Strategies to reduce out-of-pocket medication costs for Canadians with peripheral arterial disease.

BACKGROUND: Given that peripheral arterial disease (PAD) disproportionately affects people of lower socioeconomic status, out-of-pocket expenses for preventive medications are a major barrier to their use. We carried out a cost comparison of drug therapies for PAD to identify prescribing strategies that minimize out-of-pocket expenses for these medications. METHODS: Between March and June 2019, we contacted outpatient pharmacies in Hamilton, Ontario, Canada, to assess pricing of pharmacologic therapies at dosages included in the 2016 American College of Cardiology/American Heart Association guideline for management of lower extremity PAD. We also gathered pricing information for supplementary charges, including delivery, pill splitting and blister packaging. We calculated prescription prices with and without dispensing fees for 30-day brand-name and generic prescriptions, and 90-day generic prescriptions. RESULTS: Twenty-four pharmacies, including hospital-based, independent and chain, were included in our sample. In the most extreme scenario, total 90-day medication costs could differ by up to $1377.26. Costs were affected by choice of agent within a drug class, generic versus brand-name drug, quantity dispensed, dispensing fee and delivery cost, if any. CONCLUSION: By opting for prescriptions for 90 days or as long as possible, selecting the lowest-cost generic drugs available in each drug class, and identifying dispensing locations with lower fees, prescribers can minimize out-of-pocket patient medication expenses. This may help improve adherence to guideline-recommended therapies for the secondary prevention of vascular events in patients with PAD.

Predictors of Bleeding in the Perioperative Anticoagulant Use for Surgery Evaluation Study.

Background In the PAUSE (Perioperative Anticoagulant Use for Surgery Evaluation) Study, a simple, standardized, perioperative interruption strategy was provided for patients with nonvalvular atrial fibrillation taking direct oral anticoagulants (DOACs). Our objective was to define the factors associated with perioperative bleeding. Methods and Results We analyzed bleeding as the composite of major and clinically relevant nonmajor bleeding. Putative predictors of bleeding, and preoperative DOAC level were prospectively collected during recruitment. We used stratified logistic regression models for analysis. All statistical analyses were performed in R version 3.6.0. There were 3007 patients requiring perioperative DOAC interruption. More than one third of the included patients underwent a high bleeding risk procedure. The 30-day rates of major and clinically relevant nonmajor bleeding were 3.02% in apixaban (n=1257), 2.84% in dabigatran (n=668), and 4.16% for rivaroxaban (n=1082). Multivariate analysis stratified by region found more bleeding for hypertension (odds ratio [OR], 1.79; 95% CI 1.07-2.99; P=0.027), and prior bleeding (OR, 1.71; 95% CI, 1.08-2.71; P=0.021). Surgical bleed risk classification (high- versus low-risk) as a predictor of bleeding was only significant in the univariate analysis. The prediction model for major and clinically relevant nonmajor bleeding had an area under the curve of 0.71, and the preoperative DOAC level did not improve the area under the curve of the model. Conclusions In patients treated with DOACs who required an elective surgery/procedure and were managed with standardized DOAC interruption and resumption, there we did not find reversible risk factors for bleeding, suggesting that adjustment of the PAUSE management protocol to mitigate against bleeding is not needed.

Cost-Efficient Medical Education: An Innovative Approach to Creating Educational Products.

BACKGROUND: Cost is a barrier to creating educational resources, and new educational initiatives are often limited in distribution. Medical training programs must develop strategies to create and implement cost-effective educational programming. OBJECTIVE: We developed high-quality medical programming in procedural instruction with efficient economics, reaching the most trainees at the lowest cost. METHODS: The Just-In-Time online procedural program was developed at the University of Toronto in Canada, aiming to teach thoracentesis, paracentesis, and lumbar puncture skills to internal medicine trainees. Commercial vendors quoted between CAD $50,000 and $100,000 to create 3 comprehensive e-learning procedural modules-a cost that was prohibitive. Modules were therefore developed internally, utilizing 4 principles aimed at decreasing costs while creating efficiencies: targeting talent, finding value abroad, open source expansion, and extrapolating efficiency. RESULTS: Procedural modules for thoracentesis, paracentesis, and lumbar puncture were created for a total cost of CAD $1,200, less than 3% of the anticipated cost in utilizing traditional commercial vendors. From November 2016 until October 2018, 1800 online instructional sessions have occurred, with over 3600 pageviews of content utilized. While half of the instructional sessions occurred within the city of Toronto, utilization was documented in 10 other cities across Canada. CONCLUSIONS: The Just-in-Time online instructional program successfully created 3 procedural modules at a fraction of the anticipated cost and appeared acceptable to residents based on website utilization.