Medicare medication therapy Management: Beneficiary characteristics and utilization patterns in a national CMS Medicare fee-for-service sample (2013 to 2016).

BACKGROUND: The Medicare Medication Therapy Management (MTM) program has been available to eligible Medicare Part D beneficiaries since 2006, but research regarding program utilization and characterization is limited. OBJECTIVE: To describe enrollee and MTM program characteristics in a national sample of Medicare fee-for-service (FFS) beneficiaries (2013 to 2016). METHODS: Using a 5% random sample of Medicare FFS beneficiaries, we conducted a descriptive time series analysis to examine annual MTM enrollment and describe the type of MTM criteria at enrollment (Center for Medicare and Medicaid Services [CMS] vs. expanded). We investigated the offer of Comprehensive Medication Review (CMR) along with CMR receipt status, and delivery characteristics, as well as frequencies of Target Medication Reviews (TMRs). RESULT: Beneficiaries who met CMS enrollment criteria, compared to those eligible under expanded criteria, were significantly older, more likely to be of white race, more likely to be female, and had a significantly higher number of comorbidities. Of those meeting CMS criteria, the proportion receiving TMR increased from 95% in 2013% to 98.1% in 2016, and over 97% were offered a CMR. Although the proportion of beneficiaries offered a CMR was stable over the study period, the proportion who received a CMR increased from 17% in 2013% to 35.4% in 2016. Telephone CMR delivery was the most common method used (87.8% to 89.1% of CMRs over the study period). Over 95% of the CMRs were delivered by a pharmacist. CONCLUSION: During the years 2013 to 2016, enrollment in the MTM program increased, as did the proportion of enrollees receiving TMRs and CMRs. However, uptake remained low and the main factors driving participation remain unclear. Significant differences in demographic characteristics between beneficiaries enrolled under the CMS MTM enrollment criteria and the expanded criteria suggest the need to further investigate the optimal provision of such programs.

Health care resource utilization in Medicare beneficiaries obtaining medication synchronization.

BACKGROUND: An appointment-based medication synchronization (ABMS) is a service whuch aligns patients' chronic medications to a predetermined routine pickup date and includes a comprehensive medication review or other clinical appointment at the pharmacy. OBJECTIVE(S): We compared healthcare utilization outcomes (outpatient, inpatient, emergency department visits, and pharmacy utilization) of Medicare beneficiaries enrolled in a med-sync program to beneficiaries not enrolled in such a program. METHODS: This retrospective cohort study included Medicare beneficiaries obtaining medications from pharmacies providing ABMS. All Medicare inpatient, outpatient, emergency, and pharmacy claims data from 2014 to 2016 obtained from the Research Data Assistance Center. These pharmacy claims were used to create med-sync (n = 13,193) and non-med-sync cohorts (n = 156,987). All patients were followed longitudinally for 12 months before and after a 2015 index or enrollment date. Baseline characteristics were used to create a logistic regression model for propensity score matching. A 1:1 greedy nearest neighbor matching algorithm was adapted for sequentially matching both cohorts. Difference in differences (DID) was used to compare mean changes in health care utilization outcomes (outpatient, inpatient, ED visits, and pharmacy utilization) between cohorts. RESULTS: After matching, 13,193 beneficiaries in each cohort were used for analysis. DIDs for mean of health care utilizations were statistically significantly lower in the med-sync cohort than the non-med-sync cohort for outpatient visits (DID 0.012, P = 0.0073) and pharmacy utilization (DID 0.013, P < 0.0001). There was not a statistically significant DID for inpatient and ED visits between cohorts. CONCLUSION: Outpatient and pharmacy utilization changes were statistically significantly lower in the med-sync cohort than the non-med-sync cohort in the 12 months after enrollment. Lower pharmacy utilization could be caused by reducing duplicate prescriptions during synchronized refills or optimization of therapy during medication reviews if patients are enrolled in appointment-based model med-sync.

Impact of health information exchange access on medication management recommendations in a community-based pharmacy setting.

BACKGROUND: Community-based pharmacists have historically lacked access to electronic medical records and clinical markers. Research was needed to assess the impact of obtaining clinical markers from a health information exchange (HIE) on pharmacist recommendations during a medication management encounter. OBJECTIVE: The objective of this project was to quantify and characterize clinical recommendations by pharmacists, resident pharmacists, or student pharmacists within an independent pharmacy setting that had access to patient information via an HIE. PRACTICE DESCRIPTION: Moose Pharmacy is one of few community pharmacies in North Carolina with access to a large health-system HIE. PRACTICE INNOVATION: This cohort study reviewed data over 4 months. Patients were identified for medication management based on filling eligible medications for atherosclerotic cardiovascular disease (ASCVD), hypertension, diabetes, dyslipidemia, or heart disease. Pharmacy personnel used the HIE to acquire laboratory test results. At the medication management appointment, the pharmacist collected blood pressure (BP), assessed smoking history, and medication or disease concerns. ASCVD risk score, statin therapy, A1c, and BP were assessed. Follow-up with the patient or provider was determined, if needed, and documented. EVALUATION METHODS: Collected records were reviewed to quantify the number and type of clinical recommendations made by the pharmacist, and their acceptance status by the prescriber. Descriptive analyses were used to analyze results. RESULTS: Thirty-four encounters were included. Most participants had diabetes (n = 21, 62%) and hypertension (n = 31, 91%). Nearly one-third of encounters (n = 11, 32%) resulted in a pharmacist recommendation. Recommendations were for BP dose adjustments (n = 4, 36%), diabetes medication changes (n = 3, 27%), and statin initiations/escalations (n = 4, 36%). Four recommendations (36%) were accepted, with 1 requiring modifications from the provider; 3 recommendations (27%) were declined; and 3 recommendations (27%) were unanswered. CONCLUSION: Access to progress notes and laboratory values using an HIE enhanced the pharmacist's ability to provide enhanced patient care recommendations during medication management consultations.

The Impact of Health Equity-Informed Eligibility Criteria to Increase the Delivery of Pharmacist-Delivered Comprehensive Medication Management Services for Patients with High Blood Pressure.

OBJECTIVE: Evaluate a cardiovascular care intervention intended to increase access to comprehensive medication management (CMM) pharmacy care and improve vascular health goals among socially disadvantaged patients. DESIGN: Retrospective electronic health records-based evaluation. SETTING: Thirteen health care clinics serving socially vulnerable neighborhoods within a large health system. PARTICIPANTS: Hypertensive and hyperlipidemic adult patients. INTERVENTION: CMM pharmacists increased recruitment among patients who met clinical criteria in clinics serving more diverse and socially vulnerable communities. CMM pharmacists partnered with patients to work toward meeting health goals through medication management and lifestyle modification. MAIN OUTCOME MEASURES: Changes in the engagement of socially disadvantaged patients between preintervention and intervention time periods; vascular health goals (ie, controlled blood pressure, appropriate statin and aspirin therapies, and tobacco nonuse); and the use of health system resources by CMM care group. RESULTS: The intervention indicated an overall shift in sociodemographics among patients receiving CMM care (fewer non-Hispanic Whites: N = 1988, 55.81% vs N = 2264, 59.97%, P < .001; greater place-based social vulnerability: N = 1354, 38.01% vs N = 1309, 34.68%, P = .03; more patients requiring interpreters: N = 776, 21.79% vs N = 698, 18.49%, P < .001) compared to the preintervention period. Among patients meeting intervention criteria, those who partnered with CMM pharmacists (N = 439) were more likely to connect with system resources (social work: N = 47, 10.71% vs 163, 3.74%, P < .001; medical specialists: N = 249, 56.72% vs N = 1989, 45.66%; P < .001) compared to those without CMM care (N = 4356). Intervention patients who partnered with CMM pharmacists were also more likely to meet blood pressure (N = 357, 81.32% vs N = 3317, 76.15%, P < .001) and statin goals (N = 397, 90.43% vs N = 3509, 80.56%, P < .001) compared to non-CMM patients. CONCLUSIONS: The demographics of patients receiving CMM became more diverse with the intervention, indicating improved access to CMM pharmacists. Cultivating relationships among patients with greater social disadvantage and cardiovascular disease and CMM pharmacists may improve health outcomes and connect patients to essential resources, thus potentially improving long-term cardiovascular outcomes.

The viral hepatitis B care cascade: A population-based comparison of immigrant groups.

BACKGROUND AND AIMS: The global burden of viral hepatitis B is substantial, and monitoring infections across the care cascade is important for elimination efforts. There is little information on care disparities by immigration status, and we aimed to quantify disease burden among immigrant subgroups. APPROACH AND RESULTS: In this population-based, retrospective cohort study, we used linked laboratory and health administrative records to describe the HBV care cascade in five distinct stages: (1) lifetime prevalence; (2) diagnosis; (3) engagement with care; (4) treatment initiation; and (5) treatment continuation. Infections were identified based on at least one reactive antigen or nucleic acid test, and lifetime prevalence was estimated as the sum of diagnosed and estimated undiagnosed cases. Care cascades were compared between long-term residents and immigrant groups, including subgroups born in hepatitis B endemic countries. Stratified analyses and multivariable Poisson regression were used to identify drivers for cascade progression. Between January 1997 and December 2014, 2,014,470 persons were included, 50,475 with infections, of whom 30,118 were engaged with care, 11,450 initiated treatment, and 6554 continued treatment >1 year. Lifetime prevalence was estimated as 163,309 (1.34%) overall, 115,722 (3.42%) among all immigrants, and 50,876 (9.37%) among those from highly endemic countries. Compared to long-term residents, immigrants were more likely to be diagnosed (adjusted rate ratio [aRR], 4.55; 95% CI, 4.46, 4.63), engaged with care (aRR, 1.07; 95% CI, 1.04, 1.09), and initiate treatment (aRR, 1.09; 95% CI, 1.03, 1.16). CONCLUSIONS: In conclusion, immigrants fared well compared to long-term residents along the care cascade, having higher rates of diagnosis and slightly better measures in subsequent cascade stages, although intensified screening efforts and better strategies to facilitate linkage to care are still needed.

Appropriate and Potentially Inappropriate Medication Use in Decompensated Cirrhosis.

BACKGROUND AND AIMS: Patients with decompensated cirrhosis are prescribed numerous medications. Data are limited as to whether patients are receiving medications they need and avoiding those they do not. We examined a large national claims database (2010-2015) to characterize the complete medication profile as well as the factors associated with appropriate and potentially inappropriate medication use in 12,621 patients with decompensated cirrhosis. APPROACH AND RESULTS: Clinical guidelines and existing literature were used to determine appropriate and potentially inappropriate medications in decompensated cirrhosis. The total medication days' supply was calculated from pharmacy data and divided by the follow-up period for each decompensation. Ascites was the most common (86.5%), followed by hepatic encephalopathy (HE; 37.8%), variceal bleeding (VB; 17.5%), hepatorenal syndrome (6.3%), and spontaneous bacterial peritonitis (SBP; 6.1%). For patients with ascites, 55.8% filled a diuretic. For patients with HE, 32.4% and 63.3% filled rifaximin and lactulose, respectively. After VB, 60.3% of patients filled a nonselective beta blocker, and after an episode of SBP, 48.0% of patients filled an antibiotic for prophylaxis. The minority (4.5%-17.3%) had enough medication to cover >50% follow-up days. Potentially inappropriate medication use was common: 53.2% filled an opiate, 46.0% proton pump inhibitors, 14.2% benzodiazepines, and 10.1% nonsteroidal anti-inflammatory drugs. Disease severity markers were associated with more appropriate mediation use but not consistently associated with less inappropriate medication use. CONCLUSIONS: Patients with decompensated cirrhosis are not filling indicated medications as often or as long as is recommended and are also filling medications that are potentially harmful. Future steps include integrating pharmacy records with medical records to obtain a complete medication list and counseling on medication use with patients at each visit.

Editor's Choice - Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials.

OBJECTIVE: Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed. METHODS: The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation. RESULTS: A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019). CONCLUSION: Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.

Clinical Benefit of Therapeutic Drug Monitoring in Colorectal Cancer Patients Who Received Fluorouracil-Based Chemotherapy.

BACKGROUND The impact of therapeutic drug management (TDM) on reducing toxicity and improving efficacy in colorectal cancer (CRC) patients receiving fluorouracil-based chemotherapy is still unclear. MATERIAL AND METHODS A total of 207 patients (Study Group n=54, Historical Group n=153) with metastatic colorectal cancer were enrolled. All of them received 6 administrations of the 5-FU based regimens. Initial 5-FU dosing of all patients was calculated using body surface area (BSA). In the Study Group, individual exposure during each cycle was measured using a nanoparticle immunoassay, and the 5-FU blood concentration was calculated using the area under the curve (AUC). We adjusted the 5-FU infusion dose of the next cycle based on the AUC data of the previous cycle to achieve the target of 20-30 mg×h/L. RESULTS In the fourth cycle, patients in the target concentration range (AUC mean, 26.3 mg×h/L; Median, 28 mg×h/L; Range, 14-38 mg×h/L; CV, 22.4%) accounted for 46.8% of all patients, which were more than the ones in the first cycle (P<0.001). 5-FU TDM significantly reduced the toxicity of chemotherapy and improved its efficacy. The Study Group (30/289) showed a lower percentage of severe adverse events than that in the Historical Group (185/447) (P<0.001). The incidences of complete response and partial response in the Study Group were higher than those in the Historical Group (P=0.032). CONCLUSIONS TDM in colorectal cancer can reduce toxicity, improve efficacy and clinical outcome, and can be routinely used in 5-FU-based chemotherapy.

The Impact of Dietary Modifications and Medical Management on 24-Hour Urinary Metabolic Profiles and the Status of Renal Stone Disease in Recurrent Stone Formers.

BACKGROUND: Dietary modifications and patient-tailored medical management are significant in controlling renal stone disease. Nevertheless, the literature regarding effectiveness is sparse. OBJECTIVES: To explore the impact of dietary modifications and medical management on 24-hour urinary metabolic profiles (UMP) and renal stone status in recurrent kidney stone formers. METHODS: We reviewed our prospective registry database of patients treated for nephrolithiasis. Data included age, sex, 24-hour UMP, and stone burden before treatment. Under individual treatment, patients were followed at 6-8 month intervals with repeat 24-hour UMP and radiographic images. Nephrolithiasis-related events (e.g., surgery, renal colic) were also recorded. We included patients with established long-term follow-up prior to the initiation of designated treatment, comparing individual nephrolithiasis status before and after treatment initiation. RESULTS: Inclusion criteria were met by 44 patients. Median age at treatment start was 60.5 (50.2-70.2) years. Male:Female ratio was 3.9:1. Median follow-up was 10 (6-25) years and 5 (3-6) years before and after initiation of medical and dietary treatment, respectively. Metabolic abnormalities detected included: hypocitraturia (95.5%), low urine volume (56.8%), hypercalciuria (45.5%), hyperoxaluria (40.9%), and hyperuricosuria (13.6%). Repeat 24-hour UMP under appropriate diet and medical treatment revealed a progressive increase in citrate levels compared to baseline and significantly decreased calcium levels (P = 0.001 and 0.03, respectively). A significant decrease was observed in stone burden (P = 0.001) and overall nephrolithiasis-related events. CONCLUSIONS: Dietary modifications and medical management significantly aid in correcting urinary metabolic abnormalities. Consequently, reduced nehprolithiasis-related events and better stone burden control is expected.

Treatment of HCV reduces viral hepatitis-associated liver-related mortality in patients: An ERCHIVES study.

BACKGROUND & AIMS: Treating HCV infection reduces overall mortality and reduces the risk of multiple extrahepatic complications. Whether the reduction in mortality is primarily due to a reduction in liver-related causes or extrahepatic complications is unknown. METHODS: We identified HCV-positive individuals treated for HCV, and propensity score-matched them to HCV-positive/untreated and HCV-uninfected individuals in ERCHIVES between 2002-2016. We extracted cause of death data from the National Center for Health Statistics' National Death Index. Viral hepatitis-associated liver-related mortality rates among treated and untreated HCV-infected persons were calculated by treatment and attainment of sustained virologic response (SVR). RESULTS: Among 50,674 HCV-positive/treated (Group A), 31,749 HCV-positive/untreated (Group B) and 73,526 HCV-uninfected persons (Group C), 8.6% in Group A, 35.0% in Group B, and 14.3% in Group C died. Among those who died, viral hepatitis-associated liver-related mortality rates per 100 patient-years (95% CI) were: 0.28 (0.27-0.30) for Group A; 1.44 (1.38-1.49) for Group B; and 0.06 (0.05-0.06) for Group C; (p <0.0001 for both comparisons). Among HCV-positive/treated persons, rates were 0.06 (0.05-0.06) for those with SVR vs. 0.78 (0.74-0.83) for those without SVR. In competing risks Cox proportional hazards analysis, treatment with all-oral DAA regimens (adjusted hazard ratio 0.11; 95% CI 0.09-0.14) and SVR (adjusted hazard ratio 0.10; 95% CI 0.08-0.11) were associated with reduced hazards of liver-related mortality. CONCLUSIONS: Treatment for HCV is associated with a significant reduction in viral hepatitis-associated liver-related mortality, which is particularly pronounced in those treated with DAA regimens and those who attain SVR. This may account for a significant proportion of the reduction in all-cause mortality reported in previous studies. LAY SUMMARY: Treating hepatitis C virus (HCV) infection is known to reduce overall mortality. However, whether the reduction in mortality is primarily due to a reduction in liver-related causes or extrahepatic complications was previously unknown. Herein, we show that while treating HCV with direct-acting antiviral regimens has numerous extrahepatic benefits, a significant benefit can be attributed specifically to the reduction in liver-related mortality.

Real world experience of poly (ADP-ribose) polymerase inhibitor use in a community oncology practice.

OBJECTIVE: This study aims to describe the real-world experience, including the clinical and financial burden, associated with PARP inhibitors in a large community oncology practice. METHODS: Retrospective chart review identified patients prescribed olaparib, niraparib or rucaparib for maintenance therapy or treatment of recurrent ovarian, primary peritoneal or fallopian tube cancer across twelve gynecologic oncologists between December 2016 and November 2018. Demographic, financial and clinical data were extracted. One PARP cycle was defined as a single 28-day period. For patients treated with more than one PARPi, each course was described separately. RESULTS: A total of 47 patients and 506 PARP cycles were identified (122 olaparib, 24%; 89 rucaparib, 18%; 294 niraparib, 58%). Incidence of grade ≥ 3 adverse events were similar to previously reported. Toxicity resulted in dose interruption, reduction and discontinuation in 69%, 63% and 29% respectively. Dose interruptions were most frequent for niraparib but resulted in fewer discontinuations (p-value 0.01). Mean duration of use was 7.46 cycles (olaparib 10.52, rucaparib 4.68, niraparib 7.34). Average cost of PARPi therapy was $8018 per cycle. A total of 711 phone calls were documented (call rate 1.4 calls/cycle) with the highest call volume required for care coordination, lab results and toxicity management. CONCLUSIONS: Although the toxicity profile was similar to randomized clinical trials, this real-world experience demonstrated more dose modifications and discontinuations for toxicity management than previously reported. Furthermore, the clinical and financial burden of PARP inhibitors may be significant and future studies should assess the impact on patient outcomes.

Impact of Automated Targeted Medication Review Electronic Alerts to Reduce Potentially Inappropriate Medication Prescribing Among Medicare Enrolled Patients With Dementia.

BACKGROUND: Background:Finding ways to reduce prescribing of potentially inappropriate medications (PIMs) among patients with dementia is necessary. OBJECTIVES: To evaluate an automated targeted medication review (TMR) service to reduce PIM prescribing among patients with dementia. METHODS: This was a retrospective observational analysis of patients in a Medication Therapy Management (MTM) program for year 2017. Patients included if Medicare enrolled, MTM eligible, had dementia, and with PIM prescribing. Descriptive statistics described reduced PIM prescribing. Odds ratios (ORs) assessed prescriber relationship with PIM prescribing. Regression evaluated relationship between patient characteristics and discontinued PIMs. RESULTS: A total of 33 696 TMRs were triggered for 17 933 patients. Four months later, 11 608 TMRs led to a discontinued PIM among 8002 patients. Medications with the largest discontinuations were antihistamines (56%), muscle relaxants (53%), antiemetics (53%), and typical antipsychotics (40%). Physician primary care providers (PCPs) were more likely than nonphysician PCPs (OR = 4.54; 95% CI = 4.15-4.97; P < 0.001), psychiatrists (OR = 1.64; 95%CI = 1.44-1.86; P < 0.001), and neurologists (OR = 4.48; 95% CI = 4.07-4.93; P < 0.001) to prescribe medications to treat dementia and PIMs. Regression showed that younger age, female gender, higher poverty level, and a greater number of pharmacies, medications, and prescribers were associated with discontinued PIMs. Conclusions and Relevance: TMRs were effective in reducing PIM prescribing. Younger patients, individuals living in higher poverty levels, and patients with multiple prescribers or pharmacies may benefit most from this service. TMRs in primary care offices may reduce PIM prescribing.

Management of adverse events with tailored sorafenib dosing prolongs survival of hepatocellular carcinoma patients.

BACKGROUND & AIMS: Sorafenib is associated with multiple adverse events (AEs), potentially causing its permanent interruption. It is unknown how physicians' experience has impacted on the management of these AEs and consequently on clinical outcomes. We aimed to assess whether AE management changed over time and if these modifications impacted on treatment duration and overall survival (OS). METHODS: We analysed the prospectively collected data of 338 consecutive patients who started sorafenib between January 2008 and December 2017 in 3 tertiary care centres in Italy. Patients were divided according to the starting date: Group A (2008-2012; n = 154), and Group B (2013-2017, n = 184). Baseline and follow-up data were compared. In the OS analysis, patients who received second-line treatments were censored when starting the new therapy. RESULTS: Baseline characteristics, AEs, and radiological response were consistent across groups. Patients in Group B received a lower median daily dose (425 vs. 568 mg/day, p <0.001) due to more frequent dose modifications. However, treatment duration was longer (5.8 vs. 4.1 months, p = 0.021) with a trend toward a higher cumulative dose in Group B. Notably, the OS was also higher (12.0 vs. 11.0 months, p = 0.003) with a sharp increase in the 2-year survival rate (28.1 vs. 18.4%, p = 0.003) in Group B. Multivariate time-dependent Cox regression analysis confirmed later period of treatment (2013-2017) as an independent predictor of survival (HR 0.728; 95%CI 0.581-0.937; p = 0.013). Unconsidered confounders were unlikely to affect these results at the sensitivity analysis. CONCLUSIONS: Experience in the management of sorafenib-related AEs prolongs treatment duration and survival. This factor should be considered in the design of future randomised clinical trials including a sorafenib treatment arm, as an underestimate of sample size may derive. LAY SUMMARY: Sorafenib has been the standard frontline systemic treatment for hepatocellular carcinoma for over a decade. Its tolerability is limited by different adverse events, which might lead to its permanent discontinuation in a sizeable proportion of patients. After a careful analysis of potential confounders, we demonstrated that the physicians' experience in managing adverse events related to sorafenib has improved over time, with longer treatment periods and less permanent discontinuation for toxicities. More importantly, these improvements also translated into longer patient survival. Our results have relevant repercussions in clinical practice and in the design of future clinical trials.

Association of diabetes treatment with long-term glycemic patterns in patients with type 2 diabetes mellitus: A prospective cohort study.

AIM: This study aimed to analyze diabetes treatment and treatment changes in association with long-term glycemic patterns in an Asian population with diabetes. MATERIALS AND METHODS: This was a prospective cohort study of 6218 patients with type 2 diabetes managed in public primary care clinics in Singapore. Clinical data from 2011 to 2016 were extracted from electronic medical records, including serial HbA1c measurements and dispensed antidiabetic medication records. Patterns of longitudinal HbA1c trajectories were identified using latent class growth analysis, and patients' annual treatment plans were compared between subgroups with different HbA1c patterns. RESULTS: We identified four distinct HbA1c patterns. Eighty-one percent of patients were classified in the low-stable group, where monotherapy and dual therapy with oral agents were the most common treatments. We also identified three groups with poorer control, with moderate-stable (14%), moderate-increase (3%), and high-decrease (2%) HbA1c patterns. Insulin treatment was most prevalent in these groups, with 61% to 72% of subjects receiving insulin treatment in 2016. More than 60% of subjects in poorer control groups had experienced treatment intensification during follow-up. Addition of multiple insulin injections was the most common intensification in moderate-increase and high-decrease groups. CONCLUSIONS: Treatment reflected and was appropriate to the extent of dysglycemia in this population. A small group of patients had deteriorating glycemic control, in spite of being treated with multiple insulin injections, suggesting non-response or non-adherence to treatment. Further investigation is needed to identify reasons for the deteriorating control observed and design effective interventions for these patients.

Non-dispensing pharmacists' actions and solutions of drug therapy problems among elderly polypharmacy patients in primary care.

OBJECTIVE: To evaluate the process of clinical medication review for elderly patients with polypharmacy performed by non-dispensing pharmacists embedded in general practice. The aim was to identify the number and type of drug therapy problems and to assess how and to what extent drug therapy problems were actually solved. METHOD: An observational cross-sectional study, conducted in nine general practices in the Netherlands between June 2014 and June 2015. On three pre-set dates, the non-dispensing pharmacists completed an online data form about the last 10 patients who completed all stages of clinical medication review. Outcomes were the type and number of drug therapy problems, the extent to which recommendations were implemented and the percentage of drug therapy problems that were eventually solved. Interventions were divided as either preventive (aimed at following prophylactic guidelines) or corrective (aimed at active patient problems). RESULTS: In total, 1292 drug therapy problems were identified among 270 patients, with a median of 5 (interquartile range 3) drug therapy problems per patient, mainly related to overtreatment (24%) and undertreatment (21%). The non-dispensing pharmacists most frequently recommended to stop medication (32%). Overall, 83% of the proposed recommendations were implemented; 57% were preventive, and 35% were corrective interventions (8% could not be assessed). Almost two-third (64%) of the corrective interventions actually solved the drug therapy problem. CONCLUSION: Non-dispensing pharmacists integrated in general practice identified a large number of drug therapy problems and successfully implemented a proportionally high number of recommendations that solved the majority of drug therapy problems.

Perception of asthma control among asthmatics seen inChest Clinic at Tertiary Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Patient awareness of asthma severity is important for optimal asthma management. However, there is often a discrepancy between physician assessment of asthma control based on guidelines and patient discernment of control. We compared physician and patient perception of asthma control in a clinic population seen at a tertiary hospital in Addis Ababa, Ethiopia. METHODS: In this cross-sectional study, 182 consecutive patients with a physician diagnosis of asthma seen in Chest Clinic at Tikur Anbessa Specialized Hospital (TASH) between July and December 2015 were studied. Demographics, asthma symptoms, medication use in the past month, and self-perception of asthma control in the past 7 days were obtained from the clinic records. Physician assessed asthma control was based on the GINA asthma symptom control assessment tool. Lung function was measured using a Diagnostic EasyOne Plus model 2001 SN spirometer. The institutional review board approved the study protocol. RESULTS: Of the 182 subjects, 68.1% were female. The mean age was 52 ± 12 years, and the mean (SD) duration of asthma was 19.4 ± 12.7 years. Forty-four (24.2%) patients had physician determined well-controlled asthma and 138 (75.8%) patients had physician determined partly controlled/uncontrolled asthma. One hundred and fifty-one (83%) patients thought their asthma control was good. However, the degree of concordance between physician evaluation and patient perception of asthma control was low (kappa index = 0.09). On multivariate analysis, self-perceived poor asthma control was associated with any activity limitation due to asthma and inconsistent inhaled corticosteroid use. CONCLUSION: In our study, the first of its kind in Ethiopia, a high percent of patients with physician determined well-controlled asthma has appropriate perception of their disease state. However, those patients with partly controlled/uncontrolled asthma had poor self-perception of their disease, emphasizing the need for further patient education. These conclusions may be especially useful in the care of asthmatics from other low-income countries.

Identifying Medication Management Confidence and Gaps in Training Among Community Health Workers in the United States.

Community Health Workers (CHWs) are a group of trained health professionals who advocate for members within their communities on social and health care issues. CHWs are increasingly utilized due to their affordability, accessibility, and ability to relate to patients. Evaluating CHW medication management practices, confidence, and training gaps may provide a better understanding of medication management training needs. The purpose of this cross-sectional survey was to assess CHW confidence in medication management, describe medication management services, and identify areas of focus to improve CHW medication management training. A 32-item survey was administered to CHWs in Idaho, Indiana, Nevada, and Oregon through their state's CHW email listservs. The survey content covered four domains: (1) demographic information, (2) work history, (3) experience with medication management and (4) CHW training including specific questions regarding medication management training. Two free-response questions assessed whether medication management training was beneficial and gathered suggestions for medication management-specific training. A total of 77 CHWs completed the survey of which, 90.9% were female, 38.9% worked as CHWs between 1 and 3 years, and 89.6% received instate CHW training. Over three-fourths of respondents (79.2%) provide medication management-related services and 57.1% rate their confidence in medication management as 'poor' or 'fair.' CHWs reported a need for additional medication management training within CHW certificate and continuing education programs. CHWs provide medication management services but have low confidence in their ability to provide such services. A greater emphasis on medication management training should be included in CHW certificate and continuing education programs.

Medication therapy problems and vaccine needs identified during initial appointment-based medication synchronization visits.

OBJECTIVE: To characterize medication therapy problems (MTPs) and vaccines recommended and administered by pharmacists during initial appointment-based medication synchronization (ABMS) visits, in a community pharmacy setting. METHODS: A retrospective observational study evaluated comprehensive medication reviews documented by pharmacists during initial ABMS visits in 16 supermarket chain pharmacies in Central Virginia from September to December 2017. The documentation was examined to obtain patient demographics, MTPs, and recommended and administered vaccines. Other data collected included disease states, number of medications synchronized per patient, and average time spent per initial ABMS visit. Classifications of MTPs were adherence (overuse and underuse), adverse drug reaction, cost-efficacy management, drug interactions (drug-drug/drug-disease), excessive dose/duration, needs additional therapy (for chronic conditions), suboptimal drug selection, and unnecessary therapy. Data were analyzed using descriptive statistics, and Wilcoxon-Mann-Whitney test was used to compare group differences. RESULTS: One hundred eighty-four patients received an initial ABMS visit (118 female and 66 male patients). The mean age was 70 years for women and 65 years for men, range 18 to 19 years (P < 0.08). Disease states documented included asthma, benign prostatic hyperplasia, chronic pain, epilepsy, depression, diabetes mellitus, dementia, gastroesophageal reflux disease, history of myocardial infarction, human immunodeficiency virus, hyperlipidemia, and hypertension. Women had a significantly higher number of disease states than men did (P < 0.03). Thirty-seven MTPs were identified with no statistical difference between men and women (P < 0.98). Pharmacists reported spending an average of 17 minutes with patients during the initial visit for an average of 6 medications synchronized per patient. Six hundred thirty-three vaccines were recommended, and 51 were administered. CONCLUSION: Initial ABMS visit with a comprehensive medication review facilitated pharmacists in detecting medication therapy problems. Although vaccines administered were lower than recommended, community pharmacists play an important role in preventive health through vaccine screenings and recommendations. Future plans include evaluating the outcomes of MTPs identified and resolved in the ABMS service.

Community pharmacists' lack of access to health records and its impact on targeted MTM interventions.

OBJECTIVES: To describe the adequacy of health record information available to community pharmacists when completing medication therapy management (MTM) interventions and to quantify the time spent on interventions that are ultimately revealed as invalid. METHODS: This prospective cross-sectional study analyzed cases of high-risk medication use in the elderly and statin use in persons with diabetes identified by 3 MTM platforms across 15 grocery chain pharmacies. MTM interventions were completed by phone and fax following a usual care protocol. Collected data included case validity (defined as the case truly requiring a pharmacist's involvement), case success (defined as achieving the targeted goal of the intervention), time spent on the intervention, and a determination of whether information from an electronic health record (EHR) could have eliminated patient or prescriber contact. RESULTS: Among 163 cases analyzed, 54% were found to be valid and 30% successful. The most common reasons for invalidity were allergy or contraindication, patient already taking a statin, and patient not having the targeted condition. Overall, 14% of cases were valid and successful, 40% valid and unsuccessful, 17% invalid and successful, and 29% invalid and unsuccessful. Valid successful cases averaged 15.3 minutes per case, valid unsuccessful cases averaged 9.2 minutes, invalid successful cases averaged 4.2 minutes, and invalid unsuccessful cases averaged 5.1 minutes. Based on the case-by-case determination of the researchers, EHR information would have completed 39% of cases without patient or prescriber contact. The average time spent on cases needing EHR access was 5.5 minutes, compared with 9.5 minutes for cases in which EHR access would not have helped. CONCLUSION: Community pharmacists performing MTM interventions are hindered by lack of access to patient health information, imprecise patient targeting by MTM platforms, and cumbersome communication between pharmacists and prescribers.

Consumer decision making for using comprehensive medication review services.

OBJECTIVES: To identify main factors associated with older adults' decision making for using a Medicare Part D comprehensive medication review (CMR) service. DESIGN: Cross-sectional self-administered mailed survey. SETTING AND PARTICIPANTS: The survey was conducted from December 2016 to February 2017. Sampled subjects were 1) at least 65 years of age, 2) taking at least 1 prescription medication, and 3) a Medicare Part D beneficiary living in Florida (n = 310), Washington (n = 310), Wisconsin (n = 310), or Pennsylvania (n = 310) or active members of an Iowa senior registry (n = 460). MAIN OUTCOME MEASURES: Responses to survey items assessing factors in the domains of internal need, external influences, perceived risks of using CMRs, and alternatives comparison that may affect older adults' decision to use CMRs. RESULTS: The overall completed response rate was 24% (n = 381). About 28% of respondents (n = 105) reported being a CMR recipient. Recommendations from a pharmacist (P < 0.0001) or a physician (P = 0.0350), pharmacist's communication in previous encounters (P = 0.0007), perceived susceptibility to medication-related problems (P < 0.0001), and positive outcome expectancy (P = 0.0147) were positively associated with consumers' decision to participate in CMRs, whereas perceived functional risk (P < 0.0001), access to general counseling in previous experiences (P = 0.0145), and family or friends' influence (P = 0.0065) were negatively associated factors. CONCLUSION: CMR uptake remains low after being available for years. Recommendations from health professionals and understanding of service benefits were identified as main factors affecting consumers' decision making for participating in CMRs. Policy makers could consider 1) seeking collaboration with community pharmacists and physicians and 2) addressing key components and benefits of CMRs in older adults as new promotion strategies.