Assessing the impact of a financial incentive and refill reminder program on medication adherence and costs.

BACKGROUND: Improving medication adherence remains an important goal to improve therapeutic outcomes and lower health care costs. Point-of-sale prescription costs and forgetfulness remain top reasons why patients do not adhere to medications. Programs using both text message-based reminders and financial incentives may encourage patients to refill their prescriptions on time by reducing copays through discounts at the point of sale. Sempre Health, the subject of our analysis, provides both text message refill reminders and a dynamic discount incentive program to improve medication adherence. OBJECTIVE: To evaluate the impact of a financial incentive/refill reminder program on medication adherence and total cost of care for patients taking the antithrombotic agents ticagrelor, apixaban, or rivaroxaban in a large regional health plan. METHODS: After propensity-score matching on demographics, socioeconomic status, baseline copay, prior pharmacy/medical spend, and morbidity, we compared-using a difference-in-differences analytic approach-adherence (measured by proportion of days covered), unplanned health care utilization, and costs (total cost of care, medical, and pharmacy cost) of health plan members who did and did not enroll in the financial incentive/refill reminder program between February 1, 2019, and October 31, 2021, over 1 and 2 years. Because of differences in patient characteristics, we analyzed patients on ticagrelor (the antiplatelet group), apixaban, and rivaroxaban (the anticoagulant group) separately. RESULTS: There were a total of 1,292 one-to-one program and control propensity-matched patients: 166 each for the antiplatelet group and 480 each for the anticoagulant group. The average age of the anticoagulant group was 62 years; more than 60% were male, and approximately 45% had no prior unplanned care events. In contrast, the average age of the antiplatelet group was 57 years; more than 70% were male, and approximately 21% had no prior unplanned care events. In the antiplatelet group, the proportions adherent (proportion of days covered ≥80%) were 63.3% vs 42.8% (P = 0.0002) for program vs controls. Similarly, in the anticoagulant group, the proportion adherent was 77.9% vs 60.2% (P < 0.0001) for program vs controls. Reflecting improved adherence, costs of apixaban and rivaroxaban increased by $79 per member per month (PMPM) (P < 0.0001), with no statistically significant differences in other costs. Similarly, the cost of ticagrelor increased by $77 PMPM (P = 0.0102) with no statistically significant differences in other costs. Finally, there was a 16% (P = 0.032) reduction in emergency department use for those in the program. CONCLUSIONS: The financial incentive and refill reminder program was associated with improved adherence to antithrombotic medications, reduced emergency department use, and increased medication costs, but not in total pharmacy, medical, or total cost of care in both subgroups.

Ticagrelor versus clopidogrel for recurrent myocardial infarction: An outcomes-based agreement.

Background: Outcomes-based agreements (OBA) are performance-based risk-sharing agreements between manufacturers and payers which provide the opportunity for collection and evaluation of real-world outcomes to supplement clinical trials. Objectives: To describe an OBA comparing ticagrelor to clopidogrel in patients admitted with acute coronary syndrome (ACS) and proportion of recurrent myocardial infarction (MI) in a real-world setting. Methods: Commercial (CM) and Medicare (MC) insurance patients of a large regional health plan, who presented with ACS and were prescribed either ticagrelor or clopidogrel were prospectively analyzed. The cohort consisted of adults (18-85 years) discharged between January 1, 2019, and December 31, 2020, who were adherent to the study medications, within the confines of the OBA. The primary outcome of interest was the proportion of recurrent MI hospitalizations within one year of discharge. Results: There were 500 patients who met inclusion criteria in the ticagrelor cohort and 648 in the clopidogrel cohort. The mean age of patients in the ticagrelor cohort was 61.5 ± 10.5 years old and 66.5 ± 10.2 years in the clopidogrel cohort. The proportion of patients with type 2 diabetes, hypertension, or a history of congestive heart failure at baseline in the ticagrelor cohort was 31%, 85%, 14% respectively, and 43%, 90%, and 32% respectively in the clopidogrel cohort. The overall proportion of hospitalization for recurrent MI was 1.00% in the ticagrelor and 3.13% in the clopidogrel cohorts. In the follow-up propensity-matched analysis, although recurrent MI hospitalization was higher in the clopidogrel cohort (1.69% vs 1.21%) it was not statistically significant (p-value 0.5242). Conclusion: Patients presenting with ACS and treated with ticagrelor had a lower rate of hospitalization for recurrent MI compared to patients treated with clopidogrel cohort within the confines of an OBA in a real-world setting.

Assessing the impact of adding pharmacist management services to an existing discharge planning program on 30-day readmissions.

BACKGROUND: Although hospital readmission rates are declining nationally, avoidable readmissions remain a public health concern. Effective readmission interventions are multifaceted and include discharge planning and transition-of-care coordination. Clinical pharmacists are effective contributors to these processes, bringing expertise to discharge counseling, medication reconciliation, medication adherence, and postdischarge follow-up counseling. OBJECTIVE: We evaluated the impact of adding health plan clinical pharmacy management services to an existing discharge program on all-cause readmissions and postdischarge primary physician visits. METHOD: Pharmacy management services by health plan clinical pharmacists of a large regional integrated delivery system were added to an existing optimal discharge planning (ODP) program. Criteria for eligibility for these pharmacists' services included patients who prescribed a new maintenance medication after discharge, received a therapeutic substitution, had a previous discharge within 30 days, or were taking a high-risk medication. A retrospective, observational analysis of a subgroup of patients, who received the pharmacy management services as part of ODP, was performed using a difference-in-difference model, by comparing propensity-matched discharges from February 22, 2016, to January 31, 2017 (preprogram implementation) with discharges from February 22, 2017, to January 31, 2018 (implementation period), to estimate changes in 30-day readmission rates and postdischarge primary physician visits. RESULTS: A total of 111 of the propensity matched received the pharmacy management services; of these, 73% (ODP) versus 64% (non-ODP) were ≥58 years, 60% were females, and 62% (ODP) versus 52% (non-ODP) were Medicare beneficiaries. There was a 16.7% (P = 0.022) statistically significant reduction in combined inpatient and observation 30-day readmissions and a 19.7% increase in 5-day postdischarge follow-up physician visits (P = 0.037) for the subgroup who also received the pharmacy management services. CONCLUSION: Addition of pharmacist management services to an existing hospital discharge program for select at-risk patients was associated with reduced inpatient and observation 30-day readmissions.

Using citizen science to engage the public in monitoring workplace breastfeeding support in Australia.

ISSUE ADDRESSED: Returning to work is a major barrier to continued breastfeeding. While many large organisations in Australia have policies to support breastfeeding and expressing at work, it is not known how these are implemented in practice, what support is available in smaller workplaces or to what extent workplace support meets the needs of breastfeeding mothers. METHODS: This pilot study trialled a citizen science approach where members of the public provided photographs and descriptions of breastfeeding facilities and support within their workplaces. The study was promoted through community networks and social media, and data were submitted via an online survey. Data were analysed inductively to identify key themes. RESULTS: Thirty-seven participants provided data on breastfeeding support in their workplace. Three key themes were identified: physical features and facilities; workplace culture; and organisational and occupational characteristics. There was considerable variation in workplace support and around half of the participants indicated that they had to use communal, poorly equipped and/or unhygienic spaces to breastfeed or express at work. CONCLUSION: While some employers have taken important steps towards supporting mothers to combine breastfeeding and work, there is room for improvement. Through this pilot study, we have demonstrated the feasibility and value of using a citizen science approach to obtain data from a range of workplaces along with perceptions of workplace characteristics that support or hinder breastfeeding and expressing at work. SO WHAT?: Citizen science is a useful approach to capturing data on workplace support for breastfeeding and could be scaled up to enable ongoing monitoring. The findings raise important issues around the interpretation and implementation of current legislation to support mothers in the workplace.

Economic assessment of changes to an existing medication therapy management program of a large regional health plan.

BACKGROUND: Although medication therapy management (MTM) has specific eligibility criteria and is mandated for specific Medicare Part D enrollees, some health plans have expanded MTM eligibility beyond the minimum criteria to include other Medicare Part D enrollees, Medicaid, and commercial health plan patients. Differences exist in the mode of delivery, location of services, type of personnel involved in managing the service, and the subsequent outcomes. The type and intensity of MTM services delivered have evolved with time to more streamlined and robust interventions, necessitating ongoing evaluation of the effect on clinical and economic outcomes. OBJECTIVE: To assess the effect of changes to an existing MTM program on cost of care, utilization, and medication adherence. METHODS: UPMC Health Plan made changes to an existing MTM program by expanding eligibility (customized by the type of health plan), intervention types, pharmacist involvement, and patient followup contacts. After matching our intervention cohort (identified January 2017-June 2018) with the pre-2016 MTM historical controls (patients identified January 2014-June 2015 who would have been eligible if we used the intervention cohort eligibility criteria), we estimated that the effect of the program changes with a difference-in-difference model (preintervention [2014-2016] and postintervention [2017-2019]). Outcomes of interest included cost (total cost of care including medical, pharmacy, and unplanned care [i.e., unscheduled health care use such as emergency department visits] in 2017 U.S. dollars); utilization; medication adherence (proportion of days covered); and return on investment (ROI). Target population included continuously enrolled patients aged ≥ 21 years in the commercial, Medicare, and Medicaid health plans. RESULTS: Total propensity score-matched members was 10,747, 55% of which were in the historic control group. The average (SD) ages after matching the groups were similar (historical control group: 57.08 years [14.23], intervention group: 56.79 years [14.21]) and the majority was female (57%). Comorbidities identified most for patients included hypertension (77%), dyslipidemia (70%), and diabetes (52%). Forty-one percent were in the commercial, 37% in the Medicaid, and 23% in the Medicare health plans. Proportion of care activities undertaken in the intervention period compared with the control period were significantly different: "sent letter to physician" (67% vs. 87%), "sent letter to member" (15% vs. 0%), "pharmacist phone call to physician" (15% vs. 0.1%), and "pharmacist phone call to member" (13% vs. 7%). There were statistically significant reductions in unplanned care across all health plans especially in the Medicare population, in total cost of care, and increases in medication adherence in 4 therapeutic classes: anticoagulants (OR = 1.25, P = 0.005), cardiac medications (OR = 1.20, P < 0.001), statins (OR = 1.21, P < 0.001), and antidepressants (OR = 1.15, P < 0.001). There was a positive ROI of $18.50 per dollar spent, which equated to a cumulative net savings of $11 million over 24 months. CONCLUSIONS: In a large health plan, expanding MTM eligibility, intensifying patient follow-up contact and pharmacist involvement, and improving provider awareness had favorable clinical and economic benefits. DISCLOSURES: There was no funding for this project except employees' time. All authors are employees of UPMC and have no conflicts of interest to report.

Mandibular Access Osteotomy for Tumor Ablation: Could a More Tissue-Preserving Technique Affect Healing Outcome?

PURPOSE: Paramedial mandibulotomy facilitates access for the resection of tumors in the oral and oropharyngeal space; however, severe complications related to surgical techniques and radiotherapy have been reported for this procedure. This study evaluated whether preservation of the periosteum during a mandibulotomy would decrease postoperative complications owing to the increased healing capacity provided by preserving more tissue. MATERIALS AND METHODS: Patients who underwent mandibulotomy for surgical tumor ablation from 2007 through 2012 were included in a retrospective controlled cohort study. The trial was comprised of 2 groups: 1 group underwent subperiosteal and 1 group underwent supraperiosteal surgical dissection in the area of the mandibulotomy. The primary predictor variable was surgical technique and the primary outcome variable was surgical complications. The groups were matched according to tumor type, age, and gender. Clinical and radiographic follow-up was performed 12 months after surgery. Complications regarding bone exposure, plate exposure, osteoradionecrosis, nonunion, infection of the soft tissue flap, abscesses, fistulas, and gingival necrosis were recorded. Recordings of other factors, such as age, smoking habits, and timing of radiotherapy and chemotherapy, were performed and the 2 groups were compared for postoperative complications. Data analysis used the χ(2) test (Fisher exact test) to compare the sub- and supraperiosteal groups for postoperative complications. RESULTS: Thirty-two patients were included (16 per group; 14 women and 18 men; mean age, 56 yr). Thirteen patients in the subperiosteal group and 7 in the supraperiosteal group showed complications during the first 12 months. Seven patients had complications that persisted to the 12-month follow-up (6 in the subperiosteal group and 1 in the supraperiosteal group); however, the difference was not statistically relevant. CONCLUSION: This study found more persistent complications in the subperiosteal group compared with the supraperiosteal group at 12-month follow-up, which could imply that a more tissue-preserving surgical technique promotes mandibular healing in patients undergoing mandibular access osteotomy in combination with radiotherapy.