Impact of drug utilization management policy on prescription opioid use in Georgia Medicaid.

OBJECTIVE: To examine the effectiveness of changes in opioid prescription policies on opioid prescribing and health services utilization rates in Georgia Medicaid. METHODS: This study used data from the Georgia Medicaid patient enrollment, medical and pharmacy claims database from 2009 to 2014.We performed an interrupted time series analysis to examine the effect of the policy changes. Outcome measures assessed the trends in the indicators of potential inappropriate prescribing practices, including overlapping prescriptions of opioid + opioid, opioid + benzodiazepine and opioids + buprenorphine/naloxone, as well as health services utilization, including hospitalization, mean length of stay, outpatient office and emergency room visits. KEY FINDINGS: A total of 712 342 opioid users aged 18-64 were included in the study. The policies were associated with significant decreasing trend of opioid + opioid (-0.0011; 95% CI = -0.0020, -0.0002) and opioid + benzodiazepines (-0.001; 95% CI = -0.0022, -0.0006) overlapping while associated with a significant immediate decrease in and opioids + buprenorphine/naloxone after the implementations (-0.0014; 95% CI = -0.0025, -0.0003). Significant immediate decrease in level of office visits and ER visits were seen with the policy implementation (office visit: -0.2939; 95% CI = -0.5528, -0.0350, ER visit: -0.0740, 95% CI = -0.1294, -0.0185). The policies were not shown to be significantly associated with hospitalization and the mean length of inpatient stay. CONCLUSIONS: Our analysis suggests that Georgia Medicaid opioid policies were useful to contain inappropriate opioid use.

Deaths among opioid users: impact of potential inappropriate prescribing practices.

OBJECTIVES: To examine the association between potential inappropriate prescribing practices of opioids and deaths among opioid users in the Georgia Medicaid population. STUDY DESIGN: A retrospective analysis of individual pharmacy claims data from Georgia Medicaid from 2009 through 2014. METHODS: The sample was restricted to patients without cancer aged 18 to 64 years with an opioid prescription and included 3,562,227 observations representing 401,488 individuals. A descriptive analysis and a multivariate logistic regression analysis were conducted. RESULTS: Results indicate a total of 14,516 deaths among opioid users in the study sample, of whom approximately 42% experienced at least 1 incidence of potential inappropriate prescribing practices. Regression results indicate that the odds of opioid users experiencing death were 1.76 times higher for those who experienced at least 1 incidence of potential inappropriate prescribing practices of opioids compared with those who did not experience any incidence, even after controlling for other covariates (P <.001). Moreover, opioid users in managed care Medicaid were less likely to experience death compared with fee-for-service (FFS) enrollees. CONCLUSIONS: The results indicate a positive and statistically significant association between potential inappropriate opioid prescribing practices and deaths among opioid users in Georgia Medicaid, with FFS enrollees experiencing higher rates of death compared with managed care enrollees. Appropriate policies and interventions targeted at reducing potential inappropriate prescribing practices may help reduce the risk factors associated with mortality among opioid users in this population.

Evaluation of affective domain elements in a new pharmacy practice course.

INTRODUCTION: In 2016, new Accreditation Standards were implemented that required integration of affective domain elements (ADEs) into the Doctor of Pharmacy (PharmD) curriculum and admissions interview process. The purpose of this study is to analyze the relationship between admissions variables and performance in a new course, and to analyze the relationship between student self-assessment and faculty evaluation of their development and performance in ADEs. METHODS: Pre-pharmacy admission variables were evaluated for correlations with student performance in ADEs. Student self-assessments and faculty evaluations of performance in ADEs were also analyzed. RESULTS: Statistically significant positive correlations were found between student age and completion of at least a bachelor's degree with student self-assessment in communication and leadership. When evaluating faculty assessment, significant positive correlations were found for female performance in the areas of leadership and team readiness. There was a positive association between the Pharmacy College Admission Test (PCAT) quantitative score and performance in professionalism; while negative associations were seen between the PCAT comprehensive score and student self-assessment in self-awareness and professionalism, and between the PCAT quantitative score and student self-assessment in self-awareness (p < 0.05 for all). Median evaluation ranks by faculty members were significantly lower than the median self-evaluation ranks done by students. DISCUSSION AND CONCLUSION: This study suggests careful analysis of admissions variables in relation to ADEs may offer PharmD programs insight into how they design educational activities related to the affective domain. Additionally, evaluating multiple observations by both students and faculty members may identify patterns of growth and development in ADEs.

A Systematic Review of Patient-Reported Satisfaction with Oral Medication Therapy in Patients with Type 2 Diabetes.

OBJECTIVE: To provide a comprehensive comparative evaluation of the psychometric properties of satisfaction with medication surveys used for patients with type 2 diabetes (T2D) in clinical trials. METHODS: Instruments identified through a comprehensive literature search were evaluated based on the following criteria: disease specificity, peer-reviewed publication (administered in English in patients with T2D on oral therapy), and availability of psychometric properties. RESULTS: Eight instruments (Diabetes Medication Satisfaction [DiabMedSat]; Diabetes Treatment Satisfaction Questionnaire, status version [DTSQs]; Diabetes Medication System Rating Questionnaire [DMSRQ]; Diabetes Medication System Rating Questionnaire-Short Form [DMSRQ-SF]; Diabetes Tablet Treatment Questionnaire [DTTQ]; Perceptions About Medications for Diabetes [PAM-D]; Satisfaction with Oral Anti-Diabetic Agent Scale [SOADAS]; Diabetes Medication Satisfaction Tool [DMSAT]) were included in the study based on the predefined inclusion criteria. Seven of the instruments (all but DTTQ) utilized patients in the survey development process. All eight instruments could be completed within 15 minutes and thus were considered practical. DiabMedSat, DMSRQ, and DMSRQ-SF encompassed broader aspects of satisfaction than the other instruments. All of the instruments reviewed showed substantial floor or ceiling effects, except for DMSAT and DiabMedSat, without complete information. The DMSRQ and DMSRQ-SF each satisfied the criteria for reliability. DiabMedSat, DTSQs, DMSRQ, DMSRQ-SF, SOADAS, and DMSAT showed favorable convergent and discriminant validity. All of the instruments except DTTQ were determined to satisfactorily meet the criteria of responsiveness. CONCLUSION: Although it is up to researchers to decide which instrument to use according to the resources available and specific aims of their studies, DMSRQ and DSMRQ-SF were recommended based on the evaluative criteria employed in this study.

Opioid Analgesics in Georgia Medicaid: Trends in Potential Inappropriate Prescribing Practices by Demographic Characteristics, 2009-2014.

BACKGROUND: There has been a dramatic rise in the number of opioid prescriptions and opioid overdose deaths in the United States over the past 15 years. Misuse and abuse of opioids is also a growing public health concern in the United States. Medicaid enrollees are more likely to be prescribed opioids and are at higher risk of prescription drug overdose compared with non-Medicaid populations. Despite rising opioid drug overdose deaths in Georgia, prevalence of indicators for potential inappropriate prescribing practices has not been examined to date. OBJECTIVE: To examine trends in the general use of opioids and the prevalence of indicators for potential inappropriate opioid prescribing among the Georgia Medicaid population across various demographic characteristics over time. METHODS: This study used data from the Georgia individual Medicaid pharmacy claims database from 2009 to 2014. Data sample included 3,562,227 observations (patient prescriptions) representing 401,488 individuals. Outcome measures assessed the trends in the general use of opioids and the indicators of potential inappropriate prescribing practices by providers. These outcome measures were taken from previous expert panels and clinical guidelines (e.g., overlapping prescriptions of opioids, opioids and benzodiazepines, and opioids and buprenorphine/naloxone, as well as high daily doses of opioids). Analyses were stratified by gender, type of insurance (fee-for-service and managed care), age, and race/ethnicity. RESULTS: The average number of opioid prescriptions, average days supply of opioids per patient, and average daily dose of opioids per patient increased over time across all demographic categories with older, fee-for-service, male, and missing race groups experiencing higher use across all 6 years compared with their counterparts. A similar pattern was observed for average number of incidences of potential inappropriate prescribing of opioids in this population from 2009 to 2014. The percentage of Medicaid enrollees with at least 1 or more indicators of potential inappropriate prescriptions slightly increased from 17.17% to 18.21% during the study time frame. Moreover, the incidence rate of indicators for potential inappropriate prescribing of opioids also increased over time across all demographic groups, with the oldest age group (55-64 years) experiencing the largest increment. The incidence rate of potential inappropriate prescribing practices per patient increased more than 58% over the 6 years. CONCLUSIONS: The results of this study show that potentially inappropriate prescribing practices are common and are increasing over time in the Georgia Medicaid population across all demographic categories, with individuals who are listed in the missing race category, have fee-for-service plans, and are older experiencing the largest increments. These findings indicate that patients in certain demographic groups could be at higher risk for experiencing adverse health outcomes related to inappropriate prescribing of opioids. Further research is needed to explore which policy tools or interventions might be more effective in reducing inappropriate prescribing practices in this population. DISCLOSURES: This research was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R01DA039930 and the Georgia Department of Community Health, contract number 2015012. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Georgia Department of Community Health. The authors have nothing to disclose. A previous version of this paper was presented at the following conferences: International Health Economics Association 12th World Congress; July 8-11, 2017; Boston, MA, and Addiction Health Services Research Conference; October 18-20, 2017; Madison, WI.

Opioids in Georgia Medicaid: Gender and Insurance Disparities in Utilization and Potential Inappropriate Prescribing Practices.

OBJECTIVES: Medicaid populations have been disproportionately affected by the opioid epidemic. In Georgia, opioid deaths have increased at more than twice the rate of the nation at large. It is unknown if certain populations within the Medicaid unduly receive opioid prescriptions or experience inappropriate prescribing of opioids. Thus, this study examines gender and insurance disparities in the use of opioids and the prevalence of indicators for potential inappropriate prescribing of opioids in the Georgia Medicaid population. METHODS: Using individual Georgia Medicaid pharmacy claims data from 2012, disparities across gender (male/female) and type of insurance (fee-for-service (FFS)/managed care (MC)) were examined for the general use of opioids and potential inappropriate prescribing practices by providers. These outcome measures were taken from previous clinical guidelines and expert panels. T-tests were conducted to estimate significance in disparities across gender and type of insurance. KEY FINDINGS: Average number of opioid prescriptions received and average days of supply of opioids were higher among males than females (p<0.001), and among FFS patients than MC patients (p<0.001). Similarly, average incidences of potential inappropriate prescribing of opioids were higher among males (1.41) than females (0.83) (p<0.001), and among FFS patients (1.60) than MC patients (0.46) (p<0.001). CONCLUSIONS: Results indicate statistically significant disparities among male/female patients and FFS/MC patients in the general use of opioids and in potential inappropriate prescribing of opioids. Policies aimed at curbing potential inappropriate prescribing of opioids, especially among male and FFS enrollees are needed to reduce prescription drug abuse within this population.

Patient, Physician, and Health-System Factors Influencing the Quality of Antidepressant and Sedative Prescribing for Older, Community-Dwelling Adults.

OBJECTIVE: To identify determinants of potentially inappropriate (PI) antidepressant and anxiolytic/sedative prescribing for older, community-dwelling adults. DATA SOURCES/STUDY SETTING: Office visits from the 2010 National Ambulatory Medical Care Survey. STUDY DESIGN: A cross-sectional study measuring associations between various patient and physician factors and prescribing of PI antidepressants, and PI sedatives among elderly, using Beers 2012/2015 criteria, a clinical decision model, and multivariate logistic regressions. DATA COLLECTION: Visits by older adults (≥65 years) involving medications were extracted to identify visits with antidepressants and sedatives. PRINCIPAL FINDINGS: Black race, asthma, depression, osteoporosis, payment type, consultation time, and computer systems with prescribing support were associated with reduced odds of PI antidepressant prescribing among users. Income, chronic renal failure, diabetes, and obesity were associated with reduced odds of PI sedative prescribing. Female sex, white race, depression, increasing number of medications, and physician specialty were associated with increased odds of PI sedative prescribing. CONCLUSIONS: Various patient and health-system factors influence the quality of antidepressant and sedative prescribing for older community-dwelling adults. Longer consultations and the use of computer systems with prescribing support may minimize potentially inappropriate antidepressant prescribing. As medication numbers increase, exposure to PI sedatives is more likely, requiring medication review and monitoring.

Impact of Animated Spokes-Characters in Print Direct-to-Consumer Prescription Drug Advertising: An Elaboration Likelihood Model Approach.

A randomized, posttest-only online survey study of adult U.S. consumers determined the advertising effectiveness (attitude toward ad, brand, company, spokes-characters, attention paid to the ad, drug inquiry intention, and perceived product risk) of animated spokes-characters in print direct-to-consumer (DTC) advertising of prescription drugs and the moderating effects of consumers' involvement. Consumers' responses (n = 490) were recorded for animated versus nonanimated (human) spokes-characters in a fictitious DTC ad. Guided by the elaboration likelihood model, data were analyzed using a 2 (spokes-character type: animated/human) × 2 (involvement: high/low) factorial multivariate analysis of covariance (MANCOVA). The MANCOVA indicated significant main effects of spokes-character type and involvement on the dependent variables after controlling for covariate effects. Of the several ad effectiveness variables, consumers only differed on their attitude toward the spokes-characters between the two spokes-character types (specifically, more favorable attitudes toward the human spokes-character). Apart from perceived product risk, high-involvement consumers reacted more favorably to the remaining ad effectiveness variables compared to the low-involvement consumers, and exhibited significantly stronger drug inquiry intentions during their next doctor visit. Further, the moderating effect of consumers' involvement was not observed (nonsignificant interaction effect between spokes-character type and involvement).

Substance Use Attitudes, Behaviors, Education and Prevention in Colleges of Pharmacy in the United States.

This review describes and summarizes student pharmacists' substance use behavior in the United States. Current literature indicates that there are problems with alcohol and other drug use among student pharmacists. Although researchers have found variations in the type and rate of reported substance use, significant proportions of student pharmacists were identified as being at high risk for substance use disorders (SUDs). Findings from this review suggest that pharmacy schools should encourage and stimulate more research in order to implement effective screening and early intervention programs in an effort to address this important student health issue.

Direct-to-consumer advertising of predictive genetic tests: a health belief model based examination of consumer response.

Direct-to-consumer (DTC) advertising of predictive genetic tests (PGTs) has added a new dimension to health advertising. This study used an online survey based on the health belief model framework to examine and more fully understand consumers' responses and behavioral intentions in response to a PGT DTC advertisement. Overall, consumers reported moderate intentions to talk with their doctor and seek more information about PGTs after advertisement exposure, though consumers did not seem ready to take the advertised test or engage in active information search. Those who perceived greater threat from the disease, however, had significantly greater behavioral intentions and information search behavior.

Consumer preferences for the predictive genetic test for Alzheimer disease.

The purpose of this study was to assess consumer preferences for predictive genetic testing for Alzheimer disease in the United States. A rating conjoint analysis was conducted using an anonymous online survey distributed by Qualtrics to a general population panel in April 2011 in the United States. The study design included three attributes: Accuracy (40%, 80%, and 100%), Treatment Availability (Cure is available/Drug for symptom relief but no cure), and Anonymity (Anonymous/Not anonymous). A total of 12 scenarios were used to elicit people's preference, assessed by an 11-point scale. The respondents also indicated their highest willingness-to-pay (WTP) for each scenario through open-ended questions. A total of 295 responses were collected over 4 days. The most important attribute for the aggregate model was Accuracy, contributing 64.73% to the preference rating. Treatment Availability and Anonymity contributed 20.72% and 14.59%, respectively, to the preference rating. The median WTP for the highest-rating scenario (Accuracy 100%, a cure is available, test result is anonymous) was $100 (mean = $276). The median WTP for the lowest-rating scenario (40% accuracy, no cure but drugs for symptom relief, not anonymous) was zero (mean = $34). The results of this study highlight attributes people find important when making the hypothetical decision to obtain an AD genetic test. These results should be of interests to policy makers, genetic test developers and health care providers.

Pharmacists' Roles in Post-September 11th Disasters: A Content Analysis of Pharmacy Literature.

PURPOSE: To characterize the roles pharmacists have assumed in disasters and clarify the types of roles and disasters that may be less well-documented in the pharmacy literature. METHODS: This research examines how balanced or equally proportioned role categories are in the pharmacy literature, whether pharmacy journals differ in the proportion of role categories reported, and whether journals significantly differ in the proportion of reported chemical, biological, radiological, nuclear (CBRN), and natural disasters. Data coding was performed solely by the lead author using Concordance (Harvard University, Cambridge, Massachusetts), a Web-based content analysis software, and Minitab(®) (version 15; Minitab, Inc; State College, Pennsylvania) for descriptive and inferential statistical analysis. Pharmacy journals publishing at least 2 articles about pharmacist disaster roles from September 11, 2001 to September 30, 2011 were used in the study and were available electronically. RESULTS: Chi-square analyses reveal significant differences in the weighted counts of roles, roles categorized by journal, and CBRN disasters categorized by journal. CONCLUSIONS: Data suggest that pharmacists may be prepared to respond to hurricanes and biological and chemical disasters in pharmaceutical supply and patient management roles. Future research should highlight efforts to prepare health systems for the effects of nuclear, radiological, and chemical disasters.

Medication (re)fill adherence measures derived from pharmacy claims data in older Americans: a review of the literature.

Medication nonadherence is a significant public health problem that affects the health and well-being of older Americans while burdening the US healthcare system. Pharmacy claims data have gained importance in deriving objective medication (re)fill adherence measures; however, little is known about application of such measures in older Americans. The objective of this study was to assess the types and characteristics of pharmacy claims-derived medication (re)fill adherence measures used in older Americans. A comprehensive literature search strategy was employed to identify all articles using pharmacy claims data to measure (re)fill adherence to prescription medications in older Americans aged 65+ years. Included were articles reporting original research studies conducted and published in the USA in English between 1 January 2000 and 1 November 2012. The basic search used multiple key terms indicating adherence, combined with the term "medication" and the term "pharmacy claims or administrative claims." Due to the variety of measure names used in the literature, a more specific search was added to repeat the basic search for 29 previously used medication (re)fill adherence measure names. Articles identified through the database search were manually reviewed to select only articles meeting the inclusion criteria. The search resulted in a total of 36 articles. Information on medication (re)fill measurements were extracted and summarized. The 36 articles used 20 differently named measures under the three main concepts: medication adherence, persistence, and discontinuation. Measures of medication adherence cumulatively assessed the proportion of time at which medications were (not) filled over a predefined observation period (e.g., medication possession ratio). Measures of medication persistence assessed the continuity of medication filling over a specified time period, while medication discontinuation measures focused on termination of medication (re)fills. Overall, almost two thirds of all identified articles used a single medication (re)fill adherence measure. Among them, 77 % used a medication possession measure. The term "medication possession ratio" (MPR) was used most frequently (65 %), followed by the "proportion of days covered" (PDC; 30 %). No single measure can be generally recommended for the use in older Americans. The challenges in using pharmacy claims-based medication (re)fill adherence measures in older Americans include a lack of consensus terminology and algorithms among measures of the same concepts, insufficient transparency of individual measure operationalization, and inadequate consideration of unique characteristics of the older population, such as temporary nursing home care. Although medication (re)fill adherence measures may be well suited for measuring medication adherence in older Americans, little guidance is available on how to use them in this population. Further efforts need to be given to the development and standardization of pharmacy claims-based medication (re)fill measures that are specifically tailored toward use in older Americans.

Impact of celebrity pitch in direct-to-consumer advertising of prescription drugs.

Online surveys were conducted to determine the impact of endorser credibility, endorser effectiveness, and consumers' involvement in direct-to-consumer advertising. In a randomized posttest only study, using the elaboration likelihood model, survey participants (U.S. adults) were either exposed to a fictitious prescription drug ad with a celebrity or a noncelebrity endorser. There was no significant difference in credibility and effectiveness between the celebrity and the noncelebrity endorser. High involvement consumers viewed the ad more favorably and exhibited significantly stronger drug inquiry intentions during their next doctor visit. Further, consumers' involvement did not moderate the effect of celebrity endorser.

Nonbranded or branded direct-to-consumer prescription drug advertising-which is more effective?

Recently, pharmaceutical manufacturers have increased the amount of nonbranded, disease-education focused, direct-to-consumer advertisements. A comparison to branded, product-specific, ads was examined through a series of survey questions measuring consumer attitudes and the role of involvement. Nonbranded ads compared favorably to branded ads and should remain a viable part of the marketing mix. Consumers' level of disease state involvement was the strongest determinant of attitudes overall and within the two ad groupings, as highly involved consumers had significantly more positives attitudes regarding the nonbranded ads. Regardless of involvement level, however, nonbranded ads maintained positive attitude levels.

Assessment of changes in utilization of health-care services after implementation of a prior authorization policy for atypical antipsychotic agents.

BACKGROUND: In 2004, the Georgia Medicaid program implemented a prior authorization (PA) policy for certain atypical antipsychotic agents, resulting in an average savings of $2.7 million per year. OBJECTIVE: To determine whether implementation of a PA policy for atypical antipsychotic drugs increased health-care utilization in the Georgia Medicaid program from July 2003 to April 2006. METHODS: A single cohort observational study employing segmented regression and time series analysis was conducted to determine health-care services utilization, including emergency department (ED) visits, outpatient office visits, hospital admissions, and length of stay (LOS). Study subjects included continuously eligible adult Georgia Medicaid recipients with a schizophrenia-related diagnosis and documented use of an atypical antipsychotic medication (N = 12,120). Where applicable, analysis of a noncontinuously eligible population was also performed to investigate disenrollment bias in study results. RESULTS: A significant decline in post-policy trend for the average number of ED visits (absolute difference -0.042 per member per month (PMPM); relative difference -20.92%) and average number of hospital admissions PMPM (absolute difference -0.010 PMPM; relative difference -22.27%) was observed at the end of the study period. Baseline and pre-policy trends were found to be significant predictors for both endpoints. Significant models were not identified for average outpatient office visits PMPM or average LOS per admission. CONCLUSIONS: In contrast to other published studies on PA for atypical antipsychotics, patient outcomes improved after the initiation of the policy. To the extent that medical utilization reflects patient health outcomes and health status, the results of this study indicate that the PA program has potentially improved the health of schizophrenic patients in Georgia and lowered program costs.

Consumers responses to coupons in direct-to-consumer advertising of prescription drugs.

A study was conducted to understand the influence of coupons and consumers' level of involvement in direct-to-consumer advertising. Consumers exposed to prescription drug advertising with a coupon had significantly more favorable ad and brand-related attitudes, and intention to inquire about the drug to their doctor. However, there was no significant difference in perceived product risk between consumers exposed to the ad with a coupon and consumers exposed to the ad without a coupon. Highly involved consumers had significantly more favorable ad, brand, and coupon-related attitudes, drug inquiry intention, and perceptions about the risks associated with the drug.