A comparison of medication adherence indices to assess long-term inhaled corticosteroid medication use.

This study examined associations between select hypothesized adherence predictors in claims databases and long-term inhaled corticosteroid adherence. Medication adherence was measured by using medication possession indexes and a refill regularity measure in 1595 older adults using inhaled corticosteroids for 2 years. Medication possession indices were highly correlated with each other but not with the refill regularity measure. Additionally, the hypothesized predictors explained a larger percentage of the variance in the medication possession indices compared to the refill regularity measure. Although long-term retrospective medication utilization poses many measurability issues, the use of multiple indices gives a more complete picture of usage behavior.

Frequency and characteristics of cognitive services provided in response to a financial incentive.

OBJECTIVE: To determine the effects of a financial incentive on the number and types of cognitive services (CS) provided by community pharmacies to Medicaid recipients in the State of Washington. DESIGN: Prospective randomized trial. CS were reported using a problem-intervention-result coding system over a 20-month period. SETTING AND SUBJECTS: Pharmacists practicing in 110 study (financial incentive) and 90 control community pharmacies. RESULTS: Study pharmacists documented an average of 1.59 CS interventions per 100 prescriptions over a 20-month period, significantly more than controls, who documented an average of 0.67 interventions (P < .05) per 100 prescriptions. One-half (48.4%) of all CS were for patient-related problems, 32.6% were for drug-related problems, 17.6% were for prescription-related problems, and 1.4% were for other problems that did not involve drug therapy. A change in drug therapy occurred as a result of 28% of all CS documented in this demonstration. Changes were rarely (2.4%) due to generic or therapeutic substitution and almost always (90%) followed communication with the prescriber. The average self-reported time to perform CS was 7.5 minutes; 75% of interventions were < or = 6 minutes. Considerable differences existed between study and control groups in the types of problems identified, intervention activities performed, and results of interventions. CONCLUSION: A financial incentive was associated with significantly more, and different types of, CS performed by pharmacists.

Inhaled corticosteroid nonadherence and immediate avoidable medical events in older adults with chronic pulmonary ailments.

This study examined the association between nonadherence to inhaled corticosteroids and risk of an immediate avoidable medical event (emergency department visit and hospitalization) in elderly patients with chronic pulmonary ailments. The study comprised a cross-sectional analysis comparing patients with and without avoidable medical event occurrence in each year for adherence preceding the event, and a case-crossover analysis examining the same patient's adherence in years with and without events. The cross-sectional study showed risk odds reductions of nearly 20% in the partially adherent patient, and 40% in the adherent patient compared to the nonadherent patient, after controlling for potential group differences.

Inhaled corticosteroid use and associated outcomes in elderly patients with moderate to severe chronic pulmonary disease.

OBJECTIVE: This study was undertaken to examine the impact of select demographic, clinical, and medication-related factors on elderly patients' medication adherence to inhaled corticosteroid therapy. It also examined the impact of medication adherence on health outcomes and on health care service utilization and costs. BACKGROUND: Asthma in the elderly is a growing concern because of its increasing prevalence and the increase in asthma-related deaths. Poor medication utilization could be contributing to this trend in the elderly population and should be examined. METHODS: This retrospective, longitudinal, 2-year cohort study included 1595 patients aged > or =65 years with moderate to severe chronic pulmonary disease who were enrolled in a health maintenance organization. The study used sequential regression analyses to model (1) medication adherence and (2) health care service utilization and charges as functions of adherence. RESULTS: With other factors controlled for, this study found that clinical and medication-related variables including comorbidities, additional complications, and number of medications were predictive of adherence to prophylactic inhaled corticosteroid therapy in this population. Poorer medication adherence was associated with a 5% increase in total annual physician visits (P < 0.05). Better medication adherence was associated with a 20% decrease in annual hospitalization (P < 0.05). Additional pulmonary complications and severe comorbidities were associated with increases in health care utilization and costs. Patients with better adherence to prophylactic therapy were few, and the beneficial effects of better adherence were not significant when the population averages were considered. CONCLUSIONS: The results of this study indicated that the beneficial effects of better adherence to prophylactic inhaled corticosteroid therapy tended to diminish in a population with relatively poor medication adherence. Findings of this study support a policy of selectively targeting elderly patients at risk for morbidity and implementing monitoring, education, and management programs to increase medication-adherence behavior. This policy could lead to optimal resource utilization and management of chronic pulmonary disease.

Influence of a financial incentive on cognitive services: CARE project design/implementation.

OBJECTIVE: To describe the design and methods of the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project, a demonstration project in which community pharmacies were paid for cognitive services (CS) provided to Medicaid patients, its evaluation objectives, and the extent to which implementation objectives were achieved. DESIGN: Prospective randomized trial. Community pharmacies were allocated to a documentation-and-payment group, documentation-only group, and "silent" control group. CS were reported using a problem-intervention-result classification system embedded within a pseudo-National Drug Code format. Management strategies included use of area coordinators. SETTING: Pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term-care residents. PARTICIPANTS: 200 community pharmacies (110 treatment; 90 control), with another 100 randomly selected pharmacies as a silent control group. INTERVENTIONS: A modest monthly stipend. The treatment group billed Medicaid for each documented CS associated with a drug therapy-related problem. All participants received training in documentation methods. A unique coding scheme allowed documentation of CS within the constraints of the Medicaid program. Data edit checks and feedback were used to ensure data quality and completeness. Area coordinators were used to facilitate training, compliance with study procedures, and participation. MAIN OUTCOME MEASURES: Participation rates, documentation rates, coding scheme revision, data quality and completeness rates, and effectiveness of area coordinators. RESULTS: Pharmacists documented more than 20,240 CS records. Approximately 89% of records passed edit checks, and 94% did so after modification. Nearly 83% could be linked to a paid drug or CS claim. The coding system was sufficient, with minor modifications, to account for all interventions documented. Area coordinators did not function as expected. CONCLUSION: A system for documentation and payment of pharmacists' CS to Medicaid recipients was implemented successfully and relatively easily in community pharmacies.

Characteristics of pharmacies and pharmacists associated with the provision of cognitive services in the community setting.

OBJECTIVE: To determine the influence of payment, pharmacy setting characteristics, pharmacist demographics, practice setting, and attitudinal characteristics on whether cognitive services (CS) were performed by pharmacists, and the volume of CS performed. DESIGN: Prospective randomized trial. Community pharmacies were randomized to a documentation-and-payment group (study group) and a documentation-only group (control). Participating pharmacies and pharmacists were surveyed by mail, and responses were linked to a documented CS database. SETTING: Community pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents. PARTICIPANTS: 200 community pharmacies and their pharmacists (110 study, 90 control) participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project. INTERVENTION: Payment for CS. All participants documented CS. Study group pharmacies billed Medicaid for services performed in identifying and resolving drug therapy-related problems. MAIN OUTCOME MEASURE: Documentation of CS. RESULTS: Documentation of CS was more likely if the pharmacist was an owner or manager, if documentation was not perceived as burdensome, and if the pharmacy had a low ratio of prescription to total sales. Higher documentation rates were associated with study group status, lower pharmacy prescription volume as a percentage of total sales, and a higher percentage of prescriptions billed to Medicaid. Among pharmacists, two setting variables--medical center location and rural location--were associated with higher documentation rates. CONCLUSION: Performance of CS was strongly affected by payment and other situational factors, including practice setting and volume of prescriptions dispensed. Pharmacies and pharmacists were also more likely to perform CS if the target patient population represented a relatively large percentage of that pharmacy's patient clientele.

Washington State CARE Project: downstream cost changes associated with the provision of cognitive services by pharmacists.

OBJECTIVE: To determine the changes in drug costs associated with drug therapy changes resulting from pharmacists' cognitive services (CS) provided to Medicaid recipients during a 1-year period following the documented CS. DESIGN: A study-control group analysis of documented pharmacists' CS interventions linked to Medicaid prescription claims. Each CS resulting in a drug therapy change was linked to an index prescription claim and all refills for the same drug within 365 days. The drug cost change associated with the CS was calculated as the difference between the estimated cost of the prescription as originally written less the actual cost to Medicaid for the stream of refills dispensed. SETTING: Pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents. PARTICIPANTS: Approximately 200 community pharmacies participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project. Pharmacies were randomly assigned to a group that was paid a fee for each CS provided or a group that was not paid. INTERVENTION: Payment for CS. MAIN OUTCOME MEASURES: Downstream drug costs associated with CS resulting in a drug therapy change. RESULTS: CS resulting in drug therapy changes accounted for 5,417 out of 20,240 (27%) documented CS in the CARE Project. Of the 2,002 CS records analyzed in this study, 76% indicated a change in the prescribed drug or drug regimen, 9% indicated that a drug was added, 5% indicated that a current drug was discontinued, and 10% indicated that an originally prescribed drug was never dispensed. Only 9% involved generic substitution; all other changes would have necessitated prior prescriber approval. Overall, CS resulting in a drug therapy change generated a mean drug cost savings of $13.05 per CS intervention. There were no significant differences in average savings per intervention between the paid and nonpaid groups. CONCLUSION: For all result categories except "add drug therapy," the extrapolated cost savings in the paid group exceeded the savings estimated from the nonpaid group, sometimes by a considerable amount. At the payment rate used in this study, paying for CS that result in a drug therapy change (except add drug therapy) is estimated to save an additional $10 per 1,000 prescriptions dispensed. Those CS that result in addition of drug therapy are estimated to add an incremental cost of about $13 per 1,000 prescriptions. A sensitivity analysis revealed that a higher intervention rate would lead to a higher potential savings. This finding suggests that efforts to encourage CS interventions may lead to greater savings.

Patients' perceived benefit from and satisfaction with asthma-related pharmacy services.

OBJECTIVE: To determine whether patients targeted to receive intervention from an asthma management program reported receiving more services and had greater perceived benefit and satisfaction with those services compared with asthma patients not targeted by the program. DESIGN: Mailed survey. SETTING: Community pharmacy. PATIENTS: 471 community-based patients receiving asthma medications from 44 intervention pharmacies and 1,164 patients from 46 usual care (control) pharmacies. MAIN OUTCOME MEASURES: Five-point agreement scale measuring asthma services received, perceived value of the services, and satisfaction. RESULTS: Usable surveys were received from 39.0% of intervention patients and 42.4% of controls. There were no statistically significant differences between groups in the frequency of provision of listed services. Approximately 60% of respondents from both groups received written materials on asthma medications and 54% received inhaler counseling; both were rated high for perceived benefit. Fewer than 20% reported being counseled about asthma triggers. Fewer than 5% reported pharmacists talking to physicians on their behalf. General satisfaction with pharmacy services was high (78.2% agree or strongly agree), but not statistically different between groups. More than 65% believed that pharmacists spend enough time counseling patients. Several comments indicated that patients did not expect or ask for information because they were unaware that services were available and/or they had already been counseled by their physician. Responses to the statement "my asthma is better controlled because of help given to me by the pharmacist" were equivocal and not different between groups. CONCLUSION: Overall, there were few differences between groups. General satisfaction with pharmacy services is high, but patients' perceived benefit and satisfaction with cognitive services is lower. Increased public awareness of pharmacists' capabilities and a more proactive approach to providing cognitive services is needed.

A randomized controlled trial of a drug use review intervention for sedative hypnotic medications.

OBJECTIVES: Drug use review is used by both the public and private sector to influence prescribing behavior and patient drug use. Past interventions mailed to prescribers have had mixed results. The objective was to evaluate the effect of a one-time, mailed intervention on subsequent use of sedative hypnotic medication. METHODS: An experimental design was used. The intervention contained guidelines for the use of sedative hypnotics, a prescriber profile detailing sedative hypnotic prescribing, and a patient profile. Clustering of patients and their shared prescribers was done to avoid contamination bias and statistical problems associated with a lack of independence of observations. Subjects were 189 Washington State Medicaid recipients who had received at least one tablet per day of a sedative hypnotic medication for 1 year and their prescribing physicians or (when information about the physician was lacking) the dispensing pharmacy. RESULTS: A significant reduction in the use of targeted sedative hypnotic medications was measured in the intervention group (-27.6%) versus the control group (-8.5%). In the intervention group, 9.4% of patients began a new prescription for a benzodiazepine not targeted by the drug use review, whereas no control patients had new use of nontarget benzodiazepines. CONCLUSIONS: The intervention achieved a statistically significant decrease in targeted drug use, and the amount of reduction is likely to have decreased the risk of fractures associated with benzodiazepine use. This study adds to the recent evidence that mailed drug use review interventions can have a desirable impact on patient drug use.

Principal findings from the Washington State cognitive services demonstration project.

In addition to dispensing, pharmacists are ideally positioned to provide cognitive services that are targeted at optimizing drug therapy through identification and resolution of drug therapy problems. The Washington Cognitive Activities and Reimbursement Effectiveness project sought to determine: (1) if pharmacists would respond to a financial incentive by performing more cognitive services, and (2) the effect on drug cost of cognitive services they performed.

Alprazolam as an alternative to low-dose haloperidol in older, cognitively impaired nursing facility patients.

OBJECTIVES: To determine if alprazolam is equally as effective as low dose haloperidol in managing disruptive behavioral episodes associated with delirium, dementia, and amnesic and other cognitive disorders (formerly called organic mental syndromes). SETTING: Twenty-five community nursing homes in western Washington. PARTICIPANTS: Older nursing home residents (N = 48) receiving a low-dose neuroleptic for the treatment of agitation and behavioral disturbances. INTERVENTION: Randomized, double-blind, crossover trial of alprazolam and low dose haloperidol. Data were gathered at baseline and at the end of 6 and 12 weeks from direct observation and from clinical forms completed routinely by trained nurses. MEASUREMENTS: Number of behavioral episodes, activities of daily living as measured by the Blessed Dementia Scale, extrapyramidal symptoms as measured by the Abnormal Involuntary Movement Scale (AIMS), and psychopathology as measured by the Clinical Global Impressions (CGI) and the Sandoz Clinical Assessment - Geriatric (SCAG) scales. RESULTS AND CONCLUSIONS: No significant differences were observed between patients using haloperidol or alprazolam in terms of behavioral episodes per week. Further, with few exceptions, no significant differences were found in other outcome scales. Essentially the same findings were found when analyses were repeated for subgroups of patients with high levels of cognitive impairment and for patients with low and high levels of recorded problematic behavioral episodes. Alprazolam was as effective as low dose haloperidol in this population.

A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines?

BACKGROUND: The availability of clinical guidelines in isolation has generally failed to promote voluntary change in practice patterns. Accordingly, a randomized controlled trial was conducted to determine the effectiveness of academic detailing (AD) techniques and continuous quality improvement (CQI) teams in increasing compliance with national guidelines for the primary care of hypertension and depression. METHODS: Fifteen small group practices at four Seattle primary care clinics were assigned to one of three study arms--AD alone, AD plus CQI teams, or usual care. The activity of 95 providers and 4,995 patients was monitored from August 1, 1993, through January 31, 1996. Twelve-month baseline and study periods were separated by a six-month "wash-in" period during which training sessions were held. Changes in hypertension prescribing, blood pressure control, depression recognition, use of older tricyclics, and scores on the Hopkins Symptom Checklist depression scale were examined. RESULTS: Clinics varied considerably in their implementation of both the AD and the CQI team interventions. Across all sites, AD was associated with change in a single process measure, a decline in the percentage of depressives prescribed first-generation tricyclics (-4.7 percentage points versus control, p = 0.04). No intervention effects were demonstrated for CQI teams across all sites for either disease condition. Within the clinic independently judged most successful at implementing both change strategies, the use of CQI teams and AD in combination did increase the percentage of hypertensives adequately controlled (17.3 percentage points versus control, p = 0.03). SUMMARY AND CONCLUSIONS: The AD techniques and the CQI teams evaluated were generally ineffective in improving guideline compliance and clinical outcomes regarding the primary care of hypertension and depression.

Assessing compliance to antihypertensive medications using computer-based pharmacy records.

Systematic approaches for compliance problem detection and intervention are needed if the benefits of prescribed drug therapy in chronic disease management are to be optimized. As with all measures of compliance, computer algorithms based on refill patterns have advantages and disadvantages. They are unobtrusive and easily determined, but they measure the timeliness of prescription refills, not actual drug-taking. Computer-generated algorithms for assessing compliance based on refill patterns should be used by practitioners with caution, because they are not only markers for potential drug taking compliance problems, but also for discrepancies between the medical chart, pharmacy records and verbal advice given to the patient. Because patients may obtain refills before depleting their supply, compliance rates using this methodology are best determined across several refills. In particular, we urge caution in applying them over time periods of less than 60 days. Longer minimum time periods further decrease the likelihood of "false positives" but limit the number of patients for whom a compliance measure can be computed. For the health professional (eg, the pharmacist) responsible for monitoring drug-taking compliance of patients, the message seems clear: when reviewing computer-generated noncompliance "flags," the first task is to fully explore the possibility of discrepancies in drug records before initiating compliance-related interventions.

Satisfaction with prescriptive authority protocols.

OBJECTIVES: The use of prescriptive authority protocols by pharmacists and physicians in Washington was described as to: (1) types of decisions made, frequency of use, and nature of working arrangements among participants; (2) their perceived impact on professional practice and care rendered to patients; and (3) their satisfaction with the protocol arrangements. DESIGN: A mail survey of participants currently engaged in prescriptive authority was conducted. RESULTS: Responses were received from participants in 44 of 57 protocols. A total of 135 prescribers and 84 pharmacists responded. On average, 7 pharmacists and 27 prescribers were involved in each protocol, and had been involved for 6 years or more. It was estimated that approximately 10% of all active practitioners participated in protocols. Most protocols involved continuation of drug therapy or authorizing renewals. Modification of therapy (usually involving dosage or dose from changes) was practiced in two-thirds of the protocols, and initiation of therapy in about half of them. Most existed within managed care and group practice settings. Most prescribers (98%) and pharmacists (95%) were satisfied with protocol arrangements. Additionally, they generally agreed that the protocols increase patient convenience and increase the quality of patient care, and they encouraged their colleagues to use prescribing protocols. CONCLUSIONS: Protocol arrangements appear to be working well from the perspective of participants. Based on this experience, the authors encourage the development of similar protocol arrangements in other states.

Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines.

BACKGROUND: A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression. STUDY: Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners). RESULTS: The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions. SUMMARY AND CONCLUSIONS: Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.

Pharmaceutical counseling and medication adherence monitoring: an essential component of any drug benefit program.

Prescription drugs are an essential component of any health benefit. This is hardly a controversial statement, yet it is only relatively recently that prescription drugs have been included as part of the benefits package available to most Americans. The United States has lagged behind most other industrialized countries in providing a drug benefit, and such a benefit is still lacking for one of the most needy segment of our society--the elderly.

Understanding capitation and pharmaceutical care.

Although capitation has not yet emerged as the predominant mode of payment for health care, many experts believe that this will happen within a few years, and that capitation will predominate among methods to pay for pharmaceutical care services as well. Capitation is confusing because it exists in many forms. This article: Explains alternative forms of capitation for pharmaceutical care services. Offers some thoughts on what might be acceptable and not-so-acceptable forms from the perspective of the pharmacy manager.