Inclusion in limited distribution drug network reduces time to dalfampridine access in patients with multiple sclerosis at a health-system specialty pharmacy.

BACKGROUND: Dalfampridine improves walking speed in patients with multiple sclerosis (MS), but accessing specialty medications such as dalfampridine can be hindered by insurance restrictions, high costs, and limited distribution networks (LDNs) imposed by manufacturers. Some integrated health-systems specialty pharmacies (HSSPs) embed pharmacists in clinics and dispense medications from their internal pharmacies if included within the LDN. OBJECTIVE: To assess access to dalfampridine in patients at an HSSP before and after gaining admission to the LDN. METHODS: This study was conducted at Vanderbilt Specialty Pharmacy (VSP), an integrated HSSP at Vanderbilt University Medical Center (VUMC) with 2 clinical pharmacists embedded in the MS clinic. VSP gained access to the dalfampridine LDN on May 1, 2018, at which time the embedded pharmacists began to manage the comprehensive therapy initiation process. We performed a retrospective review of adult patients with MS who were prescribed dalfampridine from March 2010 to December 2018. Eligible prescriptions were new starts (no previous use) or restarts (after previous use and discontinuation). Prescriptions were classified as pre-VSP and post-VSP, which differentiates before and after VSP gained access to dispense dalfampridine. Study outcomes were insurance approval, initiation of therapy, and time from treatment decision to medication access. We used a proportional odds logistic regression model for time to medication access using the following covariates: pre-VSP versus post-VSP time period, insurance prior authorization (PA) denied versus approved/not needed, and baseline timed 25-foot walk. RESULTS: We included 262 patients and 290 prescriptions (260 pre-VSP and 30 post-VSP). In pre-VSP and post-VSP prescriptions, 97% were approved by insurance, and 93% of patients started therapy. Median time to medication access was 22 days (IQR = 11-45) for pre-VSP prescriptions and 1 day (IQR = 0-3) for post-VSP prescriptions. In the proportional odds logistic regression model, the odds of having a longer medication access time were significantly higher for pre-VSP prescriptions (OR = 83.219, P < 0.001) and prescriptions whose PA was initially denied (OR = 9.50, P < 0.001); 25-foot walk time was not significant (OR = 0.95, P = 0.277). CONCLUSIONS: After obtaining access to dispense dalfampridine, the time to access therapy was reduced, suggesting that LDNs delay patient access to therapy at HSSPs. DISCLOSURES: No funding was provided for this study. The authors have no conflicting interests to disclose. Preliminary results have been previously presented at the American Society of Health-Systems Pharmacy Midyear Meeting in December 2019, the Vanderbilt Health Systems Specialty Pharmacy Outcomes Research Summit in August 2020, and the National Association of Specialty Pharmacy Annual Meeting in September 2020.

Towards universal health coverage: a mixed-method study mapping the development of the faith-based non-profit sector in the Ghanaian health system.

BACKGROUND: Faith-based non-profit (FBNP) providers have had a long-standing role as non-state, non-profit providers in the Ghanaian health system. They have historically been considered to be important in addressing the inequitable geographical distribution of health services and towards the achievement of universal health coverage (UHC), but in changing contexts, this contribution is being questioned. However, any assessment of contribution is hampered by the lack of basic information about their comparative presence and coverage in the Ghanaian health system. In response, since the 1950s, there have been repeated calls for the 'mapping' of faith-based health assets. METHODS: A historically-focused mixed-methods study was conducted, collecting qualitative and quantitative data and combining geospatial mapping with varied documentary resources (secondary and primary, current and archival). Geospatial maps were developed, providing a visual representation of changes in the spatial footprint of the Ghanaian FBNP health sector. RESULTS: The geospatial maps show that FBNPs were originally located in rural remote areas of the country but that this service footprint has evolved over time, in line with changing social, political and economic contexts. CONCLUSION: FBNPs have had a long-standing role in the provision of health services and remain a valuable asset within national health systems in Ghana and sub-Saharan Africa more broadly. Collaboration between the public sector and such non-state providers, drawing on the comparative strengths and resources of FBNPs and focusing on whole system strengthening, is essential for the achievement of UHC.

Universal health coverage in India: Newer innovations and the role of public health.

The realization of Universal Health Coverage requires adequate healthcare financing and human resources to provide financial protection to the economically disadvantaged population by covering their medicine, diagnostics, and service costs. Conventionally, inadequate public healthcare financing and the lack of skilled human resources are considered as the major barriers towards achieving UHC in India. To strengthen the Indian healthcare system, there has been significant increase budgetary allocation towards healthcare, a national health protection scheme targeting low-income households, upgrading of primary health-care and expansion of the health work-force. Nevertheless, an evolving paradigm for improving holistic health, sanitation, nutrition, gender equity, drug accessibility and affordability, innovative initiatives in national health programs for reduction of maternal deaths, tuberculosis and HIV burden and the utilization of information technology in healthcare provision of the underserved and the marginalized is gaining rapid acceleration. These represent a genuine innovation towards fulfillment of UHC goals for India.

Mapping pharmacy deserts and determining accessibility to community pharmacy services for elderly enrolled in a State Pharmaceutical Assistance Program.

OBJECTIVES: Limited studies have investigated geographic accessibility to a nearby community pharmacy for elderly which is an essential determinant of the access to medications and pharmacy services. This research identified pharmacy deserts and investigated availability of different types of community pharmacies and their services for elderly enrolled in a State Pharmaceutical Assistance Program (SPAP). METHODS: The state of Pennsylvania in the US was used as a case to demonstrate the geographic accessibility to community pharmacy and services for elderly enrolled in SPAP. The locations of community pharmacies and households of elderly enrolled in SPAP were derived from Pharmaceutical Assistance Contract for the Elderly programs' database. The street addresses were geocoded and the distance to a nearby community pharmacy was calculated for study sample using the haversine formula. The demographic and geographic data were aggregated to Census Tracts and pharmacy deserts were identified using the predefined criteria. Descriptive statistical analysis was used to determine whether there are statistical differences in the socio-demographic profiles and distribution of different types of community pharmacies and their services in pharmacy deserts and non-deserts. This research used hot spot analyses at county level to identify clusters of pharmacy deserts, areas with high concentration of different racial/ethnic groups and clusters of high densities of chain and independent pharmacies. RESULTS: The Spatial analysis revealed that 39% and 61% Census Tracts in Pennsylvania were pharmacy deserts and non-deserts respectively (p < 0.001). Pharmacy deserts were found to have significantly more females, married and white elderly and fewer blacks and Hispanics compared to pharmacy non-deserts. Pharmacy deserts had significantly fewer chain and independent pharmacies and less delivery and 24-hour services in pharmacies than pharmacy non-deserts. Hot spot analyses showed that clusters of pharmacy deserts were more concentrated in southcentral, northwest and northeast regions of the state which represent rural areas and overlapped with clusters of high concentration of white individuals. CONCLUSIONS: The findings suggest that urban-rural inequality, racial/ethnic disparity and differences in availability of pharmacies and their services exist between pharmacy deserts and non-deserts. The methodological approach and analyses used in this study can also be applied to other public health programs to evaluate the coverage and breadth of public health services.

Obesity Treatment in the UK Health System.

In the UK, as in most other countries in the world, levels of obesity are increasing. According to the Kinsey report, obesity has the second largest public health impact after smoking, and it is inextricably linked to physical inactivity. Since the UK Health and Social Care Act reforms of 2012, there has been a significant restructuring of the National Health Service (NHS). As a consequence, NHS England and the Department of Health have issued new policy guidelines regarding the commissioning of obesity treatment. A 4-tier model of care is now widely accepted and ranges from primary activity, through community weight management and specialist weight management for severe and complex obesity, to bariatric surgery. However, although there are clear care pathways and clinical guidelines for evidence-based practice, there remains no single stakeholder willing to take overall responsibility for obesity care. There is a lack of provision of adequate services characterised by a noticeable 'postcode lottery', and little political will to change the obesogenic environment.

Propuesta de implementación del proceso de fibromialgia. Distrito Sevilla. La fibromialgia desde Atención Primaria / Proposal for implementing the fibromyalgia process. Seville district. Fibromyalgia from primary care

El objetivo de este artículo es concienciar a la Atención Primaria, Administraciones sanitarias, ayuntamientos y Asociaciones de Fibromialgia que, es posible desarrollar el Proceso Asistencial Integrado de Fibromialgia 2005 de la Consejería de Salud de Andalucía en el Distrito Sanitario Sevilla. Los recursos humanos y materiales, casi todos existen ya, solo habría que organizarlos. La Atención Primaria juega un importante papel como puerta de entrada (AU)

This article aims to raise awareness among Primary Care, Health Authorities, Municipalities and Fibromyalgia Associations that it is possible to implement the Fibromyalgia 2005 Integrated Health Process of the Andalusion Health Department in the Seville Health District. The human and material resources, already exist, and only have to be organised. Primary Care plays an important role as gateway to this process (AU)

Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia.

BACKGROUND: In many developing countries, the maternal mortality ratio remains high with huge poor-rich inequalities. Programmes aimed at improving maternal health and preventing maternal mortality often fail to reach poor women. Vouchers in health and Health Equity Funds (HEFs) constitute a financial mechanism to improve access to priority health services for the poor. We assess their effectiveness in improving access to skilled birth attendants for poor women in three rural health districts in Cambodia and draw lessons for further improvement and scaling-up. METHODS: Data on utilisation of voucher and HEF schemes and on deliveries in public health facilities between 2006 and 2008 were extracted from the available database, reports and the routine health information system. Qualitative data were collected through focus group discussions and key informant interviews. We examined the trend of facility deliveries between 2006 and 2008 in the three health districts and compared this with the situation in other rural districts without voucher and HEF schemes. An operational analysis of the voucher scheme was carried out to assess its effectiveness at different stages of operation. RESULTS: Facility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 after the introduction of voucher and HEF schemes, not only for voucher and HEF beneficiaries, but also for self-paid deliveries. The increase was much more substantial than in comparable districts lacking voucher and HEF schemes. In 2008, voucher and HEF beneficiaries accounted for 40.6% of the expected number of births among the poor. We also outline several limitations of the voucher scheme. CONCLUSIONS: Vouchers plus HEFs, if carefully designed and implemented, have a strong potential for reducing financial barriers and hence improving access to skilled birth attendants for poor women. To achieve their full potential, vouchers and HEFs require other interventions to ensure the supply of sufficient quality maternity services and to address other non-financial barriers to demand. If these conditions are met, voucher and HEF schemes can be further scaled up under close monitoring and evaluation.

Are black Americans entitled to equal health care? a new research paradigm.

This paper analyzes the health, economic and legal implications of most major health systems' reform initiatives in the 20th century and, briefly, the 19th century. The paper suggests that models of analysis grounded in science deter the development of claims for racial equality in health care. Because race is a legal construct, the paper suggests that the 14th Amendment's Equal Protection Clause is an analytical framework that better accommodates the complexity of the health system, is at the heart of our national laws and ethos, and has political rhetorical power to further the political and policy debate. Major components of the health care system, including professional training, hospital construction, and health care financing, are analyzed for racially discriminatory purpose or impact and the extent of government participation. The paper gives particular attention to: the Flexner Report and the limited number of black physicians; the Hill-Burton program and the disproportionate assistance it gave to white controlled hospitals; and, efforts to expand health insurance coverage that also disproportionately favored the needs of the white community. Given the compounding effects of numerous policy decisions made over many years, there should not be any great wonder that such gross disparities in morbidity and mortality exist between black and white Americans. Further research and analysis of the policy decisions that have constructed the current health care system as well as framing those analyses as claims for racial fairness will better develop the policy debate than more narrowly focused analytical models from biomedical science or epidemiology. The law produced slavery and segregation, which usually determined where you lived, where you went, what work you could do, and what you learned. That legally constructed system significantly determined what you earned and what health you had. The biomedical models of analysis of our health system are too narrowly focused and temporally limited to identify the broad systemic barriers to equal health and health care. An analytical framework from law more easily accommodates the complex dynamics of our health care system. The equal protection clause of the 14th amendment has been used to analyze complex social and economic models, such as housing and education and has moved those systems to greater racial equality. The equal protection clause is at the heart of our national laws and ethos and, as a claim for fair treatment from government, has considerable rhetorical power. Menefee presents an analysis of major health policies dealing with training of physicians, construction of hospitals, and financing of personal health care. He suggests it demonstrates a health system rooted in racial discrimination and perpetuating racial discrimination in education, employment and housing. The history of successes using this analytical framework in other areas of social policy validates its consideration by health policy analysts for further research.

Evaluación y garantía de calidad de la atención médica / Evaluation and guarantie of quiality of medical care

En este artículo se presenta un esquema para la asignación de un valor de calidd a los servicios médicos. El objetivo es contar con un sistema que permita identificar aquellos aspectos que no alcanzan un mínimo de calidad, registrarlos, asignar un responsable para su solución y llevar a cabo un seguimiento adecuado.

This paper presents a model for the evaluation of the quality of health services. The purpose is to create a method which allows the identification of those aspects of health care which are below standard, register them, assign a responsible for its correction and implement an adequate follow-up.