Impact of health system specialty pharmacies on total cost of care in cancer treatment, a multisite review.

INTRODUCTION: Integrated delivery networks can use medically integrated dispensing of oral oncolytics on site through health system specialty pharmacies. There is little published research examining cost savings. Our objective was to demonstrate the financial value of health system specialty pharmacies among patients receiving oral oncolytics dispensed through fully, partially, and non-integrated dispensing strategies. METHODS: This was a retrospective cohort study of adult patients from Symphony Health's Integrated Dataverse® repository who filled a prescription for an agent of interest from 7/1/16-6/30/20 that was written within 25 US health systems. Outcomes included costs, healthcare resource utilization, and duration of therapy. RESULTS: In total, 36,816 patients were included; 986 patients (2.7%) integrated, 1,822 (4.9%) partially integrated, and 34,008 (92.4%) non-integrated. Mean 6-month medical charge and oncolytic prescription costs were lower for the integrated group ($36,831; $55,786) than the partially integrated ($46,304, p = 0.053; $63,295, p = 0.071) and non-integrated groups ($54,261, p < 0.001; $65,005, p = 0.004). In most healthcare resource utilization categories, the integrated group had the lowest patient percentage utilizing medical care. Duration of therapy was lower on average by ∼3 months in the integrated vs non-integrated group, which may represent closer monitoring of patient medical records and need for fills vs autoship practices. CONCLUSIONS: Patients receiving oral oncolytics through medically integrated dispensing at health system specialty pharmacies may have lower medical and pharmacy costs and decreased healthcare resource utilization. This study adds to the growing body of literature supporting integrated delivery networks and integrated dispensing. Further research is needed to demonstrate the value of medically integrated dispensing through health system specialty pharmacies in the delivery of treatment to patients with cancer and other high-cost diseases.

History of periodontal treatment and risk for intrauterine growth restriction (IUGR).

BACKGROUND: To explore the hypothesis that maternal periodontitis is associated with increased risk for Intrauterine Growth Restriction (IUGR), we examined the risk of IUGR in relation to periodontal treatment before, during and after pregnancy. METHODS: We conducted a retrospective cohort analysis of insurance claims data from 2009 to 2012 for women who delivered a singleton live birth (n = 32,168). IUGR was examined as a function of type and timing of dental treatment, adjusting for potential confounders in logistic regression. Sensitivity analysis evaluated the potential effects of unmeasured confounding. RESULTS: Women who received periodontal treatment after delivery, indicating the presence of untreated periodontal disease during pregnancy, had significantly higher odds of IUGR compared to women who received no periodontal treatment (adjusted OR 1.5, 95% CI 1.2, 1.8). CONCLUSIONS: Periodontal treatment provided in the immediate postpartum period, a proxy for periodontitis during gestation, was associated with increased risk of IUGR.

Impact of a Web-based intervention on maternal caries transmission and prevention knowledge, and oral health attitudes.

Poor oral health knowledge is thought to significantly contribute to the incidence of early childhood caries, the most common childhood disease in the U.S. This study assessed the effectiveness of a web-based educational program in increasing oral health and caries transmission knowledge, attitudes and planned behavior among mothers and primary caregivers. Study participants were recruited from subscribers to an online health information newsletter distributed by a national dental insurance company and from visitors to a health information website sponsored by the same company. Participants completed pre- and post-intervention surveys and viewed a brief educational program. Results were analyzed for pre- to post-test changes in knowledge and attitudes. Planned behavior change was also assessed. 459 participants completed pre-and post-test surveys. The sample was typically more insured (91.3 %), and college educated (76.9 %), than the general population. At baseline, respondents were knowledgeable about caries and its prevention; however, their specific knowledge about caries transmission was limited. There was a significant increase in caries knowledge from baseline to follow-up, particularly regarding caries transmission. At baseline less than half of the participants (48.8 %) knew that mothers/primary caregivers play a large role in passing cavity causing germs to children and 43.1 % knew that there is a defined period of time when the risk of transmission of cariogenic bacteria is greatest; however in post-testing 99.6 % and 98.3 % answered these question correctly respectively (p < 0.001). Results indicate that a web-delivered oral health intervention can increase dental knowledge and increase participants' plans to prevent maternal caries transmission. The provision of web-delivered education to primary caregivers can be an effective and low cost strategy for promoting maternal and infant oral health.

Feasibility of regional center telehealth visits utilizing a rural research network in people with Parkinson's disease.

Background: Impaired motor and cognitive function can make travel cumbersome for People with Parkinson's disease (PwPD). Over 50% of PwPD cared for at the University of Arkansas for Medical Sciences (UAMS) Movement Disorders Clinic reside over 30 miles from Little Rock. Improving access to clinical care for PwPD is needed. Objective: To explore the feasibility of remote clinic-to-clinic telehealth research visits for evaluation of multi-modal function in PwPD. Methods: PwPD residing within 30 miles of a UAMS Regional health center were enrolled and clinic-to-clinic telehealth visits were performed. Motor and non-motor disease assessments were administered and quantified. Results were compared to participants who performed at-home telehealth visits using the same protocols during the height of the COVID pandemic. Results: Compared to the at-home telehealth visit group (n = 50), the participants from regional centers (n = 13) had similar age and disease duration, but greater disease severity with higher total Unified Parkinson's disease rating scale scores (Z = -2.218, p = 0.027) and lower Montreal Cognitive Assessment scores (Z = -3.350, p < 0.001). Regional center participants had lower incomes (Pearson's chi = 21.3, p < 0.001), higher costs to attend visits (Pearson's chi = 16.1, p = 0.003), and lived in more socioeconomically disadvantaged neighborhoods (Z = -3.120, p = 0.002). Prior research participation was lower in the regional center group (Pearson's chi = 4.5, p = 0.034) but both groups indicated interest in future research participation. Conclusions: Regional center research visits in PwPD in medically underserved areas are feasible and could help improve access to care and research participation in these traditionally underrepresented populations.

An examination of periodontal treatment, dental care, and pregnancy outcomes in an insured population in the United States.

OBJECTIVES: We examined whether periodontal treatment or other dental care is associated with adverse birth outcomes within a medical and dental insurance database. METHODS: In a retrospective cohort study, we examined the records of 23,441 women enrolled in a national insurance plan who delivered live births from singleton pregnancies in the United States between January 1, 2003, and September 30, 2006, for adverse birth outcomes on the basis of dental treatment received. We compared rates of low birthweight and preterm birth among 5 groups, specifying the relative timing and type of dental treatment received. We used logistic regression analysis to compare outcome rates across treatment groups while adjusting for duration of continuous dental coverage, maternal age, pregnancy complications, neighborhood-level income, and race/ethnicity. RESULTS: Analyses showed that women who received preventive dental care had better birth outcomes than did those who received no treatment (P < .001). We observed no evidence of increased odds of adverse birth outcomes from dental or periodontal treatment. CONCLUSIONS: For women with medical and dental insurance, preventive care is associated with a lower incidence of adverse birth outcomes.

Cryopreservation of Algae.

Cryopreservation has been successfully used in the banking and maintenance of cultures of microorganisms, from bacteria to yeasts, since the onset of cryobiology. Biobanking of marine biological resources is crucial for development of scientific knowledge as researchers rely on guaranteed access to reliable, stable resources. Culture collections play a key role in the provision of marine biological resources as they ensure long-term ex situ storage of biological resources that are made available for public and private sector research and education. In this chapter, we provide protocols for cryopreservation of different types of algae cultures.

Creating a learning organization to help meet the needs of multihospital health systems.

PURPOSE: The considerations that leaders of multihospital health systems must take into account in developing and implementing initiatives to build and maintain an exceptional pharmacy workforce are described. SUMMARY: Significant changes that require constant individual and organizational learning are occurring throughout healthcare and within the profession of pharmacy. These considerations include understanding why it is important to have a succession plan and determining what types of education and training are important to support that plan. Other considerations include strategies for leveraging learners, dealing with a large geographic footprint, adjusting training opportunities to accommodate the ever-evolving demands on pharmacy staffs in terms of skill mix, and determining ways to either budget for or internally develop content for staff development. All of these methods are critically important to ensuring an optimized workforce. Especially for large health systems operating multiple sites across large distances, the use of technology-enabled solutions to provide effective delivery of programming to multiple sites is critical. Commonly used tools include live webinars, live "telepresence" programs, prerecorded programming that is available through an on-demand repository, and computer-based training modules. A learning management system is helpful to assign and document completion of educational requirements, especially those related to regulatory requirements (e.g., controlled substances management, sterile and nonsterile compounding, competency assessment). CONCLUSION: Creating and sustaining an environment where all pharmacy caregivers feel invested in and connected to ongoing learning is a powerful motivator for performance, engagement, and retention.

Management of children and young people (CYP) with asthma: a clinical audit report.

An asthma attack or exacerbation signals treatment failure. Most attacks are preventable and failure to recognize risk of asthma attacks are well recognized as risk factors for future attacks and even death. Of the 19 recommendations made by the United Kingdom National Review of Asthma Deaths (NRAD) (1) only one has been partially implemented-a National Asthma Audit; however, this hasn't reported yet. The Harrow Clinical Commissioning Group (CCG) in London implemented a clinical asthma audit on 291 children and young people aged under 19 years (CYP) who had been treated for asthma attacks in 2016. This was funded as a Local Incentive Scheme (LIS) aimed at improving quality health care delivery. Two years after the publication of the NRAD report it is surprising that risks for future attacks were not recognized, that few patients were assessed objectively during attacks and only 10% of attacks were followed up within 2 days. However, it is encouraging that CYP hospital admissions following the audit were reduced by 16%, with clear benefit for patients, their families and the local health economy. This audit has provided an example of how clinicians can focus learning on patients who have had asthma attacks and utilize these events as a catalyst for active reflection in particular on modifiable risk factors. Through identification of these risks and active optimization of management, preventable asthma attacks could become 'never events'.

Investigating inpatient medication administration using the theory of planned behavior.

PURPOSE: Results of a study to determine behavioral factors that help explain why nurses often do not obtain and administer medications from automated dispensing cabinets (ADCs) "one patient at a time" are reported. METHODS: To investigate nurses' frequent failure to adhere to best-practice standards for ADC use, a 12-item questionnaire developed using information obtained from an elicitation study and a focus group session was e-mailed to 755 nurses at an academic medical center. A model based on constructs of the theory of planned behavior (attitude, subjective norm, and perceived behavioral control) was used to evaluate nurses' intent to follow ADC best practices through univariate and multivariate analyses. RESULTS: Of the 755 nurses targeted in the survey, 271 (34%) submitted usable responses. A favorable attitude toward safe ADC dispensing practices and a supportive subjective norm were strongly associated with intent to use ADCs properly; those factors remained highly correlated with intent (p < 0.001 for both) after controlling for demographic and work-related variables such as years in practice and patient workload. Eighty percent of observed variability of intent was explained by the evaluated constructs and variables (p < 0.001), suggesting that direct interventions at the patient care unit level and peer influence would likely be effective in promoting safe ADC use. CONCLUSION: A survey based on the theory of planned behavior demonstrated that attitude and subjective norm were important independent predictors of nurse intent to use ADCs properly.

An examination of periodontal treatment and per member per month (PMPM) medical costs in an insured population.

BACKGROUND: Chronic medical conditions have been associated with periodontal disease. This study examined if periodontal treatment can contribute to changes in overall risk and medical expenditures for three chronic conditions [Diabetes Mellitus (DM), Coronary Artery Disease (CAD), and Cerebrovascular Disease (CVD)]. METHODS: 116,306 enrollees participating in a preferred provider organization (PPO) insurance plan with continuous dental and medical coverage between January 1, 2001 and December 30, 2002, exhibiting one of three chronic conditions (DM, CAD, or CVD) were examined. This study was a population-based retrospective cohort study. Aggregate costs for medical services were used as a proxy for overall disease burden. The cost for medical care was measured in Per Member Per Month (PMPM) dollars by aggregating all medical expenditures by diagnoses that corresponded to the International Classification of Diseases, 9th Edition, (ICD-9) codebook. To control for differences in the overall disease burden of each group, a previously calculated retrospective risk score utilizing Symmetry Health Data Systems, Inc. Episode Risk Groups (ERGs) were utilized for DM, CAD or CVD diagnosis groups within distinct dental services groups including; periodontal treatment (periodontitis or gingivitis), dental maintenance services (DMS), other dental services, or to a no dental services group. The differences between group means were tested for statistical significance using log-transformed values of the individual total paid amounts. RESULTS: The DM, CAD and CVD condition groups who received periodontitis treatment incurred significantly higher PMPM medical costs than enrollees who received gingivitis treatment, DMS, other dental services, or no dental services (p < .001). DM, CAD, and CVD condition groups who received periodontitis treatment had significantly lower retrospective risk scores (ERGs) than enrollees who received gingivitis treatment, DMS, other dental services, or no dental services (p < .001). CONCLUSION: This two-year retrospective examination of a large insurance company database revealed a possible association between periodontal treatment and PMPM medical costs. The findings suggest that periodontitis treatment (a proxy for the presence of periodontitis) has an impact on the PMPM medical costs for the three chronic conditions (DM, CAD, and CVD). Additional studies are indicated to examine if this relationship is maintained after adjusting for confounding factors such as smoking and SES.

Identifying Multilevel Barriers to Tobacco Intervention in Postdoctoral Dental Education.

The aims of this mixed-methods study were to assess tobacco treatment behaviors among residents and faculty in dental specialty postdoctoral programs and to explore factors in training and practice related to tobacco treatment education. Surveys and focus groups were conducted with a convenience sample of participants at three postdoctoral residency programs in New York City. Surveys assessed tobacco cessation training and behaviors. Focus groups explored barriers to implementing tobacco cessation treatment in educational settings. Data were collected between May and December 2013. Among the 160 faculty and residents identified as potentially eligible for the study, 60 were invited by program directors to participate, and 50 subsequently completed the survey and participated in a focus group (response rate of 31.3%). Survey results indicated high levels of asking patients about tobacco use and advising patients to quit. In contrast, specific tobacco cessation assistance and follow-up care occurred less frequently. There were statistically significant differences in tobacco cessation intervention across the specialties surveyed, but not between residents and faculty. Focus group comments were grouped into three broad areas: clinician factors, organizational support, and structural and contextual factors. Focus group results indicated that participants experienced significant organizational and structural barriers to learning about and providing tobacco treatment. Participants from each specialty indicated that multi-level barriers impeded their provision of evidence-based tobacco cessation interventions in postdoctoral educational settings. They suggested that didactic education should be reinforced by organizational- and systems-level changes to facilitate comprehensive tobacco education and effective cessation treatment in future dental practice.

Fecal microbiota transplant for Clostridium difficile infection in older adults.

BACKGROUND: The objective of this study was to describe the safety of fecal microbiota transplant (FMT) for Clostridium difficile infection (CDI) among older adults. METHODS: We performed a case review of all FMT recipients aged 65 or older treated at Emory University Hospital, a tertiary care and referral center for Georgia and surrounding states. RESULTS: CDI resolved in 27 (87%) of 31 respondents, including three individuals who received multiple FMTs. Among four whose CDI was not resolved at follow up, three respondents did well initially before CDI recurred, and one individual never eradicated his CDI despite repeating FMT. During the study, five deaths and eight serious adverse events requiring hospitalization were reported within the study group during the follow-up period. Fecal transplant was not a causative factor in these events. The most common adverse event reported in 4 (13%) of 31 respondents was subjective worsening of arthritis. CONCLUSION: FMT is a generally safe and effective treatment option for older adults with CDI.

Fecal microbiota transplant protocol for clostridium difficile infection.

Fecal microbiota transplant has become more acceptable as a therapeutic for recurrent Clostridium difficile infection. The FDA has an enforcement discretion policy for practitioner's performing this therapy, which includes informed consent for this experimental treatment. This manuscript describes a typical procedure that can be followed that includes the important aspects of this preparation and treatment.

Somatostatin-induced gastric protection against ethanol: involvement of nitric oxide and effects on gastric mucosal blood flow.

BACKGROUND/AIMS: The mechanisms of somatostatin-mediated gastroprotection are not fully understood. Aims of this study were to determine in the rat the role of nitric oxide (NO) in somatostatin-induced effects on gastric mucosal protection and blood flow (GMBF) in the absence and in the presence of intraluminal ethanol. METHODS: Ethanol (70% v/v)-induced gastric mucosal injury after orogastric dosing was quantitated at 30 min and GMBF determined in an ex vivo gastric chamber preparation. RESULTS: Somatostatin (4 microg/kg; i.p.) protection against ethanol-induced ulceration was prevented by the NO inhibitor L-NNA and restored by L-arginine, but not D-arginine. Somatostatin (1-8 microg/kg; i.p.) did not effect basal GMBF. The gastroprotective dose of somatostatin (4 microg/kg; i.p.) prevented the decrease in GMBF caused by ethanol. L-NNA reversed this vascular effect of somatostatin. CONCLUSION: Somatostatin-induced gastroprotection and restoration of GMBF during ethanol exposure involve mechanisms which are dependent on NO generation.

Transforming growth factor alpha-mediated gastroprotection against stress ulceration in the rat: involvement of capsaicin-sensitive sensory neurons.

Exogenously administered TGF alpha has been shown to protect rodent gastric mucosa against injury caused by acid-dependent and acid-independent injury. The present study examined whether the gastroprotective effects of TGF alpha on stress-induced gastric ulceration in the rat involves activation of capsaicin-sensitive sensory neurons. Fasted male SD rats were subjected to water restraint stress (WRS) for four hours. Thereafter, rats were euthanized; the stomach opened and macroscopic areas of gastric ulceration quantitated (mm(2)). Gastric tissue contents of TGF alpha and the sensory neuropeptide, calcitonin gene-related peptide (CGRP) were determined by radioimmunoassay. Prior to stress rats received TGF alpha 50, 100 or 200 microg/kg by intraperitoneal injection. Sensory denervation was accomplished by high dose capsaicin treatment. WRS caused severe ulceration in the gastric corpus; 46.1 + 6.6 mm(2). Parenteral administration of TGF alpha caused dose-dependent reduction in gastric injury: 34.7 + 4.9 mm(2) with 50 microg/kg (p < 0.05); 25.4 + 3.6 mm(2) with 100 microg/kg (p < 0.001) and 9.4 + 0.8 mm(2) with 200 microg/kg (p < 0.001). The gastroprotective action of TGF alpha (200 microg/kg, i.p.) was abolished by capsaicin-induced sensory denervation. In addition, WRS ulceration was associated with significant reduction in gastric CGRP (-42%) and TGF alpha (-48%) content. Reduction in CGRP content was prevented by TGF alpha pretreatment. We conclude that: 1) TGF alpha caused dose-dependent gastroprotection against WRS ulceration, 2) TGF alpha-mediated gastric mucosal protection was prevented by capsaicin-induced sensory denervation and, 3) stress-induced injury was associated with significant reduction in gastric content of both TGF alpha and CGRP.

The use of 'academic detailing' to promote tobacco-use cessation counseling in dental offices.

BACKGROUND: The authors conducted this study to ascertain the feasibility of face-to-face educational outreach visits, also called "academic detailing," as a methodology to promote dentists' adoption and incorporation of tobacco-use cessation counseling activities into their practices. METHODS: The authors obtained a sampling frame of one dental health maintenance organization's, or DHMO's, enrolled dentists who practiced in one of four Northeastern states and who had more than 300 DHMO patients. Of 507 eligible dentists, 88 agreed to participate, and the authors randomly assigned them to either intervention (an academic detailing program) or control (practice as usual) conditions. Changes in practice behaviors over time were obtained by questionnaires. The authors used descriptive statistics to analyze data using a statistics software package. RESULTS: Only 9 percent of dentists who agreed to participate had received any training in decreasing patients' tobacco use. The authors associated the dentists' staff members' considerable resistance to the detailing program with issues such as having to deal with additional paperwork and uncooperative patients, the perception that only a few patients use tobacco and that counseling does not work. Many dentists also expressed concern about their lack of tobacco-use cessation knowledge. Overall, dentists' resistance to detailing decreased with follow-up detailing visits. CONCLUSIONS: It is feasible to increase and incorporate tobacco-use cessation counseling in dental offices. However, significant barriers must be surmounted first if this goal is to be achieved by use of academic detailing. CLINICAL IMPLICATIONS: Using academic detailing, dentists can be effective agents in increasing the longevity, decreasing the morbidity and improving the oral health status of their patients through the promotion of smoking cessation.

Tobacco cessation in the dental office.

Evidence-based tobacco-cessation guidelines when used by clinicians are effective in reducing tobacco use and obtaining successful quits by patients. Dentists have been encouraged to provide instruction and intervention on tobacco cessation in the dental office. The dental provider is in the unique position to relate oral findings to the patient and to provide advice to tobacco-using patients to quit. In addition, dentists are able to assess patients' self-addiction and level of readiness to quit tobacco use. With this information, dentists can assist in helping patients to stop using tobacco by providing appropriate pharmacotherapeutic aid and thus improve their oral and overall health.

Diabetes and oral disease: implications for health professionals.

"Diabetes and Oral Disease: Implications for Health Professionals" was a one-day conference convened by the Columbia University College of Dental Medicine, the Columbia University College of Physicians and Surgeons, and the New York Academy of Sciences on May 4, 2011 in New York City. The program included an examination of the bidirectional relationship between oral disease and diabetes and the interprofessional working relationships for the care of people who have diabetes. The overall goal of the conference was to promote discussion among the healthcare professions who treat people with diabetes, encourage improved communication and collaboration among them, and, ultimately, improve patient management of the oral and overall effects of diabetes. Attracting over 150 members of the medical and dental professions from eight different countries, the conference included speakers from academia and government and was divided into four sessions. This report summarizes the scientific presentations of the event.

Inhibition of epidermal growth factor receptor activation enhances in vivo histamine-stimulated gastric acid secretion in the rat.

Epidermal growth factor (EGF) and transforming growth factor alpha (TGFalpha) have been shown to inhibit gastric acid secretion through stimulation of the EGF receptor (EGFR). In this study we examined in vivo the effects of inhibition of the EGFR on histamine-stimulated acid secretion in the rat. Submaximal (1.5 mg/kg/hr) histamine-stimulated acid secretion was measured (microEq H(+)/2 hr) during infusion of EGFRtk inhibitors and ranitidine in anesthetized rats. EGFR phosphorylation in gastric mucosal tissue lysates was measured by Western blot analysis. Submaximal histamine-stimulated acid secretion was increased significantly by the EGFR inhibitors tyrphostin (Tyr) A46 and Tyr AG1478. Tyr A46 prevented TGFalpha (10 microg/kg/hr)-mediated inhibition of maximal (5.0 microg/kg/hr) histamine-stimulated acid output. Histamine caused a fourfold increase in EGFR phosphorylation which was inhibited by both Tyr and ranitidine. We conclude that the EGFRtk inhibitors, Tyr A46 and Tyr AG1478, significantly increased submaximal histamine-stimulated acid output and Tyr A46 prevented TGFalpha inhibition of histamine-stimulated acid secretion. These observations suggest that the EGFR is involved, in vivo, in the regulation of gastric acid secretion.