Opportunities to encourage mail order pharmacy delivery service use for diabetes prescriptions: a qualitative study.

BACKGROUND: Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional "brick and mortar" pharmacies to refill prescriptions. METHODS: We conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. RESULTS: A total of 28 diabetes patients participated. Participants' average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of 'Opportunity.' Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions. CONCLUSIONS: This study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems.

Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities.

PURPOSE OF REVIEW: Population care approaches for diabetes have the potential to improve the quality of care and decrease diabetes-related mortality and morbidity. Population care strategies are particularly relevant as accountable care organizations (ACOs), patient-centered medical homes (PCMH), and integrated delivery systems are increasingly focused on managing chronic disease care at the health system level. This review outlines the key elements of population care approaches for diabetes in the current health care environment. RECENT FINDINGS: Population care approaches proactively identify diabetes patients through disease registries and electronic health record data and utilize multidisciplinary care teams, personalized provider feedback, and decision support tools to target and care for patients at risk for poor outcomes. Existing evidence suggests that these strategies can improve care outcomes and potentially ameliorate existing race/ethnic disparities in health care. However, such strategies may be less effective for patients who are disengaged from the health care system. As population care for diabetes continues to evolve, future initiatives should consider ways to tailor population care to meet individual patient needs, while leveraging improvements in clinical information systems and care integration to optimally manage and prevent diabetes in the future.

Biochemical characterization of P4-ATPase mutations identified in patients with progressive familial intrahepatic cholestasis.

Mutations in the P4-ATPase ATP8B1 cause the inherited liver disease progressive familial intrahepatic cholestasis. Several of these mutations are located in conserved regions of the transmembrane domain associated with substrate binding and transport. Assays for P4-ATPase-mediated transport in living yeast cells were developed and used to characterize the specificity and kinetic parameters of this transport. Progressive familial intrahepatic cholestasis mutations were introduced into the yeast plasma membrane P4-ATPase Dnf2p, and the effect of these mutations on its catalysis of phospholipid transport were determined. The results of these measurements have implications for the basis of the disease and for the mechanism of phospholipid transit through the enzyme during the reaction cycle.

Improvements in access and care through the Affordable Care Act.

OBJECTIVES: To examine the impact of enrolling in a healthcare plan through the Affordable Care Act (ACA) healthcare exchanges on self-reported access to care. STUDY DESIGN: Cohort study using self-reported data of patients newly enrolled in Kaiser Permanente California and Kaiser Permanente Colorado through the ACA healthcare exchanges for coverage beginning January 1, 2014. METHODS: Baseline and follow-up surveys conducted via mail and telephone, with response rates of 45% and 51%, respectively. RESULTS: We found significant increases in the percentage of people who reported having a personal healthcare provider (59% vs 73%; P <.01) and significant decreases in those who reported delaying needed medical care due to costs (37% vs 25%; P <.01) before and after ACA enrollment. There was also a significant increase in the percentage of patients who reported receiving a flu shot during the prior year (41% vs 52%; P <.01). Among the people who reported having less than 4 months of healthcare coverage in 2013, these improvements were even more pronounced. This group also showed significant increases in the percentages who felt they had a place to go when they needed medical care (43% vs 56%; P <.01) and who reported they received advice to quit smoking or using tobacco (46% vs 72%; P <.05). CONCLUSIONS: These findings are an important addition to the evidence base that the ACA is improving the healthcare experience and reducing barriers due to costs for individuals obtaining insurance coverage through the healthcare exchanges.

Retention of sealants during orthodontic treatment: an in vitro comparison of two etching protocols.

OBJECTIVE: To test the retention of smooth-surface sealants bonded with different etching protocols against toothbrushing and, secondarily, to characterize the type and location of sealant loss. MATERIALS AND METHODS: Eighty-nine extracted human teeth were randomly assigned one of two etching protocols: 37% phosphoric acid etch (ETCH) or self-etching primer (SEP). Six specimens at a time were placed in a toothbrushing machine to simulate 4, 8, 12, and 24 months of toothbrush abrasion. Using black-light photographs of each specimen taken before and after brushing, four blinded coinvestigators determined new sealant loss, loss along the edge of an initial defect, and the location of sealant loss. RESULTS: Overall, there were significantly (P < .05) more teeth with sealant loss in the SEP group (38.6%) than in the ETCH group (15.5%). New loss of sealant was significantly (P < .05) more likely in the SEP group (27.2%) than in the ETCH group (2.2%). Of the teeth with new loss of sealant, all (100%) had loss at the edge, and 23% had progressive loss. There was no significant group difference in sealant loss from initial defects. Of the teeth that showed enlargement of initial defects, 91% had loss at the edge and 91% had progressive loss. CONCLUSIONS: Using SEP to apply facial sealants results in lower retention rates than using ETCH. The vast majority of sealant loss occurs at the edges. Loss of sealant due to enlargement of an initial defect is highly progressive over time.