The association between hydroxyurea adherence and opioid utilization among Texas Medicaid enrollees with sickle cell disease.

BACKGROUND: Individuals with sickle cell disease (SCD) suffer from recurrent catastrophic pain crises that are often managed by opioid analgesics. Being adherent to hydroxyurea has been associated with decreased health care resource use for pain; however, evidence of its association with opioid use is limited. OBJECTIVE: To determine if adherence to hydroxyurea is associated with opioid use among patients with SCD. METHODS: This retrospective study used Texas Medicaid data from September 1, 2011, to August 31, 2016 (study period). The index date was the date of hydroxyurea initiation. Patients who were aged 2-63 years at the index date, had ≥ 1 inpatient or ≥ 2 outpatient SCD diagnoses during the study period, had ≥ 1 hydroxyurea prescription during the identification period (September 1, 2011-August 31, 2015), had no diagnosis of other indications for hydroxyurea during the study period, and were continuously enrolled for at least 12 months after the index date were included. Hydroxyurea adherence was measured using medication possession ratio (MPR). The study outcomes (measured 1-year post-index) were (a) opioid use; (b) number of opioid prescriptions; (c) strong opioid use (morphine, hydromorphone, fentanyl, and methadone); (d) number of strong opioid prescriptions; (e) high-dose opioid use (≥ 50 mg morphine milligram equivalent [MME]); and (f) days supply for opioid prescriptions. Covariates included demographic (age and gender) and clinical (vaso-occlusive crisis [VOC], avascular necrosis, iron overload, acute chest syndrome, and blood transfusion) characteristics. Descriptive, bivariate (chi-square and Wilcoxon-Mann-Whitney tests), multiple logistic regression, and negative binomial regression analyses were performed. RESULTS: 1,146 patients (18.3 [12.3] years) met the inclusion criteria. Of these, 19.6% were adherent to hydroxyurea (defined as MPR ≥ 80%) and mean (SD) MPR was 48.3% (29.7%). In the 1 year following hydroxyurea initiation, 923 (80.5%) patients had ≥ 1 opioid prescription with 7.6 (9.4) opioid prescriptions per patient, while 259 (22.6%) patients had ≥ 1 strong opioid prescription with 1.5 (4.4) strong opioid prescriptions per patient. Average (SD) opioid dose was 41.7 (74.3) mg MME, and 27.1% had high daily MME doses (≥ 50 mg MME). Average (SD) opioid days supply was 83.1 (112.2) days. After adjusting for covariates, compared with being nonadherent, being adherent to hydroxyurea was associated with a 50.5% decreased risk of having strong opioids (OR = 0.495, 95% CI = 0.278-0.879, P = 0.0165). Additionally, SCD-related complications (VOC, avascular necrosis, and iron overload) and older age were significant factors associated with opioid use and higher MME. Post hoc analyses showed that being adherent to hydroxyurea was significantly associated with lower probabilities of experiencing SCD-related complications. CONCLUSIONS: Results showed that patients with SCD are moderately adherent to hydroxyurea. Being adherent to hydroxyurea was found to be associated with a lower risk of receiving a prescription for strong opioids. Findings suggest that close monitoring and interventions to improve adherence may help mitigate strong opioid use among these patients. DISCLOSURES: This research did not receive any specific funding. Barner and Kang report grants from Novartis Pharmaceuticals, unrelated to this work. A part of this study was presented as a poster at the American Pharmacists Association (APhA) 2019 Annual Meeting and Exposition (March 22-25, 2019, Seattle, WA) and received the 2019 APhA-APRS Presentation Award in the APhA-APRS Contributed Research Paper, Graduate Student/Fellow/Postdoctoral Scholar category.

Assessment of basal insulin adherence using 2 methodologies among Texas Medicaid enrollees with type 2 diabetes.

BACKGROUND: Basal insulin is often recommended as the initial therapy for patients with type 2 diabetes who require insulin treatment. Adequate adherence is critical to diabetes management, yet suboptimal insulin adherence has been reported. Second-generation long-acting (SGLA) insulin has higher dosing flexibility and lower hypoglycemia risk and may improve adherence. However, little is known regarding adherence to SGLA insulin and how adherence to SGLA insulin compares with intermediate-acting neutral protamine Hagedorn (NPH) and first-generation long-acting (FGLA) insulin. Measurement of insulin adherence is challenging because of the inaccuracies of recorded days supply of insulin, and traditional medication possession ratio (MPR) may be negatively affected. Adjusted MPR (aMPR) has been developed in an effort to address this issue. OBJECTIVE: To examine the unadjusted and adjusted associations between basal insulin type and adherence to basal insulin using MPR and aMPR. METHODS: This retrospective database study used Texas Medicaid prescription claims from January 1, 2014, through June 30, 2017. The index date was the date of the first basal insulin prescription without the same prescription 6 months before (pre-index), and all patients were followed for 12 months (post-index). Patients aged 18-63 years with ≥ 1 pre-index prescription of an oral hypoglycemia agent (OHA) or a glucagon-like peptide-1 receptor agonist (GLP-1 RA), without any post-index prescription of premixed insulin or a basal insulin different from index insulin, and with continuous enrollment throughout the pre- and post-index periods, were included. The dependent variable was basal insulin adherence over 12 months, measured using MPR and aMPR. Unadjusted and adjusted adherence comparisons were conducted by basal (background) insulin type (NPH, FGLA, and SGLA). Covariates included age, gender, baseline use of basal insulins and comorbid medications, total number of medications, OHA adherence, post-index number of OHAs, and use of bolus insulins and GLP-1 RAs. Analysis of variance, chi-square tests, and multiple logistic regression analyses were performed. RESULTS: Of the 5,034 patients included, NPH, FGLA, and SGLA insulin users accounted for 3.7%, 89.8%, and 6.5%, respectively. The overall mean (SD) age was 50.9 (9.9) years, and 65.9% were female. In the unadjusted bivariate analyses, SGLA insulin users had significantly higher adherence, using either MPR (SGLA 0.68 [0.25] vs. FGLA 0.59 [0.27] vs. NPH 0.55 [0.27]; P < 0.0001) or aMPR (0.83 [0.23] vs. 0.78 [0.26] vs. 0.73 [0.28]; P = 0.0001). After controlling for covariates, insulin type was not significantly associated with the likelihood of being adherent (MPR or aMPR ≥ 0.8) using either measure. CONCLUSIONS: Adherence to SGLA insulin was not different from adherence to other basal insulins after controlling for patient characteristics. Yet, MPR and aMPR have limitations and warrant further confirmation of the study findings. Before new adherence measures for insulin therapy are developed, MPR and aMPR should be used with caution. DISCLOSURES: No specific funding was received for this manuscript. The authors report no potential conflicts of interest. Part of the data from this study was presented as posters at the American Pharmacists Association 2020 Annual Meeting & Exposition, March 20-23, 2020, in National Harbor, MD, and at the International Society for Pharmacoeconomics and Outcomes Research 2020 Conference, May 16-20, 2020, in Orlando, FL.

Complementary and alternative medicine utilization in Texas hospices: prevalence, importance, and challenges.

The purpose of this study was to describe the prevalence, importance, and challenges of complementary and alternative medicine (CAM) utilization in Texas hospices. Mail surveys were sent to 369 hospices in Texas, and 110 useful surveys were returned. Results showed that a majority (n = 62, 56.4%) of hospices offer CAM to their clients, with the most popularly offered CAMs being massage, music, and relaxation therapies. Despite the availability of CAM services in most hospices, and that the utilization of CAM has the potential to improve overall quality of life of patients, our results showed that a sizeable proportion of patients in these hospices are not utilizing the provided CAMs. Funding and personnel constraints were substantial obstacles to offering CAM.

Factors associated with hospices' provision of complementary and alternative medicine.

There is limited research about the provision of complementary and alternative (CAM) in US hospices. The purpose of this study was to assess the factors that influence hospices' likelihood of providing CAM therapies. Mail surveys were sent to 369 hospices in Texas; 61 were returned undelivered, yielding a total usable response rate of 35.7% (n = 110) after an initial and one follow-up mail out. Binary logistic regression was used to assess whether the likelihood of offering CAM is related to hospice's age, geographic location, agency type, profit orientation, Medicare certification, and number of patients served annually. Results showed that profit orientation and the number of patients served by hospices were significantly related to the probability that hospices will offer CAM. Specifically, the odds of offering CAM in not-for-profit hospices were approximately 4 times higher than that in for-profit hospices (odds ratio [OR] = 3.77, P = .022, 95% confidence interval [CI] = 1.2, 11.8). In addition, for every 100 patients served by the hospices, the odds of offering CAM increases by 13% (OR = 1.13, P = .015, 95% CI = 1.02, 1.25). In conclusion, CAM offering by hospices is related to hospices' profit orientation status and number of patients served but is not related to other measured characteristics of hospices.

Assessing barriers to medication adherence in underserved patients with diabetes in Texas.

PURPOSE: The purpose of this study was to assess (1) medication adherence in individuals with diabetes, (2) barriers to adherence, and (3) what factors were related to medication nonadherence. METHODS: A self-administered anonymous survey was provided to adults with diabetes (N = 59) who used a grocery store chain pharmacy or a community clinic for the underserved. Participants were recruited by pharmacy staff to complete a 10- to 15-minute survey to assess adherence, access, barriers, medication use, and demographics. Adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS), which is a reliable and valid self-report adherence instrument. Access (e.g., use medications from Mexico, transportation), barriers (e.g., cost, language difficulties), medication use (e.g., complementary and alternative medicine, prescription medication), and demographics were also measured. The survey was available in English and Spanish. Data collection occurred from December 2010 through February 2011. RESULTS: Fifty-nine participants completed the survey. Approximately 57% of study participants were male, 85% were Hispanic, and the mean age was 50.4 ± 10.3 years. Over 50% of participants had hypertension or dyslipidemia and were taking 3 or more medications. Participants (52.6%) reported their health status as good or excellent and over one-half (56%) of the participants were nonadherent (score 0-6). The following factors were significantly (P < .05) related to nonadherence: cost, no refills, poor health status, fewer disease states, and any reason. CONCLUSIONS: This study increased awareness of barriers to medication adherence in a predominantly Hispanic underserved patient population. This may lead to more informed recommendations and perhaps address gaps in health disparities.

Use of complementary and alternative medicine for treatment among African-Americans: a multivariate analysis.

BACKGROUND: The use of complementary and alternative medicine (CAM) is substantial among African-Americans; however, research on characteristics of African-Americans who use CAM to treat specific conditions is scarce. OBJECTIVE: To determine what predisposing, enabling, need, and disease-state factors are related to CAM use for treatment among a nationally representative sample of African-Americans. METHODS: A cross-sectional study design was employed using the 2002 National Health Interview Survey (NHIS). A nationwide representative sample of adult (> or =18 years) African-Americans who used CAM in the past 12 months (n=16,113,651 weighted; n=2,952 unweighted) was included. The Andersen Health Care Utilization Model served as the framework with CAM use for treatment as the main outcome measure. Independent variables included the following: predisposing (eg, age, gender, and education); enabling (eg, income, employment, and access to care); need (eg, health status, physician visits, and prescription medication use); and disease state (ie, most prevalent conditions among African-Americans) factors. Multivariate logistic regression was used to address the study objective. RESULTS: Approximately 1 in 5 (20.2%) who used CAM in the past 12 months used CAM to treat a specific condition. Ten of the 15 CAM modalities were used primarily for treatment by African-Americans. CAM for treatment was significantly (P<.05) associated with the following factors: graduate education, smaller family size, higher income, region (northeast, midwest, west more likely than south), depression/anxiety, more physician visits, less likely to engage in preventive care, more frequent exercise behavior, more activities of daily living (ADL) limitations, and neck pain. CONCLUSIONS: Twenty percent of African-Americans who used CAM in the past year were treating a specific condition. Alternative medical systems, manipulative and body-based therapies, and folk medicine, prayer, biofeedback, and energy/Reiki were used most often. Health care professionals should routinely ask patients about the use of CAM, but when encountering African-Americans, there may be a number of factors that may serve as cues for further inquiry.

Patterns of complementary and alternative medicine use in African Americans.

OBJECTIVES: This study sought to determine (1) characteristics of complementary and alternative medicine (CAM) users in the African-American (AA) population; (2) the prevalence of CAM use; and (3) CAM use for treatment and prevention of disease. DESIGN: The authors analyzed data from the 2002 National Health Interview Survey (NHIS), which included 4256 AA adults representing 23,828,268 AA adults nationwide. Chi-squared tests based on weighted data were used to examine differences in CAM users and nonusers. OUTCOME MEASURES: CAM use was categorized as CAM Ever, CAM Past 12 Months, and CAM for Treatment. RESULTS: A total of 23,828,268 (weighted) AAs were identified in the NHIS dataset. Of those, 67.6% used CAM in the past 12 months, when prayer for health was included. Users were more likely older (43.3 +/- 0.4 versus 39.5 +/- 0.5 years; p < 0.0001); female (60.9% versus 44.0%; p < 0.0001), college educated (17.4% versus 9.8%; p < 0.0001); and insured (91.0% versus 88.1%; p < 0.0001) compared to nonusers. Prayer was the most common CAM used by more than 60% of respondents, followed by herbals (14.2%) and relaxation (13.6%). A majority utilized CAM to treat illness. The use of CAM was significantly (p < 0.0001) higher across all the disease states common in AAs compared to nonuse. CONCLUSIONS: A substantial number of AAs use CAM, with use varying across sociodemographic characteristics. Prayer was the most commonly used therapy. Overall, CAM was most often used for the treatment of specific conditions as opposed to prevention, and its use was common among AAs with prevalent disease states. The extent to which CAM served as a complement or an alternative to conventional medical treatment among AAs is unknown and should be investigated.

Community pharmacists' actions when patients use complementary and alternative therapies with medications.

OBJECTIVE: To assess actions of community pharmacists in response to their patients' concurrent use of prescription medications and complementary and alternative medicine (CAM). DESIGN: Nonexperimental, cross-sectional mail survey. SETTING: Texas. PARTICIPANTS: 107 community pharmacists. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pharmacists' self-reported rate of patient inquiry about CAM use and actions taken in response to CAM use. RESULTS: A majority (71.0%) of pharmacists had encountered patients who were using CAM, which was defined broadly in the survey to include herbal products, vitamins and minerals, homeopathic products, massage, meditation, and other types of CAM. Pharmacists documented CAM use by patients in 11.0% of cases and reported monitoring for drug-related problems in 38.4% of users. Among CAM users, pharmacists most often encouraged CAM use if medically appropriate. Pharmacists were not comfortable with responding to CAM inquiries but believed they needed adequate knowledge about CAM. In general, pharmacists rarely asked patients about their CAM use. Pharmacists' rate of inquiry about CAM use increased significantly when this information could be documented in patient profiles and when pharmacists had additional training in CAM. Also, in pharmacies that stocked herbal or homeopathic products, pharmacists were significantly more likely to encourage the use of CAM when medically appropriate and to recommend other CAM therapies appropriate for patients' conditions. When no references were available to research CAM, pharmacists tended to neither encourage nor discourage CAM use based on lack of scientific evidence of their effectiveness. CONCLUSION: Most community pharmacists had patients who used CAM, but they were not proactive in inquiring about or documenting this use. They most often encouraged CAM use if deemed medically appropriate. Pharmacists' actions differed on the basis of professional and practice setting characteristics. To ensure optimal drug therapy outcomes, pharmacists should be more proactive in identifying and documenting CAM use by patients.