evaluate the impact of a pharmacist-led MTDM program on clinical surrogate outcomes, care utilization, and cost of care among patients with diabetes mellitus. METHODS: A retrospective cohort study was conducted by utilizing electronic health records and insurance claims data. Patients were identified between February 2011 and December 2014. Data were collected from Geisinger, a large integrated health care system located in Pennsylvania and southern New Jersey. A total of 5,500 patients with diabetes mellitus were identified; 2,750 were enrolled in MTDM and were 1-to-1 propensity score-matched to a comparison cohort not enrolled in a pharmacist-led MTDM program. RESULTS: There were no differences between groups in composite HbA1c, blood pressure, or low-density lipoprotein cholesterol goal attainment at 12 months (12% vs 12%, P=0.53). HbA1c goal was reached more frequently among patients without MTDM compared to those at 12 months (57% vs 51%, P<0.0001). There were no significant differences between the two cohorts in the attainment of blood pressure or low-density lipoprotein cholesterol goals at 12 months. MTDM was associated with reduced all-cause hospitalization rate (-19.6%; P=0.02) as well as increased primary care physician visits (18.5%; P<0.001) and lower average per-member-per-month medical cost (-13%, P=0.027). CONCLUSION: Despite the lack of impact on the clinical surrogate outcomes, MTDM was associated with lower cost of care and fewer hospitalizations, possibly facilitated by increased monitoring (ie, higher primary care utilization).