Primary medication nonadherence rates to specialty disease-modifying antirheumatic drugs for rheumatoid arthritis within a health system specialty pharmacy.

BACKGROUND: Assessing primary medication nonadherence, the rate at which a medication is prescribed for a patient but is not obtained or replaced with an alternative medication within a reasonable time period, can provide a better understanding of the frequency and impact of these barriers to medication access. Previous literature has reported high rates of primary medication nonadherence, ranging from approximately 20% to 55% in patients with rheumatoid arthritis (RA) treated with specialty disease-modifying antirheumatic drugs (DMARDs). The high primary medication nonadherence rate may reflect the difficulties associated with obtaining specialty medications, such as high costs, extended prior authorizations, and pretreatment safety requirements. OBJECTIVE: To evaluate reasons for and rates of primary medication nonadherence to specialty DMARDs in patients with RA referred to an integrated health systems specialty pharmacy. METHODS: We conducted a retrospective cohort study examining eligible patients with a specialty DMARD referral from a health system rheumatology provider to the health system specialty pharmacy. Initially, pharmacy claims were used to identify primary medication nonadherence, defined as the lack of a fill event within 60 days following the medication referral for patients without a specialty DMARD claim in the 180 days prior. Referrals from July 1, 2020, to July 1, 2021, were eligible. Exclusion criteria included duplicate referrals, use for non-RA indications, switches to clinic-administered therapies, and alternate filling methods. Medical record reviews were conducted to confirm referral outcomes. Outcomes included rate of and reasons for primary medication nonadherence. RESULTS: We included 480 eligible patients, 100 of whom had no documented fill event. After medical record review, 27 patients were removed due to having a non-RA diagnosis and 65 patients were removed due to having alternative fill methods, most due to external prescription routing (83.1%). The final primary medication nonadherence rate was 2.1%. Out of the 8 cases of true primary medication nonadherence, 3 patients held specialty DMARD therapy because of other existing disease states, 3 patients were unreachable, and 2 patients were unable to afford medication. CONCLUSIONS: Rates of primary medication nonadherence to specialty DMARDs were low in patients with RA managed by a health system specialty pharmacy. A total of 8 primary medication nonadherence cases were related to safety concerns in non-RA diseases states, patient unreachability, and affordability. However, the limited number of primary medication nonadherence cases limits the generalizability of reasons for primary medication nonadherence found in this study. Key elements of the health systems specialty pharmacy model that likely contribute to low primary medication nonadherence include dedicated financial assistance navigation services, in-clinic pharmacist availability, and open communication between provider offices.

Development and implementation of a laboratory monitoring dashboard to reduce treatment gaps in inflammatory bowel disease.

PURPOSE: Patients receiving biologic therapy for inflammatory bowel disease (IBD) require routine laboratory monitoring to ensure the safety and efficacy of therapy. The purpose of this quality improvement project was to evaluate the implementation of a dashboard to prevent treatment gaps by prospectively identifying patients with IBD and outdated laboratory results receiving biologics. METHODS: We performed a pre/post analysis of dashboard implementation to assess the number of patients with overdue laboratory work resulting in treatment gaps. The dashboard combined data from the electronic health record (EHR) and pharmacy claims database to identify patients on a biologic with laboratory tests (white blood cell count, liver transaminases, C-reactive protein, and erythrocyte sedimentation rate) completed 5 or more months ago and/or a tuberculosis screen completed 11 or more months ago. After implementation, specialty pharmacists reviewed the dashboard and communicated via EHR if a new prescription and laboratory tests were needed. Messages were sent 4 weeks in advance of the next refill-eligible date. Mixed methods were used for analysis of qualitative data, including surveys, and quantitative data, assessing treatment gap length. RESULTS: A total of 40 patients who had outdated laboratory values and required a new prescription (15 before dashboard implementation and 25 after implementation) were included in the analysis. The frequency of a treatment gap decreased from 80% (n = 12) in the preimplementation phase to 32% (n = 8) in the postimplementation phase. The median gap length was shorter after dashboard implementation, decreasing from 21 days (range, 3-97 days) to 11 days (range, 2-23 days). CONCLUSION: Utilization of a quality measures dashboard decreased treatment gaps in patients with IBD receiving biologic therapy. Integrated specialty pharmacists are uniquely positioned to monitor adherence to laboratory monitoring parameters for patients on biologics.

Care for the caregiver.

The issue of caring for the midwife caregiver is a complex issue when viewed within a global context. While national health-care systems vary significantly, midwives around the world are affected by the policies of economic globalisation. Caring for the caregiver must take place within the notion of a worldwide community of midwives, where caring for the caregiver is seen as caring for each other. In this address I examine the issue of caring for the caregiver from four perspectives: global, professional, workplace and personal. As midwives living and working in stressful environments, we are called upon to examine the ways in which we may be contributing to the systems that create the stresses. From the capabilities available to us through the International Confederation of Midwives to apply political pressure to global policies, to individual workplace conditions, midwives can affect change. By exploring alternative models and attitudes and challenging the status quo, we can apply our midwifery skills of caring to each other.