Comparison of measures of medication adherence from pharmacy dispensing and insurer claims data.

OBJECTIVE: Medication nonadherence is linked to worsened clinical outcomes and increased costs. Existing system-level adherence interventions rely on insurer claims for patient identification and outcome measurement, yet suffer from incomplete capture and lags in data acquisition. Data from pharmacies regarding prescription filling, captured in retail dispensing, may be more efficient. DATA SOURCES: Pharmacy fill and insurer claims data. STUDY DESIGN: We compared adherence measured using pharmacy fill data to adherence using insurer claims data, expressed as proportion of days covered (PDC) over 12 months. Agreement was evaluated using correlation/validation metrics. We also explored the relationship between adherence in both sources and disease control using prediction modeling. DATA EXTRACTION METHODS: Large pragmatic trial of cardiometabolic disease in an integrated delivery network. PRINCIPAL FINDINGS: Among 1113 patients, adherence was higher in pharmacy fill (mean = 50.0%) versus claims data (mean = 47.4%), although they had moderately high correlation (R = 0.57, 95% CI: 0.53-0.61) with most patients (86.9%) being similarly classified as adherent or nonadherent. Sensitivity and specificity of pharmacy fill versus claims data were high (0.89, 95% CI: 0.86-0.91 and 0.80, 95% CI: 0.75-0.85). Pharmacy fill-based PDC predicted better disease control slightly more than claims-based PDC, although the difference was nonsignificant. CONCLUSIONS: Pharmacy fill data may be an alternative to insurer claims for adherence measurement.

Comparison of a new 3-item self-reported measure of adherence to medication with pharmacy claims data in patients with cardiometabolic disease.

BACKGROUND: Less than half of patients with cardiometabolic disease consistently take prescribed medications. While health insurers and some delivery organizations use claims to measure adherence, most clinicians do not have access during routine interactions. Self-reported scales exist, but their practical utility is often limited by length or cost. By contrast, the accuracy of a new 3-item self-reported measure has been demonstrated in individuals with HIV. We evaluated its concordance with claims-based adherence measures in cardiometabolic disease. METHODS: We used data from a recently-completed pragmatic trial of patients with cardiometabolic conditions. After 12 months of follow-up, intervention subjects were mailed a survey with the 3-item measure that queries about medication use in the prior 30 days. Responses were linearly transformed and averaged. Adherence was also measured in claims in month 12 and months 1-12 of the trial using proportion of days covered (PDC) metrics. We compared validation metrics for non-adherence for self-report (average <0.80) compared with claims (PDC <0.80). RESULTS: Of 459 patients returning the survey (response rate: 43.5%), 50.1% were non-adherent in claims in month 12 while 20.9% were non-adherent based on the survey. Specificity of the 3-item metric for non-adherence was high (month 12: 0.83). Sensitivity was relatively poor (month 12: 0.25). Month 12 positive and negative predictive values were 0.59 and 0.52, respectively. CONCLUSIONS: A 3-item self-reported measure has high specificity but poor sensitivity for non-adherence versus claims in cardiometabolic disease. Despite this, the tool could help target those needing adherence support, particularly in the absence of claims data.

Delayed cord clamping with stabilisation at all preterm births - feasibility and efficacy of a low cost technique.

OBJECTIVES: Meta-analysis data suggests that Delayed cord clamping (DCC) in preterm infants is associated with a 32% reduction in mortality. Reported rates of this intervention are low, particularly for caesarean deliveries. Perceived difficulties providing respiratory support and thermal care during DCC may be barriers to implementation of this intervention. Commercially available equipment to facilitate this can be expensive. This study aimed to evaluate the feasibility and efficacy of a simple, low cost technique to deliver respiratory support and thermal care during DCC at all preterm deliveries (including caesarean), with the hypothesis that this could increase rates of preterm infants receiving DCC. STUDY DESIGN: Data was collected retrospectively from 46 infants born at <32 weeks gestation in 2015. The technique was introduced in early 2017, as part of a perinatal Quality Improvement project. Data was collected prospectively from 63 infants born at <32 weeks gestation in 2017-2018. RESULTS: Rates of DCC in infants born <32 weeks gestation have increased from 12.5% in 2015 to 89.4% in 2017-2018. In 2017-2018, thermal care and respiratory support was provided to all infants who received DCC. CONCLUSION: Multidisciplinary perinatal team working allowed development of a simple, low cost technique to deliver DCC at all preterm deliveries. We have demonstrated feasibility and efficacy of this technique, and a significant and sustained improvement in rates of DCC in our preterm population. We hope that by sharing this approach, other centres will be able to implement a similar strategy, closing the gap between evidence base and translation into clinical practice, and allowing provision of DCC for preterm infants as a standard part of high quality perinatal care.

Patients' views of a behavioral intervention including financial incentives.

OBJECTIVES: Clinical trials are increasingly testing the effectiveness of paying patients' financial incentives for achieving desired clinical outcomes. Some researchers and providers are concerned that patient financial incentives will harm the doctor-patient relationship. How patients feel about these approaches, and these trials, is largely unknown. This study examined patients' perceptions of a compound behavioral and financial incentive intervention used in a large multicenter trial to lower low-density lipoprotein cholesterol (LDL-C), including their perceptions of benefits and challenges and the study's effect on patients' relationship with their primary care physicians (PCPs). STUDY DESIGN: Semi-structured telephone interviews with patients post intervention. METHODS: PCPs from 3 primary care practices in the northeastern United States were randomized to 1 of 4 arms: physician financial incentives, patient financial incentives, shared incentives between physicians and patients, and a control arm. Within each arm, 10 high, 10 medium, and 10 low performers in LDL-C reduction were interviewed. Interviews targeted reasons for enrolling in the study, the specific intervention elements that helped them reach the goal (incentives, engagement, monitoring), challenges faced in reducing cholesterol, and the impact of study participation on their relationship with their PCP. RESULTS: Patients reported positive experiences with the study: 65% described personal changes to improve health and 61% reported increased awareness. Views about financial incentives varied: 71% clearly found them motivating and 36% claimed they made no difference. Patients noted that changing lifestyle (36%) and diet (65%) was difficult. Patients who substantially lowered their LDL-C revealed themes similar to those who did not. CONCLUSIONS: Overall, behavioral interventions with financial incentives appear to be socially acceptable to patients who participate in them. Both adherence monitoring and financial incentives were well received, with little effect on the physician-patient relationship.

Factors associated with pain among ambulatory patients with cancer with advanced disease at a comprehensive cancer center.

PURPOSE: The prevalence and severity of pain have not been well described among oncology patients in ambulatory care. To better understand the burden of pain among patients with advanced cancer, we examined the prevalence of pain reported during office and treatment visits. METHODS: A retrospective study of 4,014 patients with advanced disease (stage 4 at diagnosis or metastatic progression) who completed an ambulatory visit between 2004 and 2006 was conducted at a comprehensive cancer center in Boston, Massachusetts. RESULTS: At their first visit during the study period, 74% of patients reported no pain (0 score); 12%, low pain (1 to 3 score); 9%, moderate pain (4 to 6 score); and 5%, severe pain (7 to 10 score). The prevalence of pain was highest among patients who were younger than 60 years of age, were nonwhite, did not speak English as their primary language, or were covered by Medicaid, received free care, or paid their own health care costs. Patients with thoracic, breast, and head and neck cancers had higher pain scores than those with other diseases. Pain was reported more frequently among patients whose diagnosis or metastatic progression occurred less than 3 months before the reported pain score. In multivariable regression analysis, age, race, cancer type, and time since diagnosis/progression were identified as important factors associated with severe pain. CONCLUSION: Younger age, minority race, and recent onset of advanced disease are associated with severe pain among patients with cancer. Recognizing these high-risk groups could inform targeted interventions to address pain care in ambulatory patients with advanced cancer.

Improving doctor-patient communication in the outpatient setting using a facilitation tool: a preliminary study.

QUALITY PROBLEM: Patients often do not fully understand medical information discussed during office visits. This can result in lack of adherence to recommended treatment plans and poorer health outcomes. CHOICE OF SOLUTION: We developed and implemented a program utilizing an encounter form, which provides structure to the medical interaction and facilitates bidirectional communication and informed decision-making. IMPLEMENTATION: We conducted a prospective quality improvement intervention at a large tertiary-care academic medical center utilizing the encounter form and studied the effect on patient satisfaction, understanding and confidence in communicating with physicians. The intervention included 108 patients seen by seven physicians in five sub-specialties. EVALUATION: Ninety-eight percent of patients were extremely satisfied (77%) or somewhat satisfied (21%) with the program. Ninety-six percent of patients reported being involved in decisions about their care and treatments as well as high levels of understanding of medical information that was discussed during visit. Sixty-nine percent of patients reported that they shared the encounter form with their families and friends. Patients' self-confidence in communicating with their doctors increased from a score of 8.1 to 8.7 post-intervention (P-value = 0.0018). When comparing pre- and post-intervention experiences, only 38% of patients felt that their problems and questions were adequately addressed by other physicians' pre-intervention, compared with 94% post-intervention. LESSONS LEARNED: We introduced a program to enhance physician-patient communication and found that patients were highly satisfied, more informed and more actively involved in their care. This approach may be an easily generalizable approach to improving physician-patient communication at outpatient visits.

How do black-serving hospitals perform on patient safety indicators? Implications for national public reporting and pay-for-performance.

BACKGROUND: There is increasing policy interest in public reporting and tying financial incentives to metrics of patient safety. How black-serving hospitals fare on these measures will have important implications for disparities in care. OBJECTIVES: To determine how black-serving hospitals perform on patient safety indicators (PSIs). RESEARCH DESIGN: We used national Medicare data to calculate the performance of hospitals on 11 medical and surgical PSIs. We designated US hospitals in the top decile of proportion of hospitalized patients who are black as "black-serving." We calculated overall and race-specific rates and examined the relationship between being a black-serving hospital and PSI rates. SUBJECTS: Medicare fee-for-service enrollees discharged from 4488 acute-care US hospitals. RESULTS: Black-serving hospitals performed worse than other hospitals on 6 of 11 PSIs. For example, black-serving hospitals had nearly twice the rate of postoperative pulmonary embolism or deep venous thrombosis (19.4 vs. 11.5 per 1000 discharges, P < 0.001). Adjusting for hospital characteristics had moderate effects. In race-specific analyses, we found that both white and black patients generally had higher rates of potential safety events in black-serving hospitals than they did in non-black-serving hospitals. CONCLUSIONS: Hospitals that disproportionately care for black patients have higher rates of potential safety events among both black and white patients than other hospitals. Current efforts to penalize hospitals with high PSI rates will have a greater effect on hospitals that disproportionately care for black patients.

An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care.

BACKGROUND: Because ambulatory care clinicians override as many as 91% of drug interaction alerts, the potential benefit of electronic prescribing (e-prescribing) with decision support is uncertain. METHODS: We studied 279 476 alerted prescriptions written by 2321 Massachusetts ambulatory care clinicians using a single commercial e-prescribing system from January 1 through June 30, 2006. An expert panel reviewed a sample of common drug interaction alerts, estimating the likelihood and severity of adverse drug events (ADEs) associated with each alert, the likely injury to the patient, and the health care utilization required to address each ADE. We estimated the cost savings due to e-prescribing by using third-party-payer and publicly available information. RESULTS: Based on the expert panel's estimates, electronic drug alerts likely prevented 402 (interquartile range [IQR], 133-846) ADEs in 2006, including 49 (14-130) potentially serious, 125 (34-307) significant, and 228 (85-409) minor ADEs. Accepted alerts may have prevented a death in 3 (IQR, 2-13) cases, permanent disability in 14 (3-18), and temporary disability in 31 (10-97). Alerts potentially resulted in 39 (IQR, 14-100) fewer hospitalizations, 34 (6-74) fewer emergency department visits, and 267 (105-541) fewer office visits, for a cost savings of 402,619 USD (IQR, 141,012-1,012,386 USD). Based on the panel's estimates, 331 alerts were required to prevent 1 ADE, and a few alerts (10%) likely accounted for 60% of ADEs and 78% of cost savings. CONCLUSIONS: Electronic prescribing alerts in ambulatory care may prevent a substantial number of injuries and reduce health care costs in Massachusetts. Because a few alerts account for most of the benefit, e-prescribing systems should suppress low-value alerts.